CMS Regulation Impacts on MSSP and QPP

The Top 10 Changes ACOs Need to Know

By Sanjay Seth, MD, Executive Vice President, HealthEC
Twitter: @HealthEC_LLC

ACOs participating in shared savings programs face a number of opposing forces in 2021. From a decline in the number of Medicare beneficiaries to new CMS regulations to force downside risk sooner, ACOs are carefully weighing their options in the year ahead. In fact, the number of ACOs participating in the Medicare Shared Savings Program (MSSP) dropped by 7.7% in 2021 as reported by Modern Healthcare. This nascent decline raises a red flag for everyone involved in the programs; MSSP and the Quality Payment Program (QPP). Both programs are proven to save money while improving patient care outcomes.

For example, ACOs saved Medicare $2.6B in 2019. They represent an irrefutable opportunity for patients, providers, hospitals and health systems to “enhance quality of care, reduce costs and improve outcomes” according the National Association of ACOs (NAACOS). NAACOs is actively lobbying the Biden administration and new leadership at CMS to give ACOs more time to take on risk and extend the application period for new participants. While ACOs wait to hear how CMS will address the organization’s request, there are ten other salient points included in the December 28th, 2020 final changes in the physician fee schedule (PFS) and other Part B changes to also consider.

Ten MSSP and QPP Changes to Know
ACOs should take time now to understand how final changes in the physician fee schedule (PFS) and other Part B changes and how they impact the MSSP and QPP programs in the year ahead. Amid the concerns mentioned above, there are several positive adjustments to know.

  1. Extends agreement periods: Allows ACOs whose current agreement periods expire on December 31, 2020, the option to extend their existing agreement period by one year. New guidelines also allow ACOs in the BASIC track’s glide path the option to maintain their current level of participation for performance year 2021.
  2. Adjusts for COVID-19: Adjusts program calculations to remove payment amounts for episodes of care for treatment of COVID–19.
  3. Expands Primary Care: The definition of primary care services is expanded for purposes of determining beneficiary assignment to include telehealth codes for virtual check-ins, e-visits and telephonic communication.
  4. Changes in Quality Measures Reporting: For performance year 2021, ACOs will be required to report quality data via the APP and can choose to report either the ten measures under the CMS web interface, or the three eCQM/MIPS CQM measures AND achieve a score greater than 30th percentile of the MIPS AND on at least one measure in each domain to be eligible to share in any savings.For performance year 2022 and subsequent performance years, ACOs will be required to actively report quality data on the three eCQM/MIPS CQM measures via the APP program AND achieve a score greater than 30th percentile of the MIPS AND on at least one measure in each domain to be eligible to share in any savings.
  5. Quality Measures from Claims Data: Plus CMS will calculate two measures using administrative claims data that are risk adjusted utilizing Hierarchical Condition Category (HCC) comorbidity categories and adjusted for two area level social risk factors: (1) AHRQ socio-economic status (SES) index; and (2) specialist density.
    • The Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate
    • All Cause Unplanned Admissions for Patients with Multiple Chronic Conditions (MCC)
  6. Sunsets the CMS Web Interface: The interface will no longer be used to report quality measures starting with CY 2022.
  7. Reduced Burden: ACOs will only need to report one set of quality metrics via the APP that will satisfy the quality reporting requirements under both the Shared Savings Program and the MIPS.Specifies Measures: ACOs would report under the APP on the following 3 measures:
    1. Quality ID#: 001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
    2. Quality ID#: 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
    3. Quality ID#: 236 Controlling High Blood Pressure
  8. Reporting Only Measures: The Three CMS Web Interface measures (Statin Therapy for the Prevention and Treatment of Cardiovascular Disease (Quality ID# 438); Depression Remission at Twelve Months (Quality ID# 370), and Preventive Care and Screening: Screening for Depression and Follow-up Plan (Quality ID# 134)) do not have benchmarks, and therefore, will not be scored but must be reported.
  9. Includes Telehealth: Nine out of the ten CMS Web Interface measures and all three APP measures permit the services provided via telehealth to be inclusive.

As ACOs venture into another MSSP and QPP year, it is important to stay abreast of changes and renavigate program requirements. HealthEC is an active partner in equipping ACOs for success under value-based care.

This article was originally published on the HealthEC blog and is republished here with permission.