NAACOS Calls for a Rethinking of Medicare ACO Quality Reporting

CMS Should Also Correct the ACO ‘Rural Glitch’ As Soon As Possible

In formal comments submitted in response to the proposed 2022 Medicare Physician Fee Schedule, the National Association of Accountable Care Organizations (NAACOS) (@NAACOSnews) called on the Biden administration to hold off on requiring clinical quality measures to be reported electronically until data interoperability is widely available. While thankful for a three-year delay in ACOs’ move to electronic clinical quality measures (eCQMs), NAACOS offered several ways to improve the way ACOs report and are measured on quality, which is a hallmark aspect of ACO programs. The final Physician Fee Schedule Rule will be published later this fall.

The use of eCQMs would move ACOs away from manually abstracting data from patient charts, but also its use requires providers working in ACOs to aggregate data from their various electronic health records (EHR) systems, which is mostly not possible today. Because ACOs are groups of doctors, hospitals, and other providers who come together to take accountability for the cost and quality of beneficiaries, they are by definition multiple groups of providers, who often work with different EHR systems. According to a NAACOS survey of ACOs this spring, nearly half of ACOs’ participating practices use 11 or more EHRs, and the biggest barrier cited for movement to eCQM reporting was the lack of EHR standardization. Because of this, NAACOS calls on CMS to work with ACOs and the EHR vendor community to find solutions to data aggregation problems. Until these solutions are widely available, eCQMs should not be mandated for ACOs.

“CMS must avoid making eCQMs mandatory until standard data fields exist across EHRs, and true interoperability is achieved,” the letter states. “Instead, CMS should make the use of eCQMs optional until standard data fields exist across EHRs, and true interoperability is achieved.”

Among our other comments, NAACOS suggests CMS:

  • Abandon the strategy of aligning ACO quality with the Merit-Based Incentive Payment System (MIPS) quality assessments.
  • Revise the new Medicare Shared Savings Program (MSSP) quality performance standard since it is inappropriate to compare ACO quality performance to MIPS quality performance.
  • Remove the all-payor requirement for ACOs reporting eCQMs and instead urge CMS to require reporting on a sample of ACO assigned patients meeting the denominator criteria.
  • Improve education and guidance provided to ACOs to support their successful transition to eCQM/MIPS CQM reporting and the new Alternative Payment Model [APM] Performance Pathway (APP) reporting and assessments that have been created to evaluate their quality performance in the MSSP.

Last year when the healthcare industry was in the midst of an ongoing pandemic, CMS finalized a move to eCQMs for ACOs, among other changes. The move required ACOs in the MSSP to aggregate data from disparate EHR systems, which are not interoperable, and to report on quality data on all patients regardless of payer, raising issues with collecting data from non-ACO providers and on patients with no direct connection to the ACO. The move could also widen health disparities as ACOs’ quality performance could be misrepresented as differences in quality when variation is likely due to patient access to care or complexity. In May, 11 leading healthcare organizations called on the Biden administration to delay and make significant changes to quality reporting for ACOs — citing rushed implementation, still unanswered questions on changes, and potential negative consequences to patient care.

NAACOS also urges CMS to fix the ACO “rural glitch” by making formal regulatory changes to remove ACO-assigned beneficiaries from the regional reference population, which should be implemented as soon as possible. The rural glitch systematically penalizes an ACO when it reduces costs. Specifically, when an ACO lowers the total cost of care for its assigned population, it also reduces the average regional costs and diminishes the positive effect of the regional adjustment. This defeats the purpose of a benchmark that is based in part on regional expenditure data, which CMS has acknowledged is fair and necessary for a viable ACO program long-term.

The National Association of ACOs (NAACOS) represents more than 12 million beneficiary lives through hundreds of organizations participating in population health-focused payment and delivery models in Medicare, Medicaid, and commercial insurance. Models include the Medicare Shared Savings Program (MSSP), Next Generation ACOs, and alternative payment models supported by a myriad of commercial health plans and Medicare Advantage. NAACOS is a member-led and member-owned nonprofit organization that works to improve quality of care, outcomes, and healthcare cost efficiency.