The Quality Payment Program (QPP) has allowed large organizations to use the CMS Web Interface reporting method to complete MIPS requirements since the program launched in 2017. This gave these organizations the option to report a sampling of 248 patients (selected by Medicare Part B claims) across all their practices. CMS will completely sunset the CMS Web Interface reporting option by 2025.
In 2025, all MSSP ACOs must report either eCQMs, CQMs, or Medicare CQMs across all of their practices for 365 days of the year.
Figuring out data aggregation, de-duplication, and comprehensive performance review before 2025 is the key to your success. Below is a summary of your 2024 APP requirements.
There are three reporting frameworks available in the Quality Payment Program, but MSSP ACOs can only submit to one, the APM Performance Pathway (APP) reporting framework.
Also read: A comparison of the 2024 requirements for all three reporting frameworks.
For the APP framework there are three categories, Quality, Promoting Interoperability, and Improvement Activities. Cost is weighted at 0%.
Collection types are the way you report the data to CMS. You can think of them like measures. There are six collection types in 2024.
Option 1 (<<your only option in 2025)
Option 2 (<<not available in 2025)
Option 3 (<<not available in 2025)
Quality Measures
Claims Measures
CAHPS for MIPS Survey measure
Promoting Interoperability Measures
You must submit the PI Category:
By 2025 ACOs must have all their practices off of paper and on Certified EHR Technology (CEHRT).
All APM Entities reporting through the APP Framework will be automatically assigned a score of 100% which is applied to all Eligible Clinicians reporting through their APM Entity.
In 2024, for an MSSP ACO to get the maximum shared savings they must achieve a quality performance score that is greater than or equal to a certain percentile of the benchmark and meet the Shared Savings Program Quality Performance Standard.
To get the maximum shared savings for your ACO you must:
Report ALL measures in the APP measure set
AND
Achieve the Quality Performance Standard
CMS has implemented a sliding scale to give ACOs some percentage of the Shared Savings (not max) if they don’t meet the quality performance standards but do achieve a quality performance score equivalent to or higher than the 10th percentile of the performance benchmark on at least one of the four outcome measures.
Quality Performance Standard
OR
Health Equity-Adjusted score of => 40th percentile across ALL quality performance scores
Quality Performance Standard
CMS will calculate 2024 and 2025 benchmarks for the Medicare CQMs based on performance period benchmarks. They will transition to historical benchmarks in 2026 and subsequent years.
This means that ACOs will not know the Medicare CQM benchmarks during the performance period.
CMS is NOT extending the eCQM/MIPS CQM reporting incentive to Medicare CQMs.
CMS finalized the use of historical data to establish the 40th percentile MIPS Quality performance category score used for the quality performance standard.
That means you would know what the Quality Performance Standard percentile is BEFORE the performance year starts.
40th Percentile MIPS Quality Performance Category Scores Used in the Calculation of the PY 2024 Historical MIPS Quality Performance Category Score
|
Performance Year |
40th Percentile of the MIPS Quality Performance Category Score |
|
2020 |
75.59^ |
|
2021 |
77.83^ |
|
2022 |
77.73^ |
|
2023 |
Skipped due to 1-year lag |
|
2024 |
77.05 |
^ PY 2020 through PY 2022 40th percentile scores are based on performance period data
The start date to track 365 days of Quality and Cost category measures.
Registration opens for CMS Web Interface, CAHPS for MIPS Survey, and MVP selection.
The last day to start measures in the Promoting Interoperability category to meet the minimum of 180 continuous days.
The last day to start Improvement Activities to meet the minimum requirement of 90 continuous days.
The last day to submit all of your performance data.
There has been SO MUCH discussion on this topic. I once watched an ACO representative grill a CMS representative in a live panel discussion for no less than 20 mins on this topic. I think we all left even more confused. CMS attempted to make it clearer by releasing a new guide to Data Completeness that further validates the 100% of eligible patients. They make it very clear that no one can be excluded from the Denominator population.
An ACO must submit their entire “universe” of patients. None of your practices can be excluded based on populations. The data completeness threshold really would only be applicable in a MIPS CQM situation and even in that situation you still must have the entire universe of practices/patients and only achieve 70% completeness on the denominator patients.
Take a look at pages six and eight of the APP guidance document here.
It’s an unlikely scenario. But in some cases, an abstractor can't find the documentation that’s required by the measure. In this red scenario below an abstractor answers “no” to algorithm questions for more than 30% of cases.
ACOs must learn to juggle multiple, disparate EHRs and data collection methodologies. Developing a cohesive data aggregation system is going to be a major undertaking. Your senior leadership, quality management, and information technology teams need to start planning what that looks like for your ACO now.
The most important thing you can do right now is understand what your data landscape looks like. Here are a couple of questions you should know.
This information will help you to choose whether you want to submit eCQMs or MIPS CQMs. It will also inform you as to whether or not you have to set up conversations with any practices not able to provide your group with what you need.
This is completely dependent upon your organization set up. For most of our clients, we tell them to estimate a 6–8-month implementation time before you start to see any meaningful data.
It's in your best interest to start looking at your data through the all-patients, all-payers, all-practices lens now. It is the key to unlocking so many other patient care goals for you, including improving population health, reducing health care costs, and advancing health equity. For too long, the CMS Web Interface had made quality reporting a box that organizations had to check. It’s time now for organizations like yours to lead the charge to elevate the role of quality data in patient care. Together, we have the power to put quality data to good use.
At Medisolv, we offer so much more than quality software and start-to-finish submissions management. We’re the quality improvement partner committed to deciphering and anticipating CMS’s regulatory changes for you—so that you can keep your organization ahead of the curve.
Check out some of our additional resources now:
Medisolv Can HelpAlong with award-winning software, each client receives a dedicated Clinical Quality Advisor that helps you with your technical and clinical needs. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. Especially if you use an EHR vendor right now, you’ll notice a huge difference.
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