Due to extensive advocacy efforts, CMS has delayed the requirement for ACOs to fully implement eCQMs for quality measure reporting until Performance Year (PY) 2025 and has frozen the MSSP quality performance threshold until PY 2024. This allows ACOs more time to implement the changes needed for eCQM implementation, but CHESS is disappointed that CMS did not directly address the issue of measuring the few ACO measures against the entire MIPS quality performance population, and the “all or nothing” approach to shared savings distribution.
Quality Measure Reporting Mechanism
CMS has delayed the full onset of eCQMs for three years. For Performance Year 2021 through 2024, ACOs have the option to choose to fulfill quality reporting requirements either via the Web Interface (10 measures required) or through eCQMs/MIPS CQMs (3 measures required). If the ACO decides to report with both mechanisms, CMS will take the higher of the two scores. These quality measures are in addition to the CAHPS for MIPS survey measure, as well as the two claims-based quality measures that CMS will calculate for the ACO.
In PY 2022 and 2023, CMS will offer incentives to ACOs that volunteer to report via eCQMs/MIPS CQMs ahead of schedule. CMS did not finalize the proposal to require an ACO to report at least one measure via eCQMs/MIPS CQMs for PY 2023.
For PY 2025, ACOs will be required to submit the three quality measures via eCQMs or MIPS CQMs. CMS will continue to calculate the two claims-based measures, and ACOs will continue to contract with a third-party vendor to administer the CAHPS for MIPS Survey.
Quality Measures Required Based on Reporting Type for PY 2022 and Beyond
| Measure # | Measure Title | Collection Type | Submitter Type |
| Quality ID#: 321 | CAHPS for MIPS | CAHPS for MIPS Survey | Third Party |
| Measure # 479 | Hospital-Wide, 30-day, All-Cause Unplanned Readmission Rate for MIPS Eligible Clinician Groups | Claims | N/A |
| Measure # TBD | Risk Standardized, All-Cause Unplanned Admissions for Multiple Chronic Conditions for MIPS | Claims | N/A |
| Quality ID#:001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control | eCQM/MIPS CQM/ Web Interface | APM Entity or Third Party |
| Quality ID#:134 | Preventive Care and Screening: Screening for Depression and Follow-up Plan | eCQM/MIPS CQM/ Web Interface | APM Entity or Third Party |
| Quality ID#: 236 | Controlling High Blood Pressure | eCQM/MIPS CQM/ Web Interface | APM Entity or Third Party |
| Quality ID#: 318 | Falls: Screening for Future Fall Risk | Web Interface | APM Entity or Third Party |
| Quality ID#: 110 | Preventive Care and Screening: Influenza Immunization | Web Interface | APM Entity or Third Party |
| Quality ID#: 226 | Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention | Web Interface | APM Entity or Third Party |
| Quality ID#: 113 | Colorectal Cancer Screening | Web Interface | APM Entity or Third Party |
| Quality ID#: 112 | Breast Cancer Screening | Web Interface | APM Entity or Third Party |
| Quality ID#: 438 | Statin Therapy for the Prevention and Treatment of Cardiovascular Disease | Web Interface | APM Entity or Third Party |
| Quality ID#: 370 | Depression Remission at Twelve Months | Web Interface | APM Entity or Third Party |
Quality Performance Standard
For ACOs, the Quality Performance Standard determines whether the ACO gets to share in the savings generated in the model for the performance year. Previously the quality score correlated to the amount of savings retained. For example, a 95% quality score equals 95% retention of the ACO’s savings split. But in the 2021 Physician Fee Schedule Final Rule, CMS finalized an all or nothing approach.
For PY 2021, ACOs must achieve a final quality score equal to or higher than the 30th percentile across all MIPS Quality performance category scores if reporting via Web Interface. If this threshold is passed, the ACO receives 100% of its savings split; if not, the ACO does not receive savings. Note that the current Public Health Emergency (PHE) status automatically triggers the Extreme and Uncontrollable Circumstances policy for ACOs in 2021. Therefore, ACOs will be given the higher of either their quality score or the minimum attainment standard, thereby ensuring at least the 30th percentile for the PY.
For PY 2022 and 2023, there are two ways to reach the quality performance standard and receive savings based on the reporting mechanism:
- For Web Interface: Achieve a final quality score equal to or higher than the 30th percentile across all MIPS Quality performance category scores; or
- For eCQMs/MIPS CQMs: Report 3 eCQMs/MIPS CQMS, (must meet data completeness and case minimum requirements) and achieve a quality performance score equal to or higher than the 10th percentile of the performance benchmark on at least one of the four outcome measures and a quality performance score equivalent to or higher than the 30th percentile of the performance benchmark on at least one of the remaining five measures
What does this second option mean? For those choosing to report via eCQMs/MIPS CQMs for PY 2022/2023, the ACO must report three measures plus field the CAHPS for MIPS survey. CMS will then calculate the two claims-based measures for a total of six required measures. CMS has categorized four of the six measures as Outcome Measures. Therefore, the ACO must reach a quality score equal to or higher than the 10th percentile on one of four those measures, and then 30th percentile on any of the remaining five measures.
APP Measure Set for eCQM/MIPS CQM Reporting for PY 2022/2023
| Measure # | Measure Title | Outcome Measure? | Reporting Type |
| Quality ID#: 321 | CAHPS for MIPS | No | Patient Survey |
| Measure # 479 | Hospital-Wide, 30-day, All-Cause Unplanned Readmission Rate for MIPS Eligible Clinician Groups | Yes | Claims |
| Measure # TBD | Risk Standardized, All-Cause Unplanned Admissions for Multiple Chronic Conditions for MIPS | Yes | Claims |
| Quality ID#:001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control | Yes | eCQM/MIPS CQM |
| Quality ID#:134 | Preventive Care and Screening: Screening for Depression and Follow-up Plan | No | eCQM/MIPS CQM |
| Quality ID#: 236 | Controlling High Blood Pressure | Yes | eCQM/MIPS CQM |
For PY 2024, an ACO’s final quality score must be equal to or greater than the 40th percentile across all MIPS Quality performance category scores. CMS will still allow the ACO its choice of reporting mechanisms. Finally, beginning in PY 2025, ACOs will be required to report quality via eCQMs/MIPS CQMs and the performance threshold will remain at the 40th percentile.
Thanks to many advocacy efforts, the delay of the onset of full eCQMs/MIPS CQMs for an additional year, and the freezing of the 30th percentile quality performance threshold are steps in the right direction. CHESS calls on CMS to publish data and methods used to compare the ACO quality scores and the comparable MIPS quality category scores. With shared savings on the line, ACOs require transparency to determine performance and to course correct if needed. Otherwise, the unknowns could become a barrier to providers to joining the value-based movement.
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