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CMS will use all-payer data to evaluate ACO performance. Here’s what that means for your population health strategy.

By Ye Hoffman

May 13, 2021

    CMS continues to evolve its policies for measuring quality performance. Starting 2021, the agency established significant changes that impact providers participating in Medicare Alternative Payment Models (APMs), especially those in accountable care organizations (ACOs). And because of those changes to ACO quality reporting, physician leaders need to address downstream implications for their population health strategy.

    The APM Participation Pathway: What you need know—and the blind spots to address

    A new reporting framework that requires all-payer data

    Beginning with the 2021 performance year, ACOs in the Medicare Shared Savings Program (MSSP) must switch to a new reporting framework called the APM Performance Pathway (APP). The APP is also available, but not required, in the Merit-based Incentive Payment System (MIPS) for providers who participate in certain Medicare APMs.

    CMS evaluates APP quality performance through six measures. Of those, three measures require providers to submit quality data directly to CMS:

    1. Diabetes: Hemoglobin A1c (HbA1c) Poor Control;
    2. Preventive Care and Screening: Screening for Depression and Follow-up Plan; and
    3. Controlling High Blood Pressure.

    ACOs have long been held accountable for performance on those metrics, but the APP ushers in a major change. Instead of reporting data only on Medicare beneficiaries, ACOs will have to report data from all patients, regardless of payer.

    That’s because the new APP reporting framework requires ACOs to change the way they report quality measures. MSSP ACOs historically have submitted quality measures through a special portal called the CMS Web Interface, which relies on Medicare beneficiary data. But under the APP, ACOs must either: 1) use an EHR to capture electronic Clinical Quality Measures (eCQMs), or 2) work with a registry that supports MIPS CQMs. The eCQM and MIPS CQM reporting methods evaluate quality performance based on all-payer data.

    CMS recognizes, though, that as providers continue to prioritize Covid-19 response efforts, some ACOs may not be able to transition from CMS Web Interface to eCQM or MIPS CQM reporting for 2021. The good news is that CMS allows for a one-year buffer, where MSSP ACOs can report CMS Web Interface quality measures instead of the three APP measures that must be submitted through eCQM or MIPS CQM.

    But starting 2022, the CMS Web Interface will no longer be allowed. That means all ACOs must establish a plan for reporting APP quality measures via eCQMs or MIPS CQMs—and both of those methods require submission of all-payer data.

    Now’s the time to revisit your population health strategy

    CMS’ shift toward all-payer data means physician leaders participating in an ACO must revisit their population health initiatives. Failing to bolster performance on these measures across all patients—not just Medicare beneficiaries—could risk underperforming in the APP, which affects whether an organization earns Medicare incentives or receives penalties.

    This shift comes at a time when the spotlight on population health is perhaps brighter than ever, as the Covid-19 pandemic underscored the vital need to improve Americans’ health overall. When we take a step back to consider the three APP measures that ACOs need to report, CMS is underscoring scaled chronic disease management as both a top pandemic recovery priority and business imperative for providers.

    In response, physician leaders should take a "back to basics" approach for scaled chronic disease management. Technology can be instrumental in scaling these patient interactions but it’s crucial to have a care management foundation first. This includes proactively identifying patients through universal screening and community outreach and tailoring clinical and psychosocial support during care planning. Those are core competencies of population health that ACOs will need to scale across the entire patient population, not just Medicare beneficiaries. And that approach will serve ACOs well in achieving high quality performance on the APP measures that evaluate quality based on all-payer data.

    How to scale chronic disease management programs

    Other APP blind spots to watch out for

    Reporting all-payer quality data is one of the biggest changes that ACOs need to address under the new APP reporting requirements, but there are other potential blind spots to note. The two main areas to watch out for are:

    • The highly nuanced interaction between MSSP and MIPS requirements. The APP reporting policies are aligned between both MSSP and MIPS, but each program still operates under its own specific rules for applying Medicare incentives or penalties. The MSSP quality performance standard evaluates whether the ACO earns shared savings or losses. For MIPS eligible clinicians, quality metrics are part of the overall performance score that determines their MIPS payment adjustment—either positive, negative, or neutral.

    Policy Primer: 2021 Quality Payment Program updates

    • Technical challenges with collecting and aggregating quality data. To the extent that it's technically feasible, ACOs may wish to leverage their EHR to support eCQM reporting. But if providers in the ACO use multiple EHRs, that can further complicate the process of aggregating data in the manner required by CMS.

    June 15: The APM Participation Pathway

    What you need know—and the blind spots to address

    calendarJoin Advisory Board’s webinar on Tuesday, June 15th, at 1 p.m. ET to learn how to address these potential blind spots. We'll explain what you need to know about the APP reporting framework and provide recommendations to address the most common challenges.

    Register now


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