NAACOS: CMS Must Work with ACOs to Pilot EHR-Derived Quality Data Reporting

Oct. 14, 2022
On Friday, the leaders of NAACOS, the National Association of ACOs, called on CMS officials to test-pilot the reporting of quality data pulled from EHRs before making such reporting mandatory

NAACOS, the Washington, D.C.-based National Association of ACOs, which represents most accountable care organizations (ACOs) operating inside the U.S. healthcare system, urged the federal Centers for Medicare & Medicaid Services (CMS) to test-pilot the reporting of quality data pulled from electronic health records (EHRs) before making such reporting mandatory. NAACOS’s leaders are pointing out the challenges that ACO leaders face in managing reporting derived from a variety of different EHRs at the same time.

NAACOS issued a press release on Friday morning, Oct. 14, that began thus: “CMS must work with accountable care organizations (ACOs) to establish a small pilot that tests the reporting of quality data pulled from electronic health records (EHRs) before moving to a program-wide mandate. That’s the key recommendation from a new position paper developed by a National Association of ACOs (NAACOS) task force aimed at developing recommendations for how to successfully collect and electronically report on ACOs’ quality of care through disparate health information technology (IT) systems.  The Centers for Medicare and Medicaid Services (CMS) has made it a goal to fully move to digital quality measurement by 2025. However, that’s a difficult task for ACOs, who sometimes work with dozens of EHR systems and must combine data from a myriad of doctors’ offices, hospitals, and other providers not using the same EHR. Recommendations were developed by NAACOS’s 14-person task force of leading ACO innovators in this space,” the press release noted.

And the press release quoted Katherine Schneider, M.D., chair of the NAACOS Digital Quality Measurement Task Force and past NAACOS board chair, as stating that “Numerous thought leaders from across a broad swath of ACOs spent months deliberating this issue to develop thoughtful, commonsense recommendations to move our industry to digital quality reporting. “ACOs simply cannot report quality data as easily as a single, standalone health system or physician practice,” Dr. Schneider said. “Different considerations need to be made. NAACOS absolutely supports the need to move to a more digital and less manual form of quality reporting, but more work needs to be done by both government regulators and the health IT industry before this becomes widely possible for ACOs.”

The press release went on to say that, “Also recommended by the task force, CMS must remove its current requirement for ACOs to report data on all patients, regardless of whether they are attributed to the ACO, from all payers. This would harm ACOs serving vulnerable populations because, when compared to other providers as CMS will do, they would look worse, not because of poor performance, but because they’re serving a sicker population. The task force feels the requirement would disenfranchise safety-net providers.”

Other recommendations from the paper include:

>  As CMS and the Office of the National Coordinator for Health IT (ONC) consider the future for digital quality measurement, the goal should be to improve how quality data can be captured to better support patient care at the point of care and appropriately reward high-value care.

> The transition to more digital quality measurement must be iterative and build off of previous work and investments.

> CMS should provide policy incentives to help offset the significant initial and ongoing costs associated with transitioning to electronic clinical quality measures and digital quality measures.

> CMS must enable the successful matching of patients across different providers and EHRs, and EHR certification criteria must support ACOs in eCQM and digital quality measure (dQM) reporting.

According to a NAACOS survey conducted this year, 39 percent of ACOs have more than 10 EHRs and only 17 percent have one EHR. Many rely on third-party companies to help them aggregate data, adding to the cost of their work.

Two key paragraphs in the position paper read thus:

“CMS must not move forward with the all-payer requirement for eCQMs and Merit-based Incentive Payment System (MIPS) Clinical Quality Measures (CQMs) when applied at the ACO level.  Requiring ACOs to report on eCQMs/MIPS CQMs requires ACOs to collect and report on a broader set of patients than they have been evaluated on previously. Specifically, performance is no longer limited to a sample of the Medicare-assigned beneficiaries for ACOs, but rather all patients meeting the eligible population criteria, regardless of whether the patient is an ACO-assigned patient or who the payer is. to all-payer data has unintended consequences and will result in ACOs being measured not on the clinical quality of care provided, but rather the composition of the ACO as well as the ACO’s payer mix. The all-payer requirement also exponentially broadens the patients an ACO will be assessed on, introducing new challenges and adding significant data extraction costs for certain ACOs, as well as measurement validity  concerns and privacy issues. Most importantly, the all-payer requirement has the potential to have the unintended consequence of penalizing ACOs serving high proportions of underserved patients. In this case, ACOs serving these patients may choose to exit the program or limit ACO participant practices to limit the negative effects of this requirement.”

The position paper goes on to state that “The shift to all payer data has unintended consequences and will result in ACOs being measured not on the clinical quality of care provided, but rather the composition of the ACO as well as the ACO’s payer mix.”

Further, the position paper states, “CMS must ensure all-payer performance data is not used for determining payments. If CMS does not remove  this requirement, CMS should consider alternatives such as relying on all attributed ACO patient data or applying a different attribution approach that is less broadly applicable (e.g., exclude specialists in a way similar to what is done for the MIPS cost measures).”

As for the specifics around EHRs, the position paper states that “Electronic health record (EHR) certification criteria must support ACOs in what they are required to achieve for electronic clinical quality and digital quality measurement. The current state of data standards and interoperability will not yet fully enable ACOs to meet the eCQM reporting requirements successfully. The requirements dictate ACOs will need to collect and report data from multiple practices and EHR vendors across all of their ACO participant Tax Identification Numbers (TINs). A recent survey of the NAACOS membership found that only 17 percent of respondents use one EHR, 24 percent use two-to-five different EHRs, and 20 percent use between six and 10 different EHRs. While CMS and others often assume that EHR vendor systems with 2015 Certified Electronic Health Record Technology (CEHRT) would automatically include the capability to easily report the most recent version of an eCQM for MIPS with minimal manual eff ort, that is not the case. The CEHRT requirements do not standardize the capture and reporting of individual eCQM data elements across vendor systems, and ACOs will still need to tailor data extracts and uploads across systems and participating TINs. Additionally, not all CEHRT vendors will implement every eCQM required for reporting, since it is not a CEHRT requirement, potentially leaving a gap for ACOs. This paper outlines the minimum conditions to meet current requirements for ACOs to be successful in eCQM reporting in the short-term, as well as business requirements for the longer-term/future state CMS hopes to achieve.”

Indeed, the position paper urges CMS to identify an alternate pathway to reporting, stating that, “Based on the current requirements for ACO reporting of eCQMs and MIPS CQMs, ACOs must be able to de-duplicate data across multiple practices to create the single data file for each patient necessary for each measure. These data would be generated using QRDA I fi les (patient-level), and then once patients are matched, the QRDA III fi le (aggregate at the ACO level) can be created and submitted to CMS. In the absence of a national patient identifier, ACOs must fi nd solutions to enable this patient matching. CMS must develop additional guidance and standards for ACOs regarding how CMS expects patient matching to be completed.

The full text of the position paper can be found here.

As NAACOS pointed out in the press release on Friday morning, “Since 2012, ACOs have saved Medicare nearly $17 billion in gross savings and $6.3 billion in net savings. Importantly, data show these ACOs continued to provide high-quality care and yield satisfied patients. Today, ACOs care for nearly 20 percent of all Medicare patients and nearly a third of traditional Medicare patients. Importantly in Medicare, ACOs allow patients to maintain their choice of provider, and there are no network restrictions or use of prior authorization.”

With regard to the broader issues involved, Healthcare Innovation Senior Contributing Editor David Raths in May interviewed Maria Alexander, senior director of population health at Mount Sinai Health System in New York, on the pros and cons of reporting via eCQMs during the voluntary transition period leading up to 2025. As Raths wrote in his report, Alexander “mentioned that Mount Sinai operates a clinically integrated network that has value-based contracts with a variety of payers and a Level II MSSP ACO with about 45,000 lives. She noted that how you approach this issue might depend on the number of tax ID numbers (TINs) and EMRs in use in your ACO. In terms of arguments for reporting sooner, CMS did build in some incentives to encourage ACOs to report eCQMS sooner than when they are required, Alexander explained. For one, it is easier to meet that Quality Performance standard in 2022 and 2023 — that is the threshold you have to meet in order to be eligible for shared savings.”

Further, “Another reason to consider doing it sooner would be that they do give you the benefit of getting the higher score of the two,” Alexander told Raths. “So there's not a harm from a performance perspective in reporting both ways. Finally, the most obvious reason to do it sooner is that if you haven't done this before, getting some practice before it's required and your only option, is probably a good idea.” But, as Raths wrote, Alexander told him that “There are also some reasons to not report eCQMs yet, however, or at least not going too far down that path.” “One would be that if you're going to report two ways — if you're going to report via Web Interface and eCQMs — it's going to cost you more, whether that's internal resources or vendors that you're hiring. It is not free to report both ways — you do have to put in the effort,” Alexander stressed in her interview with him.

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