CMS Drops Proposed Rule Impacting Quality Payment Program, MSSP ACOs

Aug. 4, 2020
The federal agency contends that many of the proposals are not significant since providers are overburdened with the pandemic, but early reaction on the ACO front is not positive

The Centers for Medicare & Medicaid Services (CMS) on Aug. 3 released a rule that proposes changes to the Quality Payment Program (QPP) and Medicare Shared Savings Program (MSSP) for 2021. According to federal officials, because providers must stay focused on the COVID-19 pandemic, the number of significant proposed changes to the programs are limited.

The QPP under MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) has included two payment paths that eligible Medicare-participating physicians could partake in—the Merit-based Incentive Payment System (MIPS) and the advanced alternative payment models (APM) track.

 Last year, CMS announced that a new MIPS Value Pathways (MVPs) framework, starting in 2021, will move MIPS from its current state—which requires clinicians to report on many measures across the multiple performance categories, such as Quality, Cost, Promoting Interoperability and Improvement Activities—to a system in which clinicians will report much less. Under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to APMs. MVPs will connect activities  and measures from  the four existing MIPS performance  categories that are relevant  to the population they are caring for a specialty or medical  condition, according to CMS.

 In the new Aug. 3 fact sheet, however, federal officials said they recognize stakeholder concerns about this timeline, even more so now that clinicians are working hard to address the spread of COVID-19 within their practices and communities.  As such, they are proposing to delay the MVPs framework until 2022.

Instead,  CMS is proposing a new APM Performance Pathway (APP) reporting option in 2021 to align with the MVP framework. As part of the APP introduction, the agency will also be sunsetting the CMS Web Interface as a collection type beginning in the 2021 performance period.  The APP, like an MVP, would be composed of a fixed set of measures for each performance category. Those proposals and performance thresholds can be specifically seen on pages 15-16 of the fact sheet.

As for MIPS in 2021, CMS is proposing that the MIPS performance threshold would increase to 50 points in 2021, from 45 points in 2020. The Cost category would be weighted 5 percent more, up to 20 percent from 15 percent. The Quality category would be weighted 5 percent lower to make up the difference.

MSSP Changes

For performance year 2021, CMS is proposing that accountable care organizations (ACOs) participating in the Shared Savings Program would be required to report quality measure data for purposes of the MSSP  via the APP, instead of the CMS Web Interface.

Under this new reporting approach, ACOs would only need to report one set of quality metrics that would meet requirements under both MIPS and the MSSP. The total number of measures in the ACO quality measure set would be reduced from 23 to 6 measures, and the number on which ACOs are required to actively report would be reduced from 10 to 3. In addition, CMS said it is considering adding a “Days at Home” measure that is currently under development, to the APP core measure set in future years.

The redesign also raises the quality performance standard for ACOs under the Shared Savings Program. Per the proposal, ACOs would now be required to receive a Quality performance score equivalent to or above the 40th percentile across all MIPS Quality performance category scores in order to share in savings or avoid owing maximum losses. Currently, ACOs have to completely and accurately report all measures and achieve at or above the 30th percentile on one measure in each domain to be eligible to share in savings.

Under the proposed redesign, if the quality performance standard is met, the ACO would receive the maximum sharing rate. If the quality performance standard is not met, the ACO would not be eligible to share in any earned savings. For ACOs that owe shared losses, the losses would be scaled using the MIPS Quality performance category score under Track 2 and the ENHANCED track; and under the BASIC track and the Track 1+ ACO Model, CMS would continue to apply a fixed 30 percent loss sharing rate, CMS explained.

Further for performance year 2020, all ACOs are considered to be affected by the public health emergency for the COVID-19 pandemic, and the Shared Savings Program extreme and uncontrollable circumstances policy applies, CMS announced. The agency also said it is seeking comment on an alternative scoring methodology approach under the extreme and uncontrollable circumstances policy.

In a statement reacting to the proposed changes to the MSSP, the National Association of ACOs (NAACOS) has expressed disappointment, noting that CMS “has unnecessarily proposed to completely change how ACOs are measured and report quality, replacing the current approach with a new framework and a higher performance standard. At a time when healthcare providers continue to battle the COVID-19 pandemic, CMS’s proposal to increase performance standards and make massive changes to assessments and measures is unfair and ill-timed.”

The comments, attributed to NAACOS President and CEO Clif Gaus, Sc.D., further stated that “CMS is replacing existing measures with new ones and getting rid of the reporting mechanism ACOs have relied on for years, forcing ACOs to evaluate and implement new reporting strategies with little notice. It is a considerable undertaking for ACOs to move to a new reporting process, especially while they are focused on battling a pandemic. Furthermore, CMS has ignored ACOs’ request to make quality measurement pay-for-reporting in 2020 because of the pandemic, which has caused significant utilization disruptions making it very hard to meet quality standards.”

Gaus continued, “Quality has always been a hallmark of Medicare ACO programs. No matter how much money ACOs save Medicare, they earn nothing in shared savings if they don’t hit certain quality standards, further incentivizing the best care. As a result, ACOs have outperformed fee-for-service Medicare on quality and help set the standard by which others should follow. These proposed changes are unnecessary and on balance punitive, especially if implemented during a pandemic.

Proposed changes around HIE

Also in the QPP proposed rule, CMS is proposing an optional new measure around bi-directional health information exchange that could reduce reporting burdens for clinicians, but it would require them to query for or receive health information for all new and existing patients.

The Promoting Interoperability performance category already has measures around sending and receiving health information to “support electronic referral loops.” Clinicians could either  continue to report on those existing measures and their associated exclusions or alternatively report on the new Health Information Exchange Bi-Directional measure, which CMS said would be worth 40 points. It would be reported by attestation and would require a yes/no response.

Clinicians would attest to the following:

• I participate in an HIE in order to enable secure bi-directional exchange to occur for every patient encounter, transition or referral and record stored or maintained in the EHR during the performance period.

• The HIE that I participate in is capable of exchanging information across a broad network of unaffiliated exchange partners including those using disparate EHRs and does not engage in exclusionary behavior when determining exchange partners.

• I use the functions of CEHRT for this measure.

CMS said it believes the optional measure serves as a good alternative because in order to successfully meet the measure, an eligible clinician would be required to meet an overall standard of performance on HIE that is broader than the denominators and numerators of the current measures.

The clinician or group must establish the technical capacity and workflows to engage in bi-directional exchange via an HIE for all patients seen. This includes querying for or receiving health information for all new and existing patients seen by the clinician as well as sending or sharing information regardless of known referral or transition status. The propose requirement to query for or receive health information for all new and existing patients is broader than the current measure, which includes only new patients and known transitions or referrals that occur during the performance period.

CMS noted that some HIE arrangements may not have the capacity to enable bi-directional exchange for every patient transition or referral made by a clinician, and thus would not meet the standard described in the attestation statement required to fulfill the measure. “We would exclude exchange networks that only support information exchange between affiliated entities, such as providers that are part of a single health system or networks that only facilitate sharing between health care providers that use the same EHR vendor.”

Participants can use CEHRT to transmit C-CDAs to the HIE or they can use API technology cited in the 21st Century Cures Act final rule to enable an HIE to obtain data in the CCDs or USCDI from a participant’s EHR. 

CMS also noted that although HIPAA does not require patient consent for sharing data for treatment, payment and operations, some state laws do require it. “Nothing in the attestation statement is meant to conflict with individual HIE policies that may exist related to patient consent and notification,” the proposed rule states.

CMS said it is seeking comment on whether such an optional measure would incentivize eligible clinicians to participate in HIE while establishing a high-performance standard for sharing information with other clinicians.

In other areas of Promoting Interoperability, the performance category will be weighted at 25 percent (no change from PY 2020). CMS said it would retain the Query of Prescription Drug Monitoring Program (PDMP) measure as an optional measure and proposes to make it worth 10 bonus points.

In the proposed rule, CMS also focuses on the role of third-party intermediaries such as Qualified Clinical Data Registries (QCDRs) and Qualified Registries to help reduce clinician reporting burden and improve the services clinicians receive.

CMS is proposing to allow QCDRs, Qualified Registries, and Health IT vendors to support MVPs beginning with the 2022 performance period  and the APM Performance Pathway (APP) beginning with the 2021 performance period.

CMS also proposes to establish specific data validation requirements for QCDRs and Qualified Registries, and seeking comment on whether Health IT Vendors and CAHPS survey vendors should perform similar data validation. IT is proposing to require additional information be submitted to CMS as part of any corrective action plans under the remedial action and termination policies applicable to all third-party intermediaries.

For readers looking for more specifics regarding the proposed QPP changes for 2021, they are detailed starting on page 12 of CMS’ fact sheet.  The public comment period runs until Oct. 5, 2020.

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