ACO Quality Changes Stall Drive to the Future

June 8, 2023 

Highlights:

• Accountable care organizations (ACOs) will be required to report quality via electronic clinical quality measures (eCQMs) or Merit Based Incentive Payment System (MIPS) CQMs by 2025.
• ACOs ultimately want to achieve a more seamless, efficient, and technology-enabled quality reporting system that is highly interoperable and relies on near real-time data to enable improved patient care. However, lacking interoperability today, ACOs will face many challenges and increased administrative burden and costs to try and support this work in the near term.
• NAACOS is calling on CMS to pilot-test digital measurement instead of eCQMs/MIPS CQMs to create a path forward that will accelerate the success of all ACOs. 

By:

Megan Reyna, MSN, RN, System Vice President, Population Health – Midwest, Advocate Health
Jennifer Gasperini, Director, Quality and Regulatory Affairs, National Association of ACOs 

Accountable care organizations (ACOs) will be required to report quality via electronic clinical quality measures (eCQMs) or Merit Based Incentive Payment System (MIPS) CQMs by 2025. The Center for Medicare and Medicaid Services’ (CMS) stated goal in transitioning to these new reporting approaches is to decrease administrative burden by replacing CMS’ existing manual reporting system, with electronic quality reporting. These goals are admirable but the implementation challenges ACOs face in making this change raise many concerns around interoperability that cannot be easily solved. Ultimately ACOs want to achieve the ideal state—efficient, technology-enabled quality reporting and highly interoperable real-time data that improves patient care. However, the current requirements fall short of this ideal future state and miss the true purpose of quality reporting: enabling ways to improve patient care. 

The Current Challenge for ACOs
The ingenuity of the ACO model is bringing together traditionally fragmented sectors of the larger healthcare system to provide coordinated high-quality care while lowering the total cost of care. ACOs bring together multiple providers across different care settings, which are all operating on multiple electronic health records (EHRs). Take Advocate Health’s Midwest ACOs as an example, these organizations bring together over 400 different entities, 6,000+ clinicians that includes both hospitals, an employed medical group, and independent/aligned practitioners. This approach has a long track-record of success—generating $494 million in savings since entering the program in 2012, while maintaining an average quality score of 94.76 percent. 

While coordination across a broad spectrum of providers is ideal and generates success, EHR systems have not yet achieved the real-world interoperable future state that is needed to easily combine non-standardized data from various disparate EHRs to report quality digitally. Specific challenges include:

• Collecting and submitting data electronically across an ACO’s participants, which in many cases are on many different EHRs or instances of EHRs
• Complex data matching and data mapping; these complexities grow when collecting data across a large ACO with both employed and independent practices on multiple EHRs
• Costs associated with doing this work – Advocate’s Illinois ACO has been quoted anywhere from $4-37 million to do this work 

Given these realities, CMS is essentially asking ACOs to achieve true interoperability across disparate systems, something CMS hasn’t been able to do despite many millions of dollars in incentives paid through the Meaningful Use (now Promoting Interoperability) Program. This is an unrealistic and costly expectation to place on ACOs. Sadly, conversation on meeting this new approach all revolves around getting data to CMS and has nothing to do with improving patient care, which is where ACOs should be spending their energy and resources. Time, effort, and costs of ACOs would be better spent on clinical care, such as providing transportation to patients in need for their medical appointments, hiring care coordinators and other meaningful work ACOs currently engage in today. 

Driving to a Digital Quality Future
Concurrently, CMS is working on a digital quality measures (dQM) roadmap, which aims to identify national standards to retrieve data from an array of electronic sources to reduce burden and drive quality improvement at the point of care by 2025. Similarly, the National Committee for Quality Assurance (NCQA) is engaged in a five-year roadmap to provide nearly all Healthcare Effectiveness Data and Information (HEDIS) measure specifications in digital format; alignment with this approach would greatly reduce redundancies and burden for ACOs across commercial and Medicare Advantage quality measures. In addition, dQMs align with the 21^st Century Cures Act interoperability rules and are the digital future CMS is trying to achieve across other quality and value programs. 

Yet, CMS is requiring ACOs to employ approaches that do not align with a digital quality future. This alternative focus is a wasted investment for ACOs that will need to be replaced shortly after implementation, costing additional money and staff time. In lieu of moving forward with the current approach, CMS should pilot dQMs with a wide variety of ACOs to understand the nuances, unintended consequences of such a policy change, and current state capabilities—and truly partner to move quality reporting forward. ACOs are supportive of technology-enabled quality reporting; however, these changes must align with the future state CMS is trying to achieve with dQMs, and requirements must be supported by industry capabilities that are ready to advance to the future state. Most importantly, our guiding principle needs to be improving patient care—not just reporting data to CMS in a different way. 

ACOs can serve as a guide for how others can achieve a more streamlined, digital quality reporting system and ultimately a way to support true interoperability that can enhance care coordination for all. NAACOS developed a Digital Quality Measurement Task Force which published a paper describing a path forward.