New Quality Measures Proposed for Medicare ACO Program

Ken Terry

July 18, 2014

Accountable care organizations (ACOs) that participate in the Medicare Shared Savings Program (MSSP) will face a new set of quality measures in 2015 under the proposed Medicare Part B payment rules of the Centers for Medicare & Medicaid Services (CMS). Twelve new measures will be added and 8 current metrics will be eliminated, yielding a set of 37 measures, 4 more than the current 33.

The approximately 300 ACOs in the MSSP must report on these quality measures and reach a certain threshold of performance in order to share fully in any savings they produce for CMS.

The new MSSP metrics tilt the focus of the quality measurement program from process to outcomes. For example, one proposed measure "estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a skilled nursing facility (SNF) within 30 days of discharge from a prior inpatient admission to a hospital, [critical access hospital], or a psychiatric hospital."

Three other measures gauge the rate of all-cause unplanned admissions for patients with diabetes mellitus, heart failure, and multiple chronic conditions. CMS also proposes to add a measure for "depression remission at 12 months" after diagnosis.

In addition, the new measures increase the MSSP's emphasis on chronic conditions. Besides the above-cited metrics, there are also measures for diabetic foot exam and eye exam, coronary artery disease (CAD) symptom management, and CAD antiplatelet therapy.

Among the diverse other measures being proposed for inclusion are:

  • CAHPS steward of patient resources . Using its Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, CMS seeks to find out whether ACO care teams have spoken with the patient about prescription medicine costs.

  • Documentation of current medications in the medical record . This new measure replaces the current medication reconciliation measure, which looks only at whether this was done following hospital discharge. Under the new measure, which aligns with the Physician Reporting Quality System (PQRS) and electronic health records (EHR) Incentive program measures, ACOs would also have to show the percentage of office visits at which medications were reconciled.

  • Percentage of PCPs who successfully meet meaningful use requirements . Only the name of this metric has changed: It now measures the percentage of PCPs who have qualified for EHR incentive payments.

Out With the Old

CMS proposes the deletion of 4 current measures either because they are redundant or because new clinical guidelines have rendered them obsolete.

If the proposal is finalized in its current form, ACOs would have to use the new quality measures for the 2015 reporting period and would report the data to CMS in 2016. Under the 3-year MSSP contracts, ACOs are rewarded for complete and accurate reporting in the first year; after that, they must demonstrate a certain level of performance to get their full bonuses.

In its new proposal, CMS seeks to reward quality improvement more than the original MSSP design does. It will provide up to 2 bonus points in each of its 4 domains of performance specifically for improvement. The bonus points will raise the scores used to calculate how much each ACO receives from shared savings.

That's a step in the right direction, Brett Erhardt, associate principal of strategic planning for The Advisory Board Company, told Medscape Medical News. Many of the Advisory Board's ACO clients, he noted, have complained that it's difficult to do well on the MSSP quality measures in certain markets or with certain patient populations. "So it's good that CMS is moving toward rewarding quality improvement and not just overall performance."

On balance, Erhardt said, the new quality measures are designed to reduce, rather than add to, the work that ACOs must do in quality reporting. First, he noted, there are now 4 claims-based measures (for admissions and readmissions) and 1 fewer measure that requires ACOs to review records and submit data through CMS' Web-based system for group reporting.

Also, he pointed out, the proposal reduces the minimum number of patients for whom ACOs must report on each quality measure from 411 to 248. That means that they have to do fewer chart reviews to pull data for each measure.

Some measures may increase the work of physicians in ACOs, however, he conceded. That includes the requirement that they inform patients about the costs of prescription drugs — a challenge even in Medicare Part D drug plans. And even though the measure of readmissions from SNFs is claims-based, "it's difficult for most ACOs — and especially physician ACOs — to track and make improvements on it."

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