Stakeholders Blast Medicare Reporting Changes

Ken Terry

May 06, 2021

Eleven major healthcare organizations have called on the Biden administration to make significant changes to the way accountable care organizations (ACOs) in the Medicare Shared Savings Program (MSSP) are required to report and are measured on quality.

In a May 4 letter to Health and Human Services Secretary Xavier Becerra, the physician, hospital, and ACO organizations said new regulations finalized in December were rushed out without sufficient stakeholder input and place a significant burden on ACOs that may result in some dropping out of the program.

The new rules from the Centers for Medicare and Medicaid Services (CMS), which become effective this year and next year, are included in the 2021 Medicare Physician Fee Schedule. To begin with, they require participating organizations to move from reporting through a CMS website to a new system of electronic reporting.

According to a news release from the National Association of ACOs, organizations will have to "aggregate data from disparate electronic health records systems, which are not interoperable, and report on quality data on all patients regardless of payer, raising issues with collecting data from non-ACO providers and on patients with no connection to the ACO."

The current reporting system requires ACOs to report on a sample of their attributed Medicare beneficiaries only.

The all-payer requirement in the new rules could misrepresent the quality of ACOs, among other issues, the coalition argued. "ACOs treating vulnerable populations have a different mix of payers and patients, which will cause them to appear to have lower quality," the letter stated. "This will reduce their shared savings at a time they should be receiving more resources to combat health equity issues and more support to remain on the path to value." 

In a recent survey, nearly 75% of the respondents said their ACO is either "extremely concerned" or "very concerned" with the requirement to implement the new electronic clinical quality measures or Merit-based Incentive Payment System (MIPS) measures in 2022. Moreover, 85% of the responding ACOs said that aggregating data on all patients from their participants' disparate electronic record systems would be either "difficult" or "very difficult."

The changes in the MSSP quality reporting methodology is of concern to a broad swathe of the healthcare industry. Among the organizations that signed the letter to Becerra, in addition to NAACOS, are the American Academy of Family Physicians, the American College of Physicians, the American Hospital Association, the American Medical Association, American Medical Group Association, America's Essential Hospitals, America's Physician Groups, the Association of American Medical Colleges, the Federation of American Hospitals, and the Medical Group Management Association.

Recommendations to CMS

The coalition's letter makes several recommendations and explains the rationale for each.

First, the coalition asks CMS to delay mandatory reporting of clinical quality measures, which is scheduled to begin in 2022, for at least 3 years. Most ACOs have many disparate electronic health record systems; in fact, almost 40% of ACOs include more than 15 systems, the letter says. Integrating quality data from all of these systems will require ACOs and their members to bear significant costs and system upgrades and increase their data collection burdens.

ACOs need to fund this work upfront, long before they can receive shared savings from the program, and to date, just 35% of ACOs have earned any shared savings from the program. If they must steeply increase their overhead to meet these requirements, many ACOs may drop out of the program or never join, the coalition said.

CMS should also limit quality reporting to assigned Medicare beneficiaries, the coalition said. One reason is the data access limitations will make it very difficult to expand to all-payer data. The new rules require ACOs to report on 70% of all patients served by their members, which is a giant increase "compared to the small sample [of Medicare patients] required under the web interface," the letter noted.

Moreover, it's unclear whether ACOs have the contractual or legal right to collect data on patients not covered by traditional Medicare. "It will be extremely challenging, if not impossible, due to data availability and potential violations of the Stark or HIPAA laws, for ACOs to track patients and their care when they have no direct relationship to the ACO," the letter said.

The quality of ACOs might also not be fairly represented, the coalition emphasized, if the measurement includes vulnerable populations that the ACOs don't care for and that have significant issues related to social determinants of health.

"As a result of these many concerns and the potential impact to data integrity, we believe that the expansion to all-payer data for ACOs is inappropriate," the letter said. "This change dramatically increases the complexity of the program, which is not in the best interest of Medicare beneficiaries, CMS, or ACOs. Further, the resulting quality performance scores will not represent the quality of care provided by an ACO and will also hamper CMS's ability to evaluate the impact of ACO interventions on quality of care for the patients they serve."

Quality Measure Set

The letter also maintained that CMS had changed the quality measure set without obtaining adequate input from stakeholders. The decrease in the number of metrics is welcome, the coalition said, but "the current set is too narrow and not patient-centered." Most of the measures focus on primary care services and can't be used to measure specialty care, the coalition said.

The coalition also protested the use of MIPS quality performance benchmarks to evaluate ACO performance. Because these benchmarks will be applied to all patients, not just Medicare beneficiaries, they will be unfair to some groups because of differences in access, insurance coverage, medical complexity, and other factors, the letter said.

Finally, the coalition said CMS should restore the ability of new ACOs to be paid for quality reporting for 1 year, without the results being applied to their shared savings. This "pay-for-reporting" feature is critical to ACO success because it gives ACOs time to evaluate their workflows, data capture processes, and so on before they're rated on the data, the letter noted.

CMS is reviewing the letter from the NAACOS and other stakeholders regarding the quality reporting for the MSSP, a CMS spokesperson said.

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