2021 Changes to the Quality Payment Program: Must-Know Guidelines for ACOs

2021 Changes to the Quality Payment Program:
Must Know Guidelines for ACOs

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2021 Changes to the Quality Payment Program
This guide explains four key changes CMS
made to the Quality Payment Program (QPP).
These four changes come from the 2021 QPP
Final Rule and create eight new challenges in
quality measurement for either:
1. ACOs in the Medicare Shared Savings
Program (MSSP)
2. ACO participants still required to participate
in the Merit-based Incentive Payment System
(MIPS)

NOTE:
CMS refers to MIPS-eligible ACO participants
as “MIPS APM participants.”
Specifically, a MIPS APM participant is
1. A MIPS eligible clinician that participates in a
MIPS APM, or
2. A MIPS eligible clinician that participates in an
advanced APM (A-APM) but does not achieve
the status of qualifying APM participant (QP) or
partial qualifying APM participant (partial QP).

This guide details the four key
changes from the 2021 QPP Final
Rule, the eight challenges created by
those changes, and Health Catalyst
solutions to those challenges.

Four Changes in the 2021 Quality
Payment Program Final Rule
Four key changes in the 2021 QPP Final
Rule simultaneously affect MSSP ACOs
and MIPS APM participants:
1. Discontinuation of the CMS Web Interface
2. Introduction of the APM Performance
Pathway (APP)
3. Discontinuation of the APM scoring standard
4. The addition of the APM entity as a submitter
type for MIPS.
This section explains each of the key
changes but does not yet discuss the
challenges created by those changes.

#1: Discontinuation of the CMS Web Interface
CMS announced that it would discontinue
the CMS Web Interface starting in 2022.
The CMS Web Interface is a submission
method CMS offers for quality measurement
in the MSSP and MIPS programs.
ACOs report MSSP quality data
to Medicare using the CMS
Web Interface.

#1: Discontinuation of the CMS Web Interface
Additionally, over 100 groups report
MIPS quality data to Medicare through
the CMS Web Interface.
However, these ACOs and groups can
no longer use the CMS Web Interface to
report quality data to Medicare starting
in the 2022 performance year.

#2: Introduction of the APM Performance Pathway (APP)
CMS introduced the APM Performance
Pathway (APP) in the 2021 QPP Final Rule.
The APP is a new reporting framework for
ACOs and MIPS APM participants.
The APP reporting framework includes the
same set of quality measures for ACOs and
MIPS APM participants.
However, the APP reporting framework
defines additional requirements for each
MIPS category for MIPS APM participants. (Note: CMS uses the term “reporting
framework” to refer to a unique set of
measures/activities and scoring.)

The APP for ACOs
ACOs that fulfill the APP fulfill their
requirements in the Medicare Shared
Savings Program (MSSP). The APP is
now the required reporting frame-work
for ACOs participating in the MSSP.
In other words, CMS no longer
measures ACO quality performance
using the 23 former quality measures.

The APP for ACOs
The following two tables list measures and
activities for the APP for ACOs. Notice that the
list of self-reported measures differs in each
table based on the submission method.
This means eCQMs/CQMs (Table 1) versus
the CMS Web Interface (Table 2).
ACOs submit the list of measures that
corresponds to their chosen submission
method. The CMS Web Interface will be
discontinued in the 2022 performance year.

Quality—ACOs using the CMS Web Interface
CAHPS for MIPS (counted as one measure)
Two administrative claims measures:
1. (New) Hospital-Wide, 30-day, All-Cause Unplanned
Readmission (HWR) Rate for MIPS Eligible Clinician
Groups
2. (New) Risk Standardized, All-Cause Unplanned
Admissions for Multiple Chronic Conditions for ACOs
Three self-reported measures:
1. Diabetes: Hemoglobin A1c (HbA1c) Poor Control
2. Preventive Care and Screening: Screening for
Depression and Follow-up Plan
3. Controlling High Blood Pressure
Quality—ACOs using the CMS Web Interface
1. (New) Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR)
Rate for MIPS Eligible Clinician Groups
2. (New) Risk Standardized, All-Cause Unplanned Admissions for Multiple
Chronic Conditions for ACOs
Ten self-reported measures:
2. Preventive Care and Screening: Screening for Depression and Follow-up Plan
4. Falls: Screening for Future Fall Risk
5. Preventive Care and Screening: Influenza Immunization
6. Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention
7. Colorectal Cancer Screening
8. Breast Cancer Screening
9. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
10.Depression Remission at Twelve Months
Table 1: The APP for ACOs using the CMS Web Interface.
Table 2: The APP for ACOs using the CMS Web Interface.

NOTE:
CMS simultaneously uses an ACO’s
APP submission to create a MIPS
quality category score for MIPS APM
participants in the ACO.
This MIPS quality category score
becomes part of an APM entity MIPS
score for MIPS APM participants.

The APP for MIPS APM Participants
MIPS APM participants that fulfill the APP
fulfill their requirements in the MIPS program.
MIPS APM participants can submit the APP
as a group or as an individual independent of
their APM entity (e.g.,, ACO).
Unlike the APP for MSSP ACOs, the APP is
an optional reporting framework for MIPS
APM participants.
It is not a required reporting framework.

For MIPS APM participants, the APP is
similar to a MIPS Value Pathway (MVP).
That’s because, like MVPs, the APP is a
prepackaged set of measures and activities.
However, the APP differs from an MVP
because it is limited to only MIPS APM
participants.
MIPS participants that are not MIPS APM
participants cannot submit the APP.

What follows are two tables listing measures and
activities for the APP for MIPS APM participants.
Like the APP for ACOs, notice that the list of self-
reported quality measures differs in each table
based on the submission method, meaning
eCQMs/CQMs versus the CMS Web Interface.
MIPS APM participants submit the list of
measures that correspond to their chosen
submission method.

However, remember that the CMS Web
Interface is discontinued starting in the
2022 performance year.
And unlike the APP for ACOs, notice that
the APP for MIPS APM participants defines
requirements for all four MIPS categories.

Quality—MIPS APM Participants using eCQMs/CQMs
Promoting
Interoperability
Improvement
Activities
Cost
1. (New) Hospital-Wide, 30-day, All-Cause Unplanned
Readmission (HWR) Rate for MIPS Eligible Clinician Groups
2. (New) Risk Standardized, All-Cause Unplanned Admissions
for Multiple Chronic Conditions for ACOs
Three self-reported measures:
2. Preventive Care and Screening: Screening for Depression
and Follow-up Plan
All standard measures
in the PI category
Automatic score of
100 percent
None
Table 3: The APP for MIPS APM Participants using eCQMs/CQMs.

Quality—MIPS APM Participants Using the
CMS Web Interface
Promoting
Interoperability
Improvement
Activities
Cost
1. (New) Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS
Eligible Clinician Groups
2. (New) Risk Standardized, All-Cause Unplanned Admissions
for Multiple Chronic Conditions for ACOs
Ten self-reported measures:
2. Preventive Care and Screening: Screening for Depression and Follow-up Plan
4. Falls: Screening for Future Fall Risk
5. Preventive Care and Screening: Influenza Immunization
6. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
7. Colorectal Cancer Screening
8. Breast Cancer Screening
9. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
10.Depression Remission at Twelve Months
All standard measures
in the PI category
Automatic score of
100 percent
None
Table 4: The APP for MIPS APM Participants using the CMS Web Interface.

In the APP for MIPS APM participants, notice that
CMS defers to APM requirements for both the
Improvement Activities (IA) and Cost categories.
Specifically, CMS credits participants 100 percent
of the IA category score in MIPS 2021 because
MIPS APM participants fulfill improvement
activities as part of their APM participation.

Conversely, CMS weights the Cost
category score to 0 percent because CMS
wants MIPS APM participants to focus on
their cost containment efforts in APMs.
And that’s why CMS does not include any
measures or scoring in the Cost category
in the APP.

#3: The Discontinuation of the APM Scoring Standard
CMS discontinued the APM scoring standard
in the 2021 QPP Final Rule.
The APM scoring standard only applied to the
MIPS program, not the MSSP.
However, it applied to MIPS APM participants,
including but not limited to MIPS eligible
clinicians participating in MSSP ACOs.

The APM scoring standard required that
CMS only use a MIPS APM participant’s
APM entity score to apply that participant’s
MIPS payment adjustments.
In other words, CMS used a MIPS APM
participant’s APM entity MIPS score even if
the participant had other final MIPS scores
such as group or individual.
Even if a clinician’s group or individual score
was higher than a clinician’s APM entity
score, CMS still used the APM entity score
to apply MIPS payment adjustments.

Specifically, the APM scoring standard
dictated the former MIPS scoring hierarchy.
The MIPS scoring hierarchy identifies which
final clinician MIPS score CMS would use to
apply MIPS payment adjustments for a
clinician.
The MIPS scoring hierarchy is necessary
because clinicians can have multiple final
MIPS scores.

When a MIPS APM participant had multiple
final MIPS scores, CMS only used the APM
entity score.
That’s because the former APM scoring
standard dictated the prioritization of APM
entity scores in the MIPS scoring hierarchy.
Table 5 illustrates the former MIPS scoring
hierarchy. Notice that it prioritizes APM entity
scores above other participation levels,
meaning virtual group, group, and individual.

Scenario—The Former MIPS Scoring Hierarchy Final Score Used to Determine Payment Adjustments
TIN/NPI has more than one APM entity final score The highest of the APM entity final scores
TIN/NPI has an APM entity final score and also has an
individual score
APM entity final score
TIN/NPI has an APM entity final score that is not a virtual group
score and also has a group final score
TIN/NPI has an APM entity final score and also has a virtual
group score
TIN/NPI has a virtual group score and an individual final score Virtual group score
TIN/NPI has a group final score and an individual final score,
but no APM entity score and is not in a virtual group
The highest of the group or individual final score
Table 5: The former MIPS scoring hierarchy.

CMS revised the MIPS scoring hierarchy
due to the discontinuation of the APM
scoring standard (Table 6).
Notice that CMS no longer prioritizes APM
entity scores above other final scores.

Scenario—The Revised MIPS Scoring Hierarchy Final Score Used to Determine Payment Adjustments
TIN/NPI has a virtual group final score, an APM entity final
score, an APP final score, a group final score, and/or an
individual final score
Virtual group final score
TIN/NPI has an APM entity final score, an APP final score, a
group final score, and/or an individual final score, but is not
in a virtual group
The highest of the available final scores
Table 6: The revised the MIPS scoring hierarchy.

CMS now uses the highest final MIPS score for
a participant when applying MIPS payment
adjustments (except for virtual group scores
which CMS must still use over all other scores).
For MIPS APM participants that can have up to
eight final scores (Figure 1), CMS will prioritize
the use of a virtual group score if one exists.
Otherwise, CMS will use the highest final score
at any participation level in either the APP or
traditional MIPS reporting framework.

ARM
Participation
Participation Status Framework MIPS Participation Level
Yes MIPS APM participant
Traditional
Virtual group
APM entity
Group
Individual
APP
Virtual group
APM entity
Group
Individual
Figure 1: Final scores for MIPS APM participants.

#4: The Addition of the APM Entity as a MIPS Submitter Type
CMS added APM entities to the list of MIPS
submitter types in the 2021 QPP Final Rule.
CMS defines submitter types as “individual
clinicians submitting for themselves, or
someone authorized to submit data on behalf
of a clinician or practice” (CMS, QPP Website).
As a submitter type, APM entities (e.g., ACOs)
can now submit traditional MIPS on behalf of
MIPS eligible clinicians participating in the
APM entity (e.g., ACO participants).

NOTE:
CMS now uses the term traditional MIPS to refer
to the original MIPS participation framework
where participants select any measures and
activities to report to CMS from the inventory of
209 MIPS quality measures and 100+ MIPS
improvement activities (instead of CMS pre-
packaging a set of measures and/or activities
like in the new APP framework).

CMS specifically summarized the change this way:
“The APM entity will be able to report on the Quality
and Improvement Activities performance categories.
Quality measures will be selected and reported in
the same manner and using the same options that
are available to all other MIPS eligible clinicians or
could be reported through the APP”
(CMS, 2021 QPP Final Rule Overview Fact Sheet, p. 4).

CMS will use the APM entity MIPS submissions to create a traditional MIPS
score for MIPS APM participants at the APM entity level (Figure 2).
ARM
Participation
Participation Status Framework MIPS Participation Level
Yes MIPS APM participant
Traditional
Virtual group
APM entity
Group
Individual
APP
Virtual group
APM entity
Group
Individual
Figure 2: A traditional MIPS score for MIPS APM participants at the APM entity level.

NOTE:
CMS does not score APM entities on the
Cost category and CMS averages the group
and individual Promoting Interoperability (PI)
submissions for MIPS APM participants in
the APM entity to create an APM entity PI
category score

Challenges Created by the Four
Changes in the 2021 Final Rule
The four changes create challenges for either
MSSP ACOs or MIPS APM participants, or
both. Some challenges are good challenges,
but most are not.
Some of the changes create one challenge
and some of the changes create more than
one challenge, such as the discontinuation of
the CMS Web Interface.

Challenges Created by the Discontinuation of
the CMS Web Interface
The discontinuation of the CMS Web Interface
creates four new challenges for MSSP ACOs
and MIPS participants that previously used the
CMS Web Interface to report for MIPS.
 Challenge #1: Submission Method Change
 Challenge #2: Care Delivery Changes
 Challenge #3: Data Collection Changes
 Challenge #4: Scoring Changes

Challenge #1: Submission Method Change
ACOs that previously used the CMS Web
Interface to submit their MSSP quality
performance must switch to a different
submission method (aka “collection type”).
Also, groups of MIPS participants that
previously used the CMS Web Interface to
submit their MIPS quality performance must
switch to a different submission method.

The remaining submission methods applicable to
these ACOs and groups include the following:
electronic clinical quality measures (eCQMs),
clinical quality measures (CQMs), and qualified
clinical data registry (QCDR) measures.
Submitting the APP using an
alternative submission method:
ACOs and groups of MIPS APM participants
reporting the APP must report the three self-
reported APP measures using one of the
alternative submission methods, meaning
eCQM, CQM, or QCDR.
Submitting traditional MIPS using an
alternative submission method:
ACOs and groups reporting traditional MIPS must
report at least six MIPS quality measures using
one of the alternative submission methods,
meaning eCQM, CQM, or QCDR. Different
submission methods include different lists of
quality measures. No submission method
includes all 209 MIPS quality measures.

ACOs and groups should carefully evaluate
the list of quality measures in each sub-
mission method to ensure they select
measures that match their specialty and
strengths.
Whether ACOs and groups report the APP
or traditional MIPS, alternative submission
methods differ from the CMS Web Interface
in significant ways.

Challenge #2: Care Delivery Changes
MSSP ACOs and groups of MIPS participants
may need to make care delivery changes when
switching to an alternative submission method
for two reasons.
First, alternative submission methods measure
quality for all patients, not just a sample of
Medicare patients.
Second, ACOs and groups may need to make
care delivery changes if reporting traditional
MIPS using measures that do not match
measures in the CMS Web Interface.

Care delivery changes due to measurement for
all patients:
The CMS Web Interface measured quality for only a
sample of Medicare patients. However, alternative
submission methods measure quality on all patients.
That’s not just all Medicare patients, that’s all
patients for all payers.
Consequently, ACOs and groups that previously
used the CMS Web Interface may need to make
care delivery changes to fulfill the quality measure
requirements for all patients not just Medicare
patients.

Care delivery changes if reporting a new set of
quality measures for MIPS:
CMS noted that there are 10 eCQMs and 9 CQMs
equivalent to the 10 CMS Web Interface measures.
For MIPS reporting, ACOs and groups could report
at least six of those measures if they prefer to not
switch measures.
Alternatively, ACOs and groups could report
any six measures (or more) from the list of
209 total MIPS quality measures.

Challenge #3: Data Collection Changes
New submission methods may require MSSP
ACOs and groups of MIPS participants to
make data collection changes for two reasons.
1. The measurement of quality on all patients
may require data collection changes.
2. The different value sets used in the
different submission methods may
require data collection changes.

Data collection changes due to quality measurement
on all patients:
As noted previously, alternative submission methods
require quality measurement on all patients.
In contrast, the CMS Web Interface limited quality
reporting to only a sample of Medicare patients.
Consequently, MSSP ACOs and groups of MIPS
participants could, if necessary, manually collect
data from each of the 248 patient records for each
measure.

Data collection changes due to quality measurement
on all patients:
Quality team members could review structured data
(whether mapped or unmapped) or unstructured
data (whether free text, documents, or images) to
identify data or documentation that demonstrated
fulfillment of each quality measure.
Regrettably, this manual review is impossible or
unmeaningful for quality measurement on all
patients.

Data collection changes due to different value
sets in different submission methods:
Medicare uses different versions of the same
measure in the different submission methods
(technically, it’s not the same measure, even
though it is the same clinically).
The difference between the measure versions
is mostly the difference between the value
sets in each version.

Challenge #4: Scoring Changes
Performance rates vary for the same measure
across different submission methods.
Consequently, CMS creates different bench-
marks for each submission method.
CMS likely created different benchmarks to
ensure that one submission method does not
create a competitive advantage over another.
However, the different benchmarks create
uncertainty when transitioning from one
submission method to another.

The quality score for ACOs and groups could
increase or decrease due to the transition from
the CMS Web Interface to alternative
submission methods.
That’s because the same performance rate for
the same measure can be worth more or fewer
points in the different submission methods.
Consequently, ACOs and groups should be
cognizant of the different benchmarks in
different submission methods for the same
quality measure.

For example, notice that providers with a 31
percent performance in the diabetes measure
would earn different scores in the different
submission methods (Table 7).
Specifically, providers with a 31 percent
performance earn between 7.0-7.9 points
in the eCQM submission method versus
10.0 points in the CQM submission method.
A 31 percent performance would have
earned 7.0-7.9 points in the CMS Web
Interface using MIPS scoring.

Collection Type /
Submission Method
Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10
CMS Web Interface n/a
70.00-
60.01
60.00-
50.01
50.00-
40.01
40.00-
30.01
30.00-
20.01
20.00-
10.01
<=10
eCQM
79.99-
70.01
70.00-
60.01
60.00-
50.01
50.00-
40.01
40.00-
30.01
30.00-
20.01
20.00-
10.01
<=10
CQM
>=
99.46
99.45-
92.62
92.61-
74.48
74.47-
57.09
59.08-
46.85
46.84-
37.89
37.88-
31.41
<=
31.40
Table 7: Benchmarking for diabetes: hemoglobin A1c (HbA1c) poor control >9 percent.

Collection Type /
Submission Method
Decile 3 Decile 4 Decile 5 Decile 6 Decile 7 Decile 8 Decile 9 Decile 10
CMS Web Interface n/a
30.00-
39.99
40.00-
49.99
50.00-
59.99
60.00-
69.99
70.00-
79.99
80.00-
89.99
90.00-
100
eCQM
00.11-
03.34
03.35-
16.95
16.96-
36.49
36.50-
58.40
58.41-
81.09
81.10-
92.41
92.42-
99.99
100
CQM
00.21-
11.43
11.44-
32.82
32.83-
61.63
61.64-
88.07
88.08-
99.43
99.44-
99.99
— 100
Table 8: Benchmarking for diabetes: Hemoglobin A1c (HbA1c) poor control >9 percent.
As another example, notice that providers with a 99 percent performance in the flu
shot measure would earn different scores in the different submission methods
(Table 8). Specifically, providers with a 99 percent performance earn between 9.0-
9.9 points in the eCQM submission method versus 7.0 to 7.9 points in the CQM
submission method. A 99 percent performance would have earned 10 points in the
CMS Web Interface using MIPS scoring.

The two examples above demonstrate how the
same performance rate for the same measure
can be worth more or fewer points in different
submission methods.
Consequently, ACOs and groups should be
cognizant of the different benchmarks in the
different submission methods for the same
quality measure.

The introduction of the APM Performance
Pathway (APP) creates two key challenges.
1. The APP will decrease quality
performance scores for MSSP ACOs.
2. A decrease in ACO quality scores will
decrease the APM entity MIPS scores
for MIPS APM participants.

Challenge #5: The APP Decreases Quality Performance Scores for MSSP ACOs
CMS aligned the APP with the MIPS quality
scoring methodology to create one scoring
methodology for both the MSSP and MIPS.
However, CMS estimated that the:
“…proposed methodological changes in ACO
quality scoring will reduce the mean ACO quality
score by roughly 10 to 15 percentage points
relative to recent historical performance years
where ACO quality performance scores have
averaged 90 percent or more…” (CMS, 2021
QPP Proposed Rule, p. 913).

Challenge #5: The APP Decreases Quality Performance Scores for MSSP ACOs
CMS did not specifically identify which scoring
changes will cause the decrease in ACO
quality scores.
However, significant changes include the
decrease of quality measures from 23 to 6,
the emphasis on outcome measures, and
the MIPS scoring methodology.

Challenge #6: The APP Decreases the APM Entity MIPS Scores for MIPS APM Participants
MIPS APM participants receive a MIPS score
based on the performance of their ACO (referred to
as an “APM entity” in MIPS).
The performance of the ACO is referred to as the
participant’s APM entity score in MIPS. In previous
years, MIPS APM participants benefited from high
APM entity MIPS scores.
However, as noted in the previous section,
CMS projects a 10-15 percent decrease to ACO
quality performance. That decrease in ACO
quality performance will decrease the APM entity
MIPS scores credited to MIPS APM participants.

Challenges Created by the Discontinuation of
the APM Scoring Standard
Due to the discontinuation of the APM
scoring standard, clinicians classified as
MIPS APM participants could have up to
eight final MIPS scores when a participant
has multiple MIPS submissions.
MIPS APM participants must now determine
which MIPS reporting framework (whether
APP or traditional MIPS) and which level
of MIPS participation (APM entity, group,
and individual) would put forward their
best MIPS score.

Challenges Created by the Addition of the
APM Entity as a MIPS Submitter Type
Due to the addition of the APM entity as a MIPS
submitter type, APM entities can, but do not have
to, submit traditional MIPS quality measures.
Consequently, APM entities must determine
whether they will submit traditional MIPS quality
measures on behalf of the MIPS eligible
clinicians that participate in the APM entity.
For example, ACOs must determine whether
they will submit traditional MIPS quality
measures on behalf of MIPS eligible ACO
participants.

Challenges Created by the Addition of the
APM Entity as a MIPS Submitter Type
Alternatively, ACO participants could pressure
ACOs to submit traditional MIPS quality
measures if ACO participants believe that the
APM entity MIPS score would be higher with
those measures.
Additionally, health systems that manage an
ACO and employ participants in the ACO must
determine whether submitting traditional MIPS
quality measures could increase the APM
entity MIPS score and, therefore, increase the
MIPS payment adjustment for the system’s
employed providers.

The Health Catalyst Solution for the
Challenges Created by the Four Changes
The Health Catalyst quality measures solution
overcomes each of the challenges created by
the four key changes affecting MSSP ACOs
and MIPS APM participants (and groups that
previously submitted quality data using the
CMS Web Interface).
Specifically, the Health Catalyst quality
measures solution creates a complete picture
by combining complete data from a complete
list of data sources, complete measures from
a complete list of programs, and complete
performance visualizations.

The Health Catalyst Solution for the
Challenges Created by the Four Changes
also creates a complete workflow by combining
the process for monitoring, improving, and
submitting performance to payers.
The rest of the guide explains how specific
components within the Health Catalyst quality
measures solution solve specific challenges
facing ACOs and MIPS APM participants in
the 2021 QPP Final Rule.

Solutions for the Problems Created by the
Discontinuation of the CMS Web Interface
The Health Catalyst quality measures
solution overcomes all the challenges
created by the discontinuation of the
CMS Web Interface.
Those challenges include:
1. Submission method changes
2. Care delivery changes
3. Data collection changes
4. Scoring changes

Submission Method Changes
offers clinical quality measure (CQM) submission
through its submission engine and qualified
registry (the Able Health Qualified Registry).
Quality teams can measure and submit their
performance directly to CMS from within the
Health Catalyst performance dashboard.

Submission Method Changes
Specifically, ACOs and MIPS APM
participants can submit their perform-
ance to CMS for the three self-reported
measures in the APP.
Additionally, MIPS APM participants or
groups that previously reported MIPS
quality performance through the CMS
Web Interface can report any CQM
available in traditional MIPS.

Care Delivery Changes
enables ACOs and MIPS participants to rapidly
expand care delivery for quality measures to all
patients, not just a sample of Medicare patients.
Specifically, performance dashboards create
visualizations that empower quality leaders and
providers to monitor and improve their perform-
ance throughout the performance period across
all measures and all patients (Figure 3).

Care Delivery Changes
Figure 3: A performance dashboard with visualizations for quality leaders and providers.

Data Collection
The Health Catalyst quality measures
solution includes the Health Catalyst
Data Operation System (DOS™).
DOS integrates all your source data
(claims, clinical, payer, etc.) into a single
computing ecosystem by combining
features of data warehousing, clinical
data repositories, and health information
exchanges.

Data Collection
With DOS, you can combine complete data
types and data sources into one place and then
map all your structured data to the appropriate
code types for the specific value sets used by
the measures in your new submission method.
Practically speaking, DOS allows your
physicians and care teams to use the
documentation workflow they prefer, not the
unfavorable workflow prescribed by your EHR.
Then, DOS does the heavy lifting of data
aggregation, deduplication, and normalization.

Benchmarking
CMS creates different benchmarks for the
different submission methods because of a
consistently different performance rate across
clinicians in each submission method.
The consistent performance differences
between submission methods are most likely
due to different bottlenecks in the prescribed
data collection for each submission method.
Health Catalyst solutions can offset bottlenecks
in data collection.

Benchmarking
DOS and the Health Catalyst flexible measures
engine can use all your structured data in
performance calculations, not just some of it.
The use of all your data increases your
performance rates. And an increase to your
performance rates will offset any increased
benchmarks between the CMS Web Interface
and CQM submission methods.
Additionally, the CQM benchmarks and
measure scoring are embedded into perform-
ance visualizations in Health Catalyst solutions.

Solutions for the Challenges Created by the
Introduction of the APM Performance Pathway
Health Catalyst solutions overcome the
challenges created by the introduction of
the APM Performance Pathway (APP).
Those challenges include:
1. The APP will decrease quality scores for
ACOs in the MSSP.
2. The decrease to ACO quality scores will
decrease APM entity MIPS scores for
MIPS APM participants.

Decrease in Quality Performance Scores for ACOs in the MSSP
CMS attributed the 10 to 15 percent
decrease in ACO quality performance to
changes it proposed to the revised quality
scoring methodology for ACOs.
CMS did not identify the specific factors
that would cause that decrease to ACO
quality scoring.
One key difference would be the use of
MIPS quality scoring.

Decrease in Quality Performance Scores for ACOs in the MSSP
As discussed in the previous section, Able
Health by Health Catalyst can offset bottle-
necks in data collection that reduce quality
performance for various measures in different
submission methods.
That’s because the Data Operating System
(DOS) and flexible measures engine included in
the Health Catalyst quality measures solution
can use all your data, not just some of it.
Consequently, the increase to your performance
rates can offset increased benchmarks.

Decrease in APM Entity MIPS Scores for MIPS APM Participants
allows MIPS APM participants to monitor,
improve, and submit their MIPS performance
independent of their APM entity.
Consequently, MIPS APM participants should
seek to improve and submit their MIPS
performance independent of their APM entity
since CMS estimates that ACO quality scores
will decrease by 10-15 percent.

Decrease in APM Entity MIPS Scores for MIPS APM Participants
As described in previous sections, the
Health Catalyst quality measures solution
includes improvement tooling such as
comprehensive performance dashboards
and integrated care gap lists embedded
into native EHR workflows.

Discontinuation of the APM Scoring Standard
As noted previously, clinicians classified as
MIPS APM participants could have up to
eight final MIPS scores.
And due to the discontinuation of the APM
scoring standard, CMS will now apply
payment adjustments using the highest final
MIPS score for MIPS APM participants.
Consequently, quality teams can use the
Health Catalyst quality measures solution to
monitor, improve, and submit performance
for MIPS APM participants at the different
levels of participation for both the APP and
traditional MIPS.

Here’s why that matters. Loosely speaking,
half the groups in an APM entity will have a
group score higher than the APM entity score.
Consequently, quality teams should report
these groups independent of the APM entity.
Additionally, half of individual clinicians in a
group will have an individual score higher
than the group score.
Consequently, quality teams should report
these individuals independent of the group.

CMS will receive and assign multiple final MIPS
scores for these groups and individuals.
However, due to the discontinuation of the APM
scoring standard, CMS will only use the highest
final score to assign MIPS payment
adjustments.
Consequently, monitoring, improving, and
submitting performance at all four levels of
participation will increase MIPS payment
adjustments for roughly half of MIPS APM
participants.

Addition of the APM Entity as a MIPS Submitter Type
As noted previously, APM entities can, but do not
have to, submit traditional MIPS quality measures
now that CMS includes APM entities as a MIPS
submitter type.
APM entities such as ACOs can use Health
Catalyst solutions to monitor APM entity
performance in the APP and traditional MIPS.
Health systems that manage an ACO and employ
participants in the ACO can submit the APP for
MSSP participation and traditional MIPS quality
measures to increase the APM entity MIPS score
and, therefore, increase the MIPS payment
adjustment for the system’s employed providers.

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

More about this topic
Link to original article for a more in-depth discussion.
Healthcare Process Improvement: Six Strategies for Organizationwide Transformation
A Complete Guide to MIPS Quality Measures
Rachel Katz, Senior VP Product Development; Darren O'Brien, Client Development Director, Regulatory Measures
The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care
Will Caldwell, MD, MBA, Senior VP and Executive Advisor
Medicare Advantage HEDIS and Risk Reporting: A Primer for Providers
Rachel Katz, Senior VP Product Development
The Able Health Quality Measures Solution: Why a Comprehensive Approach Matters
Tarah Neujahr Bryan, Chief Marketing Officer
Evolving CMS Quality Measures Move Towards More Patient-Centered Care, Less Burden for Clinicians
Britney Rosenau, Senior VP, Engagement Management

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Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Darren O'Brien

Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Health Catalyst is a mission-driven data warehousing, analytics and outcomes-improvement
company that helps healthcare organizations of all sizes improve clinical, financial, and operational
outcomes needed to improve population health and accountable care. Our proven enterprise data
warehouse (EDW) and analytics platform helps improve quality, add efficiency and lower costs in
support of more than 65 million patients for organizations ranging from the largest US health system
to forward-thinking physician practices.
Health Catalyst was recently named as the leader in the enterprise healthcare BI market in
improvement by KLAS, and has received numerous best-place-to work awards including Modern
Healthcare in 2013, 2014, and 2015, as well as other recognitions such as “Best Place to work for
Millenials, and a “Best Perks for Women.”

2021 Changes to the Quality Payment Program: Must-Know Guidelines for ACOs

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