The Center for Medicare and Medicaid’s (CMS) recent announcement about new eCQM (electronic clinical quality measures) requirements has created a stir among Accountable Care Organizations (ACOs) concerned about scope, implementation, and timeline.
For many ACOs, specifically those with multiple electronic medical record systems (EMRs), CMS’s proposed requirements will add a great deal of complexity to their reporting of quality and performance measures. Given that CMS is currently seeking feedback on their proposal, it’s tempting to believe that CMS will delay or significantly alter the requirements. Yet, CMS seems determined to press forward, leaving the industry to come up with solutions.
ACOs should consider the strategic advantages of implementing this reporting before it is required. Through this lens, the opportunities are potentially game-changing. eCQMs offer ACOs a forcing function to architect a data infrastructure that effectively solves the interoperability challenge, and transforms the organization’s data aggregating and analytics capabilities to accelerate data readiness.
Done right, this will not only enable ACOs to optimize their value-based care contracts but to enhance a host of other capabilities like population health management, risk stratification, decision support at-the-point-of-care, continuous care across multiple settings/providers and robust data analytics.
Over three blog posts I’m going to dig into the challenges and the transformational opportunities, starting with the basics.
1. What are eCQMs?
eCQMs are measures of clinical quality designed to conform to a standard electronic format using data extracted from the EHR (electronic health record). CMS makes eCQMs available to eligible hospitals, clinicians and critical access hospitals to measure, track and report quality of healthcare services across a number of specific areas of operation primarily for value-based care models. Currently, those quality measures include:
2. What is the timeline of implementation?
CMS began accepting quality measures by eCQM on a voluntary basis starting in 2013. In 2016, it became mandatory for eligible hospitals to report data via eCQM for the Hospital Inpatient Quality Reporting Program and the Medicare Promoting Interoperability Program. Every year, CMS updates the requirements with new codes, clarifications and measures based on evidence-based best practices.
Currently, Medicare Shared Savings Program ACOs can report measures by Web interface, but that option will end in 2025. Between the 2021-2024 performance years, ACOs will have a transition period in which they can use the web portal or eCQM to report all three CQM MIPS measures under the Alternative Payment Model Performance Pathway.
In other words, the clock is ticking, and the next three years are a critical transition period for ACOs.
3. What will be the impact on reimbursement?
As with most CMS requirements, eCQMs come with a carrot and stick.
The stick: eCQM performance will impact a hospital’s annual payment update (APU). Given that most hospitals operate on thin margins, any hit to APU can be significant, possibly amounting to millions of dollars.
The carrot: CMS added incentives to encourage eCQM adoption. In 2022 and 2023, it will be easier to meet performance standards via eCQM versus measures reported by the web portal. And if ACOs report by web portal and eCQM during that time, they’ll be measured by the higher of the two scores.
4. And on Operating Costs?
eCQM conversion will be a major multi-year undertaking, absorbing technical, workforce, financial and legal resources. EHR systems, clinical workflows and administrative processes will need to be redesigned; clinical and administrative staff retrained; and legal teams set to work reformulating or aligning EHR contracts across multiple vendors.
That’s a burden on health systems that are, overall, already struggling financially. According to the latest National Hospital Flash Report from Kaufman-Hall, halfway through 2022, hospital margins are in the red, and health systems remain under financial pressure. Expenses are at historic highs, driving cumulatively negative margins, and operating margins are significantly lower than pre-pandemic levels. And while outpatient volumes have improved, expenses remain “extremely elevated” from pre-pandemic levels.
5. The Reporting Challenge
Formerly, ACOs only reported on a sample of Medicare patients for whom they provided direct care. By 2025, ACOs will need to analyze 100% and report on 70% of all patients who meet the measuring criteria, regardless of payer. In a data ecosystem already strained by fragmented data across multiple physician practices, hospitals and other providers, this will be a challenge. See 6 for the complexity of working with data in multiple EHRs.
Once eCQM reporting is in place, don’t be surprised if CMS then requires ACOs to make their measures public. This would allow patients to compare scores when making plan and provider decisions. And it would force ACOs to operate at the top of their game.
6. The EHR Challenge
Of course, since this is healthcare, ACOs face a massive challenge in aggregating patient data across multiple EHRs serviced by multiple vendors under multiple contracts.
In 2021, only 12 out of 500 ACOs reported by eCQM. Likely, these were single-EHR organizations. A public statement by NAACOS, in this release, noted that more than 75% of ACOs have six or more EHRs, and close to 40% use more than 15 EHRs across multiple settings. Regardless of that digital complexity, all ACOs will ultimately need to submit a single aggregate quality reporting document.
As part of Meaningful Use, EHR vendors are required to meet eCQM requirements. Nevertheless, most EHRs were developed for reimbursement purposes and lack proper formatting capabilities. Much like ACOs, EHRs will undergo pain in conversion with the reporting requirements. While they must take action, some leading EHR vendors have reportedly stated that they will not begin working on new eCQM requirements until late 2023.
Clearly, CMS is of the view that ACOs with multiple EHRs need a working database of all patients. But it will be no small feat to capture, aggregate and report more data than ever before, across multiple EHR systems built by different vendors in accordance with different contracts. Delay may not be the best tactic.
7. The Patient Matching Challenge
The multi-EHR challenge also exacerbates the problem of patient matching.
EHRs lack standards for names, aliases, hyphens, spaces, etc. To ensure data quality and proper reporting standards for accurate patient matching that provides an accurate, holistic view of the patient, CMS will require ACOs to deduplicate patient data across their providers and suppliers when submitting reports.
8. Forces of Resistance
NAACOS has been out in front of new eCQM proposals, surveying ACO reactions to the requirements and developing a coherent response to CMS’s call for comments. Their task force on digital quality measurement, created in April, 2022, released a statement that ACOs are reasonably concerned about the timeline, costs and burden of the transition, the challenges of accessing all payer data across multiple EHRs with multiple permissions requirements, and the ethics of sharing non-Medicare patient health data.
As Katherine Schneider, MD, chair of the NAACOS Digital Quality Measurement Task Force and past NAACOS board chair, observes:
ACOs have broader concerns about the eCQM program as currently constructed, especially many unintended implications and consequences of mandating data reporting on total patient populations instead of just the MSSP as has been done since program inception a decade ago … As of today, digital quality reporting presents major financial and operational challenges, requiring significant investment by vendors, practices, and ACOs for readiness according to the current timeline.
CMS appears to be listening. NAACOS expects CMS to adopt a more phased-in approach before finalizing requirements. This will not stop the train but may make it easier to get on-board.
9. The Vendor Solution
Few ACOs will be able to manage this transition on their own or with their EHR partners. Third party data vendors, however, can help with data aggregation, de-duplication and reporting accuracy across EHRs while speeding up the pace of eCQM adoption and reducing the administrative burden.
The real opportunity, however, is to enable true data readiness through interoperability across the organization and with key stakeholders in the organization’s data ecosystem. I’ll dig into this issue in detail in my third article in this series to help you better understand how Innovaccer’s data platform connects all EHRs, can aggregate and normalize data from any source, and how our upcoming eCQM solution uses the resulting data readiness capabilities to make reporting fast and painless.
10. Arguments for Seizing the Day
Why is CMS demanding ACO adoption of eCQMS by 2025? Because they’re a forcing function for increasing data interoperability, enhancing clinical quality and improving ACO performance.
Mandated reporting of eCQMs will create a more challenging standard for quality on core measures, across all patients—not just Medicare beneficiaries. They also shift ACOs from manual to digital processes across structured data fields, saving time and improving accuracy. This will support participation in risk-based payment schemes and bundles that reduce costs, readmissions and medication errors.
The eCQM shift will also facilitate other highly desirable capabilities including the ability to access real-time data at the point-of-care, to provide clinicians with data-informed clinical decision support, and to improve health equity and access across vulnerable populations.
Every ACO shares those goals. They now face major strategic decisions around how (and how quickly) they should work to enable the capabilities.