October 10, 2022
Aledade asks, "Can we, and should we, move to all-payer, all-patient, all-provider, all-location electronic measurement?"
This blog is the second of a three-part series summarizing Aledade's comment letter to CMS on the 2023 proposed Physician Fee Schedule.
We are a few weeks away from the Centers for Medicare & Medicaid Services releasing the final 2023 Medicare Physician Fee Schedule. Last week, we shared a summary of some of Aledade’s comments to what CMS proposed around Medicare Shared Savings Program benchmarking. This article summarizes our comments on the quality measurement proposals in Medicare.
Quality measurement is a way to assess and influence the services and delivery of care clinicians provide. When quality measurement is thoughtfully implemented, it can enhance medical care by focusing clinical efforts toward specific beneficial health outcomes and balancing the administrative burden on practices with generating a solid report card.
CMS has set an intention to move the Advanced Payment Model Performance Pathway to all-payer, all-patient, all-provider, all-location electronic measurement – which we will refer to as all-payer eCQMs. Aledade sees two use cases for quality measurement. First, real-time monitoring of performance and even prospective intervention, closing care gaps. For this purpose, eCQMs are a powerful tool. The second use case is to create a quality report card on an accountable care organization, health plan, practice, or other entity. For reporting purposes, all-payer eCQMs are inferior to the current sampling methodology. An accurate ACO report card ensures that cost savings do not come at the expense of quality and enables relative comparisons among ACOs and MSSP to original Medicare and Medicare Advantage. All-payer eCQMs create a less accurate report card than the current methodology at a much higher burden to the ACO. More work for less accuracy is not the direction we want to travel.
The move to all payer eCQMs does not align with payment policy or patient preferences.
Today, ACOs only measure the quality of assigned Medicare beneficiaries. Under the all-payer eCQMs that CMS proposes, the population would dramatically increase in every way. The most fundamental change is not from one payer (Medicare) to all payers; it is from patients with an established relationship with a clinician or practice to every patient that walks through the door. This shift conflicts with both payment policy and with patient preferences. In our comment letter, we use the example of a dermatologist who is part of an ACO having to record a depression screen on every adult patient if they lack a record that one was done in the past year. We’ve made gains in interoperability in health care, but it’s clear that most specialists do not have access to these records for most patients. While payers may support the clinical measure, they are not willing to pay for it. Medicare will pay for only one depression screening a year. All other clinicians must either have the record of that one screen or conduct one for free to meet the quality measure.
As for patient preferences, if a patient with well-controlled diabetes sprains their wrist over the weekend and seeks urgent care, they might not want or expect their A1C measured if they reveal on the intake form they have diabetes. But if the urgent care practice doesn’t take the A1C, they risk a lower quality score.
For purposes of quality improvement, this misalignment can be dealt with at the ACO’s discretion. Quality measurement for quality improvement should help a practice have actionable insights. Is the patient overdue for a recommended screening? Has the patient’s blood pressure been taken? Suggestions can be dismissed in the cases above without ramifications. Different quality improvement efforts at different places and for different populations can be implemented. But the one-size-fits-all nature of the report card means what is appropriate for quality improvement often becomes inappropriate for quality reporting.
One ACO’s report card would become less comparable to another ACO’s report card.
Today, the comparison from one ACO to another is made on just assigned original Medicare beneficiaries. Whether an ACO is composed of a safety net hospital and urban clinics or whether it is entirely private practices in active retirement communities, the populations have meaningful commonalities. Expanding to the all-payer eCQMs removes any meaningful commonalities between the measured population of these two ACOs. While the ACO in a retirement community might see its population merely double, the ACO with a safety net hospital and urban clinics could see its population increase one hundredfold. In another proposal which we support, CMS proposes to give a health equity adjustment to ACOs based solely on the composition of its assigned original Medicare beneficiaries. We must be honest with ourselves that the equity differences between assigned Original Medicare beneficiary populations are much smaller than the equity differences between total populations of different health care providers. This move, in every case, will have safety net providers scoring worse on quality measures and disproportionately increase both the administrative and clinical burden of safety net providers compared to others.
The move to all payer eCQMs also removes the comparability to the Medicare Advantage population. Medicare Advantage plans are graded only on their members – Medicare beneficiaries with whom they have a longitudinal relationship. Finally, there is also the issue of accuracy. Many ACOs will have hundreds of thousands of patients in the denominators spread across hundreds of different record systems. Some will have millions. As statisticians can tell you, sampling is simply more accurate than trying to count everyone when the populations get to that size.
We should not move to all-payer, all-patient, all-provider, and all-location measurements because it will yield less accurate and much less comparable report cards for ACOs than we have today while vastly increasing the administrative burden of participating in MSSP. There are non-report card benefits to eCQMs; however, there are simply no attainable benefits to the all-payer aspect.
For the question of “can we” move to all payer eCQMs, we state in our comments that we do not believe it is possible to create numbers that are as accurate as would be produced by a sample methodology for report card purposes. A sample methodology allows for supplemental documentation outside of eCQM specifications on a reasonable number of people, which is impossible if the population is hundreds of thousands. Because a sample combines everything the health IT systems know on specification plus additional information gathered from the medical record upon review, it will always be more accurate than counting entire populations based on the eCQM specifications.
The transition to all-payer eQCMs would be cost- and time-intensive for practices and health centers.
We also outlined in our comments the time, effort, and costs required to transition to all-payer eCQMs. Because the work will not universally satisfy other payers’ requirements for measure submission, one measure will require multiple quality workflows and other duplications.
Many certified EHR products that are commonly used do not have certain features of technology “turned on” or available to a practice or a clinician to use without paying large fees. If they do, the data still has to be run through other vendors who charge on a per-life or per-provider basis, with costs easily getting into the six-figure range per ACO if you include all patients.