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Navigating the MSSP ACO Quality Measure Process

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Before an ACO can share in any savings generated, it must demonstrate that it met the quality performance standard for that year. Quality Reporting can be an intimidating process for new or prospective participants.  This may be the first time many of the providers have worked together and they likely operate on a variety of EMRs that aren’t yet configured for interoperability.  Some of your providers may still be on paper.

Given the “newness” of this process, there aren’t many resources to guide you. You’ll mostly be left to navigate and make sense of the CMS documentation.  To make matters worse, there’s the overwhelming risk of failing to report at all and the need to be prepared for an audit.  Despite these challenges, the quality reporting process is a manageable one.  With a good plan and an orderly execution, you can satisfy these requirements without taking your entire team off mission.  In this post, we’ll close the knowledge gap and give you the basis for your collection and reporting process. Our focus will be on the “How” of quality reporting compliance.

The ACO Quality Measures

There are 33 measures in four quality domains as follows:

  1. Patient/Caregiver Experience (8 measures)
  2. Care Coordination/patient safety: (10 measures)
  3. At-risk population (7 Measures)
  4. Preventive Care (8 measures)

The details of these measures are well documented on the CMS website and we won’t get into them here.  For practical purposes, we can break the 33 measures up into 3 groups based on what an ACO has to do from a reporting perspective:

  1. CAHPS Survey (8 measures)

The ACO must select a CMS approved vendor to manage the survey.  The vendor will conduct a mailing and place follow-up phone calls to those that don’t respond. Survey results are reported directly to CMS by the vendor to satisfy this reporting requirement.

  1. CMS Claims and Administrative Data (8 Measures)

For the claims-based measures, ACOs do not need to collect or submit additional data aside from normal billing activities. The CMS ACO Program Analysis Contractor (ACO PAC) will coordinate with CMS to obtain the necessary Medicare claims files and calculate the rates for these measures for each ACO.

  1. ACO Reported Clinical Quality Measures (17 Measures)

This is where the ACO has some work to do. These measures must be collected from clinical data found in your provider’s EMRs and reported to CMS via the GPRO Web Interface. You must be prepared to provide backup documentation for your answers in the event of an audit (NOTE: You cannot use claims data to do this).   The remainder of this post will focus on how to execute this process.

Get your Patient Population

ACOs will receive their “Quality List” from CMS around February 1 after the close of the reporting year (i.e. you’ll get your 2015 file around Feb 1, 2016).  5 XML files will be available for download from GPRO:

  1. Patients – contains the patient’s demographic information and all disease module, CARE measure, or PREV measure data, with the exception of the CARE-1 Medication Reconciliation quality measure data.
  2. Patient Discharge – contains the patient’s demographic information and CARE-1 Medication Reconciliation quality measure data.
  3. Patient Ranking – contains the patient’s demographic information and their rank in each module. This is the combined set of patients from the Patients and Patient Discharge files.
  4. Clinics – contains a list of clinics for the group.
  5. Providers – contains a list of providers for the group.

Map Patients to Providers

The first step in collecting quality information on your patients is to identify which providers might have that information.  The GPRO files mentioned above provide the top 3 NPIs by billing for providers in your group. You can use this information to map your patients, but there are a few issues you may run into:

  1. Since the NPIs are ranked by billing, it’s possible you’ll get 3 specialists and no PCP. The PCP is likely to be the best source for complete data on your patient.
  2. If there are no (or few) claims for a particular patient it’s possible you’ll get fewer than 3 NPIs. This may not be an issue if at least 1 appropriate provider is included.
  3. If the top billing providers are not in the GPRO database then their NPIs will not be provided.

Once you’ve mapped your patients to providers using the NPIs provided in the files, you’ll need to fill any gaps by using supplemental data from your own operations or tracking them down manually.

Scan your ACO clinical data warehouse (if applicable)

In an ideal situation, you’ll have a full or partial data warehouse that accumulates population health data from your practices. If you do, you’ll run your quality list against that data and answer as many questions as possible.  If you don’t have a data warehouse then you’ll have to collect all of the required data points thru manual chart reviews.

Close the Gaps with Manual Chart Reviews

At this point, you have an empty or partially filled quality list.  You’ll be missing data from practices that report to your data warehouse, practices that have EMRs that do not yet report to your data warehouse plus any paper-based practices.  You’ll need to fill the gaps in one of the following ways:

  1. Practices enter data manually into the GPRO Web Interface. You can do this by making the web interface available to the appropriate provider offices and have them enter the data. This method doesn’t give you control over quality/accuracy nor visibility into progress. In the event of an audit, it may be difficult to track down who reported what.
  2. ACO staff enters data manually into the GPRO Web Interface. This approach is similar to #1, but if well-organized it may give you more control and visibility. The major drawback here is the time, expense and distraction for your staff. In our opinion, taking staff away from care and/or operations to satisfy reporting needs flies directly in the face of the goals of the MSSP program and it won’t help you generate shared savings.
  3. Use a 3rd party or custom-developed tool to walk your practices through the reporting process. This tool should guide practice data entry, but let you control the final submission to CMS.

Prep the Clinical Quality Data

Next, you’ll combine the data from your data warehouse with that collected manually to fill in the gaps. You’ll need to eliminate duplicate information and perform any quality checks you deem necessary. It’s advisable at this point to perform a prospective audit by asking a few of your providers to supply the necessary documentation to backup their answers.  Screen shots from EMRs or copies of paper charts are a good place to start.

Submit the Quality Data to GPRO

Once you’ve collected all of the necessary data and it’s sufficiently cleaned up, you’ll need to report the results to CMS.

Option 1: Manually enter the results into GPRO patient-by-patient.  This is labor-intensive and prone to typos and other mistakes.

Option 2: Upload completed Patient and Patient Discharge XML files to GPRO.

Next Steps for the ACO

This should be seen as a minimum first step to quality measure compliance and not as a guide for the proper use of data in an ACO.  Beyond basic compliance, you should work aggressively towards regular data collection throughout the course of the reporting year so that you can use it to drive quality improvement and to inform care as soon as possible. To do this with any useful frequency you’ll need to automate the process as much as possible.