Learn how CMS quality reporting affects ACO shared savings and how the APP Plus Quality framework under the Medicare Shared Savings Program (MSSP) will raise the stakes in performance year 2025 and beyond.
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Rising healthcare expenses and increased expectations for high-quality care for Medicare beneficiaries pose significant challenges for Accountable Care Organizations (ACOs) in establishing a stable financial foundation.
Enter the Advanced Alternative Payment Model (APM) Performance Pathway Plus Quality Measure set (APP Plus), a framework designed not just as a compliance measure for ACOs participating in the Medicare Shared Savings Program (MSSP) but as a strategic avenue for ACOs to enhance their fiscal health while delivering superior patient outcomes.
According to the Physician Fee Schedule final rule, CMS is mandating that ACOs participating in the MSSP start reporting the APP Plus quality measure set beginning in the performance year 2025.
This article will unpack how adherence to APP Plus standards can catalyze financial success, transforming challenges into opportunities. We also explore how harnessing data-driven insights and fostering accountability can help MSSP ACOs avert data reporting pitfalls and pave the way toward sustainable revenue.
With CMS increasingly emphasizing value over volume through its value-based care initiatives, organizations that consistently deliver on quality will find themselves eligible for shared savings and incentive payments. However, not all ACOs are equipped to participate in such programs due to the difficulty extracting and formatting data for submissions—the requirements for which CMS often changes from year to year.
Therefore, embracing a culture of quality data reporting can empower ACOs in several ways. One, they can avoid penalties associated with subpar performance metrics. Two, accurate and timely data reporting also allows organizations to benchmark performance against peers and identify areas for improvement that directly impact their bottom line. Lastly, when ACOs submit quality data to CMS, it reinforces their commitment to high-quality, cost-efficient care.
As organizations turn data into actionable insights, they can enhance patient outcomes, including engagement and satisfaction, and foster stronger provider collaboration. In this way, accurate and complete APP Plus quality data submissions are more than just compliance tools; they can serve as strategic levers driving financial viability and better patient care under moderate to high-risk payment models.
Meanwhile, an increasing number of ACOs participate in CMS initiatives under the Quality Payment Program to care for underserved populations. According to the federal agency, ACOs serve nearly half of people with traditional Medicare, a 3 percent increase since 2023.
CMS aims to have all traditional Medicare beneficiaries in an ACO relationship with their healthcare provider by 2030 under programs such as MSSP and other initiatives designed to deliver high-quality and equitable healthcare.
Participating in APMs, however, presents ACOs with a dual-edged sword. While these programs aim to incentivize high-quality care and cost efficiency, they expose organizations to increased financial risks that can usurp their stability.
Historically, organizations participating in APMs have faced increased administrative expenses and stringent reporting obligations related to additional clinical and quality metrics. They must also meet specific benchmarks to be eligible for performance payments. Over the years, the criteria for qualifying for bonuses have become increasingly challenging for ACOs.
Not to mention, under the Medicare Access and CHIP Reauthorization Act (MACRA), APM incentive payments to eligible clinicians—a 5 percent lump sum—were available for payment years 2019 through 2024, corresponding with performance years 2017 through 2022, respectively.
However, as stipulated by legislation, the upcoming payment year of 2025 for performance year 2023 will mark the end of these incentive payments. Eliminating the 5 percent lump sum APM incentive beginning in 2025 could significantly impact organizations, leading them to cut long-standing patient programs and reduce certain investments.
Beginning in 2025, the 5 percent lump sum APM incentive will no longer be available to ACOs, which could significantly impact organizations, leading them to cut long-standing patient programs and reduce certain investments.
Facilities and practices that submit incomplete or inaccurate quality data to CMS may face reductions in future reimbursement rates, eroding potential earnings over time. These financial repercussions can create a ripple effect, jeopardizing participation in essential Medicare initiatives designed to improve patient outcomes and advance healthcare quality for all.
Also, organizations that fail to meet quality standards often diminish their credibility within the healthcare community, making it harder to forge partnerships and secure collaborative opportunities.
These circumstances make it crucial for ACOs to evaluate the financial implications of participating in APMs as participation requires significant risk-taking and demand, including increased costs associated with extensive quality data reporting.
For the performance year (PY) 2025 and subsequent performance years, CMS requires MSSP ACOs to report on the APP Plus quality measure set, which will include:
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) for the Merit-based Incentive Payment System (MIPS) Survey
• One Administrative Claim:
o Hospital-wide, 30-day, All-Cause Unplanned Readmission Rate for MIPS Eligible Clinician Groups
• Four electronic clinical quality measures (eCQMs)/MIPS CQMs/Medicare CQMs:
o Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
o Preventive Care and Screening: Screening for Depression and Follow-up Plan
o Controlling High Blood Pressure
o Breast Cancer Screening
CMS will phase in the following eCQM/MIPS CQM/Medicare CQM measures in subsequent years, increasing the total APP Plus measures to eight in PY 2026, nine in PY 2027, and 11 measures in PY 2028:
o Colorectal Cancer Screening (PY 2026)
o Initiation and Management of Substance Use Disorder Treatment (PY 2027)
o Screening for Social Drivers of Health (PY 2028)
o Adult Immunization Status (PY 2028)
In addition to the gradual implementation of the APP Plus quality measure set, it's important to highlight that CMS also updated the MSSP financial methodology by introducing a Health Equity Benchmark Adjustment (HEBA).
This adjustment increases an ACO's historical benchmark based on the proportion of Medicare beneficiaries they serve who are dually eligible or enrolled in Medicare Part D with Low-Income Subsidy assistance.
CMS is confident that this modification will encourage continued participation from ACOs that cater to underserved patient populations.
Accurate APP Plus submissions are not just a regulatory formality; they could represent the lifeblood of an ACO's financial health. Reporting on an extensive and complex set of quality metrics is directly linked to enhanced reimbursements and optimized care delivery, creating a robust feedback loop that fosters continuous improvement.
Indeed, each reporting submission could translate into tangible rewards that can bolster patient outcomes and organizational sustainability, positioning ACOs at the forefront of value-based care.
ACOs, however, need improved reporting precision without burdening administrative staff with intricate data reporting duties.
Embracing technology like Health Catalyst's MeasureAbleTM APP solution can streamline data collection and reporting and facilitate timely insights into performance metrics. By investing in such innovations, organizations can simplify the reporting process and maximize their financial outcomes—ensuring that every dollar earned and invested is a step towards greater efficiency and improved population health.
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