ACO Proposed Rule Review – Part 10: Quality & Performance (cont.)

The sections covered below can be found in the proposed rule on pages 196-201 here:

 IIE—Quality and performance measurements  Part II

  •  A CMS-specified data collection tool and a survey tool for certain proposed measures (i.e., those measures in the table where the proposed method of data submission is listed a “GPRO”) would be provided by CMS. 
  • Data for some measures would need to be collected by survey instruments.
  • During the year following the first performance period, each ACO would be required to report via the GPRO tool, when applicable, the proposed quality measures in Table 1 with respect to services furnished during the performance period.  (Links to info on GPRO: )
    •  The existing GPRO tool will be built out, refined, and upgraded to support clinical data collection and measurement reporting and feedback to ACOs under SSP.
    • CMS plans to determine a sample for each domain or measure set within the domain using a sampling methodology modeled after that methodology currently used in the 2011 PQRS GPRO for assigned beneficiaries.
    • For measures with “GPRO” listed as the method of data collection in the table, CMS plans to provide each ACO with access to a database (the GPRO data collection tool) that will include a sample of its assigned beneficiary population and the GPRO measures in Table 1. 
    • CMS will pre-populate the data collection tool with beneficiaries’ demographic and utilization information based on their Medicare claims data.
    • The ACO would be required to populate the remaining data fields necessary for capturing quality measure information on each of the beneficiaries.
    • CMS plans to require that the random sample for measures reported via ACO GPRO must consist of at least 411 assigned beneficiaries per measure set/domain. For each measure set/domain within the GPRO tool, the ACO would be required to report information on the assigned beneficiaries in the order in which they appear consecutively in the ACO’s sample.
    • Some GPRO measures will not rely on beneficiary data but rather on ACO attestation including those in the care coordination domain that pertain to HITECH meaningful use, the electronic prescribing incentive program, and patient registry use.  CMS plans to validate GPRO attestations through CMS data from the HER Incentive Program and E-Rx Incentive Program.
    • For other measures that would be reported through the GPRO tool, CMS would retain the right to validate the data entered into the tool.  If an audit is performed, it would be done by a data validation process based on the one used in phase I of the PGP demo (more info will be provided later in proposed regs).
    • In the GPRO audit process, a sample of 30 beneficiaries previously extracted for each of the quality measure domains/measure sets would be used.  The audit process would include up to 3 phases, depending on the results of the first 2 phases.  Although each sample would include 30 beneficiaries per domain, only the first 8 beneficiaries’ medical records would be audited for mismatches during the first phase of the audit.  A mismatch represents a discrepancy between the numerator or denominator exclusions in the data submitted by the ACO and CMS determination of their appropriateness based on supporting medical records information submitted by the ACO.  If there are no mismatches, the remaining 22 of the 30 beneficiaries’ records would not be audited.  If there are mismatches, the 2nd phase of the audit would occur, and the other 22 beneficiaries’ records would be audited.  A 3rd phase would only be undertaken if mismatches are found in more that 10 % of the medical records in phase 2.  If a specific error is identified and the audit process goes to Phase 3, which involves corrective action, CMS would provide education to the ACO on the correct specification process and provide the opportunity to correct and resubmit the measure(s) in question.  If, at the conclusion of the third audit process the mismatch rate in more that 10 percent, the ACO would not be given credit for meeting the quality target for any measures for which this mismatch rate still exists. 
    • Failure to report quality measure data accurately, completely and timely (or to timely correct such data) may subject the ACO to termination or other sanctions (more to come on this later in the proposed regs).
    • CMS invites comment on the proposed quality data submission requirement and on the administrative burden associated with reporting.
  • Claims-based measurers would be derived by CMS from claims submitted for services furnished during the first performance period, which would therefore not require any additional report on the part of ACO professionals.
  • CMS seeks comments on the proposed data submission requirements and on whether alternative data submission methods should be required or considered, such as limiting the measures to claims-based and survey based reporting only.
  • Certified EHR Technology—measures with the EHR Incentive Program will be aligned.  At least 50 % of an ACO’s PCPS will need to be “meaningful EHR users by the second SSP performance year in order to continue to participate in the SSP.  CMS intends to develop the capability of the GPRO web-based tool to interface with HER technology, such that EHR data could directly populate the ACO GPRO tool with the required quality data. 

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