ACO Proposed Rule Review – Part 9: Quality & Performance

The section on Quality and Performance is rather long, so it will be broken into 2 or 3 installments.  While the bulleted list below isn’t too long, to make up for it, here is a link to the 20 page table in the proposed rule that contains the 65 measures for your review and comment:  

 The sections covered below can be found in the proposed rule on pages 166- 196.  Here is the link:

 IIE—Quality and performance measurements  Part I

  • An ACO will be considered to have met the quality performance standard if they have reported quality measures and met the applicable performance criteria in accordance with the requirements detailed in rulemaking for each of the 3 performance years (note: the measures could be subject to change each year).
  • The quality performance standard would be defined at the reporting level for the first year of the Shared Savings Program (SSP) and then, in subsequent program years, the standard would be based on measure scores.   Quality measures for the remaining two years of the 3-year agreement will be proposed in future rulemaking
  • 65 measures have been proposed for use in the calculation of the ACO Quality performance Standard.
  • The ACOs would be required to report quality measures and meet applicable performance criteria, as defined in rulemaking, for all 3 years within the 3-year agreement period to be considered as having met the quality performance standard.
  • For the first year of the program, the quality performance standard would be at the level of full and accurate measures reporting; for subsequent years, the quality performance standard would be based on a measures scale with a minimum attainment level (described later in the proposed regulation).
  • ACOs that do not meet the quality performance thresholds for all proposed measures would not be eligible for shared savings, regardless of how much per capital costs were reduced.  In these instances when an ACO fails to meet the minimum attainment level for 1 or more domains, the ACO would be given a warning and would be re-evaluated the following year.  If the ACO continues to underperform in the following year, the agreement would be terminated. 
  • If an ACO fails to report 1 or more measures, CMS would send the ACO a written request to submit the required data by a specified date and to provide a reasonable written explanation for its delay in reporting the required information.  If the ACO fails to report by the requested deadline and does not provide a reasonable explanation for delayed reporting, CMS could immediately terminate the ACO for failing to report quality measures.
  • ACOs that exhibit a pattern of inaccurate or incomplete reporting or fail to make timely corrections following notice to resubmit may be terminated from the program.
  • SSP quality measures specifications whenever possible would be aligned with other existing CMS quality programs.  The specifications for the proposed measures would be available on the CMS website prior to the start of the SSP.
  • The results for the first program year measures via claims, would be calculated using the Group Practice Reporting Option (GPRO) data collection tool and survey instruments.  The ACO GPRO tool would be a new tool based on the data collection tool currently used in the Physician Quality Reporting System (PQRS—formerly PQRI) group practice reporting option (GPRO) and Physician Group Practice (PGP) demonstration.
  • For subsequent program years through additional rulemaking, CMS would refine and expand the ACO measures to enhance our ability to assess the quality of care furnished by ACOs and expand measures reporting mechanisms to include those that are directly EHR-based.  Specifically, CMS expects to expand the measures through future rulemaking to include other highly prevalent conditions and areas of interest, such as frailty, as well as measures of caregiver experience. Hospital-based care and quality measures for other settings (home health, nursing homes) would likely be added.
  • CMS invites comments on the implication of including or excluding any proposed measure or measures in the calculation of the ACO Quality Performance Standard and suggestions on variations or substitutions of measures.  Also, should the list of proposed measures be narrowed, should some be excluded from scoring purposes and be considered for quality monitoring purposes only.  CMS also seeks comments on a process for retiring or adjusting the weights of domains, modules, or measures over time.

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