Introduction
Accountable Care Organizations (ACOs) were introduced as part of the Affordable Care Act (ACA) in 2010, with the goal of reducing healthcare costs while improving quality of care. ACOs are networks of healthcare providers who voluntarily band together to coordinate care for Medicare beneficiaries. By aligning financial incentives with quality performance, ACOs aim to shift the focus from volume-based care to value-based care. Central to the success of ACOs has been the development of quality measures, which ensure that patient care does not suffer while providers work to reduce costs. Over the years, these quality measures have evolved in response to shifting priorities in healthcare and technological advancements. The Centers for Medicare & Medicaid Services (CMS) continues to refine these measures, with the latest changes proposed in the CY 2025 Medicare Physician Fee Schedule (PFS) reflecting a move towards streamlining, digitalization, and outcome-based evaluation.
Early History of Quality Measures for ACOs
When ACOs were first established in the early 2010s, CMS introduced a set of quality measures designed to ensure that cost-saving efforts did not come at the expense of care quality. These measures were part of the Medicare Shared Savings Program (MSSP), one of the primary models for ACOs. In the initial years, ACOs were evaluated on a broad range of quality measures that covered four main domains:
- Patient/Caregiver Experience: This domain included patient-reported measures such as satisfaction with care, access to providers, and communication with healthcare teams.
- Care Coordination/Patient Safety: Measures in this domain evaluated the effectiveness of care transitions, management of chronic conditions, and hospital readmissions.
- Preventive Health: These measures focused on preventive screenings, vaccinations, and other interventions that help avert future illness.
- At-Risk Population: This domain covered care quality for populations with chronic diseases, such as diabetes or heart failure.
Initially, ACOs had to report on 33 quality measures across these domains. The performance on these measures was crucial in determining an ACO’s eligibility for shared savings—financial rewards for reducing healthcare costs while maintaining or improving quality.
Evolution and Refinement of Quality Measures
Over time, the quality measurement framework for ACOs underwent several revisions. The changes were aimed at improving accuracy, reducing administrative burden, and aligning the measures with evolving healthcare priorities.
- Shift to Outcomes-Based Measures
In the early years, many quality measures were process-based, meaning they focused on whether specific healthcare services were provided rather than the outcomes of those services. For example, a process measure might track whether a patient with diabetes received an annual eye exam, while an outcome-based measure would focus on whether the patient’s diabetes was well-controlled.
As value-based care models matured, CMS began shifting towards outcome-based measures, which more directly reflect the health results of patients. These measures emphasized the effectiveness of care, such as whether a patient’s blood pressure was under control, or whether care reduced hospital readmissions or mortality rates.
- Alignment with Other CMS Programs
As various quality reporting initiatives evolved across CMS programs, such as the Merit-based Incentive Payment System (MIPS) and the Hospital Inpatient Quality Reporting (IQR) Program, CMS sought to reduce redundancy. In response to stakeholder feedback, CMS began aligning quality measures across programs to create consistency and simplify reporting for healthcare organizations involved in multiple value-based initiatives.
This alignment helped streamline efforts for providers participating in different programs, eliminating duplicative reporting and allowing for a more coordinated approach to quality measurement across the continuum of care.
- Reducing Reporting Burden
Another key trend in the evolution of quality measures was reducing the reporting burden on ACOs. Initially, the reporting process was seen as complex and resource-intensive, often requiring significant administrative effort. Over time, CMS implemented reforms to simplify the reporting process, including reducing the number of measures and introducing automated data collection systems using electronic health records (EHRs).
The reduction of measures allowed ACOs to focus more on high-priority areas, such as managing chronic conditions and improving patient outcomes, rather than getting bogged down in administrative tasks.
Proposed Changes for CY 2025: Streamlining, Digitalization, and Outcome Focus
The CY 2025 Medicare Physician Fee Schedule (PFS) proposed rule introduces significant updates to ACO quality measures, reflecting CMS’s continued efforts to enhance the performance evaluation framework for ACOs. These changes are designed to further streamline reporting, focus on outcome-based evaluation, and take advantage of advancements in digital health technology. Here are the key elements of the proposed changes:
- Greater Alignment Across Programs
The CY 2025 proposed changes continue the trend of aligning quality measures across various CMS programs. This alignment is expected to create uniformity in how healthcare providers are evaluated, reducing discrepancies and simplifying the reporting process for organizations that participate in multiple value-based care models.
CMS proposes the introduction of the APM Performance Pathway (APP) Plus quality measure set, aligning with the Adult Universal Foundation quality measures. This new set would incrementally expand from six to eleven measures between 2025 and 2028. The APP Plus set creates a streamlined framework that supports alignment with other federal and state programs, such as Medicare, Medicaid, and private payer quality initiatives. This alignment reduces the administrative burden for healthcare providers, who can now report on a core set of universal measures across multiple programs, enhancing efficiency and improving the comparability of quality performance data.
- Transition to eCQMs and Medicare CQMs for ACOs
Electronic Clinical Quality Measures (eCQMs): Tools that electronically capture and report data directly from electronic health records (EHRs) to measure the quality of care provided. These measures are based on specific clinical workflows and care processes, allowing healthcare providers to assess the effectiveness of interventions, manage patient outcomes, and drive improvements in care delivery. ACOs are encouraged to adopt eCQMs because they reduce manual data entry, streamline reporting, and offer real-time feedback, which leads to more accurate tracking of clinical performance. eCQMs focus on critical areas such as preventive care, chronic disease management, patient safety, and healthcare utilization.
Medicare Clinical Quality Measures (CQMs): Medicare CQMs, previously known as traditional paper-based measures, are another set of standardized quality measures used in reporting for Medicare programs. Unlike eCQMs, Medicare CQMs may still involve some manual data abstraction but are steadily transitioning toward full integration with digital health platforms. These measures are essential for evaluating the quality of care delivered to Medicare beneficiaries, focusing on areas such as effective clinical care, population health, and care coordination.
To report these measures, ACOs must implement certified EHR technology (CEHRT) that meets CMS requirements. For eCQMs, data is pulled directly from patient records within the EHR system and submitted through secure, automated channels to CMS. For Medicare CQMs, organizations may still need to rely on a hybrid approach, using both EHR and manually abstracted data for submission. Reporting these measures is critical for ACOs, as performance on them directly impacts shared savings eligibility, benchmarks for performance improvement, and overall success in value-based care arrangements. ACOs can streamline this reporting process by working closely with their EHR vendors, and/or qualified registries, to ensure accurate data capture and timely submission to CMS.
- Outcome-Focused Scoring and Incentives
CMS proposes to refine the scoring methodology used to evaluate ACOs, placing greater emphasis on outcome-based measures. This refined approach could involve setting performance thresholds, weighting measures based on their importance, and using regional or national benchmarks to evaluate performance.
The shift towards outcome-based scoring reflects CMS’s ongoing commitment to incentivizing high-value care. ACOs that demonstrate superior performance on outcome measures, such as reducing hospital readmissions or managing chronic diseases, could be eligible for enhanced shared savings.
Conclusion
The evolution of quality measures for ACOs reflects broader trends in healthcare reform, from focusing on process-based metrics to emphasizing outcomes, patient-centered care, and digital innovation. The proposed changes in the CY 2025 Medicare PFS signal CMS’s intent to continue refining the framework to support the long-term success of value-based care models.
By streamlining measures, incorporating digital tools, and enhancing outcome-based performance evaluation, CMS aims to reduce the burden on ACOs while ensuring that they remain focused on delivering high-quality, cost-effective care. As these changes take effect, ACOs will need to adapt to the evolving landscape, leveraging technology and patient-centered strategies to drive improvements in care quality and cost savings.
Pinnacle Healthcare Consulting has established itself as a leader in ACO management and healthcare policy, offering deep expertise in navigating the complexities of value-based care models. Our team of experts excels in guiding healthcare organizations through the intricate regulatory landscape, including the latest shifts toward eCQMs and Medicare CQMs, ensuring seamless compliance and superior performance in quality reporting. We specialize in designing tailored strategies to optimize shared savings, improve patient outcomes, and enhance overall operational efficiency for ACOs. By partnering with Pinnacle, you gain access to cutting-edge consulting services that not only address current healthcare challenges but also position your organization for long-term success in the evolving healthcare environment.
For any questions on the ever-evolving policies affecting ACOs or the Shared Savings Program, please contact Kelly Conroy or Daniela Yusufbekova.
Kelly Conroy
(561) 385-7566
KConroy@AskPHC.com
Daniela Yusufbekova, MHA, PMP
(561) 445-8303
DYusufbekova@AskPHC.com
