ACO Claims-Based Quality Metrics

For Medicare Shared Savings Program (MSSP) ACOs the 2023 measures are set forth in the Federal Register with corresponding specifications on the Medicare Quality Payment Program (QPP) website.

MSSP ACOs claims-based measures are 1) Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate and 2) Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions.

MSSP ACOs also must complete either Web-Based Interface Random Sample or APM Entity reporting of other measures listed below:

ACO REACH participants are responsible for performance in the following claims-based measures based on their entity type, however they do not have to separately report CQM or eCQM metrics to Medicare.

Risk-Standardized All-Condition Readmission (ACR) measures how many hospital stays result in a readmission within 30 days after patient discharge. This measure will apply to All REACH ACOs.

All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions (UAMCC) measures unplanned hospital admissions among Medicare FFS beneficiaries 65 years of age and older with multiple chronic conditions. This measure will apply to All REACH ACOs.

Days at Home for Patients with Complex, Chronic Conditions (DAH) measures the number of days that adults with complex, chronic disease spend at home or in community settings and out of acute and post-acute care settings (such as inpatient hospital or emergent care settings or post-acute skilled nursing). This measure will apply only to High Needs Population ACOs.

Timely Follow-Up After Acute Exacerbations of Chronic Conditions (TFU) is defined as the percentage of acute events related to one of six chronic conditions where follow-up care was received within the time frame recommended by clinical practice guidelines in a non-emergency outpatient setting. Acute events are those that required either an emergency department visit or hospitalization. The six chronic conditions include hypertension, asthma, heart failure, coronary artery disease, chronic obstructive pulmonary disease, and diabetes. This measure will apply to Standard and New Entrant ACOs only and was new in PY2022.

Now is the time to start reviewing your claims data to determine performance on the above metrics so you have no surprises at the end of the year. Book Appointment here.

Kris Gates, gates@healthendeavors.com