MarsdenAdvisors Urges CMS to Reduce Quality Reporting Burden

MarsdenAdvisors asks Centers for Medicare and Medicaid Services (CMS) to consider your experience with quality reporting programs in comments submitted on both the 2023 Quality Payment Program (QPP) proposed rule and the 2023 ASC Quality Reporting Program (ASCQR) proposed rules.

See our previous blogs for a summary of the proposed changes to the QPP and the ASCQR in 2023.

Quality Payment Program Comments

In our response to the 2023 QPP Proposed Rule, we focused on problems that our clients currently face under MIPS and anticipated problems with proposed changes.

  • Transition to 2015 Edition Cures Update Certified EHR
    • MarsdenAdvisors expressed concern over CMS’ previously finalized policy to make this EHR update mandatory in the 2023 performance year as very few vendors have achieved this certification and there are only a few months remaining to do so.
    • We also asked for clarification on how this transition would impact MIPS electronic clinical quality measures.
  • In the Quality section:
    • We emphasized that further pruning the list of available specialty-specific measures will make reporting more burdensome and will lead to less reflective measurement of the quality of care specialists provide.
    • We opposed the proposal to increase the data completeness threshold to 75% in the 2024 reporting year.
    • Our analysis of the request for comment on Screening for Social Drivers of Health (SDOH), we expressed significant concern over any future screening requirements unless they are paired with a centralized repository of issue-based resources that are community-specific. Requiring clinicians to screen for patient vulnerabilities without giving clinicians the resources they need to address the identified SDOH could severely damage the patient-provider relationship.
  • In the Promoting Interoperability (PI) section:
    • We strongly urged CMS to add an exclusion in the Query of Prescription Drug Monitoring Program (PDMP) measure for clinicians who are low-volume or never prescribers of opioid medications prior to making this measure mandatory.
    • We reminded CMS that there have been consistent issues with PI scoring when multiple scores are submitted, and advocated for the scoring practice to be altered to assign the highest of those scores. Currently, CMS assigns a 0 score if this occurs, which does not reflect the practice’s or group’s effort in this category.
  • We opposed CMS’ plan to “sunset” traditional MIPS in future years, as we believe a fee-for-service model will always be valuable, and because we do not believe that MVPs will be applicable to specialists in the timeline CMS is anticipating.
  • We advocated, again, for mid-level providers who provide specialty care. Currently, CMS sees all mid-level providers (NPs, PAs, and CCNSs) as primary care providers, which can lead to specialty practices who employ these providers being inappropriately scored on primary care measures.


ASCQR Comments

ASC-11: Cataracts – Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

CMS is proposing remove the 2025 requirement to report on this highly burdensome survey measure. This measure creates considerable burden on ASCs and there are significant concerns over the inappropriate nature of the cataract surveys being attributed to the ASC facility rather than to the individual surgeon. Last year, reporting on this measure was finalized to be mandatory in 2025, so we are excited to see a proposal to return it as a voluntary measure. In our response to the 2023 ASCQR Proposed Rule, we asked CMS to ensure that this measure remain voluntary in all future years.

Potential Future Specialty-Specific ASCQR Measure Sets

In this proposed rule CMS specifically outlined a potential ophthalmology-specific ASCQR measure set, which we opposed. The measure set includes measures for which the ASC either does not have access to the required information, or has little opportunity to impact. The measures included in the draft measure set would be more appropriate for physician rather than facility evaluation.

Potential Future EHR Promoting Interoperability Category Requirements for ASCs

In response to CMS’ discussion of a potential future EHR requirements in the ASCQR, MarsdenAdvisors reminded CMS that EHR adoption in ASCs is slower than in other healthcare sectors due to the lack of incentives being provided to ASCs in comparison to other providers under the Meaningful Use program. ASCs have unique needs from EHR systems, and the development and implementation of those appropriate systems will take time. We requested that, should CMS decide to require EHRs for ASCs, they phase in such a requirement gradually and with consideration of stakeholder feedback.

Thank You For Your Involvement

With the launch of our Comment Drafting Tool for the 2023 QPP Proposed Rule, we were excited to see our clients, their colleagues, and others who would be impacted by these proposed rules submit their comments to CMS. We know the process of drafting and compiling comments can appear daunting, and we are happy to have helped people engage in this important process, especially if it was their first time!

The more aligned and informed comments CMS receives on a rule, the more power collective advocacy has on this process. We want to thank everyone who completed the tool and submitted their comments to CMS.


Next Steps

  • Watch our webinar on the 2023 MIPS proposed changes.
  • Review our Top 2023 Proposed MIPS Changes Report for a quick rundown of major MIPS changes relevant to our specialties.
  • Subscribe to our blog using the field in our website footer below. When the finalized rules are released later this Fall, you’ll be among the first to know what new MIPS and ASCQR requirements will be in store.

If you want hands-on, personalized assistance on MIPS or the ASCQR, contact us and we will have your back.