For primary care practices exploring value-based care opportunities, participating in an ACO under the Shared Savings Program offers a structured pathway to improve patient outcomes while achieving financial rewards. A critical part of success in an ACO involves reporting quality data annually to CMS. This reporting is more than a compliance requirement - it is central to earning shared savings and signifies success through fair, transparent, and nationally recognized measures of care quality and efficiency established by CMS.
Since PY 2021, ACOs have reported through the Alternative Payment Model (APM) Performance Pathway (APP), a streamlined reporting structure designed to ease administrative burden, open new scoring opportunities under MIPS APMs, and encourage greater participation in value-based care. CMS’s quality measures aim to drive better patient outcomes, lower healthcare costs, standardize best practices, and promote health equity. For organizations and providers considering an ACO partnership, understanding and achieving these quality benchmarks is essential to thriving in a value-based care environment.
Our Approach to Quality Engagement and Performance
Achieving high quality scores requires a strategic, structured approach centered on proactive provider engagement, data-driven improvement, and a strong focus on patient-centered outcomes.
1. Early and Ongoing Provider Collaboration
- Early Engagement: We initiate collaboration with providers at the start of each performance year to align on quality goals, performance expectations, and shared accountability.
- Continuous Focus: Regular touchpoints and collaborative support ensure that quality improvement remains a consistent priority throughout the year.
2. Clear Alignment with CMS Quality Measures:
We focus on CMS-prioritized indicators most critical to long-term care and primary care populations, including:
- Hospitalizations and avoidable readmissions,
- Chronic disease management,
- Screening and preventive care compliance.
Key measures include:
- Depression Screening and Follow-up Plan (DPS and f/u Plan)
- Glycemic Status Assessment (>9%)
- Controlling High Blood Pressure
- Breast Cancer Screening
By emphasizing these metrics, we ensure providers are aligned with the benchmarks that drive overall program success.
For a complete list of current CMS measures and documentation tips, see our PY 2025 Quality Measure Provider Guide.
3. Identifying and Closing Gaps in Care and Documentation
- Data-Driven Gap Analysis: We use clinical and claims data to proactively identify gaps in care and documentation.
- Comprehensive Approach: Gaps may be clinical (e.g., overdue screenings or missed vaccinations) or documentation-related (e.g., missing risk adjustment codes impacting quality scoring).
- Incentivized Improvement: Closing care gaps not only improves patient outcomes but also strengthens financial performance under value-based contracts.
4. Focus on Preventive Care and Avoidable Events
- Reducing preventable events is a cornerstone of our quality strategy:
- Prevention First: Early identification of at-risk patients minimizes high-cost events like hospitalizations, emergency department visits, and falls.
- Proactive Management: We promote advanced care planning, fall risk assessments, and robust transitional care management following hospital discharges.
5. Actionable Performance Feedback
We provide regular, actionable feedback to providers:
- Performance Transparency: Clear, real-time insights into performance metrics help drive accountability and continuous improvement.
- Targeted Support: Data-driven guidance enables providers to course-correct proactively rather than reactively.
6. Continuous Learning and Provider Support
We foster a strong culture of excellence through:
- Ongoing Education: Providers have access to updated best practices, CMS policy changes, and evidence-based interventions.
- Collaborative Learning: Learning collaboratives, peer-sharing opportunities, and case study reviews promote the spread of high-performing strategies.
Summary
At the heart of our quality engagement strategy is a commitment to partnership, transparency, and excellence in patient care. Through early provider engagement, actionable insights, proactive gap closure, and continuous learning, we drive measurable outcomes that create value across the healthcare continuum.