Late in December, we published an article with an overview of why 2019 is more difficult, and more impactful than prior years.  Clinical Quality Measures (CQMs) are one of the key reasons why.  CMS is following an agenda for value-based, or outcome-based reimbursement and CQM is probably the biggest weapon in that battle.  Here are what we see as key components of why CQM is more difficult, and more impactful.

1. Quality measures will start to drive patient choices on which Physician will get their business - The biggest impact of CQM scoring might not be the obvious impact on Medicare Reimbursement.   It could well be that new patients, in search of physicians, will start to use public Quality Scores that are generated by MIPS. CMS has created a truly excellent website for patients to use in selecting physicians.  Really.  For sure, they have not yet done a great job of publicizing it, nor making it appear on Google Searches.  But the usability, and content is better than any of the "commercial" physician finder sites out there.  Take a look at the CMS video, describing its capabilities.  In that video, at about minute 2.00 is content showing each physician's personal "performance" measures - which will be their MIPS (or ACO) Quality scores.  So when you search out your next dermatologist, you'll see not only what patients think of them, but also side-by-side Quality comparisons.  
2. Topped-out Measures will hurt your scores - It is common for providers to choose to report CQMs where they have the easiest time hitting high percentage scores.  But if a CQM is defined as "topped out" (meaning all the reported scores are clustered near the top), its highest MIPS score will be 7, rather than 10 points, and scale down from there.  In practice this means that last year's 95% may have earned you a MIPS score of 9.2 points, and in 2018 that same score could only be worth 6.2 points.  Fortunately, the public CMS benchmarks identify which measures qualify for this treatment, if your software accounts for it.  
3. Low patient volumes will hurt your scores - If your favorite measure does not have enough patient volume to fulfill "case minimum" requirements, it won't matter in 2019 whether you hit 90 or even 100 percent.  The best you can do on "case minimum" measures will be 1 MIPS point. 
4. CMS rewards CEHRT-based measures over Registry-based measures - In the 2019 MACRA Final Rule, CMS unveils their long-term intent to eliminate claims-based CQM reporting.  Of course "long-term" is not 2019, or even 2020.  But the end-to-end CEHRT bonus will gradually be phased out under rationale that end-to-end will be the only method CMS ultimately allows.  Providers who rely on EHR based CQM - potentially supplemented with sophisticated drill down additons - will be able to conduct real time analysis of the results of each patient visit, and will be able to proactively improve quality scores, even before the scores themselves are published.  That's a great goal, but will require a lot of provider training, EHR configuration and clinical management attention.  It could be a very good idea to get started this year.  
5. ACO Quality impacted by how well their physicians use EHR - ACOs have been required to report on how many of their providers meet PI Base scores since the beginning of the program.  Simply compiling and submitting the report (referred to as ACO-11) has resulted in full credit.  In 2019 though, the ACO-11 report becomes pay-for-performance, meaning that the ACO's overall quality score depends in part on a high percentage for this report.  

Bottom Line - The greater impact of, and difficult in, achieving high Quality Scores implies that providers should implement regularly scheduled quality evaluation processes, rather than waiting until year-end to find out what the scores were.