As anesthesiologists and their groups are wrapping up the 2023 Merit-based Incentive Payment System (MIPS) reporting year, we realize that those same groups are determining their MIPS 2024 quality measures and improvement activities to report. We take a moment to share with our member community updates on quality measures available for MIPS 2024 and how regulatory actions by the Centers for Medicare & Medicaid Services (CMS) may influence your decisions on MIPS participation in future years.

Each year, CMS amends its rules governing the MIPS program as well as the criteria for each of the four MIPS components (quality, cost, improvement activities, and promoting interoperability). On one hand, individuals and their groups must identify the measures they wish to report and the improvement activities they will perform. Although CMS has kept the performance category scores the same as in 2023 (30% for quality, 30% for cost, 15% for improvement activities, and 25% for promoting interoperability), they made slight tweaks to increase the reporting rate for quality measures, from 70% to 75% of all applicable cases. Other minor regulatory changes, including the available measures and improvement activities in the MIPS Value Pathways (MVPs), are available on the ASA website under the “Managing Your Practice” tab.

On the other hand, ASA staff must ensure that our measures are vetted and approved by CMS each year. ASA Quality and Regulatory Affairs (QRA) staff completed our testing and submission of MIPS and Qualified Clinical Data Registry (QCDR) quality measures in August 2023, with final approvals secured in December 2023. The approved QCDR measures are available on the Anesthesia Quality Institute (AQI) website (aqihq.org). CMS continues to discourage anesthesiologists and other specialties from reporting topped-out measures (quality measures where the performance rate is at a level where there is no room for improvement or differentiation among providers for scoring purposes) and has increased their scrutiny on whether a measure addresses a gap in care and can be benchmarked. ASA Quality and Regulatory Affairs and AQI staff successfully met CMS testing requirements based on data elements and data validation analytics. Although we successfully met this hurdle, CMS nonetheless retired several QCDR measures for topped-out measure status and put others on alert for retirement because of a lack of sufficient participants reporting.

In 2024, anesthesiologists and their groups reporting via the AQI National Anesthesia Clinical Outcomes Registry (NACOR) will be able to choose from over a dozen quality measures and more than 50 improvement activities. Qualified Registry participants may only choose MIPS quality measures, including those in the anesthesia measure set (∗designates a proposed “high priority measure”):

  • QID #404: Anesthesiology Smoking Abstinence∗ (Intermediate Outcome)

  • QID #424: Perioperative Temperature Management∗ (Outcome)

  • QID #430: Prevention of PONV – Combination Therapy∗

  • QID #463: Prevention of Post-Operative Vomiting (POV) – Combination Therapy (Pediatrics)∗

  • QID #477: Multimodal Pain Management∗

AQI NACOR also supports MIPS measures that pain medicine, critical care, and other anesthesiologists who may report evaluation and management codes use as well. Those measures include advance care planning, screening for social determinants of health, fall prevention, and other screening measures. Please review the AQI website for more details.

For those reporting via the QCDR option in 2024, participants may choose a combination of MIPS measures as described above and QCDR measures. The following AQI/NACOR QCDR measures are available for reporting for the MIPS 2024 submission year:

  • AQI18: CABG – Prolonged Intubation

  • AQI48: Patient-Reported Experience with Anesthesia

  • AQI49: Adherence to Blood Conservation Guidelines

  • AQI65: Avoidance of Cerebral Hyperthermia for CABG

  • AQI67: Consultation for Frail Patients

  • AQI71: Ambulatory Glucose Management

  • AQI72: Perioperative Anemia Management

  • ePreop31: Intraoperative Hypotension among Non-Emergent Noncardiac Surgery Cases

  • ABG44: Low Flow Inhalational General Anesthesia

The QCDR measures highlighted above (AQI18, AQI49, AQI67, and AQI71) merit additional attention. Those four measures lack a benchmark, which means insufficient data has been submitted to CMS in previous reporting years. Because of this, CMS has placed those measures on a short retirement list for 2025 unless a critical mass of groups report those measures. We highly encourage your group to review the measure specifications and submit data on those four measures for MIPS 2024. We encourage you to do this in addition to the other measures you may normally have selected for reporting. CMS scores eligible clinicians and their groups on the highest-performing measures submitted, so there will be no harm to your score if you also send data on these four measures.

Ultimately, CMS will establish a benchmark for those measures, award points, and approve the measures in future years if enough practices submit data. If not, these measures will most likely be removed by CMS for MIPS 2025 due to lack of use and lack of data for a performance benchmark.

Each year, anesthesiologists and their groups should review available quality measures, update their systems, and ensure they are reporting recognized measures within the MIPS program. Unfortunately, because of CMS policies related to topped-out measures, CMS removed the following AQI/NACOR QCDR measures from the 2024 MIPS program:

  • AQI56: Use of Neuraxial Techniques/Peripheral Nerve Blocks for TKA

  • AQI68: Obstructive Sleep Apnea: Mitigation Strategies

  • AQI69: Intraoperative Antibiotic Redosing

  • AQI73: Prevention of Arterial Line-Related Bloodstream Infections

In collaboration with the Committee on Performance and Outcomes Measurement (CPOM), the ASA Quality Division is also building a pipeline of quality performance measures for use in quality improvement and public reporting programs, like MIPS. The goal is to have a suite of performance measures that anesthesiologists and their groups can use beyond MIPS. For instance, the CPOM-led Obstetric Technical Expert Panel is developing obstetric measures for use in quality improvement with a focus on the reduction of racial and ethnic disparities as well as intraoperative pain management. A newly formed Measure Development Workgroup under CPOM is also exploring how to fast-track quality measures for submission to CMS consideration in MIPS 2025. This workgroup will focus on gaps in care and feasibility of data generation related to ambulatory care, perioperative medicine, and care coordination. Another CPOM workgroup will assess retired QCDR measures to understand if they can be reworked or reconstituted as composite measures for public reporting once more.

We look forward to updating the community after our next submission to CMS in summer 2024.

Questions? qra@asahq.org

For further information:

Cathlin Bowman-Young, MBA, ASA Associate Director of Quality and Regulatory Affairs

Cathlin Bowman-Young, MBA, ASA Associate Director of Quality and Regulatory Affairs

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Matthew T. Popovich, PhD, ASA Chief Quality Officer

Matthew T. Popovich, PhD, ASA Chief Quality Officer

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