The Quality Conundrum for Medicare Shared Savings Program ACOs
Three things CMS can do now to position accountable quality reporting for the future
January 7, 2026
As leaders move health care quality programs toward a technology-enabled future, accountable care organizations (ACOs) can play an integral role in piloting new initiatives, such as digital quality measures (dQMs), and evaluating the feasibility of approaches. However, the Centers for Medicare and Medicaid Services (CMS) must reassess the current approach for Clinical Quality Measures (CQMs) that align Medicare Shared Savings Program (MSSP) quality measures and reporting to the Merit-based Incentive Payment System (MIPS). This inaccurate comparison unfairly burdens providers and impedes progress towards population health.
As recently highlighted in Health Affairs, ACOs in MSSP are stuck in a complex web of fragmented data, opaque unattainable requirements, and an unclear pathway to seamless, interoperable data sharing. While CMS has signaled its intent to move to dQMs, ACOs’ experiences bare the reality that the technical capabilities are not yet where they need to be to support fully digital reporting of quality measure data. Before effort and dollars are spent transitioning to new digital approaches, we must take the time to complete a comprehensive assessment of the ACO quality reporting and chart a path forward that can leverage technology to alleviate provider burden and increase accountability and value in health care.
We offer the following considerations for CMS to use in crafting a new roadmap to dQMs.
Revise data completeness and reporting requirements
The shift to CQMs in 2022 dramatically expanded the volume of ACOs’ reporting from a sample of assigned patients to all patients who interact with any provider in the ACO. CMS applied the MIPS data completeness requirements without considering differences between ACOs and individual clinicians and practices, or accounting for circumstances that prevent ACOs from identifying the entire patient population that would be used as the denominator. Additionally, even if all data were accessible, vendor capabilities do not yet support reporting requirements.
- Data access challenges: ACOs face real-world barriers accessing data beyond their assigned patient populations, including inability to extract data from EHRs, clinician retirement and practice closure, or small practices that use paper medical records with limited resources. Reporting requirements should be revised to focus on the validity and accuracy of data over artificial completeness and include common sense exceptions to account for occurrences that prevent ACOs from reporting complete data.
- Technology limitations hinder eCQMs: Current technology lacks support for data extraction, aggregation, and deduplication across practices and EHRs that are required for success. Additionally, ACOs report that many vendors are either unable to or charge significant fees to produce the QRDA I files, as well as refusing to support eCQM reporting for required measures (e.g., Breast Cancer Screening).
CMS should revise requirements and focus on building FHIR-based and API reporting that would allow ACOs to leverage multiple data sources (e.g., EHRs, labs, claims data). Once ready, CMS should work with ACOs to test and scale digital approaches.
Evaluate ACOs in comparison to other population health programs
Currently ACO quality is aligned with MIPS. This flawed approach adds to provider burden and is impeding the transition to value.
- The all-payer, all-patient approach requires ACOs to report on a massive population outside of which they’re financially accountable. This exacerbates issues with data aggregation and patient matching, setting appropriate performance benchmarks, the sizeable quantity of data reported, and attribution.
- ACO performance is evaluated against MIPS benchmarks that include the performance of individual clinicians and practices of all sizes and specialties. This lumping of performance creates very real concerns with their accuracy and relevance. Variance of benchmarks for the same measure under different reporting methods adds to these concerns.
- Requiring ACOs to report Promoting Interoperability instead of the prior approach using a simple attestation of CEHRT use significantly increases burden without any added value and is counter to congressional intent to exempt advanced alternative payment model (APM) providers from MIPS requirements.
Rather than applying MIPS’ clinician-focused approaches to population health, CMS should consider how to meaningfully evaluate and compare across population health programs such as ACOs, Medicare Advantage, and other APMs.
Increase the relevance and applicability of the APP Plus measure set to ACOs
Measures in the current APM Performance Pathway (APP) Plus set were created to assess the quality of individual clinicians and practices, particularly for primary care. ACO providers span the full care continuum and therefore their reporting includes patients who do not have a relationship with the ACO or its primary care partners.
- For ACOs with a higher proportion of specialists, they are now evaluated based on measures that are not appropriate for the care they deliver. As a result, many ACOs are dropping specialty practices from their networks and losing the opportunity to engage specialists in value-based care. This unintended consequence is hindering CMS’ goal to advance value-based specialty care.
- We urge CMS to keep the flawed measure set as-is while ACOs grapple with data and reporting challenges. In the future, CMS should align quality measures across programs to be FHIR-enabled and designed for population health models. This would enable more useful data and accurate comparisons than individual clinician measures.
By leveraging ACOs’ expertise, we can achieve an integrated measurement approach that supports quality improvement and broader specialist engagement in value-based care models.
Quality reporting in accountable care doesn’t have be burdensome. NAACOS and its members stand ready to assist CMS with these efforts.