As of January 1, 2024, the Medicare Shared Savings Program (MSSP) boasted 480 ACOs with over 634,000 providers and organizations, serving more than 10.8 million beneficiaries—making it the largest value-based care program in the U.S.
Recent policy updates by the Centers for Medicare & Medicaid Services (CMS) are set to expand the program significantly over the next decade. These changes aim to increase ACO participation and the number of beneficiaries assigned to ACOs by up to four million by 2034. The new policies focus on enhancing growth, equity, and alignment across care initiatives, aligning with CMS’s goal of having all Traditional Medicare beneficiaries in a quality-focused care relationship by 2030.
Prepaid Shared Savings
One notable change from the 2025 Quality Payment Program Final Rule is the introduction of a “prepaid shared savings” option for ACOs with a strong history of earning shared savings. Approved ACOs can receive advance payments to invest in services like meals, dental care, vision, hearing, and Part B cost-sharing support for beneficiaries or to enhance care coordination through staffing and infrastructure.
ACO Quality Measure Reporting
Additionally, quality measurement reporting requirements have been ramped up for 2025. The most wide-ranging change involves eCQM reporting for a much larger population of patients. The CMS Web Interface collection type was retired and replaced by the APM Performance Pathway (APP) Plus Quality Measure Set:
- APP Plus Quality Measure Set is now required for MSSP ACOs starting in 2025. This replaces the existing APP quality measure set. Starting with performance year 2025, ACOs will be evaluated based on six measures from the APP Plus quality measure set:
- Four eCQMs/Medicare CQMs
- CAHPS for MIPS survey
- One administrative claims-based measure
- Incremental Growth: The measure set will grow from six to eleven measures over the next few performance years.
- Streamlined Reporting: MSSP ACOs will report using electronic clinical quality measures (eCQMs) or Medicare Clinical Quality Measure collection types, eliminating the use of MIPS CQMs but requiring quality reporting for an increased patient population, potentially across multiple disparate EHRs.
- Alignment with the Adult Universal Foundation Measures. This shift is part of a broader strategy to improve the accuracy, fairness, and integrity of Shared Savings Program financial calculations.
Finalized APP Plus Quality Measure Set for MSSP ACOs:
| Quality# | Measure Title | Collection Type | Performance Year Phase In |
| 001 | Diabetes: Hemoglobin A1c (HbA1c) Poor Control | CMS 122 eCQM/Medicare CQM | 2025 |
| 112 | Breast Cancer Screening | CMS 125 eCQM/Medicare CQM | 2025 |
| 134 | Preventive Care and Screening: Screening for Depression and Follow-up Plan | CMS 2 eCQM/Medicare CQM | 2025 |
| 236 | Controlling High Blood Pressure | CMS 165 eCQM/Medicare CQM | 2025 |
| 321 | CAHPS for MIPS | CAHPS for MIPS Survey | 2025 |
| 479 | Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for MIPS Eligible Clinician Groups | Administrative Claims | 2025 |
| 484 | Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions | Administrative Claims | 2026 |
| 113 | Colorectal Cancer Screening | CMS 130 eCQM/Medicare CQM | 2026 |
| 305 | Initiation and Engagement of Substance Use Disorder Treatment | CMS 137 eCQM/Medicare CQM | 2027 |
| 487 | Screening for Social Drivers of Health | eCQM/Medicare CQM | 2028 |
| 493 | Adult Immunization Status | eCQM/Medicare CQM | 2028 |
Medicare CQMs
What are “Medicare CQMs”? Seems like a blanket term, right? Well, they are actually a stepping stone toward eCQM reporting. A Medicare CQM is a collection type that reports on the Medicare fee-for-service beneficiaries of an ACO. Medicare CQMs are similar to MIPS CQMs, but only report on ACO beneficiaries instead of all payers and patients. If you choose this route for reporting, CMS will send you a list of your ACO beneficiaries and then you only report eCQMs on this subset of patients, omitting patients who receive services from the ACO participants but use a different payor (commercial, Blue Cross, etc.). ACOs can choose to report eCQMs, Medicare CQMs or a combination of the two.
Universal Foundation Measures
The Universal Foundation is a set of quality measures for adults and children developed by CMS. The foundation’s measures include:
- Care journey: Quality measures that assess a person’s care from infancy to adulthood
- Care events: Measures for important care events like pregnancy and end-of-life care
- High-impact diseases: Measures for diseases and conditions that cause the highest mortality and morbidity in the US, such as diabetes, high blood pressure, and cancer
- Behavioral health: Measures for behavioral health conditions like depression and substance use disorders
- Social risk factors: Screenings for social risk factors
- Population-specific: Measures for specific populations like frail elders, disabled patients, and pediatric patients
The Universal Foundation’s goals are to:
- Prioritize the development of digital quality measures
- Identify disparities in care
- Reduce burden
- Focus provider attention
- Allow for cross-comparisons across programs
- Help identify measurement gaps
CMS has lists of Adult and Pediatric Universal Foundation Measures. One of their primary goals is to fully align the Shared Savings Program’s quality performance standard with the Universal Foundation measures upon the complete implementation of the APP Plus measure set.Scoring Adjustments
MIPS Quality Scores: ACOs will be scored on all measures in the APP Plus set based on APP scoring policies.
- eCQM Incentives: Starting in 2025, an adjustment will award points for each submitted eCQM that meets requirements, encouraging ACOs to report electronically.
The Shared Savings Program will also refine its financial methodologies to better support ACOs, especially those serving underserved communities. This includes a new health equity benchmark adjustment and a revised approach to handling improper payments and anomalous billing activities. Changes are also meant to simplify beneficiary information notifications and align program policies with current antitrust guidelines.
For more detailed information and to access the full text of the final rule, visit the official CMS website and review the fact sheet or the full publication.
