The Centers for Medicare and Medicaid Innovation (CMMI) have introduced the Making Care Primary (MCP) model, a new initiative aimed at transforming primary care delivery through value-based care.  

 The MCP model, announced June 8, 2023, is a 10.5-year multi-payer partnership launched July 1, 2024. This voluntary model aims to improve care management and care coordination while addressing patients' health-related social needs. 

The role of quality tracking and reporting in MCP 

MCP emphasizes whole-person care by including a diverse set of performance measures that are aligned with the MCP care delivery requirements. The MCP Performance Measure Set provides participants an opportunity to receive incentive payments via the Performance Incentive Payment (PIP) for demonstrating strong absolute performance in some areas, as well as working to improve in others.  

Mirroring CMS’ broader quality measurement strategy, measures were selected to be actionable, clinically meaningful, and aligned with measures used in current value-based programs, including the CMS Universal Measure Set, Quality Payment Program (QPP), MIPS Value Pathways (MVP), and MIPS APM Performance Pathway (APP) measure sets, and the National Quality Forum’s Core Quality Measures Collaborative (CQMC) Primary Care Core Measures. 

Quality and cost performance assessment begins in Performance Year 2 (Jan. 1, 2025-Dec. 31, 2025. PY2 and onward will be assessed in 12-month increments, aligning with calendar years and other annual quality reporting programs. Quality measures are expected to be tracked across all eligible patients seen by the providers and reported via eCQM or other formats after the close of the period. 

Key quality reporting requirements for MCP 

In the MCP model, healthcare providers are required to meet specific quality reporting standards to ensure the program’s success. These measures, outlined by the Centers for Medicare & Medicaid Services (CMS), aim to assess a wide range of factors that impact patient care.  

Below are the actual quality measures that must be reported in the MCP model.

1. Health outcome measures

MCP initiatives emphasize improving health outcomes for patients. This includes tracking and reporting the following measures: 

• Controlling High Blood Pressure (CBP): Percentage of patients aged 18-85 with hypertension whose blood pressure is adequately controlled. 
  
  
• Diabetes Care: Hemoglobin A1c Control (<8%) (HBD): Percentage of patients with diabetes whose hemoglobin A1c level is controlled to less than 8%. 
  
  
• Colorectal Cancer Screening (COL): Percentage of adults aged 50-75 who have received a colorectal cancer screening in the recommended timeframe. 
  
  
• Screening for Depression with Follow Up: Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool and if positive, a follow-up plan is documented on the date of or up to 2 days after the date of the qualifying encounter. 
  
  
• Depression Remission at 12 months: The percentage of adolescent patients 12-17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.
  
  
• Screening for Social Drivers of Health: Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety. 

These measures ensure that patients with chronic conditions are properly managed, and preventive screenings are performed on schedule to catch potential health issues early.

Here is an overview of the measures to be reported starting in 2025: 

CMS will use benchmarks for each measure to inform scoring and payment for the PIP. MCP will use national benchmarks for all electronic Clinical Quality Measures (eCQMs) and the Screening for Social Drivers of Health measure and regional benchmarks for utilization and cost measures (EDU and TPCC).  

 This will hold all participants to the same quality standard for clinical care, while recognizing geographic differences and considerations for utilization and cost data. It also incorporates the historical precedent of recognizing the value of including both regional and national standards when assessing performance.  
 
Participants will generally be compared against all peer practices, including those not in MCP, for eCQM and utilization measures. Because the Person-centered Primary Care Measure is new, practices will receive full credit in the first 2 years for successfully reporting the measure. CMS will issue further guidance on the Social Drivers of Health measure, which is still under development. 
 
Partnering commercial and Medicaid payers will align, as feasible, with Medicare measures in MCP. Partnering payers may, for example, add measures specific to their population that aren’t adequately captured by the Medicare measure set (e.g. young adults, pediatrics).

2. Claims-based measures

MCP focuses on reducing unnecessary healthcare costs. Providers will be scored on the following cost metrics:  

• Total Per Capita Cost (TPCC): The total annual cost of care per person enrolled in the program. This includes all Medicare-covered services, such as hospital visits, outpatient care, and medications. 

• Emergency Department Utilization (EDU): This measure evaluates emergency department use among health-plan members aged 18 and older. It compares observed rates of ED use to predicted rates based on the health of the member population. 

• TPCC Continuous Improvement (non-FQHCs and non-Indian Health): This measure applies to non-FQHCs and non-Indian Health participants. It assesses a participant's performance against their own historical performance, rather than using regional or national benchmarks. 

These claims-based measures are crucial components of the MCP model's quality assessment requirements, aimed at reducing unnecessary healthcare costs and improving overall care delivery. 

Ensuring Success in MCP 

The MCP initiative represents a significant shift in how healthcare is delivered, with a strong emphasis on primary care as the cornerstone of patient management. With rigorous quality reporting requirements, MCP ensures that healthcare providers are held accountable for improving outcomes, managing costs, and delivering patient-centered care. 

By tracking health outcomes, cost efficiency, patient satisfaction, care coordination, and health equity, MCP will drive improvements across the healthcare system, reducing fragmentation and improving patient health. These quality measures will play a crucial role in achieving the initiative’s goals, leading to better care for patients and a more sustainable healthcare system for all. 

How Healthmonix can assist with tracking and reporting MCP measures 

Healthmonix offers comprehensive solutions to help healthcare providers track and report quality measures for the MCP model: 

1. Data integration: Healthmonix can ease the reporting burden by gathering data on an ongoing basis through direct integrations with various EHR systems such as Epic, Allscripts, and athenahealth. This ensures that all relevant patient data is captured efficiently.

2. Real-time performance tracking: Healthmonix's APP Impact solution provides real-time performance dashboards, allowing healthcare providers to monitor their progress on MCP measures throughout the year. 

3. Comprehensive measure tracking: The APP Impact tool allows tracking of both Web Interface measures and eCQMs/CQMs, which is crucial for the MCP model's diverse set of measures.

4. Patient matching: Healthmonix's patient matching services, utilizing an EMPI algorithm, simplify the task of combining patient data from varied sources. This ensures accurate ingestion of all necessary patient data by reconciling patient identifying information and deduplicating patient files. 

5. Analytics and insights: Healthmonix offers flexible BI analytics that provide insights into patient cohorts, provider group performance, and outliers. This feature helps detect areas for improvement and allows providers to maximize their scores. 

6. Consulting services: Healthmonix provides consulting services to help organizations maximize their performance. This includes workflow training for measure collection, data integration support, gaps in care analysis, and outlier workflow recommendations. 

By leveraging Healthmonix's comprehensive tools and services, healthcare providers participating in the MCP model can streamline their quality reporting process, gain valuable insights into their performance, and work towards improving their scores and patient outcomes.