MACRA and MIPS: They Promised Simpler!

open-book-formulaThe proposed MACRA rule is here. With the goal of changing the way physicians are paid, this rule proposes how CMS intends to move toward increasingly rewarding value—meaning high quality care at a cost-effective price—over volume.

CMS claims that MACRA will simplify life for providers, (although I’m a little suspicious since it took 962 pages to explain the “simplification”). However, there is no question that the world is about to change. These proposed regs are scheduled to be finalized in November and then be effective on January 1, 2017—a rather ambitious schedule which leaves little time for planning your approach to compliance.

While I haven’t read the entire rule yet, MACRA—Medicare Access and Chip Reauthorization Act—provides two paths for physicians and other clinicians. In the long-term, APMs (Alternate Payment Models, like ACOs) will be a popular route—higher risk/higher reward—but for now, most physicians will participate in the MIPS (Merit-Based Incentive Program) option. So let me provide a few teasers about MIPS, as currently proposed:

  • If you expected an end to Meaningful Use, PQRS, and the Value-Based Payment Program, you will be disappointed for certain. MIPS just changes the names, rolls them up into one program, and adds (yet another) set of required activities.
  • Providers will be scored on a 100-point scale and compared to other providers—this year’s weighting would be 25% MU-type measures, 50% quality measures, a la PQRS, 10% cost, and 15% Clinical Practice Improvement Activities. (The rule spells out how a provider’s score is calculated and the payment adjustment is determined, but you might need an advanced math degree to follow that discussion!)
  • MU is now “Advancing Care Information”. It will have fewer required measures (proposing to eliminate CPOE, CDS, and multiple Public Health reporting requirements), no longer be all or nothing, and will provide some choices to clinicians for how they demonstrate success. CQM reporting will not be part of this component.
  • Quality measure reporting (like PQRS) will be the bulk of the score, but only 6 measures will be required. Like under the Value-Based Payment Program, performance will count, i.e., impact the provider’s score.
  • Assessment of cost will be done by CMS—providers won’t have to report anything. This is similar to how CMS currently attributes a cost factor to providers in calculating the V-BPM.
  • The new category, Clinical Practice Improvement Activities, offers providers a choice of approximately 90 activities from which to choose to earn points in that category.
  • MIPS would be reportable as an individual provider or as a group.

Stay tuned to EMR StraightTalk for more in-depth analysis of MACRA in upcoming posts. We welcome your initial comments.

 

The End of MU… Oh, Never Mind!

chameleon-315pxAccording to a recent speech by Andy Slavitt, Acting Administrator of CMS, “The Meaningful Use program as it has existed will now be effectively over.” Not surprisingly, the media picked up this news—particularly the word “now”—and ran with it, gleefully proclaiming the “End of MU in 2016,” “CIOs Celebrate End of MU,” “MU on Deathwatch,” etc. It was easy to believe that Slavitt was predicting the demise of MU to be imminent since the stated topic of his talk was “policy areas that will affect the healthcare sector in 2016.” However, in Tuesday’s CMS Blog, Slavitt—writing with Karen DeSalvo—walked his statement back a bit. That said, this is still quite significant news: CMS has formally acknowledged what Slavitt himself referred to as the frustration and burden that physicians have been dealing with since the start of MU.

The key phrase in his statement about MU is “as it has existed.” MU is to be, in Slavitt’s words, “replaced with something better”—i.e., a new and improved version of itself. It is not going away. We already knew that MU had been identified as an integral part of a new program called MIPS under MACRA, the regulations for which are still being written by CMS. MACRA, the legislation that replaces the Medicare Fee Schedule’s SGR calculation, becomes effective in 2017, with a new schedule of payment adjustments (a.k.a. incentives and penalties) beginning in 2019.

Slavitt’s “announcement” was clouded by uncertainty, but was greeted, nevertheless, with great jubilation and high expectations, some of which were dashed by the clarifications published in the subsequent CMS Blog. In his speech, Slavitt had provided little insight into exactly how MU will be restructured. It begged the questions: Will the changes to the requirements be radical enough to be perceived by physicians as “something better?” What will become of the Stage 3 Rule, which is currently undergoing finalization and is due to go into effect in no later than 2018? And, will the MU penalties scheduled for 2017 and 2018 remain in effect or be eliminated? The CMS Blog answered some of these questions, to the disillusionment of many providers:

  • The current law requires that we continue to measure the meaningful use of ONC Certified Health Information Technology under the existing set of standards.
  • We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations—including meaningful use Stage 3—are still in effect.

Despite the myriad details yet to be determined, what we do know about the future is that physicians will increasingly be rewarded for quality over quantity of care. Therefore, a critical component of the new government programs will be the demonstration and reporting of improved patient outcomes (most likely in PQRS fashion). We can also be confident that MACRA (and any new version of MU it contains) will demand heightened interoperability and patient engagement, and physicians will have to meet requirements that support these goals.

The question of timing notwithstanding, should you be excited about this announcement? I would suggest cautiously so. We are optimistic that the anticipated changes will bring some relief from the unnecessary administrative burdens with which physicians have been struggling and let them get back to focusing on the practice of medicine. But unless concomitant changes are forthcoming on ONC’s side to streamline the excessive EHR certification requirements on the books for 2017/2018, EHR developers and vendors will still not have the necessary time or freedom to focus on innovations that would deliver the efficiencies and clinical benefits that would be of maximum value to physicians and their patients.

As always, SRS will keep you up to date on all developments in this area as they are revealed over the next few months. Please feel free to contact Lynn Scheps, Vice President, Government Affairs, if you have any questions.

CMS Offers Welcome Relief for Transition to ICD-10

reliefIt’s time for those still advocating a delay of ICD-10 to abandon the fight—but they can take heart in the recent concessions offered by CMS. The AMA, concerned about the complexity of ICD-10, has asked for some measure of protection from potential adverse financial impacts of the transition to the new code set, and CMS recently agreed to a one-year compromise.

Recognizing the challenges for providers, CMS has agreed:

  • Not to deny claims based on the (lack of, or incorrect) specificity of the ICD-10 code, as long as the reported code is a valid code from the right family of codes.
  • Not to subject providers to penalties under 2015 quality reporting programs, (Meaningful Use, PQRS, or the Value-Based Payment Modifier), as long as a valid code from the right family is reported for the measure(s).
  • To create an ICD-10 Ombudsman to help negotiate solutions to ICD-10 related problems.

CMS has also acknowledged realistic challenges on its side, and is insulating providers from resulting financial harm by agreeing:

  • To authorize advance payments if Medicare contractors are unable to process claims in a timely fashion (as defined by CMS) due to problems with ICD-10.
  • Not to penalize providers under MU, PQRS, or the V-BPM if CMS “experiences difficulty calculating the quality scores.”

You can read about the above in CMS’ own words in its FAQ document.

Notwithstanding the above, it’s time to get serious about preparing for the transition to ICD-10, if you have not already begun that process. Fortunately, there are some ICD-10 solutions embedded in EHRs and PM systems that make code selection easier than others, but regardless of the particular system you employ, there is a learning curve for physicians, clinical teams, and billing staff members.

90-Day MU Reporting: Just What the Doctor Ordered

Rules & RegulationsJust as physicians were considering abandoning Meaningful Use and surrendering to future Medicare penalties, CMS issued a proposed rule for 2015 that breathes new life into the program. If full-year reporting was perceived as the insurmountable obstacle, the proposed reduction to a 90-day reporting period should recapture interest.

Although a proposed rule is not final until it is codified as a final rule—not anticipated until August—past experience has demonstrated that the major structural features typically survive as proposed. The shortened reporting period was announced as CMS’ intention in January and formally proposed last Friday. I think it is fair to say that one can be reasonably confident in this particular provision of the rule.

As for the other features of this proposed rule: In a former EMR Straight Talk post, I wrote, “Even more intriguing to me than the change in reporting period is . . . the intention to “modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” CMS has come through in this regard and proposed changes for 2015 through 2017. The revisions encourage a focus on the advanced use of EHR technology to support health information exchange, consumer/patient engagement, public health reporting, and quality improvement. This is the narrowed focus that stakeholders, (including SRS on behalf of physicians), have been demanding since the program’s inception.

The following are some other highlights of the proposed rule for 2015 through 2017:

  1. Reporting would be streamlined: Many Stage 2 measures would not be individually reportable, particularly the paper-based or box-checking measures. Caveat: this does not, however, mean that the data would no longer be required–the information would still be necessary for the patient portal, for the summaries exchanged between providers, and for CQM reporting.
  2. Patient engagement measures would be dramatically revamped:
    • The threshold for “VDT”, (View, Download, or Transmit), would be reduced from 5% to “one patient.”
    • Secure messaging would have to “be enabled,” but there would be no threshold to meet.
  1. To simplify the overall MU structure for practices that have physicians in different stages, all physicians would report on the same measures—a modified set of Stage 2 requirements. Stage 1 providers, however, would be able to exclude measures which go beyond the requirements they were expecting to report.

If you want to ensure that the above changes are included in the final rule, submit a comment to CMS by June 15. CMS receives plenty of comments opposed to particular components of its rules, but specifically asks for positive comments on the features that stakeholders do support.

Providers’ MU Prayers Answered?—Quarterly Reporting for 2015?

Meaningful Use

In the inimitable style of government-speak, CMS recently announced its “intention to consider proposals” to shorten the 2015 meaningful use reporting period from a full calendar year to 90 days. While I would advise providers to be cautious about changing their plans until the relevant rule is published (anticipated in the spring), I think it is fair to assume that CMS would not have issued even such a noncommittal-sounding announcement if it were not planning to actually implement this change.

CMS has finally yielded to the relentless lobbying by the AMA and an alphabet soup of other professional societies and HIT organizations, all of which remain concerned about provider readiness and the challenges presented by an insufficient infrastructure to support Stage 2 requirements. Objections to full-year reporting for 2015 date back to last spring, when comments were submitted in response to the (then-proposed) 2014 Flexibility Rule. At that point, CMS adamantly rejected the overwhelming number of comments that recommended—or pleaded for—quarterly 2015 reporting. Currently, however, in addition to this external pressure, the dismal number of Stage 2 attestations to date has got to have CMS worried about the future of its MU program.

The devil, as always, will be in the details:

  • When will the rule be available, and will its timing be early enough to avoid creating the aura of uncertainty that characterized last year’s mid-year revisions? (We are already one month into the 2015 physicians’ reporting period, four months into the hospitals’.)
  • Would quarterly reporting be available to all providers, even those still at Stage 1?
  • What happens to “harmonization’ with PQRS, which remains a full-year program? (This has been one of the reasons CMS has stated for its resistance to quarterly reporting.)

Even more intriguing to me than the change in reporting period is the second of the three proposals enumerated as being under consideration—that is, the intention to modify other aspects of the program to match long-term goals, reduce complexity, and lessen providers’ reporting burdens.” Is it possible that CMS is taking the advice of the AMA and other organizations to increase flexibility, reduce the number of measures, add more choice, and maybe even eliminate the all-or-nothing nature of MU? Wouldn’t that be something!

Let us know what you think by submitting a comment below.

Final “2014 MU Flexibility Rule”—What It Does and Does Not Offer

As predicted, the rule modifying meaningful use in 2014—now referred to as “The blog-103014Flexibility Rule”—was finalized basically as proposed. Pleas for future flexibility, however, were rejected. (For a review of the details, read EMR Straight Talk’s Kudos to CMS for MU 2014 Proposed Rule).The good news is that for 2014, many providers can report Stage 1 again instead of Stage 2, and some providers can report using 2011-certified EHR technology instead of 2014 CEHRT.

Providers who exercise any of the flexible options will have to attest to the following statement: “EP was unable to fully implement 2014 Edition CEHRT for a full EHR reporting period in 2014 due to delays in 2014 CEHRT availability,” and they should be prepared to support their decision if they are audited pre- or post-attestation. Potential justifications include—for example—certification delays or implementation backlogs, software problems once the EHR was implemented or upgraded, delayed installation of required integrations/interfaces, insufficient time to make necessary workflow revisions, etc. Provider inaction or delay, financial constraints, inadequate staffing, and the contention that Stage 2 is just too darn hard—while certainly understandable—are not considered legitimate justifications under the rule.

Many of the comments submitted on the Proposed Rule had asked (“pleaded” would be a more accurate word) for flexibility beyond that which was offered. The biggest “ask” in this regard was for quarterly reporting again in 2015, as it is in 2014, rather than full calendar year reporting. CMS rejected that request outright. Undeterred by that response, numerous healthcare professional organizations subsequently submitted their recommendations on the future of meaningful use directly to the Secretary of HHS and the head of ONC—the two organizations responsible for the program. In addition, “The Flex-IT Act” (recently introduced by representatives Renee Ellmers and James Matheson) attempts to mandate a return to 3-month reporting.

While it may be tempting to dream that the bill will become law or that CMS will relent, the only safe assumption at this time is that the 2015 meaningful use reporting period will begin on January 1. Therefore, any physicians who want to pursue meaningful use incentives in 2015 will need to have a 2014-certified EHR in place by January 1 (if they are not already using one), and physicians who will be at Stage 2 next year should devote the next 2 months to preparing to support the increased requirements—installing required interfaces and integrations, implementing Direct, and developing new workflows as needed.

Kudos to CMS for MU 2014 Proposed Rule

Doctors clappingYou can hear the sigh of relief—albeit mixed with a bit of uncertainty-driven anxiety—as physicians await publication of the final rule that will modify meaningful use in 2014. By relaxing the timeline, the government has finally acknowledged what so many stakeholders have been arguing for a while: Stage 2 and upgrading to a 2014 Certified EHR simply required too much of providers, too quickly. The paltry number of Stage 2 attestations to date is evidence enough—by May, only 50 physicians had attested to Stage 2; by June, just 447 had succeeded; and by July (mid-way into the year), the number had reached only 972. To put these numbers in context, over 378,000 providers have earned EHR incentives for Stage 1.

The major challenges that prompted the government’s reconsideration of the meaningful use timeline are reflected in the 1,184 comments submitted to CMS—some of which express frustration with the demands of the program in general, but almost all of which wholeheartedly support the proposed changes. (My comments, submitted on behalf of SRS physicians, are available here.) The following are the most common challenges cited:

  • Availability of 2014 Certified EHR Technology (CEHRT) – But it’s not just about the products that are not yet certified or about vendors with insufficient resources to keep up with the demand for implementations. Many of the products that have been certified were rushed out under overly aggressive and unrealistic timeframes, which has left physicians faced with not-ready-for-primetime software.
  • Overestimation of market readiness for interoperability – Sufficient infrastructure is not in place yet, so even physicians who have implemented the DIRECT messaging capability cannot find enough “trading partners” with whom they can connect to share information.
  • Dependence on non-participating parties – It takes an extraordinary amount of effort to successfully coordinate with labs, radiology providers, long-term care facilities, and registries, who are not required to conform to standards promulgated under meaningful use.
  • Reluctance of patients to embrace portal utilization – The two portal measures (patients accessing clinical information and sending messages to physicians) are cited by many commenters as the major obstacle to MU success. Changing patient behavior in this regard is turning out to be even harder to accomplish than previously anticipated.
  • Excessive workflow challenges – Meaningful use necessitates operational changes to practice workflows that are, in the words of one commenter, “daunting, at best.”

The options proposed in the rule are summarized in a handy CMS Decision Tool and include reporting Stage 1 again, instead of Stage 2, and attesting using either a 2011 or 2014 CEHRT.

So what can physicians expect and what would be a good strategy to pursue as they wait for the final rule? CMS is promising—or at least hoping—to publish the final rule in early September. The 60-day comment period ended on July 21, and CMS is obligated to read and consider all of the comments before issuing the final rule. However, I think it is reasonable for physicians to assume that the final rule will be at least as flexible as the proposed rule—maybe even more so. CMS has been asked by many commenters to definitively spell out the conditions under which physicians could avail themselves of the various reporting options, which would address the uncertainty created by the lack of clarity in the proposed rule.

In the meantime, physicians should plan to attest for any quarter during which they have met all of the requirements under one of the options provided for in the proposed rule. It can even be a quarter that precedes the publication of the final rule. They should then aggressively turn their attention to upgrading to 2014 CEHRT—if they have not done so already—and to preparing for Stage 2. Remember: as flexible as the rule may be, it only offers a 3-month reprieve. Physicians who were to be at Stage 2 in 2014 must now be ready to start a full year of reporting on Stage 2, using a 2014 CEHRT, on January 1, 2015.