Hot Topics for Orthopaedics

Diane Beatini

Diane Beatini

Vice President, Sales at SRS Health
Diane Beatini is the Vice President of Sales. She oversees the Sales, Account Management, and Sales Operations teams. She works to promote the complete SRS product suite of HCIT solutions to medical practices of varied sizes and specialties. Diane’s background includes an MBA in marketing and finance with 15 years of executive sales and customer service management experience in the radiology, medical device, and pharmaceutical industries.
Diane Beatini

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SRS Health attends the annual OrthoForums and AAOS meetings as a way of remaining in sync with the topics that are top of mind for our clients. As an HCIT solutions partner, we are continually striving to provide our clients with relevant solutions, training, and advice on resources so that they can meet challenges head on while remaining productive and focused on the practice of medicine. The forums and academy meetings provide us with additional insight outside of our day-to-day interactions, and often serve as springboards for our collaborative efforts.

This year, the prominent topics in the orthopaedic community include:

  • prescription safety
  • data mining/outcomes;
  • cost reduction/operational efficiencies; and
  • MACRA/ MIPs readiness.

Prescription safety has gained increased focus as numerous studies and reports focus on the increased use and abuse of opioids. As a result, individual states are beginning to enact laws addressing the prescribing of controlled substances. Electronic prescribing of controlled substances (EPCS) is currently legal in all 50 states. New York State was the first to pass mandatory I-Stop legislation requiring ePrescribing of all drugs, with stringent identity authentication requirements for controlled substances as of March 27, 2016. Maine has followed suit with the Act to Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program, requiring prescriber participation in the Prescription Monitoring Program and setting limits for the strength and duration of opioid prescriptions, beginning January 2017. The law also called for prescribers to undergo addiction training every two years. On February 23, 2017, New Jersey issued a bulletin regarding State Opioid Prescribing Information, alerting prescribers to components of a law governing opioid prescribing that takes effect in May. Minnesota also has a similar CDS law on its books, although not as strictly enforced. The expectation is that stringent monitoring will only become more prevalent, with mandatory requirements that will include patient education. As a result, many providers have voluntarily adopted EPCS practices, and the American Academy of Orthopaedic Surgeons has created a multimedia public service campaign, including display and radio ads, urging physicians and patients to exercise caution in prescribing and taking opioids.Painkillers Campaign Image2

As we embrace the value-based payment model, data mining and patient-reported outcomes are top of mind. The critical piece to the puzzle is the ability to collect and report on pertinent and meaningful data to demonstrate improved outcomes. Many physicians are currently considering the selection of an outcomes solution to integrate within their existing HCIT ecosystem. There is no firm consensus across the orthopaedic space of what constitutes full outcomes data requirements, and many are focused on choosing an optimal solution that delivers minimal PRO requirements—i.e., HOOS (Hip disability and Osteoarthritis Outcome Scores) and KOOS (Knee injury & Osteoarthritis Outcome Scores)—at the right price point.

As the payment model shifts and practices are faced with additional reporting complexities, the ability to drive operational efficiency and reduce costs is a critical focus. Integral to all related topics—prescription safety and the ability to demonstrate outcomes, drive down operating costs and meet regulatory requirements under MACRA/MIPs—is the ability to streamline the patient intake process, satisfy the VDT, meet secure messaging requirements, and integrate patient reported data through a quality patient-portal solution. Core functional capabilities such as ease of use and access; ability to request appointments; facilitated patient communication through notifications; integration of patient information within the EHR; and the enabling of secure messaging/exchange allow orthopaedic practices to reduce the time and resources devoted to patient intake and data input, as well as to limit appointment cancellations and/or no shows. Adoption of a patient-engagement solution supports 20 points under MIPs in 2017 and up to 40 points in 2018 with the addition of patient education. The portal also becomes a critical focal point to enhancing patient care through an ongoing dialogue and supporting patient education.

MACRA/MIPs readiness and the assurance that the EHR software employed by the practice will be 2015 certified is also a topic of interest as the marketplace continues to consolidate and EHR solutions sunset. At the outset of the MU program formulated through the HITECH Act of the American Recovery and Reinvestment Act (also known as the 2009 Economic Stimulus Plan), there were over 500 EHR solutions vendors. Today there are fewer than 300, with continued consolidation expected as companies decide whether to further invest and develop to the 2015 certification requirements. Practices should have regular dialogue with their HCIT solutions vendors regarding their investment and plans to certify; and also the availability of MACRA/MIPs training programs to support their regulatory goals.

Your First MACRA Decision: AAPM or MIPS?

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

Clinicians have two options for MACRA participation—an Advanced Alternate Payment Model (AAPM) or the Merit-Based Incentive Payment System (MIPS).MACRAs-2-Tracks-final

CMS has structured MACRA to encourage AAPM participation, offering clinicians a 5% lump-sum bonus on top of a share in the savings achieved by the organization. The following questions will help you determine whether you qualify for the AAPM option: 

  • Do you participate in an APM? (An ACO or other risk-based healthcare delivery program?)
  • Is your APM an AAPM? The APMs identified in the image above qualify as AAPMs by virtue of the fact that:
    • the hospital and the clinicians use certified EHR technology,
    • the organization bears both upside and downside financial risk, and
    • the providers report quality measures.

NOTE: The CMS CJR (Comprehensive Care for Joint Replacement) program is now considered an AAPM. (According to the CMS Fact Sheet, this program was recently added to the list of 2017 AAPMs.)

  • Do you meet the participation volume thresholds, i.e., do you derive 25% of your Medicare revenue or see 20% of your Medicare patients through one of these channels?

If the answer to all the questions above is “Yes,” you may be a QP (qualified participant) in an AAPM. Talk to the organization’s sponsor (typically a hospital) about your participation in MACRA.

If the answer is “No,” to all, or some, of these questions, your route to MACRA success will be via MIPS, or a MIPS APM, respectively.

For more information about MIPS and MIPS APMs, see the CMS QPP website or contact me at SRS Health. I also invite you to watch (or watch again) my webinar titled, “MACRA/MIPS: The Future Starts Now.”

MIPS: The Maximum Positive Adjustment Ship Has NOT Sailed

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

sail-boat-blogYou’ve come out of your eggnog-induced holiday fog and realize that you did not organize your practice for full-year MIPS reporting. With January 1 now in the rear-view mirror, you regretfully—but erroneously—conclude that you have missed out on the opportunity to earn the maximum positive payment adjustment in 2019. This is a common misconception that has been perpetuated in many MIPS-related webinars, blogs, and other communications. (That confusion exists is not surprising, given the spate of changes to MACRA in the last few months and the inherent complexity of the program itself.)

The fact is: Full-year reporting is NOT required to earn the maximum positive MIPS incentive in 2019. Rather, it is performance that counts, i.e. the number of MIPS points you earn and the level of quality you demonstrate, not the length of your reporting period or the amount of data you submit. If you look at the most recent CMS presentations, you will see images and text that clarify this point.key-takeaway-v2

It could be argued—and representatives of CMS have done so—that it might be easier to achieve a high MIPS score with a longer reporting period, particularly on certain quality measures. Perhaps so… but this does not preclude clinicians from achieving an equally high score in a shorter period.

Of course, there is no such thing as a free lunch; and there are consequences—possibly unintended—of CMS’ largess in offering the Pick Your Pace options for 2017. Regardless of how many MIPS points an eligible clinician earns in 2017, his/her 2019 payment adjustment will, of necessity, fall short of the originally planned 4% due to the legislative mandate for budget neutrality. In the Final Rule, CMS estimated that the upward adjustment potential will now be less than 1% for the base performance and under 2.4% when the additional money for exceptional performance is included. (For an explanation and graphic that explains the required “scaling process”, see pages 77340 – 77342 of the Final Rule.)

That said, however, the good news remains: You have not missed the boat! But it is time to get to work to allow yourself the time and flexibility to maximize your performance, identify the optimal reporting period, and earn the greatest reward.

What Are Specialists Faced With Today? Uncertainty and Change!

Ryan Newsome

Ryan Newsome

Vice President of Software Engineering at SRS Health
Prior to joining SRS almost 10 years ago, Ryan started his career as a software engineer for Map Info/Pitney Bowes. Throughout the years Ryan has been an expert in all things web, interoperability, and in agile leadership. He currently oversees all of product engineering at SRS and has led SRS’ transition to an Agile/Scrum Development Methodology. In his free time, you can find Ryan either skiing, cycling or spending time with his family. Fun Fact: Ryan played Division 1 Soccer at Sienna where he attended on a scholarship. Goal!
Ryan Newsome

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Changes AheadRecent Nobel-recipient Bob Dylan wrote “The Times They Are A-Changin’” in 1963—a time of growing social upheaval reflected in the song’s lyrics, which called for listeners to acknowledge and embrace the transformations taking place around them. As I listened to this song over the past weekend, I couldn’t help but draw a correlation to the radical transformations we are currently experiencing in our industry. The past several years have epitomized the term “change” as the nation has taken big steps to transform the delivery of healthcare.

The American Recovery and Reinvestment Act, signed in 2009 by President Barack Obama, was one of the catalysts for this transformation by requiring the “meaningful use” of digital systems in healthcare. Since then, change has been the only constant that we have been able to count on. Government regulations, payment models, and product innovations have continued to evolve in disruptive ways—both good and bad. As soon as we become comfortable with one wave of change, another wave is already threatening to drench us to the bone (for us, the next big one is MACRA & MIPS).

So, coming off nearly a decade of constant uncertainty, what’s next? Well, you guessed it—more change! Starting in 2017 we will have new policy leaders in place who have promised to significantly restructure the incumbent’s healthcare programs. President-elect Donald Trump’s appointment of Tom Price as the head of HHS may be indicative of the changes on the horizon. Price, a 6-term congressman from the Atlanta, Georgia, area, was formerly an orthopedic surgeon. Will a specialist at the helm help make government programs, that have typically been focused on primary and in-patient care, more meaningful for specialists?

Time will tell, but the one thing that is certain is that, as the song says, the wheel is still in spin. In other words, the times they are still a-changin’.

The End of MU… Oh, Never Mind!

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

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.

Kudos to CMS for MU 2014 Proposed Rule

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

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.

Proposed SGR Fix – It’s Different This Time

Year after year, physicians live for months with the uncertainty and angst of threatened, often draconian, Medicare reimbursement cuts born out of the Sustainable Growth Rate (SGR) budgeting formula.  And every year, intense lobbying and complex negotiations lead to short-term patches that maintain or slightly increase reimbursement rates—these solutions are commonly referred to as the Doc Fix. This year’s fix is set to expire at the end of March, which would leave physicians facing a 23.7% reduction—but on Thursday, a bipartisan piece of legislation proposed a repeal of the SGR and the creation of a new payment model that would reward quality, rather than volume of care provided. All that’s left now is to figure out how to fund the $128 billion price tag over the next 10 years.

Although I haven’t read the 200-page bill, the following is a summary of its major provisions:

  • The SGR fix would increase Medicare physician reimbursement rates by 0.5% annually for the next 5 years, i.e., through 2018. This would provide income predictability and stability for providers.
    • 2018 rates would be maintained through 2023.
    • From 2024 on, physicians who participate in Alternate Payment Models would see a 1% annual increase; non-participants would receive 0.5% increases.
  • It would create a new payment system called MIPS (Merit-Based Incentive Payment System) by 2018, which would roll up meaningful use, PQRS, and the Value-Based Payment System into one program that would tie physician reimbursement to quality and cost. Physicians would be assessed in 4 areas:
    • Quality: based on current and future quality measures from the PQRS and Meaningful Use programs
    • Resource use: assessment of cost structure using a method similar to that currently in use in the Value-Based Payment Program
    • Meaningful Use: satisfying current meaningful use requirements demonstrated by use of a certified EHR
    • Participation in practice improvement activities: a new area of measurement related to clinical improvement.
  • Physicians would receive a composite score on all of the above.  Based on total score relative to other physicians, they would receive either:
    • A negative adjustment of up to 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021
    • No adjustment
    • A positive adjustment of as much as 3 times the maximum negative adjustment for that year.
  • The new payment system would provide additional incentives (5% per year from 2018 to 2023) to providers who derive a substantial part of their income from alternative payment models that base payment on quality assessment and financial risk sharing rather than volume of services provided, (e.g., ACOs, Medical Homes, or other new healthcare delivery models).
  • It would encourage cost savings by incentivizing care coordination and adherence to Clinical Decision Support (CDS) mechanisms and Appropriate Use Criteria (AUC) aimed at reducing unnecessary testing—specifically in the area of advanced diagnostic imaging:
    • Effective 2017, physicians would be paid for advanced diagnostic imaging only if the claim shows consultation with CDS mechanisms and AUC.
    • Effective 2020, the 5% of physicians with the lowest adherence rates would require prior authorization for such tests.
  • Beginning in 2015, patients would have access to quality and cost data regarding individual physicians that would be made available on the Physician Compare Site.

MIPS would rely heavily on quality measurement, data sharing, and interoperability, so one thing is abundantly clear:  Robust EHRs and extensive data management capabilities will be critical tools for physician success in the future, even more so than they are today.