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
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.
CMS asked for comments on its Proposed Rule for Stage 2 Meaningful Use, and it got them—1,131 of them, to be exact. While the comments that have drawn media attention are those from major stakeholder organizations, the vast majority of comments were submitted by individuals—and CMS is obligated to read and consider each and every one of them as they formulate the Final Rule.
I thought it would be interesting to see whether the comments from those in the trenches—those whose everyday lives are impacted by the meaningful use regulations—are in line with the sentiments expressed by groups like the AMA, AHA, MGMA, EHRA, etc. In a review of the first 25% of the comments by individuals, (over 250 comments), a consensus clearly evolved around a few major points, and the results remained fairly consistent as we read. The graph above illustrates the prevailing sentiments.
By far, the predominant concern is that the proposed requirements are far too demanding, i.e., the bar is being set too high. An overwhelming 82 of the comments identified the sheer number of measures and components, challenging thresholds, the cost of compliance, and overly aggressive timetables—even in light of the delay to 2014—as being unrealistic.
On a similar note, another 14 addressed the complexity of the requirements, describing them as difficult to understand, ambiguous, and overly complicated. When combined with the above, approximately 40% of the 250 comments reviewed maintained that the Stage 2 requirements are simply too demanding.
As anticipated, there was a resounding concern (56 comments) about holding physicians responsible for actions by any third parties over whom they have no real control. Most comments referred to the requirement that patients view or download their charts and communicate to the physician by secure e-mail, but some asked that providers be insulated from any failure by vendors to meet the requirements or the client upgrade schedules.
The limited relevance for specialists remains an issue in Stage 2, as the program is still viewed as primary-care focused. There were 23 comments that addressed the paucity of meaningful use measures and clinical quality measures that are relevant to specialists, and some went so far as to claim that trying to meet requirements that are geared towards primary care could actually distract specialists from their own priorities and be detrimental to the quality of care they would be able to deliver.
Some comments addressed the penalties and suggested that the rules provide for a broader range of exemptions and more leeway. The suggestion that the first year of Stage 2 only require 90 days of reporting—which was suggested for other reasons as well—was supported by providers concerned with the penalties.
In response to a plea from CMS that people report what they like in the proposal, in addition to what they don’t, some commenters expressed general support for the Stage 2 recommendations, and a small number argued that the bar wasn’t raised high enough. Some—likely specialists—applauded the change in exclusions for reporting of vital signs; several approved of ensuring patient access to their clinical information; and there was support for the proposed harmonization of clinical quality measure reporting under the various government programs (meaningful use and PQRS).
Perhaps what is most interesting about the comments is the emotion and passion behind many of them—whether expressing favorable or unfavorable opinions. If you would like to browse through the public comments yourself, go to www.regulations.gov and enter “CMS-2012-0022” in the search bar.
Meaningful use is complex enough without having to sort fact from fiction when it comes to the rules, regulations, and requirements. It irks me when I hear the misinformation being disseminated by some EHR vendors in their attempts to sell their products to physicians who are not fully steeped in the nuances of the program.
The distribution of meaningful use misinformation for marketing purposes is not new. I wrote an EMR Straight Talk post titled “From EMR Vendors: Fact or Fiction?” on exactly this subject almost two years ago, when the program was still in its formative state. Sadly, unsavory marketing tactics remain the same—only the purported “facts” have changed.
The following are what I consider the most notorious misstatements about meaningful use:
It is not true that“You must demonstrate meaningful use in 2011 to qualify for the full $44,000 in incentives.” As the incentives chart illustrates, physicians can earn the full $44,000 over a 5-year period even if they start meaningful use in 2012. In fact, there are compelling reasons not to start in 2011. The first is that physicians can maximize their total revenue by focusing on earning the 1% ePrescribing bonus in 2011 and postponing meaningful use to 2012. Unfortunately, few vendors are alerting physicians that because they cannot collect both ePrescribing and EHR incentives in 2011, they would be leaving money on the table by pursuing meaningful use this year. The second advantage of waiting until 2012 is that physicians will not have to advance to the more stringent requirements of Stage 2 meaningful use until 2014 (instead of 2013), allowing more time to implement required upgrades.
It is not true that “If you wait until 2012, you will have to report on a full year’s data, rather than only 90 days.” The 90-day reporting period applies to the individual physician’s first payment year—it is not tied to calendar years. Therefore, physicians can actually start as late as October 1, 2012 and still earn the maximum incentives.
It is not true that “Providers have already received money for meaningful use of an EHR.” No one has yet demonstrated meaningful use. The incentive money distributed so far has been awarded under Medicaid, which provides first-year incentives for A/I/U (Adoption, Implementation, or Upgrading of EHR technology) and does not require the demonstration of meaningful use. In fact, although the first potential 90-day reporting period concludes at the end of March, the attestation portal (through which providers document meaningful use) will not be operational until April 18th.
It is not true that“Generating a structured, point-and-click, templated note is the only way to capture meaningful use data.” Most EHRs are built on a note-driven platform, where the design of the software traps physicians into capturing meaningful use data through over-engineered, click-heavy templates. It is disingenuous of the sales representatives of these vendors to suggest that a structured note is a requirement of meaningful use. When all you own is a hammer, every problem looks like a nail.
The response to last week’s Meaningful Use IQ Test revealed a tremendous thirst for information and a fair amount of confusion about the facts and realities of meaningful use. Neither was terribly surprising, given the recent hype surrounding the program’s launch and the complexity of the regulations.
Since the quiz was posted last week, 534 people have taken the test. The average score was 56% (see chart below and the breakdown of responses at the bottom of the page). These results mean that physicians will need a great deal of assistance from consultants, Regional Extension Centers, and vendors to succeed in their pursuit of the EHR incentives. If that aid is not forthcoming, there could be a large number of very disappointed providers when the incentives are distributed.
The following are some observations:
Only a small minority of our test-takers (9%) appear to truly understand the regulations and the requirements in their entirety. (Inga, from HIStalkPractice.com is one of the few who just might—based on her perfect score!)
Many people find the intricacies of the regulations baffling—as indicated by more than half of the respondents (300 of 534) knowing half or less of the information.
The fact that over one-third of the respondents did not know that providers cannot collect Medicare EHR incentives and Medicare ePrescribing incentives in the same year—no “double dipping” allowed—means that they have likely not analyzed their options to maximize the total revenue from the two incentive programs.
I thought it was interesting that nearly half of the respondents thought that the program requires reporting on only Medicare and Medicaid patients, when, in reality, the government is requiring providers to submit data on all patients.
Clearly, the message has come through that the program has been made more specialist-friendly, as physicians will be able to exclude measures that are not relevant to their practices. However, many do not understand how these exclusions factor into the demonstration of meaningful use.
The Meaningful Use IQ Test is still active, so if you haven’t accepted the challenge yet, you can still do so. I’m glad that it is raising awareness and providing valuable education. That was precisely its purpose!
In an unusual display of bipartisanship, Congress made it clear that they have no intentions of cutting physician reimbursement—even in a time when the country is facing severe economic challenges. By unanimous consent, the Senate passed the Medicare and Medicaid Extenders Act of 2010, extending Medicare rates through the end of 2011 and preventing the threatened 25% cut that was to go into effect on January 1. The following day, the House of Representatives passed the payment fix by an overwhelming (nearly unanimous) vote of 409 to 2, and President Obama’s signature is expected imminently.
Physicians should feel reassured that the uncertainty and concern that the SGR formula creates each year—and no doubt will until the calculation is redefined—should be tempered. This year’s resolution, albeit not an increase, can be taken as an indication that the annually feared drastic reductions are not likely. Physicians can now plan accordingly and make business decisions and capital investments that enable practice growth.
A reader raised an interesting question on the EMR and HIPAA blog this week. She asked if practices without a Medicare or Medicaid patient base are simply “out of luck” with regard to the government’s EHR incentive program. John Lynn responded:
“…not qualifying for the EMR stimulus money might just be the best thing that’s happened to your practice. That means you won’t be distracted and you don’t need to wait. You can hone in on the other EMR benefits and start reaping those benefits without all the bureaucracy.”
In other words, she can feel free from government pressure to make any particular type of EMR decision. This is exactly the same advice I give to all physicians, regardless of their eligibility for the government’s program—the voluntary nature of the EHR incentives gives you absolute freedom to make the decision that is in the best interests of your practice. Sandra Brown, M.D., reflected that feeling—shared by many physicians—in her response to a past EMR Straight Talk post, when she said that she felt “liberated” by the fact that the government couldn’t force physicians to take the money.
Physicians should use this freedom to evaluate EMRs based on ease of use, speed, flexibility, and any other criteria that they—rather than the government—feel will facilitate delivery of the anticipated benefits, such as:
A practice-wide, 100% successful adoption rate
Increased physician productivity
More efficient use of staff time
Revenue growth with decreased overhead
Enhanced patient care and service
Back-office efficiencies—improved revenue cycle
Decreased malpractice exposure
These benefits are guaranteed to far exceed an elusive $44,000 incentive, and physicians can begin realizing a significant ROI immediately—if they chose the right EMR.