2018 MACRA (MIPS) Proposed Rule: The Abridged Version

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

lynns-notesThe proposed rule is here, and it’s another long one! So for those who don’t have the patience (or the time) to read through the 1,000+ pages, here are some highlights from what CMS is suggesting for the second year of MIPS. Bear in mind that these are proposals; they must be confirmed in the Final Rule, which will be released by November. (What had already been set in stone within the MACRA legislation itself is the maximum penalty and related incentive: 5% in 2020 based on performance in 2018, up from 4% in 2019 based on performance in 2017.)

  • CMS would allow clinicians to use either 2014- or 2015-Certified EHR technology to report for 2018. Acknowledging the slower-than-anticipated pace at which EHRs are achieving the next required certification, this accommodation will facilitate more successful, non-rushed upgrades and provide sufficient time for training on the new capabilities and associated requirements. To encourage the move to 2015 CEHRT, 10 ACI bonus points would be awarded for its exclusive use.
  • The Quality reporting period returns to full year, but ACI (Advancing Care Information) and Improvement Activities remain at a minimum of 90 days. Cost is still unscored, but performance in this category will be evaluated by CMS and feedback will be provided to clinicians to prepare them for 2019 when, by law, the cost category must account for 30% of the MIPS score.
  • The proposed performance threshold separating “the winners” from “the losers”, (i.e., recipients of positive vs. negative payment adjustments), would increase from 3 points out of 100 in 2017 to 15 MIPS points in 2018—still an eminently achievable bar.
  • CMS would implement increased protection for small groups (≤15 eligible clinicians)—these are the practices that had been predicted to be the most vulnerable to penalties.
  • Many more clinicians would be exempt from MIPS altogether because the eligibility threshold would increase from $30,000 to $90,000 in annual Medicare revenue and from at least 100 to at least 200 Medicare patients.
  • Small groups that do participate in MIPS would receive 5 bonus points toward their score, in an attempt to level the playing field.
  • And my favorite proposal is one that specialists, in particular, will appreciate: the elimination of the restriction that all 6 quality measures had to be reported by the same submission method. In 2018, clinicians would be able to mix and match submission methods within a category. Specialists, who have typically been faced with an insufficient number of relevant eCQMs, would be able to continue reporting those measures which are available by EHR submission, but could supplement them with registry or claims measures that are also specialty specific. The result would be more meaningful reporting and more equitable scoring. This is a request that SRS has included in its comments to each of the previous proposed and final MACRA rules, so we were very happy to see this change.

MIPS is only one of the two MACRA participation options, and CMS has also proposed some changes designed to accelerate the shift from MIPS to Alternate Payment Models. More on that topic in a future post.

Will Robots Replace Healthcare Providers?

Khal Rai

Khal Rai

Senior Vice President, Development at SRS Health
Khal oversees the Software Engineering, Business Analysis, Quality Assurance, and Product Management teams at SRS. His 17+ years’ experience in software development and healthcare IT have resulted in a true passion for collaborating with customers, then translating their needs into innovative solutions and better service experiences. He believes that motivated employees and satisfied customers are keys to maintaining business success. He has a B.S. degree in Computer Engineering from the University of Cincinnati, and an M.S. degree in Electrical Engineering from Purdue University.
Khal Rai

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robot-blogLeveraging interpretive intelligence in clinical workflows

Automation has been making human workers superfluous for centuries, but until recently, workers whose jobs required high-level cognitive skills have been able to rest easy, confident no machine could possibly replace them when it came to making nuanced decisions based on the evaluation of complicated, sometimes contradictory data.

But that was before Artificial Intelligence (AI) came along, stepping out of the pages of science fiction and into our daily lives. It now seems possible — even probable — machines will replace many mid-level knowledge workers and the question arises whether someday robots will replace doctors and nurses.

It’s a provocative question, certainly, but not the most interesting one facing our industry. A more critical question is will the healthcare ecosystem — the vendors and the solution providers — be able to survive without AI? I ask this because I believe doctors and healthcare administrators will increasingly demand answers to questions, and solutions to the challenges, that are difficult, if not impossible, to solve without the aid of AI-driven solutions.

These questions will range from practical issues of practice management to vital questions of patients’ health. For example:

  • How much will it cost to treat this patient?
  • How much and how fast will I get paid?
  • Is medication or surgery the best treatment option for this particular patient?
  • Where and/or when should I schedule this surgery?
  • When will this patient be able to return to his/her normal routine?

Some of these, of course, are the perennial questions that have always faced healthcare practitioners, but the truth is recent changes in technology have made innovative solutions possible in a way never before imaginable. For example, all kinds of data are now readily available in consumable (discrete) forms — from PHI to financials to protocols — and storing and managing this data is getting cheaper every day.

Additionally, healthcare providers are beginning to understand the shift from service to value-based care and are seeing how it can work for them, both clinically and financially. Finally, the healthcare practitioners themselves are changing: computer- and technology-savvy clinicians who got their medical education and training in the 1990s and early 2000s (the so-called Generation X and Y) are now entering into leadership positions where they can affect change.

In other words, there is both a greater supply of data than ever before and a greater demand for it. However, this demand isn’t simply for large data-dumps of undigested information. What’s necessary is for healthcare providers and administrators to have the critical data they need, and only the data they need, when and where and in the form they need it. This is where AI can help make critical decisions about amalgamating and filtering data.

There’s enormous potential for AI (or “smart solutions”) to optimize clinical protocols by drawing on a huge pool of evidence-based results. As we move toward a value-based environment, AI will be increasingly necessary to proactively and dynamically manage patient outcomes. This, in turn, will optimize the treatment experience, leading to greater patient engagement — and this greater continuity of care will promote both healthier patients and healthier practices. Clinicians will also gain insights into how to manage risks, which leads to lower costs and better margins.

Will robots replace healthcare providers? It seems unlikely, but care teams will start to leverage interpretive intelligence in daily clinical workflow. Machine learning, along with AI, will become an integral part of the healthcare mix because the vast resources of critical data will only be truly available when clinicians have tools to track real-time data embedded in their daily workflows resulting in better patient care at a lower cost.

As seen in Health IT Outcomes.

Whether Winemaking or Medicine…It’s All About the Outcome

Helene Kaiden

Helene Kaiden

Vice President, Marketing at SRS Health
Helene Kaiden is the Vice President of Marketing for SRS, with responsibility for building brand awareness, educating the marketplace, and driving sales opportunities. Helene’s team of creative marketing professionals has a charter that includes marketing strategy and programs, product positioning, digital marketing, conferences, and analytics. Helene’s powerful commitment to excellence and dedication to helping clients address their medical-practice challenges drives her messaging strategies.

Helene received a Bachelor’s degree in Consumer Economics from Cornell University, with a concentration in Business Management. She has over 20 years of experience in sales and marketing roles.
Helene Kaiden

vintner-blogAt first glance, winemaking and specialty medicine wouldn’t seem to have much in common—most obviously, one works with plants, and the other people. On top of that, the workflows are different—vintners can invest years in cultivating a particular vine or grape, but few doctors’ patients are willing to wait that long for results. And ultimately, their aims are different, too—the mark of a great winemaker is the ability to transform a good product into an exceptional one, while even the greatest doctor must be satisfied with simply restoring patients to a state of average, everyday health.

Yet during a recent vacation in Napa Valley with my daughter, who is now in the first stages of entering the field of medicine, the similarities between the two fields kept occurring to me.

For a start, as any med student has painfully learned, treating patients is a skill that takes years and years of training to perfect. The same is true of winemaking, which is one reason why it is so often a family concern that spans generations. (Admittedly, there’s a recent trend in celebrity wines, but it’s fair to say that behind every great celebrity wine stands an already established vintner or winery.)

At the same time, despite the extensive training in both fields, ultimately, both winemaking and medicine have always involved as much art as science. Of course, the role that science plays in modern medicine is undeniable, but most people are probably unaware of the enormity of the contribution made by science to winemaking.

Related to this is the fact that both are “callings” in the old-fashioned sense of the word. For the best winemakers and doctors, it’s more than a job or a career—it’s a passion.

And finally, success in both professions is rigorously tied to outcomes. No matter how deep their involvement in the process, if the vintner doesn’t at the end deliver up a superb wine, and the doctor a healthy patient, then they have failed.

Those parallels noted, it turns out that there is actually more overlap than you would expect between winemaking and medicine—as we toured various wineries, we discovered a couple of interesting figures who have been a part of both worlds.

Robert Sinskey was a cataract surgeon, an inventor, and a teacher who pioneered modern cataract and implant surgery, driving better results by devising new instruments. The Sinskey hook is likely the most widely used eye surgical instrument to this day. A similar passion led him to develop his winery in Napa Valley in the 1980s—one of the most beautiful and well-kept in the region. The Sinskey label appears on fine wine lists around the globe, and was one of my personal favorites from my trip.

Greg Lambrecht, an MIT graduate and inventor of innovative medical technology, is also the inventor of the Coravin, a remarkably useful invention that allows you to sample a glass of wine without having to open the bottle. Coravin uses a needle-through-the-cork system that siphons wine out without allowing any oxygen in, eliminating any risk of oxidation that would spoil the remainder. It turns out that a wine cork is similar to the subcutaneous implants used for chemotherapy treatments, and so the Coravin needle was based on one inserted through the implant to inject the chemo. With the Coravin, a thin needle is inserted through the foil and cork and the bottle is pressurized with argon, an inert gas that winemakers have used for years. The positive pressure of the argon allows the wine to flow out through the needle and into the glass without admitting any oxygen. When the needle is removed, the cork naturally reseals itself, and the remaining wine can continue to age. The Massachusetts-based Coravin, Inc. has now expanded from this invention to manufacture a range of products for the wine industry.

And if that wasn’t enough, it can’t be a coincidence that winemakers live longer lives. Dr. Sinskey lived into his 90s, as did Robert Mondavi, while Mondavi’s brother Peter outlasted him to the age of 104. Back in 1976, Mike Grgich’s 1973 Chateau Montelena Chardonnay shook up the wine world by winning the famed Judgment of Paris tasting—a group of mostly French judges ranked the California wine above some of Burgundy’s best. Grgich, who was born into a wine-making family in Croatia in 1923, was virtually a spring chicken at the time; he recently celebrated his 94th birthday.

And so, to all the physicians and medical professionals, and to all our exceptional winemakers—thank you for your passion, your skill, and your desire to enhance the status quo and deliver a higher level of your craft—a better outcome. Cheers!

Reimagining a Stable Future

Lester Parada

Lester Parada

Director of Professional Services at SRS Health
Lester Parada is the Director of Professional Services overseeing the Implementation, Training & Consulting and Forms teams. He has a background in business development, product management, project management and client relations. His passion lies in maximizing client value by optimizing workflows and technology.Lester is a certified PMP, SCM and CSPO and has an MBA with a concentration in marketing.
Lester Parada

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stable-future-blog-v2HHS Secretary Tom Price, an orthopaedic surgeon, stated weeks ago that he wants to “reimagine” the federal department. I would humbly suggest—and hope—that one of the items he “reimagines” is the process by which policy is implemented as it relates healthcare technology.

Since 2011, the healthcare IT (HCIT) sector has been severely hampered by policy uncertainty. Each year, new guidelines and certification criteria are presented. These usually receive some negative reactions from healthcare providers, and then amended as the timelines extend or change. Many times, the policies have been changed a mere two months before their scheduled start date. For providers, the noise around these policy changes creates an environment in which uncertainty avoidance becomes a priority. That means retiring early, merging with a hospital or a larger group to share risks, putting off expansion plans and capital expenditures, and other strategies. For HCIT companies, it means not funding innovation and being forced to focusing on more and more functionality that customers do not value.

In macroeconomics the term “C bar” refers to “the autonomous real consumption expenditures by consumers but as it relates to their confidence.” In layman’s terms, it is the current outlook that consumers have towards the economy and their own financial situation. It reflects their level of confidence or lack thereof. A good level of confidence increases consumers’ likelihood to spend and borrow (otherwise known as their marginal propensity to consume). A poor level signals economic contraction is ahead. It is affected by many factors in our complex economy like housing prices, unemployment, and inflation. However, nothing affects confidence more than uncertainty! In general, when consumers sense they are not reasonably confident of what the future outcome of something will be, they pull back from the table and wait.

You can see evidence of this exact macroeconomic principle in healthcare today. I would venture a guess that if we tracked healthcare’s C bar, we would see that we are in negative territory and likely have been for years.

What we need is stability and a clear direction forward: setting policy and requirements early, providing sufficient time to implement changes, and then not surprising the industry with last-minute changes or corrections. Once confidence is restored, I believe that both providers and HCIT companies will experience a mini boom as all of the delayed investments and innovations work their way back into the sector.

 

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.”

Outcomes: It’s What’s Inside That Counts

Scott Ciccarelli

Scott Ciccarelli

CEO at SRS Health
Scott Ciccarelli, Chief Executive Officer at SRS, has more than 20 years of diverse management and operations experience garnered as a senior executive at GE, where he headed two of the company’s businesses—most recently, GE Healthcare’s Services, Ambulatory and Revenue Cycle Solutions. His areas of expertise include business strategy, leadership development, operational rigor (Lean Six Sigma), and the delivery of enhanced value for customers through quality improvement and innovation.
Scott Ciccarelli

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lightbulb-gears-blogTwo weeks ago, more than 40,000 people came together to network, share, and learn more about health data management at HIMSS17. As expected, we heard about the latest developments in top tech trends of tomorrow like artificial intelligence, data security and virtual care. One of the hottest discussion topics by this highly focused group was how to improve patient and practice health through meaningful and usable analytics. After much time listening to and participating in conversations on this critical subject matter, we are more committed than ever to helping our clients improve patient care through outcomes, and when it comes to outcomes, it’s what’s inside that counts.

What do I mean by that? This familiar phrase has been shared from generation to generation when describing what’s important about people. So how can these words of wisdom about humanity possibly apply to HCIT and outcomes for specialty medicine practices? It’s more appropriate than you might think…

In an ambulatory setting, specialist teams need the ability to analyze and make decisions within their HCIT ecosystem. They need insight within their workflow. They need to know how to deliver the best care at a lower cost. And the only way to do this in today’s data-driven world is by bringing insight and analytics inside their workflow. Not outside.

External solutions focus on providing isolated results rather than a holistic approach to patient and practice health. What’s an outside solution? It’s anything that requires you to offload data, thereby taking you out of the ecosphere. If that data is not contained in the ecosphere – if the information is not inside the workflow – these solutions are not actionable immediately.

We believe that the only way to achieve the best outcomes is through frictionless data solutions that provide actionable insights that net immediate, holistic results. Of course, too much data can be overwhelming, so how do we maximize data intelligence for specialists without disrupting the quality of patient care?

That very question is what led to the development of SRS EHR Smart Workflows®. We’ve replaced complexity with streamlined data relevancy in a way that helps provide the frictionless clinical experience of the future…today.

So while we continue to hear all about the amazing healthcare technologies that are on the horizon, let’s remember to turn our gaze inward. Because when it comes to best outcomes, the best solutions are about what is on the inside. Just like the best people.