Corrected to add missing chart
With the release of the Medicare physicians payment system created by the Medicare Access and ChIP Reauthorization Act of 2015 (MACRA) and, to a lesser degree the CY 2017 Outpatient Prospective Payment System final rule, federal health information technology policy shifts from the one size fits all system of Meaningful Use to a policy focused more intensely on interoperability and the free exchange of data. Most important, MACRA and now OPPS value HCIT as a component of quality care delivery and not as an end in itself.
MACRA creates two pathways for Medicare payments to physicians. The first is known as MIPS or the Merit-based Incentive Program and the other is the Advanced Alternative Payment Model. MIPS, for the purposes of analyzing changes to federal HCIT policy is the most relevant.
To be eligible to participate in the MIPS pathway, a physician, physician assistant, nurse practitioner, clinical nurse specialist or certified registered nurse anesthetist must bill Medicare more than $30,000 and provide care to more than 100 Medicare patients in a year. CMS estimates that about 500,000 clinicians are eligible to participate in MIPS.
In MIPS, clinicians will earn a payment adjustment based on quality data they submit. The quality data consists of four categories Quality, Improvement Activities, Advancing Care Information and Cost. Advancing Care Information (ACI) replaces the dreaded Meaningful Use – or Meaningless Abuse as some practitioners have called it.
The 18 HCIT measures on which clinicians were required to report under Meaningful Use have been replaced with five under MIPS. What is more, the activities that are required to be reported are focused largely on one thing – interoperability. Gone are overly prescriptive requirements like use clinical decision support software or the delivery of patient specific educational materials. Instead, the ACI portion of the MIPS payment program has four objectives for which there is a mandatory reporting requirement:
- Protect Patient Health Information
- Electronic Prescribing
- Patient electronic Access
- Health Information Exchange
These four objectives are associated with five measures that are required to be reported as part of the provider’s base score under MIPS. These measures are:
- Security Risk Analysis
- e-Prescribing
- Provide Patient Access
- Send Summary of Care
- Request/Accept Summary of Care
Clinicians can choose to participate and report on other HCIT measures as they see fit and to reach the “meaningful use” threshold score of 75 percent. The table below lists the objectives and measures under the ACI category of MIPS.
Table 1: Measures and Objective required Under MACRA
For clinicians that are ready to begin collecting the necessary data, they can do so any time between Jan., 1, 2017 and Oct., 2, 2017 for reporting to CMS by March 31, 2018. A clinician that is not prepared to submit data for 2017 will suffer a 4 percent reduction in Medicare reimbursement. If, however, a clinician submits a minimum amount of data; for example, one quality measure and one improvement measure for 2017, they will avoid the payment reduction. Clinicians that submit data for at least 90 days will receive no payment adjustment or a small upward one. Clinicians that submit data for the entire 2017 year may receive a neutral to moderate upward adjustment of up to 4 percent.
Payment increases which will be made after Jan., 1, 2019 will depend on the amount of data submitted and quality scores. Payment adjustments will increase from 4 percent in 2019 to 9 percent in 2022.
The ACI component of MACRA marks a dramatic shift in federal HCIT policy which, under the c. 2009 HITECH Act, created a highly prescriptive and complex regulation that critics referred to as “one size fits none.”
MACRA has the unintended consequence of bifurcating federal HCIT policy because it only addresses physicians practices, leaving hospitals and hospital outpatient departments using a different standard. Enter the power of administrative action. In the CY 2017 Outpatient Prospective Payment System final rule, CMS attempts to align MARCA with Meaningful Use to the extent possible given the statutory constraints.
In the CY 2017 OPPS final rule, CMS finalized a proposal that would eliminate the reporting of Clinical Decision Support and Computerized Provider Order Entry objectives and measures for Modified Stage 2 and Stage 3 for 2017 and subsequent years. These two areas have a high level of performance among hospitals and CMS felt that it could reduce the reporting burden for providers. CMS had previously opted to exclude these measures from the final MACRA rule as well.
CMS also finalized a proposal to reduce thresholds for eligible hospitals and CAHs attesting under meaningful use for reporting periods in 2017 for Modified Stage 2 and 2017 and 2018 for Stage 3. These threshold reductions more or less retain the Modified Stage 2 levels. In other words, CMS is declining to increase thresholds as required under Stage 3 thus reducing the reporting burden and creating more alignment with MACRA.
CMS is also establishing a reporting period of only 90 days instead of a full 12 months in 2016 and 2017 for Meaningful Use. This provision is also similar to the MACRA reporting period for clinicians looking to adopt the new regulatory regime a bit more slowly than others.
Taken together, changes to Meaningful Use in the CY 2017 OPPS are designed to reduce the burden Meaningful Use has had on the provider community and limit the ambitions of Stage 3. This effort more closely aligns the Meaningful Use regulatory regime with MACRA and further shits the focus of federal HCIT policy from one that demands the purchase and use of HCIT to one that is driven by patient needs.
This shift has been highlighted by CMS Acting Director Andy Slavitt every time he gets a chance to talk about it. For example, in January Slavitt appeared at the JP Morgan’s annual health care conference in San Francisco. In his speech he laid out four policy objectives:
For one, the focus will move away from rewarding providers for the use of technology and toward the outcome they achieve with their patients.
Second, providers will be able to customize their goals so tech companies can build around the individual practice needs, not the needs of the government. Technology must be user-centered and support physicians, not distract them.
Third, one way to aid this is by leveling the technology playing field for startups and new entrants. We are requiring open APIs so the physician desktop can be opened up, moving away from the lock that early EHR decisions placed on physician organizations, to allow apps, analytic tools, and connected technologies to get data in and out of an EHR securely.
And finally, we are deadly serious about interoperability. We will begin initiatives in collaboration with physicians and consumers toward pointing technology to fill critical use cases like closing referral loops and engaging a patient in their care. And technology companies that look for ways to practice “data blocking” in opposition to new regulations will find that it won’t be tolerated.
Each of those policy goals made their way into the ACI category of MACRA or the standards for CEHRTs used to meet requirements of ACI.
One particularly interesting aspect of the shift in federal policy is the way in which Slavitt and others are looking to the private sector to solve many of the problems that have plagued EHR systems under meaningful use – specifically usability and interoperability. In his comments at the news conference accompanying release of MACRA, Slavitt said:
If the HITECH Act allowed big EHR companies to form and grow, MACRA is the next shift and arguably a much richer opportunity. Tech companies will compete to simplify and support the lives and jobs of physicians so they can be more productive, communicate better with their patients and other physicians, and have the information they need in their own workflow so they can succeed at value-based care, which is really the promise of MACRA.
Letting the private sector lead on the next phase of development of HCIT is the message of the Center for Medical Interoperability which opened in Nashville earlier in the year. Initially funded by the Gary and Mary West Foundation, the Center is supported by procurers of health care devices and systems including the two largest health systems in the United States – Ascension and HCA. The Center, modeled after the Cable Lab in Denver which established standards for the cable industry, aims to do the same for health care.
At HIMSS 2016, HHS Secretary Burwell noted the role the Center would play in her department’s new approach to HCIT:
Many of our great partners are here with us today, like the new Center for Medical Interoperability. This group, started by providers, plans to take its seat at the table to help beta test technologies and make sure they work for doctors on the ground.
That commitment to cooperation and innovation will help us build our health care system into one that works best for that patient who checks in to a hospital for high quality care.
Slavitt is right in that the federal policy shift represents a great opportunity for HCIT in the long run. It remains an open question as to whether or not incumbents like Epic Systems and CERN are up to the task. For their part, CERN is at least acknowledging the need for change. CERN president Zane Burke has said “interoperability isn’t just about what’s good for Cerner’s business – it’s about doing the right thing by our patients and clinicians.” ATHN, for their part, has been outspokenly critical of HCIT vendors that have relied on the moat of non-interoperability and has built a business around challenging it.
As for Epic, Politico reported last week that specialty societies like the American Board of Family Medicine is being blocked by Epic from submitting patient data to registries – an activity for which physicians can get bonus points under MACRA.
In the near term, however, the combined effects of a more relaxed HCIT policy that is practice driven with few hard deadlines and lowered performance thresholds will only magnify the slow-down in EHR replacement discussed at length by the Hedgeye Health Care team.
Call with questions.
Emily Evans
Managing Director
Health Policy
@HedgeyeEEvans
