HIT Perspectives: Proposed Regulation

By Tony Schueth, Editor-in-Chief

What’s happening with meaningful use (MU), especially since the rumors of its demise were greatly exaggerated? Stakeholders have been eagerly awaiting the answer from the Centers for Medicare and Medicaid Services (CMS). Now we have a much better idea of its fate: CMS has rebranded and retooled the program, which is now called Advancing Care Information (ACI). Details are in a newly released Notice of Proposed Rulemaking (NPRM).

We got hints earlier this year about MU’s future when it was announced that some MU elements would be rolled up into a new program created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA provided CMS with the legislative vehicle to address physician payment reform, streamline quality-based programs payments and create an MU replacement.

But in typical government fashion, MU’s replacement is not very straightforward. It is, in fact, quite complex. ACI is a program within a program within a program. It begins as part of a new Quality Payment Program “framework,” which was created under MACRA.

The Quality Payment Program has two tracks providers can use to have their Medicare payments adjusted. The one of most interest to HIT Perspectives readers is called the Merit-Based Incentive Payment System (MIPS), which most Medicare clinicians are expected to use. The other is called Advanced Alternative Payment models. For more information, see the CMS fact sheet.

MIPS Overview. MIPS replaces Medicare’s former payment adjustment system, which was based on the reviled Sustainable Growth Rate formula. MIPS is supposed to simplify Medicare’s former patchwork of payment and quality programs by consolidating the Physician Quality Reporting System, the Value Modifier Program and MU. The health information technology (health IT) certification program by the Office of the National Coordinator for Health Information Technology (ONC) will continue as it did under MU. Certified electronic health records (EHRs) or certified modules, such as application program interfaces— must be used to achieve MIPS objectives.

However, the heart of MIPS is another carrot-and-stick incentive program. As described below, physicians will respond to and report on the following weighted metrics:

• Cost (10% of the total score). It replaces the cost component of the Value Modifier Program, also known as Resource Use. The score will be based on Medicare claims, meaning there will be no reporting requirements for clinicians. This category would use more than 40 episode-specific measures to account for differences among specialties.
• Quality (50% of the total score). It replaces the Physician Quality Reporting System and the quality component of the Value Modifier Program. Clinicians would choose to report six measures versus the nine measures currently required under the Physician Quality Reporting System. This category offers clinicians reporting options to accommodate differences in specialty and practices.
• Clinical Practice Improvement Activities (15% of the total score). Clinicians would be rewarded for clinical practice improvement activities, such as those focused on care coordination, beneficiary engagement and patient safety. Clinicians may select activities that match their practices’ goals from a list of more than 90 options. In addition, clinicians would receive credit in this category for participating in alternative payment models and in patient-centered medical homes.
• Advancing Care Information (25% of the total score). This renamed component is a repurposed version of MU. Clinicians would choose to report customizable measures that reflect how they use EHRs in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing MU program, this category would not require all-or-nothing EHR measurement or quarterly reporting.

These four components will be added together to create a base score. The base score will be used by Medicare to increase or decrease a physician’s overall Medicare payment by certain percentages. Doctors can earn bonuses (or receive penalties) of up to 4% starting in 2019, a number that grows to 9% by 2022 based on how well they perform.

CMS will begin measuring performance of doctors and other clinicians through MIPS in January 2017, with payments based on those measures beginning in 2019.

A closer look at Advancing Care Information. If MU wasn’t complicated enough, ACI is very complex, even though its underlying logic is fairly easy to understand. CMS listened to physicians, who wanted flexibility in measures and reporting. However, the devil’s in the details, —especially in how the ACI is computed.

As mentioned previously, the ACI counts toward a quarter of the MIPS payment adjustment. The overall score of 100 points in this category is comprised of subscores in three categories.
1. Base score. The first is the base score, which accounts for up to 50 points of the ACI score. It is comprised of six objectives and measures, which will sound very familiar to those who’ve been embroiled in MU over the past seven years.

• Protect Patient Health Information Using a Risk Analysis (mandatory)
• Electronic Prescribing
• Public Health and Clinical Data Registry Reporting
• Immunization registry reporting is mandatory; other registry reporting is optional
• Health Information Exchange
• Coordination of Care Through Patient Engagement
• Patient Electronic Access

2. Performance Score. Next is the performance score, which accounts for up to 80 points toward the total ACI category score. Physicians and other clinicians select the measures that best fit their practice from three objectives: electronic patient access, coordination of care through patient engagement and health information exchange. These, again, harken back to MU’s objectives and measures.

3. Public Health Registry Bonus Point. Immunization registry reporting is required. A bonus point can be earned for reporting to other public health registries.

Total Score. The base score, performance score and bonus point (if applicable) are added together to achieve the total ACI score. Note that they add up to a possible 131 points, while only 100 points are needed to receive the maximum points in the ACI category. There is no reward for exceeding the 100-point total. However, participants’ overall score in MIPS declines proportionately if they do not meet the 100-point threshold. Scoring is not all-or-nothing.

What does it mean? The Point-of-Care Partners (POCP) team will be analyzing the new NPRM and what it means to various stakeholders. We do, however, have a few top-of-mind observations.

The first is that physicians who have participated in MU should be able to easily achieve the ACI measures due to the similarity of the objectives. By the same token, they should be able to use their certified EHRs to report on quality and clinical practice improvement measures. The laggards will continue to risk having their Medicare payments dinged unless they get with the digital age, —except this time there won’t be any money available to help defray the costs of getting wired.

Protecting patient health information using a risk analysis also should be easy to attain since this is a requirement under the regulations implementing the Health Insurance Portability and Accountability Act of 1996 (HIPAA). That is likely easier said than done. We would make a healthy bet that most providers have never heard of the HIPAA security rule, even though it has been in effect for more than a decade.

MIPS will continue to push adoption of electronic prescribing (ePrescribing) through regulation. This tried-and-true approach has resulted in 80% of office-based based physicians using this technology. However, there is still room for growth. Given that the remainder are hard-core laggards, it remains to be seen how much MIPS moves the adoption needle.

It is clear that the government will be moving MIPS beyond the measurement of EHR adoption and has created a renewed focus on patient-centered care using patient-centered health information technology. This was underscored in a blog post by CMS Acting Administrator Andy Slavitt and National Coordinator Karen DeSalvo, M.D. They said MIPS is “more patient-centric, practice-driven and focused on connectivity.” We undoubtedly will continue to see this emphasis as MIPS rolls out in the future because it aligns with other ONC and CMS programs and initiatives. That said, patient-centered care hasn’t gained much traction despite the government’s best efforts to date. It’s too soon to tell whether the piling on of MIPS’ new regulatory requirements will help to create a tipping point.

Comment period. The NPRM provides for a 60-day comment period, which closes at 5 p.m. on June 27, 2016. This gives stakeholders an opportunity to make recommendations, which will be considered in the final regulation that will be issued in the fall. Because POCP will have a detailed understanding of the NPRM and its impacts, we can help you write and submit your comments. Please give us a call or send us an e-mail.