What MACRA means for meaningful use

Topics: Politics and Policy, Federal Government, Payment Reform, Physicians, Medicare, Health Information Technology, Electronic Health Records, Meaningful Use

by Joe Infantino

When CMS in January teased a plan to phase out the meaningful use program "as it has existed," stakeholders seemed ready to wish the beleaguered program good riddance -- but they wanted more details.

Robert Tennant, director of health IT policy at the Medical Group Management Association, at the time said the idea of phasing out the meaningful use program is "encouraging, but much of the details are missing."

With CMS' proposed rule for new value-based payment programs under the Medicare Access and CHIP Reauthorization Act (MACRA) (HR 2), providers finally have some answers.

CMS unveils proposed rule for value-based payment programs under MACRA >>>

Reaction has been mixed so far. American Medical Association President Steven Stack in statement said, "CMS has made significant improvements by recasting the [electronic health record (EHR)] meaningful use program and by reducing quality reporting burdens." But other health IT stakeholders have raised concerns with the agency's implementation outline.

MACRA proposed rule

The proposed rule would create the Merit-based Incentive Payment System (MIPS) -- one of two quality reporting paths eligible professionals could select.

MIPS combines the Medicare EHR incentive program with other Medicare reporting programs -- including the Physician Quality Reporting System and the Physician Value-based Payment Modifier.

The program would increase or decrease payments by up to 4 percent during its first year, with participants' overall scores broken down into four categories:

  • Advancing care information (ACI), including use of EHRs and other health IT tools, accounting for 25 percent of MIPS score;
  • Clinical practice improvement activities, accounting for15 percent of MIPS score;
  • Cost, accounting for 10 percent of MIPS score; and
  • Quality, accounting for 50 percent of MIPS score.

Medicare's meaningful use program would be folded into the ACI category.

Acting CMS Administrator Andy Slavitt and National Coordinator for Health IT Karen DeSalvo in a blog post said officials proposed combining the programs to reduce reporting burdens and increase flexibility.

Increased flexibility

CMS' intention to make the reporting requirements less burdensome is not lost on stakeholders.

"We're now putting [Medicare meaningful use] into a broader physician payment system," Chantal Worzala, vice president health information and policy operations at the American Hospital Association, said. "So you would hope that as CMS is treating it as one system, rather than five payment systems, there will be better alignment across everything that is going on."

CMS also is dropping the all-or-nothing approach to quality measures, where "you either meet everything, or you fail altogether," Worzala said.

The new ACI category also gives providers more flexibility in meeting requirements, compared with the meaningful use program. For instance, the agency proposed:

  • Allowing eligible providers to select measures that best reflect how they use EHR technology;
  • Cutting the number of measures from 18 to 11; and
  • No longer requiring that eligible professionals report on clinical decision support and computerized physician order entry.

The new ACI objectives and measures include:

  • Care coordination through patient engagement, including view/download/transmit capabilities, secure messaging and patient generated data;
  • Electronic prescribing;
  • Health information exchange;
  • Patient electronic access;
  • Protecting patient health information; and
  • Public health and clinical data registry reporting/immunization registry reporting.

How ACI could still pose a burden for physicians

Whether the new program actually will achieve its goal of reducing provider burdens is unclear -- as it still maintains some of the burdensome aspects of the program.

John Halamka, chief information officer at the Beth Israel Deaconess Medical Center and former chair of the Office of the Nation Coordinator for Health IT's Standards Committee, said he expects many providers will see the ACI's "requirements as creating more burden without enhancing workflow."

"There's still an awful lot here that needs to be reported on," Worzala said. "We know that having to keep track of all these numerators and denominators really is an administrative hassle, and it's hard for people to do."

Industry stakeholders also have raised concerns about the proposed rule's tight implementation timeline. Eligible professionals will have just three months from the release of the first set of quality measures -- expected in November -- to the start of the first reporting period in January 2017.

According to Halamka, that timeline attempts "to change too much too fast." He said, "The timeline will need to be delayed by a year or two."

Similarly, Worzala said, "I think there are some questions about how to rearrange what you're doing in a three-month period between the final rule and the start of the first reporting year." She noted that eligible professionals at the same time will be transitioning to the 2015 Edition Certified EHR technology.

"How do you also transition to the 2015 edition EHR during that switch? That's a really big ask," Worzala said.

The proposed rule does include an option for eligible professionals to use 2014 Edition Certified EHR during the first year. But those who choose to do so would be required to report on alternative measures, according to the proposal.

ACI isn't for everyone

One of the biggest questions left unanswered is the fate of the meaningful use Medicare hospital and Medicaid programs. The shift from meaningful use to the new MIPS program will only apply to eligible professionals in the Medicare program.

That's because the EHR incentive programs for Medicaid and Medicare hospitals have a different set of statutory requirements, according to CMS, and the agency needs to modify them separately.

Halamka said, "The complexity of getting [proposed rules] through the Office of Management and Budget clearance means that you have to do work in phases."

But some stakeholders don't expect that those left behind in the meaningful use program will have to wait long.

In January, Slavitt and DeSalvo said, "We will continue to explore ways to align with principles we outlined above as much as possible for hospitals and the Medicaid program." Few details were shared last month, but they said, "We are already meeting with hospitals to discuss potential opportunities to align the programs to best serve clinicians and patients, and will be engaging with Medicaid stakeholders as well."

Worzala said that delaying the transition from meaningful use for hospitals and Medicaid eligible professionals "would be a mistake." Noting the close relationship between physicians and hospitals, she said, "We need that alignment across settings or we're really setting ourselves up for some real challenges down the road, because, after all, we all need to share information."

In speculating what an ACI-like program for hospitals and Medicaid might look like, a common theme that comes up is "alignment."

Halamka said that the most efficient method would be to establish programs for hospitals and physicians that mirror each other.

"I can only hope that we align the value-based purchasing programs for clinicians and hospitals to follow similar criteria, that are simple, measurable and aligned with incentives," he said. "Creating different programs with too much variability means that no one will understand how to change their behavior."

Worzala agreed, saying, "Hospitals employ physicians, and they have relationships with physicians where they're actually supporting the compliance with these rules, so they're directly impacted in that way." She added, "If we really want to get to the point where data is following the patient, we really need a close alignment across the technology platforms used in hospitals and in other settings."