Archives August 23, 2016

MACRA Targets Meaningful in Meaningful Use

by Barry P Chaiken, MD

The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) opened the way for the U.S. Department of Health and Human Services (DHHS) to streamline the quality improvement and healthcare information technology programs built over the past several years.

Since the passage of the 2009 HITECH act, the quality reporting and meaningful use criteria grew in complexity and breadth making the following of their program guidelines difficult. The proposed MACRA rule attempts to lessen the burden for physicians – a rule for provider organizations is under development – while working to better achieve goals of improved quality of care and effective use of information technology.

Too much duplication

Currently, Medicare physicians submit data to a variety of uncoordinated quality reporting programs – accountable care organizations, the Comprehensive Primary Care Initiative, Medicare Shared Savings Program, the Physician Quality Reporting System, the Value Modifier Program and the EHR Inventive Program (i.e., meaningful use).

The proposed MACRA rule attempts to aggregate the current reporting programs into a more manageable form by offering two distinct reporting options and reducing the number of metrics required overall. The new Quality Payment Program offers two paths: the Merit-Based Incentive Payment System or MIPS, and the advanced Alternative Payment Models or APMs.

The proposed rule targets only eligible clinicians who receive payment from CMS and includes a long list of providers in addition to physicians. The quality reporting period begins in calendar year 2017 with the results impacting CMS payments in calendar year 2019.

DHHS expects most program clinicians to participate in the MIPS program. As outlined, the MIPS program adjusts reimbursement based upon four areas:

Quality – from a broader list, clinicians choose six key measures whose results account for 50% of the overall incentive score

Cost – using claims, DHHS assigns a value equal to 10% of the overall incentive score

Advancing Care Information – with emphasis on interoperability and information exchange, clinicians choose to report on their use of information technology with this measure impacting 25% of the overall incentive score

Clinical Practice Improvement Activities – from a list of 90 options, clinicians choose activities that match their practice with results impacting 15% of the overall incentive score.

Clinicians who participate to a “sufficient extent” in various advanced APMs may be exempt from the MIPS reporting requirements and qualify for incentive payments. Advanced APMs must meet three proposed requirements to earn incentive payments: 1) Use of EHRs, 2) Payment for professional services based upon acceptable quality measures, and 3) Existing as an enhanced Medical Home or bearing more than nominal risk for financial losses. Such APMs include Comprehensive Primary Care Plus (CPC+) model, Next Generation ACOs and other types of programs where clinicians accept both risk and reward for delivering high quality, patient centered, coordinate care.

DHHS expects to distribute $500 million in incentive payments in 2019 to eligible clinicians as a consequence of the MIPS program. In addition, the agency estimates the APM incentive program to disburse $200 million in incentive payments.

Impact on HIT

Although the HITECH act and the Meaningful Use program delivered on their promise to increase the availability of EHRs to clinicians, the impact of these programs remains controversial. With more than $30 billion spent on incentives, little evidence exists that quality care improved or costs were reduced. In addition, many physicians report that the use of EHRs reduced their productivity while patients continue to complain about their struggles to obtain complete medical records.

While some consider the Meaningful Use program a failure, this viewpoint contains overtones of “Monday morning quarterbacking.” Although the HITECH act focused on facilitating the implementation of EHRs, its inclusion in the broader American Recovery and Reinvestment Act (ARRA) signifies its general purpose to be part of an economic stimulus program focused on helping the US emerge from the deepest recession since the Great Depression.

In addition to improving healthcare delivery through the use of information technology, DHHS needed its Meaningful Use program to incentivize provider organizations to rapidly deploy EHRs so that the funds devoted to the program would be part of the overall ARRA stimulus effort. This probably explains why Meaningful Use stage 1 criteria contained relatively simple usage metrics.

As the Office of the National Coordinator for Healthcare Information Technology’s (ONC) meaningful use committees worked on Meaningful Use stage 2, greater scrutiny fell upon more valuable metrics focused on quality, safety, and cost savings. Unfortunately, these types of metrics required much more comprehensive and difficult to obtain data elements that exponentially increased in complexity when applied across a diverse and disparate delivery system. For example, the data elements, processes, and important performance metrics among internal medicine, obstetrics, and ophthalmology practices varies widely.

Focus on interoperability

In retrospect, the Meaningful Use program should have focused on interoperability and the simple, seamless exchange of clinical information among providers of all types and disciplines. Although a critique of the program as executed, it is not a criticism of the intent of the participants representing all stakeholders in the healthcare information technology universe. The stakeholders put forth their best efforts irrespective of the current results.

That said, now is the time to correct the program and MACRA offers that opportunity. By completely refocusing the CMS payment incentives on the items noted above – quality, cost, advancing care information, and clinical practice improvement activities – DHHS targets a less prescriptive and more flexible set of objectives that allows for innovation and flexibility among diverse practices.

To achieve proper reporting of quality and process metrics requires a robust exchange of medical information irrespective of care setting. Only through actual, reliable, and complete interoperability can providers generate the reports necessary to satisfy the MACRA reporting requirements and obtain incentive payments.

MACRA offers an opportunity to reboot the Meaningful Use program and allow it to facilitate what it should have incentivized back in 2009, comprehensive clinical information interoperability. With the value of 20-20 hindsight, it is hoped that providers, EHR vendors, and government agencies agree that MACRA offers them a do-over to get the problem of interoperability finally fixed. This time, patients are carefully watching.

Excerpts from “MACRA Targets Meaningful in Meaningful Use” published in Patient Safety and Quality Healthcare

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