Healthcare organizations lined up yesterday to file comments with the Centers for Medicare and Medicaid Services on proposed federal rules that would revamp payment approaches for physicians and dramatically restructure how the government encourages the use of healthcare information technology.
Most comments filed by organizations favored the notion of building a new reimbursement system based on quality, not the quantity of services. However, many responses to the proposed rules cited concerns regarding the complexity of the program, the short timeframe for implementing it and the potential effects on small and rural providers.
The rule addresses the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which would widely revamp approaches to physician payment to focus incentives on quality, not volume of services, through the implementation of the Merit-Based Incentive Payment System (MIPS).
While much of the proposed rule discusses payment reform, the portions that reflect changes to information technology policy are still significant, reflecting comments earlier this year by federal officials presaging changes ahead for the meaningful use program for physicians; the rule does not address changes for the MU program for hospitals.
Under the proposed rule, meaningful use is folded into the formula for how physicians are reimbursed. Under the plan, healthcare IT would be focused on achieving broad themes that federal agencies have been championing in recent months—patient engagement, healthcare information exchange, care coordination and patient-physician communication.
The proposed rule suggests that the new system would begin to go into effect on Jan. 1, 2017, and physicians would need to begin collecting data at that point to qualify for the Quality Payment Program, which focuses on rewarding physicians for measurably improving the services they provide to Medicare beneficiaries.
If the final rule is released this fall, that will leave little time for vendors of electronic health records systems adapt their products, and just a few weeks for providers to implement them, according to comments jointly filed by the Health Information Management and Systems Society (HIMSS) and the Association of Medical Directors of Information Systems (AMDIS).
Establishing the Quality Payment Program may require a number of additional changes to technologies and processes, including EHR and administrative and financial systems, the HIMSS/AMDIS comments noted. “While some preparations can be made in anticipation of the publication of the Final Rule, what must be done depends on what CMS finalizes, including changes that are made as a result of the feedback received from this NPRM.”
As a result, the HIMSS/AMDIS comments and those by other organizations urged CMS to limit reporting periods for the advancing care information portion of MIPS to 90 days in 2017, rather than require measurement over the course of the full calendar year.
The American Medical Informatics Association (AMIA) also expressed doubt over the ability of clinicians to successfully participate in a full-year reporting period. “AMIA recommends CMS issue an interim final rule with a comment period to further refine proposed policies based on stakeholder feedback, and we recommend CMS consider a 90- or 180-day reporting period in 2017.” The organization said success in the first year would be critical to the long-term success of the reforms.
In fact, comments from the Medical Group Management Association suggested that the start date for MIPS be delayed until the following year, to Jan. 1, 2018. “Following publication of the final rule and ahead of the start date, the agency must devote significant resources to educate practices about this complex program,” MGMA said. “Most importantly, beginning Jan. 1, 2018 would bring the measurement period closer to the payment year.”
In its comment letter, the American Medical Association suggested that CMS create a transitional reporting period for the first year, beginning July 1, "to allow time to prepare sufficient time to prepare physicians and enable a successful launch of the new Medicare payment and delivery system."
Some organizations sought to ensure that final rules scale back requirements for IT in the advancing care information (ACI) portion of the reimbursement formula.
The HIMSS/AMDIS comments laud proposed flexibility for physicians in achieving ACI, compared with all-or-nothing approaches used to qualify for financial incentives under the meaningful use program.
“However, there remains substantial alignment between the ACI requirements and Meaningful Use Stage 3 in terms of the functionalities required,” HIMSS/AMDIS comments noted. “Many of the technologies, as well as the process and workflow changes needed to meet these requirements, are still being developed. Therefore, providers and developers may need further time and flexibility to implement.”
The AMA's comments asked that the future ACI system not include pass-fail components and "restructure the EHR performance measures, rather than keeping the current Meaningful Use Stage 3 requirements."
In its comments, the College of Healthcare Information Management Executives (CHIME) urged that the new rule be used as a springboard to adjust the meaningful use program for hospitals, interjecting more flexibility in MU3 and pushing back requiring attestations for the program to at least 2019.
Most organizations’ comments urged CMS to simplify the approaches used to score physicians’ attainment of ACI targets.
Organizations also urged CMS to align the new program with those of the Office of the National Coordinator for Healthcare Information Technology to eliminate redundancies on surveillance and health information exchange, which were included as important components of the proposed rule.
Premier, a healthcare alliance representing 3,600 hospitals and health systems as well as 120,000 other providers, says the proposed rule places too much of the onus for health information exchange on providers.
“In our experience, data is locked in proprietary software systems, preventing providers from being able to connect and exchange information,” Premier’s comments said. “We ask that CMS oversight include monitoring EHR systems and understanding barriers, financial or other, that clinicians face in implementing EHR functions that support interoperability.”
However, the Electronic Health Record Association (EHRA), which represents vendors that develop electronic records systems, said its members will need more regulatory guidance "and clarity" about the meaning of the three major requirements that define data blocking, "if there are extenuating circumstances that would serve as exceptions, and how a provider would substantiate that they had acted in accordance with the attestation."
In addition, EHRA contends that some requirements of the data blocking attestations "go beyond what Congress intended or authorized in MACRA, and suggest that they are not necessary and should not be retained in the final rule."
To improve the current proposal and to help guide future proposals, AMIA’s comments established several principles CMS should consider related to Quality Payment Program, which included:
- Use data reporting requirements to learn, not simply to grade.
- Focus on defining clear, expected outcomes, rather than prescriptive process measures.
- Engage organizations and experts to perform scientifically rigorous, peer-review studies to determine which requirements should be retained in future years.
- Develop feedback loops that are accurate, timely and meaningful.
- Encourage increased data exchange and interoperability whenever possible.
“CMS has been tasked with changing our fundamentally flawed fee-for-service Medicare reimbursement system, and has issued an ambitious set of proposals to do so” said AMIA President and CEO Douglas B. Fridsma, MD. “While the new Quality Payments Program is complex, we are hopeful that these policies will enable informatics to play a central role in lowering costs, improving quality and delivering better outcomes.”
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