Proposed MACRA physician payment rule would revamp IT incentives

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The Medicare Electronic Health Record Incentive Program for office-based physicians and other eligible clinicians is being replaced with a simplified program under which those professionals will receive incentives for reporting measures that they can customize for their practices.

The changes were announced in a proposed rule released by the Department of Health and Human Services late Wednesday. The changes were contained in a rule by HHS that 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.

Industry stakeholders now will have a couple months to review the rule and make formal comments. The 962-page proposed rule is available here.

For eligible professionals (EPs), the new approach will replace the current incentive approach, more commonly called the meaningful use program, which has been in place for the past five years. Portions of the meaningful use approach will survive—for example, physician EHRs will need to be certified under the 2015 Edition certification criteria, although there will be changes to measures and other requirements.

And the meaningful use incentive program will continue in force for hospitals and their hospital-based clinicians, as well as providers reimbursed for EHRs under Medicaid. While the proposed rule deals primarily with significant revisions to the physician reimbursement system, aspects affect hospitals and other providers as federal agencies ramp up efforts to stop practices in which medical information is not shared, widely termed “information blocking.”

Some provider organizations reacted quickly and generally supported the long-expected release of the proposed rule, while acknowledging it will take time to review it and respond to the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology.

“Our initial review suggests that CMS has been listening to physicians’ concerns,” said AMA president Steven Stack, MD, in a statement. “In particular, it appears that CMS has made significant improvements by recasting the EHR Meaningful Use program and by reducing quality reporting burdens.” The AMA will be providing guidance on how the rule will affect practices, as well resources to help physicians through new payment models.

However, the American Hospital Association did not issue an initial reaction to the meaningful use changes, but expressed concern about the payment models the rule contains. “We are deeply disappointed by CMS’s narrow definition of alternative payment models, which could have a chilling effect on providers’ ability to experiment with new patient-centered, value-driven models. Today’s rule fails to recognize the significant resources and risk assumed by the highly motivated early adopters of alternative payment models.”

For EPs, the meaningful use program will be folded into the Merit-based Payment System (MIPS), which was created under MACRA. The meaningful use component of MIPS has been renamed Advancing Care Information.

The proposed rule represents a simplified approach for EPs, who have found multiple reporting programs to be burdensome. The existing Physician Quality Reporting System, Physician Value-based Payment Modifier and the Medicare meaningful use program will be consolidated under MIPS.

Reporting in a single program on a single platform will be customized by each EP, who will report on six measures from a range of options that accommodate differences among specialties and practices. Each EP also will select and report customized measures that reflect how they use their EHR in daily practice. This approach provides more flexibility than meaningful use, which requires providers to meet a standard set of requirements and penalizes those who are unable to meet them all.

Medicare will measure EP performance on quality, resource use, clinical practice improvement and this customized use of certified EHR technology. MIPS payments then will reflect the value of care in four these performance categories.

In the area of information technology, EPs will have streamlined measures—from 18 now to 11 under the Advancing Care Information program, emphasizing interoperability, information exchange, security and patient access to their health information through application programming interfaces (APIs). The clinical decision support and computerized provider order entry measures would be eliminated because these technologies have become widely adopted.

CMS and ONC officials believe use of APIs will pave the way for apps, analytic tools and medical devices to become plug-and-play. “Through this new direction, we look forward to developers and entrepreneurs taking the opportunity to design around the everyday needs of users, rather than designing a one-size-fits-all approach,” CMS leader Andy Slavitt and ONC head Karen DeSalvo, M.D., wrote in a blog describing their take on the new rule and its impact on healthcare IT.

While Advancing Care Information affects only payments to physician offices, the leaders note they are meeting with hospitals to discuss opportunities to align the Medicare hospital and Medicaid meaningful use programs to better serve clinicians and patients.

Under the proposed rule, as authorized by an earlier rule last October finalizing the 2015 Edition of certified EHRs, ONC will strengthen its surveillance, or oversight, of the performance of certified EHRs and other certified technology products. This includes having EHR certification entities conduct more frequent and more rigorous surveillance of EHRs in-the-field, not in a lab.

“The purpose of in-the-field surveillance is to provide greater assurance that health IT meets certification requirements not only in a controlled testing environment but also when used by healthcare providers in actual production environments,” according to the rule.

Another rule published on March 2, 2016, enables ONC to review and evaluate the performance of certified IT in certain circumstances. This includes responding to potential systemic or widespread issues, which could include interoperability and data exchange woes that ONC wants to rectify, as well as problems that pose a risk to public health, safety, security or privacy.

The requirement to submit to surveillance also pertains to hospitals. “We are proposing that as part of demonstrating that it is using certified EHR technology in a meaningful manner, an eligible clinician, EP, eligible hospital or Critical Access Hospital must demonstrate its cooperation with these authorized surveillance and oversight activities,” the rule says.

ONC, based on authorization under the Medicare Access and CHIP Reauthorization Act of 2015, also is requiring that eligible clinicians, EPs, hospitals and Critical Access hospitals must attest that they did not “knowingly and willfully take action to limit or restrict the compatibility or interoperability of the certified EHR.” Further, these entities must attest that they responded in good faith and in a timely manner to requests to retrieve or exchange electronic health information from providers and patients, regardless of a requestor’s affiliation or technology.

In a media conference call, DeSalvo emphasized that the rule changes the culture of data sharing and will help providers compare products.

If the rule is finalized, it would replace the current meaningful use program, and reporting would start Jan. 1, 2017. CMS and ONC are accepting public comment for 60 days.

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