The Medicare Access and CHIP Reauthorization Act (MACRA) will replace the fee-for-service payment model for Medicare with value-based reimbursement, relying heavily on electronic clinical quality measures.
However, the American Medical Informatics Association is concerned about the industry’s ability to generate accurate and complete eCQMs, which will play a vital role in both the new payment system and alternative payment models.
Signed into law earlier this year, MACRA repealed the Medicare sustainable growth rate methodology for updates to the physician fee schedule and replaced it with a new Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). While AMIA supports this transition to an outcomes-based payment system, it argues that the Centers for Medicare and Medicaid Services must also move away from the current quality measurement paradigm underlying the fee-for-service system.
“Despite earnest efforts, quality measurement has not become ‘a by-product of care delivered,’ as envisioned, but rather an end unto itself,” AMIA warns in a Nov. 16 letter to CMS in response to a request for information on MIPS and APMs. “We are concerned the current mode is insufficient to enable the desired state—especially as it relates to electronic clinical quality measures. The focus on collecting numerous process measures that may not reflect a patient-centered perspective on quality needs to be replaced by focusing on a more targeted number of important outcome measures.”
AMIA recommended that CMS not “reflexively expand the current approach to quality measurement” in developing policies for MIPS and APMs, but instead should “retire existing process-based measures while looking for ways to develop more outcomes-based measures.”
To improve the current approach to measures, AMIA urged CMS to devote more resources to testing both the accuracy of the measure calculation, as well as the feasibility of the data collection requirements, and pilot all new eCQMs before their release for use. According to AMIA, CMS should also establish a regular cadence of updates/revisions to eCQMs, ensuring adequate time is allowed for implementation of revisions by both vendors and providers.
“New process-based measures should be added only after carefully considering the impact on physician workflow and documentation time and assuring that the value the measure will provide is greater than the burden imposed on physician workflow,” cautions AMIA.
Based on feedback from stakeholders like AMIA, CMS intends to issue a notice of proposed rulemaking for implementation of MIPS and promotion of APMs in the late spring of 2016, with a final rule expected later in the fall.
AMIA’s letter to CMS also commented on how the agency should implement policies that require the use of certified electronic health record technology, and whether new certification criteria are needed to help providers succeed within new payment models. AMIA recommended avoiding “overly prescriptive” requirements to determine how providers use informatics tools within APMs, and instead focus on the outcomes sought by the use of such tools.
In addition, the informatics association recommended that any efforts to certify health IT functionalities related to population health and analytics meet some threshold of “demonstrated need” first, given that the optimal information systems infrastructure for managing population health or analytics functions is “not yet well understood,” according to AMIA.
“Unlike computerized provider order entry or e-prescribing, which are well-defined functionalities to which harmonization through certification has value-add, we do not yet have enough experience with how population health and other APM tools and functionalities should be defined to a degree that certification could or would provide needed value,” argues the letter, which expresses concern that certification in this emerging area may hinder development of new features and functionalities that have not yet come to the marketplace.
However, by developing a framework to evaluate demonstrated need “stakeholders can debate the rationale for certification versus other means of conformance, and officials can more confidently identify when certification is likely to have the intended impact.”
Finally, AMIA recommended that federal officials develop a public implementation roadmap, aligned with goals for shifting Medicare reimbursements from volume to value, that clearly lays out the CMS quality strategy, beginning with a focus on accurate, complete and valid eCQMs.
“If CMS continues its plan to require electronic submission of CQMs, and payment depends on those quality measures beginning in 2017, all stakeholders must be confident that those eCQMs represent an accurate picture of care delivered,” the letter concludes.
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