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Within MACRA Proposed Rule, Health IT Leaders Ponder the Complexity of the “New” Meaningful Use

April 28, 2016
by Rajiv Leventhal
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The proposed Advancing Care Information program will provide clinicians with flexibility, but brings on challenges of its own, experts say

With the release of a proposed Medicare Access and CHIP Reauthorization Act (MACRA) rule on April 27, the federal government announced changes to the existing meaningful use (MU) program, leaving Medicare physicians with nearly 1,000 pages of reading to examine how the new program, called Advancing Care Information (ACI), and others, will impact their organizations.

Indeed, officials from the Centers for Medicare & Medicaid Services (CMS) effectively said that meaningful use will be “replaced” with the new ACI program for Medicare doctors, which accounts for 25 percent of an eligible physician’s (EP) total score under the Merit-based Incentive Payment System (MIPS) in the first year. In addition to the Advancing Care Information program, doctors will be scored on Quality (50 percent of total score in year 1); Clinical Practice Improvement Activities (15 percent of total score in year 1); and Cost (10 percent of total score in year 1). Overall, how EPs score within each of these four areas will determine their reimbursement amounts for health IT. CMS would begin measuring performance for doctors and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019. For the moment, hospitals will be unaffected within this part of MACA, per the Notice of Proposed Rulemaking by the Department of Health and Human Services (HHS).

Under the Advancing Care Information category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing meaningful use reporting program, this category would not require all-or-nothing electronic health record (EHR) measurement or redundant quality reporting, according to a CMS press release. Instead, the ACI category consists of two components: the base score, in which an eligible physician can earn 50 percent of his or her total points, and a performance score to make up the rest.

Within the base score, previous thresholds under meaningful use (i.e. requiring physicians to send a secure message to 5 percent of patients) are wiped out, and are replaced with a requirement of either having one single patient perform under that objective’s measure, or report a yes/no statement as appropriate (only a yes statement would qualify for credit under the base score). Meanwhile, the performance score is based on the priority goals established by CMS to focus on leveraging certified EHR technology to support the coordination of care. Similar to the base score, there are no thresholds for a clinician’s performance score, which CMS said will provide the much-desired flexibility that physicians have long been looking for. Objectives such as computer provider order entry (CPOE) and clinical decision support, in which the median clinical performance was extremely high under the existing program, have been removed under the Advancing Care Information proposed rule.

So, does all this mean that meaningful use is, in fact, “dead?” Not so fast, says Jeffery Smith, vice president, public policy, at the American Medical Informatics Association (AMIA). Smith predicts that many detractors of MU will not be satisfied with this newfound flexibility, due to the fact that they still have to do a lot of what Stage 3 was going to originally require.  And while the new scoring methodology will give MIPS EPs flexibility, it’s also going to give a lot of them headaches due to its complexity, he says. “Meaningful use is not dead in the slightest,” Smith says. “A lot of the major components of Stage 3 are still intact. The threshold requirements are no longer there, so that’s what has changed. You can argue that the threshold requirements not being there in some ways are nullified as a benefit. This is not MU recast; it’s MU rebranded,” he says.

Smith goes on to explain what he means about how the eliminated threshold requirements nullify the potential flexibility offered to providers, giving the patient electronic access to health information objective as an example. He says under Stage 3 of the MU program, the threshold was that 80 percent of patients be provided access to view/download/transmit (VDT) their health information. Under the new Advancing Care Information program, only one patient would be required to do this for the clinician to achieve the full base score possible. But, for the performance part of the score, “CMS will still grade you on how many patients VDT their information,” Smith notes, pointing to the below sample that was provided in the Notice of Proposed Rulemaking.

Source: Department of Health and Human Services

As such, while there are no thresholds anymore for clinicians, they will still have to perform to a similar set of objectives and measures that were going to be required in Stage 3 of MU anyway. “CMS has gotten rid of the all-or-nothing approach, but they have created a situation where people still have to work their tails off to get all of those 25 points [under the ACI category],” Smith says, adding that if you score a low percent in one of the above measures, that could significantly hurt your total performance score. In fact, Smith says that a MIPS eligible professional who aces the MU Stage 3 test would receive a B- in proposed MIPS scoring schema.