The day after the federal Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would make changes in the second year of the Quality Payment Program (QPP) under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, affecting Medicare-participating physicians covered either under the MIPS (Merit-based Incentive Payment System) program, or participating in APMs (advanced payment models), healthcare industry leaders are reacting to the content of the proposed rule, mostly with a sense of relief, or of broad satisfaction, even as they wonder exactly how the final rule will play out.
In interviews with Healthcare Informatics editors, industry leaders say that the broad outlines of the proposed rule appear to be reasonable, and that it appears that CMS officials have taken a middle path as they try to prod U.S. practicing physicians forward into value-based reimbursement and quality measurement in the context of a rapidly shifting Medicare payment environment. Issues around pace, incentives, specificity of measurement, and the welter of data gathering- and information technology-related issues to consider, are keeping industry leaders focused on both the broad outlines and the complex details embedded in the 1,058-page proposed rule, which dropped late in the afternoon on June 20.
HIMSS and CHIME Weigh In
Leaders at the major healthcare IT professional associations expressed satisfaction over the moderate elements related to data and information technology in the proposed rule. Jeff Coughlin, senior director of federal and state affairs at the Chicago-based Healthcare Information and Management Systems Society (HIMSS), says, “I would say that the biggest takeaway is the flexibility that’s provided for providers, that’s in the rule. HIMSS spent time earlier this year, in 2017, talking about 2015 edition certified electronic health record technology (CEHRT) and about how where we were in terms of the level of adoption and availability of 2015-edition CEHRT products, and how we didn’t think we could get to the place we needed to be,” says the Washington, D.C.-based Coughlin. “This is one example of the flexibility in terms of allowing more time for providers to adopt 2015-edition CEHRT.”
What’s more, Coughlin says, “CMS also spent a lot time, in the rule, talking about the benefits of 2015 edition certified EHRs, and how important it is to transition and all the benefits from that transition for providers, and at the same time, providing more time for those providers, mostly likely small providers, that need the extra time to implement 2015 edition CEHRT products. But it does have bonus points, in the ACI [Advancing Care Information] performance category related to adopting and using that [2015-edition CEHRT] to report in 2018. It is, directionally, the right place to be,” he says. “I would emphasize,” he adds, “that we thought it was great to see the amount of time that CMS spent in the rule singing the praises of the 2015 edition CEHRT and what that transition would mean for providers and patients. There are several pages in the proposed rule focused on that, and that’s exactly the message that we tried to get across in April, that the 2015 edition CEHRT is definitely a step that we need to take, we just need a longer on-ramp to get there. I think at this point, I think it’s probably directionally appropriate.”
Leslie Kriegstein, vice president for congressional affairs at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), said that, “Overall, it looks like CMS heeded a lot of the provider community’s calls for another transition year. So going from the minimum necessary of 3 points to 15 points, seems reasonable in terms of keeping people in the program and marching in the right direction,” said the Washington, D.C.-based Kriegstein. “The fact that 2015-certified technology would be bonus instead of mandatory, was positive, but also leaves a lot of questions for hospitals still participating in meaningful use,” under a program that was bifurcated when the meaningful use program for physicians was incorporated into the MIPS program after the passage of the MACRA law. “And you still have hospital-based and employed physicians leveraging technology they need for MIPS,” she noted.
Meanwhile, despite the complexity of different sets of requirements for hospitals and physicians in terms of using federally certified electronic health record (EHR) technology under the terms of two different programs, Kriegstein says she is glad that this proposed rule does not require 2015 certification on the part of practicing physicians. “The extra time to be able to use 2014-certified technology was an imperative,” she says. “When we surveyed our members, a sizable proportion of our membership won’t have access to 2015 cert even before the end of the year. So in our IPPS [Inpatient Prospective Payment System rule-making] comment, we said, per CEHRT, that that’s a huge problem. So that should be a huge relief to the doctors that they can use 2014. Because it’s a huge fallacy that large numbers of doctors could use 2015 this year. So that gives us hope regarding what they might do for the hospitals.”
In sum, Kriegstein says, “On the whole, it looks like they’ve prioritized small practices, with all of the different bonus opportunities, and the fact that they can file for an exemption from ACI. So I would anticipate that the small providers must feel some relief. That’s not as applicable to our membership, but that’s something they should welcome.
Looking at the Incentives for Physicians of Different Types
What about the incentives embedded in the proposed rule, for physicians to move forward around payment for value? “What I see is that there’s more flexibility for sure, particularly for small practices,” in the proposed rule,” says Tom Lee, Ph.D., CEO of the Chicago-based SA Ignite consulting and software services firm. “That also means there are more levers for optimizing your score. But it also means there are more decisions to make, and no one wants to make a wrong decision and leave money on the table.”
Importantly, Lee reminds everyone of the payment regime under MACRA, “It’s a competitive system, and winners will be paid by losers. And there’s a 2.9 percent maximum incentive estimated for 2018. And that incentive could actually go substantially higher if it turns out that the actual number of people who participate is only 10 percent lower than the number who participate. Also, they’ve repeatedly said that the 2019 performance year is locked into the legislation,” so that in 2019, the law will necessarily require physicians to be measured—and paid—against a system of national average-based performance measurement. In 2017, physicians are subject to only a 3-point differential, out of a total of 100 possible points measuring their performance across several categories; but the proposed rule calls for a 15-point differential for 2018, and, Lee points out, CMS officials openly state in their proposed rule release that they might raise that differential from 15 points to 30 or more points. “They’ve estimated that the actual value is significantly higher, because they want to give people a fair-step way of getting to 2019, where the MIPS performance threshold has to equal the national average of MIPS point value in a historical period,” he says. “So the 3 points this year and the 15 points next year, do not reflect a national average. The overall rigor of the proposed rule is about right, Lee thinks.
Not everyone agrees. Among those who feel that the proposed rule is not rigorous enough to stimulate rapid innovation is Chester A. (Chet) Speed, vice president, public policy, for the Alexandria, Va.-based American Medical Group Association (AMGA), which represents 440 large medical groups, encompassing more than 175,000 physicians. “The proposed rule recognizes that there’s a tension in getting to value,” Speed says. “On the one hand, everyone wants to get to value, which is essentially improved care quality at lower cost. At the same time, HHS [the Department of Health and Human Services] recognizes that getting to measured value can be a real burden on physician practices. So they’ve excluded a fairly big chunk of small practices from MACRA, recognizing that it’s a burden on them. At the same time, those who have invested in the people and technology to improve care and lower costs, the typical AMGA members, are not being rewarded for these investments and efforts, which frankly take millions of dollars and many hundreds of hours of people efforts, to get to value.”
The problem, Speed says, speaking of CMS officials, is that “They expect that those groups with over 100 doctors, which represent 99 percent of AMGA members, their MACRA bonus will only be 1.4 percent. And the maximum is 5 percent. So by excluding all these small practices, you’re crunching the bell curve and reducing rewards to high performers. So that’s the tension involved; you’re not rewarding those that have done all the work to get to value. So I think about our members who have put millions of dollars into this and have spent so much leadership time and effort to get to value; 1.4 percent in MACRA hardly rewards you for all the effort you’ve made; and it’s not really the signal you want to say, we’re going to value.”
Moving Forward—Into Uncharted Territory
On Wednesday morning, the Bethesda, Md.-based American Medical Informatics Association (AMIA), a nationwide association of medical informaticists, released a statement attributed to Douglas B. Fridsma, M.D., Ph.D., the association’s president and CEO. “It is vital that we continue our collective march towards modernizing healthcare delivery and the patient’s experience,” Fridsma said in the statement. “While there are numerous details to review, AMIA is pleased that CMS has proposed a flexible set of requirements meant to encourage health IT-enabled care. Specifically, the proposal to reward those clinicians who demonstrate more advanced use of health IT to support patient care through 2015 Edition CEHRT will improve interoperability for providers and provide patients with better access to their data. Meanwhile, clinicians who need additional time to upgrade or adopt 2015 Edition CEHRT will benefit from another 90-day reporting period, and the option to use legacy versions of CEHRT in 2018. We also applaud CMS for expanding the list of Improvement Activities that can count as bonus payments for the MIPS Advancing Care Information performance category. This approach helps credit clinicians for using health IT within a care improvement context, and we see this as a more outcomes-focused approach to measuring health IT use. We look forward to looking into the rule in more detail and providing our feedback.”
Doug Fridsma, M.D., Ph.D.
There is much to unpack in the proposed rule, Fridsma says. One of the broad questions remains, will this proposed rule, as well as the entire set of regulations and requirements under the MACRA law, move the industry forward into payment for value in a way that is set at the right pace and with the right broad incentives to encourage physicians forward in an optimal way, in this moment in the evolution of U.S. healthcare? When presented with the “Goldilocks” metaphor of the mythical little girl who goes into a house in the woods in which three bears are eating porridge that is too hot, too cold, or just right, and sleeping in beds that are too hard, too soft, or just right, and so on, says, “Well, you know, we’ve never been to Grandmother’s house! Is it too hot, too cold, or just right? We don’t really know. We could always speculate about whether they did too much or not enough” in how this proposed rule was crafted, Fridsma says. But we have to recognize that we’re moving in this direction for the first time. And to what extent are the measures process-based or outcomes-based? Do we even have the right thermostat?? I think it’s hard to say.”
Fridsma goes on to say, “Given the regulatory climate and where we are, we’ve got to make sure that whatever we do is put in place to help the patient and to improve healthcare. That’s ultimately the only thing that matters, with regard to being too hot or too cold. If you create incentives that don’t align with that, it won’t be the porridge you want eat! But you know, the thing is, and I’ve said this before, we want to take the path of least regret. We want to make sure that we’re continuing to improve HIT such that it can improve care delivery and improve the quality of the patients’ lives, and of the work that the physicians do.”