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Senior Healthcare Consultant on MU: Providers Need More Breathing Room

August 7, 2015
by Rajiv Leventhal
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When the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for Stage 3 of the meaningful use program in March, and then again for program modifications from 2015-2017 in April, immediate industry feedback and commentary followed. Since then, over the early summer months, all was quiet on the meaningful use front. But now, as the calendar reads August, and final rules could be on the verge of being published, health IT stakeholders have once again geared up for one last push to get the feds to address their concerns with the program.

Indeed, starting in late July, the calls from Congress began for a Stage 3 delay when during a Senate Health, Education, Labor & Pensions (HELP) Committee hearing, Sen. Lamar Alexander (R-TN), chair of the committee, said that he has requested that the U.S. Department of Health and Human Services (HHS) push it back from its scheduled start in 2017. Then, in a July 31 letter to HHS, several healthcare stakeholder organizations wrote a letter to HHS urging the department to publish the final rule for the modifications to the meaningful use program from 2015-2017. Also thrown into the mix was the recent introduction of the Flexibility in Health IT Reporting and Advancing Interoperability Act of 2015 or “Flex-IT 2” (H.R. 3309) into Congress by Congresswoman Renee Ellmers (R-NC-02). The legislation offers improvements to the meaningful use program, including a delay in the release Stage 3 rules.

Put all together, it’s become clear that the industry wants some answers—and soon. As such, HCI recently spoke with Jason Fortin, senior advisor at the Naperville, Ill.-based Impact Advisors about what’s in store for meaningful use throughout the rest of 2015, if stakeholders will get what they want, and what providers are grappling most about. Below are excerpts of t hat interview.

The health IT industry has been pretty up in arms lately about MU. What impact do you see this having at the end of the day?

First off, I haven’t heard anything that you haven’t regarding when things might happen regarding the MU modifications rule. There is a formal process to it that involves CMS publishing the rule in the Federal Register. I don’t know when it could happen, but it should be soon. If history is any indication, it should be in the next few weeks. The sooner the better for providers, since you are talking about changes to this reporting year and next year too. Until we hear something definitive though, we just don’t know. CMS isn’t tipping their hand either, and that could be because they can’t talk about it at this point.

Jason Fortin

In regard to the modifications rule, what changes do you see from the feds’ proposal?

I think they will keep a lot of what they proposed. I will be shocked if they don’t align the reporting periods on the calendar and move to a 90-day reporting period. For hospitals, if there wasn’t a proposed rule, the reporting period ends at end of September. That’s not enough time.

It could get tricky if they decide to add back in some of the measures they proposed to drop. There are a few things they said they might not require anymore because they are redundant, but if they add those back in that could be tricky even if they are measures that hospitals or EPs have met before. Everything they proposed would make this year easier, but the tough thing is for 2016. Take e-prescribing in hospitals for instance. If you are a hospital waiting for Stage 3 in 2018 to do e-prescribing, and all of a sudden, that will be something that is required in 2016 based on how the changes for Stage 2 measures are restructured. So 2016 is a year where some of the heartburn could occur. 

Back to patient engagement—what is the logic behind going from having 5 percent of patients view/download/transmit (VDT) their information down to one single patient, and finally back up to 25 percent in Stage 3?

The patient engagement measure is one change they have to make when you consider how hard that has been for providers. I wish I could tell you the logic behind that. Some of the logic for the 25 percent is that they would allow access through an ONC-certified API, but anything that requires certification is a big unknown. There isn’t a technology out there that could get us to 25 percent as is. There are pockets regionally that could do it, but at the level of 25 percent, it’s not really about technology anymore, but more about a fundamental shift in behavior about how patients look at their information.

Also, the transitions of care (TOC) measure went from 10 percent to 50 percent via CMS’ proposal, but the transitions could occur via any electronic means. What about Direct, where does it fit in? They left that open for comments so that will be interesting too. When this rule first came out, 10 percent didn’t seem nearly as bad and then people started implementing it and realized that it’s very hard.

Onto Stage 3, will the calls for a delay have any traction?

I wouldn’t be too surprised if a final rule is published and the timeline doesn’t change because it’s more about the process that HHS has to follow. I don’t know how flexible HHS will be—it could be that they’re done with the rule and it’s under review by someone else. But I do think Congress is quite likely to get involved for a delay. I don’t know if HHS has had enough time to react to the recommendations from the Senate HELP committee, which carries weight. It wouldn’t surprise me at all if Congress passes something like the 21st Century Cures bill for meaningful use changes. If the Stage 3 will be delayed or modified in some capacity, I would think it would happen through Congress, who would say that Stage 3 can start no later than X date, and HHS will provide guidance and will be on the hook to [make it happen]. The timing is a big awkward, but it has been the whole time.

Do you think providers need another reporting year before heading to Stage 3?

They are not ready for what was proposed by CMS, that’s for sure. I think a gentler Stage 3 is something they can be ready for 2018, but if you look at what was proposed, it’s hard to even get past the 25 percent conversation. Another tricky thing about Stage 3 is there are new measures, and with them, we don’t know how hard they will be. On paper it’s one thing, but if you look at it, no one knew that when Stage 2 first came out just how hard the TOC measure would be. Anything that’s new is challenging. Patient-generated data is such an unknown for instance, so yes, providers can certainly use an extra year to implement and get accustomed to those new measures.

I think there are some things that CMS has to back off from, and that’s the nature of rulemaking process—you start high as a bargaining chip. From my perspective, something that was closer to Stage 2 would have been something that people could be ready for in 2018. Another rule won’t hurt as it let’s folks catch up. Meaningful use has taken up a lot of resources and time, and I don’t think it would be bad to have that extra year. People need breathing room. If they do delay, maybe they use that as a way to say that this was the time for providers to get up to speed on the measures they have set. But again, without knowing their thinking and logic behind it, it’s really hard to say. 

Do you think Stage 3 is necessary? Would it be better to just move on?

Many in the industry would be relieved if that happened, as they rightfully see  these requirements as overly prescriptive. But if you look at the Merit-based Incentive Payment System, or MIPS, in 2019, meaningful use will be weighted as part of an overall score. That’s where things are headed on the outpatient side, and I can see that on the inpatient side too where the use of IT is one component of an overall score. But maybe there will be a de-emphasis over time. It will be interesting to see if there are other health IT provisions in the 21st Century Cures bill, which seems to be a vehicle that lawmakers are targeting.

Other than the measures we have already talked about, what is it about this program that providers dislike most?

It’s the uncertainty of the timing, not knowing when something will happen or if it will happen. If Stage 3 is published, for example, people can’t rely on the fact that it actually will happen in 2018 given all the changes that happen last minute. That is a big frustration—the government sets the requirement and then you have to go through last minute changes. Providers have so much going on, not just meaningful use. It’s hard to juggle priorities when you don’t know when the deadline will be, something that we’re seeing with ICD-10 too.  It will be interesting to see what CMS has taken from the experience of the last few years, particularly from 2014 with the problems with certification and having to issue last minute changes. We will see what they have learned when the Stage 3 rule comes out.


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