Ever since the Centers for Medicare & Medicaid Services (CMS) released the final rule for Stage 3 of the meaningful use (MU) program in October, providers have not hidden their displeasure regarding measure thresholds and program requirements, and its overall lack of flexibility. What’s more, they want the current MU trajectory to slow down; they have urged CMS to hit the pause button, to wait until more providers have attested to Stage 2, and to focus more on interoperability rather than burdensome requirements that have led to more angst for doctors.
These are the words of physicians themselves, spoken out through groups such as the American Medical Association (AMA), American Hospital Association (AHA), and the American Academy of Family Physicians (AAFP), among others. But recently, I came across a different perspective that caught my attention from the Consumer Partnership for eHealth (CPeH), a Washington, D.C.-based patient advocacy group led by the National Partnership for Women & Families, who argued that the current structure of MU should be maintained, not overhauled.
I was so intrigued by CPeH’s meaningful use comments, also signed by 24 other consumer and health organizations, that I called its director of health information technology policy and programs, Mark Savage, to get more insight. My interview with Savage, published last week, can be read here, but in this space I want to take a deeper dive into the two opposing perspectives. It should be noted that CPeH doesn’t include providers themselves, but Savage says the Partnership does have long-term working relationships with many of the provider groups that are so outspoken against meaningful use.
During our conversation, Savage brought up some very interesting points to me, perhaps the biggest regarding the number of eligible professionals (EPs) and eligible hospitals (EHs) that have reached Stage 2 already. Specifically, the AMA and other provider organizations have pointed out several times that only 12 percent of physicians have been able to successfully participate in Stage 2 of meaningful use. "The statistic speaks volumes about how physicians embrace new technology while ill-conceived regulations hold back progress,” the AMA said in a November letter to CMS, also signed by 110 other medical associations. This 12 percent number has been one of the main points that provider organizations have hammered home in their argument that most physicians are not nearly ready for Stage 3.
Indeed, recent CMS statistics show that there are 483,233 combined EPs and EHs who are qualified for meaningful use incentive payments. The numbers also show that of those 483,233 who are eligible, a combined 62,163 have attested to Stage 2—or a little more than 12 percent, as the AMA and others have said.
However, Savage interprets this data in a different way. While yes, there are nearly 500,000 EPs and EHs in the MU program, many of those are still stuck in Stage 1, meaning they aren’t yet eligible for Stage 2. Looking again at the CMS data, there are 124,336 EPs and EHs are who actually eligible for Stage 2—not the 483,233 that is often reported. This means that there are a great deal of EPs and EHs who aren’t yet ready for Stage 2. So, in that sense, the Stage 2 attestation rate for those who are eligible for this stage is actually more like 50 percent (62,163/124,336)—not 12 percent. After all, Savage argues, how can all of the EPs and EHs who are still in Stage 1 be counted towards the Stage 2 attestation rates?
The point Savage makes is an interesting one, for sure. Perhaps, for the providers who are legitimately eligible for Stage 2, attesting isn’t as hard as is publicly perceived? On the other hand, it’s hard not to think about all of those eligible providers still stuck in Stage 1 in the fourth full year of the program.
Clearly, for many physicians, climbing the meaningful use ladder has not been easy, so when associations such as the AMA, AHA and the College of Healthcare Information Management Executives (CHIME) ask CMS to wait until 75 percent of eligible providers have attested to Stage 2 before mandating Stage 3, I think this position has real merit. I went back to Savage and brought up this point, the idea that Stage 3 should not be required as early as 2018, as currently outlined by CMS. He said that for those struggling in earlier stages of the program, there is a modified and simplified course; for example, the provider in Stage 1 goes through a modified Stage 2 in 2016 and 2017 to a simplified Stage 3 in 2018. Still, to me, it’s hard to imagine that Stage 1 provider being ready for any version of Stage 3 by 2018—simplified or not.
To this end, Savage also brought up that while providers will point to the lack of flexibility in the program, there actually is much more leeway than people think in terms of hardship exemptions and low minimum thresholds. However, there has been controversy over who is eligible for the hardship exemptions. While recent legislation that will apparently will make it easier for providers to receive hardship exemption from financial penalties for failing to meet Stage 2 requirements is waiting for President Obama’s signature, a Dec. 22 Politico morning eHealth report says that the bill “doesn't clearly outline which categories of eligible professionals would be newly eligible for hardship exemptions this year.” This is especially important right now as the CMS final rule was published with fewer than 90 days left in 2015, making it difficult for providers to meet the program's 90-day reporting period. The Politico report continues, “The consequences are big for doctors, since meaningful use penalties are set at 3 percent of Medicare reimbursements in 2017 for docs who don't meet meaningful use standards in 2015—unless they got a hardship exemption.”
Regarding the minimum thresholds, Savage says that requiring one single patient, or even 5 percent of patients, to do a certain act should not be difficult to achieve at all. In fact, he says that CMS reported that doctors and hospitals were doing far better than 5 percent in terms of online access and secure messaging. Nonetheless, providers in the trenches have long said that penalizing them for actions outside of their control is not fair in the slightest.
Additionally, CPeH argues that a 365-day reporting period should be mandated, as opposed to providers choosing a 90-day period of their liking. “With 90-day reporting periods, people work on the issue for 90 days, but don’t work on it for the 270 other days. You can imagine what happens on interoperability if one system chooses one 90-day reporting period, but another system chooses another 90-day period and they don’t sync up,” Savage says.
Providers, however, point to the time needed to plan for upgrades, technology fixes, and optimizing software. A full-year reporting period offers very little, if any time to allow for these unforeseen circumstances, they say. In this sense, I agree with them. They key concept of the reporting period is that you can consistently do something successfully. But you shouldn’t have to constantly prove that you can do it, just like you don’t have to check your car’s oil level every day—every three months is suffice.
At the end of the day, while I am fascinated by the back-and-forth in this debate, it’s hard for me to take a hard and firm stance, not being a doctor on the ground myself. While I am a big advocate of the core intention of the meaningful use program, I think it’s fair to question some of the specifics embedded inside it. That being said, the consumer advocacy group CPeH makes some fair points as well, which can be seen as “refreshing” coming during a time when all we hear is negativity. The important question going forward is, will CMS make any of the changes that providers themselves have asked for? No matter what happens, you can be sure of one thing—one of these two sides will be left feeling dissatisfied.