AMIA, MGMA, AMGA Offer Comments on CMS’ Latest E&M, Quality Payment Program Proposals | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

AMIA, MGMA, AMGA Offer Comments on CMS’ Latest E&M, Quality Payment Program Proposals

September 10, 2018
by Rajiv Leventhal, Managing Editor
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Leading health IT associations have varying sentiments and recommendations for the Centers for Medicare & Medicaid Services (CMS) regarding the federal agency’s Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) proposed rule that was released in July.

On July 12, CMS proposed changes that the agency believes will “fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information.”

Included in the proposal were both changes to documentation requirements for Evaluation and Management (E&M) codes; modifications to how Medicare clinicians would be paid for virtual services rendered; as well as year three proposals for MACRA’s (the Medicare Access and CHIP Reauthorization Act of 2015) Quality Payment Program, including streamlining MIPS (Merit-based Incentive Payment System) participation, which includes the newly renamed Promoting Interoperability (PI) Program.

Healthcare Informatics covered the core takeaways from these proposals, particularly for how they impact the health IT community, in a story following the rule’s release in July

Now, in a letter delivered by the AMGA (formerly American Medical Group Association), the group noted that under the proposed rule, CMS would replace the current E/M codes with a new, single blended payment rate for E/M Level 2 through 5 visits. At the same time, CMS would apply a minimum documentation standard to provide Medicare Part B physicians with a choice of time, Medical Decision Making (MDM), or the use of the current 1995 or 1997 documentation guidelines. AMGA believes CMS is conflating two distinct or separate issues: documentation requirements and the complexity of a patient’s care needs represented by a billing code.

“Providing physicians with a choice in how to document beneficiary E/M visits would be a welcome development,” said AMGA President and CEO Jerry Penso, M.D. “It indicates CMS is serious about addressing administrative burden, particularly since these billing codes represent nearly one-third of all Medicare physician visits. Unfortunately, pairing paperwork reforms with a significant change in categorizing patient complexity and reimbursement may very likely undermine care quality and coordination and cause disruption in physician workflow and referral patterns.”   

What's more, in comments submitted CMS, the American Medical Informatics Association (AMIA) applauded federal officials “for aligning physician and hospital EHR requirements and advancing policies that further incentivize the adoption of health IT for patient care.” AMIA also supported CMS efforts to reduce documentation burden through new options to use time or Medical Decision Making as a basis to determine E&M visit level.

As part of E&M guideline reforms, CMS proposed to allow physicians the option to use time or MDM as a basis to determine E&M visit level. In its comments to CMS, AMIA said it supports both the use of MDM and time as alternative means to determine appropriate level of E/M visit. “However,” the group noted, “determining levels of MDM is a convoluted and complex task under current guidelines. This complexity must be addressed with an eye towards how IT and informatics can be leveraged so the simplicity of these solutions can be realized.”

AMIA specifically recommended that CMS support their proposed E&M reforms with focused and well-resourced efforts to leverage these current functions and develop emerging functions, such as natural language processing, medical device data, voice recognition software, and the use of sensors to capture clinical activity. “Acknowledging that these and other informatics tools are still early in development,” AMIA said, “CMS should support pilots and otherwise incentivize efforts meant to use these kinds of technologies and evaluate their use for documentation purposes.”

“Our current documentation paradigm is incompatible with the digital age,” noted Joseph Kannry, chair of AMIA’s public policy committee and lead technical informaticist at Mount Sinai Health System and Professor of Medicine Icahn School of Medicine at Mount Sinai. “While imperfect, CMS must proceed with E&M documentation reforms to address growing dissatisfaction and declining wellness among clinicians. Our billing-focused health IT ecosystem must be reoriented to patient care.”

Meanwhile, the Medical Group Management Association (MGMA), in its comments, said it “urges CMS to reconsider options for reducing documentation associated with E/M office visits to avoid harming physician practices that treat the sickest patients. This proposal oversimplifies the most common yet most diverse patient interactions while doing little to reduce paperwork.” Specifically, MGMA believes that CMS should not move forward with its proposal to collapse payment rates for eight office visits for new and established patients down to two each, as there are many unanswered questions and potential unintended consequences that would result, the group stated.

QPP Recommendations

AMIA said in its comments that by mirroring proposals finalized for hospitals in 2019, CMS would require the use of 2015 Edition CEHRT (certified EHR technology) 2019 and continue a 90-day EHR reporting period through 2020. The PI Program would also include a new points system scoring methodology and fewer required measures for hospitals to report. AMIA largely supported these proposals, while recognizing that important functionalities related to retired patient engagement measures, such as secure messaging, education, and use of patient-generated health data, must remain part of CEHRT, the group stated.

“Meaningful Use has served as a valuable vehicle to help digitize care delivery in the United States and thereby enable informatics-driven improvements in patient safety and clinical care,” said Peter J. Embi, M.D., AMIA board chair, and president and CEO, Regenstrief Institute. “But now is the time to think differently about how this program should evolve to meet the rapidly-changing, and often challenging, environment of care delivery. These new proposals position the program to build on progress made to-date, and our recommendations provide impetus for even more innovative changes focused on the ultimate goals of improving health and healthcare.”

MGMA, meanwhile, believes that CMS ought to simplify MIPS and reduce redundancies by awarding multi-category credit. As implemented, MGMA noted, “MIPS reflects a continuation of the agency’s historically siloed approach to quality reporting, consisting of four programs under one umbrella. To reduce burden, CMS should award credit in multiple categories for overlapping efforts, such as using clinical-decision support or capturing patient-reported outcomes.”

Related to MIPS, MGMA also attested that CMS should:

•             Permanently shorten the minimum reporting period to any 90 consecutive days;

•             Provide clear and actionable feedback about MIPS performance at least every calendar quarter;

•             Increase opportunities to participate in Advanced Alternative Payment Models (A-APMs);

•             Permit MIPS and APM participants to use 2014 or 2015 CEHRT in 2019 and 2020.

What's more, CMS, via the rule, is proposing an avenue for excluded clinicians who would like to participate voluntarily to “opt in,” which AMGA sees as a positive development. In addition, this policy improvement suggests CMS recognizes—as AMGA has argued—that excluding providers from the MIPS program is counterproductive for both those excluded and those included.

“Excluding providers from MIPS has a tangible impact on those clinicians who are working to succeed in the program,” said Penso. “AMGA members will continue to deliver high-value quality care, but these exclusions prevent MIPS from recognizing and rewarding their efforts to create value for Medicare.”

Virtual Care Proposals

Beginning in January 2019, CMS proposed to reimburse physicians for engaging in “virtual care,” for “brief communications,” “remote evaluation,” and “interprofessional consultation.” AMIA applauded CMS for recognizing the increased state of digitization in healthcare delivery and thus proposing to reimburse providers accordingly.

“We view these policies as addressing long-standing Medicare reimbursement barriers to widespread adoption of virtual care tools meant to reach more patients in more places, especially those in underserved and rural areas,” AMIA said. However, AMIA noted specific concerns related to the context of these new virtual care codes and encouraged CMS to consider issues related to clinical effectiveness, patient authentication, and proliferation of data silos derived from telehealth applications.

MGMA, meanwhile, noted in its comments, “MGMA supports CMS’ efforts to increase access to care by providing reimbursement for communications-based technology and telehealth services. This is a step in the right direction toward recognizing that medical practices connect with patients using new technologies.”

MGMA added that CMS “should modernize the Medicare program by finalizing coverage for virtual care, interprofessional consultation, and remote patient monitoring services. To facilitate widespread adoption of new non-face-to-face services, CMS should permit practices the flexibility to implement any new covered codes in a manner that best fits their practice and avoid overly restrictive billing requirements.”

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Gazing Into the Crystal Ball with LRVHealth’s Keith Figlioli

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2019 Predictions on Value-Based Care, Digital Startups, EHR Trends

Here’s a confession: I am much better at writing end-of-year review stories than I am at looking into the crystal ball for preview pieces at the beginning of the year. I might be able to make educated guesses about which issues we will be writing about in the coming year, but I prefer leave predictions about what is actually going to happen to others.

Luckily, people braver and more knowledgeable than I am are willing to weigh in. For instance, Dave Levin, M.D., chief medical officer of Sansoro Health recently shared his predictions for 2019 with Healthcare Informatics. One of his predictions is that “the excitement around new health IT players like Apple and Amazon will fade in late 2019. We need fresh ideas, but in the short-term, expect disappointments and missteps. Health IT (and healthcare in general) is much harder than it looks and the winners in the long-run will master the mash-up of the best of old and new. Health IT history is littered with companies like these that underestimate this challenge.” Good point!

Dave’s company, Sansoro Health, provides a set of APIs that read and write to EHRs. One of its investors is Boston-based LRVHealth, and one of LRVHealth’s general partners is Keith Figlioli, who served as senior vice president of healthcare informatics at Premier Inc. for nearly a decade. In December I spoke with Keith about some of his predictions for 2019.

One is that capital will be less abundant for digital health startups in 2019. I asked him why he thought that would be the case. “There already is a tremendous amount of capital in this space, including capital coming from other industries. The threat is that capital could be less abundant,” Figlioli said. “We are starting to see earlier stage companies have a little harder time raising capital. What that signals to us is that the greater market is pushing capital to later stages. Because capital can be harder to get in earlier rounds, valuations tend to float down a bit. The other thing is that the greater macro economy does feel like things are shifting a bit and that will also have an effect. I think 2019 may be a peaking year for valuations. I don’t think we are going to go much higher than we are right now.”

While Dave Levin had predicted that the enthusiasm about outside disruption from Big Tech might fade by the end of 2019, Figlioli predicted that these emerging entrants will start showing their cards. “Some of these guys are fairly secretive in their moves, but Apple has been hiring in healthcare and Amazon acquired PillPack. My sense is that we are going to know more about the ones that have been secretive,” he said. Now that the CVS/Aetna deal is done they will start to reveal more, he added. “We are going to see more announcements from these players over the course of 2019. People will be able to start deciphering what their plans are, at least out of the gate.” With its leadership in place, the Amazon/Berkshire Hathaway/JP Morgan entity will reveal an initiative, he predicted.

He also noted that Walgreens made some strategic announcements in 2018. “I call them the sleeping giant now, because CVS and Aetna made all the noise with their purchase deal. But Walgreens is making some very calculated moves with the incumbent players.”

Figlioli predicts that in 2019 the pace will pick up again on value-based care activity. “At LRVHealth, we have a saying that value-based care is inevitable but it is gradual,” he said. “I think we are finally going to get back up on the hamster wheel with things that really matter, because it feels like we have basically been at a dead stop since Trump took office.” He expects to see a handful of new mandatory and voluntary programs across cancer, cardiac and new bundled payment models. “When [HHS Secretary] Azar came in, it revved the engine back up and he is talking very publicly about ramping up mandatory programs. I think another signal is him talking more about CMMI [the Center for Medicare & Medicaid Innovation] and what may come out of it in terms of social determinants of health. I think we will see one or two CMMI pilots in 2019 dedicated to social determinants.”

In a related prediction, he said we should expect to see community programs such as local food banks become more closely affiliated with healthcare providers and payers. And just as there have been startups in the transportation area of social determinants, expect to see a few food-as-medicine related startups emerge in 2019, he added.

Figlioli’s final prediction touches on something I have written about a few times, the new “app store” approach to EHR add-ons. With open APIs gradually becoming the norm, he said, more CIOs who will become comfortable layering best-of-breed applications on top.

“There has been this lure in the CIO suite to say that the EHR vendor is going to do everything.  But because of what Cerner and Epic are doing and what athena has done all along, we are finally getting to a place where the average CIO is going to going to be OK going back to more of a hybrid model.” He stressed that the core EHR is not going anywhere. “You can think about them the same way you do about ERP systems. Over the last five years there has been a proliferation of overlays on top of them. And I feel like we are finally going to get to that with the EHR. It is not going to be clean or easy. There are going to be issues. It is going to be a pretty messy situation depending on how FHIR gets implemented. But it will become more of a cultural norm that Epic and Cerner don’t have to do everything. CIOs will say, ‘we are OK with them being our core workflow tool, but now we are allowing an overlay to take place.’”

 

 

 

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Research: Physician Burnout is a Public Health Crisis; Improving EHR Usability is Critical

January 18, 2019
by Heather Landi, Associate Editor
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Physician burnout is a public health crisis and addressing the problem requires improving electronic health record (EHR) standards with a strong focus on usability and open application programming interfaces (APIs), according to a new report from leading healthcare researchers.

The report is a “call to action,” the researchers wrote, “to begin to turn the tide before the consequences grow still more severe.” The researchers also recommend “systemic and institutional reforms” that are critical to mitigating the prevalence of burnout.

The result of collaboration between researchers with the Massachusetts Medical Society, the Massachusetts Health and Hospital Association, the Harvard T. H. Chan School of Public Health, and the Harvard Global Health Institute, the report's aim is to inform and enable physicians and health care leaders to assess the magnitude of the challenge presented by physician burnout in their work and organizations, and to take appropriate measures to address the challenge, the researchers say.

The report also offers recommended actions for healthcare leaders to take, which the researchers acknowledge are not exhaustive, but “represent short-, medium-, and long-term interventions with the potential for significant impact as standalone interventions.”

The authors of the report include Ashish K. Jha, M.D., the K.T. Li Professor of International Health at the Harvard T. H. Chan School of Public Health, and director of the Harvard Global Health Institute; Andrew Iliff, lead writer and program manager, Harvard Global Health Institute; Alain Chaoui, M.D., president of the Massachusetts Medical Society; Steven Defossez, M.D., vice president, clinical integration, Massachusetts Health and Hospital Association; Maryanne Bombaugh, M.D., president-elect, Massachusetts Medical Society; and Yael Miller, director, practice solutions and medical economics, Massachusetts Medical Society.

In a 2018 survey conducted by Merritt-Hawkins, 78 percent of physicians surveyed said they experience some symptoms of professional burnout. Burnout is a syndrome involving one or more of emotional exhaustion, depersonalization and diminished sense of personal accomplishment. Physicians experiencing burnout are more likely than their peers to reduce their work hours or exit their profession, according to the report.

By 2025, the U.S. Department of Health and Human Services predicts that there will be a nationwide shortage of nearly 90,000 physicians, many driven away from medicine or out of practice because of the effects of burnout.  Further complicating matters is the cost an employer must incur to recruit and replace a physician, estimated at between $500,000-$1,000.000. 

“The growth in poorly designed digital health records and quality metrics has required that physicians spend more and more time on tasks that don’t directly benefit patients, contributing to a growing epidemic of physician burnout,” Dr. Jha, a VA physician and Harvard faculty member, said in a statement in a press release accompanying the report. “There is simply no way to achieve the goal of improving healthcare while those on the front lines – our physicians – are experiencing an epidemic of burnout due to the conflicting demands of their work. We need to identify and share innovative best practices to support doctors in fulfilling their mission to care for patients.”

The beginning of the physician burnout crisis can be traced back to several events, according to the researchers, including the “meaningful use” of electronic health records, “which transformed the practice of many physicians, and was mandated as part of the 2009 American Reinvestment and Recovery Act.” Going back further, the 1999 publication of the Institute of Medicine’s “To Err is Human” highlighted the prevalence of medical errors, brought new attention to quality improvement and the value of physician reporting and accountability, the report states.

The researchers note that the primary impact of burnout is on physicians’ mental health, “but it is clear that one can’t have a high performing health care system if physicians working within it are not well. Therefore, the true impact of burnout is the impact it will have on the health and well-being of the American public,” the researchers wrote.

The researchers note, “If we do not immediately take effective steps to reduce burnout, not only will physicians’ work experience continue to worsen, but also the negative consequences for health care provision across the board will be severe.”

And, while individual physicians can take steps to better cope with work stress and hold at bay the symptoms of burnout, “meaningful steps to address the crisis and its root causes must be taken at a systemic and institutional level,” the researchers wrote.

According to the researchers, the primary drivers of physician burnout are structural features of current medical practice. “Only structural solutions — those that better align the work of physicians with their mission — will have significant and durable impact,” the researchers wrote in the report.

To that end, the researchers’ immediate recommendation is for healthcare institutions to improve access to and expand health services for physicians, including mental health services.

In the medium term, technology can play a large role. Addressing physician burnout will require “significant” changes to the usability of EHRs, the researchers wrote, including reform of certification standards by the federal government; improved interoperability; the use of application programming interfaces (APIs) by vendors; dramatically increased physician engagement in the design, implementation and customization of EHRs; and an ongoing commitment to reducing the burden of documentation and measurement placed on physicians by payers and health care organizations.

New EHR standards from the Office of the National Coordinator for Health IT (ONC) that address the usability and workflow concerns of physicians are long overdue, the researchers state. One promising solution would be to permit software developers to develop a range of apps that can operate with most, if not all, certified EHR systems, according to the report. The 21st Century Cures Act of 2016 mandates the use of open APIs, which standardize programming interactions, allowing third parties to develop apps that can work with any EHR with “no special effort.” There already have been efforts on this front, such as Epic’s “App Orchard,” the researchers note, but more work remains to be done.

To expedite this critical process of improvement, the report recommends physicians, practices, and larger health care delivery organizations, when seeking to purchase or renew contracts for health IT, adopt common RFP language specifying and requiring inclusion of a uniform health care API.

The researchers also say that artificial intelligence (AI) can play a promising role as AI technologies can support clinical documentation and quality measurement activities.

Long term, healthcare institutions need to appoint executive-level chief wellness officers who will be tasked with studying and assessing physician burnout. Chief wellness officers also can consult physicians to design, implement and continually improve interventions to reduce burnout, the researchers wrote.

“The fundamental challenge issued in this report is to health care institutions of all sizes to take action on physician burnout. The three recommendations advanced here should all be implemented as a matter of urgency and will yield benefits in the short, medium, and long term,” Jha and the research team wrote.

 

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GAO Report: Patient Matching Efforts Can Be Significantly Improved

January 17, 2019
by Rajiv Leventhal, Managing Editor
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The report did conclude that no single effort would solve the challenge of patient record matching

There is a lot that can be done—such as implementing common standards for recording demographic data—to improve patient matching, according to a new Government Accountability Office (GAO) report that closely examined the issue.

The 21st Century Cures Act included a provision for GAO to study patient record matching, and in this report, GAO describes (1) stakeholders' patient record matching approaches and related challenges; and (2) efforts to improve patient record matching identified by stakeholders.

The 37 stakeholders that GAO interviewed, including representatives from physician practices and hospitals, described their approaches for matching patients' records—comparing patient information in different health records to determine if the records refer to the same patient.

The respondents explained that when exchanging health information with other providers, they match patients' medical records using demographic information, such as the patient's name, date of birth, or sex. This record matching can be done manually or automatically. For example, several provider representatives said that they rely on software that automatically matches records based on the records' demographic information when receiving medical records electronically.

Stakeholders further said that software can also identify potential matches, which staff then manually review to determine whether the records correspond to the same patient. They said that inaccurate, incomplete, or inconsistently formatted demographic information in patients' records can pose challenges to accurate matching. For example, records don't always contain correct information (e.g., a patient may provide a nickname rather than a legal name) and that health IT systems and providers use different formats for key information such as names that contain hyphens.

Those who GAO interviewed identified recent or ongoing efforts to improve the data and methods used in patient record matching, such as the following:

  • ·         Several stakeholders told GAO they worked to improve the consistency with which they format demographic data in their electronic health records (EHR). In 2017, 23 providers in Texas implemented standards for how staff record patients' names, addresses, and other data. Representatives from three hospitals said this increased their ability to match patients' medical records automatically. For example, one hospital's representatives said they had seen a significant decrease in the need to manually review records that do not match automatically.
  • ·         Stakeholders also described efforts to assess and improve the effectiveness of methods used to match patient records. For example, in 2017 the Office of the National Coordinator for Health Information Technology (ONC) hosted a competition for participants to create an algorithm that most accurately matched patient records. ONC selected six winning submissions and plans to report on their analysis of the competition's data.

Those who were interviewed said more could be done to improve patient record matching, and identified several efforts that could improve matching. For example, some said that implementing common standards for recording demographic data; sharing best practices and other resources; and developing a public-private collaboration effort could each improve matching.

Stakeholders' views varied on the roles ONC and others should play in these efforts and the extent to which the efforts would improve matching. For example, some said that ONC could require demographic data standards as part of its responsibility for certifying EHR systems, while other stakeholders said that ONC could facilitate the voluntary adoption of such standards. Multiple stakeholders emphasized that no single effort would solve the challenge of patient record matching.

To this end, a recent report from the Pew Charitable Trusts outlined several key themes related to patient matching, while also suggesting recommendations to improve matching and the infrastructure needed for more robust progress in the medium and long term.

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