Thursday, May 5, 2016

A Deep Dive on the MACRA NPRM

As promised last week, I’ve read and taken detailed notes on the entire 962 page MACRA NPRM so that you will not have to.

Although this post is long, it is better than the 20 hours of reading I had to do!

Here is everything you need to know from an IT perspective about the MACRA NPRM.

1.  What is the MACRA NPRM trying to achieve with regard to healthcare IT?

The MACRA NPRM proposes to consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs), creating a single set of reporting requirements.  The rule would sunset payment adjustments under the current PQRS, VM, and the Medicare EHR Incentive Program for eligible professionals.

2.  Who is affected?

In the MACRA NPRM, the word Eligible Professional is replaced with the term Eligible Clinician, expanding the population of individuals covered by Merit-based Incentive Payment Programs (MIPS).  MIPS eligible clinicians will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians.   Hospitals are not affected by this rule and  hospital-based MIPS eligible clinicians are not required to participate in the information technology portions of MACRA, since they may not have direct control over the software implemented by the hospital.

3.  When does the rule take effect?

The rule proposes that the first performance period would start in 2017 for payments adjusted in 2019.   It’s not exactly a stimulus program - some clinicians will see reduced payments for non-performance and some will see enhanced payments for exemplary performance - a zero sum redistribution of payments.

4.  Does Meaningful Use and electronic clinical quality measure reporting go away?

MACRA’s enactment altered the EHR Incentive Programs such that the existing Medicare payment adjustment for a eligible professionals ends after calendar year 2018.  Generally,  MACRA did not change hospital participation in the Medicare EHR Incentive Program or participation for professionals in the Medicaid EHR Incentive Program.

Meaningful use of certified EHR technology is renamed to  “advancing care information” and the criteria are streamlined - removing the CPOE and Clinical Decision Support requirements.   In 2017, clinicians may still use 2014 edition certified technology and report on eight Stage 2 measures.   By 2018, clinicians need to use 2015 edition certified technology and report on six Stage 3 measures, described below.

Quality measures will be selected annually through a call for quality measures process.

5.  What is the role of ONC and Certification?

On March 2, 2016, ONC published the ONC Health IT Certification Program: Enhanced Oversight and Accountability proposed rule, which would expand ONC’s role to strengthen oversight, requiring that clinicians give access to their EHR for “field inspection” of functionality by ONC.

The MACRA NPRM proposes that clinicians must attest they have cooperated with ONC surveillance and oversight activities.  Further, they must attest they have not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.

6.   What are the MACRA advancing care information objectives and measures that have replaced Meaningful Use?

The six criteria which are required as of calendar year 2018 are

1. Protect Patient Health Information - Security Risk Analysis
2. Electronic Prescribing
3. Patient Electronic Access - Patient Access, Patient-specific education
4. Coordination of Care through Patient Engagement - View/Download/Transmit, Secure Messaging, Patient Generated Health Data
5. Health Information Exchange - Patient Care Record Exchange, Request/Accept Patient Care Record, Clinical Information Reconciliation
6. Public Health and Clinical Data Registry Reporting - Immunization Registry Reporting

Here are examples of the actual measurements:

Secure Messaging Measure: For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).

View, Download, Transmit (VDT) Measure: During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either—(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician’s certified EHR technology; or (3) a combination of (1) and (2).

7.  So what must a clinician do and when?

For the period January 1, 2017 to December 31, 2017 (yes, it’s a full year, not 90 days), clinicians must
a.  Use a 2014 or 2015 Edition Certified EHR
b.  Report on either eight stage 2 or six stage 3 advancing care information objectives and measures:
c.  Attest to their cooperation in good faith with the surveillance and ONC direct review of their EHR
d.  Attest to their support for health information exchange and the prevention of information blocking.
e.  Continue to practice medicine

Sorry, e. was an attempt at humor.    Listening to each patient’s story, being empathic, and healing are optional.     After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought.    Sometimes when you remodel a house, there is a point when addtional improvements are impossible and you need to start again with a new structure.    The 962 pages of MACRA are so overwhelmingly complex, that no mere human will be able to understand them.    Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes.    This may sound cynical, but there are probably only two rational choices for clinicians going forward - become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.

The folks at CMS are very smart and  well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested.   I will watch closely for comments from organizations such as the AMA, AHA, and clinician practices.    I’m guessing that many will see the ONC Surveillance provisions as overly intrusive and the "advancing care information" requirements as creating more burden without enhancing workflow.    Maybe the upcoming Presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves.    As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.


MB said...

Wow, I feel exactly the same as you do. As a front line ortho provider in a small group. I think now I get the message. CMS and ONC wants us out of private practice, either retire, or join as a salaried doc or hospital employee. That is the only justification for this 1000 page nightmare.
You forgot to hit on the continued PQRS silliness, with 6 measures and now one outcome measure AND
dont forget! Clinical practice improvement activity. Which has the great formula of "high" and "medium" activity
which count as 20 and 10 points each and you need 60 points to get the 100 percent in that section! Woohoo! just what I want
yet ANOTHER thing to count and attest!
Isn't the definition of insanity doing the same thing over and over again and expecting a different result? This is like tell us they are going to stop hitting us with a bat and start hitting us with a shoe instead, and maybe a belt for good measure.
I am now in 17 years, and everyday I am planning my retirement from this torture. We really need ONC and CMS to stop demanding certified EHR. We need innovation, we need vendors to work with providers for things we need, not what ONC wants. Second the AAPM section may be the MOST confusing awful idea ever presented. Bring your team of lawyers, accountants and policy wonks to make that work. Its literally reads like a joke.
At some point when we are all gone, CMS and ONC is going to ask what happened. And the same problems of big pharma costs and patient factors like smoking and IT charges, etc will still be causing the most cost in the system, they will still say its the fault of the doctor that the costs are going up.
Is there anyone at CMS and ONC listening to real front line providers out here? We are demoralized, overburdened and devastated by these programs. Is that the plan? Seems like it. I agree, it wont be long till I'm gone. And BTW they penalize me every year, even though my data shows I have the highest quality and lowest costs for total knees and total hips in the entire state of Ohio (Thank you propublica!). Yep CMS penalizes me. That makes sense. I'll take the shoe and belt now. Its time for my daily beating.

Anonymous said...

Why are there only two options? How about experimenting with alternative models such as direct care? Or, how about splitting ones private practice into two---one that is concierge and one that is traditional insurance third party based, perhaps with a physician supervising a PA? I think this is an invitation to experiment as being an employee on the Medicare 7 minutes treadmill is not my idea of medicine. All types of models can be done that do create affordability for patients , better access and freedom from the new versions of PRQS, MU, etc. I have successfully attested now for five years, but this looks impossible. In addition, we attended a CMS webinar on MIPPS that even if we were part to the 10% of solo IM practices that could attest successfully ( we think we may be) that the 9% bonus is not even a guarantee. Why? Because if they don't get enough practices that are fined, they may just make our bonus 0% ! I think it is time for doctors to experiment with membership models, at least in the hybrid state.

Anonymous said...

Federal NPRM are always long, impossible to understand much less implement. But, who reads them other then us nerds who are deeply into public policy and HIT? And what would you propose instead? The SGR that MACRA replaced offered a recurring nightmare of massive payment cuts that always had to be rescued at the last minute--and rarely to the physician's gain and satisfaction. Hopefully, some vendor out there will come up with a solution set that can actually meet these needs. We certainly see the investment dollars flowing in. I agree with you that Federally driven interventions this deep into a market usually results in a painful, bureaucratic and unsatisfying set of activities for those subject to the regs. On the other hand, I went to my doctor to get checked out from all my behavioral driven health care issues--diet, weight, stress-- and am still struck at how pathetic our HIT is. She had NextGen and was so proud of all the technological sophistication she had. But, the algorithms that were supposed to track my preventive health measures (colonoscopy...) gave wrong recommendations, the portal they offered was useless for my needs, and the prescription process remains a nightmare of phone calls-- oh yes, but the script was transmitted electronically-- of course the refill instructions did not jive with the health plan refill rules so it generated more unneeded phone calls. It's hard for me to get too angry at the Feds when we are this pathetic in our solution set. On the other hand, maybe you are right-- it's time to take a step back and re-think our entire approach.

Tom said...

Hey John, I feel your pain, but I have to say after ingesting the various ACA proposals, and going from a pre MU world to where we are today, MACRA does not look that bad. The changes proposed are more incremental than sweeping with respect to IT , and many of the changes are natural extensions and needed improvements to the requirements. As a vendor and founder of several HIT companies I can see a path where the independent physician can stay independent and compete leveraging technology that is designed for their needs. I do agree the bonus/penalty system needs work, and there needs to be full transparency on the proposed oversight process. The shift from volume to value needs to occur and this is just phase one in that transition.

Scott Mace said...

Doesn't the fault lie not with CMS but with Congress, which wrote MACRA? How could CMS write a rule implementing MACRA any differently? said...

You and I were hopeful with HITECH and other initiatives. As you've alluded to, some of the policy makers are indeed intelligent, passionate and well meaning. I remember, sitting on a subcommittee for ONC-HIT, hearing someone say "At the 30,000 foot level....". I later retorted, "Well, at the 5 foot 9.5 inch level (I've shrunk!)...". Not every "good" idea is well implemented at the 5 foot 9.5 inch level.

I, as well as you and many others, should advocate, STOP, DROP and BREATHE! CMS (and others) should take a collective breath and give health care a chance to catch up!

Tripp Bradd, MD
Skyline Family Practice
Front Royal, VA

docms said...

We all love Google and our iphones, marvel at their sophisticated technology, and then lament, what can't health IT be the same?.
Remember, Google and Apple are not what they are because government regulation forced them to advance their technology. HealthIT is so pathetic because it has been hampered by endless regulations that only get more onerous.

Medical Quack said...

Everyone has their own opinion on this but I'm of the belief that you don't take a model and put it on top of one that is already broken, Meaningful Use and that's pretty much what we have here. A smarter move I think would have been to write an "exit" model for Meaningful Use and begin with a "new" model that won't be carrying over the complexities and undesirable aspects of the broken model. This happens all the time too in finance where another model is basically put on top of one that is broken and you get the same results.

We need fewer levels of complexity, not more. Programmers and engineers will always be present to argue that point, especially when they want to sell more Health IT analytics and software:) Besides all of this, I'm still chuckling over "Information Blocking" as this has been talked about and presented like there's folks writing code to do such, a perception folks get who are not acquainted with what goes on with coding and software development:)

Overall, I call what we have going on in the world today as "Excess Scoring" and it lives outside of healthcare too sadly.