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Medicare reimbursement reform efforts bring pros and cons for healthcare technology use
The path to the new Medicare physician payment system known as the Quality Payment Program (QPP), which began on January 1, is strewn with pitfalls for doctors. Among those are some of the provisions related to health IT, which in various forms is interwoven throughout the program.
Further reading: Why have EHRs failed to deliver their promised efficiency benefits?
Still, the final rule for the Medicare Access and CHIP Reauthorization Act (MACRA), which established the payment reform, softens the transition considerably in comparison to the MACRA proposal released by the Centers for Medicare & Medicaid Services (CMS) last spring, observers say.
Advancing Care Information (ACI), the successor to Meaningful Use, now requires eligible clinicians to meet five measures, down from 11 in the proposed rule. These metrics support goals that include clinical effectiveness, information security, patient safety, patient engagement and health information exchange. Extra credit is available for electronic reporting to public health and clinical data registries or for using certified electronic health records (EHRs) for certain clinical practice improvement activities (see the QPP website at qpp.cms.gov).
However, there are a couple of caveats. For one, the core ACI measures include the exchange of electronic care summaries. Because of the poor state of interoperability between EHRs, physician practices will continue to find it difficult to trade these summaries, notes David Zetter, CHBC, a practice management consultant in Mechanicsburg, Pennsylvania.
Physicians can use Direct secure messaging, based on a standardized internet protocol, to send and receive clinical summaries without interoperability between their EHRs. But to do that, they must use a health information service provider (HISP), and that entity may not be able to communicate with the HISPs used by other practices. Edward Gold, MD, the leader of a 70-doctor group in Emerson, New Jersey, says his practice cannot exchange Direct messages with most other groups in his area because of non-communicating HISPs.
Consequently, he says, health information exchange measures are “the hardest to meet. The way they’ve got it structured, the goals are somewhat unrealistic.”
Michael Munger, MD, a primary care physician in Overland Park, Kansas, agrees that some practices that lack interoperable EHRs may not be able to meet these requirements. He adds, however, that most practices should be able to exchange summaries electronically with enough partners to satisfy the requirement.
Another key challenge is that, starting in 2018, all physicians in the Quality Payment Program-whether they participate through the Merit-based Payment Incentive System (MIPS) or an Advanced Alternative Payment Model (APM)-use EHRs that have been certified to meet standards originally designed for Stage 3 of the Meaningful Use program. In 2017, physicians can continue to use their current EHRs if those have been certified under the previous standards.
But the transition to the new EHRs is expected to be rocky. “Very few vendors have recertified so far,” notes Robert Tennant, a senior policy adviser to the Medical Group Management Association (MGMA). “And if you’re stuck with an EHR that’s not going to be upgraded, you’ve got to rip and replace it.”
Next: Quality reporting
Besides ACI, the MIPS track will include quality performance and clinical practice improvement activities in 2017. (The “cost” component of MIPS, which is based on Medicare claims, has been postponed for a year.) According to a fact sheet from the Office of the National Coordinator for Health IT, MIPS participants can earn bonus points in the ACI category if they use certified EHRs for practice improvement activities related to high-priority quality measures, improved patient outcomes “and other key delivery system reform goals.”
Physicians who fully participate in MIPS will have to report on only six quality measures selected from a list of 271. But they may still find it difficult to track these metrics across their Medicare population, and they must also report on the other categories of MIPS.
Practices that do end-to-end electronic reporting of quality measures may also be eligible for bonus points in the quality category, which in 2017 will be worth 60% of the total MIPS score. However, the majority of practices that report to the Physician Quality Reporting System use a claims-based method that requires entering special codes.
Acceptable end-to-end electronic reporting methods in all MIPS categories include direct reporting from EHRs, reporting through vendor-based registries and reporting through qualified clinical data registries operated by specialty societies, quality improvement collaboratives, and other entities. Groups of 25 or more eligible clinicians can use a CMS web interface for reporting.
To help practices make the transition, CMS is allowing third-party vendors to submit data for practices on quality measures, clinical practice improvement activities and ACI measures. Some vendors may be able to report on all three, while others will report just quality data.
Physicians who belong to an accountable care organization (ACO) that already reports quality data to the Medicare Shared Savings Program do not have to report the information individually to CMS under MIPS. Similarly, those who belong to a qualified patient-centered medical home will automatically get full credit for clinical practice improvement activities.
The final rule excludes from MIPS any provider who bills less than $30,000 in Medicare allowed charges or who has 100 or fewer Medicare patients. This threshold exempts 384,000 providers, nearly half of whom work in practices with fewer than 10 physicians.
That’s a big win for doctors, as is the provision that allows any practice with two or more eligible clinicians to report to CMS as a group under its tax identification number, Tennant says. Nevertheless, he points out, physicians who exceed the threshold for being subject to MIPS must report data even if some of their colleagues in the same practice are exempt. Only if 75% or more of the eligible clinicians in a practice are exempt can the whole practice avoid MIPS.
Next: APMs and small practices
Zetter advises that even if just some providers in a group must report to MIPS, the group should still measure everyone’s performance. “It all comes down to quality and value,” he notes. “Most payers are moving toward value-based reimbursement; in fact, commercial payers are moving much faster than Medicare. So if you have the data, why not just improve your overall practice?”
CMS wants as many physicians as possible to participate in advanced APMs. In fact, CMS officials recently said they expect 125,000 physicians to take part in these payment models in 2018.
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“The intent of Congress was to drive physicians into these APMs, not keep them in the MIPS track in perpetuity,” Tennant says.
Doctors in advanced APMs have to use certified EHRs, just like physicians in MIPS do. Moreover, the health IT required to drive APMs is more complicated than the basic EHRs needed to collect performance data in MIPS. So if this is the direction CMS is headed in, practices should start gearing their health IT to a model like a medical home or an ACO.
However, the APMs available to physicians in 2017 are limited. They include ACOs that participate in track 2 or 3 of the Medicare Shared Savings Program. Because the ACOs in those tracks must take substantial downside risk, most ACOs in the shared savings program are in track 1. The other options include end-stage renal disease and oncology arrangements, the Next Generation ACO Model, and the Comprehensive Primary Care Plus (CPC+) program, which launched this year with a nationwide panel of 20,000 physicians.
CMS recently announced plans to add more advanced APMs in 2018. These will include a new ACO Track 1+ in the shared savings program and several bundled payment models. Additionally, CMS will reopen applications for the CPC+ program. All of these new APMs require doctors to use certified EHRs.
CPC+ is an advanced medical home model that aims to strengthen primary care through multi-payer payment reform and care delivery transformation. A five-year initiative, it will build on the CPC program that has been running since 2012.
Further reading: Is DPC a viable way to MACRA-proof your practice?
ACO Track 1+ requires participating ACOs to take downside risk, but CMS will cap the risk at 8% of an ACO’s Medicare revenues for the first two years. According to Andy Slavitt, acting administrator of CMS, Track 1+ will make it “more reasonable and tenable for small practices” to participate in ACOs that take financial risk from CMS. If their ACO does well, they can share in the savings, while also receiving the 5% annual bonus for advanced APM participants, he notes.
Munger, president-elect of the American Association of Family Physicians, agrees that Track 1+ will help get more small practices into the advanced APM track. “It’s not something that will necessarily happen immediately,” he notes. “But when they start that in 2018, especially with the 8% cap, I think you’ll see more doctors embrace the newer payment models.”
Gold’s group applied for CPC+ and can meet the MIPS requirements if it’s not accepted. He’s skeptical that smaller practices will be able to cope with either track of the QPP. “Doctors who have half-heartedly put in EHRs and half-heartedly used them for Meaningful Use are going to be lost,” he says.
Munger takes a more optimistic view. Reducing utilization and the cost of care will be difficult for two- or three-doctor practices, he says, and their quality scores can be skewed by a few adverse outcomes because of small sample sizes. But small practices can succeed. “Part of what a smaller practice has is a personal touch. They know their patient panel and are able to deliver quality,” he says.