Can You Just Forget Meaningful Use?
When a federal official stated in January 2016 that the meaningful use (MU) program was “effectively over,” it set off a wave of speculation that’s still rippling through the physician community.
The remarks by Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services , prompted physicians to wonder what would happen to MU—the federal government’s electronic health record incentive program. Can you relax a little about EHR performance reporting? Or is that just wishful thinking?
Here’s what you need to know.
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1. Is meaningful use really going away?
No, but it will change significantly.
“The meaningful use program as it has existed, will now be effectively over and replaced with something better”—that was Slavitt’s full quote in a speech on January 11.
The bottom line is that MU will cease to be a self-standing program next year, and it is expected to function very differently from now. The program will be folded into the new Merit-Based Incentive Payment System (MIPS), which is scheduled to start in 2017.
In a few rather broad statements since the speech, Slavitt has indicated that MU goals will be very different under MIPS from what they are now. For example, he has talked about creating outcomes-based measures to replace MU’s process-based measures. In a speech[2] to the American Medical Association on February 23, he said that CMS should be “rewarding providers for the outcomes that technology helps them achieve, not for using technology.”
If CMS shifts to outcomes-based MU measures, “I’d be excited big-time,” says Marc Probst, the chief information officer at Inter mountain Healthcare in Utah. He says MU has become “irrelevant,” but under the changes Slavitt is talking about, “it would be a new program.”
CMS is expected to detail the new MU goals in a proposed rule that will be issued around June 1, and a final rule will be out in the fourth quarter of 2016.
2. Will any changes be made this year?
CMS officials say their hands are tied until 2017. Although the MIPS program was authorized back in April 2015, under the Medicare Access and CHIP Reauthorization Act , it won’t be implemented until next year. Until then, CMS officials say, the MU program is operating under its enabling legislation—the Health Information Technology for Economic and Clinical Health Act—and the old law won’t allow them to make significant changes.
Kate Goodrich, director of the Center for Clinical Standards and Quality at CMS, says her office is still acting under HITECH’s “performance period.” The MACRA performance period “could start as early as January 1, 2017, but that has not been decided yet,” she says, referring to the ongoing rule-making process.
Goodrich’s view echoes statements by Slavitt and Karen DeSalvo, MD, head of the Office of the National Coordinator for Health Information Technology . “The current law requires that we continue to measure the meaningful use of ONC Certified Health Information Technology under the existing set of standards,” they wrote in a CMS blog on January 19. Then, under MACRA, CMS will have “an opportunity to adjust EHR payment incentives.”
Many observers, however, think that CMS and the ONC could change MU whenever they wanted to. Steve Waldren, MD, director of the Alliance for eHealth Innovation at the American Academy of Family Physicians, says it was the ONC and CMS, and not HITECH, that created details of the program, such as the stages of MU. “But they don’t believe they have that authority,” he says, “so they’re waiting for the implementation of MACRA in 2017 to make those changes.
What About My Current EHR?
3. I spent a lot of money to buy the right EHR and comply with MU. Now what?
You might think that buying your EHR system and complying with MU was a bad investment, but the genie is already out of the bottle. CMS has no plans to furnish refunds. Despite all the talk of change, the government’s basic commitment to EHR technology does not seem to be shaken.
The program’s initial goal of incentivizing physicians and others to buy and EHR system and getting them to use it was a very positive step, says Robert M. Wachter, MD, author of The Digital Doctor: Hope, Hype and Harm at the Dawn of Medicine’s Computer Age and interim chair of the department of medicine at University of California, San Francisco.
“Having everyone achieve a certain level of technology is healthy and expected,” Dr Wachter says. “MU worked best when it was a program to incentivize doctors to use IT and did not micromanage how they used it.” He thinks the bad part of MU came later, in the current stages of the program.
The program has certainly achieved its goal of getting most doctors to use EHRs. According to a 2014 Medscape survey, 83% of physicians said they had installed EHRs and 4% more were currently doing so. But the survey shows doctors are split on whether EHRs are actually helping them. Whereas 63% said their EHRs improved documentation and 39% said they improve collections, 38% said they worsen patient services and 35% said they worsen clinical operations.
4. Can physicians now ignore MU? Can I stop reporting?
No. Even when the new MIPS program gets under way, MU will continue rewarding and penalizing physicians. However, MU performance will be folded into MIPS, along with that of two other Medicare incentive payment programs—the Physician Quality Reporting System and the value-based payment modifier as well as a new measurement for clinical practice improvement .
An overall penalty or payment will be assessed under MIPS. That is, physicians will receive a total yearly score based on performance in all four categories—MU, PQRS, VBPM, and CPI—and MU performance will represent 25% of the total. Depending on the total score, doctors will either receive a payment or have money removed from their Medicare reimbursements, on the basis of performance 2 years beforehand. In that performance period, doctors will be required to report all four measures.
MIPS performance reporting is expected to start in 2017, and under the 2-year payment lag, doctors will begin to see reimbursement changes in 2019. The maximum reimbursement changes will be ± 4% in 2019. Then that figure rises to 5% in 2020, 7% in 2021, and 9% in 2022, at which point it levels off.
What About Penalties?
5. Is it true that there won’t be any MU penalty for 2015 performance?
Yes, if you submit an exemption application to CMS by July 1, 2016. Physicians have an opportunity to avoid paying MU penalties for 2015 performance, owing to CMS’ tardiness in issuing a new rule last year. But this exemption, affecting 2017 payments, is not automatic. It must be applied for.
The chance to avoid a penalty in 2017 is welcome news, because MU penalties have been steadily rising each year. They started in 2015at a rate of 1% of a physician’s Medicare reimbursements, based on 2013 performance. Then they rose to a 2% rate in 2016, based on 2014 performance, and are slated to reach 3% in 2017, for 2015 performance.
However, in the 2015 performance year, CMS was late in releasing a new regulation. The regulation, which covered changes in stage 2 of MU, replaced the old 12-month reporting period with a new 90-day period. However, the release date, in first week of October, meant there was less than 90 days left in the calendar year to measure 2015 performance.
Physicians who had been awaiting the new rule before they started to measure performance would have been in a jam—there simply weren’t enough days left in the year to meet the requirement. Congress reacted to this bureaucratic Catch-22 by passing the Patient Access and Medicare Protection Act in late December. The act said that doctors and other providers could apply for a hardship exemption from MU penalties; this exemption is usually used when the EHR vendor makes a mistake.
The AMA is advising all physicians, even those not affected by the delay, to file for the CMS hardship exemption. “The AMA is encouraging ALL physicians subject to the 2015 Medicare MU program to apply for the hardship,” the organization stated in a release. “CMS has stated that it will broadly accept hardship exemptions because of the delayed publication of the program regulations.”
The exemption is good news for tens of thousands of physicians who expected to pay penalties. CMS reported that nearly 257,000 physicians and other eligible professionals had to pay penalties in 2015 for 2013 performance.
Physicians can cite the CMS snafu when applying, and the usual documentation requirements will be waived, says Elizabeth Holland, senior technical advisor in the Division of Health Information Technology at CMS. In addition, she says, groups of providers can file a single application, and the deadline was recently extended from March 15 to July 1.
A CMS FAQ explains the application process. Anyone “for whom the timing of the rule caused a significant hardship” should fill out the application, it says. Also, if physicians file for an exemption but are expecting a payment rather than a penalty—which could happen if they are part of groups that files—don’t have to worry about losing those payments. CMS says qualifying for the exemption does not waive your right to payment.
The open-ended exemption is a one-time deal, only for payments in 2017. But Holland says that in the future, some of the changes that streamline the application process might be preserved, such as allowing physicians to apply in groups.
6. What will the new MU look like?
CMS has already divulged some objectives, although exactly how the revamped MU program will operate will be described later this year.
There’s some good news. CMS aims to encourage interoperability and “to minimize provider burden by collecting data that are part of the existing clinical workflow,” according to the agency’s Draft Quality Measure Development Plan, a document released in December. The plan also stated that MU rules should be “based as much as possible on existing provider workflows and inherently created as a by-product of providing clinical care.”
Other changes that are on the horizon: The program should be “rewarding providers for the outcomes technology helps them achieve with their patients,” and it should give providers “the flexibility to customize health IT to their individual practice needs,” according to a January 2016 blog post by Slavitt and Dr DeSalvo.
If MU can be aligned with outcomes, “It won’t be important whether you used your technology to improve outcomes,” says Probst, the Intermountain CIO. “The important thing will be that outcomes were improved.” This greater emphasis on outcomes could reduce the reporting burden on physicians, he adds.
The CMS officials’ January blog post also said that MU should emphasize interoperability, which so far MU has failed to create for many EHR systems. They said CMS should push for “federally recognized, national interoperability standards and focusing on real-world uses of technology, like ensuring continuity of care during referrals or finding ways for patients to engage in their own care.”
CMS has already begun its push for interoperability. In March, the government announced that EHR vendors representing 90% of systems in use had pledged to a three-step plan to promote interoperability.
Will Things Become Easier for Doctors?
7. What will happen to the stages of MU?
Dr Wachter says that whereas stage 1, which focused on capturing patient data, was basically a success, stages 2 and 3 have been an overreach that have hindered practices more than they have helped them. He notes that even former supporters of MU have taken to calling the program “meaningless abuse.”
The fate of the stages is unclear. CMS officials have not yet said what happens to the three stages of MU, which will still be playing out when the MIPS program starts. The fate of the MU stages will be revealed in the proposed rule that comes out later this spring.
Stage 2 began in 2014, became a requirement in 2015, and continues through 2017. The final rule for stage 3 was released in October; this stage doesn’t get under way until the MIPS program starts, and critics are waiting to see whether it will be substantially rehauled in the upcoming MIPS rules, or perhaps even set aside. When MIPS starts in 2017, stage 3 will just be getting off the ground, and it is first required in 2018.
In response to the complaints, CMS has made some changes to stages 2 and 3, but Dr Wachter is hoping for a complete overhaul. Rather than “continuing to push highly prescriptive standards that get in the way of innovation,” he thinks stage 3 should simply focus on interoperability.
8. Will doctors have any input into the new program?
As CMS officials tell it, they’re extremely interested in what physicians have to say about MU. Now that they are about to totally revamp the program, they are reaching out to physicians and are even organizing focus groups of them.
Goodrich says that the agency has been holding focus groups with “front-line” physicians. “We’re not just listening; we’re hearing and absorbing,” she says.
She repeats back what she has learned. “For both individual physicians and groups,” Goodrich says, “the general themes are the same: The program is too burdensome and takes time away from taking care of patients. MU has not been meaningful to them, because it tends to be one size fits all. They want flexibility. They want to tailor what they report to us, based on their individual practice needs.”
Slavitt, in his comments this January at the J.P. Morgan conference, said CMS’ listening process with doctors started late last year. Since then, “We have been working side by side with physician organizations across many communities,” he said, “and have listened to the needs and concerns of many. We will be putting out the details on this next stage over the next few months.”
Considering the Future of Your EHR
9. If I’m thinking of getting a new EHR, should I wait until the new program is out — or will that not matter?
It’s better to wait at least until the proposed regulations come out around June 1. Slavitt has indicated there will be major changes in MU standards, which could radically change what you need your EHR to do, but he has not provided enough detail to know what specifically what these changes will be.
However, you can start thinking about the general direction MU might take. For example, Slavitt said that EHRs should be customized to the needs of each practice, suggesting that MU rules wouldn’t be dictating your choice of EHR. Instead, the main factor in EHR choice would be value-based payment arrangements, which are being ushered in under MACRA. These include shared savings, patient-centered medical homes, and bundled payments.
Under value-based arrangements, your EHR would need to be interoperable with other systems to help you exchange data with other providers. You would need to keep close track of patients through robust patient portals and links with patients’ mobile devices. And your EHR should help you develop clinical registries to track patients and help you compare your quality outcomes with national benchmarks.
10. Do MU administrators admit that the original program was a big mistake?
Slavitt and Dr DeSalvo weren’t present at the creation of MU, so they cannot take personal responsibility for any mistakes that occurred then. Slavitt arrived at CMS in 2014, and Dr DeSalvo took her current post about 2 years ago.
Slavitt has been quite critical of MU. “Regulations in their current form slow [physicians] down, create documentation burden and often distract them from patient care,” Slavitt told[10] a meeting of the Healthcare Information and Management Systems Society on March 2. “They find their EHR technology hard to use and cumbersome. It slows them down [and] doesn’t speed their path to answers.”
Slavitt’s comments about how MU has to change have impressed many healthcare IT experts, including Dr Wachter. “What I get out of Andy Slavitt’s comments is that CMS recognizes that the way MU as structured is not working, and that changes in the program need to happen,” he says.
Date: April 20, 2016