A highly anticipated final rule for reforming Medicare payment gives physicians more flexibility by easing some burdensome data-reporting requirements. But experts say it's going to put added pressure on smaller vendors to meet certification requirements that might derail efforts to make technology more patient-friendly, relevant and specialty-specific.
The final Medicare Access and CHIP Reauthorization Act rule sunsets the payment adjustments under the electronic health record incentive program, but parts of the program resurface under the Merit-based Incentive Payment System, known as MIPS.
MACRA requires physicians to participate in one of two payment tracks: MIPS or advanced alternative payment models. In MIPS, physicians will be paid based on success in four performance categories, including quality, cost, clinical practice improvement and “advancing care information,” which replaces the meaningful-use program. For the 2017 reporting period, cost won't count toward the physician's score.
Providers that choose alternative payment models will be exempt from MIPS reporting, but they also must use certified EHR technology.
Beginning in 2018, physicians must use EHR technology that is certified for 2015 instead of 2014. That could be a problem, since more than 75% of the providers participating in the Medicare EHR Incentive Program as of July had 2014-certified edition technology, according to the Office of the National Coordinator for Health Information Technology, which establishes the certification criteria.
That requirement may burden small EHR vendors more than larger ones, said Corinne Proctor Boudreau, senior manager of marketing for physician experience at Meditech, a Westwood, Mass.-based developer of hospital and physician EHRs.
Under the meaningful-use program, “you have seen some of those smaller vendors not be able to make those requirements. But this is the direction the industry has been going in. It's a little bit the cost of doing business,” Boudreau said.
“This situation is unfortunate for providers who have invested in an EHR that does not acclimate to agile change at scale,” but it's not an issue for Athenahealth, according to a statement from Allison LaValley, executive director for quality performance and value-based care at the vendor. “As a cloud-based network, we are very nimble and can adapt not just to MACRA but to anything the government throws forward.”
Leigh Burchell, vice president of government affairs at Chicago-based EHR Allscripts, said the company will deploy 2015 versions of its EHRs “well in time” to meet physician requirements.
Still, vendors are not required by MACRA to update their technology and so physicians will be at their mercy, said Robert Tennant, director of health information policy for the Medical Group Management Association, a trade association for managers of physician office-based practices.
He added that the certification rule “proposes a potential hardship for smaller practices that may have invested in one of the smaller EHR vendors” that don't plan to recertify their technology in time.
“For them to require that level of certification when there's absolutely no indication of how many vendors will be moving in that direction is a little bit irresponsible,” Tennant said.
Tennant's group will be making the case to the CMS for providers to continue using 2014-certified EHRs. The group will also educate members about technology upgrades in their contracts with vendors, he said.
The CMS did make other tech-related concessions.
Instead of taking an all-or-nothing approach to EHR requirements as in the past, the final MACRA rule reduced the total number of required measures to five from 11 in the proposed rule. That's down from 18 requirements under meaningful use. They include: security risk analysis, e-prescribing, providing patient access, sending a summary of care and requesting and accepting a summary of care. The rule also no longer requires reporting on measures for clinical decision support and computerized provider order entry.
The CMS “reduced the number of measures … but the measures you do have to meet are predicated on interoperability,” which is often outside the control of the physician, said Mari Savickis, vice president of federal affairs at the College of Healthcare Information Management Executives, an association of chief information officers at hospitals and health systems.
But interoperability-related measures such as sending and receiving a summary of care through EHRs “have been out there for a while for physicians that have been (participating in) meaningful use,” Boudreau said. She added that the reduction in required measures under MACRA gives vendors some “breathing room” to develop certain tech capabilities.
LaValley said vendors such as Athenahealth have “skin in the game” regarding their clients' success under MACRA. More importantly, "the industry is rife with EHRs that are not architected to enable cross-continuum care coordination and connectedness, which is critical to long-term MACRA success.”
The CMS also finalized the requirement that physicians attest that they aren't blocking the exchange of data. But Savickis and others say the CMS should instead require vendors to provide an information-blocking attestation. The CMS, however, said that the rule is a “first step towards increasing accountability for certain types of information-blocking in the specific context of meaningful EHR users.” The CMS did say physicians wouldn't be held accountable if there are problems with the EHR technology itself.
The EHR reporting moves away from “a bunch of check-the-box exercises” toward activities that help achieve better outcomes, like “care coordination across sites of care, patient engagement—really the hard things,” said Dr. Farzad Mostashari, former national coordinator for health IT and now CEO of Aledade, which establishes and operates physician-led ACOs.
In 2017, physicians have the option of reporting for a 90-day period instead of a full year to avoid a negative payment adjustment, which is “a pathway to reporting (that) is far more reasonable,” Savickis said.
Physicians who don't report at all will see their payments docked by the maximum of 4%. The CMS also said that in 2017 it will award bonus points for providers completing “improvement activities” through their EHRs and for reporting to public health and clinical data registries. One of these improvement activities is telehealth.
The acknowledgement of telehealth as a way to gain points is “a huge shift in how the program views tech in general and something we are very supportive of,” said Robert Horne, executive director at Health IT Now, a coalition of payers, provider organizations and patient-advocacy groups.
At the same time, MACRA backed away from allowing physicians to combine their reporting in virtual groups, which would have supported MACRA implementation and performance while relieving some of the reporting burdens on smaller physician groups, Horne said.
Still, it's possible the CMS will allow virtual groups down the road: “CMS wants to make sure the virtual group technology is meaningful and simple to use for clinicians, and we look forward to stakeholder engagement on how to structure and implement virtual groups in future years of the program,” the rule states.
Horne also praised the rule for identifying ways third-party health IT vendors can facilitate reporting into the program. The rule states that these vendors can act as intermediaries on behalf of MIPS-eligible physicians to submit data quality, improvement activities, and advancing care information performance categories, thus decreasing some of the burden.