Watching CMS Listen to Providers

Oct. 4, 2016
Last week’s announcement on the part of CMS officials proposing significant changes to Medicare payment for physicians signaled an increasing willingness on their part to dialogue iteratively with providers about what needs to be changed---and when

Last week was a fascinating week in healthcare policy, for those who have been tracking policy issues for the last few years. The Centers for Medicare & Medicaid Services’ (CMS) announcement last week Wednesday was quite significant, along a number of dimensions.

As we reported last week, “In a dramatic policy move, federal healthcare officials announced on Wednesday afternoon, Apr. 27, that the Centers for Medicare & Medicaid Services (CMS) is introducing a new program that will replace the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act, for physicians participating in the Medicare program (for the moment, hospitals will be unaffected). The new program,” we wrote, “called Advancing Care Information (ACI), was introduced Wednesday as a Notice of Proposed Rulemaking by the Department of Health and Human Services (HHS), under the terms of the Medicare Access and CHIP Reauthorization Act (MACRA). The new program, with its associated changes, was announced on the CMS website, and via two succeeding press conferences, the first one involving Andy Slavitt, Acting CMS Administrator, and Patrick Conway, M.D., Deputy Administrator for Innovation & Quality and Chief Medical Officer for the agency, and the second one involving Slavitt and Karen DeSalvo, M.D., National Coordinator for Health IT, along with Kate Goodrich, M.D., Director of the Center for Clinical Standards and Quality at CMS.”

The proposed rule published by CMS last week has many implications, including many implications around healthcare IT and outcomes measures reporting, as it essentially “folds in” the meaningful use program into the new “Advancing Care Information” program under the MIPS (Merit-based Incentive Payment Program), for Medicare-accepting physicians. And even though CMS officials made clear that hospitals are not affected by last week’s announcement and proposed rule, CMS’s Slavitt also noted that he and other CMS officials were actively dialoguing with hospital leaders about what to do about MU on the hospital side as well.

Here’s the thing: for all those in the industry who have been (sometimes quite loudly) complaining that CMS officials “never listen” when it comes to concerns and dissatisfaction from healthcare providers, it seems quite clear this time around that CMS officials have in fact been listening. Of course, officials’ hands are at least partly tied: because the meaningful us program originated as part of the HITECH (Health Information Technology for Economic and Clinical Health) Act under the ARRA (American Recovery and Reinvestment Act), they cannot simply “scrap” meaningful use; that is not one of their options.

What’s more, their options are further constrained by the passage by Congress of MACRA a year ago. So CMS officials, facing mounting dissatisfaction among both physicians and hospitals around some of the rigidities embedded in MU, chose to do something very practical: they took the provisions of MACRA/MIPS and refashioned some of the MU requirements, and moved them under MIPS. Et voila!

Is it a perfect solution? No. No solution to some of the problems that had emerged under meaningful use could be perfect. But what their move does do is to streamline some requirements, and move the rest under a new superstructure that was being put in place anyway. And it aligns well with a number of other moves that CMS has been making to align a variety of payment shifts towards value-based payment, across both the acute-care and ambulatory care sectors.

Leslie Kriegstein, vice president of congressional affairs at the College of Healthcare Information Management Executives (CHIME), wrote this in her Washington Debrief for Healthcare Informatics on Monday, “Why it Matters: In an unusual move, CMS published the long-anticipated proposed rule on the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) program stemming from the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) of 2015. Collectively, CMS is referring to these programs as the Quality Payment Program. CMS says their goal with the Quality Payment Program is to continue to support health care quality, efficiency, and patient safety. MACRA reforms the long-time sustainable growth rate formula dictating the way physicians and other clinicians are paid,” Kriegstein noted, “and replaces it with a new system that rewards value and outcomes.  The law also consolidates the current Meaningful Use, Physician Quality Reporting System, and Value-based Payment Modifier programs.  Components of each are a part of the new system.”

Now, it’s important to be clear that meaningful use is not going to be truly replaced; instead, what’s important is how CMS is going to revise the way in which providers participate in and perform in the new program, Naomi Levinthal, senior consultant, research and insights at Washington, D.C.-based The Advisory Board Company, told HCI Managing Editor Rajiv Leventhal last week. “They are still going to rely on the core of meaningful use, which is all of those objectives and measures already in place,” Levinthal told Leventhal. “In 2017, when MIPS officially begins for the performance period, you will have the opportunity as an eligible Medicare provider to choose to do modified Stage 2 measures as they were created, or you can advance to Stage 3, which was the same position for their eligible hospital and Medicaid EP counterparts. Nothing in the individual measures outside of removing thresholds changes that much,” she noted.

Still, the same day that the CMS announcement was made, important healthcare professional associations praised CMS’s having listened to the pleas of providers. The Chicago- and Washington, D.C.-based American Medical Association (AMA) expressed satisfaction with the announcement of the new program in a statement released Wednesday evening and attributed to Steven J. Stack, M.D., the AMA’s president. In a statement, Dr. Stack said, “It is hard to overstate the significance of these proposed regulations for patients and physicians. When Congress overwhelmingly passed MACRA last year, lawmakers signaled that they wanted to transform Medicare by promoting flexibility and innovation in the delivery of care, changes that could lead to improved quality and better outcomes for patients.”

And he went on to say that “Our initial review suggests that CMS has been listening to physicians’ concerns. In particular, it appears that CMS has made significant improvements by recasting the EHR [electronic health record] Meaningful Use program and by reducing quality reporting burdens.” In the statement, Stack also said that “The existing Medicare pay-for-performance programs are burdensome, meaningless and punitive. The new incentive system needs to be relevant to the real-world practice of medicine and establish meaningful links between payments and the quality of patient care, while reducing red tape,” he added, and stated that AMA leaders would be carefully reviewing the details of the proposal and would participate in providing to comments to CMS during the 60-day comment period.

And Jeffery Smith, vice president of public policy at the Bethesda, Md.-based American Medical Informatics Association (AMIA), said, “While there is a tremendous amount of detail yet to understand, AMIA applauds CMS proposals that address the “all or nothing” and threshold legacies of Meaningful Use.  We also support the proposals that refocus requirements on those aspects of the program that are important, such as patient data access and patient engagement, care coordination and health information exchange.  These changes will enable all stakeholders – providers and policymakers – to leverage program participation as a means to learn rather than simply grade.”

Meanwhile, CHIME’s Branzell said last Wednesday that “We are encouraged that CMS Acting Administrator Andy Slavitt said the agency will continue to meet with hospital officials to create alignment across health IT programs. We look forward to working with the administration to address critical issues impacting CHIME members, including adopting a 90-day reporting period and removing the pass-fail construct for attestation.”

The timing of this announcement, meanwhile, is important; it comes at the same time as CMS continues to rework the various accountable care organization (ACO) programs under the Medicare program’s aegis, while using all the levers at its disposal to push providers of all kinds into value-based care delivery and payment and alternative payment models, as under the MACRA legislation. So it increasingly feels like a combination of carrot and stick—with the agency pushing providers further into the new healthcare, while simultaneously making changes that soften the edge of that push.

So, while only time will tell how all of this ultimately plays out, one thing is very clear: federal healthcare officials are hearing what patient care leaders have to say. And while they’re not necessarily meeting or are going to meet, every demand of providers, it is clear that CMS senior officials are calibrating program changes to do everything possible to get providers motivated to move forward into the new healthcare. It’s not subtle, but it’s not Stalinist, either. And, given the broad outlines of the policy and payment shifts taking place, the trends are very clear now. The next two years will be pivotal for physicians, given these changes under Medicare; and soon, additional changes should be coming for hospitals as well. But let’s be clear: the overall trends are clear, and it’s time for providers to move forward to anticipate these changes, and take advantage of this new flexibility, while the time is ripe to anticipate change.

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