Within MACRA Proposed Rule, Health IT Leaders Ponder the Complexity of the “New” Meaningful Use

Oct. 4, 2016
With the release of a proposed MACRA rule on April 27, the federal government announced changes to the existing MU program, leaving Medicare physicians with nearly 1,000 pages of reading to examine how the new program, called Advancing Care Information, and others, will impact their organizations.

With the release of a proposed Medicare Access and CHIP Reauthorization Act (MACRA) rule on April 27, the federal government announced changes to the existing meaningful use (MU) program, leaving Medicare physicians with nearly 1,000 pages of reading to examine how the new program, called Advancing Care Information (ACI), and others, will impact their organizations.

Indeed, officials from the Centers for Medicare & Medicaid Services (CMS) effectively said that meaningful use will be “replaced” with the new ACI program for Medicare doctors, which accounts for 25 percent of an eligible physician’s (EP) total score under the Merit-based Incentive Payment System (MIPS) in the first year. In addition to the Advancing Care Information program, doctors will be scored on Quality (50 percent of total score in year 1); Clinical Practice Improvement Activities (15 percent of total score in year 1); and Cost (10 percent of total score in year 1). Overall, how EPs score within each of these four areas will determine their reimbursement amounts for health IT. CMS would begin measuring performance for doctors and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019. For the moment, hospitals will be unaffected within this part of MACA, per the Notice of Proposed Rulemaking by the Department of Health and Human Services (HHS).

Under the Advancing Care Information category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing meaningful use reporting program, this category would not require all-or-nothing electronic health record (EHR) measurement or redundant quality reporting, according to a CMS press release. Instead, the ACI category consists of two components: the base score, in which an eligible physician can earn 50 percent of his or her total points, and a performance score to make up the rest.

Within the base score, previous thresholds under meaningful use (i.e. requiring physicians to send a secure message to 5 percent of patients) are wiped out, and are replaced with a requirement of either having one single patient perform under that objective’s measure, or report a yes/no statement as appropriate (only a yes statement would qualify for credit under the base score). Meanwhile, the performance score is based on the priority goals established by CMS to focus on leveraging certified EHR technology to support the coordination of care. Similar to the base score, there are no thresholds for a clinician’s performance score, which CMS said will provide the much-desired flexibility that physicians have long been looking for. Objectives such as computer provider order entry (CPOE) and clinical decision support, in which the median clinical performance was extremely high under the existing program, have been removed under the Advancing Care Information proposed rule.

So, does all this mean that meaningful use is, in fact, “dead?” Not so fast, says Jeffery Smith, vice president, public policy, at the American Medical Informatics Association (AMIA). Smith predicts that many detractors of MU will not be satisfied with this newfound flexibility, due to the fact that they still have to do a lot of what Stage 3 was going to originally require.  And while the new scoring methodology will give MIPS EPs flexibility, it’s also going to give a lot of them headaches due to its complexity, he says. “Meaningful use is not dead in the slightest,” Smith says. “A lot of the major components of Stage 3 are still intact. The threshold requirements are no longer there, so that’s what has changed. You can argue that the threshold requirements not being there in some ways are nullified as a benefit. This is not MU recast; it’s MU rebranded,” he says.

Smith goes on to explain what he means about how the eliminated threshold requirements nullify the potential flexibility offered to providers, giving the patient electronic access to health information objective as an example. He says under Stage 3 of the MU program, the threshold was that 80 percent of patients be provided access to view/download/transmit (VDT) their health information. Under the new Advancing Care Information program, only one patient would be required to do this for the clinician to achieve the full base score possible. But, for the performance part of the score, “CMS will still grade you on how many patients VDT their information,” Smith notes, pointing to the below sample that was provided in the Notice of Proposed Rulemaking.

Source: Department of Health and Human Services

As such, while there are no thresholds anymore for clinicians, they will still have to perform to a similar set of objectives and measures that were going to be required in Stage 3 of MU anyway. “CMS has gotten rid of the all-or-nothing approach, but they have created a situation where people still have to work their tails off to get all of those 25 points [under the ACI category],” Smith says, adding that if you score a low percent in one of the above measures, that could significantly hurt your total performance score. In fact, Smith says that a MIPS eligible professional who aces the MU Stage 3 test would receive a B- in proposed MIPS scoring schema.

Naomi Levinthal, senior consultant, research and insights at Washington, D.C.-based The Advisory Board Company, agrees with Smith in that it’s a misnomer to say that meaningful use has been replaced, but rather the way CMS applies the way providers participate and perform in the program will be revised. “They are still going to rely on the core of meaningful use, which is all of those objectives and measures already in place,” Levinthal says. “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 notes.

What’s more, Levinthal adds that the new ACI program feels like MU as it existed before this rule came out for Medicare providers. “There are some new ‘gotchas’ in the proposed program,” she says.  “What’s fascinating to me is CMS’ attempt to use more advanced health IT processes, such as health information exchange, care coordination, patient engagement, so they chose those things as the additional points that providers can make up for [in their score]. They took what was ‘easy about meaningful use’ out of that part of the equation and place heavy emphasis on what’s arguably toughest to do within MU.”

Smith goes on to note that in talking with physicians and physician associations, there was a hope that MU would be severely pulled back. “I would argue that in the early stage of using technology, you need training wheels. There was a hope that MACRA would provide clinicians the opportunity to take off the training wheels and let technology be used in a way that would suit their needs," he says. "But, clearly with this proposal, the training wheels are still on. They will tell you that they aren’t keeping track of thresholds, however, you will score poorly if you just meet the base score, and not the performance score,” he says.

The other side of the coin is that the removal of the pass/fail structure will render moot the issues that Smith outlines above, as opined by Leslie Krigstein, vice president of congressional affairs, at the College of Healthcare Information Management Executives (CHIME). Krigstein says that under the old MU, as it stands today, clinicians would fail the whole program if they don’t meet a specific threshold. “So yes your score will get hurt if your [performance score under ACI is low], but you won’t fail the entire program,” she says. “Also, all of your performance categories are being rounded up into one larger score, as there are other categories, in addition to meaningful use, under MIPS,” she explains. Smith agrees to this point of removing the all-or-nothing construct, noting that “it will take some time to figure out how well that flexibility translates into reality. But the intention of CMS was to address these concerns, and they have done it a way that keeps the pressure on,” he says.

Krigstein also points to the fact that CMS is allowing you to get more than the 50 points in the performance score—you can actually score up to 80 points. According to the details in the rule, this will allow clinicians to “focus on measures which are most relevant to their practice to achieve the maximum performance category score, while deemphasizing concentration in other measures which are not relevant to their practice.” There are also bonus points that can be earned for public health and clinical data registry reporting.

Nonetheless, Smith feels that the complexities of this new program speak to a broader point, which is CMS’ intention is to pay the high MIPS performers with the loss of the bad performers. “The thinking was, how much of the bottom half would have to lose in order to pay the top half? If you have 5 percent of the MIPS field do very well, the bottom 80 percent would be paying for it. So there is a bias in all of this against having a lot of high performers,” he says.

Smith also points to the notion that there are some major components of MU Stage 3 that the provider field has no experience with, such as application program interfaces (APIs) with patient engagement, clinical reconciliation, and patient-generated health data. As such, he says, “I suspect those areas are where there will be major pain points. They are trouble spots in Stage 3 and they will be issues in this new paradigm too.”