An HIT Expert Dives into the Details of CMS’ Proposed Hospital Payment Rule

May 1, 2018
With ongoing discussion about the implications of CMS' proposed hospital payment rule, Jeff Smith, vice president of public policy at AMIA, dives into the details of the rule, including how CMS might be raising the interoperability stakes.

On April 24, the Centers for Medicare & Medicaid Services (CMS) released an 1,883-page proposed rule on meaningful use rebranding with new emphasis on interoperability and burden reduction, along with indications that the agency may be raising the interoperability stakes.

The meaningful use (Medicare and Medicaid EHR Incentive Programs) program has been around since 2011 with the intent to encourage eligible providers to demonstrate meaningful use of certified EHR (electronic health record) technology. CMS is now proposing a shakeup of the initiative with a rethinking of industry priorities. In a press release, the federal agency said that it will be proposing to re-name the meaningful use program to “Promoting Interoperability.” CMS said the goals of the new program will be to: make it more flexible and less burdensome; emphasize measures that require the exchange of health information between providers and patients, and incentivize providers to make it easier for patients to obtain their medical records electronically.  According to CMS, the rule applies to about 3,300 acute care hospitals and 420 long-term care hospitals, and would take effect Oct. 1.

Since the rule dropped, there has been ongoing discussion about the changes in the proposed rule and if the government will be forcing providers to participate in health information exchange activities, and you can read some of that reaction in this article posted last week. For that article, Healthcare Informatics Associate Editor Heather Landi spoke with Jeff Smith, vice president of public policy at AMIA (the American Medical Informatics Association) about CMS raising the interoperability stakes. Below are excerpts from that interview.

What are your initial takeaways of this proposed rule?

This is the first rulemaking cycle that the new Administration has the ability to put its fingerprints on. The thing I’m struck most with is the fact that they have been talking about the need to reduce reporting burden and the need to improve interoperability, particularly patient data access. I do think those themes come through pretty loud and clear with these proposals. Now, one quibble is whether or not the total effort is reduced by how many measures they removed. CMS states that they have reduced total measures and objectives from 16 down to six. The question is, is it three times easier to do? The answer is, probably not. But, certainly, there is in these proposals an attempt to try to align meaningful use (MU) more with what I presume will be the strategy for MIPS [Merit-based Incentive Payment System) and Advancing Care Information (ACI). Now, we have to wait for that rule to come out. I think if the goal here is to reduce the reporting burden, align MU with MIPS and to try to make progress on interoperability and patient data access, I think these proposals, in total, at least on paper, are pointed in the right direction.

In this proposed rule, CMS is proposing a new scoring methodology. What is your perspective on the scoring methodology?

I think that they’re taking a page out of the MIPS and ACI playbook. It will be interesting to see what the reaction is. I think clearly what they are trying to do is create the opportunity for more flexibility and the preamble does reference the Bipartisan Budget Act of 2018, that was just passed at the beginning of the year. That legislation has allowed CMS to propose policies that are not intrinsically more difficult over time by eliminating the provision requiring more stringent measures of meaningful use. And, you can see that by how CMS is giving people the ability to submit data on fewer measures and by setting the overall composite score at 50 [points needed to avoid Medicare payment adjustments]. So, again, it borrows from the MIPS playbook by recalibrating a composite score and I think this will be largely helpful for those who are worried about the all-or-nothing component of MU. How much extra work and headache it’s going to save, is still another question

CMS also changed the name of the meaningful use program to Promoting Interoperability. How do the changes to the scoring methodology and the metrics support that?

I think there’s nothing you could do within the measures and objectives themselves to improve interoperability in a meaningful way. What you have to do is look at the totality of the program and the requirements, and that is inclusive of a 90-day reporting period and inclusive of the need to adopt 2015 edition certified EHR technology. I think the other thing that we have to keep in mind here is that it will probably take more policy levers than just these measures and objectives to improve interoperability.

Having said that, I do think there are some areas worth exploring a little more closely, and that includes the health information exchange objective. One of the important changes about this is that you no longer have to send the full suite of information and data in the C-CDA (consolidated clinical document architecture). Without getting too technical, what the proposal would allow is for clinicians to send component pieces of the C-CDA, depending on the situation. There’s a common complaint around sending these C-CDAs, that there’s a lot of information in there, mountains of information that are not helpful. What they are proposing is to allow providers to constrain the information in the summary of care record to support the transition of care. That will be interesting to see what the spillover effect is.

By allowing people to send a more constrained amount of information over, one could envision that information is more important and therefore, gets read more frequently, and needs to be integrated in a more workable way. An optimistic potential is that by allowing providers to send a more constrained amount of information, that will make that information more useable and actionable, and essentially, you’re going to have to have computers that can integrate and use this information. So, think of it as, if someone sends a whole bucketful of information, you’re not going to do anything with it. But if someone sends more finite, smaller pieces, then you might go out of your way to figure out how to use the information, and if you’re using an EHR, try to figure out how to incorporate that into your EHR. In terms of improving interoperability, you’re going to have to have a wider view of how this program sits within a larger portfolio of policy levers before we can say with any confidence that this has moved the needle.

Drilling down into the request for information (RFI) on Interoperability section of the proposed rule, what is your take on what CMS is considering?

I think last year you saw this Administration say ‘okay, we’re not making any changes, just do whatever you can and avoid a penalty.’ This year, you’re starting to see a little bit more fingerprint on the actual policy and there’s no better example than the request for information that is focused on the future directions. First, earlier in the rule, there is a table where it lists the measure proposals; some of the measures they are keeping the same, some of the measures they are dropping completely and some measures they are combining and renaming. If you look at the removed measures, they have removed view, download or transmit, they have removed patient generated health data and patient-specific education. What’s interesting about this is that CMS is doing away with one of the things that hospitals have complained a lot about, which is this notion of view, download or transmit. But, what this RFI seems to be signaling is that they are not saying it’s not important to allow patients to view, download and transmit their information; quite the opposite, they think it’s more important than participating in this little program that could cost you a percentage point or two in reimbursement. They think it’s so important that you don’t get to participate in Medicare. So again, on the one hand, they have tried to be responsive to the complaints and concerns about the burden that providers have discussed relative to view, download and transmit, but on the other hand, I couldn’t imagine many hospital executives who would trade MU Stage 3 patient data access measures and objectives, for conditions of participation. That raises the stakes significantly.

One of the really interesting things is that nestled away it says CMS may consider revising the current CMS Conditions of Participation for hospitals that would require them to transfer medically necessary information upon a patient discharge or transfer and to do so electronically, require hospitals to send discharge information to community provider via electronic means, if possible, and require hospitals to make information available to patients or a specific third- party application via electronic means, if requested.

My read on this is [about] participation in the TEFCA [the U.S. Department of Health and Human Services’ draft Trusted Exchange and Common Agreement]. Earlier in the same RFI, the same portion, they do talk about TEFCA and mentioned participation in TEFCA could count as the HIE measure and objective. One of the critiques of TEFCA is that it is voluntary and if you make it too hard, they won’t do it. I always thought that was flawed logic, because the ONC EHR certification program is voluntary, but nobody treats it like it’s voluntary if they want to be part of this world. I’d always assumed that TEFCA would be voluntary, sure, but the government would figure out a way to encourage participation. If you think about TEFCA as essentially requiring all these things, if they were to try to make Conditions of Participation align with the general outline of TEFCA, that would be a pretty strong motivation to participate. It sure seems to me that making information available to other facilities upon transfer or discharge and requiring discharge information go to community providers, and making sure that information is available to patients or third-party apps, pretty much is a large swath of what TEFCA is trying to accomplish.

The proposed rule also requires the adoption of 2015 edition certified electronic health record technology (CEHRT) in 2019. What is your perspective on this timeline?

The fact that they have proposed to move forward with the 2015 edition [CEHRT] in 2019 is really important. I think CMS did a good job of rationalizing it and looked at it pretty closely even last year. They said, the 2014 edition is out of date and insufficient for provider needs. From a purely logical mindset, if people don’t upgrade to the newest edition of the technology, then how do you expect for new standards and new functionalities to make their way out into the world, unless by virtue of some free market mechanism? I think we’re clearly at a point in time where policy has to be concerned with not just allowing or enabling innovation by ensuring that minimum standards are adhered to. I think the fact that they are putting a strong line in the sand that says, in 2019, you have to have 2015 technology, is good. We’re going to look at this proposal through the prism of, are the requirements meaningful within the context of what CMS can and can’t do? And, then we’re going to look at the things that they are dropping, and say, does this matter? The fact that view, download, or transmit is no longer required, I think that means, without much room for doubt, that the old way of viewing, downloading and transmitting information is going to change, and yes, I think patients will still to be able to access their information. I don’t see people rushing out to unhook their patient portals.

I’m hoping ONC gives us some time to get through this, before their rule drops, because I think that’s going to be an interesting piece to this puzzle; trying to understand how this relates to TEFCA is going to be an important thing to understand. And then understanding what comes after 2015. The 2015 edition CEHRT is going to be required in 2019, but it’s been five years since the last edition. So, is ONC going to continue with this edition construct? Is there going to be something else? There’s going to be a lot of additional interesting policies that will have a pretty big impact even on this.