CMS’ Latest Proposed MU Changes Again Raise Questions around Patient Engagement

Oct. 4, 2016
Earlier this month, CMS announced that it was streamlining reporting requirements for hospitals and EPs participating in the meaningful use program. But, other new proposals from CMS bring on more questions about patient engagement.

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) announced that it was streamlining reporting requirements for hospitals and eligible providers (EPs) participating in the meaningful use (MU) program, by proposing a 90-day electronic health record (EHR) reporting period in 2016, rather than a full calendar-year one, as the agency had earlier seemed to be insistent on.

The shorter reporting period for 2016 is something that EPs have long clamored for; they point to the time needed to plan for upgrades, technology fixes, and optimizing software. A full-year reporting period offers very little, if any, time to allow for these unforeseen circumstances, they say. In a blog I wrote last year after the then-final meaningful use rules were released, I compared a full-year reporting period to checking your car’s oil level every day. It’s simply not necessary; every three months is suffice. CMS seems to have gotten that message.  

Naturally, the reporting period relief that CMS has proposed has gotten the bulk of the attention of late. But if you dug a little bit deeper into the 764-page Notice of Proposed Rulemaking (NPRM) released on July 6, there was a lot more in the rule that didn’t get as much industry attention, but can potentially give providers much desired relief. Indeed, the agency is calling for the reduction of numerous thresholds in MU Stage 3 and in modified Stage 2 levels for 2017 and 2018. Several of the more noteworthy threshold reductions do revolve around requiring patient action.  

For instance, for EHR reporting periods in calendar year 2017, CMS has proposed adjusting the threshold of the modified Stage 2 View, Download, Transmit (VDT) measure under the Patient Electronic Access objective from 5 percent of patients having to VDT their health information to one single patient. This threshold originally was scheduled to increase from one patient in 2016 to 5 percent in 2017, and 10 percent for Stage 3, per the final rules from last fall. But now, under the new proposal, this patient engagement requirement will be just one patient—even in Stage 3.

In the rule, CMS explained this decision: “We are proposing to reduce the threshold because we have heard from stakeholders including hospitals and hospital associations that they have faced significant challenges in implementing the objectives and measures that require patient action. These challenges include, but are not limited to, patients who have limited knowledge of, proficiency with, and access to information technology, as well as patients declining to access the portals provided by the eligible hospital or CAH [critical access hospital] to view, download, and transmit their health information via this platform.”

What’s more, for the Secure Messaging measure under Stage 3, CMS has proposed reducing the threshold for those attesting from more than 25 percent down to only more than 5 percent. Here, CMS said that the reason for the reduction is that for patients who are in the hospital for an isolated incident, the hospital may not have significant reason for a follow up secure message. Also, patients may decline to access the messages received through this platform.

Proposed Stage 3 Patient Engagement Objectives and Measures for 2017 and 2018 for Eligible Hospitals and CAHs Attesting Under the Medicare EHR Incentive Program. Source: CMS

This patient electronic access conundrum is not new. Time after time I have heard frustrated doctors say that the number of patients who VDT their health data electronically is “out of their hands,” and that they shouldn’t be penalized for requirements that are out of their physical control. Broadly speaking, it’s hard to argue with this, and it seems like CMS has finally gotten that message as well.

But I also go back to a conversation I had last winter with Mark Savage, director of health information technology policy and programs for the Consumer Partnership for eHealth (CPeH), a Washington, D.C.-based patient advocacy group led by the National Partnership for Women & Families. Savage, obviously, a devout advocate for greater patient engagement, has outwardly been against dropping the VDT requirement to just one single patient. In our discussion last December, Savage said, “As a number, one patient is not enough. To go from 5 percent originally, then back to one patient, and for secure messaging, to just turn it on and then not having any patients use it, what kind of a message does that communicate to folks? That it’s important? No, it doesn’t; it suggests that the level of value has shifted in CMS’ mind.”

Savage added, “Physicians may not be able to control 100 percent of what happens because it’s a partnership, meaning that it’s about the patients too. But doctors are certainly influential. If they explain why online access is available, and explain where you go to do it and why it’s important, that’s being influential. Doctors are among the most trusted people for patients, we know that. It’s an opportunity to help patients help doctors get them well. It’s a win-win situation.”

I thought Savage’s points about patients needing to be partners with their physicians were fair at the time and I still do; maybe a mandate of one single patient is too low. Is 5 percent really an unachievable number? And keep in mind that with the release of the meaningful use rules last fall, the VDT threshold actually did increase to 10 percent for Stage 3. Now, with the revised proposals, CMS is not asking providers to go that high, or even close to it.   

Our Senior Contributing Editor David Raths again caught up with Savage after these new proposals, and he had many of the same thoughts: “Dropping the threshold to one patient for online access just doesn’t seem right. It is the wrong signal to send to patients and families, and it sends the wrong signal to providers.  That undermines the commitment to making patients and families true and equal partners. We need to send a better signal,” he said.

He further noted, “In this NPRM, I didn’t see any mention of consulting with patients or patient organizations that were asking for these changes. The Consumer Partnership for eHealth has been providing lots of resources and thinking that have made their way into regulation, so if we were asked, perhaps there are ways that we could be helping with some of the issues that CMS sees now, so they are not just hearing from hospitals saying this isn’t working. They could hear form patient organizations about how to make it work.”

Savage said that that the proposed rule suggests that CMS is certainly listening and responding to complaints from hospitals. In the NPRM, CMS has confirmed that’s indeed the case. And that’s how it should be—providers in the trenches should be the ones who have the greatest say in these rules.

It does seem however, that now, patient advocates like Savage might be losing the patient engagement battle, at least in the short term. I’m hoping that in the big picture, due to the way that the “new” healthcare is taking form, providers do realize how important it is to make patients a bigger part of their care—even if there’s not a box to check telling them to do so.

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