Congress Authorizes Changes to MIPS

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

mips-blogHow many times have you heard the expression, “It would take an act of Congress.”? Well, Congress has acted! Had this blog been posted just 2 weeks ago, the message would have been slightly different and a little more ominous in tone. I would have said—and you may have read articles elsewhere where I did—that the MIPS transition period is coming to an end, and providers should begin to prepare in earnest for 2019, when by law, the MIPS threshold would be much higher and the cost category would account for 30% of the MIPS score. These provisions in MACRA were not subject to CMS’ discretion; but apparently, Congress has been persuaded to extend CMS increased flexibility. As part of the Bipartisan Budget Act of 2018, Congress has pushed out the full implementation of MIPS from 2019 to 2022, effectively making 2019, 2020, and 2021 three additional transition years.

This means that:

  • There will still be winners and losers since budget neutrality remains a requirement; however, CMS is now not obligated to set the MIPS threshold at the mean (or median) of prior performance until 2022. Instead, the threshold will be gradually increased to that level over the intervening years, the good news being that it will not be as challenging to avoid a downward adjustment for a few more years. The consequence of this, however, is that the amount of money available to winners will continue to be less than the maximum provided for in the law, (i.e., 5% related to the 2018 performance year, 7% for 2019, and 9% from then on.)
  • The Cost category does not jump to 30% of the MIPS score in 2019. CMS can hold off on the increase until as late as 2022, with the flexibility to set the rate at between 10% and 30% each year until then and to make it 30% only when the Secretary is confident that the resource use, (i.e., cost), measures are ready for adoption. In addition, the bonus points for year-over-year improvement in this category have been eliminated.

Through these changes, Congress has relieved some of the immediate pressure for providers. However, this does not change the fact that it will become progressively harder to score well as providers gain experience, making MIPS increasingly competitive in the coming years:

  • The Quality and Cost categories will remain distinguishing factors among providers.
    • It will become progressively harder to score well in the Quality category. Benchmarks will be more aggressive as providers build experience. The 2018 benchmarks have been posted on the QPP website, and you can already see differences from the 2017 deciles for some measures.
    • Improving your comparative Cost position is not something you can do overnight; it takes time. So, it’s not too early to address this area more vigorously.
  • MIPS performance has implications beyond Medicare payment adjustments. Your reputation could be impacted as CMS makes more and more performance data publicly available on its Physician Compare website. Consider what you want patients, referring physicians, and payers to see about you when they are researching your practice.

So, don’t let down your guard. Take advantage of the additional transition years to secure your future success.

CMS Overpaid $729MM in MU Payments: What Does That Mean for You?

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

overpaid-blogIt’s been all over the press for the past week—CMS paid a lot of money in the form of EHR incentives (Meaningful Use) to providers who did not truly earn them. These inappropriate payments were revealed in a report by the OIG (Office of the Inspector General) that reviewed CMS’s compliance with Federal requirements in the Medicare EHR Incentive Program for eligible professionals from 2011-2014. Although the subject of the OIG’s audit was CMS—in contrast to the audits of providers (pre- and post-payment) that have been conducted by Figliozzi and Company—there are some important implications for providers.

Here are two of the OIG’s major conclusions:

  • 14 EPs (Eligible Professionals), out of a sample of 100 who attested to having met MU one or more times did not actually meet the MU requirements. They either could not support their attestation with sufficient evidence or had errors in their attestation. Affected payments to these providers totaled $291,222. Extrapolating on this data, the auditors estimated that CMS inappropriately paid over $729 million.
  • In addition, 471 payments to EPs who switched between the Medicare and Medicaid incentive programs were incorrectly calculated, accounting for another $2.3 million.

The report recommended that CMS:

  • recover the $291,222 from the EPs who had the unfortunate luck to have been sampled [editorial comment is mine, not the OIGs!] and found to be non-compliant;
  • recover the $2.3 million in overpayments to EPs who switched programs; and
  • try to recover some of the estimated inappropriate payments made to other providers.

It’s likely that CMS will pursue the first two recommendations, but yet to be determined what—if anything—they will do about the third. That said, however, one thing is certain: CMS will intensify its oversight going forward. (This was another of the OIG’s recommendations.) Does this mean you should abandon your plans to participate in MIPS and/or MU (Medicaid program)? Absolutely not! It does, however, imply that it will now be more important than ever to keep full documentation to support everything you submit. And, make sure to keep it somewhere that will survive any future changes in software, hardware, and/or practice staff.

90-Day MU Reporting: Deja-Vu All Over Again!

Lynn Scheps

Lynn Scheps

VP, Government Affairs & Consulting Services at SRS Health
Lynn Scheps is a leading resource on MACRA, MIPS, and Meaningful Use. She is the SRS liaison with government policy makers. Representing the voice of specialists and other high-performance physicians, she develops strategies to respond effectively to government initiatives.
Lynn Scheps

flag-money-stethLast week, in keeping with what seems to have become a mid-year tradition, CMS issued a proposed rule that—amidst its 700-plus pages related to hospital payments—reduces the 2016 MU reporting period from the full calendar year to any 90 consecutive days. (Note that this applies only to providers participating in the Medicare, not Medicaid, EHR Incentive Program, and has no effect on PQRS reporting.) Would it have been better if the announcement had come in a more timely fashion—i.e., at the beginning of the year instead of the middle? Absolutely! But don’t let that keep you from taking advantage of this opportunity.

This is good news for providers who had given up on MU for 2016—or who got off to a slow start on the program this year. Here’s an opportunity to get back in the game and avoid the 2018 payment adjustment (3% or 4%, to be set at the discretion of the Secretary of HHS). It also provides a bit of a breather for those who are successfully demonstrating meaningful use and may be able to identify an already-completed 90-day period during which they met all the requirements. These providers can now turn their attention to preparing for MACRA, which is proposed to be effective on January 1 and in which MU (renamed “Advancing Care Information”) is only one of the four components.

So, what accounted for this change? Is it an indication of a kinder and gentler CMS to come? The CMS Fact Sheet states that CMS is trying to “assist health care providers by increasing flexibility in the program.” Was it in response to the deluge of comments to the MACRA rule that screamed “Help!,” or to the repeated requests for relief submitted by providers, organizations, and members of Congress? Let us know below what you think brought about this change of heart.

Proposed SGR Fix – It’s Different This Time

Year after year, physicians live for months with the uncertainty and angst of threatened, often draconian, Medicare reimbursement cuts born out of the Sustainable Growth Rate (SGR) budgeting formula.  And every year, intense lobbying and complex negotiations lead to short-term patches that maintain or slightly increase reimbursement rates—these solutions are commonly referred to as the Doc Fix. This year’s fix is set to expire at the end of March, which would leave physicians facing a 23.7% reduction—but on Thursday, a bipartisan piece of legislation proposed a repeal of the SGR and the creation of a new payment model that would reward quality, rather than volume of care provided. All that’s left now is to figure out how to fund the $128 billion price tag over the next 10 years.

Although I haven’t read the 200-page bill, the following is a summary of its major provisions:

  • The SGR fix would increase Medicare physician reimbursement rates by 0.5% annually for the next 5 years, i.e., through 2018. This would provide income predictability and stability for providers.
    • 2018 rates would be maintained through 2023.
    • From 2024 on, physicians who participate in Alternate Payment Models would see a 1% annual increase; non-participants would receive 0.5% increases.
  • It would create a new payment system called MIPS (Merit-Based Incentive Payment System) by 2018, which would roll up meaningful use, PQRS, and the Value-Based Payment System into one program that would tie physician reimbursement to quality and cost. Physicians would be assessed in 4 areas:
    • Quality: based on current and future quality measures from the PQRS and Meaningful Use programs
    • Resource use: assessment of cost structure using a method similar to that currently in use in the Value-Based Payment Program
    • Meaningful Use: satisfying current meaningful use requirements demonstrated by use of a certified EHR
    • Participation in practice improvement activities: a new area of measurement related to clinical improvement.
  • Physicians would receive a composite score on all of the above.  Based on total score relative to other physicians, they would receive either:
    • A negative adjustment of up to 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021
    • No adjustment
    • A positive adjustment of as much as 3 times the maximum negative adjustment for that year.
  • The new payment system would provide additional incentives (5% per year from 2018 to 2023) to providers who derive a substantial part of their income from alternative payment models that base payment on quality assessment and financial risk sharing rather than volume of services provided, (e.g., ACOs, Medical Homes, or other new healthcare delivery models).
  • It would encourage cost savings by incentivizing care coordination and adherence to Clinical Decision Support (CDS) mechanisms and Appropriate Use Criteria (AUC) aimed at reducing unnecessary testing—specifically in the area of advanced diagnostic imaging:
    • Effective 2017, physicians would be paid for advanced diagnostic imaging only if the claim shows consultation with CDS mechanisms and AUC.
    • Effective 2020, the 5% of physicians with the lowest adherence rates would require prior authorization for such tests.
  • Beginning in 2015, patients would have access to quality and cost data regarding individual physicians that would be made available on the Physician Compare Site.

MIPS would rely heavily on quality measurement, data sharing, and interoperability, so one thing is abundantly clear:  Robust EHRs and extensive data management capabilities will be critical tools for physician success in the future, even more so than they are today.

 

 

Stage 2 Meaningful Use: The Public Has Spoken

CMS asked for comments on its Proposed Rule for Stage 2 Meaningful Use, and it got them—1,131 of them, to be exact. While the comments that have drawn media attention are those from major stakeholder organizations, the vast majority of comments were submitted by individuals—and CMS is obligated to read and consider each and every one of them as they formulate the Final Rule.

 

I thought it would be interesting to see whether the comments from those in the trenches—those whose everyday lives are impacted by the meaningful use regulations—are in line with the sentiments expressed by groups like the AMA, AHA, MGMA, EHRA, etc. In a review of the first 25% of the comments by individuals, (over 250 comments), a consensus clearly evolved around a few major points, and the results remained fairly consistent as we read. The graph above illustrates the prevailing sentiments.

  • By far, the predominant concern is that the proposed requirements are far too demanding, i.e., the bar is being set too high. An overwhelming 82 of the comments identified the sheer number of measures and components, challenging thresholds, the cost of compliance, and overly aggressive timetables—even in light of the delay to 2014—as being unrealistic.
  • On a similar note, another 14 addressed the complexity of the requirements, describing them as difficult to understand, ambiguous, and overly complicated. When combined with the above, approximately 40% of the 250 comments reviewed maintained that the Stage 2 requirements are simply too demanding.
  • As anticipated, there was a resounding concern (56 comments) about holding physicians responsible for actions by any third parties over whom they have no real control. Most comments referred to the requirement that patients view or download their charts and communicate to the physician by secure e-mail, but some asked that providers be insulated from any failure by vendors to meet the requirements or the client upgrade schedules.
  • The limited relevance for specialists remains an issue in Stage 2, as the program is still viewed as primary-care focused. There were 23 comments that addressed the paucity of meaningful use measures and clinical quality measures that are relevant to specialists, and some went so far as to claim that trying to meet requirements that are geared towards primary care could actually distract specialists from their own priorities and be detrimental to the quality of care they would be able to deliver.
  • Some comments addressed the penalties and suggested that the rules provide for a broader range of exemptions and more leeway. The suggestion that the first year of Stage 2 only require 90 days of reporting—which was suggested for other reasons as well—was supported by providers concerned with the penalties.
  • In response to a plea from CMS that people report what they like in the proposal, in addition to what they don’t, some commenters expressed general support for the Stage 2 recommendations, and a small number argued that the bar wasn’t raised high enough. Some—likely specialists—applauded the change in exclusions for reporting of vital signs; several approved of ensuring patient access to their clinical information; and there was support for the proposed harmonization of clinical quality measure reporting under the various government programs (meaningful use and PQRS).

Perhaps what is most interesting about the comments is the emotion and passion behind many of them—whether expressing favorable or unfavorable opinions. If you would like to browse through the public comments yourself, go to www.regulations.gov and enter “CMS-2012-0022” in the search bar.

Meaningful Use Stage 2: Speak Now, or Forever Hold Your Peace

Meaningful Use Stage 2: Speak Now, or Forever Hold Your PeaceYesterday, the Proposed Rule defining Meaningful Use Stage 2 was officially posted in the Federal Register. This means that the clock has begun ticking on the 60-day comment period, and the opportunity to influence the decision makers will end on May 6. It is critical that physicians speak up, particularly now that some will be able to respond from the perspective of their experiences in—or familiarity with—Stage 1.

In upcoming posts (after we have had the time to read, re-read, and analyze the lengthy Proposed Rule), I will discuss specific measures that I believe require modification due to their limited practicality and/or potentially adverse impact on physician workflows. Today I want to provide some high-level observations drawn from an initial evaluation of the Rule and highlight a few major implications that immediately come to mind:

  • The bar has definitely been raised! The emphasis on interoperability, patient engagement, and more extensive quality measure reporting impose very demanding requirements that represent a huge step up in capability and effort. The term “more stringent”—which is used in the ARRA legislation to characterize successive stages of meaningful use—does not begin to describe the relative intensity of Stage 2.
  • Expectations are very high, despite the fact that a vast number of physicians have not even begun to participate in Stage 1. Although CMS claims that the number of core and menu measures remains steady at a total of 20 (through some sleight-of-hand counting magic!), the actual requirements have expanded in number, complexity, and depth.
  • The proposed leap forward in the exchange of clinical data is monumental in scope. Although this is an important long-term program goal, it must be reconsidered in light of the dismal experience in this area in Stage 1. The requirement to simply test the ability to exchange clinical data met with such confusion and failure that the measure has been retroactively eliminated for 2013—the second year of Stage 1.
  • Patient engagement is another area of focus in Stage 2. Again, this is a noble goal, and physicians should be rewarded for doing everything possible to encourage patient and family involvement in care. The Proposed Rule, however, defines meaningful use to include specific patient actions, such as e-mailing their physician and accessing their information on a portal. It is unacceptable to make a provider’s incentive payment dependent upon actions by patients over which he or she has no ultimate control.
  • The Rule proposes some appealing options for streamlining clinical quality measure (CQM) reporting and harmonizing the various CMS programs that involve CQMs. However, the number of measures has exploded, and the administrative aspects of the various options will be very difficult for providers to discern.

Those are my first impressions. I will follow up with more information on these and other issues and on the procedure for submitting comments to CMS. In the meantime, I am interested in hearing your thoughts and/or concerns about the Proposed Rule and how it could impact your practice.

Stage 2 Meaningful Use Delayed to 2014: What’s It Really About?

HHS has made it official—Stage 2 of meaningful use will be pushed back to 2014. The announcement by HHS Secretary Sebelius came as no surprise, following as it did the recommendation made by the HIT Policy Committee and the endorsement by ONC head Farzad Mostashari. The change only affects providers whose first incentive payment year is 2011, since they are the only providers who would be subject to Stage 2 regulations in 2013 had the delay not been implemented—everyone was already entitled to 2 years of meaningful use at Stage 1.

What I find interesting about all the hoopla that has accompanied the announcement is the spin the government put on the decision. According to the press release from HHS, “To encourage faster adoption, the Secretary announced that HHS intends to allow doctors and hospitals to adopt health IT this year, without meeting the new standards until 2014. Doctors who act quickly can also qualify for incentive payments in 2011 as well as 2012.”

Isn’t it a bit late for a provider to decide to adopt health IT this year? In reality, this announcement is too last-minute to change any adoption-related behavior or to accelerate EHR adoption. The announcement continued, “Perhaps most importantly, we want to provide an added incentive for providers attesting to meaningful use in 2011.” Apparently, the goal is to accelerate attestation rather than adoption—to encourage physicians who were already using certified EHR technology in a “meaningful way” to attest and to collect an incentive payment this year, instead of holding off attesting until 2012. This would create a potential PR benefit for the incentive program, which currently boasts nearly 115,000 registered providers, but reports that only 10,155 (9%), have successfully attested.

The benefit of the schedule delay accrues only to the early adopters, who now can earn 3 years of incentives under the less stringent requirements of Stage 1 (only, however, if they are willing to forego their 2011 Medicare ePrescribing bonuses—not a worthwhile trade-off for high-revenue physicians with large Medicare volumes). In its statement, HHS acknowledged the pushback from providers regarding how challenging even the Stage 1 requirements are. Perhaps, it would truly spur program participation and EHR adoption if all providers—not just the early adopters—were entitled to 3 years of meaningful use under Stage 1 rules. Also, if CMS has so little confidence that physicians will succeed at Stage 2, shouldn’t it reconsider how much it plans to raise the bar?