- Breaking news from CMS doesn’t always make the healthcare industry very happy, but Acting Administrator Andy Slavitt unveiled a pleasant surprise for providers late last week by announcing increased flexibility for participating in MACRA.
In a blog post on September 8, Slavitt gave stakeholders a sneak peek into a novel “pick your own pace” roadmap for the hotly contested successor to meaningful use, which includes four increasingly arduous tracks for avoiding negative Medicare payment adjustments in the near future.
The four options, which range from a quick dip in MACRA waters to full-blown participation in an Advanced Alternative Payment Model (APM), may be geared towards bringing success to the largest possible number of eligible clinicians.
But will this staggered approach reduce the effectiveness of a program intended to even out the health IT competencies of the nation? How will it impact the industry’s data analytics and interoperability stragglers? Does it really provide as much flexibility as it seems?
What does “pick your own pace” mean?
Medicare reimbursement rates are CMS’ primary lever for driving change in the health IT landscape, and the fear of payment cuts has been a recurring theme in the agency’s quality improvement, patient safety, and EHR adoption programs.
But the new “pick your own pace” MACRA framework may be taking the teeth out of this useful – but supremely frustrating – weapon by allowing almost everyone to avoid negative payment adjustments simply by submitting “some data” to the Quality Payment Program (QPP).
The Quality Payment Program is the collective term for MIPS and APMs.
Under the first new option for participation, eligible clinicians need only submit a portion of the required MIPS data to dodge a MACRA-related Medicare cut.
“As long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment,” Slavitt wrote. “This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.”
CMS has not released data on how many eligible providers have avoided Medicare payment cuts in 2017 due to successful attestation to the EHR Incentive Program, but did recently note that 98 percent of eligible hospitals and critical access hospitals will not be penalized due to approved Stage 1 or Stage 2 meaningful use participation.
Details about what “some data” really means in the context of MACRA will not be available until November 1, when CMS expects to publish the final rule. But the high penalty avoidance numbers for hospitals do indicate that many stakeholders are likely to be prepared to send at least a portion of the required reports.
For those who are ready to jump into the MIPS portion of the QPP but aren’t sure they can report for an entire calendar year, CMS has created a partial year participation option. This second pathway will allow providers to begin their reporting after the January 1, 2017 start date and still earn a “small” positive payment adjustment.
“For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment,” Slavitt said. “You could select from the list of quality measures and improvement activities available under the Quality Payment Program.”
Again, details are scarce, and CMS does not outline exactly how long an acceptable reporting period will be. A number of stakeholders have lobbied hard for a 90-day reporting period throughout the EHR Incentive Program era, but Slavitt does not commit to a three-month block in his initial comments.
Instead, he moves straight on to discussing full-year participation, which will earn successful providers a “modest” incentive package.
“For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year,” he said. “This means your first performance period would begin on January 1, 2017.”
“For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment.”
CMS expects that “many” providers will be ready to take on full-year reporting, but the agency has not yet defined how much more reimbursement these ambitious participants stand to gain, and whether or not the higher positive adjustment rate will be worth it.
Slavitt does state that providers who take the fourth option – full participation in an Advanced Alternative Payment Model (APM) will be eligible for a 5 percent incentive payment in 2019. APMs include certain approved patient-centered medical homes, accountable care organizations like Track 2 and Track 3 of the Medicare Shared Savings Program (MSSP), and other value-based reimbursement models that leverage financial risk and health IT tools to improve care quality.
What isn’t going to change under the new tiered system?
While some providers breathed a heavy sigh of relief when Slavitt announced the new options, and initial reactions from groups like the AMA and AAFP have been very positive, the new options aren’t going to change the core of what MACRA is about.
Slavitt doesn’t specifically address the technology requirements for participating in the lowest level of the program, but it is unlikely that providers will permanently escape the need to upgrade to 2015 Certified Electronic Health Record Technology (CEHRT), even if CMS decides to change the implementation timeline for this new standard.
In April, Slavitt touted MACRA’s close association with 2015 CEHRT standards – and the flexibility of a modular approach to data analytics – as a major positive development.
“Because this proposal is aligned with the 2015 CEHRT, physicians will be using technology with open APIs to allow analytics tools and devices easier connectivity,” he said. “We urge developers and the technology community to take advantage of the proposed flexible regulations when they’re ultimately finalized so they can design around the everyday needs of users, rather than designing around the one-size-fits-all regulated approach.”
Nor will providers be able to completely dodge the health information exchange and interoperability components of the new framework, because they still need to demonstrate that their reporting and communication systems work.
Even providers who are only submitting some data to the QPP must have the tools in place to get their reports to CMS, and will likely be required to include at least some proof of basic interoperability to prepare them for full participation later on.
It is especially important to note that Slavitt expects broader participation as early as 2018 for these lowest tier testers, which doesn’t give providers much time to waste on putting off infrastructure investment.
CMS is also unlikely to back down too far on its Application Programming Interface (API) provisions, due to the widespread industry acknowledgement that this interoperability technology is one of the most promising standardization tools available.
And successful quality improvements related to MIPS clinical quality measures will still rely on a familiarity with basic big data analytics techniques.
Providers who hope to quality for any of the positive payment adjustment levels will need to invest in the data-driven tools necessary to demonstrate continuous improvement in the realms of care coordination and population health management, which will likely keep the technology market in growth mode for quite some time.
How do the pathways align with the requests of industry stakeholders?
The flexibility provisions are extremely welcome to stakeholders who have felt overwhelmed and unable to cope with the breakneck pace of the EHR Incentive Programs, but it is not yet clear how much CMS is willing to bend to industry input.
Dozens of comment letters poured in during the mandatory public comment period, and many asked for the one thing CMS does not appear prepared to give: extra time before the current January 1, 2017 start date.
Before the announcement of the flexibility program, the AMA argued strongly for an “initial transitional period” between July 1 and December 31 of 2017 instead of the January 1 date favored by the agency, which would give participants another six months to gear up for the switch.
The professional society pointed out that CMS is only leaving a scant few months between the publication of the final rule, expected by November, and the first-of-the-year start to the program, which may pose significant problems for provider education and technology upgrades.
“We have serious concerns that there will be inadequate time to not only include new measures but also to test and ensure the data submitted is accurate and reliable,” the AMA said. “The timeframe proposed simply does not allow for these entities to validate new data entry and testing tools, which can also worsen usability and add to the existing problems with this technology.”
HIMSS joined the AMA in expressing concerns about the compressed timeline, which will give providers “just weeks” to prepare for the start date. QPP preparation may require changes a number of basic data systems, including administrative and financial tools, qualified clinical data registries, reporting systems, and CMS’ own technical infrastructure.
“While some preparations can be made in anticipation of the publication of the Final Rule, what must be done depends on what CMS finalizes,” HIMSS and AMDIS noted.
In addition, CMS will still need to further define certain terms and concepts, such as information blocking, to allow for a meaningful attestation that it is not happening.
Currently, participants will be required to state that their electronic health records are not actively engaged in preventing the flow of data across disparate systems and into the hands of patients, but the industry has not come to a consensus on what that really means in practice.
CHIME points out that it is exceedingly difficult to distinguish between the inherent limitations of EHR technology and malicious data blocking, nor does CMS make much of an attempt to suss out the differences in its proposed rule.
“Technology, social, economic and community factors must all be accounted for and meticulously evaluated when determining what constitutes ‘information blocking,’” CHIME writes.
“If providers are being asked to attest that they have been compliant with the standards applicable to exchange information, it’s imperative that such standards are clearly defined and appropriately matured to facilitate meaningful data exchange.”
HIMSS, the AMA, the American College of Physicians, and ACO facilitator Aledade, which includes former National Coordinator Farzad Mostashari, also urged CMS to reevaluate its information blocking provision.
What do the new options mean for EHR and analytics infrastructure investment?
While it may appear on the surface that allowing less-intensive participation routes will lead many providers to slow down their investment in infrastructure development until the very last minute, MACRA and meaningful use aren’t the only drivers of big data analytics tools and services.
The general move towards value-based reimbursement, even outside of the major regulatory programs, have been fostering an environment where providers have to innovate if they want to keep their doors open.
CMS and private payers have been relatively successful in their quest to promote the overall importance of data-driven population health management, not just as a way to tick off another box on the attestation form, but as the key to truly improving the quality of care.
MACRA promotes this ideal in several ways, including a requirement to integrate patient-generated health data into 2015 Certified EHRs.
“MIPS eligible clinicians will be using CEHRT and other tools which leverage interoperable standards for data capture, usage, and exchange in order to facilitate and enhance patient and family engagement, care coordination among diverse care team members, and, in continuous learning and rapid-cycle improvement leveraging advanced quality measurement and safety initiatives,” the proposed rule says.
Additionally, the emphasis on APMs reserves the highest monetary rewards for the providers who learn how to leverage big data analytics most effectively.
Only early adopters of value-based care and population health management principles will reap top-level dividends from their foresight in the first few years of MACRA’s reign.
The rest of the industry will need to start making significant investments in population health, business intelligence, revenue cycle management, and patient engagement technologies if they wish to catch up – and the flexibility options aren’t likely to change that fundamental reality, especially since full participation will be required for the majority of providers in the relatively near future.
The timeline for MACRA may be tight, but the writing has been on the wall for several years already.
While many of the organizations submitting public comments would like to see even more flexibility, later timeframes, and lower thresholds for clinical quality measure reporting and other quality improvement efforts, none argue with the idea that data-driven care with an emphasis on value is the future of the healthcare industry.
“As a nation, we’ve made significant advances in transitioning the healthcare system to one that pays for quality, encourages coordinated care and smarter spending, and focuses on better outcomes for people,” Slavitt said in a media call in April.
CMS officials have repeatedly stated that MACRA is about using technology for quality improvements – “paying for what works,” in Slavitt’s words – not just adopting health IT for adoption’s sake.
This approach may help to unravel the “big data paradox,” which has led physicians to feel overwhelmed by the amount of data they must handle without gleaning much actionable information from the deluge.
“We’ll be smart if we look at the Quality Payment Program as a framework we can work with that if implemented with care, can begin the process of turning things around towards a more sensible, simpler approach where physicians and other clinicians will feel supported by laws and regulations, the technology vendors, and the infrastructure that surrounds them,” Slavitt said at the 2016 Annual Meeting of the AMA.
“This is why we need to be so committed to a collaborative implementation, increased transparency, and a continual improvement process, so that over the next several years we allow feedback on the ground to inform the policies we implement.”
As CMS clarifies its “pick your own pace” rules and refines its approach to implementing MACRA, eligible clinicians will have a better idea of what analytics tools and systems will be required for long-term success under the new framework.
If Slavitt and his colleagues can help providers transition away from viewing regulation as a burden and towards true quality improvements driven by a sturdy administrative framework, MACRA may even have a chance of doing what meaningful use could not: creating an interoperable, data-rich community of providers delivering uniformly high quality care.