Bio: Former CIO / InfoSec Consultant / expert systems designer / Administrator for OB/GYN & OccMed practices / Family Therapist. Masters in Computer Science and Psychology; author of two books on artificial intelligence. In my "copious" free time I am a professional storyteller and inspirational speaker.
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Last week The Centers for Medicare and Medicaid (CMS) Acting Administrator Andy Slavitt issued an official blog post announcing proposed reporting options for the Quality Payment Program (QPP), the program stemming from the Medicare Access and CHIP Reauthorization Act (MACRA), for program year 2017. The intent of these options is to give participants more flexibility during the initial year of this significant program.
For 2017, the blog post identifies four options:
1) Submit “test” data to CMS for any period of time within 2017. Choosing this option will eliminate any penalties from the MIPS program.
2) Submit complete data for a portion of program year 2017. Choosing this option will provide the opportunity for a partial incentive payment, if any is earned.
3) Submit complete data for all of program year 2017. Choosing this option provides the opportunity for a full incentive payment, if any is earned.
4) Participate in an advanced Alternative Payment Model, as outlined in the QPP rule.
Participating clinicians or practices do not need to finalize which of these four options they will choose until the point of attestation, which will be allowed only in early 2018. However, it is clear that the CMS intends these changes to ensure that all eligible clinicians see a path of some sort to participate in the program and avoid payment adjustments.
We do not yet know if the CMS will change reporting options for advanced Alternative Payment Models, nor what other adjustments the CMS might make in the final rule. While this post appears to offer new flexibility, Mr. Slavitt emphasized that questions about these options cannot be answered until the QPP final rule is issued, currently expected in October or November.
Until the details of the final rule are available, we advise clients to proceed with their plans for active and full participation in the QPP to ensure that they are ready for any option presented. For frequently asked questions about this subject, read A beginner’s guide to MACRA.
Contact Allscripts Consulting if you would like to schedule an introductory consultation.
MACRA is perhaps the most significant piece of proposed healthcare regulation I’ve ever seen. We’ve had a series of webinars to help clients understand the key points, and distilled them here in a Q&A format.
What is MACRA?
MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015. It is Medicare payment reform designed to help lower the cost of health care, while delivering better quality and improving health outcomes. It creates a more comprehensive value-based framework for payment and combines different quality-based measures into one system.
Is MACRA final?
No. MACRA was enacted in April 2015, but a public comment period has been open from April through June 27, 2016. The government is estimating the final rule will be available in October 2016.
If it’s not final, why should I worry about this now?
MACRA includes many changes, and arguably the most critical impact is the introduction of a new payment model that will affect all providers. While 2019 is the official start date for the new payment models, 2017 will be the performance year that determines 2019 payment adjustments. Providers must start taking action now to be ready by the end of 2016.
What’s new about how MACRA will determine payments?
MACRA repealed the Sustainable Growth Rate (SGR) formula, which was a method based on outdated assumptions. This new distribution of quality payments offers providers two tracks to choose from: 1) Merit-based Incentive Payment System (MIPS) and 2) Alternative Payment Models (APMs).
The default track for all providers will be MIPS, which has lower incentives and is ultimately the less attractive option. The Centers for Medicare and Medicaid Services (CMS) anticipates initial participation to be 89% in MIPS and 11% in APMs. However, the tracks are designed to encourage increasing participation in the APM track.
How does the MIPS track work?
Providers that chose the MIPS track will earn a composite performance score based on four categories:
1) Quality of outcomes (50%) – These are familiar clinical quality measures, many the same as Physician Quality Reporting System (PQRS)
2) Cost of outcomes (10%) – No reporting is necessary, as it is measured solely on a claims basis.
3) Clinical Practice Improvement Activity (15%) – This is a new category focused on better processes in nine areas. Each activity has “all or nothing” scale for scoring.
4) Advancing Care Information/Use of Health IT (25%) – This is the most complicated category, because there are three types of scores in this category.
Scores in these four categories will translate into a 100-point scale MIPS score, which translates into a penalty or reward. The incentive/penalty bar will move each year based on national performance of participants. The more participants who do well, the lower the incentive, because this program is to remain budget neutral.
How does the APM track work?
Providers that chose the optional APM track are agreeing to higher risk and higher potential reward. This track is not a single model, but rather is a category of payment models that share assumed risk, provide financial benefit for achieving quality and requires sharing of information across care locations.
Only advanced APMs are eligible for MACRA, which currently includes Medicare Shared Savings Program (MSSP) Track 2 and Track 3, Next Generation Accountable Care Organizations (ACO), Comprehensive Primary Care Plus (CPC+), Comprehensive ESRD care Model (renal dialysis organizations), and an Organization Care Model available in 2018. Surprising omissions from this list include MSSP Track 1, Comprehensive Joint Replacement (CJR) and Patient-Centered Medical Homes.
These models require less investment up front, for the promise of greater rewards upon meeting certain milestones. They also require providers to bear more than a nominal financial risk. To be successful, providers may need to create new organizational systems for clinical and financial management to manage quality.
Help! What do all these acronyms mean?
We’ve compiled a list of “MACRAnyms” associated with this rule:
ACO – Accountable Care Organization, payment and care model based on quality metrics
APM – Alternative Payment Model, quality-based financial incentive structures for physician practices
AAPM – Advanced Alternative Payment Model, has higher levels of risk and reward which are required for MACRA participation
CHIP – Children’s Health Insurance Program, administered by states according to federal requirements
CJR – Comprehensive Joint Replacement, an alternative payment model not eligible for MACRA
CMS – The Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services and covers 100 million people
CPC+ – Comprehensive Primary Care Plus, an advanced alternative payment model eligible for MACRA
EHR – Electronic Health Record
EC – Eligible clinicians, Medicare clinicians who participate in MACRA. ECs include EPs plus more clinician types (such as “mid-levels”).
EP – Eligible professional, people who can participate in CMS programs. In MACRA, this only refers to Medicaid professionals.
MACRA – Medicare Access and CHIP Reauthorization Act of 2015 to reform Medicare payment models
MIPS – Merit-based incentive payment system, created by MACRA to combine Meaningful Use, PQRS and VBM starting in 2017 performance year
MSSP – Medicare Shared Saving Program, a voluntary ACO model that rewards providers for quality
NPRM – Notice of Proposed Rule Making, public notice issued by law when the government intends to change a rule or regulation
ONC – Office of the National Coordinator for Health Information Technology, part of the U.S. Department of Health and Human Services dedicated to coordinating national health technology efforts. This entity issues certification standards.
QPP – Quality Payment Program, CMS financial models based on quality, rather than fee for service. MIPS and Advanced APMs are part of QPP.
PCMH – Patient-Centered Medical Home, a status recognized by a number of different organizations. Some will be eligible for MACRA as advanced APMs, but currently they only qualify for MIPS.
PQRS – Physician Quality Reporting System, CMS quality program which will be part of MIPS
SGR – Sustainable Growth Rate, a formula used to calculate payments and was repealed by MACRA
VBM – Value-Based Modifier, CMS claims-based cost quality program, which will be part of MIPS
What should I be doing now to prepare for MACRA?
MACRA’s impact is unique to each provider. The first step is to understand the proposed rule and how it may affect you. Allscripts offers webinars for clients that can help explain these programs in greater detail.
Again, while this rule will not be final until the fall, it is important to begin preparing for the changes ahead to be ready for the first performance year in 2017. Contact Allscripts Consulting if you would like to schedule an introductory consultation on what this means for your organization.
The healthcare industry is hard at work reviewing recent significant regulatory developments from the U.S. Department of Health & Human Services. We can be certain that elements of these proposals will change when the final versions come out, but nonetheless, there are some big ideas to process in each of them.
We’re in the midst of a 60-day public comment period. Here’s a summary of the big three proposed rules from Centers of Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC):
1. CMS: Definitions of Meaningful Use – Changes to Stage 3
We anticipate CMS will finalize this rule in August or September. It focuses heavily on interoperability, laying the groundwork for a focus on quality and outcomes-based payment models.
It proposes an option in 2017 of moving to Stage 2 or 3, and all participants would move to stage 3 in 2018. Effectively, CMS would abolish stages at that point. All reporting periods also would become one calendar year.
CMS eliminated several measures in an attempt to make Meaningful Use simpler. While it says you only have to attain eight objectives, in reality these are eight categories including a total of 21 measures. But several redundant or “topped-off” measures – things that people are now doing consistently – no longer require reporting.
The proposed rule also continues to consolidate Clinical Quality Measures (CQMs) into a single set for all its incentive programs. Ultimately participants will need to submit these electronically.
2. ONC: Definitions of certifications – Facilitate interoperability
This proposed rule’s main purpose is to improve accessibility and exchange of data with a single certification program that serves several types of programs.
Software certification would no longer be exclusively tied to Meaningful Use under the proposals. This means that certified systems would need to be able to provide functionality that is not only about what Meaningful Use participants are measured on but also that which is helpful to other advanced payment models, such as ACOs.
One change is the announcement that on-site field audits are likely coming. The ONC intends to randomly survey (an ambitious) 10% of all installations. It’s unclear exactly what such an audit would look like, but it would test the software, not your workflows.
We expect this rule to be final in late summer. Participants don’t need to focus on the details within this rule, but there is more work for software vendors here, and any unrealistic timing from the regulators could impact developers’ ability to execute efficiently.
3. CMS: Meaningful Use modification rules for 2015-17
This is a rule that everyone is eager to see finalized because it affects 2015. CMS has suggested it will finalize the rule in July, which is an aggressive timeframe.
There are a couple of changes to the reporting periods. 2015 becomes a 90-day floating reporting period, no matter what stage or year you’re in. Eligible hospitals would also move to a calendar year, which would give them three extra months this year.
Other proposed changes came as more of a surprise. The work wouldn’t change; the measures would stay the same or get easier. However, the rule would restructure the reporting of measures – something for us to take care of. Luckily, however, there would be no changes to certification, meaning no need for a new system or any upgrades.
CMS proposes not allowing attestation for 2015 activity until January 2016. If you started in 2014 or 2015, you will get some exceptions in a “special” Stage 2, for 2015 only (several exclusions apply).
5 tips for regulatory success
In processing these three proposed rules, it’s good to understand what steps providers could take even as the government reviews and finalizes the rules. Smart providers know that preparation is key to success when it comes to regulatory compliance. A few specific action items include:
1. Respond to public comment. It’s in your best interest to do so. As someone who reviews these rules regularly, I’ve seen that your comments mean a great deal to the government – in fact, we’ve been told explicitly that your comments are the most important ones they receive. The public comment period for the first two proposed rules will close May 29, the third rule on June 15.
2. Treat 2015 as a full year. While you may only need to report on 90 days, don’t stop demonstrating your success. If you stop trying to achieve these goals, only to return to them later, it’s like jumping off a moving bus and trying to jump back on. And the reality is the modification rule is only proposed, so you should act as if it’s not changing until it’s finished.
3. Be vigilant with patient engagement. These are the thorniest of measures in many ways. It takes time to build success here, and the thresholds if adopted as proposed will be high in 2018. It’s not something you can do just by installing software, but rather it takes a long, dedicated effort. Get started, and never let up on the effort.
4. Watch out for workflows involving paper. It’s a good idea to wean your organization completely off of paper-based processes. Remember that giving paper to patients and documenting electronically after the fact will not count.
5. Stay tuned for more information. Clients can access more information on ClientConnect, including a full webinar presentation on this topic.
What’s your reaction to these proposed rules? Share your thoughts in the comments below.
Many providers are finishing up their 2014 attestation period for Meaningful Use, the Centers for Medicare and Medicaid (CMS) incentive program for successful use of electronic health record (EHR) technology.
Several changes in the regulations in 2014 have prompted questions. Using information available today, I’ve answered some of the most frequently-asked questions here:
Q. Do we need to attest several times throughout 2015, or do we attest only one time after the end of 2015?
As of today, if you’ve attested for Meaningful Use before, you only need to attest once. You will demonstrate for all of 2015 and attest before February 29, 2016. (Exception: people who have never demonstrated before will have a 90-day demonstration period.)
However, on January 29, 2015, the Chief Medical Officer of CMS issued a significant communication about some possible future adjustments to the Meaningful Use program. Two of the more noteworthy changes are shortening the 2015 reporting periods from a year to 90 days, and aligning reporting periods to the calendar year (not Federal fiscal year).
We anticipate the proposed changes will be released in the spring. In the meantime, we recommend that people continue to move toward full adoption of current requirements.
Q. Can I use the Flexibility option and get an extension?
Providers can apply for a Flexibility option if they have had some combination of software and operational issues that prevented full implementation. It does not relieve them of demonstrating Meaningful Use or change the attestation period; it just allows them to demonstrate Stage 1 instead of Stage 2.
I encourage people who exercise this option to have good documentation to support their claims. The criteria are not very precise, and CMS will require this information.
Q. Should I claim exclusions when measures don’t apply to me?
You must do the minimum number of core and menu measures to successfully attest in both Stage 1 and Stage 2. Unlike previous years, you cannot “get credit” for claiming an exclusion in either stage. We recommend (with the exception below) that you do not claim exclusions if you don’t need them for Stage 1, because it has caused issues for some clients on the CMS website.
However, there is a flaw on the CMS’ website that may affect Stage 1 participants. If you should happen to qualify for exclusions in both Immunization Registries (IR) and Syndromic Surveillance (SS), you should only have to demonstrate four other menu measures to successfully attest. The website, however, will not allow you to proceed unless you claim exclusions for all remaining measures – even though you have met four (plus the two exclusions for IR & SS).
In this case, CMS directs participants to claim exclusions to all remaining menu measures, even if they are not entitled to them, as a workaround (read more in a related FAQ here).
Q. How should I prepare for Stage 3?
The proposed rule that will define Stage 3, and redefine the other stages, is due in March of 2015. It will likely become a final rule late in 2015. At this point in time, current rule would start in 2017, but that may be delayed.
You’ll repeat Stage 2 until Stage 3 is available, through at least 2016. My advice? Don’t worry about Stage 3 now, just keep working to continuously improve.
Q. How does PQRS figure in to Meaningful Use attestations?
PQRS is a separate CMS program with its own incentives, requirements and penalties.
Q. What types of messages count towards the “Secure Messaging” measure that requires 5% patient participation?
Messages must be clinically relevant, but what that means has been a matter of some debate. CMS did not define what is clinically relevant and left it up to providers to determine. Some portals (such as FollowMyHealth®) may classify messages for you.
Remember that it is perfectly acceptable to send patients a message to which they reply, as long as the reply is clinically relevant. Those messages will count toward this measure.
Q. Can I skip a year of MU?
You can always skip a year, but you will pay a price. Medicare providers forfeit that year’s incentive and incur a penalty. Medicaid providers can skip a year and pick up where you left off with no penalty. The only limit there is that they have to take their last incentive payment by 2021, and could potentially run out of opportunity to collect payments.
The best advice I can give is to keep your foot to the pedal, and keep moving forward. If you’re a client, you can view a recent webinar or contact us to learn more about Meaningful Use consulting services.
A pilot program to improve primary care is showing signs of success at SAMA Healthcare, a family practice serving southern Arkansas.
Centers for Medicare & Medicaid Services (CMS) selected SAMA as one of 497 practices to participate in its Comprehensive Primary Care Initiative (CPCI). Funding from the program enabled SAMA to make several improvements, including new color-coordinated care teams.
What the CMS is doing to improve primary care
CPCI is a four-year pilot project. It is a collaboration among public and private payers to strengthen primary care. By investing more in primary care practices, the partners hope to achieve better health, better care and lower healthcare costs.
The CPCI aims to improve primary care in two ways:
1) Practice redesign. These providers must comprehensively address five primary care functions: risk-stratified care, access and continuity, population health management, patient engagement, and care coordination. CMS outlines nine key milestones for the first year, ending with successful attestation for Stage 1 of Meaningful Use.
2) Payment redesign. The Medicare fee-for-service remains in place. The CMS and private payers will deliver a Per-Beneficiary-Per-Month (PBPM) fee and will share savings with practices. Providers may use non-visit-based money to support care teams, technology investments or non-billable practitioner time.
If these approaches work in the pilot, CMS will implement them nationwide.
SAMA started the program in August 2012, relying on Allscripts Professional EHRTMand Allscripts Practice ManagementTM along the way. SAMA used CPCI funding to remodel parts of its clinic, upgrade equipment and move to a new staffing model that helps better coordinate patient care.
SAMA’s colorful approach to care coordination
In SAMA’s old staffing model, each doctor, nurse practitioner and physician’s assistant would work with a nurse or two to deliver care. It was challenging to provide continuity to patients, especially walk-in patients with acute care needs.
Now SAMA embraces a team concept. Each doctor leads a team that consists of a nurse practitioner, three nurses and a care coordinator. Each team wears a single color to help patients easily identify their caregivers.
First year outcomes are encouraging
Several measures are improving care at SAMA already. For example, a renewed focus on preventative care has increased diabetic foot exams 400% in one quarter. And increased colon cancer screenings led to early diagnoses for several patients.
Learn more in this video featuring SAMA Healthcare team members talking about their experience with CPCI.
While primary care physicians always put patients first, their focus is intensifying as the healthcare industry makes the seismic shift to value-based care.
The National Committee for Quality Assurance (NCQA) is one of a number of organizations that support the recognition of Patient-Centered Medical Homes (PCMH) through a formal program. It aims to improve primary care by using standards that describe clear and specific criteria, which help practices organize care around patients, work in teams and track progress over time.
Most everyone agrees that these are laudable goals. But the certification process strikes fear in the hearts of many well-intentioned practices.
According to those who have achieved NCQA’s highest certification (Level 3), it may be easier than you think. Two experts — Barbara Johnson, nursing director at Elmwood Health Center in New York, and Deb Donovan, operations director at Derry Medical Center in New Hampshire – share these helpful tips with NCQA/PCMH applicants:
1. Remain calm. The certification process is not as complicated as it looks. You will probably find you are already doing many of the required processes, and these are strengths you can build on.
2. Read the entire survey before you start. Focus on the “must pass” elements of the survey first.
3. Involve your whole team from the beginning. Not everyone needs to be directly involved with completing the assessment, but everyone needs to support it. Explain to all staff how these standards help improve patient care and the financial health of the practice.
4. Phrase your questions with “How” instead of “If.” When clarifying problems for your practice to solve, engage your teams by focusing on how you will achieve goals, instead of whether or not you will attempt the goal.
5. Stay organized. Print out the survey, divide up the work and note who needs to help with each section. You can keep track of responses on the master copy. To help keep track of all the documentation, name each file to correspond with the question it supports in the survey.
6. Be prepared to change your workflow and job descriptions. While Barbara and Deb did not have to hire new staff to accomplish certification, they advise you might have to do things a little differently. Be open to change.
7. Use screen shots to document your processes. When elements require reports, often a screen shot of your software will suffice. Just be sure to remove all patient names. And remember you are able to link one document to multiple elements.
8. Get to the intent of standards. NCQA is not looking for cookie-cutter responses to the survey. Instead, it wants to know what your process is, and how you know it is working. Processes can be different as long as you’re getting to the right outcome.
9. Don’t overthink it. NCQA has a lot of applications to read, so keep your responses simple and direct. NCQA can always follow up if they need more information.
10. Ask for help. NCQA responds quickly to questions. Reps can explain in detail what they are looking for in each element. You can find contact information on the NCQA website.
Editor’s Note: Jim derived the content of this post from a webinar available only to Allscripts Regional User Groups. It is one of the many resources available to these groups, to help clients network with one another as part of the Connected Community of HealthTM. For more information visit the ARUG Directory on ClientConnect.