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Who’s Eligible for MIPS? – MACRA Monday

Posted on August 22, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of MACRA.

In years 1 and 2 of MACRA, those that are eligible to participate are going to be very similar to past programs. However, the secretary does have the option in year 3 to look at expanding the program to include other healthcare providers that don’t meet the initial requirements. You can see this illustrated in the graphic below.
MIPS Eligibility

There are three exceptions to the above graphic. The first exception is if you’re a first year partipant in Medicare Part B. This gives these doctors time to get up to speed before they’re required to participate in MIPS. They will have to participate in year two. There is also a MIPS exception for low volume providers. If you’re a provider that has Medicare billing charges that are less than or equal to $10,000 and providers care to 100 or fewer Medicare patients in a year, then you are not required to participate in MIPS. The third exception is those providers that are already participating as an advanced APM (see what we wrote about Advanced APM eligibility for more details) are not allowed to participate in MIPS. Here’s a summary of these exceptions:
Not Eligible for MIPS

If all of this Advanced APM and MIPS eligibility is confusing to you, here’s a flow chart which will walk you through the process of knowing whether you’re an advanced APM, whether you must participate in MIPS or whether you’re not subject to MIPS:
APM or MIPS - Where Do You Fit Into MACRA

Next up, we dive into the details of MIPS and the 4 MIPS categories.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA program.

Is Interoperability Worth Paying For?

Posted on August 18, 2016 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of EHRSelector.com, a free service for matching users and EHRs. For the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manger doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst.

A member of our extended family is a nurse practitioner. Recently, we talked about her practice providing care for several homebound, older patients. She tracks their health with her employer’s proprietary EHR, which she quickly compared to a half-dozen others she’s used. If you want a good, quick EHR eval, ask a nurse.

What concerned her most, beyond usability, etc., was piecing together their medical records. She didn’t have an interoperability problem, she had several of them. Most of her patients had moved from their old home to Florida leaving a mixed trail of practioners, hospitals, and clinics, etc. She has to plow through paper and electronic files to put together a working record. She worries about being blindsided by important omissions or doctors who hold onto records for fear of losing patients.

Interop Problems: Not Just Your Doc and Hospital

She is not alone. Our remarkably decentralized healthcare system generates these glitches, omissions, ironies and hang ups with amazing speed. However, when we talk about interoperability, we focus on mainly on hospital to hospital or PCP to PCP relations. Doing so, doesn’t fully cover the subject. For example, others who provide care include:

  • College Health Systems
  • Pharmacy and Lab Systems
  • Public Health Clinics
  • Travel and other Specialty Clinics
  • Urgent Care Clinics
  • Visiting Nurses
  • Walk in Clinics, etc., etc.

They may or may not pass their records back to a main provider, if there is one. When they do it’s usually by FAX making the recipient key in the data. None of this is particularly a new story. Indeed, the AHA did a study of interoperability that nails interoperability’s barriers:

Hospitals have tried to overcome interoperability barriers through the use of interfaces and HIEs but they are, at best, costly workarounds and, at worst, mechanisms that will never get the country to true interoperability. While standards are part of the solution, they are still not specified enough to make them truly work. Clearly, much work remains, including steps by the federal government to support advances in interoperability. Until that happens, patients across the country will be shortchanged from the benefits of truly connected care.

We’ve Tried Standards, We’ve Tried Matching, Now, Let’s Try Money

So, what do we do? Do we hope for some technical panacea that makes these problems seem like dial-up modems? Perhaps. We could also put our hopes in the industry suddenly adopting an interop standard. Again, Perhaps.

I think the answer lies not in technology or standards, but by paying for interop successes. For a long time, I’ve mulled over a conversation I had with Chandresh Shah at John’s first conference. I’d lamented to him that buying a Coke at a Las Vegas CVS, brought up my DC buying record. Why couldn’t we have EHR systems like that? Chandresh instantly answered that CVS had an economic incentive to follow me, but my medical records didn’t. He was right. There’s no money to follow, as it were.

That leads to this question, why not redirect some MU funds and pay for interoperability? Would providers make interop, that is data exchange, CCDs, etc., work if they were paid? For example, what if we paid them $50 for their first 500 transfers and $25 for their first 500 receptions? This, of course, would need rules. I’m well aware of the human ability to game just about anything from soda machines to state lotteries.

If pay incentives were tried, they’d have to start slowly and in several different settings, but start they should. Progress, such as it is, is far too slow and isn’t getting us much of anywhere. My nurse practitioner’s patients can’t wait forever.

MIPS Overview – MACRA Monday

Posted on August 15, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

This post is part of the MACRA Monday series of blog posts where we dive into the details of MACRA.

The Merit-based Incentive Payment System or MIPS as we now know it is going to be a big part of most practices future. As we mentioned previously, most practices will be participating in the MIPS program as opposed to the APM program under MACRA. Here’s a quick overview of the MIPS program. Over the next months, we’ll be diving deeper and deeper into the details of MIPS.

MIPS replaces 3 programs that will likely be familiar to most readers: PQRS, the Medicare EHR Incentive Program (Better known as meaningful use), and the Value-Based Payment Modifier (VBM). The last one might not be as familiar to people, but PQRS and Meaningful Use are likely very familiar. In future posts, we’ll dive into the changes to these programs that come as they’re rolled into MIPS.

It’s worth noting that these programs will continue to run in their current from through 2018. Plus, the Medicaid EHR Incentive Program and the Medicare EHR Incentive Program for Hospitals will continue. Along with rolling the 3 current programs into MIPS, MACRA also adds a new program to MIPS called the Clinical Practice Improvement Activities (CPIA).

The first performance period for MIPS is 2017 with MIPS adjustments happening in 2019. At least that’s the way it’s listed in the proposed rule. Many are suggesting that there’s no way that MIPS will be for all of 2017. They argue that it has to be either delayed or moved to a 90 day reporting period (which is basically a 9 month delay). We’ll see what they finally decide when the MACRA final rule finally comes out.

The potential MIPS adjustments to your Medicare Part B payment are 4% in 2019 and grow to 9% in 2022. Remember that these adjustments can be both positive and negative based on how well you participate in the MIPS program. We’ll dive into the MIPS Composite Score that determines your MIPS payment adjustment in a future post. Here’s a charge which illustrates the MIPS timeline and incentives:
MIPS Incentives and Penalties
That’s all for our MIPS overview. Next up we’ll dive into who is eligible for MIPS and who is not eligible for MIPS.

You can see how if you’re already participating in PQRS, Meaningful Use, and the Value-Based Modifier, then you are well positioned to do well in MIPS. This will become even more clear when we discuss the weighted scoring that each of these pieces of MIPS receives. Of course, if you haven’t been participating in these programs, then MIPS will definitely be a pretty big hill to climb.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA program.

A Look At RECs Success or Failure

Posted on July 28, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

ONC has recently put out a report evaluating the performance of the REC (Regional Extension Center) program. The report is only 124 pages, so you might want to save the light reading for the weekend. If you want something more consumable, you can read this blog post from Thomas A. Mason, MD which includes this nice summary:

Survey data included in the report released today indicates that 68 percent of the eligible professionals who received incentive payments under Stage 1 of the incentive program were assisted by an REC, compared to just 12 percent of those that did not work with a REC. The survey also found that many providers working with RECs received frequent and tailored help – often face to face, for as long as it was needed. Many RECs also created both structured and informal opportunities for clinicians to learn from one another, creating economies of scale to reach more providers with limited resources and spread providers’ EHR product-specific knowledge.

In the same blog post he also points out ONC’s numbers that “nearly all hospitals and approximately three-quarters of doctors reported using certified EHRs.”

That all sounds like a success to me. All these rosy numbers about people being helped. Lest we think this report doesn’t matter, HHS has already announced another $100 million over 5 years for what I’d call REC like support money for those participating in MACRA. I expect many of the RECs to get this money, but we’ll see.

What’s clear to me is that these REC organizations did indeed help many organizations get access to the meaningful use money. Only in the government could you spend money to get people to have you spend more money, but I digress. Most of the REC organizations that I met with really did a lot to help small practices with the meaningful use program. Some of their EHR selection efforts could be questioned, but not the MU help they provided. I can’t remember how many posts I’ve written about the random methodology that RECs seemed to use in their efforts to help their clients choose an EHR. It was a mess and full of weird influences (Note: There were some exceptions where certain RECs just supported everyone and every EHR or at least did a good job having their clients drive the process of which EHR to support).

When you look at the recent study be Deloitte that many doctors don’t know about MACRA, that could partially be because the RECs did a lot of the meaningful use education for doctors. We don’t have that yet for MACRA.

Personally, I’m torn on how valuable the RECs have been to the progression of health IT. Did they really help practices choose the right EHR and implement it in an effective way? What would have happened if they weren’t there? At the end of the day, the cost of the RECs is small potatoes next to the billions we spent on meaningful use. I’m sure some rural practices would have never considered participating in meaningful use if it weren’t for the RECs. No doubt that’s who the politicians are thinking about when they included the money for RECs and now for MACRA support.

The harder question to answer is if healthcare is better off with all these rural practices being “meaningful users” of EHR.

What’s the Impact of MACRA on Small Practices?

Posted on July 22, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I recently had a chance to sit down and chat with Tom Giannulli, MD, Chief Medical Officer of Kareo and Michael Sherling, MD, MBA, Chief Medical Officer and Co-founder of Modernizing Medicine, to talk about the impact of the MACRA legislation on small practices. Both of these CMOs at EHR vendors rode the meaningful use wave and now they’re preparing to ride the new MACRA wave as well. So, they were the perfect people to talk about the impact of MACRA on small practices and how a small practice should prepare themselves for the new MACRA legislation. If you’re a small practice that’s wondering about MACRA (or doesn’t even know what it is), then take the time to watch the video below to see what it means for small practices.

After our formal interviews, we always like to hold what we call the “after party.” We never know how it’s going to go. Sometimes people join in and offer their insights and ask questions and sometimes they don’t. In this case, we continued our conversation about the MACRA and small practices, but we also talked about the impact that legislation like MACRA has on an EHR vendors development lifecycle. You can learn more about MACRA in the video below:

This post was a great way to wrap up the week and also for us to announce a new blog post series we’re starting on Monday called MACRA Monday. Long time readers may remember the Meaningful Use Monday series of blog posts we did every Monday for a few years. This will be similar as we dive into the MACRA legislation and help small medical practices understand the details of what’s coming in MACRA. Watch for that on Monday!

CMS Opens Door to Possible MACRA Delay

Posted on July 15, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

In related news to yesterday’s meaningful use REBOOT relief legislation, Andy Slavitt, Acting Administrator of CMS, testified about MACRA before the Senate Finance committee. In his hearing, Senator Orrin Hatch (R-Utah), chairman of the committee commented “Physicians will only have about two months before the program goes live. This seems to be a legitimate concern. Considering the MACRA law does give CMS flexibility as to the start of the physician reporting period, what options is CMS considering to make sure this program gets started on the right foot?”

In response to this Slavitt responded that CMS was open to options such as postponing implementation and establishing shorter reporting periods (both of which were widely requested during the MACRA comment period).

Both Slavitt and Senator Hatch talked about the importance of the MACRA legislation not killing the small practice physician. A delay and shorter reporting periods would be a great start. However, so many small practices have been burned by meaningful use that it might be too late for MACRA. It seems that MACRA is dead on arrival for many physicians based on historical experience with meaningful use and certified EHR. I’m not sure CMS could do anything with MACRA to really stem the tide.

This is reflected in a survey that Deloitte recently did to assess physician’s awareness of MACRA. The survey found that 21% of self-employed physicians and those in independently owned medical practices report they are somewhat familiar with MACRA versus 9% of employed physicians surveyed. 32% of physicians only recognize the name.

Basically, physicians barely even know about MACRA. Although, I’m quite sure if we asked them if they liked the MACRA government legislation they’d all say an emphatic No! (Kind of reminds me of Jimmy Kimmel’s Life Witness News) It’s too bad, because if doctors have already been participating in PQRS and Meaningful Use, MACRA won’t be that bad. Of course, the same can’t be said for those that haven’t participated in either program.

During the hearing mentioned above, Senator Hatch highlighted Andy Slavitt’s comment that “the focus must be focused on patients and not measurement.” Plus, he suggested that more needed to be done in this regard. Andy Slavitt responded that they need to reduce the documentation requirements so doctors can spend more time with patients.

Take those comments for what their worth. They’re hearing the right messages and I think they’re heading the right direction. Let’s hope we see that in the MACRA final rule.

Meaningful Use Relief from New REBOOT Legislation

Posted on July 14, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

John Thune has introduced a new legislation called the Electronic Health Record (EHR) Regulatory Relief Act (S. 3173) to provide some relief to hospitals and eligible providers participating in the Medicare EHR Incentive Program (Better known as Meaningful Use). You can find the legislative text (ie. legalese) and the summary document (ie. readable).

This legislation was written by the “REBOOT members” John Thune (S.D.), Lamar Alexander (Tenn.), Mike Enzi (Wyo.), Pat Roberts (Kan.), Richard Burr (N.C.) and Bill Cassidy (La.) who previously released a white paper on their Health IT concerns.

Here’s a short summary of what the legislation would do:

  • Codify the 90-day reporting period for meaningful use
  • Remove the All-or-Nothing approach to Meaningful Use and set a 70% threshold
  • Increased flexibility in Hardship Exceptions

If I’m reading the legalese right, it also opens the door for the HHS Secretary to allow a 90 day reporting period for MIPS as well. It’s interesting that it wasn’t highlighted in the summary document.

Regardless, these are all changes that will be welcomed by the healthcare community. What I like most about these proposals is that I don’t think any of them will impact how a hospital or doctor was previously planning to use their EHR. At least it won’t impact care in any sort of adverse way. Doctors will still be using an EHR. However, it will provide some reporting relief and will open the door of meaningful use to organizations that wouldn’t have been able to comply previously. Of course, I’m sure there are a few people out there that will settle for nothing less than a repeal of meaningful use completely. I predict that such a thing will never happen.

What do you think of this proposed legislation? Are they enough? Should they be providing more relief? Will this change your meaningful use plans?

Physician Data Paradox

Posted on June 29, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

“[Doctors] are overloaded on data entry and yet rampantly under-informed.”
-Andy Slavitt at Health Datapalooza

This quote from Andy Slavitt at Health Datapalooza has really stuck with me. He calls it the physician data paradox. It’s an ugly paradox and is at the heart of so many doctors discontent with EHR software. Andy Slavitt is spot on with his analysis. Doctors spend hours entering all of this data and get very little return value from that data or the volume of health data that is being captured.

My friend Dr. Michael Koriwchak has made an interesting request. In a recent blab interview he was on he said that CMS should only require the collection of data they’re actually going to use.

My guess is that the majority of meaningful use data would not need to be collected if Dr. Koriwchak’s rule was in place. CMS hasn’t really even collected the data from doctors, so they’re certainly not using it. Some of the principles of meaningful use would still exist like interoperability and ePrescribing, but we wouldn’t be turning our doctors into data entry clerks of data that’s not being used.

Think about the reality of meaningful use data collection: CMS doesn’t use the data. Clinicians don’t use the data.

We’ve basically asked doctors and other medical staff to spend millions of hours collecting a bunch of data that’s not being used. Does that make sense to anyone? You could make the argument that the data collection is creating a platform for the future. There’s some value in this thinking, but that’s pretty speculative spending. Why not do this type of speculative data collection with small groups who get paid for their efforts and then as they discover new healthcare opportunities? We can expand the data collection requirement to all of healthcare once doctors can do something meaningful with the data they’re being required to collect.

In fact, what if we paid docs for telling CMS or their EHR vendor how EHR data could be used to benefit patients? I’d see this similar to how IT companies pay people who submit bug reports. Not using health data the right way is kind of like reporting a bug in the health system. Currently, there’s no financial incentive for users to share their best practices and discoveries. Sure, some of them do it at user conferences or other conferences, but imagine how much more interested they’d be in finding and sharing health data discoveries if they were paid for it.

If we finally want to start putting all this health data to work, we’re going to have to solve the physician data paradox. Leveraging the power of the crowd could be a great way to improve the 2nd part of the paradox.

Long Standing EHR Issues That Remain Unaddressed

Posted on June 17, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Dr. Jayne has presented a pretty great voice of reason in her blog posts about the realities of being a doctor in the meaningful use era. In a recent post she offered this comment which I’ve heard from many doctors:

And while we as physicians are having to cope with arduous workflows as a result of the regulations, there are advancements that would really benefit us that remain unaddressed.

I realize that EHR vendors have to prioritize requests from users. Plus, they have to deal with massive government regulation which has made it hard to prioritize user requests over government regulations. However, I know from the end user standpoint Dr. Jayne’s comment about the advancements that could be made in an EHR that still haven’t been added creates a really awful feeling.

Dr. Jayne also added this sad observation:

We’re forced to gather loads of information that could be put to good use but isn’t. For example, we collect information on race, ethnicity, religious preference, language preference, sexual orientation, and more. In many cases, it’s not used to further clinical care. It would have been great to have a prompt to ask about religious fasting the other night when I was treating a patient with profound dehydration. Although it occurred to me to ask, it didn’t occur to my patient care technician or to the resident I was supervising.

The optimistic side of me says that comments like this are a very good thing. 5-10 years ago, doctors wouldn’t have even thought to request this kind of feature. All they wanted to do was automate the paper charts. So, it’s progress that now we’re talking about ways we can incorporate the data in an EHR at the point of care in a much more effective way.

Now if EHR vendors can just be given the flexibility to work on these challenging problems instead of a list of prescriptive goverment regulations which just add to the burden of doctors as opposed to creating magical experiences.

Government Involvement in Healthcare IT – How Meaningful Use Went Wrong

Posted on June 15, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I have about 150 draft blog posts on EMR and EHR. Most of them are ideas for future posts. Unfortunately, I get so many new ideas, a lot of the drafts remain draft blog posts for long periods of time. I probably should create a better process for tracking my blog post ideas, but this was worked so far. Plus, it’s fun to go back and see what past ideas I had for posts and then think about how things have changed or whether that insight has stood the test of time.

This post is an example of that and the draft blog post contained a tweet that Greg Meyer shared during a #HITsm Twitter chat back in December 2014. Here’s the tweet:

No doubt Greg’s tweet resonated with me back in 2014 and still resonates with me today. In meaningful use, the government got way too deep into the how and caused all sorts of unintended consequences. We’d be in a much better position if the government would have just defined the measures and functions and not how you actually got there.

What’s interesting is that this is more or less what I’ve been hearing from Andy Slavitt in regards to MACRA. I’m not sure CMS has executed this vision well, but it’s at least hopeful that their leader is espousing a similar approach to what Greg describes above.

I’d also point out an insight I believe I first heard from Dr. Michael Koriwchak. He espoused the principle that CMS shouldn’t require the collection of any data which it wasn’t going to actually use. Think about how meaningful use would have been totally different if they’d employed this rule. What value is there to healthcare if we collect a whole bunch of data that’s never actually used to improve care?

Do you think CMS will get this right with MACRA? Share your thoughts in the comments.