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2019 MACRA Final Rule Overview

Posted on November 5, 2018 I Written By

The following is a guest blog post by Joy Rios, Health IT Consultant at Chirpy Bird.

It happened right on time this year. The 2019 MACRA Final Rule was released on Thursday, Nov. 1, the weekend of Daylight Savings Time – so those of us who track these laws carefully got one extra hour to read through the 2878-page document. Thanks CMS!

First, I’d like to point out that we expect the rules to change each year. If fact, my colleague, Robin Roberts, and I often joke that CMS starts writing the next rule before the ink is dry on the one they just released. However, this year it feels like there’s a lot more to get up to speed on than that which we’ve grown accustomed.

The expansion of the rule’s title alone, which is both comprehensive and overwhelming, hints that this year’s ruling is far-reaching and will impact a great many stakeholders across healthcare.

Look for yourself: The difference between the proposed and finalized titles:

Proposed Title:

Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program

Finalized Title:

Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; Quality Payment Program–Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year; Provisions from the Medicare Shared Savings Program–Accountable Care Organizations–Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act

The subtitles from the Finalized rule that I reviewed are broken out below with the main bullet points:

1. Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019

  1. Supports access to care using telecommunications technology.
  2. Medicare will pay providers for new communication technology-based services, such as brief check-ins between patients and practitioners, and pay separately for evaluation of remote pre-recorded images and/or video.
  3. CMS is also expanding the list of Medicare-covered telehealth services.
  4. CMS is delaying implementation of E&M coding reforms until 2021.

“Physicians will see some immediate changes in 2019 that reduce burden and even more significant burden reduction in 2021, when broader changes to the E&M framework take effect,” said Seema Verma.

2. Quality Payment Program

a. MIPS: 2019 Performance Year

General Program Changes

  1. Amount at risk to Medicare Part B services:
    1. Max 7% penalty
    2. 7x incentive, which could result in an adjustment above or below 7%
  2. Avoid a penalty: 30 points (double the 2018 threshold of 15)
  3. Earn Exceptional Performance to capture part of the $500M bonus pool: 75 points (up from 70 in 2017 & 2018)
  4. Expansion of Eligible Clinician types:
    1. PT, OT, Speech & Language, Audiologists, Clinical Psychologists, Registered Dieticians/Nutrition Professionals
  5. Low-volume threshold now includes a third criterion. To be excluded from MIPS, clinicians or groups need to meet one or more of the three criterion.
  6. New Opt-in policy for clinicians or groups who meet or exceed at least one, but not all three of the low-volume threshold criteria.
  7. Virtual Groups must designate a representative and email election to MIPS_VirtualGroups@cms.hhs.gov by Dec. 31, 2018 for the 2019 performance year.
  8. Finalizing a policy to assign a weight of 0% to each of the four performance categories and a final score equal to the performance threshold when:
    1. A MIPS eligible clinician joins an existing practice (existing TIN) in the final three months of the performance period year and the practice is not participating in MIPS as a group
    2. A MIPS eligible clinician joins a practice that is a newly formed TIN in the final three months of the performance period year
  9. Small practice bonus 5 to 6, but applied at the Quality Category level, rather than being applied to overall CPS.

Category Changes

Quality

  1. Category weight: 45%
  2. Different quality measures may now be submitted via different collection types. For example, a group or clinician may submit some measures through an EHR and some through a QCDR, and the measures will be scored together as part of one set.
  3. Claims can be reported by individuals or groups (again), but only by clinicians in a small practice (15 or fewer ECs)
  4. Groups who report 5 or fewer quality measures and do not meet the CAHPS for MIPS sampling requirements, will have their quality denominator reduced by 10 and the missing measure will receive zero points
  5. NEW: Extremely Topped-Out Measures: A measure attains this status when the average mean performance is within the 98th to 100th percentile range. Such measures will be proposed for removal in the next rule-making lifecycle for other topped-out measures.
    1. QCDR measures are excluded from the topped-out measure life cycle.

Promoting Interoperability

  1. Category weight: 25%
  2. Requires 2015 Edition CEHRT
  3. Two new measures: Opioid Treatment Agreement & Query of PDMP
  4. PI Score based on a single, smaller set of measures, no longer divided into Base, Performance, and Bonus

Cost

  1. Category weight: 15%
  2. Adding 8 new episode-based measures
    1. Case minimum 10 for procedural episodes
      1. CMS will attribute episodes to each MIPS EC who renders a trigger service
    2. Case minimum 20 for acute inpatient medical condition episodes
      1. CMS will attribute episodes to each MIPS EC who bill inpatient E&M claim lines during a trigger inpatient hospitalization under a TIN that renders at least 30% of the inpatient E&M claim lines in that hospitalization

Improvement Activities

  1. Category weight: 15%
  2. Added 6 new activities, modified 5 existing activities, removed 1 activity

b. APM Performance Year 2019

  1. Several references to 2025 and beyond
  2. CEHRT requirements of Advanced APMs: 75% of Eligible Clinicians in each APM Entity
  3. Other Payer Advanced APMs: 75% beginning in 2020
  4. Expanding the 8% revenue-based nominal amount standard for AAPMs and Other Payer AAPMs through 2024
  5. Quality – must report at least one outcome measure
  6. All-Payer Combo Option and Other Payer AAPMS
    1. Established a multi-year streamlined determination process where payers and Eligible Clinicians can provide info on the length of the agreement as part of their initial submission, and have any resulting determination be effective for the duration of the agreement (or up to 5 years)
    2. Allowing QP determinations at the TIN level, in addition to the APM Entity and individual EC levels
    3. Allowing all payer types to be included in the 2019 Payer Initiated Other Payer AAPM determination process for the 2020 QP performance period
  7. Multi-Year Other Payer AAPMs
    1. Payers and eligible clinicians with payment arrangements determined to be Other Payer Advanced APM must re-submit all information for CMS review and redetermination on an annual basis.
      1. At the time of the initial submission, the payer and/or eligible clinician will provide information on the length of the agreement, and attest at the outset that they will submit information about any material changes to the payment arrangement during its duration.
      2. In subsequent years, if there were no changes to the payment arrangement, the payer and/or eligible clinician do not have to annually attest that there were no changes to the payment arrangement
    2. Updated the MIPS APM measure sets that apply for purposes of the APM scoring standard

c. Public Reporting via Physician Compare

  1. Quality – all measure under MIPS Quality are available for public reporting, unless the measure itself is new (i.e. in its first or second year.)
  2. Cost – subset of Cost measures is available for public reporting, except new measures
  3. PI – Include an indicator for Eligible Clinician or group “successful” performance
  4. PI – include objectives, activities, and/or measures

3. Quality Payment Program–Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year;

CMS has had to respond to some hard-to-face realities* since the proposed rule was released in July. Of note, the first policy addition to the rulemaking provides relief for ACOs, in addition to other MIPS eligible clinicians affected by fires, hurricanes, natural or man-made disasters that have a significant negative impact on healthcare operations, area infrastructure or communication systems. They will have the option to self-attest and receive a hardship exception.

*Climate Change is real.

4. Provisions from the Medicare Shared Savings Program–Accountable Care Organizations–Pathways to Success;

This policy provides a new direction for the Shared Savings Program by establishing pathways to success through redesigning the participation options available under the program to encourage ACOs to transition to two-sided models, in which they may share in savings and are also accountable for repaying any shared losses.

It also offers to:

  1. Further promote interoperability
  2. Grant voluntary 6-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018.
  3. Align CEHRT with QPP

5. Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act

This policy outlines plans to reimburse physicians for virtually checking in with patients and remotely evaluating recorded images.

As it turns out, people treated remotely for psoriasis did just as well as those treated in person — and were much happier about not having to travel to see their doctors.

The final Medicare physician payment rule also expands payment for treatments for stroke, kidney disease, mental health and substance abuse by removing restrictions on originating sites. Those are all provisions from the budget and opioid packages.

************************

You could take any of these sections and write opinion pieces, draw dotted lines to affected stakeholders, and venture down about 1000 rabbit holes with this rule.

CMS Administrator Seema Verma acknowledges that transitioning to value-based care will require all of us to stretch and maybe sit with a bit of discomfort.

In her words, “If we’re going to move our system to a patient-centered, value-based system, change is inevitable, and change is always hard for those whose livelihood is dependent on the status quo.”

If you’re looking for some direction with MIPS, ACOs, or your place in the value-based care ecosystem, get in touch.

If you want to hear Robin and I geek out over this rule, be on the lookout for a special episode of the HIT Like a Girl podcast, to which you can subscribe here.

Quality Payment Program Tops List Of Regulatory Burdens On Medical Practices

Posted on October 10, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new survey by the Medical Group Management Association has found that meeting the demands of the Medicare Quality Payment Program tops the list of regulatory burdens named by respondents in medical practices.

The survey, which collected responses from 426 medical groups, found that their regulatory burdens were climbing, with 86% reporting that such burdens had increased over the past 12 months. A smaller but similar share of respondents (79%) reported that the overall regulatory burden associated with participating in Medicare specifically had increased during the same period.

When asked to name the regulatory requirements they considered to be very or extremely burdensome, 88% named the Quality Payment Program, followed by prior authorization (82%), lack of EHR interoperability (80%), government EHR requirements (77%) and audits/appeals (68%). In contrast, just 49% of respondents saw compliance with HIPAA privacy and security requirements to be a major concern.

Given the challenges it imposes on practices, it’s no wonder that the MGMA respondents struggle with MIPS, with just 9% stating that they were satisfied or very satisfied with the performance feedback the program offers. Two-thirds of respondents told the MGMA that at least in its current form, MIPS doesn’t support their practice’s clinical quality priorities.

Perhaps the most irksome aspects of the MIPS program seemed to be the full-year quality reporting period and scoring methodology. Roughly two-thirds of respondents were dissatisfied or very dissatisfied with these aspects of the program. “The lack of clarity and constant readjusting of the MACRA regulations regarding MIPS/APMs is also frustrating,” one group member said.

In addition, despite ongoing efforts to support patient data exchange, the percent of respondents who rated a lack of EHR interoperability as very or extremely burdensome has climbed over the last 12 months, from 68% last year to 80% in 2018.

Ultimately, this problem could have serious financial consequences for some organizations. “Interoperability will never be achieved at the rate we’re going without bankrupting most private medical practices,” wrote one respondent. “As each of the EHR vendors moves towards their own interpretation of interoperability, they create different versions of their own software that cost all of us more to implement and we can’t afford any more.”

If these issues aren’t addressed, it seems likely Medicare’s drive toward value-based payment will be less successful than its leaders would hope.  Seventy-nine percent of practices responding to the MGMA survey said they didn’t think the move toward value-based payment had been successful to date, and it doesn’t seem likely that this will change if physicians continue to feel overburdened and misunderstood

QPP (Quality Payment Program) 2019 Changes, Medicare Telemedicine Reimbursement, and Physician Fee Schedule E&M Changes

Posted on July 12, 2018 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.

Today, CMS came out with some big changes as part of the 2019 Physician Fee Schedule and proposed rule for the QPP for 2019. These are some of the biggest efforts I’ve seen to try and change what Medicare has been doing for a while.

CMS has put together a fact sheet on the 2019 Physician Fee Schedule proposed rule. Plus, you can also view the fact sheet for the 2019 Quality Payment Program (QPP) proposed rule. If you like all the details, you can find the full rule for both the 2019 Physician Fee Schedule and QPP 2019 (1473 pages) on the Federal Register.

That’s a lot of information and changes to process, but here are some initial thoughts. While what CMS and HHS are saying in their announcement is directionally good, the devil is always in the details. Here are a few of the highlights that could have a big impact on the healthcare IT and EHR world.

E/M Documentation Requirement Changes
The biggest change in this announcement is the change in E/M coding requirements. As part of CMS’ goal to streamline E/M documentation requirements, they’ve proposed some of the biggest changes to E/M since 1997. The one that will likely be talked about most is the opportunity for providers to bill Medicare using “medical decision-making or time.” Here’s a description of the change:

To improve payment accuracy and simplify documentation, we propose new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services. As a corollary to this proposal, we propose to apply a minimum documentation standard where Medicare would require information to support a level 2 CPT visit code for history, exam and/or medical decision-making in cases where practitioners choose to use the current framework, or, as proposed, medical decision-making to document E/M level 2 through 5 visits. In cases where practitioners choose to use time to document E/M visits, we propose to require practitioners to document the medical necessity of the visit and show the total amount of time spent by the billing practitioner face-to-face with the patient. Practitioners could choose to document additional information for clinical, legal, operational or other purposes, and we anticipate that for those reasons, they would continue generally to document medical record information consistent with the level of care furnished. However, we would only require documentation to support the medical necessity of the visit and associated with the current level 2 CPT visit code.

There are other changes to E/M that could be a big deal as well including having providers focus their documentation on what’s changed since the last visit as long as they review and update the previous information. Plus, providers can now just review and verify the information entered by ancillary staff or the patient rather than having to re-enter it.

The goal is quite clear. CMS is trying to battle against the bloated notes that are getting generated by EHRs today to justify a certain billing code level. Doctors will no doubt celebrate this as most doctors describe notes from their peers as awful and difficult to use because of all the note bloat. I don’t know how many times I heard from my medical billing friends at AHIMA that it doesn’t matter what’s actually done if it’s not documented. With the changes mentioned above, CMS is looking to change this.

Of course, EHRs aren’t going to be able to change their interfaces overnight. The new E/M changes are going to take a while to incorporate into EHR software. Plus, we’ll have to see how the non-Medicare payers react to these changes. If they don’t follow Medicare’s lead, that puts the EHR vendors in a tough position. We’ll have to see how that plays out.

Many doctors complain about hating their EHR software. I’ve long argued that the EHR is just the whipping boy for doctors’ ire. What doctors really hated was the crazy billing documentation requirements that were reflected in the EHR. If the changes above go far enough, maybe we’ll finally see if the EHR vendor really is to blame for provider burnout. However, as I mentioned, it will take some time for this to happen.

Medicare Telemedicine and Telehealth Reimbursement
The next biggest thing in today’s announcement was Medicare’s plans to reimbursement for what we would call Telemedicine or Telehealth services. 2 G codes (HCPCS code GVCI1 and GRAS1) were announced that seem like they could present a lot of opportunity for healthcare IT companies to finally get paid for the services they can provide:

Brief Communication Technology-based Service, e.g. Virtual Check-in (HCPCS code GVCI1)

Remote Evaluation of Recorded Video and/or Images Submitted by the Patient (HCPCS code GRAS1)

Practitioners could be separately paid for the Brief Communication Technology-based Service when they check in with beneficiaries via telephone or other telecommunications device to decide whether an office visit or other service is needed. This would increase efficiency for practitioners and convenience for beneficiaries. Similarly, the Remote Evaluation of Recorded Video and/or Images Submitted by the Patient would allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.

Travie Broome offered some interesting insights into these codes:

CMS also proposed a number of CPT codes for “Chronic Care Remote Physiologic Monitoring” and “Interprofessional Internet Consultation” as follows:

We are also proposing to pay separately for new coding describing Chronic Care Remote Physiologic Monitoring (CPT codes 990X0, 990X1, and 994X9) and Interprofessional Internet Consultation (CPT codes 994X6, 994X0, 99446, 99447, 99448, and 99449).

The also proposed adding HCPCS codes G0513 and G0514 for Prolonged preventive service(s) which seems to include ESRD (end-stage renal disease) patients who receive dialysis at home and mobile stroke units.

QPP (Quality Payment Program, better known as MACRA and MIPS) Changes
I have to admit that the changes to the QPP program didn’t feel nearly as substantial. The QPP 2019 Fact Sheet seemed short on details and I haven’t had a chance to fully digest the full rule. A few highlights though:

  • 2019 QPP will remove the MIPS process-based quality measures
  • MIPS Expands to PTs, OTs, CSWs and clinical psychologists (which was required by law)
  • It will overhaul the “Promoting Interoperability” category (pretty generic and haven’t figured out what this really means, but they say it will focus on interoperability, imagine that!)
  • The Promoting Interoperability scoring has changed and so has some of the weighting, but nothing major
  • Many of those excluded from MIPS in 2018 can opt in to participate if they want in 2019
  • $500 million pool is available for exceptional performance (whith is now at 80 points vs 70 in 2017)
  • Must use a 2015 Certified EHR (officially a 2015 Edition CEHRT)

Those are some of the big changes I saw offhand.  I’d suggest that this is mostly business as usual for the most part.  Significant if you’re in the MACRA and MIPS weeds, but isn’t likely going to change your MACRA and MIPS strategy.

One change I’m still processing is this one:

Changing the application of MIPS payment adjustments, so that the adjustments will not apply to all items and services under Medicare Part B, but will now apply only to covered professional services paid under or based on the Physician Fee Schedule beginning with 2019, which is the first payment year of the program.

Does this change the analysis that Jim Tate did previously that MIPS Penalties (and incentives for that matter) included Medicare Part B drugs? Sounds like it to me. If I’m reading it right, this change means that the penalties will be less for those getting penalized, but the payments will be less for those participating in the program as well. Not a good thing for a program that already has incentive problems. Is that right or am I reading it wrong?

On that note, this explains why the final rule is 1473 pages long. Time to do some reading of the final rule and see what all the experts find as they analyze it. Let us know what we missed in the comments or any analysis of this that we got wrong. We can all learn what this means together.

Plus, remember that this is just the proposed rule and CMS even asked for comment on if it should go into effect in 2019 or 2020. I encourage you all to provide your feedback on the proposed rule so it can be improved when it goes final.

2017 MIPS Final Score and Performance Feedback Is Out

Posted on June 29, 2018 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.

Big news just came out for those that are participating in MACRA and MIPS. CMS Announced it on Twitter:

That’s right, you can now visit the QPP website and login to see and verify your 2017 MIPS final score and performance feedback. Interesting that they would choose to push this out late on a Friday. You’ll want to verify this information to make sure you’re paid correctly and to make sure they have the right data for you before they make all the MIPS scores public.

I looked at the Physician Compare website and unless I just didn’t look in the right places, I don’t see the MIPS Quality scores available on the website yet, but I expect they will be soon. Plus, they’re likely going to make the data available for download as a dataset. Once they do, websites like ZocDoc, Vitals, HealthGrades and the rest of the physician ratings and review websites will pull the data and incorporate it into their physician profiles. So, you’ll want to make sure your data is accurate.

I will say that when I was looking at physicians on the Physician Compare website, I was fascinated by the note they put as a popup for someone who had “Used electronic health record”:

To be fair, they did use the word “may”, but I think most doctors would say this is a far cry from what EHR software has accomplished. However, it’s clear what the intent of the legislation and CMS was when it came to adoption of EHR software.

Have you had a chance to look at your MIPS score and performance feedback? We’d love to hear about your experiences. We’ll be interested to see how these MIPS quality scores are used by doctors and patients.

How Will CMS Handle Issues Surrounding MACRA Changes?

Posted on May 14, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

As most readers will know, when CMS released details on MIPS and the Alternative Payment Model incentives it embarked on a new direction for quality programs generally. As most readers will know, MIPS consolidated PQRS, the Physician Value-based Modifier and the Medicare EHR Incentive Program for EPs (Meaningful Use). But CMS is still updating the Medicaid incentive program.

If I were a physician, I’d be even more interested in the CMS initiative dubbed Promoting Interoperability. In some of the biggest news to come out of the agency in ages, CMS is restructuring the EHR Incentive Programs to become the Promoting Interoperability Programs. Promoting Interoperability replaces the Advancing Care Information category of MIPS.

Whoa. That would be a big enough deal on its own, but the issues the rule raises are an even bigger one.

CMS’s has been working towards this goal for a few years. Per HIMSS, here are some changes suggested in the proposed rule that might have the biggest impact on the health IT world:

  • The rule would cut down measures from 16 to six
  • It would use a new performance-based scoring methodology which would include measures of performance on e-prescribing, health information exchange, provider to patient exchange and public health and clinical data exchange
  • The agency will define and work to prevent “information blocking”

On a related note, CMS has posted a request for information asking for stakeholder feedback on program participation conditions. This is pretty unusual for the agency.

Like many CMS proposals, this one leaves some important questions open. (Apparently, CMS itself wonders how this thing will work, as the request for information suggests.)

For example, the new performance-based scoring method will award providers anywhere from 0 to 100 points. Measuring health IT performance is always a tricky thing to do, and there’s little doubt that if this becomes a final rule, both providers and CMS will have to go through some struggles before they perfect this approach. In the meantime, providers face some big challenges. How will they adapt to them? Its too soon to say.

Addressing so-called “information blocking” should be an even bigger challenge. Everyone from members of Congress to providers to vendors acts as though there’s one way to describe this practice, but there’s still a lot of wiggle room. Honestly, I’ll be amazed if CMS manages to pin it down the first time around.

Still, the time is more than overdue for CMS to take on interoperability directly. Without real data interoperability, many promising digital health schemes will collapse under their own weight. If CMS can figure out how to make it happen, it will be pretty neat.

Learn the Latest ACI (Advancing Care Information) Details as Required in MACRA-MIPS

Posted on March 16, 2018 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.

We’ve been partners with 4Med for a long time and offered a wide variety of courses over the years. Many of you reading this have probably taken their HIPAA security courses or possibly one of their previous PQRS and meaningful use courses.

Of course, the meaningful use and PQRS courses have now evolved into training around MIPS and MACRA. You know how complex these can be and that’s why I’m grateful that 4Med has put together these concise courses to teach you and your practice what you need to know. Plus, as part of these courses you also get a certification and possibly CEUs (depending on which CEUs you need).

With this in mind, 4Med recently announced their next ACI (Advancing Care Information, formerly known as Meaningful Use) course along with the CMAP (Certified MACRA-MIPS ACI Professional) Certification. This is a great course for those wanting to hear the latest info from the 2018 final rule.

Here’s a full summary of topics the ACI course will cover:
* Introduction to ACI for MIPS ECs
* ACI Reporting 2018
* ACI Reporting Options for 2017
* Required Objectives for the ACI Category
* Optional ACI Objectives for ECs Using a 2015 CEHRT
* Optional ACI Objectives for ECs Using a 2014 CEHRT
* Focus on Protecting Patient Health Info
* Patient Electronic Access
* Coordination of Care Through Patient Engagement
* Health Information Exchange
* ACI Scoring

This course is a live online workshop held on April 18, 19, 25, and 26 and are led by Trisha Conway, RN, BSN, CEO and Principal Consultant at eHealth Consulting. Of course, if you can’t attend the live sessions, then they’ll be recorded and available to you after the live event as well.

If this course interests you, you can register now and save $150 off your registration thanks to Healthcare Scene’s partnership with 4Med. The promo code to get the discount is HCSEARLYBIRD150, but if you click this link the discount will be applied automatically.

Changes Coming to MACRA Announced at #HIMSS18

Posted on March 7, 2018 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.

At the HIMSS18 Annual Conference in Las Vegas, Seema Verma announced a new HHS initiative called MyHealthEData. It’s not actually clear to me how this initiative works. It says that it will make clear that “patients deserve to not only electronically receive a copy of their entire health record, but also to be able to share their data with whomever they way, making the patient the center of the healthcare system.”

All of us as patients love this idea. What’s not clear to me from this announcement is what HHS and Seema Verma are going to do to make this a reality. It’s nice that they’re pushing it, but will they use something that will really motivate healthcare organizations to change?

As an almost afterthought in the press release for the MyHealthEData initiative was this section on MACRA:

Additionally, CMS intends to overhaul its Electronic Health Record (EHR) Incentive Programs to refocus the programs on interoperability and to reduce the time and cost required of providers to comply with the programs’ requirements. CMS will continue to collaborate with ONC to improve the clinician experience with their EHRs.

Administrator Verma said CMS has implemented laws regarding information blocking – a practice in which providers prevent patients from getting their data. Under some CMS programs, hospitals and clinicians must show they have not engaged in information blocking activities.

The Administrator also highlighted other CMS plans to empower patients with data:

  • CMS is requiring providers to update their systems to ensure data sharing.
  • CMS intends to require that a patient’s data follow them after they are discharged from the hospital.
  • CMS is working to streamline documentation and billing requirements for providers to allow doctors to spend more time with their patients.
  • CMS is working to reduce the incidence of unnecessary and duplicative testing which occurs as a result of providers not sharing data.

This definitely isn’t clear what changes are coming to MACRA (or Electronic Health Record (EHR) incentive programs as she calls it), but it is clear that CMS is going to work to simplify the requirements for MACRA. We’ll all be watching this with a keen eye. I also found the push for interoperability fascinating since it’s what I’ve suggested would be a much narrower goal that could be achievable with the right incentives.

I was also interested with the bullet point about streamlining documentation and billing requirements. We all can’t wait for this, but I think it’s much harder to change than I think most of us think.

Change is coming to MACRA. What’s your prediction on the changes that will be made to MACRA?

There’s a Disturbance in the Force We Know as MACRA

Posted on February 13, 2018 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.

Yesterday Anne Zieger wrote about AAFP’s proposals to reduce the EHR Administrative Burdens and then we got this tweet from CMS Administrator Seema Verma:

That’s some really strong language from the CMS Director.

If you care about this topic, you should go and read all of Seema Verma’s tweets, but here are two more for those who don’t want to read them all:

Change is in the air it seems. Many providers are rejoicing if you look through the replies to Seema Verma’s tweets.

Dr. Ronald Hirsch asked the question that I’m sure many doctors were asking:

The short answer is no MACRA and MIPS aren’t going away. If my understanding of policy is right, Seema Verma doesn’t have the authority to make MACRA go away. That would take actions from Congress and I don’t know anyone holding their breath on that one. However, Seema can streamline the way MACRA and MIPS are implemented to make it much easier for doctors. That seems to be what’s happening now.

What will this mean for the future of MACRA? I don’t think anyone knows the answers to that question. However, what does seem clear from these tweets is that change is in the air. We’ll have to wait and see what those changes are and who influences the changes they make.

What do you think this means for MACRA and MIPS? I’d love to hear your thoughts in the comments.

AAFP Proposes Tactics For Reducing EHR Administrative Burdens

Posted on February 12, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

The American Academy of Family Physicians has proposed a series of approaches it says will reduce the administrative burdens EHRs impose on primary care doctors.

The recommendations, which come in the form of a letter to CMS, address health IT simplification, prior authorization and standardization of quality measurement. However, the letter leads off with EHR concerns and much of the content is focused on making physician IT use easier.

Few would argue that the average physician spends too much time struggling with EHR-related administrative work. The AAFP backs this assertion up with a couple of studies, including one finding that primary care physicians spend almost 6 hours per day interacting with EHRs. It also cites research concluding that four types of specialist spent almost 2 hours using the EHR for every hour of direct patient care.

To address these concerns, the AAFP recommends taking the following steps:

  • Eliminating HIT utilization measures in MIPS: The group argues that such measures are not needed anymore now that MIPS includes quality, cost and practice improvement measures.
  • Updating documentation requirements: With the agency’s Evaluation and Management recommendation guidelines having been developed 20 years ago, prior to the widespread use of EHRs, it’s time to rethink their use, the letter asserts. Today, the group says, they have a negative impact on EHR usability and hinder interoperability. The group recommends eliminating documentation requirements for codes 99211-99215 and 99201-99205 entirely and allowing any care team member to enter medical information.
  • Rethinking data exchange policies: The AAFP is asking CMS and ONC to focus on how and when data is exchanged rather than demanding that specific data types be included. The group also urges CMS and ONC to penalize healthcare organizations not appropriately sharing information, using its authority granted by the 21st Century Cures Act.
  • Creating standardized clinical data models: To share data effectively across the healthcare ecosystem, the AAFP argues, it’s necessary to develop nationally-recognized, consistent data models that can be used to share data efficiently. It recommends that such principles be developed by physicians and other clinicians rather than policymakers, vendors or engineers.

I don’t know about you, but I find much of this to be a no-brainer. Of course, the decades-old E/M guidelines need to be reformed, consistent data models must emerge if we hope to improve interoperability and physicians need to lead the charge.

Unfortunately, it’s hard to tell whether CMS and ONC are willing and prepared to listen to these recommendations. In theory, leaders at ONC should be only too glad to help providers achieve these goals and CMS should support their efforts. But given how obvious some of this is, it should have happened already. The fact that it hasn’t points up how hard all of this could be to pull off.

Two Medical Practices’ Reactions to MACRA Ruining Healthcare

Posted on January 31, 2018 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.

Last week I wrote a post that discussed whether MACRA was ruining Healthcare. It’s an important discussion to have as we look at where healthcare IT legislation should go in the future.

In response to the article I got some pretty heated responses from medical practices that I thought were worth sharing with the wider audience who doesn’t get a chance to read the comments (yeah, I know that’s most of you).

The first comment is from Billy who said the following:

I wouldn’t say MACRA is ruining healthcare, but it’s starting to drive the decision train, which may be the first step.

From my corner of healthcare in America, our practice is forcing adherence to MACRA to set the tone for an ever growing portion of the workflow. The benefit from such is viewed as non-existent aside from protecting revenues. We have compliant doctors (with plenty of grumblings), but no happy ones that are doing this in the belief it’s good for medicine.

Taking two parts of your post I think I can speak towards in view of that…

“All of this leaves doctors I know upset with MACRA and MIPS. They wish it would go away and that the government would stop being so involved in their practice.”

They’re upset at the government because MACRA is seen as an intrusion with no benefit. At best, it’s a threat to their income (both to the business and their end of year salary), and at worst, they don’t trust the government entering the realm of “quality” which traditionally was limited to clinical relevancy. We’ve had plenty of internal discussions of how MACRA quality measures are worlds away from what the physicians view as truly important quality measures for their profession.

“Let’s imagine for a minute that Congress was functional enough to pass a law that would get rid of all of MACRA. Then what? Would doctor’s problems be solved?”

This doesn’t account for the primary reason MACRA was passed in the first place- controlling the costs of Medicare. They can talk about quality all they want, the government needed to eliminate the near automatic 2.5% (or thereabouts) increase in Medicare fee reimbursements. They do that with the freeze in rate increases, and making the physicians battle each other for what remains with the reward/penalty system.

Congress will never get rid of MACRA, it’s their plan to keep Medicare costs from blowing up until 2025 as the boomer generation keeps adding to the rolls.

So, MACRA is seen as having no benefit but a lot of downside in income and daily operations. About the only other thing that could have brought these emotions about would come from the IRS, but this is worse in some ways, as it’s forcing changes in clinical operations for the purpose of checking a box to protect income.

Welcome to the new normal.

It’s hard to think that Billy is right that this is the new normal. Should it be? Could we do something to make it so it’s not?

The next comment was from a long time reader who’s been commenting against MACRA and meaningful use before that (ie. a long time). Here’s meltoots’ take on the question of if MACRA is ruining healthcare:

Yep.
Count me as another mid career MD that sees the futility in any hope for the future of medicine. We are doomed. I do everything I can to talk everyone out of becoming an MD. Including my children.

We have 100% of the accountability and zero authority. Worse I am penalized by our government because I refuse to play stupid counting and clicking games. I was just discussing again (seems daily) my plans to exit this career. Too bad as I am one of only 4 orthopaedic surgeons left at our hospital. 20 years ago we had 35 on staff.

Every single person on earth seems to be saying all this data entry by MDs is silly, inefficient, useless, complex and frankly a huge costly waste of time. Everyone is speaking to burdens and the ridiculous nature of all this forced mindless data entry, super complex reporting, terrible auditing and penalizing for no good reason. When we look back a decade from now and wonder how we made medicine like the postal service, I know I can say I did try to point out better ways. But no one listened. At all.

If all these programs are so wonderful, tell me all the great things that have come out of MU, PQRS, VBM, QPP? So you got MDs to buy EHRs. Great. Everyone hates them. Great work.

HITECH set back real IT innovation in medicine at least a decade.

CMS touts patents over paperwork with absolutely no action, even worse, they made the MACRA program even more burdensome this year. AAPM, you want me to take even MORE risk, and hire more admins to run it? For 5%? Come on.

I have finally come to realization, that medicine has been destroyed by administrators, CMS /ONC, regulators, bean counters and the dozens of people I support just trying to stay ahead of the complexity. Its like the movie Office Space when I forget to click something in the 1000 clicks I have to do a day, I get 10 admins telling me about my TPS reports on what I did wrong.

What is really the worst part, is that I am pretty darned good at what I do, I am super busy and loaded with patients, too many. So I will be yet another MD, that has just had enough, that left the game in his prime. We should all be ashamed at what we did to our physicians.