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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.

Early Lessons from the Front Lines of Value-based Care: How One APM Has Impacted Community-Based Oncology Practices

Posted on June 11, 2018 I Written By

The following is a guest blog post by Dr. Charles Saunders, CEO, Integra Connect.

The Oncology Care Model (OCM) – an alternative payment model introduced in July 2016 by the Center for Medicare and Medicaid Innovation – launched with the ambitious goal to further delivery of higher quality, more coordinated cancer care at a lower cost. Participants include 184 practices representing approximately one-third of community oncologists in the US. They receive a so-called “MEOS” (monthly enhanced oncology services) payment of $160 per beneficiary per month for the duration of a qualifying 6-month chemotherapy period, plus the opportunity to earn a share of savings if they exceed a target threshold. In return, oncologists are expected to take on increasing accountability for patient outcomes and well-being, while also generating sustainable cost savings across all co-morbidities and care settings, into the patient home.

OCM Performance Period 1 Results Exposed an Unexpected Misalignment   

As part of the OCM program, CMS tracks practices during 6-month intervals – so-called “performance periods” – then shares results back about one year later. In February 2018, practices participating in the OCM program received visibility into Performance Period 1 (PP1) data, including savings achieved, aggregate quality score, and effectiveness of identifying eligible patients. While most practices were unsurprised by their performance scores, many did not anticipate the extent to which CMS would recoup MEOS payments that it deemed paid in error. The most common scenario involved patients with co-morbidities who, while receiving chemotherapy and related services, also visited other providers regularly. Therefore, the oncology practice did not represent the required plurality of E/M codes for that beneficiary. It was not uncommon for practices to be asked to return up to 30% of the sum they had been paid – a major financial hit.

Lack of Data Hinders Practices’ Ability to Accurately and Proactively Identify Beneficiaries

In May 2018, practices received their Performance Period 2 (PP2) Attribution Lists, which summarized which CMS beneficiaries met OCM eligibility criteria, which episodes were attributed to each respective practice, and episode start dates from January 1, 2017 through June 30, 2017. Unfortunately, because there is a significant lag between actual Performance Period and delivery of CMS findings – delayed up to nearly a year after each performance period has ended – OCM participants were unable to retroactively apply PP1 learnings to PP2.

Why is this especially problematic? Practices are faced not only with MEOS recoupments for erroneous payments but, with only a 1-year window to submit claims, are often unable to bill in full for patients who were missed. Indeed, there are many opportunities to miss appropriate patients, as practices needed to have an accurate view of: 1) all beneficiaries; 2) those with a qualifying diagnosis; 3) those with a new chemo episode; 4) those not only prescribed an oral agent, but those who subsequently filled it; 5) those not in a hospice; and more. Given all the dimensions to track and measure, practices without advanced tools face delivering enhanced services that they cannot correctly bill for.

Best Practices from Community-Based Oncology Practices Include Robust Data

What best practices arose to get attribution right? A vanguard of OCM practices realized that they would need to take proactive steps to enable near real-time visibility into their patient populations, embracing the tenets of population health management. Below is an example of the best practices adopted by several of these community-based oncology practices:

  • Increased transparency into oral chemotherapies: Existing practice protocols did not open an episode when oral agents were prescribed, since there was no in-office administration. To address this, the practice introduced a rule-based algorithm to identify all OCM eligible patients, including those who had been prescribed orals. In addition, they enlisted a combination of automated and personal follow-ups to validate qualification and ensure orals had been filled.
  • Avoidance of duplication: To identify missed billing opportunities while also reducing the risk of duplicated claims, practice leadership invested in a robust analytics tool that enabled personalized queries at the patient level. These reports compared eligibility against their practice management report to identify gaps, from unpaid and unbilled to denied.
  • Targeted patient intervention: To balance the practice’s financial and clinical objectives while optimizing OCM performance, the practice introduced complex care management services and employed a series of triage pathways. This approach ensured engagement with attributed beneficiaries and decreased avoidable high-cost events among at-risk patients, such as inappropriate ER visits and inpatient stays.
  • Optimized treatment choices. As part of its commitment to ensure each patient received the most effective treatment for his or her disease, the practice provided increased transparency around the availability of equally effective generic or biosimilar drugs. They also supported better end-of-life planning for patients facing second or third-line therapies not expected to provide any clinical benefits, but that could significantly degrade remaining quality of life.
  • Continuous performance improvement: To track the effectiveness of these quality improvement initiatives, the practice leveraged its analytics tool to monitor resource utilization and care management performance, then intervened to address outliers in real-time.

In short, to optimize performance under the OCM, practices are beginning to leverage the data to which they already have access – both clinical and financial – to risk-stratify their patient populations; identify OCM eligible patients; and gain near real-time visibility into quality and cost performance. Practices are also investing in better data integration and analytics that enable rules-based identification of eligible patients.

Population Health Analytics Help Practices Be Proactive and Succeed Under the OCM

Oncology is on the forefront of value-based care adoption and these early experiences from the OCM have provided a guide for other specialties. Based on their early results, what has come to the forefront is the need for a combination of comprehensive data management and robust analytics, coupled with the principles of population health management, which enable practices to step up and take control of the cost and quality for their attributed populations.

Meaningful Use Becomes Advancing Care Information Becomes Promoting Interoperability – MACRA Monday

Posted on May 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.

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

I’m quite sure you’ve all seen the news coming out from CMS about the name change for the various Medicare EHR Incentive and MACRA programs. I decided to not dive into it in depth here since so many organizations are already doing it. Plus, this is just the proposed rule. However, if you want some light reading, here’s all 1883 pages of the Promoting Interoperability proposed rule.

The name change of Meaningful Use/Advancing Care Information to Promoting Interoperability is an interesting way for CMS to signal what they want these programs to accomplish. It’s always been clear that ONC has wanted to find a way to promote interoperability. Now they literally have a program that will work to drive that goal.

I’ll admit that I’ve been a fan of this idea since May 15, 2014 when I suggested that ONC and CMS blow up meaningful use and just focus it on interoperability. It only took 4 years for them to figure this out.

While I still think this is directionally an interesting way to go, I’m afraid that the current programs aren’t a big enough incentive for CMS to really move the needle on interoperability. Plus, can CMS really create a rule that would push effect interoperability? I’m skeptical on both counts.

What’s interesting is that CMS could really push interoperability if it wanted. It could just say, if you want to get paid for Medicare, then you have to start sharing data. No doubt there are some complexities to this idea, but if CMS is really serious about promoting interoperability, that’s what they’d really do. That would move the needle much better than thousands of pages of rule making that won’t cause doctors and healthcare organizations to change.

What are your thoughts on the proposed rule? Were there big pieces of it that you saw and you think others should be watching? Are these changes going to relieve doctors of the massive reporting burden they should today? Please share your thoughts in the comments or on Twitter with @HealthcareScene

MIPS Twitter Roundup – MACRA Monday

Posted on December 11, 2017 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 the MACRA Quality Payment Program (QPP) and related topics.

As we near the end of 2017, I found a number of tweets from CMS and other people that I thought would be useful to those that are interested in MACRA and MIPS.

First up is this tweet from CMS that it’s not too late to still participate in MIPS and collect some performance data before the end of 2017. This is them promoting the Test Option which would allow you to avoid the 4% penalty:

Next up is a fact sheet from CMS which outlines the different between 2017 and 2018 when it comes to MACRA/MIPS. I particularly like page 6 of the document. As you go through it, you’ll realize why 2018 is going to be much harder than 2017.

Next up is a stat from MGMA. I’d be interested in learning about the 14% of practices that think that their value-based reimbursement is going to decrease. Are these people going to direct primary care? I don’t see it going down for almost anyone. What do you think?

Finally, Matt Fisher asks a question about whether MIPS should be voluntary. I don’t think they can make it any more voluntary given the current legislation and do any of us think that congress is going to take up this topic? I don’t. So, it’s kind of a moot point. However, there is a lot of doctor angst about MIPS/MACRA. I just don’t see enough of it to really move the needle on things. I think we’re stuck with MACRA/MIPS for the forseeable future.

MIPS Penalties Include Medicare Part B Drugs – MACRA Monday

Posted on November 13, 2017 I Written By

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

I’m sure most regular readers can tell that we’re pretty worn out and tired of MACRA, MIPS, and related government regulation. No doubt you’ll see us posting fewer MACRA Mondays going forward, but we’ll still try to cover major MACRA events as they occur. We just won’t be publishing MACRA Monday every Monday like we’ve been doing.

Jim Tate recently posted about the Real MIPS Timeline which included:

  • Phase 1 – Denial
  • Phase 2 – Shock/Anger
  • Phase 3 – Acceptance

You should read his full writeup, but he’s right. There’s a lot of denial that’s going to lead to shock and anger until the majority of healthcare have to finally accept that MIPS and MACA aren’t going anywhere.

Jim Tate also wrote another important piece related to the MIPS penalties and Medicare Part B drugs. You can read the full details of the change, but for those too lazy to click over, here’s the summary:

  • Many organizations argued that Medicare Part B Drug Costs Shouldn’t be Included in the MIPS Penalties (I mean…payment adjustments)
  • The MACRA Final rule still includes Medicare Part B drug costs (for the majority of people) in the MIPS reimbursement and eligibility calculations

If you’re a practice with a high volume of part B drugs, you better start figuring out your MIPS strategy now! Otherwise, that payment adjustment is going to hit pretty hard.

Thanks Jim for the great insights into MACRA and MIPS. If you need help with MIPS, be sure to check out Jim’s company MIPS Consulting.

MACRA Twitter Roundup – MACRA Monday

Posted on October 30, 2017 I Written By

This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

We took last week off from our MACRA Monday series of blog posts. It seems like we’re in a kind of lull period for the program. Either you’ve started collecting the data you’ve needed or you haven’t. Plus, we’re kind of waiting for the next MACRA Final rule to drop for more details.

With that in mind, I did want to see what some of the latest things that were being shared on Twitter when it comes to MACRA. I found a lot of strong opinions about the program, some good resources, and some forward-looking thoughts on what could be coming in the next MACRA final rule.


It’s hard to argue with John. Not just because he’s a smart guy, but because he’s right that it’s hard to imagine a path forward that’s fee for service and doesn’t include a shift to value based care in some form or fashion. At least given the current market dynamics.


This caution from Workflow Chuck should have us all nervous about the shift. I see a lot of healthcare organizations going after the target as opposed to the goal of value based care.


MACRA is going to impact your biz. I liked the way Kelly broke it out into 4 areas. No doubt some of these things could be argued both ways.


This is still how most doctors I know feel about MACRA and even meaningful use before it. They feel like they’ve been thrown under the bus.

Here are two forward looking resources that look at what we might get from the MACRA Final Rule:

What else are you hearing about MACRA? Would love to hear your thoughts, insights, questions, perspectives, rants, etc in the comments.

Optimizing Your EHR for MIPS and Other Quality Payment Programs – MACRA Monday

Posted on October 9, 2017 I Written By

The following is a guest blog post by Meena Ande currently acts as Director of Implementation for Advantum Health. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program (QPP) and related topics.

As quality reporting requirements ramp up under value-based payment programs like MIPS, healthcare organizations are busy retrofitting their EHRs to make way for new measures. In some settings, not much has changed by way of tech utilization since initial EHR investments were made. Many outpatient settings still lack the internal expertise needed to optimize their implementations.

The truth is many EHRs have the functionality providers need for quality reporting, but many providers don’t know that due to limited exposure to the system. Couple that stunted tech knowledge with the well documented lack of familiarity with MACRA and the recent rise of the service model in healthcare is no surprise. Many practice administrators are relying on their EHR vendor or engaging outside experts to help lead the charge on system reconfiguration to meet Quality Payment Program demands.

There are several EMR capabilities providers can take advantage of to support QPP reporting efforts. Here are a few tips to keep in mind as you customize your EHR for MIPS and other value-based models.

Don’t boil the ocean when selecting CQMs.

Most EHRs give the option of tracking more than what is required for quality reporting. Initially, track applicable measures that exceed reporting requirements. After three to four weeks you’ll know which are your strong areas. Pick the best of the litter and proceed.

Providers can be overwhelmed by too many measures, particularly in multi-specialty practice settings. While it can be difficult to find overlap in measures between specialties, taking advantage of shared metrics whenever possible can reduce reporting burdens. Sit down as early as possible and develop an EHR configuration that works for your practice’s various clinicians.

Case in Point:

A gastroenterologist and a cardiologist may work in the same multi-specialty organization and on the same EHR, but the clinical quality measures they care about differ. There is no reason to give the gastroenterologist access to the cardiology problem list in the EHR. Specialty views improve ease-of-use and support more complete documentation.

Most EHRs offer role-based and specialty-based customization. Administrators can enable or disable EHR features related to some quality measures at the practice level and sometimes at the individual provider level. Clinical quality measures are based on details about the patient, but what is captured at each point of care should be tailored to the specific provider role.

Consider the roles impacted by different CQMs.

Keep the role of the person who may be responsible for different quality measures and Advancing Care Information workflows in mind when selecting and carving out space for CQMs in your EHR. Select measures that spread reporting work across multiple roles to relieve clinicians of unnecessary burdens.         

Case in Point:

The insurance eligibility verification required under Meaningful Use is managed by the front office. Front-office staff members should be made aware of the processes they need to complete before a patient checks in, and where to document that task in the EHR.

Control what is included in MIPS denominators.

Like Meaningful Use, patient encounter volume is important under MIPS. The size of the patient pool under any given quality measure directly impacts your adherence percentage. While most primary care encounters do meet patient visit requirements under MACRA, that is not always the case in specialty settings. Clinicians can exercise some control in determining what is included in patient denominators when reporting under MIPS.

Case in point:

Some primary care visits can be omitted. Let’s say a two-physician practice sees 50 patients a day. Only 15 of those patients might be seen by a physician. The rest of the patients may be there for a simple procedure like a blood pressure screening, stress test, or echocardiogram, where quality reporting elements are not verified. Such visits should be excluded.

Evaluate your reporting paths.

MIPS offers both EHR-based and registry-based reporting paths. Most specialties can submit CQM data via their EHR while others will have to rely on paid registry reporting. Additional reporting options might include submitting through associations that member clinicians are affiliated with, or through registries created by large hospital affiliates to help related providers.

Another hurdle for clinicians is deciding whether to submit data as a group or independently. Groups interested in participating in MIPS via the CMS web interface or administering the CAHPS for MIPS survey had until June 30, 2017, to register. Beyond that, clinicians have until the March 31, 2018, MIPS submission deadline to decide whether to report independently or as a group.

Case in point:

Big groups with different levels of EHR proficiency among providers may be better suited reporting at an individual level. Individual reporting takes more time for attestation, but the advantage is that higher-performing clinicians can avoid a penalty if the group doesn’t collectively meet reporting criteria.

Each month, sample 10 percent of EHR CQM data, including instances where criteria have been met and where it has not. Catch outliers with trouble following through on processes and extend targeted training to the team members bringing numbers down.

Conclusion

Optimizing the EHR and other tech resources providers have in place can be a huge MIPS enablement factor. Up-front customization work helps providers meet reporting requirements and save time over the long run. EHR optimization also enables future value-based care initiatives and lays the groundwork for population health management programs. Gains made in EHR use benefit the life of the practice through increased efficiency and, at the end of the day, better patient care.

About Meena Ande
Meena Ande currently acts as Director of Implementation for Advantum Health where she manages Implementation of services along with EHR optimization, with emphasis on workflow management for value-based reporting.