The Centers for Medicare and Medicaid Services (CMS) staff informed the American College of Radiology (ACR) that the denominator for the current “medications reconciliation” Stage 1 and Stage 2 Meaningful Use measure can be limited to the subset of patients that comprise the physician’s “seen” definition.
In the explanatory preamble of CMS’ September 2012 Stage 2 MU rule, the agency clarified: “for an EP who is on the receiving end of a transition of care or referral, (currently used for the medication reconciliation objective and measure), the denominator includes first encounters with a new patient and encounters with existing patients where a summary of care record (of any type) is provided to the receiving provider.” This was a major change from the 2010 Stage 1 MU rule which clearly distinguished the term “transitions of care” from “referrals” in which the referring provider maintained management of the patient. Ultimately, the 2012 clarification meant that referral-based care was to be included in the “medications reconciliation” objective/measure moving forward.
Many MU participating radiologists have used the “seen patients” flexibility to appropriately reduce their denominators for applicable objectives to more manageable numbers. Previously, “medications reconciliation” was not thought of as being an applicable objective because the denominator of “received transitions of care” does not refer to “patients seen by the EP.” So, whereas a radiologist could have been meeting other percentage-based MU measures on a smaller subset of their overall patient volume, they would have needed to use their full patient volume for the “medications reconciliation” measure under the 2012 clarification.
However, CMS staff recently indicated to ACR that the word “encounters” in the 2012 clarification (“…first encounters with a new patient and encounters with existing…”) could be interpreted the same as the physician’s defined “seen” patients. This view would limit the application of the “received transitions of care” denominator to the smaller subset of “seen” patients used in most of the physician’s other applicable MU objectives. Moreover, if a physician could somehow define their “seen” patients as not including services that meet the 2012 “received transitions of care” clarification, they could once again qualify for the exclusion from the “medications reconciliation” objective.
On April 29, the American Medical Association (AMA) hosted the American College of Radiology and approximately 25 other specialty societies, for a meeting with the Centers for Medicare and Medicaid Services (CMS) and HHS Office of the National Coordinator for HIT (ONC) on the three recent proposed rules to update the requirements of the EHR Incentive Program (“meaningful use”) and HIT certification program.
CMS and ONC provided presentations covering the three proposed rules and opened the floor for questions. I asked how many eligible professionals were avoiding MU penalties in 2015 through the significant hardship exception mechanism. The answer was roughly 55,000. I believe the 55,000 number must be exclusive to manual applications for hardship—i.e., did not include the automatically-awarded hardship exception for radiologists, pathologists, and anesthesiologists. Otherwise, it would have been much higher.
Under the draft paradigm in the Stage 3 MU proposed rule, any eligible physician who uses significant hardship exceptions to avoid penalties in 2015, 2016, 2017, 2018, and 2019 would need to successfully participate in MU beginning on January 1, 2018 to avoid CY 2020 payment penalties… If 257,000 noncompliant physicians are currently getting Medicare payment penalties, 55,000 are currently avoiding penalties via manual but time-limited hardship exceptions, and roughly 60,000-85,000 are avoiding penalties via the automatic but time-limited hardship exception, 2018 could end up being a much bigger “D-Day” than anyone is currently predicting.
Of course, the Merit-Based Incentive Program (MIPS) mandate from the SGR reform legislation should significantly impact this predicament, hopefully in a positive way.
On April 15, the Centers for Medicare and Medicaid Services (CMS) formally published its proposed rule to modify the EHR Incentive Program requirements in 2015 through 2017. As with the recent proposals for 2017 and beyond, the latest proposed rule would create a smaller set of Meaningful Use (MU) objectives, revise several (not all) of the problematic requirements, and establish a ninety-day reporting period in calendar year (CY) 2015 for all participants.
Reporting Period Changes
For 2015 only, the reporting period for all participants would be any continuous 90 days in the CY. This change was promised back in January via a CMS staff blog announcement.
As a technicality, CMS’ revisions to the online attestation system would not roll out until January 1, 2016. Thus, first-year participants in 2015 would attest by the end of February 2016 to avoid 2016 payment reductions. These rookies would also have a period of time in which they receive payment reductions. CMS would reprocess and reconcile those reduced Medicare payments when rookies’ 2015 MU attestations are processed. Veteran participants would be unaffected by this technicality.
MU Objectives for 2015, 2016, and (optional) 2017
The proposed rule would eliminate the concept of “core” and “menu” objectives, instead requiring all participants, regardless of Stage, to complete the Stage 2 MU objectives listed below.
Stage 1 participants in 2015 could use the Stage 1 thresholds through “alternative measures.” These participants would have new exclusions available to them to negate increased thresholds and new requirements taken from Stage 2.
- Protect health information/HIPAA
- Enable CDS functionality
- Meds, labs, and radiology orders captured using CPOE
- Summary of care creation/transmittal for transitions of care and referrals (modified)
- Patient specific educational resources
- Medications reconciliation for received transitions of care
- View/Download/Transmit (modified to reduce reliance on patient action)
- Secure electronic messaging (modified to only require enabling the functionality)
- Public health/registries (modified to consolidate the registry-related objectives – choose to actively engage with 2 or 1 registries depending on MU Stage)
As proposed, most diagnostic radiologists would likely need to complete the measures of four total MU objectives: (1) protect health information, (2) CDS, (8) patient view/download/transmit (if exclusion not met), and (10) public health/registries (if exclusions not met).
The “imaging results access” Stage 2 objective is one of the many objectives that would be eliminated by the proposed rule.
Although it is unclear if this was intended by CMS, the proposed language appears to separately define and no longer explicitly include referrals as transitions of care in the “medications reconciliation” objective. On the flip side, referrals would be included alongside transitions of care in the “summary of care” objective for referring providers.
The component of MU that requires reporting of clinical quality measures (CQMs) would mostly remain the same. Veteran participants could choose to report CQMs for their 90-day reporting period via attestation in 2015 (as first-year participants do) versus one of the other CQM reporting options.
Significant Hardship Exceptions
CMS does not propose any changes to the hardship exceptions currently in the regulations. Therefore, radiologists would continue to avoid penalties automatically for up to 5 years per individual.
“Hospital-Based” Determination / Eligibility
CMS requested public comment on whether Place of Service Code 22, or other settings, should be used in the hospital-based determination.
Following the close of the sixty-day public comment period, CMS will review the submissions and draft a final rule for promulgation later in 2015. American College of Radiology members who wish to submit feedback for potential inclusion in ACR’s future comments should please contact Michael Peters, ACR Director of Regulatory and Legislative Affairs, at firstname.lastname@example.org or 202-223-1670.
The Centers for Medicare and Medicaid Services (CMS) released a proposed rule to modify the EHR Incentive Program (“meaningful use”) participation requirements for the period between 2015 and 2017. The “MU fix” rulemaking is intended to increase flexibility and reduce the reporting burden for participating physicians and hospitals and is separate from the “Stage 3” proposed rule published a few weeks ago. It will be published in the Federal Register on April 15 for a 60-day comment period.
- CMS proposed rule, “Electronic Health Record Incentive Program—Modifications to Meaningful Use in 2015 through 2017” (pre-publication)
The American College of Radiology Government Relations team is currently reviewing the content.
Legislation to replace the Sustainable Growth Rate (SGR) formula passed the U.S. House of Representatives on March 26, and could pass the Senate following the Congressional recess. As with last year’s failed legislation to permanently fix the SGR, certain language meant to encourage “pay for performance” would significantly impact the landscape of health IT policy.
The included “Merit-Based Incentive Payment System (MIPS)” concept would consolidate the three active Medicare incentive programs—the Physician Quality Reporting System (PQRS), EHR Incentive Program (“meaningful use”), and Value Based Modifier (VBM)—into an umbrella carrot-and-stick program that eligible professionals could do as an alternative to mandated participation in alternative payment models (APMs). MIPS would award incentive payments or payment reductions based on a “composite performance score” of 0-100 comprised of activities in four areas: quality, resource use, meaningful use, and clinical practice improvement activities. This score-based system would replace the current Medicare programs’ payment adjustments with potentially bigger reductions for some physicians; however, most physicians would avoid penalties or obtain incentive bonuses.
As was the case last year, the bill directs regulators to consider the applicability of the various requirements that comprise the composite performance score to “non-patient-facing” professionals and others. This language could conceivably result in alternative pathways to compliance, removal of individual programs (such as MU and VBM) from the score for certain professionals, or even 1:1 replacement requirements for non-patient-facing professionals that fulfill the same goals.
The Centers for Medicare and Medicaid Services (CMS) and Office of the National Coordinator for HIT (ONC) will publish proposed rules to update the EHR Incentive Program’s meaningful use (MU) requirements and health IT certification requirements on March 30. Pre-publication versions of the proposed rules (CMS / ONC) were made publicly available on March 20. The American College of Radiology Government Relations team reviewed both documents and released a draft summary of the highlights of interest to radiologists on March 23.
The CMS proposed rule would establish Stage 3 MU requirements. In 2017, participants could choose Stage 3 or another Stage. In 2018 and every year thereafter, Stage 3 would be the only option. The eight total Stage 3 MU objectives would be: (1) Protect Patient Health Information, (2) eRx, (3) CDS, (4) CPOE, (5) Patient Electronic Access to Health Information, (6) Coordination of Care Through Patient Engagement, (7) Health Information Exchange (HIE), and (8) Public Health and Clinical Data Registry Reporting. Of these proposed objectives, most diagnostic radiologists would likely need to do four— (1), (3), (7), and (8)—because of proposed exclusions from measures that go with the other objectives.
While CMS proposes to continue the (original) hardship exceptions that protect radiologists and others from MU penalties for up to 5 total years per individual, the start date for MU compliance would be moved up to January 1, 2018 for physicians who used up all of their hardship exceptions in 2015 through 2019. The reason: CMS proposes to eliminate the 90-day reporting period for rookie MU participants. Thus, beginning in 2017, all MU participants would have yearlong reporting periods, and all participants would avoid penalties via MU compliance 2 years before the penalty year in question (e.g., 2018 compliance to avoid 2020 penalties).
CMS proposes that the clinical quality measure (CQM) reporting requirement of MU would be updated via future Medicare payment rules (beginning with 2016 Physician Fee Schedule for 2017 MU). The goal is to further align CQM reporting across the CMS quality incentive programs, such as PQRS, which are currently updated through the annual payment rulemakings instead of via standalone rulemakings.
Proposed S3 MU for most diagnostic radiologists in 2018+ (optional in 2017):
1. Four Stage 3 MU objectives (non-excludable by most radiologists):
- Protect patient info (HIPAA)
- Enable CDS functionality
- Request Summary of Care Records/C-CDAs from referring providers and incorporate/reconcile info of interest
- Actively engage with 3 registries
2. CQM reporting requirements (TBD in 2016 payment rules)
3. CEHRT equipped at location(s) where >50% patient encounters
Note that CMS is planning a separate rulemaking to address flexibility in the current Stage 1 and Stage 2 MU requirements for 2015-2017. That proposed rule should be published around Spring/Summer if all goes to plan.
Unlike the various regulatory framework changes in the CMS proposed rule, the ONC’s proposals for the health IT certification program would not be substantially different from a radiologist end-user’s perspective. There would be the requisite updates in the form of the 2015 Edition Health IT (no longer “EHR”) certification criteria (mandatory in 2018), new and revised standards and implementation guides, changes to the privacy/security scheme, new post-certification surveillance and transparency requirements, removal of “Complete EHR” certification status, and a slightly updated Base EHR definition. Additionally, the responsibility for defining “certified EHR technology” (CEHRT) for MU purposes would shift from ONC to CMS as ONC expands its HIT certification program beyond MU exclusivity. Most of these proposals were expected based on discussions included in an earlier ONC rulemaking.
In terms of ONC’s imaging-specific 2015E certification criteria, the “image results” and “CPOE-diagnostic imaging” certification criteria would be unchanged from the previous 2014 Edition/2014 Edition Release 2 versions (the CMS proposed rule provides clarification about “diagnostic imaging” would mean in the context of CPOE [i.e., all modalities], but it would not significantly alter the previous understanding of that requirement). The “view online, download, and transmit to a 3rd party” certification requirements which support patients’ electronic access to their data via portals, PHRs, and 3rd party applications would include “Diagnostic Image Reports”—thus, HIT modules certified for the V/D/T criterion would need to be technically capable of sharing these reports with patients.
For more information, please see ACR’s draft summary (subject to change).
If ACR members have additional questions, or would like to offer feedback for potential inclusion in ACR’s future comments on either of the proposed rules, please contact Michael Peters, Director of Regulatory and Legislative Affairs, ACR Government Relations, at email@example.com / 202-223-1670.
Moments ago, the Centers for Medicare and Medicaid Services (CMS) and HHS Office of the National Coordinator for HIT (ONC) published their proposed rules to update the EHR Incentive Program (“meaningful use”) participation and software certification requirements.
- CMS proposed rule, “Electronic Health Record Incentive Program Stage 3” (pre-publication)
- ONC proposed rule, “Health Information Technology Certification Criteria, Base Electronic Health Record Definition, and ONC Health IT Certification Program Modifications” (pre-publication)
The American College of Radiology Government Relations team is currently reviewing both proposed rules.