The American College of Radiology (ACR) government relations staff participated in an American Medical Association (AMA)-hosted meeting of the national specialty societies regarding the future of the Medicare/Medicaid EHR Incentive Program on June 24, 2015.
Regulatory affairs staff from approximately 25-30 different national specialty societies participated in the discussions, and all presented their members’ concerns regarding the Centers for Medicare and Medicaid Services’ (CMS) and Office of the National Coordinator for Health IT’s (ONC) ongoing rulemakings to update the program’s requirements.
Noteworthy from the meeting was that all national physician associations continue to share many of the same concerns about the current status and future outlook of the program. While some specialists have unique challenges, the shared concerns include:
- Alarmingly low participation levels
- Overly optimistic agency outlook and timetables for the program
- Health IT certification expansion beyond Meaningful Use (MU) applications
- Yearlong reporting periods for all participants in 2018 and beyond
- Lack of full alignment between PQRS and MU’s clinical quality measure reporting
- Relevance of requirements to workflow/scope of practice
- Uncertain future MIPS implementation hanging over the current pre-MIPS MU rulemakings
- And more…
AMA has held one or two specialty society meetings per year on MU-related topics since the establishing Recovery Act was signed into law in 2009. ACR GR staff have worked closely with AMA GR counterparts on various advocacy activities and letters dedicated to improving the program over the years. Yesterday’s discussions reinforced the fact that, despite some advances, CMS and ONC have a lot of work left to do on this issue.
The American College of Radiology (ACR) formally submitted comments to the Centers for Medicare and Medicaid Services (CMS) on June 15 addressing the agency’s proposed rule to reform the EHR Incentive Program in 2015 through 2017. The ACR’s comments are accessible here.
The ACR submitted similar comments in response to CMS’ proposed rule for Stage 3 MU last month.
The U.S. Senate Committee on Health, Education, Labor and Pensions (HELP) convened a full committee hearing regarding “Health Information Exchange: A Path Towards Improving the Quality and Value of Health Care for Patients” on June 10, 2015. The witnesses were Neal Patterson (CEO, Cerner), Christine Bechtel (National Partnership For Women & Families), Dr. Thomas Payne (American Medical Informatics Association), and Craig Richardville (CIO, Carolinas HealthCare System).
The hearing broadly surveyed some of the general challenges facing health information exchange (the verb). A lot of time was also spent on anxiety related to the Medicare/Medicaid EHR Incentive Program (“meaningful use” or MU) and the recent Stage 3 proposed rule for MU in 2018 and beyond. The Chairman, Senator Lamar Alexander (R-TN), and a couple of the witnesses suggested that Stage 3 final rule be delayed until Stage 2 experiences have been collected and leveraged. It did not seem well understood that the Stage 3 proposals were more simplified and flexible for participants than the MU regulations that are currently in effect.
Christine Bechtel, who served on the Office of the National Coordinator for HIT’s Health IT Policy Committee from 2009 to 2015, also attacked the Centers for Medicare and Medicaid Services’ proposal to reduce patient action requirements in the “MU fix: 2015-2017” rulemaking. This proposed change has been misunderstood by some stakeholders as a proposed elimination of the patient electronic access requirement in MU. Bechtel’s written testimony stated:
“We must preserve both the requirement that the technology is in place, and the requirement that a percentage of patients use it at least one time during the reporting period. Regardless of whether the number is five percent or something else, CMS’s recent proposal to drop this threshold to just a single patient will completely undermine efforts by consumers who want to have and use their data. Requiring providers to actively engage with a percentage of patients is an essential mechanism for changing consumer expectations and enabling consumers as a force for change.”
No explanation was provided in the written or verbal testimony for why the proposed change would “undermine efforts by consumers who want to have and use their data.” The MU requirement that patients be enabled to view, download, and transmit their data would not be reduced; only the secondary requirement that a percentage of patients actively use this capability. This secondary requirement has been shown to be controversial and unfair to referral-based specialists, such as diagnostic radiologists, who do not typically have ongoing, continuous relationships with their patients. It has also been shown to be unfair to rural providers with minimal internet/mobile connectivity and those with patient populations who do not enthusiastically engage with their personal health data online.
The Senate HELP Committee will convene additional hearings in the coming weeks to explore the issues of physician regulatory burden and ownership of exchanged health data.
The American College of Radiology (ACR) formally submitted comments to the Centers for Medicare and Medicaid Services (CMS) on May 28 addressing the agency’s proposed rule to implement Stage 3 of the EHR Incentive Program. The ACR’s comments are accessible here.
The ACR also plans to comment next month on CMS’ proposed rule to reform EHR Incentive Program participation requirements in 2015 through 2017. If interested in providing feedback on that rulemaking, please contact Michael Peters, ACR Director of Regulatory and Legislative Affairs, at 202-223-1670 or firstname.lastname@example.org.
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 email@example.com or 202-223-1670.