Late last week, the Centers for Medicare and Medicaid Services (CMS) and the HHS Office of the National Coordinator for HIT (ONC) announced plans to extend Meaningful Use (MU) Stage 2, delay the upcoming Stage 3 and 2017 Edition certification criteria rulemakings, and implement a 2015 Edition of EHR certification criteria.
The most noteworthy piece of the announcement was that CMS will delay the “Stage 3 MU” rulemaking by several months. The agency is now targeting a fall 2014 release of the proposed rule and a mid-2015 release of the final rule. ONC plans to release the “2017 Edition EHR certification criteria” proposed and final rules on the same timeline.
Additionally, ONC will conduct an extra, off-cycle rulemaking to establish so-called 2015 Edition EHR certification criteria. They plan to use that rulemaking to fix problems EHR developers might be having with the 2014 Edition requirements, as well as modify the way standards and implementation specifications are referenced in ONC’s regulations. The 2015 Edition will apparently be an optional alternative of sorts to the 2014 Edition.
The Stage 2 “extension” piece of the announcement will be a third year for participants who entered Stage 2 in 2014 (i.e., those physicians and hospitals who began MU in 2011 or 2012). This is akin to the Stage 1 extension that 2011 participants were able to receive for 2013. As described, the plan does not appear to delay the beginning of Stage 2 for those participants who are moving up next year. It also does not seem to delay the mandatory implementation of 2014 Edition certified products in 2014. Delays of that nature would require a rulemaking to modify the existing regulations; a process that would take considerably more time than what we have left.
ACR and RBMA Request Long-Term Reprieve from Meaningful Use Penalties for Certain Physicians Located in Unhelpful Hospitals
Prior to the holidays, the American College of Radiology (ACR) and Radiology Business Management Association (RBMA) sent a letter to the Centers for Medicare and Medicaid Services (CMS) requesting the establishment of an alternative process by which certain hospital-located physicians could optionally become ineligible for the EHR Incentive Program (“meaningful use” or MU) and its associated penalties.
While many ACR members are already temporarily protected from MU penalties for up to 5 years max, this request would provide long-term reprieve for a specific subset of physicians who have the misfortune of being located in hospitals that are not adequately enabling participation in the program.
Access the details of the ACR and RBMA request here.
For readers interested in learning more about the EHR Incentive Program and the American College of Radiology’s related advocacy efforts, I am participating in a refresher course at RSNA 2013 on December 5 at 8:30AM titled “Latest Developments in Meaningful Use: Ask the Experts” (RC626). The session will be held in room E451A.
Curtis P. Langlotz MD, PhD will moderate, and Keith J. Dreyer DO, PhD and I are slated to present. There should be plenty of time and opportunity for extensive Q&A.
On November 6, the Office of the National Coordinator for HIT (ONC) HIT Policy Committee held its first business meeting since the federal government shutdown. The most interesting discussion was an update from ONC staff on the certification status of products supporting the Medicare/Medicaid EHR Incentive Programs (“meaningful use” or MU).
As of October 21, only 33 vendors with 2011 Edition certified products used by eligible professionals (EPs) in previous years of MU are now offering 2014 Edition certified products. Of those, only 22 vendors now offer products certified for all criteria in the “Base EHR” definition. Note that this data is limited to vendors with 2011 Edition certified products that were the primary components of actual meaningfully used certified EHR technology (CEHRT).
Alarmingly, only about half of the vendors whose 2011 Edition certified products were the primary component of diagnostic radiologists’ certified EHR technology (CEHRT) in previous years of MU now offer 2014 Edition certified products. Of the vendors who do, only slightly more than half now offer products certified for all criteria in the Base EHR definition.
The point is that everyone participating in MU must use 2014 Edition certified products next year. Moreover, everyone must have the Base EHR definition covered, plus any additional criteria that correspond with CMS MU measures they need to meet, in order to have a product combination that meets the regulatory definition of “CEHRT” in 2014 and beyond. Therefore, previous MU participants should be fully cognizant of their vendors’ certification plans; EPs should not just assume they will be taken care of by their existing vendor.
On October 30, the Senate Finance and House Ways and Means Committees released a bipartisan, bicameral discussion draft paper titled “SGR Repeal and Medicare Physician Payment Reform.” The draft proposes a framework for a permanent Sustainable Growth Rate (SGR) formula fix, encourages alternative payment models, and aligns various Medicare incentive programs, including the EHR Incentive Program (“meaningful use” or MU). The purpose of the proposal is to solicit comments from the public.
In terms of MU and various other incentive programs, the proposal would rework the imminent penalties and reintroduce incentives in an interesting way beginning in 2017. There would be an umbrella Value Based Performance (VBP) Payment Program based on a “composite score” determined by a physician’s compliance with MU, PQRS/quality, Value Based Modifier/resource use, and clinical practice improvement activities (including participation in Medicare Alternative Payment Models, work in federal Health Professional Shortage Areas, and so on). A high or low composite score will determine whether the physician is incentivized or penalized for VBP as opposed to individual program penalties. The funding pool created by payment reductions to those with low composite scores will be used to pay incentives to those with high composite scores. The penalties and incentives will amount to 8% Medicare payments in 2017, 9% in 2018, and 10% in 2019. After 2019, the funding pool can be increased, but not lowered, by HHS.
While each of the components of the composite score are weighted to a certain percentage (MU, for example, would be up to 25% of the composite score if fewer than 75% of eligible professionals are compliant), the draft proposal does not address what “high” or “low” composite scores specifically are. For example, would 50% of physicians be incentivized while 50% are penalized, or would it scale like the Value Based Modifier system where only the outliers are penalized? The future legislation will likely address these and other details.
Note that the discussion draft covered other subtopics beyond the aforementioned VBP program. The most exciting of the proposals for radiology was the inclusion of appropriateness criteria-guided decision making for physicians who order diagnostic imaging. See the American College of Radiology’s website for more information.
On October 24, the Government Accountability Office (GAO) released a report exploring Medicare EHR Incentive Program (“meaningful use” or MU) participation in 2011 and 2012. Some highlights:
- 183, 712 or 31% of all eligible professionals (EPs) received Medicare EHR Incentive Program payments in 2012
- Over 56% of those EPs who received incentives were “specialty practice physicians”
- “General practice physicians” were 1.5 times more likely to have received an incentive payment than specialists
- 12% of radiologist EPs received an incentive payment in 2012
While only a few specialties were covered individually, the report was striking for how many specialties are surpassing radiology in terms of MU participation. For example, 31.7% of ophthalmologist EPs received MU incentive payments in 2012. Only two specialties specifically called out in GAO’s report had lower levels of participation—psychiatry and dentistry—but we know from the Centers for Medicare and Medicaid Services (CMS) and Office of the National Coordinator for HIT (ONC) public data that several other major specialties, including pathology and anesthesiology, were also lower than radiology in 2012.
Clearly, the data shows that CMS and ONC have a long way to go to meet the 75% EP participation goal by 2018.
…In other GAO health IT news, the agency also released its list of new appointments to ONC’s HIT Policy Committee. A big part of the problem highlighted in the aforementioned participation report is a lack of specialty representation on the federal advisory committees that provide MU-related recommendations to ONC and, indirectly, CMS.
It has been a week since the federal government shutdown ended. Many health IT-related federal agencies are still getting back on track.
The National Institutes of Health (NIH) Office of Extramural Research published a series of guide documents and blog entries on the resumption of activities. NIH also put together a convenient website compiling links to all shutdown and post-shutdown information for extramural grantees, as well as a helpful batch of FAQs.
The Office of the National Coordinator for HIT’s federal advisory committees and related workgroups continued to experience cancellations of their virtual meetings for several days after the shutdown. The HIT Policy Committee’s Privacy and Security Tiger Team was the first such advisory body to publicly convene as scheduled. It appears ONC’s advisory committee/workgroup calendar will be back to normal beginning October 24.
The Centers for Medicare and Medicaid Services (CMS) FAQ website is back up. This critical source of first-party guidance regarding the EHR Incentive Program (and all other CMS programs and initiatives) was totally unavailable for the duration of the shutdown.
I had the honor of presenting with Judy Burleson, Senior Advisor, Metrics in the American College of Radiology’s (ACR) Quality and Safety Department during the third annual ACR Imaging Informatics Summit & Data Registries Forum in Washington, DC. Our October 11 breakout session featured updates on Medicare quality initiatives and incentive programs, including the Physician Quality Reporting System, EHR Incentive Program, Value-based Purchasing, and more. The session was intended to provide a closer examination of each of the federal government initiatives mentioned in the keynote presentation, “Future of Registries – Alignment Across Quality Efforts,” by Louis H. Diamond, MBChB, FCP, (SA), FACP, FHIMSS (President, Quality in Health Care Advisory Group, LLC).
Ms. Burleson covered various complex subtopics in admirable detail inside of 40 minutes. My presentation was a simplified, ten-slide overview of the 2014 participation requirements for the Medicare version of the EHR Incentive Program (“meaningful use”) for eligible professionals.
The payment adjustments (penalties) for nonparticipation in the EHR Incentive Program (“meaningful use” or MU) are scheduled to begin in calendar year (CY) 2015. Eligible radiologists have two ways to avoid the penalties:
Option 1: Comply on time
- Prior MU participants must comply in the year that is two years before the penalty year.
- First time MU participants must complete attestation by October 1 of the year before the penalty year. To complete attestation in time, the reporting period must begin by July 1.
Option 2: Obtain a significant hardship exception
CMS can grant a temporary “significant hardship exception” to a physician on an annual basis for up to 5 years maximum. Exceptions that require manual applications have an application submission deadline of July 1 of the year before the penalty year. CMS has not yet released technical details about the future application process. The various significant hardship exceptions are as follows:
- Lacking broadband/infrastructure: The physician was located in an area without sufficient Internet access to comply for any 90-day period of time from the beginning of the year that is 2 years before the penalty year to July 1 of the year before the penalty year. Moreover, the physician must have faced insurmountable barriers to obtaining the internet connectivity.
- Newly practicing: The physician has been practicing for less than 2 years.
- Extreme and uncontrollable circumstances: a) A previous MU participant faced extreme and uncontrollable circumstances in the year 2 years before the penalty year. Or, b) a physician who has never participated in MU faced extreme and uncontrollable circumstances in the year before the penalty year.
- Inability to influence availability of certified EHR technology (CEHRT): The physician practiced at multiple locations, and lacked control over the availability of CEHRT at one or more locations where he/she had more than 50% of his/her patient encounters.
- Lack of face-to-face/telemedicine interaction with patients AND lack of need for follow-up: The physician can demonstrate difficulty in meeting MU on the basis of lack of face-to-face or telemedicine interaction with patients and lack of need for follow up with patients.
- Primary specialty listing in PECOS: The physician has a primary specialty listed in PECOS as radiology, anesthesiology, or pathology 6 months before the penalty year. For radiology, the primary specialty listing would need to be “diagnostic radiology” (30), “nuclear medicine” (36), or “interventional radiology” (94). The plan is that this exception will be automatically granted by CMS based on PECOS status, and therefore will not require a manual application. CMS has not released information about how to “opt out” if the radiologist was MU compliant in time and does not need to obtain an exception in 2015.
On September 24, Sen. John Thune (R-SD), Sen. Lamar Alexander (R-TN) and other Republican Senators sent a letter to the Secretary of Health and Human Services (HHS) requesting a one-year extension of Stage 2 meaningful use (MU) for any participants who are not ready. While the letter confuses the concepts of “Stage 2” and “2014 edition certified EHR technology (CEHRT),” and does not mention the clinical quality measures (CQM) set or CQM reporting changes in 2014, the primary asks seem to be:
- Delay the mandatory implementation of 2014 Edition certified EHR products (and next set of CQMs and CQM reporting options) for those in Stage 1.
- Allow those who would be entering Stage 2 MU in 2014 to remain in Stage 1 MU using 2011 Edition certified products (and the current set of clinical quality measures and CQM reporting options) until 2015.
- Allow those who already implemented 2014 Edition CEHRT to enter Stage 2 in 2014 and comply as originally planned.
Again, it is not clear what actions they want HHS to take; only that HHS should not hold providers’ feet to the fire on MU participation and technology changes in 2014.