ehr developments · slavittat the j.p. morgan annual health care conference, jan. 11,2016. american...

$: EHR Developments · Slavittat the J.P. Morgan Annual Health Care Conference, Jan. 11,2016. American Institute of CPAs ®\ Industry Comments Continued. ACI, under MIPS, and Meaningful$
EHR Developments

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Christopher P. KennySenior Associate King & Spalding LLPWashington, DC(202) 626-9253 [email protected]

American Institute of CPAs®\

AgendaMeaningful UseMACRAAdvanced Payment ModelsMerit-Based Incentive ProgramsMACRA and the “end” of Meaningful UseOther EHR Concerns

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Meaningful Use


Meaningful Use BackgroundIn 2011, CMS launched the Medicare and Medicaid EHR Incentive Programs The Programs provide incentive payments for eligible professionals (EPs) and hospitals who adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology• EPs can receive up to $44,000 in the Medicare program or

$63,750 in the Medicaid program• Eligible hospitals can receive over $2 million

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Meaningful Use - Process1. Utilize certified EHR technology2. Meaningfully use EHR technology

- Connecting certified EHR technology in a manner that allows for health information exchange to improve the quality of healthcare

- Exchange can occur between providers or providers and patients

3. Report measures collected- Come in the form of provider attestations

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Meaningful Use – CMS Initial Stages

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STAGE 12011 – 2012

Data Sharing & Capture

STAGE 22014

Advance Clinical Process

STAGE 32016

Improved Outcomes

• Electronically capture health information in a standardized format

• Use health information to track clinical conditions

• Coordinate care based on information obtained

• Early stages of clinical quality measure reporting

• Use the information to engage patients in their care

• More stringent health information exchange

• Increased e-prescribing requirements/incorporate lab results

• Electronic transmission of patient care summaries across multiple platforms

• Additional patient controlled data

• Improve quality, safety, and efficiency, in turn improving outcomes

• Decision support for national high-priority conditions

• Patient access to self-management portals

• Improving population health

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Meaningful Use – Program ChangesIn October 2015 CMS announced changes to the Meaningful Use program in 2015 to 2017Based on provider feedback and poor Stage 2 performance the changes were made to implement the following goals:• Simplify the program• Reduce the burden • Focus the program on advanced use of EHRs (interoperability

and quality reporting)


Meaningful Use – Modified StagesBeginning in 2015 all providers are considered to be at “Modified Stage 2”Stage 2 providers remain in Stage 2 for 2015 and 2016Stage 1 providers are in “Modified Stage 2” for 2015 and Stage 2 in 2016All providers can choose to complete Stage 3 in 2017 or remain in Stage 2Stage 3 is mandatory for all providers in 2018

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Meaningful Use – Modified ReportingAll providers in 2015 complete a 90 day reporting periodStage 2 measures requiring patient engagement were greatly reducedMany data-entry measures were eliminatedCore menu and objective measures were simplified into 10 objectives (9 for eligible hospitals)


Physician EHR Adoption56% of office-based physicians have demonstrated meaningful use of certified EHR

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Lessons from Meaningful Use

Updating electronic health record systems for changing regulations takes a couple of yearsNot all quality measures are supportedIt can take time to build out new measuresWorkflow changes may be requiredTools for tracking interim performance needed

MACRA

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MACRA OverviewOn April 14, 2015 Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Permanently repealed the Sustainable Growth Rate (SGR) formula for determining payments for clinician servicesEstablished a new framework for rewarding physicians for value over volume and consolidated quality reporting programs into a single system

Alternative Payment Models

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APMs At a GlanceParticipation in APMs is a separate pathway to Medicare increases

Advanced APMs that meet payment thresholds• A 5% bonus annually during 2019-2024

• A higher fee schedule update for 2026 and onward

• Are not subject to MIPS

Advanced APMs that do not meet payment thresholds• No 5% bonus payment

• Exempt from MIPS but can participate for favorable MIPS adjustments

Non Advanced APMs• Required to participate in MIPS but receive favorable scoring weights


Advanced APM Criteria1. Program Options

- A Center for Medicare and Medicaid Innovation (CMMI) model,- Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO),- CMS demonstration under § 1866C of the SSA; or- A demonstration required by Federal law

2. The APM requires participants to use CEHRT

3. The APM bases payment on quality measures comparable to those in the MIPS quality performance category

4. The APM either: 1. Requires APM entities to bear more than nominal financial for monetary

losses; OR2. Is a Medical Home Model expanded under CMMI authority

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Use of Certified EHR TechnologyThe APM requires participants to use CEHRT

The participation threshold increases after the first year

CEHRT standards are the same for APMs and for MIPsFor the Shared Savings Program, the APM may apply a penalty or reward to APM entities based on the degree of CEHRT use among clinicians

Merit-based Incentive Payment System

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MIPS Overview

Beginning in 2019, CMS will incorporate a budget-neutral, performance-based adjustment to individual fee-for-service physician payment ratesCritical Point: While payment adjustments do not begin until CY 2019, performance is based on 2017 data!


MIPS Overview - ContinuedLeverages/collapses existing physician reporting programs• Physician Quality Reporting System (“PQRS”)• Physician Value-based Payment Modifier (“VM”)• Medicare Electronic Health Record Incentive (“EHR”)

a.k.a. Meaningful Use• CMS aims to give physicians maximum

flexibility in selection of measures/activities suitable to their practice

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MIPS EligibilityEligible: Physicians, PAs, NPs, clinical nurse specialists, CRNAs

Exempt: • New clinicians• APM participants • Low-volume practitioners (less than $10,000 in allowable claims

and fewer than 100 Medicare patients)


MIPS ScoringComposite Performance Score (CPS) will be compared to the MIPS performance threshold (either median or mean of all CPS scores, as determined by the Secretary)Additional performance threshold for exceptional performance• Calculated at 25% of all performers that exceed the

performance threshold • Will be published along with performance threshold

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MIPS Incentive Payments


MIPS Performance Categories

Section 1: Quality ←Section 2: Advancing Care InformationSection 3: Resource UseSection 4: Clinical Practice Improvement Activities

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Quality – OverviewReplaces PQRS but adopts majority of PQRSmeasuresAccounts for 60 percent of total score in Year OneAllows specialist-specific reporting using measures grouped by specialtyRequires 6 PQRS-based measures, including an “outcomes” measureEvaluates performance using decile benchmarking


Quality - Submission

* Comply with Medicare Part B patient sampling requirements

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MIPS Performance CategoriesSection 1: Quality Section 2: Advancing Care Information ←Section 3: Resource UseSection 4: Clinical Practice Improvement Activities


Advancing Care Information – OverviewReplaces Meaningful Use Program Accounts for 25 percent of score in Year OneMust continue to use Certified EHRClinicians select menu of options; no more all-or-nothing determinationsScore is comprised of a base and performance score plus a bonus• Meet 5 required measures and report for 90 days on up to 9

others for minimum of 90 days

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Advancing Care Information – Key ChangesEliminates “all or nothing” threshold for measurementEliminates one-size-fits-all approach to measure weightingEliminates two Meaningful Use Objectives and their associated measures• Clinical Decision Support • Computerized Provider Order Entry


Advancing Care Information – ScoringBase Score

• Required reporting on five measures:- Security Risk Analysis- E-Prescribing- Providing patient access- Sending summary of care- Request/accept summary of care

Performance Score• 50% of total ACI score• Earns additional points above the base score • Point calculation corresponds to performance rate (e.g. 77% performance rate = 7.7

points)

Bonus Points!• Reporting to a Public Health and Clinical Data Registry

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MIPS Performance CategoriesSection 1: Quality Section 2: Advancing Care InformationSection 3: Resource Use ←Section 4: Clinical Practice Improvement Activities


Resource Use - OverviewReplaces VMNot used in Year One; will be used in CY 2018Claims-based evaluation so no additional reporting• All claims must be submitted within 90 days of close of reporting year

CMS will differentiate “episodic measures” specific to specialties for “apples-to-apples” comparisons• Two VM holdovers:

- total cost per capita for all attributed beneficiaries- total Medicare spending per beneficiary (“MSPB”)

Evaluated only on those measures applicable to practice

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MIPS Performance CategoriesSection 1: Quality Section 2: Advancing Care InformationSection 3: Resource Use Section 4: Clinical Practice Improvement Activities ←


Clinical Practice Improvement Activities (CPIAs) – Overview

New category – not an existing programCMS proposes 93 measures in 9 objectivesAccounts for 15 percent of score in Year OneEarn up to 60 points using a combination of “medium” and “high” priority category measure submissionsCPIAs must be performed for at least 90 days during the performance period to receive creditFuture additional measures based on stakeholder input

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CPIAs – SubcategoriesSubcategory Example of Performance Activity EHR ?Expanded practice access Same day appointments for urgent needs and afterhours access to clinician advice

Population management Monitoring health conditions of individuals to provide timely health care interventions

Care coordination Timely communication of test results

Beneficiary engagement Establishment of care plans for individuals with complex care needs

Patient safety and practice assessment

Use of clinical or surgical checklists

Participation in an APM Defined in section 1833(z)(3)(C) of the Act.

Achieving health equity Achievement of high quality is rewarded at a more favorable rate for high quality for underserved populations

Emergency preparedness and response

MIPS eligible clinician participation in the Medical Reserve Corps

Integrated behavioral and mental health

Measuring or evaluating such practices as: co-location of behavioral health and primary care services


CPIAs – High Scoring Activity ExamplesCPIA activities are weighted differently and some score higher than othersHigh scoring activities include:

Activity EHR?

Participation in the Transforming Clinical Practice Initiative

Seeing new and follow-up Medicaid patients in a timely manner in the provider’s State Medicaid Program

An activity identified as a public health priority (such as anticoagulation management or utilization of prescription drug monitoring programs)

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EHRs Can Help Keep Your Practice Stay on the “Positive” Side of MIPS

Quality Bonus Points• EHR Reporting• Reporting beyond the required measures

Advancing Care Information• Target Advancing Care Information categories that are end-user

friendly and will yield the most rapid improvement CPIAs• Utilize categories that can be implemented with EHR • Work with CEHRT vendors to achieve high scoring activities

MACRA and the “End” of Meaningful Use

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Industry Comments“Now that we effectively have technology into virtually every place care is provided, we are now in the process of ending Meaningful Use and moving to a new regime culminating with the MACRAimplementation. The Meaningful Use program as it has existed, will now be effectively over and replaced with something better.”

- Comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan Annual Health Care Conference, Jan. 11, 2016


Industry Comments ContinuedACI, under MIPS, and Meaningful Use “are the same”

“Our goal was to not make people have to do something completely different or buy any new technology.”

- Comments of the director of the CMS Center for Clinical Standards and Quality, Kate Goodrich, MD, at a joint meeting of the Health IT Policy and Standards committees on May 17, 2016

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MACRA – The Plus SideReduced the number of quality measuresEliminated all EHR quality measuresPass/Fail system largely eliminatedMore reporting flexibility: claims, EHR, web, registriesMore options/measures to choose from More flexibility


MACRA – Not a Perfect SolutionMany health IT experts believe MACRA, while more streamlined, will still leave providers checking a lot of boxesSome believe there are too many measures and many of the Meaningful Use problems will rear their heads againTherefore providers need to engage with EHR vendors now to ensure that their systems can meet MACRA requirements• Costly and time consuming upgrades may be necessary

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MACRA – HospitalsThe meaningful use program will continue uninterrupted for hospitals• Stage 3 will commence in 2017 for early adopters and will be

mandatory in 2018Although MACRA does not apply to hospitals, they will nonetheless incur implementation costs for their physicians Hospitals can participate in Advanced APMs to help physicians they partner with obtain incentives

EHR Related Concerns

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Potential False Claims Act (FCA) Liability MIPS eligible clinicians must attest to CMS that they did not “data block” during the performance periodThe attestations may be reviewable records during an auditThe attestations may also be the subject of FCAwhistleblower allegationsProviders and hospitals found blocking data could be liable for the money collected through the MIPS program


Hidden Time RequirementsRequired to cooperate with surveillance and ONCdirect review of CEHRT used by provider• Respond in a timely manner and in good faith to requests for

information • Accommodating requests for access to the provider’s production

environment - Including data stored in such certified EHR technology- Okay under HIPAA: “health oversight agency”

• Demonstrate capabilities and other aspects of the technology

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Information BlockingThree-part attestation• Did not disable interoperability features• Implemented to the greatest extent possible

- Connected- Compliant with all health information exchange standards- Patient electronic access (ultimately including APIs)

• Timely, good faith response to health information exchange requests from providers and patients

Reality: this is hard, costly, and not perfect

Copyright © 2013 American Institute of CPAs. All rights reserved.

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Thank You

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ehr developments · slavittat the j.p. morgan annual health care conference, jan. 11,2016. american...

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