Centers for Medicare and Medicaid Services (CMS) says Meaningful Use (MU) will live on in MACRA. If you thought Stage 3 of the Electronic Health Record (EHR) Incentive Program was being consigned to the regulatory ether given the newly proposed Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule, time for some new thinking.

CMS published a proposed rule on the implementation of MACRA providing details on the new Merit-Based Incentive Payment System (MIPS) for eligible clinicians by consolidating components of three existing programs: Physician Quality Reporting System (PQRS); Physician Value-Based Payment Modifier; and the Medicare EHR Incentive Program for Eligible Professionals (EP) or groups under the physician fee schedule. The proposed rule also establishes incentives for participation in certain alternative payment models (APM).

In the rule, the Department of Health and Human Services (HHS) and CMS identified three central priorities for MACRA:

  • Improved interoperability and the ability of physicians and patients to easily move and receive information from other physicians’ systems
  • Increased flexibility in the MU program
  • User-friendly technology designed around how a physician works and interacts with patients

CMS is proposing that the MIPS performance period would be the calendar year 2017 – two years earlier that the year in which the MIPS adjustment is applied.

Now, with most of the regulatory patois and acronyms out of the way, let’s turn our attention to the key takeaways:

  1. Many providers were excited when Mr. Slavitt announced the end of MU in January. “We are now in the process of ending meaningful use and moving to a new regime culminating with the MACRA implementation,” he said at the J.P. Morgan Annual Health Care Conference. “The meaningful use program as it has existed, will now be effectively over and replaced with something better.”
  1. This statement was further clarified in a CMS blog post by Mr. Slavitt and Karen DeSalvo, MD, acting assistant secretary of HHS. They opined that MACRA is an opportunity to adjust EHR-related payment incentives, but it does not eliminate EHR-related payment systems, nor will it eliminate meaningful use concerns overnight. While MACRA details are hammered out, MU Stage 3 is still in effect.
  1. Meaningful Use for EP would no longer be a standalone program. EHR use requirements—referred to as Advancing Care Information (ACI)–would account for 25 percent of a provider’s total MIPS composite performance score under the MACRA regulations. That composite score, in turn, would be used to adjust a Medicare provider’s payments upward or downward, or keep them flat. The total maximum downward adjustment for Year 1 would be negative.
  1. Since MACRA is directed at the EP community, this raises concerns about the impact of the new ACI model on hospital operations.
  1. The participation component relates to a “base score” that awards providers 50 points of the total possible 100-point ACI category score. To receive the base score, providers would need to complete a security risk analysis, be in active engagement with an immunization registry (or qualify for an exclusion), and report a numerator (of at least one) and denominator for all remaining measures. Failure to report all base score requirements would result in a zero score.
  1. The performance score consists of additional points awarded for certain objectives. No minimum threshold would be required for each individual measure. Rather, providers would receive up to 10 points for certain measures; in theory these measures could sum up to greater than 50 points, but CMS caps this part of the category’s score at 50. CMS focuses the performance score on the Stage 3 Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange objectives (or their associated Modified Stage 2 measures in 2017). Additionally, providers can add up to one public health bonus point if they achieve Active Engagement with a public health registry (e.g., Syndromic Surveillance, or Specialized Registry).

Of principal concern is the new programs would reduce alignment between MU EPs and Eligible Hospitals.  This could reverse gains that CMS took great pains to achieve in 2015. In fact, ACI would be governed by different standards than those governing EPs and EHs in MU. Staff members responsible for MU could have difficulty keeping track of dissimilar program requirements and effectively onboard their EPs to MIPS/APM. For example, MU EPs that are still eligible for MU incentives (potentially, through 2021) would be required to continue to participate in the MU program.  If they have Medicare Part B claims, they would need to meet MIPS/APM requirements. This would result in duplicate reporting and confusion, as providers’ performance is graded differently in MU and in MIPS/APM.

In the final analysis, there is no clear-cut answer on whether MU would be improved under MACRA.  Until the comments phase is completed and the rule is finalized, CMS may make further changes. What we can say for sure is: MU isn’t going anywhere anytime soon. It will continue for years to come, both as a standalone program and as part of MIPS/APM model for Medicare clinicians.

Rich Curtiss

Rich Curtiss

Principal Consultant at Clearwater Compliance
Mr. Curtiss has over 35 years of diverse, executive IT experience across several verticals including Healthcare, Finance, Department of Defense, Intelligence Community and Consulting Services.Rich has served in executive information technology and cybersecurity positions as a CIO, CISO, Director and Program Manager. He's a member of the Clearwater consulting team.
Rich Curtiss