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Rules proposed by the Centers for Medicare & Medicaid Services (CMS) and by the Office of the National Coordinator for Health IT (ONC) in February 2019 focus on interoperability of electronic health records (EHRs) to make patient data more useful and transferrable. CMS proposed the Interoperability and Patient Access Proposed Rule, which includes policy changes to support its My HealthEData initiative. ONC’s proposed rule “promotes secure and more immediate access to health information for patients and their healthcare providers and new tools allowing for more choice in care and treatment.”
Several industry leaders have responded to the new proposed CMS and ONC rules in a positive manner. As reported by Health Data Management, “Matt Eyles, president and CEO of America’s Health Insurance Plans, said that healthcare payers are committed to establishing new, innovative ways to integrate and share data with patients and providers.” Eyles noted that “AHIP and our members support seamless access to health information by providers and patients to make better choices about care and treatment.”
Organizations such as the College of Healthcare Information Management Executives (CHIME) support interoperability of electronic health information and have asked members to provide input on the new proposed rules. Liz Johnson, chief innovation officer at Tenet Healthcare and vice chair of the CHIME Policy Steering Committee, stated that “Speeding interoperability and patient access to their records are priorities for our members.”
Don Crane, president and CEO of America’s Physician Groups, noted that the proposed rules “puts power back in the hands of patients by streamlining their ability to access health information literally from the palm of their hand.” Crane added that “Having this information readily accessible can help patients and providers make more informed choices about their care more quickly. And it can help preserve valuable healthcare resources by reducing waste, such as duplicate tests and unnecessary procedures.”
CMS is accepting comments on the major provisions in this proposed rule and the RFIs (CMS-9115-P) until early April (exact date will be updated upon posting at the Federal Register); it can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.
Greg Miller March 5, 2019Read
In 2015, the U.S. Department of Health and Human Services (HHS) launched a public-private partnership known as the Health Care Payment Learning & Action Network (HCP LAN). That same year, HHS announced its goal of tying 30% of fee-for-service (FFS) Medicare payments to quality or value through Alternative Payment Models (APMs) by 2016 and 50% by 2018. An APM is a payment approach that gives added incentive payments for high-quality and cost-efficient healthcare services.
The HCP LAN has collected data among payers to track the progress of the value-based payment numbers. The report released in October 2018, “Measuring Progress: Adoption of Alternative Payment Models in Commercial, Medicaid, Medicare Advantage, and Fee-for-Service Medicare Programs,” found a steady increase in healthcare payments tied to APMs.
The results of the 2017 data collection “show progress, with 34% of total U.S. health care payments tied to alternative payment models (APMs) in 2017, a steady increase from 23% two years ago.” The report highlights include:
The collected data shows “a continued move away from a fee-for-service system that reimburses only on volume, and towards patient- and value-centered APMs.”
LAN’s data collection began on May 15, 2018, and ended on July 15, 2018, using “metrics to determine the extent of APM adoption, asking health plans and states to report dollars paid in either CY 2017 or in the most recent 12 months for which it had data.” Data collection participants included “61 health plans, 3 managed FFS Medicaid states, and Medicare FFS, representing approximately 226.3 million of the nation’s covered lives and 77% of the national market.”
Healthcare payers participating in the data collection were optimistic about the future of value-based care and payments tied to APMs. In fact, the researchers found that “90% of health plans believe that APM adoption will increase in the next 24 months.”
Greg Miller February 19, 2019Read
Pathways to Success has been billed as an “overhaul of Medicare’s ACO program” by the Centers for Medicare & Medicaid Services (CMS). Seema Verma, Administrator for CMS, announced the new program for Accountable Care Organizations (ACOs) as well as changes to the organization’s shared savings program in December 2018.
Seema noted that “the American healthcare system is on an unsustainable trajectory, with one in five dollars spent in our economy projected to be spent on healthcare by 2026,” so healthcare providers and CMS have a responsibility to “to ensure that patients are getting value for the care that is provided.” Pathways to Success introduces a new structure for the ACO Medicare Shared Savings Program (MSSP) that emphasizes value-based care.
(1) BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk that, at the highest level, would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program
(2) ENHANCED track, based on the program’s existing Track 3, which provides additional tools and flexibility for ACOs that take on the highest level of risk and potential reward. Appendix A summarizes the characteristics of the participation options.
Seema notes that CMS is “setting the shared savings rate at 40 percent for ACOs not assuming risk for healthcare costs and 50 percent for ACOs at BASIC track levels of risk, to strengthen the on-ramp to the program while rewarding ACOs that take on greater risk with higher shared savings rates.”
ACOs will enter into 5-year agreements to participate in Pathways to Success, with 12-month performance years based on calendar years. Seema emphasized that part of the change is to reduce the amount of time an ACO can participate in the shared savings program “without taking accountability for healthcare spending.”
Greg Miller February 6, 2019Read
A report required by the 21st Century Cures Act has been published by the Office of the National Coordinator (ONC) for Health Information Technology (IT). The report, Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs, is focused on improving the use of electronic health records (EHRs) and reducing the regulatory burdens placed on physicians.
ONC acknowledges that “clinicians and other health care providers point to the implementation, use, and regulation of health IT and the EHR as a key support tool for care delivery” but that there are also challenges involved. The organization indicates it has “heard from health care providers, practice managers, and hospitals that they experience challenges with EHR system design and the regulatory and administrative burdens associated with the use of EHRs during care delivery, required reporting activities, and documentation of claims for payment.”
The report lays out a series of strategies and recommendations that HHS is considering taking to mitigate EHR-related burden for health care providers, including strategies for EHR Reporting and Public Health Reporting. Strategies outlined for Clinical Documentation and Health IT Usability are also included in the report:
Clinical Documentation Strategies
Strategy 1: Reduce regulatory burden around documentation requirements for patient visits.
Strategy 2: Continue to partner with clinical stakeholders to encourage adoption of best practices related to documentation requirements.
Strategy 3: Leverage health IT to standardize data and processes around ordering services and related prior authorization processes
Health IT Usability Strategies
Strategy 1: Improve usability through better alignment of EHRs with clinical workflow; improve decision making and documentation tools.
Strategy 2: Promote user interface optimization in health IT that will improve the efficiency, experience, and end user satisfaction.
Strategy 3: Promote harmonization surrounding clinical content contained in health IT to reduce burden.
Strategy 4: Improve health IT usability by promoting the importance of implementation decisions for clinician efficiency, satisfaction, and lowered burden.
ONC Health IT is only accepting comments on the report electronically, at: https://www.healthit.gov/topic/usability-and-provider-burden/strategy-reducing-burden-relating-usehealth-it-and-ehrs.
Comment attachments should be in Microsoft Word, Excel, or Adobe PDF. The deadline for comment submission is 11:59 p.m. E.T. on January 28, 2019. ONC will review, analyze, and post on their website all public comments that are received by 11:59 p.m. E.T. on January 28, 2019.
Greg Miller January 28, 2019Read
Recognizing that healthcare does not always happen in a provider’s office, the Centers for Medicare & Medicaid Services (CMS) has included payment for a number of virtual services in its Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019.
The revised fee schedule provides payment for certain types of telemedicine provided to Medicare patients. New codes enable independent physicians to be paid for “two newly defined physicians’ services … using communication technology:
Previously, the physician was not able to bill Medicare for services provided outside the office visit. However, patients often call or communicate electronically to clarify instructions or to ask questions regarding a diagnosis or plan of care. Responding to the patients requires the physician’s time and attention, both to research and prepare the response as well as the actual response time. As of January 1, 2019, those physicians can be reimbursed for that time.
CMS has acknowledged that these virtual services have the potential to “increase efficiency for practitioners and convenience for beneficiaries.” Patients and providers can also take advantage of technology-based communication to determine whether an office visit is even necessary. Prior to calendar year (CY) 2019, the physician would not have been reimbursed for teleservices designed to help a Medicare patient avoid an unnecessary trip to the provider’s office.
In addition, in CY 2019, CMS “finalized payment for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit.” RHCs and FQHCs can bill for teleservices using “a newly created RHC/FQHC Virtual Communication Service HCPCS code, G0071.”
Providers responding to a recent survey conducted by Reaction Data indicated that the new billing codes for virtual services would accelerate their plans to take advantage of technology such as telemedicine in providing quality, value-based care for their patients.
Greg Miller January 22, 2019Read
Recognizing the concern that many physicians have regarding MACRA compliance, the Centers for Medicare & Medicaid Services (CMS) is searching for a contractor who can gather additional feedback and help clarify the requirements. The options under the Quality Payment Program (QPP), in particular, are confusing to independent physicians. The choice between the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APM) is challenging and especially crucial to provider payments.
CMS has issued a notice seeking a contractor to support all existing and future QPP system development and policy development with user research and human centered design. The task order “aims to solve current challenges faced by the Quality Payment Program (QPP), to identify and implement a consistent user experience for the clinician market, based on comprehensive user insights through market research with clinicians as well as to create a unified product strategy, visual identity, and smooth user experience across QPP products based on industry best practices.”
Cost performance will account for 30% of a provider’s MIPS score, as of 2021, and it is vitally important that the criteria for provider payments are clear. CMS recognizes that the “Cost performance category feedback presents the greatest challenge for providing feedback, since the measures are highly complex, the data is extracted from claim submissions and is not consciously submitted by clinicians. There is complex patient attribution rules, and cost normalization processes which are completely foreign to the average clinician.”
The transition of QPP to a Scaled Agile Framework (SAFe) has “created an opportunity to think holistically about the user experience for clinicians and ways in which our QPP teams can identify a product strategy, establish measurable objectives, and execute a plan aligned with the overall QPP vision through program increment planning.”
CMS has stated that the contractor will also work closely with the policy team to ensure Human-Centered Design (HCD), the process it uses to understand the people for whom it writes policies, and creates programs and services, is incorporated into policy writing.
Greg Miller January 9, 2019Read
In a blog post published on November 8, 2018, Seema Verma, Administrator for the Centers for Medicare & Medicaid Services (CMS), shared data on the Quality Payment Program (QPP) Year 1 Performance. The results were overwhelming positive, with 93 percent of MIPS eligible clinicians receiving a positive payment adjustment for their performance in 2017 and 95 percent overall avoiding a negative payment adjustment.
CMS calculated that “1,057,824 MIPS eligible clinicians will receive a MIPS payment adjustment, either positive, neutral, or negative. Of that population, 1,006,319 MIPS eligible clinicians reported data as either an individual, as a part of a group, or through an Alternative Payment Model (APM) and received a neutral payment adjustment or better. Additionally, under the Advanced APM track, 99,076 eligible clinicians earned Qualifying APM Participant (QP) status.”
In her blog post, Verma provided a chart that illustrates the numbers for the various payment adjustments:
CMS recognizes that even though the majority of providers received a positive payment adjustment, those adjustments were “modest.” MIPS has a budget neutrality requirement, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In addition, during the transition year of 2017, CMS offered providers a relatively low overall performance threshold for MIPS as well as a “pick your pace” option that provides three reporting options of test, partial year, or full year. These accommodations were offered to encourage flexibility and more robust provider participation.
Verma emphasized that, going forward, CMS is “committed to continue leveraging our Patients over Paperwork framework to review many of the MIPS requirements to reduce burden and add additional flexibilities so clinicians can successfully participate without sacrificing the time they spend with patients.” Providers are encouraged to send CMS feedback to “help identify areas of immediate need as well as shape the program for future performance years.”
Greg Miller December 14, 2018Read
Adding payment options for virtual services and a subset of changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) are two of the updates included in the final rule released by the Centers for Medicare & Medicaid Services (CMS) on November 1, 2018. The final rule includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.
Many of the updates relate to communication technology, telemedicine, and virtual check-ins. One of the new payment provisions is listed under the category of “Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services.” CMS is finalizing proposals to pay separately for two newly defined physicians’ services provided using communication technology:
In a move toward making healthcare more efficient and more convenient, these payment provisions would mean that healthcare providers would be paid for “the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.”
Recognizing the value of telemedicine in the continuing efforts to reduce opioid addiction, CMS is also implementing a provision that removes the originating site geographic requirements from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, adding the home of the patient as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019.
In regard to ACOs, the CMS final rule addresses a number of changes, including:
The final rule spans 2,378-pages; however, CMS has published a fact sheet on “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019,” providing a list of the updates and changes to the PFS for calendar year (CY) 2019.
Greg Miller December 10, 2018Read
In November 2018, Americans went to the polls to vote on mayors, senators, representatives, and governors, as well as local measures impacting a range of community and state concerns. One of the biggest concerns among voters was healthcare. In fact, preliminary exit polls found that 41% of voters said that healthcare was the top issue facing the country. Healthcare ranked ahead of immigration, the economy, and gun policy for midterm voters.
The results of the midterm elections included a new Democratic majority in the House of Representatives. Many experts believe that this shift in the House will ensure that the Affordable Care Act (ACA), also known as Obamacare, will remain intact for the foreseeable future. Expanded Medicaid also became a reality for many voters. Fortune reports that:
… one of Obamacare’s most popular provisions, its optional state-by-state expansion of the Medicaid program for low-income Americans, was a big winner in several traditionally conservative states. Voters in Idaho, Nebraska, and Utah overwhelmingly endorsed ballot initiatives to approve Medicaid expansion. What’s more, Kansas, Maine, and Wisconsin all elected Democratic governors who are gung-ho expansion proponents, possibly setting up a significant rise in coverage for poor, working residents.
Medicaid expansion may impact the independent physician, who will potentially see more patients seeking care under their new healthcare coverage plan.
Other healthcare initiatives that may be impacted by the midterm elections and that may affect independent physicians include potential opioids legislation and a furthering of the attempt to lower prescription drug prices. On the other hand, with a divided government, some experts think that little healthcare legislation will be passed. HealthLeaders reports that John Kelliher, Managing Director of Berkeley Research Group, believes that “divided government has historically been good for the healthcare industry, especially when Democrats gain relative power, but doubted much legislation will pass in the upcoming Congress.”
Greg Miller December 3, 2018Read
As part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Centers for Medicare & Medicaid Services (CMS) created the Quality Payment Program (QPP). The QPP rewards value and outcomes through two tracks: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). For independent physicians, the choice of tracks is a matter of eligibility and the level of risk involved.
CMS recognizes that it may be challenging for independent physicians to participate in MIPS, so it does tailor some flexibility for groups of 15 or fewer clinicians. Independent physicians are eligible if they meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule. Physicians may participate as individuals or groups, including virtual groups.
Performance in the MIPS track is measured through the data clinicians report in four areas – Quality, Improvement Activities, Promoting Interoperability (formerly Advancing Care Information), and Cost. CMS designed MIPS to update and consolidate previous programs, including: Medicare Electronic Health Records (EHR) Incentive Program for Eligible Clinicians, Physician Quality Reporting System (PQRS), and the Value-Based Payment Modifier (VBM).
The APM track involves taking on more risk but offers additional incentive payments. There are two types of APMs:
Advanced APMs – In the Advanced APM track of the Quality Payment Program, physicians may earn a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. Independent physicians who achieve these thresholds are excluded from the MIPS reporting requirements and payment adjustment. There are a number of APM models available to the independent physician.
MIPS APMs – Most Advanced APMs are also MIPS APMs so that if an eligible provider participating in the Advanced APM does not meet the threshold for sufficient payments or patients through an Advanced APM in order to become a Qualifying APM Participant (QP), thereby being excluded from MIPS, the MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.
Through the QPP tracks of MIPS and APMS, the CMS focus is for independent physicians to be rewarded for providing value-based healthcare that improves patient outcomes.
Greg Miller November 29, 2018Read