Healthcare Technology Featured Article

March 21, 2016

Meaningful Use: Not Entirely Gone But Certainly Not Forgotten

There was high-fiving all around the provider and vendor communities when Andy Slavitt — acting administrator of the Centers for Medicare and Medicaid Services (CMS) — announced plans to phase out the meaningful use (MU) program as we know and love it. Not everyone heard all of that message. Many, in fact, reacted as though the program had a stake through its heart. You could almost hear the popping of champagne corks.  

But a closer look at his remarks shows that CMS is not totally getting rid of the program. What remains is a monster mash up: some MU elements will stay but be combined with new statutory requirements created through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Needless to say, many technical and implementation details have yet to be determined.

What are we to make of this? Here’s the initial take from my team.

Some consider MU a success. On Wednesday, February 3, the National Coordinator for Health Information Technology, Karen DeSalvo, MD, called MU “successful” at the eHealth Initiative 2016 Annual Conference. We can see where she’s coming from. The original goal was to encourage adoption of electronic health records (EHRs), and the EHR incentive component of the landmark American Recovery and Reinvestment Act of 2009 (ARRA) certainly did that. In 2014, three-quarters of office-based physicians had a certified EHR as compared with none in 2010, when ARRA's EHR adoption incentives kicked in. In addition to leading US efforts to leverage technology for better health, Dr. DeSalvo occupies a position from which she can evaluate how the US stacks up against the rest of the world and believes that we've jumped ahead in terms of adoption of EHRs by physicians and hospitals. At the same conference, Steven Stack, MD, president of the American Medical Association, noted that while physicians continue to be frustrated with EHRs, there’s a positive trend toward their liking them.

We’re not surprised by the changes. Mr. Slavitt’s news was not unexpected. Meaningful use was running toward its statutory deadline and maxing out its incentive payment kitty, so we did not think it would be extended. Meanwhile, providers and others had been lobbying CMS and Congress very hard to either kill MU or replace it with something else. The logic was fairly compelling. Although the vast majority of providers are now using EHRs, at last count some 60% of hospitals and 90% of physicians had yet to attest to MU stage 2. And if stage 2 was unattainable, the more prescriptive requirements of stage 3 were perceived as totally beyond the realm of possibility. A significant number of providers are opting out of MU, frustrated by the work-flow challenges posed by regulatory requirements and willing to accept penalties rather than continue. Providers have said enough is enough; MU was adjusted but not killed entirely. 

Provider concerns are only part of the issue, however. A bigger challenge is the sequencing of MACRA on top of the “final” rule for stage 3 and modifications to stage 2. MACRA rolls up CMS’ quality reporting systems into the Merit-Based Incentive Payment System (MIPS). Now parts of the Physician Quality Reporting System, the Value Modifier (or Value-based Payment Modifier) and the Medicare Electronic Health Record incentive program will become components of a single program based on quality, resource use, clinical practice improvement and meaningful use of certified EHR technology.

The result: MACRA ties EHR use to physician payment. Plus, because MACRA has clear elements of MU in it, CMS took the unusual step of asking for another round of comments on the MU3 final rule. Clearly, something needed to be done to get things synced up and simplified.  That seems to be the intent of CMS’ latest actions.

Here’s What We Know. While many details have yet to be determined, there is still a lot we do know. For example:

  • MU isn’t totally gone. Meaningful use will still be around despite agitated suggestions to the contrary in trade press. MACRA still has MU elements; specifically, meaningful use of certified electronic health records (MU of CEHRT), which will base physicians’ Medicare Part B payments in 2019 on 2017 performance. MACRA states that EHR use will account for a quarter of physician performance scoring under the MIPS program. Doctors can receive penalties or bonuses of up to 4% starting in 2019, a number that grows to 9% by 2022, depending on how well they perform on MIPS. The idea is to focus more on quality and less on prescriptive EHR usage. The EHR certification program will survive in some form or another.
  • Penalties could be significant. The failure to achieve MU of CEHRT could cost eligible providers a quarter of their maximum composite MIPS score. This could have a huge impact—far greater than the current payment adjustment under the regular MU program.
  • Bring on the apps. The new program, as yet unnamed, is a push toward supporting a system of loosely coupled, best-of-breed program applications (apps). We’ve heard hints of this approach before, as in the JASON Committee’s report, which was released late in 2014.

So, how will it work? The vision is pretty rosy. For example, physician practices won't need to rip out their EHR because doctors can use an alternative app to document care or review gaps in care. Nurses can use something else that suits their work flow. Focused tools for care managers and other providers and administrators, up to and including management dashboards, are also available. Presumably, all of these apps will connect seamlessly. We remain cautiously optimistic that this rosy vision will come to fruition.

  • The door is opened for customization and innovation. The app approach also will allow for customization and innovation. Providers might even choose their own suite of apps and tools and plug them in to the EHR platform of their current workplace. The same programming interfaces could also allow an innovative vendor to build software to export data from an old system, reducing the cost of migration. This would allow competition between platforms and the ability of users to switch, similar to moving from Apple to Android. Naturally, the big EHR vendors are in a race to see who can bring the most popular platform with the most apps.
  • MU actually did some good. Despite its shortcomings, we agree with Dr. DeSalvo that MU has some good points. It provided $30 billion in funding to push forward EHR adoption in the middle of the nation’s recent financial crisis. That money wouldn’t have been available otherwise and it motivated a good number of providers to purchase EHRs, which they might not have done so otherwise. We didn’t see anybody returning the money.

MU also established a floor of functionality, stimulated the creation of new health IT standards and created a certification system. Thanks to MU, EHRs are here to stay and will increasingly shape how medicine is practiced. Even at the most basic level, medical practices have technology that can document the current status of a patient and run some quality metrics. Implemented properly, EHRs can improve the patient experience and satisfaction. At the same time, they can capture patient and administrative data used to measure quality and outcomes.

  • A practice technology gap still exists. Thanks to MU, large practices now have the tools to increase efficiency and quality and be rewarded for a quality improvement. Small practices continue to be at a disadvantage as a result of a "practice technology gap," which inhibits their ability to use their current technology. This gap is measurable. In fact, the Healthcare Information and Management Systems Society’s analytics group has a technology gap scale that providers can use to determine where they rank.

What We Don’t Know. There’s probably more that we don’t know at this point. We expect implementation details and regulations to dribble out over 2016 and maybe into 2017, if the next administration doesn’t put a hold on things. (Whether the presidency stays in the hands of the Democrats or changes to the Republicans, our experience is that there are always changes.)

  • Which meaningful use measures will survive? Nobody knows. Even the Medicare Payment Advisory Commission (MedPAC) — the federal advisory group on Medicare fiscal issues — said publicly it has no idea what CMS would require for EHR use measures, which would translate into MIPS payments or penalties. Mr. Slavitt gave some hints in his speech, saying CMS would move away from technology use and start rewarding outcomes. He also said providers would be able to customize their goals as opposed to the government dictating what must be done.
  • How many doctors will be subject to MIPS? Those who have a certain percentage of their Medicare payments tied to alternative payment models are excluded from the MIPS program. Who will make the cut is still a large question mark. The MIPS and alternative payment model tracks appeal to different groups of providers for different reasons. And as MedPAC commissioners noted, certain alternative payment models are targeted more squarely at primary care doctors.
  • What about standards? Standards are a major issue to be addressed. The new program will be based on open source. Perhaps using open standards will help make apps portable rather than being locked to a particular platform/system. See the SMART on FHIR (Fast Healthcare Interoperability Resources) app gallery for a glimpse at what things might look like if this approach works. On the other hand, it strikes us that there is still a place for the various transaction and other standards that are now integral parts of EHRs and health data exchange. How will the various health care Standards Development Organizations work in an open-source world? Who will decide?    
  • What about oversight? Regardless of your opinion about them, oversight and governance issues still must be considered. App companies can discontinue or limit availability or features. Terms and conditions of use can change dramatically at any time. Prices can escalate. Companies offering apps can simply go out of business, leaving the user high and dry. The health IT landscape is changing so rapidly that an app that is necessary in today’s world may not be needed tomorrow. In the worst case, what if a patient is harmed as a result of an app failure? The app company could cease to exist in a New York minute, so who will end up dealing with the liability? Somebody needs to be minding the store. Who gets the nod? Or, will we end up with a whole new gaggle of federal advisory groups whose opinions are more than just advisory?
  • What happens in 2017? MIPS is planned to start in 2019 and, like meaningful use, will be based on performances two years prior. That means that whatever EHR measures are included in payment adjustments would come from performance in 2017 (and from 2018, in 2020). This means it is almost impossible for doctors to avoid MU stage 3 because CMS won't be able to replace the program with finalized MIPS measures by the end of 2016. As a result, measures won't be ready to be applied to the first year or two of MIPS.

Will this new program be workable? Will it be better or worse than the devil we know in MU? Will it be enough to win over the “hearts and minds” of providers, as Mr. Slavitt said in his address?  Time will tell.  

Edited by Stefania Viscusi
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