Click to edit Master title style Meaningful Use: Past, Present and Future Bruce Maki, MA M-CEITA / Altarum Institute Regulatory Analyst and Project Manager 8/24/2016 1 1
Agenda Overview of M-CEITA Meaningful Use Where have we been? Where are we now? Where are we headed? Questions and Answers 2
Who is M-CEITA? Michigan Center for Effective Information Technology Adoption (M-CEITA) One of 62 ONC Regional Extension Centers (REC) originally funded to provide education & technical assistance to primary care providers across the country Founded as part of the HITECH Act to accelerate the adoption, implementation, and effective use of electronic health records (EHR), e.g. 90-days of MU Originally Funded by ARRA of 2009 (Stimulus Plan) Purpose: support the Triple Aim by achieving 5 overall performance goals THE TRIPLE AIM Improve patient experience Improve population health 3Reduce costs Improve Quality, Safety & Efficiency Engage Patients & Families Performance Measurement Improve Care Coordination Improve Population And Public Health Meaningful Use Ensure Privacy And Security Protections Certified Technology Infrastructure 3
M-CEITA Services Meaningful Use Support Technical assistance, including workflow redesign, security risk assessment and MU compliance. (e.g. patient portal and clinical quality measures) Security Risk Assessment Support meeting the requirements of MU Measure: Protect Electronic Health Information, including an assessment using our exclusive tool. Audit Preparation A review of Meaningful Use attestation documentation using our exclusive Audit File Checklist to correct any issues before completing the process. Targeted Process Optimization (Lean) A workflow analysis and redesign of core processes using Lean principles to increase efficiency and reduce duplication. (e.g. chart prep, document management, test tracking, revenue cycle, etc.) PQRS Support Technical Assistance for the Physician Quality Reporting System including measure selection as well as reporting method selection and assistance. GLPTN - Great Lakes Practice Transformation Network No cost Technical Assistance to eligible providers in support of quality improvement initiatives, PQRS support, and preparing for upcoming advanced payment model changes under MACRA/MIPS. 4
The Past A Brief History of Meaningful Use 5
Healthcare s Shifting Paradigm Role Changing Paradigm Healthcare Combating Illness Improving Wellness Physicians Directors of Care Collaborators in Care Patients Passive Recipients Active Participants Health Information Siloed and Episodic Integrated and Longitudinal Health IT Supporting Tasks Enhancing Understanding This paradigm shift requires significant investments, innovative people and extensible tools. 6
HITECH Act: Transformation Catalyst Health Information Technology for Economic and Clinical Health Act Paper Records HITECH Act HIT & HIE Pre 2009 2009 2014 A system plagued by inefficiencies EHR Incentive Programs and 62 Regional Extension Centers (RECs) Widespread adoption and meaningful use of HIT 7
Meaningful Use as defined by CMS Meaningful Use is using certified electronic health record (EHR) technology to: Improve quality, safety, efficiency, and reduce health disparities Engage patients and families Improve care coordination and population and public health Maintain privacy and security of patient health information Ultimately, it is hoped that Meaningful Use compliance will result in: Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health systems 8
Meaningful Use: A path to better outcomes and quality Stage 2 Advanced clinical processes Stage 3 Improved outcomes Stage 1 Data capture and sharing Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health systems For more information on meaningful use of EHRs, visit: http://www.cms.gov/ehrincentiveprograms/35_meaningful_use.asp 9
2013 MU Stage 1 Summary of Measures 15 Core Measures (EPs must meet all) 1 CPOE for medications (entered into the electronic record) 30% 2 Drug-drug and drug-allergy interaction checks (enable only) YES 3 Problem list of current & active diagnoses 80% 4 E-Prescribing (transmission to pharmacy) 40% 5 Active medication list 80% 6 Active medication allergy list 80% 7 Demographics recorded as structured data 50% 8 Record/chart changes in vitals (height, weight and blood pressure, etc.) 50% 9 Record smoking status as structured data, 13+ years old 50% 10 Clinical Quality Measures (CQM) YES 11 Implement (1) clinical decision support rule YES 12 Electronic copy of patient health information, upon request w/in 3 days 50% 13 Clinical Summaries, within 3 business days 50% 14 Electronic exchange of key clinical information among providers of care YES 15 Protect electronic health information (SRA) YES 10
2013 MU Stage 1 Summary of Measures 10 Menu Measures (EPs must meet 5 of 10) 1 Drug Formulary Checks implemented (enable only) YES 2 Clinical lab test results (as structured data) 40% 3 Patient lists (by specific condition) YES 4 Patient reminders (65+ years, and < 5 years) 20% 5 Patient electronic access (patient portal) 10% 6 Patient-specific education resources 10% 7 Medication reconciliation 50% 8 Transition of care summary 50% 9 Immunization registries data submission YES 10 Syndromic Surveillance data submission YES *Public health objective: At least one public health objective must be selected. 11
The Present Modified Stage 2 12
Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 3 and Modifications to Meaningful Use in 2015 Through 2017 Final Rule with Comment Period (aka Modified Stage 2 / Stage 3 Final Rule) Released: October 6, 2015 Published: October 16, 2015 Effective: December 15, 2015 13
Key changes in the Modified Stage 2 Rule Stage 1 and Stage 2 objectives and measures restructured to align with Stage 3 Streamlined the program by removing redundant, duplicative, and topped out (RDT) measures One set of objectives and measures for all participants Patient engagement objectives that require patient action were modified Limited accommodations for Scheduled Stage 1 EPs in 2016 (CPOE) Significant changes to the Public Health objective Optional Alternate Exclusions added to Public Health (2015-2016) No proof of intent/documentation required to claim Alt Exclusions 14
Meaningful Use Reporting Periods 2016 New Participants: Any continuous 90 days within the Calendar Year (CY) Returning Participants: Full Calendar Year (366 days) NPRM (notice of proposed rule making) will likely reduce this to 90 days. Final Rule due by Nov 1 2017 New Participants: Any continuous 90 days within the CY Providers electing Stage 3: Any continuous 90 days within the CY (requires 2015 CEHRT) Returning Participants: Full Calendar Year (365 days) 15
Measures removed under Modified Stage 2 ( but Still Meaningful ) 16
Modified Stage 2 Meaningful Use Objectives: 1. Protect Patient Health Information (SRA) Not Episodic, should cover entire program year Conduct within same CY as reporting period, acceptable to be conducted outside of reporting period if reporting period is < CY but must be conducted prior to attestation 2. Clinical Decision Support (CDS) (2 measures) Implement CDS Interventions Implement Interaction Checks 3. Computerized Provider Order Entry (CPOE) (3 measures) Medication Orders Laboratory Orders** Radiology Orders** ** EPs scheduled to be in Stage 1 in 2016 are not required to report on Lab and Radiology orders, only Medication orders 17
Modified Stage 2 MU Objectives (cont d): 4. Electronic Prescribing (erx) 5. Health Information Exchange (formerly Summary of Care) 6. Patient Specific Education 7. Medication Reconciliation 8. Patient Electronic Access (VDT/Pt Portal) (2 measures) Timely Access Usage 9. Secure Electronic Messaging 10. Public Health Reporting (3 measures) Immunization Registry Syndromic Surveillance Registry Specialized Registry 18
Meaningful Use Progression for EPs 2011-2013 2014 2015-2017 2018 Stage 1 15 Core 5 Menu 6 CQMs Stage 1 13 Core 5 Menu 9 CQMs Stage 2 17 Core 3 Menu 9 CQMs Modified Stage 2 10 Objectives 9 CQMs Stage 3 Optional: 2017 8 Objectives, some with lowered thresholds Stage 3 8 Objectives CQM reporting is required by regulations; Medicare rulemaking to address reporting requirements 19
The Future STAGE 3 or MACRA/MIPS/APM or both! 20
Meaningful Use Stage 3 Modified Stage 2 Crosswalk to Stage 3 Objectives Modified Stage 2 Stage 3 (2018)* SRA Conduct or Review during CY and prior to attestation including addressing encryption/security of data created or maintained in CEHRT Medications > 60% > 60% CPOE Labs > 30% > 60% Radiology > 30% > 60% erx > 50% of all permissible prescriptions are queried for a drug formulary AND transmitted electronically > 60% of all permissible prescriptions are queried for a drug formulary AND transmitted electronically Clinical Decision Support Rules Interactions 5 Enabled for Entire Reporting Period (RP) Enabled for Entire Reporting Period (RP) 21
Meaningful Use Stage 3 (cont d) Objectives Modified Stage 2 Stage 3 (2018)* Patient Education > 10% Incorporated into Patient Electronic Access View, Download and Transmit (VDT) Access > 50% w/in 4 days Incorporated into Patient Electronic Access Usage > 5% Incorporated into Coordination of Care through Patient Engagement Patient Electronic Access Access Patient Education N/A Secure Messaging > 5% > 80% of all unique patients are provided timely access to VDT their health information AND ensure health information is available for the patient to access using any application of their choice that is configured to meet the technical specifications of the API in the EPs CEHRT For > 35% of unique patients, CEHRT is used to identify educational resources to which electronic access is provided Incorporated into Coordination of Care through Patient Engagement 22
Meaningful Use Stage 3 (cont d) Coordination of Care through Patient Engagement Objectives Modified Stage 2 Stage 3 (2018)* VDT Secure Messaging Patient Generated Health Data N/A > 10% of unique patients engage with EHR by either 1) VDT health information or 2) access health information via an API or 3) a combination of both > 25% of unique patients, or in response to a secure message sent by patient > 5% of unique patients incorporate non-clinical setting data into the CEHRT Medication Reconciliation > 50% Incorporated into Health Information Exchange 23
Meaningful Use Stage 3 (cont d) Objectives Modified Stage 2 Stage 3 (2018)* Provide SoC Electronically Use CEHRT to create a SoC AND transmit electronically for > 10% of ToCs Use CEHRT to create a SoC AND transmit electronically for > 50% of ToCs Health Information Exchange Receive or Retrieve SoC N/A EP receives or retrieves a SoC for > 40% of ToCs in which the EP has never encountered the patient AND incorporates it into the patient s CEHRT record Reconciliation of Clinical Information N/A Perform a reconciliation of clinical information for > 80% of transitions/referrals or for patient encounters in which the EP has never encountered the patient 24
Meaningful Use Stage 3 (cont d) Objectives Modified Stage 2 Stage 3 (2018)* Imms Registry Syndromic Surveillance Actively Engaged w/2 of 3 Specialized Registry Public Health Electronic Case Reporting N/A Actively Engaged w/3 of 5 PH Registry Reporting Clinical Data Registry Reporting Included as Specialized Registry * As Stage 3 is optional in 2017, some measure thresholds have been reduced to allow early adopters ease in transitioning to the 2018 Stage 3 required thresholds 25
MACRA: Paying for Value and Quality 26
MACRA: What is it? Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). [AKA Doc Fix bill] Bipartisan legislation (yes, really) that replaced the flawed Sustainable Growth Rate (SGR) formula by paying clinicians for the value and quality of care they provide MACRA is more predictable than SGR. It will increase the number of physicians participating in alternative payment models, with those in high quality, efficient practices benefiting financially Extends funding for Children s Health Insurance Program (CHIP) for two years MANY of the details have yet to be determined, and there were several areas where feedback was sought from the health care community And introduces 27
Two Paths to Payment Reform Merit-based Incentive Payment System (MIPS) Payment rates in 2019 will be maintained through 2025 but with + / - adjustments based on the composite performance score of each eligible physician or other health professional on a 0-100 point scale based on four performance measures (more to come on the measures). Incentives: More to come on that too Alternative Payment Model (APM) Clinicians who receive a substantial portion of their revenues (at least 25% of Medicare revenue in 2018-2019 and threshold will increase over time) from qualifying alternative payment mechanisms will not be subject to MIPS. Incentives: They will receive a 5% bonus each year from 2019 to 2024 (based on aggregate payments from Medicare for the preceding year). 28
The Quality Payment Program Part of a broader push towards VALUE and QUALITY 29
CMS Framework for Alternative Payment Models (APMs) 30
MACRA s Long-term Aim Note: Size of bubble indicates overall investment in each category of APM Over time, APMs will move up the Y-axis and there will be more investment in the higher categories *Source: CPR 2014 National Scorecard on Payment Reform, based on the National commercial market using 2013 data. 31
Path 1: Merit-Based Incentive Payment System What is MIPS? Combines multiple Medicare Part B quality reporting programs into a single program This new, single program is based on: Quality (PQRS/VM-Quality Program) Resource Use (Cost) (VM-Cost Program) Advancing Care Information (Medicare MU) Clinical Practice Improvement (new category) *MACRA does not alter or end the Medicaid EHR Incentive Program 32
Merit-Based Incentive Payment System MIPS payment adjustments based on Composite Performance Score (CPS) increasing from +/- 4% in 2019 to +/- 9% in 2022 and later* Budget neutral unless an exception applies Additional funding for positive adjustments for exceptional performance (2019 2024) Incentive payments for certain eligible clinicians (ECs) who participate in Alternative Payment Models (APMs) Higher update rate for qualifying APM participants (QPs) beginning in 2026 *Note: The upward adjustment may differ somewhat since it is scaled to achieve budget neutrality 33
MIPS Performance Categories A MIPS Composite Score (CPS) will be calculated based on the performance of 4 weighted categories: Resource Use 10% Clinical Practice Improvement Activities 15% Advancing Care Information 25% Quality 50% 34
Advancing Care Information MIPS Advancing Care Information Objectives and Measures Objective Protect Patient Health Information Electronic Prescribing Patient Electronic Access Coordination of Care Through Patient Engagement Measure Security Risk Analysis eprescribing Patient Access Patient-Specific Education View, Download and Transmit (VDT) Secure Messaging Patient-Generated Health Data Health Information Exchange Exchange Information with Other Physicians or Clinicians Exchange Information with Patients Clinical Information Reconciliation Immunization Registry Reporting Public Health and Clinical Data Registry Reporting (Optional) Syndromic Surveillance Reporting (Optional) Electronic Case Reporting (Optional) Public Health Registry Reporting (Optional) Clinical Data Registry Reporting 35
MIPS Composite Performance Score: Weights may be adjusted if there are not sufficient measures and activities applicable for each provider type, including assigning a scoring weight of 0 for a performance category ACI (aka MU) weighting can be decreased and shifted to other categories if Secretary estimates the proportion of physicians who are meaningful EHR users is 75% or greater (statutory floor for ACI weight is 15%) Performance threshold will be established based on the mean or median of the composite performance scores during a prior period (Yrs 1 and 2 HHS Secretary will establish threshold) Those who score below the threshold will see negative payment adjustments, those who score above it will see positive adjustments 36
Payment Adjustments MIPS - Incentives and Penalties Adjustments applied 2 years after performance year (e.g. 2019 payment adjustment is based on 2017 performance year) Performance threshold is mean or median of the composite score for all MIPS providers (except in first 2 years where Secretary will set) Linear payment adjustment based on composite score, as compared to performance threshold (may be +, - or =) If you score in the lowest quartile of providers, you will automatically be adjusted down to the maximum penalty Higher scores receive proportionally larger incentive payments, up to three times the maximum positive adjustment for the year (4% x 3 = 12% in 2019) Highest performers are eligible for an exceptional performance bonus Additional payment adjustment of +10% for MIPS providers exceeding the 25 th percentile of all MIPS scores above the performance threshold (through 2024) 37
MIPS Incentive Payment Formula MIPS Incentives and Penalties *MACRA allows potential 3x upward adjustment which will be used to maintain budget neutrality 38
Alternative Payment Models The other fork in the path to Quality Payments 39
Alternative Payment Models (APMs) What are they? Alternative Payment Model or APM is a generic term describing a payment model in which providers take responsibility for cost and quality performance and receive payments to support the services and activities designed to achieve high value According to MACRA, APMs include: Medicare Shared Savings Program (MSSP) ACOs Demonstrations under the Health Care Quality Demonstration Program CMS Innovation Center Models Demonstrations required by Federal Law (i.e. door is open for others to form) MACRA does not change how any particular APM pays for medical care and rewards value APM participants may receive favorable scoring under certain MIPS performance categories Only some of these APMs are Advanced APMs 40
ADVANCED APMs Advanced APMs offer greater potential inherent risks and rewards than MIPS Under MACRA, qualifying APM participants in eligible APMs: Are exempt from MIPS Receive annual 5% lump sum bonus payments from 2019-2024 Receive a higher fee schedule update for 2026 and onward (.25% or.75%) 41
Proposed Financial Risk Criterion Narrows Current Options 42
Volume Thresholds for Advanced APMs A qualifying APM is one that meets increasing thresholds for the percentage of charges that pass through the APMs methodology An individual Eligible Clinician (EC) in a qualifying APM is a Qualified APM Participant or QP QP status is awarded to all advanced APM participants collectively (or to none as the case may be) What if the threshold for QP status is not met? If ECs advanced APM does not meet the volume threshold to qualify it s members for QP status, members are considered Partially Qualifying If an individual EC chooses to stay in the APM track, s/he will not receive the 5% bonus, but also will not be subject to MIPS If EC chooses, s/he can report MIPS measures and participate in the MIPS incentive track 43
Note: At first, most clinicians will be subject to MIPS 44
What path do I take in the Quality Payment Program? 45
TIMELINE 46
Resources Modified Stage 2 Final Rule: http://federalregister.gov/a/2015-25595 MIPS/APM Proposed Rule: https://s3.amazonaws.com/publicinspection.federalregister.gov/2016-10032.pdf 2016 Tipsheet: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_EP WhatYouNeedtoKnowfor2016.pdf Modified Stage 2 Tipsheet: https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage3Ov erview2015_2017.pdf 2016 Program Requirements and Tools https://www.cms.gov/regulations-and- Guidance/Legislation/EHRIncentivePrograms/2016ProgramRequire ments.html 47
Questions? www.mceita.org Bruce Maki bruce.maki@altarum.org 734-302-4744 48