MACRA Targets Meaningful in Meaningful Use

August 3, 2016 ‐ PSQH

Clinicians who participate to a “sufficient extent” in various advanced APMs may be exempt from the MIPS reporting requirements and qualify for incentive payments. Advanced APMs must meet three proposed requirements to earn these payments: 1) use of EHRs, 2) payment for professional services based on acceptable quality measures, and 3) existing as an enhanced medical home or bearing more than nominal risk for financial losses. Such APMs include the Comprehensive Primary Care Plus (CPC+) model, Next Generation ACOs, and other types of programs where clinicians accept both risk and reward for delivering high-quality, patient-centered, coordinated care.

DHHS expects to distribute $500 million in incentive payments in 2019 to eligible clinicians as a consequence of the MIPS program. In addition, the agency estimates the APM incentive program will disburse $200 million in incentive payments.

Impact on health IT

Although the HITECH Act and the meaningful use program delivered on their promise to increase the availability of EHRs to clinicians, the impact of these programs remains controversial. With more than $30 billion spent on incentives, little evidence exists that quality of care improved or costs were reduced. In addition, many physicians report that the use of EHRs reduced their productivity, and patients continue to complain about their struggles to obtain complete medical records.

While some consider the meaningful use program a failure, that viewpoint has overtones of Monday morning quarterbacking. Although the HITECH Act focused on facilitating implementation of EHRs, its inclusion in the broader American Recovery and Reinvestment Act (ARRA) signifies its general purpose: to serve as part of an economic stimulus program focused on helping the U.S. emerge from the deepest recession since the Great Depression.

In addition to improving healthcare delivery through the use of information technology, DHHS needed its meaningful use program to incentivize provider organizations to rapidly deploy EHRs so that the funds devoted to the program would be part of the overall ARRA stimulus effort. This probably explains why meaningful use stage 1 criteria contained relatively simple usage metrics.

As the Office of the National Coordinator for Healthcare Information Technology’s committees worked on meaningful use stage 2, they also scrutinized more valuable metrics focused on quality, safety, and cost savings. Unfortunately, those metrics required much more comprehensive and difficult-to-obtain data elements that greatly increased in complexity when applied across a diverse and disparate delivery system. For example, the data elements, processes, and performance metrics vary widely among internal medicine, obstetrics, and ophthalmology practices.

Focus on interoperability

In retrospect, the meaningful use program should have focused on interoperability and the simple, seamless exchange of clinical information among providers and disciplines. This is a critique of the program as executed, not of the intent of the participants, who represented all stakeholders in the healthcare information technology universe. They put forth their best efforts, irrespective of the current results.

That said, now is the time to correct the program, and MACRA offers that opportunity. By completely refocusing the CMS payment incentives on quality, cost, advancing care information, and clinical practice improvement activities, DHHS targets a less prescriptive and more flexible set of objectives that allows for innovation and flexibility among practices.

To achieve proper reporting of quality and process metrics requires a robust exchange of medical information, regardless of care setting. Only through actual, reliable, and complete interoperability can providers generate the reports necessary to satisfy MACRA reporting requirements and obtain incentive payments.

MACRA offers an opportunity to reboot the meaningful use program and allow it to facilitate what it should have incentivized back in 2009: comprehensive clinical information interoperability. With the value of 20-20 hindsight, let’s hope providers, EHR vendors, and government agencies agree that MACRA offers them a do-over to get the problem of interoperability fixed once and for all. This time, patients are watching carefully.

Barry Chaiken is the president of DocsNetwork Ltd. and has more than 25 years of experience in medical research, epidemiology, clinical information technology, and patient safety. He is board certified in general preventive medicine and public health and is a fellow, and former board member and chair of HIMSS. At DocsNetwork, Chaiken has worked on quality improvement studies, health IT clinical transformation projects, and clinical investigations for the National Institutes of Health, UK National Health Service, and Boston University Medical School. He is currently an adjunct professor of informatics at Boston University’s School of Management. Chaiken may be contacted at bchaiken@docsnetwork.com.