Encore’s eMeasure Research and Review Board (eMRB) provides direction and common perspective on how eMeasures are applied in a value-based reimbursement environment. To help keep others informed and share our knowledge, eMRB provides this high level monthly recap summarizing everything eMeasure-relevant that happened in May.
As you read through this May recap, you will notice a central theme around a new way of thinking about some of those terms that have become “old hand” such as Meaningful Use. The month has been noteworthy; we are embarking on some new territory and we share with you some of our first learnings. You’ll find this under the Watch List section. Under Question of the Month, we provide a clarification on the eCQM programs, and we close with a note to check out our most recent point of view on managing the transition to eMeasures.
Reading time: 15 minutes
Watch List 2016
What have we learned in May?
Since our last monthly update in March, CMS published both of the proposed rules we were expecting in April. Ah – so comfortable the first one, and so complicated the second. Let us review!
Proposed Rules Subject to Change Pending Publication of the Final Rules
1) FY 2017 IPPS Proposed Rule – hospital based
- The FY 2017 Hospital Inpatient Prospective Payment System (IPPS) Proposed Rule (NPRM) was filed on April 18 and published in the Federal Register on April 27, 2016.
- eMRB’s review was posted on our website on April 26, 2016.
- In case you missed it, here is a link to it: Analysis & Summary: Proposed Changes and Implications of FY 2017 eCQM Reporting for CMS Programs
- The proposed rule is in comment period until June 17 and the final rule is scheduled for publication on August 1, 2016.
What are the key implications to hospitals?
- The requirement for eCQM submission is proposed as a full year of data for 15 electronic clinical quality measures (eCQMs), which means hospitals have a limited timeline for making sure their workflow and EHR support reporting of all the proposed eCQMs.
- A lot of the 15 eCQMs are not measures that hospitals have previously had in scope, such as AMI-8 (Acute Myocardial Infarction measure) and PC-01 (Perinatal Care measure).
- The eCQMs that were removed could potentially impact an organization if one of those removed measures was selected to support the Meaningful Use (MU) Clinical Decision Support (CDS) rules objective.
- There is evidence of inconsistency between abstract values and values reported in the Quality Reporting Document Architecture (QRDA) files; this will require time and resources to assess and optimize an organization’s EHR and associated workflows in order to improve their eCQM measure performance. For more on this topic, see the Announcements section below where you can link to Encore’s recent point of view, Managing the Transition to Electronic Clinical Quality Measures.
Now we move on to the second proposed rule that is turning our world around.
2) Medicare Program MIPS and APMs Incentive Proposed Rule – physician based
- The Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models Proposed Rule was filed on April 27, 2016 and published in the Federal Register on May 9, 2016. For our initial review, we used the Pre-publication version.
- This is the first annual proposed rule under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation.
- The provisions in this proposed rule would be effective beginning on January 1, 2017 and they would require a full reporting year.
- The proposed rule is in comment period until June 27, 2016 and the final rule is scheduled for publication by November 1, 2016.
What is this rule proposing?
- Remember when CMS first published the American Recovery and Reinvestment Act of 2009 (ARRA)? And that introduced us to Meaningful Use (MU) or the EHR Incentive Programs for both Medicare and Medicaid.
- Now, this new CMS proposed rule, which stems from the MACRA legislation, is introducing us to a new Quality Payment Program (QPP) for Medicare providers.
- The MACRA legislation (Medicare Access and CHIP Reauthorization Act of 2015) was signed into law on April 16, 2015. It is the Act that identifies the objectives and measures of the MIPS program, just as the Meaningful Use rules specify the objectives of the EHR Incentive program that was legislated by ARRA.
- This new program, replaces the Sustainable Growth Rate (SGR) formula by paying clinicians for the value and quality of care they provide.
- The Quality Payment Program has two paths. One path is the Merit-Based Incentive Payment System (MIPS) program; the other is Advanced Alternative Payment Models (APMs).
- Did you notice that we said paying clinicians rather than eligible professionals (EPs)? CMS has introduced a new term applicable to the Quality Payment Program and that is Eligible Clinician (EC), which now includes physicians, physician assistants, nurse practitioners, clinical nurse specialists, and nurse anesthetists.
- But don’t erase EP from your memory. EP Meaningful Use for Medicaid is still intact. The Quality Payment Program only impacts Medicare providers.
- With the QPP MIPS path, CMS is proposing to consolidate components of three existing physician-based programs: the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals (EPs).
- They have proposed four performance categories for the MIPS path. Here’s how they align.
- The Quality performance category replaces PQRS and the clinical quality measures of the Meaningful Use Program.
- The Resource Use performance category replaces the cost component of the VM Program and performance would be calculated using administrative claims data.
- The Clinical Practice Improvement Activities (CPIA) performance category is new. Eligible Clinicians (ECs) will be rewarded for activities such as care coordination, beneficiary engagement and patient safety.
- The Advancing Care Information (ACI) category replaces the non-quality objectives and measures (formerly known as Core and Menu measures) in the Medicare EHR Incentive Program, or Meaningful Use (MU) for EPs. Requirements for the ACI performance category continue to support the foundational objectives of the Health Information Technology for Economic and Clinical Health (HITECH) Act (that was part of ARRA), health information exchange and patient engagement, which align with the modified Stage 2 and Stage 3 measures.
- So with the QPP as proposed, we would no longer have EP MU (except for EP MU Medicaid) or PQRS or VM. We would have ECs participating in the QPP and being paid for value based on their performance through claims data, quality measures, a CPIA activity, and a tiered scoring of ACI objectives and measures.
- Under ACI – Advancing Care Information – one proposal would eliminate the requirement for two objectives and measures that were finalized in the EHR Incentive Program Stage 3 and Modifications Final Rule of October 2015: Clinical Decision Support (CDS) and Computerized Provider Order Entry (CPOE). In addition, the requirements for Public Health Reporting are proposed to be reduced, with the requirement for Immunization reporting remaining as the only required measure.
- The Quality Payment Program will start with all ECs participating in the MIPS path in 2017. The 2017 results will be used to calculate payment adjustments, positive or negative, in 2019. For 2017 and 2018, payment adjustments will continue to depend on participation and performance in the current MU, PQRS, and VM programs based on data submitted in 2015 and 2016, respectively.
We’re resting here…
- This proposed rule is very complicated. It combines the three separate programs. It doesn’t change the hospital meaningful use requirements and it doesn’t change the Medicaid meaningful use requirements. And it introduces several new terms.
- We will be publishing more InfoAlerts on this rule, but for this month, your take away is to recognize the new program (QPP), and that meaningful use for EPs is referred to under this program as Advancing Care Information (ACI) for Eligible Clinicians (ECs).
- If you need a good source to reference, CMS has been hosting several great Webinars of which you can link to them through the new Quality Payment Program website and the QPP Webinar page.
This leads to the next subject and that is…
What about Meaningful Use?
3) What happened to Meaningful Use Stage 3? What do we know…
- In October 2015, CMS published a final rule covering the Medicare and Medicaid Programs: Electronic Health Record Incentive Program — Stage 3 and Modifications to Meaningful Use in 2015 through 2017.
- The catch was, they identified it as a final rule with comment period for the Meaningful Use Stage 3 provisions. Many are wondering if the Stage 3 objectives and measures are finalized.
Here’s what we can provide.
- The CMS 2016 Program Requirements web page identifies the October 2015 final rule’s provisions for Stage 3 in 2018. It states that:
- In October 2015, CMS released a final rule that specifies criteria that eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) must meet in order to participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The final rule’s provisions encompass 2015 through 2017 (Modified Stage 2) as well as Stage 3 in 2018 and beyond.
- The final rule from October 2015 stated this:
- Public comments received may be considered as we plan for the incorporation of meaningful use into MIPS, and any policies developed would be addressed in future rulemaking.
Stage 3 Status: Subsequent to the October 2015 final rule, we have seen two proposed “future rule” makings. The FY 2017 Hospital Inpatient Prospective Payment System (IPPS) proposed rule did not propose changes to MU Stage 3 provisions for eligible hospitals, but the MIPS and APMs proposed rule did propose modifications for the eligible clinicians (ECs). Using the term Stage 3 is now a bit more complex with the MACRA proposed rule and its incorporation into the QPP MIPS program, which separates it from the EHR Incentive Program. The QPP (Quality Payment Program) modified the requirements for ECs participating in ACI (Advancing Care Information) performance improvement category; but, the requirements are based on the same objectives and measures (except for CDS and CPOE). However, CMS did not change the MU requirements for eligible hospitals (EHs), critical access hospitals (CAHs), or EPs participating in Medicaid MU. Based on the final rule with comment period, the MU Stage 3 objectives and measures are as they were documented in the October ruling.
Bottom line, the requirements for Modified Stage 2 and Stage 3 for 2017 and 2018 were finalized in October 2015. Providers can either submit Modified Stage 2 or Stage 3 in 2017, but in 2018, Stage 3 is required. The MACRA legislation and the MIPS and APMs proposed rule would change how ECs will participate in the new QPP Medicare meaningful use/Advancing Care Information requirements, but leaves the MU requirements for Hospitals intact.
For more on the Stage 3 provisions, you may want to revisit the eMRB InfoAlert published on October 14, 2015: eMRB InfoAlert: Highlights and Takeaways from CMS and ONC Final Rules.
Question of the Month
eMeasure Research and Review Board’s Question of the month…
Observation: We noticed in our review of the FY 2017 IPPS Proposed Rule, that CMS made an inconsistent statement on which version of the CQM electronic specifications would be required for reporting in 2017. We submitted an inquiry to the QualityNet support team and below, we provide their response.
The impact: It would be most concerning to report in 2017 the measures being released in the spring of 2017. In the past, “most recent version” meant the version released the year prior to the reporting period, meaning the April 2016 release would be used for 2017. It isn’t feasible for vendors to develop and hospitals to remediate EHR build and workflows for measures released only 7-9 months prior to the end of the reporting year. This basically means the versions of the CQMs released this Spring in April could only be used for attestation purposes, but vendors would have no incentive to develop them (or hospitals to remediate to them) since they could continue using an older version for attesting. And also concerning is that vendors and hospitals can’t really wait another 4 months for the final rule to determine what to do with the April 2016 specifications.
The text in question from the proposed rule: “We are proposing to continue our policy that electronic submission of CQMs will require the use of the most recent version of the CQM electronic specification for each CQM to which the EHR is certified. In the event that an eligible hospital or CAH has certified EHR technology that is certified to the 2014 Edition and not certified to all 16 CQMs that would be available for reporting in 2017 under our proposals, we are proposing to require that an eligible hospital or CAH would need to have its EHR technology certified to all such CQMs in order to meet the reporting requirements for 2017. For electronic reporting in 2017, this means eligible hospitals and CAHs would be required to use the Spring 2017 version of the CQM electronic specifications available on the eCQI Resource Center Web page (https://ecqi.healthit.gov/).” (Reference pages 1226 and 1227 in the pre-publication version.)
We sought clarification on the statement: “use the Spring 2017 version of the CQM electronic specifications” as it conflicts with the first statement stating that CMS proposes to continue the policy to use the most recent version of the CQM electronic specification for each CQM. If continuing with the current policy, for eCQM reporting in 2017, hospitals would use the 2016 version of the CQM electronic specifications that were published in April of 2016 (Spring 2016).
The response: QualityNet responded that, unfortunately, they were unable to interpret the Proposed Rule due to it being in comment period. However, they pointed us to the eCQM Library and the eCQI Resource Center which indicates in the version headers, the eCQM measures needed for the reporting year based on the reporting period.
Here is the header information showing that the April 2016 version of the eCQM specifications would be the correct version for reporting in 2017.
As shown on the eCQM Library page:
eCQMs for Eligible Hospitals and Critical Access Hospitals
eCQMs for eReporting for the 2017 Reporting Period (as of April 2016)
An Encore Point of View — Managing the Transition to Electronic Clinical Quality Measures
Encore’s recent point of view published on our website covers clinical measures from abstraction to the eCQM counterparts. It talks about the eCQM specifications and the Certified EHR Technology (CEHRT) functionality needed to support eCQM calculation and reporting, and the differences between abstracted measures and eCQMs. It identifies the risk areas, the required capabilities, the data governance, and the programmatic approach fundamental to eCQM reporting. Given the increase in value-based contracts and government programs, it is essential organizations understand, monitor and improve performance levels of eCQMs, and this paper is a great read on what it takes to adjust workflow and capture all the data required for reporting eCQMs appropriately.
Here’s a link: Managing the Transition to Electronic Clinical Quality Measures. An Encore Point of View by Randy L. Thomas, FHIMSS, Managing Director for Value Realization & Performance Analytics, Liz Richard, MBA, MHS, Managing Director for Value Realization Solutions, and Sophia Batallas, MSN, RN, Associate Director, Value Realization Solutions. May 2016.
Advancing Care Information (ACI); Alternative Payment Model (APM); American Hospital Association (AHA); Calendar Year (CY); Centers for Medicare and Medicaid Services (CMS); Certified EHR Technology (CEHRT); Clinical Practice Improvement Activities (CPIA); Critical Access Hospital(CAH); Electronic Clinical Quality Measures (eCQMs); Electronic Health Record (EHR); Eligible Clinicians (EC); Eligible Hospital (EH); Eligible Professional (EP); eMeasure Research and Review Board (eMRB); Fiscal Year (FY); Hospital Inpatient Quality Reporting Program (IQR); Inpatient Prospective Payment System (IPPS); Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA); Medicare Electronic Health Record (EHR) Incentive Program / Meaningful Use (MU); Merit-based Incentive Payment System (MIPS); Notice of Proposed Rule Making (NPRM); Office of the National Coordinator for Health Information Technology (ONC); Quality Payment Program (QPP); Quality Reporting Document Architecture (QRDA); U.S. Department of Health and Human Services (HHS).
To read previous versions of the eMeasures News You Can Use, you can locate them on Encore’s Website under the Press Room.
Points of view and interpretation were relevant at time of authorship; however, they are subject to change over time.
Points of view and interpretation were relevant at time of authorship; however, they are subject to change over time.
Encore’s eMeasure Research and Review Board (eMRB) is made up of Encore’s industry thought leaders and eMeasure experts who are responsible for understanding the current state and future direction of quality and value-based programs for our business. In order to communicate relevant information to our consultants and our clients, eMRB produces periodic InfoAlerts, which provide information on recent and important news.
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