The CY 2017 OPPS Proposed Rule brings an awaited response to the October 2015 EHR Incentive Programs Final Rule with comment period

eMRB InfoAlert - The CY 2017 OPPS Proposed Rule brings an awaited response to the October 2015 EHR Incentive Programs Final Rule with comment period

Description:  CMS is proposing changes to the EHR Incentive Program measures for Modified Stage 2 and Stage 3 measures and reporting requirements.  This InfoAlert provides a summary of the proposed changes.

Background

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. This final rule was with comment period for certain provisions and CMS stated that comments received may be considered as they plan for the incorporation of meaningful use into the Merit-based Incentive Payment System (MIPS), and any policies developed would be addressed in future rulemaking.

The May 2016 MIPS and APMs Proposed Rule brought changes to physician-based Medicare Meaningful Use, which CMS covers under the Advancing Care Information performance category for eligible clinicians (ECs). That rule did not address eligible hospital (EH) or eligible professional (EP) Medicaid participation in Meaningful Use, and the proposed requirements differed from the requirements of Meaningful Use for eligible hospitals, critical access hospitals (CAHs), and Medicaid participants.

On July 6, 2016, CMS filed its annual Hospital Outpatient Prospective Payment System (OPPS) proposed rule, and this rule includes proposed changes to the Medicare EHR Incentive Program for eligible hospitals.  However, it does not propose any changes to the Medicaid EHR Incentive Program.

Proposed Changes to the EHR Incentive Program

In this latest rule (CY 2017 OPPS Proposed Rule), CMS is proposing changes to the Modified Stage 2 and Stage 3 measures and also the reporting requirements for 2016, 2017, and 2018.  The changes support better alignment between the EP and hospital EHR reporting requirements.  If the OPPS and the MIPS and APMs proposed rules were to be finalized, the meaningful use requirements for eligible hospitals and CAHs, and the proposed MIPS advancing care information performance category requirements for eligible clinicians would be closer aligned.

Below is a summary of the proposed changes, subject to change with publication of the above mentioned final rules due out in November 2016.  Comments to the CY 2017 OPPS proposed rule are due by September 6, 2016 and the final rule is scheduled to be published in November 2016; comments to the MIPS and APMs proposed rule were due on June 27, 2016 and that final rule is expected to be published by November 1, 2016.

Highlights

In brief, CMS is proposing to:

• Change the EHR reporting period in 2016 to any continuous 90-day period within the calendar year (CY) of January 1 andDecember 31, 2016.
• Eliminate the Clinical Decision Support (CDS) and Computerized Provider Order Entry (CPOE) objectives and measures.
• Reduce the thresholds for a subset of the objectives and measures.
• Require first time attesters in 2017 to attest to the Modified Stage 2 objectives and measures.
• Establish a one-time significant hardship exception from the 2018 payment adjustment for certain EPs who are new participants in the EHR Incentive Program in 2017 and are transitioning to MIPS in 2017.
• Change the policy on measure calculations for actions outside the EHR reporting period.

Key Proposed Changes

In more detail, below are specifics about the proposed changes.  Page references are to the pre-publication version of the CY 2017 OPPS proposed rule.

C – Proposed Revisions to Objectives and Measures for Eligible Hospitals and CAHs (reference page 586)

1 – Removal of the Clinical Decision Support (CDS) and Computerized Provider Order Entry (CPOE) Objectives and Measures for Eligible Hospitals and CAHs

• CMS is proposing to eliminate the CDS and CPOE objectives and associated measures for eligible hospitals and CAHs attesting under the Medicare EHR Incentive Program beginning with the EHR reporting period in CY 2017.
• This proposal would not apply to eligible hospitals and CAHs attesting under a State’s Medicaid EHR Incentive Program.
• Eligible hospitals and CAHs may continue to independently measure and track activities related to the CDS and CPOE objectives and measures for their own quality improvement goals as the Certified EHR Technology (CEHRT) functionality will continue as part of the 2015 Edition of CEHRT, even though the objectives and measures would no longer be required.

2 – Proposed Reduction of Measure Thresholds for Eligible Hospitals and CAHs for 2017 and 2018

• CMS is proposing to reduce a subset of the thresholds for eligible hospitals and CAHs attesting under the Medicare EHR Incentive Program for EHR reporting periods in CY 2017 for Modified Stage 2 and in CY 2017 and 2018 for Stage 3.
• CMS is proposing to update the measures for EPs, eligible hospitals and CAHs with a new naming convention to align with the measure nomenclature proposed for the MIPS.  Rather than referencing a measure as measure 1 or measure 2, the measure names are specific to the measure.  For example, the Patient Electronic Access objective measure 1 would be called Patient Access Measure, and measure 2, would be called View, Download, Transmit (VDT) measure.
• This proposal would not apply to eligible hospitals and CAHs attesting under a State’s Medicaid EHR.

Proposed Changes to the Objectives and Measures for Modified Stage 2

• The proposed modifications to the meaningful use objectives and measures would be applicable only to eligible hospitals and CAHs attesting under the Medicare EHR Incentive Program for an EHR reporting period in CY 2017.
• CMS is proposing to reduce the threshold for the Patient Electronic Access, View Download Transmit (VDT) Measure from more than 5 percent to at least one patient.
• With the proposed elimination of the CDS and CPOE objectives and measures, there is a proposed list of 7 objectives and 10 measures for Modified Stage 2.

Proposed Changes to the Objectives and Measures for Stage 3 in 2017 and 2018

• CMS is proposing to modify a subset of the Stage 3 measure thresholds.
• The proposed modifications would apply to eligible hospitals and CAHs attesting under the Medicare EHR Incentive Program.
• The proposed modifications would not apply to eligible hospitals and CAHs attesting under a State’s Medicaid EHR Incentive Program.
• CMS is proposing to modify the following objectives and measures:
  • For the Patient Electronic Access to Health Information objective, CMS is proposing to reduce the threshold:
    • For the Patient Access measure from more than 80 percent to more than 50 percent.
    • For the Patient-Specific Education measure from more than 35 percent to more 10 percent.
  • For the Coordination of Care Through Patient Engagement objective, CMS is proposing to:

• Maintain that providers must attest to the numerator and denominator for all three measures, but would only be required to successfully meet the threshold for two of the three measures.
• Reduce the threshold of the View, Download Transmit (VDT) measure from more than 5 percent to at least one patient.
• Reduce the threshold of the Secure Messaging measure from more than 25 percent to more than 5 percent.
• For the Health Information Exchange (HIE) objective, CMS is proposing to:

• Maintain that providers must attest to the numerator and denominator for all three measures, but would only be required to successfully meet the threshold for two of the three measures.
• Reduce the threshold for the Patient Care Record Exchange measure from more than 50 percent to more than 10 percent.
• Reduce the threshold for the Request/Accept Patient Care Record measure from more than 40 percent to more than 10 percent.
• Reduce the threshold for the Clinical Information Reconciliation measure from more than 80 percent to more than 50 percent.
• For the Public Health and Clinical Data Registry Reporting objective, CMS is proposing to:
  • Reduce the reporting requirement for Public Health and Clinical Data Registry Reporting from any combination of six measures to align with the Modified Stage 2 requirement of any combination of three measures.
• With the proposed elimination of the CDS and CPOE objectives and measures, there is a proposed list of 6 objectives and 13 measures for Stage 3.

D – Proposed Revisions to the EHR Reporting Period in 2016 for EPs, Eligible Hospitals and CAHs (reference page 614)

• CMS is proposing to change the EHR reporting periods in 2016 for returning participants from the full CY 2016 to any continuous 90-day period between January 1, 2016 and December 31, 2016.
• The proposed change applies to all EPs, eligible hospitals, and CAHs.
• The applicable incentive payment year and payment adjustment years for the EHR reporting period in 2016 and the deadlines for attestation and other related program requirements, would remain the same as established in prior rulemaking.

E – Proposal to Require Modified Stage 2 for New Participants in 2017 (reference page 617)

• CMS has determined that, due to cost and time limitation concerns related specifically to 2015 Edition CEHRT updates in the EHR Incentive Program Registration and Attestation System, it is not technically feasible for new participants to attest to the Stage 3 objectives and measures in 2017.
• CMS is proposing that any EP or eligible hospital new participant seeking to avoid the 2018 payment adjustment by attesting for an EHR reporting period in 2017 through the EHR Incentive Program Registration and Attestation system, or any CAH new participant seeking to avoid the FY 2017 payment adjustment by attesting for an EHR reporting period in 2017 through the EHR Incentive Program Registration and Attestation System, would be required to attest to the Modified Stage 2 objectives and measures.
• This proposal does not apply to EPs, eligible hospitals, and CAHs that have successfully demonstrated meaningful use in a prior year (returning participants) attesting for an EHR reporting period in 2017.

F – Proposed Significant Hardship Exception for New Participants Transitioning to MIPS in 2017 (reference page 619)

• CMS is proposing to allow certain EPs to apply for a significant hardship exception from the 2018 payment adjustment.
• This proposal is limited to EPs who:

• Have not successfully demonstrated Meaningful Use in a prior year.
• Intend to attest to Meaningful Use for an EHR reporting period in 2017 by October 1, 2017 to avoid the 2018 payment adjustment.
• Intend to transition to MIPS and report on measures specified for the Advancing Care Information performance category under the MIPS in 2017.

• This proposed significant hardship exception is based upon the MIPS and APMs Proposed Rule to establish 2017 as the first performance period of the MIPS.  If a different first performance period for MIPS is finalized, CMS may determine that this proposed significant hardship exception is not necessary.
• An EP would need to submit an application for this significant hardship exception by October 1, 2017.

G – Proposed Modifications to Measure Calculations for Actions Outside the EHR Reporting Period (reference page 622)

• CMS is proposing that, for all meaningful use measures, unless otherwise specified, actions included in the numerator must occur within the EHR reporting period if that period is a full calendar year, or if it is less than a full calendar year, within the calendar year in which the EHR reporting period occurs.
• This would retract FAQ8231, which stated that for all meaningful use measures, unless otherwise specified, actions may fall outside the EHR reporting period timeframe but must take place no earlier than the start of the reporting year and no later than the date of attestation.

Implications

• The proposed EHR Incentive Program changes to Medicare in the CY 2017 OPPS Proposed Rule reduce some of the measure thresholds for eligible hospitals.
• The proposed changes are focused on Meaningful Use attestation.  If an eligible hospital is planning to electronically submit clinical quality measures (eCQMs) through QualityNet to fulfill both the Medicare IQR program and the EHR Incentive Program requirements in 2017, CMS has proposed to require one full year of eCQM data for all required eCQMs; this would mean two separate reporting periods to manage with a continuous 90-day period of data for the MU objectives and measures.
• The CY 2017 OPPS final rule will not be published until November 2016 giving a short time period to submit for reporting a full year in 2016 versus any continuous 90-day period if the proposed EHR Reporting period is not finalized.
• The proposed modification to measure calculations could reduce some measure thresholds, and organizations will need to determine their approach for updating their measure calculations.
• If larger organizations have hospitals participating in both the Medicare and Medicaid EHR Incentive Programs, they will have dual measure and reporting requirements.

Links to the legislation and Information Sources: 

• CY 2017 OPPS Proposed Rule, Full Title – Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Procurement Organization Reporting and Communication; Transplant Outcome Measures and Documentation Requirements; Electronic Health Record (EHR) Incentive Programs; Payment to Certain Off-Campus Outpatient Departments of a Provider; Hospital Value-Based Purchasing (VBP) Program.

• Pre-publication version filed on 7/6/2016.
• Scheduled to be published in Federal Register on 7/14/2016.
• Comments are due by September 6, 2016.
• The Final Rule is scheduled to be displayed and published in November 2016.

• CMS Fact Sheet – CMS Proposes Hospital Outpatient Prospective Payment Changes for 2017
• The above summary is based on the Pre-publication version of the CY 2017 OPPS proposed rule and the EHR Incentive Program changes covered on pages 582 through 623.
• Final Rule with Comment Period: Medicare and Medicaid Programs: Electronic Health Record Incentive Program — Stage 3 and Modifications to Meaningful Use in 2015 through 2017.
• Proposed Rule – 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.  Pre-publication version filed on 4/27/2016; published in Federal Register on 5/9/2016.

Acronyms/Terms

Advancing Care Information (ACI); Alternative Payment Models (APMs); Calendar Year (CY); Centers for Medicare & Medicaid Services(CMS); Certified EHR Technology (CEHRT); Clinical Decision Support (CDS); Computerized Provider Order Entry (CPOE); Critical Access Hospitals (CAHs); Electronic Clinical Quality Measure (eCQM); Electronic Health Record (EHR); EHR Incentive Program / CMS’ Meaningful Use Program (MU); Eligible Clinician (EC); Eligible Hospitals (EH); Eligible Professional (EP); eMeasure Research and Review Board (eMRB); Fiscal Year (FY); Health Information Exchange (HIE); Hospital Inpatient Prospective Payment System (IPPS); Hospital Inpatient Quality Reporting (IQR) Program; Hospital Outpatient Prospective Payment System (OPPS); Merit-based Incentive Payment System (MIPS); View, Download, Transmit (VDT).