Halamaka Takes a Deep Dive on the MACRA NPRM

John D. HalamkaAs promised last week, I’ve read and taken detailed notes on the entire 962 page MACRA notice of proposed rulemaking (NPRM) so that you will not have to. Although this post is long, it is better than the 20 hours of reading I had to do! Here is everything you need to know from an IT perspective about the MACRA NPRM.

1) What is the MACRA NPRM trying to achieve with regard to healthcare IT?

The MACRA NPRM proposes to consolidate components of three existing 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), creating a single set of reporting requirements. The rule would sunset payment adjustments under the current PQRS, VM, and the Medicare EHR Incentive Program for eligible professionals.

2) Who is affected?

In the MACRA NPRM, the word Eligible Professional is replaced with the term Eligible Clinician, expanding the population of individuals covered by Merit-based Incentive Payment Programs (MIPS). MIPS eligible clinicians will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians. Hospitals are not affected by this rule and  hospital-based MIPS eligible clinicians are not required to participate in the information technology portions of MACRA, since they may not have direct control over the software implemented by the hospital.

3) When does the rule take effect?

The rule proposes that the first performance period would start in 2017 for payments adjusted in 2019. It’s not exactly a stimulus program - some clinicians will see reduced payments for non-performance and some will see enhanced payments for exemplary performance - a zero sum redistribution of payments.

4)  Does Meaningful Use and electronic clinical quality measure reporting go away?

MACRA’s enactment altered the EHR Incentive Programs such that the existing Medicare payment adjustment for a eligible professionals ends after calendar year 2018.  Generally,  MACRA did not change hospital participation in the Medicare EHR Incentive Program or participation for professionals in the Medicaid EHR Incentive Program.

Meaningful use of certified EHR technology is renamed to  “advancing care information” and the criteria are streamlined - removing the CPOE and Clinical Decision Support requirements. In 2017, clinicians may still use 2014 edition certified technology and report on eight Stage 2 measures. By 2018, clinicians need to use 2015 edition certified technology and report on six Stage 3 measures, described below.

Quality measures will be selected annually through a call for quality measures process.

5) What is the role of ONC and Certification?

On March 2, 2016, ONC published the ONC Health IT Certification Program: Enhanced Oversight and Accountability proposed rule, which would expand ONC’s role to strengthen oversight, requiring that clinicians give access to their EHR for “field inspection” of functionality by ONC.

The MACRA NPRM proposes that clinicians must attest they have cooperated with ONC surveillance and oversight activities. Further, they must attest they have not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.

6) What are the MACRA advancing care information objectives and measures that have replaced Meaningful Use?

The six criteria which are required as of calendar year 2018 are

1. Protect Patient Health Information - Security Risk Analysis
2. Electronic Prescribing
3. Patient Electronic Access - Patient Access, Patient-specific education
4. Coordination of Care through Patient Engagement - View/Download/Transmit, Secure Messaging, Patient Generated Health Data
5. Health Information Exchange - Patient Care Record Exchange, Request/Accept Patient Care Record, Clinical Information Reconciliation
6. Public Health and Clinical Data Registry Reporting - Immunization Registry Reporting

Here are examples of the actual measurements:

Secure Messaging Measure: For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).

View, Download, Transmit (VDT) Measure: During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either—(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician’s certified EHR technology; or (3) a combination of (1) and (2).

7) So what must a clinician do and when?

For the period January 1, 2017 to December 31, 2017 (yes, it’s a full year, not 90 days), clinicians must:

a.  Use a 2014 or 2015 Edition Certified EHR

b.  Report on either eight stage 2 or six stage 3 advancing care information objectives and measures:

c.  Attest to their cooperation in good faith with the surveillance and ONC direct review of their EHR

d.  Attest to their support for health information exchange and the prevention of information blocking.

e.  Continue to practice medicine

Sorry, e. was an attempt at humor. Listening to each patient’s story, being empathic, and healing are optional. After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought. Sometimes when you remodel a house, there is a point when addtional improvements are impossible and you need to start again with a new structure. The 962 pages of MACRA are so overwhelmingly complex, that no mere human will be able to understand them. Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes. This may sound cynical, but there are probably only two rational choices for clinicians going forward - become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.

The folks at CMS are very smart and  well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested. I will watch closely for comments from organizations such as the AMA, AHA, and clinician practices. I’m guessing that many will see the ONC Surveillance provisions as overly intrusive and the "advancing care information" requirements as creating more burden without enhancing workflow. Maybe the upcoming Presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves. As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.