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8/24/2016 1

Meaningful Use: Past, Present and Future

Bruce Maki, MAM-CEITA / Altarum Institute

Regulatory Analyst and Project Manager

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Agenda

▲Overview of M-CEITA

▲Meaningful Use

– Where have we been?

– Where are we now?

– Where are we headed?

▲Questions and Answers

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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

Meaningful Use

Improve

Quality, Safety &

Efficiency

Performance Measurement

Certified Technology Infrastructure

Engage

Patients &

Families

ImproveCare

Coordi-nation

ImprovePopulation

AndPublicHealth

EnsurePrivacy

AndSecurity

Protections

Improve patient experience

Improve population health

Reduce costs3THE TRIPLE AIM

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Meaningful Use Support

Security Risk Assessment

Targeted Process Optimization (Lean)

Audit Preparation

M-CEITA Services

Technical assistance, including workflow redesign, security risk assessment and MU compliance. (e.g. patient portal and clinical quality measures)

Support meeting the requirements of MU Measure: Protect Electronic Health Information, including an assessment using our exclusive tool.

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.)

A review of Meaningful Use attestation documentation using our exclusive Audit File Checklist to correct any issues before completing the process.

PQRS SupportTechnical Assistance for the Physician Quality Reporting System including measure selection as well as reporting method selection and assistance.

GLPTN - Great Lakes Practice Transformation NetworkNo 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.

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The Past

A Brief History

of Meaningful Use

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Healthcare’s Shifting Paradigm

Role Changing Paradigm

Healthcare Combating Illness Improving Wellness

Physicians Directors of Care Collaborators in Care

Patients Passive Recipients Active Participants

HealthInformation

Siloed and Episodic Integrated and Longitudinal

Health IT Supporting Tasks Enhancing Understanding

This paradigm shift requires significant investments, innovative people and extensible tools.

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HIT & HIE

HITECH Act: Transformation CatalystHealth Information Technology for Economic and Clinical Health Act

HITECH Act

Pre 2009 2009 2014

A system plagued by inefficiencies

Paper Records

EHR Incentive Programs and 62 Regional Extension

Centers (RECs)

Widespread adoption and meaningful use of HIT

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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

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Stage 1

Data capture and sharing

Stage 2

Advanced clinical processes

Stage 3

Improved outcomes

Meaningful Use: A path to better outcomes and quality

For more information on meaningful use of EHRs, visit: http://www.cms.gov/EHRIncentivePrograms/35_Meaningful_Use.asp

Better clinical outcomes Improved population health outcomes Increased transparency and efficiency Empowered individuals More robust research data on health

systems

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15 C

ore

Meas

ure

s (

EPs

mu

st m

eet

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

2013 MU Stage 1 – Summary of Measures

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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.

2013 MU Stage 1 – Summary of Measures

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The Present

Modified Stage 2

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▲Released: October 6, 2015

▲Published: October 16, 2015

▲Effective: December 15, 2015

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)

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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

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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)

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Measures removed under Modified Stage 2 (…but “Still Meaningful”)

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“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

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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

“Modified Stage 2” MU Objectives (cont’d):

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Meaningful Use Progression for EPs

2011 -2013

20142015 -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

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The Future

STAGE 3 or MACRA/MIPS/APM

…or both!

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Meaningful Use Stage 3

Modified Stage 2 Crosswalk to Stage 3

Objectives Modified Stage 2 Stage 3 (2018)*

SRAConduct or Review during CY and prior to attestation including

addressing encryption/security of data created or maintained in CEHRT

CPOE

Medications > 60% > 60%

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 5 Enabled for Entire Reporting Period (RP)

Interactions Enabled for Entire Reporting Period (RP)

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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

N/A

> 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

Patient Education

For > 35% of unique patients, CEHRT is used to identify educational resources to which electronic

access is provided

Secure Messaging > 5%Incorporated into Coordination of Care through

Patient Engagement

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Meaningful Use Stage 3 (cont’d)

Objectives Modified Stage 2 Stage 3 (2018)*

Coordination of Care through

Patient Engagement

VDT

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

Secure Messaging> 25% of unique patients, or

in response to a secure message sent by patient

Patient Generated Health Data

> 5% of unique patients incorporate non-clinical

setting data into the CEHRT

Medication Reconciliation > 50%Incorporated into Health

Information Exchange

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Meaningful Use Stage 3 (cont’d)

Objectives Modified Stage 2 Stage 3 (2018)*

Health Information

Exchange

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

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

InformationN/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

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Meaningful Use Stage 3 (cont’d)

Objectives Modified Stage 2 Stage 3 (2018)*

Public Health

Imms Registry

Actively Engaged w/2 of 3

Actively Engaged w/3 of 5

Syndromic Surveillance

Specialized Registry

Electronic Case Reporting N/A

PH Registry ReportingIncluded as Specialized

RegistryClinical Data Registry Reporting

* 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

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MACRA:

Paying for Value and Quality

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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…

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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).

Payment rates in 2019 will be maintainedthrough 2025 but with + / - adjustmentsbased on the composite performancescore of each eligible physician or otherhealth professional on a 0-100 point scalebased on four performance measures(more to come on the measures).

Incentives: More to come on that too…

Merit-based Incentive Payment System

(MIPS)

Alternative Payment Model

(APM)

Two Paths to Payment Reform

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Part of a broader push towards VALUE and QUALITY

The Quality Payment Program

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CMS Framework for Alternative Payment Models (APMs)

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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.

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Path 1: Merit-Based Incentive Payment System

▲ 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)

What is MIPS?

*MACRA does not alter or end the Medicaid EHR Incentive Program

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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

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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%

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Advancing Care Information

Objective Measure

Protect Patient Health Information Security Risk Analysis

Electronic Prescribing ePrescribing

Patient Access

Patient-Specific Education

View, Download and Transmit (VDT)

Secure Messaging

Patient-Generated Health Data

Exchange Information with Other Physicians or Clinicians

Exchange Information with Patients

Clinical Information Reconciliation

Immunization Registry Reporting

(Optional) Syndromic Surveillance Reporting

(Optional) Electronic Case Reporting

(Optional) Public Health Registry Reporting

(Optional) Clinical Data Registry Reporting

MIPS Advancing Care Information Objectives and Measures

Patient Electronic Access

Coordination of Care Through Patient Engagement

Health Information Exchange

Public Health and Clinical Data Registry Reporting

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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

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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 25th

percentile of all MIPS scores above the performance threshold (through 2024)

Payment Adjustments

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MIPS Incentive Payment Formula

*MACRA allows potential 3x upward adjustment which will be used to maintain budget neutrality

MIPS – Incentives and Penalties

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The other fork in

the path to

Quality

Payments

Alternative Payment Models

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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”

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▲ 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%)

ADVANCED APMs

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Proposed Financial Risk Criterion Narrows Current Options

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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

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Note: At first, most clinicians will be subject to MIPS

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What path do I take in the Quality Payment Program?

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TIMELINE

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Resources

Modified Stage 2 Final Rule: http://federalregister.gov/a/2015-25595

MIPS/APM Proposed Rule: https://s3.amazonaws.com/public-

inspection.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

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Bruce Maki

bruce.maki@altarum.org

734-302-4744

Questions?www.mceita.org