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MACRA doesn't replace meaningful use, it just changes it

Although a top CMS official has declared meaningful use dead, health IT observers say it is still quite alive but that it will change under the new MACRA healthcare law.

Meaningful use is not dead.

But MACRA, the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act, which Congress passed last year, will eventually transform the now seven-year-old federal EHR incentive program, health IT observers say.

Essentially, what MACRA does, in addition to repealing the so-called Sustainable Growth Rate formula and thereby shielding physicians from automatic annual Medicare rate cuts, is provide a legal framework for the national shift toward value-based Medicare reimbursement.

MACRA applies to physician providers

MACRA applies not to hospitals and large hospital-based health systems but only to individual physicians, whether working alone or in group practices.

That is because MACRA is based on the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs), both of which apply only to individual practitioners, health IT experts have noted in blogs and other commentary.

MIPS is a new program that rates physicians on clinical quality, resource use, meaningful use of health IT and clinical practice improvement, and adjusts Medicare payments accordingly by up to 4% of clinicians' total Medicare payments starting in 2019. MIPS also combines the Physician Quality Reporting System, the Value-Based Payment Modifier and the EHR incentive part of meaningful use, according to CMS.

MACRA sets forth a timeline for merit-based reimbursement from 2015 until 2025, when payment adjustments will reach 9% and beyond. APMs are new ways for CMS to reimburse healthcare providers for care they provide to Medicare beneficiaries. These include paying new kinds of provider groups and approaches, such as accountable care organizations, patient-centered medical homes and bundled payment models, and paying lump sum reimbursement to some participating providers.

The fate of meaningful use

Meanwhile, 2016 started with controversy in the health IT world around the supposed phase-out of meaningful use when CMS acting administrator Andy Slavitt said at a J.P. Morgan healthcare conference on Jan. 11: "The meaningful use program as it has existed will now effectively be replaced by something better."

That "something" apparently is a whole new set of incentives, including meaningful use of EHRs, specified by MACRA.

But replacing meaningful use, if that is CMS' intent, will be a long and complicated process, particularly because the program would first have to be repealed or modified by federal rule-making, noted Jeff Smith, vice president of public policy at the American Medical Informatics Association (AMIA).

"You have to realize that meaningful use is a law and that the regulations underpinning it are still the law," Smith said. For now and into the foreseeable future, Smith said, providers, both individual physicians and health systems, must still attest to meaningful use to avoid Medicare penalties.

Unfortunately, what ails quality measurement in healthcare will not be fixed by programmatic tweaks to existing processes for certification.
Douglas B. Fridsma, M.D.president and CEO, American Medical Informatics Association

In order for CMS to change meaningful use significantly, the agency would have to issue a notice of preliminary rulemaking, hold a 90-day comment period, and then finalize the new rule. "Nothing will actually change in 2016 and probably until the end of 2017," Smith said.

Meanwhile, ONC is still charged with certifying health IT software programs for use in Medicare-eligible healthcare, and no changes are expected there because health IT will continue to be a major part of MIPS, Smith said.

Debate over care quality measures

AMIA, along with the American College of Physicians, among other health IT groups, has been involved in one of the early skirmishes around MACRA. This MACRA debate centers on the direction of the clinical quality measures (CQMs) to be used by MIPS to rate doctors' performance.

Late last year, CMS issued a Request for Information for changes the agency is proposing to the CQM program. ONC wants to increase the frequency of recertification of EHRs around CQMs.

AMIA, however, wants to go in a different direction and adjust and tailor CQMs by medical specialty rather than in EHR certification. Under AMIA's proposal, medical specialty societies would determine specific CQMs for their disciplines.

"Unfortunately, what ails quality measurement in healthcare will not be fixed by programmatic tweaks to existing processes for certification," AMIA president and CEO Douglas B. Fridsma, M.D., said in a Feb. 1 release. "We need a better process that constructs measures based on the capabilities of EHRs and other health IT, includes pilot testing to ensure those measures can be implemented and strives for simple measures that leverage high-quality electronic data. We need to understand the costs of data collection in addition to the benefits to patients."

Others weigh in on MACRA and meaningful use

Meanwhile, David Harlow, a health privacy lawyer who blogged recently about MACRA, said he welcomed Slavitt's statement of direction for meaningful use and value-based reimbursement, and emphasis on certified APIs and interoperability standards. "I think it's a terrific step forward," Harlow said.

In other developments, Beth Israel Deaconess Medical Center CIO John Halamka, M.D., on Jan. 14 posted on his blog a letter to Department of Health and Human Services Secretary Sylvia Burwell signed by 31 healthcare organizations, including his own, calling on CMS to reconsider stages 2 and 3 of meaningful use.

"The Stage 3 final rule, like its predecessor rules, is too focused on pass-fail requirements and lacks emphasis on outcomes," the letter says. "By maintaining this flawed structure, we do not believe Stage 3 will support movement towards more innovative care models or encourage continued participation."

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