Staying In the Know on MACRA

As a follow up to our last post, we want to give an update on the state of MACRA’s Merit-based Incentive Payment System and reporting tips. First, let’s address continued year 1 reporting.

Data Submission
Given feedback from clinicians across the country, CMS is working to lessen reporting confusion and burden. The center recently launched a data submission system for Quality Payment Program (QPP) participation. With the new platform, clinicians will need to create a login to submit and manage year 1 data, which is due by March 31, 2018. The system will connect clinicians to the Taxpayer Identification Number (TIN) associated with their National Provider Identifier (NPI) as eligible clinicians report either as individuals or a group. The system provides immediate feedback with real-time scoring as data is entered. However, scoring may change based on additional data input or new quality measure submission. To learn more, check out CMS’ QPP 2017 Data Submission Factsheet.

MIPS’ Future
Though CMS recently unveiled QPP year 2’s final rule, the group is now accepting recommendations for new specialty measure sets or revisions for 2019’s MIPS program year. CMS will accept suggestions until Feb 9, 2018.

While program planning moves along, pushback from the Medicare Advisory Board (MedPAC) arose. The advisory body to Congress recently suggested replacing MIPS with an alternative program model that is less burdensome and complex for participants. Meeting notes are here, and no changes have been officially made.

As each MACRA public discussion and policy adjustment occurs, clinicians may find more and more uncertainty. Our goal is to keep readers in the know, so they can focus on quality patient care.

Assessing QPP Year 2’s Final Rule

In the last leg of 2017, CMS has issued the MACRA Quality Payment Program (QPP) final rule for year 2.

After gathering feedback during the lengthy comment period, Acting Administrator of CMS, Seema Verma said, “During my visits with clinicians across the country, I’ve heard many concerns about the impact burdensome regulations have on their ability to care for patients. These rules move the agency in a new direction and begin to ease that burden by strengthening the patient-doctor relationship, empowering patients to realize the value of their care over volume of tests, and encouraging innovation and competition within the American healthcare system.”

As medical and health IT professionals across the country work to assess the 1,653-page published final rule, let’s address key provisions.

MIPS Final Performance Categories
In calendar year 2018, the performance categories shift in weight to Quality at 50 percent, Improvement Activities at 15 percent, Advancing Care Information at 25 percent and Cost, the most significant change, moves to 10 percent of the final score. The final rule projects Cost to increase to 30 percent of the total MIPS performance score by the 2021 payment year.

Much to organizations like MGMA and CHIME’s dismay, both Cost and Quality require a full year of reporting. The MIPS performance threshold increased as well from just three points in 2017 to 15 points in 2018. CMS is also finalizing changes to 27 existing Improvement Activities with plans to introduce an additional 21 to the inventory.

Exemption and Bonus Opportunities
For QPP year 2, the low-volume threshold for MIPS exemption stands at 200 Medicare patients, while the reimbursement threshold is $90,000 in Part B.

As seen in the proposed rule, year 2 allows up to five bonus points toward the MIPS final score for treating complex patients. Bonus is also possible under the Advancing Care category for providers solely using 2015 certified EHR technology (CEHRT). However, 2014-edition CEHRT is permitted; the bonus just does not apply.

CMS has made concentrated effort toward small practices, which are defined by MACRA as 15 eligible clinicians or fewer. Small practices can earn a bonus of five points toward the final MIPS score. A hardship exemption also applies under Advancing Care Information for MIPS, providing three points even if small practices submit quality measures below data completeness standards.

In light of recent natural disasters, year 2’s final rule automatically weights the Quality, Advancing Care Information, and Improvement Activities performance categories at 0 percent for final score for those impacted by Hurricane Harvey, Irma, Maria or other natural disasters

MIPS Virtual Groups
As previewed in the proposed rule, QPP year 2 enables virtual group participation in the MIPS program. This is helpful for small practice clinicians, since they can team up for MIPS reporting on an aggregate basis, regardless of specialty or location. Those reporting under virtual groups must opt in by Dec. 31, 2017 for QPP year 2.

Advanced APMs
Under Advanced APMs, CMS extended the nominal amount standard of 8 percent until the 2020 performance year. The Medical Home Model holds a 2.5 percent risk with plans to gradually increase over time.

Starting in 2019, qualified payers (QPs) can leverage the All Payer Combination Option. An eligible clinician must participate in an Advanced APM with CMS as well as an Other Payer Advanced APM for this.

While most of the final rule’s provisions were previewed in the proposed rule, the industry is still assessing how the 2018 plan will impact clinicians and their practices. Stay tuned for part II of our QPP year 2 final rule follow-up, discussing implications and tips for success.

Staying afloat as a CIO amidst industry pressures

Across the country, over 80 percent of healthcare organizations now have an EHR system in place. While initial implementation no longer serves as a major issue, with the new technology comes added CIO pressures, including reimbursement program requirements, technology disparities and security challenges.

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Reimbursement reporting challenges

With year 1 of the Medicare Access and CHIP Reauthorization Act (MACRA) Quality Payment Program (QPP) well underway, the healthcare industry forges ahead in the transition to value-based care reimbursement. While the shift aims to advance patient care, many providers find themselves swimming in reporting requirements or completely oblivious to the program altogether. According to a NueMD survey, 50 percent of physicians are unfamiliar with the reimbursement legislation, and 49 percent have never encountered any information about it at all.

IT can help clinical care fill in knowledge gaps by facilitating assessment of current patient care and technology practices that meet QPP measure requirements. By strategically aligning data capture, maintenance and analysis with outlined QPP measures while looking ahead to potential year 2 program leniencies, providers can ease burden. With a little preparation, IT can help find the low-hanging fruit for the reporting quick wins that will help avoid QPP penalties while maximizing the program’s financial bonuses.

Rural health disparity

As value-based care requirements elevate, critical access, small and rural healthcare providers lag behind. From 2008 to 2015, only one-third of hospitals surveyed by the American Hospital Association had at least eight of 10 performance management EHR functions in place. Just 33 percent of hospitals with fewer than 100 beds adopted such systems.

Discrepancies in technology advancement between rural or small providers and large medical systems creates a digital divide across the country. Small providers face the decision of closing shop, joining group purchasing arrangements, becoming part of ACOs or sticking it out on their own. These struggling providers need continued representation in HIT policy and government regulations beyond progress with the 21st Century Cures Act for vendor transparency or MACRA’s QPP year 2 leniencies.

Cybersecurity concerns

While advancing technology is vital for new patient care needs and expectations, its growing significance also puts healthcare providers at risk. In a recent MGMA survey, only 55 percent of healthcare professionals have confidence in their organizations’ IT infrastructures against cyber attacks, while almost one-third have faced a cyberattack.

As healthcare ranks poorly at 13th in U.S. industries for cybersecurity practices, more and more HIT departments are turning to outsourcing expertise. Total IT budget spent on outsourcing has increased from 10.6 percent in 2016 to 11.9 percent in 2017. Now, healthcare organizations are turning to third-party advisors to train and certify staff on security best practices, while partnering with external security providers and adding defense tools to the HIT suite of applications.

Despite these three areas of concern, by strategically planning for value-based care requirements, today’s healthcare CIO stand better equipped against mounting pressures, while assessing market trends, turning to third-party expertise and staying on top of industry policy change.

Progress for small and rural health

Today’s small and rural healthcare providers still find themselves hindered by financial and staffing limitations amidst growing industry standards and regulations. As patient expectations evolve in the transition to value-based care, these organizations’ IT capabilities fall behind the curve. Lack of budget prevents the ability to transition EHR vendors or bring in outside resources to aid with optimization initiatives. With limited staff, practices cannot pull individuals away from regular duties to focus on IT training. In turn, practices struggle with moving beyond inefficient workflows and processes or being able to effectively gather and analyze data for quality measures. For rural health, geographic location also limits patient engagement and population health management capabilities. Patients are less likely to complete wellness visits or additional health maintenance when they have long commutes or limited access to physicians.

Despite these small and rural health IT challenges, positive progress across the industry can aid these struggling providers.

Mobile health- Mhealth app usage doubled from 2013 to 2015, according to a PwC survey, and growth is expected to continue in 2017. Mobile health applications can help isolated healthcare providers improve outreach, population health management and patient engagement efforts, while keeping patients out of the hospital. Mhealth capabilities can also expand rural providers’ impact on patient follow-up care and wellness decisions for improved care delivery. M-health capabilities can expand small and rural providers’ impact on patient follow-up care and wellness decisions for improved care delivery.

Telemedicine- According to a recent survey, 20 percent of patients would switch their current primary care provider if another provider offered them telehealth visits. Congress’ 2016 passing of the Expanding Capacity for Health Outcomes (ECHO) Act offers opportunity for remote and rural health providers to offset budget, specialty care and staffing limitations. ECHO expands Project ECHO’s model that pairs academic medical specialists with primary-care providers through virtual clinics for mentoring with behavioral and population health management. Proven through several academic studies, Project ECHO’s model overcomes rural physicians’ physical isolation through cost-effective access to specialty care best practices.

HRSA funding- The Health Resources and Services Administration (HRSA) allocated more than $16 million toward rural health telehealth and quality improvement initiatives. Administered by the Federal Office of Rural Health Policy, funding benefits 60 rural communities amongst 32 states. Of that, seven Rural Health Research Centers will receive $700,000 annually to investigate the health, economic and access challenges among these populations and how federal programs are impacting care and outcomes.

Interoperability- Small and rural health providers are often at the mercy of their EHR vendors in terms of willingness and capability of data sharing, as well as necessary version updates to meet with reporting requirements. With the passing of the 21st Century Cures Act, the U.S. government now clearly defines data blocking while issuing a commitment to holding the private sector accountable for transparency in health IT. This puts pressure on vendors to enable interoperability, which better connects small and rural providers for better patient care and safety across patients’ medical journeys.

Making Sense of MACRA

After a slew of feedback from healthcare and HIT professional organizations, like CHIME, AMA and MGMA, CMS announced new flexibilities in the Medicare Access and CHIP Reauthorization Act (MACRA) final rule. Though CMS released the final ruling several weeks ago, physicians still struggle to grasp the impact or even understand what the new reimbursement structure is.

MACRA replaces the old sustainable growth-rate formula for physician pay. Under MACRA, physicians can pick from one of two Medicare reimbursement tracks – the Merit-based Incentive Payment Program (MIPS) or Advanced Alternative Payment Models (APMs). To better aid physicians with these programs, CMS has set up additional resources:

  1. With $700 million in funding, CMS created practice transformation networks as frontline assistance focusing on elevating clinicians’ population health to enable physician success under MIPS and eventually transition them APMs.
  2. With $100 million in funding, CMS specifically directed aid toward solo, small and rural health practices to get them up to speed and in the know about reporting requirements and means for success.

Beyond these initiatives, how can you become better informed? For a breakdown of MACRA and questions to consider, check out our slide set Making Sense of MACRA.

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Tips for Negotiating with EHR Vendors

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Before signing the contract with a new EHR vendor, think about the immediate and future implications on your healthcare organization, end users, workflow, business operations and the patient community. Be willing to consider the following questions when approaching this daunting IT decision:

1.What is the main goal we are trying to achieve?

Don’t buy or opt in for additional or added features when you don’t need them for your practice. Additional functionality and available modules can always be negotiated from a pricing standpoint (which you should be able to be lock in for at least two years) as an option exercised at a later date if the scope of the practice changes and there is a need for the additional product. Another thing to remember is, just like cars and furniture, software is always on sale. The level of discount you are able to achieve will depend on a number of factors, including success of the vendor, timing in the quarter or fiscal year and length of agreement you are willing to enter into.

2.What’s the best way to achieve win-win outcomes in the negotiation with a new EHR vendor?

Remember that the best executed software agreement is one that both the customer and the vendor feel good about. The goal is for the agreement to be a win-win result. It should provide a quality and supportable product for the medical practice in an agreement that the vendor feels good about to provide the appropriate support. With a win-win agreement, the vendor is much more likely to go the extra mile in assisting the customer when issues arise outside of the normal support process.

There doesn’t necessarily need to be a bad guy in the negotiating scenario if open and honest communication is on the table during the negotiation process. Both the customer and the vendor are going to having non-negotiable items that they cannot concede on for various reasons. These should be communicated at the appropriate time during the process. Good representation from the right individuals from both a financial and clinical perspective will help to ensure that expectations are communicated for what is required and what the vendor is offering to meet the needs.

3.What else should you consider when working with a new EHR vendor?

Reference checks are the key to making this very important decision for your practice. Ask for a minimum of three references and at least one of those references should be a “bad” reference provided by the vendor. Although it may not have necessarily completely been the vendors’ fault for the bad references, it will provide you, the potential customer, with some insight on why that reference failed with the implementation or has not been able to fully utilize the capabilities the vendor is proposing to your healthcare organization. Good references are just that, but take the time to learn as much as possible from them about how they feel they successfully implemented the product. What was their staffing model? How long did the implementation take? Did it stay within the budget parameters? What would they have done differently to make it an even better implementation? Exchange contact information with the good references in hopes of communicating with them further in the future.

Best of luck in your negotiations,
Sheri Stoltenberg, CEO, Stoltenberg Consulting, Inc.

Today’s Healthcare Industry Pressures Call for New Executive Capabilities

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When you think about individuals in a hospital c-suite, what characteristics come to mind? Perhaps passion and drive with combined analytical and relational skills? These characteristics unite to meet the needs of today’s patients and industry demands while aiding cross-organizational collaboration. Collaboration is a critical component in leading a complex and integrated healthcare system of care. No longer can separate facets of a healthcare organization operate in individual information silos, and CIOs hold an increasingly important role in connecting a hospital through technology. Considering the building pressures of executives, here are three quick tips for healthcare leadership:

Planning for the Future

Healthcare organizations now look to leaders who are seasoned team players, willing to offer up fresh perspectives affecting the whole. While much of the healthcare industry is in flux, looking toward the future may seem difficult. However, long-term strategies are important for executives new to a position or an organization, especially when considering demands to stretch tightening budgets.

Leading by Example

Frontline staff, from check-in to patient visit follow up, play a crucial role in patient satisfaction. With such a significant role, healthcare leaders need to motivate and lead these individuals by example to impact their actions and decisions toward each patient interaction. C-suite leaders should take the time to engage one-on-one when possible with frontline staff. Those who deliver valuable care are incredibly important to the success of a healthcare organization.

In an article by Becker’s Hospital Review, former Modern Healthcare publisher and author/public speaker Chuck Lauer said the following:

“The healthcare field needs new ideas and courageous leaders to make them happen. Leaders must show resolve and a willingness to change if the conditions merit doing so. On the other hand, a leader must also be consistent and mature in their personal behavior. After all, a leader sets the tone of a given organization and if they are not consistent that can often sow the seeds of unrest and stress. Any of those things can be a major component of failure and consequently must be avoided!”

Addressing “No”

By all means do we understand the incredible juggling act that c-suite executives manage in balancing multiple projects, but what happens when stakeholders want an exciting new project that really isn’t within bandwidth? Within the same Becker’s article, Beth Israel Deaconess Medical Center CIO John Halamka shared that “What not to do is as important as what to do, because each of us gets this laundry list of hundreds of things that stakeholders want. The technique I usually use is not to say ‘No.’ ‘No’ is such a negative word, so loaded with emotion. So, I say, ‘Not now.’ My role on the resource side is not to create fear, uncertainty and doubt, but to explain to the board what we need to do.”