Promoting Innovative Care Delivery and Payment ... - Health IT Now

Promoting Innovative Care Delivery and Payment Models SGR Reform Law Promotes Health Information Technology Tools to Improve Outcomes, Costs Background On April 16, the President signed into law H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, an agreement to reform Medicare’s physician payment program, sending it to the President for his consideration. The package updates payments to providers who are reimbursed under the Medicare fee schedule, while improving and providing new incentives to deliver quality, efficient care. Briefly, the law would: 

Repeal SGR, avoiding annual double digit payment cuts;

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Consolidate various Medicare incentive payments into one program that rewards performance based on value and improvement; and

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Encourage flexibility through alternative payment models, such as medical homes and shared risk arrangements.

Many of the provisions outlined in the law will improve incentives for the adoption and use of health IT, reduce regulatory burdens on providers, and promote better health outcomes at lower costs. The health IT provisions of the agreement are outlined in this document. Meaningful Use and Incentive Programs (Title 1) Updates to Payments The law repeals the SGR and provides stable updates to providers paid under the physician fee schedule. The update is: 

For July 1 through 2019, 0.5 percent

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For 2020 to 2025, the update is based on performance as outlined below.

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From 2019-2025, physicians participating in an APM will get paid a five percent bonus.

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From 2026 forward, there are two update factors, one for qualified alternative payment models like medical homes (0.75 percent), and one for non-qualified APMs (0.25 percent).

Merit-Based Incentive Payment System (MIPS)

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Starting in 2019, the law rewards certain providers (MDs, DOs, dentists, podiatrists, optometrists, chiropractors, PAs, NPs, Clinical Nurse Specialists, and CRNAs) based on performance on several quality measures, including Meaningful Use of EHRs. Other providers may be added beginning in 2022. This program, the Merit-Based Incentive Payment System (MIPS), basically consolidates Meaningful Use, physician quality reporting, and the value based payment programs. Current penalties associated with these programs are repealed and new performance based incentives would begin starting in 2019. Providers would be assigned a composite score, and, based on the score, would receive negative, positive, or zero updates. Performance is based on: 1. Quality (30 percent). The Secretary would be required to align quality measures across programs and encourage professionals. Measures would be updated annually. Use of outcomes measures and qualified clinical data registries would be encouraged, and HHS must encourage providers report on MIPS measures via EHRs. 2. Resource Use (30 percent). Based on measures of quality and efficiency with risk

adjustments made for clinical severity. 3. Meaningful Use (25 percent). To avoid reporting duplication, professionals who report quality measures via EHRs for the MIPS quality category will be deemed to meet the MU clinical quality components. All other MU measures (eRx, problem lists, summary of care exchange) will continue to apply and likely evolve. 4. Clinical Practice Improvement Activities (15 percent). This category includes participation in qualified clinical registries, use of remote monitoring or telehealth, timely exchange of clinical information to patients and timely communication of test results and beneficiary engagement. Participation in a medical home earns the highest potential score. Participation in other APM models will earn at least half the maximum automatically Initial incentives would be between +/-4 percent in 2019, +/-5 percent in 2020, +/-7 percent in 2021, and +/-9 percent in 2022 and subsequent years. The average for one year becomes the new performance bar for the subsequent year. Exceptional performers would receive additional incentives totaling $500 million annually through 2024. Comparative Information - Sec. 106 (c)(3) Information on a provider’s performance in each category would be made publicly available on the CMS Physician Compare web site. Consumers would thus be able to determine if their provider was a meaningful user of EHRs and how effectively they used the technology to improve quality, efficiency or pursed practice improvement activities.


Alternative Payment Models Providers who receive a substantial share of revenues from Alternative Payment Models, such as medical homes or risk sharing arrangements that include quality measurement, would receive additional bonuses of five percent annually from 2019 to 2024. APMs must use certified EHR technology. Providers who qualify for an APM would be excluded from MIPS requirements. Impact By building MU, telehealth, and clinical information exchange more directly into Medicare’s incentive payments, all dollars in the payment stream would incent the adoption and use of health IT. Indirect incentives for care coordination, risk sharing, and performance will foster the use of information across teams of providers and necessitate a new generation of interoperable technologies. Interoperability and Information Blocking - Sec. 106 (b) Interoperability The law declares it a national objective to achieve widespread exchange of health information through interoperable certified EHR technology nationwide by December 31, 2018. The legislation defines interoperability as the ability of two or more health information systems or components to exchange clinical and other information and to use the information that has been exchanged using common standards as to provide access to longitudinal information for health care providers in order to facilitate coordinated care and improved patient outcomes. No later than July 1, 2016, the law establishes metrics to determine whether the widespread interoperability objective has been met. If the goal of nationwide interoperability is not achieved by the end of 2018, HHS must issue a report by the end of 2019 that identifies the barriers to the objective and that makes recommendations to address the barriers, which may include adjustments to provider payments or criteria for decertification of EHR products. Information Blocking One year after enactment, the law requires eligible providers and eligible hospitals in the Meaningful Use program to demonstrate, through a process such as attestation, that the entity has not knowingly and willfully taken any action to limit or restrict the compatibility or interoperability of certified EHR technology. Comparing EHRs The law requires HHS to conduct a study on the feasibility of establishing measures and creating a public web site to allow users of EHRs to directly compare the functionality of different EHRs.


Telehealth Incentives As already noted, the law recognizes telehealth and remote monitoring as a clinical practice improvement activity under the MIPS program. Thus, the use of telehealth and remote monitoring would improve provider performance scores and eligibility for bonuses. In addition, the law (Sec. 101(z)(5)) clarifies that providers in APMs may provide telehealth services even if the service is not reimbursed under the Medicare fee schedule. The combination of the two changes will expand telehealth use. The law allows “virtual” groups of providers to qualify for MIPS incentive payments. Virtual groups would be physician collectives of not more than 10 eligible professionals, who agree to report and base their performance together on MIPS measures. Studies - Sec. 106(c) The law requires GAO to study issues that facilitate or inhibit the use of telehealth, including professional licensure, changing technologies, privacy and security, infrastructure development, and various needs across urban and rural areas. The study also requires an examination of how the definition of telehealth across various Federal programs can inform the use of telehealth in Medicare, the potential implications of greater use of telehealth in Medicare, and how CMS monitors payments made for telehealth services. GAO is also required to study the use of remote monitoring. Both reports may contain recommendations for legislative and administrative action on each issue. Expanded Use of Medicare Data (Sec. 105) Beginning July 1, 2016, the law expands the use of Medicare claims data by allowing Qualified Entities (QEs) to provide or sell non-public data (combined Medicare and commercial data) to physicians, suppliers, medical specialty societies and hospital associations for developing and participating in quality and patient care improvement activities, including developing new models of care. QEs may provide or sell aggregated data analysis to employers only for purposes of providing health insurance to employees and retirees. QEs may not provide or sell analysis to insurers unless the insurer provides claims data to the QE. Data is subject to use agreements and are subject to privacy and security protections, and new breach penalties. Clinical quality registries will receive QE data if requested. HHS may expand data under the program to include Medicaid and CHIP data.
