CMS Merit Based Incentive Payment System (MIPS) in 60 Day Comment Period, Sunsetting of Meaningful Use

May 12th, 2016

New Federal healthcare industry payment models based on the April 27th, release of a proposed rule propose MIPS, MACRA, and APM methodologies for calculating healthcare reimbursement.  There are 962 pages in a document that proposes once in a generation changes in how healthcare providers are compensated.  The Meaningful Use program is eight years old and the Medicare payment system is 25 years old.  What follows is a summary of the proposed rule as of May 2016.

The Premise for these changes is a continuing effort to achieve efficiencies in healthcare.  CMS and other industry leaders generally believe that 30% of healthcare expenditures are still wasted.

CMS Proposed Rule-making on MIPS and MACRA

According to the Centers for Medicare and Medicaid (CMS), “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repeals the Medicare sustainable growth rate (SGR) methodology for updates to the physician fee schedule (PFS) and replaces it with a new Merit-based Incentive Payment System (MIPS) for MIPS eligible clinicians or groups under the PFS. This proposed rule would establish the MIPS, a new program for certain Medicare-enrolled practitioners.

  • MIPS would 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),
  • It would continue the focus on quality, resource use, and use of certified EHR technology (CEHRT) in a cohesive program that avoids redundancies.
  • This proposed rule also would establish incentives for participation in certain alternative payment models (APMs) and includes proposed criteria for use by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) in making comments and recommendations on physician-focused payment models.”  (See

The Quality Payment Program and HHS Goals

The Secretary announced new goals including 30% of payments based on alternate payment models by end of 2016

By 2018 the goal is to have 50% of payment tied to value based models by 2018

U.S. Health and Human Services Goals for Value Based Care

U.S. Health and Human Services Goals for Value Based Care. Source: GE Healthcare IT

MIPS – Fresh Start for Value Based Care

The goal is to measure E.H.R. usage under care coordination.  The entry ticket to MIPS is that providers are a Meaningful User of Electronic Health Records

  • Quality
  • Resource Usage
  • Clinical Practice Improvement
  • Advancing Care Information

Expanded Participation

In years one and two, Physicians (MD / DO and DMD / DDS, PAs, NPs, nurse specialists, certified registered nurse anesthetists

Program may be broader, including Physical or occupational therapists, speech language pathologists, audiologists, nurse midwives, clinical social workers, clinical psychologists, dietitians / nutritional professionals

Who is Excluded from MIPS?

    • First year Medicare Part B providers
    • Below low patient volume threshold of less than $10,000 and provides care for 100 or fewer Medicare patients in one year

CMS Policy and Performance Category Weights – Determined by Statute

The prioritization of performance is illustrated in the graph below.  A MIPS Advancing Care Information Performance Category aggregate score would be composed of:

  • Base score of 50 points for advancing care information
  • 80 points for advancing care information performance
  • 1 point for total advancing care information performance – bonus
  • Which equates to a composite score of 100 points or more possible

There is a proposal to eliminate clinical decision support and clinical provider order entry (CPOE) objectives which are more rudimentary measures of the current Meaningful Use program.  The new measures are again focused more on more advanced usage of E.H.R. technology.

Source: GE Healthcare IT

Source: GE Healthcare IT

Risk Adjustment Mechanisms for Value Based Care – Stay Tuned

There are no firm commitments from CMS but we can expect revisions to Risk Adjustment methods in the future.

The Affordable Care Act (ACA) provides for a program of risk adjustment in the individual and small group markets in 2014 as Marketplaces are implemented and new market reforms take effect. The purpose of risk adjustment is to lessen or eliminate the influence of risk selection on the premiums that plans charge.

Related Posts

Expert witness HITECH Act, Meaningful Use Electronic Health Records

Meaningful Use Audit defense

Meaningful Use Information Safeguards

HIPAA Privacy and Security 



Interoperability in Healthcare: Are Anti-Competitive Forces Limiting Innovation and Patient Benefits?

April 6th, 2016

Salt Lake City - Government Health PlanAccording to a physician in Utah, Health Information Exchanges don’t work very well yet.  Dr. Raymond Ward MD is a member of the Utah State Legislature.  “When I try to look up patients sometimes I find them via the HIE, sometimes I don’t.”  Dr. Ward is both a practicing physician and a passionate legislator for improvement of healthcare regulations and interoperability.  Utah  is known for its leadership in interoperability and was the first in the nation to found a widely accepted and respected health information exchange (See UHIN).  Yet,  Utah health industry interoperability falls short of physician expectations.  According to Dr. Ward, “Utah has one urban area, four major hospitals that 70% of the market.”  That should make Utah a strong candidate to coordinate care via interoperability, Dr. Ward reasons, since the majority of the providers serving Utah patients are concentrated in one urban area.  “Yet, when I use the Clinical Health Information Exchange (CHIE), HCA has radiology and lab reports but not other information I need,” states Dr. Ward.

Even non-physicians can easily understand why health data interoperability is important.  If a patient is being seen by a primary care doctor, an oncologist to manage a cancer diagnosis, a behavioral health professional to manage depression, a pain management specialist for pain caused by cancer, is under treatment for substance abuse related to addiction to pain medication, has had images of their cancer taken by a radiology lab, and subsequently interpreted by a diagnostic radiologist, shouldn’t all of these providers be able to see that patient’s information electronically via a unified platform?   Though some regions like Utah have led innovation, the U.S. as a whole hasn’t achieved this goal yet.

According to  Teresa Rivera, CEO of UHIN and head of the CHIE, there are still regulatory challenges to improving data interoperability.  For example, as Ms. Rivera noted, “Substance Abuse Confidentiality Regulations 42 CFR Part 2 currently limit what may be shared.”  According to Rivera, the HHS Substance Abuse and Mental Health Services Administration (SAMHSA) will be revisiting methods for enabling interoperability while protecting patient information, particularly for behavioral health.

Though one can understand Dr. Ward’s frustration as a care provider, Ms. Rivera has a point too.  According to current regulations (as I write this on April 6, 2016), once a patient has revokes a Part 2 consent to share their behavioral health information, that revocation should be immediately communicated to the HIO by the entity obtaining the patient’s revocation so that it implements the revocation decision and no longer transmits the Part 2 program’s protected patient information to those one or more parties. Part 2 permits a patient to revoke consent orally [42 CFR §2.31(a)(8),(c)(8)]. In an HIE environment, the revocation with respect to one or more parties should be clearly communicated to the Health Information Organization (HIO)as well as noted in the patient’s record.  Since UHIN is working with SAMHSA to improve the way this works electronically, and is arguably a leader in interoperability, why can’t we make this work across in the U.S.?

In my opinion, based on personal experience working in the Utah market as an expert witness and an advisor to health systems and health insurance firms, Utah is one of the leaders in U.S. health care data interoperability. UHIN has been a model for innovation and collaboration. So the question one may ask next is, if Utah sets the standard on interoperability, but still falls short of physician expectations, why is the U.S. healthcare industry still falling short on interoperability goals?

Some vendors have refused to open their Health IT and Electronic Health Record systems to complete bidirectional interoperability and the U.S. Health and Human Services Office of the National Coordinator (ONC) has not used enough of the hammer to enforce interoperability on EHRs and HIT vendors, according to 85% of hospital leaders, 88% of physicians and 92% of payers participating in a recent survey.

Black Book Research conducted its annual survey of hospital and health system executives, physician administrators and payer organization IT leaders to identify key interoperability trends and understand the challenges they face in their efforts to exchange patient information with other healthcare organizations.  All user types were polled to understand the importance of interoperability in their strategic planning initiatives, as well as their ongoing and new challenges in areas such as connectivity and data exchange:

  • 2,012 provider Health Information Exchange (HIE) users
  • 2,300 payer HIE users
  • 4,100 prospective HIE users

Between Q3 2015 and Q1 2016, the survey recorded :

  • growing HIE user frustration over the lack of standardization and readiness of unprepared providers and payers.
  • 26% of self-identified connectivity-ready hospitals intend to keep expanding into robust exchanges for value-based payment prospects with primed payers
  • delays by peer providers to electronically share patient data beyond Meaningful Use

“Every stakeholder in the healthcare delivery process cannot establish the infrastructure needed to support interoperability, as evidenced by :

  • 83% of physician practices responding
  • 40% of hospitals currently admit they are still in the planning and catch up stages of sending and sharing secure, relevant data

Of those still lagging behind in prioritizing interoperability, collectively :

  • only 17% place the blame on their organization’s available funding or executive interest level
  • 57% place culpability on their HIT/EHR vendors for connectivity defects and siloes or data blocking
  • 20% blame their respective government agencies for slow progress in development and standards
  • A variety of other and combined forces are found liable by the remaining 6%.

“The misalignment of requirements and protocols has hampered all the stakeholders’ interoperability efforts,” said Doug Brown, Managing Partner at Black Book. “This disorder is ushering in a new replacement revolution, this time for those HIEs failing to meet the expectations of their users, payers and providers alike”.

63% of hospitals & hospitals systems report they in the active stages of replacing their current HIE system, whether private, public, homegrown or EHR-dependent with a variety of options including middleware and more advanced HIE systems. Nearly 94% of payers surveyed intend to totally abandon their involvement with public HIEs and work directly in regions and states to create and/or bolster private enterprise HIEs which more directly meet their needs to facilitate accountable care initiatives with providers.

“The value-based payment reform concept enabled by a robust HIE requires all stakeholders including physicians, insurers, post-acute care, and diagnostic facilities, not just hospitals to reach the goals of dynamic population health,” said Brown, “Focused, private HIEs also mitigate the absence of a reliable Master Patient Index and the continued lack of trust in the accuracy of current records exchange.” According to the survey results, 39% of hospitals currently implementing or evaluating private regional networks intend to participating in regionally-centered enterprise HIEs with contracted payers to ensure greater connectivity among the stakeholders with whom they network within a geographic healthcare market. “The challenge of turning silos of medical and financial information into a linked, complete, accurate secure lifetime medical record is still tenuous,” said Brown.

90% of polled hospitals see private HIEs as a potentially more profitable model that can be sustained as the industry evolves faster towards a values-based and outcome-based healthcare delivery and reformed payment model.

Black Book™ also noted that payers have been largely absent in the development of dozens of private HIEs until late 2014 because data sharing was viewed as mainly benefitting providers.

“Public HIEs and EHR-dependent HIEs were viewed by 79% of providers as disenfranchising payers from data exchange efforts and did not see payers not as partners because of their own distinct data needs and revenue models,” said Brown.

However, 88% of hospitals and 95% of payers in Q1 2016 see secure data exchanges where all parties pay a fair share in the development and maintenance is creating a more collaborative trusting relationship.

Since 2013, the number of private HIEs involving a payer/multiprovider collaboration have increased steadily. 60% of providers that year reported they distrust payer guided HIE initiatives. In 2016, 93% of providers are considering cooperative HIE to satisfy the growing need for data particularly to manage complex patients and integrate clinical and financial data sets.

“Progressive payers are moving rapidly into the pay-for-value new world order and require extensive data analytics capabilities and interoperability to launch accountable care initiatives,” said Brown.

In response to alleviate concerns of HIEs with poor connectivity outside their IDNs and hospital systems, interoperability middleware is also a fast growing consideration according to 16% of hospital systems IT leaders with EHR-dependent HIE grievances, in particular.

“The middleware software sits within the data pipeline and translates data from disparate EHRs which shows promise for private HIEs, particularly payer-centric enterprise models,” said Brown. “It creates a business intelligence layer that provides information to all stakeholders in real time.”

Middleware is gaining popularity fast by hospitals using EHR-dependent HIE systems with extremely expensive custom development for data sharing outside the network. Black Book evaluated middleware vendors in an associated Q1 2016 user survey, ranking these vendors highest in satisfaction among new users.

  • HealthMark
  • Zoeticx
  • Arcadia Healthcare Solutions

In 2013, 82% of all payers and 60% of participating hospitals agreed that an operational national HIE is at least a decade off. In 2015, 91% of all payers and 74% of providers believe that a robust, meaningful national HIE will now be achievable by 2020 if more private or enterprise HIEs are created and a patient locator system is implemented.

Promises made in the recent interoperability pledge for three core commitments from EHR developers (providing patient access, eliminating information blocking, and implementing federal connectivity standards) won’t be the reason why interoperability succeeds, predicts Black Book’s survey results.

Key Trends:

  1. The global healthcare analytics market is projected to grow to $18.4 billion in 4 years (by 2020) and the need for that complex data will propel the interoperability needs of providers and payers. “The only way to accomplish that is robust bidirectional interoperability and that’s what will ultimately force comprehensive interoperability into reality, not government-scripted vendor pledges”, said Brown. “Value based care, payer participation in private HIEs, patient locator systems and analytics will be the real forces that push interoperability ahead next.”
  2. Patients agree on the need for medical data exchanges according to Black Book™. A Q3 2015 survey of recently discharged patients of 70 US hospitals evidenced 94% expressing the desire to have their medical and insurance information held and freely shared electronically among their personal providers and payers.
  3. 57% of providers also confirm their beliefs that the whole interoperability industry will evolve by leaps by 2018 if some basic issues are addressed, with or without a vendor pledge. “Progressive FHIR standards can allow EHRs to talk to other EHRs should standard definitions develop on enough actionable data points as we are enter a hectic period of HIE replacements, centering on the capabilities of open network alliances, mobile EHR, middleware and population health analytics as possible answers to standard HIE,” said Brown.

Thrusting HIE system replacements in Q1 2016 according to current provider users are:

  • 97% Potential for data breaches, Privacy & Security issues
  • 93% Cost of Custom Interfaces, Constrained Budgets
  • 90% Lack of connectivity with EHR Centric HIEs
  • 75% Complexity of current HIE Technologies
  • 72% Questionable sustainability of HIE vendors or agencies

Current users ranked six HIE vendors as top performers in their specialty theatres of engagement. Ranking first in their respective categories in the interoperability marketplace for 2016 are:

  • McKesson RelayHealth – Core Private Enterprise Platform and Packaged HIE Solutions
  • Infor – Complex Data Integrators and Outsourced HIEs
  • Optum – Private Payer and Commercial Insurer Centric HIEs
  • Aetna Medicity – Core Public/Government and Agency HIEs Systems
  • Cerner –EHR/HIT-based HIE, Open Networks
  • Epic Systems– Closed Network, EHR-Dependent HIE
  • Other vendors scored well in specific key HIE performance indicators were: Availity, Allscripts, CSC, Greenway, ICA, Medecision, and QSI Mirth.
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