The Impact of Meaningful Use and MACRA on Long-Term Care
Annals of Long-Term Care: Clinical Care and Aging® sought out a physician to provide an expert opinion regarding meaningful use and its reincarnation under MACRA. We spoke with geriatrician Rajeev Kumar, MD, CMD, FACP, who serves as medical director at both AMITA Health Geriatrics and Adventist St. Thomas Hospice and Palliative Care (Hinsdale, IL).
The Electronic Health Record (EHR) Incentive Programs developed by Centers for Medicare and Medicaid Services (CMS) provide incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate “meaningful use” of certified EHR technology.1
In July 2010, CMS published a final rule that established three phases of the EHR Incentive Program. These three stages were designed to support eligible professionals and hospitals with implementing and using EHRs in a meaningful way to help improve the quality and safety of the nation’s health care system. Stage I of the EHR Incentive program began in 2011, with Stages II and III to be established by future CMS rules.2 Simply put, “meaningful use” means that providers need to show that they are using certified EHR technology to improve quality, safety, and efficiency in measurable ways.
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On April 14, 2015, with bipartisan support, President Obama signed into law the Medicare and CHIP Reauthorization Act of 2015 (MACRA), repealing the sustainable growth rate (SGR) formula for determining Medicare payments for clinicians’ services, which had been predicted to make 25–30% cuts annually in physicians’ payments for services provided to Medicare beneficiaries.3 MACRA establishes a new payment policy with the goal of developing and enhancing the alignment between value-based health care delivery and payment models. As of 2019, most physicians who treat Medicare patients will have to choose between two payment tracks—the merit-based incentive payment system (MIPS) and alternative payment models (APMs).4
The new rule will reimburse physicians based on four factors, grading them with a composite performance score on quality measures (30%), resource use (30%), clinical practice improvement activities (15%), and meaningful use (25%). Toward its goal of consolidating CMS reporting rules while expanding the number of providers participating in value-based payment (VBP) initiatives, MACRA paves the way for eligible professionals to take part in quality programs through either MIPS or other alternative payment models such as accountable care organizations, patient-centered medical homes, or bundled payments.5
Physicians have already been reporting on quality measures for some time under a few separate Medicare reporting programs (the Physician Quality Reporting System, meaningful use, e-prescribing, and the Value-Based Payment Modifier program), all of which have resulted in positive or negative annual adjustments to physician payments based on the reporting rules associated with each program. Under the new legislation, these programs will be combined into the single MIPS.6
With the multitude of reactions to these regulations, particularly to meaningful use and its widespread impact on health care professionals and patients, Annals of Long-Term Care: Clinical Care and Aging® sought out a physician to provide an expert opinion regarding meaningful use and its reincarnation under MACRA. We spoke with geriatrician Rajeev Kumar, MD, CMD, FACP, who serves as medical director at both AMITA Health Geriatrics and Adventist St. Thomas Hospice and Palliative Care (Hinsdale, IL).
In your own experience, how has meaningful use affected patient outcomes and care experiences?
At AMITA Health Geriatrics, we have a geriatrics practice with 13 physicians and 3 advanced practice nurses. Much of our work is in post-acute and long-term care (PA/LTC) settings. While we are subject to the meaningful use penalties for all PA/LTC evaluation and management encounters, the PA/LTC facilities themselves were excluded from the HITECH [Health Information technology for Economic and Clinical Health] Act that created meaningful use. Therefore, while we were given incentives to purchase EHRs and satisfy meaningful use, the facilities have had no similar incentive or obligation. Thus, we have encountered numerous challenges and hurdles specific to these places of service. Reliable internet connections are not always available. Unlike office settings, we don’t have access to support staff in nursing facilities to enter vitals, medications, allergies, lab results, and other data into our EHR. Sometimes we are asked to use the facility’s EHR rather than our own.
Moreover, the patients in PA/LTC settings have unique characteristics and care needs, but the quality measures developed for meaningful use were intended for patients in hospitals or in ambulatory settings. Some basic requirements, such as e-prescribing and electronic communication with patients, are irrelevant or impossible to achieve in LTC. Physicians’ practice EHR and the nursing facilities’ EHR often tend to be separate products with no interoperability and no functional interface. It is a common misconception that, because the PA/LTC sector was excluded from meaningful use, the physicians that work in that setting don’t have to worry about it. All physicians have to worry about all of the patients in their Medicare population, regardless of the care setting. The unfair nature of this program forces many physicians who are able to meet meaningful use requirements and receive bonus payments from their office practice to either forgo getting the bonus payment or see fewer PA/LTC patients to ensure they meet the meaningful use requirement and remain compliant with thresholds for meaningful use. That’s certainly not the way this program was designed to work, and, in its present form, meaningful use in PA/LTC work setting only hurts patients’ access to care.
What do you think has contributed to the challenges associated with meaningful use?
The incentives for participation and penalties for noncompliance have contributed to the success or failure of meaningful use. The “all or nothing” approach to satisfying meaningful use has led the majority of eligible professionals working in PA/LTC to seek hardship exemptions or accept the penalties. If this approach did not exist, and if the focus was not on penalties, I don’t think that the program would have had the limited success it has had. On the contrary, the further along physicians are with meaningful use compliance, the harder and less meaningful it has turned out to be. When we are already burdened with so many meaningless tasks to complete a patient visit, clicking a few more boxes just to satisfy a US government mandate has provided little to no improvement in clinical outcomes, no movement towards interoperability, and a proven dip in patient and physician satisfaction. This problem is largely what has caused meaningful use to fail in its final years.
Do you think MACRA improves on the meaningful use concept, or is it just meaningful use reincarnated? How will interoperability be affected by MACRA?
The SGR was the Damocles’ sword hanging over physicians, and its repeal is the biggest impact of MACRA. However, we now have to contend with MIPS and APMs, which still rely on reportable metrics including meaningful use. The US government is realizing that meaningful use is not realistic and too burdensome, but some of the elements are quite important to the success of VBP in general. Physicians have to dissect MACRA, MIPS, and APMs to understand the pros and cons of participating in innovative models of care. Interoperability remains the biggest hurdle, especially to the success of [accountable care organizations] and [clinically integrated networks]. EHR vendors are capitalizing on the lack of a clear and binding directive by the US government mandating interoperability. Interfaces are very expensive.
We hope that MACRA provides an opportunity for CMS to hit the reset button and truly assess the needs of patients in PA/LTC settings. Meaningful use must be changed to focus on interoperability and care coordination between physicians, pharmacies, and settings of care. This will truly address the needs of patients and their families rather than the current “check box” approach. If they simply roll the previous version of meaningful use (and other VBP) programs into MIPS, I am afraid we are on our way to a monumental failure.
What impact do you think MACRA will have on LTC residents and providers? Who will “win” and “lose” under MACRA?
MACRA is primarily a physician payment overhaul, but there has been little thought given to how it impacts physicians practicing in PA/LTC facilities. Under MIPS, the majority of the measures remain ambulatory care–based, and physicians who see the sickest (and the most expensive to care for) patients in PA/LTC settings will continue to lose in the game of value, accountable care, and appropriate utilization of resources until CMS addresses these differences in its attribution and risk adjustment methodologies. The same is true for APMs, which will remain ambiguous until CMS issues regulatory language to clarify implementation of the legislation.
Unfortunately, to date, much of the focus has been on various specialty societies, and PA/LTC residents and professionals who see them have been an afterthought. The US government tends to make policies without much input from those of us that practice in this sector. If the limitations faced by physicians and the unique characteristics of PA/LTC populations are considered in determining meaningful reportables for MIPS and APMs, then we have a fair chance to succeed under MACRA programs.
Do you have alternative suggestions to affect change that perhaps MACRA does not cover?
The US government should mandate interoperability of EHRs and functional health information exchanges and make EHR vendors responsible for setting up and maintaining interfaces; assist PA/LTC operators and practitioners in obtaining functional EHRs; modify reporting requirements based on patient characteristics; provide accurate and timely data for participants in VBP programs; come up with reliable and predictive attribution and risk stratification algorithms for patient populations to meaningfully measure cost of care; include PA/LTC operators and practitioners in shared savings programs; and align incentive programs under MACRA and the IMPACT Act [Improving Medicare Post-Acute Care Transformation Act of 2014] to ensure that physicians that see patients/residents in PA/LTC are working under the same incentive structure as the facilities themselves. Most importantly, they should consider the value of any quality reportable from the perspective of improving clinical outcomes; that is essential to make any of these ideas “meaningful.”
1. US Department of Health and Human Services. Meaningful Use Stage 1 Clinical Quality Measures for the Safety New Community. HRSA Web site. http://www.hrsa.gov/healthit/meaningfuluse/MU%20Stage1%20CQM/index.html. Accessed March 21, 2016.
2. US Department of Health and Human Services. What is “Meaningful Use”? HRSA Web site. http://www.hrsa.gov/healthit/meaningfuluse/MU%20Stage1%20CQM/whatis.html. Accessed March 21, 2016.
3. Myers, N. MACRA Establishes new medicare payment policies. Pharmacy Times. Published online March 9, 2016. http://www.pharmacytimes.com/news/macra-establishes-new-medicare-payment-policies. Accessed March 21, 2016.
4. Miller H. How the federal government can accelerate successful health care payment reform. Center for Healthcare Quality & Payment Reform Web site. chqpr.org/downloads/ImplementingAPMsUnderMACRA.pdf. Accessed March 21, 2016.
5. Miliard, M. Meaningful use will still be part of MIPS reimbursement, CMS official says. Healthcare IT News. Published online March 2, 2016. http://www.healthcareitnews.com/news/meaningful-use-will-still-be-part-mips-reimbursement-cms-official-says. Accessed March 21, 2016.
6. Doherty R. How Medicare fee-for-service is like a 1965 Ford Mustang. Published May 2015. American College of Physicians Web site. acpinternist.org/archives/2015/05/washington.htm. Accessed March 21, 2016.
