Meaningful Confusion II, and III

Meaningful Use Lives On

As promised in one of my last posts, MEANINGFUL USE IS DEAD, this is the whole story...so far.

Acting Director of CMS,  Andy Slavitt's most recent statement regarding meaningful use was unclear. 

by Brian Ahier, iHealthBeat, Tuesday, January 19, 2016

On Oct. 6, 2015, CMS and the Office of the National Coordinator for Health IT released the final rules for Stage 3 of the Electronic Health Record Incentive Program and the 2015 Edition Health IT Certification Criteria. Through this rulemaking, the agencies hoped to simplify requirements and add some new flexibilities for providers. They moved from fiscal year to calendar year reporting for all providers beginning in 2015, and they offered a 90-day reporting period for all providers in 2015, for new participants in 2016 and 2017, and for any provider moving to Stage 3 in 2017. They reduced the number of Stage 2 meaningful use objectives from 18 to 10 in 2015-2017, with no change in clinical quality measures. For Stage 3, there will be eight meaningful use objectives (with about 60% of them requiring interoperability).

They also requested additional feedback about Stage 3 of the EHR Incentive Program going forward, in particular with the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which established the Merit-based Incentive Payment System (MIPS) and consolidated certain aspects of a number of quality measurement and federal incentive programs into one more efficient framework. They plan to use this feedback to inform future policy developments for the EHR Incentive Program, as well as consider it during rulemaking to implement MACRA, which is expected to take place in the spring of 2016.

During last week's J.P. Morgan Healthcare Conference, CMS acting Administrator Andy Slavitt made some comments that threw the health IT industry into a tizzy about the future of the meaningful use program.
He said:

"The meaningful use program, as it has existed, will now be effectively over and replaced with something better. Since late last year we have been working side by side with physician organizations across many communities -- including with great advocacy from the [American Medical Association] -- and have listened to the needs and concerns of many. We will be putting out the details on this next stage over the next few months, but I will give you themes guiding our implementation.
For one, the focus will move away from rewarding providers for the use of technology and towards the outcome they achieve with their patients.
Second, providers will be able to customize their goals so tech companies can build around the individual practice needs, not the needs of the government. Technology must be user-centered and support physicians, not distract them.
Third, one way to aid this is by leveling the technology playing field for start-ups and new entrants. We are requiring open APIs [so] the physician desktop can be opened up and move away from the lock that early EHR decisions placed on physician organizations [to] allow apps, analytic tools and connected technologies to get data in and out of an EHR securely.
And finally, we are deadly serious about interoperability. We will begin initiatives in collaboration with physicians and consumers toward pointing technology to fill critical use cases like closing referral loops and engaging a patient in their care. And technology companies that look for ways to practice 'data blocking' in opposition to new regulations will find that it won't be tolerated."
A careful parsing of his statement does not lead to the conclusion that meaningful use as a construct is over, rather that it is being absorbed into MIPS. The program is designed to shift Medicare reimbursement from fee-for-service to pay-for-performance.

How MIPS Works
Starting in 2018, payments under the new system would be adjusted based on performance in the new MIPS incentive system, which consolidates three incentive programs:

• The Physician Quality Reporting System (PQRS), which provides incentives for physicians to report on the quality of care measures;
• The Value-Based Payment Modifier (VBM), which adjusts payment based on quality use of resources; and
• Meaningful use of certified EHRs.

There are four categories that will be used to asses performance under MIPS:

• Quality -- In addition to measures used in the existing quality performance programs (PQRS, VBM, meaningful use), HHS will develop additional measures.
• Resource Use -- The resource use category will include measures used in the current VBM program.
• Meaningful Use -- Certified health IT will be required in order to get credit in this category.
• Clinical Practice Improvement Activities -- Professionals will be assessed on their efforts to engage in clinical practice improvement activities. Incorporation of this new component gives credit to professionals working to improve their practices and facilitates future participation in alternative payment models.

Meaningful use accounts for 25% of the scoring towards reimbursement under MIPS. The current EHR meaningful use requirements, demonstrated by use of a certified system, will continue to apply in order to receive credit towards incentives in the new system. However, to prevent duplicative reporting, professionals who report quality measures through certified EHR systems for the MIPS quality category are deemed to meet the meaningful use clinical quality measure component. The scoring breakdown is as follows:

The law provides flexibility to participate in MIPS in a way that best suits a particular practice environment. These options could include:

• Use of EHRs;
• Use of qualified clinical data registries maintained by physician specialty organizations; and
• Being assessed as a group, as a "virtual" group, or with an affiliated hospital or facility.

Meaningful Use Going Forward

This next year will be very busy as the rules for implementing the program are released.
Note that Slavitt said the meaningful use program as it has existed will now be effectively over. But meaningful use as a means of measuring progress is still required to receive payments from CMS above the baseline. There has been basic agreement among stakeholders that the EHR Incentive Program as it is currently constructed has achieved the goal of widespread EHR adoption and laid a strong foundation for interoperability.

The recent letter from 31 large health systems (posted on John Halamka's blog) to HHS Secretary Sylvia Matthews Burwell asking the agency to reconsider Stage 3 meaningful use will apply additional pressure for change.

There has been some frustration expressed by physician groups that meaningful use is slowing them down and ultimately not improving care. Many commenters have said that it is time to move beyond process measures and begin measuring outcomes. This requires new thinking and workflows. CMS and commercial payers have made strong commitments to move away from fee for service into paying for value. The technology foundation established through the meaningful use and other programs would help achieve these goals.

MACRA also eliminates penalties in the EHR Incentive Program after 2017 to be replaced by the payment structure within MIPS. And finally, on December 28, 2015 President Obama signed the Patient Access and Medicare Protection Act, which among other provisions will provide flexibility in applying for a meaningful use hardship exception. This means that CMS no longer has to deal with the exemptions on a case-by-case basis. It also extends the timeframes to apply to apply for an exception.

According to the latest data from CMS almost 209,000 doctors and other health care providers will receive 2% cuts in their Medicare payments in 2016 for failing to meet meaningful use standards in 2014. Hardship exceptions will give relief and allow providers to pivot towards MIPS and alternative payment models. We may finally be reaching a tipping point in the transformation to paying for quality instead of quantity of care.

Source: iHealthBeat, Tuesday, January 19, 2016

Practice Fusion Said to Hire JPMorgan Chase to Explore I.P.O. - The New York Times

"SAN FRANCISCO — Practice Fusion, an electronic health records start-up, hired JPMorgan Chase last year to explore an initial public offering in 2017, according to people with knowledge of the matter, though the discussions are now in flux because of market volatility.

At the time, JPMorgan estimated that Practice Fusion could get a public market valuation of around $1.5 billion if it went public next year, according to a document prepared by both companies that was reviewed by The New York Times. The valuation was based on estimated revenue of $181 million for 2018."

Practice Fusion and Ron Howard (founder) and I have known each other since 2005. I was a founder of the Inland Empire Health Information Exchange.  Don Berwick, the initial ONCHIT head mentored me through the startup process of what was then called a Regional Health Information Exchange (RHIO)  We worked in an unknown landscape, more enigmatic than Pluto.  We spent most of our time educating physicians, hospitals and other providers.  Pioneers are never prophets in their own lands. I was greeted with skepticism, and quickly dismissed by most of my peers.

Ryan Howard presented a webinar for our group, which was at the time a seldom used medium for presentations.  Our medical society boardroom had a broadband internet connection and a large projection system.  At the same time we set up a voice conference using our tabletop conference phone.  For the time we were on the cutting edge.  Although we did not purchase Practice Fusion for the HIE the presentation turned heads and was a major factor in promoting our ideas..

The Practice Fusion model was one of the first attainable cloud EMR solutions and had the potential to work as the 'node' for any practice using Practice Fusion, and serve a dual purpose for hosting an EMR in the cloud as well as linking medical practices as a health information exchange.

It also was about the first subscription EMR solution,  breaking the standard client-server hardware configuration.  The advantages were enormous, easier non disruptive updates for all users. Elimination of software maintenance.  Minimal expense for hardware, and a GUI based on browsers (html).  

I would not be suprised if many other health information exchanges have an IPO offering. It suits the public service and would produce the capital outlay for further HIT development.  Federal and state grants are not reliable and often cease after the first two years.  This caused many other HIE's to fail.   The IHIE business model was to be self-sustaining from the first day.  In our region we were fortunate to have two or three 'anchor' users and build upon that base.

Some regions are not so fortunate and an IPO may well serve a purpose in those circumstances.

The outcome of the Practice Fusion IPO may fortell the potential. It will certainly be an excellent exit strategy for Mr Howard.  

The success of failure of an IPO depends upon many other factors, including market timing, other simultaneous IPO offerings and investor knowledge, 

Practice Fusion Said to Hire JPMorgan Chase to Explore I.P.O. - The New York Times

Meaningful Use is Dead !

Andy Slavitt puts meaningful use on ice; Read his J.P. Morgan speech transcript | Healthcare IT News

Another foolish CMS mandate results in a 15-20 billion dollar debacle.....Much time and effort and capital wasted for a meaningless mandate



MEANINGFUL USE IS DEAD !!

Meaningful Use Is Going to Be Replaced – #JPM16 | EMR and HIPAA

Meaningful use is facing strong resistance from providers.

Despite graphic presentations such as this one:



















During 2015, over 200,000 doctor's flatly rejected MU II for any number of reasons, indicating one year ago they had no plan to be able to accomplish that federal mandate due to cost, lack of vendor support, or outright rejection of the federal mandate's effort to collect 'big data' for analysis. (JP Morgan annual healthcare conference in San Francisco.)

Even prior to this John Lynn (The HIT Consultant) had a plan to blow up Meaningful Use.

"If you live, work, touch healthcare IT, then your world has been dominated for the past 3-5 years with something called Meaningful Use. The concept is a good one. The government gave $36 billion of "shovel ready" (Sorry, I just love the irony of the shovel ready stimulus being only half spent 5 years later) stimulus money for Electronic Health Records (EHR) and wanted to make sure that doctors would actually be "meaningful users" of the EHR software. Where this falls apart is that much of meaningful or that many of the meaning has already been achieved."

Among the current 'buzz words' this decade are big data, analytics, predictive modelling, mobile health, telemedicine, algorithms and more.. The feds ambition to employ more statisticians and/or keep CMS and/or their contractors occupied has been judged by providers to be a well intended goal, which should be overidden by common sense. effort. Meaningful use has no relationship to quality of care, nor the functionality of the electronic health record. 

Figures such as $ 15 - $ 20 billion have been quoted for the cost of M.U.  While this may be a small percentage of the total CMS expanditures it is not a small number.  The alternative allotment of these funds could be put to better use, and there are too many to outline here (This goes well beyond the scope of this article)

Federal ambition to harness EHR usage is stumbling badly.  The usual lemming behavior of providers to follow 'leadership' is rapidly being replaced with "I am mad as hell, and I am not taking it anymore".

Common sense has been replaced with Orwellian thought  and 1984 (Franz Kafka) thinking that government will control it all.   In some sectors this has taken place in the U.S. and around the world.

This is not to say that analyzing the cost of 18% of the GDP is not worthwhile. 

I expect this is just the beginning of the provider revolt sparked by the Affordable Care Act.  and
fueled by poorly conceived mandates of the law.

The 2016 elections and partisan discord may override thoughtful process as to where we go from here. At the least we will see significant amendments to the ACA, or an outright dissolution and replacement with a thoughtful replacement.

Nancy Pelosi was correct in her prediction "We won't know what is in it until we pass it"

Her statement was accurate and expressed even her doubt about the ability to plan health care in a monolithic law.  We now what is in the ACA. is a reflection of the comlexity of the American health system....

Stay tuned.

gml