Meaningful Use gets a facelift under MACRA—but is it better? Here's our view.

Naomi Levinthal, Health Care IT Advisor

The big news in health care this week is CMS's proposed rule to revamp how Medicare pays doctors. The rule would reward value and outcomes through two new programs: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Many of our members have asked how these new programs, established through the Medicare Access and CHIP Reauthorization Act (MACRA), would affect the existing Meaningful Use (MU) initiative. First, let's review what would stay the same and what would change under the proposed rule. Then we'll consider the question: Will the government's EHR incentive program be better under MACRA?

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What would stay the same?

  • The proposal would not change 2016 program year requirements. Providers would still be required to report Modified Stage 2 MU in order to collect any remaining incentives, and avoid payment adjustment in 2018.

  • The proposal applies only to clinicians who bill Medicare Part B. In future years, Medicaid Eligible Professionals (EPs) and all hospitals would continue to work within the existing MU program.
  • CMS would keep their "two-year lookback" policy. For example, performance in 2017 would determine payment adjustments in 2019.
  • Providers traditionally excluded from MU would not be scored on EHR use. This includes hospital-based providers, those facing an applicable hardship, and advanced practitioners—at least for the first performance year.

What would change?

  • MU would no longer be a standalone program. EHR use requirements—now referred to as Advancing Care Information (ACI)–would account for 25 percent of a provider's total MIPS composite performance score. That composite score, in turn, would be used to adjust a Medicare provider's payments upward or downward, or keep them flat. The total maximum downward adjustment for Year 1 would be negative 4 percent, and the maximum upward adjustment is 12 percent.
  • The proposal abandons MU's "all-or-nothing" approach. Currently, MU requires that providers meet all measure requirements, including specific performance thresholds. Under MACRA, CMS plans to reward providers for both participation and performance toward EHR use—even if they don't meet performance goals.
  • The participation component relates to a "base score" that awards providers 50 points of the total possible 100-point ACI category score. To receive the base score, providers would need to complete a security risk analysis, be in active engagement with an immunization registry (or qualify for an exclusion), and report a numerator (of at least one) and denominator for all remaining measures. Failure to report all base score requirements would result in a zero score. In that respect, this part of the proposal is "all or nothing."
  • The performance score consists of additional points awarded for certain objectives. No minimum threshold would be required for each individual measure. Rather, providers would receive up to 10 points for certain measures; in theory these measures could sum up to greater than 50 points, but CMS caps this part of the category's score at 50. CMS focuses the performance score on the Stage 3 Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange objectives (or their associated Modified Stage 2 measures in 2017). Additionally, providers can add up to one public health bonus point if they achieve Active Engagement with a public health registry (e.g., Syndromic Surveillance, or Specialized Registry).

Will MU be better under MACRA?

The proposal improves parts of MU for Medicare providers. It gets rid of the "all-or-nothing" approach, which often frustrated providers. The ACI scoring method would afford more flexibility, letting providers choose to target certain measures to boost their scores—even if they underperform on other metrics.

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However, the new programs would reduce alignment between MU EPs and Eligible Hospitals (EH)—reversing gains that CMS took great pains to achieve in 2015. In fact, ACI would be governed by wildly different standards than those governing Medicaid EPs and all EHs in MU. Staffers who are responsible for MU could struggle to keep track of varying program requirements and onboard their Medicare EPs to MIPS/APM in short order. For example, MU EPs that are still eligible for Medicaid MU incentives (potentially through 2021) would be required to continue to participate in the Medicaid MU program—and if they have Medicare Part B claims, they would need to also meet MIPS/APM requirements. This would result in double-reporting and potential confusion, as providers' performance is graded differently in Medicaid MU and in MIPS/APM.

Ultimately, there's no clear-cut answer on whether MU would be improved under MACRA, and CMS may make further changes in the final rule. What we can say for sure is this: MU isn't going anywhere. It will persist for years to come, both as a standalone program for certain providers and as part of MIPS/APM for Medicare clinicians.

Learn more about MU under MACRA

Join us for a webconference on June 7, 2016 at 3pm ET, where my colleague Ye Hoffman will dive into the details of the proposal, provide action items to prepare for the transition to MIPS/APM, and suggest key considerations for public comment.

Register now

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