MACRA, the End of Meaningful Use, and Beyond

The move from meaningful use to the value-based payment world of MACRA, MIPS, and the APMs is coming into focus.

This article first appeared in the July/August 2016 issue of HealthLeaders magazine.

Meaningful use as we knew it changed on April 14, 2015. And what it's becoming is still being discerned by physicians, healthcare executives, and the industry at large.

On that date, a large bipartisan majority in Congress passed the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA. MACRA permanently repeals the flawed Sustainable Growth Rate formula for determining Medicare payments for clinicians' services. According to the Centers for Medicare & Medicaid Services, it also establishes a new framework for rewarding clinicians for value over volume, and streamlines other existing quality-reporting programs into a single new system.

But before any of that can occur, the entire healthcare industry must gain a better understanding of MACRA, policies and procedures must be implemented, and technology needs a serious upgrade. In January 2016, Acting CMS Administrator Andy Slavitt created some confusion in the industry by describing MACRA as the end of meaningful use as we knew it, when, in fact, later clarifications more accurately described it as an evolution of meaningful use for physicians as expressed by Congress in the MACRA legislation.

The true scope of MACRA became clearer on April 25, 2016, when CMS released the 962-page Notice of Proposed Rulemaking (NPRM) for MACRA, and opened a two-month comment period. As Slavitt had to emphasize in January, the meaningful use program would continue uninterrupted for hospitals. In fact, stage 3 of meaningful use for hospitals, which is also a component of moving toward value-based care, is due to commence in 2017 for early adopters, and in 2018 for hospitals in general.

But on the physician side, as spelled out in the MACRA legislation, meaningful use was indeed being replaced by a program given the new name Advancing Care Information (ACI), which is just one component in the larger matrix of CMS physician incentive programs that kick in January 2017 and that will trigger increased or decreased payment adjustments starting in 2019.

Those incentive programs, known as the Merit-Based Incentive Payment System (MIPS), and Alternative Payment Models (APM) will start to move all physicians toward a goal expressed in the 2010 Affordable Care Act: for physicians to be reimbursed not for services rendered, but instead for outcomes.

How to get from fee-for-service to value-based care is still a journey of many unknown turns for providers, not all of whom are convinced that ACI will do away with the busywork physicians had to perform under meaningful use.

"Based on what I'm seeing so far of MACRA, I think we're still going to be clicking a lot of boxes" in 2017, says Randy McCleese, vice president of information services and chief information officer at St. Claire Regional Medical Center, a 159-licensed-bed Morehead, Kentucky, hospital with 100 physicians, six primary care clinics, and two specialty clinics.

Like many of his executive counterparts, McCleese, a past board chairman of the College of Healthcare Information Management Executives, spent the weeks following the release of the MACRA NPRM on numerous conference calls, as the industry struggles to make sense of the proposed rule and chart a path forward. "We, as an organization, are just starting to get our hands around MACRA," he says.

Some of the organization's physicians believe that MACRA means the end of meaningful use. "The meaningful use program is just being rolled into and consumed into something bigger and something broader," McCleese says.

McCleese welcomes the consolidation of overlapping quality measures outlined both in meaningful use stage 3 and in the proposed MACRA rule. At present, "we've got to report the same thing in three or four different formats to different agencies that need the same data," he says.

Also challenging McCleese under the current meaningful use program: MACRA and meaningful use, going forward, require electronic reporting of quality measures, but various EHR software, including the Meditech EHR software in use at St. Claire, isn't yet set up to automate that reporting. Instead, St. Claire staff must export the data from the EHR to spreadsheets and prepare it for electronic submission, adding to a cumbersome process.

Some broad governance implications of the move from meaningful use to the value-based payment world of MACRA, MIPS, and the APMs is also coming into focus for McCleese. Fast fading are the days of CIOs managing the meaningful use program in relative isolation from the rest of the executive team.

"It is going to have to be a multidisciplinary governance area, in our case, that will heavily involve our CMO and vice president for quality, and we're also going to have to bring in nursing," McCleese says.

McCleese also echoes the concerns in the industry that the MACRA legislation itself, on top of the HITECH legislation that created the meaningful use program, requires physicians to report on too many quality measures too soon. "If we try to get all of them, I'm not sure we're going to do a very good job at any of them," he says. "If we focus on five measures in each of the specialties, then 10, then 15, then 20, we'd be better off."

Karen Wilding, director of IT operations at the 12-hospital University of Maryland Medical System, headquartered in Baltimore, says, "Meaningful use objectives are going to remain. We are still expected to adhere and be successful. They are part of our ongoing operations and expectations, and now we have an ability to build on what we've already been successful on previously."

The key to that success is a physician governance structure that allows for frequent physician engagement and feedback, Wilding says. "Also, we have end-user work groups that have allowed our staff that work in the practices and in the hospitals to provide feedback on the day-to-day impact of the program."

Wilding is responsible for the day-to-day operations of the IT department as well as the meaningful use program for the medical system. "Ongoing analysis continues as we seek to better understand how the new proposed legislation directly impacts our employed providers and the medical system at large," she says.

UMMS' implementation of the Epic EHR makes Wilding confident that "while we still have some build and testing we're going to have to roll out as a result of MACRA changes, we believe it's manageable."

"How fast do you burn your existing fee-for-service structures down to replace them with value-based care? It's where you've got point-of-care systems built into your EMR to where the doc can know what needs to happen on this patient right now."

Wilding also says she thinks that MACRA may resolve some physicians' concerns. "You had these silly metrics that were kind of arbitrary and didn't necessarily mean that you were providing better care or were more efficient."

One potential distraction at UMMS: upgrading by this fall from the 2012 version of Epic to the 2015 version, Wilding says.

Two other health systems represent the wide spectrum of preparedness to leave fee-for-service behind, the desired outcome for MACRA.

At Mosaic Life Care, anchored by a 350-licensed-bed hospital in St. Joseph, Missouri, Joe Boyce, MD, chief technology officer and chief medical information officer, says the key to thriving in the age of MACRA comes down to "how fast do you burn your existing fee-for-service structures down to replace them with value-based care. It's where you've got point-of-care systems built into your EMR to where the doc can know what needs to happen on this patient right now."

"We were ahead of the ACO curve by 2 or 3 years for most people, but again for our size, it's kind of like, let's invent this lifeboat before we need it," Boyce says. "We just said let's evolve it ourselves quicker to this new payment model."

Mosaic set the stage in 2012 when it entered its first accountable care organization arrangement with CMS. Modifying its Cerner EHR software, Mosaic was able to create a summary page "that basically shows all of the quality measures we've got for a patient, and which ones are overdue, and which ones are due next or when they were done," Boyce says. The system has been so effective, it is becoming difficult for him to find records of any patients who have significant gaps in care, he says.

Mosaic also minimized some of the transition pain by moving into a new market 55 miles south of St. Joseph. "By opening our clinics in the Kansas City area, as an outpatient move, we wouldn't hurt our inpatient services as much," Boyce says.

Then there are the systems for which fee-for-service is still the norm, and the path ahead is steepest of all.

At Spartanburg Regional Healthcare System, which consists of three hospitals and 23 primary care practices, "I still live and breathe in fee-for-service," says E.G. "Nick" Ulmer Jr., MD, CPC, vice president of clinical integration and medical director of case management. "We're really now looking at quality not only on the inpatient side, but we have a medical group here of 300-plus physicians that are employed."

Given its experience with PQRS and meaningful use, "it's become very complex in the last couple of years, and even more so in the last year as we start to educate physicians on MACRA, MIPS, and alternate payment models," Ulmer says.

Spartanburg does have some contracts "where there is a shared-savings type of opportunity, which is not the Medicare Shared Savings, but it's a contract where there are quality metrics tied to our revenues," Ulmer says. "There are quality metrics in some contracts where we get bonuses, but we're still fee-for-service underneath those. It's not that we're given a dollar to manage the care. It's that we're getting paid a negotiated fee-for-service rate with opportunities to get bonuses that are linked to cost and quality and things along the lines of safety, like readmissions and ED utilization."

As a way of understanding the upside and downside risk MIPS and APMs may impose upon Spartanburg moving forward, Ulmer has partnered with SA Ignite, a company with meaningful use readiness tools that are now evolving into MIPS calculator tools, allowing those in the C-suite and others to see how much money is at stake, showing both the potential upside and the downside of the MIPS and APM payment models.

"We have a high level of anxiety about being ready, and some of it's because there's so much that we still just don't quite understand," Ulmer says. "We have two governance buckets here of meaningful use and other quality metrics, so we are now trying to have an aligned quality message to eliminate gaps in reporting on either the inpatient or the outpatient side.

"We have talked about Medicare Shared Savings, but we just don't know. We're trying to go into one of these payment models, but we may not be ready yet. But that's our goal."