Data-sharing attestations by providers as required by the proposed rule are drawing renewed criticism.


July 15—Medicare’s administrator recently revealed his agency was considering delaying the implementation of a new physician payment system. Although many clinicians and others in the healthcare industry support a delay, some are concerned about adverse impacts from the way in which the program could be pushed back.

Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services (CMS), told a congressional committee this week that his agency is considering delaying implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed rules implementing the law would require most physicians paid under Medicare to begin tracking various quality indicators on Jan. 1, 2017.

A representative of the American Medical Association (AMA) cheered the possible delay at a briefing for congressional staff and noted the organization had sought a start-date delay to July 1, 2017.

“We think that is reasonable,” Laura Hoffman, the AMA’s assistant director of federal affairs, said about a six-month delay. Such a delay would turn 2017 into a “transition year,” with data only reported for the last half of the year.

Why a Delay

Postponing MACRA’s start would give small and solo practices more time to prepare, including through the formation of “virtual groups,” which would be permitted under the rules to ease the data-reporting burden on individual providers. CMS is waiting until next year to issue rules for the creation of such virtual groups.

The additional time also would give the Physician-Focused Payment Model Technical Advisory Committee more time to recommend additional alternative payment models (APMs) as part of MACRA, Hoffman said.

Physicians who are part of advanced APMs will be able to skip MACRA’s complex quality-reporting requirements in favor of those required by the APM in which they participate. They also will garner an annual bonus of 5 percent of their prior year’s Medicare payments from 2019 through 2025. In comparison, low-scoring physicians not in advanced APMs can lose up to 4 percent of their Medicare pay starting in 2019 and up to 9 percent starting in 2022.

However, CMS has designated only six existing payment models as advanced APMs, meaning as few as 30,000 physicians will qualify for the APM track when payment begins in 2019. CMS estimated 687,000 to 746,000 physicians will be in the non-APM payment category, known as the Merit-based Incentive Payment System (MIPS).

Mark Segal, vice president of government and industry affairs for GE Healthcare IT and the former chairman of the EHR Association, agreed that the existing timeline is too short but warned that a “worse thing” would be a CMS decision to delay the start of MACRA after the final rules are released around Nov. 1.

“There’s potential for enormous waste with midcourse corrections because everything wasn’t considered the first time,” Segal said at the congressional briefing.

Fred D. Rachman, MD, former vice chair of the board of HIMSS North America, urged CMS to instead roll out the payment model through a pilot, although he acknowledged the agency may not have considered such an approach. However, that approach would help identify unintended impacts of the physician payment changes.

HIMSS has not requested a specific new implementation timeline, and neither have some other prominent healthcare advocacy groups, such as the American Hospital Association. HFMA urged a one-year delay of the MIPS and APM incentive payment provisions.

“Given the sheer scale of the changes contemplated to physician payments by MACRA, the potential for unforeseen adverse consequences on both patients and providers is significant,” HFMA’s MACRA comment letter said (login required). “If a one-year delay is not possible, HFMA encourages CMS to use whatever statutory flexibility it has at its disposal to delay implementation or phase in certain facets.”

The need for further physician education was highlighted by a Deloitte survey of 600 physicians that was released this week and found slightly more than half of non-pediatric physicians have heard of MACRA.

Info-Blocking Concerns

Both the AMA and the EHR Association waned against MACRA requirements that physicians sign an attestation that they would not block data sharing. Those requirements followed nonbinding pledges not to block EHR data sharing that were signed by several large health systems and most EHR vendors in March.

“Physicians are not trained in health IT, and these requirements are very complex,” Hoffman said. “At this point, asking them to attest on these things needlessly imposes risk on them.” Additionally, she said, the requirement is unneeded because many certified EHRs come with data-sharing functions activated, and physicians may not know how to turn them off.

The AMA’s comment letter urged CMS to revisit the attestation issue later.

Segal agreed that attestation “would expose them to enormous risk and uncertainty” and that physicians’ fears of audits “chill” the need for action. Instead of using attestation, Segal said CMS should let MACRA provisions naturally incentivize the exchange of data by encouraging a shift in provider focus from volume to value.

Mariann Yeager, CEO of the Sequoia Project, a not-for-profit focused on increasing interoperability, said that the issue is “very, very nuanced” and goes well beyond intentional blocking of data. Factors impacting patient data exchange can include business practices, software terms and conditions, and security and architectural decisions by a provider’s EHR vendor.

Standards being rolled out across data-sharing networks allow for certain terms and conditions regarding data sharing, but not for data related to patient treatment.

“We would suggest looking to the work that’s taking place in the implementation community and learning from that before taking a regulatory approach,” Yeager said at the briefing.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C. office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Friday, July 15, 2016