A Deep Dive on the MACRA NPRM

Screen Shot 2016-05-05 at 4.20.36 PMAs promised last week, I’ve read and taken detailed notes on the entire 962 page MACRA NPRM so that you will not have to.

Although this post is long, it is better than the 20 hours of reading I had to do!Here is everything you need to know from an IT perspective about the MACRA NPRM.

1.  What is the MACRA NPRM trying to achieve with regard to healthcare IT?

The MACRA NPRM proposes to consolidate components of three existing programs, the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier (VM), and the Medicare Electronic Health Record (EHR) Incentive Program for eligible professionals (EPs), creating a single set of reporting requirements.  The rule would sunset payment adjustments under the current PQRS, VM, and the Medicare EHR Incentive Program for eligible professionals.

2.  Who is affected?

In the MACRA NPRM, the word Eligible Professional is replaced with the term Eligible Clinician, expanding the population of individuals covered by Merit-based Incentive Payment Programs (MIPS).  MIPS eligible clinicians will include physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include such clinicians.   Hospitals are not affected by this rule and  hospital-based MIPS eligible clinicians are not required to participate in the information technology portions of MACRA, since they may not have direct control over the software implemented by the hospital.

3.  When does the rule take effect?

The rule proposes that the first performance period would start in 2017 for payments adjusted in 2019.   It’s not exactly a stimulus program – some clinicians will see reduced payments for non-performance and some will see enhanced payments for exemplary performance – a zero sum redistribution of payments.

4.  Does Meaningful Use and electronic clinical quality measure reporting go away?

MACRA’s enactment altered the EHR Incentive Programs such that the existing Medicare payment adjustment for a eligible professionals ends after calendar year 2018.  Generally,  MACRA did not change hospital participation in the Medicare EHR Incentive Program or participation for professionals in the Medicaid EHR Incentive Program.

Meaningful use of certified EHR technology is renamed to  “advancing care information” and the criteria are streamlined – removing the CPOE and Clinical Decision Support requirements.   In 2017, clinicians may still use 2014 edition certified technology and report on eight Stage 2 measures.   By 2018, clinicians need to use 2015 edition certified technology and report on six Stage 3 measures, described below.

Quality measures will be selected annually through a call for quality measures process.

5.  What is the role of ONC and Certification?

On March 2, 2016, ONC published the ONC Health IT Certification Program: Enhanced Oversight and Accountability proposed rule, which would expand ONC’s role to strengthen oversight, requiring that clinicians give access to their EHR for “field inspection” of functionality by ONC.

The MACRA NPRM proposes that clinicians must attest they have cooperated with ONC surveillance and oversight activities.  Further, they must attest they have not knowingly and willfully taken action (such as to disable functionality) to limit or restrict the compatibility or interoperability of certified EHR technology.

6.   What are the MACRA advancing care information objectives and measures that have replaced Meaningful Use?

The six criteria which are required as of calendar year 2018 are

1. Protect Patient Health Information – Security Risk Analysis
2. Electronic Prescribing
3. Patient Electronic Access – Patient Access, Patient-specific education
4. Coordination of Care through Patient Engagement – View/Download/Transmit, Secure Messaging, Patient Generated Health Data
5. Health Information Exchange – Patient Care Record Exchange, Request/Accept Patient Care Record, Clinical Information Reconciliation
6. Public Health and Clinical Data Registry Reporting – Immunization Registry Reporting

Here are examples of the actual measurements:

Secure Messaging Measure: For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the electronic messaging function of certified EHR technology to the patient (or the patient-authorized representative), or in response to a secure message sent by the patient (or the patient-authorized representative).

View, Download, Transmit (VDT) Measure: During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician. An MIPS eligible clinician may meet the measure by either—(1) view, download or transmit to a third party their health information; or (2) access their health information through the use of an API that can be used by applications chosen by the patient and configured to the API in the MIPS eligible clinician’s certified EHR technology; or (3) a combination of (1) and (2).

7.  So what must a clinician do and when?

For the period January 1, 2017 to December 31, 2017 (yes, it’s a full year, not 90 days), clinicians must
a.  Use a 2014 or 2015 Edition Certified EHR
b.  Report on either eight stage 2 or six stage 3 advancing care information objectives and measures:
c.  Attest to their cooperation in good faith with the surveillance and ONC direct review of their EHR
d.  Attest to their support for health information exchange and the prevention of information blocking.
e.  Continue to practice medicine

Sorry, e. was an attempt at humor.    Listening to each patient’s story, being empathic, and healing are optional.     After spending 20 hours reading the MACRA NPRM, I had one overwhelming thought.    Sometimes when you remodel a house, there is a point when addtional improvements are impossible and you need to start again with a new structure.    The 962 pages of MACRA are so overwhelmingly complex, that no mere human will be able to understand them.    Above, I have only covered the HIT related concepts, which are a small subset of all the changes to payment processes.    This may sound cynical, but there are probably only two rational choices for clinicians going forward – become a salaried employee delivering clinical care or become a hospital-based clinician exempted from the madness.

The folks at CMS are very smart and  well meaning, but it’s hard for me to imagine implementing the NPRM as written in the timeframes suggested.   I will watch closely for comments from organizations such as the AMA, AHA, and clinician practices.    I’m guessing that many will see the ONC Surveillance provisions as overly intrusive and the “advancing care information” requirements as creating more burden without enhancing workflow.    Maybe the upcoming Presidential transition (whoever is elected) will give us time to pause and reflect on what we’ve done to ourselves.    As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory.

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16 replies »

  1. Actually not at all surprised by this post from John as we both have been looking on with what has been happening in DC for the last few years, increasingly shaking our heads.

    First it was MU and how it became so prescriptive as to become completely meaningless, leading to the oft-used phrase, Meaningless Use.

    Now MACRA hits the streets. Having read about half of it – came much to the same conclusion as John. Sad thing though is that in reading it, you can see that its authors are honestly sincere and trying to do the right thing – from their vantage point. They did away with the highly prescriptive nature of MU and actually removed big pieces (CPOE, CDS). They provided more flexibility for physicians to choose what quality measures to report out on – measures that reflect their practice, not one size fits all. These are things physicians were asking for.

    But despite these efforts, rather than making it easier for physicians, CMS has created a Rube Goldberg policy and reimbursement framework in MACRA. All the flexibility in MACRA has created an exponential growth on complexity. Physicians/clinicians have every right to be thoroughly dismayed as it looks like the only winners here will be the consultants who will come out of the woodwork to advise on MACRAnomics and best path forward.

  2. If CMS does not have Dr. Halamka, he has lost the entire physician community. However, as a non-physician I would offer the following:

    1. I agree that the 962 page NPRM is a disaster, impractical and a total waste of time. The people at CMS live in their own fantasy world. They have gotten a lot of blowback on Meaningful Use, and they just don’t get it.

    2. Every physician I know hated the SGR. Med societies worked with Congress for years to repeal the SGR. They did so but replaced it with MACRA. If you are a physician and you are in a Med Society that lobbies Congress you have to call them up and in the immortal words of Donald Trump ask them “what the hell is going on?” MACRA was supposed to be something you could live with.

    3. With all that being said, this is CMS attempt (albeit pathetic) to implement a new system that reins in cost. Our healthcare costs in the country are out of control. They are so high that they threaten our GNP much more so than ISIS. You should read or follow David States on Twitter. When I have talked to physicians in the past, they could give a rats *** about cost. Physicians need to understand that cost containment and reduction is paramount in today’s healthcare environment. The attitude of “let the insurance pay for it” is just not acceptable. This represents a change in thinking for many people, patients included.

    4. Not a criticism of physicians, because they have been providing care under the current “rules of engagement”. The new rules need to be focused on containing cost and need to be reasonable to implement within the day-day practice of medicine. So, IMHO, MACRA should be focused entirely on cost containment. If you are commenting, provide supportive feedback on anything that relates to cost containment that you think is reasonable. This obsession with quality measures is insane. Throw all that stuff out the window. Theoretically it would be nice to have them, but that is theoretically. No one can even agree on what the measures should be.

    5. Of course, in America, the government does not innovate. The private sector does. The good news is that there are a lot of things being done in the private sector to reduce cost. The government should really be focusing on those things and reflecting them in the NPRM.

    6. I do not know Andy Slavitt, but I think he means well. He is not a lifelong healthcare policy wonk. He came to CMS after he fixed up the healthcare exchanges. I have read some comments he has made about the NPRM, and I think he thinks it is awful. He has encouraged people (tacitly) to make their thoughts known.

    Just like in elections, low voter turnout brings bad results. Since MACRA is such a piece of ****, do what you can do. Make comments. Here is the URL:


    Let them know what you think! I am sure that an avalanche of comments will get their attention.

  3. Agree. Part of the problem is that all the attempts to correct quality and value have been extremely top-down. There is not much interest in enabling patients to assess quality on their own terms — patient-centered HIT wd be necessary but not sufficient — and there should be.

  4. I’m not sure direct pay is scalable and sustainable either, but we have to hunker down and survive somewhere.

  5. I’ve got my congressman, senators and others on speed-dial–will call them today and start giving them the DOCTOR side of the story and that they MUST shut this madness down. AMA is AWOL, as usual, waiting to see which way the wind blows. I hope a change in the regime will throw out the garbage accumulating in the hallway. And make no mistake, this is pure garbage, there is no way the million+ clinicians can become unpaid data entry clerks AND attempt to cure disease and suffering in a very complex, increasingly old society.

  6. The futility of trying to regulate health information technology in the 21st century is becoming clear. Medicine is traditionally regulated in two balanced ways: devices are regulated at the vendor level (by the FDA or foreign equivalents) and medical practice is regulated as a profession by tort and admitting privileges at the edges of the system. MU and MACRA are an attempt to introduce a third kind of regulation of medicine, based on centralized remote control of the practitioners by an overlapping mess of employers, giant vendors, state, and federal bureaucracies. This folly has been shown to undercut the two established vendor and practice regulatory methods while adding no benefit to the public interest.

    It’s time to move on to patient-centered health information technology and let doctors be doctors regardless of whether they are in direct pay or employed situations.

  7. As a family physician who was once solo, independent, and at the time using EHRs and had initially opted out of Medicare in 2009 because of MU (the irony!) to make it work only to close down and switch to direct pay in 2012, I feel like primary care physicians (especially those that want to work with the chronically ill, multiple co-morbidities, working with mental health when there already is a crisis of not enough mental health providers) continue to be abused by these “programs” that only continue to marginalize and I believe worsen the availability and access of primary care physicians for these vulnerable patient populations (elderly, disabled). It’s not even kicking the can down the road…it’s kicking the can off the cliff is what I think is going on. I’m not sure how sustainable direct pay is going to be to address these more vulnerable patient populations but it’s the only way I can continue to use my skills while this apocalypse is unfolding…How sad…

  8. John is one of the respected leaders of HealthIT in the US. When he speaks people do listen (but do not act). He since resigned his post, and during his stay could not move the needle on this while participating in the rooms with the CMS and ONC knuckleheads over the past few years. John’s grave assessment speaks volumes. He only reviewed the MU part, I mean Advancing Care ( or Crap, I might as well start now) Information, and that is only one part of the huge MACRA disaster. Quality (was PQRS) is still there in nearly full form and complexity and now they added a Clinical Practice Improvement Activity which is like kicking me in the head after we all tapped out of the fight. To add further insult to injury, you can try to form a Advanced APM, but I can hear the authors at CMS giggling as the wrote it. I mean you really need a team of lawyers, accountants and health policy advisors to even come near it, and there is no way on this planet that anyone could come close to complying with that nightmare. So forget AAPM’s, they are just nonstarters. So when you take the “vision” or overall idea behind this, it appears CMS wants every practicing physician to 1. Quit Medicare/Retire 2. Kill themselves 3. Take full penalties 4. Become employed by a hospital. Its like they lined up a firing squad for the hundreds of thousands of small providers. Its perfectly clear now. CMS and ONC want to destroy physician practice and that will reduce cost, since there will be no one left to see any CMS patients and they can crank down costs by just not paying for any services to the poor souls left employed by huge institutions. I also feel AMA has sold us down the river, along with most organized specialty societies and leaders. Their day of reckoning is coming soon similar to ABIM. It also fries me that Andy and Karen and the MACRA team claim to have spoken to hundreds front line physicians throughout this process, yet I have yet to meet one that thinks any of this is a good idea. Not one. I tell everyone I can, tweet them, comment them, comment the rule, make our position known. MACRA is a disaster and a nonstarter. If that doesn’t work, go congressional (ugh). Even John sees the writing on the wall with the most damning statement I have ever seen him write. “As a practicing clinician for 30 years, I can honestly say that it’s time to leave the profession if we stay on the current trajectory” Wow, if that is not the most depressing thing I have heard from him, I don’t know what to think. I will fight on, but deep down, I know, I may get in a few licks with tweets, comments, responses, but the tsunami is rapidly approaching, and that will be it for me, its too bad, because I am a pretty darn good doctor.

  9. Nice summary, albeit sobering. So, isn’t there a third option for clinicians: opting out and going to direct pay?

    I must say that when I decided to opt-out four years ago, I saw it as a temporary solution while my kids were small and while I reset my career over a period of a few years. But now I’m wondering how I’ll go back…the salaried front-line docs I know are pretty unhappy.

  10. The medical societies claim they were part of the process. Now the are acting like they have no idea what will transpire.

  11. Wow. I did not expect that ending after all the homework you did. Thank you for your effort. Yes, our medical societies will have some explaining to do. Is unimplementable an adequate term? If legislation becomes so complex that no physician can comply with it, no oversight body can reinforce it, and funding is inadequate…
    I feel very badly for the people who are sick and really need medical care.

  12. I find it interesting that the physician advocacy organizations – the AMA – for instance are sitting on the sidelines for now. Steven Stack the current head of the AMA – is actually ‘cautiously optimistic’ about MACRA and awaits public comments from physicians. How can a physician advocacy organization be cautiously optimistic about a 962 page document that saps the last vestiges of hope from any practicing physician charged with attempting to implement this? The only folks that seem to be salivating are the health care consultants promising to teach the harried physician about ‘MACRAnomics’. Here is a tip: In 2016, you cannot call yourself a physician advocacy organization if you support tying up your members with meaningless metrics that don’t add value or reduce cost. Arguing about which metric or performance measure to include misses the point completely, and will still leave plenty of unhappy people (See michael millenson’s post on the inadequacy of patient engagement in MACRA https://thehealthcareblog.com/blog/2016/05/01/you-wont-believe-what-medicare-just-did-on-patient-engagement/). While the AMA may be waiting for my comment on MACRA, the AMA’s stance, or lack of one in the coming months will speak volumes for how relevant of an organization it is.

  13. Cliff Notes from @jhalamka are, as always, friggin amazing. This man is a national treasure in re health policy.

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