There are a lot of elements of MIPS that should concern physicians, but Advancing Care Information isn't one of them.
Physician practices have found plenty to be unhappy about in the CMS' Quality Payment Program. The overall complexity of the Merit-Based Incentive Payments System (MIPS) is staggering, because it requires practices to determine which quality and improvement activities to focus on. But the technology-related segment of MIPS, Advancing Care Information (ACI), which makes up 25 percent of the overall score, has been a smoother transition, because there has been a logical progression from Meaningful Use (MU), consultants and providers say.
“If you have been successful in MU, ACI should not really be a challenge for you,” says Dan Golder, MD, a principal with Chicago-based healthcare IT consulting firm, Impact Advisors LLC. “MIPS as a whole is another whole story,” Golder stresses, “but I think ACI correlates fairly well to MU.”
Not Many Differences
Other consultants agreed that if a provider reported MU for the 2016 reporting year, they should have little problem with the ACI portion of MIPS in 2018. With the reporting period remaining at 90 days for 2018, a provider can use either a 2014- or 2015-certified EHR. If using a 2014 certified EHR, the provider will report on what CMS calls the “transition measures,” which are a subset of the modified Stage 2 measures reported by everyone for 2016. If your EHR system is 2015-certified, you can choose to report either the 2017 ACI transition measures set or the ACI measures set. Using the 2015- certified EHR gets providers extra credit.
Among the ACI base measures, providers should already have experience doing a security risk analysis for MU. Most are already e-prescribing and offering patients electronic access to their records through a portal. “Sending summaries of care has always been a bit tricky in MU, but people should have that down by now,” Golder says.
The main difference between MU and ACI is in the scoring, explains Jeanne Chamberlin, a practice management consultant with MSOC Health in Charlotte, N.C. “Under MU, you had to meet the threshold or an exception for each measure - the whole program was all or nothing. ACI is much easier,” she says. Using the transition measures, a provider is required to report four measures with a “yes” attestation or threshold of one patient to receive the base score of 50 points (out of 100). Additional points are based on how high your performance score is on these and other measures. You can choose not to enter data for a specific measure and still receive the highest possible score of 100 points.
One challenge is that the overall complexity of MIPS finds many smaller practices reliant on their EHR vendors to prepare for the requirements and reporting, and many of those vendors are struggling to keep up, Chamberlin says. She says CMS delaying the requirement to have a 2015-certified version and some Stage 3 MU measures until 2019 is extremely helpful.
"But I expect many EHR vendors will not be ready for that new deadline of 90 days in Calendar Year 2019 either,” she says. There are differences between the larger EHR vendors and smaller ones in terms of being able to adjust to the fluidity of the rules in time to help providers, Golder says.
Practice managers and physicians say they have had to work hard at MIPS, but ACI is the least of their headaches.
“The move from MU to ACI has not been a huge deal for us,” Abha Batta, billing manager for Ashim Arora, MD, who has a pulmonology practice in Simi Valley, Calif., with two physician assistants. “When we saw MIPS coming, we decided to join an accountable care organization to be part of a bigger entity,” she says. “They are submitting the improvement activities and quality information on our behalf, and we are submitting the ACI information ourselves." Batta’s practice is using the 2014-certified version EHR from drchrono, which includes a MIPS scorecard she says lets them proactively see progress on quality metrics to ensure success.
Ogechika Alozie, MD, has seen the transition from MU to ACI from two different perspectives. He has a private practice focusing on infectious diseases and he also serves as chief health information officer at Texas Tech University Health Science Center in El Paso. The transition from MU to ACI wasn’t difficult in his private practice, he says.
Alozie credits his EHR vendor, athenahealth, for providing the tools to help with the shift from one data-based program to another.
“They would send e-mails and a monthly scorecard so you could see if your numbers were not where you wanted them to be on some measures and you could take steps to improve them," he says
In his role at Texas Tech, one challenge he sees is that some providers have been in the Medicaid MU program and others in MIPS, yet they're using the same health IT platform. Although MIPS has fewer burdensome requirements than MU, “you always have some providers who do not want to engage and see this as a burden,” Alozie says. “They are digital immigrants, not digital natives, and they see this only as boxes to be checked.”
Practices tend to have the most trouble with view, download and transmit requirements and sending summaries of care, Alozie says. Providers of all sizes still having problems with transitions of care, he adds, saying that the industry as a whole needs to work on interoperability. “I have patients with HIV and hepatitis and I still have trouble getting consistent transition-of-care summaries from hospitals.”
MSOC’s Chamberlin says many providers in rural areas refer to other small practices rather than to large hospital-based clinics. Many of these referral partners haven’t done MU or MIPS and don’t have secure e-mail accounts set up to receive the summary of care document. “The exclusion finalized in the 2018 Final MIPS rule is really helpful for these folks, but it will continue to be a problem when the reporting period for ACI eventually moves from a 90-day period to the full calendar year,” she says.
A Focus on Care Coordination
ACI can be seen as a stripped-down version of MU focused on improving care coordination, says David H. Smith, assistant director of HIT and outpatient services manager for HealthInsight, a nonprofit quality improvement organization for a four-state region serving Nevada, New Mexico, Oregon and Utah.
“I think CMS has really focused on retaining the care coordination aspects of MU. In Oregon, we have been encouraging practices to do more management of their electronic inbox."
Practices can use the core part of ACI to improve their overall MIPS score. “With the Cost category in 2018, they are going to be scored on Medicare spending per beneficiary, and total per capita costs, so I think it makes sense to work on care coordination to understand more about what is happening outside their offices,” Smith explains. “Often providers will say they can’t control what happens outside their offices. To a certain extent that is true, but you can control where you send patients and you can check in with them to ensure that they are on the correct medications, and you can use these technology tools for those purposes.”
In other parts of MIPS, there are improvement activities that give you extra credit for ACI. One example: “Provide 24/7 access to eligible clinicians who have access to patient’s medical record.” However, one common improvement activity that gives you full credit for Improvement Activities but does not give you extra credit for the ACI category is being a certified patient-centered medical home (PCMH), Smith says. “Consequently, some clinics we have spoken to in Oregon use an ACI bonus improvement activity rather than electing to use something like PCMH to claim the improvement activity part of MIPS due to the extra points given for ACI.”
Practices also get bonus points for submitting data to a qualified clinical data registry (QCDR). “A few months ago I spoke with an ENT doctor who was concerned about MIPS,” Smith recalls. “We showed him the QCDR for ENT doctors and he got excited at that point. He had been working with this academy but didn’t realize it had a MIPS-supporting registry, so he was interested in taking advantage of that.”
Keep Eye on Cost Category
Just as HealthInsight’s Smith suggests that practices could use their technology tools required for ACI to focus on other parts of MIPS, Golder stresses that the Cost category is the one to keep an eye on.
“The MIPS final rule reinstated cost at 10 percent for 2018 and 30 percent for 2019,” he says. If everybody is scoring well on quality, improvement activities and ACI, the only thing left to differentiate providers is cost. If cost is 30 percent in 2019, and everyone is doing well on the other 70 percent of MIPS, cost is going to make a difference, he says. “Remember that MIPS is required by law to be budget-neutral, which means there has to be winners and losers. It comes down to how well you control cost. This is my forecast: In a large practice, you have the resources to help control cost by assigning a case manager to higher-cost patients. Smaller practices can’t afford that. They will not be able to compete with larger practices on controlling costs.”
MSOC Health’s Chamberlin recommends practices focus on the transition to a 2015-certified EHR and whether their vendor will be ready by early 2019. “But many are still focused on 2017 reporting and 2018 requirements – mostly in areas of MIPS other than ACI.”