New reimbursement plan may eliminate need for Stage 3

Physicians and other eligible professionals under the electronic health records meaningful use program were tasked to make significant investments in EHRs; in large part, they did under Stage 1. Stage 2 imposed tougher steps in EHR capabilities that much of the industry was not ready for, and many providers dropped out of the program.

Now, changes to Stage 2 muddy water waters; in part, they would ease reporting requirements for eligible professionals but also impose several confusing new requirements in a proposed rule issued in April and authorized by the Medicare Access and CHIP Reauthorization Act of 2015, known as MACRA.

Stage 2 EHRs already have functions necessary under MACRA to support accountable care and population health management. And Stage 2 as originally implemented already is tough to successfully complete.

Now comes Stage 3, which is voluntary for eligible professionals starting in 2017 but mandatory for 2018. However, if the overall goal of Stage 2 was to help providers get better at accountable care and population health management, is Stage 3 overkill or does it have real value?

Robert Tennant, director of health information policy at the Medical Group Management Association, believes Stage 3 is a non-issue.

That’s because the new Merit-based Incentive Payment System (MIPS) authorized under MACRA incorporates a number of Stage 3 requirements to measure physician performance within the modified Stage 2 rule that has been proposed. Performance measures include electronic prescriptions, enabling patients to view/download/transmit their electronic healthcare data, and secure messaging.

The big concern for MGMA is whether there will be enough time for EPs and their vendors to prepare for changes to Stage 2 next January and the start of Stage 3 in January or in 2018. Normal processes for major rules would have the final rule coming out in November or December and MGMA members fear they may only have one or two months to comply with final rule requirements, which Tennant contends is an impossible task.

Further, all the new policy changes in the rules from the Centers for Medicare and Medicaid Services are confusing, and providers don’t have enough time to do everything. What are their options? Do eligible professionals get ready for modified Stage 2, or focus getting ready for Stage 3, while the same time needing to prepare for MIPS?

Vendors also are concerned about how they should focus resources. Do they start research and development on proposed rule requirements, or do they wait until they see a final rule? The reality, Tennant says, is that vendors are not covered entities—they are businesses that may or may not make changes to support modified Stage 2 and upgrades to 2015 certification criteria, along with helping EPs now using 2014 EHRs get upgrades, and build Stage 3 EHRs. “You can’t start the rule on January 1; that’s almost a given,” he adds.

Fortunately, regulatory relief (not from CMS but elsewhere) is likely if the agency is pushing hard to get a final rule out. President Obama leaves office in January, and incoming administrations frequently place new or pending rules on hold for review.

MGMA isn’t the only provider association that saw its members rebel about Stage 3 and doesn’t necessarily see a bright future for Stage 3. “Meaningful Use 3 was predicated on an incredibly flawed Stage 2, and many of our members walked away from it,” says Wanda Filer, president of the American Academy of Family Physicians.

The proposed new rules for modified Stage 2 and Stage 3 do offer the chance for eligible professionals to get more robust EHRs from vendors, Filer acknowledges. But AAFP is seeing a reduction in EHR use because of poor performance and high costs; vendors have work to do to regain trust.

AAFP has the same fear as MGMA; that CMS will rush out a rule late this year, according to Filer. AAFP is looking for a delay in Stage 2 modifications and Stage 3 to July 2017 at worse and January 2018 at best.

But overall, rulemaking will make it difficult for physicians to focus on their core duties, and the changing payment models under MIPS aren’t helping either, Filer says. “Our members want to take care of patients, have more time with them and get paid for it.”

Whether anyone wonders if Stage 3 is finalized may be a moot point, warns Justin Barnes, a long-time executive at vendor firms now known as Greenway Health, Relay Health and HBOC, and leader of Justin Barnes Advisors, a consulting firm.

He counsels providers that they have to move toward accountable and value-based care anyway. Further, objectives in Stage 3—electronic prescribing, patient access to their data, security risk analyses, public health and clinical data registry reporting, health information exchange and care coordination—will help them succeed.

If providers quit meaningful use and do not report quality measures, they will make progressively less money from Medicare reimbursements starting in 2018 and going forward, as well as Medicaid and private payers that continue to cut their reimbursement rates, Barnes cautions. “There’s no place to go run and hide; you’ve got to do this.”

Stage 3 gives an indication of where future payments and quality measures will go, so use it to be ready, he counsels. “Look three years in advance now to see where you will be.”

Barnes envisions new companies coming into the EHR market with software that layer on top of existing EHRs and support value-based care and population health management. Pick those companies carefully, he says; look for managers in new companies that have substantial health information technology expertise and look for innovation in new products currently unavailable from many EHR vendors.