Physicians exempt from Medicare incentive payment system will do more harm than good

The Center for Medicare and Medicaid Services’s (CMS) proposed rule to exempt two-thirds of the nation’s clinicians from the Medicare Incentive Payment System (MIPS) will do more harm than good. However, the difficulties to comply with quality reporting measures and the resulting burden on providers are significant.

As much as possible, we need to give physicians less paper and computer work and more time with their patients. However, excluding most of the country’s clinicians from CMS Quality Payment Program’s Merit-based Incentive Payment System (MIPS) will penalize clinicians, result in direct patient harm, and disable the infrastructure of electronic health records (EHRs) that has been subsidized with $37 billion taxpayer dollars.

{mosads}Rural clinicians are exempt from quality reporting, and according to the federal government, have provided lower quality care. The National Rural Accountable Care Consortium has direct experience in rural quality reporting. Formed in 2013 by rural providers to create the first national rural Accountable Care Organization (ACO), the 501 non-profit organization represents 23 rural ACOs and more than 10,000 clinicians whose small and rural practices have fewer than 10 clinicians each, exactly the profile of practices proposed to be excluded from quality reporting.

In our first year as an ACO, we learned our aggregate quality score was much lower than average (69 percent vs. 91 percent). We expanded our care teams with nurses to provide Chronic Care Management and Annual Wellness Visits, and in less than a year, prevented hundreds of avoidable hospitalizations and delivered ACO quality scores above 95 percent. It was not an unmanageable burden on our practices and improved the health of our patients.

Two important quality measures CMS wants to exclude providers from reporting are pneumococcal and influenza vaccines. Our data clearly shows that more vaccines means fewer patients going to the hospital and fewer pneumonia-related deaths. Within 12 months, we increased our influenza and pneumococcal vaccine rates by 43 percent and 17.6 percent, respectively, and reduced pneumonia hospitalizations by 25 percent.

According to the Centers for Disease Control (CDC), pneumonia and influenza are the third most common causes of admission for seniors. Ten percent of patients do not recover from the illnesses. With 55.5 million Medicare patients in 2015, one-third did not receive the recommended vaccinations, resulting in 674,000 avoidable visits to the Emergency Department (ED) and hospital, and 50,622 avoidable deaths. The bottom line is Medicare patient’s lives are being saved because ACOs are required to report on quality.

The proposed increase of the low-volume threshold may have unintended consequences of encouraging exempted physicians to abandon their EHRs.

The foundation for what developed into the Office of the National Coordinator for Health Information Technology (ONC) was laid during President George W. Bush’s administration.

Following President Barack Obama’s signing into law of the American Recovery and Reinvestment Act (ARRA) in 2010, Meaningful Use incentives were established. As of June 2017, more than 531,100 health care providers received payment for participating in the Medicare and Medicaid Electronic Health Record Incentive Programs, spending $37 billion. This investment allowed the US health care system to create the foundation for integrating health care and breaking down silos of information, although true interoperability remains elusive.

EHRs are neither perfect, nor universally loved and accepted by clinicians, but they are a critical component of delivery system reform. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Meaningful Use program for ambulatory clinicians. When two-thirds of clinicians are excluded from MACRA they are also excluded from Meaningful Use.

There will no longer be financial incentives for clinicians to purchase, upgrade or maintain their EHRs. Only 35 percent of clinicians used an EHR in 2007. With the implementation of EHR incentives and penalties in 2009, 87 percent of all clinicians used an EHR by 2015. Providers who are excluded from MIPS will not be required to use EHRs or be eligible for EHR incentives.

Additionally, if clinicians are excluded from MIPS, their payment is essentially frozen at 2015 levels, with annual increases between zero and .75 percent — not enough to keep up with inflation. By 2026, a clinician’s purchasing power will decline by at least 18 percent if they are excluded from MIPS, assuming a two percent inflation rate.

The exclusion of two-thirds of all providers from MIPS will harm patients, providers, and taxpayers. CMS can simplify reporting using outcomes data and claims data, lowering advancing care information requirements to simply using a certified EHR, and allowing all clinicians to participate in a reasonable, balanced program that protects patients and continues to improve the effectiveness of our health care delivery system.

Lynn Barr, MPH, is the Chief Executive Officer of Caravan Health, leading the development and execution of nationwide programs that bring better care to patients and help health care providers achieve financial success.