To: Mr. Andy Slavitt, Acting Administrator, Centers for Medicare & Medicaid Services
November 17, 2015
We have a few concerns about how requirements from the Medicare EHR Incentive Program will translate into the MIPS Meaningful Use Category. For a subset of palliative care providers, particularly those operating out of hospice or working in small hospitals and/or standalone clinics, this will be the first time they are held accountable for their use of certified EHR technology.
Editor's note: CAPC used a hypothetical physician to demonstrate its points. (see sidebar, below)
When Kim provides services at her two hospitals, she uses their EHRs. She has no control over these systems and finds that they do not include many of the fields that she typically uses when delivering services to her patients. As the hospitals do not allow outside access to their EHRs, Kim has to report her billing and quality measures to her organization using a separate tool the practice developed. When she delivers care in her outpatient clinic, she uses the hospice’s EHR, which she finds more practiceappropriate than the hospital or primary care EHR. Up until this point, she has not been required to participate in the EHR Incentive Program, yet she is aware that the Meaningful Use is one of the performance categories under MIPS and the ONC does not currently certify hospice EHRs. Switching or modifying the practice’s EHR in any great capacity is not possible in the near term, and when her vendor has called CMS for technical assistance, he has been informed that “hospices are exempt”. She is unclear what options are available to her moving forward.
Given the potential challenges that a small but critical subset of our clinicians will face with the adoption and use of certified EHR technology, we recommend that CMS exempt palliative care providers working in non-hospital settings from reporting under this category until such point as the ONC develops a process for certifying hospice and other non-primary care-based EHRs OR the field develops an alternative that will allow these providers to satisfy both CMS and ONC reporting requirements.
Meanwhile, for palliative care clinicians who are able to attest for meaningful use and meet a certain percentage of the measures, we strongly urge CMS to discard its “pass-fail” approach to compliance. Rather, we favor providing partial credit to physicians who demonstrate that they are making a good faith effort to meet the requirements for certified EHR use.
Kim is a physician who works in a palliative care consultation-based practice that is operated out of hospice. She is in the process of obtaining her board certification in Hospice and Palliative Medicine; however, she is currently classified in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) under her primary specialty of Family Medicine. She sees patients in two mid-size community hospitals as well as in a freestanding outpatient clinic the organization just opened. As Kim typically treats patients who are not dying (and therefore not eligible for the Medicare Hospice Benefit under Part A), she bills Part B – making her an eligible professional (EP) under the various CMS quality reporting programs. When she provides care in the two hospitals, she uses their EHRs; however, when she is in the outpatient clinic, she uses the hospice’s EHR. Given that her patients have a wide range of diagnoses and she and her colleagues are primarily concerned with treating patients’ symptoms, her hospice has developed its billing system around ICD-10 codes.
From the June 27, 2016 letter:
We fully support CMS’s push to accelerate the use of CEHRT in patient care. Health information technology (HIT) done well can unlock previously unheard of capacity to effectively and efficiently communicate between providers; this is made all the more important given the increasing emphasis on following patients over time and across care settings. In order to survive in this new world, all providers must be able to access to pertinent clinical information electronically, and participating in health information exchange so that information can follow the patient.
Concerns and Recommendations
Our primary concerns in this category are those of time and money. Palliative care providers – particularly those in standalone or community-based practices – have disproportionately struggled to stay afloat under FFS. Even in large hospitals, FFS reimbursement generally covers only about
one-third of the palliative care department operating budget; the rest comes from hospital overhead and philanthropy. Some hospitals are willing and able to invest in their palliative care clinicians, but programs in many of our important service sites (e.g., SNFs, NFs, home care, assisted living, office settings, and PACE) have not had this luxury. In their efforts to stay afloat, many were not able to participate in the early years of the Meaningful Use EHR Incentive Program (MU) that would have provided them with some of the startup funds required to invest in CEHRT. As adoption was not required, these practices had to make difficult decisions around priorities.
Another situation that may be unique to palliative care is the fact that several practices are actually business lines being run under the corporate umbrella of a hospice. Hospice EHRs were exempt from MU, and so a majority of hospice-based EHRs are not compliant with MU standards. This means that many palliative care providers employed by a hospice but billing Part B for non-hospice palliative care patients cannot receive credit for EHR activities.
MACRA has now changed the game. All clinicians understand that they must adopt CEHRT in a rapid timeframe or close their doors. Unfortunately, many palliative care practices remain in the same position that they were five years ago – completely under-resourced – but now there are no longer MU incentives available to ease their transition. As the Advancing Care Information calculations currently stand, palliative care clinicians are at such an extreme disadvantage as to threaten their ongoing viability. Therefore, we request that CMS make new money available to help support the purchase and adoption of CEHRT for palliative care practices – especially small practices and those based out of hospices – that missed the MU incentive payments. We suggest that CMS also build in new timelines for EHR adoption in small practices, since EHR use is essentially the cornerstone of all the other reporting mechanisms under MIPS, and yet a majority of these practices are unlikely to successfully launch their EHRs by January 2017.
©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org