Hardship may be the key to saving palliative care providers from the bind they are in following CMS's implementation of MACRA legislation. (See HCTR, January 4 for background on MACRA.) We spoke with Stacie Sinclair, Policy Manager for the Center to Advance Palliative Care to understand the nuances of MACRA and learned of a loophole that may save hospice-based palliative care providers a year of headaches, not to mention unbearable costs.
In partnership with the National Coalition for Hospice and Palliative Care, of which the National Hospice and Palliative Care Organization (NHPCO) is a member, CAPC and other organizations including the American Academy of Hospice and Palliative Medicine (AAHPM), the Hospice and Palliative Nurses Association (HPNA), and the Health Care Chaplaincy Network (HCCN) provided two webinars on MACRA. Congress passed The Medicare Access and CHIP Reauthorization Act of 2015, requiring that CMS create payment systems based on quality and cost outcomes for Medicare participating physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.
This new Quality Payment Program (QPP), which created two new payment tracks – the Merit-based Payment System (MIPS) and Advanced Alternative Payment Models (APMs) – will apply to palliative care providers participating in Medicare Part B who bill more than $30,000 and see more than 100 traditional Medicare patients. This is regardless of whether they operate out of hospitals or hospices. (see qpp.cms.gov for more details and exclusions.), whether they operate out of hospitals or hospices.
Ms. Sinclair taught us two things during our recent conversation. In response to numerous comments on the proposed rule, CMS has introduced the concept of "Pick Your Pace," which allows providers to gradually ease into MACRA compliance between now and January 2018 as they are able, even though the rule technically took effect on January 1 of this year. Second, she informed us, there may be a loophole to one particularly vexing requirement.
The requirement becomes a problem for palliative care providers operating within hospices. As we explained in our January 4 article, the Advancing Care Information (ACI) performance category in MIPS requires that certain quality outcomes must be reported, according to the legislation, using certified EMR software. Hospital-based palliative care operations should not encounter too many barriers reporting through the hospital's certified EMR but hospice software vendors, as all healthcare at home software companies, have never had a reason to seek certification. Post-acute care was excluded from the ACA's EMR incentive program. As the ACI category will account for 25% of the MIPS composite score in early years of the program, non-compliance can result in future "negative payment adjustments."
Faced with two bad options, either urge their current vendor to seek certification -- unlikely, as the hospice-based palliative sector is very small -- or, feasible but costly, switch to one of the two healthcare at home software products that did bother to become certified: HealthMEDX, now a NetSmart company, and NDoc Software from Thornberry Ltd.
According to Ms. Sinclair, CMS included language into its 2017 Final Rule that establishes a hardship exception. If a provider can make the case that one of four conditions applies, it can be exempted from the certified software reporting requirement. The third of those four conditions is highlighted below.
From the Federal Register, 11/4/16, printed page 77241:
Section 1848(a)(7)(B) of the Act provides that the Secretary may exempt an EP who is not a meaningful EHR user for the EHR reporting period for the year from the application of the payment adjustment under section 1848(a)(7)(A) of the Act if the Secretary determines that compliance with the requirements for being a meaningful EHR user would result in a significant hardship. In the Stage 2 final rule (77 FR 54097-54100), we defined certain categories of significant hardships that may prevent an EP from meeting the requirements of being a meaningful EHR user. These categories include:
Additional MACRA Provisions
As previously mentioned, providers can choose to participate in the Quality Payment Program through one of two tracks: Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). Participants in APM may earn incentive payments through Medicare Part B. MIPS participants earn performance-based payment adjustments, up or down.
CMS made a change from its proposed rule, following comments from the public. MIPS applies to providers seeing at least 100 Medicare beneficiaries and billing more than $30,000 per year. And it now has 4 parts:
The fourth part is the only new category, the others having been based on previous programs. It requires reporting of "improvement activities," programs and measures instituted to improve patient care.
Note that this is the basic structure of the program, but there are a number of variations depending on factors such as the size of your practice, whether you will report as an individual or group, and which reporting mechanism you select. Again, see qpp.cms.gov for more details.
About the Center to Advance Palliative Care
CAPC is a national, non-profit association established in 1999 by Dr. Diane Meier, with funding from the Robert Wood Johnson Foundation. It provides tools and training to palliative care providers to help improve program quality. CAPC develops materials for programs: operational training, new program establishment, and clinical training to ensure that not only specialists but all clinicians develop skills in palliative care. While it initially focused on hospital-based programs, CAPC has recently expanded its offerings to include resources for community-based palliative care, including private homes, Long Term Care facilities and office/clinic practices.
©2017 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