Meaningful Use Update for Anesthesiologists and Pain Physicians; Hardship Exception Application
The Medicare requirement that eligible professionals and hospitals demonstrate “meaningful use” (MU) of electronic health record (EHR) technology has received a lot of attention from provider organizations and in the media recently. Two significant MU developments have occurred in the last few weeks: (1) the Centers for Medicare and Medicaid services (CMS) launched a streamlined process for claiming a hardship exemption and (2) CMS Acting Administrator Andy Slavitt stated publicly that the MU program “will now be effectively over and replaced with something better.”
Before explaining those two events, let us first assure readers that the MU program has not changed as far as its impact on anesthesiologists is concerned: all physicians with the specialty designation “anesthesiology” (“05”) in the Medicare Provider Enrollment Chain and Ownership System (PECOS) continue to benefit from an automatic exemption from the MU requirements. Let us remind you, too, that any physician who satisfies the MU requirements may still qualify for the incentive payment, and also that nurse anesthetists are not “eligible professionals” for purposes of the MU program.
Physicians with the PECOS designation “72” (pain management) or “09” (interventional pain management) who did not satisfy the MU requirements in 2015, however, may want to apply for a hardship exception and thus avoid penalties in 2017. Any “critical care/intensivist” with the PECOS code“81” who does not qualify for the exception for hospital-based physicians—those who provide 90 percent or more of their covered services in a hospital inpatient or emergency room setting—might also apply.
The simplified process for claiming the hardship exception came about as a result of the Patient Access and Medicare Protection Act (PAMPA), enacted in late December 2015. A provision in PAMPA granted CMS expanded authority to process meaningful use hardship exceptions for the 2015 performance year by category of provider rather than on a case-by-case basis. Organized medicine had lobbied for the change because of the delayed release of the 2015-2017 meaningful use modifications rule, which prevented many eligible professionals and hospitals from satisfying the MU requirements in 2015.
On January 22, 2016 CMS released instructions on and an application form for the streamlined hardship exception.
- The deadline to submit the application for eligible professionals is March 15, 2016. The completed form can be emailed or faxed to CMS. (CMS will continue to accept hardship applications on a traditional case-by-case basis until July 1st.)
- A single application can be submitted for multiple physicians in a group.
The information that must be provided includes the grounds for the exception. There are two exceptions under the heading “Extreme and Uncontrollable Circumstances” of particular interest:
- Issues with the certification of the EHR product or products such as delays or decertification, issues with the implementation of the Certified EHR Technology (CEHRT) such as switching products, or issues related to insufficient time to make changes to the CEHRT to meet CMS regulatory requirements for reporting in 2015, and
- Inability to control the availability of CEHRT at a location or locations constituting more than 50 percent of patient encounters.
“Inability to control the availability” of CEHRT might apply to physicians who are locked in to their hospitals’ or surgery centers’ EHRs. Other exceptions listed on the application are lack of internet connectivity, bankruptcy or closing of practice or hospital, lack of face-to-face patient interaction and natural disasters. All that is necessary is an attestation by the practice representative that the exception applies; details are not required.
In the past, CMS has granted more than 85 percent of case-by-case hardship applications.
The hardship exception will only cover the 2015 performance year and avert payment adjustments in 2017. The MU program is set to continue through 2018, however.
CMS Acting Administrator Slavitt caused a major stir when he said, at the J.P. Morgan Annual Health Care Conference on January 11th, that the MU program was “effectively over” and that it will be “replaced with something better.” The “something better” would be the EHR component of the Merit-Based Incentive Payment System (MIPS) created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MIPS will measure and compensate physicians on four distinct elements: quality, practice improvement, cost, and use of technology. Within MIPS will be elements of meaningful use. Rather than rewarding physicians for using technology, beginning in 2019 MIPS will aim to pay them for using it to improve their outcomes.
Slavitt’s comments were welcomed by many providers and Health Information Technology officers, who expressed relief at the eventual demise of the Byzantine, rigidly prescriptive MU program—the requirements of which are still changing. (Mace S. "Meaningful Use ‘Bombshell' Leaves Nary a Mark.” HealthLeaders Media online, January 19, 2016.) But MU Stage 2 is still in effect. In 2017, participation in Stage 3 will be optional, and in 2018 all providers are expected to implement Stage 3 certified EHR technology. (See ABC Alert dated October 26, 2015, CMS Releases Final Electronic Health Record Incentive Program Stage 3 Rules – Anesthesiologists Retain Exemption) The details of MIPS are a black box until CMS publishes proposed regulations, as it is expected to do this spring. Slavitt did not give any particulars on how and when CMS would organize the transition from MU to MIPS.
Within days, Slavitt made it clear that changes would take time, stating in a blog post: “We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations—including meaningful use Stage 3—are still in effect."
Thus the MIPS version of MU is due to be proposed in March or April and finalized before the end of this year. Payment adjustments in 2019, the first year of MIPS, will most likely be based on 2017 performance. As things stand now, physicians are apparently expected to begin meeting the MU requirements of MIPS in 2017—and then to implement Stage 3 of the earlier EHR incentive program in 2018. Anesthesiologists are automatically exempt from Stage 3—but will they be exempt from the MIPS requirements regarding the use of EHRs?
Does CMS even have the ability to decide to terminate the MU program early, given that its basis is in legislation passed by Congress?
Could it be more confusing?
“Clearly, CMS has a lot to work out. What is undeniable, though, is that the Stage 3 rule was finalized without consideration of the changes to Medicare mandated by MACRA. Now, the agency is trying to reconcile the two, with the Meaningful Use program not so gracefully bowing out.” (Commentary, “The Speech Heard Around the Healthcare Industry.” Health Data Management online, January 15, 2016.)
We hope that the reconciliation will be to our readers’ benefit.