Advancing Care Information: What Physicians Need to Know

The Physicians Practice 2017 Technology Survey results show a split on whether practices understand the Advancing Care Information (ACI) section of the Merit-based Incentive Payment System (MIPS) track of Medicare payment reform. (MACRA). The guidelines of ACI, which detail how Medicare physicians must use certified health IT, were understood by just 50 percent of respondents.

In the latest proposed rule outlining the Quality Payment Program, ACI is worth 25 percent of a clinician's overall MIPS score. The others components of the MIPS score, for the 2018 performance year, are Quality (60 percent of a physician's overall score) and Improvement Activities (15 percent). In the future, a Cost category, based on claims data, will also play a role in a physician's score.

Of the 50 percent of respondents that said they don't understand the ACI guidelines, 38 percent say they are having trouble understanding the Quality Payment Program in general, while 28.4 percent say they don't know the difference between ACI and Meaningful Use, the program ACI replaced. 

Physicians Practice recently spoke to industry experts who explained what physicians need to understand about Medicare payment reform in general, the MIPS track for payment and ACI.

ACI vs Meaningful Use

MIPS consolidates the Meaningful Use, PQRS, and all other reporting criteria together. With this structure, physicians get to choose what they report on.

Despite similar metrics, ACI has a different structure than Meaningful Use. "Meaningful Use measures were all or nothing; a clinician had to meet thresholds for each measure. ACI is different in that it is broken up into two different parts. The first portion of the score is the base score, which a clinician has to complete in order to avoid getting a zero, and the second part of the score is performance," says Naomi Levinthal, a practice manager at Advisory Board, who believes the base score will be easy for physicians to achieve in 2018.

To achieve the base score of ACI, physicians need to complete tasks including performing a security risk analysis, sending out an electronic prescription, providing patient access to the portal, and sending a summary of care record with a patient that has been referred or transferred to another healthcare organization. "Those are things that are done commonly in the course of practice," Levinthal says.

For the performance portion of the ACI score, there are up to 10 performance points available per measure a clinician reports for, up to a maximum of 100 percentage points, according to the Centers for Medicare and Medicaid Services (CMS). For 2017, physicians will have nine performance score measures to choose from, including secure messaging, patient-specific education, and immunization registry reporting.

This differs from Meaningful Use, which did not include clinical performance as part of a clinician's base score. For 2018, there will also be a 5-point bonus for small practices and those who care for complex patients will get an extra three points added to their final score.

"Because you can reach the full (ACI) score with a combination of the different measures, you can target the ones that will get you to the highest percentage, so you may find that ACI is a lot easier to do than you thought it was," says Levinthal.

Lastly, there are hardship exemptions and you can request to be re-weighted for ACI. During re-weighting, a certain calculation is zeroed out depending on the hardship. Some hardship examples include insufficient internet bandwidth and no control over EHR availability, according to Charles Saunders, MD and CEO of Integra Connect, which provides healthcare organizations cloud-based technology. 

Tech is Everything

When it comes to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and specifically MIPS, experts agree that it is impossible to succeed in the payment reform tracks without utilizing the right technology. For 2018, clinicians can use a 2014 certified EHR or a combination of 2014/2015 software to report for MIPS for a 90-day reporting period, according to CMS.

There's no alternative to the EHR when it comes to allowing physicians to report the required measures for MIPS and submit them to CMS.

"There's no submission mechanism that allows (physicians) to report all of the category requirements together, except for ones that are tech-related such as the registry, EHR, the CMS web interface," says Levinthal.

Rowley adds that with MACRA, physicians need technology to be able to improve. "Monetary income is now dependent on knowing how you are doing with various population based criteria that can be shown to you in registries at the click of a button, so you need technology that can do that," he says.

Rowley also cites interoperability as a reason that technology is necessary for MACRA participation. This is because a big chunk of ACI revolves around interoperability under MIPS. To satisfy the required measures, physicians need to prove they are providing patients with access to their health records and that their facility can share protected health information (PHI) with another organization.

Moreover, under MIPS, technology needs to be able to do the reporting and this burden remains on the individual practices like it has been for PQRS and Meaningful Use. If physicians participate in MACRA via the Advanced Alternative Payment Model (APM) track, their organization does the reporting on their behalf so they don't have that burden individually, according to Rowley.

"Some EHRs collect the information and do the reporting on your behalf. A doctor in a large clinic does not need to worry about reporting, the institution will report for them. Individual physicians must report for themselves," says Rowley, who believes healthcare has a long way to go before it achieves the goal of a true fee-for-performance model.

Stay Ahead

Tom Lee, CEO of SA Ignite, warns physicians to stay ahead of the curve as best they can. He says if a doctor has no idea what their MIPS score is currently, that's something to be concerned about. "For the 2017 performance year, clinicians will not get their performance reports until the fall of 2018, and then 2019 is almost about to start. If you don't know what your MIPS score is now, you're running behind. There are companies that can predict your score using [predictive analytics]," says Lee.

For physicians looking to calculate their MIPS score, CMS itself or advocacy groups such as AAPC, feature tools for calculating MIPS scores, which can point them in the right direction.

MIPS scores stick with clinicians for the remainder of their career, Lee says. For example, when a physician is given a score based on this year’s data, it will be attached to their record tagged by their National Provider Identifier (NPI) number. If that same physician moves across the country and begins work at another practice, come 2019, the practice will inherit the MIPS payment adjustment the physician earned in 2017. "A lot of physician don't realize this. This is their resume we're talking about here … this level of transparency is unprecedented," says Lee.

Staying ahead will be challenging, experts say, as they are in agreement when it comes to the length and language of MACRA being difficult for a physician to digest.  "I don't understand how a practicing physician could take a 600-page proposal and understand it to the degree they need to. CMS needs to make it less complicated to understand, this rule is not helping physicians who are struggling with regulatory burdens leading to burnout," says Levinthal.

Where to Go?

It is important for clinicians to reach out for help before they fall further behind.

"You can start with CMS.gov, but the information there is fairly high level. There are also consulting firms that can help" says Saunders, who adds that some of the struggles are due to outdated technology that gets in the way of a physician reporting.

The data physicians need to report is not always readily available in the EHR. Ideally, the calculations are able to be automated by pulling data from the EHR, but that only works if the data is complete. Another problem that can occur is data not being in structured fields, which means physicians cannot use a process such as a sequel query to easily pull the data out.

"In some cases, physicians are documenting by hand on paper and then scanning the docs into a PDF and inserting that into the EHR as an image note, making it difficult to extract data from an EHR," says Saunders.

If additional information is needed on technology in a practice, physicians can take it upon themselves to have an open line of communication with their EHR vendor. They can ask the vendor what they are going to do to help with MIPS reporting. Having a good relationship with a vendor allows physicians to know the strengths and limitations of the technology they are using.

"CMS is going to continue to reward providers that are using technology. They are laying out ways for organizations to reap some of the benefits from technology investments they have made in the past," says Levinthal.