Shaping the Substance of MACRA: EHRA Comments Set Foundations for Success

Few, if any, health care payment and delivery initiatives underway promise to have as much impact on the nation’s shift from volume to value-based reimbursements, holistic clinical delivery, and overall system sustainability as the Medicare Access and CHIP Reauthorization Act (MACRA).

By establishing distinct and relatively complex delivery and payment tracks – the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) – programmatic vigilance and collaboration is needed by all healthcare stakeholders.

And with current and future healthcare information technology solutions a critical part of the equation – building upon similar public and private payer programs such as patient-centered medical home (PCMH) and accountable care organization (ACO) structures – the Electronic Health Record Association (EHRA) submitted detailed comments November 17 to the Centers for Medicare & Medicaid Services (CMS) in response to the agency’s MACRA request for information (RFI).

Overall, we applaud the bundling of disparate incentive programs and sun-setting individual payment adjustments, as well as advancing more clinically relevant and financially beneficial APMs focused on population health and analytics.

To make MACRA a success for all stakeholders in the short timeframe proposed, EHRA offered guidance in key areas on behalf of its health IT developer members and the provider organizations and clinicians we support.

Certification and APMs

EHRA does not support the creation of a new or specific certification program for APMs. Technology requirements should be the same between MIPS and APMs, especially in cases where providers desire to migrate from the MIPS to APM tracks.

As we noted, “a provider meeting the 25% APM threshold should not be held in the MIPS track because they do not own an ‘APM certified’ module that they did not need to successfully move 25% of their revenue to an APM.”

Further, since the 2015 Edition final rule carries with it a current start date of 2017 – which coincides with the first MIPS performance scoring year – we see little time for all stakeholders to reconcile an effective process given that the MACRA final rule is anticipated in the fall of 2016.

Instead, we believe a subset of finalized certification criteria should be identified to support interoperability, patient engagement, and care coordination to establish a foundation for all APM models and functionality. These would include transitions of care, data export, view/download/transmit (VDT), and secure messaging. From this foundation, providers involved with different types of APMs could select any additional health information technology needed to accomplish other goals, and remain in line with the EHR Incentive Program, and technology would not create a barrier for transitioning from MIPS to the APM program.

We emphasize this guidance both in terms of the RFI and to the ONC HIT Policy Committee’s Advanced Health Models and Meaningful Use Workgroup which is currently examining the need for an APM-specific certification as part of the implementation of MACRA.

MIPS Measures and Reporting

With its expanded emphasis on clinical quality measures within the MIPS track and its four scoring elements, a lot of attention needs to be paid to this process, both in terms of lessons learned and improvements.

We fully support the goal to align MIPS clinical quality measure (CQM) requirements with other Medicare and Medicaid programs, and caution that the industry is still in the early stages of migrating from claims-based measures to electronic CQMs, as well as from process-based to outcomes-based payments.

To that end, EHRA will strive to continue to work with CMS and ONC to identify and implement improvements with testing infrastructure, submissions, standards, and the process for annual measure updates.

We recommended that quality scores should be calculated using only the data from one method of submission in order to prevent duplicate reporting.

We strongly recommended that MIPS clinical practice improvement activities be reported via attestation, and that overall attestation should follow an annual cadence. We do not believe that EHRs should be used to track process measures for clinical practice improvement, as adding data capture requirements for the sole purpose of process-measurement reporting is frustrating to providers and creates inefficiencies in the care-delivery workflow.

Finally, we also strongly recommended that a system be developed wherein providers can track and manage their own MIPS performance via simplified measures, so they can anticipate performance scores and manage workflows ongoing. This should be an in-house or dashboard endeavor, and not done through reporting to CMS during the performance period.

MACRA represents a significant opportunity to improve care coordination and payment stability, supported by best practice health IT approaches. EHRA looks forward to ongoing collaborations with all stakeholders to take all advantage of the time still available to reach its goals.


Suzanne Travis (McKesson), Chair, Delivery System Reform Workgroup

Greg Fulton (Greenway Health), Vice Chair, Delivery System Reform Workgroup



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