The Centers for Medicare and Medicaid Services has proposed a new rule for its Quality Payment Program in an effort to simplify reporting requirements with updates for the second and future years of the program.
In October 2016, CMS published a final rule to implement the Quality Payment Program (QPP) under the Medicare Access and CHIP Reauthorization Act (MACRA), designed to reward providers for value and improved health outcomes. As part of the program, clinicians have two tracks to choose from—the Merit-Based Incentive Payment System (MIPS) or the Advanced Alternate Payment Models (APMs), based on their practice size, specialty, location or patient population.
The new reimbursement approach in MACRA incorporates payments to reward providers for their use of information technology and data.
“The proposed rule would amend some existing requirements and also contains new policies for doctors and clinicians participating in the Quality Payment Program that would encourage participation in either APMs or the MIPS,” according to the agency’s June 20 announcement.
“Additionally, CMS has used clinician feedback to shape the second year (2018) of the program,” states the announcement. “If finalized, the proposed rule would further advance the agency’s goals of regulatory relief, program simplification, and state and local flexibility in the creation of innovative approaches to healthcare delivery. Moreover, CMS is making it easier for rural and small providers to participate.”
The agency says it is sensitive to stakeholder concerns that small, independent and rural practices in particular are not sufficiently prepared for the Quality Payment Program. By providing additional flexibility in its proposed rule, CMS contends that barriers will be reduced further, enhancing the ability of small practices to participate successfully.
In particular, the rule calls for an increased low-volume threshold that will exempt eligible MIPS clinicians with less than $90,000 in allowed charges or fewer than 200 Medicare Part B beneficiaries from having to participate in the program. The threshold in 2017 was $30,000 in allowed charges or fewer than 100 beneficiaries.
“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” said CMS Administrator Seema Verma in a written statement. “That’s why we’re taking a hard look at reducing burdens.”
When it comes to health IT, CMS proposes reduced burdens and increase flexibility to help clinicians to successfully participate in QPP by continuing to allow the use of 2014 Edition Certified Electronic Health Record Technology, while encouraging the use of 2015 edition CEHRT.
“By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork,” Verma added. “CMS will continue to listen and take actionable steps towards alleviating burdens and improving health outcomes for all Americans that we serve.”
Industry groups were quick to respond to the proposed rule with praise for the agency’s flexibility, including the American Medical Association.
“CMS is proposing a number of policies to help physicians avoid penalties under the Quality Payment Program. In particular, it is suggesting several actions to assist small practices,” said AMA President David Barbe, MD. “The administration showed it heard the concerns raised by the AMA on behalf of practicing physicians.”
Barbe pointed out that “not all physicians and their practices were ready to make the leap, and many faced daunting challenges.” However, he believes that CMS’s “flexible approach will give physicians more options to participate in MACRA and takes into consideration the diversity of medical practices throughout the country.”
Likewise, Tom Nickels, executive vice president of the American Hospital Association, said AHA was “encouraged by CMS’s proposal for a facility-based clinician reporting option that may promote better alignment and collaboration on efforts to improve quality among hospitals and clinicians.”
In particular, Nickels applauded CMS’s proposal to “provide much-needed relief from unrealistic, unfunded mandates for EHR capabilities by extending the use of modified Stage 2 Meaningful Use requirements through 2018,” and he encouraged the agency to “provide the same relief to hospitals.”
AHA also encouraged CMS to provide additional opportunities for clinicians to earn incentives for partnering with hospitals to provide better quality, more efficient care through advanced alternative payment models.
“We will review the details of the proposed rule and will provide input to the agency to help ensure CMS’s polices enable patients to benefit from the transformation of care envisioned by MACRA,” Nickels concluded.
CMS will accept comments on the proposed rule until 5 p.m. on August 21. However, not all industry groups responded favorably to the agency’s proposed rule.
While the American Medical Group Association said it recognizes the burden MACRA places on small practices and appreciates the options for them to participate, it said it’s concerned that the proposed rule delays the transition to value and does not recognize the investment that its members have made in preparing for a value-based healthcare system.
“If CMS wants to transition to value-based payment for care, the program needs to be fully implemented,” said Chester Speed, AMGA’s vice president for public policy. “We recommend that CMS revise its proposal to fully incentivize high performers in the Medicare program.”
Dr. Lawrence L. Weed, who introduced a system for organizing patient data in the 1950s that is now used in hospitals all over the world, and who led the way in developing a computerized method for aiding in the diagnosis and treatment of diseases, died on June 3 at his home in Underhill, Vt. He was 93.
His son Lincoln confirmed the death.
In the early 1950s, Dr. Weed was a professor of medicine and pharmacology at Yale, where he spent most of his time doing research on microbial genetics. On occasion, though, he would accompany students on their hospital rounds and watch as they struggled to interpret the often chaotic patient notes left by doctors.
It was a sobering experience. “I realized then — and it was very upsetting — that they weren’t getting any of the discipline of scientific training on those wards,” Dr. Weed told The Journal of the American Medical Informatics Association in 2014. “When I pick up a chart that is a bunch of scribbles, I say: ‘That’s not art. It certainly isn’t science. Now, God knows what it is.’”
He responded by creating the problem-oriented medical record, or POMR, a way of recording and monitoring patient information. Two of its features have become nearly universal in health care: the compiling of problem lists and the SOAP system for writing out notes in a patient chart. SOAP stands for subjective, objective, assessment and plan, reflecting the steps that doctors and other health care providers should follow as they move from an initial patient encounter to tests, diagnosis and treatment.
Dr. Weed presented his new method in a two-part article in The New England Journal of Medicine, “Medical Records That Guide and Teach.” Published in 1968, it is one of the most frequently cited articles in the field of medical informatics.
“Saying that POMR was revolutionary almost understates it,” Dr. Charles Safran, the chief of the division of clinical informatics at Beth Israel Deaconess Medical Center and Harvard Medical School, told The Economist in 2005. “There’s probably no one who has more fundamentally affected the way we organize our work than Larry Weed. He fundamentally changed American medicine.”
With a grant from the Department of Health Education and Welfare (now Health and Human Services), Dr. Weed developed a computerized version of POMR that came to be known as Promis — the Problem-Oriented Medical Information System.
This led him, in the 1980s, to another innovation: “knowledge coupling” software linked to a database of medical knowledge derived from thousands of journal articles. Doctors could input the information gathered in the POMR process and then receive a list of possible diagnoses and treatment options, with arguments for and against each option.
Many doctors took a dim view of Dr. Weed’s innovation, regarding it as a challenge to their professional expertise. Dr. Weed saw it as a solution to an intractable problem — the unrealistic expectation that one brain, no matter how well trained, can store and apply the medical knowledge required to make proper decisions.
“For every complaint, for chest pain or abdominal pain, there can be 50 or 60 causes, and the doctor cannot remember all of them,” he told The Boston Globe in 1987. In an interview with The Permanente Journal in 2009, he said, “An epidemic of errors and waste is occurring as we persist in trying to do the impossible.”
Lawrence Leonard Weed was born on Dec. 26, 1923, in Troy, N.Y. His father, Ralph, was a salesman. His mother, the former Bertha Krause, was a homemaker.
Lawrence, known as Larry, was a gifted pianist with a fine baritone voice, but an interest in science led him to earn a chemistry degree from Hamilton College in Clinton, N.Y., in 1945.
After receiving a medical degree from Columbia University in 1947, he took mixed internships in medicine, chest medicine, surgery and clinical pathology at University Hospital in Cleveland and Bellevue Hospital in Manhattan.
Before completing a residency at Johns Hopkins University, he did basic research in biochemistry and microbial genetics at Duke University, the University of Pennsylvania and Walter Reed Army Medical Center (now the Walter Reed National Military Medical Center) in Washington. He then accepted a double appointment at Yale in pharmacology and medicine.
In 1952 he married Laura Brooks, a fellow intern in Cleveland with a medical degree from Yale. She died in 1997. In addition to his son Lincoln, he is survived by two other sons, Christopher and Jonathan; two daughters, Dinny Adamson and Becky Weed; a sister, Nancy Weed; two granddaughters; and two stepgranddaughters.
Dr. Weed’s eagerness to bring scientific rigor to medical record keeping led him in 1956 from Yale to Bangor, Me., where he accepted an offer to direct the new medical internship and residency program at Eastern Maine General Hospital. There he worked out the concepts of POMR.
After four years he became an assistant professor of microbiology at Case Western Reserve University in Cleveland, where, beginning in 1964, he also directed the outpatient clinic of Cleveland Metropolitan General Hospital. In his spare time, he sang with the Cleveland Orchestra Chorus under Robert Shaw.
It was in Cleveland that he began working with computers to develop the Promis system, which he took to the University of Vermont in 1969, where he became professor of community medicine. In the early 1980s he left to start the Problem-Knowledge Coupler Corporation, which developed knowledge-coupling software as well as a PC-based version of the POMR. He left the company in 2006. It was acquired in 2012 by the Atlanta-based company Sharecare, whose AskMD app uses Dr. Weed’s coupling software.
Dr. Weed could be a prickly ambassador for his ideas. He was not shy about criticizing American medical education — he proposed that traditional medical schools be radically restructured — and went a few steps beyond tough love in telling doctors about their limitations.
At one medical conference, as he argued for the superiority of his computer programs over traditional medical expertise, an unhappy surgeon rose to protest. Surely, the surgeon said, experience and intuition counted for something. Dr. Weed met him halfway.
“Well, I’m not saying you don’t have intuitive feelings,” he recalled answering in The Journal of the American Medical Informatics Association. “What I’m suggesting is that they may be worthless.”
Dr. Weed was the author of “Medical Records, Medical Education, and Patient Care: The Problem-Oriented Record as a Basic Tool” (1969); “Your Health Care and How to Manage It: Your Health, Your Problems, Your Plans, Your Progress” (1975); “Knowledge Coupling: New Premises and New Tools for Medical Care and Education” (1991); and “Managing Medicine” (1993).
His last book, the polemical “Medicine in Denial” (2011), written with his son Lincoln, outlined his plan for an overhaul of medical practice, with education aimed at fostering skills rather than knowledge.
He was impatient to see changes. “People have been saying to me since the 1960s, ‘You’re ahead of your time,’” he told the journal Modern Healthcare in 2012. “I say, ‘My God, you want me to live until 160? How long are you going to take?’”