Preliminary Thoughts on CMS MIPS IP NPRM: A Public Health Perspective
The Centers for Medicare and Medicaid Services (CMS) has now released a new Notice of Proposed Rulemaking (NPRM), titled Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program. The purpose of this NPRM is to address proposed changes for Year 3 of MIPS, the provider (as opposed to hospital) side of the Quality Payment Program. The part that is most relevant to public health is the Medicaid Promoting Interoperability (IP) Program for Eligible Professionals (EP)” (the EHR Incentive Programs have been renamed). A major goal of this NPRM is to synchronize as much as possible the EP program with the hospital-based program that was addressed in a previous NPRM just a few months ago.
Of course, this document is complicated so I welcome any corrections or comments to my interpretation of what’s in the rule. And I apologize in advance as much of what’s here is cryptic to anyone who has not been exposed to this before and I don’t make much of an attempt to explain the context (or even the acronyms).
Key points include (page numbers reference the Federal Business Opportunities official version cited above):
- With respect to Syndromic Surveillance reporting, CMS proposes that any eligible professional deemed appropriate by the public health authority, not just those in urgent care settings, are eligible for this measure. The exclusion criteria remain unchanged. 
- There is renewed commitment to advance the MyHealthEData initiative related to patient access to data and promoting sharing of data between providers. There may be some public health implications to this down the line (e.g., patient access to Immunization Information Systems data directly or through EHRs). 
- The way MIPS works, Eligible Clinician (or EC, as MIPS now refers to Meaningful Use Eligible Professionals) data from the reporting period in 2019 (the relevant year for this NPRM) is evaluated in early 2020 and the results affects claims reimbursement in 2021. The potential payment at risk for poor performance rises to 7% (from 5% in Year 2). This makes the stakes higher, and the potential for participation also higher as a result. 
- CMS is proposing to expand the definition of MIPS ECs to now include a physical therapist, occupational therapist, clinical social worker, and clinical psychologist (they would propose to add even more types if the quantity of quality measures they propose to eliminate are not in fact removed). The addition of these clinicians may increase the burden of on-boarding and operations on public health (to the degree that they participate in the various public health reporting programs based on their clinical activities), or may simply increase the level of help desk interactions as they query about exclusions and the necessary documentation. 
- CMS is proposing changes to the low-volume eligibility criteria (which exclude practices with a low dollar amount of aggregate Medicare claims and a small number of Medicare patients, now adding also a low number of Medicare services) to allow these clinicians to opt-in and voluntarily participate in the program if they exceed at least one of the low-volume thresholds. The additional participants may increase the burden of onboarding and operations for public health. 
- The NPRM reaffirms that the ECs need to use 2015 Edition CEHRT only. 
- The NPRM proposes a new scoring method more in line with the Hospital/CAH NPRM. The public health objective would be allocated 10 points out a total of 100 points for the program. CMS proposes removing the “bonus” for additional public health reporting (and some other things). [35908, 35914, 35917-8]
- A new optional measure for Query of Prescription Drug Monitoring Program (PDMP) under the e-prescribing objective is introduced optionally for one year before becoming part of the core measures in Year 4. Once fully in place, any exclusions would shift the relevant points to other measures in the e-prescribing objective. This measure is optional in 2019 (earns bonus points) but would become required in 2020. It is not clear whether this measure could also qualify as a public health reporting measure (in addition to or instead of an eRx measure). [35915; for a fuller discussion see 35922-5]
- For the public health objective, an EC would be required to meet at least two of the following five measures by submitting a “yes/no” response: Immunization Registry Reporting, Electronic Case Reporting, Public Health Registry Reporting, Clinical Data Registry Reporting, and Syndromic Surveillance Reporting. [35916; for a fuller discussion see 35929-30]
- If an EC claims exclusion for both public health measures, the points associated with this measure would be redistributed to the Provide Patients Electronic Access to their Health Information measure instead. If an EC fails to report, or claims exclusion inappropriately, the EC would receive a score of zero. [35916, 35915]
- As before, an EC may claim exclusion from a public health measure if (among other things) the jurisdiction has not declared its readiness at least six months before the start of the performance period. [35929 as one example]
- CMS stated their intent to remove public health measures altogether for CY2022 and beyond. 
- CMS is seeking comment on, “…whether the Promoting Interoperability performance category is the best means for promoting sharing of clinical data with public health entities.” Hm. 
- In describing future rulemaking considerations, CMS describes “public health priority sets” which “…would seek to provide clinicians with sets of measures and activities that are most meaningful to them, with an emphasis on improving quality of life and outcomes for patients.” The initial sets would be related to opioids; blood pressure; diabetes; and general health (healthy habits). 
- The NPRM continues the option for facilities-based measurement for an EC who spends at least 75% of his/her time practicing in an in-patient setting, albeit with some refinements. 
- The NPRM includes a series of Request for Information (RFI) questions, including a somewhat lengthy one (“Request for Information on Promoting Interoperability and Electronic Healthcare Information Exchange through Possible Revisions to the CMS Patient Health and Safety Requirements for Hospitals and Other Medicare- and Medicaid-Participating Providers and Suppliers”) which asks about ideas related to provider-to-provider interoperability, provider-to-patient interoperability, and help “…identifying fundamental barriers to interoperability and health information exchange, including those specific barriers that prevent patients from being able to access and control their medical records.” [36006-9]
Yikes. My initial take on this is:
- For core public health measures, this seems to be an improvement over the current Year 2 guidelines (no specific public health core measures required, but up to 10 points for eligible measures; bonus points if public health measures are selected up to a cap) with two public health measures required. On the other hand, an EC could choose less central public health and/or clinical registries and avoid major public health measures like immunization or laboratory reporting.
- The expansion of the definition of eligible Syndromic Surveillance ECs seems appropriate.
- Any expansion in the definition of EC or “opt-in” for low-volume ECs should not have a significant negative impact on public health.
- Before an EC should have public health points redirected to the consumer access measure that all possible public health reporting measures should be exhausted. It is not clear whether an EC can claim exclusion from two public health measures when capable of participating in another measure as a way to avoid public health measures altogether.
- It is not clear where guidance comes from for required technology for public health measures that is not specifically identified in 2015 CEHRT (e.g., for many clinical registries). Previous rules had mentioned grandfathering of pre-existing technology if it was already in place and acceptable to the jurisdiction before the new rule became effective.
- Public health must continue to resist any future plans by CMS to eliminate public health reporting altogether, and must insist that core public health objectives – such as those related to disease prevention – are included in any new CMS constructs (such as public health priority sets).
One final note: As this NPRM was released, the CMS Administrator, Seema Verma, published an open letter to doctors which is focused on reducing the burden on doctors so they can spend more time with physicians. HL7 has begun a similar initiative on reducing clinical burden. So the key question is: Does this NPRM go far enough to reduce provider burden in the spirit of Dr. Verma’s letter?