Michael Peters, ACR: The MU–MIPS connection and Stage 3 MU

According to CMS’s latest attestation data, some 4,720 unique diagnostic radiologists have at least one year of participation in Stage 1 or Stage 2 Meaningful Use under their belts. This cohort has made around 9,000 unique attestations since 2011, showing quantifiable and clinically significant use of certified EHR technology.

These figures sound impressive at first blush. However, only around 28% of those 4,720 participants have stuck with MU for more than a year. This means a lot of radiologists who do participate are either “one and done” or just began in 2014.

What’s holding up the profession from broader, deeper and more committed participation? Mainly the fact that so many barriers exist beyond the reach of individual radiologists’ sphere of control. Not least among the barriers are hospital decisions, practice decisions and the availability of certified health IT products.

That’s according to Michael Peters, ACR’s director of regulatory and legislative affairs. In a recent conversation with imagingBiz, he laid out the landscape of these and related matters as things stand now and as the ground may shift in the coming months.

Q. The perception is that many radiologists have proactively opted for the hardship exception under Provider Enrollment, Chain, and Ownership System (PECOS) specialty code 30, citing lack of face-to-face contact with patients. How close is perception to reality?

Peters: To be clear, individuals with primary PECOS specialty codes of diagnostic radiology, nuclear medicine and interventional radiology do not need to take actual, manual action to obtain that particular hardship exception from the penalty. So essentially all of ACR’s non-radiation oncologist members are getting this automatically awarded exception.

We should also note that many radiation oncologists are probably obtaining one of the various other available hardship exceptions that they can manually apply for. They just can’t take advantage of this particular auto-exception for the imaging subspecialties.

So all of the imaging subspecialties should be getting this automatically awarded exception. No one should be getting penalties right now unless something is wrong with their PECOS data.

Q. In light of the announcement by HHS Secretary Sylvia Burwell earlier this year about the Merit-based Incentive Payment System (MIPS) and the accelerated timetable for value-based payment in the Medicare program, has the value proposition of participation in MU changed for radiologists?

Peters: This is an interesting question and critical to understanding the universe over the next several years. When it comes to Meaningful Use specifically in MIPS, there are three facts to consider. The first is that Meaningful Use is one of the four performance categories that comprise MIPS  and would count for about 25% of the MIPS composite score. The overall composite score determines whether the physicians get incentives, penalties or stay flat under MIPS.

The second fact is that the statute directs the secretary to consider circumstances and potential alternatives for ‘non-patient facing professionals’—which, depending on the regulatory implementation, could even mean a Meaningful Use alternative or substitute.

Number three, and I think most critically to this conversation, is that we just don’t know how CMS will implement the law in regulation. The agency recently published a request for information for stakeholder input on the future MIPS rulemaking. But the bulk of the actual, foundational rulemaking activity isn’t going to happen until next year. So, literally, the book on MIPS has not yet been written.

Q. Many hospital-based radiology practices have had difficulty getting the hospital’s support, which they need to participate in MU. What are your observations there?  

Peters: One of the many positives of the appropriate-use criteria (AUC) mandate is that it should promote ongoing dialogue between radiologists and referring providers. I don’t know if these opportunities for communication will better enable radiology practices to convince hospitals to actively facilitate Meaningful Use compliance. If it does, that would obviously be another positive side effect to the AUC mandate.

I do think that, moving forward, CMS needs to address the overall problem that you’re alluding to here—hospital barriers to Meaningful Use by on-site physicians. This is something that ACR, RBMA, the College of American Pathologists, the American Society of Anesthesiologists and others have been working toward for several years and on numerous different fronts.

Coming back to MIPS, certain aspects could enable facility-level performance to be attributed to individuals in some fashion yet to be detailed in regulation.

Q. In light of the Oct. 6 publication in the Federal Register of the MU 2015-17 fix and 2015E final rules, what do you see coming in MU Stage 3 that will be most relevant for radiology?

Peters: Stage 3 MU will be far less burdensome for radiologists than any previous stage, including the “modified Stage 2” requirements that were in the same final rule. Radiologists without office visits will likely be excluded from the most difficult and controversial Stage 3 requirements that are facing other physicians.

Diagnostic radiologists without office visits will likely complete the measures of three or four Stage 3 MU objectives related to protecting PHI/HIPAA security, enabling CDS functionality, incorporating and reconciling certain minimum data sets from available summary of care records (C-CDAs) into CEHRT and active engagement with three “ready” registries listed in the future CMS registry repository. It is conceivable that certain radiologists will be able to exclude themselves from the third, depending on certain circumstances I won’t dive into here.

The clinical quality measure (CQM) and CQM reporting options will be hashed out in the future payment rules, and MIPS also will obviously play a factor there too. The requirement that physicians have CEHRT “equipped”—accessed remotely, brought in on mobile device, or installed—at a location or combination of locations in which they have greater than 50% of their patient encounters will continue.

As we discussed, technology access and assistance is a huge problem for many hospital-located radiologists who are not enabled by their facilities. CMS did little to help that situation, but indicated that they will reexamine the issue during the MIPS rulemaking next year.

I think any radiologists who are still participating in MU in 2017 will opt to enter Stage 3 for the optional 90-day reporting period instead of remaining in the far more challenging modified Stage 2 for the full year reporting period. That is, if health IT products with 2015 Edition certification status are available by then. That’s a question mark, given the 2013 experience with the then-optional 2014 Edition certification.

Still, most radiologists won’t think about MU until the MIPS picture comes into focus with the 2016 rulemaking. Will there be alternatives to MU’s 25% of the MIPS composite score for non-patient-facing radiologists? And will those alternatives be more attractive than Stage 3? Time will tell.

Q. And the value proposition of radiologist MU participation also is unclear?

Peters: That is essentially correct for radiologists who never participated in MU prior to this current post-incentive, pre-MIPS and hardship exception-protected environment.  First-time meaningful users in 2015 can no longer obtain MU incentive payments for successful participation.  However, many radiologists who were meaningful users prior to this year can still participate and get MU incentive payments in 2015 and 2016.  The remaining bonus amounts for prior participants depend on the year they first participated.  For example, those who began the program in 2013 or 2014 can still get up to $8,000 for 2015 and $4,000 for 2016. 

Beyond the next couple of years, implementation of MIPS, particularly its ‘non-patient facing professionals’ provision, will ultimately define the long-term future of MU’s relationship to radiology.  For instance, what if MU’s 25% of the MIPS composite score for non-patient-facing radiologists was comprised of alternatives like registry participation, image sharing, facilitation of e-ordering and structured reporting instead of MU as we know it today? What if some combination of health IT-enabled, Imaging 3.0 principles served as sort of a 1-to-1 substitute for meaningful use in the MIPS scoring?

So, while most physicians are understandably concerned about MIPS implementation on the horizon and the potential threat of additional regulatory burden, there also is some leeway in the statutory language to make the Medicare quality programs work better for the radiology community and their patients.

Many of the ACR’s best and brightest economics, informatics, and government relations leaders are working hard on preparations and policies in advance of CMS’ 2016 MIPS and Alternative Payment Models rulemaking. There is an opportunity there to make an impact on the specialty’s future.  The challenge, as always, will be convincing CMS to get in the car.