Welcome to Value-Based Care, Regulatory Environment. This is lecture c. In this lecture, we will discuss other key pieces of legislation, the Health Information Technology for Economic and Clinical Health or HITECH Act, the Medicare Access and CHIP Reauthorization Act or MACRA, and the Physician Quality Reporting System. The objectives for this lecture, other regulations are to describe the Health Information Technology for Economic and Clinical Health Act or HITECH Act, describe the Medicare Access and CHIP Reauthorization Act or MACRA, and describe the Physician Quality Reporting System, PQRS. Strategies for improving the healthcare delivery system emphasize increased coordination across providers and the continuum of care, including transfer of information about patients across these providers. The availability of clinical decision support tools, so that clinicians can make informed decisions on behalf of their patients, and payment approaches that incentivize providers to improve the quality of care and produce good health outcomes. The glue or mechanism for delivery system redesign is the availability and use of health information technology or HIT. HIT can improve the flow of information. However, for a long time, the United States was behind other countries in adopting HIT within the delivery system. For example, in this chart produced by the Commonwealth Fund, in 2006, only 28% of US primary care physicians had electronic medical records To address the slow pace of adoption of health information technology, Congress passed the Health Information Technology for Economic and Clinical Health, or HITECH Act, as a part of the American Recovery and Reinvestment Act of 2009. The act authorized the spending of nearly $44.7 billion to support providers becoming meaningful users of electronic health records specifically, and health information technology more broadly. Qualifying physicians and institutions received incentives not just for purchasing HIT systems and EMRs, but also by demonstrating that they were using the systems in a meaningful way. The Centers for Medicare and Medicaid Services developed the regulations governing requirements for meaningful use. Using EHR in a meaningful way means that the technology is being used in the manner for which it was intended, such as e-prescribing, the electronic exchange of health information and to submit quality measures. Goals for meaningful use are to improve quality, engage patients in their healthcare, improve care coordination and to improve population health, while maintaining the privacy and security of the patient's information. The HITECH Act has been successful at speeding the adoption of information technology in hospitals. This study by Julia Adler-Milstein and her colleagues using data from the American Hospital Association charts the growth in electronic health record adoption among general acute care hospitals in the US. The researchers found that 75% of hospitals had at least a basic system in 2014, up from 59% in 2013. In 2014, 34% of hospitals had comprehensive systems compared to 25% of hospitals in 2013. Despite this progress, small and rural hospitals were less likely to have at least a basic system. Among hospitals that did not meet the threshold for having a basic EHR, most had adopted some functionality with about 75% of this group with eight or more basic EHR functions in place. The requirements for receiving incentives were designed to become more stringent over time in stages. For instance, the percentage of patients for whom e-prescribing was used increased in stage two compared to stage one. And stage two also required hospitals to develop systems to exchange clinical information using a certified EHR in order to receive monthly payments. By 2014, 76% of hospitals reported being able to exchange information with providers outside the system, an improvement from 41% in 2008. HITECH not only encouraged the adoption of electronic health records in hospitals, but in physician offices as well. By 2013, 78% of office-based physicians reported adopting some type of EHR system with 48%, having a basic system defined as having seven electronic capabilities. Recording patient history and demographic information, maintaining patient problem lists, recording clinical notes, recording medication and allergy lists, viewing lab results, viewing imaging reports and using computerized prescription ordering. Despite the fairly rapid adoption of EHRs, post-implementation of HITECH, only 39% of office-based physicians reported having any health information exchange with other providers. So in terms of promoting adoption of EHRs, HITECH was fairly successful, but many of the changes leading to increased quality of care that were envisioned and had begun, but were not yet widespread in 2015. The Physician Quality Reporting System was started in 2006, as part of the Tax Relief and Health Care Act. Providers who participated in the program would transmit quality metrics for their Medicare patients to the Centers for Medicare and Medicaid Services. As a result of the Affordable Care Act, beginning in 2015, physicians' providers will now receive penalties if they do not satisfactorily report their quality measures for Medicare Part B, physician component services. Additional legislation, known by the acronym MACRA, increased the pressure to focus not just on adoption of EHRs, but on using them to improve the quality of care. Medicare fee for service reimbursement to doctors has long been based on what is known as the sustainable growth rate formula or SGR. The SGR formula sought to limit spending growth in the Medicare fee for service model that rewarded physicians for the number and intensity of services provided. It reduced fees paid to physicians, if overall physician spending exceeded some target based on overall economic growth. That is if physician expenditures, for a previous year, were greater than expected, reimbursement to physicians, in the subsequent year, would be reduced. A study published by the Commonwealth Fund described a number of criticisms of the SGR including that it cuts fees for every service, and for every provider under the Medicare fee schedule, regardless of the provider's contribution to spending growth. Lacks incentives for improving quality, fails to address volume and intensity which are significant drivers of Medicare spending growth and penalizes providers who do control their costs. The Medicare Access and CHIP Reauthorization Act or MACRA, authorized in 2015, is intended to not only reduce uncertainty associated with physician payments, but also to reduce the emphasis on volume based fee-for-service reimbursement. Under MACRA, physician fees will increase by .5% until 2019, and then will remain level through 2025. MACRA also supports alternative payment models, such as Accountable Care Organizations and Patient-Centered Medical Homes. To encourage high quality performance among physicians, the Merit-Based Incentive program or MIPS will be established in 2019. MIPS consolidates and replaces three existing payment programs. The physician quality reporting system that encourages practices to report on the quality of care provided to Medicare beneficiaries, the EHR Incentive Program that we discussed in the previous slides, and the physician value-based modifier that adjust payments based on performance. Providers that participate in alternative payment models or, example, Accountable Care Organizations or Patient-Centered Medical Homes, can receive additional payments. Or, if eligible, those in alternative payment arrangements can choose to opt out of the MIPS, but they are required to use certified EHR technology. MACRA creates four categories of measures that are weighted to create an overall MIPS score. These include quality, resource use, clinical improvement activities and meaningful use of EHR technology. Under MACRA, the previous incentive programs are changing from standalone programs with often conflicting requirements to better aligned and coordinated programs. CMS is currently in the rule-making stage, which will better define how the merit-based performance program will work. This concludes lecture c on Regulatory Environment. In this lecture, we discussed two additional pieces of legislation that will have substantial impact on how care is provided. The HITECH Act provided incentives to encourage the meaningful use of electronic health records. Since the Act's passage, the US has seen significant growth in the use of EHRs in hospitals and in physicians' offices. MACRA changes how physicians are reimbursed within Medicare. The new reimbursement mechanism is intended to incentivize doctors to improve the quality of care.
