On April 24, CMS released the Fiscal Year 2019 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital Prospective Payment System (LTCHPPS) Proposed Rule, and Request for Information (the “Proposed Rule”). The IPPS and LTCHPPS are the payment methodologies that CMS uses to calculate payments to acute care hospitals for inpatient stays. Each year CMS updates the payment rates under the IPPS and LTCHPPS to account for changes in prices for services and items and other economic and non-economic factors. 

In addition to general updates to Medicare payment policies and rates under the IPPS and LTCHPPS, the Proposed Rule proposes significant changes to the Medicare and Medicaid EHR Incentive Programs (i.e., Meaningful Use Program) and the hospital quality and value-based purchasing programs. 

Interoperability

The HITECH Act authorizes certain incentive payments under Medicare and Medicaid for the adoption and meaningful use of certified electronic health record technology (CEHRT). Further, eligible hospitals and critical access hospitals (CAHs) that do not successfully demonstrate meaningful use of CEHRT for certain reporting periods are subject to downward payment adjustments. The current structure of the Stage 3 objectives of Meaningful Use for eligible hospitals and CAHs requires them to report on 6 objectives that include 16 measures. 

 CMS proposes to overhaul the Meaningful Use Program as follows:   

• The Medicare and Medicaid EHR Incentive Programs will now be called, “Promoting Interoperability Programs.” 
• CMS continues to emphasize that eligible professionals, eligible hospitals and CAHs should utilize the 2015 Edition of CEHRT beginning in CY 2019, which includes key updates to functions and standards that support improved interoperability and clinical effectiveness, including (i) application programming interface (API) functionality and (ii) certification criterion specifying a core set of data that healthcare providers have noted are critical to interoperable exchange and can be exchanged across a wide variety of other settings and use cases (Common Clinical Data Set).
• EHR reporting periods in 2019 and 2020 for new and returning participants attesting to CMS or their State Medicaid agency would be a minimum of any continuous 90-day period within each of the calendar years 2019 and 2020.
• New performance-based scoring methodology with fewer measures.

Objectives

The new performance-based scoring methodology would apply to eligible hospitals and CAHs (Medicare-only and dual eligible, but not Medicaid-only) that submit an attestation to CMS under the Medicare Promoting Interoperability (PI) Program beginning with the EHR reporting period in CY 2019. CMS proposes to reduce the overall number of required measures from 16 to 6. The performance-based scoring methodology would be based on 4 objectives, each with certain identified measures: (i) e-Prescribing, (ii) Health Information Exchange, (iii) Provider to Patient Exchange, and (iv) Public Health and Clinical Data Exchange. Each measure would be scored based on the eligible hospital or CAH’s performance for that measure, except for the Public Health and Clinical Data Exchange objective, which would require a yes/no attestation. An affirmative “yes” attestation for the Clinical Data Exchange objective would be required in order to qualify for the Promoting Interoperability Program incentives.

The Stage 3 objective – Protect Patient Health Information and its associated measure of Security Risk Analysis – will remain part of the program, but no longer scored. To earn any score in the PI Program, CMS proposes that eligible hospitals and CAHs attest that they completed the actions included in the Security Risk Analysis measure at some point during the calendar year. 

Scoring

Each measure would contribute to the eligible hospital or CAH’s total Promoting Interoperability score and the scores would be added together to calculate the total PI score of up to 100 possible points. A total score of 50 points or more would satisfy the requirement to report on the objectives and measures of meaningful use. Eligible hospitals and CAHs scoring below 50 points would not be considered meaningful EHR users.  Regarding the new performance-based scoring methodology, CMS believes “this proposal allows eligible hospitals and CAHs to achieve high performance in one area where they excel, in order to offset performance in an area where they may need additional improvement.” Where a hospital claims an exclusion under the Interoperability Program, the points associated with the corresponding measure will be redistributed. 

The proposed Performance-Based Scoring Methodology for EHR Reporting Periods in 2019 and 2020, with associated proposed point distribution is set forth in the charts below.

Alternative Proposal

CMS is also considering an alternative approach in which scoring would occur at the objective level, instead of the individual measure level, and eligible hospitals or CAHs would be required to report on only one measure from each objective to earn a score for that objective. The eligible hospital or CAH’s total PI score would be based on only 4 measures – one measure from each objective. Bonus points would be awarded for reporting any additional measures beyond the required 4 measures.  CMS seeks feedback regarding this approach. 

If CMS does not finalize a new scoring methodology, CMS indicates that it will maintain the current Stage 3 methodology with the same objectives, measures and requirements, but would include the two new opioid measures.

Request for Information

As part of the Proposed Rule, CMS released a Request for Information (RFI) to obtain stakeholder feedback on positive solutions to better achieve interoperability (sharing of healthcare information among providers and suppliers). Specifically, CMS is interested in stakeholder feedback regarding revisions to or use of the Conditions of Participation, Conditions for Coverage and Requirements for Participation to advance electronic exchange of information that supports safe, effective transitions of care between hospitals and community providers. Examples that CMS includes in the RFI include: (i) requiring hospitals transferring medically necessary information to another facility upon a patient transfer or discharge to do so electronically; (ii) requiring hospitals to send required discharge information to a community provider via electronic means if possible and if a community provider can be identified; and (iii) requiring hospitals to make certain information available to patients and third-party payers, like discharge instructions via electronic means.  The specific questions are located at Section XII of the Proposed Rule. 

Meaningful Measures

CMS proposes to reduce the number of measures that acute care hospitals must report in the five quality and value-based purchasing programs. The Proposed Rule proposes to remove 19 measures from the quality programs, de-duplicate another 21 measures, and would adopt 1 new claims-based readmission measure. A list of the measures that CMS proposes to remove for each program can be found here.

Transparency

Finally, CMS is updating its guidelines for hospitals to make public a list of standard charges. Now, hospitals will be required to make public a list of their standard charges via the internet.

The Proposed Rule can be found here. 

Additional Information

If you have questions regarding the proposed changes to the meaningful use program or the updates to hospital reporting requirements, please contact one of the authors.