The Inpatient Prospective Payment System (IPPS) proposed rule: opioids, the new meaningful use, and burden reduction
The regulatory season is in full swing. In this post, we will discuss the recent proposed rule for the Inpatient Prospective Payment System (IPPS), particularly the elements we expect to impact the ambulatory market. Specifically, we’ll explore how the new rule addresses the opioid crisis through technology, how the Centers for Medicare and Medicaid Services (CMS) is redesigning “Meaningful Use,” and how reducing the administrative burden of quality measure reporting affects providers.
OPIOID CRISIS MEASURES
While most of the activity on opioids is before Congress, the administration and CMS are taking steps, as well. CMS is proposing two new measures that would be optional in 2019, and required, subject to exclusions, by 2020. Specifically, they are proposing measures called Query of Prescription Drug Monitoring Program (PDMP) and Verify Opioid Treatment Agreement.
The PDMP measure looks at how frequently an eligible hospital or critical access hospital queries a PDMP for prescription drug history when writing a Schedule II opioid. The Verify Opioid Treatment Agreement measure looks for how often an eligible hospital or critical access hospital seeks to identify a signed opioid treatment agreement for patients prescribed a Schedule II opioid and incorporate it into the electronic health record.
Each proposed measure presents challenges and opportunities, and could find its way into the Physician Fee Schedule (PFS). Neither measure is limited to the acute space from a clinical perspective, and could translate to ambulatory environments without too much tweaking. Querying PDMPs may assist in identifying patients who are habitual users or overprescribed. Verifying opioid treatment agreements can assist in the coordination of care. However, like immunization registries, PDMPs nationwide vary tremendously in their level of readiness and requirements. Similarly, the Verify Opioid Treatment Agreement measure does not specify a document type or architecture that physicians should look for, making it a challenge to automate measure calculations.
REDESIGNING MEANINGFUL USE
On the Meaningful Use front, CMS is renaming the program to Promoting Interoperability. In addition to a new name, CMS is proposing several changes to its measures. Notably, CMS is proposing to remove measures that require a patient to proactively act — such as downloading his or her health record — because it puts an undue burden on the hospital. The following measures are being proposed for removal:
- Patient-specific education
- Secure messaging
- Patient-generated health data
- View, Download, Transmit
The same logic could apply to the ambulatory space. Under MIPS today, those measures are not “base” measures, or required. They can only help physicians because there is no associated threshold. In contrast, hospitals had required thresholds. However, Promoting Interoperability’s new scoring methodology for hospitals largely accomplishes the same, so it seems likely these would be removed from MIPS, too.
In addition, CMS is seeking to change how it measures interoperability. Under the IPPS, the most significant measure change is to how to credit providers for receiving summaries of care electronically. There are two measures today — querying other hospitals’ summaries of care and reconciling clinical information in the EHR. A new measure, which would combine the two, is titled “Support Electronic Referral Loops by Receiving and Incorporating Health Information.”
Rather than crediting providers for proactively querying for records, it would reward them when they receive an electronic record and then reconcile the Medication, Medication Allergy, and Current Problems List fields. Ambulatory providers face the same challenge with respect to burden as hospitals, so it is likely that these measures’ equivalents under MIPS could go through similar changes.
REMOVING QUALITY MEASURES
Finally, CMS is proposing to remove a host of 14 quality measures from Part A Promoting Interoperability (formerly Meaningful Use). However, it is not likely they would remove quality measures from MIPS for the same reason. The measures under Part A Promoting Interoperability were reported in other programs and therefore duplicative — and mandatory. The quality measures for MIPS are à la carte. At most, providers report on six out of more than 250 quality measures. That high number is there to give providers flexibility with respect to program participation, especially specialists. It is unlikely they would roll that back. However, CMS is soliciting comments on items that may be of interest to ambulatory physicians — specifically on reducing administrative burden and encouraging the adoption and testing of new measures.
If the IPPS is anything to go by, we can expect a lot of new material, measures, and requirements for MIPS in 2019. When CMS issues the PFS in June, expect action on opioids, how we measure the use of technology in healthcare and share information electronically, and quality measure specifications and burden.
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 The Spring 2018 Unified Agenda of Regulatory and Deregulatory Actions does not include the Quality Payment Program and/or MIPS and MACRA. However, CMS is required to issued regulations around it each year. Since MACRA applies to Part B physician payments, it is likely that it will be included as part of the PFS instead.