2016: Looking Back, Looking Forward

The holidays are behind us and we are off to a great start in 2016. I am sure you have each enjoyed your lucky New Year’s Day meal and have made several resolutions, which hopefully will come to fruition. The first blog post of the New Year is traditionally a time of reflection, and with the honor in the rotation, I hope not to disappoint. Let’s start with a look back at 2015 and finish with a look ahead to 2016.

MACRA

2015 witnessed many events at the intersection of nephrology and health information technology. Perhaps the boldest occurred in March with the passage of the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). This piece of legislation contained two very important components for practicing nephrologists. First, it ended the nightmare known as the Sustainable Growth Rate, an annual scourge that kept many a nephrologist and practice manager on edge at the end of every year. Second, and perhaps more importantly, MACRA created the framework CMS believes will more quickly move us away from a healthcare system that pays for volume to one that rewards value and better care. That framework consists of two paths for nephrology providers:

1. Merit-based Incentive Payment System (MIPS)—MIPS basically combines parts of PQRS, the Value-based Payment Modifier (VM), and the Meaningful Use (MU) program while sprinkling in a new Clinical Practice Improvement module. Your MIPS score will determine what percentage of the Physician Fee Schedule you collect when providing care to Medicare beneficiaries. The stand-alone PQRS, VM, and MU programs will ride off into the sunset at the end of 2018.
2. Alternative Payment Models (APMs)—This path is the one that seems more appealing to yours truly. APMs are things like Accountable Care Organizations, Patient Centered Medical Homes, and ESCOs. If a large enough percentage of your Medicare revenue flows through an APM, you can avoid MIPS and, while you are at it, enjoy a 5% bump in your fee schedule. Not bad work if you can get it!

CMS has posted this MACRA timeline on their website. As noted below, we can expect to see more detail in the months ahead.

ICD-10

October was a remarkably busy month. On October 1, the moment we were all dreading came and went with about as much excitement as Y2K. At the 11^th hour, CMS provided physicians with a reprieve regarding specificity. That reprieve has a 12-month shelf life meaning that on October 1, 2016, they expect your ICD-10 codes to be as specific as the medical documentation will support. This is unlikely to be as much of an issue for nephrology as it will be for others (now would be a great time to thank yourself for not going into to Orthopedics), but keep an eye on this as it may come back to bite us.

ESCOs

Although not originally planned to coincide with ICD-10, the ESRD Seamless Care Organizations (ESCOs) also launched on the first day in October. An ESCO is basically and ACO for Medicare beneficiaries receiving dialysis for ESRD. Participants include nephrologists and dialysis facilities. The stated objective for the ESCO program is to test whether financial risk arrangements with guaranteed discounts to the Medicare program will improve outcomes and reduce Medicare costs for beneficiaries with ESRD. The Center for Medicare & Medicaid Innovation (CMMI) is supporting 13 ESCO “experiments” around the country. Keep a close eye on this program. If successful, ESCOs could experience a growth rate comparable to that of their cousin the ACO.

Meaningful Use

After much debate and speculation, CMS released combined final rules during the first week of October, shedding light on the future of the EHR incentive program. In one of the most widely read Acumen blog posts, Diana Strubler unpacked the proposed changes to Stage 1 and Stage 2. Almost six months later the final rule arrived. Remarkably, the final rule was published so late that most providers could make the case they cannot attest in 2015 because the final rule was published after the start of the last 90-day reporting period. Not surprisingly, the Stage 3 final rule was met with substantial pushback from organized medicine. In spite of that, as it stands today, all providers will be compelled to report Stage 3 in 2018.

Hardship Exceptions

The number of nephrologists attesting for MU in 2014 dropped to fewer than 1,800, a 60% decline from 2013. The reason? As the financial incentives decline and the MU requirements become more arduous, nephrologists are flocking to the hardship exceptions. Last week Diana highlighted the Patient Access and Medicare Protection Act, which among other things will make the hardship exception process easier. With President Obama’s signature last week that Act became law. As a result, one might imagine the number of nephrologists attesting will be at a record low in 2015. As noted above, CMS recognizes the late publication of the final rule will likely increase the number of hardships they receive.

2016

With such a flurry of activity in 2015, what can we expect in 2016? Not surprisingly, much of what we can expect is related to what happened last year. A few things to keep your eyes on this year include:

MIPS

This spring we should have our first look at what’s expected with MIPS in the form of a proposed rule. Along with last year’s Meaningful Use final rule, CMS issued a request for information regarding the implementation of MIPS and the APM framework. As you may recall, the publication of the proposed rule for EHR incentive program (Meaningful Use) preceded the passage of MACRA. MACRA is tightly interwoven with MU, PQRS, and the VM. Much of what we know about MACRA today has been gleaned from the legislation, and as always the devil will be in the details. Many of us will be paying close attention to this one.

Hardship Date

The penalty for not demonstrating meaningful use in 2015 is a 3% reduction in your 2017 Medicare Physician Fee Schedule. If you are not able to demonstrate MU in 2015, the only way to avoid the penalty is to successfully file for one of the four hardship exceptions. We have previously highlighted those exceptions and have spent time exploring one that is popular in the nephrology space. The key date to keep in mind is July 1, 2016, which is the filing deadline for the 2015 reporting period to avoid the 3% 2017 haircut. The hardship exception application is not yet posted on the CMS website, but look for it over the next few months.

Nephrology Shortage

The past few years have witnessed a troubling trend among nephrology training programs: An increasing number of nephrology fellowship positions are going unfilled. Last year Dugan Maddux highlighted this issue, which has the attention of the American Society of Nephrology. Should the national nephrology training program “fill rate” be considered a leading indicator for your ability to hire docs in the future? Many believe so, making this another important issue to watch in 2016.

FHIR

Interoperability remains the Holy Grail for health information technology, and many believe FHIR (Fast Healthcare Interoperability Resources) is the best path to the Promised Land. A group of prominent private stakeholders are working diligently to make this more than a dream. Keep your eyes on the Argonaut Project as 2016 unfolds.

Election Year

When we started the Acumen blog over five years ago, we collectively recognized politics and religion were two topics best avoided. I still believe that’s sound advice, so without taking sides, let’s be clear that odd things can happen during an election year. Sometimes the machine comes to a grinding halt; other times unusual alliances develop, creating outcomes few of us would predict. I am sure many of you are contemplating the impact of the November 8 elections. There is certainly a chance the outcome will influence the intersection of nephrology and health information technology.

As always, it is much easier to recount the past than it is to forecast the future. We had an exciting 2015, and it looks like 2016 will build upon the foundation created last year. All of us at the Acumen blog hope that you had a wonderful 2015, and we wish you a safe and prosperous New Year.

Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.