Goodbye measures of data quantity, hello data quality measures of MACRA

Measurement and payment incentive
In the MIPS part of MACRA, the 4 factors of clinical quality, resource use, clinical practice improvement, and meaningful use of EHR will be combined in a formula to determine where each practitioner lies in comparison to his or her peers.

Now the bad news: Instead of receiving a bonus by meeting a benchmark, the bonus funds will be subtracted from those providers on the low end of the curve, and given to those at the top end. No matter how well the group does as a whole, no additional money will be available, and the bottom tier will be paying the bonuses of the top tier. The total pool of money to be distributed by CMS in the MIPS program will only grow by 0.5% per year for the foreseeable future. But MACRA does provide an alternative model for reimbursement, the Alternative Payment Model.

Alternative Payment Model
The Alternative Payment Model is basically an Accountable Care Organization—a group of providers agree to meet a certain standard of care (eCQMs again) and, in turn, receive a lump sum of money to deliver that care to a population. If there is some money left over at the end of a year, the group runs a profit. If not, they run a loss. One advantage of this model is that, under MACRA, the pool of money paid to “qualified” groups will increase at 5% per year for the next 5 years. This is certainly a better deal than the 0.5% increase of MIPS.

For specialists in general obstetrics and gynecology it may very well be that the volume of Medicare patients we see will be insufficient to participate meaningfully in either MIPS or the Alternative Payment Model. Regulations are still being crafted to exempt low-volume providers from the burdens associated with MACRA, and the American Congress of Obstetricians and Gynecologists (ACOG) is working diligently to advocate for systems that will allow members to see Medicare patients without requiring the substantial investments these programs likely will require.

The EHR: The single source of truth
The push to make the EHR the single source of truth will streamline many peripheral activities on the health care delivery side as well as the payer side. These requirements will present a new challenge to health care professionals, however. No one went to medical school to become a data entry clerk. Still, EHRs show the promise to transform many aspects of health care delivery. They speed communication,⁸ reduce errors,⁹ and may well improve the safety and quality of care. There also is some evidence developing that they may slow the rising cost of health care.¹⁰

But they are also quickly becoming a major source of physician dissatisfaction,¹¹ with an apparent dose-response relationship.¹² Authors of a recent RAND study note, “the current state of EHR technology significantly worsened professional satisfaction in multiple ways, due to poor usability, time-consuming data entry, interference with face-to-face patient care, inefficient and less fulfilling work content, insufficient health information exchange, and degradation of clinical documentation.”¹³

This pushback against EHRs has beenheard all the way to Congress. The Senate recently has introduced the ‘‘Improving Health Information Technology Act.’’¹⁴ This bill includes proposals for rating EHR systems, decreasing “unnecessary” documentation, prohibiting “information blocking,” and increasing interoperability. It remains to be seen what specific actions will be included, and how this bill will fare in an election year.

So the practice of medicine continues to evolve, and our accountability obligations show no sign of slowing down. The vision of the EHR as a single source of truth—the tool to streamline both the data entry and the data analysis—is being pushed hard by the folks who control the purse strings. This certainly will change the way we conduct our work as physicians and health care professionals. There are innovative efforts being developed to ease this burden. Cloud-based object-oriented data models, independent “apps,” open Application Programming Interfaces, or other technologies may supplant the transactional billing platforms¹⁵ we now rely upon.

ACOG is engaged at many levels with these issues, and we will continue to keep the interests of our members and the health of our patients at the center of our efforts. But it seems that, at least for now, a move to capturing discrete data elements and relying on eCQMs for quality measurements will shape the foreseeable payment incentive future.

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