How CME is Changing: The Influence of Population Health, MACRA, and MIPS

How CME is Changing: The Influence of Population Health, MACRA, and MIPS

Table of Contents Population Health: Definition and Use Case The Future of Population Health and Performance Improvement MACRA and MIPS: Introduction MIPS and Education MIPS and Association Managers MACRA MIPS: Reporting Qualifying under MACRA and MIPS Reporting Clinical Practice Improvement

Introduction Data analytics touch many aspects of our modern lives. Whether users are asking Siri for directions or searching for information on Google, companies use large swaths of data to better serve its users. The medical community is no exception. There have been recent changes in methods of storing patient records to changes in medical law. Both are a general drive toward a healthcare system that rewards quality of care and better patient outcomes. This change has implications for the online education of both doctors and patients. In this white paper, we explore these innovations in healthcare.

Population Health: Definition and Use Case Population health has been defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group according to Improving Population Health. However, the definition is still abstract and has not reached its full potential. Population health is now moving into the electronic health record (EHR) space as a healthcare improvement initiative. The goal is for an EHR system to be utilized as a data collector made up of collected individuals health records, broken down into different population health segments. For example, let s use the population of diabetes. Anyone who is diabetic and sees a care provider with an EHR will be represented as a small piece of data in the larger data base that contains the health records of all those with diabetes in the world. The vast amount of data on a specific health group will allow doctors to understand and better treat those with the same medical affliction. Let s go back to the patient with diabetes. Let s say that they have a special case that requires more than just the basic prescription and instructions. Their doctor has been giving them a specialized treatment that has been working better than their previous treatment. This new specialized treatment has been recorded in their EHR and would then feed into a large diabetes population health database such as a clinical data registry. At another hospital, located across the country, a patient with a similar case of diabetes has entered her doctor s office. The doctor wants to try a new treatment, but wants to see what other physicians have tried to get better results. After doing a little research, the data collected from the first patient is available, scrubbed of personally identifiable information as part of aggregate statistics on patients in this population, and the doctor can see how they were treated. The second patient is given the new treatment plan and their health and well-being improves. This is the eventual goal for population health. The obvious issue will be working with HIPAA and patient privacy. However, one of the larger, more ambiguous challenges is how to have physicians utilize the data created from these EHR records to make informed decisions. HealthIT has an article that discusses the implementation of Population Health analytics in more detail. Although it won t happen overnight, population health analytics will benefit the healthcare industry greatly with the potential to help patients all over the world.

The Future of Population Health and Performance Improvement The previous section introduced the concept of Population Health (PH) and how PH is being applied in healthcare. We re interested in how Population Health can have an impact on the professional development of medical professionals. Currently, the data needed for Population Health is most likely to be found in EHRs maintained by health providers and, increasingly, in clinical data registries (CDRs) maintained by professional societies and boards. Actual PH analytics may be accessible to physicians through the EHR, CDR, or other tools that might create useful views into that data. We d like to see these data sources connect more easily with online learning tools to provide more effective and efficient Performance Improvement programs for physicians. The goal for Population Health and CME is to create a new education and professional development strategy that facilitates better outcomes for patients and reimbursement based on performance, not the volume of patients or procedures. Currently, CourseStage HEALTH is being used by thousands of clinicians for CE. By providing those clinicians with education clearly tied to population health analytics, we could create a Clinician Education Program that is more focused on individual physicians professional development. Clinician-facing views of population health data in EHRs and CDRs could link out to an online learning platform. The learning platform would be able to track clinician s education gaps and provide an education program specific to the physician s learning needs. On-demand CME and PD could even act as a Clinical Support Tool. This integration of EHRs, CDRs, and online learning tools will save time for busy clinicians by helping them to meet CME and MOC requirements while they seek out information needed to improve their practice. Online learning tools should use emerging certification interoperability standards to connect to certification board platforms or provide learning portfolio management tools to reduce the time clinicians currently spend on self-reporting MOC and CE activities. Population Health is not just creating a community of people that are grouped together by their health status. The merging of functionality among EHRs, CDRs, and learning platforms

is also creating communities of doctors who are able to network and pass information along to one another. This powerful intelligence generated by information sharing will become a vital tool to the future of healthcare. Eventually the inflow and outflow of medical information from the Population Health database will not only better educate the medical professional, but the patient as well. MACRA and MIPS On October 14, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA was officially signed into law on April 16, 2015, in order to make significant adjustments to how Medicare pays for physician services. Importantly for our purposes at Managing elearning, these changes directly tie reimbursement to performance, and even to participation in performance improvement activities that is, learning. Some of the major changes to occur are: Shifting from rewarding healthcare providers by volume-based performance to value-based performance Stopping the use of the Sustainable Growth Rate (SGR) formula (what was used to determine Medicare payments for healthcare providers) Combining existing quality reporting programs into one new system Meaningful Use Physician Quality Reporting System Value-Based Payment Modifier The Quality Payment Program is the result of these changes created by the Centers for Medicare & Medicaid Services. The program can be broken down into two different tracks: Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). MIPS will combine the existing quality reporting programs, whereas APMs will cover physicians who receive a significant share of their revenue through APMs. The goal of MIPS will be to reduce the level of financial penalties physicians could have faced and also to provide a greater potential for bonus payments.

Payment adjustments under MIPS will be based on performance. The composite performance score (CPS) will be made up of four measurements: Quality, Advancing Care Information, Improvement Activities, and Cost. These categories were created to consolidate existing quality reporting programs and create one merit-based formula. The CMS will create a cumulative score by weighing the four performance categories, and then determine a reimbursement amount for physicians. The following weights have been applied to the performance categories: The old quality reporting programs replacements are shown below: Quality Replaces current Physician Quality Reporting System (PQRS) program Advancing Care Information Replaces Meaningful Use (MU) program Clinical Practice Improvement Activities New category Cost Replaces current Value-Based Modifier (VBM) program Cost will not require data submission from physicians. CMS will calculate it from adjudicated claims.

MIPS and Education Education and Performance Improvement will play a large role under MIPS. Physicians looking to qualify for a positive payment adjustment (i.e., bonus pay) under MIPS will need to participate in performance improvement (PI) activities. A proposed rules list defines what will qualify as a Clinical Practice Improvement Activity (CPIA). More information on reporting under MIPS can be found on the American Medical Association s Medicare Payment Reform page. A comprehensive list of what is defined as a CPIA can be found at the Centers for Medicare & Medicaid Services Quality Payment Program website. A few examples of improvement activities: Expanded practice access Population management Care coordination Patient engagement (care plans, shared decision making) Patient safety and practice assessments (checklists, MOC) In order to track and report on CPIAs, we suggest an innovative learning technology such as a performance improvement platform. A performance improvement platform will enhance the tracking of physician activity and suggest learning activities for improvement. Over time, the PI activities suggested will ideally be incorporated into the physician s practice and increase their Quality CPS measurement. MIPS and Association Managers Managers of associations can leverage MACRA & MIPS by providing CPIAs, which members can participate in, potentially qualifying for payment adjustments. In the case of Clinical Practice Improvement Activities, medical association managers should explore LMSes that offer performance improvement capabilities. Not only will a PI platform and LMS track and report activities for MIPS, but it will provide valuable feedback for physicians seeking to make meaningful improvements in quality of care. A beneficial PI platform should be able to provide statistical evidence that PI activities are making an impact on quality of care. Performance Improvement measures can be linked to the physician s improvement in the quality of their practice. Performance Improvement platforms can be utilized to improve physician s patient outcomes, and in turn, achieve better results under the Quality component of MIPS. If a physician performs well

in both the Quality and Clinical Practice Improvement categories, they will receive larger reimbursements from Medicare. By providing both reporting for PI activities and improvement in quality of patient care and outcomes, medical associations can provide more value to their members. MACRA and MIPS Reporting Now that the final rule for the Quality Payment Program has been passed under MACRA, the new Medicare payment program have begun to go into effect. MACRA and the Quality Payment Program have become one of the main discussion topics among physicians and healthcare professionals. How do you qualify for MACRA and the Quality Payment Program? In order to qualify for MACRA and to report under one of the payment programs, a clinician must bill more than $30,000 to Medicare patients, and provide care for more than 100 Medicare patients each year. These individuals must also be in one of the following healthcare fields: Physician Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetists The first performance period for the new Quality Payment Program (QPP) began in January 2017 - but there s still time to participate. In order to be considered for the 2019 adjustment year, you must begin your data collection by October 2, 2017, and submit all performance data by March 31, 2018. The data collected will be used for the adjustment year that will begin on January 1, 2019. One of the most important steps a clinician can take to prepare for the QPP is to ensure your electronic health record system is certified by the Office of the National Coordinator for Health Information Technology (ONC). All EHRs certified by the ONC should be able to capture the required data. [T]the bedrock of the Quality Payment Program is high-quality, patient-centered care followed by useful feedback, in a continuous cycle of improvement The Centers for Medicare & Medicaid Services

Reporting One of the two reporting tracks under the QPP is called the Merit-based Incentive Payment System (MIPS). Clinicians who prefer to stay with the traditional Medicare Part B payment program should choose to participate in the MIPS track of the QPP. As we discussed in the previous section on MACRA and MIPS, the new formula for Medicare B payment adjustment under MIPS will consist of four performance categories. Either an individual or a group can report their performance data to the CMS. However, each will have different forms of reporting required. As discussed earlier, an essential part of reporting under MIPS will be to have an electronic health record system certified by the ONC. One of the goals of MIPS is to encourage the widespread use of electronic clinical quality measure (ecqm) reporting. This will be achieved by using APIs (application programming interfaces) to allow the interoperability of healthcare and information software with an EHR. With APIs, patients and clinicians can use smartphone apps to access medical information from other programs (other than just an EHR), which is a key initiative for the CMS to make electronic health information available when and where it matters most. It will be important for clinicians to correctly utilize their EHR data and reporting capabilities, to ensure high quality information is submitted under the Advancing Care Information, Quality and Improvement Activities of the MIPS performance categories. The ONC listed certified health IT objectives for each of these categories. The objectives hope to achieve a new healthcare system in which certified EHRs and health IT [are used] as tools to improve the flow of health information among clinicians and, ultimately, improve the quality of care provided to patients (ONC). Clinical Practice Improvement Activities (CPIA) The Centers for Medicare and Medicaid Services provides a list of activities that qualify as a CPIA. Each of the activities listed will have one of two different weights assigned to it. CPIAs can have either a high weight or a medium weight, earning 20 or 10 points each, respectively. In order to achieve full credit under the Clinical Practice Improvement Activities, a clinician must submit a total of 60 points. The performance activities under CPIA will all fall within one of eight proposed subcategories:

Expanded Access to Care Population Management Care Coordination Beneficiary Engagement Patient Safety & Practice Assessment Achieving Health Equity Emergency Response & Preparedness Integrated Behavioral & Mental Health MOC Part IV, for example, falls under the subcategory Patient Safety & Practice Assessment. The activity weight is 10 points, or a medium weight. MOC Part IV can be fulfilled in a variety of ways. One way is for a clinician to join a local, regional or national outcomes registry or quality assessment program. To participate, a clinician must document performance of monthly activities across their practice, and regularly assess their performance. The performance data is then reviewed to identify areas in their practice that could be improved upon, which is followed by creating activities designed to improve performance in that area. Another way is for the clinician to create the MOC Part IV activities themselves, and to have their documentation and improvement activities approved by an accredited portfolio provider. Clinicians who have found documenting and creating improvement activities to be tedious and time consuming have turned to performance improvement platforms to assist them. Performance Improvement platforms are designed to document and track clinicians practice, assess them to identify areas in need of improvement, and make intelligent recommendations for learning to address gaps. Performance Improvement platforms may be provided by a healthcare provider or by a professional society. The data collected from completing MOC Part IV can be submitted to the Centers for Medicare and Medicaid Services by attestation, a Qualified Clinical Data Registry (QCDR), a Qualified registry, an EHR or by administrative claims if technically feasible (no submission required). At Web Courseworks, we see a need to for CME and performance improvement platforms to automate reporting on CPIAs to EHRs and government platforms in order to reduce the administrative burden on clinician learners.

Conclusion Medical education changes as developments in medical practice occur. In this instance, changes in the format of medical records and medical law pave the way for CME that is more data driven and informed. It is our hope that these innovations in medical practice result in better training for medical professionals and better patient outcomes.