AMA seeks to remedy 'cumbersome' Stage 2 rules

By Mike Miliard
02:47 PM
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Arguing that changes "are necessary to ensure that the meaningful use program lives up to its intended purpose," the American Medical Association on Monday submitted its comments on proposed Stage 2 criteria to Centers for Medicare and Medicaid Services Acting Administrator Marilyn Tavenner.

Joined by 98 state and specialty medical societies, the AMA sought more flexibility in its formal comments on the proposed rules for Stage 2 of the Medicare and Medicaid electronic health record incentive programs.

Citing the "technological and other challenges" many doctors are experiencing as they work to meet meaningful use, AMA officials offered suggestions for "synchronizing the multiple health IT and quality programs currently underway" in a bid to drive up physician participation.

[See also: AMA mounts campaign to halt ICD-10.]

“The AMA is supportive of widespread adoption and meaningful use of EHRs by physicians, but the cumbersome proposed criteria will make successful physician participation extremely difficult,” said AMA Board Chair-elect Steven J. Stack, MD.

“Due to physicians’ limited ability to exchange data with other healthcare partners, many of the proposed Stage 2 measures will require extensive manual data entry, which is not an efficient way of practicing medicine or improving quality care outcomes for patients,” he added.

In order too make the Stage 2 more achievable, the AMA's comment letter made the following recommendations:

  • Evaluate Stage 1 to inform final Stage 2 requirements. The AMA suggested CMS survey physicians who participated in the first round – as well as those who chose not to – in order to identify barriers to participation.
  • Create more flexibility, ensuring measures include exclusions where appropriate and factor in relevancy. Reasonable exclusions for many requirements should be included, so docs can opt out of the measures that have little relevance to their routine scope of practice, AMA argued.
  • Get rid of high thresholds for new measures – and for those that can't be met with available tools. High thresholds should be eliminated for measures that cannot be attained due to the lack of available, affordable, well-tested tools or abundant bidirectional health information exchanges.
  • Focus more on measures within a physician’s control. The AMA suggested measures requiring adherence from a party other than the physician, such as those based on patient’s use of technology, should be eliminated.
  • Include any proposed new measures for Stage 2 in the menu set of options. Additionally, if an increase in the threshold percentage of a Stage 1 measure is warranted in Stage 2, then the increase for Stage 2 should be no more than 10 percent, it was argued
  • Allow a significant good faith effort to meet measures in Stage 2 to count for incentives and for avoiding penalties. Physicians should not have to meet all 20 measures, plus clinical quality measure reporting, to prove that they're meaningful users, the AMA contended, arguing that letting docs opt-out of a certain number of measures – three or more, say – is the type of flexibility needed to encourage more physician participation.
  • Medicare/Medicaid meaningful use rules should only apply to relevant patient populations. CMS should make it clear that physicians are not required to apply the Medicare/Medicaid meaningful use program requirements to their non-Medicare/Medicaid patient populations in order to be eligible for EHR incentives or to avoid penalties, officials said.
  • Eliminate back-dating the meaningful use penalty program and establish a number of exemption categories for hardship cases. The AMA expressed opposition to CMS’ proposal to back-date the meaningful use reporting requirements under the penalty program, so a physician would face the 2015 penalty based on 2013 or 2014 data. A number of exemption categories should be established, the group argued, and the exemptions should apply for five calendar years to minimize filing burdens and to allow time for CMS to reassess program requirements and timelines.
  • Synchronize overlapping health IT and quality program requirements. CMS should add more exemption categories to the Medicare e-prescribing and meaningful use programs, so that physicians are not unfairly penalized for participating in one program over the others, argued AMA officials.
  • Establish an appeals process under both the meaningful use and e-prescribing programs. The AMA urged CMS to provide physicians with 180 days to file an appeal under the meaningful use program after receiving actual notice of determination(s) subject to appeal.
  • Reduce the burden of reporting and testing for clinical quality measures (CQMs). The AMA offered several recommendations with regard to CQMs. Chief among them was to consider a third CQM reporting option, which would allow eligible professionals (EPs) to report six clinically relevant CQMs, covering at least two domains; if an EP doesn't have clinically relevant measures, then EP’s system must demonstrate zeros in the denominator for six measures covering at least two domains. Another suggestion was that CMS exempt EPs from CQM requirements until measures are tested and vendors have shown they've met the certification requirements for the specific EHR technology being utilized by an EP.

[See also: AMA to HHS: Medicare e-Rx penalty policy 'unreasonable'.]

Ultimately, AMA officials argued, while the Stage 2 delay until 2014 was a good thing, "physicians need to be assured that their EHRs will be able to support Stage 2 measures well in advance" of that date. For that to happen, "physician practices need adequate training and have to adjust workflows," they wrote.

Additionally, the AMA expressed concern that "our previous recommendations for developing Stage 2 measures were not adequately considered by CMS."

For the past year, "we urged CMS to build flexibility into the meaningful use incentive program to accommodate all specialists and their varying practice patterns and patient populations," the letter read. "By doing so, we believe more physicians would be able to take advantage of the EHR meaningful use incentives, which would help us achieve the desired outcome for the Medicare/Medicaid EHR program – accelerating the widespread meaningful use of technology by physicians and other healthcare providers to improve our nation’s healthcare delivery system."

[See also: AMA urges CMS to put physicians at the heart of ACOs.]

“Overall, the proposed Stage 2 requirements need to provide more flexibility to foster widespread EHR adoption,” said Stack. “Physicians are at varying stages of implementing health IT into their practices and should get credit for making a good faith effort to meet the meaningful use requirements.”

Click here (pdf) to read the AMA's suggestions for Stage 2 meaningful use.