The U.S. Department of Health and Human Services issued a long-awaited proposed rule for the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, on Wednesday, ushering in some big changes for the ways physicians are assessed for quality of care and use of information technology.

HHS recognizes that physicians are currently buckling under the demands of a "patchwork" of quality- and value-measuring programs such as ACOs, the Comprehensive Primary Care Initiative and the Medicare Shared Savings Program – as well as the Physician Quality Reporting System, the Value Modifier Program and, of course, the Medicare EHR Incentive Program, or meaningful use.

The new proposed rule would streamline aspects of many of those into something called the Quality Payment Program, which includes two paths: the Merit-based Incentive Payment System, or MIPS, and advanced Alternative Payment Models, or APMs.

The majority of Medicare docs will participate, at least at first, in MIPS, according to HHS. That program allows Medicare clinicians to be reimbursed by showing success in four categories: quality, cost, advancing care information, and clinical practice improvement activities. Under the MIPS proposed rule:

• Quality accounts for half of a total score in year one of the program. Clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices.
• Cost accounts for 10 percent of total score in year one. The score would be based on Medicare claims, meaning no reporting requirements for clinicians, HHS points out. This category would use 40 episode-specific measures to account for differences among specialties.
• Advancing Care Information counts for 25 percent of total score in year one. Here, clinicians choose to report customizable measures reflecting their use of technology in day-to-day practice – with a particular emphasis on interoperability and information exchange. HHS emphasizes that, unlike current reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.
• Clinical Practice Improvement Activities count for 15 percent of total score in year one – rewarding clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities that match their practices' goals from a list of more than 90 options.

CMS would begin measuring performance for doctors and other clinicians through MIPS in 2017, with payments based on those measures beginning in 2019.

[Also: MACRA-economics 101: Prepare today for tomorrow's outcomes]

As for Advanced Alternative Payment Models, Medicare docs who participate "to a sufficient extent" in various APMs could be exempt from MIPS reporting requirements and qualify for financial bonuses, according to HHS, but the burden to prove that seems high. These models include the recently-unveiled Comprehensive Primary Care Plus (CPC+) model, Next Generation ACOs and others "under which clinicians accept both risk and reward for providing coordinated, high-quality care."

"We’ve developed this program using three principals," said Andy Slavitt, acting administrator of the Centers for Medicare and Medicaid Services during a conference call Wednesday afternoon.

"First, to be patient-centered to promote our true goal, the highest quality and most coordinated care for beneficiaries," he said. "Second, to be practice-driven, so physicians can select among measures that are right for their practices. And third, consistent with the goals of the legislation to make it as simple as possible for physicians, we have thought about ways to unlock the role of information technology to support physicians. The meaningful use program is being replaced with a simpler program."

Unlocking the full potential of health IT
In a blog-post coauthored by Slavitt with National Coordinator Karen DeSalvo, MD, the officials reemphasized that all these changes impact only Medicare payments to physician offices – not Medicare hospitals or any Medicaid programs.

They did note, however, that CMS and ONC are "already meeting with hospitals to discuss potential opportunities to align the programs to best serve clinicians and patients, and will be engaging with Medicaid stakeholders as well."

Meanwhile, they offered some further insight into what the Advancing Care Information component of MIPS would mean for physicians' use of health information technology and the shift away from meaningful use.

Enabling providers to be more "patient-centric, practice-driven and focused on connectivity" is essential, they said, but the existing Medicare meaningful use program for physicians wasn't always helping further that goal.

[Also: Slavitt, DeSalvo: Health IT has to work better for doctors]

In contrast, the new MIPS program aims to "support the vision of a simpler, more connected, less burdensome technology."

Advancing Care Information would allow physicians to report on the measures that best reflect how they use IT, simplify the process for achievement by offering multiple means of success and eliminate an all-or-nothing approach to EHR measurement or quality reporting, they said.

In addition, the rule would offer simplifications such as reducing reporting to a single public health immunization registry, exempting certain physicians from reporting "when EHR technology is less applicable to their practice" and allowing physicians to report as a group.

The proposed MIPS rule also focuses on "an all-time low of 11 measures" according to the post, and no longer requires docs to report on clinical decision support or computerized provider order entry.

The program would be aligned with ONC's 2015 Edition Health IT Certification Criteria, with an emphasis on interoperability, health information exchange, security measures and patient access.

With newly-certified technology required to use APIs, the rule would broaden the connectivity options open to physicians, enabling them to make wider use of apps, analytics tools and other consumer devices.

By ensuring health IT is "more open and plug-and-play," the aim was to "put the power back in the hands of physicians," said Slavitt on Wednesday's conference call. "We have designed a powerful program that is much easier to use, lower-burden and that promotes connectivity and innovative technology."

Read the MACRA proposed rule here.
It is available for public comment for 60 days; submit comments here.

Healthcare IT News Managing Editor Bill Siwicki contributed to this story.