MIPS (Merit based Incentive Payment System for Medicare); Should I get a EHR system to meet MIPS?

2017 was the first year for MIPS reporting. MIPS stands for the Merit Based Incentive Payment System for Medicare. It sounds complicated and painful, but if you are starting a practice from scratch and take time to figure out how to meet MIPS your first year as a solo doc when you’re not seeing a ton of patients, it makes it very easy to meet the criteria in future years. If you already have a practice on paper charts, or are buying a practice without EHR, the equation becomes more complicated.

Before MIPS existed, there were two programs: meaningful use of EHRs and PQRS. Meaningful use resulted from the passage of the HITECH Act in 2009, to create jobs part of the Obama economic stimulus plan after the stock market crash and recession of 2008. PQRS was passed as an incentive only program as part of a 2006 tax act, but in 2010 Obamacare (the Affordable Care Act) changed it to penalty only for those who did not comply with PQRS.

Meaningful use of electronic health records, according to the healthit.gov website, is supposed to “Improve quality, safety, efficiency, and reduce health disparities, engage patients and family, and improve care coordination and public health”, leading to “better clinical outcomes, increased transparency and efficiency, and empowered individuals.” In my personal opinion, it has done none of these things. It was basically a way to siphon money away from doctors to computing companies. I guess at least it created jobs for those companies.

In 2005 a study (probably sponsored by EHR companies) declared that adaption of EHRs would save $81 million in health costs, convincing the politicians to pass HITECH. I am very skeptical of any studies that have shown that using EHR leads to better outcomes or lower costs. Having said that, I’m extremely happy with my EHR system. Even if the government did not provide any incentives or penalties to use EHR, I would most definitely still choose to, I’ll explain more below. I feel that the government should have let the free market for EHRs organically evolve; as technology got better and the prices came down, more physicians would see the benefits of using them and choose on their own to adapt EHR, rather than do it just to get bonus payments or avoid the penalty on medicare payments (1%, then 2% in 2016 and 3% in 2017). But I suppose the rules passed by the government worked; at a recent conference I attended, I heard that as of 2016 about 75% of ophthalmologists have adapted EHR.

If you started attestation in 2013, you would get bonus payments from CMS of $15,000 in 2013, $12,000 in 2014, $8000 in 2015, and $4000 in 2016. This money was supposed to be used for the purchase of the EHR, the EHR monthly or annual fees, and computer equipment. Of course, anytime the government subsidizes something, companies charge more. Nowadays in 2018 compared to the “stone ages” of 2013, computing and storage is moving towards cloud based rather than server based systems, which would significantly reduce the cost of implementing EHR. My computers and server were about $15,000, my EHR’s initial setup fee was $10,000 and I am charged a $300 per month user fee, which includes all updates and support.

The first time I attested in 2013 it was a huge pain and time consuming to set everything up, but since it has become part of my workflow now it is relatively effortless. I no longer think or worry about it. On the other hand, when I worked for my big group, they made me attend hours of mind numbing meetings about this. I actually think it was easier and cheaper for me to figure it out than to do it with my group, but maybe it’s because my EHR company was a big help.

PQRS (Physicians Quality Reporting System) was supposedly a way to measure quality of care. The criticism of the fee based model was that physicians were incentivized to perform more surgeries and testing to line their pockets, and if there was a model where payments would be linked to the quality of care delivered, it would improve quality and decrease costs. Of course, the unintended consequence of this is that physicians will cherry pick the “easy” cases or ones anticipated to get good results, and not operate on difficult cases where morbidity might be high. The problem with PQRS measuring care was that many of the measures are not clinically relevant to what we do in the office, or that a 1% change in the measure would move you from the 15th percentile to the 85th percentile. Finally, recently if you simply submitted data through a registry you could avoid the 2% penalty.

If you add the potential 2017 penalties of 3% for meaningful use and 2% for PQRS, that’s 5%. The penalties apply only to medicare and not commercial payments (they do not apply to medicare advantage plans), so if the average ophthalmologist receives $400,000 in medicare payments, that’s a $20,000 penalty. Ophthalmologists typically derive about 50% of their income from Medicare; most other fields are significantly lower, so take into account your specialty. But it wouldn’t surprise me if sometime years down the road, that the commercial plans follow suit and use MIPS scores to adjust their payments. Who knows what will eventually happen?

You could meet PQRS by claims submission, or manually entering data into a clinical registry, even if you had paper charts. Some folks on our google groups did this, but it sounded painful and merely reading their emails about how to do so made my head spin. The easiest way to meet PQRS (now the “quality” part of MIPS) was to use a clinical registry which integrates with your EHR system. So again this was a push from the government against doctors to use EHR systems. The American Academy of Ophthalmology created a registry called the IRIS registry which extracts data directly from your EHR for reporting purposes. For those of you non- ophthalmologists out there, check with your specialty society for their registry. So I integrated my EHR with the IRIS registry in 2014, and have spent less than two hours per year worrying about meeting PQRS or the “quality” portion of MIPS.

MIPS replaced Meaningful Use and PQRS with “Quality” and “Advancing Care Information”, but you basically had to do the same things as MU and PQRS to meet them. It also added a category called “Improvement activities” which was not that hard to meet. You just have to check boxes to attest for two activities such as “sending notes back to referring doctors” and “antibiotic stewardship” (have a written policy of not giving antibiotics to patients with viral conjunctivitis).

Meaningful use was all or nothing, but now it is scored depending on how many criteria you meet. Your total MIPS score is between 0 and 100. All you had to do to avoid the penalty for 2017 reporting was to simply report some type of data- quality didn’t matter at all! Your performance in 2017 is used to adjust payments in 2019, and the maximum negative adjustment in 2019 is 4%; for 2020 it is 5%, for 2021 it is 7%, and for 2022 it is 9%. Unless our medical societies lobby Congress and CMS for changes or exceptions, which would not surprise me in the least. I urge every doctor to become involved in their professional society and donate to their PAC; for ophthalmologists, ophthpac has lobbied CMS to change relax MIPS requirements- including a five point bonus for solo doctors.

Here’s my post on the 2018 version of MIPS scoring and what it means for solo docs.

So let’s go back to the question: should I get a EHR? If you are starting a solo practice from scratch, I would say the answer is definitely yes. Don’t go with the cheapest EHR possible and save a few bucks, thinking when you get busy you will switch to a better program. When you are seeing four patients a day, this is the time to develop all of your fast plans and templates and learn the ins and outs, so when in a few years you are seeing 20 patients per day everything runs like a well oiled machine. And if you get a EHR, it makes sense to find one that integrates with a clinical registry to make quality reporting easier, as so called “quality” counts as 60% of your MIPS score. You also want to make sure your EHR integrates with your practice management software to avoid duplicate efforts in entering demographics, and for the flow of your billing.

As an employee, I didn’t hate my EHR but didn’t particularly like it either. As a solo doc running their own business, I couldn’t imagine practicing without a EHR. My documentation is better, I can easily generate notes to referring doctors with the click of a button and have my front desk fax them directly from the EHR, it suggests plans and CPT and ICD 10 codes, which automatically cross over to my practice management system to be sent out for billing- saving me a ton of time and employee work.

For existing practices the equation is a bit different. After the adaptation of a EHR system, your office will likely become more efficient, but it is a very painful, time and money consuming disruptive process to select and implement a EHR. It depends on how long you plan to practice, and what your Medicare revenues are. The closer you are to retirement, the less you have to worry about taking penalties for years and years (in fact, part of me thinks this is a conspiracy to make doctors retire to make it harder for patients to be seen thus cutting costs). If you’re two years out of training and purchased a practice it probably makes sense to implement EHR. But it also depends on how much revenue you get from Medicare. As I previously stated, the average ophthalmologist might collect $400,000 per year from Medicare, and if the penalty for 2020 performance is 9%, that’s $36,000 which isn’t chump change.

If you are a oculoplastics practice focusing on cosmetics with very few Medicare patients, it might financially make sense to take the penalty. At a recent meeting at the American Academy of Ophthalmology, I spoke with someone older than me who thought that young docs would have a easier time adapting to EHR. In our soloeyedocs google group, there have been many docs recently out of training that have a difficult time with choosing and implementing EHR when joining a busy practice. The three most difficult things for solo docs who purchased a practice to handle are EHR, bringing billing in house or managing in house billing, and managing employees.

My opinion is that I like my EHR system and it makes my practice run more efficiently, and that if I had the choice of going back to paper I most definitely wouldn’t. But I doubt that EHR systems have made it easier for doctors to communicate with each other nor save health care costs. I strongly feel that physicians should be able to make their own choice of paper vs EHR for themselves, rather than to meet some silly federal regulations that were designed by folks who don’t practice medicine.

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