A review of recommendations to CMS by professional nursing organizations.
As early adopters gear up for optional 2017 Meaningful Use Stage 3 participation, the provider community as a whole anxiously awaits the “sometime before November 1st” release of the MACRA Final Rule. Industry discussions subsequent to the April publication of the MACRA Proposed Rule reflect steady concern among physicians and nurses as new members of the multidisciplinary governance teams which are required to successfully implement this new regulation. Physicians are apprehensive regarding MACRA’s complexity with regard to a short timeline to the 2017 reporting period. Nurses, with equal concern, believe MACRA as it stands in the Proposed Rule, falls short for the nation’s advanced practice registered nurses (APRNs) as providers of highly accessible, efficacious, and affordable care.
Prior to the Proposed Rule release, acting CMS director Andy Slavitt, acknowledging that the new regulation would shift Meaningful Use efforts to a user-centered orientation, offered during a panel discussion at HIMSS2016, “So our policies need to communicate what’s important – improved patient care, better spending, and healthier people – without invading the space or how to get there,” noting also that interoperability was essential to identify the precision medicine which will impact better patient outcomes in the future.
In the continued effort toward fee-for-performance, MACRA intends to streamline CMS’s existing quality programs through the creation of one clinical quality standard by which providers will be measured and reimbursed through two payment methods. Value-based payment modifiers, the physician quality reporting program, and Medicare’s electronic health record (EHR) incentive program will comprise the Merit-Based Incentive Payment System (MIPS). Four components will be used to calculate a MIPS composite quality score, which will drive the MIPS bonus structure: meaningful use of a certified EHR; quality; resource use; and clinical practices improvement. Conversely, certain groups of providers caring for defined patient populations will qualify to participate in Alternative Payment Models (APMs). Under an eligible APM, MIPS adjustments are augmented by a five-percent incentive payment annually through 2024, certain providers are excluded from MIPS requirements, and APM providers will receive a higher fee-schedule reimbursement for 2026 and beyond. Examples of APMs are listed by CMS as ACOs, patient centered medical homes, and bundled payment models.
Herein lies a considerable disadvantage for APRNs according to leading professional organizations representing nurses. In a joint response to a request for comment on the Proposed Rule at the end of June, 27 organizations, associations, and societies of professional nursing advised CMS that MACRA is not appropriately inclusive of APRNs, which include Nurse Practitioners (NPs), clinical nurse specialists (CNS), certified nurse-midwives (CNMs), and certified registered nurse anesthetists (CRNAs). According to these organizations, the lack of inclusion not only inhibits APRN opportunities for reimbursement in the Alternative Payment Models, but also inadequately captures and attributes the quality of care and clinical outcomes to which APRN care management was essential. Perhaps the most vocal in their concern for APRNs under MACRA is the American Nurses Association (ANA), which in addition to endorsing the joint response provided an independent comment to CMS and continues to raise to the question of APRN treatment under MACRA. These nursing organizations have asked CMS to consider the following responses in the MACRA Final Rule preparation:
- Certified EHR Technology (CEHRT) – Regarding the requirements for the use of CEHRT, CMS is asked to include a requirement for the attribution of work completed by non-physician providers such as APRNs. The ANA specifically notes, “In addition, we urge CMS to avoid any guidance that would assign to the nurse the role of acting as a scribe for physicians. Like physicians, nurses are involved in direct patient care that drives outcomes and quality. Limiting the ability of nurses to provide such care by shifting the entry of data from the physician to the nurse could have a significant, detrimental impact on the quality of care delivered to patients,” (ANA Comment Letter).
- Policy barriers to the use of APRNs in APMs – In the joint response, nursing’s ability to participate was questioned, “We remain concerned with the extent to which APRNs will be able to participate in the new Alternative Payment Models (APMs) under development. Although NPs, CRNAs, and CNSs were included in the description of APMs under Medicare Access and CHIP Reauthorization Act (MACRA), there is no requirement that APMs include APRNs in their networks as independent providers eligible for direct billing and participating in potential incentives such as shared savings or quality bonuses,” (Joint Comment to CMS). The ANA further elaborates in their response with an examination of the CMS Open Payments Data from 2014. In a review of the approved charges and Part B patient counts for APRN providers, the ANA also noted thresholds for practice size and Medicare-approved charges would be obstacles for practices which are predominantly pediatric, obstetric/ gynecologic, or Medicaid under MACRA. “When the effective exclusion percentages were applied to the 2016 provider counts, more than half of APRNs will be excluded from MIPS at the outset [CNMs at 99.3% exclusion] . . . The opportunity to earn Medicare EHR bonuses through MIPS will likely be unrealized, as most APRNs will continue to be excluded regardless of their EHR status. For many APRNs who are Part B providers, MACRA will offer no replacement incentive programs for recognizing quality and efficiency,” (ANA Comment Letter).
- Appropriately attributed services – With great concern, the joint responses noted that incident-to billing will result in a downward turn for APRN MIPS composite calculation, as services provided incident-to a physician will not be attributed to the APRN providing the care. The ANA notes this detriment will be significant for NPs who are primary care providers. The ANA recommends modifiers to identify incident-to care at the line-item level, as well as inclusion of the National Provider Identifier (NPI) of the provider rendering the care.
- Reweighting options for MIPS-eligible clinicians unable to participate in APMs – The Proposed Rule outlines two reweighting options to arrive at a composite practice score (CPS) for providers unable to participate in the advancing care information performance category. According to the joint nursing organization response, these options reiterate the concern for incident-to billing, “Both proposed reweighting options would increase the importance of the quality performance category in determining the CPS, creating a significant problem for those APRNs who provide care in practices in which their services are subject to incident-to billing.” The group further notes, “ . . . the problems associated with practices such as incident-to billing are well recognized: obscuring the rendering provider, seriously undermining the ability of CMS to accurately calculate cost and quality performance and hindering providers from being individually responsible and accountable for the care they render patients,” (Joint Comment to CMS).
- Clinical Practice Improvement Activities – Reporting of clinical practice improvement activities beyond the first year has not yet been determined. The represented nursing organizations through the joint response urged CMS to allow APRN participation in the development, implementation, and evaluation of these activities, which should be relevant to both APRNs and physicians.
- Physician-focused payment models – Disappointment that the definition of physician-focused payment models was not broadened to include other healthcare providers was clearly stated in both the joint and ANA responses, “APRNs can and do lead payment and care delivery models . . . The healthcare industry is increasingly recognizing APRNs and other nurses for their leadership role in clinical, educational and academic, executive, board, legislative, and regulatory domains,” (Joint Letter to CMS).
- Expansion of MIPS eligibility – The ANA specifically urged CMS to use its authority to include CNMs as eligible participating clinicians. The joint response specifically called upon the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to evaluate whether PFPMs support and encourage APRNs to practice to their full professional education, skills, and scope of practice” noting PFPM applicants should be required to demonstrate APRNs are being used accordingly (Joint Letter to CMS).
Revealed in these responses is a strong voice for advanced practice nurses as significant contributors to high-quality care delivery and improved patient access and outcomes – tenets of nursing practice. It remains to be seen if that voice is being heard and if the policy really will communicate what is important.