EHR Costs, Staffing Still Trouble Small, Rural Practices in MIPS

July 09, 2018 - Financial challenges plaguing small and rural practices under legacy Medicare value-based purchasing programs are likely to persistent under the Merit-Based Incentive Payment System (MIPS), the Government Accountability Office (GAO) recently found.

For one, the high costs of initial and ongoing investments needed for participation in legacy value-based purchasing programs is impacting the success of small and rural practices in MIPS, stated 23 physicians, practice administrators, practice associations, and other stakeholders interviewed by the GAO.

“To participate in legacy programs or in MIPS, stakeholders told us that practices of all sizes needed to make an upfront financial investment in technology, such as purchasing an EHR system, and staffing,” the GAO report stated. “They said that these investments are especially challenging for small and rural practices for several reasons, including that the practices may have smaller amounts of revenue with which to fund these investments or fewer providers to share the investment costs.”

One stakeholder estimated that a new EHR system can cost around $400,000, and others added that ongoing investments in EHR systems can be just as expensive. For example, vendors regularly charge fees for services, such as including specific quality measures in EHR systems or upgrading to new certification standards.

In addition, practices also reported investing in EHR upgrades to ensure their system can address certain legacy program and MIPS measures, such as connecting patients through a portal. These capital investments troubled small and rural practices, with one administrator reporting that participating in Medicare’s Physician Quality Reporting System (PQRS) resulted in net revenue losses because of ongoing costs.

READ MORE: 4 Strategies for Merit-Based Incentive Payment System Success

“Some stakeholders told us that because small and rural practices tend to have fewer resources, paying for EHR vendor support may affect small and rural practices disproportionately and make it more difficult for them to be successful in legacy programs,” the report stated.

The financial challenges associated with initial and ongoing investments will likely continue as clinicians adapt to the new value-based purchasing program, MIPS. A lack of staffing resources was another top financial challenge small and rural practices experienced with legacy value-based purchasing program participation. This will also impact MIPS success, the GAO reported.

“Stakeholders reported that practices had to take on additional responsibilities if they wanted to successfully participate in legacy programs, which was particularly challenging for small and rural practices that had few staff and, according to some stakeholders, did not have the financial resources to hire additional staff,” the federal watchdog wrote.

One stakeholder told GAO that small and rural practices oftentimes have to require their staff to perform multiple roles. However, this limits the employee’s ability to become true experts in the new responsibility areas.

In contrast, larger practices have the capital to hire specialized staff in new areas, like quality improvement and reporting. This makes it easier for larger practices to not only participate in value-based purchasing programs, but succeed at them.

READ MORE: Pay-for-Performance Strategies for Independent Physicians, Small Practices

Limited staffing also means that small and rural practices cannot send their employees to educational events or have them conduct planning activities that would improve program performance.

“Financial and staff resources may continue to pose a challenge for small and rural practices in MIPS because of the need for staff time to report and the staff expertise necessary to choose, track, and report on measures,” GAO contended.

Additionally, the interviews uncovered several other challenges related to technology and legacy program requirements that are likely to persist in MIPS. The obstacles included in the report were:

• Issues with EHR functionality, operation, and maintenance
• Lack of EHR vendor support and timely updates
• Challenges with measures required for legacy program participation that did not align with patient care practices
• Troubles with staying abreast of program requirement changes and managing compliance with program requirements
• Issues with the timeliness of performance feedback and frequent program changes
• Lack of provider control over performance metrics, such as measurements associated to patient behavior and those related to care from other providers

“Since MIPS uses many of the same reporting and measurement mechanisms as the legacy programs, some stakeholders believe that small and rural practices may be less equipped to manage the administrative, technological, and financial burdens that they may face as they participate in MIPS,” GAO wrote.

To help small and rural practices overcome persistent challenges with value-based purchasing models, stakeholders offered several MIPS program design recommendations.

READ MORE: MIPS Quality Reporting Flexibilities Trouble Providers, EHR Vendors

Specifically, stakeholders suggested that CMS provide timely information about program requirements. The interviewees called for program requirements made through rule-making to occur earlier in the year, giving practices more time to align their workflows with the program changes. CMS should also promote improved EHR functionality and standardization, stakeholders advised.

Several interviewees advocated for uniform standards for EHR systems, while one stakeholder recommended that all MIPS measures be included in every EHR system and another wanted vendors to guarantee EHR interoperability. In addition, stakeholders wanted CMS to maintain MIPS measures over time to promote continuity and ensure measures truly benefit patient care.

GAO also reported that stakeholders called for minimal changes to MIPS and an opt-in participation option for clinicians who are below the low-volume threshold.

Besides MIPS program redesigns, GAO also found that stakeholders wanted improved outreach and education efforts, as well as increased technical assistance. Making relevant communication efforts was key for stakeholders who wanted MIPS documents communicated on the CMS or Quality Payment Program website. They also urged CMS to increase the frequency of communication near the end of the MIPS performance period.

CMS should also contract with membership organizations to provide technical assistance and boost the availability of personalized assistance for practices, stakeholders said.

The federal agency has attempted to help small and rural practices participate in and succeed under MIPS. For example, the agency finalized virtual group participation for eligible clinicians in small practices and included additional scoring or report exceptions for small practices.

Additionally, CMS has employed several outreach and educational efforts to support practices with MIPS participation. The Quality Payment Program website is a critical component of the agency’s efforts, as well as $100 million in technical assistance funding for fiscal years 2016 through 2020.

Despite CMS efforts to prepare and support small and rural practices with MIPS, stakeholders are still troubled by similar challenges they faced under legacy value-based reimbursement models, GAO found. Until CMS can specifically target the financial, administrative, and technical obstacles these small practices are facing, eligible clinicians in small and rural practices may see their revenue decrease as the first MIPS payment year approaches in 2019.