On Wednesday, April 27, 2016 the Centers for Medicare and Medicaid Services (CMS) released its proposed regulation to implement the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed rule creates a “Quality Payment Program” to replace old reporting programs. There two tracks, the first called the Merit-based Incentive Payment System (MIPS) and a second track involves alternative payment models (APM). MIPS is based on a 100 point score with clinical practice improvement activities (CPIA) representing 15 percent of the score. This is an area where CME should play an important role in helping CMS achieve its quality measure objectives. The proposed rule leaves great discretion to the Secretary of HHS to define what will be included in these activities. As stated in the rule’s preamble: “Clinical Practice Improvement Activity (CPIA) means an activity that relevant eligible clinician organizations and other relevant stakeholders identify as improving clinical practice or care delivery and that the Secretary determines, when effectively executed, is likely to result in improved outcomes.”
Background on MIPS
On April 16, 2015, President Obama signed into law the “Medicare Access and CHIP Reauthorization Act of 2015” (“MACRA”), which permanently repealed the Sustainable Growth Rate (SGR) payment formula for physician reimbursement under Medicare. This sweeping change requires the Centers for Medicare & Medicaid Services (CMS) to implement, by 2019, a new two-track payment system for physicians and other eligible professionals. The two tracks will tie an increased percentage of physicians’ Medicare fee-for-service payments to outcomes through the new Merit-based Incentive Payment System (MIPS) and encourage the adoption of “alternative payment models” (APMs) which move payment away from fee-for-service reimbursement. Providers’ pay will instead be based on the quality and cost of care for particular episodes or defined patient populations.
The MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program in which eligible professionals will be measured on quality, resource use, meaningful use of certified EHR technology, and a new area—clinical practice improvement activity. The term "clinical practice improvement activity" is defined as an activity that relevant eligible professional organizations and other stakeholders identify as one that improves clinical practice or care delivery and that the Secretary of Health and Human Services determines is likely to result in improved outcomes. These activities will assess healthcare professionals on their effort to engage in continuing education and working to improve their practices and facilitate future participation in APMs.
The MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Modifier (Value-based Payment Modifier), and the Medicare Electronic Health Record (EHR) incentive program into one single program in which eligible professionals will be measured on quality, resource use, meaningful use of certified EHR technology, and a new area—clinical practice improvement activity. The term "clinical practice improvement activity" is defined as an activity that relevant eligible professional organizations and other stakeholders identify as one that improves clinical practice or care delivery and that the Secretary of Health and Human Services determines is likely to result in improved outcomes. These activities will assess healthcare professionals on their effort to engage in continuing education and working to improve their practices and facilitate future participation in APMs.
CPIA and CME
According to the statute, any CPIA measure must be “relevant to an existing CPIA subcategory (or a proposed new subcategory)” as defined in §414.1365. Unfortunately, those subcategories do not currently include a specific reference to medical education or a related area. The subcategories outlined in the proposed rule include: (1) expanded practice access; (2) population management; (3) care coordination; (4) beneficiary engagement; (5) patient safety and practice assessment; (6) participation in an APM; (7) achieving health equity; (8) emergency preparedness and response; and (9) integrated behavioral and mental health.
However, the language defining CPIA, and authority granted to the Secretary of HHS as proposed, offers an opportunity for advocates of CME to argue that CME should be included in the measurement category. In §414.1355, CMS proposes that CPIA be defined on an annual basis and must meet certain criteria – much of which aligns closely with the goals of CME. While CME may not be directly relevant to an existing CPIA subcategory, it does improve beneficiary outcomes, leads to practice improvement, can be performed by providers of all types, is feasible to implement, can be validated by CMS, and is evidence-based.
However, the language defining CPIA, and authority granted to the Secretary of HHS as proposed, offers an opportunity for advocates of CME to argue that CME should be included in the measurement category. In §414.1355, CMS proposes that CPIA be defined on an annual basis and must meet certain criteria – much of which aligns closely with the goals of CME. While CME may not be directly relevant to an existing CPIA subcategory, it does improve beneficiary outcomes, leads to practice improvement, can be performed by providers of all types, is feasible to implement, can be validated by CMS, and is evidence-based.
Defining CPIA to Include CME
The Secretary of Health and Human Services is required to define clinical practice improvement activities. Even if no changes were made to the proposed rule, a strong case can be made to the Secretary as to why CME should be included in the CPIA score. Subcategories of these activities are specified in the MACRA statute and include several that are particularly relevant to CME, such as population management, care coordination, patient safety practice assessment and beneficiary engagement. All of the subcategories for clinical practice improvement activities would benefit from provider participation in continuing medical education in and around those topics. Additionally, many believe that the previous programs included in MACRA such as PQRS, Meaningful Use and Value Modifier would have achieved significantly greater success had physicians received the education and training on these topics that certified CME provides.
To understand the breadth of CME for physicians, according to the Accreditation Council for Continuing Medical Education (ACCME), in 2014 there were 147,024 courses that offered 1,033,615 hours of instruction, and 13,599,687 physician interactions with an additional 11 million other healthcare providers participating in accredited CME courses.
To understand the breadth of CME for physicians, according to the Accreditation Council for Continuing Medical Education (ACCME), in 2014 there were 147,024 courses that offered 1,033,615 hours of instruction, and 13,599,687 physician interactions with an additional 11 million other healthcare providers participating in accredited CME courses.
Reasons to Include CME in MIPS
Continuing medical education (CME) should be recognized as a clinical practice improvement activity within MIPS because CME has long been recognized as a means by which physicians demonstrate engagement in continued professional development. This encourages physicians to develop and maintain the knowledge, skills, and practice performance that leads to optimal patient outcomes.
Lifelong learning, assessment, and improvement are integrally related. Learning is a necessary component of the change process that results in meaningful, sustained clinical performance improvement. Without this professional development, the measurement of adherence to quality metrics and use of health information technology are insufficient to produce clinical performance improvement.
Patients will continue to need health care professionals that engage in lifelong learning, assessment, and improvement in practice, so it is important these activities be recognized and rewarded in value-based payment programs promulgated by CMS and private payers.
CMS and private payers can also reduce burdens on physicians by counting CME and continuing education as progress toward program goals. Eligible professionals should be credited for their effort to stay current with clinical practice and quality measures by utilizing CME. The inclusion of CME as a clinical practice improvement activity recognized by CMS will help these professionals retain credit for the time they invest in learning about practice improvement.
Additionally, the sources of information on quality improvement requirements for professionals is limited and participation can only be increased with education. Failure to learn about the major changes in healthcare reform place health care professionals at risk financially, operationally, and clinically. Fortunately, accredited education is an understandable and predefined measure to help avoid these concerns.
Physicians have a professional responsibility to keep up-to-date through CME and there is a preexisting infrastructure to record participation in CME activities. Currently 45 states plus the District of Columbia require participation in CME to maintain licensure. CME is a familiar activity for physicians and giving CPIA credit for participation in CME will help to align the interests of physicians with the value being driven by alternative payment models.
The mechanisms already in place ensure that accredited/certified CME activities are designed to address clinicians’ practice-relevant learning needs and practice gaps. The programs are also measured to evaluate the educational and clinical impact of the activity. Finally, they are planned and provided independent from commercial influence or other biases.
We strongly urge CMS to consider adding CME to MIPS.
Lifelong learning, assessment, and improvement are integrally related. Learning is a necessary component of the change process that results in meaningful, sustained clinical performance improvement. Without this professional development, the measurement of adherence to quality metrics and use of health information technology are insufficient to produce clinical performance improvement.
Patients will continue to need health care professionals that engage in lifelong learning, assessment, and improvement in practice, so it is important these activities be recognized and rewarded in value-based payment programs promulgated by CMS and private payers.
CMS and private payers can also reduce burdens on physicians by counting CME and continuing education as progress toward program goals. Eligible professionals should be credited for their effort to stay current with clinical practice and quality measures by utilizing CME. The inclusion of CME as a clinical practice improvement activity recognized by CMS will help these professionals retain credit for the time they invest in learning about practice improvement.
Additionally, the sources of information on quality improvement requirements for professionals is limited and participation can only be increased with education. Failure to learn about the major changes in healthcare reform place health care professionals at risk financially, operationally, and clinically. Fortunately, accredited education is an understandable and predefined measure to help avoid these concerns.
Physicians have a professional responsibility to keep up-to-date through CME and there is a preexisting infrastructure to record participation in CME activities. Currently 45 states plus the District of Columbia require participation in CME to maintain licensure. CME is a familiar activity for physicians and giving CPIA credit for participation in CME will help to align the interests of physicians with the value being driven by alternative payment models.
The mechanisms already in place ensure that accredited/certified CME activities are designed to address clinicians’ practice-relevant learning needs and practice gaps. The programs are also measured to evaluate the educational and clinical impact of the activity. Finally, they are planned and provided independent from commercial influence or other biases.
We strongly urge CMS to consider adding CME to MIPS.