You Won’t Believe What Medicare Just Did on Patient Engagement!

DVD cover of the BBC’s 1967 “Dr. Who” episode. (Click to view “The Macra Terror” episode’s Wikipedia page.)

Quick summary for the impatient: Michael’s post urges public comment in the upcoming comment period, and ends with this: “If we in the patient community do not raise questions and objections to this critically important MACRA rule, you will definitely not believe what happens next.” – e-Patient Dave

Sure, I’ve always wanted to write a clickbait headline that sounds like a promo for the bastard child of Buzzfeed and the Federal Register. But, seriously: you will not believe what Medicare just did about patient engagement in a draft new rule dramatically changing how doctors are paid.

And, depending upon the reaction of the patient community, you definitely won’t believe what happens next.

By way of background, the Centers for Medicare & Medicaid Services (CMS) just issued long-awaited regulations for implementation of a law as important to the health care delivery system as Obamacare was to health insurance. The Medicare and CHIP Reconciliation Act (MACRA) passed with an overwhelming bipartisan majority in both houses of Congress in 2015, in large part because it eliminated the sustainable growth rate (SGR) pay formula for doctor payment that doctors hated.

In place of the SGR, MACRA links doctor pay to either their being part of a value-based arrangement such as certain accountable care organizations or participating in the Merit-Based Incentive Payment System (MIPS). By law, the MIPS score determines provider bonuses or penalties based on four domains: quality measures, efficiency measures, meaningful use of electronic health records and clinical practice improvement activities.

As I wrote in an Urban Institute white paper with colleague Robert Berenson, measures mentioned in the law include “patient-reported outcome and functional status measures; patient experience measures; care coordination measures; and measures of appropriate use of services, including measures of overuse.”

Naturally, when the draft MACRA rule was issued by CMS late on April 27, I immediately did a search through its 962 pages to see what patient empowering provisions it contained. (The PDF has all those details missing in the CMS YouTube version, though it’s way less fun.)

Functional assessment tools and patient experience measures are, indeed, part of a very long list of possible MIPS measures. Some of these are extraordinarily progressive. For instance, there’s a measure of the percentage of patients undergoing a non-emergency surgery “who had their personalized risks of postoperative complications assessed by their surgical team” and then discussed with the patient. The “steward” of that measure is the American College of Surgeons.

But in the section entitled, “Coordination of Care Through Patient Engagement,” the standards related to use of certified electronic health record (EHR) technology are startling in their laxity. Here are a few key excerpts. Emphasis added:

“During the performance period, at least one unique patient (or patient-authorized representatives) seen by the MIPS eligible clinician actively engages with the EHR made accessible by the MIPS eligible clinician.”

“For at least one unique patient seen by the MIPS eligible clinician during the performance period, a secure message was sent using the…EHR….”

“Patient-generated health data or data from a non-clinical setting is incorporated into the certified EHR technology for at least one unique patient….”

That’s right: one instance of “active engagement” with the EHR, one secure message exchange and one use of patient-generated health data among the doctor’s entire Medicare patient load during calendar year 2017 (the first performance period) qualifies a clinician for part of the MIPS bonus. I’m not a lawyer, so I don’t know whether “unique” patient means three different individuals or if three interactions with the same person – a designated “e-patient”? – would count.

I know what you’re thinking: the rules say “at least one” patient because CMS knows that patient engagement is like eating potato chips! Nobody can stop with just one. Perhaps. But here’s a different perspective. Monday, Jan. 2, 2017 is a federal holiday. That gives doctors four days to send and receive three emails before checking off the tough regulatory burden of electronic patient engagement until the first week of 2018.

The MACRA rule is available as a download on this government website. It will be formally published by CMS in the Federal Register on May 9 and open for public comment until June 27. (Details are at the beginning of the document.) Perhaps some pointed questions might be asked by attendees at this year’s Health Datapalooza, where a host of senior Obama administrations will provide preening perorations on their commitment to open data and patient empowerment.

If we in the patient community do not raise questions and objections to this critically important MACRA rule, you will definitely not believe what happens next.


Posted in: medical records | policy issues




6 Responses to “You Won’t Believe What Medicare Just Did on Patient Engagement!”

  1. Nancy Finn says:


    Thank you for pointing out this important legislation and the shortcomings related to patient engagement. I believe this same one patient metric was in the Meaningful Use statute with the result that nothing much was accomplished. Although I agree with you that the legislation is basically sound and will advance the payment system in a beneficial way for all healthcare stakeholders, the weak requirements regarding patient engagement are appalling. Until patients make their voices heard, the important changes in our healthcare system that will reduce our cost of care as well as the reducing the huge national healthcare expenditure of tax dollars in our nation will not be forthcoming.

    • You’re right, Nancy, that the metric came from Meaningful Use. In my opinion, we as a community should ask for some standard along the lines of showing “regular engagement” with patients in the indicated ways. The requirement to engage “one” unique patient is silly, but I’m not sure we want to get into a numbers game, either. Others’ thoughts?

      • Teresa Masters says:

        Michael, late age , medical mishaps by “evidence based” physicians, led me toIntegrative Medicine, where patient care focuses first on the whole patient.

        My EMR will show this level of care and nutrition have reversed 7 chronic diseases. I no longer need active care of cardiac, pulmonary, specialists, my primary has far fewer concerns, I am not on any prescribed meds. My active participation in my health has reduced my medical care. In such a case my Primary’s compensation should be rewarded, probably is not.
        My voluntary membership on a PFCC Council shows me regularly how difficult it is to influence physician Fiefdoms. How do you put a cost factor on that?

        • Great points, Teresa. By the way, Medicare (although not private) ACOs have to have a beneficiary representative on the governance committee. That doesn’t mean there will be a patient and family advisory council, but it’s a push towards that.

        • Marc Braman says:

          Yes, yes, yes!! This is the answer to our healthcare system problems!

          All the system changes we talk about, as good as they are, are very secondary to a fundamentally different paradigm of what constitutes healthcare. This is what I and others have been working on.

          As we participate in the structural and functional changes so necessary, I hope we also recognize and prioritize our advocacy for the fundamentally different paradigm of healthcare that it must be built upon and facilitate.

  2. David Harlow says:

    For background on the last time this issue came up, a year ago (the Federales changed nothing on this point in response to our comments and those of many others)

    Stay tuned for more info on commenting on the present rule.

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