On The Issues

November 15th, 2013

SGR and Value-based Performance Statement

Creating Medicare payment stability and a foundation for value-based medicine

November 12, 2013

The Honorable Max Baucus
Committee on Finance
U.S. Senate

The Honorable David Camp
Committee on Ways and Means
U.S. House of Representatives

The Honorable Orrin Hatch
Ranking Member
Committee on Finance
U.S. Senate

The Honorable Sander Levin
Ranking Member
Committee on Ways and Means
U.S. House of Representatives

Dear Chairman Baucus, Chairman Camp, Ranking Member Hatch and Ranking Member Levin:

Greenway Medical Technologies, Inc. supports more than 100,000 primary care and specialty providers nationwide through an integrated healthcare information technology platform utilized in healthcare enterprises, ambulatory practices, public health, retail and other clinical settings.

These provider-customers are currently embracing an array of care coordination programs based on quality and value over episodic or procedural care. This approach toward a preventive, evidence-based and truly sustainable delivery system aligns with the committee’s initiative to repeal the annual Sustainable Growth Rate (SGR), enact payment stability within Medicare and instill a comprehensive and long-term approach to value-based medicine.

We provide to our caregivers innovations around data exchange, analysis and reporting as the foundation for calculating quality measures, participating in care coordination programs and ultimately improving patient outcomes.

Providers utilizing these innovations - along with those of patient engagement, clinical decision support, revenue cycle management and more - are currently practicing within CMS Shared Savings (MSSP), patient-centered medical home (PCMH), meaningful use, PQRS, CPCi, e-prescribing and various private payer accountable care programs.

Greenway supports the committee’s initiative to merge the tenets of these types of models into a value-based performance (VBP) program built around quality, resources, clinical functions and most significantly, the importance of and scoring weight attributed to electronic health records (EHRs), as well as the emphasis on progressing the meaningful use initiative and the intent to utilize certified EHRs as the mechanism for the VBP’s quality measure reporting. In addition, we believe that the elimination of payment penalties associated with PQRS, the value-based modifier and meaningful use will attract providers to this structure and to the ongoing success of the meaningful use program itself. Overall, we believe this structure will position providers to embrace and succeed in current and future alternative payment models (APMs).

Greenway also applauds an approach that recognizes and rewards providers – as early as 2016 – who are already involved in certain APMs. Further, rewarding providers already practicing within a medical home model, for example, which would translate into the highest possible score within the clinical functions category, shows committee foresight.

Clinical Quality Measures

With respect to the use of clinical quality measures (CQMs), the continued harmonization of measures across public and private payer reporting programs cannot be overstated. Attaining standard sets of CQMs focused on outcomes that can be progressed over time and that prevent duplicative reporting – as is the committee’s intent – requires a comprehensive and collaborative approach among physician organizations and EHR developers, and should draw upon those put forth in recent years by the National Quality Forum and the National Library of Medicine, as well as by CMS and ONC.

We would seek clarity here from the discussion draft on the intent to utilize quality measures from “other incentive programs” along with the specific language around PQRS and meaningful use.

For a payment system founded on data and the measurement of quality and efficiency, measures must be developed that are suitable for implementation in EHRs and be consistent with – not additive to – provider workflows. Measurement and quality reporting should build upon data already in the patient record as opposed to driving clinical workflows for the sake of measurement.

This same collaborative approach should be undertaken with regards to the proposed VBM’s scoring weight around the submission of “resource use” and “clinical practice improvement activities” data.

Through our close collaborations with providers to fulfill their care delivery needs through a technological platform, we have seen first-hand their uncertainty concerning a changing CQM and payment landscape, and reconciling those changes with a long-term investment in healthcare information technology.

Greater harmonization of measurable CQMs and reporting requirements across care coordination and incentive programs would reduce the burden on care providers challenged with complying with multiple primary care or specialist quality incentive programs.

The healthcare information technology industry itself is continuing to advance a collaborative marketplace to further aid caregivers in the pursuit of a streamlined and community-based approach to patient care built around standardized and actionable data.

Collaborations such as the CommonWell Health Alliance, the Electronic Health Record Association (EHRA), the Healtheway eHealth Exchange program and longstanding memberships within the Healthcare Information Management & Systems Society (HIMSS), are a few examples of technology provider organizations that regularly work with CMS and ONC on standards and certifications directly in line with delivery and payment advances.

Together, and with the continued unfettered ability to provide innovative health IT platforms, the greater movement toward national care coordination built from shared savings, risk-based or quality payment structures further harmonized through programmatic and measurable means, will benefit our nation’s physical and economic health.

Meaningful Use

As to the general integration of the incentive program into the framework of VBP, the initial weighting of 25 percent for meaningful use should be maintained, rather than a reduction to 15 percent of scoring once adoption hits 75 percent, to continue to ensure that meaningful use is pursued into its current timeline, which will help maintain stability within a new VBP structure. We would also suggest that, if the proposed approach is taken, that the focus of the 75 percent trigger should be adoption of certified EHRs rather than achieving meaningful use, which establishes a more deserved broader role for EHRs within the VBP and other APMs.

Likewise, in order to fully evaluate the impact of this proposal regarding EHR non-meaningful use penalties it will be important to compare the likely impact of non-meaningful use on the actual bonuses and penalties to be paid, as well as the importance of EHR use to achieving other VBP thresholds, to ensure that the new program continues to provide appropriate incentives for EHR adoption and meaningful use.

Given the shift in focus for meaningful use, elimination of meaningful use-specific penalties, and the general integration into the overall VBP program, we urge that the Congress and the Administration take a very focused and prioritized approach to Stage 3 of the incentive program, to allow technologies to advance that enable VBP, such as those that support population health management, care coordination and quality improvement. The latest approach under consideration by the HIT Policy Committee would add a number of new meaningful use and especially certification requirements, not all of which directly support providers participating in a VBP program. We also urge thoughtful consideration in regard to the timing of Stage 3 in order to avoid overly burdening providers.

With the inclusion of meaningful use into the VBP program, we also suggest that the overall expectation of moving through a continuous set of stages be revisited, with the recognition that market forces will drive future product functionality as physicians have the need to succeed in VBP and APM programs. Moreover, with increasing numbers of physicians in such programs, and the very robust levels of functionality in the Stage 2 measures and certification, careful consideration should be given to defining meaningful use for all physicians engaged with VBP or an advanced APM in which meaningful use is defined as use of a certified EHR.

We also urge that explicit attention be given to physician specialties for which CMS has already acknowledged that the current meaningful use and certified EHR approach does not work well (e.g., radiology, anesthesiology, and pathology), those granted hardship exceptions, and non-physician providers not eligible for the Medicare EHR incentive program

With regards to other specific proposals within the committee’s discussion draft:

- Greenway sees great value in rewarding professionals undertaking complex chronic care management services. This emphasis is in line with the August, 2013 Principles and Strategy for Accelerating Health Information Exchange and Advancing Interoperability document put forth by the Department of Health & Human Services in collaboration with CMS and ONC. This proposal offers a conditional payment within the CMS Physician Fee Schedule for providers showing the ability to exchange summary of care for these patients during transitions of care (ToC). As well as being in line with ToC data exchange as required in Stage 2, the overriding need for national, standards-based interoperability as a focal point of success within current and future healthcare sustainability also cannot be overstated. Greenway and its leadership colleagues in the health IT industry are working hard to advance standards-based interoperability, and we welcome the committee’s efforts to reconcile, if necessary, these initiatives around complex chronic care.

- Toward further encouraging participation in APMs of two-sided risk and quality measurement tied to the discussion draft’s 5 percent bonus, we would support an examination of programs both relevant to specialists and aligning with private and state-based programs. We would encourage that the same collaborative approach be undertaken as is urged in the VBP’s construction of overall CQMs as described above to assure that EHR reporting and provider workflows are well considered.

- With respect to transparency around the increased posting of provider utilization and payment data, Greenway has actively engaged our providers on the growing movement toward data transparency and patient consumerism. We believe that expanded use of the Physician Compare website – consistent with prior review before information is posted - will aid our nation’s move to a more trusted and competitive system that will also lead to greater sustainability. Likewise the related proposal to expand the dissemination and categories of Medicare data and analysis to providers, health insurers and employers to gauge quality improvement can also achieve evidenced-based medicine and sustainability goals.

Overall, we support swift Congressional success in establishing this definable and stable future within the Medicare payment structure already shown to be a foundation and critical driver for other public and private delivery and payment models evidenced by the MSSP program, and as a way to forestall the impending 24.4 percent cut estimated for 2014.

As Medicare currently shoulders 21 percent of national healthcare expenditures, and is further stretched as approximately 10,000 Americans become Medicare-eligible on a daily basis, Greenway supports, on behalf of our provider customers, this bipartisan and bicameral approach to creating a smarter and sustainable healthcare system in America.

Thank you and Greenway stands ready to provide any assistance needed throughout this transition.


Justin T. Barnes
Vice President, Industry & Government Affairs