New Stage 3 MU comments may not provide CMS with the guidance it wanted

I don't envy the Centers for Medicare & Medicaid Services these days. The agency spent months creating a proposed rule implementing Stage 3 of the Meaningful Use program, only to see large swaths of it preempted by the brand new Medicare Access and CHIP Reauthorization Act and a different electronic health record incentive program, the Merit Based Incentive Program System (MIPS). MIPS effectively carves physicians out of Stage 3 of the Meaningful Use program.

So when CMS issued the final rule for Stage 3 in October, it asked for more public comment to "facilitate additional feedback" about Stage 3 of the program, "in particular" to handle MACRA and MIPS.

The proposed rule generated hundreds of comments, about 31 pages worth on

CMS has now received another whopping 18 pages of comments on the new rule.

That's a lot of new reading. But I'm not sure that CMS received what it was looking for.

Many of the new comments from providers and other industry representatives are pretty consistent, urging for changes in the rule and further delays in its implementation. Measures should be simplified; the reporting period for Stage 3 should be only 90 days, at least in the first year; and interoperability should be more front-and-center. Many also called for the hardship exemptions to be expanded.

But I think CMS was looking for more concrete advice regarding how to reconcile Stage 3 with MACRA and MIPS.  

Sure, the comments give lip service to MACRA and MIPS. For instance, the American Hospital Association suggested that Stage 3 shouldn't start before MIPS, which is slated to begin in 2019. It also recommended that hospital requirements in Stage 3 should be aligned with MIPS.

The American Academy of Family Physicians, which wants Stage 3 of the program transformed, warned that Meaningful Use is a "barrier" to MACRA and MIPS, and that the Meaningful Use program needs to be aligned with MIPS.

All that HIMSS' Electronic Health Records Association said was that changes due to MIPS or other reasons could cause work already invested would be wasted, incomplete or insufficient.

Then you've got the American Medical Association, no fan of the Meaningful Use program, cloaking its comments is clever language, suggesting, not a "complete redesign" of Stage 3 because the industry is rather stuck with EHRs as currently designed, but instead that it "provide a glide path" to MIPS and alternative payment models. At the same time, AMA reiterates that many of the same changes it's asked for previously, such as eliminating the pass/fail aspect of attestation and the imposition of measures, remain outside of a physician's control.

And those are just some of the more publicized comments. A deep dive into the comments reveals concern and fear about Stage 3 and Meaningful Use, with some saying the program is getting in the way of patient care, and others calling the system a "nightmare."

To top it off, Congress, which created the Meaningful Use program and MACRA, but didn't tell anyone how to reconcile the two, is also complaining about the program, calling for laws that would delay Stage 3 and other changes.

I don't think a law has become so disliked since prohibition.

But how much of this is productive? CMS was frankly looking for a bit of help here. Yes, commenters provided technical comments on the Stage 3 objectives, and a few of them offered support of specific components of Stage 3, but how should the agency align Stage 3 with the new law? Can it even be done? Or do you scratch it and start over?

It may be that the commenters don't really know. They're still trying to shape the existing Meaningful Use program, and taking that second bite of the apple to weigh in before dealing with the next problem in their inbox. And if that's the case, then CMS will have to forge ahead with MIPS on its own.

But the Meaningful Use program arguably was shaped with at least some stakeholder input. Here, CMS asked for input, but so far is coming up a little short. Without such input, chances are that the new problem won't be shaped to anyone's liking. - Marla (@MarlaHirsch and @FierceHealthIT)