Making MACRA Less Painful for Docs: Health and Human Services Digital Service
On October 16, 2016, the Centers for Medicare and Medicaid (CMS) released the final rule (2,220 pages to be exact!) for the most sweeping change to Medicare in years — the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
MACRA was a response to the increase in Medicare spending which is rapidly outpacing the Gross Domestic Product (GDP) — it contained several elements, but the most sweeping came to be called the Quality Payment Program (QPP). MACRA’s target is to use quality of care provided as the key indicator upon which doctors are paid, rather than simply the number of procedures performed. This dramatic shift across all of Medicare naturally includes many complexities with broad impact but CMS decided very early in the process that a key goal of implementation and the final rule should be to create the best possible user-experience for doctors.
So, CMS set out on a journey, which began immediately after the notice of public rule making (nprm) was issued, with the United States Digital Service (USDS), to provide the information and tools clinicians’ need to ensure compliance with QPP in the simplest and most user-centric way possible.
When clinicians ask, “Do I need to do anything right now to comply with MACRA?” the answer needs to be quick and painless. If clinicians could have this question answered and forget that they needed to ask it, all the better.
Making Compliance Painless with Technology
With reducing clinician burden for QPP as the focus for 2017, CMS put plans in place to build and launch a new website tool at the end of January that would help clinicians easily figure out what they need to do just by entering their clinician ID (this is called an NPI or National Provider Identifier number.) This was a major contrast to most CMS programs, where clinicians often have to pore through spreadsheets of legal criteria, and then look back at their own claims to figure out if they are eligible.
As January of 2017 quickly approached, it became clear that for a variety of reasons that more investment into the foundations of the QPP codebase was required to ensure the success of the program. It also became apparent that moving the agency to a more user-centered and iterative design approach would require additional engagement and guidance, since this was not something CMS had experience in.
To accomplish this, a tiger team from the Health and Human Services (HHS) Digital Service team rolled up their sleeves and jumped in to help get the new QPP Website tool on solid footing.
Beginning in February of 2017, a product lead, designer, content writer, and a handful of engineers set out on this foundation setting journey. While the engineers focused on unifying multiple disparate data sources into a single schema, layering an API to access the data, and presenting to the user through an intuitive UI, the product, content writer and designer set off to refresh the initial designs.
Designing with Doctors
In testing the design concepts for the new MIPS Participation Lookup tool with clinicians and the regional chief medical offices (CMOs) at CMS, the team quickly uncovered the need to add a new feature highlight box on the homepage. This would make it easier for users, who primarily access the site via the homepage, to quickly discover the new information they were looking for.
Also, the new NPI Lookup tool and the “Check Now” button were moved to the front page and above the fold of the browser page. Users told us that checking their ability to participate in the Merit-based Incentive Payment System (MIPS) was the number one thing they wanted to do on the site and did not want to go through multiple clicks to get the answer.
Building a Solid Foundation
In attempting to build out the technical solution, the team discovered that first a process needed to be in place to unify the multiple data sets across CMS. After building a standard ETL, we discovered that like almost anywhere, the data was not consistent across the enterprise. Some of the data was dated, missing, or not reflective of how physicians were now doing business. Some data was from recent programs, some was from programs specified in the mid-nineties — with no one really knowing exactly why certain formatting and storage choices had been made. Data hurdles took the otherwise straightforward task of data standardization and introduced an array of edge cases and outlier scenarios. The process of reconciling data took quite a few more months than expected.
Next, the data needed to be made accessible to both the scoring engine, which is at the heart of the QPP program, and to external consumers via the QPP website. Building with an API-first strategy was an essential step forward as it allowed the team to establish the foundation for information sharing regardless of what current or future data consumer needs might be.
Since shipping, the team has been hard at work documenting all the nuances associated with the data and system overall to ensure a smooth hand-off to the new development team. There’s a strong product roadmap, including the launch of a public API for third party application developers.
This collaborative approach to validating and designing products with customers and building technology by defining the architecture and data model upfront is core to the way teams at USDS work. This approach has allowed our team at CMS repeated success with contract teams, and has paved the way for CMS to re-define how it thinks about building products and tools for our customers.
Kerry Lenahan is a product manager with the United States Digital Service.
Benno Schmidt is a designer with the United States Digital Service.
Anitra Appa was a copywriter with the United States Digital Service.
Aaron Burt, Joseph Crobak, Froilan Irizarry, Scott Haselton are software engineers with the United States Digital Service.
