Relevant Federal Program Environment

The passage of both the federal economic stimulus package in 2009 (the American Recovery and Reinvestment Act of 2009 (ARRA)) and health care reform legislation in March 2010 (the Patient Protection and Affordable Care Act and an associated bill, the Healthcare and Education Reconciliation Act of 2010), has implications for Medicare and Medicaid providers. Several provisions in the legislation are relevant to providers participating in the EHRD, as the federal government will implement new programs and policies over the next several years that will overlap and provide complementary opportunities for providers participating in EHRD. We summarize some of these upcoming programs and policy changes below.

The HITECH Act. The Health Information Technology for Economic and Clinical Health Act (HITECH) was passed as part of ARRA. Of the several programs created by HITECH legislation,8 _{the most relevant ones are the Medicare and Medicaid EHR Incentive Programs for} demonstrating “meaningful use” of EHRs. The meaningful use concept in the HITECH Act is the same as that which is the focus of the demonstration—if EHRs are to bring benefits to the health care system, they must be intentionally used in ways that promote quality care. Parameters of these programs for the first two years (2011-2012) were finalized through a final rule published by CMS on July 28, 2010. Beginning in 2011, eligible providers can begin receiving payments under either the Medicare or Medicaid EHR Incentive Programs for demonstrating meaningful EHR use, which includes meeting a core set of required criteria and several criteria providers may choose from a menu set. The criteria overlap with but also contain differences from the demonstration’s EHR criteria. Appendix B provides an overview of the overlaps and divergence of the two efforts. Participation in the EHRD does not preclude

8 _{To find more information on all of the HITECH programs, visit ONC’s website:}

providers from receiving payments through the Medicare or Medicaid incentive program. Beginning in 2015, Medicare payments will be reduced for providers who do not submit data on quality measures for covered professional services.

Also of relevance, due to the EHRD’s requirement that certified EHRs be used, are provisions establishing an EHR certification process for the Medicare and Medicaid EHR Incentive Programs. While the CCHIT has been the only EHR certification entity through year 1 of the demonstration, the national need to certify EHRs that are capable of supporting meaningful-use requirements led the Office of the National Coordinator (ONC) to establish a temporary certification program in 2010 and to name additional organizations that are authorized to certify EHRs. (CMS is allowing practices to meet EHRD certification requirements if their EHR is certified by these entities.)

There are other programs initiated by the HITECH Act that are relevant to both EHRD practices and other physician practices. We briefly describe some of them below.

• State Health Information Exchange Cooperative Agreement Program. This is a grant program to support states or state-designated entities in establishing health information exchange (HIE) capability among health care providers and hospitals in their jurisdictions. When operational, these entities could help practices participating in EHRD achieve higher scores on the OSS. Grants were awarded to Maryland, South Dakota, Louisiana, and Pennsylvania in February - March 2010.

• Health IT Extension Program. Health IT Regional Extension Centers (RECs) have been and continue to be established under this program. RECs will offer technical assistance, guidance, and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of EHRs. Funds were awarded to begin the RECs in February - April 2010. The RECs covering all four sites of the demonstration were still gearing up to provide these services at the time of our interviews in May and June 2010. In future years, however, demonstration practices may take advantage of these resources to improve their EHR use. In three instances, the lead community partner organization for EHRD is a part of the REC.

• Beacon Community Program. This a grant program designed for communities to build and strengthen their health IT infrastructure and exchange capabilities. Policymakers envision these communities demonstrating ways by which hospitals, physician practices, and patients may effectively share data to facilitate efficient and high-quality patient care. In May 2010, ONC made awards in the form of cooperative agreements to 15 nonprofit organizations, and two more were added in September 2010. One was in the New Orleans area, potentially boosting performance over time of Louisiana demonstration participants.

PQRS provisions in the Patient Protection and Affordable Care Act. The Affordable Care Act extends the Physician Quality Reporting System (PQRS, formerly known as the Physician Quality Reporting Initiative) through 2014. Since some of the reporting measures dovetail with the demonstration quality measures, synergy between these efforts could foster greater attention to demonstration measures and quality improvement. Historically most reporting to PQRS has been through claims, however, this may be changing; for 2011, 20 PQRS measures can be reported through EHRs, including some of the measures that are the focus of the EHR demonstration. For years 2011-2014, the Affordable Care Act also allows an additional

incentive payment increase by 0.5 percentage points for physicians who satisfactorily submit data on quality measures for a year through a Maintenance of Certification Program.9

Medicare Shared Savings Program. The Affordable Care Act also establishes several demonstrations and programs. The Medicare Shared Savings Program, to be established by January 12, 2012, is another potential opportunity for practices in EHRD (as well as outside it) to build on their pay-for-performance involvement. The program will allow qualifying providers to organize as an Accountable Care Organization (ACO). Providers in ACOs become jointly responsible for the quality and cost of care provided to patients assigned to their ACO. Providers in an ACO will share in any cost savings they achieve.10

These federal initiatives and the state and private-sector initiatives described below appear largely complementary to the demonstration and thus could enhance the effectiveness of incentives over an environment where supports were less available. However, they are in the early stages; if they prove to compete for practices’ attention, the demonstration’s effects could dampen the effects of the demonstration over a less complicated environment.

Because of the demonstration’s randomized design, the evaluation will capture the net, unbiased effect of the incentives beyond the other initiatives faced by practices in each site. The evaluation’s implementation analysis will track the role of other initiatives in influencing practice change through a few questions on EHR Incentive Program participation within the Office Systems Survey, two sets of calls to withdrawn practices that will identify whether participation in other initiatives is affecting program participation, and another round of site visits near the end of the demonstration that will explore the role of other initiatives as well as the demonstration in prompting changes.