Texas Medicaid EHR Incentive Program

Texas Medicaid EHR Incentive Program

Medicaid HIT Team

July 23, 2012

Why Health IT?

Benefits of Health IT

A 2011 study* found that 92% of articles

published from July 2007 to February 2010 reached conclusions that showed overall positive effects of health information

technology on key aspects of care, including quality and efficiency of care.

3

* Buntin et al. 2011 “The Benefits of Health Information Technology:

A Review of the Recent Literature Shows Predominantly Positive Results” Health Affairs

http://content.healthaffairs.org/content/30/3/464.short

Benefits of EHR Adoption

Adoption of electronic records by Medicaid providers means better care to the State’s most vulnerable citizens through:

• Enhanced care coordination,

• Improved quality and safety,

• More engagement of the patient and family,

• More complete longitudinal health record, and

• Assistance with decision support, which helps to reduce

errors and cost of care.

Quality of Diabetes Care:

Patients Treated by Physicians using EHR vs. Paper Medical Records

Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from

http://www.nejm.org/doi/full/10.1056/NEJMsa1102519#t=article * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<0.001

% of Patients Receiving Care

5 A significantly higher

proportion of patients being treated by physicians

with EHRs received care that aligns with accepted

treatment standards *

Health Outcomes for Diabetes Patients:

Patients treated by Physicians using EHR vs.

Paper Medical Records

A significantly higher proportion of patients

being treated by physicians with EHRs

obtained better outcomes*

* Even after adjusting for patient demographic characteristics and insurance type,

% of Patients Obtaining Outcome Standards

Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of

Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from

6

* Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<0.001

% of Patients Receiving Care

A significantly higher proportion of patients being treated by physicians

with EHRs received care that aligns with accepted

treatment standards *

Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa1102519#t=article

Quality of Diabetes Care at Safety Net Practices:

Patients Treated by Physicians using EHR vs. Paper Medical Records

7

% of Patients Obtaining Outcome Standards

* Even after adjusting for patient demographic characteristics and insurance

A significantly higher proportion of patients

being treated by physicians with EHRs

obtained better outcomes *

Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from

Health Outcomes for Diabetes Patients at Safety Net Practices:

Patients treated by Physicians using EHR vs. Paper Medical Records

8

Texas Medicaid Electronic Health

Record (EHR) Incentive Program

Overview

• Two separate sections of the American Recovery and Reinvestment Act (ARRA) of 2009 comprise the Health Information Technology for Economic and Clinical Health (HITECH) Act, which:

• Promotes the adoption and meaningful use of health IT, including EHRs, exchange of health information, etc.

• Authorizes the EHR Incentive Program.

• The EHR Incentive Program incentivizes eligible

medical providers and hospitals for adoption and

meaningful use of certified EHR technology.

Texas Medicaid EHR Incentive Program: Overview

• Eligible professionals (EPs) can receive incentives of up to

$63,750 for the adoption and meaningful use of certified electronic health record (EHR) technology.

• Payment is not a reimbursement for expenses incurred.

• First year payment can be received in 2011 through 2016.

• Final payment can be received up to 2021 for EPs, and 2018 for EHs.

• Incentives are based on the individual, not the practice.

• In the first of year of participation, EPs and EHs must adopt,

implement, or upgrade (AIU) to a certified EHR. In subsequent

participation years, they must demonstrate meaningful use (MU).

• Eligible provider type.

• Physicians (M.D. or D.O.)

• Dentists

• Nurse Practitioners

• Certified Nurse Midwives

• Physician Assistants (PA) in federal qualified health centers (FQHCs) or rural health clinics (RHCs) led by a PA

• Acute care hospitals

• Children’s hospitals

• Must meet Medicaid patient volume thresholds, except children’s hospitals.

• For MU: At least 50% of all encounters must be at a site or sites with certified EHR technology.

• Hospital-based EPs are not eligible for incentives (unless an FQHC or RHC providers).

Eligibility

Payment Year by EP Type Incentive Amount

Maximum cumulative

incentive over 6 years

Year 1 for most EPs $21,250 $63,750

Years 2-6 for most EPs $8,500

Year 1 for pediatricians and pediatric

dentists with a minimum 20%, but less than 30%, Medicaid patient volume

$14,167 $42,500

Years 2-6 for pediatricians and pediatric dentists with a minimum 20%, but less than 30%, Medicaid patient volume

$5,667

Incentive Payments – EPs

Incentive Payments – Hospitals

• The basic calculation is the product of two factors:

• Overall EHR amount.

• The Medicaid share.

• Calculation spreadsheet can be found in the Hospital section of this webpage:

http://www.tmhp.com/Pages/HealthIT/HIT_EHR_GettingStarted.

aspx.

• Payment will be made one time per year.

• Payment will be made in the first monthly date after the incentive is approved.

• Hospital payout schedule for Texas Medicaid is:

• Year 1 – 50 percent

• Year 2 – 40 percent

• Year 3 – 10 percent

Skipping Years in the Program

• Skipping years is permissible in the Medicaid incentive program.

• You may skip one or more years.

• For example, a provider might enter the program in 2011 with AIU and then skip two years. They would re-enter the program in 2014 with Stage 1 (other providers might be in Stage 2 at that point).

• Keep in mind that the program ends in 2021, so if you start in 2016 (the last year you can begin the program), you would need to participate in consecutive years if you want all 6 payments.

Skipping is still allowed, but you wouldn’t receive all 6 payments.

• There are two reporting periods that apply for the Medicaid EHR Incentive Program:

• For patient volume, an eligible professional (EP) should use any continuous, representative 90-day period in the prior calendar year.

• For demonstrating meaningful use, EPs should use the EHR reporting period associated with that payment year:

o First payment year that an EP is demonstrating meaningful use, the reporting period is a continuous 90-day period

within the calendar year.

o Subsequent years, the period is the full calendar year.

Reporting Periods

Provider Type

Medicaid Patient Volume Threshold

Additional Volume Consideration

Eligible Professionals

Physicians 30% If the Medicaid EP

practices predominantly in a Federally Qualified Health Center (FQHC) or

Rural Health Clinic (RHC)

— 30% needy individual patient volume

threshold - Pediatricians and Pediatric

Dentists

20%

Dentists 30%

Nurse Practitioners 30%

Certified Nurse Midwives 30%

Physician Assistants (PAs) when practicing at an FQHC/RHC that is led by a PA

30%

Eligible Hospitals Acute Care Hospitals

(includes critical access hospitals)

10%

Children's Hospitals No requirement

Patient Volume Requirements

FQHC Specific Requirements

Practices Predominately: An EP needs to work in an FQHC for over 50 percent of total encounters for a six-month period in most recent calendar year.

Physician Assistants (PA) at an FQHC "so led" by a PA is defined as when a PA is:

• the primary provider in the clinic; or

• a clinical or medical director at the clinic.

If the FQHC is led by a PA, all PAs at that clinic may qualify for the

EHR incentive.

Needy Patient Volume Calculation for FQHCs

Medicaid + CHIP + Other Allowable Patient Encounters X 100 Total Patient Encounters

The methodology for calculating patient volume for FQHCs is the

“Needy Patient” volume calculation. It is based on patient encounters over three full consecutive months that includes:

• Medicaid clients.

• CHIP clients.

• Client services provided as uncompensated care.

• Client services provided at either no cost or reduced cost based

on a sliding scale determined by the individual’s ability to pay.

Meaningful Use Requirements

• Use of certified EHR:

• In a meaningful manner (e.g., electronic prescribing).

• For electronic exchange of health information to improve quality of health care.

• To submit clinical quality measures (CQM) and other such measures selected by the Secretary.

• For Year 1, Medicaid providers do not need to report meaningful use data, only attest to “adopting, implementing, or upgrading” to a certified EHR.

• If a hospital meets meaningful use for Medicare, they meet meaningful use for Medicaid.

Note: For the complete list of reportable measures, go to

http://www.cms.gov/Regulations-and-

Stage 1—effective in 2012—focuses on:

• Electronically capturing health information in coded format.

• Using that information to track key clinical conditions.

• Communicating that information for care coordination.

• Initiating the reporting of clinical quality measures.

Stage 2—effective in 2014—will focus on:

• Disease and medication management.

• Clinical decision support.

• Support for patient access to their health information.

• Bi-directional communication with public health agencies.

Stage 3—effective in 2015—will focus on:

• Patient access to self-management tools.

• Access to comprehensive patient data.

• Improving population health outcomes. ²¹

Meaningful Use Stages

20 measures for Eligible Professionals (EPs):

• Must meet 15 from the “core set.”

• Must select 5 of 10 from “menu set.”

EPs must report total of 6 CQMs:

• 3 Core or Alternate Core* CQMs:

• Core: Blood pressure reading, tobacco use assessment and intervention, adult weight screen and follow up.

• Alternate Core: Flu immunization for patients 50+, weight assessment and counseling for children and adolescents, and childhood immunization status.

• 3 from list of clinical measures of the provider’s choice.

Must include at least one Public Health measure:

1) Immunizations 2) Reportable Labs

3) Syndromic Surveillance

EPs: Stage 1 Meaningful Use and Clinical Quality Measures

* Insofar as the denominator for one or more of the core measures is zero,

19 measures for Eligible Hospitals (EHs):

• Must meet 14 from the “core set.”

• Must select 5 of 10 from “menu set.”

Hospitals must report 15 CQMs:

• 4 CQM overlap with CHIPRA initial core set.

Must include at least one Public Health measure:

1) Immunizations 2) Reportable Labs

3) Syndromic Surveillance

Hospitals: Stage 1 Meaningful Use

and Clinical Quality Measures

Medicaid EHR Incentive Program Process Flow

Federal/State File Exchange

Register

with CMS NLR

Generate Payment State and Federal Validations

Acknowledge Payment Validate

Certified EHR Confirm AIU

Enter Patient Volumes

Federal Level Registration

State Level

Enrollment Email Notifications

Verify

Provider

Information

• Office of National Coordinator (ONC)

publishes standards for software vendors.

• Vendors submit software for certification.

• Software receives an ONC certification

number # (http://oncchpl.force.com/ehrcert).

• Vendor must recertify for each MU phase.

Certified EHR Technology

• EPs must pick one program.

• Eligible hospitals may be eligible to participate in both programs.

• EPs can switch programs once.

• Slightly different rules, including penalties for non- participation in the Medicare incentive program.

• Higher incentive payments under Medicaid.

• Medicare incentive program is administered by the Centers for Medicare & Medicaid Services (CMS).

• The Medicaid EHR Incentive Program is

Medicare or Medicaid?

1. Register at CMS: https://ehrincentives.cms.gov.

2. Verify enrollment as a Texas Medicaid provider, with an active TPI. If you assign payment to yourself, your SSN must be listed in your TMHP profile.

3. Gather required information and documentation:

• EHR certification number.

• Group or individual attestation choice.

• Patient volume information (numerator and denominator).

• AIU documentation.

4. Log into the portal and attest. Go to www.tmhp.com and log in.

Scroll down to “Manage Provider Account” and select “Texas Medicaid EHR Incentive Program.”

How to Register and Attest

27 For the full checklist of steps: Go to www.tmhp.com and select Providers; go to the

“Health IT” page and select “EHR Program Information” from the list on the left; click

Attestation: Important Notes

• Attestations:

• All self-reported information (e.g., patient volume, provider types, etc.) are legally binding.

• Information entered into the portal should come from auditable sources in case you are selected for an audit.

• Providers can file an appeal for any of the following reasons:

• Incentive payment amount.

• Provider eligibility determination.

• Support for “adopt, implement, or upgrade” to a certified EHR.

• Achievement of meaningful use requirements.

• Both AIU and MU Stage 1 attestations will be audited.

• Providers must be able to generate reports that show the underlying data that went into MU and CQM measure calculations.

• For each year of program participation,

providers must maintain auditable records related to incentive program attestations for six years.

Audit

• Payment adjustments and penalties begin in 2015 for the Medicare incentive program.

• Stage 2 MU attestation opens in 2014. Providers that attest to stage 1 in 2012 will be required to attest to stage 2 by the end of 2014 (unless they skip a year).

• Electronic submission of CMS quality measure data.

• Possible incentives for meeting selected quality measures.

• Stage 2 MU measures consolidated, augmented.

• More CMS measures required.

Beyond 2012

CMS Quality Measures

For Stage 1, MU measure #10 requires the provider to report 6 ambulatory clinical quality measures to the state.

• 3 core (or alternate core), and 3 additional (select from list of 38 measures).

• The 3 core measures are:

• NQF0013 Hypertension: BP measurement

• NQF0028 Tobacco: Query, Intervention

• NQF0421 Adult Weight Screening

NQF0028 Tobacco: Query, Intervention

• Intervention comes in two forms – prescriptions and counseling.

• The use of prescriptions should generate an Rx drug code in the patient record.

• The other should generate a CPT code.

Example CQM

Medication Medication active

A_c423 RxNorm 12 / 2009 105075, 198029, 198030, 198031, 198406, 198407, 199677, ….

Medication Medication active

A_c423 RxNorm 12 / 2009 105075, 198029, 198030, 198031, 198406, 198407, 199677, ….

Procedure Procedure performed

A_c424 CPT 2010

99406, 99407

Sample from the Clinical Quality Measure Set 2011 – 2012

Example CQM

Example CQM

Structured, coded data

• Make sure your EHR is configured to record

“meaningful” data.

• Problem areas: vitals, in-house labs, even outside lab electronic results, radiology,

specialists, small procedures.

Example CQM

36

Health Information Technology Regional Extension Centers

Contact the Regional Extension Center (REC) in your area for information on the support and assistance they can provide.

• Gulf Coast Regional Extension Center

http://www.uthouston.edu/gcrec/index.htm

• CentrEast Regional Extension Center http://www.centreastrec.org/

• North Texas Regional Extension Center http://www.ntrec.org/

• West Texas Health Information Technology Regional Extension Center

http://www.ttuhsc.edu/

Stage 1 and 2 Meaningful Use

Stage 1 Meaningful Use

• Attestation began April 1, 2012 because Jan 1 – March 31 was the earliest 90-day Meaningful Use reporting period.

• Volume calculation is determined from the previous calendar year.

• Must attest to AIU before attesting to Stage 1.

• One attestation per year.

• 15 core (required) measures; pick 5 more from “menu set” of 10 measures.

• One of the core measures contains the CQM

reporting.

Clinical Quality Measures (CQMs)

• 44 measures published by CMS.

• Must report 6 measures.

• 3 core (required) measures (or alternate core) + 3 electives.

• Core 1 – blood pressure recorded.

• Core 2 – tobacco use assessment and intervention.

• Core 3 – adult weight screening and follow-

up.

Stage 1 Core Measures

• The following measures are automatically achieved by using a certified EHR or are simpler to implement:

• Recording demographics, vitals, medications, and medication orders electronically.

• Maintain a problem list.

• E-Prescribing.

• Drug interaction checks.

• Ability to supply patients with an electronic copy of their health record.

• Provide clinical summaries at end of encounter.

• Implement one clinical decision support (CDS) rule.

Stage 1 Core Measures – CDS Rule

• Adult / pediatric immunization schedules.

• Cervical cancer screenings.

• Each EHR will have its own list of

available CDS rules.

Stage 1 Core Measures – The Harder Ones

• Allergy lists.

• Smoking status.

• CMS Clinical Quality Measures (CQMs).

• Privacy and Security – for example, security risk analysis

• Exchange Key Clinical Data – generate a

Continuity of Care Document (CCD) and

transmit it via secure email (this measure

may be removed in 2013).

Stage 1 Menu Set

• Drug formulary checks.

• Medication reconciliation.

• Patient lists – for example, by condition (ICD code)

• Patient portal for self-service record retrieval.

• Provider portal for manual HIE.

Stage 1 Menu Set

• Send patient reminders to > 20% of patients.

• Provide patient-specific education to >

10%.

• Public health measure – immunization data test.

• Public health measure – lab data test.

• Public health measure – syndromic

surveillance.

Stage 1 Exclusions

• Available for both core and menu sets.

• It is up to the provider to decide which exclusions are applicable to their practice.

CMS has issued the following statement about exclusions:

“We encourage EPs to select menu objectives that are relevant to their scope of practice, and claim an exclusion for a menu objective only in cases where

there are no remaining menu objectives for which they qualify or if there are no remaining menu objectives that are relevant to their scope of practice. For example, we hope that EPs will report on 5 measures, if there are 5 measures

that are relevant to their scope of practice and for which they can report data,

even if they qualify for exclusions in the other objectives.”

Stage 1 Exclusions

• Immunization reporting - “EP who administers no immunizations during the reporting period or where no immunization registry has the capacity to receive the information electronically”.

• Relevant vs. Uncommon – the vitals measure example.

• It is uncommon to check BP in a dentist’s office.

However, BP is relevant. So dentists should not

exclude themselves from this measure.

Stage 1 Exclusions

• CMS and ADA are collaborating on

guidance for dentists.

PROPOSED Big Changes to Stage 1

• Final rule for stage 2 may contain modifications.

• Blood pressure can be separated from weight and height vitals requirements where this

makes sense (like dentistry).

• The Health Information Exchange (HIE) requirement is deleted as of 2013.

• Look for these when the final rule is published

in late summer 2012.

PROPOSED Stage 2 Meaningful Use

• NPRM published in March 2012.

• Comments taken until May.

• Final Rule to be published at end of summer.

• Will contain stage 2 requirements,

changes to stage 1, new CQMs.

Timeline

PROPOSED Stage 2 Meaningful Use

• Structure of requirements has changed.

• 17 core measures (required).

• 5 “menu set” measures (pick 3).

• No more exclusions for menu set measures.

• Most stage 1 measures still present, but with increased compliance

percentage.

PROPOSED Stage 2 Meaningful Use - Core

• Smoking status recorded – 50% to 80%.

• Record vital signs – 50% to 80%.

• Receive electronic lab results – 40% to 55%.

• E-Prescribing – 40% to 50%.

• Computerized Physician Order Entry (CPOE)

goes from 30% to 65% AND will include labs

and radiology.

PROPOSED Stage 2 Meaningful Use - Core

• Increase to 5 CDS rule implementations.

• Patient reminders now required on core set.

• Provide online access to health info (patient portal) with > 10% of patients accessing it.

• Patient education moved to core set.

• More than 10% of patients sent a secure message to a provider.

• > 10% of referrals and transitions of care have

summary of care sent electronically.

PROPOSED Stage 2 Meaningful Use - Core

• Successful, ongoing transmission of immunization data.

• Conduct security analysis and

incorporate into risk management

process.

PROPOSED Stage 2 Meaningful Use – Menu Set

• Syndromic surveillance reporting (not just a test).

• Ability to access imaging results, > 40%

of results.

• Reporting to cancer registry.

• Reporting to a second registry of choice.

• Record family history.

PROPOSED Stage 2 CQM Reporting

• Not an MU measure anymore, but a separate part of attestation, like volume.

• Options- 12 provider-selected CQMs or participation in PQRS, formerly PQRI

(electronic reporting capability for PQRS is required of EHR vendors by 2014).

• 125 proposed CQMs.

• Starting in stage 2, CQM reporting period is

full calendar year.

Learn about the Texas Medicaid EHR Incentive Program through a self- guided e-learning tool: www.texasehrincentives.com.

Get technical assistance through the Regional Extension Centers at www.txrecs.org.

Review program information on the CMS website:

http://www.cms.gov/ehrincentiveprograms/.

Review additional Texas Medicaid EHR Incentive Program information at:

(http://www.tmhp.com/Pages/HealthIT/HIT_EHR.aspx).

Learn about a recent study on EHRs and healthcare outcomes:

http://www.nejm.org/doi/full/10.1056/NEJMsa1102519.

Sign up for e-mail updates at

https://public.govdelivery.com/accounts/TXHHSC/subscriber/new and enter your email address. On the subscription topics page, go to the Projects section and select “Health Information Technology”.

Submit questions by sending an email to [email protected] or calling 1- 800-925-9126, option 4.

Additional Resources