MEANINGFUL USE OF CERTIFIED
ELECTRONIC HEALTH RECORDS:
MEDICARE AND MEDICAID INCENTIVE PAYMENTS
Alabama Psychiatric Association
March 24, 2011
by:
D. Brent Wills, Esq.
Kaufman Gilpin McKenzie Thomas Weiss, P.C.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1.
February 18, 2009 – President Obama signed “stimulus” bill (including
HITECH Act)
2.
June / July 2010 – CMS and ONC established “Stage 1” certification /
meaningful use requirements
3.
Fall 2010 – ONC appointed ONC-ATCBs, ONC-ATCBs began certifying
EHRs
4.
January 1, 2011 – Registration began for Medicare incentives programs
5.
January
19,
2011
–
ONC
HIT
Policy
Committee
published
recommendations for Stage 2 meaningful use requirements
6.
April , 2011 –
EPs may begin attesting to meaningful use for 2011 Medicare incentives
Registration will begin for Alabama Medicaid incentives program
EPs may begin attesting to acquiring, implementing or upgrading
certified EHRs for 2011 Medicaid incentives
7.
May 2011 – CMS and Alabama will begin paying incentives to EPs
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE AND
MEDICAID INCENTIVES
Medicare Incentives Program vs. Medicaid Incentives Program
With respect to physicians and other eligible professionals (“EPs”):
3
Medicare Alabama Medicaid
Administrator CMS Alabama Medicaid – SMHP (CMS approved)
Eligible Professionals Physicians – 42 U.S.C. 1395x(r) Includes non-physician providers (e.g., NPs, some PAs)
Program Participation Medicare Part B FFS (no volume requirement)
Medicaid patient volumes (defined in SMHP)
Commencement January 1, 2011 (First payments: May 2011)
April 1, 2011 (First payments: May 2011)
Duration Through 2016 Through 2021
Last Year to Qualify for Incentives 2014 2016 Last Date to Qualify for Maximum
Incentives
October 3, 2012 December 31, 2016
Initial Qualification First Year: Meaningful Use for 90 days First Year: Acquire, implement, upgrade Second Year: Meaningful use for 90 days Maximums 5 consecutive years / $44,000 total 6 years / $63,750 total
Penalties Beginning in 2015 (all Medicare EPs) None Payment Calculation Varies with Medicare patient volume
(75% FFS allowable charges)
4
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
EPs may qualify for either Medicare or Medicaid incentives in
a year, but not both (one switch pre-2015).
EPs in a group practice will qualify separately for Medicare or
Medicaid incentives (per NPI).
EPs may reassign Medicare or Medicaid incentives to one
employer / group (one TIN).
Single, lump sum payment per year.
EPs who already have certified EHRs are eligible
5
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives
(a) Prerequisites
(b) Certified EHR technology - must have EHR that is
certified by an ONC-ATCB pursuant to ONC requirements
(c) Eligibility – must be “eligible professional”
(d) Meaningful Use
2. Payment of Medicare and Medicaid Incentives
(a) Medicare Incentives
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (a) Prerequisites
Register (once, not annually) on CMS website – will direct Medicaid EPs to Alabama registration site
CMS registration:
https://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp
Alabama Medicaid registration:
http://al.arraincentive.com/
Don’t have to be ready for meaningful use; don’t need certified EHR National Provider Identifier (“NPI”)
User account in National Plan and Provider Enumeration System (“NPPES”)
Register with Provider Enrollment Chain and Ownership System (“PECOS”) – Medicare only
NOTE: Registration for Medicare incentives began January 1. Registration for Medicaid incentives begins April 1.
NOTE: Must register not later than two (2) months after end of first payment year.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1.
Requirements to qualify for Medicare / Medicaid Incentives
(continued)
(b) Certified EHR Technology – must be certified by
ONC-ATCB
6 ONC-ATCBs so far: CCHIT, Drummond Group, InfoGard,
SLI Global Solutions, ICSA Labs, Surescripts
400+ certified EHRs; up-to-date list available on ONC
website
ONC-ATCBs will certify either (i) “complete” EHR” or (ii)
combinations of EHR “modules”
8
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (c) Eligibility (continued)
(i) Eligible Professionals (continued) (A) Medicare – Three requirements: (1) Must be:
Doctor of Medicine Includes Psychiatrists Doctor of Osteopathy
Doctor or Oral Medicine Doctor of Podiatry
Doctor of Optometry Chiropractor
(2) Must participate in (and/or submit patient claims to) Medicare Part B fee-for-service program No volume requirement
(3) Must not be “hospital based” (90%+ ER / inpatient)
9
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE AND
MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (c) Eligibility (continued)
(i) Eligible Professionals (continued) (B) Medicaid – Three requirements: (1) Must be:
Physician Includes Psychiatrists Dentist
Nurse Practitioner (“NP”) Certified Nurse Midwife
Physician Assistant (only in PA – “led” FQHC / RHC) (2) Must meet one of three patient volume thresholds:
(a) Pediatricians – 20% Medicaid
(b) Work predominantly (50%+ encounters) in FQHC / RHC, and treat 30%+ needy
individuals (Medicaid + SCHIP + uncompensated + ability to pay) in that setting
(c) All other Medicaid EPs – 30% Medicaid (3) 2(a) and 2(c) must not be “hospital based”
NOTE: Alabama SMHP provides specifications to determine patient volumes.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1.
Requirements to qualify for Medicare / Medicaid Incentives (continued)
(d) Meaningful Use – To demonstrate “meaningful use”:
(i)
Must satisfy all 15 “core” objectives and measures
(ii) Must satisfy any five of the remaining “menu” of 10 objectives
and measures
(iii) Certain core / menu items may be excluded – must meet
exclusion criteria
(iv) Core objectives include reporting clinical quality measures
(“CQMs”)
3 core (or 1 or more of 3 “alternative” core) + 3 additional
CQMs
may not exclude CQMs; report “zero” for inapplicable
measures
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued)
EHR Reporting Periods – EPs may qualify for Medicare and Medicaid Incentives by:
(1) First payment year (2011 or later year):
(i) Medicare – meaningful use for continuous 90-day period
(ii) Medicaid – acquire, implement or upgrade certified EHR (no minimum period)
(2) Second payment year:
(i) Medicare – meaningful use year-round
(ii) Medicaid – meaningful use for continuous 90-day period (3) Thereafter, meaningful use year-round
NOTE: To qualify in 2011 / first payment year (or second payment year, for Medicaid EPs), EPs must begin meaningful use not later than October 2.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued)
Reporting / Attestation
(1) Payment year 2011 - To demonstrate meaningful use:
(i) Attest to compliance with meaningful use objectives and measures (including CQM)
“Yes” or “No” – Have you done this?
Calculation – Have you done this / captured this information
for a certain percentage of patients? (report numerator, denominator and percentage)
(2) Payment year 2012 (and after) - To demonstrate meaningful use:
(i) Report CQMs electronically – electronic specifications, procedures, etc. t/b/d
(ii) Attest to compliance with other meaningful use objectives NOTE: Attest only once per year, at end of reporting period.
NOTE: Medicare and Medicaid EPs may attest beginning in April, 2011.
NOTE: In first payment year, Medicaid EPs must attest only that they have acquired, implemented or upgraded a certified EHR.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use – (continued)
“Core” meaningful use objectives:
Computerized physician order entry (CPOE) E-Prescribing (eRx)
Report clinical quality measures to CMS/States Implement one clinical decision support rule
Provide patients with an electronic copy of their health information, upon request Provide clinical summaries for patients for each office visit
Drug-drug and drug-allergy interaction checks Record demographics
Maintain an up-to-date problem list of current and active diagnoses Maintain active medication list
Maintain active medication allergy list Record and chart changes in vital signs
Record smoking status for patients 13 years or older
Capability to exchange key clinical information among providers of care and patient-authorized entities electronically
Protect electronic health information
NOTE: Corresponding meaningful use measures and applicable exclusions listed in
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use – (continued)
“Menu” meaningful use objectives: Drug-formulary checks
Capture clinical lab test results
Generate lists of patients by specific conditions
Reminders to patients per patient preference for preventive/follow up care Provide patients with timely electronic access to their health information Use certified EHR technology to identify patient-specific education resources Medication reconciliation
Summary of care record for each transition of care/referrals
Capability to submit electronic data to immunization registries/systems*
Capability to provide electronic syndromic surveillance data to public health agencies*
*Must select at least one public health objective.
NOTE: Corresponding meaningful use measures and applicable exclusions listed in
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1.
Requirements to qualify for Medicare / Medicaid Incentives (continued)
(d) Meaningful Use (continued)
Sample “core” meaningful use objectives, measures and exclusion criteria:
15
Objective Measure Exclusion Criteria
Use CPOE for medication orders directly entered by licensed health care professional who can enter orders into the medical record per state, local and professional standards
More than 30% of unique patients with at least one medication in their medication list seen by EP have at least one medication ordered entered using CPOE
EPs who order less than 100 medications during EHR reporting period
Implement drug and drug-allergy interaction checks
EP has enabled this functionality for entire EHR reporting period
None
Generate and transmit permissible prescriptions electronically (eRx)
More than 40% of all permissible prescriptions written by EP are transmitted electronically using certified EHR
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives
(continued)
(d) Meaningful Use (continued)
Stage 1 “core” CQMs – report all three (3).
(1) Record blood pressure for patients with hypertension
whom EP saw more than once
Not applicable to
psychiatrists – report “zero” denominator.
(2) Report assessment and cessation intervention for
tobacco patients at least once within two years.
(3) Record BMI and, if BMI is outside parameters, plan
for follow up. May not apply to psychiatrists – if not,
report “zero” for denominator.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives
(continued)
(d) Meaningful Use (continued)
Stage 1 “alternative core” CQMs – may be required to report, if
core CQMs don’t apply.
(1) Weight assessment and counseling for children.
Not
applicable to psychiatrists – report “zero” denominator.
(2) Flu immunization for patients 50+ years old.
Not
applicable to psychiatrists – report “zero” denominator.
(3) Immunization status. Not applicable to psychiatrists –
report “zero” denominator.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives (continued) (d) Meaningful Use (continued)
Additional clinical quality measures – must report 3 out of 38. The additional CQMs most likely applicable to psychiatrists are:
(1) Capture the percentage of patients 18+ years old diagnosed with new episodes of major depression, treated with antidepressants during acute and continuation processes.
(2) Capture the percentage of patients 18+ years old whom EP (i) advised to quit smoking; or (ii) discussed cessation medications, methods or strategies. May not be applicable to psychiatrists – if not, report “zero”
denominator.
(3) Capture the percentage of patients (any age) with new episodes of alcohol / drug dependence who (i) initiate treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of diagnosis; and (ii) initiate treatment and have two or more additional services with “AOD” diagnosis within 30 days thereafter.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
1. Requirements to qualify for Medicare / Medicaid Incentives
(continued)
(d) Meaningful Use (continued) – Three stages:
19
Payment Year
First Payment
Year 2011 2012 2013 2014 2015
2011 Stage 1 Stage 1 Stage 2 Stage 2 T/B/D 2012 Stage 1 Stage 1 Stage 2 T/B/D 2013 Stage 1 Stage 2 T/B/D
2014 Stage 1 T/B/D
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
2. Payment of Medicare and Medicaid Incentives (i) Medicare
(A) May qualify for up to five consecutive years, $44,000 aggregate incentives.
(B) Payment = 75% allowed Medicare Part B FFS charges, subject to annual maximums (+10% for HPSA)
(C) Based on claims submitted not later than two months after year-end.
(D) CMS will impose penalties on all Medicare EPs beginning in 2015 (1%, +1% each year, at least through 2017; 3-5% each year thereafter)
NOTE: For max Medicare incentives, must begin meaningful use in 2011 or 2012. NOTE: CMS anticipates paying Medicare incentives (i) within 15 – 46 days after attestation; and (ii) beginning in May, 2011.
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE AND
MEDICAID INCENTIVES
2. Payment of Medicare and Medicaid Incentives (continued) (ii) Medicaid
(A) May qualify for up to six years (consecutive or non-consecutive), $63,750 aggregate incentives, as follows:
(B) Incentive payments reflect 85% of “net average allowable costs” (determined by CMS), not actual costs.
(C) No penalties
NOTE: Pediatricians (with 20-30% Medicaid volume) may only receive 2/3 of the allowable incentives ($42,500 total).
NOTE: Alabama Medicaid anticipates paying incentives (i) within 30 days of attestation;
and (ii) beginning in May, 2011. 21
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
STAGE 2 MEANINGFUL USE REQUIREMENTS
January, 2011 – ONC HIT Policy Committee published recommendations for Stage 2 meaningful use requirements:
1. Convert all Stage 1 “menu” options to “core” requirements
Ex: Drug formulary checks, syndromic surveillance data, lab results 2. Increase thresholds for existing measures
Ex: E-prescribing – from 40% to 50%
CPOE – from 30% to 60% and include lab and radiology orders Vital signs – from 50% to 80%
3. New measures: Ex:
Electronic physician notes
Offer downloads of clinical encounter, health record information Ensure patient use of online portal, secure messaging
Record patient preference for communication medium Record longitudinal care plans
Generate list of care team members
4. CMS to promulgate Stage 2 regulations later in 2011
NOTE: Stage 2 will apply beginning in 2013 and 2014 for established meaningful
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
IN SUMMARY: LIVING THE (HITECH) DREAM
Reduced qualifications (especially for Medicaid)
Incentive amounts are per EP – Opportunity for group practices?
Opportunity to get benefits quickly –
May receive substantial incentives ($30,000 Medicare, $29,750
Medicaid) by end of 2012
For Medicaid EPs, flexibility –
Don’t have to start till 2016 (when Medicare EPs are paying
penalties) to get maximum Medicaid incentives
May meet Medicaid patient volume requirements “by proxy”
Flexibility to exclude objectives and measures not relevant to specialties
Meaningful use will improve quality, safety and efficiency; reduce
disparities;
engage
patients
and
families;
improve
patient
care
coordination; improve public health
Commercial payors, health plans may also provide incentives. No plans
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
IN SUMMARY: REALITY CHECK
Incentives, not reimbursements – Benefits are capped; (potential)
costs are not.
Medicare EPs lose maximum incentives after 2012, begin paying
penalties in 2015
Hurried implementation disrupts work flow, damages morale, etc.
Physician resistance, buyer’s remorse, vendor disparities /
implementation “creep”
Incentive payments subject to:
Income tax
Offset / recoupment
Audit
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
IN SUMMARY: WHAT TO DO
Talk to your similarly situated colleagues (e.g., same specialty,
practice size) – best information to evaluate vendors / products, plan
for adoption and implementation
Talk to EHR vendors, confirm your EHR is ONC certified
Talk to your accountant – EHRs will substantially impact business
operations
Talk to your lawyer – Vendor reps and warranties, license and
purchase terms, your rights and remedies are especially critical
“Be quick, but don’t be in a hurry.” – John Wooden
Plan and budget for implementation
Solicit physician / provider “buy-in”
Vet your vendor(s)
It’s not all about the incentives
MEANINGFUL USE OF CERTIFIED EHRs: MEDICARE
AND MEDICAID INCENTIVES
For additional information:
CMS – https://www.cms.gov/ehrincentiveprograms/ Registration and Attestation
-https://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp Meaningful Use Measures and Objectives
- https://www.cms.gov/EHRIncentivePrograms/Downloads/EP-MU-TOC-Core-and-MenuSet-Objectives.pdf
Meaningful Use List Serve –
CMSlists@subscriptions.CMS.hhs.gov Alabama Medicaid –
Registration and Attestation –
http://al.arraincentive.com/jumpstart.aspx
Kim Davis Allen, Alabama Director for Health IT kim.davis-allen@medicaid.alabama.gov
Alabama Health Information Exchange – http://onehealthrecord.alabama.gov/ Alabama Regional Extension Center (“AL-REC”)
University of South Alabama www.al-rec.org / (251) 414-8170
