Medicare/Medicaid EHR Incentives and Some of the Details                               Last Update:  5/31/2011

The American Recovery and Reinvestment Act of 2009 (ARRA) provides funding for incentives to promote the adoption and meaningful use of certified electronic health records technology.  Just what is required of eligible professionals to access those funds is a complicated question.

The material below presents background and details gleaned from various sources, including the Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule, published July 28, 2010, available at: 

http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf

Corrections to the Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule were released December 29, 2010.  The corrections are limited to typographical and technical errors.  The document is available at:

http://www.federalregister.gov/articles/2010/12/29/2010-32861/medicare-and-medicaid-programs-electronic-health-record-incentive-program-correcting-amendment

This summary is not intended to be comprehensive and is generally limited to Eligible Professionals and the Medicare/Medicaid EHR incentive payments arising from ARRA.  Topics include:

§  Eligible Professional (EP)

§  Reporting Requirements and Periods

§  Meaningful Use (MU)

§  Clinical Quality Measure (CQM)

§ Relationship with Physician Quality Reporting Incentive (PQRI) and Electronic Prescribing Incentive Program (eRx)

§  Medicare vs. Medicaid EHR Incentive Program

§  Medicare EHR Payment Incentives and Penalties for Eligible Professionals

§  Medicaid EHR Payment Incentives for Eligible Professionals

§  Certified EHR Technology

§  Health Information Technology Extension Program

§  Glossary

Eligible Professional (EP)

Neither Medicare nor Medicaid considers a hospital-based provider an EP.  A hospital-based provider is any provider delivering 90% or more of his services in an emergency room or inpatient setting.

Only the following may be Medicare EPs:

§  Doctor of Medicine or Osteopathy

§  Dentist

§  Podiatrist

§  Optometrist

§  Chiropractor

Medicaid EP types are:

§  Doctor of Medicine or Osteopathy

§  Dentist

§  Certified Nurse Midwife

§  Nurse Practitioner

§  Physician Assistant practicing in a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC)

One of the following must be also be true for an EP to qualify for the Medicaid EHR incentive payments:

§  At least 30% of the provider’s patient volume (20% for pediatricians) must be Medicaid OR

§  The provider practices predominantly in a FQHC or RHC, with at least 30% of patient volume being needy individuals.

The incentives in both the Medicare and Medicaid programs are per EP.  That is, each EP in a practice is eligible for incentive payments according to the incentive program chosen by the EP.  Not every EP in a practice must choose the same EHR incentive program.

Reporting Requirements and Periods

The EHR incentive programs require reporting on two types of objectives and their associated measures.  The first set addresses the Meaningful Use of a certified EHR system.  The second addresses Clinical Quality Measures and focuses on processes and outcomes.

The reporting period for Year 1 of Meaningful Use is a minimum of 90 continuous days (Medicare) or 3 full calendar months (Medicaid) within a single calendar year.  The reporting period for subsequent years of Meaningful Use is the full calendar year for both programs.

Meaningful Use is not required for new EHR adopters in their first year of participation in the Medicaid EHR incentive program.  There is, therefore, no reporting period.  For these EPs, Year 2 of Participation is Year 1 of Meaningful Use.

Meaningful Use

Stages and Timing

Meaningful Use criteria will be defined in 3 stages.  The stages will be progressively more stringent.

Final objectives, standards and thresholds for Stage 1 were released on July 13, 2010. (Meaningful Use – Stage 1 Objectives, Criteria and Thresholds for EPs is available by request made to info@symbioticsols.com.)

The final rule for Stage 2 is expected in mid-2012.  As of this writing, serious consideration is being given to pushing the earliest date applicable to Stage 2 compliance back to 2014.   Three factors currently argue AGAINST EPs participating in the Medicare EHR incentive program attesting to Meaningful Use in 2011:

§  There is no EHR incentive penalty for waiting to attest until 2012.  EPs entering the Medicare EHR incentive program no later than 2012 are eligible for maximum total incentives.

§  Given the anticipated mid-2012 release of the Stage 2 final rule, there is concern that vendors and EPs may not be able to meet the Stage 2 requirements by January 1, 2013.  NOTE:  The reporting period for all years after Year 1 of Meaningful Use is the full calendar year.

§  If Stage 2 is moved to 2014, there is a possibility that EPs attesting to Meaningful Use in 2011 may lose a year of Medicare incentive eligibility.  NOTE:  The concern seems to derive from two issues:

o   Medicare EPs must participate for each subsequent year after Year 1 of Meaningful Use, or loose the incentive payment for that year.

o   Stage 1 cannot be the threshold requirement for more than 2 years.  (Author was not able to find any direct statement of the reason for the possibility of a lost incentive year, but this inference seems reasonable.)

An EP can achieve Meaningful Use in 2011 and choose not to attest to Meaningful Use until 2012.  Meeting Stage 1 criteria and attesting to Meaningful Use for the purpose of applying for Year 1 incentives are independent acts.  The earliest date in 2012 to attest to Year 1 Meaningful Use is April 1, delaying receipt of the annual incentive payment only slightly from a reporting period in the latter part of 2011.

Stage of Meaningful Use Criteria By Payment Year as of 6/13/2010

Core and Menu Objectives

The Stage 1 Meaningful Use objectives are in two groups: Core and Menu.  Stage 1 Meaningful Use criteria require an EP to achieve all 15 of the Core Objectives and 5 of 10 Menu Objectives.  (Meaningful Use – Stage 1 Objectives, Criteria and Thresholds for EPs is available by request made to info@symbioticsols.com.)

Exclusions are available for many of the Meaningful Use objectives.  Some exclusions derive from volumes, e.g., less than 100 prescriptions written or no patient requests for electronic copies of health care records during the reporting period.  Others result from the objective not being applicable to the EP’s specialty.  Claiming an exclusion to a Meaningful Use objective produces the same result as achieving the objective.

Two of the 10 Menu Objectives for Stage 1 relate to public health.  At least one of the 5 Menu Objectives reported in Stage 1 must be from the public health list.  If an exclusion applies to one of the public health objectives, the EP must report the other as achieved or claim an exclusion for it.

Clinical Quality Measure (CQM)

Each clinical quality measure is expressed as a percentage and has 4 elements:

§  NQF Measure Number & PQRI Implementation Number

§  CQM Title & Description

§  CQM Steward & Contact Information

§  Electronic Measure Specifications Information

For 2011 and 2012 there are 3 Core, 3 Alternate Core, and 38 other CQMs. See Table 6 of http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf for details of the CQMs.

An EP must report on 3 Core CQMs for the reporting period.  If a Core CQM has a denominator of zero, the EP must report on an Alternate Core CQM as well.  If the EP’s patient population is not addressed by any of the Core or Alternate Core CQMs, the EP reports that each of the six has a denominator of zero.

Regardless of the values reported for the Core and/or Alternate Core CQMs, an EP must report on 3 of the 38 remaining CQMs.  If all of the 38 have a denominator of zero the EP can attest that the CQMs are not relevant to the practice. 

Stage 1 does not establish threshold values for the CQMs.  The EP is required only to submit the EHR calculations for the specified CQMs.

Electronic reporting of the CQMs is not required for 2011.  Electronic reporting is expected to be required when HHS can receive it.

Relationship with Physician Quality Reporting Incentive (PQRI) and Electronic Prescribing Incentive Program (eRx)

PQRI incentives are independent of Medicare and Medicaid EHR incentives.  That is, an EP can receive payments for both in the same year.

An EP cannot receive payments for both eRX and Medicare EHR incentives in the same year.

An EP can receive payments for both eRx and Medicaid EHR incentives in the same year.

Medicare vs. Medicaid EHR Incentive Program

An EP cannot receive incentive payments from both the Medicare and Medicaid programs in the same year.  EPs eligible for both programs must make an election.  After having made an election, such EPs may change their program selection once before 2015.

Medicare EHR Payment Incentives and Penalties for Eligible Professionals

Incentive Payments

•    For purposes of the incentives, EPs could not begin to demonstrate meaningful use before January 2011. 

•    The incentive payment for each reporting period is equal to 75 percent of Medicare allowable charges for covered services furnished by the EP, subject to annual maximums.

•       For EPs who predominantly furnish services in a health professional shortage area (HPSA), incentive payments will be increased by 10 percent.

•      If Meaningful Use of an EHR is not demonstrated in any subsequent year after Year 1 of Meaningful Use, the incentive available to the EP for that year is not recoverable.

•       EHR incentive payments for the Medicare program end after the reporting year 2016.

Penalties

•       Medicare payment reductions will begin in 2016 for EPs who do not demonstrate meaningful use in 2015 and each subsequent year.

 

Medicare Payment Incentives

Medicaid EHR Payment Incentives for Eligible Professionals

•   Individual states have some latitude in setting requirements and administering the program.  The following information should be confirmed with the appropriate agency in the EP’s state.

•       Eligibility for the Medicaid incentives depends upon patient population.

•       30% of EP patient encounters during the reporting period must be attributed to Medicaid

EXCEPTION: 

•       The threshold percentage for pediatricians is 20%.

•       Pediatricians with at least 20%, but less than 30%, of patient encounters attributed to Medicaid, are eligible for 2/3 of the maximum incentive payment.

•       Pediatricians with 30% or more of patient encounters attributed to Medicaid are eligible for the maximum incentive.

•       Medicaid program payments can span as many as 6 years

•       The payments can begin as early as 2011.

•       They can extend as late as 2021.

•     EPs are allowed to skip interim years without affecting their ability to receive 6 years of incentive payments.

•    Incentive payments are calculated as 85% of the EPs net average allowable EHR costs for the reporting period, limited by annual maximums.

•       Existing EHR users

•   Year 1 of Participation is also Year 1 of Meaningful Use, i.e., these EPs must attest to Meaningful   Use in Year 1 of participation.

•        They can receive up to the full amount of the Year 1 participation incentive.

 

Medicaid Payment Incentives

Certified EHR Technology

ARRA is definite about the use of certified EHR technology because specific standards are necessary for the efficient exchange of health-related information. 

The Recovery Act gives the Office of the National Coordinator for Health Information Technology (ONC) authority for certifying EHR technology.  ONC has established two certification programs for the purpose of testing and certifying health information technology:  one temporary and one permanent. 

The final rule for the temporary certification program was released June 24, 2010.  Once the final rule for the permanent certification program is released, ONC will require EHR technology certified under the temporary certification program to be certified under the permanent certification program.

Certification of a particular EHR technology solution may be either complete or modular.

Individual releases of EHR technology are certified, so a statement that an EHR technology is certified must include the version number.  That is, it is incomplete to say that SUPER SOLVE YOUR PROBLEMS is certified, but it can be accurate to say that SUPER SOLVE YOUR PROBLEMS v. 6.2 is certified.

The list of ONC Authorized Testing and Certifying Bodies (ONC-ATCB) is available at http://healthit.hhs.gov/portal/server.pt?open=512&mode=2&objID=3120.  The first product certifications were announced in October 2010.  A listing of certified health IT products can be found at http://onc-chpl.force.com/ehrcert.

Health Information Technology Extension Program

The HITECH Act provides for a Health Information Technology Extension Program, comprised of Health Information Technology Regional Extension Centers (RECs) and a national Health Information Technology Research Center (HITRC).

Each REC serves a specific geographic area.  There are 60 RECs across the US, and 4 in Texas. The Texas RECs have established a statewide coordinating group and developed relationships to provide a cohesive point of collaboration for health information management. The coordinating group is comprised of the leadership from each REC, Texas Department of Health and Human Services, Medicaid, The Texas Medical Association, and the TMF Quality Health Institute.

The Gulf Coast Regional Extension Center (GCREC) serves South and Gulf Coast Texas.  UT Health School of Biomedical Informatics in Houston is its coordinating entity.  The UT School of Public Health’s Regional Campus in Brownsville is the other point of coordination in South Texas.

Regional Extension Centers

§  Offer information and guidance to help with EHR selection and implementation

§  Provide training and support services to assist doctors and other providers in adopting EHR

§  Give technical assistance as needed

The REC program is focused on primary care providers:

§  Family Practice, Internal Medicine, Pediatrics, and Obstetrics/Gynecology

§  Practices of less than 10 providers, although some larger practices may also qualify.

For eligible EPs, the enrollment fee is $300/provider/year.  Services may also be available to other EPs.