arra & hit: what do they mean to you? - aamc.org · pdf file2009 annual meeting...

2009 Annual Meeting

Stewardship and Service

ARRA & HIT: What Do They

Mean to You?

An Update on the EHR

Incentives

November 8, 2009

Ivy Baer, J.D., M.P.H.

Director & Regulatory Counsel

Lori Mihalich-Levin, J.D.

Senior Policy Analyst

2009 Annual Meeting


•Review the timeline for future rulemaking and other activities

•Explain the ARRA Medicare and Medicaid incentives for EHR adoption for hospitals and physicians

•Discuss what we know about meaningful use,

•Take questions; try to provide some answers

Today’s Goals:

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2009 Annual Meeting


The Two Major Players

in HHS:

• ONC (Office of the National Coordinator of Health Information Technology; formerly known as ONCHIT)

– David Blumenthal (National Coordinator)

– HIT Policy Committee & HIT Standards

Committee

• CMS – Office of e-Health Standards and Services

– Tony Trenkle (Director)

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2009 Annual Meeting


3 Regulations,

Likely by Dec. 31

•HHS/ONC interim final rule re: standards, implementation specifications, certification criteria

•HHS/ONC proposed rule on certification

•CMS proposed rule on EHR incentives

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2009 Annual Meeting


Regulatory Timeline (cont.)

October 2010: Earliest CMS will start paying Medicare incentives to hospitals

January 2011: Earliest CMS will start paying Medicaid incentives to hospitals and Medicare and Medicaid incentives to physicians

2015: Medicare penalties begin for hospitals and “eligible professionals” failing to meet definition of “meaningful use”

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2009 Annual Meeting


Where Are We with EHR Use

Right Now?

Hospitals:

• < 2% have fully implemented comprehensive EHRs in all units

• < 8% have basic EHRs

• <17% have CPOE fully implemented

• 75% have electronic lab/image reports

(Source: Blumenthal, NEJM, April 16, 2009)

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2009 Annual Meeting


Where Are We with EHR Use

Right Now?

Ambulatory Settings:

• 4% of physicians have fully-functional EHR

• 13% have basic EHRs

• 16% purchased but not implemented

• 26% plan to purchase within 2 years

(Source: Blumenthal, NEJM, June 18, 2008)

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2009 Annual Meeting


Physicians

•Medicare or Medicaid or E-prescribing

•Incentives for max of 5 years

•CBO estimates 2009-2019:

• Bonuses: $15.2 b

• Penalties: $1.3 b

Hospitals

•Medicare and Medicaid

•Incentives for max of 4years

•CBO estimates 2009-

2019:

• Bonuses: $8.7 b

• Penalties: $2.6 b

$20 Billion in Incentives

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2009 Annual Meeting


• Medicare maximum (for early adopters; 2011-2012): $44,000

• $18,000; $12,000; $8,000; $4,000; $2,000

• 10% increase if in health professional shortage area

• Amount is a cap--75% of allowed charges for all covered services furnished by the EP during the year

Where’s the money? (EPs)

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2009 Annual Meeting


• Medicaid maximum: $63,750

• E-prescribing bonus (MIPAA, not ARRA):

• 2010: 2% Part B allowable charges

• 2011: 1% Part B allowable charges

• 2012: 0.5% Part B allowable charges

Where’s the money?

(EPs cont.)

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2009 Annual Meeting


• The floor:

Using EHR technology in a meaningful manner, including e-prescribing

Exchanging health information electronically to improve quality of care

Reporting on clinical quality measures

• Measures of meaningful use are to be more stringent over time

Meaningful User:

EPs/Medicare

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2009 Annual Meeting


Hospital-based professionals (pathologist, anesthesiologist, emergency physician)

• Generally expected to use EHR system of the hospital

• Based on site of service

• Not disqualified merely on the basis of some association or business relationship with the hospital

• “Good news”: no penalties

Who’s ineligible

for incentives?

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2009 Annual Meeting


Letter from Reps. Eshoo and Speir to Sec. Sebelius:

Also letters from Exe. Stabenow & Rougel

“We are concerned that this provision will also exclude physicians who are practicing in ambulatory clinics owned by hospitals. We believe the Conference Report is clear when it states that the legislation does not disqualify otherwise eligible professionals merely on the basis of some association or business relationship with a hospital [such as] professionals who are employed by a hospital to work in an ambulatory care clinic . . .”

July 7, 2009

Hospital-Based: Take 3

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2009 Annual Meeting


Selection of quality measures:

• Look to proposed PFS „10: preference for measures endorsed by an entity with a contract with the Secretary: NQF

More on MU:

Quality Measures

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2009 Annual Meeting


“PQRI could potentially provide invaluable experience and serve as a foundation for establishing the capacity for eligible professionals to send, and for CMS to receive, data on quality measures via EHRs.”

Federal Register Display Copy, Proposed Rule, Physician Fee Schedule for CY 2010, p. 212

Proposed PFS 2010

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2009 Annual Meeting


Calls for development of a plan to integrate clinical reporting on quality measures with reporting requirements related to meaningful use of electronic health records. The measures would demonstrate:

Meaningful use of an electronic health record and

Clinical quality of care furnished to an individual

House Bill

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2009 Annual Meeting


•How is the money paid?

• Consolidated payment or periodic installments

• Rules to be promulgated to coordinate incentives for an eligible professional furnishing services in more than one practice; cannot be paid more than the capped amount for any payment year

Suppose MU has

been achieved…

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2009 Annual Meeting


•Attestation

•Submission of claims with appropriate coding

•Survey response

•Reporting

•Other

How will the government

know you’ve achieved MU?

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2009 Annual Meeting


•Fee schedule reductions for eligible professionals who do not achieve meaningful use:

• 2015: 1%

• 2016: 2%

• 2017 and after: 3%

• 2018 and after: if less than 75% of eligible professionals are meaningful users, further reductions possible, but cannot be less than 95%

• Significant hardship on case-by-case basis if practice in rural area without sufficient internet access

What happens 2015 and after?

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2009 Annual Meeting


Website posting of individuals and groups receiving incentive payments

Other details:

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2009 Annual Meeting


• Not hospital-based

• At least 30% of patient volume attributable to Medicaid beneficiaries; or

• A pediatrician who has at least 20% of patient volume attributable to Medicaid beneficiaries; and

• Practices predominantly in a FQHC or rural health clinical and has at least 30% patient volume attributable to “needy individuals”

Medicaid Incentives:

Eligibility

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2009 Annual Meeting


•1st year: demonstrate that are engaged in efforts to adopt, implement, or upgrade certified HER technology

•Subsequent years: demonstrate meaningful use through a means approved by the state and HHS

Medicaid MU

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2009 Annual Meeting


Medicare Payments

to Hospitals

Key Points:

Hospitals are eligible for both Medicare and Medicaid incentives (because based on inpatient discharges)

Must be an “eligible hospital”

Must use “certified” EHR technology

Status as “meaningful user” will be posted on internet

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2009 Annual Meeting


Medicare Payments

to Hospitals

What is the payment formula?

[[(Base amount + Discharge related amount) x Medicare share] x Transition factor

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2009 Annual Meeting


Medicare payments to hospitals (continued)

Base Amount:

$2 million

Discharge Related Amount:

$200 for each hospital discharge between 1,150 and 23,000 within 12 month period

Medicare Payments

to Hospitals

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2009 Annual Meeting


Medicare Payments to Hospitals

Medicare Share:

• Numerator: total Part A and C inpatient days.

• Denominator: total inpatient days adjusted to exclude any charges attributable to charity care

• Note: if no data available on charity care, uncompensated care will be used as proxy and adjusted downward to eliminate bad debt data.

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2009 Annual Meeting


Medicare Payments

to Hospitals

Transition Factor

First payment year: 100%

Second payment year: 75%

Third payment year: 50%

Forth payment year: 25%

Any succeeding payment year: 0

If a hospital adopts an EHR after 2015, the transition factor is 0.

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2009 Annual Meeting


Medicare Payments

to Hospitals

What are the payment penalties?

75% of inpatient payment update at risk.

2015: 1/3 reduction (i.e. 25% of update)

2016: 2/3 reduction (i.e. 50% of update)

2017 on: full reduction (i.e. 75% of update)

(Note: Remaining 25% of update based on successful quality reporting)

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2009 Annual Meeting


Payment Year

Year of

AdoptionFY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017

2011 100% 75% 50% 25%

2012 100% 75% 50% 25%

2013 100% 75% 50% 25%

2014 75% 50% 25%

2015 50% 25%

No adoption

by 2015

¾* of

percentage

increase in

market-basket

reduced by 33

1/3%

¾* of

percentage

increase in

market-basket

reduced by 66

2/3%

¾* of

percentage

increase in

market-basket

reduced by

100%

Hospital Incentive Payment

and Penalty Timeline

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2009 Annual Meeting


EXAMPLE

Assume:

•20,000 discharges; 50,000 A & C days; 100,000 total days

•Charity care charges as 20% of total charges

•Year 1 of implementation is 2012

Base amount = $2 million + (20,000 x $200) = $6 million

Medicare Share = 50,000/(100,000 x 80%) = 50,000/80,000 = .625

Transition Factor = 1

Total = $6 million x .625 x 1 = $3.75 million

________________________________________________________________

Now assume same facts except with charity care charges as 10% of total charges:

Medicare share = 50,000/(100,000x90%) = 50.000/90,000 = .56

Total = $6 million x .56 x 1 = $3.36 million

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2009 Annual Meeting


Medicare Payments

to Hospitals

What are the open issues?

Definition of “meaningful EHR user”

Definition of “certified EHR technologies”

Multi-campus providers

Interaction between meaningful EHR use and quality programs, ICD-10 adoption

EHR reporting period

Definition of “charity care”

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2009 Annual Meeting


Medicaid Payments

to Hospitals

• Hospital Medicaid payments are in addition to hospital Medicare payments.

• 10% Medicaid Volume Requirement

– Except Children‟s Hospitals, which are eligible regardless of Medicaid volume

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2009 Annual Meeting


Medicaid Payments

to Hospitals

What is the payment formula?

[(Base amount + Discharge related amount) x Medicaid share] x Transition factor

(i.e. same as Medicare formula but with “Medicaid Share”)

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2009 Annual Meeting


Medicaid Payments

to Hospitals

Limits :

• 6 year limit on payments

• 2016 deadline

• No more than 50% of the total payments may be made in one year or 90% in two consecutive years

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2009 Annual Meeting


“The ultimate vision is one in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities.”

-HIT Policy Committee, “Meaningful Use. A Definition,”Recommendations from the Meaningful Use Workgroup to the Health IT Policy Committee, June 16, 2009

HIT Policy Committee’s

“Ultimate Goal”

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2009 Annual Meeting


What is the HIT Policy

Committee?

• Advisory Committee established by ARRA, holds monthly public meetings.

• Goals:

Policy framework for development of nationwide HIT infrastructure

Identify areas where standards, implementation specifications, and certification criteria are needed (in order of priority)

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2009 Annual Meeting


HIT Policy Committee (cont.)

• Required to make recommendations to National Coordinator in 8 areas, including:

Privacy and security

Utilization of a certified EHR for everyone in the US by 2014

Use of certified EHR to improve quality

• Chair: David Blumenthal

• Vice Chair: Paul Tang

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2009 Annual Meeting


What is the HIT Standards

Committee?

• Advisory Committee established by ARRA, holds monthly public meetings

• HIT Policy Committee Sets Standards Committee‟s Priorities

• Goal: recommend standards, implementation specifications, and certification criteria to National Coordinator

• Chair: Jonathan Perlin

• Vice Chair: John Halamka

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2009 Annual Meeting


Helpful HIT Web Resources:

• ONC: www.hit.hhs.gov

• CMS: http://www.cms.hhs.gov/Recovery/11_HealthIT.asp

• AAMC: http://aamc.org/hit

• (for an HIT laugh) http://rossmartinmd.com/f/blog.htm

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http://www.hit.hhs.gov/

http://www.cms.hhs.gov/Recovery/11_HealthIT.asp

http://rossmartinmd.com/f/blog.htm

2009 Annual Meeting


• Meeting with David Blumenthal and CMS

• Providing written comments on proposals

• Keeping members informed of all activities through a list serve

• Tracking ONC and CMS developments

• Attending all Advisory Committee meetings

• Keeping the AAMC HIT webpage current

• Coordinating efforts with other associations

The AAMC is:

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2009 Annual Meeting


Join our Health IT list serv by sending a blank email (leave the subject line and body blank) to [email protected]

(You will receive a confirmation e-mail to confirm your subscription; please respond to this e-mail as instructed in the message or your subscription will not be complete.)

Interested in more frequent

updates?

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mailto:[email protected]



2009 Annual Meeting


2009 Annual Meeting


*- The HIT Policy Committee recommends that incentives be paid according to an “adoption year” timeframe rather than a calendar year timeframe. Under this scenario, qualifying for the first-year incentive payment would be assessed using the “2011 Measures.” The payment rate and phaseout of payments would follow the calendar dates in the statute, but qualifying for incentives would use the “adoption-year” approach. Prepared by Will Dardani 7/23/09

Health Outcomes

Priority Policy

Care Goals 2011 Objectives* for Eligible Providers

Goal is to electronically capture in coded format and to report health information and

to use that information to track key clinical conditions

2011 Measures* for Eligible Providers

Improve quality, safety,

efficiency, and reduce health

disparities

Provide access to

comprehensive patient health

data for patient’s health care

team

Use evidence-based order sets

and CPOE

Apply clinical decision support

at the point of care

Generate lists of patients who

need care and use them to

reach out to patients (e.g.,

reminders, care instructions,

etc.)

Report to patient registries for

quality improvement, public

reporting, etc.

Use CPOE for all orders1

Implement drug-drug, drug-allergy, drug-formulary checks

Maintain an up-to-date problem list of current and active diagnoses based on

ICD-9 or SNOMED

Generate and transmit permissible prescriptions electronically (eRx)

Maintain active medication list

Maintain active medication allergy list

Record demographics:

o Preferred language

o Insurance type

o Gender

o Race2

o Ethnicity

Record advance directives

Record vital signs:

o Height

o Weight

o Blood pressure

Calculate and display:

o BMI

Record smoking status

Incorporate lab-test results into EHR as structured data

Generate lists of patients by specific conditions to use for quality

improvement, reduction of disparities, and outreach

Report ambulatory quality measures to CMS

Send reminders to patients per patient preference for preventive/follow up

care

Implement one clinical decision rule relevant to specialty or high clinical

priority

Document a progress note for each encounter

Check insurance eligibility electronically from public and private payers,

where possible

Submit claims electronically to public and private payers

Report quality measures to CMS including:

o % diabetics with A1c under control

o % hypertensive patients with BP under control

o % of patients with LDL under control

o % of smokers offered smoking cessation counseling

% of patients with recorded BMI

% of orders (for medications, lab tests, procedures, radiology, and

referrals) entered directly by physicians through CPOE

Use of high-risk medications (Re: Beers criteria) in the elderly

% of patients over 50 with annual colorectal cancer screenings

% of females over 50 receiving annual mammogram

% of patients at high-risk for cardiac events on aspirin prophylaxis

% of patients who received flu vaccine

% of lab results incorporated into EHR in coded format

Stratify reports by gender, insurance type, primary language, race,

ethnicity

% of all medications entered into EHR as generic, when generic

options exist in the relevant drug class

% of orders for high-cost imaging services with specific structured

indications recorded

% of claims submitted electronically to all payers

% patient encounters with insurance eligibility confirmed

1 - CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but electronic

interfaces to receiving entities are not required in 20112 - Race and ethnicity codes should follow federal guidelines (see Census Bureau)

2009 Annual Meeting


Health Outcomes

Priority Policy

Care Goals 2011 Objectives* for Eligible ProvidersGoal is to electronically capture in coded format and to report health information

and to use that information to track key clinical conditions

2011 Measures* for Eligible Providers

Engage patients and

families

Provide patients and

families with timely

access to data,

knowledge, and tools to

make informed decisions

and to manage their

health

Provide patients with an electronic copy of their health

information (including lab results, problem list, medication

lists, allergies) upon request3

Provide patients with timely electronic access to their health

information (including lab results, problem list, medication

lists, allergies)3

Provide access to patient-specific education resources

Provide clinical summaries for patients for each encounter

% of all patients with access to personal health information

electronically

% of all patients with access to patient-specific educational

resources

% of encounters for which clinical summaries were

provided

Improve Care

Coordination

Exchange meaningful

clinical information

among professional

health care team

Capability to exchange key clinical information (e.g., problem

list, medication list, allergies, test results), among providers of

care and patient authorized entities electronically4

Perform medication reconciliation at relevant encounters and

each transition of care5

% of encounters where med reconciliation was performed

Implemented ability to exchange health information with

external clinical entity (specifically labs, care summary and

medication lists)

% of transitions in care for which summary care record is

shared (e.g., electronic, paper, e-Fax)

Improve populations

and public health

Communicate with

public health agencies

Capability to submit electronic data to immunization registries

and actual submission where required and accepted6

Capability to provide electronic syndromic surveillance data to

public health agencies and actual transmission according to

public law

Report up-to-date status for childhood immunizations6

Ensure adequate

privacy and security

protections for

personal health

information

Ensure privacy and

security protections for

confidential information

through operating

policies, procedures, and

technologies and

compliance with

applicable law

Provide transparency of

data sharing to patient

Compliance with HIPAA Privacy and Security Rules7,8

Compliance with fair data sharing practices set forth in the

Nationwide Privacy and Security Framework

Full Compliance with HIPAA Privacy and Security Rules

Conduct or update a security risk assessment and implement

security updates as necessary


3 - Electronic access to and copies of may be provided by a number of electronic methods (e.g., PHR, patient portal, CD, USB Drive)4 – Health information exchange capability and demonstrated exchange to be specified by Health Information Exchange Work Group of HIT Policy Committee5 – Transition of care defined as moving from one health care setting or provider to another6 – Applicability to Medicare versus Medicaid meaningful use is to be determined7 – The HIT Policy Committee recommends that CMS withhold meaningful use payment for any entity until confirmed HIPAA privacy or security violation has been resolved8 - The HIT Policy Committee recommends that state Medicaid administrators withhold meaningful use payment for any entity until any confirmed state privacy or security violation has been resolved

2009 Annual Meeting


Health

Outcomes

Policy

Priority

Care Goals 2011* Hospital ObjectivesGoal is to electronically capture in coded format and to report health

information and to use that information to track key clinical conditions

2011* Hospital Measures

Improve quality,

safety,

efficiency, and

reduce health

disparities

Provide access to

comprehensive patient

health data for patient’s

health care team

Use evidence-based

order sets and CPOE

Apply clinical decision

support at the point of

care

Generate lists of

patients who need care

and use them to reach

out to patients (e.g.,

reminders, care

instructions, etc.)

Report to patient

registries for quality

improvement, public

reporting, etc.

10% of all orders (any type) directly entered by authorizing

provider (e.g., MD, DO, RN, PA, NP) through CPOE1

Implement drug-drug, drug-allergy, drug-formulary checks

Maintain an up-to-date problem list of current and active

diagnoses based on ICD-9 or SNOMED

Maintain active medication list

Maintain active medication allergy list

Record demographics:

o Preferred language

o Insurance type

o Gender

o Race2

o Ethnicity

Record advance directives

Record vital signs:

o Height

o Weight

o Blood pressure

Calculate and display:

o BMI

Record smoking status

Incorporate lab-test results into EHR as structured data

Generate lists of patients by specific conditions

Report hospital quality measures to CMS

Implement one clinical decision rule related to a high priority

hospital condition

Check insurance eligibility electronically from public and

private payers, where possible

Submit claims electronically to public and private payers

Report quality measures to CMS

including:

o % of smokers offered smoking cessation

counseling

% of eligible surgical patients who

receive VTE prophylaxis

% of orders (for medications, lab tests,

procedures, radiology, and referrals)

entered directly by physicians through

CPOE

Use of high-risk medications (Re: Beers

criteria) in the elderly

% of lab results incorporated into EHR in

coded format

Stratify reports by gender, insurance

type, primary language, race, ethnicity

% of all medications entered into EHR as

generic, when generic options exist in the

relevant drug class

% of orders for high-cost imaging

services with specific structured

indications recorded

% of claims submitted electronically to

all payers

% patient encounters with insurance

eligibility confirmed


1 - CPOE requires computer-based entry by providers of orders (medication, laboratory, procedure, diagnostic imaging, immunization, referral) but electronic interfaces to receiving entities are not

required in 20112 - Race and ethnicity codes should follow federal guidelines (see Census Bureau)

2009 Annual Meeting


Health Outcomes

Policy Priority

Care Goals 2011* Hospital ObjectivesGoal is to electronically capture in coded format and to report health information and to use that information to track key

clinical conditions

2011* Hospital Measures

Engage patients and

families

Provide patients and

families with timely

access to data,

knowledge, and tools to

make informed

decisions and to manage

their health

Provide patients with an electronic copy their health information (including lab results,

problem list, medication lists, allergies, discharge summary, procedures) upon request3

Provide patients with an electronic copy of their discharge instructions and procedures at time

of discharge, upon request3

Provide access to patient-specific education resources

% of all patients with access to personal health

information electronically

% of all patients with access to patient-specific

educational resources

Improve Care

Coordination

Exchange meaningful

clinical information

among professional

health care team

Capability to exchange key clinical information (e.g., discharge summary, procedures,

problem list, medication list, allergies, test results), among providers of care and patient

authorized entities electronically4

Perform medication reconciliation at relevant encounters and each transition of care5

Report 30-day readmission rate

% of encounters where med reconciliation was

performed

Implemented ability to exchange health information

with external clinical entity (specifically labs, care

summary and medication lists)

% of transitions in care for which summary care

record is shared (e.g., electronic, paper, e-Fax)

Improve populations and

public health

Communicate with

public health agencies

Capability to submit electronic data to immunization registries and actual submission where

required and accepted6

Capability to provide electronic submission of reportable data to public health agencies and

actual transmission where it can be received

Capability to provide electronic syndromic surveillance data to public health agencies and

actual transmission according to applicable law and practice

% reportable lab results submitted electronically

Ensure adequate privacy

and security protections for

personal health

information

Ensure privacy and

security protections for

confidential information

through operating

policies, procedures, and

technologies and

compliance with

applicable law

Provide transparency of

data sharing to patient

Compliance with HIPAA Privacy and Security Rules7,8

Compliance with fair data sharing practices set forth in the Nationwide Privacy and Security

Framework

Full Compliance with HIPAA Privacy and Security

Rules

Conduct or update a security risk assessment and

implement security updates as necessary

3 - Electronic access to and copies of may be provided by a number of electronic methods (e.g., PHR, patient portal, CD, USB Drive)4 – Health information exchange capability and demonstrated exchange to be specified by Health Information Exchange Work Group of HIT Policy Committee5 – Transition of care defined as moving from one health care setting or provider to another6 – Applicability to Medicare versus Medicaid meaningful use is to be determined7 – The HIT Policy Committee recommends that CMS withhold meaningful use payment for any entity until confirmed HIPAA privacy or security violation has been resolved8 - The HIT Policy Committee recommends that state Medicaid administrators withhold meaningful use payment for any entity until any confirmed state privacy or security violation has been resolved


arra & hit: what do they mean to you? - aamc.org · pdf file2009 annual meeting...

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