pya offers regulatory updates and operational implications of meaningful use

August 13, 2013

Prepared for Nashville MGMA

Meaningful Use: Regulatory and Operational

Implications

Nashville MGMA

August 13, 2013

August 13, 2013


Agenda

• Data and quality clinical outcomes

• Regulatory information highlights and audits

• Meaningful Use (MU) implications for

– Staffing/Roles

– Alliances/Referrals

– Meaningful data

August 13, 2013


Quality Outcomes

August 13, 2013


Quality Data in the Exam Room

xx% of my patients over 18 who have their tonsils removed experience post-surgical hemorrhaging.

These outcomes are less than the national average of yy% of patients over 18.

August 13, 2013


Quality DataWhat’s the source of the data?

August 13, 2013


Communicating About Quality

If he’s using clinical outcomes statistics in the exam room, where else is he using them?

August 13, 2013


Doctor’s Lounge

Communicating with referring physicians?

August 13, 2013


Board Table

Quality contractual requirements between hospitals and physicians

– Employment arrangements

– Clinical co-management

– ACOs

– Other partnerships

August 13, 2013


Negotiating Table

Once quality metrics are operationalized for one payor, the provider can build on that strength to discuss quality with other contracting payors.

August 13, 2013


Website

How is he attracting patients to his practice based on quality outcomes?

August 13, 2013


Take Away #1

• What story are you telling about the physicians in your practice using the quality data collected in the MU process?

• Focus on a core measure metric or clinical quality metrics and develop the story.

August 13, 2013


MU Statistics as of June 2013

$-

$500,000,000

$1,000,000,000

$1,500,000,000

$2,000,000,000

$2,500,000,000

$3,000,000,000

2011 2012 2013 YTD

Medicare EP.s Medicaid EP.s

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/June_PaymentRegistration_Summary.pdf

Almost 6 billion

dollars to EP.s to-

date

August 13, 2013


Real World Impact of MU

• More than 458 million test results were entered into the EHR by 111,954 Eligible Providers (EP.s).

• Medication reconciliation was performed on over 40 million patient transitions of care by 83,035 EP.s.

• More than 4.3 million patient transitions of care summaries were generated by 24,827 EP.s.

By Robert Tagalicod, Director, Office of E-health Standards and Services http://www.cms.gov/eHealth/ListServ_RealWorldImpact_MeaningfulUse.html

August 13, 2013


Meaningful UseHeadlines

• July 25, 2013 – AMA and AHA ask for flexibility in Meaningful Use program requirements.

• July 30, 2013 – AHA and AMA, as well as CHIME (College of Healthcare Information Management Executives), request more time for Stage 2.

• July 30, 2013 –AHA report calls for a delay of Eligible Hospital Stage 2 deadline of October 1, 2013.

As reported in HealthLeaders Media.

August 13, 2013


Meaningful UseCurrent Details

• Stage 2 Meaningful Use (MU) Attestation begins in calendar year 2014 for Eligible Providers (EP.s).

– If a provider began MU in 2011, he/she will meet three consecutive years of MU before beginning Stage 2 in 2014.

– All other providers meet two years of MU before advancing to Stage 2 in their third reporting year.

• For 2014 only, all providers – regardless of MU stage – are only required to demonstrate MU for a 3 month reporting period.

• Beginning in 2015, Medicare eligible professionals who do not successfully demonstrate meaningful use will be subject to a payment adjustment.

August 13, 2013


Public Health Reporting Objectives:

Providers must perform at least one test of their certified EHR technology’s capability to

send data to public health agencies.

Timing/Compliance:

Required in 2013 and beyond for all Stage 1 public health objectives.

Affected Providers:

EPs, eligible hospitals, and CAHs

What It Means:

The intent of this modification is to encourage all EPs, eligible hospitals, and CAHs to submit public health data, even when not required by State/local law, if authorized. Public health reporting objectives include submitting data

to: an immunization registry, a syndromic surveillance database, OR lab results to a public health agency.

What’s New in MU Stage 1 in 2013

Required, if authorized

August 13, 2013



Electronic Exchange of Key Clinical Information:

Removal of electronic exchange of key clinical information

objective for Stage 1 for EPs, eligible hospitals, and CAHs

Timing/Compliance:

Removed in 2013 and beyond

Affected Providers:


What It Means:

Providers will no longer have to meet or attest to this objective for the EHR incentive programs. MU Stage 2 will include a more robust requirement for electronic health information exchange associated

with a transition of care or referral.

Removed from Stage 1

August 13, 2013



Computerized Physician Order Entry (CPOE):

Addition of an alternative measure based on the total

number of medication orders creating during the EHR

reporting period.

Timing/Compliance:

Option to choose the alternative measure in 2013 and beyond.

Affected Providers:


What It Means:

Providers will have the option of using the original measure or the alternative measure to meet the CPOE objective.

Alternative

August 13, 2013



Record and Chart Changes in Vital Signs:

Increase in age limit for recording blood pressure in

patients to age 3; removal of age limit requirement for height

and weight.

Timing/Compliance:

Optional to implement the changes in 2013; required in 2014 and beyond.

Affected Providers:


What It Means:

In 2013, providers have a choice of reporting under either the original or new age limits. However, in 2014, all providers must

report under the new age limits.

Alternative

August 13, 2013



Electronic Prescribing:Additional exclusion to the

objective for electronic prescribing for providers who are not within a 10 mile radius

of a pharmacy that accepts electronic prescriptions.

Timing/Compliance:

Optional to select the additional exclusion starting in 2013 and beyond.

Affected Providers:

EPs

What It Means:

EPs may select the additional exclusion if they qualify.

Additional Exclusion

August 13, 2013



Record and Chart Changes in Vital Signs:

New exclusion for EPs: If they see no patients 3 years or older;

if all three vital signs are not relevant to their scope of

practice; if height and weight are not relevant to their scope of practice; or if blood pressure is not relevant to their scope of

practice.

Timing/Compliance:

Optional to select new exclusion criteria in 2013; replaces current exclusion criteria starting in 2014.

Affected Providers:

EPs

What It Means:Previously, EPs could only exclude the objective if all three vital signs were not relevant to their scope of practice or if they saw no patients

3 years or older. Beginning in 2013, EPs can also now be excluded from reporting blood pressure if blood pressure is not relevant to

their scope of practice, or recording height and weight if both height and weight are not relevant to their scope of practice.

New Exclusion

August 13, 2013


MU Stage 1 to Stage 2

• Increase in required percentage of qualifying unique patients in percentage-based objectives.

• All clinical quality measures (CQMs) will be submitted electronically to CMS.

• New requirements for summary of care documents at transition of care/referrals and patient electronic access via secure messaging.

August 13, 2013


Penalty Scenarios

First Year of MU

Requirement to Avoid Penalty

2015 2016 2017

2011 Achieve MU in 2013 (365 days)

Achieve MU in 2014 (One 3-month

quarter)Achieve MU in 2015

(365 days)

2012 Achieve MU in 2013 (365 days)



(365 days)

2013Achieve MU in 2013

(Any 90-consecutive-day period)



(365 days)

2014

Achieve MU in 2014 (Any 90-consecutive-day

period ending no later than 3 months before the

end of the reporting period)



(365 days)

August 13, 2013


EHR Incentive Programs (MU)Supporting Documentation

• Retain ALL relevant supporting documentation for SIX YEARS post-attestation.

• Audit letters will be sent electronically from CMS email address.

• Pre-payment audits:

– Both random and targeted (based on suspicious or anomalous data).

– Supporting documentation will be requested prior to payment of incentive monies.

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_SupportingDocumentation_Audits.pdf

August 13, 2013


EHR Incentive Programs (MU)Supporting Documentation (cont.)

• Post-payment audits:

– Initially conducted as “desk” (off-site) audits using requested copies of documentation.

– Follow-up data requests and even on-site reviews in the provider office could be done.

– Be sure to retain a report from the certified EHR to validate all clinical quality measure (CQM) data.

– For non-percentage-based documentation, screenshots from the EHR during the reporting period may be required.

August 13, 2013


Favorite Government Audits Techniques

• . Audit Method IRS MU Example

Discriminant Function System (DIF) Scoring

Analyze population groupings, standards and trends for potential abnormal circumstances based on past experience. E.g., zip code = Bel Air; DMV tags = Lamborghini; pay interest on a $1 million mortgage; BUT declare less than $100,000 of income.

Hospital with certain higher level of IP days or discharges but low volume on percentage based measures

Hot-Spot Market Segments

Every year the IRS selects a particular industry for compliance examinations. E.g., foreign trusts, s-corps, restaurant servers

Certain EP specialties, hospitals of a certain size or location

Information Matching

Employers, banks, brokerage firms, independent contractors all file documents with the IRS and send the same documents to tax payers e.g., Forms 1099, W2.

Unusual variations in volume of percentage based measures among EPs within the same TIN; or between MU and PQRS

August 13, 2013


MU Role in New Care Model Development

• Consolidation/M&A

• ACOs

• Clinically Integrated Networks

• Private Payor Network Development/Contracting

• Others

August 13, 2013


MU & Consolidation

• Weathering the storm with a bigger ship:

– From 2000 to 2010, hospital physician employment rose 32%.

– Hospitals directly employ about a quarter of all U.S. physicians.

– By 2013, 2/3rds of physicians will work for hospitals or large groups.

• Strategic Consideration:

– Affiliate or Merge with an organization without an MU plan or at risk of a penalty?

August 13, 2013


MU & Consolidation

• Transaction Due Diligence Consideration:

– Meaningful Use due diligence now occurs in most health care transactions.

– Organizational readiness for Meaningful Use Attestation requires detailed supporting documentation.

August 13, 2013


MU & ACOs

• Public Payor

• Medicare

• Medicaid

• Private Payor

• Private Payors (Blue Cross, United, Cigna, Aetna)

• ACOs with private insurers in effect or development at four times the rate of Medicare ACOs

• Large Employers

• Self-Insured Hospitals and Health Systems

August 13, 2013


MU & ACOs

• ACO 33 Quality Measures include:

– Percent of PCPs who Successfully Qualify for MU Payment

– CQMs overlap with ACO measures

August 13, 2013


Clinical Quality Measure (CQM) Overlap with ACO and Other Programs

Stage 2 2014 CQM Measure Other CMS Program

Controlling High Blood Pressure Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

ACO; EHR PQRS; Group Reporting PQRS

Use of High-Risk Medications in the Elderly PQRS

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

ACO; EHR PQRSGroup ReportingPQRS

Use of Imaging Studies for Low Back Pain

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

EHR PQRS; ACO; Group Reporting PQRS

Documentation of Current Medications in the Medical Record PQRS; EHR PQRS

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

EHR PQRS; ACO; Group Reporting PQRS

August 13, 2013


2013 PQRS

• If you have EPs that meet MU, don’t leave money on the table:

– 2013: 0.5% incentive

– 2015: 1.5% penalty

• Assess crosswalk opportunities for quality reporting across programs.

August 13, 2013


MU & Private Payor Contracting• A growing number of private payers have added the

MU requirements to their P4P programs:

– Aetna, United and WellPoint

– Highmark modified "Quality Blue" program to include MU:

• Require copy of attestation

• Incorporate CQM for physician practice best practice indicator program

• Payors not setting up proprietary mini-MU programs

– Rather use developed MU system

– Similar to using DRGs as a reference price for rates

August 13, 2013


Take Away #2

• Incorporate MU into Compliance Program.

– Compliance Officer involvement in attestation and annual review.

• Ensure Attestation documentation is consistent with CMS’s recommendations.

• Prepare for more oversight – not just from CMS.

• Maximize MU attestation benefits with other payors and alliances.

August 13, 2013


Operationalizing

to imperfect users.

Adapting a perfect

program

August 13, 2013


Much more about the people,

than the systems.

Operationalizing

August 13, 2013


Meaningful Use Progression

The systems need to carry the burden to prompt users to do the right

thing.

As Meaningful Use

requirements progress there

will be a higher volume

of data requirements

and more complexity.

August 13, 2013


We can only do so much

August 13, 2013


Meaningful Use Attestation

Stage 1 only

Stage 1 and planningFor Stage 2 in 2014

Not yet attested

August 13, 2013


Meaningful Use Attestation

Comments:

• Working on it [Meaningful Use attestation].

• Small office and older physician who is not going to [attest].

• We plan on attesting for Stage 1 by the end of this year.

August 13, 2013


MU Staffing Changes?

Increased clerical staff(i.e., Front Office, Billingor Support)Increased clinical staff

Increased IT staff

No staffingchanges made

Other (please specify)

Previous survey: 20 % increased IT

August 13, 2013


MU Staffing Changes?

Comments:

• Increased data input demands on current staff.

• Hired dedicated quality manager.

• Shift in resources in IT department to focus on MU readiness.

• We used outside consultants for MU attestation.

August 13, 2013


MU Staffing Changes

Increased duties and responsibilities of

current staff, including Administrator/Director.

Use of consultants for MU implementation and attestation process.

New IT team members: Quality staff, EMR analysts, and EMR trainers

Comments from previous survey:

August 13, 2013


New IT Staff Positions for MU?

Yes

No

August 13, 2013


New IT Staff Positions for MU?

Comments:

• Not yet, but we are discussing these.

• Hired a portal manager.

August 13, 2013


IT Positions Added for MU

Help desk staff

Clinical data analyst

Report/data specialist

Training/front line

Implementation support

staff

Information exchange/Network

specialist

Other - Additional Roles not yet Determined

August 13, 2013


Staff Positions Added in IT

Report/Data Specialist

Clinical data analyst

Help desk staff

Information exchange/network

specialist

Training/front lineImplementation support staff.

Other

Previous survey

August 13, 2013


Staffing Changes

Source: 7 Hottest IT Healthcare Skills http://www.cio.com/slideshow/detail/70112#slide1 www.CIO.com October 18, 2012

EMR Build Specialists

Healthcare Analytics

Project Management

Program Management

Application Development

Data Architecture

Quality Assurance

http://www.cio.com/slideshow/detail/70112

http://www.cio.com/

August 13, 2013


IT Functional Roles Changing

• Anticipate increased need of support for

– New hardware

– Networking

– Remote access

– Interoperability issues

2012 HIMSS Leadership Survey

August 13, 2013


Staff Role ChangesDriven by MU

Increase in support/helpdesk functionality withinthe organization.

Increase in liaison/networkingsupport with healthcarepartners/alliances.

Increase in leadership/management to supportstrategic initiatives.

Other

August 13, 2013


Referral/Alliance Decisions Driven by MU

Our organization askspotential referrers/partners about MU

Our organization

only has referrals/

partners with MU attested

providers

Not considered

Other(please specify)

Previous survey: 84% Not considered

August 13, 2013


Partnership Strategy with ‘Quality’ Providers

Yes – 44.4%

No – 16.7%

Unknown – 38.9%

Previous survey: 40% YES

August 13, 2013


Biggest Barrier toMU Success

Practicebudget/financing

Internal resourcesfor training

Practice culture/resistanceto change.

Complexity ofregulations and programinstructions.

August 13, 2013


Survey Statistics

• Organization description:

– 90% Independent Physician Practices

– 10% Hospital-Owned Physician Practices

• Average practice size: 27 physicians

• Practice size range: 1 to 1,000 physicians

August 13, 2013


Take Away #3

• Re-assess staff skills and training for EHR usage.

• Determine possible staff duty changes.

• Document process and workflow redesign for EHR/MU implementation.

• Update all affected policies and procedures.

• Redesign monthly reports and dashboards to include key MU metrics.

August 13, 2013


The Meaningful Use Goal

❝Language is the road map of a culture. It tells you where its people come from and

where they are going.❞‒Rita Mae Brown

Healthcare executives are engaged in developing a new language.

August 13, 2013


Thank you!

Linda ClenDening, MS, CMPE

Manager

PYA

[email protected]

615-305-5218

865-684-2735

mailto:[email protected]

pya offers regulatory updates and operational implications of meaningful use

Health & Medicine

clinical quality

ehr incentive

alternative

blood pressure

reporting

quality outcomes

electronic

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