EHR Incentives for Professionals and Hospitals Paul Forlenza, VP - - PowerPoint PPT Presentation

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EHR Incentives for Professionals and Hospitals Paul Forlenza, VP - - PowerPoint PPT Presentation

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EHR Incentives for Professionals and Hospitals Paul Forlenza, VP Policy, VITL updated October 1, 2010 v.8.1 Disclaimer Not legal analysis or advice Analysis based on reviewing Centers for Medicare and Medicaid Services (CMS) Final

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EHR Incentives for Professionals and Hospitals

Paul Forlenza, VP Policy, VITL updated October 1, 2010 – v.8.1

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Disclaimer

  • Not legal analysis or advice
  • Analysis based on reviewing Centers for

Medicare and Medicaid Services (CMS) Final Rule (800+ pages) and analysis by other health care policy organizations

Contact: Paul Forlenza, VP Policy Vermont Information Technology Leaders, Inc. 802-223-4100 x103 pforlenza@vitl.net

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Topics

  • Health Outcome Priorities
  • Stages for Implementing Meaningful Use
  • Eligible Professionals

– Eligibility – Requirements to Achieve Meaningful Use – Clinical Quality Measures – Medicare and Medicaid Incentive Payments – Timeline and Next Steps

  • Eligible Hospitals
  • Appendix - Details about MU subjects

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EHR INCENTIVES FOR PROFESSIONALS

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Health Outcome Priorities

  • 1. Improve quality, safety, efficiency

and reduce health disparities

  • 2. Engage patients and families in

their health care

  • 3. Improve Care Coordination
  • 5. Improve population and public

health

  • 4. Protect privacy and security of

personal health information

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Which program am I eligible for?

Medicare

  • Doctors (PFS *):

– Medicine and Osteopathy – Dental Surgery or Medicine – Doctor of Podiatric Medicine – Doctor of Optometry – Chiropractors

  • Incentive for practicing

in a Health Professional Shortage Area (10%)

Medicaid

  • Patient Volume

Thresholds

– Physicians – Pediatricians – Nurse practitioners – Certified Nurse Midwives – Physician Assistants at FQHC/RHC led by PA – Dentists

* Physician Fee Schedule

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Who is not eligible for incentives?

  • Professionals that perform substantially (90%)

all of their services in an inpatient hospital setting or emergency room are not eligible

Eligible? Professionals Place of Service Codes

NO Hospitalists ER Physicians Radiologists Anesthesiologists POS 21 and 23 YES Professionals in

  • utpatient setting

POS 22

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Do I qualify for the Medicaid Program?

Eligible Professionals 1st YR 90-day Patient Volume * Comments Physicians 30% Pediatricians 20% Nurse Practitioner 30% PAs at FQHC/RHC 30% Certified Nurse Midwives 30% Dentists 30% * Second year requires a full year of patient volume Threshold for Eligible Professionals , predominantly practicing in FQHC/RHC, must have a 30% "needy individual" patient volume

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Patient Volume

  • Eligible professional: calculate using patient

encounters or patient panel

  • Alternative: use practice/clinic volume
  • CMS also allows states to develop alternative

methods to calculate patient volume

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Calculating Patient Volume

Patient Encounter Method

Total Medicaid patient encounters in any 90-day period in the Preceding calendar year Total patient encounters in that same 90-day period

x 100

= %

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Patient Volume Example

Patient Encounter Method

100 Medicaid patient encounters 300 Total patient encounters

x 100

= 33% Physician qualifies for Medicaid Program

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Calculating Patient Volume

Patient Panel Approach

Total Medicaid patients assigned to EP’s panel in any representative, continuous 90 days in the preceding calendar year Total patients assigned to a EP in same 90 day period with at least one encounter with patient during year prior to 90 day period

x 100 = %

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Stages for implementing Meaningful Use

Capture data in structured form and limited sharing Advanced clinical processes and robust health information exchange Improved

  • utcomes

Stage 1: 2011 Stage 2: 2013 Stage 3: 2015

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How do I achieve Meaningful Use?

  • A. Use certified Electronic Health Record

(EHR) in a meaningful manner

  • B. Electronically exchange health information

to improve quality of care

  • C. Report Clinical Quality Measures to CMS

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What is a certified EHR?

  • Previously EHRs certified by Certification

Commission for Health Information Technology (CCHIT)

  • ONC now selecting “Authorized Testing and

Certification Bodies”(9-23-10)

– Certification Commission for HIT (CCHIT) – Drummond Group, Inc. (DGI) – InfoGard Laboratories, Inc.

  • Certified EHRs to be post on ONC website

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  • A. How do I use a certified EHR

in a meaningful manner?

  • EPs: 15 Core Objectives (EHs: 14)

– use certain functions of EHR like e-Prescribing – maintain active problem lists – Report clinical quality measures (CQMs)

  • EPs and EHs 5 of 10 Menu Set Objectives

– generate lists of patients by specific conditions – capture clinical lab results in structured format – Implement drug-formulary checks

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  • B. How do I exchange health

information?

  • Must be with an unaffiliated organization

– Connect to the VT Health Information Exchange – Connect directly (point to point)

  • Examples

– Accept lab results as structured data into EHR – use e-Rx (generate and transmit electronically)

  • Robust bi-directional exchange delayed

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  • C. What clinical quality measures

must I report?

  • Clinical Quality Measurers based on

PQRI/NQF * – 3 core CQMs – Or 3 alternate core – Plus 3 additional from list of 38 CQMs

*PQRI: Physician Quality Reporting Initiative; NQF: National Quality Forum

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Maximum Medicaid incentives ?1,2

Payment Year

Total Incentive Payments

2011 2012 2013 2014 2015 2016 2017-21 Stage 1 $21,250 Stage 1 $8,500 Stage 2 $8,500 Stage 2 $8,500 Stage 3 $8,500 Stage 3 $8,500

$63,750

Stage 1 $21,250 Stage 1 $8,500 Stage 2 $8,500 Stage 3 $8,500 Stage 3 $8,500 Stage 3 $8,500

$63,750

Stage 1 $21,500 Stage 2 $8,500 Stage 3 $8,500 Stage 3 $8,500 Stage 3 $8.5k*2

$63,750

Stage 1 $21,500 Stage 3 $8,500 Stage 3 $8,500 Stage 3 $8.5k*3

$63,750

Stage 3 $21,500 Stage 3 $8,500 Stage 3 $8.5k*4

$63,750

  • 1. Flat fee payment based on 85% of EHR “net allowable costs”
  • 2. Max. incentive for Pediatrician, with 20% patient threshold, $42,500

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First year A/I/U option for Medicaid

  • No EHR prior to Incentive Program

– Adopt (acquired and installed) – Implement (started use of EHR)

  • Existing EHR

– Upgrade (expanded/upgraded to certified EHR

technology or added new functionality)

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What are maximum Medicare incentives?

Payment Year

Total Incentive Payments

2011 2012 2013 2014 2015 2016

Stage 1* $18,000 Stage 1 $12,000 Stage 2 $8,000 Stage 2 $4,000 Stage 3 $2,000 $44,000 Stage 1 $18,000 Stage 1 $12,000 Stage 2 $8,000 Stage 3 $4,000 Stage 3 $2,000 $44,000 Stage 1 $15,000 Stage 2 $12,000 Stage 3 $8,000 Stage 3 $4,000 $39,000 Stage 1 $12,000 Stage 3 $8,000 Stage 3 $4,000 $24,000 Payment Adjustments

  • 1%
  • 2%
  • 3%

1. No Medicare early adoption option 2. Payment based on 75% of PFS

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CMS Menu Set Measures Core Measures Clinical Quality Measures State Medicaid Office Register using CMS web-based portal. Single, annual, consolidated payment. Tied to NPI but can be transferred to practice/clinic.

Medicaid 2011 Adopt/Implement/Upgrade 2012 Attest; report 90 days data 2013 Attest; report data for 1 yr Medicare 2011 Attest to MU & report aggregate data for 90 days 2012 Attest & report for 1 year

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How do I get my Medicare/Medicaid incentive payments?

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Other Considerations for EPs

  • Medicare or Medicaid; not both; switch once
  • Meaningful use for professional; not practice
  • Calculate thresholds by provider or practice
  • FQHC/RHC “Needy Individuals” threshold

– Medicaid patients – Uncompensated care – No cost or sliding scale fee patients – Children Health Insurance Program (CHIP) enrollees

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38 Clinical Quality Measures CMS or State 10 Menu Set Objectives 15 Core Objectives

Stage 1: Reporting Requirements

  • r 3 alternate

1 must be public health measure State can move 4 public health measures from menu to core Hypertension Tobacco use Adult weight Alternate: Children Weight Flu Immunization > 50 yrs Children Immunization

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What are the differences between the EHR Incentive Programs?

Medicare

No patient thresholds No mid-levels

  • $44,000 maximum
  • 10% HPSA bonus
  • 75% allowable PFS charges

Payments over 5 yrs ( 2011-2016) Can not skip a year 1st yr must demonstrate Meaningful Use Penalties starting 2015

Medicaid

Patient volume thresholds Mid-levels included

  • $63,750 maximum
  • based on 85% of EHR

“net allowable costs” Payments over 6 yrs (2011-2021) Can skip a year Adopt, implement or upgrade

  • ption for 1st yr

No penalties

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Timeline for EHR incentives

  • Jan. 2011:

– Medicare/Medicaid registration begins – Earliest date for States to launch program

  • April 2011:

– Attestation for Medicare begins – State sets date for Medicaid attestation

  • May 2011: Medicare incentive payments begin
  • Feb. 2012: Last day for EPs to register and

attest to receive CY2011incentive payment

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CMS Plans for Stage 2

  • Add menu set objectives to core set
  • Aggressively advance threshold levels
  • More robust information exchange
  • Increase structured formats
  • Add behavioral/mental health objectives
  • Re-introduce specialty reporting

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What can VITL Offer you?

If you have an EHR:

  • Self-assessment tool of metrics
  • Assistance in filling any gaps
  • Incentive calculation Tool

If you are getting ready to deploy an EHR:

  • Full staff education in MU metrics
  • Workflow redesign support
  • Planning to ensure full compliance

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Next steps

  • VITL is a Regional HIT Extension Center

(REC) with funding from HHS/ONC to provide direct assistance to Vermont primary care providers

– If you have not signed a Direct Services Agreement (DSA), contact Larry Gilbert lgilbert@vitl.net – If you have signed a DSA, contact Carol Kulczyk ckulczyk@vitl.net 802-223-4100

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Additional VITL Resources

  • VITL Summit Presentations vitlsummit.net
  • Federal rule and other resources

vitl.net/incentives

  • CMS EHR Incentives

cms.gov/EHRIncentivePrograms/

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Questions?

Questions

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Brattleboro Memorial Hospital Central Vermont Medical Center Copley Hospital Fletcher Allen Health Care Gifford Medical Center Grace Cottage Hospital

  • Mt. Ascutney Hosp. & Health Center

North Country Hospital Northeastern VT Regional Hospital Northwestern Medical Center Porter Hospital Rutland Regional Medical Center Southwestern VT Medical Center Springfield Hospital

EHR

HOSPITAL INCENTIVES

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Health Outcome Priorities

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  • 1. Improve quality, safety, efficiency

and reduce health disparities

  • 2. Engage patients and families in

their health care

  • 3. Improve Care Coordination
  • 5. Improve population and public

health

  • 4. Protect privacy and security of

personal health information

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Eligible Hospitals 1

  • Medicare

– Acute Care

  • 25 beds or less
  • CCN 2

– Critical Access

  • Medicaid Patient

Thresholds

– Acute Care 10% – Critical Access 10% – Cancer 10% – Children’s none

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1.One incentive payment for each CMS Certification Number (CCN)

  • 2. CCN series 0001-0879 and 1300-1399
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How do I achieve Meaningful Use?

  • A. Use certified EHR * in a meaningful

manner

  • B. Electronically exchange health information

to improve quality of care

  • C. Report Clinical Quality Measures to CMS

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* Certified by ONC Authorized Testing & Certification Body

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  • A. How do I use a certified EHR

in a meaningful manner (EH)?

  • Core Objectives (14 of 14)

– CPOE – maintain active problem lists – report clinical quality measures (CQMs)

  • Menu Set Objectives (5 of 10)

– generate lists of patients by specific conditions – capture clinical lab results in structured format – implement drug-formulary checks

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  • B. How do I exchange health

information?

  • Electronic exchange with an unaffiliated
  • rganization

– VT Health Information Exchange – Point to point

  • Robust bi-directional exchange delayed until

stage 2 (2013)

  • C. Clinical quality measures
  • 15 of 15 CQMs (PQRI/NQF)

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Eligible Hospital Medicare Incentive

First Payment year Incentive Payments # of years FY2011 FY2011-FY2014 4 years FY2012 FY2012-FY2015 FY2013 FY2013-FY2016 FY2014 FY2014-FY2016 3 Years FY2015 FY2015-FY2016 2 Years

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Medicare Hospital Incentives a

Medicare discharges 1,150 – 23,000 b $200 per discharge Multiple by Transition factor 1st yr: 1.00 2nd yr : .75 3rd yr: .50 4th yr: .25 Multiple by Medicare share of acute care discharges %

(a) Hospitals are eligible for both Medicaid and Medicare incentives. (b) Discharge limits for yrs 2-4 increased by 3 yr historic growth rate.

$2 million for each year plus $ per discharge

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Medicare Incentives - CAHs

  • Reasonable costs incurred for the purchase of

depreciable assets, (computers, associated hardware and software) necessary to administer certified EHR in cost reporting period and;

  • Any similarly incurred costs from previous

cost reporting periods to the extent they have not been fully depreciated as of the cost reporting period involved and … (more)

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Medicare Incentives - CAHs

  • CAH’s Medicare share equals the Medicare

share as computed for eligible hospitals, including adjustment for charity care, plus

  • 20% points (but not to exceed 100 percent).
  • Percentage adjustment used instead of 101%

typically applied to a CAH’s reasonable costs,

  • and the incentive payments would be in lieu
  • f payments that would otherwise be made

………. (more)

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Medicare Incentives - CAHs

  • Reductions if not Meaningful User FY2015

– FY2015: 101% of reason costs to 100.66% – FY2016: to 100.33% – FY2017: and subsequent years to 100%

  • Exemption from reduction could be allowed
  • May appeal statistical and financial

amounts from the Medicare cost report

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Eligible Hospital Medicaid Incentives

  • 1st year alternative to Meaningful Use

– Adopt, Implement or Upgrade – Certified EHR by ONC-ATCB* – Qualifies for 1st year payment

  • Reporting Clinical Quality Measurers

– 1st year is by attestation – Report numerator, denominator, exclusion data – Subsequent years require electronic submission

* ONC Authorized Testing and Certifying Body

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Medicaid Hospital Incentives a

$2 million for base year plus $ per discharge Medicaid discharges 1,150 – 23,000 b $200 per discharge Multiple by Transition factor 1st yr 1.00 2nd yr .75 3rd yr .50 4th yr .25 Multiple by Medicaid share of acute care discharges %

  • a. Hospitals eligible for Medicaid and Medicare incentives
  • b. Discharge limits for yrs 2-4 increased by 3 yr historic growth

(Total EHR Cost) x (Medicaid Share) OR

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Eligible Hospital Incentives

Rule

Annual Preliminary Payment Final Payment Payment duration Achieve Meaningful Use by certain date Limitations Payment Adjustments Medicaid State to decide State to decide FY2011-FY2021 (3-6 yrs) No later than FY2016 May be non-consecutive 1 Yr Payment not > 50% 2 Yr not > 90% None

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Medicare Based on prior year discharges Based on current yr FY2011-FY2016 (4 yrs) FY2013 for full incentive Consecutive years Begin FY2015

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Questions?

Questions

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Appendix

Eligible Professional

  • Physician Assistance,

FQHC, RHC

  • Data Exchange

Requirements

  • Core Objectives
  • Menu Set Objectives
  • Clinical Quality

Measures

Eligible Hospital

  • Core Objectives
  • Menu Set objectives
  • Clinical Quality

Measures

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Physician Assistant at FQHC/RHC

  • PA eligible at FQHC/RHC if led by a PA

– PA is primary provider in a clinic – PA is clinical or medical director at a clinic site – PA is owner of RHC

  • FQHC includes section 330 organizations:

– Community Health Centers, Migrant Health Centers, Healthcare for the Homeless Programs, Public Housing Primary Care Programs, Federally Qualified Health Center Look-Alikes, and Tribal Health Centers.

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Data Exchange: EP Core Set

  • 1. Provide patients an electronic copy of their

ambulatory, ED or inpatient summary of care record

  • 2. Transmit prescriptions
  • 3. Capability to exchange key clinical

information among care providers and patient authorized entities

  • 4. Report clinical quality measures

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Data Exchange: EP Menu Set

  • 1. Incorporate clinical lab tests results into

EHRs as structured data

  • 2. Provide summary care record for patients

referred/transition to another provider

  • 3. Capability to submit data to immunization

registries, provide syndromic surveillance and lab data to public health agencies

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Must include at least one public health transaction

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EP –15 Core Objectives

  • 1. Computerized physician order entry (CPOE)
  • 2. E-Prescribing (eRx)
  • 3. Report ambulatory clinical quality measures
  • 4. Implement one clinical decision support rule
  • 5. Provide patients with an electronic copy of their

health information, upon request

  • 6. Provide clinical summaries for patient office visit
  • 7. Drug-drug and drug-allergy interaction checks

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EP –15 Core Objectives

  • 8. Record demographics
  • 9. Maintain up-to-date problem list

10.Maintain active medication list 11.Maintain active medication allergy list 12.Record and chart changes in vital signs 13.Record smoking status for patients 13 years or older 14.Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 15.Protect electronic health information

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EP Menu Set Objectives

Stage 1: pick 5 of 10

  • 1. Drug-formulary checks
  • 2. Incorporate clinical lab test results as structured

data

  • 3. Generate lists of patients by specific conditions
  • 4. Send reminders to patients per patient preference for

preventive/follow up care

  • 5. Provide patients with timely electronic access to their

health information ……… more

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EP Menu Set Objectives

Stage 1: pick 5 of 10

  • 6. Use certified EHR to identify patient-specific

education resources and provide to patient

  • 7. Medication reconciliation
  • 8. Summary of care record for each transition of

care/referrals

  • 9. Capability to submit electronic data to immunization

registries/systems* 10.Capability to provide electronic syndromic surveillance data to public health agencies*

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* Must include at least one public health transaction

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EP Core and Alternate Clinical Quality Measures

Core

  • 1. Hypertension: Blood

Pressure Measurement

  • 2. Preventive Care and

Screening Measure

a. Tobacco Use Assessment b. Tobacco Cessation Intervention

  • 3. Adult Weight Screening

and Follow-up

Alternate

  • 1. Weight Assessment and

Counseling for Children and Adolescents

  • 2. Preventive Care and

Screening:

Influenza Immunization for Patients 50 Years Old or Older

  • 3. Childhood

Immunization Status

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EP Clinical Quality Measures Pick 3 of 38

  • 1. Diabetes: Hemoglobin A1C poor control
  • 2. Diabetes: LDL Management and Control
  • 3. Diabetes: BP Management
  • 4. Heart Failure: Ace/ARB Rx for LVSD
  • 5. CAD: Beta Blocker therapy for prior MI
  • 6. Pneumonia Vaccination for Older Adults
  • 7. Breast CA screening
  • 8. Colorectal Cancer screening

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EP Clinical Quality Measures Pick 3 of 38

  • 9. CAD: Oral Antiplatelet Therapy Prescribed

for Patients with CAD 10.Heart Failure: Beta Blocker Therapy for LVSD 11.Anti-depressant medication management:

a. Effective acute phase treatment b. Effective continuation phase treatment

12.Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation

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EP Clinical Quality Measures Pick 3 of 38

13.Diabetic Retinopathy: Documentation of presence or absence of Macular Edema and level of severity of retinopathy 14.Diabetic Retinopathy: Communication with the Physician managing ongoing diabetes 15.Asthma Pharmacologic Therapy 16.Asthma Assessment

  • 17. Appropriate testing for children with

pharyngitis

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EP Clinical Quality Measures Pick 3 of 38

18.Oncology Breast Cancer: Hormonal Tx for Stage IC-IIIC Estrogen/Progesterone Receptor Positive CA 19.Oncology Colon Cancer: Chemo for Stage III CA patients 20.Prostate CA: Avoid overuse of Bone Scan for Staging Low Risk pts 21.Smoking/Tobacco Use Cessation

a. Advise smokers and tobacco users to quit b. Discuss smoking/tobacco use cessation medications c. Discussing smoking/tobacco use cessation strategy

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EP Clinical Quality Measures Pick 3 of 38

22.Diabetes: Eye Exam

  • 23. Diabetes: Urine screening
  • 24. Diabetes: Foot Exam

25.CAD: Drug therapy for lowering LDL

  • 26. Heart Failure: Warfarin therapy for A-Fib
  • 27. IVD: BP Management
  • 28. IVD: Use of aspirin or another antithrombotic
  • 29. Initiation and engagement of alcohol and
  • ther drug dependence treatment: Initiation

and Engagement

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EP Clinical Quality Measures Pick 3 of 38

  • 30. Prenatal Care: Screening for HIV
  • 31. Prenatal Care: Anti-D Immunoglobulin
  • 32. Controlling High BP

33.Cervical Cancer Screening 34.Chlamydia Screening for Women

  • 35. Use of Appropriate Medications for Asthma
  • 36. Low Back Pain: Use of Imaging Studies
  • 37. IVD: Complete Lipid Panel and LDL Control
  • 38. Diabetes: HBA1C Control (<8.0%)

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EH –14 Core Objectives

Need all 14

  • 1. Computerized physician order entry (CPOE)
  • 2. Drug-drug and drug-allergy interaction checks
  • 3. Record demographics
  • 4. Implement one clinical decision support rule
  • 5. Maintain an up-to-date problem list of current

and active diagnoses

  • 6. Maintain active medication list
  • 7. Maintain active medication allergy list
  • 8. Record and chart changes in vital signs
  • 9. Record smoking status for patients 13 years or
  • lder

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EH –14 Core Objectives

Need all 14

10.Report hospital clinical quality measures 11.Provide patients with an electronic copy of their health information, upon request 12.Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request 13.Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 14.Protect electronic health information

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EH Menu Set Objectives

Stage 1: Pick 5 of 10

1. Drug-formulary checks 2. Record advanced directives for patients 65 years or

  • lder

3. Incorporate clinical lab test results as structured data 4. Generate lists of patients by specific conditions 5. Use certified EHR technology to identify patient- specific education resources and provide to patient, if appropriate

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EH Menu Set Objectives

Stage 1: pick 5 of 10

6. Medication reconciliation 7. Summary of care record for each transition of care/referrals 8. Capability to submit electronic data to immunization registries/systems* 9. Capability to provide electronic submission of reportable lab results to public health agencies*

  • 10. Capability to provide electronic syndromic

surveillance data to public health agencies* *At least 1 public health objective must be selected

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slide-66
SLIDE 66

EH Clinical Quality Measures

Need all 15

1. Emergency Department Throughput –admitted patients –Median time from ED arrival to ED departure for admitted patients 2. Emergency Department Throughput –admitted patients –Admission decision time to ED departure time for admitted patients 3. Ischemic stroke –Discharge on anti-thrombotics 4. Ischemic stroke –Anticoagulation for A-fib/flutter 5. Ischemic stroke –Thrombolytic therapy for patients arriving within 2 hours of symptom onset

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slide-67
SLIDE 67

EH Clinical Quality Measures

Need all 15

6. Ischemic or hemorrhagic stroke –Antithrombotic therapy by day 2 7. Ischemic stroke –Discharge on statins 8. Ischemic or hemorrhagic stroke – Stroke education 9. Ischemic or hemorrhagic stroke –Rehabilitation assessment

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slide-68
SLIDE 68

EH Clinical Quality Measures

Need all 15

  • 10. VTE prophylaxis within 24 hours of arrival
  • 11. Intensive Care Unit VTE prophylaxis
  • 12. Anticoagulation overlap therapy
  • 13. Platelet monitoring on unfractionated heparin
  • 14. VTE discharge instructions
  • 15. Incidence of potentially preventable VTE

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