Medicare & Medicaid EHR Incentive NPRM
Implementing the American Reinvestment & Recovery Act of 2009
Office of E-Health Standards and ServicesCenters for Medicare & Medicaid Services
2
• American Reinvestment & Recovery Act (Recovery Act) – February 2009
• Electronic Health Record (EHR) Incentive Notice of Proposed Rulemaking (NPRM) on Display – December 30, 2009; published January 13, 2010
• NPRM Comment Period Closes – March 15, 2010
Overview
3
• Definition of Meaningful Use (MU)• Definition of Eligible Professional (EP) and Eligible
Hospital/Critical Access Hospital (CAH)• Definition of Hospital-Based Eligible Professional• Medicare Fee-for-service (FFS) EHR Incentive
Program• Medicare Advantage (MA) EHR Incentive Program• Medicaid EHR Incentive Program• Collection of Information Analysis (Paperwork
Reduction Act)• Regulatory Impact Analysis
What is in the CMS EHR Incentive program NPRM?
4
• Information about applying for grants• Changes to HIPAA• Office of the National Coordinator (ONC)
Interim Final Rule (IFR) – Health Information Technology (HIT): Initial Set of Standards, Implementation Specifications, and Certification Criteria for EHR Technology
• EHR certification requirements• ONC NPRM - Establishment of Certification
Programs for Health Information Technology • Procedures to become a certifying body
What is not in the CMS NPRM?
5
• Harmonizes MU criteria across CMS programs as much as possible
• Closely links with the ONC certification and standards IFR
• Builds on the recommendations of the HIT Policy Committee
• Coordinates with the existing CMS quality initiatives
• Provides a platform that allows for a staged implementation over time
What the NPRM Does
6
• Medicare FFS◦ Eligible professionals (EPs)◦ Eligible hospitals and critical access hospitals
(CAHs)• Medicare Advantage (MA)
◦ MA EPs◦ MA-affiliated eligible hospital
• Medicaid◦ EPs◦ Eligible hospitals
Eligibility Overview
7
Eligible Providers in Medicare
Eligible Professionals (EPs) Doctor of Medicine or Osteopathy
Doctor of Dental Surgery or Dental Medicine
Doctor of Podiatric Medicine
Doctor of Optometry
Chiropractor
Eligible Hospitals*Acute Care Hospitals
Critical Access Hospitals (CAHs)
Who is a Medicare Eligible Provider?
*Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or DC (including Maryland hospitals)
8
Eligible Providers in Medicare Advantage (MA)
MA Eligible Professionals (EPs) Must furnish, on average, at least 20 hours/week of patient-care services and be employed by the qualifying MA organization
-or-
Must be employed by, or be a partner of, an entity that through contract with the qualifying MA organization furnishes at least 80 percent of the entity’s Medicare patient care services to enrollees of the qualifying MA organization
Qualifying MA-Affiliated Eligible HospitalsWill be paid under the Medicare Fee-for-service EHR incentive program
Who is a Medicare Advantage Eligible Provider?
9
Who is a Medicaid Eligible Provider?
Eligible Providers in MedicaidEligible Professionals (EPs)
Physicians (Pediatricians have special eligibility & payment rules)
Nurse Practitioners (NPs)
Certified Nurse-Midwives (CNMs)
Dentists
Physician Assistants (PAs) who lead a Federally Qualified Health Center (FQHC) or rural health clinic (RHC) that is directed by a PA
Eligible HospitalsAcute Care Hospitals
Children’s Hospitals
10
• Hospital-based EPs do not qualify for Medicare EHR incentive payments
• Most hospital-based EPs will not qualify for Medicaid EHR incentive payments
• Defined as an EP who furnishes 90% or more of their services in a hospital setting (inpatient, outpatient, or emergency room)
Hospital-based EPs
11
• The Recovery Act specifies the following 3 components of Meaningful Use:1. Use of certified EHR in a meaningful manner
(ex: e-prescribing)2. Use of certified EHR technology for electronic
exchange of health information to improve quality of health care
3. Use of certified EHR technology to submit clinical quality and other measures
What is Meaningful Use?
12
• Definitiono To be determined by Secretaryo Must include quality reporting, electronic
prescribing, information exchange• Process of defining
o NCVHS hearingso HIT Policy Committee (HITPC) recommendationso Listening Sessions with providers/organizationso Public comments on HITPC recommendationso Comments received from the Department and the
Office of Management and Budget (OMB)
Defining Meaningful Use
13
Data capture and sharing
Advanced clinical processes
Improved outcomes
Conceptual Approach toMeaningful Use
14
• Meaningful Use will be defined in 3 stages through rulemaking◦ Stage 1 – 2011◦ Stage 2 – 2013*
◦ Stage 3 – 2015*
*Stages 2 and 3 will be defined in future CMS rulemaking.
Meaningful Use Stages
15
• Improving quality, safety, efficiency, and reducing health disparities
• Engage patients and families in their health care
• Improve care coordination• Improve population and public health • Ensure adequate privacy and security
protections for personal health information
Stage 1 – Health Outcome Priorities*
*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.
16
First Payment
Year
CY 2011
CY 2012 CY 2013 CY 2014 CY 2015 and later**
2011 Stage 1 Stage 1 Stage 2 Stage 2 Stage 3
2012 Stage 1 Stage 1 Stage 2 Stage 3
2013 Stage 1 Stage 2 Stage 3
2014 Stage 1 Stage 3
2015 and later*
Stage 3
Proposed Stages of Meaningful Use Timeline
*Avoids payment adjustments only for EPs in Medicare EHR Incentive Program**Stage 3 criteria of meaningful use or a subsequent update to criteria if one is established
17
• EPs◦ 25 Objectives and Measures◦ 8 Measures require ‘Yes’ or ‘No’ as structured data◦ 17 Measures require numerator and denominator
• Eligible Hospitals and CAHs◦ 23 Objectives and Measures◦ 10 Measures require ‘Yes’ or ‘No’ as structured
data◦ 13 Measures require numerator and denominator
• Reporting Period – 90 days for first year; one year subsequently
Meaningful Use Summary
18
1. Use CPOE2. Implement drug-drug, drug-allergy, drug-
formulary checks3. Maintain an up-to-date problem list of
current and active diagnoses based on ICD-9-CM or SNOMED CT®
4. Maintain active medication list5. Maintain active medication allergy list6. Record demographics 7. Record and chart changes in vital signs
Meaningful Use Objectives for EPs & Eligible Hospitals/CAHs
19
8. Record smoking status for patients 13 years and older9. Incorporate clinical lab-test results into EHR as structured
data10. Generate lists of patients by specific conditions to use for
quality improvement, reduction of disparities, and outreach11. Report ambulatory quality measures to CMS or the States12. Implement 5 clinical decision support rules relevant to
specialty or high clinical priority, including diagnostic test ordering, along with the ability to track compliance with those rules
13. Check insurance eligibility electronically from public and private payers
14. Submit claims electronically to public and private payers
Meaningful Use Objectives for EPs & Eligible Hospitals/CAHs
20
15. Provide patients with an electronic copy of their health information upon request
16. Capability to electronically exchange key clinical information among providers of care and patient-authorized entities
17. Perform medication reconciliation at relevant encounters and each transition of care
18. Provide summary care record for each transition of care and referral19. Capability to submit electronic data to immunization registries and
actual submission where required and accepted20. Capability to provide electronic syndromic surveillance data to public
health agencies and actual transmission according to applicable law and practice
21. Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities
Meaningful Use Objectives for EPs & Eligible Hospitals/CAHs
21
1. Generate and transmit permissible prescriptions electronically
2. Send reminders to patients per patient preference for preventive/follow-up care
3. Provide patients with timely electronic access to their health information within 96 hours of information being available to the EP
4. Provide clinical summaries for patients for each office visit
Additional Meaningful Use Objectives for EPs Only
22
1. Provide patients with an electronic copy of their discharge instructions and procedures at time of discharge, upon request
2. Capability to provide electronic submission of reportable lab results, as required by state or local law, to public health agencies and actual submission where it can be received.
Additional Meaningful Use Objectives for Eligible Hospitals/CAHs Only
NPRM changes from HITPC Recommendations Deletions Additions
Record advance directives Provide summary care record for each transition of care and referralDocument a progress note for each
encounter
Provide access to patient-specific education resources
Changes
Adding date of birth to record demographics and cause and date of death for hospitals
Adding growth charts to record vital signs
Limiting smoking status to age 13+
Increasing clinical decision support (CDS) rules from 1 to 5
Removed “where possible” from insurance eligibility checks
Changed the provision of clinical summaries from “each encounter” to “each office visit”
Changed compliance with HIPAA to protect electronic health information maintained by certified EHR technology
23
NPRM changes from the HITPC Recommendations Measures• Ensured every objective is matched to a measure• Added a % threshold to measures recommended as “% of
…”• Calculated some % based on “unique patients seen” as
not every action would be taken for every office visit• Narrowed lab results to those “whose results are in a
positive/negative or numeric format”• For exchange of information changed “implemented
ability” to “Performed at least one test”• Clinical quality measures were greatly expanded to
accommodate the diversity of specialists meeting the definition of an eligible professional
24
25
• 2011 – Providers required to submit summary quality measure data to CMS or States by attestation
• 2012 – Providers required to electronically submit summary quality measure data to CMS or States
• EPs are required to submit clinical data on the 2 measure groups: core measures and a subset of clinical measures most appropriate to the EP’s specialty
• Eligible hospitals are required to report summary quality measures for applicable cases
Clinical Quality Measures Overview
26
• Preventive care and screening: Inquiry regarding tobacco use
• Blood pressure management• Drugs to be avoided by the elderly:
o Patients who receive at least one drug to be avoided
o Patients who receive at least two different drugs to be avoided
Core Quality Measures for EPs
27
EPs will need to select one of the following specialties
Cardiology Obstetrics and Gynecology
Pulmonology Neurology
Endocrinology Psychiatry
Oncology Ophthalmology
Proceduralist/Surgery Podiatry
Primary Care Radiology
Pediatrics Gastroenterology
Nephrology
Specialty Quality Measures for EPs
28
• Hospitals are required to report summary data to CMS on 35 clinical measures
• For Medicaid, hospitals have the option to select 8 alternative Medicaid clinical quality measures if the 35 measures do not apply to their patient population
• Hospitals only eligible for Medicaid will report directly to the States
• For hospitals in which the measures don’t apply, they will have the option of selecting an alternative set of Medicaid clinical quality measures
Clinical Quality Measures for Eligible Hospitals
29
• EPs◦ Medicare FFS◦ Medicare Advantage◦ Medicaid
• Eligible Hospitals and CAHs◦ Medicare FFS◦ Medicare Advantage (paid under Medicare FFS)◦ Medicaid
EHR Incentive Payments Overview
30
• Eligible professionals (EPs)o Calendar Yearo 2011-2016 (Medicare) – Up to $44,000 over 5 years
if “meaningful EHR user”o 2011-2021 (Medicaid) – Up to $63,750 over 6 years
– Adopt/Implement/Upgrade or meaningful use in Year 1, MU Years 2-6
o 2015 and later – If not “meaningful EHR user” up to 3% payment adjustment in Medicare reimbursement
o We propose that after the initial designation, EPs be allowed to change their program selection only once during payment years 2012 through 2014
Incentive Payments for EPs
31
First Calendar Year in which the EP receives an Incentive Payment
Calendar Year
CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 and later
2011 $18,000
2012 $12,000 $18,000
2013 $8,000 $12,000 $15,000
2014 $4,000 $8,000 $12,000 $12,000
2015 $2,000 $4,000 $8,000 $8,000 $0
2016 $2,000 $4,000 $4,000 $0
TOTAL $44,000 $44,000 $39,000 $24,000 $0
Incentive Payments for Medicare EPs
32
First Calendar Year in which the EP receives an Incentive Payment
Calendar Year
CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 and later
2011 $1,800
2012 $1,200 $1,800
2013 $800 $1,200 $1,500
2014 $400 $800 $1,200 $1,200
2015 $200 $400 $800 $800 $0
2016 $200 $400 $400 $0
TOTAL $4,400 $4,400 $3,900 $2,400 $0
Additional Incentives for Medicare EPs Practicing in HPSAs
33
Incentive Payments for Medicaid EPsFirst Calendar Year in which the EP receives an
Incentive Payment
Calendar Year
CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016
2011 $21,250
2012 $8,500 $21,250
2013 $8,500 $8,500 $21,250
2014 $8,500 $8,500 $8,500 $21,250
2015 $8,500 $8,500 $8,500 $8,500 $21,250
2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250
2017 $8,500 $8,500 $8,500 $8,500 $8,500
2018 $8,500 $8,500 $8,500 $8,500
2019 $8,500 $8,500 $8,500
2020 $8,500 $8,500
2021 $8,500
TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750
34
• Eligible hospitals◦ Federal Fiscal Year◦ $2M base + per discharge amount (based on
Medicare/Medicaid share)◦ Hospitals meeting Medicare MU requirements may be
deemed eligible for Medicaid payments◦ Payment adjustments for Medicare after 2015◦ Medicare hospitals cannot receive payments after
2016. For Medicaid, hospitals cannot initiate payments after 2016 but can receive payments if they initiated the program before 2016
◦ No penalties for Medicaid◦ NPRM has narrative and sample calculation
Incentive Payments for Eligible Hospitals
35
• Medicare can pay incentives to EPs no sooner than January 2011
• Medicare can pay eligible hospitals and CAHs no sooner than October 2010
• Medicaid EPs can potentially receive payments as early as 2010 for adopting, implementing or upgrading
Incentive Payment Timeline
36
• More information on registration will be released following the publication of the final rule in Spring 2010
• Providers must be enrolled in Medicare FFS, MA or Medicaid to qualify for incentive payments
• Medicare incentive is based on 75% of Medicare allowable charges subject to maximum payments
• All providers must have a National Provider Identifier
• For Medicare – Must be using an EHR that is certified for the EHR Incentive Program
Registration Requirements
37
1. Name of the EP, eligible hospital or qualifying CAH
2. National Provider Identifier (NPI)3. Business address and business phone4. Taxpayer Identification Number (TIN) to which
the provider would like their incentive payment made
5. Eligible Hospitals – CMS Certification Number (CCN)
6. Eligible Professionals – Medicare or Medicaid program selection (may only switch once over the course of the program)
To register, the following are required:
38
Other Medicare Incentive Program
Eligible for HITECH?
Medicare Physician Quality Reporting Initiative (PQRI)
Yes, if the PQRI incentive is extended in its current format beyond 2010, EPs can participate in both if they are eligible
Medicare Electronic Health Records Demonstration (EHR Demo)
Yes, if the EP is eligible
Medicare Care Management Performance Demonstration (MCMP)
Yes, if the practice is eligible. The MCMP demo will end before EHR incentive payments are available
Electronic Prescribing Incentive Program (eRx)
If the EP chooses to participate in the Medicare EHR Incentive Program, they cannot participate in the Medicare eRx Incentive Program simultaneously. If the EP chooses to participate in the Medicaid EHR Incentive Program, they can participate in the Medicare eRx Incentive Program simultaneously
Participation in HITECH and other Medicare Incentive Programs for EPs
39
Medicare Medicaid
Feds will implement (will be an option nationally)
Voluntary for States to implement (may not be an option in every State)
Fee schedule reductions begin in 2015 for providers that are not Meaningful Users
No Medicaid fee schedule reductions
Must be a meaningful user in Year 1 A/I/U option for 1st participation year
Maximum incentive is $44,000 for EPs Maximum incentive is $63,750 for EPs
MU definition will be common for Medicare
States can adopt a more rigorous definition (based on common definition)
Medicare Advantage EPs have special eligibility accommodations
Medicaid managed care providers must meet regular eligibility requirements
Last year an EP may initiate program is 2014; Last payment in program is 2016; Payment adjustments begin in 2015
Last year an EP may initiate program is 2016; Last payment in program is 2021
Only physicians, subsection (d) hospitals and CAHs
5 types of EPs, 3 types of hospitals
Notable Differences Between the Medicare & Medicaid EHR Programs
• HIT Policy and Standards Committees Input - March 1, 2010
• Public comment period ends March 15, 2010
• CMS review of comments• Draft final regulation• CMS/HHS/OMB clearance• Final rule publication - Spring 2010
40
Next Steps
41
• Visit http://www.regulations.govo Document type: Proposed Ruleo Keyword or ID: CMS-2009-0117-0002
• Comments are due March 15, 2010 at 5 p.m.
How to Comment on the NPRM
42
• A/I/U – Adopt, implement or upgrade• CAH – Critical Access Hospital• CCN – CMS Certification Number• CDS – Clinical Decision Support• CMS – Centers for Medicare & Medicaid
Services• CY – Calendar Year• EHR – Electronic Health Record• EP – Eligible Professional• eRx – E-Prescribing• FFS – Fee-for-service• FY – Federal Fiscal Year• HHS – U.S. Department of Health and
Human Services• HIT – Health Information Technology• HITECH Act – Health Information
Technology for Electronic and Clinical Health Act
• HITPC – Health Information Technology Policy Committee
• HIPAA – Health Insurance Portability and Accountability Act of 1996
• HPSA – Health Professional Shortage Area
• IFR – Interim Final Rule• MA – Medicare Advantage• MCMP – Medicare Care Management
Performance Demonstration• MU – Meaningful Use• NPI – National Provider Identifier• NPRM – Notice of Proposed Rulemaking• OMB – Office of Management and
Budget• ONC – Office of the National Coordinator
of Health Information Technology• PQRI – Medicare Physician Quality
Reporting Initiative• Recovery Act – American Reinvestment
& Recovery Act of 2009• TIN – Taxpayer Identification Number
Acronyms