EHR Incentives for Professionals and Hospitals. Paul Forlenza, VP Policy, VITL updated October 1, 2010 v.8.1

Transcription

1 EHR Incentives for Professionals and Hospitals Paul Forlenza, VP Policy, VITL updated October 1, 2010 v.8.1

2 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 x103 2

3 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 3

4 EHR INCENTIVES FOR PROFESSIONALS 4

5 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 4. Protect privacy and security of personal health information 5. Improve population and public health 5

6 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 6

7 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? NO YES Professionals Hospitalists ER Physicians Radiologists Anesthesiologists Professionals in outpatient setting Place of Service Codes POS 21 and 23 POS 22 7

8 Do I qualify for the Medicaid Program? Eligible Professionals 1 st YR 90-day Patient Volume * Physicians 30% Pediatricians 20% Nurse Practitioner 30% PAs at FQHC/RHC 30% Certified Nurse Midwives 30% Dentists 30% Comments Threshold for Eligible Professionals, predominantly practicing in FQHC/RHC, must have a 30% "needy individual" patient volume * Second year requires a full year of patient volume 8

9 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 9

10 Calculating Patient Volume Patient Encounter Method Total Medicaid patient encounters in any 90-day period in the Preceding calendar year x 100 = % Total patient encounters in that same 90-day period 10

11 Patient Volume Example Patient Encounter Method 100 Medicaid patient encounters x 100 = 33% 300 Total patient encounters Physician qualifies for Medicaid Program 11

12 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 x 100 = % 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 12

13 Stages for implementing Meaningful Use Stage 2: 2013 Stage 3: 2015 Stage 1: 2011 Capture data in structured form and limited sharing Advanced clinical processes and robust health information exchange Improved outcomes 13

14 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 14

15 What is a certified EHR? Previously EHRs certified by Certification Commission for Health Information Technology (CCHIT) ONC now selecting Authorized Testing and Certification Bodies ( ) Certification Commission for HIT (CCHIT) Drummond Group, Inc. (DGI) InfoGard Laboratories, Inc. Certified EHRs to be post on ONC website 15

16 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 16

17 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 17

18 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 18

19 Maximum Medicaid incentives? 1,2 Payment Year Total Incentive Payments 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, Flat fee payment based on 85% of EHR net allowable costs 2. Max. incentive for Pediatrician, with 20% patient threshold, $42,500 19

20 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) 20

21 What are maximum Medicare incentives? Payment Year Total Incentive Payments 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 21

22 How do I get my Medicare/Medicaid incentive payments? Core Measures Menu Set Measures Clinical Quality Measures Medicare 2011 Attest to MU & report aggregate data for 90 days 2012 Attest & report for 1 year Medicaid 2011 Adopt/Implement/Upgrade 2012 Attest; report 90 days data 2013 Attest; report data for 1 yr CMS State Medicaid Office Register using CMS web-based portal. Single, annual, consolidated payment. Tied to NPI but can be transferred to practice/clinic. 22

23 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 23

24 Stage 1: Reporting Requirements 15 Core Objectives State can move 4 public health measures from menu to core 10 Menu Set Objectives CMS or State 1 must be public health measure or 3 alternate Hypertension Tobacco use Adult weight Alternate: Children Weight Flu Immunization > 50 yrs Children Immunization 38 Clinical Quality Measures 24

25 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 ( ) Can not skip a year 1 st 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 ( ) Can skip a year Adopt, implement or upgrade option for 1st yr No penalties 25

26 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 26

27 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 27

28 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 28

29 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

30 Additional VITL Resources VITL Summit Presentations vitlsummit.net Federal rule and other resources vitl.net/incentives CMS EHR Incentives cms.gov/ehrincentiveprograms/ 30

31 Questions Questions? 31

32 EHR HOSPITAL 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 INCENTIVES 32

33 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 4. Protect privacy and security of personal health information 5. Improve population and public health 33

34 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 1.One incentive payment for each CMS Certification Number (CCN) 2. CCN series and

35 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 * Certified by ONC Authorized Testing & Certification Body 35

36 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 36

37 B. How do I exchange health information? Electronic exchange with an unaffiliated organization 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) 37

38 Eligible Hospital Medicare Incentive First Payment year FY2011 FY2012 FY2013 Incentive Payments FY2011-FY2014 FY2012-FY2015 FY2013-FY2016 # of years 4 years FY2014 FY2014-FY Years FY2015 FY2015-FY Years 38

39 Medicare Hospital Incentives a $2 million for each year plus $ per discharge Medicare discharges 1,150 23,000 b $200 per discharge Multiple by Transition factor Multiple by Medicare share of acute care discharges 1 st yr: nd yr :.75 3 rd yr:.50 4 th yr:.25 (a) Hospitals are eligible for both Medicaid and Medicare incentives. (b) Discharge limits for yrs 2-4 increased by 3 yr historic growth rate. % 39

40 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) 40

41 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 of payments that would otherwise be made. (more) 41

42 Medicare Incentives - CAHs Reductions if not Meaningful User FY2015 FY2015: 101% of reason costs to % FY2016: to % FY2017: and subsequent years to 100% Exemption from reduction could be allowed May appeal statistical and financial amounts from the Medicare cost report 42

43 Eligible Hospital Medicaid Incentives 1 st year alternative to Meaningful Use Adopt, Implement or Upgrade Certified EHR by ONC-ATCB* Qualifies for 1 st year payment Reporting Clinical Quality Measurers 1 st year is by attestation Report numerator, denominator, exclusion data Subsequent years require electronic submission * ONC Authorized Testing and Certifying Body 43

44 Medicaid Hospital Incentives a (Total EHR Cost) x (Medicaid Share) OR $2 million for base year plus $ per discharge Medicaid discharges 1,150 23,000 b $200 per discharge Multiple by Transition factor Multiple by Medicaid share of acute care discharges 1 st yr nd yr.75 3 rd yr.50 4 th yr.25 a. Hospitals eligible for Medicaid and Medicare incentives b. Discharge limits for yrs 2-4 increased by 3 yr historic growth 44 %

45 Eligible Hospital Incentives Rule Annual Preliminary Payment Final Payment Payment duration Achieve Meaningful Use by certain date Limitations Payment Adjustments Medicare Based on prior year discharges Based on current yr FY2011-FY2016 (4 yrs) FY2013 for full incentive Consecutive years Begin FY2015 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 45

46 Questions Questions? 46

47 Appendix Eligible Professional Physician Assistance, FQHC, RHC Data Exchange Requirements Eligible Hospital Core Objectives Menu Set objectives Clinical Quality Measures Core Objectives Menu Set Objectives Clinical Quality Measures 47

48 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. 48

49 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 49

50 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 Must include at least one public health transaction 50

51 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 51

52 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 52

53 EP Menu Set Objectives Stage 1: pick 5 of 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 53

54 EP Menu Set Objectives Stage 1: pick 5 of 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* * Must include at least one public health transaction 54

55 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 55

56 EP Clinical Quality Measures Pick 3 of 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 56

57 EP Clinical Quality Measures Pick 3 of 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 57

58 EP Clinical Quality Measures Pick 3 of 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 58

59 EP Clinical Quality Measures Pick 3 of 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 59

60 EP Clinical Quality Measures Pick 3 of 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 other drug dependence treatment: Initiation and Engagement 60

61 EP Clinical Quality Measures Pick 3 of 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%) 61

62 EH 14 Core Objectives Need all 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 older 62

63 EH 14 Core Objectives Need all 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 63

64 EH Menu Set Objectives Stage 1: Pick 5 of Drug-formulary checks 2. Record advanced directives for patients 65 years or older 3. Incorporate clinical lab test results as structured data 4. Generate lists of patients by specific conditions 5. Use certified EHR technology to identify patientspecific education resources and provide to patient, if appropriate 64

65 EH Menu Set Objectives Stage 1: pick 5 of 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 65

66 EH Clinical Quality Measures Need all 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 66

67 EH Clinical Quality Measures Need all 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 67

68 EH Clinical Quality Measures Need all 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 68