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Medicare & Medicaid EHR Incentive NPRM Implementing the American Reinvestment & Recovery Act of 2009 Office of E-Health Standards and Services Centers for Medicare & Medicaid Services
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Medicare & Medicaid EHR Incentive NPRM

Implementing the American Reinvestment & Recovery Act of 2009

Office of E-Health Standards and ServicesCenters for Medicare & Medicaid Services

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• 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

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• 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?

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• 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?

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• 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

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• 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

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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)

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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?

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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

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• 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

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• 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?

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• 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

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Data capture and sharing

Advanced clinical processes

Improved outcomes

Conceptual Approach toMeaningful Use

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• 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

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• 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.

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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

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• 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

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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

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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

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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

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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

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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

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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

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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

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• 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

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• 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

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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

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• 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

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• EPs◦ Medicare FFS◦ Medicare Advantage◦ Medicaid

• Eligible Hospitals and CAHs◦ Medicare FFS◦ Medicare Advantage (paid under Medicare FFS)◦ Medicaid

EHR Incentive Payments Overview

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• 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

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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

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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

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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

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• 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

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• 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

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• 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

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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:

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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

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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

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• 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

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Next Steps

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• 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

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• 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


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