Implementing the American Reinvestment & Recovery Act of 2009

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

HITECH Legislation: Purpose

Improve outcomes, facilitate access, simplify care and reduce costs by providing:

• Major financial support to providers and States

• Learning opportunities created and leveraged through TAfrom CMS and others

• Far-reaching frameworks are being established that will orchestrate federal, State and local, public and private health care resources for generations to come

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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

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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

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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

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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 and external stakeholders

• Coordinates with the existing CMS quality initiatives

• Provides a platform that allows for a staged implementation over time

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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

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Eligible Providers in MedicareEligible Professionals (EPs)

Doctor of Medicine or OsteopathyDoctor of Dental Surgery or Dental MedicineDoctor of Podiatric MedicineDoctor of OptometryChiropractor

Eligible Hospitals*Acute Care HospitalsCritical Access Hospitals (CAHs)

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*Subsection (d) hospitals that are paid under the PPS and are located in the 50 States or DC (including Maryland hospitals)

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

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Eligible Providers in MedicaidEligible Professionals (EPs)

Physicians (Pediatricians have special eligibility & payment rules)Nurse Practitioners (NPs)Certified Nurse-Midwives (CNMs)DentistsPhysician Assistants (PAs) who lead a Federally Qualified Health Center (FQHC) or rural health clinic (RHC) that is directed by a PA

Eligible HospitalsAcute Care HospitalsChildren’s Hospitals

• 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)

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Entity Minimum Medicaid patient volume

threshold

Or the Medicaid EP practices

predominantly in an FQHC or RHC—30%

needy individual patient volume

threshold

Physicians 30%- Pediatricians 20%

Dentists 30%CNMs 30%PAs when practicing at an FQHC/RHC that is so led by a PA

30%

NPs 30%Acute care hospitals 10% Not an option for

hospitalsChildren’s hospitals No requirement

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EP is also eligible when practicing predominantlyin FQHC/RHC providing care to needy individuals

Proposes practicing predominantly is when FQHC/RHC is the clinical location for over 50% of total encounters over a period of 6 months in the most recent calendar year

Needy individuals (specified in statute) include: ◦ Medicaid or CHIP enrollees; ◦ Patients furnished uncompensated care by the provider;

or ◦ furnished services at either no cost or on a sliding scale.

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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

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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)

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Datacapture and sharing

Advanced clinical processes

Improvedoutcomes

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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.

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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

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*Adapted from National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America’s Healthcare. Washington, DC: National Quality Forum; 2008.

• 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

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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

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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

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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

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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

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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.

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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

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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 avoidedo Patients who receive at least two different drugs to

be avoided

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EPs will need to select one of the following specialtiesCardiology Obstetrics and GynecologyPulmonology NeurologyEndocrinology PsychiatryOncology OphthalmologyProceduralist/Surgery PodiatryPrimary Care RadiologyPediatrics GastroenterologyNephrology

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• Hospitals are required to report summary data to CMS or States on 35 clinical quality measures

• For the Medicaid program incentive, hospitals have the option to select 8 alternative Medicaid clinical quality measures to meet the requirements for reporting if the 35 measures do not apply to their patient population

• Hospitals only eligible for Medicaid will report directly to the States

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Adopt, implement, upgrade (AIU)◦ First participation year only

Meaningful use (MU)◦ Successive participation years; and◦ Proposed option for early adopters in year 1

States may propose to CMS for approval limited additional criteria for MU, beyond the NPRM◦ NPRM is the MU base-level requirement

Prioritizing coordination between:◦ CHIPRA and HITECH

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Adopt: Acquired and installed - e.g., evidence of acquisition, installation etc.

Implement: Commenced utilization- e.g., staff training, data entry of patient demographic information into EHR, data use agreements

Upgrade: Version 2.0; expanded functionality- e.g., ONC EHR certification (short-term) or additional functionality such as clinical support or HIE capacity (longer-term)

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Eligible hospitals, unlike EPs, may receive incentives from Medicare and Medicaid◦ Subsection(d) hospitals, also acute care

Hospitals meeting Medicare MU requirements may be deemed for Medicaid , even if the State has an expanded (approved) definition of meaningful use

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There is a deliberate overlap between the CHIPRA core measures and the Stage 1 measures for MU. ◦ BMI 2-18 yrs old◦ Annual hemoglobin A1C testing (all children and

adolescents diagnosed with diabetes)◦ Pharyngitis - appropriate testing 2-18 yrs old◦ Follow-up care for children prescribed attention-

deficit/hyperactivity disorder (ADHD) medication

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The Medicaid EHR Incentive Program starts in 2011 and ends in 2021

The latest that a Medicaid provider can initiate the program is 2016

A Medicaid provider can initiate the program under the Adopt, Implement and Upgrade bar but in their 2nd and subsequent years, they must meet MU at the stage that is in place, per rule-making (Stage 3 by 2015).

• EPs◦ Medicare FFS◦ Medicare Advantage◦ Medicaid

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

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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

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First Calendar Year in which the EP receives an Incentive Payment

CalendarYear

CY 2011 CY 2012 CY 2013 CY 2014 CY 2015and later

2011 $18,0002012 $12,000 $18,0002013 $8,000 $12,000 $15,0002014 $4,000 $8,000 $12,000 $12,0002015 $2,000 $4,000 $8,000 $8,000 $02016 $2,000 $4,000 $4,000 $0TOTAL $44,000 $44,000 $39,000 $24,000 $0

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First Calendar Year in which the EP receives an Incentive Payment

CalendarYear

CY 2011 CY 2012 CY 2013 CY 2014 CY 2015and later

2011 $1,8002012 $1,200 $1,8002013 $800 $1,200 $1,5002014 $400 $800 $1,200 $1,2002015 $200 $400 $800 $800 $02016 $200 $400 $400 $0TOTAL $4,400 $4,400 $3,900 $2,400 $0

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First Calendar Year in which the EP receives an Incentive Payment

CalendarYear

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

• 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

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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

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Prior approval for reasonable administrative expenses (P-APD, I-APD)

Establish a State Medicaid HIT Plan (SMHP) State may receive 90% FFP and 100% FFP for

the payments themselves NPRM defines numerous previously undefined

terms in CFR ◦ Medicaid Management Information Systems (MMIS)◦ Medicaid IT Architecture (MITA)

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Statutory Conditions of Use of the HITECH Admin Funds:

1. Administration of incentives, including tracking of meaningful use by Medicaid EPs and eligible hospitals;

2. Oversight, including routine tracking of meaningful use attestations and reporting mechanisms; and

3. Pursuing initiatives to encourage the adoption of certified EHR technology for the promotion of health care quality and the exchange of health care information.

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3 Key Elements: What is the current HIT landscape? What is the State’s Vision for the next 5 years? How will they implement and oversee a successful EHR Incentive Program?

NPRM proposes States uses MITA principles in developing SMHP

SMHP will include State’s methodologies for verifying eligibility; disbursing payments; coordinating with stakeholders; contracting; privacy & security; curtailing fraud & abuse; and other activities

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States and CMS must assure there is no duplication of payments to providers (between States and between States and Medicare)

States are required to seek recoupment of erroneous payments and have an appeals process

CMS/Medicaid has oversight/auditing role including how States implement the EHR Incentive Program (90% FFP) and how they make correct payments to the right providers for the right criteria (100% FFP).

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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

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Medicare MedicaidFeds 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 yearMaximum incentive is $44,000 for EPs Maximum incentive is $63,750 for EPsMU 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 hospitals46

• Public comment period ends March 15, 2010• CMS review of comments• Draft final regulation• CMS/HHS/OMB clearance• Final rule publication - Spring 2010• CMS On-going review of States’ Planning

APDs• CMS to issue additional guidance on Medicaid

90/10 Implementation funding • On-Going Federal HIT Coordination (ONC,

AHRQ, HRSA, IHS, FCC, etc)

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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.

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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• MITA- Medicaid Information Technology

Architecture• 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

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