Pediatric Updates in South Carolina


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Pediatric Updates in South Carolina

  1. 1. American Recovery and Reinvestment Act of 2009 Preparing for HIT Transformation in SC We Live in Challenging and Changing Times March 2010
  2. 2. The HITECH Act  The HITECH Act is contained in the American Recovery and Reinvestment Act (ARRA) and Congress legislated HIT transformation. The programs include  Standards and Certification IFR  Funding for  Regional Extension Centers (CITIA-SC)  State HIE Programs (SCHIEx)  Community College and University Programs  HIT Research Projects  Beacon Communities  New privacy and security regulations  Accounting for disclosures  Breach notification
  3. 3. Summit 2 Recap Meaningful Use
  4. 4. ARRA Incentive HIT Funding Flow 4
  5. 5. SC will participate in the Medicaid EHR Incentive Program
  6. 6. Three New Rules CMS Notice of Proposed Rule Making (NPRM) for EHR Incentive Program Defines the provisions for incentive payments to eligible professionals and hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified EHRs. Deadline for Public Comments……March 15, 2010 Final Rule Released………………...Late Spring, 2010 ONC Interim Final Rule (IFR) on Standards & Certification Criteria Proposes initial set of standards, implementation specifications, and certification criteria to “enhance the interoperability, functionality, utility, and security of health IT and to support its meaningful use.” Deadline for Public Comments…March 15, 2010 Final Rule Released……………...IFR goes into effect automatically approximately February 15, 2010 ONC Rule on Certification Process Proposes the process by which EHR systems will be certified or by which accreditation/certification entities can become recognized by CMS in order to certify EHR systems. Deadline for Public Comments…. April 9 for temporary certification; May 10 for permanent certification Final Rule Released…………...Summer, 2010 7
  8. 8. What are the conditions to receive the incentive payments? An eligible provider and an eligible hospital shall be considered a meaningful EHR user if they meet these 3 requirements: 1. Demonstrates use of certified EHR technology in a meaningful manner; 2. Demonstrates to the satisfaction of the Secretary that certified EHR technology is connected in a manner that provides for electronic exchange of health information to improve quality of health care such as promoting care coordination, in accordance with all laws and standards applicable to the exchange of information: and 3. Using its certified EHR technology, submits information in a form and manner specified by the Secretary, to HHS on clinical quality measures and other measures specified by the Secretary 9
  9. 9. What is a qualified EHR?  A Qualified EHR is an electronic record of health- related information on an individual that:  Includes patient demographic & clinical health information, such as medical history and problem lists AND  Has the capacity to perform all of the following:  Provide clinical decision support  Support physician order entry  Capture & query information relevant to health care quality  Exchange electronic health information and integrate with such information from other sources 10
  10. 10. Incremental Approach to Meaningful Use 2011 Capture/Share Data • Prescribing/10% of all orders through CPOEs • Drug-drug,-allergy,- formulary checks, medication lists/reconciliations • Lab results delivery • Patient e-copies of their health information • Claims and eligibility checking • Quality and immunization reporting…. • 25 Stage 1 criteria for EPs • 23 Stage 1 criteria for EHs 2013 Advanced care processes with decision support • CPOE for all order types • Evidence-based order sets • Clinical decision support at the point of care • Record all clinical documentation in EHR • Health summaries for continuity of care • Registry reporting and reporting to public health • Population PHRs…. • Under development 2015 Improve Outcome • Achieve minimal levels of performance on quality , safety, efficiency measures • Implement clinical decision support for national high priority conditions • Access comprehensive data from all available sources • Experience of care reporting • Medical device interoperability • Dynamic/ad hoc quality reports • Real-time surveillance…. • Under development
  11. 11. 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 2 Stage 2 Stage 3 2013 Stage 1 Stage 2 Stage 3 2014 Stage 1 Stage 3 2015 and later* Stage 3 12 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
  12. 12. Who is eligible?  Medicare 1. Doctor of medicine or osteopathy 2. Doctor of dental surgery or medicine 3. Doctor of podiatric medicine 4. Doctor of optometry 5. Chiropractor 6. Hospitals (Subsection (d) hospitals paid under IPPS & located in US)  Medicaid* 1. Physicians 2. Dentist 3. Certified nurse-midwives 4. Nurse Practitioners 5. Physician assistants practicing in an FQHC or RHC that is so led by a physician assistant 6. Acute Care Hospitals 7. Children’s Hospitals * Must meet volume requirements 13
  13. 13. Who is not eligible?  Hospital-based physicians  90% of claims submitted with Place of Service (POS) code indication a hospital-based status  POS 21 – Inpatient Hospital  POS 22 – Outpatient Hospital (Senate jobs bill removes this)  POS 23 – Emergency Room, Hospital 14
  14. 14. When does the program actually start?  Medicare  Starts October 1, 2010 (FFY) for eligible hospitals  Payment year is defined as any fiscal year beginning with 2011  Starts January 1, 2011 (CY) for EPs  Payment year is defined as any calendar year beginning with 2011  Medicaid  Intentions are to mirror Medicare  CMS must approve our Medicaid HIT Plan before we can pay the dollars 15
  15. 15. When do I have to be live, and for how long?  First year of demonstration: Any continuous 90-day period within the payment year in which you successfully demonstrate Meaningful Use  January 1, 2011 to April 1, 2011  March 13, 2011 to June 11, 2011  September 1, 2001 to November 30, 2011  Unallowable: November 1, 2011 to January 31, 2012 because it crosses into the next year  Second payment year and beyond: The EHR reporting period will mean the entire payment year 16
  16. 16. Do I have to use an EHR 100% of the time?  50% or more of your patient encounters during the EHR reporting period must be at one or more practices/locations equipped with a certified EHR  Allows not only for the minimal levels of down- time expected from an EHR product, but for providers to still participate who work in multiple locations with varying adoption levels 17
  17. 17. Can I switch between the programs?  May switch one time from one program to the other  If switching, you will continue in the new program at whichever payment year you would have attained in the first program had you not switched  i.e., if two years were complete in Medicaid but you no longer met the 30% threshold of patient volume, you would be allowed to switch to the Medicare program in the third year payment of that program  Last year to switch is CY 2014
  18. 18. How will they track individual behavior?  Tracking will be done at the unique National Provider Identifier (NPI) level  Required information includes  Name, NPI, business address and phone  Taxpayer Identification Number (TIN) to which you want the incentive payment made  Choice to participate in the Medicare or Medicaid EHR incentive program  There will be a single program data repository to track participation in both Medicare and Medicaid
  19. 19. How will payments be made?  Payments will be a single, consolidated, annual incentive payment  Medicare will be paid via CMS  Medicaid will be paid by the State Medicaid agency  Payments will be made on a rolling basis as soon as you  Demonstrate of Meaningful Use for the applicable reporting period  90 days for the 1st yr or the calendar yr for subsequent years  Reach the threshold for maximum payment  Reassignment to your employer or an entity with which you have a valid employment agreement is permitted and limited with only one entity
  20. 20. What does “Proving Meaningful Use” mean?  Provide attestation through a secure mechanism, such as claims-based reporting or an online portal  Must identify the certified EHR technology in use  Describe your performance on all the functional measures associated with Meaningful Use  This is not the clinical quality measures you will submit on the care delivered to patients  This measure your use of the EHR  CMS expects to move to electronic reporting to some degree starting in 2012
  21. 21. Where do I find the MU measures? Medicare & Medicaid EHR Incentive’s Program proposed rule Released Dec 30, 2009
  22. 22. What are clinical quality measures?  Includes “measure of processes, experience, and/or outcomes of patient care, observations or treatment that relate to one or more quality aims for healthcare such as effective, safe, efficient, patient-centered, equitable, and timely care.”  Draws primarily from PQRI & NQF endorsed measures  NQF is starting work now on modifying existing quality measures to meet MU requirements  Quality reporting will be done by attestation in 2011 & be electronic means in 2012 (web portal, connection to HIEs and connection to specialty registries)  Reporting does not have to be limited to Medicare or Medicaid patients  Use certified EHR technology to capture data elements and calculate the results
  23. 23. Where do I find the quality measures to report on? Medicare & Medicaid EHR Incentive’s Program proposed rule Released Dec 30, 2009
  24. 24. • Preventive care and screening: Inquiry regarding tobacco use • Blood pressure management • Drugs to be avoided by the elderly: • Patients who receive at least one drug to be avoided • Patients who receive at least two different drugs to be avoided Core Quality Measures for EPs
  25. 25. 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 26 Specialty Quality Measures for EPs
  26. 26. • Hospitals are required to report summary data on 43 clinical quality measures to CMS • 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 27 Clinical Quality Measures for Eligible Hospitals
  28. 28. How will my incentive be calculated?  Calculated by multiplying your submitted allowable charges to Medicare by 75%, up to the capped amount for the year  Part B claims for the Fee for Service program  Items in the Medicare Physician’s Fee Schedule  Only the “professional” components, not the “technical”  Only those furnished by the EP  A physician aiming to collect the full incentive payments of $18,000 in 2011 will need to submit allowable charges of at least $24,000  If your allowable charges are less, you’ll still be able to participate – you just won’t hit the cap
  29. 29. Medicare Schedule of Payments for EPs Calendar Year Adopt 2011 Adopt 2012 Adopt 2013 Phasedown Adopt 2014 Phasedown Adopt 2015 & Beyond 2011 $18K -- -- -- -- 2012 $12 $18K -- -- -- 2013 $8K $12K $15K -- -- 2014 $4K $8K $12K $12K -- 2015 $2K $4K $8K $8K -- 2016 $0 $2K $4K $4K -- 2017 $0 $0 $0 $0 -- Total $44K $44K $39K $24K Less than Stage 3 MU = Penalty Health Shortage Area (additional 10%) $48,400 $48,400 $42,900 $26,400
  30. 30. What happens if you are not a Stage 3 Meaningful User?  Reduced payments start in 2015 for those who are not meaningful users  Medicare fee schedule adjusted yearly  1%, 2%, 3% (between 3-5% after 2017)
  31. 31. Medicare Incentives for Hospitals  The Compensation formula is the “Initial Amount” times “Medicare Share” times “Transition Factor”  “Initial Amount” is $2 Million plus  $200 for each discharge between the 1,150th to 23,000th discharge in a 12 month period  $0 for the first 1,149 and $0 for each discharge after 23,000 32
  32. 32. Medicare Incentives for Hospitals  “Medicare Share” is a fraction:  Numerator equals: Inpatient-bed days attributed to Part A plus inpatient-bed days attributable to Part C  Denominator equals: Total number of inpatient-bed days times (a) Non-charity care charges divided by (b) Total amount of charges  Critical Access Hospitals increase the Medicare Share by 20 percentage points as long as the Medicare Share does not exceed 100%  “Transition Factor” is a point value which declines each year from 1.0 to 0 33
  33. 33. Medicare Transition Factor for Hospitals Federal Fiscal Year Adopt FY 2011 Adopt FY 2012 Adopt FY 2013 Adopt FY14 Phasedown Adopt FY15 Phasedown Adopt FY16 & Beyond 2011 1.0 -- -- -- -- -- 2012 0.75 1.0 -- -- -- -- 2013 0.50 0.75 1.0 -- -- -- 2014 0.25 0.50 0.75 0.75 -- -- 2015 0 0.25 0.50 0.50 0.50 -- 2016 0 0 0.25 0.25 0.25 -- 2017 0 0 0 0 0 -- Incentive payment calculation: ($2m + Discharge Amount)(Medicare Share)(Transition Factor)
  34. 34. What are the penalties with the Medicare Incentives?  Beginning in FY 2015, if an eligible hospital is not a stage 3 “meaningful EHR user” then the applicable Market Basket Adjustment percentage shall be reduced as illustrated below. First Payment Year Reduction in Medicare Fee Schedule as a result of non-compliance FY 2011 -- FY 2012 -- FY 2013 -- FY 2014 -- FY 2015 - 33.33% FY 2016 -66.66% FY 2017 & forward -100% 35
  36. 36. What are the volume requirements to participate in the Medicaid incentives? 37
  37. 37. How do you determine if you meet the volume requirements?  30% of all your patient encounters (visits) must be attributable to Medicaid over any continuous 90- day period within the most recent calendar year  Will apply a plain meaning test  Cannot count a short-term temporary Medicaid outreach program  Required to annually re-attest to patient volume thresholds  Pediatricians can qualify with 20%  Incentive is reduced by a third
  38. 38. How are the FQHC/RHC volume requirements defined?  Must “practice predominantly” (more than 50%) in an FQHC or RHC  Must have a minimum of 30% patient volume attributable to “needy individuals” over any continuous 90-day period within the most recent calendar year  Needy individuals:  Receive medical assistance from Medicaid or CHIPRA  Receive care by the provider for which they are uncompensated  Receive services furnished at no cost or reduced cost based on a sliding scale determined by the individual’s ability to pay  Bad debt is consistent with this definition
  39. 39. What are the Medicaid EHR Incentives? 40 Medicaid incentives are flat fees intended to cover the “net average allowable” cost of purchasing, implementing and maintaining an EHR CMS Avg allowable cost for the purchase & implementation is $54,000 CMS Avg allowable cost related to maintenance defined to be $20,610
  40. 40. How does the timing work under Medicaid?  First year must “engage in efforts to adopt, implement upgrade of technology”  Adopt = acquired and installed  Implement = trained staff, deployed tools, exchanged data  Upgrade = expanded functionality or interoperability  Must demonstrate “meaningful use” of certified EHR technology in second & subsequent years of incentives  Requires clinical quality measure reporting to the state  Medicaid payments span a decade (2011 – 2021)  Last year to start is 2016  There are no financial penalties associated with the Medicaid incentives; there are financial penalties with Medicare 41
  41. 41. What if I care for Medicaid patients from several states?  If you practice in multiple states or Medicaid patients from several states come to your office, you will be required to choose only one state from which to receive Medicaid incentive payments  You can change that state choice annually when you reattest to your ability to meet the threshold
  42. 42. Medicare Medicaid Feds will implement (will be an option nationally); Voluntary for States to implement (may not be an option in every State) Penalties begin in 2015 for providers & Hospitals that are not Meaningful Users No Medicaid fee schedule reductions Must be a meaningful user in Year 1 Adopt/Implement/Upgrade option for 1st participation year Maximum incentive is $44,000 for EPs; HPSA 10% bonus Maximum incentive is $63,750 for EPs; No minimum # of patients & does not include mid- level providers 30% threshold; 20% for pediatricians Does not include mid-level providers Does include mid-levels; NPs, CMW, Pas only if lead provider in a rural health clinic Last year an EP may initiate program is 2014; Last payment in program is 2016. Last year an EP may initiate program is 2016; Last payment in program is 2021 Only providers, subsection (d) hospitals and CAHs 5 types of EPs, 3 types of hospitals Notable Differences Between the Medicare & Medicaid EHR Programs
  43. 43. Next Steps for SC  Quarterly HIT Summits  April 22, 2010 at Brookland Baptist Church in Columbia  Go to to register  SC will receive a 9.6m HIE grant to scale the South Carolina Health Information Exchange (SCHIEx) for statewide use  Executive Order created interim governance committee  H.4538 introduced to make governance committee permanent  DHEC is a grant partner; grant administered by SCDHHS; ORS will run SCHIEx  Go to for information on how to connect  HSSC submitted the Regional Extension Center grant  Directs resources to individual providers to facilitate HIT adoption  Contact Todd Thornburg at for help  AHEC conducts provider education campaign on HITECH act and requirements  January – December 2010  Contact David Garr at  DHHS will publish bulletin guidance on Medicaid EHR Incentive Program  CMS will publish information on Medicare EHR Incentive Program
  44. 44. The Challenges Ahead  The program is voluntary although payment adjustments will be imposed on Medicare providers who are unable to demonstrate meaningful use starting in 2015;  The criteria for the demonstration of meaningful use of certified EHR technology have not been finalized and will change over time;  Criteria for certified EHR technology is just now being developed  The impact of the financial incentives and payment adjustments on the rate of adoption of certified EHR technology by EPs, eligible hospitals, and CAHs, is difficult to predict; and  The ultimate impact of certified EHR technology on expenditures for medical treatments (for example, reducing errors, expedited treatment) cannot be known with certainty at this time.
  45. 45. Questions