Effective Use of Regional Extension Center (REC) Partnerships with Health IT Leadership & State Medicaid Agencies

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1 New Jersey Health Information Technology Extension Center (NJ-HITEC) in Partnership with the New Jersey Department of Human Services, Division of Medical Assistance and Health Services Effective Use of Regional Extension Center (REC) Partnerships with Health IT Leadership & State Medicaid Agencies Introduction When the 2009 American Recovery and Reinvestment Act (ARRA) and Health Information Technology for Economic and Clinical Health (HITECH) Act were enacted, substantial economic and support services became available to health care providers if they met certain professional or threshold requirements established in the legislation. Incentive Funding Those providers with a Medicaid patient volume of 30 percent or more qualify for $63,750 in Medicaid Electronic Health Record (EHR) incentive payments over six years if they achieve Meaningful Use of their EHR system as prescribed by the ONC. Pediatricians, qualify for two-thirds of the full payment if they have percent Medicaid patient volume. Providers eligible for the Medicaid EHR Incentive Program include all physicians (M.D.s and D.O.s), nurse practitioners, certified nurse-midwives, dentists, and physician assistants (PA) in PA-led Federally Qualified Health Centers (FQHCs) and rural health clinics. In the case of Medicare, there is a graduated incentive payment to $44,000 based on the amount of the providers Medicare billing. In the case of Medicare, incentives can be claimed by doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, and chiropractors. In the case of Medicaid and Medicare, eligible provider types qualify for the payments regardless of discipline. Thus, Primary Care Providers (PCPs) and specialists qualify on the condition that they attain Meaningful Use and have the requisite patient or billing volume. Regional Extension Center Services The Extension Program offers providers assistance in the selection, acquisition, implementation, and Meaningful Use of electronic health records (EHRs) to improve health care quality and outcomes. Regional Extension Centers (RECs) are permitted to provide these services to PCPs who practice internal medicine, family medicine, OB/GYN, gerontology, and pediatrics. In the case of Medicaid qualified practices, PCPs also include nurse practitioners and physician assistants. Furthermore, there is a priority assigned to low income, under insured, and uninsured areas as well as providers who render services to the people who reside in those areas. These providers are identified as Priority Primary Care Providers (PPCPs) and specifically include FQHCs and Public Hospitals defined as any hospital with more than 20 percent Medicaid or Charity Care patients. Thus RECs are obligated by the ARRA and HITECH to only expend their resources on those providers that fit within the definitions of 1

2 PPCPs and PCPs as listed above and to give substantial emphasis to Medicaid and Charity Care health care providers. Gaps In a highly dense, populated state like New Jersey, that chronically suffers from deteriorated urban regions, these definitions and limitations have a profound impact that results in gaps in the type of providers that can qualify for the services that are offered by New Jersey s REC, NJ-HITEC. For instance, there are many specialist providers that selflessly work in underserved urban areas who will fully qualify for the Medicaid incentive funds, but do not qualify for the battery of expert services and consultative support that can be provided by NJ-HITEC to PPCPs and PCPs. With great regret, RECs are required to deny assistance to many otherwise qualified medical doctors and osteopaths in urban areas simply because they are specialists in orthopedics, behavioral health, dentistry, neurology, surgery, etc. This further exacerbates pernicious chronic illnesses that have a much more debilitating and costly impact on the uninsured and under-insured population in lower income areas. Patients in these areas desperately need the routine care of specialists to cope with chronic illnesses; however, they are much more likely to seek acute care management rather than having their chronic illnesses maintained in an effective ongoing course of case management delivered by specialists who effectively utilize EHRs in the delivery of care. The specialists in these areas receive a low Medicaid reimbursement rate and thus do not have the necessary resources to invest in the purchase of health IT and interoperability even though they might, in the end, qualify for the incentive funding. Notwithstanding NJ-HITEC s desire to serve the providers that service the poor, RECs are not permitted to expend resources for specialists even though the PCPs that serve in these areas might be fully qualified to receive the maximum priority level as a low income, under-insured, and uninsured area. In such an instance, NJ-HITEC is able to deliver the full complement of services to PCPs, but is not able to provide any assistance to specialists. The impact of this REC service delivery gap is compounded in the case of those medical doctors and osteopaths that practice in the field of psychiatry and behavioral health. Most patients in need of this kind of health service provider are uninsured, underinsured, receiving Medicaid benefits, or in need of Charity Care assistance. Furthermore, they desperately need the benefits of EHRs as these patients are transitioned from one level of care to another, such as when leaving a crisis center and being reintroduced to society in general. Disruptions in medications and consultative services can easily undo all the good accomplished during inpatient care. RECs and all health care providers are perplexed by this gap that prohibits services to these specialists, notwithstanding the fact that the majority of their patients would be classified as the priority and targeted populations. Filling the Gaps The confluence of circumstances and assets in New Jersey revealed opportunities to leverage various federal funding sources to confront and resolve the gaps in REC service delivery that are described above. Some of these factors are: 2

3 1. The formation of a highly functioning collaborative leadership team and cooperative structure. In New Jersey, there is a small group of key people that assemble in person each week to discuss current issues, problems, events, opportunities, resources, common themes and messages, and overall diverse health IT issues during one central, formalized, and choreographed discussion. The members of this group always include the New Jersey Health IT Coordinator, leadership from the State Department of Human Services, Division of Medical Assistance and Health Services, Department of Health and Senior Services, Department of Banking and Insurance, the Office of Information Technology, and New Jersey s REC, NJ-HITEC. This ad hoc group is known as the Health IT Action Team (HAT), although the group has no official status, the group functions very effectively to ensure that New Jersey stays focused on the advancement of our common goals and that we combine resources wherever and whenever possible. 2. The value of this collaborative strategy cannot be underestimated or over-stated. New Jersey is a state that has suffered from years of substantial budget shortfalls and under funding in the investment of health information technology infrastructure. Consequently, New Jersey lacks many of the core networks and structures that other states have leveraged to rapidly move forward when ARRA and HITECH were enacted. Notwithstanding these limitations, there is a highly cooperative, collaborative, and collegial atmosphere that permeates all those who work in any capacity in the health care delivery community. Not only is there a close collaboration among the various government entities described above, there is also a much larger community of private associations, hospitals, institutions, and trade associations that routinely join together to promote the sharing of resources to accomplish New Jersey s common goal of improving health care delivery through health IT. 3. CMS issued SMD# Guidance for Federal Funding for Medicaid HIT Activities on August 17, This Guidance addressed many issues related to State Medicaid obligations pursuant to ARRA and HITECH including the obligation to create a State Medicaid Health Information Technology Plan (SMHP) and an Health Information Technology Implementation Advance Planning Document (HIT IAPD). These documents address many issues and contain a strong recommendation that State Medicaid Directors coordinate with the federal resources provided to the RECs, especially those efforts related to Meaningful Use technical assistance opportunities. Essentially, each state has to develop an SMHP and IAPD that would include, among many other things, the obligation to create and deploy outreach activities to providers to assist them with the implementation of Meaningful Use. 4. NJ-HITEC and NJ Medicaid, with the approval of the New Jersey HIT Coordinator, embarked on the development of a plan through a contractual relationship to jointly outreach and provide Meaningful Use training for PPCPs and Medicaid Specialists, due to the high degree of cooperation and communication in New Jersey as a result of the HAT meetings. 3

4 From the REC s point of view, NJ-HITEC was eager to join forces with NJ Medicaid and the Medicaid Managed Care Payers to actively recruit PPCPs to join NJ-HITEC and become Meaningful Users of EHR. NJ-HITEC has funding from the ONC as part of the REC contract to support up to 5,000 PCPs in this effort and is required to give priority to PPCPs. From the NJ Medicaid juxtaposition, the REC has substantial resources to assist PPCPs which could help energize the State s IAPD and SHMP and would also free up funds necessary for NJ Medicaid to support an outreach and training effort, if it did not align with NJ-HITEC. Thus, it became readily apparent that there was a substantial benefit for all concerned for NJ Medicaid and NJ-HITEC to join forces to advance health IT in New Jersey. The first tangible result of this effort is the attached letter signed by the NJ Medicaid Director, the CEOs of all of the NJ Managed Care Organizations, and NJ-HITEC urging all PCPs to immediately become members of NJ-HITEC. This letter was sent via several ways to at least 15,000 New Jersey providers. This letter and several other factors quickly lead to NJ-HITEC s leap in membership, which well exceeds the 5,000 PCP goals set by the ONC. 5. It was then that NJ-HITEC and NJ Medicaid, once again with the approval and support of the New Jersey Health IT Coordinator and the Department of Health and Senior Services, turned its attention to the plight of the Medicaid specialists. As previously noted, these doctors qualify for receipt of the Medicaid incentive funds by reason of their patient volume, but are excluded from receiving the services and consultation of NJ- HITEC simply because they are specialists. Once again, New Jersey s commitment to succeed led to further cooperation and creative thinking by NJ Medicaid and NJ-HITEC to agree and sign a contract wherein the New Jersey Division of Medical Assistance and Health Services would hire NJ-HITEC at the same rate used in the ONC REC program to recruit, train, and educate 500 qualified NJ Medicaid Specialists for the same services and support that NJ-HITEC provides to PPCPs. 6. NJ-HITEC hired a core staff of qualified health IT and Meaningful Use subject matter experts to deliver its services to Specialists subject to the approval and guidance of NJ Medicaid, in furtherance of the NJ Medicaid Specialists Contract, The Medicaid HITECH funding for the Medicaid Specialist Program is kept separate from the ONC funding and the Specialist Program has its own separate office. There is some sharing of outreach programs that are designed to recruit providers as members and offer CME credits to PCPs and specialists alike; however, for the most part, functionality and management of the two REC programs are kept apart and separate. This kind of creative and collaborative thinking makes it possible for New Jersey to fill some of the gaps that have become apparent in the ARRA and HITECH plans. The NJ-HITEC Medicaid Specialist Program has already enlisted more than 150 Medicaid behavioral health doctors and dentists as well as a full complement of other Specialists that would not otherwise qualify for NJ-HITEC s services. 4

5 Lessons Learned 1. The power and capacity of creative and cooperative thinking that emerges from teamwork can be employed to develop and leverage existing resources and talent to solve common problems to benefit all. 2. Understand and use all the resources that are being offered by ARRA, HITECH, and CMS to advance health IT. 3. CMS has made it clear that Medicare and Medicaid are and will be run like a business. Investments will be made in worthwhile technology and infrastructure when there is a clear and proven return on investment that advances the three aims. 4. The ability to identify service gaps and address them is crucial to the advancement and pursuant of ARRA and HITECH as well as the overall State Medicaid Health IT Plan. 5. Finally, combine resources wherever and whenever possible. Presented by: William J. O Byrne Executive Director NJ-HITEC (New Jersey's Regional Extension Center) obyrne@njhitec.org Office: (973) Twitter : Tom Jordan Chief Information Officer Division of Medical Assistance and Health Services Thomas.Jordan@dhs.state.nj.us Office: Stuart Dubin Fiscal Coordinator Health Information Technology Division of Medical Assistance and Health Services Department of Human Services stuart.dubin@dhs.state.nj.us 5

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