Texas Medicaid EHR Incentive Program

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1 Texas Medicaid EHR Incentive Program Medicaid HIT Team July 23, 2012

2 Why Health IT?

3 Benefits of Health IT A 2011 study* found that 92% of articles published from July 2007 to February 2010 reached conclusions that showed overall positive effects of health information technology on key aspects of care, including quality and efficiency of care. * Buntin et al The Benefits of Health Information Technology: A Review of the Recent Literature Shows Predominantly Positive Results Health Affairs 3

4 Benefits of EHR Adoption Adoption of electronic records by Medicaid providers means better care to the State s most vulnerable citizens through: Enhanced care coordination, Improved quality and safety, More engagement of the patient and family, More complete longitudinal health record, and Assistance with decision support, which helps to reduce errors and cost of care. 4

5 Quality of Diabetes Care: Patients Treated by Physicians using EHR vs. Paper Medical Records A significantly higher proportion of patients being treated by physicians with EHRs received care that aligns with accepted treatment standards * % of Patients Receiving Care Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365: Retrieved from * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<

6 Health Outcomes for Diabetes Patients: Patients treated by Physicians using EHR vs. Paper Medical Records A significantly higher proportion of patients being treated by physicians with EHRs obtained better outcomes* % of Patients Obtaining Outcome Standards Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365: Retrieved from * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<

7 Quality of Diabetes Care at Safety Net Practices: Patients Treated by Physicians using EHR vs. Paper Medical Records A significantly higher proportion of patients being treated by physicians with EHRs received care that aligns with accepted treatment standards * % of Patients Receiving Care Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365: Retrieved from * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<

8 Health Outcomes for Diabetes Patients at Safety Net Practices: Patients treated by Physicians using EHR vs. Paper Medical Records A significantly higher proportion of patients being treated by physicians with EHRs obtained better outcomes * % of Patients Obtaining Outcome Standards Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365: Retrieved from * Even after adjusting for patient demographic characteristics and insurance type, differences remain significant p<

9 Texas Medicaid Electronic Health Record (EHR) Incentive Program

10 Overview Two separate sections of the American Recovery and Reinvestment Act (ARRA) of 2009 comprise the Health Information Technology for Economic and Clinical Health (HITECH) Act, which: Promotes the adoption and meaningful use of health IT, including EHRs, exchange of health information, etc. Authorizes the EHR Incentive Program. The EHR Incentive Program incentivizes eligible medical providers and hospitals for adoption and meaningful use of certified EHR technology. 10

11 Texas Medicaid EHR Incentive Program: Overview Eligible professionals (EPs) can receive incentives of up to $63,750 for the adoption and meaningful use of certified electronic health record (EHR) technology. Payment is not a reimbursement for expenses incurred. First year payment can be received in 2011 through Final payment can be received up to 2021 for EPs, and 2018 for EHs. Incentives are based on the individual, not the practice. In the first of year of participation, EPs and EHs must adopt, implement, or upgrade (AIU) to a certified EHR. In subsequent participation years, they must demonstrate meaningful use (MU). 11

12 Eligibility Eligible provider type. Physicians (M.D. or D.O.) Dentists Nurse Practitioners Certified Nurse Midwives Physician Assistants (PA) in federal qualified health centers (FQHCs) or rural health clinics (RHCs) led by a PA Acute care hospitals Children s hospitals Must meet Medicaid patient volume thresholds, except children s hospitals. For MU: At least 50% of all encounters must be at a site or sites with certified EHR technology. Hospital-based EPs are not eligible for incentives (unless an FQHC or RHC providers). 12

13 Incentive Payments EPs Payment Year by EP Type Incentive Amount Year 1 for most EPs $21,250 $63,750 Years 2-6 for most EPs $8,500 Maximum cumulative incentive over 6 years Year 1 for pediatricians and pediatric dentists with a minimum 20%, but less than 30%, Medicaid patient volume $14,167 $42,500 Years 2-6 for pediatricians and pediatric dentists with a minimum 20%, but less than 30%, Medicaid patient volume $5,667 13

14 Incentive Payments Hospitals The basic calculation is the product of two factors: Overall EHR amount. The Medicaid share. Calculation spreadsheet can be found in the Hospital section of this webpage: aspx. Payment will be made one time per year. Payment will be made in the first monthly date after the incentive is approved. Hospital payout schedule for Texas Medicaid is: Year 1 50 percent Year 2 40 percent Year 3 10 percent 14

15 Skipping Years in the Program Skipping years is permissible in the Medicaid incentive program. You may skip one or more years. For example, a provider might enter the program in 2011 with AIU and then skip two years. They would re-enter the program in 2014 with Stage 1 (other providers might be in Stage 2 at that point). Keep in mind that the program ends in 2021, so if you start in 2016 (the last year you can begin the program), you would need to participate in consecutive years if you want all 6 payments. Skipping is still allowed, but you wouldn t receive all 6 payments. 15

16 Reporting Periods There are two reporting periods that apply for the Medicaid EHR Incentive Program: For patient volume, an eligible professional (EP) should use any continuous, representative 90-day period in the prior calendar year. For demonstrating meaningful use, EPs should use the EHR reporting period associated with that payment year: o First payment year that an EP is demonstrating meaningful use, the reporting period is a continuous 90-day period within the calendar year. o Subsequent years, the period is the full calendar year. 16

17 Patient Volume Requirements Provider Type Medicaid Patient Volume Threshold Eligible Professionals Additional Volume Consideration Physicians 30% If the Medicaid EP - Pediatricians and Pediatric Dentists 20% Dentists 30% Nurse Practitioners 30% Certified Nurse Midwives 30% Physician Assistants (PAs) when practicing at an FQHC/RHC that is led by a PA Acute Care Hospitals (includes critical access hospitals) Children's Hospitals 30% Eligible Hospitals 10% No requirement practices predominantly in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) 30% needy individual patient volume threshold 17

18 FQHC Specific Requirements Practices Predominately: An EP needs to work in an FQHC for over 50 percent of total encounters for a six-month period in most recent calendar year. Physician Assistants (PA) at an FQHC "so led" by a PA is defined as when a PA is: the primary provider in the clinic; or a clinical or medical director at the clinic. If the FQHC is led by a PA, all PAs at that clinic may qualify for the EHR incentive. 18

19 Needy Patient Volume Calculation for FQHCs The methodology for calculating patient volume for FQHCs is the Needy Patient volume calculation. It is based on patient encounters over three full consecutive months that includes: Medicaid clients. CHIP clients. Client services provided as uncompensated care. Client services provided at either no cost or reduced cost based on a sliding scale determined by the individual s ability to pay. Medicaid + CHIP + Other Allowable Patient Encounters X 100 Total Patient Encounters 19

20 Use of certified EHR: Meaningful Use Requirements In a meaningful manner (e.g., electronic prescribing). For electronic exchange of health information to improve quality of health care. To submit clinical quality measures (CQM) and other such measures selected by the Secretary. For Year 1, Medicaid providers do not need to report meaningful use data, only attest to adopting, implementing, or upgrading to a certified EHR. If a hospital meets meaningful use for Medicare, they meet meaningful use for Medicaid. Note: For the complete list of reportable measures, go to Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html 20

21 Meaningful Use Stages Stage 1 effective in 2012 focuses on: Electronically capturing health information in coded format. Using that information to track key clinical conditions. Communicating that information for care coordination. Initiating the reporting of clinical quality measures. Stage 2 effective in 2014 will focus on: Disease and medication management. Clinical decision support. Support for patient access to their health information. Bi-directional communication with public health agencies. Stage 3 effective in 2015 will focus on: Patient access to self-management tools. Access to comprehensive patient data. 21 Improving population health outcomes.

22 EPs: Stage 1 Meaningful Use and Clinical Quality Measures 20 measures for Eligible Professionals (EPs): Must meet 15 from the core set. Must select 5 of 10 from menu set. EPs must report total of 6 CQMs: 3 Core or Alternate Core* CQMs: Must include at least one Public Health measure: 1) Immunizations 2) Reportable Labs 3) Syndromic Surveillance Core: Blood pressure reading, tobacco use assessment and intervention, adult weight screen and follow up. Alternate Core: Flu immunization for patients 50+, weight assessment and counseling for children and adolescents, and childhood immunization status. 3 from list of clinical measures of the provider s choice. * Insofar as the denominator for one or more of the core measures is zero, EPs will be required to report results for up to three alternate core measures. 22

23 Hospitals: Stage 1 Meaningful Use and Clinical Quality Measures 19 measures for Eligible Hospitals (EHs): Must meet 14 from the core set. Must select 5 of 10 from menu set. Hospitals must report 15 CQMs: 4 CQM overlap with CHIPRA initial core set. Must include at least one Public Health measure: 1) Immunizations 2) Reportable Labs 3) Syndromic Surveillance 23

24 Medicaid EHR Incentive Program Process Flow Register with CMS NLR Federal Level Registration Federal/State File Exchange State Level Enrollment Notifications Verify Provider Information Enter Patient Volumes Confirm AIU Validate Certified EHR Acknowledge Payment State and Federal Validations Generate Payment 24

25 Certified EHR Technology Office of National Coordinator (ONC) publishes standards for software vendors. Vendors submit software for certification. Software receives an ONC certification number # (http://oncchpl.force.com/ehrcert). Vendor must recertify for each MU phase. 25

26 Medicare or Medicaid? EPs must pick one program. Eligible hospitals may be eligible to participate in both programs. EPs can switch programs once. Slightly different rules, including penalties for nonparticipation in the Medicare incentive program. Higher incentive payments under Medicaid. Medicare incentive program is administered by the Centers for Medicare & Medicaid Services (CMS). The Medicaid EHR Incentive Program is administered by Texas. 26

27 How to Register and Attest 1. Register at CMS: https://ehrincentives.cms.gov. 2. Verify enrollment as a Texas Medicaid provider, with an active TPI. If you assign payment to yourself, your SSN must be listed in your TMHP profile. 3. Gather required information and documentation: EHR certification number. Group or individual attestation choice. Patient volume information (numerator and denominator). AIU documentation. 4. Log into the portal and attest. Go to and log in. Scroll down to Manage Provider Account and select Texas Medicaid EHR Incentive Program. For the full checklist of steps: Go to and select Providers; go to the Health IT page and select EHR Program Information from the list on the left; click on Getting Started with EHR Incentive Program 27

28 Attestation: Important Notes Attestations: All self-reported information (e.g., patient volume, provider types, etc.) are legally binding. Information entered into the portal should come from auditable sources in case you are selected for an audit. Providers can file an appeal for any of the following reasons: Incentive payment amount. Provider eligibility determination. Support for adopt, implement, or upgrade to a certified EHR. Achievement of meaningful use requirements. 28

29 Audit Both AIU and MU Stage 1 attestations will be audited. Providers must be able to generate reports that show the underlying data that went into MU and CQM measure calculations. For each year of program participation, providers must maintain auditable records related to incentive program attestations for six years. 29

30 Beyond 2012 Payment adjustments and penalties begin in 2015 for the Medicare incentive program. Stage 2 MU attestation opens in Providers that attest to stage 1 in 2012 will be required to attest to stage 2 by the end of 2014 (unless they skip a year). Electronic submission of CMS quality measure data. Possible incentives for meeting selected quality measures. Stage 2 MU measures consolidated, augmented. More CMS measures required. 30

31 CMS Quality Measures For Stage 1, MU measure #10 requires the provider to report 6 ambulatory clinical quality measures to the state. 3 core (or alternate core), and 3 additional (select from list of 38 measures). The 3 core measures are: NQF0013 Hypertension: BP measurement NQF0028 Tobacco: Query, Intervention NQF0421 Adult Weight Screening 31

32 Example CQM NQF0028 Tobacco: Query, Intervention Intervention comes in two forms prescriptions and counseling. The use of prescriptions should generate an Rx drug code in the patient record. The other should generate a CPT code. 32

33 Example CQM Sample from the Clinical Quality Measure Set Medication Medication Procedure Medication active Medication active Procedure performed A_c423 RxNorm 12 / , , , , , , ,. A_c423 RxNorm 12 / , , , , , , ,. A_c424 CPT ,

34 Example CQM

35 Example CQM Structured, coded data Make sure your EHR is configured to record meaningful data. Problem areas: vitals, in-house labs, even outside lab electronic results, radiology, specialists, small procedures. 35

36 Health Information Technology Regional Extension Centers Contact the Regional Extension Center (REC) in your area for information on the support and assistance they can provide. Gulf Coast Regional Extension Center CentrEast Regional Extension Center North Texas Regional Extension Center West Texas Health Information Technology Regional Extension Center 36

37 Stage 1 and 2 Meaningful Use

38 Stage 1 Meaningful Use Attestation began April 1, 2012 because Jan 1 March 31 was the earliest 90-day Meaningful Use reporting period. Volume calculation is determined from the previous calendar year. Must attest to AIU before attesting to Stage 1. One attestation per year. 15 core (required) measures; pick 5 more from menu set of 10 measures. One of the core measures contains the CQM reporting. 38

39 Clinical Quality Measures (CQMs) 44 measures published by CMS. Must report 6 measures. 3 core (required) measures (or alternate core) + 3 electives. Core 1 blood pressure recorded. Core 2 tobacco use assessment and intervention. Core 3 adult weight screening and followup. 39

40 Stage 1 Core Measures The following measures are automatically achieved by using a certified EHR or are simpler to implement: Recording demographics, vitals, medications, and medication orders electronically. Maintain a problem list. E-Prescribing. Drug interaction checks. Ability to supply patients with an electronic copy of their health record. Provide clinical summaries at end of encounter. Implement one clinical decision support (CDS) rule. 40

41 Stage 1 Core Measures CDS Rule Adult / pediatric immunization schedules. Cervical cancer screenings. Each EHR will have its own list of available CDS rules. 41

42 Allergy lists. Smoking status. Stage 1 Core Measures The Harder Ones CMS Clinical Quality Measures (CQMs). Privacy and Security for example, security risk analysis Exchange Key Clinical Data generate a Continuity of Care Document (CCD) and transmit it via secure (this measure may be removed in 2013). 42

43 Drug formulary checks. Medication reconciliation. Stage 1 Menu Set Patient lists for example, by condition (ICD code) Patient portal for self-service record retrieval. Provider portal for manual HIE. 43

44 Stage 1 Menu Set Send patient reminders to > 20% of patients. Provide patient-specific education to > 10%. Public health measure immunization data test. Public health measure lab data test. Public health measure syndromic surveillance. 44

45 Stage 1 Exclusions Available for both core and menu sets. It is up to the provider to decide which exclusions are applicable to their practice. CMS has issued the following statement about exclusions: We encourage EPs to select menu objectives that are relevant to their scope of practice, and claim an exclusion for a menu objective only in cases where there are no remaining menu objectives for which they qualify or if there are no remaining menu objectives that are relevant to their scope of practice. For example, we hope that EPs will report on 5 measures, if there are 5 measures that are relevant to their scope of practice and for which they can report data, even if they qualify for exclusions in the other objectives. 45

46 Stage 1 Exclusions Immunization reporting - EP who administers no immunizations during the reporting period or where no immunization registry has the capacity to receive the information electronically. Relevant vs. Uncommon the vitals measure example. It is uncommon to check BP in a dentist s office. However, BP is relevant. So dentists should not exclude themselves from this measure. 46

47 Stage 1 Exclusions CMS and ADA are collaborating on guidance for dentists. 47

48 PROPOSED Big Changes to Stage 1 Final rule for stage 2 may contain modifications. Blood pressure can be separated from weight and height vitals requirements where this makes sense (like dentistry). The Health Information Exchange (HIE) requirement is deleted as of Look for these when the final rule is published in late summer

49 PROPOSED Stage 2 Meaningful Use NPRM published in March Comments taken until May. Final Rule to be published at end of summer. Will contain stage 2 requirements, changes to stage 1, new CQMs. 49

50 Timeline 50

51 PROPOSED Stage 2 Meaningful Use Structure of requirements has changed. 17 core measures (required). 5 menu set measures (pick 3). No more exclusions for menu set measures. Most stage 1 measures still present, but with increased compliance percentage. 51

52 PROPOSED Stage 2 Meaningful Use - Core Smoking status recorded 50% to 80%. Record vital signs 50% to 80%. Receive electronic lab results 40% to 55%. E-Prescribing 40% to 50%. Computerized Physician Order Entry (CPOE) goes from 30% to 65% AND will include labs and radiology. 52

53 PROPOSED Stage 2 Meaningful Use - Core Increase to 5 CDS rule implementations. Patient reminders now required on core set. Provide online access to health info (patient portal) with > 10% of patients accessing it. Patient education moved to core set. More than 10% of patients sent a secure message to a provider. > 10% of referrals and transitions of care have summary of care sent electronically. 53

54 PROPOSED Stage 2 Meaningful Use - Core Successful, ongoing transmission of immunization data. Conduct security analysis and incorporate into risk management process. 54

55 PROPOSED Stage 2 Meaningful Use Menu Set Syndromic surveillance reporting (not just a test). Ability to access imaging results, > 40% of results. Reporting to cancer registry. Reporting to a second registry of choice. Record family history. 55

56 PROPOSED Stage 2 CQM Reporting Not an MU measure anymore, but a separate part of attestation, like volume. Options- 12 provider-selected CQMs or participation in PQRS, formerly PQRI (electronic reporting capability for PQRS is required of EHR vendors by 2014). 125 proposed CQMs. Starting in stage 2, CQM reporting period is full calendar year. 56

57 Additional Resources Learn about the Texas Medicaid EHR Incentive Program through a selfguided e-learning tool: Get technical assistance through the Regional Extension Centers at Review program information on the CMS website: Review additional Texas Medicaid EHR Incentive Program information at: (http://www.tmhp.com/pages/healthit/hit_ehr.aspx). Learn about a recent study on EHRs and healthcare outcomes: Sign up for updates at https://public.govdelivery.com/accounts/txhhsc/subscriber/new and enter your address. On the subscription topics page, go to the Projects section and select Health Information Technology. Submit questions by sending an to or calling , option 4. 57

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