posted by Kevin Heubusch
Feb 24, 2010 04:21 pm
AHIMA Meaningful Use White Paper Series
Paper no. 7
Preceding papers in this series have reviewed the requirements in the notice of proposed rulemaking on meaningful use, published by the Centers for Medicare and Medicaid Services in January 2010. This paper summarizes the proposed process for qualifying for the program and also offers a look at the program’s next steps.
CMS published its program requirements as a notice of proposed rulemaking (NPRM) in order to solicit public comment. That comment period closes March 15. CMS will then proceed to write a final rule with the assistance of the Office of the National Coordinator for Health Information Technology (ONC). The rule will then be reviewed by the Office of Management and Budget before its official publication in the Federal Register.
CMS is targeting late spring or early summer for publication. The number and variety of comments will affect the timeliness as well as the content. For the most part, it should be presumed that the proposed requirements will not be significantly increased in a final rule. The debate over the NPRM has been whether there are too many reporting requirements, and indeed CMS has requested comment to this effect, and the best that can be predicted is that some requirements will be eliminated in the final rule.
For eligible hospitals, the meaningful use program is scheduled to begin FY 2011, which for the government starts October 1, 2010. The program begins January 1, 2011, for eligible professionals (EPs). Thus the sooner CMS can produce a final rule, the more time providers will have to assess their readiness and begin preparing to qualify. Final definitions also will allow the regional extension centers, IT vendors, and the Medicaid and Medicare programs to prepare.
Each of these parties is currently trying to determine which provisions of the NPRM will become requirements under the final rule. They face similar uncertainty in considering the ONC’s related rule on IT certification standards. The requirements outlined within ONC’s interim final rule identify the standards and criteria that will enable the meaningful use reporting through an electronic health record (EHR).
In the coming weeks and months, eligible professionals and hospitals will continue to learn and assess the proposed requirements; prepare comments on their value and feasibility; determine how the proposed rule would affect their own practice, process, and systems; and identify what changes they would need to make to receive incentive payments. The starting point for each eligible provider will be different, dependent upon its current use of IT.
It should be noted that in the first year of the program, eligible participants may qualify by meeting the requirements during any 90-day period.
Qualifications for Participation
To be eligible for the meaningful use program, a professional or hospital must participate in one or more Medicare or Medicaid programs: Medicare Fee-for Service, Medicare Advantage, or Medicaid. The provider’s patient mix and volume will to some extent dictate which program will yield the best incentive.
Eligible hospitals can qualify for both Medicare and Medicaid incentives; however, EPs must choose between the programs, and they have only one opportunity to switch their choice before 2015 (p. 1904).
EPs that see Medicaid patients from more than one state may receive incentive payments from only one state, but they can change states each year. The incentive payment should be the same no matter which state the provider chooses, but states have the option of adding requirements in addition to those specified by CMS.
EPs participate in the incentive program as individuals, and it will be up to the individual and the practice how the individual might reimburse the organization. For purposes of the program, CMS defines a physician as a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, or a chiropractor. The volume and mix will be determined by the EP, not the practice.
Only short-term, acute hospitals are eligible under the Medicare proposal. Critical access hospitals will be paid under a different reimbursement rules than the Fee-for-Service program. Requirements and payments also vary for EPs and hospitals when services are rendered in a federally qualified health center or a rural health clinic.
Hospital-based physicians are not eligible for the program as proposed in the NPRM. CMS’s definition of hospital-based in this instance extends beyond the typical groups such as anesthesiologists and emergency physicians to include EPs performing more than 90 percent of their services in a hospital setting, including hospital outpatient departments on or off the campus.
The exclusion is intended to prevent duplicate payments, since CMS assumes that all of these providers are using the hospital’s EHR system. Of note is the fact that hospital outpatient services are not part of the calculation for hospital incentive payments.
The qualifications are even more specific with regard to Medicaid, which sets patient volume thresholds for EPs. Five types of professionals are eligible: physicians, dentists, certified nurse-midwives, nurse practitioners, and physician assistants practicing in a federally qualified health center or rural health clinic led by a physician assistant (p. 1930).
To qualify for Medicaid incentives, these professionals cannot be hospital-based, with the exception of EPs practicing predominantly in a federally qualified health center or rural health clinic.
The Medicaid incentive program also includes additional qualifications for acute hospitals (an average patient stay of 25 days or fewer) and children’s hospitals (separately accredited).
The incentive program related to Medicare Advantage contains its own set of additional requirements, since some entities may qualify for multiple Advantage programs (pp. 1920–28).
To avoid duplicate payments among the states and Medicare, CMS proposes a single repository that would uniquely identify each participating provider and indicate which incentive program the provider has selected.
To qualify as meaningful users, EPs and hospitals must use certified electronic health record technology as defined in the NPRM and ONC’s certification and standards IFR. ONC specifies that the standard it describes will be the sole standard to determine meaningful use eligibility.
There is some exception to the certification requirement in the Medicaid program, which allows payment to “certain Medicaid providers to adopt, implement, upgrade, and meaningfully use certified EHR technology.” Participants will have to attest that the technology-which can be either a single EHR system or a collection of EHR modules-is certified. Providers will have to work with their vendors to determine their systems meet the requirements.
The reporting methods vary over the initial two years of the program, given the capabilities of CMS and the states to receive electronic reporting (see papers 5a and 6a for providers and papers 5b and 6b for hospitals.) Initially participants will demonstrate that they meet the functional and clinical quality measures requirements through attestation. Specific reporting requirements are detailed on pages 1901–3.
As technology advances, the requirements for meaningful use and clinical quality reporting will increase in stages 2 and 3 of the incentive program. EHR systems thus must be capable of adapting to future changes, which is one requirement for certification.
State Medicaid programs have the option of starting payments in 2010; however, with a short period of time between the final rule and the end of 2010, and with a number or administrative processes to be established and tested, very few states will likely take advantage of this early payment option.
Payments will vary across each of the programs, but CMS prop oses they be the same across state Medicaid programs. Payments will vary by the type of provider and when the provider enters the program. It should be noted that for the most part payments are made after the provider has invested in an EHR and its implementation.
The following table locates the detailed description of eligibility and payment processes by program and type of provider.
|Incentive Program, |
|Administrative Processes |
|Medicare Fee-for-Service || || |
|EP ||1907–11 ||1919 |
|Hospital ||1911–16 ||1919 |
|Critical Access Hosp. ||1916–19 ||1920 |
|Medicare Advantage || || |
|EP ||1920–21 ||1923–28 |
|Hospital ||1922 ||1923–28 |
|MA Organization ||1922–23 ||1923–28 |
|Medicaid || || |
|Acute Hospital ||1930, 1931–33 ||1937–39, 1940–43 |
|Children’s Hospital ||1930, 1931–33 ||1937–39, 1940–43 |
|EP ||1930, 1931–33 ||1937–39, 1940–43 |
ARRA provides additional state grant and loan payments for EHR adoption, and the Department of Health and Human Services and ONC have already provided some funding to the states and Indian tribes for this purpose. Providers can follow up with their states to determine what additional funding might be available. The Medicare program also has an option for payment through “Entities Promoting the Adoption of Certified EHR Technology,” described on pages 1932–33, and as noted above, limited potential for payment in 2010.
CMS suggests that some of the current reporting required under Medicare and Medicaid, such as the cost report, be used in determining payment amounts. However, a number of the volume reports required for eligibility and for describing meaningful use are new, and they will require changes to internal processes.
In determining payments CMS also notes that its calculations include the cost of hardware, software, and workforce training associated with system implementations. This is described throughout the document and especially in section V, “Regulatory Impact Analysis.” However, as CMS notes, it is difficult to estimate the cost, because participation in the incentive program is voluntary and those who do participate will begin from varying starting points.
In February ONC announced funding for additional programs designed to assist providers in their EHR implementation, including the first contract awards to regional extension centers. It is too early to identify how these resources will be made available to providers, but their availability should be monitored.
This is the last paper in this series to review the NPRM. The next paper will describe AHIMA’s comments to CMS.