ny medicaid hitechehr incentive program james j. figge, m.d., m.b.a. medical director, office of...

NY MedicaidHITECH EHR Incentive Program

James J. Figge, M.D., M.B.A.Medical Director, Office of Health Insurance Programs

January, 2011

MSSNY Town Hall Seminars:The Road to Meaningful Use and The HITECH EHR Incentive Program

The Medicaid Incentive Program: Collaborate for Better Patient Care


Topics• NY Medicaid programs that complement the

federal Health Information Technology for Economic and Clinical Health (HITECH) program:– Electronic Prescribing (eRx) Incentive– Patient-Centered Medical Home (PCMH)

Incentive

• NY Medicaid HITECH EHR incentive program

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ObjectivesUpon completion of this activity, physicians

will:• learn about NY Medicaid incentive programs for

e-prescribing and the patient-centered medical home;

• learn the components of meaningful use of a certified EHR under HITECH;

• learn the importance of adoption relative to the federal incentive programs.

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Electronic Prescribing• Nationwide:

– In 2009, 12% of the 1.63B original prescriptions were transmitted electronically

• Accelerating trend:– 2007-2008: +130%– 2008-2009: +181%

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Source: 2009 National Progress Report on E-Prescribing, Surescripts LLC.


NY Medicaid eRx IncentiveProvides an incentive payment for dispensed

ambulatory Medicaid e-prescriptions

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Eligible Practitioners

Physicians (M.D./D.O.)

Dentists

Nurse Practitioners

Podiatrists

Optometrists

Licensed Midwives

Prescriber Incentive

$0.80 per prescription/refill*

Pharmacy Incentive

$0.20 per prescription/refill*

* Max 1 original plus 5 refills per 180-day period.


eRx Incentive Requirements

• Prescriber– must have an individual NPI, and – must be enrolled in Medicaid fee-for-

service (FFS)

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eRx Incentive Requirements

• Incentive only applies to prescriptions created electronically, and transmitted via computer-to-computer electronic data interchange– faxed prescriptions are not eligible– [faxed prescription] ≠ eRx

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eRx Incentive Requirements• Electronic transaction must comply with

Medicare Part D standards– NCPDP SCRIPT 8.1 or 10.6– Includes prescriber's individual NPI

• Incentive only applies to prescription medications – No OTC medications or medical supplies– No controlled substances at this time

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Patient-Centered Medical Home

• PCMH is a care model where each patient has an ongoing relationship with a personal clinician who leads a team that takes collective responsibility for patient care

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Patient-Centered Medical Home

• Care is supported by electronic tools– patient registries, EHRs, e-prescribing, and

health information exchange (HIE)– goal is to improve care coordination, quality,

and patient safety

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NCQA PCMH Recognition Program• National Committee for Quality Assurance

(NCQA), Patient-Centered Medical Home program – Three levels:

• Level 1 can be achieved without an EHR• Level 2 requires some electronic functions• Level 3 requires a fully functional EHR

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NY Medicaid PCMH Incentive

• Eligibility for enhanced payments:– Office-based practices (e.g., physicians and

nurse practitioners)– Federally Qualified Health Centers (FQHCs)– Diagnostic & Treatment Centers– Hospital Outpatient Departments (Medicaid

managed care program only)

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NY Medicaid PCMH Incentive

• Incentive payments available through Medicaid fee-for-service (FFS) and Medicaid managed care programs

• Incentive amount varies based on NCQA PCMH level achieved

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Medicaid EHR Incentive Program• Created by the HITECH Act

• Administered by the States under guidance and oversight of the Centers for Medicare and Medicaid Services (CMS)

• Designed to provide financial incentives for adoption and meaningful use of certified EHRs

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Medicaid EHR Incentive Program• Meaningful use of certified EHR technology

includes:

– Electronic Prescribing– Electronic exchange of health information to

improve the quality of health care– Reporting of clinical quality measures

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Who Is Eligible?• Physicians (M.D. and D.O.)• Nurse Practitioners• Certified Nurse-Midwives• Dentists• Physician Assistants, only if practicing in a

FQHC or Rural Health Clinic (RHC) led by a Physician Assistant

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Patient Volume Requirements• Eligible professionals (EPs) must demonstrate

that 30% of patient encounters are Medicaid– Exceptions:

• Pediatricians may receive 2/3 incentive amount with 20% Medicaid patient volume

• EPs in FQHCs and RHCs may qualify by demonstrating 30% of encounters are “needy individuals”

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Calculating Patient Volume

• Standard formula uses number of Medicaid patient encounters relative to total encounters in any 90-day period in the preceding calendar year

• Alternate formula takes into account a practitioner's entire managed care or medical home patient panel

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Calculating Patient Volume• Clinics and group practices may use overall

clinic/practice patient volume as a proxy for each EP– Some limitations apply: 42 CFR 495.306(h)

• All methods include alternate 20% threshold for pediatricians and use of “needy individuals” criteria for FQHCs/RHCs

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How Much is Available?

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All Practitioners (at least 30% Medicaid/needy)

Pediatricians (at least 20% but less than 30% Medicaid)

Year 1 $21,250 $14,167

Year 2 $8,500 $5,667

Year 3 $8,500 $5,667

Year 4 $8,500 $5,667

Year 5 $8,500 $5,667

Year 6 $8,500 $5,667

Total $63,750 $42,500Note: program participation years do not need to be contiguous.


Restrictions on EP Eligibility• EPs may not be "hospital-based"

– defined as 90% or more of services rendered in inpatient hospital or emergency room settings

• Must select either the Medicare or Medicaid program (one-time option to switch)

• May only participate in one state under the Medicaid option

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Adoption, Implementation and/or Upgrading EHR Technology

• First year: – EPs must demonstrate adoption,

implementation, and/or upgrade• Adopt: Acquire and install system• Implement: Training, data migration, commence

utilization• Upgrade: Expand and improve existing system

to meet definition of certified EHR technology22


Meaningful Use of EHR Technology

• Subsequent years:– Meet meaningful use and clinical quality

metric reporting requirements

• For Stage 1 meaningful use (2011-2012), same core and menu set as Medicare*

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* States may request permission from CMS to mandate certain public health reporting options

NY MedicaidHITECH EHR Incentive Program 24

Defining Meaningful Use• HITECH Act specifies three components:

– Electronic prescribing

– Electronic exchange of health information

– Submission of clinical quality measures


Stage 1 EP Meaningful Use Criteria

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Core Set Menu Set

Meaningful Use Objectives 15 core objectives 5 of 10

menu set objectives

Clinical Quality Measures

3 core measures, or 3 alternate core measures

3 of 38 menu set measures

• Stage 1 meaningful use objectives and clinical quality measures include required core set and menu set choices


EP Clinical Quality Measures• EPs must submit six measures for Stage 1 MU:

– 3 core or 3 alternate core– 3 of 38 from menu set

• Aligned with Physicians Quality Reporting Initiative (PQRI) and CHIPRA initial core set

• Submit by attestation for 2011– in 2012, EPs must submit electronically

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EP Clinical Quality Measures

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NQF Measure Number/PQRI Implementation Number

EP Clinical Quality Measure(Core Set)

NQF 0013 Hypertension: Blood pressure measurement

NQF 0028Preventive Care and Screening Measure Pair:

a)Tobacco Use Assessmentb)Tobacco Cessation Intervention

NQF 0421PQRI 128 Adult Weight Screening and Follow-up


EP Clinical Quality Measures

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NQF Measure Number/PQRI Implementation Number

EP Clinical Quality Measure(Alternate Core Set)

NQF 0024 Weight Assessment and Counseling for Children and Adolescents

NQF0041PQRI 110

Preventive Care and Screening: Influenza Immunization for

Patients 50 Years Old or Older

NQF 0038 Childhood Immunization Status


Enrollment Process (1)

• Login to CMS Registration website:– Supply demographic/financial information– Select program (Medicare/Medicaid)– Select state

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Enrollment Process (2)

• Login to NY Medicaid website:

– Verify eligibility

– Attest to adopt, implement, upgrade or meaningful use of certified EHR technology

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Medicaid EHR Incentive Timeline

• CMS registration website opens for EHR Incentive Programs (both Medicare and Medicaid in some states) on January 3, 2011

• NY Medicaid web-based attestation functions expected to begin fourth quarter-2011, dependent upon CMS and state approvals

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Medicaid EHR Incentive Timeline

• Last year to initiate participation is 2016

• Participants may skip a year, but no payments will be issued after 2021

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Incentive Payments for Medicare EPs

First Calendar Year (CY) for which the EP Receives an Incentive Payment

CY 2011 CY 2012 CY 2013 CY2014 CY 2015 and later

CY 2011 $18,000

CY 2012 $12,000 $18,000

CY 2013 $8,000 $12,000 $15,000

CY 2014 $4,000 $8,000 $12,000 $12,000

CY 2015 $2,000 $4,000 $8,000 $8,000 $0

CY 2016 $2,000 $4,000 $4,000 $0

TOTAL $44,000 $44,000 $39,000 $24,000 $0

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Additional 10% Incentive Payment for Medicare EPs Practicing in HPSAs


Medicare Penalties for Not Achieving Meaningful Use

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Notable Differences Between the Medicare & Medicaid EHR Programs

Medicare Medicaid

Federal Government will implement (will be an option nationally)

Voluntary for States to implement (may not be an option in every State)

Payment reductions begin in 2015 for providers that do not demonstrate Meaningful Use

No Medicaid payment reductions

Must demonstrate MU in Year 1 A/I/U option for 1st participation year

Maximum incentive is $44,000 for EPs (bonus for EPs in HPSAs)

Maximum incentive is $63,750 for EPs

MU definition is common for Medicare States can adopt certain additional requirements for MU

Last year a provider may initiate program is 2014; Last year to register is 2016; Payment adjustments begin in 2015

Last year a provider may initiate program is 2016; Last year to register is 2016

Only physicians, subsection (d) hospitals and CAHs

5 types of EPs, acute care hospitals (including CAHs) and children’s hospitals

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Appendices

• Contact Information

• Meaningful Use Core Set of Objectives – EP

• Meaningful Use Menu Set of Objectives – EP

• Clinical Quality Measures – Menu Set – EP

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Contact InformationFor New York State Department of Health:James J. Figge, M.D., M.B.A., Medical DirectorNYS Department of Health, Office of Health Insurance ProgramsOne Commerce Plaza, Suite 826 Albany, NY 12260(518) 474-8045 [email protected]

For The Medical Society of the State of New York: Ron Pucherelli [email protected]

Eileen Clinton [email protected]

(518) 465-80853737


Stage 1 MU Criteria – EP Core Set (1)

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Health Outcomes Policy Priority Stage 1 Meaningful Use Objective (EPs)

Improving quality, safety, and

efficiency, and reducing health

disparities

Use Computerized Provider Order Entry (CPOE) for medication orders

Implement drug-drug and drug-allergy interaction checks

Generate and transmit permissible prescriptions electronically (eRx)

Record patient demographics (preferred language, gender, race, ethnicity, DOB)

Maintain an up-to-date problem list of current and active diagnoses



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disparities

Maintain active medication list

Maintain active medication allergy list

Record and chart changes in vital signs (height, weight, blood pressure, BMI, growth charts)

Record smoking status (patients 13 and older)

Implement one clinical decision support rule

Report ambulatory clinical quality measures to CMS or the State



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Improve care coordination

Capability to exchange key clinical information electronically among providers of care and patient-

authorized entities

Ensure adequate privacy and security for personal health

information

Implement systems to protect privacy and security of patient data in the EHR

Engage patients and families in their

health care

On request, provide patients with an electronic copy of their health records

Provide patients with clinical summaries for each office visit


Stage 1 MU Criteria – EP Menu Set (1)

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disparities

Implement drug-formulary checks

Incorporate clinical lab test results into certified EHRs as structured data

Generate lists of patients by specific conditions

Send reminders to patients (per patient preference) for preventive and follow-up care

Improve care coordination

Perform medication reconciliation between care settings

Provide summary of care record for patients referred or transitioned to another provider or setting


Stage 1 MU Criteria – EP Menu Set (2)

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Engage patients and families in their

health care

Provide patients with timely electronic access to their health information

Use certified EHR technology to identify patient-specific education resources and provide to patient

as appropriate

Improve population and public health

Capability to submit electronic syndromic surveillance data to public health agencies (one test)

Capability to submit immunization data electronically to State immunization registry (one test)


CQM: EP Menu Set (1)1. Diabetes: Hemoglobin A1c Poor Control 2. Diabetes: LDL Management and Control 3. Diabetes: Blood Pressure Management4. Heart Failure : ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction5. Coronary Artery Disease: Beta-Blocker Therapy for Patients with Prior MI6. Pneumonia Vaccination Status for Older Adults7. Breast Cancer Screening8. Colorectal Cancer Screening9. Coronary Artery Disease: Oral Antiplatelet Therapy10. Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction11. Anti-depressant medication management12. Primary Open Angle Glaucoma: Optic Nerve Evaluation 13. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level

of Severity of Retinopathy 14. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care15. Asthma Pharmacologic Therapy 16. Asthma Assessment17. Appropriate Testing for Children with Pharyngitis18. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen

Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients

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CQM: EP Menu Set (2)20. Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate

Cancer Patients21. Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and

Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies

22. Diabetes: Eye Exam23. Diabetes: Urine Screening24. Diabetes: Foot Exam25. Coronary Artery Disease: Drug Therapy for Lowering LDL-Cholesterol26. Heart Failure : Warfarin Therapy Patients with Atrial Fibrillation27. Ischemic Vascular Disease: Blood Pressure Management 28. Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic 29. Initiation and Engagement of Alcohol and Other Drug Dependence30. Prenatal Care: Screening for Human Immunodeficiency Virus31. Prenatal Care: Anti-D Immune Globulin32. Controlling High Blood Pressure 33. Cervical Cancer Screening34. Chlamydia Screening for Women 35. Use of Appropriate Medications for Asthma 36. Low Back Pain: Use of Imaging Studies 37. Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control 38. Diabetes: Hemoglobin A1c Control (<8.0%)

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