nymedicaid 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

September 2010


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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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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• 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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• 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

• Must demonstrate 15 percent financial contribution toward the "net average allowable costs" (NAAC) of certified EHR technology

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NY MedicaidHITECH EHR Incentive Program 21

EP Financial Contribution• EPs must contribute 15% of the NAAC

– $3,750 first year for most EPs– $1,500 each subsequent year

• Many contributions count towards EP share:– Costs incurred by employer for implementing certified

EHR system (e.g., FQHC, RHC, or group practice)– Costs of training and workflow redesign– In-kind contributions (technology, support, etc.)


Calculating the NAAC

• The first year "average allowable costs" were set by CMS at $54,000

• Cash received by the EP from most other sources (certain exceptions apply) must be deducted from the average allowable costs to yield the NAAC

• NAAC cannot exceed $25,000 (statutory limit)

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• Average allowable costs (first year): $54,000

• Cash received from other sources: $29,000

• Net average allowable costs: $25,000

• 15% EP contribution: $3,750

• 85% Incentive payment amount: $21,250

Incentive Calculation Example #1

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$54,000

$25,000

$21,250

$29,000




• Net average allowable costs: $25,000 (maximum = $25,000)




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$54,000

$25,000

$21,250

$10,000




• Net average allowable costs: $22,000




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$54,000

$22,000

$18,700

$32,000


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 technology

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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 28

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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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



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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


Hospital Eligibility• Acute Care Hospitals - at least 10% Medicaid

• Average Length of Stay ≤ 25 days• CCN in 0001–0879 or 1300–1399• Includes general short-term hospitals, cancer care

hospitals and critical access hospitals (CAHs)

• Children’s Hospitals – no Medicaid minimum• CCN in 3300–3399 (77 hospitals total)• Not children’s wings of larger hospitals

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Hospital Payment Overview• Overall incentive payment amount is based on

four-year calculation• Each year’s payment is a base amount ($2M) plus

a discharge volume adjustment (accounting for change over time), scaled by a yearly factor

• Overall incentive payment is then scaled based on Medicaid share

• Actual payment spread over 3–6 years

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Medicaid Share• Based on proportion of inpatient bed days

attributable to Medicaid (fee-for-service or managed care) to overall inpatient bed days

• “Extra credit” given for charity care (in the form of a reduction in overall bed days)

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Hospital Payment Schedule• State has flexibility to determine schedule

• No more than six years• No fewer than three years

• Fastest disbursement allowable by law:• 1st year - 50% of total incentive• 2nd year - 40% of total incentive• 3rd year - 10% of total incentive

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Stage 1 EH Meaningful Use Criteria

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Core Set Menu Set

Meaningful Use Objectives 14 core objectives 5 of 10

menu set objectives

Clinical Quality Measures 15 core measures N/A

• Stage 1 objectives include required core set and menu set choices; clinical quality metrics are all required


Enrollment Process (1)

• Login to National Level Repository (NLR) 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, and– Attest to 15% contribution towards NAAC

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Medicaid EHR Incentive Timeline

• Registration for EHR Incentive Programs begins January 2011

• NY Medicaid attestation functions expected to begin mid-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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Appendices

• Contact Information• Meaningful Use Core Set of Objectives – EP• Meaningful Use Menu Set of Objectives – EP• Meaningful Use Core Set of Objectives – EH• Meaningful Use Menu Set of Objectives – EH• Clinical Quality Measures - EH

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Contact InformationJames J. Figge, MD, MBAMedical DirectorNYS Department of HealthOffice of Health Insurance ProgramsOne Commerce Plaza, Suite 826Albany, NY 12260(518) [email protected]

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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


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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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)


Stage 1 MU Criteria – EH Core Set (1)

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



disparities

Use Computerized Provider Order Entry (CPOE) for medication orders

Implement drug-drug and drug-allergy interaction checks

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

date/preliminary cause of death in the case of mortality in the hospital)

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



50




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 hospital clinical quality measures to CMS or the State



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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


health care

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

On request, provide patients with an electronic copy of their discharge instructions


Stage 1 MU Criteria – EH Menu Set (1)

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disparities

Implement drug-formulary checks

Record advance directives for patients 65 years old or older

Incorporate clinical lab test results into certified EHRs as structured data

Generate lists of patients by specific conditions


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 – EH Menu Set (2)

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health care

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)

Capability to submit electronic data on reportable (as required by state or local law) lab results to public

health agencies (one test)


EH Clinical Quality Measures

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Measure Number Identifier

EH Clinical Quality Measure: Emergency Department (ED)

ED-1NQF 0495

Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility

ED-2NQF 0497

Median time from admit decision time to time of departure from the emergency department of patients admitted to inpatient status



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EH Clinical Quality Measure: Stroke

Stroke-2NQF 0435

Ischemic stroke patients prescribed antithrombotic therapy at discharge

Stroke-3NQF 0436

Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge

Stroke-4NQF 0437

Acute ischemic stroke patients who arrive within 2 hours and for whom IV t-PA was initiated within 3 hours of time last known well

Stroke-5NQF 0438

Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2

Stroke-6NQF 0439

Ischemic stroke patients with high or unmeasured LDL, or who were on a lipid lowering medication, who are discharged with statin prescription

Stroke-8NQF 0440

Ischemic or hemorrhagic stroke patients or their caregivers who were given appropriate educational materials during the hospital stay

Stroke-10NQF 0441

Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services



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EH Clinical Quality Measure: Venous Thromboembolism (VTE)

VTE-1NQF 0371

Patients receiving VTE prophylaxis within 24 hours of admission or surgery, or have documentation why no prophylaxis was given

VTE-2NQF 0372

Patients who received timely VTE prophylaxis on admission or transfer to ICU, or have documentation why no prophylaxis was given

VTE-3NQF 0373

Patients diagnosed with confirmed VTE who received an overlap of parenteral anticoagulation and warfarin therapy

VTE-4NQF 0374

Patients diagnosed with confirmed VTE who received IV Unfractionated Heparin therapy dosages and had their platelet counts monitored

VTE-5NQF 0375

Patients diagnosed with confirmed VTE discharged on warfarin that are given appropriate written discharge instructions

VTE-6NQF 0376

Patients diagnosed with confirmed VTE during hospitalization (not present on arrival) who did not receive VTE prophylaxis

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

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