Transcript The New HIPAA Privacy and Security Amendments

HITECH Act and EHR
Stimulus Payments
Gerald “Jud” DeLoss
Susan E. Ziel
Disclaimer
This content is provided for general
information purposes and is not intended
as legal advice. Competent legal counsel
should be sought before taking any action
in reliance on this content.
Copyright © 2010
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Background and History
 Health Information Portability and Accountability
Act of 1996
 Privacy Regulations (2003)
 Security Regulations (2005)
 American Recovery and Reinvestment Act of
2009 (“ARRA”) (2/17/09)
 Title XIII: Health Information Technology for Economic
and Clinical Health Act (“HITECH”)
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CMS EHR Meaningful Use
 Notice of Proposed Rule-making (NPRM)
announced December 30, 2009 and published
January 13, 2010
 NPRM comment period closed March 15, 2010
 Separately, on January 13, 2010, Office of the
National Coordinator (ONC) issued Initial Set of
Standards, Implementation Specifications, and
Certification Criteria for EHR Technology
 On March 10, 2010, ONC issued NPRM on
establishment of certification programs for HIT
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Overview of EHR Incentive
Program NPRM
 Defines “meaningful use” for purposes of
qualifying for incentive payments and
avoiding reductions
 Medicare
 Medicare Advantage
 Medicaid
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Key Items for Incentives
 Medicare and Medicaid are distinct programs
 Key Distinctions
 Eligibility differs
 Payment structures and amounts are different
 Incentive payments may be available sooner through
Medicaid
 Medicaid programs will depend upon State actions
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Eligible Professionals

Medicare Eligible Professionals (EPs)
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Doctors of osteopathy (D.O.s), medical doctors (M.D.s), dentists, podiatrists, optometrists,
and chiropractors
Medicare Advantage (MA) Eligible Professionals (EPs)

Medicare EP who is either



Medicaid Eligible Professionals (EPs)

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M.D.s, D.O.s, dentists, certified nurse midwives, nurse practitioners, and physician assistants
in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) led by a
physician assistant
Hospital-based professionals are excluded

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Employed by a qualifying MA organization
Employed by or a partner of an entity that through a contract with a qualifying MA organization
furnishes at least 80% of entity’s Medicare patient services to enrollees of the MA organization
Exclude EPs who furnish 90% or more of their covered professional services in an inpatient
hospital, outpatient hospital, or emergency room of a hospital.
Site of service code used for determination
Medicaid providers practicing predominantly in an FQHC or RHC are not subject to the
hospital-based exclusion
An EP is identified by his/her unique National Provider Identifier (NPI)
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MA EPs
 MA EPs must meet threshold
requirements
 Furnish at least 80% of professional services
covered under Medicare to enrollees of a
qualifying MA organization
 Furnish on average at least 20 hours per
week of patient care services to enrollees of
the qualifying MA organization during the
reporting period
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Medicaid EPs
 Medicaid EPs must meet one of the
following for each year he/she is seeking
incentive payment
 Minimum of 30% Medicaid Patient Volume
 Pediatrician with a minimum of 20% Medicaid
Patient Volume
 Over 50% of patient encounters in a FQHC or
RHC and have minimum of 30% of volume be
attributable to Needy Individuals
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Eligible Hospitals
 Medicare
 “Subsection (d) hospitals” that are paid under the hospital
Inpatient Prospective Payment System (IPPS)
 Includes Medicare FFS and MA participants and Critical Access
Hospitals (CAHs)
 Psychiatric, rehabilitation, long term care, children’s, and cancer
hospitals are excluded
 Medicaid
 Only acute care hospitals and children’s hospitals are eligible
hospitals
 A hospital is determined by its unique CMS Certification
Number (CCN)
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MA Eligible Hospitals
 MA Affiliated Eligible Hospitals are EHs
 Under common corporate governance with a
qualifying MA organization
 More than 2/3 of Medicare beneficiary
patients are enrolled under MA plans
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Medicaid Eligible Hospitals
 Medicaid Eligible Hospitals are EHs
 Acute care hospital must have at least 10%
Medicaid Patient Volume for each year
 Children’s hospitals are exempt from a Patient
Volume threshold
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Program Selection
 Eligible Professionals may participate in only
one program: Medicare or Medicaid
 A one-time only switch between programs is
permitted prior to 2015
 If eligible, hospitals may participate in both
programs simultaneously
 If a provider serves a multi-state population and
participates in the Medicaid program, the
provider can participate only in the Medicaid
incentive program through a single State in any
year
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Certified EHR Technology
 Certification criteria as set forth by ONC
 Even if EHR satisfies those requirements, if not
certified, then not sufficient
 Options for EHRs
 Complete EHR: All-in-one EHR solution that is
certified to meet all criteria
 EHR Module: Any service, component or
combination thereof that is certified to meet at least
one criterion
 May include, software as service, interface allowing
participation in health information exchange, quality measure
reporting service
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Certified EHR Technology
 Utilization of EHR Modules
 It is the responsibility of the EP or EH to ensure that
EHR modules are certified
 Each EHR Module certified
 All criteria among modules certified
 Utilization of Certified EHR Technology
 Limited to qualifying for incentives
 Does not mean all HIPAA or other legal requirements
are satisfied
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Meaningful Use Stages
 Meaningful Use defined in three stages
 Stage 1 -- deadline 2011
 Capture health information in coded format
 Use information to track key clinical conditions and
communicate for care purposes
 Implement clinical decision support
 Report clinical quality measures and public health information
 Stage 2 -- deadline 2013
 Likely require the exchange (transmission and receipt) of
data
 Stage 3 -- deadline 2015
 Criteria expected to target more systemic health care
improvements
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Stages
Progression through Stages
First
Payment
Payment Year
Year
2011
2012
2013
2014
2011
Stage 1 Stage 1 Stage 2 Stage 2
2012
Stage 1 Stage 1 Stage 2
2013
Stage 1 Stage 2
2014
Stage 1
2015
2015
Stage 3
Stage 3
Stage 3
Stage 3
Stage 3
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Stage 1
 Improve quality, safety, and efficiency of
healthcare and reduce disparities
 Engage patients
 Improve care coordination
 Improve public health
 Ensure privacy and security of PHI
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Stage 1 Criteria
 Eligible Professionals
 25 objectives and measures
 8 measures require “Yes” or “No” as structured data
 17 measures require usage of numerator and
denominator
 Eligible Hospitals
 23 objectives and measures
 13 measures require numerator and denominator
 Reporting period is 90 days for year one and
one year thereafter
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Quality Measures
 Preventive care and screening
 Blood pressure management
 Drug avoidance among elderly patient
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Quality Measures for Specialty EPs

Specific quality measures

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

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Cardiology
Podiatry
Radiology
Gastroenterology
Neurology
OB/GYN
Ophthalmology
Primary Care
Nephrology
Pediatrics
Nephrology
Endocrinology
Oncology
Psychiatry
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Quality Measures for EHs
 EHs under Medicare/MA to report
summary data to CMS
 EHs under Medicaid to report directly to
states
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Incentive Payments
 Eligible Professionals
 75% of charges for Medicare-covered services for the
year, capped at annual maximum
 Cap depends on:
 Year in which provider first qualified for the incentive payment
(first payment year)
 Number of years the provider has earned the incentive
 Providers who furnish services in a geographic
Health Professional Shortage Area (HPSA) are
eligible for a 10% increase
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Medicare Payments to EPs
 Highest payments to early adopters (2011 and 2012),
with gradual reduction
Calendar Year
First Calendar Year in which EP Receives an Incentive Payment
2011
2012
2013
2014
2015 +
2011
$18,000
-
-
-
-
2012
$12,000
$18,000
-
-
-
2013
$8,000
$12,000
$15,000
-
-
2014
$4,000
$8,000
$12,000
$12,000
-
2015
$2,000
$4,000
$8,000
$8,000
$0
2016
-
$2,000
$4,000
$4,000
$0
Total Potential
Incentive
Payment
$44,000
$44,000
$39,000
$24,000
$0
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Payment Timing
 Payment Years
 For Medicare EPs, a payment year is a calendar year beginning
on January 1, 2011
 For Eligible Hospitals and critical access hospitals, the federal
fiscal year -- FY 2011 begins on October 1, 2010
 For Medicaid programs, payment availability can begin as early
as October 2010
 For purposes of incentive payments, the first payment
year is the year for which the first incentive payment is
received
 First Medicare payment for EPs can be no earlier than
January 2011 and EHs October 2010
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Eligible Hospital Payments

Formula
 Primarily focused on hospital discharges
 Also factors in Medicare share, which considers the amount of charity care, and
percentage of Medicare-covered inpatient days related to the hospital’s total
number of inpatient days
 Discharges will vary based on numbers of discharges in the year, between a floor
of less than 1,150 discharges and a ceiling of 23,000 discharges


Hospitals may qualify for financial incentive payments for four consecutive
years
Incentive payments will be reduced each year


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The first year, 100% of calculated incentive payment
In the second year, only 75%
50% in the third year
25% in the fourth year
Hospitals that become meaningful users later (after FY 2013) will either
receive reduced payments or be ineligible for any incentives
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Medicaid EP Payments
 85% of “net average allowable costs” costs for EHR
 “Net average allowable costs” is term to be defined by Secretary
 “Net average allowable costs” capped at $25,000 for first
year and $10,000 in each of five for subsequent years
 Pediatricians with under 30% Medicare patient volume may
receive only 2/3 of these amounts
 Maximum incentive of $63,750 (85% of $75,000), over a
6-year period
 Medicaid EPs must begin receiving incentive payments
no later than CY 2016
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Medicaid Eligible Hospital
Payments
 Payments are similar to the calculation for
Medicare hospital incentive payments
 Incentive amount calculated using an EHR amount
multiplied by Medicaid share
 EHR amount largely based on discharge volume
 States may pay up to 100% of the aggregate
EHR hospital incentive amount over a minimum
of a 3-year period and a maximum of a 6-year
period
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Planning for Payments
 Strategies for maximizing incentive payments
 EHR adoption generally takes 1 ½ to 2 years
 Start the selection process now
 Determine which program best suits you
 Vendors will be hard-pressed to meet deadlines
 Ensure that contracts are tightly written
 Engage legal team and consultants to ensure
technology, certification, and eligibility
requirements are met
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Questions?
Gerald “Jud” DeLoss
(312) 423-9307
[email protected]
Susan Ziel
(317) 238-6244
[email protected]
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