MSSNY Town Hall Seminars:
The Road to Meaningful Use and
The HITECH EHR Incentive Program
The Medicaid Incentive Program:
Collaborate for Better Patient Care
James J. Figge, M.D., M.B.A.
Medical Director, Office of Health Insurance Programs
January, 2011
NY Medicaid
HITECH EHR Incentive Program
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
NY Medicaid
HITECH EHR Incentive Program
2
Objectives
Upon 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.
NY Medicaid
HITECH EHR Incentive Program
3
Electronic Prescribing
• Nationwide:
– In 2009, 12% of the
1.63B original
prescriptions were
transmitted electronically
• Accelerating trend:
– 2007-2008: +130%
– 2008-2009: +181%
Source: 2009 National Progress Report on E-Prescribing, Surescripts LLC.
NY Medicaid
HITECH EHR Incentive Program
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NY Medicaid eRx Incentive
Provides an incentive payment for dispensed
ambulatory Medicaid e-prescriptions
Eligible Practitioners
Prescriber Incentive
Physicians (M.D./D.O.)
$0.80
per prescription/refill*
Dentists
Nurse Practitioners
Pharmacy Incentive
Podiatrists
$0.20
Optometrists
per prescription/refill*
Licensed Midwives
* Max 1 original plus 5 refills
per 180-day period.
NY Medicaid
HITECH EHR Incentive Program
5
eRx Incentive Requirements
• Prescriber
– must have an individual NPI, and
– must be enrolled in Medicaid fee-forservice (FFS)
NY Medicaid
HITECH EHR Incentive Program
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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
NY Medicaid
HITECH EHR Incentive Program
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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
NY Medicaid
HITECH EHR Incentive Program
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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
NY Medicaid
HITECH EHR Incentive Program
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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
NY Medicaid
HITECH EHR Incentive Program
10
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
NY Medicaid
HITECH EHR Incentive Program
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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)
NY Medicaid
HITECH EHR Incentive Program
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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
NY Medicaid
HITECH EHR Incentive Program
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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
NY Medicaid
HITECH EHR Incentive Program
14
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
NY Medicaid
HITECH EHR Incentive Program
15
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
NY Medicaid
HITECH EHR Incentive Program
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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”
NY Medicaid
HITECH EHR Incentive Program
17
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
NY Medicaid
HITECH EHR Incentive Program
18
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
NY Medicaid
HITECH EHR Incentive Program
19
How Much is Available?
All Practitioners
Pediatricians
(at least 30% Medicaid/needy)
(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
$42,500
Note: program participation years do not need to be contiguous.
NY Medicaid
HITECH EHR Incentive Program
20
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
NY Medicaid
HITECH EHR Incentive Program
21
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
NY Medicaid
HITECH EHR Incentive Program
22
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*
* States may request permission from CMS to mandate
certain public health reporting options
NY Medicaid
HITECH EHR Incentive Program
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Defining Meaningful Use
• HITECH Act specifies three components:
– Electronic prescribing
– Electronic exchange of health information
– Submission of clinical quality measures
NY Medicaid
HITECH EHR Incentive Program
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Stage 1 EP Meaningful Use Criteria
• Stage 1 meaningful use objectives and clinical
quality measures include required core set
and menu set choices
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
NY Medicaid
HITECH EHR Incentive Program
25
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
NY Medicaid
HITECH EHR Incentive Program
26
EP Clinical Quality Measures
NQF Measure Number/
PQRI Implementation Number
EP Clinical Quality Measure
(Core Set)
NQF 0013
Hypertension: Blood pressure measurement
NQF 0028
Preventive Care and Screening Measure Pair:
a) Tobacco Use Assessment
b) Tobacco Cessation Intervention
NQF 0421
PQRI 128
Adult Weight Screening and Follow-up
NY Medicaid
HITECH EHR Incentive Program
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EP Clinical Quality Measures
NQF Measure Number/
PQRI Implementation Number
EP Clinical Quality Measure
(Alternate Core Set)
NQF 0024
Weight Assessment and Counseling for
Children and Adolescents
NQF0041
PQRI 110
Preventive Care and Screening:
Influenza Immunization for
Patients 50 Years Old or Older
NQF 0038
Childhood Immunization Status
NY Medicaid
HITECH EHR Incentive Program
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Enrollment Process (1)
• Login to CMS Registration website:
– Supply demographic/financial information
– Select program (Medicare/Medicaid)
– Select state
NY Medicaid
HITECH EHR Incentive Program
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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
NY Medicaid
HITECH EHR Incentive Program
30
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
NY Medicaid
HITECH EHR Incentive Program
31
Medicaid EHR Incentive Timeline
• Last year to initiate participation is 2016
• Participants may skip a year, but no payments
will be issued after 2021
NY Medicaid
HITECH EHR Incentive Program
32
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
$2,000
$4,000
$4,000
$0
$44,000
$39,000
$24,000
$0
CY 2016
TOTAL
$44,000
Additional 10% Incentive Payment for Medicare EPs Practicing in HPSAs
NY Medicaid
HITECH EHR Incentive Program
33
Medicare Penalties for Not
Achieving Meaningful Use
0%
-1%
-2%
2015
2016
2017
2018 and
beyond
-1%
-2%
-3%
-3%
-4%
-5%
up to
-5%
-6%
NY Medicaid
HITECH EHR Incentive Program
34
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
NY Medicaid
HITECH EHR Incentive Program
35
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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
NY Medicaid
HITECH EHR Incentive Program
36
Contact Information
For New York State Department of Health:
James J. Figge, M.D., M.B.A., Medical Director
NYS Department of Health,
Office of Health Insurance Programs
One 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) 465-8085
NY Medicaid
37EHR Incentive Program
HITECH
37
Stage 1 MU Criteria – EP Core Set (1)
Health Outcomes
Policy Priority
Stage 1 Meaningful Use Objective (EPs)
Use Computerized Provider Order Entry (CPOE) for
medication orders
Improving quality,
safety, and
efficiency, and
reducing health
disparities
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
NY Medicaid
HITECH EHR Incentive Program
38
Stage 1 MU Criteria – EP Core Set (2)
Health Outcomes
Policy Priority
Stage 1 Meaningful Use Objective (EPs)
Maintain active medication list
Maintain active medication allergy list
Improving quality,
safety, and
efficiency, and
reducing health
disparities
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
NY Medicaid
HITECH EHR Incentive Program
39
Stage 1 MU Criteria – EP Core Set (3)
Health Outcomes
Policy Priority
Stage 1 Meaningful Use Objective (EPs)
Improve care
coordination
Capability to exchange key clinical information
electronically among providers of care and patientauthorized 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
NY Medicaid
HITECH EHR Incentive Program
On request, provide patients with an electronic copy
of their health records
Provide patients with clinical summaries for each
office visit
40
Stage 1 MU Criteria – EP Menu Set (1)
Health Outcomes
Policy Priority
Stage 1 Meaningful Use Objective (EPs)
Implement drug-formulary checks
Improving quality,
safety, and
efficiency, and
reducing health
disparities
Improve care
coordination
NY Medicaid
HITECH EHR Incentive Program
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
41
Stage 1 MU Criteria – EP Menu Set (2)
Health Outcomes
Policy Priority
Engage patients and
families in their
health care
Improve population
and public health
NY Medicaid
HITECH EHR Incentive Program
Stage 1 Meaningful Use Objective (EPs)
Provide patients with timely electronic access
to their health information
Use certified EHR technology to identify patientspecific education resources and provide to patient
as appropriate
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)
42
CQM: EP Menu Set (1)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Diabetes: Hemoglobin A1c Poor Control
Diabetes: LDL Management and Control
Diabetes: Blood Pressure Management
Heart Failure : ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction
Coronary Artery Disease: Beta-Blocker Therapy for Patients with Prior MI
Pneumonia Vaccination Status for Older Adults
Breast Cancer Screening
Colorectal Cancer Screening
Coronary Artery Disease: Oral Antiplatelet Therapy
Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
Anti-depressant medication management
Primary Open Angle Glaucoma: Optic Nerve Evaluation
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level
of Severity of Retinopathy
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care
Asthma Pharmacologic Therapy
Asthma Assessment
Appropriate Testing for Children with Pharyngitis
Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen
Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
NY Medicaid
HITECH EHR Incentive Program
43
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CQM: EP Menu Set (2)
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate
Cancer Patients
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
Diabetes: Eye Exam
Diabetes: Urine Screening
Diabetes: Foot Exam
Coronary Artery Disease: Drug Therapy for Lowering LDL-Cholesterol
Heart Failure : Warfarin Therapy Patients with Atrial Fibrillation
Ischemic Vascular Disease: Blood Pressure Management
Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic
Initiation and Engagement of Alcohol and Other Drug Dependence
Prenatal Care: Screening for Human Immunodeficiency Virus
Prenatal Care: Anti-D Immune Globulin
Controlling High Blood Pressure
Cervical Cancer Screening
Chlamydia Screening for Women
Use of Appropriate Medications for Asthma
Low Back Pain: Use of Imaging Studies
Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
Diabetes: Hemoglobin A1c Control (<8.0%)
NY Medicaid
HITECH EHR Incentive Program
44
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