kareo - ehr meaningful use stage 1 for small practices

KAREO | CONFIDENTIAL

What Small Medical Practices Need to Know

about Meaningful Use NowWe will begin in just a bit…



about Meaningful Use NowStarting Now…


Your Hosts Today…

Barbara Drury,BA, FHIMSS, and President, Pricare, Inc.

Terry DouglasDirector Brand Marketing, Kareo


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Our Schedule for Today…

1 Introduction & Welcome Barbara

2 What Small Medical Practices Need to Know about Meaningful Use Now

3 Discover Kareo’s Role

4 Answer Questions


Barbara Drury, BA, FHIMSS

Health information technology consultant

Speaks and writes on office-based computer systems for groups like MGMA, HIMSS, & AHIMA

Appointee to the ONC’s Technical Expert Panel on Unintended Consequences of HIT adoption

Fellow of the Healthcare Information and Management Systems Society

Serves on the HIMSS Public Policy Committee

Recipient of the December 2004 and April 2009 Spirit of HIMSS award

Barbara Drury, BA, FHIMSSPresident, Pricare, [email protected]






4 Answer Questions


Disclaimers• Only Eligible Professionals (EP)• Mostly Medicare, not MA, MCD• Not Interactions between the MU program, PQRS,

ACO, eRX, SGR, Sequestration, etc.• Not combo situations (MCD program w/MCR PFS)• Rules are a starting point. CMS and ONC FAQs will

clarify nuances and change frequently• The IFR for Certification is related but not addressed

here since it is addressed towards EHR vendors


Learning Objectives

• Genealogy of “Meaningful Use”• Meaningful Use “basics”• MU2 Interim Final Rule (IFR) impact on MU1• Money stuff: Maximum Incentives and Penalties• Discussion


The Grand Plan

• The government wants to incent providers to use electronic health record (EHR) systems.

• The government wants evidence that providers are using EHRs for particular things.

• Accepting the incentive from the government is optional, not required.


What and Who Is Crafting Meaningful Use

• Congress and the President = The LAW: ARRA – American Recovery and Reinvestment Act, aka Stimulus Bill, HITECH Act (section).

• Health & Human Services, Centers for Medicare and Medicaid Services (CMS)– Secretary Sebelius– The National Coordinator, currently Dr. Farzad

Mostashari– The HIT Policy and the HIT Standards Committees– Multiple Work Groups of Volunteers


How Does This Work?

American Recovery and Reinvestment Act. Public Law 111-5• Congress and the President.• Stimulate Economy (jobs, mortgages, unemployment

benefits, “HITECH”).• February 17, 2009 signed into law. • Only changed by Congress.

1. THE LAW

Work Groups, Staff, hold hearings to inform the proposed rule.


How Does This Work?

Meaningful Use January 13, 2010 from HHS/CMS

2. THE proposed RULE

Public Comment Period ends. HHS considers comments

1. THE LAW


How Does This Work?

Meaningful Use, Certification, Privacy & Security, etc.

2. THE proposed RULE

Further guidances to clarify the interim final rule

1. THE LAW

3. THE INTERIM final RULE


How Does This Work?

Customarily 60 days after the Interim Final Rule, but sometimes sooner or

later or never (DEA on erx).

2. THE proposed RULE1. THE LAW

3. THE INTERIM final RULE4. THE effective DATE


Why Should You Care?

• Implementing and using an EHR is a life-changing event.

• An EHR may or may not be advantageous.• Electronic records are considered ‘expensive’.• Other players may expect you to use an EHR:

– Your customers (the patient)– Your staff and peers– Hospitals, payers, etc.– Public health agencies


Who May Earn the Incentive?• EP = eligible professional

– Individual physicians, not practices– Doctors, not mid-levels (some rural exceptions)– Non-hospital based plus hospital-employed physicians working in

ambulatory clinics (POS 11)

• Linked to either Medicare or Medicaid– Medicare FFS maximum = 75% of allowable charges– Medicaid fixed amounts per year provided EP meets eligibility

thresholds ( >30% for all, >20% for peds), no eligibility threshold for Medicare.

– Medicare Advantage if 80% of revenue comes from MA. If not, then MCR FFS or MCD applies

• Change incentive program once – from MCR to MCD or MCD to MCR, or MA to either MCR PFS or MCD.


The Carrots• Incentive paid after the fact.• This “maximum” could be less if you

don’t bill ‘enough’ in that year.• Medicare: Demonstrate Meaningful

Use met throughout all periods. • Medicaid differences:

– Year 1: shop and implement– Year 2: demonstrate Meaningful Use

throughout years 2 through 6.– Administered by the state.– Appeal process mandatory.


Maximum Available for MCR FFS Program?

MCR PFS $44,000 if MU all 5 yearsWhat time is it in “MU-Land”? Q2-2013 with $15,000 incentive available for Yr 1 if in 2013 calendar year, the EP bills at least $20,000 to original Medicare. If Y3 in 2013, then MCR must equal $10,667 to earn $8000 (75% of $10,667 = $8000).


Maximum Available for MCD Program?

MCD $63,750 if MU at least 6 out of 10 years (goes out to 2021)


Are You…..

In a health professional shortage area? • You may get more money.

A pediatrician with 20% to 29% Medicaid visits? • You may get less money.

Less than 80% revenue from Medicare Advantage? • You’ll need to consider MCR FFS or MCD incentives.

You were still using paper charts through 2012? • You will get less money.

Sticking with paper charts because ……? • You cannot participate in the incentive programs and beginning

2015, Medicare will pay less.


Learning Objectives



Key Lingo When Discussing MU

> Year> Stage> ARRA $$$> Report Period> MCR Fee %

= 1st, 2nd, 3rd

= MU1, MU2, MU3, MU4, etc.= Maximum incentive available= 90 days, 365 days, quarter= % of MCR PFS each EP is paid


Some Timing Concepts to Remember

MU1-2014MU 2-2014

MU1-2013MU1-2012MU1-2011

2013 CY: Vendor’s

capability to permit options for

2013 with the 2011 Edition?

Is one option more advantageous for your patients and the practice? Do you KNOW what your denominator metric is? Will you be able to ‘pick’ which denominator is to your advantage?

2014 CY: Vendor’s

capability to permit options for

MU1 with the 2014 Edition?

2011 Edition Vendor’s capability is based on

MU1 as defined in IFR of July 2010.


Tidbits: the Numerator, Denominator Thing

DENOMINATOR IS: All VisitsAll

PatientsAll

Orders MCR POS 11 Allowable $MD #1: 100 appts/week, few repeat customers 5200 2600 3900 14,000$ MD #2: 100 appts/week, mostly repeat customers 5200 870 13000 300,000$

THRESHOLD All VisitsAll

PatientsAll

OrdersMD #1: 50% 2600 1300 1950MD #2: 50% 2600 435 6500

EHR Incentive in a $12k yearMax Incentive based on MCR POS 11 Allowable $

MD #1: EHR Incentive $ 10,500 MD #2: EHR Incentive $ 12,000

PS: Numerator and Denominator are payer agnostic.


More MU Lingo to Understand• MEASURE describes the calculation and minimum

threshold you must achieve to meet the particular Core or Menu Set Measure

• CORE or MENU SET means– Core = all are required to be met– Menu Set = you can pick, with some pre-set requirements, which

Measures in the Menu Set you will report on.

• OBJECTIVE is a description of what you need to ‘do’ with the EHR

• EXCLUSION is CMS’s ‘pass’ if something doesn’t apply to your EP and your specialty. Some MEASURES have NO Exclusions.


Stage 1 (MU1) Samples

CORE MEASURE: Record smoking statusOBJECTIVE: Record smoking status for patients 13 years old or older.MEASURE: More than 50 percent of all unique patients13 years old or older seenby the EP have smoking status recorded as structured data.EXCLUSION: Any EP who sees no patients 13 years or older.

MENU SET MEASURE: Immunization Registries Data SubmissionOBJECTIVE: Capability to submit electronic data to immunization registries and actual submission according to applicable law and practice.MEASURE: Performed at least onetest of EHR’s capacity to submit electronic data to immunization registries and follow up submission if the test is successful (unless none of the registries has the capacity to receive the information electronically).EXCLUSION: An EP who administers no immunizations.


Some Measures have “children” Measures (Measure 10 – Report Clinical Quality Measures to CMS – choose 6 from 44)

shaded shows CQMs for all specialties. Differences between MU1 and MU2 CQMs.

NQF #

MU1: Table 6 for EPs

2011‐2013

MU2: Table 8 for EPs CY2014

Clinical Quality Measures for Submission by EPs (2011‐2013, choose 6 from CORE/AltCore. If NA, then fill in from other 38).

(2014‐pick 9 from 3 domains)

0421 Q‐CORE Adult Core Adult (18 yrs +) BMI and Follow‐up Plan in past 6 months or current visit

0013 Q‐CORE out for MU2 Adult (18 yrs +) VISITS for patients with diagnosis of hypertension

0028 Q‐CORE Adult Core Adult (18 yrs +) Tobacco Assessment and Cessation intervention within past 24 months

0041 Q‐CoreALT 6 mos and up

Influenza Immunization for >= 50 years old Sept through February

0024 Q‐CoreALT Peds Core Child (2 to 17 yrs) BMI and Follow‐up Plan during measure year

0038 Q‐CoreALT Peds Core Two‐year old Immunization Status by second birthday (nine rates)


CQMs (Clinical Quality Measures)• If a CQM is found to be scientifically invalid, would

take immediate action to remove without the rulemaking process, approximately annually.

• Look for CQMs that have an NQF #. Without, may mean electronic specifications are still in development

• MU1&2: must submit numerator/denominator. No threshold required.

• MU2: must be calculated by the CEHRT and reported exactly as generated by the CEHRT, even if not all relevant data is recorded in the CEHRT


CQMs, continued• MU2: must only report on CQMs that the EHR is

certified for. If not certified for NQF 0049 then EP cannot report on NQF 0049. CQM an important rule out when choosing EHR.

• The EHR Vendor will choose which CQMs it wants to be certified for (MU1 not all 44 are required for certification, minimum of 9. MU2 not all 64 are required for certification, minimum of 20)

• The CEHRT must capture, export, electronically submit accurate data elements as specified in the Certification IFR

KAREO | CONFIDENTIAL 33Cardiology =1 of 11

Peds =2 of 3

OB/Gyn =3 of 7

Meets “minimum 9 of 44 CQMs”


Learning Objectives



Clarifications for MU1 in the IFR for MU2

• This IFR was effective upon publication in Federal Register: 9/4/12.

• Reaffirmed that if less than 75% of all EPs in US are meaningful users by 2015, then MCR penalties can go up to 5% (95% of full allowable PFS)


Clarifications for MU1, Part 2• MU1 allowed ‘picking’ a menu option and then

taking the exclusion for that same menu option. Beginning in 2014, if still MU1, then OK to claim an exclusion but MUST pick another from the Menu options for MU1.

• Makes a clarification between Stages of MU (MU1 and MU2) and ‘edition’ of the certified EHR (2011 edition or 2014 edition)

• Clarified that for some measures, in the year 2014, the measure will be the same for MU1 and MU2


Clarifications for MU1, Part 3• Leaving a ‘list’ blank does not qualify, i.e.”no

allergies”, “no medications”, “no problems/diagnoses”

• CPOE for MU1 = medication orders for ‘patients’ – the denominator was patients. Alternate denominator for MU1 year is ‘medication orders’

• Vitals for MU1 = H/W/(BMI)/BP. Alt. for 2013 MU1, option H/W/(BMI) or BP. Exclusion is if not relevant, not if you don’t have a scale or BP cuff. Ask referring provider, ask patient is OK. Ages 3 and up. Also rolled into 2014 forward.


Clarifications for MU1, Part 4• Test of Exchange for MU1 = in for 2011, in for 2012,

out for 2013 of MU1 (on-going required).• If 2014 is still MU1, then ‘electronic copy to patient’

is removed and ‘timely access’ is removed. MU1 beginning in 2014 will be replaced with “view online, download, and transmit”. Means portal in 2014 for MU1 if late adopter (Yr 1 = 2013, or Yr 1 = 2014)

• Public Health Objectives (Immunizations or Syndromic Surveillance, 1 of 2 in menu set). Added “except where prohibited by law”; if not prohibited, then pick one. CMS thinks everybody ‘should’.


Wii Anyone?


Learning Objectives



Some Incentive $$$ FYIs• At HIMSS Policy Summit, 9/12/2012, Dr.

Mostashari said the incentives were, basically, an entitlement program: you do, therefore you get.

• Fine print in ARRA – each year’s incentive is a maximum, not a guarantee– Sequestration (budget cuts across the board) and

SGR can impact the max


MAXIMUM Allowable Charges for

Incentive Calc 0.7590 days of charges

365 days of charges

$ 24,000 $ 18,000 Yr 1 + 2014all other

years of MU

$ 20,000 $ 15,000 Yr 1 + 2014all other

years of MU

$ 16,000 $ 12,000 Yr 1 + 2014all other

years of MU

$ 10,667 $ 8,000 Yr 1 + 2014all other

years of MU

$ 5,333 $ 4,000 Yr 1 + 2014all other

years of MU

$ 2,666 $ 2,000 Yr 1 + 2014all other

years of MU

365 days of MU, 365

days of charges

Links: Period, Charges, Amounts in MCR

90 days of MU, 365 days of charges


Incentive or Penalty (for a $12k year)EHR Reporting Period Lots of MCR Smidge MCRAllowable Charges $ 100,000 $ 13,000 Maximum Incentive $12k is up to 75% of $16k $ 16,000 $ 16,000 Maximum Incentive = $ 12,000 $ 9,750 Incentive

VERSUSAllowable Charges $ 100,000 $ 13,000 LESS Penalty (98% of fee schedule) $ (2,000) $ (260) Penalty

NET Allowable Charges $ 98,000 $ 12,740

Lots of MCR Smidge MCR

"….to EHR, or" 12,000$ 9,750$ "not to EHR" (2,000)$ (260)$

• To EHR: costs, workflow changes, people impact• Not to EHR: stuck on penalty step, other payers participation, other members of the care team, patients


Show me the $$$ (or not?)• Begins 2015 and goes from 100% PFS in 2014 to 99% in

2015, 98% in 2016, 97% in 2017.• Once a penalty is applied, you can never go back to 100%

but are stuck at that penalty level.• Applies to entire PFS, not just office encounters• If less than 75% of the US EPs are NOT MUs in 2017,

then 96% in 2018, 95% in 2019.– Hospital-based EPs are excluded from the 75%

• CMS look-back is generally two years prior, or July 1st

prior to penalty year– Avoid overpayment and refund issues with CMS systems and

banking– Avoid beneficiary over/under co-insurance issues


Hardship Exemptions• Case-by-case by Secretary of HHS, max of 5

years by law, designated annual by the IFR• No exemption for EPs over 60, or for part-time

EPs• Identified Hardships in IFR

– Lack of internet (4mb), annual re-apply– Newly-practicing EP gets 2 years from EP date (changing

specialty does not count)– Scope of practice: i) no face to face w/patients or no follow-

up needed, anesthesiology, pathology, radiology in non-hospital settings (5 years), ii) 50%+ in ASC or NH w/o CEHRT, (1 year)


Other Hardships Identified

• Extreme Hardships listed:– Practice closes– Hospital closes– Natural disaster that “destroys EHR”– EHR vendor out of business– EHR vendor unable to get certified for next stage– EP in a debt consolidation or bankruptcy process

• IFR recommends if anticipating any of these in 2013, apply to the Secretary in early 2013 to avoid penalty in 2015


Penalty Timing Concepts (for MCR)

ARRA $$$ Incentive Years

1 2 3 4 5ARRA Drop-dead $$$ Year

2016 last ARRA payment if started by 2014

MCR Penalty STARTS

2015 MCR Penalty 99% of PFS

3 4 5 6 72-year look-back for MU

NOTE: Dip-in, Dip-out doesn’t stop the Incentive $$$ countdown

6MUST adopt no later than 2014


‘Playing’ Medicare Penalty BINGO• Cell colors: Green = Stage 1 (MU1), Yellow = Stage 2 (MU2),

Light red = Stage 3 (MU3), Grey = Stage 4 (MU4)• Order of text within cells (upper right double-lined cell)

– Participation Year (YR 1, YR 2, YR 3, etc.)– MU Stage (MU1, MU2, MU3, MU4, MU5 (really!))– ARRA Incentive $$$ (at maximum)– EHR Reporting Period (90 day or 365 day)– Medicare PFS either 100%/na/no penalty or 99%, 98%, 97%– Comment

• Row 6: Example of a dip-in, dip-out EP• Many other variations not shown but can be developed

KAREO | CONFIDENTIAL 49

MCR only

2011 2012 2013

2014 ALL using 2014 edition of EHR, 90

days

2015 20162017

?75% of US EPs?

2018 2019 2020 2021

1. Start 2011YR 1, MU 1,

$18k, 90 days, Penalty=na

YR 2, MU 1, $12k, 365 days, Penalty = na

YR 3, MU 1, $8k, 365 days,

Penalty = na

YR 4, MU 2, $4k, 90 days, Penalty

= na, 2014 edition

YR 5, MU 2, $2k, 365 days,

Penalty = 0% if MU in 2013

YR 6, MU 3, no $$$, 365 days or ?, Penalty = 0% if MU in

2014


2015

YR 8, MU 4?, no $$$, 365 days or ?, no penalty if MU in 2016


2. Start 2012 > > > > > > > >YR 1, MU 1,


YR 2, MU 1, $12k, 365 days, Penalty = na


= na, 2014 edition

YR 4, MU 2, $4k, 365 days,

Penalty = 0% if MU in 2013

YR 5, MU 3, $2k, 365 days or ?, Penalty 0% if MU in 2014


2015



3. Start 2013 > > > > > > > > > > > > > > > >YR 1, MU 1,

$15k, 90 days, penalty=na

YR 2, MU 1, $12k, 90 days, penalty=na, 2014 edition

YR 3, MU 2, $8k, 365 days,

Penalty 0% if MU in 2013

YR 4, MU 2, $4k, 365 days,

Penalty 0% if MU in 2014


2015


2016



6. Start in 2012 but not 2013, not 2016

> > > > > > > >YR 1, MU 1,


YR 2, NOT MU for this year (2013), 365

days, penalty=na


= na, 2014 edition

YR 4, MU 2, $4k, 365 days,

Penalty 99%, not MU in 2013

YR 5, NOT MU for this year (2016), 365 days, penalty 99% (prior yr)


2015

YR 7, MU 4, no $$$, 365 days or ?, Penalty = 98% not MU in

2016

YR 8, MU 4?, no $$$, 365 days or ?, penalty

98% MU in 2017

YR 9, MU 4?, no $$$, 365 days or ?, penalty 98% if MU in

2018

> Year> Stage> ARRA $$$> Report Period> MCR Fee %> Comment

ROW 1 & ROW 2: Early EHR Meaningful Users, no missed years of MU Measures

ROW 3: Later EHR Meaningful Users, no missed years of MU MeasuresROW 6: Later EHR MU, but missed MU in 2013 and missed MU in 2016

© 2013 Pricare Inc.99% 99% 99% 98% 98% 98%


A Peek at the Impact of the 2% from Sequestration

50

Visit Calculation No Sequestration With SequestrationBilled to Original Medicare 200.00$ 200.00$ MCR Allowable for 99214 153.00$ 153.00$ Sequestration 2% new 'allowable' ‐$ 149.94$ MCR 80% (122.40)$ (119.95)$ Patient/2nd 20% (30.60)$ (29.98)$ Adjustment down to Allowable (47.00)$ (50.06)$

In a $12k Incentive Year No Sequestration With SequestrationBilled allowable required 16,000.00$ 16,000.00$ # of visits required to generate $16k in allowable charges

105 visits @$153 ea 107 visits @$149.94 ea

Incentive Earned 12,000.00$ 12,000.00$


Way too much, right?

And + or - really does depend on Your perspective (and the ‘others’ from

“Who cares?”)






4 Answer Questions


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