ny medicaid hitechehr incentive program james j. figge, m.d., m.b.a. medical director, office of...
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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
NY MedicaidHITECH 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
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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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 MedicaidHITECH EHR Incentive Program
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.
NY MedicaidHITECH EHR Incentive Program
eRx Incentive Requirements
• Prescriber– must have an individual NPI, and – must be enrolled in Medicaid fee-for-
service (FFS)
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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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 MedicaidHITECH EHR Incentive Program
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 MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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.
NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
Enrollment Process (1)
• Login to CMS Registration website:– Supply demographic/financial information– Select program (Medicare/Medicaid)– Select state
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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
Medicare Penalties for Not Achieving Meaningful Use
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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
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
NY MedicaidHITECH EHR Incentive Program
Stage 1 MU Criteria – EP Core Set (2)
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Health Outcomes Policy Priority Stage 1 Meaningful Use Objective (EPs)
Improving quality, safety, and
efficiency, and reducing health
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
NY MedicaidHITECH EHR Incentive Program
Stage 1 MU Criteria – EP Core Set (3)
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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 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
NY MedicaidHITECH EHR Incentive Program
Stage 1 MU Criteria – EP Menu 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
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
NY MedicaidHITECH EHR Incentive Program
Stage 1 MU Criteria – EP Menu Set (2)
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Health Outcomes Policy Priority Stage 1 Meaningful Use Objective (EPs)
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)
NY MedicaidHITECH EHR Incentive Program
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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NY MedicaidHITECH EHR Incentive Program
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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