Wednesday, September 23, 2009

Meaningful Use for Specialists

I was recently asked how specialists, such as pediatric surgeons with few Medicare or Medicaid patients, can participate in ARRA and implement EHRs with meaningful use.

First, let's review how ARRA stimulus payments work:

Medicare incentive payments are capped at 75% of allowable Medicare charges, up to $18,000 for the first payment year. Incentive payments are reduced in subsequent years: $15,000, $12,000, $8,000, $4,000, and $2000.

For eligible professionals in a rural health professional shortage area, the incentive payment amounts are increased by 10 percent.

Physicians who do not adopt/use a certified EHR will face reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and -3% in 2017 and beyond. ARRA allows HHS to increase penalties beginning in 2019, but penalties cannot exceed -5%. Exceptions can be made on a case-by-case basis for significant hardships (i.e. rural areas without sufficient Internet access).

What does 75% of allowable Medicare charges really mean? A provider's office which has allowable Medicare charges totaling $24k or more can receive the full $18k in ARRA stimulus money. A provider with $13.3k in allowable Medicare charges is eligible for only $10k in ARRA stimulus money. Several providers have told me that an office needs about 7-8% of their patients to be Medicare beneficiaries to receive the full stimulus.

Office-based physicians whose patient mix includes at least 30 percent Medicaid beneficiaries are eligible for up to $63,750 over six years, as long as they are able to demonstrate "meaningful use" of healthcare IT. A lower 20 percent threshold applies to pediatricians.

Physicians who predominantly practice at Federally Qualified Health Centers and other settings can qualify if 30 percent of their patient base is characterized as "needy," including those covered by Medicaid, those who receive uncompensated care and patients who are charged income-related, sliding-scale fees.

Providers cannot participate in both the Medicare and Medicaid programs - they must choose one.

My interpretation of ARRA and everything I'm hearing from Washington suggests that the Interim Final Rule and Notice of Proposed Rulemaking planned for December are not likely to change this.

What is the alternative?

In my experience, the private sector and government need to collaborate to accomplish societal change. Private payers need to support clinicians who do not qualified for ARRA incentives. Why?

EHRs reduce cost and enhance quality via care coordination, reduction of redundant testing, and decision support that results in the right care at the right time. The largest portion of the financial benefits of EHRs accrue to payers. Payers should gainshare this savings with clinicians.

Malpractice insurers are another possible source of incentives. The Harvard affiliated clinicians are covered by a self insured risk management pool administered by CRICO/Risk Management Foundation. In discussions with CRICO, I learned that a large proportion of malpractice assertions arise from test results that are not reviewed/acted upon and by referral workflow that is never completed i.e. a PCP and specialist do not coordinate the patient's care. Meaningful use emphasizes the need to implement electronic lab workflow, decision support, and care coordination. If specialists, such as those with few Medicare and Medicaid patients, participate in EHR implementation and healthcare information exchange, it is highly likely that malpractice assertions will decrease.

This blog is a call to the private sector - private payers and malpractice insurers have much to gain from EHR and Healthcare Information Exchange adoption. It's time to gainshare and fill the ARRA donut hole, ensuring that all clinicians, including specialists with few Medicare and Medicaid patients, are meaningful users of healthcare information technology.


Anonymous said...


I read your blog daily, constantly impressed with the insight you deliver. Unfortunately, today I am a bit surprised by your stance. Maybe I underestimate your clout with the private sector (and if I do, my apologies), but to assert that without any external pressure the payers and insurers will gainshare is on the verge of laughable. All this heavy lifting is being done on the clinician side without any real forced change to the payer/insurers. If I were in their shoes, I would see this as what it is, a windfall. I am not in their shoes, so it is just another case of letting a profitable private industry continue to benefit from the fruits of the labor of masses and the incentives provided by our federal gov't.

Chip Hart said...

Why focus on just the pediatric sub-specialists? How about plain ol' pediatricians, who take an inordinate number of Medicaid patients but don't participate in Medicare?

The overwhelming focus on the ARRA payments is, at best, a distraction.

I wrote a piece about pediatricians and ARRA for the AAP's SOAPM newsletter a little while back - some of the then-unknowns are now known, but it doesn't change the fundamental premise: most physicians, and especially pediatricians, would be better off financially and clinically by increasing their productivity by 1-2% and purchasing the right EHR...rather than racing to get the "free" money and purchasing the wrong one.

Anonymous said...

Obviously, "pediatric -insert any specialty here-" would not treat the Medicare population. However, I would be interested in reading an entry on your blog about what the ONC HIT Policy and Standards Committees are doing to address meaningful use criteria for (non-pediatrics) specialists in non-hospital settings who, in fact, do see many Medicare patients -- more so than many primary care physicians in non-hospital settings.

John Lynn said...

So, you're original question was "I was recently asked how specialists, such as pediatric surgeons with few Medicare or Medicaid patients, can participate in ARRA and implement EHRs with meaningful use."

The short answer is "You can't get any ARRA money."

My addition is "That might be the very best thing that can happen to you since you can focus on choosing the right EHR and not the stimulus money."

Anonymous said...

I too, like the Sept 23rd post says, am skeptical that payors will move forward and do their part. In our project, we are working with a host of convened payors who never cease to amaze me with their lack of initiative, slow moving processes, and their desire to sit on the sidelines while the (EHR) opportunity of a lifetime passes them by... They don't seem to realize that if they don't participate in this monumentous focus on EHR adoption, they will be forever relegated to claims based data analysis (awful), and rising cost of premiums that they will have a hard time passing off to employers.
The time has come for payors to get in the game in a real and meaningful way, as opposed to the toe-dipping "pilots" (tools of appeasement, I think) they hide behind now.