Differences Between the Medicare and Medicaid EHR Incentive Programs

With the exception of dually-eligible hospitals, providers can only participate in one of the EHR Incentive Programs—Medicare or Medicaid—each year. This listserv message outlines key differences between the Medicare and Medicaid EHR Incentive Programs to help you determine which EHR Incentive Program is right for you.

Who is eligible?

For the Medicare EHR Incentive Program, eligible participants include: Doctors of medicine or osteopathy Doctors of dental surgery or dental medicine Doctors of podiatry Doctors of optometry Chiropractors "Subsection (d) hospitals" in the 50 states or DC that are paid under the Inpatient Prospective Payment System (IPPS) Critical Access Hospitals (CAHs) Medicare Advantage (MA-Affiliated) Hospitals

For the Medicaid EHR Incentive Program, eligible participants include: Physicians (primarily doctors of medicine and doctors of osteopathy) Nurse practitioners Certified nurse-midwives Dentists Physician assistants who furnish services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant Acute care hospitals (including CAHs and cancer hospitals) with at least 10% Medicaid patient volume Children's hospitals (no Medicaid patient volume requirements)

Dually-Eligible Hospitals

If you represent a hospital that meets all of the following qualifications, you are dually-eligible for the Medicare and Medicaid EHR Incentive Programs:

• You are a subsection(d) hospital in the 50 U.S. States or the District of Columbia, or you are a CAH; and


• You have a CMS Certification Number ending in 0001-0879 or 1300-1399; and


• You have 10% of your patient volume derived from Medicaid encounters.

We encourage potential participants to review CMS' comparison chart to learn more about the differences between the two EHR Incentive Programs, and use the Eligibility Wizard to determine for which program they may be eligible.

Want more information about the EHR Incentive Programs?
Make sure to visit the EHR Incentive Programs website at for the latest news and updates on the EHR Incentive Programs.

CMS Proposes More Loopholes for E-Prescribing Penalty

July 19, 2011 — The federal government will begin to penalize some physicians next year for not electronically transmitting their Medicare patients' prescriptions to pharmacies. At the same time, the government wants to help physicians avoid paying those penalties.

In proposed policies for the 2012 Medicare Physician Fee Schedule (PFS) released earlier this month, the Centers for Medicare and Medicaid Services (CMS) unveils a plan to lower the bar for complying with its e-prescribing imperative, as well as giving physicians more time to do what it takes to avoid the penalty, euphemistically called a "payment adjustment." That adjustment for "unsuccessful" e-prescribers is 1% of PFS charges in 2012, 1.5% in 2013, and 2% in 2014.

The penalties come alongside bonuses for successful electronic prescribers in Medicare: 2% of PFS charges in 2009 and 2010, 1% in 2011 and 2012, and 0.5% in 2013. In its new policy recommendations, CMS states that the criteria for incurring the penalty need not be identical to the criteria for earning the bonus.

"In general, we believe that an incentive should be broadly available to encourage the widest possible adoption of electronic prescribing, even for low volume prescribers," CMS states. "On the other hand, we believe that a payment adjustment should be applied primarily to assure that those who have a large volume of prescribing do so electronically, without penalizing those for whom the adoption and use of an electronic prescribing system may be impractical given the low volume of prescribing."

In addition, CMS said that physicians and other prescribers who qualify for the bonus "have sufficiently demonstrated their adoption and use of electronic prescribing technology and thus should not be subject to the payment adjustment in a future year."

Less Work Needed to Avoid Penalty Than to Earn Bonus

As with its incentive program for electronic health records (EHRs), CMS is waving financial carrots and sticks to encourage clinicians to e-prescribe for the sake of patient safety and cost control. Both the federal government and the healthcare industry define electronic prescribing as transmitting a script from a clinician's computer to a pharmacy's, as opposed to writing a script with software and either faxing it or printing it out for hand delivery.

To receive the bonus for 2011, clinicians must generate at least 25 e-prescriptions on separate visits throughout the year, in conjunction with 56 particular billing codes for medical services, mostly having to do with evaluation and management. These codes must account for at least 10% of the clinician's Medicare allowed charges. In addition, clinicians must use a qualified e-prescribing software program.

It takes less work to avoid the penalty than to earn the bonus. Physicians will see their Medicare reimbursement shrink by 1% in 2012, the first year for payment adjustments, if they failed to generate at least 10 e-prescriptions through the first half of 2011. The penalty will not apply to physicians who lack at least 100 claims involving the 56 billing codes through the first half of the year, lack prescribing privileges, or were not licensed practitioners as of June 30, 2011. In addition, physicians also can claim a hardship exemption if they practice in a rural area without sufficient high-speed Internet access, or where pharmacies do not receive electronic prescriptions.

The penalty in 2013 currently depends on one's prescribing performance in 2011. If clinicians qualify for an incentive payment this year, they avoid the payment adjustment 2 years later.

In May, CMS proposed 4 other hardship exemptions for the 2012 penalty and a longer deadline for claiming one. One new exemption widely praised by physicians involves the federal incentive program for EHRs, which requires participants to e-prescribe. Under the May proposals, clinicians who register for the EHR incentive program and adopt certified EHR technology would be exempt from the e-prescribing penalty in 2012. The comment period on these recommendations ends July 25.

The CMS proposals released on July 1 would give clinicians a second chance to avoid penalties in 2013 and 2014. In case they failed to earn an e-prescribing bonus in 2011, clinicians also could escape the 1.5% reduction in 2013 if they report submitting at least 10 electronic prescriptions in the first half of 2012. In addition, these 10 prescriptions could be associated with any PFS billing code, not just the 56 codes required to earn the incentive.

The same rules would govern the 2014 payment adjustment: The adjustment would not hit clinicians who earn a bonus in 2012 or report at least 10 electronic prescriptions in the first half of 2013, regardless of the services rendered during those visits.

Proposals Fail to Lower Bar Enough, Says AAFP Official

The July proposals also apply 2 of the 4 new hardship exemptions from the 2012 penalty to 2013 and 2014; namely, the inability to e-prescribe because of local, state, or federal restrictions, and prescribing fewer than 100 scripts during a 6-month reporting period for payment adjustments. CMS did not recommend extending the exemption for clinicians who register in the EHR incentive program to 2013 and 2014, which was a decision that disappointed Steven Waldren, MD, director of the Center for Health Information Technology at the American Academy of Family Physicians.

Preserving the exemption based on participation in the EHR incentive program "would definitely lower the bar" for clinicians seeking to avoid the e-prescribing penalty, Dr. Waldren told Medscape Medical News. He also said that CMS should have addressed the issue of physicians finding it difficult to verify with the agency that they are complying with e-prescribing requirements.

As they stand, the proposed changes to the e-prescribing incentive program "lower the bar some," but nevertheless amount to "small potatoes," according to Dr. Waldren.

The comment period for the July 1 proposal, posted on the Federal Register, ends on August 30. The draft regulations explain several ways to submit comments.

More information on the e-prescribing incentive program, and on how to apply for an exemption, is available on the CMS Web site.

CMS has attestation resources to help you

Take a Look at CMS' Attestation Resources

Are you an eligible professional (EP) or eligible hospital participating in the Medicare Electronic Health Record (EHR) Incentive Program?  CMS has resources to help you attest to having met meaningful use requirements in order to receive your EHR incentive payment.

Attestation resources located on the CMS EHR website include:

• An Attestation page on the CMS EHR website, where participants in the Medicare EHR Incentive Program can find important information on attestation.
  
  


• The Meaningful Use Attestation Calculator allows EPs and eligible hospitals to check whether they have met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EP's or eligible hospital's specific measure summary.
  
  


• The Attestation User Guide for Medicare Eligible Professionals and the Attestation User Guide for Eligible Hospitals provide step-by-step guidance for EPs and eligible hospitals participating in the Medicare EHR Incentive Program on navigating the attestation system.
  
  


• Attestation Worksheets for EPs and Eligible Hospitals allow users to fill out their meaningful use measure values, so they have a quick reference tool to use while attesting.
  
  


• An Eligible Professional Medicare EHR Incentive Program Attestation Webinar, which is a video version of the user guides for EPs and walks viewers through how to complete the attestation process.

Attestation is currently open for all participants in the Medicare EHR Incentive Program. You can attest via CMS' Medicare & Medicaid EHR Incentive Program Registration and Attestation System.

Want more information about the EHR Incentive Programs?
Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

AHA looks to collaborate with docs

The American Hospital Association, which lobbied to stop physicians from owning hospitals, has created a new organization to represent doctors who now are owned by hospitals. 

The AHA kicked off its Physician Leadership Forum at a breakfast meeting in San Diego today at the AHA's Leadership Summit. The organization will represent the interests of physicians who are working closely with hospitals on new models of care delivery. Specifically, the new organization will focus its energy on four objectives: education and leadership; physician advocacy and policy development; quality and patient safety; and partnerships with other healthcare organizations.

Information about the new group is available at www.ahaphysicianforum.org.

"The AHA's initiative is particularly timely," said Dr. William Jessee, president and CEO of the Medical Group Management Association. "We see more and more of our members becoming members of hospitals and integrated delivery systems. The forum will help meet the needs of physicians in AHA member organizations."

The MGMA is a partner organization of the new Physician Leadership Forum, and Jessee spoke at the kick-off breakfast.

Other external partners of the new group include the American Board of Medical Specialties, the Accreditation Council on Graduate Medical Education, the American Medical Association, the Joint Commission and the Society for Hospital Medicine.

A 20-member advisory board will oversee the new group chaired by Dr. Mike Rock, the chief medical officer, at the Mayo Clinic. Other notable members of the all-physician advisory board include Dr. Jonathan Perlin, president of the clinical and physician services group at HCA, and Dr. Glenn Steele Jr., president and CEO of Geisinger Health System.

Dr. John Combes, AHA senior vice president, said the intent of the new organization is not to compete with the AMA or organized medicine. Combes also spoke at today's breakfast.

"We are not representing physicians' interests to Congress," Combes told Modern Healthcare. Rather, the new group "provides an avenue for physicians to affect AHA policy."

The AHA along with the Federation of American Hospitals successfully lobbied to have severe restrictions on physician-owned hospitals added to the Patient Protection and Affordable Care Act.

We've Posted New FAQs to the EHR Website

We want to keep you updated with the latest information about the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. Fifteen new FAQs on meaningful use, payment information for eligible hospitals, eligibility, and additional information for eligible hospitals have been added to our website. Take a minute and review these new FAQs.

Payment Information for Critical Access Hospitals

• What cost report data elements are used in the EHR incentive payment calculation for Medicare Subsection (d) Hospitals? Read the answer.


• How are Medicare EHR Incentive Payments Calculated for Critical Access Hospitals (CAHs)?  Read the answer.


• What costs can be included in the CAH's Medicare EHR incentive payment? Read the answer.

And even more new FAQs for Critical Access Hospitals:

FAQ # 10716. FAQ # 10719. FAQ # 10721. FAQ # 10722. FAQ # 10723.

FAQ # 10724. FAQ # 10725. FAQ # 10726. FAQ # 10727.

Meaningful Use

• If my certified EHR technology is capable of submitting batch files to an immunization registry using the standards adopted by the Office of the National Coordinator of Health Information Technology (HL7 2.3.1 or 2.5.1, and CVX), is that sufficient to meet the Meaningful Use objective "submit electronic data to immunization registries" for the Medicare and Medicaid EHR Incentive Programs? Read the answer.


• If my certified EHR technology only includes the capability to submit information to an immunization registry using the HL7 2.3.1 standard but the immunization registry only accepts information formatted in the HL7 2.5.1 or some other standard, will I qualify for an exclusion because the immunization registry does not have the capacity to receive the information electronically? What if the immunization registry has a waiting list or is unable to test for other reasons but can accept information formatted in HL7 2.3.1, is that still a valid exclusion? Read the answer.

Eligibility

• How does CMS define pediatrician for purposes of the Medicaid EHR Incentive Program? Read the answer.

Want more information about the EHR Incentive Programs?
Make sure to visit the CMS EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Four New State Medicaid EHR Incentive Programs Launched in July

Arizona, Connecticut, Rhode Island, and West Virginia Launch Medicaid EHR Programs This Month

On July 4th, the Medicaid Electronic Health Record (EHR) Incentive Program launched in Arizona, Connecticut, Rhode Island, and West Virginia. This means that eligible professionals and eligible hospitals in these four states will be able to complete their EHR Incentive Program registration at the state level and receive incentive payments. More information about the Medicaid EHR Incentive Program can be found on the Medicare and Medicaid EHR Incentive Program Basics page of the CMS EHR website.

If you are a resident of Arizona, Connecticut, Rhode Island or West Virginia and are eligible to participate in the Medicaid EHR Incentive Program, visit your State Medicaid Agency website for more information on your state's participation in the Medicaid EHR Incentive Program:

• Arizona


• Connecticut


• Rhode Island


• West Virginia

Twenty-one states have launched Medicaid EHR Incentive Programs, and 14 states have issued incentive payments to Medicaid eligible professionals and eligible hospitals who have adopted, implemented, or upgraded certified EHR technology. CMS looks forward to announcing the launches of additional states' programs in the coming months.

For a complete list of states that have already begun participation in the Medicaid EHR Incentive Program, see the Medicaid State Information page on the CMS EHR website.

Want more information about the EHR Incentive Programs?
Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs. 

Shortage of Physicians, APNs, PAs Predicted for 2025

July 11, 2011 — Advanced practice nurses (APNs) and physician assistants (PAs) are frequently touted as the solution to the physician shortage, but there will not be enough of all 3 professionals combined to meet the nation's healthcare needs in 2025, according to a study published in the June issue of the Journal of the American College of Surgeons.

Lead author Michael Sargen, a medical student at the University of Pennsylvania in Philadelphia, and coauthors write that although the United States needs to expand the workforce of these 3 types of "advanced clinicians," healthcare personnel with less training must assume more patient care responsibilities, especially as more Americans gain insurance coverage under the Affordable Care Act.

Right now, the nation fields close to 300 advanced clinicians for every 100,000 Americans. That number is roughly 7% less than needed, based on the demand for services, which the authors extrapolate from healthcare spending. The authors write that if training programs for PAs and APNs — which include nurse practitioners — grow as currently projected while physician residency programs fail to expand, the per capita supply of advanced clinicians in 2025 will resemble the current level.

However, the workforce of 2025 in this scenario will be 20% less than needed because of burgeoning demand for services. The authors cite government studies that forecast a 65% increase in healthcare spending from 2009 to 2025 based on its historic growth rate of 2.5% above the growth of the gross domestic product (GDP).

The healthcare reform law aims to reduce that growth rate to 1% above GDP, the authors write, but even if reformers hit this target, demand for services will still outstrip the supply of advanced clinicians.

Coauthor Richard Cooper, MD, an authority on physician workforce issues and a professor at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, chalks up the continued rise in spending not only to costly technologies but also to the sheer proliferation of new therapies.

"Research is finding ways to treat diseases that were once untreatable," Dr. Cooper told Medscape Medical News. "We once didn't treat lung cancer. Now we do. We don't treat Alzheimer's disease now, but we will in the future."

"Everyone Should Work to Their Level of Education"

A 20% shortfall in the advanced-clinician workforce in 2025 is the study's worst-case scenario. The nation will more likely face a 15% shortage that year, the authors write, given the pressure to add more first-year slots to residency programs.

The study authors mention several wild cards that were not factored into their analysis but that could aggravate the shortage. Physicians, they write, are working fewer and fewer hours. And all clinicians are increasingly pulled away from patient care by chores such as documenting what they do for the sake of getting paid. These factors could increase unmet demand for advanced clinicians by an additional 10% to 15%, according to the authors.

Wild cards aside, even under the rosiest scenario for advanced-clinician head counts, the nation still "must broaden the spectrum of healthcare workers who can assist in delivering services," write the authors. That means advanced clinicians must learn to delegate responsibilities that can be performed by personnel with less training and to focus on the services that only they can provide, Dr. Cooper told Medscape Medical News.

"Everyone should work to their level of education," he said. "This is easy to talk about when you work in a hospital with a lot of people [to delegate to]," he said. "It's more difficult when you're a solo practitioner."

The need to spread out the work, he predicts, will drive more physicians to join larger, more organized systems, such as hospitals and large group practices.

The authors have disclosed no relevant financial relationships.

J Am Coll Surg. 2011;212:991-999. Abstract

Avoid Medicare eRx Penalties: CMS Gives Second Chance

Did you miss the June 30 deadline for implementing e-Prescribing (eRx)? If so, you were to receive a 1% penalty on all Medicare payments in 2012. It is too late to code 10 visits with G8553, attesting to eRx for those patient encounters.

However, CMS will give you a second chance. If you implement and attest to meaningful use of an EMR in 2011, then you may avoid the penalties altogether. The Centers for Medicare and Medicaid Services (CMS) has proposed just such a revision to the eRx portion of the Medicare EHR Incentive Program. If adopted, as is fully expected, then you need full implementation of an EMR certified for Meaningful Use before October 1, 2011. This benefit is in addition to the $44,000 per physician in the EHR Stimulus program.

The American Medical Association (AMA) has been among the medical organizations that have been requesting changes to the eRx program - a program with even more stringent requirements than Meaningful Use that many physicians are struggling to meet.

"Eliminating unreasonable penalties and burdensome requirements and providing physicians with more flexibility through an exemption process will help ensure more physicians are able to successfully participate in the e-prescribing incentive program," said AMA President Cecil B. Wilson, MD, in an interview with American Medical News. "The AMA has continually stressed to CMS that these changes were essential and is pleased to see them become a reality in a rule that will be finalized later this summer."

CMS will accept comments on the proposed changes through July 25. Comments can be submitted:

• Online at www.regulations.gov . Enter keyword CMS-3248-P for the document file code.


• By mail to Centers for Medicare & Medicaid Services, Dept. of Health and Human Services, Attn: CMS-3248-P, P.O. Box 8013, Baltimore, MD 21244-8013.

Click here to read the CMS Fact Sheet on the proposed rule.

E-Prescriptions Just as Error-Prone as Paper Scripts

July 1, 2011 — Government and the healthcare industry have placed big bets on digital technology, and electronic prescribing in particular, for the sake of patient safety, but a new study reports that the error rate with computer-generated prescriptions in physician offices roughly matches that for paper scripts: about 1 in 10.

However, results from the study, published online June 29 in the Journal of the American Medical Informatics Association, are not as damning as they may initially appear. Error rates varied widely depending on the type of e-prescribing software used, with some programs outperforming pen and paper. In addition, software improvements could eliminate more than 80% of the mistakes, most of them involving omitted information.

In 2010, an estimated 190,000 physicians were electronically prescribing, the technical term for transmitting scripts directly to a pharmacy computer, according to a pharmacy industry group called Surescripts. That number does not include physicians who create a prescription with computer software and then either fax it to the pharmacy or give patients a printout.

Since 2009, the federal government has been paying hundreds of millions of dollars in Medicare bonuses to physicians and other clinicians who electronically prescribe. The government operates an even pricier incentive program for electronic health records, and e-prescribing is one of the prerequisites for earning a 6-figure bonus.

The new study study examined nearly 3900 computer-generated prescriptions received by a pharmacy chain in 2008 in Florida, Massachusetts, and Arizona, regardless of whether they were faxed or electronically transmitted to pharmacies or were printed out. Of those prescriptions, 11.7% contained at least 1 error. Researchers did not ascertain whether errors were corrected by the pharmacy chain or whether they led to an actual adverse drug event. Lead author Karen Nanji, MD, MPH, writes that the 11.7% figure is "consistent with the literature on manual handwritten prescription error rates."

Roughly one third of the errors represented potential adverse drug events, none of them life-threatening.

Software Improvements Must Be Physician-Friendly

Omitted information such as drug dose, duration, and frequency accounted for almost 61% of the errors detected by the authors. The rest of the errors stemmed from unclear, conflicting, or clinically incorrect information.

Software improvements, Dr. Nanji and coauthors write, could eliminate the vast majority of these mistakes. E-prescribing programs can incorporate so-called forcing functions that would prevent physicians from completing a prescription unless they enter required information, including complete drug names and proper abbreviations. Likewise, decision-support tools can issue alerts about a wrong drug dose or frequency. However, the authors note, physicians may rebel against e-prescribing software if antierror safeguards make it too slow or annoying to use.

Some e-prescribing programs included in the study appeared to give users a technological edge. The error rate associated with one such program was only 5.1% compared with a whopping 37.5% for another. However, the study did not assess whether the root cause was system design or how well or poorly the systems were implemented in physician offices. Training physicians and staff on new software systems, the authors note, is often given short shrift.

The study was supported by the federal Agency for Healthcare Research and Quality and the Harvard Risk Management Foundation. The authors have disclosed no relevant financial relationships.

J Am Med Inf Assn. Published online June 29, 2011. Abstract