American Recovery and American Recovery and Revitalization Act of Revitalization Act of 2009: The Stimulus2009: The Stimulus

Health Care ProvisionsHealth Care Provisions

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Health Care ProvisionsHealth Care Provisions

Three main areas: Three main areas: – Health Information TechnologyHealth Information Technology– Comparative Effectiveness ResearchComparative Effectiveness Research– Prevention and Wellness Prevention and Wellness

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Health Information Health Information TechnologyTechnology

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Healthcare Information Healthcare Information Technology for Economic Technology for Economic and Clinical Health Act and Clinical Health Act (HITECH)(HITECH) Title XIII of the billTitle XIII of the bill Electronic health records (EHRs) are to Electronic health records (EHRs) are to

focus on clinical information and focus on clinical information and coordination of carecoordination of care

Effectively puts the focus on Effectively puts the focus on evaluating and making evaluating and making recommendations about individual recommendations about individual patientspatients

This is not about billing, it is a care This is not about billing, it is a care management toolmanagement tool

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HITECH, cont.HITECH, cont.

Building on an Executive Order from Pres. Building on an Executive Order from Pres. Bush in 2004, creates an Office of the Bush in 2004, creates an Office of the National Coordinator for Health National Coordinator for Health Information Technology who reports Information Technology who reports directly to the Secretary of HHSdirectly to the Secretary of HHS

Role: Will work with a HIT Policy Role: Will work with a HIT Policy Committee and a HIT Standards Committee and a HIT Standards CommitteeCommittee

Health Technology Research Center Health Technology Research Center (national and regional offices) to play (national and regional offices) to play important role in actual implementationimportant role in actual implementation

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HITECH, cont.HITECH, cont.

Initial set of standards, implementation Initial set of standards, implementation specifications, and certification criteria specifications, and certification criteria must be adopted using the rulemaking must be adopted using the rulemaking process by Dec. 31, 2009process by Dec. 31, 2009

Such standards will continue to be Such standards will continue to be updated—federal HIT expenditures updated—federal HIT expenditures when they occur have to use products when they occur have to use products that fit those standards, specifications, that fit those standards, specifications, criteriacriteria

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Funding to Encourage Funding to Encourage Providers to Utilize Providers to Utilize EHRsEHRsELIGIBILITY FOR PAYMENTELIGIBILITY FOR PAYMENT An eligible professional is defined as a physician An eligible professional is defined as a physician

as defined by section 1861 (r) of the Social as defined by section 1861 (r) of the Social Security code. This includes medical doctors, Security code. This includes medical doctors, dentists, podiatrists, optometrists and doctors of dentists, podiatrists, optometrists and doctors of chiropractic.chiropractic.

Payments will be made to outpatient physicians Payments will be made to outpatient physicians who have demonstrated that they are a who have demonstrated that they are a meaningful EHR user. meaningful EHR user.

Hospital-based physicians such as pathologists, Hospital-based physicians such as pathologists, anesthesiologists, emergency physicians or anesthesiologists, emergency physicians or hospitalists who furnish substantially all of their hospitalists who furnish substantially all of their services in a hospital setting through the facilities services in a hospital setting through the facilities and equipment of the hospital are and equipment of the hospital are not eligiblenot eligible. .

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RequirementsRequirements

There are three requirements to be met:There are three requirements to be met: 1)  Use of certified EHR technology 1)  Use of certified EHR technology

including electronic prescribing.including electronic prescribing. 2)  The EHR technology is connected in 2)  The EHR technology is connected in

a manner that provides electronic a manner that provides electronic exchange of health information.exchange of health information.

3)  The eligible professional submits 3)  The eligible professional submits information for the period on the information for the period on the clinical quality measures and other clinical quality measures and other measures selected by the Secretary; measures selected by the Secretary; you must report on quality of care.you must report on quality of care.

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Requirements etc.Requirements etc.

The Secretary is also empowered to The Secretary is also empowered to accept individual State accept individual State determinations of meaningful EHR determinations of meaningful EHR usage with Medicaid as meeting usage with Medicaid as meeting these requirements. This provision these requirements. This provision allows practices that see relatively allows practices that see relatively little Medicare populations but large little Medicare populations but large Medicaid populations to qualify.Medicaid populations to qualify.

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Amount of PaymentAmount of Payment AMOUNT OF PAYMENTAMOUNT OF PAYMENT

The payment is designed for physicians who have a substantive Medicare The payment is designed for physicians who have a substantive Medicare patient base. The incentive payments will equal to 75% of the amount paid to patient base. The incentive payments will equal to 75% of the amount paid to eligible professionals by Medicare. Payments are limited to the following eligible professionals by Medicare. Payments are limited to the following schedule:schedule:Year 1: Year 1:

           $18,000 if the first payment year is 2011 or 2012 $18,000 if the first payment year is 2011 or 2012 (more than (more than $25k Medicare billing)$25k Medicare billing)

$15,000 if the first payment year is 2013$15,000 if the first payment year is 2013$12,000 if the first payment year is 2014$12,000 if the first payment year is 2014

Year 2: $12,000Year 2: $12,000Year 3: $8000Year 3: $8000Year 4: $4000Year 4: $4000Year 5: $2000Year 5: $2000

The final payment year is 2015. The final payment year is 2015. 

The method of payment is up to the discretion of the Secretary. It may be The method of payment is up to the discretion of the Secretary. It may be made as a lump sum or by incremental payments. Claims for a specific made as a lump sum or by incremental payments. Claims for a specific reporting year must be submitted within two months of the end of the year in reporting year must be submitted within two months of the end of the year in order to be eligible for EHR bonus payment.order to be eligible for EHR bonus payment.

   The above payment limitations are 25% higher for eligible providers in areas The above payment limitations are 25% higher for eligible providers in areas

designated as health professional shortage areas.designated as health professional shortage areas.

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EligibilityEligibility

PROOF OF ELIGIBILITYPROOF OF ELIGIBILITYProfessionals may satisfy the requirements Professionals may satisfy the requirements proving use of the EHR and electronic health proving use of the EHR and electronic health exchange by methods to be determined by the exchange by methods to be determined by the Secretary which could include:Secretary which could include:a) an attestation (swearing that you have EHR)a) an attestation (swearing that you have EHR)b) submission of claims with a CPT code b) submission of claims with a CPT code indicating the use of certified EHR technology indicating the use of certified EHR technology (most likely)(most likely)c)  a survey responsec)  a survey responsed) submission of quality measure data (most d) submission of quality measure data (most likely)likely)e) other methods determined by the Secretarye) other methods determined by the Secretary

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Public ReportingPublic Reporting

PUBLIC REPORTINGPUBLIC REPORTING

CMS will post on a public website, CMS will post on a public website, in an understandable format, the in an understandable format, the names, business addresses, and names, business addresses, and business phone numbers of eligible business phone numbers of eligible professionals and group practices professionals and group practices who are meaningful EHR users and who are meaningful EHR users and receiving incentive payments.receiving incentive payments.

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PenaltiesPenalties

PENALTY FOR NOT USING AN EHRPENALTY FOR NOT USING AN EHRBeginning in 2015 there will be a reduction in Beginning in 2015 there will be a reduction in Medicare payments for professional services Medicare payments for professional services furnished by in an eligible professional if that furnished by in an eligible professional if that professional is not a meaningful EHR user. professional is not a meaningful EHR user. The amount of Medicare payments (with The amount of Medicare payments (with some exceptions) will besome exceptions) will bea)      2015 – 99%a)      2015 – 99%b)      2016 – 98%b)      2016 – 98%c)      2017 and beyond – 97%c)      2017 and beyond – 97%

Above timetable seems ambitious; dates may Above timetable seems ambitious; dates may be pushed backbe pushed back

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MEDICARE ADVANTAGE PLANSMEDICARE ADVANTAGE PLANS In general the provisions also apply to physicians In general the provisions also apply to physicians

delivering most of their services through a Medicare delivering most of their services through a Medicare Advantage plan.Advantage plan.

Eligible professionals in this category would be those Eligible professionals in this category would be those who are employed by the organization, are a member who are employed by the organization, are a member or employee of an organization which furnishes 80% or employee of an organization which furnishes 80% of its patient care services to a Medicare Advantage of its patient care services to a Medicare Advantage plan and furnishes 75% of the services of the eligible plan and furnishes 75% of the services of the eligible professional to the organization and furnishes at least professional to the organization and furnishes at least 20 hours per week of patient care services.20 hours per week of patient care services.

There are limitations to avoid duplication of payment There are limitations to avoid duplication of payment and the maximum number of physicians per and the maximum number of physicians per organization is capped at 5000.organization is capped at 5000.

Will HHS allow physicians who bill for Part B and Part C Will HHS allow physicians who bill for Part B and Part C to meet the eligibility threshold combined?to meet the eligibility threshold combined?

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In general…In general…

Much of the detail in this measure is Much of the detail in this measure is undefined and left to the discretion of undefined and left to the discretion of the Secretary of Health and Human the Secretary of Health and Human Services. Services.

The implementation plans are required The implementation plans are required to be published in the Federal Register to be published in the Federal Register for public comment, thus the actual for public comment, thus the actual payment mechanisms and the exact payment mechanisms and the exact requirements to qualify for payment are requirements to qualify for payment are not fully defined.not fully defined.

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HIT SUMMARYHIT SUMMARY

Outpatient practitioners who wish to qualify for Outpatient practitioners who wish to qualify for the full benefit of the $44,000 in EHR incentive the full benefit of the $44,000 in EHR incentive payments should have a certified EHR in place payments should have a certified EHR in place by 2011 capable of eprescribing, by 2011 capable of eprescribing, interoperability, and quality measure reporting. interoperability, and quality measure reporting.

Detailed specifications from CMS have not yet Detailed specifications from CMS have not yet been developed to implement this act.been developed to implement this act.

Providers should definitely keep an eye out for Providers should definitely keep an eye out for the standards, specifications, and criteria the standards, specifications, and criteria recommendations that will come down from the recommendations that will come down from the Office of the National HIT Coordinator later in Office of the National HIT Coordinator later in 20092009

ACA will of course, keep the profession apprised ACA will of course, keep the profession apprised as the rulemaking process developsas the rulemaking process develops

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Comparative Effectiveness Comparative Effectiveness ResearchResearch

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$1.1 Billion for $1.1 Billion for Comparative Comparative Effectiveness ResearchEffectiveness Research $700,000,000 to the Agency for $700,000,000 to the Agency for

Healthcare Research and Quality Healthcare Research and Quality (AHRQ)(AHRQ)– $400,000,000 of this goes to the $400,000,000 of this goes to the

Office of the Director of NIHOffice of the Director of NIH $400,000,000 at the discretion of $400,000,000 at the discretion of

the Secretarythe Secretary

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Comparative Comparative Effectiveness: Setting Effectiveness: Setting Research PrioritiesResearch Priorities

Sect 804 establishes a new, Sect 804 establishes a new, Presidentially-appointed body called Presidentially-appointed body called the Federal Coordinating Council for the Federal Coordinating Council for Comparative Effectiveness ResearchComparative Effectiveness Research

The mission of the Council is to The mission of the Council is to foster coordination of comparative foster coordination of comparative effectiveness/related research within effectiveness/related research within federal agenciesfederal agencies

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How to Spend $1.1 How to Spend $1.1 BillionBillion The new Federal Council for The new Federal Council for

Comparative Effectiveness Research Comparative Effectiveness Research and Institute of Medicine (IOM) both and Institute of Medicine (IOM) both have reports due by June 30, 2009 on:have reports due by June 30, 2009 on:– Current Federal work in this area (an Current Federal work in this area (an

overview of infrastructure, etc)overview of infrastructure, etc)– Recommendations for the national Recommendations for the national

priorities in this areapriorities in this area These reports will greatly determine These reports will greatly determine

where the research funding goeswhere the research funding goes

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Prevention and WellnessPrevention and Wellness

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$1 Billion for $1 Billion for Prevention and Prevention and WellnessWellness $650 million to:$650 million to:

““carry out evidence-based clinical and carry out evidence-based clinical and community-based prevention and wellness community-based prevention and wellness strategies authorized by the [U.S.] Public strategies authorized by the [U.S.] Public Health Service Act, as determined by the Health Service Act, as determined by the [HHS] Secretary, that deliver specific, [HHS] Secretary, that deliver specific, measurable health outcomes that address measurable health outcomes that address chronic disease rates.” chronic disease rates.”

Proposed allocation of and priorities for Proposed allocation of and priorities for spending due to House/Senate spending due to House/Senate Appropriations Committee 90 days Appropriations Committee 90 days after the act is signed into lawafter the act is signed into law

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SUMMARY OF SUMMARY OF HEALTHCARE PROVISIONSHEALTHCARE PROVISIONS

Bill consistently refers to research as a Bill consistently refers to research as a cornerstone for healthcare decision cornerstone for healthcare decision making, whether it be re: EHRs, making, whether it be re: EHRs, prevention and wellness, or prevention and wellness, or comparative effectiveness.comparative effectiveness.

Many of the critical details related to Many of the critical details related to actually implementing these provisions actually implementing these provisions will be determined by federal agencies will be determined by federal agencies over the next several months.over the next several months.

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Myths and Facts on Myths and Facts on the Stimulusthe Stimulus

Myth: One new bureaucracy, the National Coordinator Myth: One new bureaucracy, the National Coordinator of Health Information Technology, will monitor of Health Information Technology, will monitor treatments to make sure doctors are doing what the treatments to make sure doctors are doing what the federal government deems appropriate and cost federal government deems appropriate and cost effective.effective.

Fact: It is true that the bill creates a National Fact: It is true that the bill creates a National Coordinator of Health Information Technology. Coordinator of Health Information Technology. However, there is not one piece of language that However, there is not one piece of language that authorizes, empowers or even so much as addresses authorizes, empowers or even so much as addresses the Coordinator’s role as being one that will monitor the Coordinator’s role as being one that will monitor treatments to ensure that a health provider is “treatments to ensure that a health provider is “doing doing what the federal government deems appropriate and what the federal government deems appropriate and cost effectivecost effective.” The section speaks solely to the .” The section speaks solely to the development of an EHR system and how it can be development of an EHR system and how it can be most effectively used to share patient and clinical most effectively used to share patient and clinical information to improve the information to improve the qualityquality of medical care. of medical care.

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Myths and Facts on Myths and Facts on the Stimulusthe Stimulus Myth: The goal of the Federal Coordinating Myth: The goal of the Federal Coordinating

Council for Comparative Effectiveness Council for Comparative Effectiveness Research is to slow the development and use Research is to slow the development and use of new treatments and technologies because of new treatments and technologies because they are driving up costs. they are driving up costs.

Fact: The goal of the Council is to create Fact: The goal of the Council is to create (from the bill) “opportunities to assure (from the bill) “opportunities to assure optimum coordination of comparative optimum coordination of comparative effectiveness and related health services effectiveness and related health services research conducted or supported by relevant research conducted or supported by relevant Federal departments and agencies, with Federal departments and agencies, with the the goal of reducing duplicative efforts and goal of reducing duplicative efforts and encouraging coordinated and complementary encouraging coordinated and complementary use of resources.” use of resources.” The goal simply is to see The goal simply is to see what treatments work.what treatments work.

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Questions?Questions?

ACA Department of Government ACA Department of Government AffairsAffairs

703-812-0224703-812-0224 gr@acatoday.orggr@acatoday.org