With Marlowe Greenberg

Foothold Technology

Meaningful Use Is Only The Beginning

By The Numbers www.kff.org/medicaid/upload/8165.pdf | www.CMS.gov

$374 billion Total annual spending on 52 million Medicaid beneficiaries $201.9 billion Annual spending on 2.6 million beneficiaries with complex health needs alone That is…5% of Medicaid beneficiaries comprise 54% of Medicaid’s cost In New York State… $2,338: Average monthly spending on complex enrollees $890: Average monthly spending on a typical enrollee

This is true even for people who are not Medicaid/Medicare beneficiaries

Synthesizing all this data, we can see why almost every reform idea put forward in ARRA (Stimulus) and the PPACA (Health Reform) seeks to address these very high utilization rates. Meaningful Use, Health Homes, RHIOs and other reform ideas centered around more efficiently targeting the most intensive consumers of healthcare are the future of healthcare for all of us.

Remember… 5% of Medicaid Beneficiaries comprise 54% of Medicaid’s cost

Spending as a percent of GDP

ARRA & Meaningful

Use

PPACA and

Health Homes

Fewer ER Visits = Lower Costs

Title IV of the HITECH act established incentive payments to those “eligible professionals” (EPs) who adopt and use a certified EHR. The act recognizes psychiatrists and advanced practice registered nurses (APRN) as “eligible professionals” (EPs) for either Medicaid or Medicare incentive payments. Each EP is only eligible for one incentive payment per year, regardless of how many practices or locations at which he or she provides services. EP must meet one of the following criteria:

> Have a minimum 30% Medicaid patient volume > Have a minimum 20% Medicaid patient volume, and is a pediatrician > Practice predominantly in a Federally Qualified Health Center or Rural Health Center and have a minimum 30% patient volume attributable to needy individuals

Beginners Guide: https://www.cms.gov/EHRIncentivePrograms/Downloads

/Beginners_Guide.pdf

Eligibility Tool: https://www.cms.gov/EHRIncentivePrograms/15_Eligibili

ty.asp#TopOfPage

ONLY INDIVIDUALS ARE ELIGIBLE NOT ORGANIZATIONS

Evaluate current provider agreements to determine whether Incentive Payments are covered. Usually not, only for services rendered. You can amend the current agreements to include EHR incentive payments or attach an addendum that addresses it directly.

Meaningful Use: the mechanics “The Medicaid EHR Incentive Program (MU) will provide incentive payments to eligible professionals, eligible hospitals, and CAHs as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in their first year of participation and demonstrate meaningful use for up to five remaining participation years.” Eligible professionals can receive up to $63,750 over the six years that they choose to participate in the program. ($10,625/year for software) (They can start ANY TIME up to 2015.)

An Eligible Professional (EP): ► Physicians ► Nurse practitioner (APRN) ► Certified nurse-midwife ► Dentist ► Physician assistant in a FQHC or Rural Health Clinic

Year

Started Incentives Over Time Penalty?

2011 $21,250

2012 $8,500 $21,250

2013 $8,500 $8,500 $21,250

2014 $8,500 $8,500 $8,500 $21,250

2015 $8,500 $8,500 $8,500 $8,500 $21,250 1% penalty

2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250 2% penalty

2017 $8,500 $8,500 $8,500 $8,500 $8,500 3% penalty

2018 $8,500 $8,500 $8,500 $8,500

2019 $8,500 $8,500 $8,500

2020 $8,500 $8,500

2021 $8,500

TOTAL $63,750 $63,750 $63,750 $63,750 $63,750 $63,750

1 CPOE for medication, laboratory and radiology orders

Any EP who writes fewer than 100 medication, laboratory, and radiology orders during the EHR reporting period.

2 Generate and transmit permissible prescriptions electronically (eRx).

Any EP who writes fewer than 100 prescriptions during the EHR reporting period or does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions

3 Record the following demographics: preferred language, sex, race, ethnicity, date of birth.

N/A

4 Record and chart changes in the following vital signs: height/length and weight (no age limit); blood pressure (ages 3 and over); calculate and display body mass index (BMI); and plot and display growth charts for patients 0-20 years, including BMI.

Any EP who-- (A) Sees no patients 3 years or older is excluded from recording blood pressure; (B) Believes that all three vital signs of height/length, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them; (C) Believes that height/length and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure; or (D) Believes that blood pressure is relevant to their scope of practice, but height/length and weight are not, is excluded from recording height/length and weight

5 Record smoking status for patients 13 years old or older.

Any EP who sees no patients 13 years old or older.

6 Use clinical decision support to improve performance on high-priority health conditions.

A. Implement five clinical decision support interventions related to five or more clinical quality measures, if applicable, at a relevant point in patient care for the entire EHR reporting period; B. The EP has enabled the functionality for drug-drug and drug-allergy interaction checks for the entire EHR reporting period.

7 Provide patients the ability to view online, download and transmit their health information

Any EP who orders no lab tests whose results are either in a positive/negative or numeric format during the EHR reporting period.

8 Provide clinical summaries for patients for each office visit.

N/A

9 Protect electronic health information. Any EP who has had no office visits in the 24 months before the beginning of the EHR reporting period.

10 Incorporate clinical lab-test results into Certified EHR Technology as structured data.

Any EP who neither orders nor creates any of the information listed for inclusion as part of this measure is excluded

11 Generate lists of patients by specific conditions Any EP who has no office visits during the EHR reporting period.

12 Patients should receive reminders for preventive/follow-up care.

Any EP who has no office visits during the EHR reporting period.

13 Identify patient-specific education resources and provide those resources to the patient.

Any EP who was not the recipient of any transitions of care during the EHR reporting period.

14 Medication reconciliation for patient transfers. Any EP who neither transfers a patient to another setting nor refers a patient to another provider during the EHR reporting period is excluded from both measures.

15 A summary care record for each transition of care or referral.

A. The EP does not administer any of the B. The EP operates in a jurisdiction for which no immunization registry or immunization information system is capable of receiving electronic immunization data

16 Submit electronic data to immunization registries

N/A

17 Use electronic messaging to communicate with patients

Any EP who has no office visits during the EHR reporting period.

1* Capability to submit electronic syndromic surveillance data to public health agencies except where prohibited, and in accordance with applicable law and practice.

A. The EP doesn’t collect ambulatory syndromic surveillance information on their patients during the EHR reporting period. B. There is no public health agency is capable of receiving electronic syndromic surveillance data in the specific standards required for Certified EHRs at the start of their EHR reporting period. C. The EP operates in a jurisdiction for which no public health agency is capable of accepting the version of the standard that the EP's Certified EHR Technology can send.

2* Record electronic notes in patient records. N/A

3 Imaging results consisting of the image itself and any explanation or other accompanying information are accessible through CEHRT.

Any EP who does not perform diagnostic interpretation of scans or tests whose result is an image during the EHR reporting period

4* Record patient family health history as structured data.

Any EP who has no office visits during the EHR reporting period

5* Capability to identify and report cancer cases to a public health central cancer registry

A. Does not diagnose or directly treat cancer; or B. Operates in a jurisdiction for which no public health agency is capable of receiving electronic cancer case information.

6* Capability to identify and report specific cases to a specialized registry.

A. Does not diagnose or directly treat any disease associated with a specialized registry; or B. Operates in a jurisdiction for which no registry is capable of receiving electronic specific case information.

National Quality Forum Measure number and name

Clinical Quality Measure Description

0105 Antidepressant medication management:

(a) Effective Acute Phase Treatment (b) Effective Continuation Phase Treatment

The percentage of patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported.

(a) Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks) (b) Percentage of patients who remained on an antidepressant medication for at least 180 days

0004 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment:

(a) Initiation (b) Engagement

The percentage of patients 13 years of age or older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.

(a) Percentage of patients who initiated treatment within 14 days of the diagnosis (b) Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit

0028 Preventive Care and Screening: Tobacco Use—Screening and Cessation Intervention

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND received cessation counseling intervention if identified as a tobacco user.

0022 Use of High-Risk Medications in the Elderly

Percentage of patients ages 65 years and older who received at least one high-risk medication. Percentage of patients 65 years of age and older who received at least two different high-risk medications.

(a) Percentage of patients who were ordered at least one high-risk medication (b) Percentage of patients who were ordered least two high-risk medications

0101 Falls: Screening for Fall Risk

Percentage of patients aged 65 years and older who were screened for future fall risk during the measurement period.

0104 Major Depressive Disorder (MDD): Suicide Risk Assessment

Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of MDD who had a suicide risk assessment completed at each visit during the measurement period.

0108 ADHD: Follow-Up Care for Children Prescribed Attention Deficit Hyperactivity Disorder Medication

Percentage of children 6–12 years of age as of age and newly dispensed a medication for attention deficit/hyperactivity disorder (ADHD) who had appropriate follow up care. Two rates are reported.

(a) Initiation Phase: Percentage of children who had one follow up visit with a practitioner with prescribing authority during the 30-day initiation phase (b) Percentage of children who remained on ADHD medication for at least 210 days and who had at least two additional follow-up visits with a practitioner within 270 days after the initiation phase ended

0110 Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.

0418 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age-appropriate standardized depression screening tool AND, if positive, a follow up plan is documented on the date of the positive screen.

0419 Documentation of Current Medications in the Medical Record

Percentage of specified visits for patients 18 years and older for which the eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over the counter, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency, and route of administration.

0421 Adult Weight Screening and Follow-Up

Percentage of patients aged 18 years and older with a calculated body mass index (BMI) AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented within the past 6 months or during the current reporting period. Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30. Age 18–64 years BMI ≥ 18.5 and < 25.

0710 Depression Remission at 12 Months

Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at 12 months defined as PHQ-9 score less than 5.

0712 Depression Utilization of the PHQ-9 Tool

Adult patients age 18 and older with the diagnosis of major depression or dysthymia who have a PHQ-9 tool administered at least once during a 4-month period in which there was a qualifying visit.

1365 Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment

Percentage of patient visits for those patients aged 6–17 years with a diagnosis of major depressive disorder with an assessment for suicide risk.

Not Yet Endorsed Dementia: Cognitive Assessment

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.

ARRA & Meaningful

Use

PPACA and

Health Homes

Fewer ER Visits = Lower Costs

Either to other providers in a point-to-point network;

as with a Health Home

Or back and forth to a central hub; as with a

RHIO or HIE

Health/Behavioral Health data is going to move…

Would require Direct Project protocol through NwHIN

(Nationwide Health Information Network)

WHAT DATASET?

HOW IS IT GOING TO MOVE?

CCD

C32 (CCD)

HEAL 17

HIPAA 837

XDR/ XDS

Web Services

HL7/ SFTP

Other

PRIVACY & CONSENT

HIPAA

State Regs

42CFR Part 2

Other

So the questions are…

Behavioral Health Agency

RHIO

Other Statewide RHIOs

Labs Hospital Mental Health Agency

Care Coordination

State Billing

In a word, Centralization: Combining complementary providers in a harmonizing structure to provide a single network of care-provision for each care recipient. No one will come and tell you you’re out of business, but as more and more dual and multi-diagnoses individuals are sent to these networks, be they health homes or anything else, there will be fewer and fewer individuals who receive care outside of that structure. Fee-for-service will whither as its replaced by daily capitated rates based on diagnoses and dependent upon outcomes (such as the CQMs). You must be part of this! You may not have EPs, you may not do any primary care at all, but you must become part of a network or collaborative that provides these things. To the degree that you can proactively engage with other care providers in your area, whether through pre-existing federal or state programs such as Health Homes, or on your own, that is the degree to which you too can Survive and Thrive in our new world.