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
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.

Medicaid
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.