Question

Health care IT is being driven through policies and reimbursement incentives such as the Meaningful Use initiative. Discuss the impact of meaningful use criterion on Medicare and Medicaid hospital and hospital provider reimbursement .

Answer 1

In the context of health care IT, meaningful use is a term used to define minimum U.S. government standards for electronic health records (EHR), outlining how clinical patient data should be exchanged between healthcare providers, between providers and insurers and between providers and patients.

Electronic health records (EHRs) have emerged as a major topic in health care and are central to the federal government’s strategy for transforming healthcare delivery in the United States. Recent federal actions that aim to promote the use of EHRs promise to have significant implications for laboratories and for pathology practices. Under the HITECH (Health Information Technology Economic and Clinical Health) Act, an EHR incentive program has been established through which individual physicians and hospitals can qualify to receive incentive payments if they achieve “meaningful use” of “certified” EHR technology. The rule also establishes payment penalties in future years for eligible providers who have not met the requirements for meaningful use of EHRs. Meaningful use must be achieved using EHR technology that has been certified in accordance with functional and technical criteria that are set forth a regulation that parallels the meaningful use criteria in the incentive program. These actions and regulations are important to laboratories and pathologists for a number of reasons. Several of the criteria and requirements in the meaningful use rules and EHR certification criteria relate directly or indirectly to laboratory testing and laboratory information management, and future stage requirements are expected to impact the laboratory as well.

The problems that face our national health care delivery systems include fragmentation of the provider base, poor communication among providers and with patients, misaligned incentives among stakeholders, lack of a common governance structure, and insufficient financial and expert resources for instituting and managing change even where the will to do so exists. Although widespread adoption of electronic health records (EHRs) is frequently and correctly cited as necessary to meet the challenge of doing better with less, technology alone will not accomplish this. Societal change within both the medical system and the population that the medical establishment interacts with must accompany the adoption of health information technology (HIT). The reliance on financial incentives and disincentives to control medical behavior, improve value, and bend the rising burden of health care on the nation's economy will fail unless physicians and their professional societies are included as meaningful partners in health care reform. We will begin to advance health care only if we succeed in creating a new socio-technologic ecosystem that includes providers, patients, and payers.

The meaningful use (MU) criteria that unlock the American Recovery and Reinvestment Act (ARRA) stimulus dollars matter because these criteria are the tangible first efforts to redesign how health care is delivered while acknowledging the central role of HIT and EHRs.

MU combines technology adoption by providers and hospitals, health information exchange, practice redesign, and consumer engagement in order to improve outcomes and efficiency of health care delivery. The Institute of Medicine (IOM) has been instrumental in laying out the underlying principles for the design of a more efficient health care delivery system capable of increasing value by simultaneously improving the quality of care delivered and reducing resources expended. Five overarching goals to achieve this have been identified by IOM and were subsequently adopted by the Office of the National Coordinator for Health Information Technology (ONC) as the underlying basis for MU:

1.    Improve quality, safety, efficiency, and reduce health care disparities.

2.    Engage patients and families.

3.    Improve care coordination.

4.    Improve population and public health.

5.    Ensure adequate privacy and security protections for personal health information.

The EHR incentive program establishes the criteria, reporting requirements, incentive payments, and (future) penalties for eligible professionals and hospitals related to achieving the meaningful use of EHRs. Eligible professionals and eligible hospitals are those that participate in the Medicare or Medicaid programs. There are separate but related incentive programs for both Medicare and Medicaid-eligible providers and hospitals. Although there are some differences in some provisions of the administration of the Medicare and Medicaid programs, the meaningful use criteria and required quality measures are largely common to both. The Medicaid program will be voluntarily offered by individual states.

Medicare defines Eligible professionals (EPs) as doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry and chiropractors. Hospital-based physicians such as pathologists and emergency room physicians are not eligible for reimbursement. Hospital-based is defined as providing 90% or more of care in a hospital setting. The exception is if more than 50% of a physician’s total patient encounters in a six-month period occur in a federally qualified health center or rural health clinic. Physicians may select reimbursement by Medicare or Medicaid, but not both. They cannot receive Medicare EHR reimbursement and federal reimbursement for e-prescribing. They can receive Medicare reimbursement as well as participate in the Physicians Quality Reporting System (PQRs). If they participate in the Medicaid EHR incentive program they can participate in all three programs.

Medicaid Eligible professionals (EPs) are defined as physicians, nurse practitioners, certified nurse midwives, dentists and physician assistants (physician assistants must provide services in a federally qualified health center or rural health clinic that is led by a physician assistant). Medicaid physicians must have at least 30% Medicaid volume (20% for pediatricians). If a clinician practices in a federally qualified health center (FQHC) or rural health clinic (RHC), 30% of patients must be needy individuals. The Medicaid program will be administered by the states and physicians can receive a one-time incentive payment for 85% of the allowable purchase and implementation cost of a certified EHR in the first year, even before Meaningful use is demonstrated. Medicaid is also different from Medicare in the following: payment over six years does not have to be consecutive and there are no penalties for non-participation.