Next Stop on the Meaningful Use Road Trip Stage 2 AMGA Quality Council Meeting March 7, 2012

Background EHR Incentive Program was created by the American Recovery and Reinvestment Act of 2009 AMGA advocated for inclusion of physician who had been “early adopters” of EHRs, like many AMGA members Stage 1 public comments were very effective, resulting in a much more workable framework for initial implementation Health Information Technology Policy Committee requested public comments in 2011 on draft framework for Stage 2 Proposed rule for Stage 2 reflects input received by the committee and helped shape their recommendations to the Centers for Medicare and Medicaid Services (CMS) Early days, still digesting 455 page document Official regulatory text published in today’s Federal Register I apologize in advance for any obvious gaps in my knowledge of these proposals, since they are so new. If there are questions I can’t yet answer, I will research them and get back to you if you give me your contact information. Once the annual conference is in the rear-view mirror, we will follow the standard process of seeking input from AMGA’s ad hoc Regulatory Response Team to help shape our response to the proposed rule.

Outline Extension of Stage 1 Changes to Stage 1 Criteria Stage 2 Meaningful Use Overview Stage 2 Clinical Quality Measures Proposed Medicaid Policies Medicare Payment Adjustments and Available Exceptions CMS Questions for stakeholders

Extension of Stage 1 The HITPC heard loudly and clearly from stakeholders that 2013 implementation of Stage 2 was too much, too soon Software vendor community chimed in, as well, saying that they could not get certified products to market quickly enough for 2013 start of Stage 2 Therefore, CMS included a delay of one year in the proposed regulations Those attesting to MU for 2011 will have an additional year to meet Stage 2 criteria (2014 instead of 2013) Pinto/Ferrari? Pinto will get there more slowly, but eventually everyone will be in the same place.

Changes to Stage 1 Criteria In response to feedback from providers, CMS is proposing several changes that would apply to the remainder of Stage 1, many of which are optional until 2014 Changes modify exclusions to some objectives and allow “splitting” of certain objectives if parts do not apply to the practice of an EP Summary of proposed changes is found in Table 3 of proposed regulation text CMS is open to public comment on these proposed changes An example of an objective that would be modified is “Record and chart changes in vital signs.” CMS is proposing to change the age and split the EP exclusion as follows for EPs who: 1) Sees no patients 3 years or older is excluded from recording blood pressure; 2) Believes that all three vital signs of height, weight, and blood pressure have no relevance to their scope of practice is excluded from recording them; 3) Believes that height and weight are relevant to their scope of practice, but blood pressure is not, is excluded from recording blood pressure; or 4) Believes tat blood pressure is relevant to their scope of practice, but height and weight are not, is excluded from recording height and weight.

Stage 2 Meaningful Use Overview Stage 2 criteria focuses on the increased capture of health information in structured format and increasing information exchange between providers during care transitons Core/menu structure retained from Stage 1 Eligible professionals must meet 17 core objectives (or qualify for an exception), 3 of 5 menu objectives, and 12 ambulatory clinical quality measures (CQMs) Eligible hospitals and CAHs must meet 16 core objectives (or qualify for an exception), 2 of 4 from the menu set, and 24 CQMs

Modifications to Certain Objectives “Exchange of key clinical information” has been modified to more robust “transitions of care” “Provide patients with an electronic copy of their health information” has been replaced with “electronic/online access” core objective Some Stage 1 objectives have been combined, and the thresholds for meeting them have been increased

Clinical Quality Measures (CQMs) CMS is proposing clinical quality measures for Stage 2 that align with other quality reporting programs such as the Physician Quality Reporting System (PQRS), the Medicare Shared Savings Program (MSSP), and the National Council for Quality Assurance (NCQA) Statutory mandate for CMS to align, to the extent possible, reporting requirements across programs by 2012

CQMs-Con’t Reporting must include at least one measure from each of the following 6 domains: Patient and family engagement Patient safety Care coordination Population and public health Efficient use of healthcare resources Clinical process/effectiveness Finalized list of measures that would apply for EPs in 2014 will be published in final rule.

Reporting Medicare EPs in first year of Stage 1 may report clinical quality measures through attestation for a continuous 90-day reporting period Subsequent reporting would be done through an aggregate reporting method that entails logging onto CMS-designated portal and submission through an upload process

Group Reporting Options for 2014 In Stage 1, reporting was done on a per EP basis CMS is proposing group reporting options, beginning in 2014 These options available if all EPs in group are beyond the first year of Stage 1 Group reporting option limited to core and menu set objectives Clinical quality measures must be reported separately through electronic submission process

Group Reporting Options-Con’t Option 1: Reporting would represent all Medicare EPs within group in cases of two or more EPs identified with a unique NPI associated with the TIN of a group (must be beyond first year of Stage 1 for all options) Option 2: Medicare EPs participating in the Medicare Shared Savings Program and testing the Pioneer ACO model who use Certified EHR Technology to submit ACO measures Option 3: Medicare EPs who satisfactorily report PQRS measures using Certified EHR Technology

Eligible Hospital (and CAH) CQMs Preference given to CQMs selected for purposes of the Hospital Inpatient Quality Reporting Program CMS continuing to propose CQMs that would apply to both Medicare and Medicaid Incentive Programs Measures categorized into same 6 domains mentioned earlier for EP reporting

Revisions and Clarifications to Medicaid Program Medicaid EPs can now attest that they have adopted, implemented, upgraded or meaningfully used certified EHR technology, allowing CMS to set average costs (previously, EPs had to provide documentation of certain costs) Twelve children’s hospitals will be provided with an alternative number for the sole purpose of participation in the Medicaid EHR program (guidance forthcoming) CMS proposes a revision to method of calculating total Medicaid patients assigned to an EP that allows a longer look-back period for the purpose of counting encounters Currently, CMS allows calculation of total Medicaid patients assigned to EP in any representative, continuous 90-day period in the preceding calendar year OR (new part) in the 12 months preceding the EP’s attestation when at least one Medicaid encounter took place with the Medicaid patient in the 24 months prior to the beginning of the 90-day period. Children’s hospitals do not have Medicare identification number, and will now have their own way of being identified.

Medicare Payment Adjustments Any Medicare meaningful user in 2013 would avoid a payment adjustment in 2015 Any Medicare provider that first meets meaningful use in 2014 would avoid the penalty if they meet registration and attestation requirements by July 1, 2014 (hospitals) or October 1, 2014 (EPs)

What Are the Payment Adjustments? For 2015, 99 percent For 2016 98 percent For 2017, and each subsequent year, 97 percent For 2015 only, an EP could also be subject to the payment adjustment for not being a successful electronic prescriber (additional one percent)

Additional Consideration By calendar year 2018, if the Secretary of HHS finds that the proportion of EPs who are meaningful users is less than 75 percent, the applicable percent will be decreased by another one percent for non-meaningful users In no case going lower than 95 percent of fee schedule payments

Available Exceptions CMS proposes exceptions to the payment adjustments for three reasons: Lack of availability of internet access or barriers to obtaining the necessary infrastructure A time-limited exception for newly practicing EPs or newly established hospitals Unforeseen circumstances such as natural disasters, to be determined on a case-by-case basis CMS is soliciting comments on a fourth category, a combination of features limiting providers’ interaction with patients and a lack of availability of Certified EHR product Newly practicing EPs would receive a 2 year exception. For hospitals, it would be a one full year cost reporting period.

CMS Questions CMS is soliciting public feedback on mechanisms for electronic CQM reporting, including aggregate-level electronic group reporting options, and through existing quality reporting systems CMS is proposing an 80 percent threshold for having vital signs recorded as structured data (from 50 percent) CMS is proposing an 80 percent threshold for recording smoking status (from 50 percent) CMS solicits comments on whether the problem list should be extended to include “when applicable, functional and cognitive limitations” or whether a separate list should be included for these limitations I’ve alluded to a few areas that CMS is requesting input about. The public comment period is a great opportunity to provide comments not only on the topics the agency is asking for, but to provide them with any other suggestions you may have based on your experiences implementing Stage 1 criteria.

CMS Questions-Con’t CMS solicits comment on a wide-ranging list of 125 potential measures for EPs and 49 potential measures for eligible hospitals and CAHs, finalizing only a subset CMS solicits comment on the “core” measures listed in Table 6, chosen for their relevance to conditions that contribute most to morbidity and mortality, population health priorities, health disparities, and conditions that are major cost drivers CMS solicits comment on the number and appropriateness of measures for hospitals and CAHs, found in Table 9

Next Steps CMS will accept public comments on the proposed Stage 2 framework until May 7, 2012 Consider submitting your own comments, or pass along your recommendations so that they can be included in the AMGA comment letter

Thank you! Karen Ferguson Associate Director, Regulatory Affairs kferguson@amga.org