APA Responds to CMS’s EHR Stage 2 Proposed Rule

Tue May 01, 2012

(Arlington, VA) - At the end of February 2012, the Centers for Medicare & Medicaid (CMS) issued a proposed rule for Stage 2 requirements for the Medicare and Medicaid Electronic Health Record Incentive Programs (EHRIP). Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, eligible health care professionals (EPs, aka “physicians”), eligible hospitals and critical access hospitals (CAHs) can qualify for Medicare and Medicaid incentive payments when they adopt certified Electronic Health Record (EHR) technology and use it to demonstrate “meaningful use” and become “meaningful users” (MUs) of EHR technology by achieving objectives set by CMS. To become Stage 2 MUs, under this proposed rule, physicians would need to fulfill 17 “core” measures, 3 of 5 “menu” measures, and 12 “clinical quality measures” (CQMs). 

The APA responded to the Medicare and Medicaid Programs- Electronic Health Record Incentive Program, Stage 2 Meaningful Use, and to the ONC’s proposed rule on Certification Criteria for Electronic Health Record Technology, 2014 Edition

Meaningful Use Policy Goals

The APA is encouraged by efforts CMS has undertaken in this proposed rule to make achievement of Stage 2 MU requirements achievable for specialists, like psychiatrists. The proposed Stage 2 measures contain higher percentage thresholds than was characteristic of the same measures in Stage 1.  The APA shares with CMS its heightened concern that many of the Stage 2 measures’ percentage thresholds may be too high for many EPs to satisfy.

 Development of Stage 2 Meaningful Use Criteria

The proposed Stage 2 MU criteria are based on a series of specific objectives, each of which is tied to a proposed measure that all eligible professionals (EPs) and hospitals must meet by way of the measure’s objective criteria or exclusion criteria in order to demonstrate that they are MUs of certified EHR technology.

Stage 2 Meaningful Use “Core” and “Menu” Measures

In this proposed rule, CMS proposes that EPs must fulfill 17 “core” measures and 3 of 5 “menu” measures. In instances in which an EP cannot fulfill the objective criteria of a core or menu measure, he/she may fulfill a particular measure by falling within the measure’s exclusion criterion.  Where an EP can satisfy a measure’s exclusion criteria, he/she need not meet the measure’s objective criteria to be deemed a meaningful user. 

The APA commends CMS for creating enough “menu” measure exclusions which psychiatrists can satisfy in cases in which the “menu” measures’ objective criteria is not relevant to a psychiatrist’s medical practice. While most psychiatrists would be unable to fulfill 3 of 5 “menu” measures through satisfaction of these menu measures’ objective criteria, they can fulfill these menu measures via these measures’ exclusion criterion.

Greater Applicability to Specialists

The proposed rule proposes “core” and “menu” measure exclusions as well as new clinical quality measures (CQMs) that have greater applicability to many specialty providers, including psychiatrists. The addition of these objectives recognizes the leadership role that many specialty providers have played in the meaningful use of health IT for quality improvement purposes with respect to:

•           Imaging results and information accessible through certified EHR technology

•           Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice

•           Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice

Stage 2 Reporting of Clinical Quality Measures

CMS proposes that EPs, eligible hospitals, and CAHs be required to report on twelve clinical quality measures (CQMs) in order to qualify for incentive payments under the Medicare and Medicaid Electronic Health Records Incentive Program (EHRIP).

For EPs, CMS is proposing a set of measures that align Stage 2 CQMs with existing quality programs by aligning measures with the Physician Quality Reporting System (PQRS), Medicare Shared Savings Program, and National Council for Quality Assurance (NCQA) for medical home accreditation, as well as measures proposed under the Children’s Health Insurance Program Reauthorization Act (CHIPRA) and under section 1139A of the Social Security Act (as added by Section 2701 of the Affordable Care Act).

Payment Adjustments and Exceptions

Medicare payment adjustments are required by statute to take effect in 2015. CMS proposes that any Medicare EP or hospital that demonstrates meaningful use in 2013 would avoid payment adjustment in 2015. Also, any Medicare provider that first demonstrates meaningful use in 2014 would avoid the penalty if he/she meets the attestation requirement by July 3, 2014 (eligible hospitals) or October 3, 2014 (EPs).

The APA strongly opposes the back-dating of payment adjustments for physicians participating in the Stage 2 MU program.  In effect, CMS has pushed up deadlines for participation by a full year or more. 

CMS proposes three exceptions to payment adjustments for EPs who do not become meaningful users. The three categories of exceptions would be based on:

•           Availability of internet access or barriers to obtaining IT infrastructure;

•           A time-limited exception for newly practicing EPs who would not otherwise be able to avoid payment adjustments; and

•           Unforeseen circumstances such as natural disasters that would be handled on a case-by-case basis.

The APA urges CMS to be flexible in creating MU exceptions for physicians. We’re in the infancy of using EHR technology, and new circumstances will arise which necessitate the creation of an additional MU participation exceptions for physicians. 

Burden Estimates

CMS concludes it will take each EP, using the least burdensome menu criteria, a minimum of 10 hours and 15 minutes to satisfy the requisite measures during the EHR reporting period. The APA thinks this overall burden estimate is too low, given many of the measures tied to it will likely comprise lengthier periods of a physician’s time than estimated by CMS. For example, the APA thinks it likely will take longer than CMS’s burden estimate of one minute for most physicians to satisfy the “core” quality measure of implementing five clinical decision support interventions related to five or more quality measures at a relevant point in patient care for the entire EHR reporting period.

The APA thinks many of the proposed measures will take physicians more time than what CMS estimates to fulfill. The APA worries that if fulfillment of requisite Stage 2 MU measures is too burdensome for psychiatrists, fewer psychiatrists will treat Medicare beneficiaries, thus resulting in Medicare beneficiaries having diminished access to quality mental health care.

To view the APA's comments on other related issues, visit our Medicare, Medicaid, and Public Health section.  

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