American Recovery and Revitalization Act of 2009: The Stimulus

1. American Recovery and Revitalization Act of 2009: The Stimulus Health Care Provisions

2. Health Care Provisions • Three main areas: • Health Information Technology • Comparative Effectiveness Research • Prevention and Wellness

3. Health Information Technology

4. Healthcare Information Technology for Economic and Clinical Health Act (HITECH) • Title XIII of the bill • Electronic health records (EHRs) are to focus on clinical information and coordination of care • Effectively puts the focus on evaluating and making recommendations about individual patients • This is not about billing, it is a care management tool

5. HITECH, cont. • Building on an Executive Order from Pres. Bush in 2004, creates an Office of the National Coordinator for Health Information Technology who reports directly to the Secretary of HHS • Role: Will work with a HIT Policy Committee and a HIT Standards Committee • Health Technology Research Center (national and regional offices) to play important role in actual implementation

6. HITECH, cont. • Initial set of standards, implementation specifications, and certification criteria must be adopted using the rulemaking process by Dec. 31, 2009 • Such standards will continue to be updated—federal HIT expenditures when they occur have to use products that fit those standards, specifications, criteria

7. Funding to Encourage Providers to Utilize EHRs ELIGIBILITY FOR PAYMENT • An eligible professional is defined as a physician as defined by section 1861 (r) of the Social Security code. This includes medical doctors, dentists, podiatrists, optometrists and doctors of chiropractic. • Payments will be made to outpatient physicians who have demonstrated that they are a meaningful EHR user. • Hospital-based physicians such as pathologists, anesthesiologists, emergency physicians or hospitalists who furnish substantially all of their services in a hospital setting through the facilities and equipment of the hospital are not eligible.

8. Requirements There are three requirements to be met: • 1)  Use of certified EHR technology including electronic prescribing. • 2)  The EHR technology is connected in a manner that provides electronic exchange of health information. • 3)  The eligible professional submits information for the period on the clinical quality measures and other measures selected by the Secretary; you must report on quality of care.

9. Requirements etc. • The Secretary is also empowered to accept individual State determinations of meaningful EHR usage with Medicaid as meeting these requirements. This provision allows practices that see relatively little Medicare populations but large Medicaid populations to qualify.

10. Amount of Payment • AMOUNT OF PAYMENT The payment is designed for physicians who have a substantive Medicare patient base. The incentive payments will equal to 75% of the amount paid to eligible professionals by Medicare. Payments are limited to the following schedule: Year 1:       $18,000 if the first payment year is 2011 or 2012 (more than $25k Medicare billing) $15,000 if the first payment year is 2013 $12,000 if the first payment year is 2014 Year 2: $12,000 Year 3: $8000 Year 4: $4000 Year 5: $2000 The final payment year is 2015.  • The method of payment is up to the discretion of the Secretary. It may be made as a lump sum or by incremental payments. Claims for a specific reporting year must be submitted within two months of the end of the year in order to be eligible for EHR bonus payment. • The above payment limitations are 25% higher for eligible providers in areas designated as health professional shortage areas.

11. Eligibility • PROOF OF ELIGIBILITY Professionals may satisfy the requirements proving use of the EHR and electronic health exchange by methods to be determined by the Secretary which could include: a) an attestation (swearing that you have EHR) b) submission of claims with a CPT code indicating the use of certified EHR technology (most likely) c)  a survey response d) submission of quality measure data (most likely) e) other methods determined by the Secretary

12. Public Reporting • PUBLIC REPORTING CMS will post on a public website, in an understandable format, the names, business addresses, and business phone numbers of eligible professionals and group practices who are meaningful EHR users and receiving incentive payments.

13. Penalties • PENALTY FOR NOT USING AN EHR Beginning in 2015 there will be a reduction in Medicare payments for professional services furnished by in an eligible professional if that professional is not a meaningful EHR user. The amount of Medicare payments (with some exceptions) will be a)      2015 – 99% b)      2016 – 98% c)      2017 and beyond – 97% Above timetable seems ambitious; dates may be pushed back

14. MEDICARE ADVANTAGE PLANS • In general the provisions also apply to physicians delivering most of their services through a Medicare Advantage plan. • Eligible professionals in this category would be those who are employed by the organization, are a member or employee of an organization which furnishes 80% of its patient care services to a Medicare Advantage plan and furnishes 75% of the services of the eligible professional to the organization and furnishes at least 20 hours per week of patient care services. • There are limitations to avoid duplication of payment and the maximum number of physicians per organization is capped at 5000. • Will HHS allow physicians who bill for Part B and Part C to meet the eligibility threshold combined?

15. In general… • Much of the detail in this measure is undefined and left to the discretion of the Secretary of Health and Human Services. • The implementation plans are required to be published in the Federal Register for public comment, thus the actual payment mechanisms and the exact requirements to qualify for payment are not fully defined.

16. HIT SUMMARY • Outpatient practitioners who wish to qualify for the full benefit of the $44,000 in EHR incentive payments should have a certified EHR in place by 2011 capable of eprescribing, interoperability, and quality measure reporting. • Detailed specifications from CMS have not yet been developed to implement this act. • Providers should definitely keep an eye out for the standards, specifications, and criteria recommendations that will come down from the Office of the National HIT Coordinator later in 2009 • ACA will of course, keep the profession apprised as the rulemaking process develops

17. Comparative Effectiveness Research

18. $1.1 Billion for Comparative Effectiveness Research • $700,000,000 to the Agency for Healthcare Research and Quality (AHRQ) • $400,000,000 of this goes to the Office of the Director of NIH • $400,000,000 at the discretion of the Secretary

19. Comparative Effectiveness: Setting Research Priorities • Sect 804 establishes a new, Presidentially-appointed body called the Federal Coordinating Council for Comparative Effectiveness Research • The mission of the Council is to foster coordination of comparative effectiveness/related research within federal agencies

20. How to Spend $1.1 Billion • The new Federal Council for Comparative Effectiveness Research and Institute of Medicine (IOM) both have reports due by June 30, 2009 on: • Current Federal work in this area (an overview of infrastructure, etc) • Recommendations for the national priorities in this area • These reports will greatly determine where the research funding goes

21. Prevention and Wellness

22. $1 Billion for Prevention and Wellness • $650 million to: “carry out evidence-based clinical and community-based prevention and wellness strategies authorized by the [U.S.] Public Health Service Act, as determined by the [HHS] Secretary, that deliver specific, measurable health outcomes that address chronic disease rates.” • Proposed allocation of and priorities for spending due to House/Senate Appropriations Committee 90 days after the act is signed into law

23. SUMMARY OF HEALTHCARE PROVISIONS • Bill consistently refers to research as a cornerstone for healthcare decision making, whether it be re: EHRs, prevention and wellness, or comparative effectiveness. • Many of the critical details related to actually implementing these provisions will be determined by federal agencies over the next several months.

24. Myths and Facts on the Stimulus • Myth: One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure doctors are doing what the federal government deems appropriate and cost effective. • Fact: It is true that the bill creates a National Coordinator of Health Information Technology. However, there is not one piece of language that authorizes, empowers or even so much as addresses the Coordinator’s role as being one that will monitor treatments to ensure that a health provider is “doing what the federal government deems appropriate and cost effective.” The section speaks solely to the development of an EHR system and how it can be most effectively used to share patient and clinical information to improve the quality of medical care.

25. Myths and Facts on the Stimulus • Myth: The goal of the Federal Coordinating Council for Comparative Effectiveness Research is to slow the development and use of new treatments and technologies because they are driving up costs. • Fact: The goal of the Council is to create (from the bill) “opportunities to assure optimum coordination of comparative effectiveness and related health services research conducted or supported by relevant Federal departments and agencies, with the goal of reducing duplicative efforts and encouraging coordinated and complementary use of resources.” The goal simply is to see what treatments work.

26. Questions? • ACA Department of Government Affairs • 703-812-0224 • gr@acatoday.org