April 12, 2010

RAC Rules : HITECH Act Electronic Health Record Incentive Program- Bonus or Penalty for Anesthesiologists?

Most physicians have heard that they are going to be eligible for a federal payment of up to $44,000 between 2011 and 2015 if they use an electronic health record (EHR). Anesthesiologists continue to wonder, however, whether they will qualify for the bonus, since they rarely invest directly in EHRs or electronic anesthesia records, relying more typically on the hospital’s information technology (IT).

They will not qualify, in all likelihood. First, anesthesiologists do not use a standard EHR or a system having the requisite functionalities spelled out in CMS’ proposed rule implementing the EHR incentive program , which was created as part of the Health Information Technology for Economic and Clinical Health Act (HITECH) provisions in the American Recovery and Reinvestment Act of 2009. (Other physicians claim correctly that every clinical specialty has different IT requirements). An anesthesia information management system (AIMS) “is the anesthesia-specific version of an EHR and it is a very different information technology system …. An AIMS is integrated, or ‘hard-wired,’ with monitors, anesthesia machines and other equipment in the preoperative area, operating room and post-anesthesia care unit.” (Letter from Alexander A. Hannenberg, MD, President, American Society of Anesthesiologists, to the CMS Acting Administrator commenting on the proposed rule, Medicare and Medicaid Programs; Electronic Health Record Incentive Program; RIN 0938-AP-78, March 15, 2010.) An AIMS does not transmit prescriptions electronically, as does a typical office EHR, for example. Nor does an AIMS submit claims to payers, although it collects the elements that must be documented in claims.

Second, the HITECH Act requires physicians to report approved clinical quality measures through an EHR, and there are no applicable measures – the Act does not recognize the three measures that anesthesiologists can report under the Physician Quality Reporting Initiative (PQRI).

Third, it will be out of the question for most anesthesiologists to satisfy the HITECH Act’s 80% threshold for reporting on many of the EHR functionality requirements because they are likely to work in at least some anesthetizing locations where there are no installed AIMS at all.

The news gets worse. Not only are anesthesiologists generally excluded from the EHR incentive payments; they also risk the same payment penalties as do other physicians who fail to purchase and undertake “meaningful use” of an EHR by 2015. The payment adjustment will be a 1% reduction in the allowed amount for services if the physician (or hospital) is not a “meaningful user” in 2015, a 2% reduction in 2016, and a 3% reduction thereafter (subject to some modifications.)

This double whammy is attributable to the statutory definition of “hospital-based eligible professionals” (EPs). Hospital-based EPs are not eligible to participate in the incentive program. The statute defines a hospital-based EP as “an eligible professional, such as a pathologist, anesthesiologist, or emergency physician, who furnishes substantially all of such services in a hospital setting (whether inpatient or outpatient) and through the use of the facilities and equipment, including qualified health records, of the hospital.” CMS has proposed to require that the EP furnish at least 90% of services in a hospital (inpatient or outpatient) setting in order to qualify for hospital-based status. Ambulatory surgical centers (ASCs) are not eligible for the EHR incentive program, and professional services provided in ASCs are not counted either.

As ASA points out in its thoroughly substantiated letter, a large proportion of anesthesiologists work in more than one facility and on any given day may provide anesthesia services in the hospital’s inpatient OR, outpatient surgery center, labor and delivery unit, the ICU, and perhaps a private pain clinic. ASA analyzed Medicare site-of-service data for the year 2008 and found that only 57.5% of claims for anesthesia services were submitted in the hospital setting:

Given these data, it will be difficult for a lot of anesthesiologists to satisfy the 90% hospital site-of-service criterion that will exempt them, under the HITECH Act, from payment penalties beginning in 2015 for not “meaningfully using” a certified EHR.

Even the minority of anesthesiologists who do purchase and use their own AIMS at their primary facility – at an approximate cost of $25,000-$30,000 per OR, according to ASA – are probably not going to be eligible for the incentive because they will still (1) provide more than 10% of their services at non-hospital sites and (2) there are no AIMS that will allow anesthesiologists to report on all 25 of the EHR measures (functionalities) in the proposed rule. Pain physicians who purchase and meaningfully use certified EHRs in their private offices may qualify for the incentive, however.

ASA makes a solid argument both for the benefits of AIMS, stating “we believe it is critical to have AIMS available at each anesthetizing location to ensure proper patient care coordination,” and for the modifications to the proposed EHR regulation that will help, not hinder the adoption of AIMS. We recommend downloading a copy of the letter and using it whenever you might need to explain the difference between AIMS and the HITECH rules’ EHR – to hospital management, for example.

We also remind our readers that Medicare is providing a separate bonus for electronic prescribing – but an EP who participates in the HITECH EHR incentive program can’t also participate in the e-prescribing incentive program. See the March 15 Alert for further information on the e-prescribing program.

In case you are worried about whether there are enough HIT professionals to make it all work, on April 2nd the Department of Health and Human Services announced awards totaling $84 million to 16 universities and junior colleges that will support training and development of more than 50,000 new health IT professionals. “ Additionally, Strategic Health IT Advanced Research Projects (SHARP) awards totaling $60 million were provided to four advanced research institutions ($15 million each) to focus on solving current and future challenges that represent barriers to adoption and meaningful use of health IT. Both sets of awards are funded by the American Recovery and Reinvestment Act of 2009. Today’s awards are part of the $2 billion effort to achieve widespread meaningful use of health IT and provide for the use of an electronic health record (EHR) for each person in the United States by 2014.”

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