Meaningful Use: The Final Rule
What Does it Mean?
writeen and revised by Donna Weinstock
Most of us in the healthcare arena are familiar with the HITECH (Health Information Technology) Act and the potential to offer stimulus money to healthcare providers. Do you understand what it means to your practice?
ARRA (American Recovery and Reinvestment Act) was originally signed in February 2009 by President Barack Obama. It was designed as a Medicare and Medicaid Electronic Health Record (EHR) incentive Program. By having either a large Medicare or Medicaid patient population and showing Meaningful Use (MU), providers became eligible for the incentive dollars.
July 13, 2010, the definition of Meaningful Use was clarified in what has been known as “The Final Rule.” This clarification from the original definition offers greater flexibility to meet and report certain objectives for meaningful use. It is no longer an all or nothing to prove Meaningful Use. In the first reporting of the HITECH Act, all 25 objectives had to be met. That is no longer the case. Now, 15 metrics are in the core set and must be met. In addition, there are 10 metrics in the menu set, of which providers must pick 5.
There are lower metrics for EHR use in most or many instances as well as a reduced number of clinical quality measures. Critical Access Hospitals (CAH) are now eligible for Medicaid incentives.
Other changes that make the Final Rule friendlier are:
- Recognition of “metric irrelevance” – 2 metrics were removed and 2 metrics were added
- Thresholds are generally lower. In some cases they went from 80% to 30%
- Removal of revenue cycle management metrics
- Addition of two metrics related to patient education materials and advance directives
- Significant reduction in the number of clinical quality measures –went from 90 down to 44
- Three core measures which are required of everyone
- Choice of three measures chosen from a subset, as most appropriate given the EP’s specialty
- No longer specialty-oriented
There are several things that were not changed, just clarified:
- Metrics are now based on actions with patients tracked in EHR which virtually eliminates administrative work around reporting
- States are allowed to tailor Stage 1 requirements for Medicaid incentives with regard to public health objectives and data registries, but nothing else
- Clarification of ambiguities: the answers may not be what we want to hear, but they are answers to our questions
- Registration for the ambulatory incentives will begin in January 2011 which is different from hospitals
The 15 Meaningful Use Core Set Objectives for the Final Rule for physician practices are:
- Computerized physician order entry (CPOE)
- E-Prescribing (eRx)
- Report ambulatory clinical quality measures to CMS/States
- Implement one clinical decision support rule
- Provide patients with an electronic copy of their health information, upon request
- Provide clinical summaries for patients for each office visit
- Drug-drug and drug-allergy interaction checks
- Record demographics
- Maintain an up-to-date problem list of current and active diagnoses
- Maintain active medication list
- Maintain active medication allergy list
- Record and chart changes in vital signs
- Record smoking status for patients 13 years and older
- Capability to exchange key clinical information among providers of care and patient-authorized entities electronically
- Protect electronic health information
In addition, 5 of the following 10 Menu Sets must be implemented:
- Drug-formulary checks
- Incorporate clinical lab test results as structured data
- Generate lists of patients by specific conditions
- Send reminders to patients per patient preference for preventative/follow up care
- Provide patients with timely electronic access to their health information
- Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate
- Medication reconciliation
- Summary of care record for each transition of care/referrals
- Capability to submit electronic data to immunization registries/systems
- Capability to provide electronic syndromic surveillance data to public health agencies
The Final Rule still has 3 stages to proving Meaningful Use. The first stage is designed to improve quality, safety, efficiency and to reduce health disparities as well as to engage patients and families in their health care. It is designed to improve care coordination, improve population and public health and ensure adequate privacy and security protections for personal health information. The first phase may begin as early as January 2011, but to be eligible for the first monies, must begin no later than October 2011 (the first phase is 90 days and all 90 days must be in the same calendar year).
To meet these objectives 80% of the patients must have records in the certified EHR technology, eligible professionals must report on 20 of the 25 Meaningful Use objectives (while eligible hospitals must report on 19 of their 24 Meaningful Use objectives).
Stage two concentrates on reevaluating the measures, possibly setting higher standards and includes a greater emphasis on health information exchange across institutional boundaries. For this stage there are two types of percentage-based measures which are included to address the burden of demonstrating Meaningful Use.
- Denominator is all patients seen or admitted during the EHR reporting period. This means all patients whether or not their records are kept using a certified EHR technology
- Denominator is actions or subsets of patient seen or admitted during the EHR reporting period. The denominator only includes patients, or actions taken on behalf of those patients, whose records are kept using certified EHR technology.
Stage three focuses on outcomes, improved public health and robust, patient-entered health information exchange.
The first stimulus money is available in May 2011 with practices being eligible for up to $44,000 based on when they begin to prove Meaningful Use. A practice who is eligible for stimulus money must register and attest to their use of a certified EHR.
Not all practices are eligible for stimulus money. An eligible Medicare Provider is defined as a:
- Doctor of Medicine or Osteopathy
- Doctor of Dental Surgery or Dental Medicine
- Doctor of Podiatric Medicine
- Doctor of Optometry
- Chiropractor
- Acute care hospital
- Critical Access Hospital
A Medicaid Provider is defined as:
- Physicians
- Nurse Practitioners
- Certified Nurse Midwives
- Dentists
- Physician Assistants working in a qualified health center or rural health clinic
- Acute Care Hospital
- Children’s Hospital
Not all practices will be eligible for stimulus dollars. Practices with few Medicare or Medicaid patients won’t get the government money. The stimulus money should not be the determining factor on whether a practice should transfer to electronic health records. A practice should weigh the benefits to their practice, do their homework (that may mean hiring a professional who can help you make the best decision) and make the right decision for your patients and their care. The preliminary planning phase is essential to a smooth transition.
Donna Weinstock is a healthcare consultant who works with practices to improve processes, implement EHR and help practices grow. She is a writer, speaker and trainer. Donna can be reached at (847) 205-9797; donna@officemanagementsolution.com or www.officemanagementsolution.com
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What is an RVU?
by
Leora Ardizzone, Esq.
The Medicare Resource-Based Relative Value Scale (RBRVS) is the method by which Medicare sets reimbursement rates for each Current Procedural Terminology (CPT) code assigned to every physician encounter; thus physicians’ services are counted in RVU’s. For example, a level one office visit may be assigned an RVU of 1, a level three office visit might be assigned an RVU of 1.5, and a surgical procedure might be assigned an RVU of 20.
RVUs are published in the Federal Register each November. Medicare bases RVUs on the following: (i) Physician work, which takes into account the physician’s expertise, the time and technical skill spent in performing the entire service including the mental effort and judgment expended by the physician prior to, during and after the patient encounter terminates, including documentation of the service; (ii) Practice expense, which accounts for the cost to operate a medical practice; and (iii) Professional liability insurance expense, which estimates the relative risk of services/cost to insure against the risk of loss in providing the service.
Each component of the relative value unit (work, practice expense and professional liability) assigned to each CPT Code, is then multiplied by the Geographic Practice Cost Index (GPCI) for each Medicare locality, which takes into account the cost of delivery of health care services based on locale, which is then further adjusted by a conversion factor that is set by the Centers for Medicare and Medicaid Services (“CMS”) on an annual basis. The Medicare Conversion Factor (CF) is a national value that converts the total RVUs into the dollar amounts paid by Medicare to physicians for the services they provide.
In New York City Suburbs/Long Island, New York the GPCI for the Work RVU, PE and Malpractice are 1.051, 1.289, and 1.235 respectively. The Physician practice conversion factor for calendar year 2010 was $36.0846. Thus, the formula for deriving the dollar amounts paid by Medicare for any service performed by a physician would be as follows:
[(Work RVU x 1.051) + (PE RVU x 1.289) + (MP RVU x 1.235)] x 36.0846.
The advantage of using RVUs as a measure of productivity is that the RVU is independent of the physician’s charge schedules, patients’ insurance coverage, the reimbursement fee schedules assigned by any payor for any CPT code, or the practitioner’s ability to collect reimbursement revenue for any physician encounter. In addition, the RVU method of measuring productivity reflects the reality that every patient encounter is not equal.
The WRVU lends itself to methods of setting compensation because the RVU is a reliable and objective measure of productivity. The RVU is derived by simple math, using verifiable data published by CMS, at least annually. The RVU eliminates any risk to the physician related to employer negotiated rates, captivated fees, reductions in reimbursement rates or failure or delays in collections.
Author Leora Ardizzone is a health care attorney in Long Island with over seventeen years experience in health and finance law .She can be reached at ‘lardizzone@optonline.net’
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Thought this article from ” USA Today” last week was well worth a read by every doctor.
SOME DOCTORS TRY TO PROFIT ON COSMETIC SURGERY’S RISE
Jennifer Siegel has had more than her share of unsolicited medical advice.
Her OB/GYN offered to do a tummy tuck after she delivered Siegel’s third child. Her eye doctor suggested injectables for the wrinkles between her brows when she went in for an eye exam. And when she asked her dentist about some simple cosmetic dentistry, he offered to nearly overhaul her entire mouth.
Cosmetic procedures — from dental veneers to Botox — have proved to be financial boons to many dentists and doctors. But what’s good for the physicians may not always be in the best interest, at least financially, of the patients. Porcelain veneers can cost as much as $2,000 a tooth; each area of wrinkles treated with Botox can run $400. Few cosmetic procedures are covered by insurance, and high-pressure sales pitches are far harder to spurn when you’re in an examination room. After all, turning down the person you’ve turned your health over to is a lot harder than dissing the perfume lady at your local department store.
“People mistakenly think that doctors and people in positions of authority are the voice of truth,” says psychotherapist and “money coach” Olivia Mellan. “Consumers have to learn to be their own advocates.”
Siegel, of Westfield, N.J., has gotten good at saying no but wishes she didn’t have to be so on guard with health care providers. It was during a visit to her eye doctor to update her contact lens prescription that the doctor suggested she get the filler Restylane for the furrow between her eyebrows. She was nearing her 40th birthday at the time. He even tried to convince her that it would be a good birthday present to herself.
“I was horrified,” says Siegel. “Now, if I were going to have the furrow filled, I certainly wouldn’t have it done by my eye doctor.”
With cosmetic procedures soaring in popularity, it’s going to get increasingly harder to avoid pitches. Consumers opted for 69% more cosmetic procedures — everything from a shot of collagen to a face-lift — in 2009 compared with 2000, according to an April report from the American Society of Plastic Surgeons. Botox injections increased 509% during that period, the report says.
Revenue from cosmetic dentistry climbed to $2.75 billion nationwide in 2007, up 15% from 2005, according to the most recent numbers available from the American Academy of Cosmetic Dentistry.
With so many elective procedures, Cleveland-based dentist Matthew Messina says he tries to explain to patients what’s available but also what’s truly necessary.
“Part of the practice of dentistry today is making sure your patients understand what opportunities exist for them,” Messina says. “But at the same time, that doesn’t mean that everything needs to be done for everybody.”
Messina says he and his patients evaluate whether to address only medical needs, such as decay or infection, or to consider cosmetic procedures, such as teeth whitening or veneers. He recommends patients ask if a procedure being recommended is elective and, if so, why they should consider going through with it. He adds that patients should ask their dentist if the procedure will be covered by insurance.
Many procedures performed by dermatologists — such as removing benign skin lesions — aren’t covered by most insurance providers, including Medicare, says Vernon, Conn.-based dermatologist Robert Greenberg. But insurance providers will usually cover the removal of lesions if there’s a chance they’re harmful.
Greenberg says he writes down the pertinent information about any diagnosis or procedure he recommends so patients can check with their insurance providers to see if it’s covered.
Many procedures fall into a “gray zone” between medical and cosmetic, says Daniel Rousso, president of the American Academy of Facial Plastic and Reconstructive Surgery. These include the removal of scars, surgery on the outside of the nose to complement surgery to fix a problem inside the nose and surgery on the upper eyelids.
“If it’s not enough of a visual problem, then it’s not going to be covered,” he says.
Grant Tarbox, Aetna’s medical director for the Dallas-Fort Worth region, says some procedures may seem cosmetic but are still covered by insurance because they’re done out of medical necessity. Examples include breast-reduction surgery to treat back problems or breast augmentation following a prophylactic mastectomy.
Consumers have mixed feelings about the move toward multipurpose medicine.
Ellen Bernstein of Manahawkin, N.J., says she’s never had a doctor or dentist try to sell her a product or service that wasn’t medically necessary. If they did, “I would be very angry and probably find a new doctor,” she says.
Jill Jarvis of New Castle, N.H., says she’d be offended if she went to, say, a dermatologist for a medical issue and had a cosmetic procedure suggested. But if “they approached the subject delicately and with courtesy and respect,” it wouldn’t bother her as much.
Mellan, co-author of the book Overcoming Overspending, says no matter how soft the sell, consumers still need to be on guard when cosmetic procedures are involved.
“Looking perfect … can be another addictive purchase,” Mellan says.
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Prescribing a plan for healthier practices
By Al E. Canal, Executive Vice President of Bankers Healthcare Group, Inc.
It is no secret that the recent spate of pressures and unpredictability in our political and financial systems have created a climate of uncertainty. Daily, the morning paper and the evening news are crowded with stories about healthcare reform, Medicare on the verge of bankruptcy and uninsured Americans. But for all of the focus on the healthcare system, there is little mention of the ways in which this storm has converged on healthcare professionals. Office-based physicians find themselves squeezed between the political mandates, like EHR and the reduction in reimbursements, and the financial crisis, which has reduced revenue and tightened credit. Thankfully, there is something that you can do to regain control of your bottom-line in the midst of the tumult.
A common and understandable error that many physicians make is the failure to see their practices as a business. In fact, every practice is a business. Dr. Steve Morris, MD JD FACP and CEO of Galen Advisors, LLC (the nation’s leading advisory group for physicians) states, “I believe physicians must run their practice as efficiently as any other business.” And every business needs a business plan. The good news is that a business plan need not be overly complicated, but it can mean the difference between financial success and struggle.
The first two steps in creating a business plan are reflective: thinking about your business as it stands today. First, you need to write a concise mission statement that identifies your guiding principles. Next, outline the overall structure and organization of your business. In other words, how does your business work? Who does what? What services do you provide? What are the key policies and procedures that guide your daily activities? How do you market your business? How much money do you earn and spend? While it may be time-consuming, the act of writing down a thorough overview of your business will accomplish two pivotal goals: making you aware of your practice as a business and laying a critical foundation for the next several steps.
The next two steps require you to project your future desires for your business: set goals, and then create strategies and timelines to meet those goals. While your goals may range from the esoteric to the mundane, some of them must be focused on the financial well-being of your business. Keep in mind that it is this financial well-being that equips you to meet all of your other valuable objectives. Dr. Morris suggests, “By having a profitable and ‘healthy’ practice, physicians are able to offer pro bono care, maintain modern equipment and infrastructure, and accept the lower paying Medicare and Medicaid population. Conversely, a practice that is losing money will soon close or be forced to deny care to the groups that pay poorly”.
For example, let’s say that you would like to streamline your delivery of healthcare services to increase patient volume and receive some of the thousands of dollars in financial incentives provided in the American Recovery and Reinvestment Act of 2009 for physicians by installing and utilizing Electronic Health Records. First, you need to determine exactly what you want to achieve and when. Perhaps you want to purchase EHR software this year and begin a pilot implementation with two doctors in your practice with the goal of having these two doctors “up and running” by the end of the year. Then you need to craft a strategy to meet that goal. Let’s say you intend to accomplish this by temporarily investing in an IT specialist to install and provide training on the software and hardware required and a clerical worker to assist with the time-consuming task of scanning records into the new system. With this strategic and detailed plan in place, you become a creative, problem-solving business owner capable of navigating the fjord of political mandates and economic recession.
The last step, and arguably the most important one, in your business plan is the financial planning phase. You cannot hire the staff and purchase the supplies to meet your goals without money. For obvious reasons, it is crucial to manage your investments wisely. However, as with all businesses, there are times when you may have a need for alternative funding. Keith Drayer, Vice President of Henry Schein Financial Services points out, “Today’s office-based healthcare practitioners who are doing projects need access to working capital, funds for contractors, plumbers, electricians, website development, marketing, etc…” Traditional or broad-based lenders may not have the expertise or willingness to provide the targeted needs of a healthcare provider. Fortunately, there are now financial institutions that work exclusively to provide financial products and working capital solutions that cater to healthcare providers. Think about it like this: a patient in need of a knee replacement is not going to go to his family doctor; he will go to an orthopedic surgeon. The same holds true with the financial solutions partner you choose to help you grow and develop your business into a healthy practice.
As an office-based physician, you are not only a provider of health care to your patients, you are a business owner, employer and CEO. You have the enviable position of being able to govern yourself and your business. It is not inevitable that the whims of our political system or the stock market determine your success or failure. A well thought out business plan will place you firmly at the helm of your financial future.
Bankers Healthcare Group is nationally recognized and has been trusted by over 50,000 healthcare providers for their working capital needs. In 2005 BHG was ranked the 5th fastest growing company by Inc. Magazine and honorably mentioned in 2007, 2008 and 2009. For more information please contact Al E. Canal at 315-408-3064 or email acanal@bhg-inc.com.
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The Physicians’ Need to Understand and Influence Their Online Reputation
By Jeffrey Segal, M.D., J.D. and Michael J. Sacopulos, J.D.
The observation that social media is experiencing explosive growth is hardly novel. Moreover, social media is significantly influencing the medical profession. CNN Money.com reported that Facebook passed the milestone of half a billion signed on users half a year into 2010. [1] The professional and legal ramifications from the rapid growth of social media touch almost every aspect of physicians practicing today. One of the most challenging of these ramifications is a physician’s online reputation.
Pew Internet and American Life Project recently released numbers that document just how important of the source of information regarding medicine and physicians the internet has become. Sixty-one percent (61%) of American adults look on-line for health information. [2] Forty-nine percent (49%) of Internet users report researching a specific disease or medical problem on the Internet. Forty-seven percent (47%) report seeking information about their physician or other healthcare professionals from on-line sources. [3]
Finally, five percent (5%) of “E-Patients” have posted a review online of a doctor.[4] It is these very reviews from a small subset which form the basis of a physician’s reputation on-line.
“Reputations are forged when people make judgments upon the mosaic of information available about us.”[5] Viewed in this light, ratings, blog postings, and web pages are the pieces of the reputation mosaic. Unfortunately, all it takes is one or two bad pieces for the mosaic to be marred. The implications of a damaged online reputation are extensive.
Most physicians equate a tainted online reputation with a direct loss of business. The analysis is simple; the worse the online reputation, the fewer the patients. There are certainly many examples to support this reasoning.
Dr. Linda Morrison, a physician practicing in Indiana, experienced first hand the harm that arises from an online reputational attack. In July of 2000, Dr. Morrison noticed that an anonymous individual was posting defamatory statements about her via the internet. Dr. Morrison received e-mails from this individual under a pseudonym “Surfycity45” that, among other things, made threats against her medical license. The attacks continued into the fall of 2000. Dr. Morrison ultimately learned that “Surfycity45” had been circulating defamatory comments about her while simultaneously encouraging others to do the same. “Surfycity45” worked hard to organize a cyber mob with Dr. Morrison as its target. [6]
Dr. Morrison, via counsel, attempted to enjoin Defendant American Online, Inc. from the continued posting of the defamatory statements about her by the anonymous subscriber. For a variety of legal reasons, the United States Northern District Court of Indiana ruled against the injunction. Although Dr. Morrison alleged that “Surfycity45” statements were false, defamatory, and had resulted in damage to her professional reputation as a physician, she was unable to have these remarks removed from the Internet in a timely fashion.[7] The damage was done.
The implications of a physician’s online reputation now extends beyond patients. At least twenty seven (27) states have a recognized cause of action for negligently credentialing a physician.[8] Given this liability, credentialing committees will likely perform detailed background checks using all available search tools, including social network sites.
“Health institutions making credentialing or hiring decisions currently face a dilemma when it comes to information about physicians contained in social network profiles. Although there may be some risks in searching against them (as discussed in the next section), the potential liability for making a panel decision in the absence of such information likely tips the balance.”[9]
It is not just patients and credentialing committees which are scrutinizing physicians’ online reputations. In any medical malpractice action, physicians should assume that the plaintiff’s attorney will checking the doctor’s online reputation. Geoffrey Vance, a thirty eight (38) year old partner at McDermott, Will and Emry, makes use of social networking sites to gather facts about the opposing side for trials. “I make it a practice to use as many sources as I can to come up with and to find information about the other side” Vance said. “We used to run Lexus Nexus; we still do that. We always look at cases, and now we use the internet – Google, and social networking sites.”[10]
Mr. Vance is not alone. Paul Kiesel, a lawyer in Los Angeles County, admits to using social media not only to investigate the opposing side, but also to help select jurors. “Last month I had fifty (50) jurors, and as the Court Clerk read out the names, I had two (2) people in the courtroom and the third person back at the office, with all three (3) of them doing research.”[11]
Lawyers are not the only actors in a courtroom who are using social media at trial. Courts across the country are grappling with the serious problem of “Internet-tainted” jurors. In case after case, judges and lawyers have discovered that jurors are doing independent research via cell phone during trials. Last year in Arkansas, a state court judge allowed a 12.6 million dollar verdict to stand even though a juror sent eight (8) messages via Twitter from his cell phone.[12]
In another case, a juror decided to seek the wisdom of the masses by holding a Facebook online poll. “I don’t know which way to go, so I’m holding a poll, wrote the democratic juror.” Upon learning of this misadventure, the juror was dismissed and the case proceeded.[13]
Physicians’ online reputations are being examined with increasing frequency at crucial moments in their professional career. It is no longer prudent for a physician to fail to monitor his or her online reputation. “Physicians should carefully monitor their online reputation. I have seen examples of ex-spouses, past employees, and competitors all posing as disgruntled patients in an online effort to damage a physician’s reputation. This is a real threat that is not going away,” says Rivera.
Whether physicians work through organizations such as Medical Justice or Search Engine Optimization companies or go it alone, they need to guard their online reputations. In the words of Benjamin Franklin “It takes many good deeds to build a good reputation, and only one bad one to lose it.”
[1] http://money.cnn.com/2010/07/21/technology/facebook_500_million/index.htm
Accessed July 21, 2010
[2] Pew Internet and American Life Project, at page 6;
[3] Pew Internet and American Life Project, at page 11;
[4] Pew Internet and American Life Project, at page 13;
[5] Solove, Daniel., “The Future of Reputation,” Yale University Press, page 30;
[6] Morrison v. America Online, Inc. 153 F. Supp.2d 930 at 931
[7] Id at 935
[8] Larson v. Wasemiller, 738 N.W. 2d, 300 (Minn. 2007)
[9] Physicians and patients who “friend” or “tweet”: Constructing a legal framework for social networking and hire in a highly regulated domain. By Nicholas P. Terry, Indiana Law Review, vol. 43, No. 2 (2010) at page 322
[10] How lawyers are using social media” found on the American Lawyers law.com legal blog watch, http://legalblogwatch.typepad.com/legal_watch/2009/03/how-lawyers-are-using-social-media/accessed March 22, 2010.
[11] Lawyers use web to sort through jury pool, Techcheck, Publication of the American Bar Association Journal, found at http://www.abajournal.com/magazine/article/tech_check accessed 6-23-2010.
[12] Juror Abuse of the Internet, New York Law Journal, by Daniel A. Ross, published September 8, 2009.
[13] Id.
