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Medicaid and CHIP Health Information Exchange (HIE) Advisory Committee Meeting August 2, 2010


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Title: Medicaid and CHIP Health Information Exchange (HIE) Advisory Committee Meeting August 2, 2010

Medicaid and CHIP Health Information Exchange
(HIE)Advisory CommitteeMeeting August 2,
1000 - 1015 Welcome and Introductions Approval of the Minutes
1015 - 1030 1030 - 1130 Background Briefing Items Update of Medicaid Health Information Technology Initiatives Follow-up from Previous Advisory Committee Meeting Recent Federal Regulatory Activity Statewide Health Information Exchange Plan
1130 - 1215 Lunch
1215 - 230 State Medicaid Health Information Technology Plan Overview As Is and To Be Landscape Administering the Electronic Health Record (EHR) Incentive Program Roadmap to Meaningful Use Provider Outreach and Education
230 - 300 Public Comment and Meeting Wrap-Up
Update on Medicaid Health IT Initiatives
  • e-Prescribing and Health Information Exchange
    (HIE) Pilot
  • Transfer to new pharmacy claims administrator
    still in transition, delaying the implementation
    of e-prescribing and the HIE pilots exchange of
    medication history.
  • Controlled substances can now be electronically
  • Medicaid Eligibility and Health Information
    Services (MEHIS)
  • Contract sent to the Centers for Medicare
    Medicaid Services (CMS) last week for approval.
  • Anticipate contract to be executed by October.

Follow-up from Junes HIE Advisory Committee
  • Consent option decision still pending
  • Briefing with the Executive Commission scheduled
    for August 9
  • Standard for medication history in e-prescribing
    is one year
  • Sensitive information and implications for
    Medicaid HIE

Medicaid HIE Privacy and Security Workgroup
  • Presenter
  • LaDair Wright
  • Team Lead for Privacy and Security Workgroup
  • Medicaid and CHIP Division

Sensitive Information and Implications for
Medicaid HIE
  • Substance abuse treatment information is
    confidential, except that it may be made
    available to a health information exchange
    organization if
  • A qualified service organization agreement exists
    between the HIE organization and a Part 2 program
    (federally-assisted program providing alcohol or
    drug abuse diagnosis, treatment or referral) and
  • The patient signs a Part 2-compliant consent

Sensitive Information and Implications for
Medicaid HIE
  • HIV/AIDS test results are confidential, except
    that they may be released to
  • State, local and federal health authorities.
  • Physicians, nurses or other health care personnel
    ordering the tests or who have a need to know in
    order to provide for their protection and for the
    patients health and welfare.
  • Patients tested or persons legally authorized to
    consent to the test on the patients behalf.
  • Spouses of persons who test positive for HIV or
  • Courts that have directed testing of persons
    indicted for sexual assault, or have granted a
    request by the victim.
  • First responders or correctional/juvenile
    probation staff exposed to HIV infection.
  • County or district courts to comply with rules
    relating to control and treatment of communicable
    diseases and health conditions.

Sensitive Information and Implications for
Medicaid HIE
  • Psychotherapy notes are confidential except that
    they may be made available with authorization
    that mentions only psychotherapy notes.
    Authorization is not required for
  • Use by the creator of notes for treatment.
  • Use by a covered entity for its own training
    programs or to defend itself in a proceeding
    brought by the subject of the notes.
  • Disclosure to the Secretary of Health and Human
    Services (HHS) to determine Health Insurance
    Portability and Accountability Act (HIPAA)
  • As required by law for oversight of the creator
    of the notes.
  • Disclosure to medical examiner for duties
    authorized by law.
  • Disclosure that is necessary to prevent or lessen
    a serious threat to a person or the public.

Sensitive Information and Implications for
Medicaid HIE
  • Mental Health Other than psychotherapy notes,
    communications between a patient and a mental
    health professional and the patients medical
    records are confidential.
  • May be disclosed with written consent or to
    medical staff in the course of treatment.
  • Mental Retardation The identity, diagnosis,
    evaluation or treatment of a person in a program
    or activity related to mental retardation are
    confidential, but may be disclosed with prior
    written consent, or for
  • Delivery of services to clients.
  • Medical personnel during a medical emergency.
  • Personnel for audits, program evaluations, or
    research approved by the Department of Aging and
    Disability Services (DADS).
  • Personnel authorized to conduct investigations of
    abuse and denial of rights.
  • Payment for services.

Sensitive Information and Implications for
Medicaid HIE
  • Genetic information from a genetic test or
    scientific/medical genetic characteristic
    determination is confidential.
  • May be disclosed with written consent that
    includes a specific description of the
    information to be disclosed.
  • Sexually-transmitted disease information provided
    to a state or local public health agency that
    relates to cases or suspected cases of diseases
    or health conditions is confidential.
  • Treatment of a minor Minors have more authority
    to control their health information when
  • State law does not require parental consent for
    the minor to obtain health care services, and
  • The minor consents to the treatment.

Should not affect the disclosure of Medicaid
information to providers for treatment but may
affect providers ability to grant parental
access to their childs medical information
Federal Health IT Regulatory Activity
  • Electronic Prescribing of Controlled Substances
    Interim Final Rule
  • Allows the option of e-prescribing controlled
    substances with the use of two of the following
    authenticating factors password, token, or
    biometric published March 31, 2010
  • Medicare and Medicaid EHR Incentive Program Final
  • Establishes EHR Incentive Program requirements,
    including criteria for provider eligibility,
    payment methodologies, meaningful use, and
    program oversight published July 13, 2010
  • Standards and Certification for EHR Final Rule
  • Establishes the capabilities, standards, and
    implementation specifications for certified EHR
    technology to support meaningful use. The Office
    of the National Coordinator (ONC) for Health
    Information Technology is accepting applications
    for authorized testing and certification bodies
    under a temporary certification program
    published July 13, 2010
  • Proposed Rule Change to HIPAA
  • Expands rights and restricts certain types of
    disclosures requires business associates to be
    under same rules as the covered entities sets
    limitations on the use health information for
    marketing and fundraising and prohibits the sale
    of protected health information posted for
    comment July 14, 2010

Statewide HIE Plan
  • Presenter
  • Stephen Palmer, Director
  • Office of e-Health Coordination
  • Health and Human Services Commission

Statewide HIE PlanBackground
  • Funding authority from the American Recovery and
    Reinvestment Act (ARRA), Section 3013 for
    planning and implementation grants to states or
    qualified state-designated entities to facilitate
    and expand HIE.
  • Grant opportunity with ONC.
  • Coordinated effort between HHSCs Office of
    e-Health Coordination and Texas Health Services

Statewide HIE PlanTimeline
  • February 2009 ARRA passed.
  • August 2009 Funding Opportunity Announcement
  • October 2009 Texas application submitted.
  • March 2010 Texas award of 28.8 million over
    four years announcement released.
  • August 2, 2010 Draft Texas HIE plans published
    for public comment.
  • August 16, 2010 Comments due.
  • September 1, 2010 Final target submission date
    for plans.

Statewide HIE PlanCollaborative Planning Process
  • Workgroups
  • Governance and Finance
  • Technical Infrastructure
  • Privacy and Security
  • EHR Adoption and Consumer Engagement
  • Strategic and Operational Plans
  • Environmental Scan
  • Governance
  • Finance
  • Business and Technical Operations
  • Policy and Legal

State Medicaid Health Information Technology
  • Presenters
  • Kathleen Costello, Yvonne Sanchez, Noel
    Villarreal,Anna Sicher, and Julia
    AlejandreMedicaid and CHIP Division

EHR Incentive Program andMeaningful Use
  • Final federal rules on the EHR Incentive
    Programincluding meaningful use (MU)
    criteriareleased July 13, 2010
  • An eligible provider and hospital will be
    considered a meaningful EHR user if they meet the
    following three requirements
  • Demonstrates the use of certified EHR technology
    in a meaningful manner.
  • Demonstrates that certified EHR technology is
    connected in a manner that provides for the
    electronic exchange of health information to
    improve the quality of health care.
  • Using its certified EHR, submits information on
    clinical quality measures and other measures as
  • MU criteria to be defined in stages
  • Stage 1 criteria in current proposed rule.
  • Stage 2 criteria to be defined in 2013.
  • Stage 3 criteria in 2015.

MU Comparison NPRM to Final Rule
NPRM Final Rule
States could propose requirements above/beyond MU floor, but not with additional EHR functionality States flexibility in Stage 1 MU is limited - with CMS approval, 4 public health-related objectives may be moved from menu to the required core measures
Core clinical quality measures (CQM) and specialty measure groups for EPs Modified Core CQM and removed specialty measure groups for EPs
90 CQM total for eligible professionals (EPs) 44 CQM total for EPs must report total of 6
Not all CQM had electronic specifications at time of NPRM All final CQM have electronic specifications at time of final rule publication
35 CQM total for eligible hospitals with 8 alternate Medicaid CQM 15 CQM total for eligible hospitals
5 CQM overlap with CHIPRA initial core set 4 CQM overlap with CHIPRA initial core set
MU Comparison NPRM to Final Rule
NPRM Final Rule
Meet all MU reporting objectives Must meet core set Can defer 5 from optional menu set
25 measures for EPs 23 measures for eligible hospitals 25 measures for EPs 24 for eligible hospitals
Measure thresholds range from 10 to 80 of patients or orders (most at higher range) Measure thresholds range from 10 to 80 of patients or orders (most at lower to middle range)
Denominators To calculate the threshold, some measures required manual chart review Denominators No measures require manual chart review to calculate threshold
Administrative transactions (claims and eligibility) included Administrative transactions removed
Measures for patient-specific education resources and advanced directives discussed but not proposed Measures for patient-specific education resources and advanced directives (for hospitals) included
State Medicaid Health Information Technology Plan
  • The SMHP provides a common understanding of the
    activities that Medicaid will be engaged in over
    the next five years relative to implementing
    Section 4201 of ARRA.
  • CMS is interested in how Medicaid plans to
  • Make provider incentive payments.
  • Monitor the payments.
  • Coordinate with the Statewide HIE planning
    initiative and Regional Extension Centers (RECs)
    supported by ONC.
  • Integrate other Medicaid HIT projects and
  • CMS expects annual and as-needed updates to keep
    it informed as the SMHP evolves.

Technology Adoption Curve
92 Laggards Skeptics
84 Late Majority Conservatives
The Chasm
50 Early Majority Pragmatists
16 Early Adopters Visionaries
2.5 Innovators Enthusiasts
Consumer seeks technology and performance
Consumer seeks solutions and convenience
The technology adoption lifecycle and curve is
based on research by Joe M. Bohlen, George M.
Beal and Everett M. Rogers The chasm concept was
popularized in the book Crossing the Chasm,
Geoffrey A. Moore
Model for Quality Improvement
  • Step 1 Plan
  • Plan the test or observation, including a plan
    for collecting data.State the objective of the
  • Predict what will happen and why.
  • Plan to test the change. (Who? What? When? Where?
    What data need to be collected?)
  • Step 2 Do
  • Try out the test on a small scale. Carry out the
  • Document problems and unexpected observations.
  • Begin analysis of the data.
  • Step 3 Study
  • Set aside time to analyze the data and study the
  • Complete the analysis of the data.
  • Compare the data to your predictions.
  • Summarize and reflect on what was learned.
  • Step 4 Act
  • Refine the change, based on what was learned from
    the test.
  • Determine what modifications should be made.
  • Prepare a plan for the next test.

SMHP Project Schedule
SMHP Overview
Plan for health care reform enabled by meaningful
use of certified EHRs

Current EHR HIT use Vision 2014 Begin with end in Mind Administration of incentive payment Program integrity processes controls Metrics to assess progress towards envisioned future
  • Medicaid Vision for Health Care Reform
  • By 2014, what goals and objectives does Medicaid
    need to achieve?
  • How will Medicaid address the needs of varying
  • How will Medicaid assess and provide technical
    assistance for providers?
  • What governance processes and structures need to
    be established?
  • What legislative or regulatory changes are

As Is LandscapeTexas Medicaid
  • Medicaid serves a population of approximately 3.6
    million unique clients per year and an average of
    2.7 million in any given month.
  • The percentage of Medicaid clients in managed
    care was 71 percent in 2008.
  • Medicaid accounted for 25 percent of the
    appropriated Texas budget for the 2006-2007
  • 29 percent of Medicaid budget spent on children
    in 2007.
  • 21 billion (all funds) spent for Medicaid in
    federal fiscal year 2007.
  • 1.9 billion in total Medicaid payments (all
    funds) to nursing homes in federal fiscal year
  • 2.1 billion in total Medicaid payments made to
    hospitals in federal fiscal year 2007 (excluding
    disproportionate share hospital DSH and upper
    payment limit payments).

As Is Landscape
  • Conduct an environmental scan and assessment of
    current practitioner and hospital EHR
  • Consider federally qualified health center
    (FQHC), rural health clinic (RHC), Veterans
    Administration and Indian Health Service clinical
    facilities with EHR capabilities describe any
    Health IT funding.
  • Describe role of Medicaid Management Information
    Systems (MMIS) in current Health IT environment
    and in coordination with Medicaid Information
    Technology Architecture (MITA) transition plans.

As Is Landscape
  • Assess and describe broadband internet access,
    including grants.
  • Explain Medicaids relationship with Statewide
    HIE planning initiative and RECs supported by ONC
    and other programs.
  • Describe the interoperability status of the
    states immunization registry and public health
    surveillance reporting database(s).
  • Describe any activities that will encourage
    adoption of EHRs consider health care service
    access that crosses state borders.

As Is Landscape
  • Medicaid is conducting a survey, in coordination
    with the statewide HIE and the four Health IT
    RECs, directed to hospitals and all providers in
    the eligible professional category.
  • Surveys will be used
  • To meet program planning requirements.
  • As a benchmark for program evaluations.
  • Surveys disseminated in early July 2010 with
    preliminary results and analysis in August 2010.
  • Medicaid is seeking the support of committee
    members and professional associations to
    encourage completion of the survey.

As Is LandscapeMedicaid Claims Systems
  • MMIS is a distributed group of procedures and
    computer processing operations and subsystems.
  • HHSC contracts with a coalition of vendors headed
    by Affiliated Computer Systems State Health Care,
    working under the name of the Texas Medicaid
    Healthcare Partnership (TMHP) to provide MMIS
  • TMHP provides the necessary services to process
    and adjudicate Medicaid claims (with the
    exception of capitated arrangements between
    health plans).

As Is LandscapeMedicaid Claims Systems
  • TMHP performs services to support the following
    claim and non-claim related areas of MMIS
  • Compass 21 Supports processing of Medicaid
  • Case Management/Health Education Supports case
    management and health education functions for
    Primary Care Case Management (PCCM) members.
  • Provider Network Management Supports provider
    network management, credentialing and enrollment
    for PCCM providers.
  • Member Management Supports member processing
    for PCCM members
  • Claims Submission (TexMedConnect) Provider
    application that supports claims submission,
    eligibility verification and claims status
  • Claims Management System and Service
    Authorization System Long-term care service
    authorization and claims processing engine.
  • Encounters Datamart Stores managed care
    encounter data from contracted managed care

To Be LandscapeNew Capabilities
System Description
Medicaid Eligibility and Health Information Services (MEHIS) will replace the current paper Medicaid identification form with a permanent plastic card automate eligibility verification provide a claims-based EHR for Medicaid clients offer an e-prescribing tool establish a foundation for future HIE target implementation is March 2011
Medicaid electronic prescribing (e-Rx) designed to get Medicaid formularies and medication history into e-prescribing programs will satisfy the meaningful use objective of information exchange
HIE Pilot Medicaid will exchange medication history data with regional health information exchange organizations
To Be Landscape HIE Connectivity
  • THSA is evaluating options for statewide HIE
  • MEHIS provides an infrastructure for Medicaid HIE
  • MEHIS will enable HHSC to exchange data with the
    statewide HIE

To Be LandscapeMedicaid Enterprise Vision
  • Texas HHSC will become a value purchaser of
    health care quality and outcomes by supporting
    and e-enabling these capabilities
  • Develop value purchaser capabilities.
  • Utilize clinical decision support capabilities to
    analyze Medicaid health care administrative and
    clinical data from across the state and
    enterprise and to meaningful use patient summary
    information to improve health care delivery and
    cost effectiveness.
  • Establish and maintain a comprehensive and robust
    provider network capable of providing quality
    care based on population needs, unique care
    conditions, and locus of service needs.
  • Implement effective and efficient primary and
    integrated care approaches.
  • Ensure the secure and private exchange of health
    care information across the Medicaid enterprise
    consistent with national standards, including
    specialty providers.
  • Increase health care coverage through insurance
    exchanges under national health reform that
    effectively enrolls new clients in Medicaid or
    other health care coverage and ensures timely
    access to quality care.

To Be LandscapeProvider Level Vision
  • Improve the health and well-being of citizens of
    Texas through the widespread adoption and
    meaningful use of certified EHRs to
  • Improve quality, safety, efficiency, and reduce
    health disparities.
  • Engage patients and families in their health
  • Improve care coordination.
  • Ensure privacy and security protection for
    personal health information.
  • Improve population and public health.

EHR Incentive ProgramOverview
  • Payment is an incentive for using certified EHRs
    in a meaningful way
  • Not a reimbursement and not intended to penalize
    early adopters.
  • First year payment can be received in 2011
    through 2016
  • Final payment can be received up to 2021
  • Eligible professionals must meet certain
  • Eligible provider type.
  • Medicaid patient volume thresholds.
  • MU of certified EHRs for at least 50 percent of
    patient encounters during the reporting period.

EHR Incentive Program Enrollment Process
Provider Registers with CMS at the National
Level Repository (NLR)
Forwarded to HHSC Providers receive an automated
mailing giving web link and emphasizing
importance of enrolling with Medicaid before
Provider fills out online application attesting
to all eligibility criteria
Provider fills out
Provider does not fill out but registers with
HHSC confirms licensed and unsanctioned
No Reject
EHR Incentive Program Payment Process
HHSC reviews attested volume and compares
reported information to Medicaid data sources
Volume fails validity check request additional
Volume Sufficient
Volume insufficient Reject
Adopt, Implement and Upgrade (AIU) Year 1 only
No documentation provided Request
Purchase/Upgrade Verified
Does not meet AIU Reject
Meaningful Use (MU) and Clinical Quality Measures
(CQM) Year 2 and beyond
Attest MU but did not provide CQM Request CQM
Attest and submit to MU/CQM measures
MU/CQM not met Reject
EHR Incentive Program Payment Process
Payment calculated
Provider paid
Eligibility Patient Volume
Provider Minimum Medicaid Patient Volume Threshold OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Physicians 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
- Pediatricians 20 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Dentists 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Nurse Practitioners 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Certified Nurse Midwives 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Physician Assistants (PAs) when practicing at an FQHC/RHC that is led by a PA 30 OR if the Medicaid EP practices predominantly in a Federal Qualified Health Clinic (FQHC) or Rural Health Clinic (RHC) 30 needy individual patient volume threshold
Acute Care Hospitals 10 Not an option for hospitals
Children's Hospitals No requirement Not an option for hospitals
Eligible ProviderEstimates
Eligible Provider Types Enrolled Medicaid Providers Potentially Eligible
Eligible Hospitals Eligible Hospitals Eligible Hospitals
Acute Care 1480 310
Critical Access 77 TBD
Childrens 8 8
Eligible Professionals Eligible Professionals Eligible Professionals
Physicians 32,453 TBD
Pediatricians 5,122 3,150
Dentists 5,431 3,400
Certified Nurse Midwives 186 150
Nurse Practitioners 3,545 TBD
Physician Assistants that leads an FQHC or RHC TBD TBD
FQHC/RHC (64 grantees operating multiple sites) 304 sites n/a
Estimate of eligible providers are based on a
preliminary counts of enrolled Medicaid
providers, claims history and eligibility
criteria from the NPRM.
Proposed Process for Provider Eligibility
  • Goal is to complete application reviews within 90
  • As applications come in, the clock starts based
    on when documentation is complete.
  • Requests for additional information issued within
    60 days.
  • For eligible professionals, a single application
    must show sufficient Medicaid practice volume,
    EHR costs, and EHR use.
  • For hospitals, a single application must show
    sufficient Medicaid practice volume, incentive
    formula, and EHR use.

Proposed Process for Provider Eligibility
  • All providers will attest to their number of
    patient encounters by payor source with separate
    tabs in the application for
  • Medicaid fee-for-service.
  • Medicaid managed care listed by managed care
  • PCCM payments.
  • In order to facilitate pre-eligibility
    verification and post-payment audits as
    necessary, will require the 90-day period for
    demonstrating EP Medicaid share to equate to
    three full calendar months.
  • Encounters will be defined around count of
    procedures per performing provider rather than
    count of submitted claims.

Patient Volume Calculation
  • Defined encounter for three scenarios
  • Fee-for-service.
  • Managed care and medical homes.
  • Hospitals.
  • Two main options for calculating patient volume
  • Encounters.
  • Patient panel.
  • State picks from these or proposes new method for
    approval. May use approved approach of another

Entities Promoting the Adoption of EHRs
  • States may designate entities promoting the
  • EPs may voluntarily assign their incentive
    payments to these entities.
  • Promotion would include
  • Enabling and oversight of the business
    operational and legal issues involved in the
    adoption and implementation of EHR and/or the
    secure exchange and use of electronic health
  • Maintaining the physical and organizational
    relationship integral to the adoption of
    certified EHR technology by EPs.
  • Required transparency guidelines for selection.

EHR Incentive ProgramPayment Processes
  • Ensure that there is no duplication of Medicare
    and Medicaid incentive payments to EPs.
  • Ensure that incentive payments are made for no
    more than six years and that no EP or hospital
    begins receiving payments after 2016.
  • Ensure that incentive payments are not paid at
    amounts higher than 85 percent of the net average
    allowable cost of certified EHRs and do not
    exceed yearly maximum allowable payment
  • Ensure timely and accurate payments to EPs and
  • Ensure that any monies paid inappropriately will
    be recouped and federal financial participation
    (FFP) is repaid.

Incentive Payments forEligible Professionals
First Calendar Year in which the EP receives an Incentive Payment First Calendar Year in which the EP receives an Incentive Payment First Calendar Year in which the EP receives an Incentive Payment First Calendar Year in which the EP receives an Incentive Payment First Calendar Year in which the EP receives an Incentive Payment First Calendar Year in which the EP receives an Incentive Payment
Year CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016
2011 21,250
2012 8,500 21,250
2013 8,500 8,500 21,250
2014 8,500 8,500 8,500 21,250
2015 8,500 8,500 8,500 8,500 21,250
2016 8,500 8,500 8,500 8,500 8,500 21,250
2017 8,500 8,500 8,500 8,500 8,500
2018 8,500 8,500 8,500 8,500
2019 8,500 8,500 8,500
2020 8,500 8,500
2021 8,500
TOTAL 63,750 63,750 63,750 63,750 63,750 63,750
Source Centers for Medicare and Medicaid Services
Proposed Payment Process for EPs
  • Provide option for EPs practicing in a group to
    impute the groups Medicaid share for their
    individual application, referencing the groups
    Texas Identification Number (TIN), but under the
    individual providers National Provider
    Identifier (NPI).
  • Will require EPs to attest that this is the only
    group TIN that they are applying under.
  • Still requires an individual online
    application/attestation for each provider
    claiming incentives, but can be batched together
    by TIN.
  • One time per year with annual payment dates
    staggered monthly.
  • For part-time providers, if the attested total
    billing is less than the amount of the incentive
    they are trying to claim, will require submission
    of Form 1099 and documentation of the nature of
    the providers engagement with the group or

Incentive Payments forEligible Hospitals
  • Medicaid hospital incentive payments based on a
    formula similar to Medicare hospital methodology.
  • A product of the overall EHR amount multiplied by
    the Medicaid share.
  • Payment is calculated, then disbursed over three
    to six years.
  • Payments in any one year cannot exceed 50 percent
    of the total payment cap and payment in any two
    years cannot exceed 90 percent of this limit.
  • Data to be derived from the hospital cost reports
    and other auditable data sources.
  • Will propose that hospitals attest regarding
    their own most recent fiscal year (which will
    overlap with the most recent federal fiscal year).

Incentive Payments forEligible Hospitals
  • The basic calculationperformed for each of four
    projected years
  • 2,000,000 200/discharge
  • (for number of discharges between 1,150 to
  • x
  • transition factor based on the hospitals current
    payment year
  • x
  • providers average annual rate of growth
  • for the most recent 3 year period
  • x
  • Medicaid share
  • (12 month Medicaid bed days total bed days x
    (total charges - charity care) total charges)

Proposed Payment Process for Hospitals
  • One time per year with annual payment dates
    staggered monthly.
  • Payment will be made in the first monthly date
    after incentive is approved.
  • Medicaid has the flexibility to spread out
    hospital incentive payments over as few as three
    or as many as six years
  • Texas proposes to use a five year payout for the
    incentives according to the following schedule

Five Year Payout Schedule for Hospitals Five Year Payout Schedule for Hospitals Five Year Payout Schedule for Hospitals Five Year Payout Schedule for Hospitals Five Year Payout Schedule for Hospitals
Year 1 Year 2 Year 3 Year 4 Year 5
40 20 20 10 10
Provider Appeals
  • Medicaid needs to ensure that appeal processes
    are established for and consistent with all
    criteria, including verification of
  • Provider eligibility determinations.
  • Incentive payments and amounts.
  • Demonstration of efforts to adopt, implement or
    upgrade and meaningful use eligibility.

Proposed Process for Oversight and Auditing
  • Four stages of review and appeals for
  • Attestation.
  • Compare attestation to Medicaid data sources for
    that provider.
  • Additional information (e.g., billing data)
    needed for significant discrepancies.
  • If information provided is inconsistent with
    Medicaid data or other third party data source,
    application is rejected and providers will have
    the opportunity to file an initial appeal to
  • TMHP will have two EHR application adjudication
    entities, one to conduct initial eligibility
    determinations and another to conduct appeals.
  • If TMHP rejects appeal, the final appeal will be
    to HHSCs Medicaid/CHIP Health IT division.

Discussion Questions
  1. The final rule provides options for counting
    encounters for patient volume reporting.
    What method provides the most flexibility for
  2. Eligible professionals without an NPI, but seeing
    Medicaid clients under another billing providers
    NPI, will be required to obtain one and enroll in
    Medicaid for purposes of receiving an incentive
    payment. Would this be considered a barrier to
  3. Entities that promote adoption will need to
    enroll and obtain state approval. What factors
    should Medicaid consider when approving their
    enrollment to receive incentive payments on
    behalf of providers who opt to assign their
    payment to these entities?

Roadmap to MU
  • MU of a certified EHR requires
  • Use of certified EHRs in a meaningful manner such
    as e-prescribing.
  • That the certified EHR is connected in a manner
    that provides for the electronic exchange of
    health information to improve the quality of
  • In using this technology, the provider submits
    information on clinical quality measures (CQM)
    and such other measures selected by the Secretary
    of HHS.

Applicability of MUObjectives and Measures
  • Some MU objectives are not applicable to every
    providers clinical practice, thus they would not
    have any eligible patients or actions for the
    measure denominator.
  • Examples
  • Dentists who do not perform immunizations.
  • Certified nurse midwives who do not prescribe
  • In these cases, the eligible professional or
    hospital would be excluded from having to meet
    that measure.

Measures for Meaningful Use
  • 20 measures for EPs
  • Must meet 15 from the core set.
  • Must select 5 of 10 from menu set.
  • 19 measures for eligible hospitals
  • Must meet 14 from the core set.
  • Must select 5 of 10 from menu set.
  • Professionals must report total of 6 CQMs
  • Blood pressure reading.
  • Tobacco status.
  • Adult weight screen and follow up or alternate if
    not applicable.
  • 3 from list of clinical measures of the
    providers choice.
  • Hospitals must report 15 CQMs
  • 4 CQM overlap with CHIPRA initial core set.

States Flexibility to Revise Meaningful Use
  • Medicaid can seek CMS approval to require four MU
    objectives as core measures for providers
  • Generating lists of patients by specific
    conditions for quality improvement, reduction of
    disparities, research or outreach.
  • Submit electronic data on immunizations to
  • Submit electronic data on reportable lab results
    to public health agencies.
  • Submit electronic syndromic surveillance data to
    public health agencies.
  • Can specify for providers how to test the data
    submission and to which specific destination.
  • Medicaid is still determining options as whether
    or not to require these MU measures.

Proposed Plan to Meaningful Use
  • Establish a Medicaid Quality Outcomes workgroup
    to streamline and align current outcome measures
    and prioritize quality improvement initiatives
    and strategies. The workgroup will
  • Obtain stakeholder input.
  • Address current and future data analytical staff
  • Identify the need for decision support system
    capabilities to produce data driven decisions and
    improve health outcomes, care quality, and cost
  • HHSC plans to
  • Collect and verify meaningful use quality data
    through a single point of entry for client and
    provider data.
  • Simplify provider reporting to the extent
  • Begin data collection in 2012.

Adoption Rate and Provider Participation
  • A baseline for provider adoption of EHR
    technology and participation in the incentive
    program will be established in 2011.
  • Subsequent years will have projected target
    adoption rates.

Provider Type 2011 Baseline (Estimate) 2012 2013 2014
EH - Acute Care 10 20 40 70
EH Childrens Hospital 20 40 60 85
EP Physician 5 10 25 45
EP Pediatrician 5 10 25 45
EP CNMs 5 10 25 45
EP Nurse Practitioners 5 10 25 45
EP PAs when practicing at an FQHC/RHC 3 10 20 35
EP Dentists 3 6 8 15
Discussion Questions
  1. The Medicaid Program has the flexibility to move
    four public health menu measures into required
    core measures. Should Medicaid make these
    menu options required?
  2. Are targeted adoption rates achievable?
  3. Are there any additional recommendations in terms
    of goals or targets for the HIT Roadmap?
  4. Any suggestions how the Medicaid Program can best
    utilize the reported MU Measures?

Provider Outreachand Education
  • Use a variety of communication methods to reach
    providers and other stakeholders around the
  • Provide information regarding the incentive
    payment process and details via web site, call
    centers, and presentations.
  • Leverage existing communication channels and
    build additional ones as appropriate.
  • Develop webinars and other web-based educational
    materials for convenient access.
  • Develop the communication strategy and structure
    for ongoing outreach and education.

Provider Outreach and Education Methods
  • Medicaid Bulletin
  • e-newsletter now includes an Health IT corner
  • HHSC websites (i.e., TMHP, Office of e-Health
    Coordination) and related links (e.g., CMS)
  • Health IT page
  • Contact Us form
  • Communication through professional associations
  • Health IT Regional Extension Centers (RECs)
  • Provider presentations that are convenient,
    accessible and flexible to schedules

Key Considerations in Communication Plan
  • Consistency of information across communication
    channels and with CMS.
  • Coordination of information across Health IT and
    HIE organizations in Texas, especially the four
  • Accuracy and timeliness of information in a
    dynamic environment.
  • Responsiveness to provider questions and
  • Other considerations.

Collaboration with RECs
  • Weekly conference calls with RECs and the Office
    of e-Health Coordination.
  • Continuing discussion regarding collaborative
    relationship to provide support for Medicaid
  • Leveraging opportunities for provider outreach
    and education statewide.

Provider OutreachImportant Links
  • Medicaid EHR Incentive Program Informationwww.tmh
  • Texas Regional Extension Centers
  • Texas Health Services
  • Medicaid Provider SurveyPractitioner

SMHP Stakeholder Feedback August 3, 2010
  • Open for comment until August 6.
  • Feedback on practical implications to the plan.
  • All input will be reviewed and considered for
    inclusion in the plan.

HIE Advisory Committee Meeting Wrap-Up
  • Public Comments
  • Review of Action Items for Next Meeting
  • Next Meeting October 6, 2010 1000 a.m. - 300
    p.m. Public Hearing Room, Winters Bldg.
  • This presentation is available at