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This will be a pivotal year for providers that first attested to meaningful use between 2009 and 2011. Early attesters will be judged by the Centers for Medicare and Medicaid Services (CMS) on their 2013 performance when it comes time to start assessing meaningful use penalties in 2015. For many, this is their last chance to avoid payment adjustments.

Rob Anthony, health insurance specialist in the Office of E-Health Standards and Services at CMS, chatted with SearchHealthIT to help make sense of the myriad deadlines providers must meet to avoid financial penalties. He also explained the rationale of basing the penalties on past performance and why 2015 might be a strange year for some providers.

What is the most important date for providers to keep in mind to avoid meaningful use penalties?

Rob Anthony: There are multiple deadlines, and a lot of it depends upon when you began attesting. But the easiest thing to focus on is to tell people, if you've already attested, then 2013 is an important year for you to continue meaningful use because it will be the period we look back at for those payment adjustments in 2015. But it's not too late if you're not yet a meaningful user to avoid those payment adjustments.

I think the big deadline is October 1, 2014. For eligible professionals, that is the absolute last day to attest to being a meaningful user and be able to avoid the payment adjustments. However, I would encourage people to become meaningful users this year, because then you can at least get three years of incentive payments in 2013, 2014 and 2015. It's always better to get more of an incentive payment than less.

There are many different deadlines depending on what type of provider you are and when you first attested. Have you seen providers who are having a hard time figuring out where they fit in and what deadlines are relevant for them?

Anthony: Absolutely. Definitely. And that's why we're trying to do some outreach. We know that people have a general awareness of payment adjustments existing on the Medicare side. I think there is confusion about when those dates are and what they have to do. I think a lot of people may think that it is too late. It is not too late. But there certainly is confusion about what period applies to you. When you break it down and look at it, it's relatively simple.

We had a choice when we started doing payment adjustments: to look at the current period you were in or to look at a previous period, a prospective approach. We chose the prospective approach so that we wouldn't have to put providers through claims reprocessing, which is something of a nightmare. Instead we are focusing on an earlier period to figure out whether payment adjustments apply to you. So that earlier period is either 2013 or 2014, depending on when you become a meaningful user.

If you become a meaningful user in 2011 or 2012, then we're looking for a full year of meaningful use in 2013. If 2013 is your first year, then we're just looking for a 90-day period. You could also do the 90-day period in 2014, but we need some time to process your attestation to make sure you're not assigned that payment adjustment. We've essentially given ourselves a three-month period at the end of that year. That means you basically have nine months of the calendar year 2014 to get that 90 days in and avoid that payment adjustment.

Because payment adjustments are based on what hospitals do in 2013, we could start seeing some weird scenarios where a hospital is penalized for 2013 performance but then receives incentives for their work in 2014. So, conceivably we could see hospitals that receive payment adjustments in the same year as incentive payments. Will that happen?

Anthony: It is actually possible. If you began as a hospital in 2012, but if you missed meaningful use in 2013, that's the period we would look at for the 2015 payment adjustments. You could be given a payment adjustment for your failure to be a meaningful user in 2013, while being successful again in 2015 and receiving the last of your incentive payments.

We see that high performance [of hospitals] holds pretty true from year to year, which gives us the indication that once you implement meaningful use and an EHR in your clinical workflow, it becomes an established part of your workflow.

Rob Anthony, 
health insurance specialist, 
CMS Office of E-Health Standards and Services

But again, this is what happens when you look at it from a prospective period. The other choice was to look at everything from the same period, and it means that hospitals would have needed to resubmit claims for processing, and that would be a huge financial burden for them -- [it would expend] a lot of staff hours -- and it turns out to be a severe burden from an operations side, which means a higher cost for taxpayers. So, we went for that prospective period.

I will say, however, that most hospitals are definitely prepared to meet that 2013 goal. As we have looked at the performance of hospitals in their first year compared to their second year, we see that high performance holds pretty true from year to year, which gives us the indication that once you implement meaningful use and the use of an EHR in your clinical workflow, it becomes an established part of your workflow. It's less of managing to the measures and more of actually incorporating that as an important tool for managing patient care.

Once the CMS starts assessing provider performance and determining the appropriateness of meaningful use penalties, how strict will you be in holding providers to meeting 100% of the measures?

Anthony: Unfortunately, the way that meaningful use works is you have to meet all the measures in order to be deemed a meaningful user. That was true for receiving incentive payments and will also be true for payment adjustments.

We find, however, that while there are a small number of people who are close to those thresholds, by and large both eligible professionals and eligible hospitals are far outperforming what those thresholds are for the individual measures.

So I think that's a testament to once you implement, you implement everywhere and don't necessarily manage to the measures. We haven't seen a lot of evidence of that so far. We're much more concerned about providers not being prepared for their first 90 days of meaningful use.

The incentive payments are front-loaded, with most of the money coming early in the program. For providers who missed out on the early portion of incentive payments, do you think the threat of penalties is going to be enough to get them to get started with EHR implementation?

Anthony: It's a good point and we've heard that so far. There are some folks who are doing a return-on-investment analysis on that, and it makes sense for providers to do that. I will say we have some indications from talking with physicians that payment adjustments are a driver. So, I do think people are looking at those payment adjustments and looking at ways to avoid them.

I do think that -- what we've discovered in talking to a lot of practices -- while there's a learning curve; there are a lot of practices that are having success with that EHR. It's allowing them to manage their patient populations better and be more successful and see more patients, and that translates to efficiencies and reduced costs for them. So, even though the incentive payment may be reduced, there are certainly additional financial incentives to having an EHR. And then, of course, there's the incentive to having an EHR of providing better care.

A lot of information on the meaningful use penalties talks about the program extending beyond the year 2020. Will the program still be run through the framework of meaningful use at that point?

Anthony: When Congress put the HITECH Act in place, it didn't specify a particular end date for payment adjustments. It did specify a timeframe for incentive payments, but it did not specify an end to payment adjustments. So, there is a certain extent to which payment adjustments will continue and meaningful use will become the floor on which everyone will operate.

I think the use of certified EHRs and meaningful use in general will likely continue into the future, but what the future is going to look like, I think we'll get a better idea as we move into next year and start looking at some of the stage 3 notice of proposed rulemaking.

Let us know what you think about the story; email Ed Burns, news writeror contact @EdBurnsTT on Twitter.

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