Background
Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required the Secretary to establish a new reporting program for eligible professionals who are successful electronic prescribers as defined by MIPPA, beginning on January 1, 2009.  While the eRx Incentive Program has similarities in structure and processes to the Physician Quality Reporting System (formerly the Physician Quality Reporting Initiative or PQRI), this program is a separate program with distinct reporting requirements and associated incentive payments and payment adjustments.

In addition to the electronic prescribing incentive payment, MIPPA called for a Medicare Physician Fee Schedule (MPFS) payment adjustment that will apply beginning in January 2012 to eligible professionals who are not successful electronic prescribers, as defined in the Calendar Year (CY) 2011 MPFS final rule. For eligible professionals who are subject to the 2012 eRx payment adjustment, the fee schedule amount for covered professional services furnished by eligible professionals during the year shall be 1 percent less than the fee schedule amount that would otherwise apply for 2012.  The potential MPFS reductions in the future are a 1.5 percent reduction for 2013 and 2.0 percent reduction for 2014.

Provisions of the 2012 eRx Payment Adjustment Established in the CY 2011 MPFS Final Rule

In addition to establishing the requirements for successful reporting of the electronic prescribing measure for the 2011 eRx incentive, the CY 2011 MPFS Final Rule also establishes the program requirements for purposes of avoiding the 2012 payment adjustment.

An eligible professional will not be subject to the 2012 payment adjustment if one of the following applies:

• The eligible professional is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of June 30, 2011 (This determination is based on the primary taxonomy code in the National Plan and Provider Enumeration System (NPPES)) and does not generally have prescribing privileges, and reports g-code G8644 (defined as not having prescribing privileges) at least one time on an eligible claim prior to June 30, 2011;
• The eligible professional does not have at least 100 cases containing an encounter code in the electronic prescribing measure’s denominator;
• The eligible professional’s allowed charges for covered professional services submitted for the electronic prescribing measure’s denominator codes is less than 10 percent of the eligible professional’s total 2011 Medicare Part B PFS allowed charges;
• The eligible professional reports a significant hardship code and CMS determines that the hardship code applies (see “Significant Hardship Exemptions” section below) and is granted an exemption; OR
• The eligible professional becomes a successful electronic prescriber for purposes of the 2012 payment adjustment by reporting the electronic prescribing measure via claims for at least 10 unique electronic prescribing events for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.

A group practice that is participating in the 2011 eRx group practice reporting option will not be subject to the 2012 payment adjustment if one of the following applies:

• The group practice reports a significant hardship in its 2011 self-nomination letter for participation in the eRx Incentive Program group practice reporting option (see “Significant Hardship Exemptions” section below) and is granted an exemption; OR
• The group practice becomes a successful electronic prescriber.  The group practice becomes a successful electronic prescriber for purposes of the 2012 payment adjustment by reporting the electronic prescribing measure via claims for between 75-2,500 unique electronic prescribing events (depending on the group practice size) for patients in the denominator of the measure between January 1, 2011 and June 30, 2011.

Significant Hardship Exemptions.  Section 1848(a)(5)(B) of the Act provides that the Secretary may, on a case-by-case basis, exempt an eligible professional from the payment adjustment, if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship.  In the CY 2011 MPFS Final Rule, CMS established the following two significant hardship exemptions in the form of g-codes for purposes of the 2012 payment adjustment:

• The eligible professional practices in a rural area without sufficient high speed internet access (report code G8642)
• The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (report code G8643)

In order to request consideration for an exemption from the 2012 payment adjustment via one of the two aforementioned significant hardship g-codes, the eligible professional must report the g-code at least one time on a claim between January 1, 2011 and June 30, 2011.

A group practice participating in the eRx group practice reporting option for 2011 must have requested the significant hardship exemption at the time the practice self-nominated to participate.

Changes to the Medicare eRx Incentive Program for Calendar Year 2011

Since publication of the 2011 MPFS Final Rule, CMS has received public comments raising concerns that the Medicare eRx Incentive program did not better align with the Medicare or Medicaid EHR Incentive Program as well as the need for additional significant hardship exemption categories.  To address these concerns, we are finalizing the following changes:

Modify the existing 2011 electronic prescribing measure to address uncertainties related to the technological requirements of the Medicare eRx Incentive Program: The existing 2011 electronic prescribing measure is revised to indicate that a qualified electronic prescribing system includes certified EHR technology as defined at 42 CFR 495.4 and  45 CFR 170.102.

Provide additional significant hardship exemption categories for purposes of the 2012 payment adjustment: The eligible professional or group practice must demonstrate that one of these situations applies to the respective practice:

• Eligible professionals who register to participate in the Medicare or Medicaid EHR Incentive Programs and adopt certified EHR technology;
• Inability to electronically prescribe due to local, state, or federal law or regulation;
• Limited prescribing activity; or
• Insufficient opportunities to report the electronic prescribing measure.

Extend the deadline for requesting significant hardship exemptions to November 1, 2011. This extended reporting deadline would apply to the two significant hardship exemptions established in the CY 2011 MPFS Final Rule as well as the additional significant hardship exemption categories above.

Require submission of significant hardship exemption requests for the 2012 eRx payment adjustment via a web-based tool for individual eligible professionals and via a mailed letter for group practices that are participating in the 2011 eRx group practice reporting option. Instructions on how to request a hardship via the web-based tool will be available on the eRx Incentive Program website at http://www.cms.gov/ERXincentive/.

The final rule can be found at http://www.ofr.gov/OFRUpload/OFRData/2011-22629_PI.pdf.

For more information about this announcement, read the http://blog.cms.gov/2011/08/31/greater-flexibility-in-e-prescribing-means-greater-success/

Providers participating in the EHR incentive program had been concerned about being penalized for missing e-prescribing system deadlines under the eRx incentive program which was launched earlier. As the EHR program also requires providers to adopt an e-prescribing system and fulfill related functions, there was an overlap between the two programs, which has been straightened out by the new rule.

Such providers will now have more time to report their e-prescribing quality measures under the modified eRx incentive program. Also, a certified EHR technology will be accepted as a qualified e-prescribing system thereby exempting such providers from penalties under the new rule.

The proposed rule, however, states that Medicare eligible professionals (EP) and group practices cannot earn an incentive under both the eRx and the EHR incentive programs for the same year. Also, EPs will be subject to an e-prescribing payment adjustment if they do not meet the requirements under the eRx program, regardless of whether they participate in and earn an incentive under the EHR program.

Under the eRx incentive program, physicians who use a qualified e-prescribing system are eligible for an additional 1% in Medicare Part B payments in 2011 and 2012, and a 0.5% increase in 2013. But providers who fail to complete at least 10 paperless electronic prescriptions using such a system between January 1 and June 30, 2011 will receive a 1% cut in Medicare reimbursements in 2012, a 1.5% cut in 2013, and a 2% cut in 2014.

The American Medical Association welcomed the flexibility of the proposed rule and the elimination of unreasonable penalties. “Physicians who are working to adopt e-prescribing and other health IT should not be unfairly penalized for practice patterns that do not fit neatly within the current, limited exemption process,” said Dr. Cecil Wilson, AMA president, in a statement.

Among the requirements, e-prescribing systems must be able to generate and transmit prescriptions and active medication list; check for drug-drug interactions; and check whether drugs are in a health plan’s formulary or preferred drug list.

The EHR program also requires the EHR technology to be tested and certified by a certification body authorized by the National Coordinator for Health Information Technology, and even the eRx system to be certified by bodies like Surescripts. Surescripts has the nation’s largest e-prescription network. The eRx incentive program, however, does not require adoption of a certified e-prescription system.

(Source: CMS & Government Health IT)

The guide — titled “A Clinician’s Guide to Electronic Prescribing” — was first published in 2008 (Commins, HealthLeaders Media, 4/28).

The organizations that collaborated on the update are the:

• American Academy of Family Physicians;
• American College of Physicians;
• American Medical Association;
• Center for Improving Medication Management;
• e-Health Initiative; and
• Medical Group Management Association (Robeznieks, Modern Physician, 4/26).

Details of the Guide

The updated guide incorporates changes brought about by the federal health reform law, the HITECH Act and a Drug Enforcement Agency rule to allow E Prescription of controlled substances (Goedert, Health Data Management, 4/27).

The guide provides information on:

• E-prescribing requirements that physicians will face in 2011; and
• How the meaningful use program relates to e-prescribing.

Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments (HealthLeaders Media, 4/28).

Source   :   http://www.ihealthbeat.org/articles/2011/4/28/health-care-groups-update-electronic-prescribing-guide.aspx

According to MGMA, eligible professionals could be unfairly penalized by the programs’ inconsistent requirements (Goedert, Health Data Management, 3/17).

Details of Incentive Programs

Under 2009 economic stimulus package, health care providers who demonstrate meaningful use of certified electronic health records can qualify for incentive payments through Medicaid and Medicare (CMIO, 3/18).

The e-prescribing program started paying out incentives in 2009 and will continue to do so through 2013. Medicare providers who do not e-prescribe would face penalties beginning in 2012 (iHealthBeat, 2/22).

Letter Details

In its letter to HHS Secretary Kathleen Sebelius, MGMA said that e-prescribing incentive program rules conflict with similar rules within the meaningful use program.

Eligible professionals participating in the e-prescribing program must report successful transmission on claims for at least 10 e-prescriptions in the first six months of 2011 to avoid a 1% Medicare payment cut next year. They also must submit 25 e-prescriptions by the end of 2011 to avoid another payment adjustment in 2013 (Health Data Management, 3/17). However, eligible professionals must attest to meeting less stringent requirements under Stage 1 of the meaningful use program (CMIO, 3/18).

The letter states, “This makes it possible for an [eligible professional] to earn incentives through the EHR incentive program but still be penalized through the e-prescribing program for submitting the same number of e-prescriptions” (Health Data Management, 3/17).

Recommendations

Some of MGMA’s recommendations include:

• Allowing more health care providers to be exempt from possible e-prescribing payment reductions in 2012 and 2013; and
• Allowing eligible professionals who attest to meeting Stage 1 meaningful use criteria, during any 90-day window this year, to avoid any e-prescribing payment penalties in 2012 and 2013 (CMIO, 3/18).

Source    :    http://www.ihealthbeat.org/articles/2011/3/18/mgma-align-rules-that-govern-eprescribing-meaningful-use.aspx

The federal government, which strongly supports EMRs, has touted bonuses to physicians who go electronic. A new survey shows just how interested the health care community is in such financial motivation. Forty-one percent of office-based physicians and four in five hospitals plan to take advantage of federal incentive payments for adoption and meaningful use of full-featured, certified EMRs, according to the survey, issued Jan. 13 by the Office of the National Coordinator for Health Information Technology.

Another inducement is from the Medicare electronic prescription incentive program, created by the Medicare Improvements for Patients and Providers Act of 2008 and started Jan. 1, 2009. The five-year program provided a payment to eligible physicians equal to 2% of their total Medicare payments for the year in 2010. The amount is 1% in 2011 and 2012, then will dip to 0.5% in 2013.

While that is a positive step, there also are penalties for those who do not adopt E Prescription systems. A new regulation, which took effect Jan. 1, says eligible practices should meet e-prescribing criteria in at least 10 Medicare office visits between Jan. 1 and June 30. If they don’t, they will pay the government a penalty equal to 1% of their Part B earnings in 2012. The entire 2011 calendar year will determine punishment for 2013.

The American Medical Association and 103 state and specialty medical societies have raised concerns about the penalty and are fighting to revise the policy. In a Dec. 9, 2010, letter to Dept. of Health and Human Services Secretary Kathleen Sebelius, they take issue with the timing. They say the Centers for Medicare & Medicaid Services had indicated that eligible physicians would not be able to get incentives from both the Medicare e-prescribing and Medicare EMR incentive programs simultaneously. Therefore, doctors should choose to take part in only one of these programs, the letter says.

Many doctors who have not yet purchased an e-prescribing or a limited EMR system have decided to forgo the e-prescribing incentives and invest in a comprehensive EMR, the organizations say. But CMS changed its policy at the eleventh hour with the November 2010 publication of its 2011 final fee schedule rule, the letter states. The sudden change doesn’t allow enough time to educate doctors on the need to take part in the 2011 e-prescribing incentive program to avoid penalties in 2012 and 2013.

The major last-minute policy change will compel doctors to spend additional time and money to implement and use e-prescribing software and applications that most will discard when they move to a complete EMR.

The AMA and the organizations strongly oppose basing the 2012 and 2013 e-prescribing penalties on activity that occurs during 2011. At the very least, they say, CMS should extend the reporting period from June 30 to Oct. 31 — an extra four months — to avoid penalties. In addition, the agency should add more exception categories for health professionals, allowing physicians who meet meaningful use criteria in 2011 or 2012 to be exempt from e-prescribing penalties.

The decision to move forward with an EMR can be complicated and costly. Physicians who took the time to make a prudent choice should not be penalized or forced into a wasteful, short-term solution.

Source    :     http://www.ama-assn.org/amednews/2011/01/24/edsa0124.htm

Details of Meaningful Use, E-Prescribing Incentives

Both the meaningful use program and the E Prescription program will provide incentive payments to encourage the adoption of health IT. Under the 2009 economic stimulus package, health care providers who demonstrate meaningful use of certified electronic health records can qualify for Medicaid and Medicare incentive payments (Mosquera, Government Health IT, 2/18).

According to the GAO report, the meaningful use program allocates incentive payments from 2011 to 2016 and starts penalizing health care providers in 2015 for failing to meaningfully use health IT.

Meanwhile, the e-prescribing program started paying out incentives in 2009 and will continue to do so through 2013. Health care providers who do not e-prescribe would face penalties beginning in 2012 (Zigmond, Modern Healthcare, 2/18).

Inconsistencies in Incentive Programs

According to the report, both programs encourage health care providers to adopt health IT that can perform similar activities related to e-prescribing. However, the meaningful use program requires adoption of health IT systems certified to meet specific criteria, while the e-prescribing program has no such certification requirement (Government Health IT, 2/18).

The report noted, “As a result, providers have no assurance that the systems they invest in will meet the electronic prescribing program’s requirements” (Modern Healthcare, 2/18).

The two programs also set up separate reporting benchmarks for e-prescribing. The meaningful use program contains five e-prescribing reporting requirements, compared with one in the e-prescribing program.

Linda Kohn — director of health care issues at GAO — said these inconsistencies could lead to uncertainty among health care providers as to what type of health IT to acquire (Government Health IT, 2/18).

Recommendations

GAO recommended that the CMS administrator:

• Advise health care providers to adopt certified EHR systems;
• Eliminate any overlapping e-prescribing reporting requirements in the two programs; and
• Review whether health care providers who receive e-prescribing incentive payments are meeting the program’s requirements (Modern Healthcare, 2/18).

Source    :     http://www.ihealthbeat.org/articles/2011/2/22/gao-advises-cms-to-resolve-incentive-program-disparities.aspx

The Electronic Prescription network will use a representation of the Direct Project standards and services for simple health information exchanges, according to an announcement Feb. 15 by AAFP and Surescripts.

AAFP Physicians Direct will be available to 75,000 primary care providers across the U.S., and will be offered as a monthly subscription service for $15 per physician user.

The Direct Project is an effort of the Office of the National Coordinator for Health IT to extend health information exchange to individual physicians and small practices who have limited resources and technology assets, so they can meet meaningful use requirements for simple exchanges of referrals, patient summaries and lab results with other providers.

“AAFP Physicians Direct is a health IT innovation that will help providers achieve meaningful use and support continuity of care, which will reduce costs and medical errors,” said Dr. Farzad Mostashari, ONC’s deputy national coordinator for programs and policies.

The Direct Project is a streamlined version of the standards and services of the nationwide health information network (NHIN) that enables providers to exchange patient data securely through the Internet. With Direct, providers send data through secure messaging.

AAFP physicians will be able to connect to the Surescripts network and share information securely through the new AAFP Physicians Direct Web portal or a choice of electronic health record systems.

AAFP’s new service, which is available to physicians and other health care providers serving large and small communities, will help “ensure that everyone can take part and benefit from the digital transformation of the nation’s health care system,” Totonis said.

The Surescripts network will enable providers to exchange clinical data with each other by eliminating communication barriers due to incompatible technology and a lack of interoperability standards.

Dr. David Blumenthal, national coordinator for health IT, has said that health information exchange and clinical interoperability are critical to improving patient outcomes and coordinating care. The next stage of meaningful use measures will require more comprehensive health information exchange, he has said.

“AAFP Physicians Direct will make slow, fragmented and cumbersome patient referrals and follow-up care a thing of the past,” said Dr. Steven Waldren, director of the AAFP Center for Health IT.

Subscribers to AAFP Physicians Direct will be able to securely exchange messages with any other provider on the Surescripts network. Message recipients will retrieve messages from a secure web page within the Physicians Direct portal and reply to messages for free.

It will support federal and state policies and standards for health information exchange, including privacy and security standards as well as standards and technology for exchange, such as Continuity of Care Record (CCR) developed by ASTM International and the Continuity of Care Document (CCD) standard from Health Level 7 to communicate patient summaries.

Source    :    http://www.govhealthit.com/newsitem.aspx?tid=77&nid=76331

DEA’s interim final rule, “Electronic Prescriptions for Controlled Substances,” could make things easier for many physicians who are already electronically prescribing noncontrolled drugs, according to Steven Waldren, MD, director of the Center for Health Information Technology at the American Academy of Family Physicians.

“There are advantages from a quality, safety, and efficiency standpoint” that have already been shown with electronic prescribing, Waldren told MedPage Today. “The same thing needs to be applied to controlled substances. There is also one workflow that can [now] be applied to writing scripts electronically,” instead of needing to have a separate procedure for controlled substances.

Although some people have expressed concern that E Prescription of controlled substances may not be as secure as paper prescriptions, “my personal opinion is that it’s more secure,” Waldren said.

Kevin Nicholson, vice president and pharmacy adviser at the National Association of Chain Drug Stores (NACDS) in Alexandria, Va., agreed that electronic prescribing was actually safer. “Right now, most controlled substances can be called in by telephone, and only certain ones have to be written in on a prescription blank,” he said in an interview. “We feel it’s easier to forge a prescription on paper or fake being a doctor over the phone, than to forge one electronically.”

To make electronic prescribing of controlled substances extra secure, the new DEA rule requires that prescribers provide two of the following: something the person knows (such as a password), something the person has (such as a “hard token” device that generates a random number to be typed into the computer), and something the person “is” (such as a retina scan or fingerprint).

Using two of these factors “will constitute the legal signature of the DEA-registered prescribing practitioner,” according to the agency. Once the two factors have been completed, the computer must “digitally sign” the prescription and archive the DEA-required prescription information.

Although the rule went into effect this week, it could be a long time before physicians will actually be able to put it to use, even if they are already prescribing electronically, Waldren said.

That’s because vendors need to get up to speed with the programming needed to manage hard tokens and biometrics, “and a typical software development cycle is about 18 months,” according to Waldren.

In addition, CMS will need to issue its own new electronic prescribing standard under Medicare or grant a waiver to its current standards in order to allow physicians to meet the DEA requirements.

On the pharmacy side, it will probably be at least six months before pharmacies are ready for e-prescribing of controlled substances, said Nicholson.

Pharmacies “will have to reprogram their systems, and the system has to be certified by an entity approved by the DEA,” he told MedPage Today.

The rule from the DEA has been a long time in coming — 15 years, to be exact, according to Nicholson. One apparent reason for DEA’s foot-dragging was that the agency felt that paper forgeries would be easier to prosecute than electronic ones.

“That was one reason they gave us,” Nicholson said. “If you’re prosecuting a case, it’s much easier using paper as evidence than to have to subpoena an electronic record.” But pressure from the Department of Health and Human Services (HHS) helped to move things along.

“The HHS Office of the National Coordinator has a mission for widespread adoption of electronic health records by 2015,” said Nicholson. “Physicians are going to be much more willing to adopt electronic health records if they are prescribing electronically.”

The new rule will also allow physicians to take fuller advantage of the CMS bonus offered to physicians who prescribe electronically.

Now that the federal government has issued its rule, the NACDS will be working with state pharmacy boards and other state agencies to modify any state regulations that are barriers to electronic prescribing of controlled substances, Nicholson said.

“There are a number of state laws and regulations that might still have some prohibitions. States aren’t putting up barriers in response to the DEA’s rule, but there may be laws and regulations that have been on the books for a while that no one’s ever changed.”

Source   :   http://www.medpagetoday.com/PracticeManagement/InformationTechnology/20457

Surescripts, based in Arlington, Va., will verify that EHR modules for e-prescribing and privacy and security meet meaningful use standards and certification criteria, ONC said in a Dec. 23 announcement.

In October, Surescripts began to expand its E Prescription network to offer health information exchange services for all types of clinical information. The Surescripts network will let EHRs, health system networks and smaller exchanges connect to its national backbone, which in turn can connect them with any other network.

The e-prescriber already connects healthcare providers with retail pharmacies and pharmacy benefit managers.

As an ONC-Authorized Temporary Certification Body (ATCB), Surescripts joins the Certification Commission for Health IT (CCHIT), the Drummond Group, InfoGard Labs, ICSA Labs and SLI Global Solutions. All but Surescripts may certify both complete EHRs and EHR modules, ONC said.

The temporary program, which expires in December 2011, is designed to ensure health IT vendors have their products and services certified in time for providers to meet 2011 deadlines for qualifying for first stage meaningful use requirements.

ONC’s Certified Health IT Product List includes more than 150 EHRs and modules that the authorized groups have certified to date since September, as well as the criteria they cover.

Certification assures healthcare providers that the EHR technology they acquire can perform the functions they need to participate in the Medicare and Medicaid EHR incentive program. Physicians and hospitals that become meaningful users of certified EHRs and modules are eligible for incentive payments under the HITECH Act.

ONC is developing a permanent certification program, in which separate organizations will perform testing and certification activities, for subsequent years of the incentive program.

Source  :  http://www.govhealthit.com/newsitem.aspx?tid=77&nid=75774

The letter, sent by the AMA to HHS Secretary Sebelius on Dec. 10, stated that the groups believe the e-Rx penalty policy will hurt efforts to implement widespread health IT adoption among physician practices and cause them to take on needless financial and administrative burdens.

“The last minute decision to require E Prescription in 2011 will force physicians to spend additional financial and administrative resources to purchase e-prescribing software that most of them will end up discarding when they transition to a complete EHR system,” said AMA Board Secretary Steven J. Stack, MD.

According to the Centers for Medicare and Medicaid Services (CMS) physicians cannot receive incentives from both the Medicare e-prescribing incentive program and the Medicare EHR incentive program simultaneously. However, if physicians choose not to participate in the 2011 e-prescribing program, they will face penalties in 2012 and 2013. Officials said that not aligning these programs will ultimately delay physicians’ efforts to adopt a complete EHR.

“This unreasonable policy leaves many physicians with little choice but to purchase and use a stand-alone e-prescribing program during the initial months of 2011 just to avoid penalties,” said Stack. “HHS must take action now to align the e-prescribing and EHR incentive programs in order to alleviate confusion and reduce financial and administrative burdens on physician practices working to adopt health IT.”

Source    :     http://www.healthcareitnews.com/news/ama-hhs-medicare-e-rx-penalty-policy-unreasonable