Meaningful Use and Pediatrics

The American Recovery and Reinvestment Act of 2009 (ARRA) contained a portion (Title XIII of Division A), referred to as HITECH, that is intended to support a broad effort to accelerate the adoption of Health IT and utilization of qualified Electronic Health Records (EHRs).

The main way that HITECH tries to encourage widespread adoption of EHRs is through bonus payments to physicians who are able to demonstrate “meaningful use of a certified EHR.” These payments are to be paid out through the Centers for Medicare and Medicaid Services (CMS) – after all, HITECH incentive moneys are public moneys, and it makes sense to pay them out through the current pubic option of healthcare payments (Medicare and Medicaid). CMS has issued its Meaningful Use “ notice of proposed rulemaking” (NPRM), and is currently in the 60-day open comment period before issuing finalized rules.

Physicians can qualify for Meaningful Use incentive payments through one of several avenues. For physicians who participate in Medicare fee-for-service payments, the 2011 incentive payments would be 75% of the total Medicare allowed charges billed by the physician, up to a limit of $18,000. The bonuses diminish each year, and cumulatively add up to $44,000.

Physicians and hospitals who participate in Medicare Advantage programs (Medicare HMOs) can also access Meaningful Use incentive moneys, if their Medicare Advantage (MA) organization (e.g. a risk-taking IPA) submits a request to participate this way. MA organizations must make sure their physicians did not already receive the maximum incentive moneys through the Fee-for-Service pathway already, so as to avoid “double dipping” into the incentive pool.

A third pathway through which physicians can receive Meaningful Use incentives is through Medicaid. States, at their option, can receive HITECH money to encourage physician adoption of EHR technology. The states administer the distribution of these moneys, like they administer the distribution of Medicaid payments at the state level.

To qualify for Meaningful Use incentives through the Medicaid path, a physician needs a minimum threshold Medicaid volume in his/her practice – 30% of all patients served must be Medicaid (during a 90-day reporting period); or if the physician practices in a FQHC or RHC, then 30% of the patient load must be “needy individuals” as defined by those programs. Pediatricians only need to demonstrate 20% of their volume coming from Medicaid, and acute care hospitals only need 10% of their volume to qualify (see table 26, page 288 of the NPRM).

So, where does this leave pediatricians? After all, pediatrics is a major cornerstone of the primary care base of any coordinated health care delivery system. Does this leave pediatrics at a disadvantage?

The nature of pediatric practice is such that Medicare is not a significant part of their practice (except for disabled children), and thus the major thrust of Meaningful Use incentives doesn’t apply here. Therefore, the only avenue left for pediatrics is the Medicaid option – and it only works for practices that have more than 20% of their volume as Medicaid.

Medicaid patients are unevenly distributed among healthcare practitioners, largely owing to low reimbursement and high administrative costs – a study in 2006 showed a growing trend where Medicaid patients are increasingly concentrated among a smaller proportion of physicians who tend to practice in large groups, hospitals, academic medical centers and community health centers. The result is that most community pediatricians, not affiliated with these institutions, do not significantly service the Medicaid population – and certainly do not have more than 20% of their practice as Medicaid.

Perhaps this is an unanticipated result from the HITECH Meaningful Use incentive system. Except for the relatively small percentage of “Medicaid doctors,” most pediatricians do not have a pathway for access to Meaningful Use incentives. Yet the intent of ARRA, and of the Office of the National Coordinator for health IT (ONC), is to encourage physicians everywhere to adopt EHRs. For this important pillar of primary care, however, such incentives are effectively cut off. Appreciation of this fact is important, going forward, and hopefully CMS and the ONC will find a way to address it – pediatricians, like all others, need to have access to the same kind of incentives, support and encouragement to adopt and meaningfully use modern EHR technology.

Robert Rowley, MD
Chief Medical Officer, Practice Fusion, Inc