House GOP Urges Halt to EHR Bonuses

October 11, 2012

October 11, 2012 — Federal bonuses for "meaningful use" of electronic health records (EHRs) have become a political football, with House Republicans calling for their immediate suspension and healthcare groups rising to their defense.

Last week, 4 powerful House Republicans told US Department of Health and Human Services (HHS) Secretary Kathleen Sebelius in a letter that "insufficient standards" for EHR meaningful use have left physicians and other providers with systems that cannot "talk with one another." They urged Sebelius to suspend incentive payments until HHS issues "universal interoperable standards" and to otherwise raise the bar for physicians to receive the cash bonus.

Without such changes, they write, the nation will have "a less efficient system that squanders taxpayer dollars and does little, if anything, to improve outcomes for Medicare."

The congressmen signing the letter were Dave Camp (R-MI), chair of the House Ways and Means Committee; Wally Herger (R-CA), chair of the Ways and Means Subcommittee on Health; Fred Upton (R-MI), chair of the House Energy and Commerce Committee; and Joe Pitts (R-PA), chair of the Energy and Commerce Subcommittee on Health.

The incentive program, launched last year by the Centers for Medicare and Medicaid Services (CMS), awards up to $44,000 under Medicare or up to $64,000 under Medicaid to clinicians who use EHRs in specified ways to improve and streamline patient care. In 2015, Medicare will begin to penalize physicians who fail to meet meaningful-use standards, which are supposed to become more and more challenging over time.

The Republican criticism of the incentive program centers on the so-called Stage 2 rules, or standards, which take effect in 2014. These rules represent only a slight escalation of the Stage 1 rules now in place, according to the congressmen. For example, under Stage 1, physicians must electronically transmit at least 40% of their prescriptions to pharmacies as part of qualifying for the bonus. Stage 2 standards raise that threshold to 50%, which the congressmen call "woefully inadequate."

They note in their letter that the proposed Stage 1 rules released in 2009 had called for a far higher threshold — 75% — right off the bat. "This is but one example of how the Stage 2 rules ask less of providers and do less for program efficiency," they write.

The GOP congressmen said the incentive program "appears to be doing more harm than good," citing a recent New York Times story that detailed how EHRs made it easier for hospitals and physicians to inflate their Medicare bills at taxpayers' expense.

Healthcare Still "Trapped in Information Silos"

More than anything, though, the congressmen complained that the Stage 2 rules do not do enough to make different EHR systems more interoperable; that is, able to freely exchange information. Instead, "our healthcare system [remains] trapped in information silos, much like it was before the incentive payments." They said that although Stage 1 rules require physicians to test whether their EHR systems can swap data with other systems, the Stage 2 rules do not.

"It is safe to say that we are no closer to interoperability in spite of nearly $10 billion [in incentive cash] spent," wrote the Republican House leaders.

Their letter of discontent came a day after the release of a survey showing that more than 70% of physicians using EHRs view the lack of interoperability or an information exchange network — as well as the cost of this technology — as a major barrier to sharing data. The survey was conducted on behalf of a group called Doctors Helping Doctors Transform Health Care. The American College of Physicians (ACP) played a major role in developing the survey, fielding it, and analyzing the results.

In their letter, the congressmen appear to overlook a provision in the Stage 2 rules that resembles the interoperability testing requirement in its predecessor. The Stage 1 rules have a stand-alone requirement for providers to conduct at least one test of electronically transmitting patient data — it could be for a fictional patient — to another provider's EHR. This requirement, as such, did not migrate to Stage 2. However, Stage 2 does mandate a similar test — in this case, with a CMS-designated test EHR — if a provider does not pull off at least one data swap with a provider using a different kind of system.

This test option is part of a Stage 2 requirement for the sharing of "summary of care" documents. It states that a physician must electronically transmit a care summary to other providers for more than 10% of patients who are referred elsewhere or shifted into a new care setting, such as a nursing home (the congressmen called this threshold too low). A physician satisfies this standard whether or not the other provider uses the same EHR system. For the sake of promoting true interoperability, CMS added an additional requirement for either a single, real-life transmission of a care summary to a provider with a different HER or the test with a dummy EHR, the agency explained in its published regulations.

"The Incentives Are Working"

The letter from the GOP congressmen provoked a rebuttal the next day from the Healthcare Information and Management Systems Society (HIMSS), a large trade organization for professionals and vendors in that field.

In a press release, HIMSS stated that it opposes suspending meaningful-use incentive payments until HHS issues universal interoperability standards. The group said the Stage 2 rules move "the nation definitely towards interoperability."

"There are clear indicators that the incentives are working," HIMSS stated.

The ACP challenges the House Republican letter as well. Michael Barr, MD, MBA, who directs the ACP's division of medical practice, professionalism, and quality, said that if meaningful-use bonuses are suspended, "the [incentive] program would lose momentum" and the switch to EHRs would stall for some physicians.

Contrary to what the Republican congressmen assert, "there is a lot in Stage 2 that will try to solve these interoperability issues," Dr. Barr told Medscape Medical News. One example, he said, was the requirement for physicians to electronically transmit a care summary for more than 10% of patients sent to a new provider or care setting.

Dr. Barr also took issue with the allegation raised by the New York Times and other media outlets that physicians are exploiting the documentation and coding power of EHRs to overcharge Medicare.

"I don't know what percentage is potentially fraud or not," said Dr. Barr. "The ACP is against any kind of fraudulent billing. But as the history goes, EHRs have helped physicians document more thoroughly." This, in turn, leads to the selection of more appropriate billing codes.

"What we emphasize," he said, "is appropriate coding for appropriate documentation for the benefit of care."

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