Take a leadership role in this 'once-in-a-lifetime opportunity' for Medicaid HIT
Take a leadership role in this 'once-in-a-lifetime opportunity' for Medicaid HIT
State Medicaid directors may have taken a close look at implementing health information technology (HIT) for some time now, but in large part these investments have been held back due to budget problems. However, the economic stimulus package is jump-starting many of these shelved plans. The Health Information Technology for Economic and Clinical Health Act, passed as part of the American Recovery and Reinvestment Act of 2009 (ARRA), establishes payment incentives in the Medicaid and Medicare programs to encourage providers to adopt HIT.
"Without the funding, I don't believe New Hampshire Medicaid would have the opportunity to implement any type of health information technology," says Kathleen A. Dunn, MPH, director of New Hampshire's Office of Medicaid Business and Policy.
Like all state Medicaid programs, New Hampshire is waiting for the Centers for Medicare & Medicaid Services (CMS) to release official guidance on the utilization of the stimulus funds, including the expectations for the certification and monitoring of the use of HIT dollars. Ms. Dunn notes that during a recent conference call hosted by the National Association of State Medicaid Directors, CMS officials indicated that the guidance will not be available until the end of 2009.
The ARRA requires state Medicaid directors to develop an advanced planning document that must be submitted to CMS for approval on how the state proposes to utilize Medicaid funds, how the state proposes to certify any Medicaid HIT-related systems, and how the state Medicaid program will monitor the usage of the technology.
"From the perspective of the role of the state Medicaid director, I believe it is vitally important to take a leadership role in the process," says Ms. Dunn. "Not only is the state Medicaid director responsible for assuring compliance with the federal regulations, but this is probably a once-in-a-lifetime opportunity to help the Medicaid program realize its full potential as a purchaser of quality health care services for over 10% of our total population."
Ms. Dunn says she envisions the development of a common HIT platform that allows health care providers to do real-time communication with each other using electronic health records, "thereby truly coordinating an individual's health care needs on a local level through a patient-centered medical home model."
Avoid 'technology islands'
New Hampshire is currently attempting to promote electronic medical record (EMR) installation and use, and has undertaken efforts to speed the adoption of e-prescribing.
According to Ned Helms, director of the University of New Hampshire's Institute for Health Policy and Practice, the money in the stimulus that provides $19 billion nationally for HIT "is going to make a difference, especially for those practices that do not have the financial capacity for the initial outlay for the hard costs of EMR installation and startup.
"What will be critical, however, is to assure that we are not setting up 'technology islands' in our state," he adds. "We must assure that HIT is moving hand in hand with health information exchange."
Mr. Helms says his organization has found that in many of the state's hospital catchment areas, as much as 60% of the inpatient and outpatient care given to residents is provided outside their catchment area. "Portability will be the critical ingredient, and we anticipate that the Department of Health and Human Services will play a critical role in assuring that outcome," he says.
In 2007, Connecticut was awarded a Medicaid Transformation Grant to implement an e-prescribing system. "We have awarded contracts to Electronic Data Systems, E-Health Connecticut, and the University of Connecticut School of Pharmacy to work on the project, and we expect to be operational in October 2009," reports David Parrella, director of Medical Care Administration at the Connecticut Department of Social Services. "That is our first entry into what is generally referred to as HIT."
In addition, the state is looking at some summary dashboard utilities that could be a precursor to a full EMR, as possible add-ons to its Medicaid management information system. Mr. Parrella says one limiting factor is the available staff with the direct IT knowledge to be able to plan and implement these concepts.
"Full stimulus funding for HIT is probably at least a year and a half away, given that the National Coordinators Office in Baltimore needs to convene and develop the requirements for the national electronic health record standards," he adds.
HIT a national goal
According to Frank O'Connor, a Delaware Medicaid program administrator, "implementing information technology throughout the health care industry is a broad national goal and involves many more stakeholders than the Medicaid program." He notes that HIT essentially involves converting patient health records from paper to electronic formats and making the electronic records available among various health care providers who may be involved in treating a particular patient over time. Medicaid is a government-run health insurance program that pays for health care services for eligible enrollees and does not maintain patient health care records.
"However, for the first time, the ARRA provides for HIT funding through the Medicaid program, as well as other programs such as Medicare that would not involve the state Medicaid agency," says Mr. O'Connor. "The federal Medicaid stimulus funds can be used for 90% of state Medicaid administrative costs related to implementing HIT."
In addition, Medicaid federal funds can be used to make payments directly to certain health care providers to cover a portion of their costs for initial implementation and operation of an HIT system. "So, under the stimulus package, Medicaid will certainly have the ability to play some role in implementing HIT," says Mr. O'Connor.
However, since there was no funding for HIT through the Medicaid program until the passage of the ARRA, "this is a completely new area for the Medicaid program," he says. "Because this is a new endeavor for Medicaid, there are no past rules, regulations, policies, or practices to follow or build on."
To date, the federal government has not issued any written regulation or even any guidelines to establish the role that Medicaid can play in the HIT area. "Some obstacles that were discussed in a recent phone call among states and representatives of the federal government include a number of terms in the law that need to be defined," says Mr. O'Connor.
For example, Medicaid can pay for HIT for a doctor who has at least a 30% Medicaid patient volume, but that is not a statistic that is currently known or even defined. Also, the amount that Medicaid could pay to a particular provider has to be based on "net average allowable cost" and there is no definition of that term. "Medicaid can only pay for 'certified' technology, but the certification process has to be done by a federal agency and will not be known for approximately a year," says Mr. O'Connor.
Meaningful use of HIT
Deborah Bachrach, director of New York's Medicaid program, says, "The congressional authors of the ARRA envisioned HIT as a tool for improving the quality of health care. Hence, clinicians and hospitals must demonstrate 'meaningful use' of an EHR to qualify for incentive funds under ARRA. New York Medicaid shares this vision."
Ms. Bachrach says the recently enacted state fiscal year 2009-2010 Health Budget authorized Medicaid to implement two critical incentive programs that will align with ARRA and stimulate adoption of HIT among Medicaid clinicians. The first program is an incentive to promote electronic prescribing, with $0.80 paid to the prescriber and $0.20 to the pharmacist for each dispensed e-script.
"E-prescribing is, itself, a component of 'meaningful use' under ARRA," says Ms. Bachrach. "E-prescribing in Medicaid will eventually reduce medication errors, encourage pharmaceutical practices that produce better patient outcomes, and yield savings."
Secondly, New York's budget authorizes Medicaid incentive payments for the development of patient-centered medical homes in New York. Hospitals and community clinics, as well as doctors and nurse practitioners who coordinate and integrate their patients' care in accordance with medical home standards, will receive additional fee-for-service and managed care payments through this initiative.
"HIT is a critical component required for successful implementation of a medical home," says Ms. Bachrach. "New York Medicaid expects that these initiatives will be further advanced by the ARRA stimulus package."
In addition to providing incentives for adoption of e-prescribing and EHRs in the patient-centered medical home, New York Medicaid is implementing a statewide infrastructure to support e-prescribing and care coordination by providing 90 days of medication history extracted from pharmacy claims.
"These data can be used by practitioners, with patient consent, to help construct a reconciled medication list for each Medicaid beneficiary in a clinician's practice," says Ms. Bachrach. The data can be used in point-of-care electronic prescribing software applications to minimize medication errors by detecting drug-drug interactions and therapeutic duplication. The data also can help the clinician assess the adherence of a given patient to the prescribed medication regimen.
However, in a pilot implementation of this program, Medicaid learned that provider adoption was disappointingly slow. "Practice workflow re-engineering is required to help clinicians integrate this rich source of data into their daily workflows," she says. "Medicaid also learned that patient privacy, security, and consent issues are complex."
Ms. Bachrach stresses that "it is critical to develop sophisticated policy and technical responses to these issues. Committed leadership from the state, providers, and consumers is imperative to set the vision and direction for an initiative of this degree of complexity."
According to Theresa Eagleson, Illinois' Medicaid director, "The goals of HIT are very similar to the goals of Medicaid programs. It's all about having better data to deliver more efficient, better-quality care. We have certainly been very interested in this for some time, and we now have some resources to move this forward."
Currently, a $3 million program to administer grants around the state for health information exchange planning is under way. "That is something we are doing right now to get this off the ground. Most of the money in the stimulus package comes in the form of Medicaid rate add-ons, so we are trying to do everything we can to help providers get prepared for this," says Ms. Eagleson. "We really want to be in the best position possible to take advantage of the federal rate incentives when they come."
Sixteen training areas have been established to educate providers about the request for applications that the state is putting out to encourage the implementation of health information exchange. The goal is to reduce duplicative services and errors and enhance coordination of patient care for all provider types.
A program started in 2006 and enhanced last year involves paying small bonuses to physicians for meeting goals such as immunizing children or managing a patient's asthma. "Hopefully, we can drive quality through the way we pay providers as well," says Ms. Eagleson. "If we can do more rate setting based on those things, we can drive the whole system toward better quality."
Contact Ms. Bachrach at (518) 474-3018 or [email protected], Ms. Dunn at (603) 271-5258 or [email protected], Ms. Eagleson at (217) 782-2570, Mr. O'Connor at (302) 255-9615 or [email protected], and Mr. Parrella at (860) 424-5219 or [email protected].
State Medicaid directors may have taken a close look at implementing health information technology (HIT) for some time now, but in large part these investments have been held back due to budget problems. However, the economic stimulus package is jump-starting many of these shelved plans.Subscribe Now for Access
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