Will Health Information Exchange Become Medicare Payment Criterion?

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The use of interoperable electronic health record (EHR) systems to share information could eventually become part of reimbursement criteria in the Medicare and Medicaid programs, according to a new position paper from the Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid Services (CMS).

The report, "Principles and Strategy for Accelerating Health Information Exchange (HIE)," states the government's principles in three categories: accelerating health information exchange, advancing standards and interoperability, and consumer/patient engagement. The strategies were informed by the stakeholder comments that ONC received in response to a request for information it issued earlier this year.

To accelerate the use of interoperable systems, the paper said, "HHS [Department of Health and Human Services] will implement policies that could encourage HIE incrementally and could evolve from incentive and reward structures to ultimately considering HIE a standard business practice for providers."

The report also said that to encourage information sharing among providers, "CMS is evaluating strategies that begin with incentives or rewards through value-based payment programs and end with defining well-established types of HIE as part of quality standards related to reimbursement under Medicare and Medicaid."

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Meaningful Use stage 2 requires electronic information exchange at transitions of care, such as hospital discharges and specialty referrals. But Meaningful Use is ostensibly a voluntary program for eligible professionals and hospitals that wish to receive government incentives for the use of EHRs. What CMS and ONC are talking about in this report is tying reimbursement of providers directly to interoperability.

Physicians and hospitals that don't meet the criteria for Meaningful Use of EHRs, which include interoperability, will see their Medicare payments reduced starting in 2015. From that viewpoint, many providers are already being coerced into using EHRs to exchange information. But the new proposal might increase the penalties further and affect additional providers.

The report also proposes another lever for interoperability in an ongoing CMS program: "Meeting the standards for MU of EHRs has been identified in the CY 2014 Medicare Physician Fee Schedule proposed rule as a potential requirement for practices to furnish a new billable service for complex care management of chronically ill beneficiaries." In a related webinar, Patrick Conway, MD, chief medical officer of CMS, reportedly said that this proposed requirement would include the electronic exchange of care summaries.

Another theme of the report was the need to exchange information across care settings. The agencies pointed out that about 40% of Medicare beneficiaries discharged from hospitals are sent to post-acute settings such as rehabilitation hospitals and skilled nursing facilities, but there is little capacity in the system today to support HIE across these settings. A primary reason is that only 6% of long-term-care facilities, 4% of rehab hospitals, and 2% of psychiatric hospitals have a basic EHR system.

These long-term and post-acute care (LTPAC) providers and behavior health facilities are not eligible to receive incentives for adopting EHRs under the Meaningful Use program. Some of those who commented on the RFI said the government should change that policy.

The report didn't directly address that shortcoming in the HITECH Act, which authorized the EHR incentive program. But it noted that the CMS Innovation Center has made some funding available for HIE and EHR adoption among long-term care and behavioral health providers. In addition, it said that the HHS Entrepreneurs Program is developing "targeted, open source toolkits" for promoting Direct secure messaging and admission, discharge and transfer (ADT) alerts that can be deployed by a wide range of healthcare entities, including those not eligible for federal EHR incentives.

ONC and CMS listed a number of other government activities that are promoting interoperability. Interestingly, however, the paper did not mention the private sector and public/private initiatives that are also moving the ball forward. These include the work of Commonwell Health Alliance, Surescripts and the Healtheway-EHR/HIE Interoperability Work Group consortium.