ARRA History
ARRA and Meaningful Use Background: a Rural Perspective
Chapter 1: President Obama Backs Health Information Technology
There has long been bipartisan agreement that electronic health records have the potential to improve care quality and reduce healthcare costs. In his 2004 State of the Union address, President Bush set a national goal of implementing electronic health records for most Americans within ten years. But not until President Obama took office in 2008 did we see a significant push for federal funds to be used to assist in the effort.
As legislators started working on the then-called Stimulus Package, President Obama argued for the inclusion of nineteen billion dollars for the digitization of medical records.
From a rural provider perspective, this seemed like promising news. Due to various challenges—minimal access to capital and technical expertise among them—rural providers have lagged far behind their urban counterparts when it comes to EHR adoption. President Obama’s health IT initiative appeared to be the perfect opportunity to eliminate or at least reduce this “digital divide.”
Chapter 2: Rurals Express Concern, Especially with the House Version
High expectations turned to concern when the House released its version of the Stimulus Package. While President Obama’s $19 billion in HIT funds were included in the form of CMS incentive payments, the methodology for payment was structured in a way that would largely benefit providers already far ahead in their EHR adoption efforts. Incentive payments would only be made to providers that achieved an adoption standard called “meaningful EHR use,” and there was no mechanism for distinguishing between providers at early and advanced stages of EHR adoption. According to former National Coordinator for Health Information Technology, David Brailer:
“Many hospitals in urban markets have put their IT prowess on display as proudly as they do their latest magnetic resonance imaging (MRI) scanner. However, many other hospitals are left behind: smaller hospitals, rural hospitals, inner-city hospitals, safety-net hospitals, and critical-access hospitals do not have access to the capital or know-how to purchase and implement EHRs. Many of them must navigate a shadowy EHR market dominated by vendors with systems that could not compete in the mainstream hospital EHR market.
“Despite this adoption gap, Congress has funded incentives to be directed to hospitals across the board for EHR adoption. Whether a hospital is large or small, urban or rural, for-profit or nonprofit, catering to a “white glove” patient base or struggling along in the safety net, the hospital gets an incentive for EHR adoption under the stimulus bill’s provisions. Congress did Authorize Medicaid grants to safety-net hospitals to support health IT adoption, but the amount of this funding is quite small and won’t be enough to overcome the basic business case against adoption for these providers. And even if a hospital put its EHR in place years before or has already committed the capital to EHRs, it gets no less incentive than one that is struggling to come along today.
“We cannot bring the health care industry into the digital era unless all hospitals use electronic records. Congress could have, and in my opinion, should have, targeted its incentive to those facilities that cannot and have not put EHRs in place. In addition to reducing wasteful federal spending, this would have closed a growing digital gap between the have and the have-nots, and it would have truly stimulated job growth in both rural and inner city markets, where the stimulus is most needed. Unless the administration can recalibrate this incentive, this is a lost opportunity that will eventually need to be addressed.”[1]
David Brailer’s assessment is accurate in all but one respect: a hospital that has already purchased and implemented its EHR would not only get “no less of an incentive;” it would in all likelihood get significantly more of an incentive.
The main reason for this had to do with the legislation’s treatment of critical access hospitals (CAHs). Rural advocates were stunned to see that the House version of the Stimulus Package excluded CAHs altogether. The rationale given for the exclusion was that since CAHs received cost reimbursement for their Medicare patients, they didn’t need any HIT incentive payments. This rationale ignored the facts that on average only 35% of CAH capital costs are reimbursed through Medicare, and that even under cost-based reimbursement CAHs have about half the EMR adoption rates of prospective payment system (PPS) hospitals.[2]
The Senate version rectified this problem by providing Medicare incentive payment parity between PPS hospitals and CAHs. Had this version passed, rural provider advocates would likely have universally supported the final legislation.
Chapter 3: Final ARRA Language Creates Reduced CAH Incentive
Instead of providing CAH and PPS hospital incentive parity, the American Recovery and Reinvestment Act created a distinctive CAH incentive structure that tied the CAH incentive payment to a portion of the amount that a CAH spent on “certified EHR expenses.” The practical effect of this was that CAHs that became meaningful users would receive only a fraction of what they would’ve received under the Senate language, and only a fraction of what “meaningful user” PPS hospitals would receive, even if the PPS hospital had already implemented its EHR.
But even without CAH/PPS parity, many rural advocates believed that ARRA incentives still had the potential to significantly increase rural EHR adoption, and not just in CAHs, but in rural physician practices, in Federally Qualified Health Centers, and of course in rural PPS hospitals.
The answers to two questions would ultimately determine the true benefits of ARRA to rural providers. Would the “meaningful EHR use” standard be reasonably attainable by rural providers? And, for CAHs, would “certified EHR expenses” be defined in a way that truly covered the various significant costs of hospital EHR adoption?
Chapter 4: HIT Policy Committee Defines Meaningful Use
Neither of these questions will be fully answered until CMS releases the final incentive rules sometime in 2010, but the issue of “meaningful EHR use” has already been taken up by the HIT Policy Committee, which was established in ARRA to provide HIT policy recommendations to the Office of the National Coordinator for Health Information Technology.
The HIT Policy Committee contains representatives from urban PPS hospitals and systems, university hospitals, large hospital EHR vendors, government agencies, and others. Unfortunately, there is no Committee representation for rural and/or underserved providers. The result is that not a single voice on the Committee has effectively stood up for the needs of rural providers and the cause of reducing the digital divide.
When the HIT Policy Committee issued its preliminary recommendation for “meaningful EHR use,” rural advocates expressed concern that the proposed standards were set so high they would be effectively unachievable for a large percentage of rural providers. The Rural HIT Coalition, a coalition of state, regional, and national rural organizations (including the National Rural Health Association, the National Organization of State Offices of Rural Health, the American Health Quality Association, the Rural Health Resource Center, the Rural Wisconsin Health Cooperative, and many others) issued comments to the Committee that included the analysis below:
“The National Rural HIT Coalition, or Coalition, is supportive of the HIT Policy Committee’s ultimate vision, “in which all patients are fully engaged in their healthcare, providers have real-time access to all medical information and tools to help ensure the quality and safety of the care provided while also affording improved access and elimination of health care disparities.” Indeed, we strongly believe that HIT, if implemented with the significant upfront planning, workflow assessment, and change management that are required for success, will be a critical tool to help all providers achieve this vision over time.
“As currently structured, however, the meaningful use draft definition threatens to undermine the ability of small and rural providers—those that are most in need of assistance (including rural acute care hospitals, critical access hospitals (CAH), rural health clinics (RHC), and other rural healthcare entities)—to participate in the promised healthcare transformation.
“We strongly urge you to consider the following factors:
- The 2011 meaningful use draft requirements roughly correspond to reaching stage 4 of the 7 stage Healthcare Information Management Systems Society (HIMSS) Electronic Medical Record (EMR) Adoption model.
- CAHs and rural acute care hospitals average 1.2 on HIMSS EMR Adoption Scale, whereas general medical-surgical hospitals average 2.5.
- A “reasonable” time required for any hospital to implement from stage 1 to stage 4 (considering what is required for appropriate vendor selection, workflow assessment, education, and implementation) is 3-5 years.
- Many CAHs and rural acute care hospitals will be required to essentially start from scratch after determining that their existing vendors will not position them to become meaningful users, and this will add to the “reasonable” time required.
- Many CAHs and rural acute care hospitals will need to address critical network infrastructure and HIT staff expertise challenges that will also add to the “reasonable” time required.
- Rural clinics have an analogous HIT adoption disparity and related challenges
“If the above factors are granted, then average CAHs and rural acute care hospitals that begin their implementation process now will not be able to achieve the 2011 requirements until 2013 or later and as a result will receive no reimbursement.
“They will next be faced with the daunting challenge of reaching roughly stage 5.5 on the HIMSS adoption scale in literally no time and with no incentive dollars to assist the process.
“The draft definition claims to achieve a balance between on the one hand: (1) currently available EHR capabilities, (2) the time needed to implement, and (3) the implementation challenges associated with small practices (and presumably small hospitals); and on the other hand: (1) the urgent need for health reform, and (2) the desire to substantively improve health outcomes.
“Our analysis indicates that the draft definition only achieves this balance for providers that have already made significant strides in their EHR adoption efforts. If the Meaningful Use Matrix is aggressive yet achievable for hospitals that average 2.5 on the HIMSS adoption scale, we question the practicality of it also being achievable for a hospital that averages 1.2 or 0. Given that achievability is one of the tenants of the HIT Policy Committee, we implore the Committee to reconsider a course of action that will result in the vast majority of the providers most in need of assistance being effectively excluded from receiving ARRA HIT incentive funds.”[3]
The Rural HIT Coalition raised a critical question: how is it possible for a meaningful use standard to be challenging yet achievable for providers at dramatically different levels of EHR adoption? How can a provider that is just starting out on an EHR journey meet a standard designed for a provider already quite far along?
The HIT Policy Committee never addressed these questions and concerns, and in July 2009, the Committee unanimously approved their original “meaningful use” recommendations with minor modifications.
Chapter 5: Regional Extension Centers Funds Exclusive to Physicians
Even as it was becoming clear that small, rural, and underserved provider needs would likely get lost in a decision making process dominated by large hospital, system, and bureaucratic interests, there remained hope that the ARRA provision for the establishment of Regional Extension Centers would provide at least some relief in the form of much needed technical assistance.
After all, ARRA had clearly defined and prioritized the providers to be helped by these Regional Extension Centers. Prioritized providers included CAHs, FQHCs, and small group practices. According to ARRA:
“Each regional center shall aim to provide assistance and education to all providers in a region but shall prioritize any direct assistance first to the following:
- Public or not-for-profit hospitals or critical access hospitals.
- Federally qualified health centers (as defined in section 1861(aa)(4) of the Social Security Act).
- Entities that are located in rural and other areas that serve uninsured, underinsured, and medically underserved individuals (regardless of whether such area is urban or rural).
- Individual or small group practices (or a consortium thereof) that are primarily focused on primary care.[4]
But when the Office of the National Coordinator issued the Extension Center funding announcement, the definition of prioritized provider had somehow been revised:
“Pursuant to requirements of the HITECH Act, priority shall be given to providers that are primary-care providers (physicians and/or other health care professionals with prescriptive privileges, such as physician assistants and nurse practitioners) in any of the following settings:
- individual and small group practices (ten or fewer professionals with prescriptive privileges) primarily focused on primary care;
- public and Critical Access Hospitals;
- Community Health Centers and Rural Health Clinics; and
- other settings that predominantly serve uninsured, underinsured, and medically underserved populations.”[5]
The ARRA language clearly states that Critical Access Hospitals are to be prioritized, but the grant guidance indicates that only “primary care physicians with prescriptive privileges” that practice in Critical Access Hospitals, among other “settings,” are prioritized. This redefinition ultimately means that while REC funds can be expended to help primary care physicians in CAHs achieve meaningful use, they cannot be expended to help CAHs or other hospitals achieve meaningful use. ONC staff confirmed and emphasized this point in the first REC guidance call.
Obviously small physician practices, rural health clinics, and FQHCs need the assistance. But so do CAHs, as well as other hospitals at early stages of EHR adoption. How and why they were excluded by ONC from REC prioritization remains a puzzle.
The story continues in posts that can be accessed from the home tab, including these:
http://www.worh.org/hit/2010/02/cms-proposed-rule-how-to-stretch-without-breaking/
http://www.worh.org/hit/2010/01/how-the-cms-proposed-rule-will-raise-the-cost-of-rural-healthcare/
http://www.worh.org/hit/2010/01/what-cms-says-and-doesnt-say-about-small-and-rural-providers/
http://www.worh.org/hit/2010/08/final-hit-incentive-rule-stage-1-quality-metrics-objective/
http://www.worh.org/hit/2010/12/meaningful-use-in-2010-summary-of-key-events/
http://www.worh.org/hit/2011/07/cms-issues-restrictive-ehr-cost-and-other-faqs-for-cahs/
http://www.worh.org/hit/2011/11/hhs-secretary-intends-to-extend-stage-2-mu-deadline/
http://www.worh.org/hit/2012/01/2011-rural-hit-recap-the-year-of-meaningful-use/
http://www.worh.org/hit/2012/02/proposed-stage-1-revision-and-stage-2-objective-and-cqm-tables/
http://www.worh.org/hit/2012/02/preliminary-comments-on-proposed-stage-2-meaningful-use-objectives/
References
[1] David Brailer, [Health Affairs 28, no. 2 (2009): w392–w398 (published online 9 March 2009; 10.1377/hlthaff.28.2.w392)]
[2] HIMSS Analytics: http://www.himssanalytics.org/hc_providers/emr_adoption.asp
[3] The Rural HIT Coalition, Comments to ONC regarding Proposed Meaningful Use Matrix, June 25, 2009
[4] ARRA, Section 3012(a)(b)(4), 2/25/2009
[5] HIT Extension Program Funding Announcement and Grant Application Instructions
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