Electronic Prescribing
CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the Use of Health Information Technology
GAO-11-159, Feb 17, 2011
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Congress established two CMS-administered programs--the Electronic Prescribing Program and the Electronic Health Records (EHR) Program--that provide incentive payments to eligible Medicare providers who adopt and use health information technology, and penalties for those who do not. The Medicare Improvements for Patients and Providers Act of 2008 required GAO to report on the Electronic Prescribing Program. To do so, GAO examined how CMS determines which providers receive incentive payments and avoid penalties from that program and how many providers received incentive payments in 2009. Also, GAO was asked to examine how the requirements of the two programs compare. GAO reviewed relevant laws and regulations, interviewed CMS officials, and analyzed CMS data on incentive payments made for 2009, which were the most recent data available for a full year.
CMS analyzes information reported by eligible providers on their Medicare Part B claims--which are used to submit charges for covered services--to determine which Medicare providers should receive Electronic Prescribing Program incentive payments or be subject to penalties. In 2009--the first year the program provided incentive payments--CMS paid approximately $148 million in incentive payments to about 8 percent of the approximately 600,000 Medicare providers who had an applicable patient visit--that is, supplied 1 of 33 CMS-designated services typically provided in the office or outpatient setting. For 2009, CMS examined Part B claims to determine whether, after each applicable patient visit, providers marked any one of three electronic prescribing reporting codes used to report information on the adoption and use of electronic prescribing systems. To receive an incentive payment that year, the provider had to report the codes for at least 50 percent of applicable patient visits, and at least 10 percent of the provider's total allowed Medicare Part B charges for the year had to be from the applicable patient visits. CMS made changes in the reporting requirements for 2010. For example, the agency reduced the number of reporting codes to one and required that individual providers report the code after at least 25 applicable visits, instead of for 50 percent of applicable visits. From 2012 through 2014, the Electronic Prescribing Program will assess penalties on providers that do not adopt and use electronic prescribing. Individual providers will have to submit the electronic prescribing reporting code at least 10 times in the first 6 months of 2011 to avoid penalties in 2012. Although GAO found similarities in the technology and reporting requirements for both programs, GAO also found that the requirements of the two programs are inconsistent in several areas. The EHR Program provides incentives from 2011 to 2016 and introduces penalties beginning in 2015, while the Electronic Prescribing Program provides incentives from 2009 to 2013 and provides for penalties from 2012 to 2014, when the program ends. Both the EHR and Electronic Prescribing Programs require providers to adopt and use technology that can perform similar electronic prescribing-related activities. However, the EHR Program requires providers to adopt and use certified EHR systems that meet criteria established by HHS, which include electronic prescribing-related capabilities, while the Electronic Prescribing Program does not have a certification requirement. As a result, providers have no assurance that the systems they invest in will meet the Electronic Prescribing Program's requirements. Additionally, the two programs have established separate reporting requirements related to electronic prescribing, potentially requiring physicians--the largest and only group of providers eligible to earn incentive payments in both programs--to report to both programs from 2011 through 2014. CMS recognizes that this duplication places additional burden on physicians; however, CMS is still in the process of developing a strategy to address this duplication. GAO is recommending that the CMS Administrator take four actions, including (1) encourage physicians and other providers in the Electronic Prescribing Program to adopt certified technology and (2) expedite efforts to remove the overlap in reporting requirements for physicians who may be eligible for incentive payments or subject to penalties under both programs. CMS generally agreed with three recommendations and disagreed with a fourth recommendation, which GAO clarified based on CMS's comments.
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Recommendations for Executive Action
Recommendation: To help improve the effectiveness of the Electronic Prescribing and EHR Programs to encourage the adoption of health information technologies among Medicare providers, the Administrator of CMS should encourage physicians and other health care providers in the Electronic Prescribing Program to adopt certified electronic prescribing technology.
Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open
Comments: As part of our review of the Centers for Medicare & Medicaid Services' (CMS) Electronic Prescribing Program and Electronic Health Records (EHR) Program, both of which provide incentive payments to eligible Medicare providers who adopt and use health information technology, we found that inconsistencies in the requirements might limit the programs' effectiveness in encouraging the use of health information technologies. Specifically, we found that the Electronic Prescribing Program required the use of a "qualified electronic prescribing system" and lacked a certification process like that established for the EHR Program and that EHR systems certified for the EHR Program or certified EHR modules integrated together to perform the electronic prescribing-related capabilities could meet the current requirements of the Electronic Prescribing Program. Therefore, we recommended that the Administrator of CMS encourage physicians and other health care providers in the Electronic Prescribing Program to adopt certified electronic prescribing technology. HHS has taken some actions that, if fully implemented, will address our recommendation. In September 2011, CMS plans to issue a final rule affecting Electronic Prescribing Program incentive payments for 2011 and penalties for 2012. It also issued a proposed rule on July 19, 2011, affecting Electronic Prescribing Program incentive payments for 2012 and 2013 and penalties for 2013 and 2014. Specifically, these rules, if implemented, will allow providers to use a "qualified electronic prescribing system" or certified EHR technology for purposes of the Electronic Prescribing Program. CMS notes in these rules that this change is to address inconsistencies between the Electronic Prescribing Program and the EHR Program which GAO identified in its report.
Recommendation: To help improve the effectiveness of the Electronic Prescribing and EHR Programs to encourage the adoption of health information technologies among Medicare providers, the Administrator of CMS should expedite efforts to remove the overlap in reporting requirements for physicians who may be eligible for incentive payments or subject to penalties under both the Electronic Prescribing and EHR Programs by, for example, aligning the reporting requirements so that successfully qualifying for incentive payments or for avoiding penalties under the EHR Program would likewise result in meeting the requirements for the Electronic Prescribing Program.
Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open
Comments: As part of our review of the Centers for Medicare & Medicaid Services' (CMS) Electronic Prescribing Program and Electronic Health Records (EHR) Program, both of which provide incentive payments to eligible Medicare providers who adopt and use health information technology, we found that the two programs have established separate reporting requirements related to electronic prescribing, requiring some physicians who elect to report to the EHR Program to report to both programs in 2011 and potentially requiring physicians to report to both programs through 2014, when penalties for the Electronic Prescribing Program end. Therefore, we recommended that the Administrator of CMS expedite efforts to remove the overlap in reporting requirements for physicians who may be eligible for incentive payments or subject to penalties under both the Electronic Prescribing and EHR Programs by, for example, aligning the reporting requirements so that successfully qualifying for incentive payments or for avoiding penalties under the EHR Program would likewise result in meeting the requirements for the Electronic Prescribing Program. HHS has taken some actions that, if fully implemented, may address our recommendation. In September 2011, CMS plans to issue a final rule affecting Electronic Prescribing Program incentive payments for 2011 and penalties for 2012. It also issued a proposed rule on July 19, 2011, affecting Electronic Prescribing Program incentive payments for 2012 and 2013 and penalties for 2013 and 2014. Specifically, the former rules, if fully implemented, would exempt physicians from penalties in 2012 if they register to participate in the Medicare or Medicaid EHR Incentive Programs and adopt certified EHR technology by October 1, 2011. The latter, proposed rule would allow physicians to submit data via a certified EHR system to avoid the penalties. Previously, physicians were restricted to submitting their electronic prescribing code through their Part B claims. Additionally, CMS proposes expanding the number of cases for which a physician can include as applicable electronic prescribing instances for avoiding the penalty by not limiting the submission of the electronic prescribing code to certain applicable patient visits (i.e., generally office visits). These changes, if implemented, should bring the data that must be submitted for the two programs into better alignment and thereby reduces the burden placed on physicians subject to both the Electronic Prescribing and EHR Programs, and would, therefore, address our recommendation.
Recommendation: To help improve the effectiveness of the Electronic Prescribing and EHR Programs to encourage the adoption of health information technologies among Medicare providers, the Administrator of CMS should identify factors that helped or hindered implementation of the Electronic Prescribing Program to help support the ongoing implementation of the EHR Program. CMS could include consideration of such factors in the integration plan that the agency is required to develop by January 1, 2012.
Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open
Comments: In written responses to GAO regarding open recommendations received on June 24, 2011, CMS noted that it recognizes that differences in the use of EHR technology as well as reporting requirements have hindered the alignment between the two programs. It its response, CMS did not comment on whether it is taking other efforts to identify factors that helped or hindered implementation of the Electronic Prescribing Program to help support the ongoing implementation of the EHR Program or if it intends to include consideration of such factors in the integration plan that the agency is required to develop by January 1, 2012.
Recommendation: To help ensure that Electronic Prescribing Program resources are used appropriately, the Administrator of CMS should develop a risk-based strategy to audit a sample of providers who received incentive payments from the Electronic Prescribing Program to help ensure that providers who receive incentive payments meet that program's requirements. A risk-based strategy could, for example, focus on those providers who received larger incentive payments.
Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services
Status: Open
Comments: In written responses to GAO regarding open recommendations received on June 24, 2011, CMS noted that it has not yet adopted a method to audit a sample of providers who have received incentive payments from the Electronic Prescribing Incentive Program, but note that they recognize the need for an audit strategy to ensure that providers receiving incentive payments truly meet the program?s requirements. They note that such a strategy could be incorporated into a program evaluation contract scheduled to be awarded on September 30, 2011.