Anyone who knows even a little bit about behavior modification theory intuitively understands that offering rewards and/or punishments is an effective way to encourage people to do what you want them to do. The government clearly understands this principle and has been using incentives and penalties to motivate physicians to participate in its programs—PQRS, ePrescribing, and, most recently, the EHR incentives.
The EHR incentives have already prompted a great deal of EHR activity, but the program is too new to quantify cause and effect yet. A direct correlation between government policy and provider behavior, however, is evidenced by the history of my company’s ePrescribing license purchases, so I thought EMR Straight Talk readers would find the analysis of my company’s experience interesting.
As illustrated above, ePrescribing sales tracked the MIPPA legislation as follows:
2009 was the first year of ePrescribing bonuses, and the requirements (a 50% threshold) made it important to start ePrescribing early in the year. As you can see, this created a huge demand for ePrescribing licenses during the first half of 2009.
Sales continued in late 2009 and early 2010—although at a more moderate rate—as later adopters decided to take advantage of the last year of 2% bonuses and as the easier-to-meet threshold of 25 ePrescribing encounters was introduced.
Imminent penalties caused a spike in sales in the beginning of 2011, when providers first learned that 2012 penalties would be based on ePrescribing activity—or lack thereof—in the first 6 months of 2011.
Another interesting observation that can be made is that, for some providers, penalties are a much more effective behavior modification tool than incentives, regardless of the relative amounts of money at stake. My experience with ePrescribing—illustrated by the 2011 surge in licenses—was that many physicians who had not been persuaded by the 2% bonuses in 2009 and 2010 felt compelled to move ahead when faced with a 1% penalty for 2012. Regardless of whether a particular physician attributes more weight to the carrot or to the stick, the data above—although not unexpected—confirms the effectiveness of the government’s strategy.
While physicians are working feverishly to understand the complexities of meaningful use, their efforts are complicated by the demands of other government incentive programs that have similar goals but different rules. Two of the three cornerstones of ARRA are ePrescribing and reporting on quality measures, yet it is still necessary to comply separately with the regulations of EHR incentives (ARRA’s meaningful use), ePrescribing (MIPPA), and PQRS if physicians wish to maximize—or, in the near future, preserve—practice revenue.
The chart to the right is taken from a 6-page CMS document that addresses the complicated interrelationships among EHR incentives, ePrescribing, and PQRS. For physicians, the challenge goes beyond understanding the potential payments; of greater significance is the administrative burden created by the discrepancies in reporting metrics and reporting periods among the three disparate programs. The following represent just a few of the inconsistencies inherent in the programs:
Under Medicare, physicians cannot receive both an EHR incentive and an ePrescribing (MIPPA) incentive in the same year. They can, however, receive both an EHR incentive and a PQRS incentive in the same year.
Future penalties for failure to demonstrate both meaningful use and PQRS will be additive. Whether cumulative penalties will apply for physicians who are not meaningful users and do not ePrescribe is not addressed in the CMS chart, but the prevailing understanding is that, instead, the harsher of the two penalties will prevail.
Because ePrescribing benchmarks differ, a physician could be deemed a successful ePrescriber under ARRA but not under MIPPA, and vice-versa.
Regardless of whether or not a physician receives incentives under ARRA, he/she must continue to comply with the MIPPA ePrescribing requirements (i.e., G-Coding) to avoid future MIPPA penalties. (Ironically, a physician could demonstrate meaningful use in 2011, receive an EHR incentive, but be penalized 1% under MIPPA in 2012 for failure to report G-Codes—a MIPPA, but not a meaningful use, requirement.)
Although many of the quality measures are common to both meaningful use and PQRS, separate reporting is required. Differences exist in the applicability of thresholds and in the reporting periods.
I am glad to see that the lack of program harmonization is being recognized—and I hope it will be successfully addressed in the next round of rule-making. Recently, the AMA distributed a survey “seeking physicians’ input on rules and regulations that increase their administrative costs and paperwork burden, or that interfere with patient care without a significant benefit to patients and/or the government.” Last week, the Government Accounting Office issued a recommendation to CMS that they eliminate overlapping ePrescribing requirements. Harmonizing the rules will go a long way toward encouraging widespread and successful participation in government programs that are aimed at increasing quality of patient care.