Niagara Syndrome and the EHR Incentive Program

"Failure to plan is planning to fail."

The first I heard of the The Niagara Syndrome was from Tony Robbins.  The syndrome occurs when one can be metaphorically described as floating down a river and simply going with the flow without too much regard for where the current is heading - only to suddenly find oneself ten feet from the top of Niagara Falls in a boat with no oars and then saying, "Oh, shoot!".

The looming waterfall in my mind is the penalties, or "Medicare payment adjustments", that will begin in 2015 for professionals who are eligible for the Medicare EHR Incentive Program but who have not adopted Certified EHR Technology and achieved Meaningful Use.  Professionals who have already achieved meaningful use for 2013 will not be subject to the 2015 penalty, but must continue to achieve MU to avoid penalties in future years.  It's not yet too late for professionals who are not yet meaningful users, but time is running out quickly.

The carrots are about to turn into sticks.  Although there's been ample publicity about the program, I know that many providers aren't fully aware of the details.

There are some peculiarities in the program that pertain to those EPs that will be entering the Medicare EHR Incentive program in 2014, i.e. achieving meaningful use for the first time.  For these first-timers, in order to avoid the 2015 penalty, they will have to:

• Adopt 2014 Certified EHR Technology
• Achieve Meaningful Use for a 90-day period
• Attest no later than October 1, 2014.

EPs who have done all of this will be eligible for an incentive payment up to $12,000 and will avoid having their Medicare fees "adjusted" in 2015 and 2016.

A slightly different scenario would be where the EP cannot meet the October 1 deadline but instead:

• Adopts 2014 Certified EHR Technology
• Achieves Meaningful Use for a 90-day period by December 31, 2014
• Attests no later than (presumably) February 28, 2015

In this scenario, the EP would be eligible for an incentive payment up to $12,000, would be subject to a 1% Medicare fee schedule adjustment in 2015 (i.e. would get an incentive AND a penalty), but would not be subject to a penalty in 2016.

In both of these scenarios, continuing to be a meaningful user in 2015 and 2016 would make the EP eligible for additional incentive payments of $8,000 and $4,000 respectively, and  would protect the EP from penalties in 2017 and 2018.

In contrast, let's say that the EP does not become a meaningful user in 2014 but does successfully do so in 2015.  In this scenario, the EP would receive no incentives whatsoever.  The EP would also be subject to a 1% Medicare fee schedule adjustment in 2015 and a 2% adjustment in 2016 before getting relief in 2017.

That's a pretty big difference, especially for primary care providers who see a lot of Medicare patients.  My fear is that a significant number of those EPs won't realize that they're about to go over the falls until late in 2014, by which time it will be far too late for anyone to pull them to shore.

Looking ahead to 2014

2014 is almost upon us and promises to be another challenging year for the health care and health information technology industries, with several deadlines and milestones.

From CMS, here are some of the important eHealth milestones:

• January 1, 2014: 
  • Start of Stage 2 for eligible professionals (EPs) beginning their third or fourth year of participation in the Medicare and Medicaid EHR Incentive Programs. Learn more about Stage 2.
  • Final eRx payment adjustment of 2% will be applied during the 2014 calendar year (EPs subject to the payment adjustment will receive 98% of their Medicare Part B PFS amount for covered professional services). For more information, review the eRx Payment Adjustment Fact Sheet and the eRx Updates for 2013 Fact Sheet.

Please note that Medicare EPs in their second year or beyond of demonstrating meaningful use will need to electronically report their CQMs for the full calendar year of 2014 (January 1, 2014 to December 31, 2014). This means providers will submit their CQM data between January 1, 2015 and February 28, 2015.
 

• February 28, 2014:
  • Deadline for EPs to submit their calendar year (CY) 2013 data to receive a Physician Quality Reporting System (PQRS) incentive payment for 2013. It is also the last day for Medicare EPs participating in the Electronic Reporting Pilot to submit quality data to satisfy both PQRS and the CQM requirement of the EHR Incentive Program. Learn more about the PQRS program, and the EHR Incentive Program Electronic Reporting Pilot.
  • Deadline for EPs to register and attest to demonstrating meaningful use for the Medicare EHR Incentive Program to receive an incentive payment for the 2013 reporting year. Medicaid registration and attestation deadlines may differ by state.
• October 1, 2014:
  •  Transition date from ICD-9 to ICD-10 codes for diagnoses and inpatient procedures. Step-by-step CMS resources can help you make sure you’re prepared for the transition.
  • Last day for Medicare EPs to begin their three months of meaningful use in 2014. Medicare EPs who do not achieve meaningful use in 2013 and 2014 will be subject to payment adjustments in 2015 and 2016, respectively.  (Medicare EPs who haven't started meaningful use before 2014 will have one last chance*). Payment adjustments start at 1% and are cumulative for every year that an EP does not participate.

*Note that Medicare EPs who first demonstrate meaningful use in 2014 must demonstrate meaningful use for a 90-day reporting period in 2014 to avoid payment adjustments in 2015. This reporting period must occur in the first 9 months of calendar year 2014, and EPs must attest to meaningful use no later than October 1, 2014, in order to avoid the payment adjustments.

Observers haven't given up hope that the start of meaningful use stage 2 might be delayed, but all that has been announced to date is a delay in the start of stage 3.  It seems even less likely that ICD-10 implementation will be delayed again in spite of ample evidence that the industry isn't ready yet.

As Bette Davis might say, "Fasten your seatbelts.  It's going to be a bumpy night."