MU and the Dialysis Facility: A Tale of Two Cities

Recently I participated in a conversation with a large nephrology practice based in North Carolina. The topic of discussion was meaningful use and the impact of the nephrologist’s encounters within the dialysis facility. The topic is more confusing than it should be, but recently CMS helped clarify the possible permutations and combinations of care delivered by nephrology groups in the dialysis setting. Today let’s spend some time clearing up the confusion surrounding this important topic.

 

The 50% Rule

 

The confusion has its origin, in my view, with our old friend the 50% Rule. In an effort not to penalize primary care providers who see a few patients in a satellite office not equipped with certified EHR technology (CEHRT), the architects of the meaningful use framework crafted an eligibility requirement that goes something like this:

 

In order to participate in the meaningful use program, at least half of the provider’s outpatient encounters during the reporting period must occur in a location or locations equipped with CEHRT.

 

The phrase “outpatient encounters” specifically refers to all encounters that use a place of service code other than 21 (inpatient-hospital) or 23 (emergency room-hospital). Notice that dialysis facilities and vascular access centers are included in this calculation, and therein lies the rub. Many nephrologists have more patient encounters in the dialysis facility than they do in their office, which creates an interesting challenge with respect to the meaningful use program.

 

As you may recall dialysis facilities and vascular access centers, along with nursing homes and a variety of other venues of care, share the dubious distinction of NOT being included in the meaningful use program. Only hospitals and “eligible professionals” like doctors, dentists, podiatrists, optometrists and chiropractors can participate in the program. In fact, the EHR certification paths are restricted to the inpatient path (hospitals) and the ambulatory path (provider offices).

 

The First City (where the Dialysis Information System is not certified)

 

I’m sure some of you were compelled to read the Dickens’ classic in school, but the two cities I am blogging about today are not Paris and London. Instead, I have in mind two settings, one a reality and one largely fictitious, at least as I type today. In the first city, the information system resident within the dialysis facility (let’s call it the dialysis information system or DIS for short) is not certified for meaningful use. Ignoring the complexity a vascular access practice brings to the table, there are two groups of nephrologists living in this city:

1. Those for whom more than half of their outpatient encounters occur in the office, and
2. Those for whom more than half of their outpatient encounters occur in the dialysis facility.

The path for the nephrologists in group 1 is the simplest. More than half of their outpatient encounters occur in the office, so they are eligible to participate in the program and when they submit their attestation to CMS, they are only obliged to report on their office-based encounters. Per CMS, providers in this bucket have the option of reporting those encounters that occurred outside of the reach of the certified EHR, but unless you need help exceeding performance targets within the meaningful use framework, nephrologists in this group will have a hard time justifying the extra work required to capture meaningful use data for the patients they see in the dialysis facility.

 

Group 2 is a little more complicated, largely because these nephrologists have a choice to make. If more than half of your outpatient encounters during the reporting period occur in a location(s) not equipped with CEHRT and the decision to deploy CEHRT is outside your control, you can file for one of the new CMS hardship exceptions and basically opt out of the program. Note that you will not collect the declining incentive, but more importantly you will avoid the looming penalty. The other choice you might make is to “access” your office-based CEHRT from within the dialysis facility, duplicate the data entry necessary to meet the MU objectives, and thereby meet the 50% eligibility requirement. In this circumstance, when you submit your attestation to CMS you would include those dialysis encounters along with your office-based encounters. I have been writing about group 2 for quite some time and was delighted to see this perspective reaffirmed during a recent CMS National Provider call. For those interested in taking a deeper dive, check out the transcript  for that call, specifically the Q & A on page 30 between Justin Williams and Travis Broome of CMS.

 

The Second City (where the DIS is certified)

 

This city is largely a work of fiction at this point in time, but I think it is worth considering the perspective of a nephrologist living in such a city. As in the First City, there are again two groups of nephrologists living here:

1. Those for whom more than half of their outpatient encounters occur in the office, and
2. Those for whom more than half of their outpatient encounters occur in the dialysis facility.

Notice what has changed however. The fact that the DIS is certified for meaningful use removes the options available in the first city, and life is now tougher for the nephrologist in several respects. Nephrologists living in the second city are now compelled to participate in the meaningful use program (not the end of the world), but as opposed to simply reporting the meaningful use data collected in their office-based EHR, they must also report the meaningful use data captured in the certified DIS. In effect, when a nephrologist living in the second city logs into the CMS portal to complete their meaningful use attestation, they must “combine the fractions” so to speak. More specifically, suppose I had 500 unique patient encounters in the office, and of those 450 had a problem on their problem list. Further, suppose I had 100 unique patient encounters in the dialysis unit, and 90 of those had a problem on their problem list. As a second city nephrologist, when attesting to CMS regarding meaningful use, for the Stage 1 problem list objective I would report 500 + 100 or 600 patients in the denominator and 450 + 90 or 540 in the numerator. I would then go through this exercise for each of the meaningful use objectives. If I am seeing patients in the office and in two dialysis facilities, I would combine three fractions for each measure. I think you see where this is going.

 

In addition to the heavy lifting regarding reporting objectives in the second city, let’s not forget the excitement generated by a meaningful use audit. As many as 10% of the eligible professionals participating in the meaningful use program will be subject to an audit. The audit basically requires the provider to produce documentation substantiating the data submitted to CMS. Gathering this information from your office-based EHR is one thing, rounding it up from your dialysis facilities simply adds to the burden placed on the second city nephrologist’s shoulders.

 

One final point, remember the vast majority of nephrologists are taking the “Medicare path” to meaningful use. The incentive in this path is time-stamped, with most of the financial incentive recognized in years 1–3. This program is very quickly changing from one in which the provider is chasing a financial incentive to one in which they will be running from a penalty.

 

In which city would you live?

 

Life will clearly be tougher for the nephrologists in the second city where the DIS is certified for meaningful use. One might argue the extra work would be worth it if patient care improved, but as we will discuss in the weeks ahead, there is no evidence to support the hypothesis that a certified DIS will lead to better care for our patients with ESRD. Do you have thoughts about this Tale of Two Cities? Drop us a comment and join the conversation.