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Curbside Consult with Dr. Jayne 4/4/11

April 4, 2011 Dr. Jayne 5 Comments

Surprise, surprise. At least someone in the federal government agrees with the rest of us that there is a conflict between the two CMS programs for e-prescribing. American Medical News reports that the Government Accountability Office has criticized CMS for “failing to align the two programs.”

Practically speaking, this means that some physicians are buying standalone e-prescribing systems (or using free ones) to avoid a Medicare penalty in the future, even though they may be in the process of implementing a certified EHR to take advantage of the Meaningful Use program. The article covers how various groups are lobbying to have this situation remedied. But in response to a reader question, I also emailed the HIStalk Medicine Cabinet for their thoughts. Thank you to all the members of the Medicine Cabinet who responded with your thoughts on this issue.

Dr. Jayne,

You offered to answer questions about the incentive programs, so here is mine. It may sound complex and obscure, but it is actually relevant to a large number of physicians, so please bear with me.

  1. The e-prescribing incentive turns into a penalty in 2012. The penalty is determined by whether or not you use e-prescribing this year. You must use it and report the appropriate code in the first half of 2011 to avoid penalties in 2012-15.
  2. The largest portion of the Meaningful Use incentive is earned for 2011.
  3. According to CMS, you cannot get both of these payments; if you get the eRx incentive, you cannot get MU, and vice versa.

If you use the G-codes in early 2011 to avoid the penalties in later years, do you eliminate your chance of getting the (much larger) Meaningful Use incentive? Or are you better off not using the eRX codes, taking those penalties over the years, but getting the MU money? It seems that we must make a choice.

Can you offer a solution to this dilemma?

Thanks very much,



Respondent 1

On the question at hand, it’s true that you can’t qualify for both incentives in 2011. However, you can delay the launch of your MU odyssey until 2012 and still qualify for the full MU incentive – it will just be shifted out one year. If you want to maximize the incentives across both programs, go for the eRX incentive in 2011 and start MU in 2012. Just make sure that you don’t let your first MU adoption year slip into 2013 — that’s when you’ll start to see decreases in the total MU payment stream.

Another note: due to a bureaucratic snag, if you choose to go for MU in 2011 and give up the eRX incentive, you still have to check the box on the eRX incentive program in order to avoid the penalties in the out years. Such are the wild and wacky ways of federal government programs!

Respondent 2

Since you can’t receive eRX and MU Medicare payments in the program year same year, I would report on eRx in 2011 to avoid later penalties and then start MU reporting in 2012. Ignoring the time value of money issue, one is still eligible for the maximum MU payment by starting in 2012. This approach assumes that all of the money will be available in the out years of the program (I think it will, but if you don’t think the money will be there, it would then make more sense to skip eRx and just pursue the MU dollars).

Just in case there is some confusion, you can get both eRx and Medicaid payments in the same year. It is only Medicare where you must pick.

Respondent 3

This is a perfect example of the left hand not knowing what the right hand will do.

The real crux of all of this is that you have to being willing to see CMS-sponsored patients (Medicare / Medicaid). The issue I have with both these regulations is that most practices cannot even survive financially if they see the required amount of patients that are needed to fulfill criteria to get the incentive payments.

As a pathologist, the e-prescribing and Meaningful Use do not apply. My wife is a psychiatrist and I spend a lot of time with her IT systems. As a solo practitioner, she has simply opted out. But I think if she were participating, the Meaningful Use payments are more money depending on the volume of patients you see.

My guess is that no one will have the volume required. Now don’t get me wrong, there are valuable other reasons to do e-prescribing or an EMR. My wife is using an EMR and will be switching to e-prescribing now that the Controlled Substances Act has allowed it for electronic submission. Before, it didn’t make sense to be doing manual prescribing for controlled psychiatric meds and electronic for others. She is not using either for incentive programs as she doesn’t qualify for either.

The bottom line: physicians should not chase the money, but do what is right for their patients.

Respondent 4

Meaningful Use incentive — total possible $63,750 for EPs (or thereabouts)

eRx incentive — 2% incentive program (2% of the group practice’s total estimated Medicare Part B Physician Fee Schedule). This falls to 99% of PFS in 2012, 98.5% of PFS in 2013, and 98% of PFS in 2014.

I’d make the assumption that both are not available, since that is the supposition, and calculate which provides the greatest return (this does not take account of cost of compliance both in pure monetary terms as well as disruption / effort / resources).

The numbers will depend on how long you think this lasts or applies, but I would assume at least six years (given the MU current timeline payout).

Respondent 5

The maximum incentives for the e-prescribing program were available in the earlier years of the program, 2009 and 2010 (2% of allowed charges). For 2011, the incentive is 1%.

True, you cannot receive e-rx payment concurrently with EHR incentives. But if you decided to participate in the e-prescribing program and collect incentives and not participate in the EHR program until 2012, that’s OK. You just can’t accept incentives from both in the same year (i.e. participate and collect incentives in e-rx program and EHR program in 2011).

Where it has gotten confusing is that while you cannot "double dip," so to speak, by collecting incentives for both at the same time, you are still required by CMS to report the G codes for the e-rx program during the first six months of 2011 just to avoid the penalty for 2012. It is completely permissible to collect EHR incentives in 2011, report the G code for e-rx for the first six months of 2011 to avoid the e-rx 2012 penalty, AND collect incentives for the EHR program for participation in 2011.

The other thing is there is no registration process for the e-prescribing program, but you must register for the EHR program. If you register for the EHR program and report the G code for the e-prescribing, CMS should know that you intend to collect the EHR incentives.

CMS has a FAQ on this. It doesn’t touch 100% on this, but does to some degree.

So there you have it. Providers should make their decisions based on the facts available at this point in time. It’s not clear whether there will be any regulatory, administrative, or legislative remedy to this any time soon. For those of you who are pediatricians seeing greater than 20% Medicaid patients, or other specialties seen greater than 30%, take your Medicaid incentive checks and run! Be glad you don’t have to deal with this silly business and be kind to the rest of us who do.

E-mail Dr. Jayne.

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Currently there are "5 comments" on this Article:

  1. You left out one big, probably the best option:

    — As a provider, getting rid of Medicaid/Medicare, after which the provider doesn’t have to worry about the beaurocracy of the rebate-style-all-or-none MU payments. The provider would save (conservatively) about $60000.00 or more per year, year-after-year without the added burden of reporting and having to take care of the most sickest, poorly paid patients on the planet. When Medicare goes bankrupt in 2017 the provider won’t have to worry about getting stuck with a lousy EHR bought only to make the Feds happy.

    URL on yearly costs: http://www.hcplive.com/mdnglive/articles/PC_Medicare_HIT_mandate

    I won’t have any cash-for-clunkers scheme in my office. Obama and his buddy Glen Tullman can take their eRx and HITECH schemes and try to peddle this unproven, political kickback-based software off elsewhere. In the meantime I’ll vote for the Tea Party- who knows, they might get rid of these “low hanging fruit” programs in the near future among the other $4 trillion that they plan on cuttng.


  2. To correct Respondent #4, the $$ he/she quoted for MU are Medicaid $$, not Medicare $$ (which is up to $44K for EPs).

  3. Wow. I appreciate all the information provided by the respondents; however, I couldn’t help but note that patients weren’t mentioned. Has my greatest fear come true? Has the ARRA and healthcare reform successfully shifted the focus from the patient to the dollar? If the respondents are typical a great deal of thought has been put into how to maximize the dollars. Fine. Is there no thought to maximizing benefit to the patient? The whole idea was to provide incentives to improve patient care…not incentives to improve the incentives. Maybe it’s just me…

  4. You don’t need to “improve” patient care- we already have one of the best healthcare systems in the world. Involving Big Government in any private enterprise will only destroy it.

    Surprised, those “incentives” will soon turn into “sticks” which will be used as a type of tax on already strained physicians who care for the poor and elderly. What doctors are trying to do is figure out the best way to survive this government takeover of the healthcare sector without going totally bankrupt while trying to take care of their patients.

    It will be the patients who will end up footing the bill one way or another, just so that President Obama can provide quid-pro-quo kickbacks to those in the technology sector who have lobbied hard to get HITECH and eRx approved so as to enrich their bottom line.

    You should download my PPT presentation “HIT in the USA 2009” which discusses the various lobbyists from the health technology sector who surround President Obama. URL: http://msofficeemrproject.com/Page3-3.htm

    The only “hope and change” that I see is my hope that the 2012 elections will bring back some sanity back into healthcare, specifically HIT, and that we get a change back to the core principles that used to guide physicians before the intervention of Washington DC political pinheads.


  5. Al, I don’t disagree with anything you’ve said. As you correctly stated, Obama’s interest is driven by dollars, not concern for patient welfare. I’m just concerned that the mess he is creating will cause those of us in the healthcare trenches to lose focus…
    Thanks for your reply.

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