Health plans consider adding "meaningful use" criteria in physician contracts

As the government enters the final stages of defining what it means for physicians to be meaningful users of electronic medical records, it appears that the financial implications for not meeting that definition are likely to affect more than Medicare pay.

Private insurers are latching onto the government's meaningful use definition to bolster their own efforts to promote EMR use and possibly impose their own financial penalties for nonuse among contracted physicians, according to the author of a new study looking at the challenges physicians face with meeting meaningful use.

Because there will be a widely accepted standard for how physicians should use EMRs to gain the most benefit, "the criteria are also almost certain to become default industry standards for using [EMRs] well into the future," according to a report by Jane Metzger, a principal researcher with the Waltham, Mass.-based technology consultant and research arm of the technology firm CSC.

Metzger told American Medical News that she expects insurers to bolster their efforts to encourage EMRs, including tying financial incentives to meaningful use as defined by the federal government.

The Centers for Medicare & Medicaid Services is in the final stages of defining meaningful use, as it takes into consideration feedback made during the public comment period on the rule. The American Medical Association and other medical organizations submitted letters asking for more flexibility and an incremental approach to adoption, rather than the currently proposed standard of adopting all 25 meaningful use criteria at once.

While the exact criteria and timeline for meeting meaningful use might change, there is consensus that the meat of the document, which focuses heavily on interoperability of systems, will remain the same.

Under the government's plan, physician practices could earn up to $44,000 in Medicare incentives, or $64,000 in Medicaid incentives, over five years, starting in 2011, for meeting meaningful use criteria. Those incentives turn to penalties in 2015 if the criteria are not met.

Metzger said many efforts to promote EMR use existed long before the legislation was passed. But many of those efforts were unsuccessful, because everyone had a different opinion of what it meant to be an EMR user.

Estimates on physician use of EMRs have ranged from 9% to 29%, partly because of the varying definitions of "use." In 2007 and 2008, a team of investigators, with assistance from the Dept. of Health and Human Services Office of the National Coordinator for Health Information Technology, tried to solidify those definitions.

The team conducted a national survey of physicians and their use of EMRs. Specific functions were identified that would qualify a system as fully functional. The study found that 4% of physicians had a fully functional EMR and that 13% had a basic system, which wouldn't meet the proposed meaningful use criteria. The survey was published in the July 3, 2008, New England Journal of Medicine.

Metzger's report indicated that only 6% of all physicians could meet meaningful use today. But many more than that use EMRs, she said.

Several insurers have incentive plans for physicians who use information technology, and those are expected to be augmented by the meaningful use criteria.

However, Metzger also said -- although it wasn't included in her report -- that many insurers are now in the process of expanding their EMR initiatives to include penalties for nonuse. She said several plans are writing contract clauses that would require doctors to follow federal meaningful use standards for EMRs.

Robert Zirkelbach, spokesman for America's Health Insurance Plans, said that although he was unaware of any efforts by plans to use contract clauses to enforce or promote meaningful use, he said he has seen how meaningful use has helped advance existing initiatives, such as pay-for-performance incentives for EMR use.

"It's creating more standards. It's giving more incentives for people to participate and use these types of tools," he said.

In 2008, Massachusetts passed a law requiring all physicians to use EMRs by 2015. But many physicians were still apprehensive, afraid to adopt a system that didn't meet their needs, said Alice Coombs, MD, president of the Massachusetts Medical Society.

"Meaningful use is helpful, because now people are looking at EMRs and seeing what's important. Until you get some consensus around the best practices for EMR use and what's the best product, it's hard to get everyone on board," she said.

Blue Cross Blue Shield of Massachusetts invested $50 million in 2004 to form the Massachusetts eHealth Collaborative, a nonprofit aimed at promoting and studying EMR implementations in the state. It started by forming three test communities to develop best practices that could be implemented statewide. The MMS also was involved in the project.

Dr. Coombs said Massachusetts physicians have not yet reported seeing any contract clauses regarding meaningful use -- whether as an incentive for use, or a penalty for nonuse.