oversight

Electronic Health Records: Number and Characteristics of Providers Awarded Medicare Incentive Payments for 2011

Published by the Government Accountability Office on 2012-07-26.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

United States Government Accountability Office
Washington, DC 20548



           July 26, 2012

           Congressional Committees

           Subject: Electronic Health Records: Number and Characteristics of Providers
                    Awarded Medicare Incentive Payments for 2011

           Widespread use of health information technology, such as electronic health records
           (EHR), has the potential to improve the quality of care patients receive and reduce
           health care costs. However, studies have estimated that as of 2009, 78 percent of
           office-based physicians and 91 percent of hospitals had not adopted EHRs. 1 Among
           other things, the Health Information Technology for Economic and Clinical Health
           (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of
           2009 (Recovery Act) 2 provided funding for various activities intended to promote the
           adoption and meaningful use of certified EHR technology. 3 The largest of these
           activities, in terms of potential federal expenditures, are the Medicare and Medicaid
           EHR programs. 4 Starting in 2011, these programs have provided incentive payments
           for certain providers, including both hospitals and health care professionals such as
           physicians and dentists, that demonstrate meaningful use of certified EHR
           technology and meet other program requirements established by the Centers for
           Medicare & Medicaid Services (CMS). Beginning in 2015, the Medicare EHR

           1
            See C. J. Hsiao, E. Hing, T. C. Socey, and B. Cai, “Electronic Medical Record/Electronic Health
           Record Systems of Office-Based Physicians: United States, 2009 and Preliminary 2010 State
           Estimates,” National Center for Health Statistics Health E-stat (2010); and A. K. Jha, C. M.
           DesRoches, P. D. Kralovec, and M. S. Joshi, “A Progress Report on Electronic Health Records In
           U.S. Hospitals,” Health Affairs, no.10 (2010):1951-1957.
           2
            The HITECH Act was enacted as title XIII of division A and title IV of division B of the Recovery Act.
           Pub. L. No. 111-5, div. A, tit. XIII, 123 Stat. 115, 226-279 and div. B, tit. IV, 123 Stat. 115, 467-496
           (2009).
           3
            Congress defined “meaningful use” in this context to reflect that the user of health information
           technology demonstrates to the satisfaction of the Secretary of the Department of Health and Human
           Services (HHS) that the technology is certified and being used in a meaningful manner, that the
           technology is connected in a manner that provides for the electronic exchange of health information
           to improve the quality of health care, and that such information is submitted in a form and manner
           specified by the Secretary. See Pub. L. No. 111-5, § 4101(a) 123 Stat. 467-472. To be certified, EHR
           technology must meet certain criteria established by HHS’s Office of the National Coordinator for
           Health Information Technology that describe minimum related performance standards and
           implementation specifications.
           4
            See Pub. L. No. 111-5, §§ 4101-4201, 123 Stat. 467-494. Medicare is a federal program financing
           health care for individuals aged 65 and older, certain disabled individuals, and individuals with end-
           stage renal disease. In 2010, Medicare covered 47 million beneficiaries. Medicaid is a federal-state
           program financing health care for certain low-income individuals. In fiscal year 2009, Medicaid
           covered over 65 million beneficiaries.



           Page 1                                                     GAO-12-778R Electronic Health Records
program is generally required to begin applying a payment adjustment—that is, a
payment reduction—for Medicare providers that do not demonstrate meaningful use.
The Congressional Budget Office estimated total spending for the Medicare and
Medicaid EHR programs to be $30 billion from 2011 through 2019, of which
spending for the Medicare EHR program accounts for more than half—$17.7 billion.
This report focuses on the Medicare EHR program.

Provisions in the HITECH Act defined the types of hospitals and professionals that
may be eligible to receive Medicare EHR incentive payments. 5 Eligible hospitals
include acute care hospitals and critical access hospitals. 6 Eligible professionals
include doctors of medicine, dental medicine or surgery, optometry, osteopathy, and
podiatric medicine, and chiropractors. 7 During 2011, the first year of the program,
2,802 hospitals and 141,649 professionals registered for the Medicare EHR
program, which is a necessary first step to participate in the program. 8 Hospitals can
receive Medicare EHR incentive payments for up to 4 years, and professionals can
receive such payments for up to 5 years. 9 The incentive payment amounts are
determined as follows:

•   For acute care hospitals, the incentive payment amount for any given year is
    generally based on the hospital’s annual discharges and Medicare share, which
    is the percentage of the hospital’s inpatient bed days that were attributable to
    Medicare patients. Theoretically, $6,370,400 is the maximum possible Medicare
    EHR incentive payment for an acute care hospital for 2011. This assumes that all
    patients served were Medicare patients and that the hospital had at least 23,001
    discharges, which is the highest number of discharges CMS includes in the
    calculation of Medicare EHR incentive payments.




5
 The HITECH Act created incentive programs for Medicare fee-for-service, Medicare Advantage, and
Medicaid. Under the Medicare Advantage EHR program, Medicare Advantage Organizations
(MAO)—private companies that provide Medicare health insurance coverage to beneficiaries for
hospital, physician, and other services—receive incentive payments for certain affiliated professionals
and hospitals that meet program requirements. Pub. L. No. 111-5, §§ 4101(c), 4102(c) 123 Stat. 473-
476, 484-486. CMS requires MAOs to receive payment through their affiliated hospitals, which we
include as hospital payments in this report. MAOs directly receive Medicare EHR incentive payments
for their affiliated professionals that are based on services provided to Medicare Advantage plan
enrollees. In this report, we refer to the incentive programs for Medicare fee-for-service and Medicare
Advantage collectively as the Medicare EHR program.
6
 Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are
paid under the inpatient prospective payment system in the 50 states and the District of Columbia,
including those affiliated with a qualifying MAO.
7
 Professionals must practice in the 50 states, the District of Columbia, or a U.S. insular area to be
eligible for the Medicare EHR program.
8
 For hospitals, see CMS, “Medicare and Medicaid EHR Incentive Program Payment and Registration
Report, November 2011.” For professionals, see CMS, “Medicare and Medicaid EHR Incentive
Program Payment and Registration Report, February 2012.”
9
 In order to maximize the total amount of Medicare EHR incentive payments that could be awarded,
acute care hospitals must begin participating in the program by the 2013 program year, and critical
access hospitals and professionals must begin participating by the 2012 program year.



Page 2                                                     GAO-12-778R Electronic Health Records
•     For critical access hospitals, the incentive payment amount is generally based on
      the hospital’s Medicare share as well as reasonable costs incurred for the
      purchase of depreciable assets necessary to administer certified EHR
      technology, such as computers and associated hardware and software. CMS has
      not established a maximum incentive payment amount for these hospitals.

•     For professionals, the amount of incentive payment in any given year is generally
      based on the professional’s (1) Medicare Part B charges or (2) revenue for
      services provided to Medicare Advantage plan enrollees of a qualifying Medicare
      Advantage Organization (MAO), subject to an annual limit. 10 For most
      professionals, the amount of the incentive payment for 2011 could not exceed
      $18,000. For professionals who predominately furnish services in geographic
      areas designated as a health professional shortage area, the amount of the
      incentive payment for 2011 generally could not exceed $19,800. 11

The HITECH Act requires us to report on, among other things, the impact of its
provisions on adoption of EHRs by providers. 12 In response to this requirement, in
April 2012 we reported on CMS’s efforts to oversee the Medicare EHR program
during its first year as well as challenges encountered by providers and strategies
they used to participate in the program. 13 We recommended that CMS take steps to
enhance its processes to verify that providers met the requirements to receive
incentive payments. On behalf of CMS, the Department of Health and Human
Services agreed with most of our recommendations.

Concerns have been raised that various factors, such as location in urban or rural
areas or the size of hospitals and professional practices, may affect the extent to
which different providers will respond to the provisions of the HITECH Act that aim to
encourage the meaningful use of EHR technology. Identifying the number and
characteristics of providers that participated during the first year of the Medicare
EHR program can provide important information on whether certain types of
providers were more likely than others to participate. This information could also
provide an early indication of the types of providers that may be more likely to
receive payment reductions in future years of the program. As discussed with the
committees of jurisdiction, in this report we provide information on providers that
were awarded Medicare EHR incentive payments for 2011, the first year of the
program. We have ongoing work on the Medicaid EHR program and will issue a
future report that will provide information on providers awarded incentive payments
for the first year of that program, such as the number of award recipients and their
characteristics.

10
 Medicare Part B covers hospital outpatient, physician, and other services for persons aged 65 and
over, certain individuals with disabilities, and individuals with end-stage renal disease.
11
  The maximum incentive payment that could be awarded to an MAO on behalf of an eligible
professional was $18,000.
12
    Pub. L. No. 111-5, § 13424(e), 123 Stat. 278-279.
13
  See GAO, Electronic Health Records: First Year of CMS’s Incentive Programs Shows Opportunities
to Improve Processes to Verify Providers Met Requirements, GAO-12-481 (Washington, D.C.:
Apr. 30, 2012). In our April 2012 report, we analyzed partial-year data that Medicare providers
reported to CMS to demonstrate that they meaningfully used their certified EHR technology.



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To provide information on providers—that is, hospitals and professionals—awarded
Medicare EHR incentive payments for 2011, we analyzed data related to the 2011
program year that CMS collected from January 3, 2011, through April 2, 2012, as
well as data from CMS and other government and private sources on provider
characteristics. 14 We used these data to

•    determine the number of providers that were awarded a Medicare EHR incentive
     payment;

•    estimate the percentage of eligible providers that were awarded a Medicare EHR
     incentive payment;

•    determine the amount of Medicare EHR incentive payments awarded to
     providers; and

•    examine the characteristics of providers that were awarded Medicare EHR
     incentive payments.

To determine the number of providers that were awarded a Medicare EHR incentive
payment for 2011, we counted the number of providers that had an incentive
payment disbursed to them or had an incentive payment that was approved and
being processed by CMS, but had not yet been disbursed. To estimate the
percentage of eligible providers awarded a Medicare EHR incentive payment for
2011, we divided the number of providers awarded an incentive payment by the total
number of eligible providers, that is, providers that were eligible for the Medicare
EHR program, regardless of whether they were awarded an incentive payment. To
determine the total amount of Medicare EHR incentive payments awarded to
providers, we summed the Medicare EHR incentive payments awarded to providers.
We also examined the distribution of the Medicare incentive payments across
providers. Specifically, for hospitals, we determined the minimum, maximum, and
median Medicare EHR incentive payment amount. For professionals, we determined
the percentage who were awarded an incentive payment of various amounts.

To examine the characteristics of providers awarded Medicare EHR incentive
payments for 2011, we analyzed data from CMS, the Health Resources and
Services Administration, the Office of the National Coordinator for Health Information
Technology (ONC), and Surescripts. 15 As part of our analysis, we compared the
characteristics of providers that were awarded Medicare EHR incentive payments for
2011 to those of other providers that were eligible for the Medicare EHR program but
were not awarded a payment for that year. For hospitals, these characteristics


14
  Our analysis includes participating hospitals that were affiliated with MAOs, but does not, in general,
include data on participating professionals who were affiliated with MAOs. We included professionals
who were affiliated with an MAO if they qualified to receive the maximum incentive payment amount
based on Medicare Part B charges, which are outside the Medicare Advantage plan. At the time of
our analysis, CMS had not yet determined which professionals would receive incentive payments
through an MAO.
15
 Surescripts operates the nation’s largest electronic prescription network and collects data on,
among other things, the number of electronic prescriptions sent to pharmacies in its network.



Page 4                                                    GAO-12-778R Electronic Health Records
included, for example, whether the hospital was classified as an acute care hospital
or critical access hospital and whether the hospital was a member of a chain. For
professionals, these characteristics included whether the professional had previously
participated in CMS’s electronic prescribing program 16 or signed an agreement to
receive technical assistance from a Regional Extension Center. 17 To ensure the
reliability of the various data we analyzed, we interviewed officials from CMS, ONC,
and Surescripts; reviewed relevant documentation; and conducted electronic testing
to identify missing data and obvious errors. On the basis of these activities, we
determined that the data we analyzed were sufficiently reliable for our analysis.
Enclosure I provides additional information on our scope and methodology.

We conducted this performance audit from January 2012 to July 2012 in accordance
with generally accepted government auditing standards. Those standards require
that we plan and perform the audit to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.

In summary, 761 hospitals and 56,585 professionals were awarded a total of
approximately $2.3 billion in Medicare EHR incentive payments for 2011. These
761 hospitals represented 16 percent of the estimated 4,855 eligible hospitals, and
were awarded $1.3 billion in Medicare EHR incentive payments for 2011. While the
amount of EHR incentive payments awarded to each hospital ranged from $22,300
to $4.4 million, the median payment amount was $1.7 million. About 61 percent of
hospitals accounted for about 80 percent of the total amount of incentive payments
awarded to hospitals. Among hospitals awarded an incentive payment for 2011, we
found that

•    the largest proportion (44 percent) were located in the South, and the lowest
     proportion (12 percent) were located in the Northeast;

•    about two-thirds (67 percent) were in urban areas;

•    more than four-fifths (86 percent) were acute care hospitals; and

•    almost half (46 percent) were in the top third of hospitals in terms of number of
     beds.


16
  The electronic prescribing program, which was established by the Medicare Improvements for
Patients and Providers Act of 2008, provides incentive payments from 2009 through 2013 to
physicians and certain other Medicare professionals, such as physician assistants and nurse
practitioners, who have prescribing authority and who adopt and use systems that meet CMS’s
definition of a qualified electronic prescribing system. Pub. L. No. 110-275, § 132(a), 122 Stat. 2492,
2527. From 2012 through 2014, the program may apply a payment adjustment, or penalty, on the
program’s eligible providers that do not adopt and use such systems. See GAO, Electronic
Prescribing: CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the
Use of Health Information Technology, GAO-11-159 (Washington, D.C.: Feb. 17, 2011).
17
 The regional extension center program was established by the HITECH Act and is administered by
ONC to help some types of providers, such as those located in rural areas, to participate in CMS’s
EHR programs.



Page 5                                                   GAO-12-778R Electronic Health Records
Hospitals with certain characteristics were more likely to have been awarded a
Medicare EHR incentive payment for 2011. For example, acute care hospitals were
more than 2 times more likely than critical access hospitals to have been awarded
an incentive payment. Hospitals in the top third in terms of numbers of beds were
2.4 times more likely than hospitals in the bottom third to have been awarded an
incentive payment. Further, nonprofit and for-profit hospitals were 1.1 and 1.5 times
more likely than government-owned hospitals, respectively, to have been awarded
an incentive payment.

The 56,585 professionals who were awarded a Medicare EHR incentive payment for
2011 represented about 9 percent of the estimated 600,172 professionals eligible for
the program, and were awarded a total of about $967 million in incentive payments.
Among professionals awarded an incentive payment for 2011, we found that

•   the largest proportion (32 percent) were located in the South, and the lowest
    proportion (17 percent) were located in the West;

•   a significant majority (89 percent) were in urban areas;

•   half (50 percent) were specialty practice physicians and over one-third
    (38 percent) were general practice physicians;

•   nearly three-quarters (71 percent) did not previously participate in CMS’s
    incentive program for electronic prescribing; and

•   about half were in the top third in terms of 2010 Medicare Part B charges
    (46 percent) and 2010 Medicare Part B patient encounters (51 percent).

Professionals with certain characteristics were more likely to have been awarded a
Medicare EHR incentive payment for 2011. For example, general practice
physicians were 1.8 times more likely than specialty practice physicians to have
been awarded an incentive payment. Professionals who had previously participated
in CMS’s electronic prescribing program were almost 4 times more likely to have
been awarded an incentive payment than those who had not participated in the
electronic prescribing program, and professionals who had signed an agreement to
receive technical assistance from a Regional Extension Center were more than
twice as likely to have been awarded an incentive payment. Professionals in the top
third in terms of 2010 Medicare Part B charges or number of 2010 Medicare Part B
encounters were more than 3 times more likely to have been awarded an incentive
payment compared to those in the bottom third for charges or number of encounters.

See enclosure II for more information on the characteristics of hospitals that were
awarded a Medicare EHR incentive payment for 2011. See enclosure III for more
information on the characteristics of professionals who were awarded a Medicare
EHR incentive payment for 2011.




Page 6                                           GAO-12-778R Electronic Health Records
We provided a draft of this report to the Department of Health and Human Services
for comment. In its written comments, reproduced in enclosure IV, the department
stated that our analysis was informative and that it will use the information to
enhance its outreach and education efforts related to the EHR programs. The
department also suggested that GAO’s future work in this area consider the impact
of other federal programs on providers’ participation in the EHR programs.

                                      –––––

We are sending copies of this report to the Secretary of Health and Human Services,
the Administrator of CMS, the National Coordinator for Health Information
Technology, and other interested parties. In addition, the report will be available at
no charge on GAO’s website at http://www.gao.gov. If you or your staffs have any
questions about this report, please contact me at (202) 512-7114 or at
kohnl@gao.gov. Contact points for our Office of Congressional Relations and Office
of Public Affairs can be found on the last page of this report. Major contributors to
this report were E. Anne Laffoon, Assistant Director; Julianne Flowers; Krister
Friday; Melanie Krause; Shannon Legeer; Monica Perez-Nelson; and Eric Peterson.




Linda T. Kohn
Director, Health Care
Enclosures – 4




Page 7                                          GAO-12-778R Electronic Health Records
List of Committees

The Honorable Max Baucus
Chairman
The Honorable Orrin G. Hatch
Ranking Member
Committee on Finance
United States Senate

The Honorable Tom Harkin
Chairman
The Honorable Michael B. Enzi
Ranking Member
Committee on Health, Education, Labor, and Pensions
United States Senate

The Honorable Fred Upton
Chairman
The Honorable Henry A. Waxman
Ranking Member
Committee on Energy and Commerce
House of Representatives

The Honorable Dave Camp
Chairman
The Honorable Sander M. Levin
Ranking Member
Committee on Ways and Means
House of Representatives




Page 8                                      GAO-12-778R Electronic Health Records
Enclosure I

                                    Scope and Methodology

This enclosure provides additional details regarding our analysis of data from the
Centers for Medicare & Medicaid Services (CMS) and other government and private
sources to (a) determine the number of providers that were awarded a Medicare
electronic health record (EHR) incentive payment; (b) estimate the percentage of
eligible providers 1 that were awarded a Medicare EHR incentive payment;
(c) determine the amount of Medicare EHR incentive payments awarded to
providers; and (d) examine the characteristics of providers that were awarded
Medicare EHR incentive payments.

Number of providers that were awarded a Medicare EHR incentive payment. To
determine the number of providers that were awarded an incentive payment, we
analyzed data on providers that were awarded Medicare EHR incentive payments
for 2011 from CMS’s National Level Repository. 2 We analyzed data related to the
2011 program year that CMS collected from January 3, 2011, through April 2, 2012.
As a result, we generally included full-year information in our analysis, since the first
program year for hospitals ended on November 30, 2011, and the first program year
for professionals ended on February 29, 2012. 3 Specifically, we counted the number
of providers that had an incentive payment disbursed to them or whose payment
was approved and being processed by CMS. 4

Estimate of the percentage of eligible providers that were awarded a Medicare
EHR incentive payment. To estimate the percentage of providers that were
awarded an incentive payment, we divided the number of providers that were
awarded an incentive payment by the total number of eligible providers, that is,
providers that were eligible for the Medicare EHR program, regardless of whether
they were awarded an incentive payment. We identified eligible hospitals as those
that fit the following three criteria: (a) were acute care hospitals, including those that
were affiliated with a Medicare Advantage Organization (MAO), or critical access

1
 We use the term eligible providers to refer to hospitals and professionals that were generally eligible
for the Medicare EHR program, regardless of whether they were awarded a Medicare EHR incentive
payment for 2011, as described in greater detail later in this enclosure.
2
 The National Level Repository is a database that contains information on providers pertaining to the
Medicare EHR program, including information on providers that are registered for the incentive
program, whether those providers have met program requirements to receive an incentive payment,
and the amount of incentive payments, if applicable. The National Level Repository also contains
some information on providers pertaining to the Medicaid EHR program, which we generally did not
include in our analysis.
3
 Due to various reasons, including the time needed to process providers’ payments, the total number
of providers that received Medicare EHR incentive payments for 2011 and the total amount of
incentive payments awarded may increase.
4
 Our analysis includes participating hospitals that were affiliated with Medicare Advantage
Organizations (MAO), but does not, in general, include data on participating professionals who were
affiliated with MAOs. We included professionals who were affiliated with an MAO only if they qualified
to receive the maximum incentive payment amount based on Medicare Part B charges, which are
outside the Medicare Advantage plan. At the time of our analysis, CMS had not yet determined which
professionals would receive incentive payments through an MAO.



Page 9                                                     GAO-12-778R Electronic Health Records
Enclosure I

hospitals; (b) were located in one of the 50 states or the District of Columbia; and
(c) were not terminated from participating in the Medicare program on or before
January 2, 2011. 5 We identified eligible professionals as those that fit the following
three criteria: (a) have specialty types that are eligible for the Medicare EHR
program, which include all medical doctor/doctor of osteopathic medicine specialties,
chiropractors, doctors of dental medicine or surgery, podiatrists, and optometrists;
(b) were not hospital-based professionals; 6 and (c) had greater than $0 in Medicare
Part B charges in 2010. 7

Amount of Medicare EHR incentive payments awarded to providers. We
determined the total amount of the incentive payments that were awarded to
providers by summing the Medicare EHR incentive payments that had been
disbursed or were approved and being processed by CMS. We also examined the
distribution of the Medicare incentive payments across providers. Specifically, for
hospitals, we determined the minimum, 25th percentile, median, 75th percentile, and
maximum Medicare EHR incentive payment amount. For professionals, we
determined the percentage who were awarded an incentive payment amount of
(a) $18,000, which was the maximum Medicare EHR incentive payment amount for
most professionals, (b) greater than $18,000, but less than or equal to $19,800, and
(c) less than $18,000. 8

Characteristics of providers that were awarded Medicare EHR incentive
payments. To examine the characteristics of providers that were awarded Medicare
EHR incentive payments for 2011, we analyzed data on provider characteristics from
CMS, the Health Resources and Services Administration, the Office of the National
Coordinator for Health Information Technology (ONC), and Surescripts. 9 (See
table 1.) Each characteristic is divided into two or more categories. For example, the
characteristic “geographic region” is divided into four categories—Midwest,
Northeast, South, and West regions. As part of this analysis, we also compared the

5
 Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are
paid under the inpatient prospective payment system. Hospitals that are affiliated with an MAO are
hospitals described in Section 1886(d) of the Social Security Act, which are under common corporate
governance with a qualifying MAO and for which at least two-thirds of their discharges are of
individuals enrolled under Medicare Advantage plans. 42 C.F.R. § 495.200.
6
 CMS defines hospital-based professionals as those who furnish 90 percent or more of their services
in either an inpatient or an emergency department of a hospital. We determined whether
professionals were hospital-based by using an electronic data file provided by CMS that indicated for
specific professionals whether 90 percent or more of their Medicare services in 2010 were provided in
an inpatient or emergency department of a hospital.
7
 Medicare Part B charges refers to “allowed charges” set by Medicare that determine the amount of
payments received by professionals for physician, outpatient hospital, home health care, and certain
other services.
8
 The maximum incentive payment for 2011 that could be awarded to professionals practicing in a
health professional shortage area was generally $19,800. Health professional shortage areas are
areas designated by the Health Resources and Services Administration as having shortages of
primary medical care, dental, or mental health providers.
9
 Surescripts operates the nation’s largest electronic prescription network and collects data on, among
other things, the number of electronic prescriptions sent to pharmacies in its network.



Page 10                                                   GAO-12-778R Electronic Health Records
Enclosure I

characteristics of providers that were awarded a Medicare EHR incentive payment to
those of eligible providers that were not awarded such payments. To do so, we
calculated relative risk ratios that indicate how much more likely a provider in each
category was to have been awarded an EHR incentive payment than a provider in
the category that was least likely to have been awarded a payment.

Table 1: Data Sources Analyzed to Examine Characteristics of Eligible Providers

                                                                                                  Date of extract,
    Agency or entity              Data source                                                     download, or release
    CMS                           National Level Repository                                       April 2012
                                  2010 Medicare Part B claims                                     January – December 2010
                                  National Plan and Provider Enumeration System Data              February 2012
                                                     a
                                  Dissemination File
                                                                                              a
                                  Provider Enrollment, Chain, and Ownership System                February 2012
                                  Provider of Services File                                       April 2012
                                  Online Survey, Certification, and Reporting System              May 2011
                                  Fiscal Intermediary Standard System                             December 2011
                                  Integrated Data Repository                                      December 2010
                                  2011 primary care health professional shortage areas            November 2010
                                  2010 recipients of incentive payments from CMS’s                July 2011
                                  electronic prescribing program
                                                        b
    Health Resources and          Area Resource File                                              August 2010
    Services Administration
    Office of the National        Regional Extension Center Customer Relationship                 March 2012
                                                                 c
    Coordinator for Health        Management System extract file
    Information Technology                                                                d
                                  List of zip codes serviced by a Beacon Community                March 2012
    Surescripts                   Extract file containing county-level information on             January – December 2011
                                  electronic prescription transactions and prescribers
Source: GAO.
a
    Data contained in this data source are generally self-reported by providers to CMS.
b
 Although the Area Resource File is typically released annually, at the time of our analysis, the 2010-2011 Area Resource File
had not yet been made publicly available.
c
 The Regional Extension Center program was established by the Health Information Technology for Economic and Clinical
Health Act and is administered by the Office of the National Coordinator for Health Information Technology to help some types
of providers, such as those located in rural areas, to participate in CMS’s EHR programs.
d
 The Office of the National Coordinator for Health Information Technology provided funding to support 17 Beacon Communities
to build and strengthen their health information technology infrastructure and exchange capabilities. These communities were
selected for various reasons, including the progress they had already made in adopting EHRs. The 17 Beacon Communities
focus on specific and measurable improvement goals in three areas for health systems improvement—quality, cost-efficiency,
and population health—to demonstrate the ability of health information technology to affect local health care systems.




Page 11                                                                    GAO-12-778R Electronic Health Records
Enclosure I

Using the data obtained from the sources listed in table 1, we examined the
following provider characteristics:

•    Regional characteristics. We analyzed data on the following regional
     characteristics: 10

     •   Geographic region. We used the Health Resources and Services
         Administration’s Area Resource File to identify the U.S. census region—
         Midwest, Northeast, South, or West—where providers were located or
         practiced. 11

     •   Location. We used the Health Resources and Services Administration’s Area
         Resource File to determine whether providers were located in a metropolitan
         area—an area that has at least one urbanized area of 50,000 people. We
         then categorized providers located in metropolitan areas as being located in
         urban areas and providers that were not as being located in rural areas. 12

     •   Average county volume of electronic prescribing based on transactions per
         professional who submits electronic prescriptions. We used data from
         Surescripts to calculate, for each county during 2011, the average number of
         electronic prescriptions submitted per month from an ambulatory care setting
         by each professional who submitted electronic prescriptions. Using these
         aggregated data, we created three categories: (a) low—less than or equal to
         the 33.3rd percentile, (b) middle—greater than the 33.3rd percentile but less
         than the 66.7th percentile, and (c) high—greater than the 66.7th percentile.




10
  In most cases, in order to link the information from these files to individual providers, we obtained
zip codes for hospital locations from CMS’s Provider of Services file and zip codes for professional
practice locations from CMS’s National Plan and Provider Enumeration System and CMS’s Provider
Enrollment, Chain, and Ownership System. Then, with the assistance of a zip code to Federal
Information Processing Standard code crosswalk file we obtained from CMS, we were able to
determine the counties in which hospitals were located and professionals practiced. We were able to
match hospital zip codes to the crosswalk for all hospitals in our analysis. However, we were unable
to match professional practice zip codes to the crosswalk for 207 professionals (less than 1 percent).
Consequently, we generally excluded these 207 professionals from our analysis of regional
characteristics, except for our analysis of geographic region. To analyze information on geographic
region, we were able to use state information rather than zip code information.
11
  Information on U.S. census region was available for all eligible hospitals. We excluded four
professionals (less than 1 percent) from our analysis of geographic region due to missing data for the
practice state.
12
  Information on whether providers were located in urban or rural areas was missing for two hospitals
(less than 1 percent). In addition to the 207 professionals for whom we could not match zip codes
which are, therefore, excluded from our analysis of all regional characteristics (except geographic
region), we excluded an additional 8 professionals (less than 1 percent) from our analysis of location
due to missing data.



Page 12                                                    GAO-12-778R Electronic Health Records
Enclosure I

      •   Whether a provider is located in a county with a Beacon Community. We
          used data from ONC to categorize providers as either being located in a
          Beacon Community or not. 13

      •   Whether a professional practices in a health professional shortage area. We
          used the list from CMS that identifies the zip codes that were designated as
          primary care health professional shortage areas for bonus payments in 2011
          to categorize providers as either being located in a health professional
          shortage area or not. 14

•     Hospital type. We analyzed data on the following categorizations of hospital type:

      •   Hospital classification. We determined whether hospitals were classified as
          acute care hospitals, including hospitals that were affiliated with a MAO, or
          critical access hospitals by using data from CMS’s Provider of Services file. 15

      •   Major teaching hospital. We determined whether or not hospitals were listed
          as having a major affiliation with a medical school in CMS’s Provider of
          Services file. 16

      •   Ownership type. We primarily used data on ownership type from CMS’s
          Provider of Services file to create three categories of ownership: (a) for-profit
          by combining private for-profit and physician ownership, (b) nonprofit by
          combining church and private not-for-profit, and (c) government-owned by
          combining four government designations (federal, state, local, and hospital
          district or authority) and tribal. In instances in which ownership type was listed
          as “other” in the Provider of Services file, we obtained information needed to
          classify hospitals as for-profit, nonprofit, or government-owned from another
          CMS data source—the Online Survey, Certification, and Reporting System. 17

      •   Chain membership. We categorized hospitals as being a member of a chain if
          the hospital has a chain home office listed in CMS’s Provider Enrollment,
          Chain, and Ownership System. All other hospitals with a record in CMS’s



13
  ONC provided funding to support 17 Beacon Communities to build and strengthen their health
information technology infrastructure and exchange capabilities. These communities were selected
for various reasons, including the progress they had already made in adopting EHRs. The 17 Beacon
Communities focus on specific and measurable improvement goals in three areas for health systems
improvement—quality, cost-efficiency, and population health—to demonstrate the ability of health
information technology to affect local health care systems.
14
 CMS’s list of zip codes for health professional shortage areas does not contain zip codes that were
only partially in a shortage area.
15
    Information on hospital classification was available for all eligible hospitals.
16
    Information on hospital affiliation with a medical school was available for all hospitals.
17
    Information on hospital ownership type was available for all eligible hospitals.



Page 13                                                        GAO-12-778R Electronic Health Records
Enclosure I

          Provider Enrollment, Chain, and Ownership System were designated as not
          being a member of a chain. 18

•     Hospital size. We analyzed data on the following measures of hospital size from
      CMS’s Provider of Services file and Fiscal Intermediary Standard System: 19

      •   Total beds. Using data from CMS’s Provider of Services file on the total
          number of hospital beds, we created three categories: (a) low—less than or
          equal to the 33.3rd percentile, (b) middle—greater than the 33.3rd percentile
          but less than the 66.7th percentile, and (c) high—greater than the
          66.7th percentile. 20

      •   Medicare inpatient bed days. Using data from CMS’s Fiscal Intermediary
          Standard System, for each hospital we counted the number of Medicare
          inpatient bed days. Using these aggregated data, we created three
          categories: (a) low—less than or equal to the 33.3rd percentile, (b) middle—
          greater than the 33.3rd percentile but less than the 66.7th percentile, and
          (c) high—greater than the 66.7th percentile. 21

      •   Total discharges. Using data from CMS’s Fiscal Intermediary Standard
          System on the total number of discharges for each hospital, we created three
          categories: (a) low—less than or equal to the 33.3rd percentile, (b) middle—
          greater than the 33.3rd percentile but less than the 66.7th percentile, and
          (c) high—greater than the 66.7th percentile.

•     Hospital charges. We analyzed data on the following measures of hospital
      charges from CMS’s Fiscal Intermediary Standard System: 22

      •   Total charges. Using data on the total amount of charges, we created three
          categories: (a) low—less than or equal to the 33.3rd percentile, (b) middle—

18
 Information on chain membership was missing for 247 hospitals (about 5 percent) because those
hospitals did not have a record in our extract from CMS’s Provider Enrollment, Chain, and Ownership
System.
19
  Data from CMS’s Fiscal Intermediary Standard System were missing for 453 acute care hospitals
(about 13 percent) and 988 critical access hospitals (about 74 percent) because, at the time of our
data extract, CMS had not yet populated the system with information on those hospitals.
Consequently, we excluded these 1,441 hospitals from our analysis of Medicare inpatient bed days
and total discharges.
20
    Information on total beds was available for all eligible hospitals.
21
 In addition to the 1,441 hospitals for which we were missing data on Medicare inpatient bed days,
we excluded an additional 6 hospitals from our analysis of Medicare inpatient bed days after
determining that the hospitals’ data were unreliable because the number of Medicare inpatient bed
days exceeded the total number of inpatient bed days.
22
  Data from CMS’s Fiscal Intermediary Standard System were missing for 453 acute care hospitals
(about 13 percent) and 988 critical access hospitals (about 74 percent) because, at the time of our
data extract, CMS had not yet populated the system with information on those hospitals.
Consequently, we excluded these 1,441 hospitals from our analysis of hospital charges.



Page 14                                                        GAO-12-778R Electronic Health Records
Enclosure I

         greater than the 33.3rd percentile but less than the 66.7th percentile, and
         (c) high—greater than the 66.7th percentile. 23

     •   Charity charges. Using data on charity charges, we created three categories:
         (a) low—less than or equal to the 33.3rd percentile, (b) middle—greater than
         the 33.3rd percentile, but less than the 66.7th percentile, and (c) high—
         greater than the 66.7th percentile. 24

•    Professional characteristics. We included in our analysis the following five types
     of professional characteristics:

     •   Professional specialty. We primarily obtained data on professionals’ primary
         specialty from CMS’s National Plan and Provider Enumeration System
         Downloadable File. Then, with the assistance of a crosswalk we obtained
         from CMS that aggregates specialty taxonomy codes into a smaller number of
         specialties, we created the following six categories: (a) general practice
         physician, (b) specialty practice physician, (c) chiropractor, (d) dentist,
         (e) optometrist, and (f) podiatrist. 25 In instances in which the professional
         specialty information was missing from the National Plan and Provider
         Enumeration System, we obtained information on professionals’ specialty
         from another CMS data source—the Provider Enrollment, Chain, and
         Ownership System. To examine variation among different types of specialty
         practice physicians, we used information from the CMS crosswalk to assign
         specialty practice physicians to one of 27 specialty categories, such as
         cardiology, surgery, and psychiatry. Professionals who had missing
         information on professional specialty in both data sources and had not been
         awarded a Medicare EHR incentive payment for 2011 were dropped from our
         analysis, since we were unable to determine whether they were eligible to
         receive an incentive payment. 26 Information on professional specialty was




23
 In addition to the 1,441 hospitals for which we were missing data on hospital charges, we excluded
an additional 3 hospitals from our analysis of total charges after determining that the hospitals’ data
were unreliable because the amount of charity charges exceeded the total amount of charges.
24
  Charity charges reflect the cost of providing inpatient and outpatient hospital services for which the
hospital is not compensated. In addition to the 1,441 hospitals for which we were missing data on
hospital charges, we excluded an additional 3 hospitals from our analysis of charity charges after
determining that the hospitals’ data were unreliable because the amount of charity charges exceeded
the total amount of charges.
25
 We classified doctors of medicine and osteopathic medicine that specialize in family practice,
general practice, or internal medicine as general practice physicians; all other doctors of medicine
and osteopathic medicine were classified as specialty practice physicians.
26
  Information on professional specialty was missing for 72,107 professionals who were not awarded a
Medicare EHR incentive payment.



Page 15                                                    GAO-12-778R Electronic Health Records
Enclosure I

         missing for 35 professionals who had been awarded a Medicare EHR
         incentive payment (less than 1 percent). 27

     •   Number of professionals in the practice. We estimated the number of
         professionals in each practice by counting the number of professionals who
         were listed as members of each professional practice in CMS’s Provider
         Enrollment, Chain, and Ownership System. We subsequently created four
         practice size categories: (a) solo practice, (b) practice of 2 to 10
         professionals, (c) practice of 11 to 50 professionals, and (d) practice of 51 or
         more professionals. We also created a fifth category for professionals who
         were associated with more than one group practice. 28

     •   Whether the professional had signed an agreement to receive technical
         assistance from a Regional Extension Center. We obtained data on whether
         professionals (identified by National Provider Identifier) had signed an
         agreement to receive technical assistance from a Regional Extension Center
         from ONC’s Regional Extension Center Customer Relationship Management
         System. 29 We then categorized professionals as either having signed an
         agreement to receive technical assistance or not.

     •   Whether the professional had received an incentive payment from CMS’s
         electronic prescribing incentive program in 2010. We obtained data from CMS
         on whether professionals received an incentive payment from CMS’s
         electronic prescribing program in 2010. 30 We then categorized professionals
         as either having received such an incentive payment or not.

     •   Years since the professional’s degree was awarded. Using data on when
         professionals had received their degree from CMS’s Provider Enrollment,
         Chain, and Ownership System, we determined the number of years since

27
  CMS provided documentation to support the statement that the 21 professionals for whom we were
missing information on professional specialty had permissible professional specialties. We excluded
an additional 14 professionals (less than 1 percent) from our analysis of professional specialties
because, although they had specialty information, the information needed to classify those
professionals into one of our professional specialty categories was not available in either CMS
system.
28
  Information on the number of professionals in the practice was missing for 86,850 professionals
(about 14.5 percent).
29
 The regional extension center program was established by the Health Information Technology for
Economic and Clinical Health Act and is administered by ONC to help some types of providers, such
as those located in rural areas, to participate in CMS’s EHR programs.
30
  The electronic prescribing program, which was established by the Medicare Improvements for
Patients and Providers Act of 2008, provides incentive payments from 2009 through 2013 to
physicians and certain other Medicare professionals, such as physician assistants and nurse
practitioners, who have prescribing authority and who adopt and use systems that meet CMS’s
definition of a qualified electronic prescribing system. Pub. L. No. 110-275, § 132(a), 122 Stat. 2492,
2527. From 2012 through 2014, the program may apply a payment adjustment, or penalty, on the
program’s eligible providers that do not adopt and use such systems. See GAO, Electronic
Prescribing: CMS Should Address Inconsistencies in Its Two Incentive Programs That Encourage the
Use of Health Information Technology, GAO-11-159 (Washington, D.C.: Feb. 17, 2011).



Page 16                                                   GAO-12-778R Electronic Health Records
Enclosure I

         each professional’s degree was awarded. We dropped data on years since
         the professional’s degree was awarded if the data were potentially
         unreliable—that is, if the number of years exceeded 75. We subsequently
         created three categories: (a) low—less than or equal to the 33.3rd percentile,
         (b) middle—greater than the 33.3rd percentile but less than the
         66.7th percentile, and (c) high—greater than the 66.7th percentile. 31

•    Professional practice size. We analyzed data on the following two measures of
     practice size from CMS’s calendar year 2010 Medicare Part B claims: 32

     •   Total amount of 2010 Medicare Part B charges. For each professional
         (identified by National Provider Identifier), we summed the amount of
         Medicare Part B charges over the year. Subsequently, we created three
         categories by aggregating total charges by professional: (a) low—less than or
         equal to the 33.3rd percentile, (b) middle—greater than the 33.3rd percentile
         but less than the 66.7th percentile, and (c) high—greater than the
         66.7th percentile. 33

     •   Total number of 2010 Medicare Part B encounters. For each professional
         (identified by National Provider Identifier), we counted the number of
         Medicare Part B encounters—that is, distinct Medicare patient visits.
         Subsequently, we created three categories by aggregating total encounters
         by professional: (a) low—less than or equal to the 33.3rd percentile,
         (b) middle—greater than the 33.3rd percentile but less than the
         66.7th percentile, and (c) high—greater than the 66.7th percentile. 34

To ensure the reliability of the various data we analyzed, we interviewed officials
from CMS, ONC, and Surescripts; reviewed relevant documentation; and conducted
electronic testing to identify missing data and obvious errors. On the basis of these
activities, we determined that the data we analyzed were sufficiently reliable for our
analysis. Although the amount of missing data was generally low, in instances in
which data were missing for 6 percent of providers or more, we noted this explicitly.




31
 Information on the number of years since the professional’s degree was awarded was missing for
27,661 professionals (about 4.6 percent).
32
 Information on 2010 Medicare Part B claims was missing for 1,195 professionals who were
awarded a Medicare EHR incentive payment (less than 1 percent).
33
 Percentiles were created using information on 2010 Medicare Part B charges for all professionals
who had greater than $0 in charges.
34
  Percentiles were created using information on 2010 Medicare Part B encounters for all
professionals who had at least one encounter.



Page 17                                                 GAO-12-778R Electronic Health Records
Enclosure I

We conducted this performance audit from January 2012 to July 2012 in accordance
with generally accepted government auditing standards. Those standards require
that we plan and perform the audit to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable basis for
our findings and conclusions based on our audit objectives.




Page 18                                      GAO-12-778R Electronic Health Records
Enclosure II

               Information on Hospitals That Were Awarded Medicare
                         EHR Incentive Payments for 2011

This enclosure provides information on the number and percentage of hospitals that
were awarded Medicare EHR incentive payments for 2011, the amount of incentive
payments awarded to hospitals, and the characteristics of hospitals that were
awarded incentive payments. This enclosure also compares different categories of
eligible hospitals to determine which were more likely and which were less likely to
have been awarded an incentive payment.

Of the estimated 4,855 eligible hospitals, 16 percent or 761 hospitals were awarded
a Medicare EHR incentive payment for 2011. 1 The percentage of eligible hospitals
that were awarded a Medicare EHR incentive payment varied across states. For
example, more than 20 percent of eligible hospitals in New Hampshire were
awarded a Medicare EHR incentive payment for 2011, whereas less than 5 percent
of eligible hospitals in New Mexico were awarded an incentive payment. (See fig. 1.)




1
 In contrast to professionals, certain hospitals may receive an incentive payment from both the
Medicare and Medicaid EHR programs in the same year. Through April 2, 2012, 485 hospitals were
awarded an incentive payment from both programs for 2011.


Page 19                                               GAO-12-778R Electronic Health Records
Enclosure II

Figure 1: Percentage of Eligible Hospitals That Were Awarded a Medicare EHR Incentive Payment for
2011, by State




Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the
number of hospitals that were awarded a Medicare EHR incentive payment includes hospitals that had a Medicare EHR
incentive payment for 2011 disbursed to them or had an incentive payment that was approved and being processed by CMS
but had not yet been disbursed. Our analysis also includes hospitals that were affiliated with Medicare Advantage
Organizations.


Of the approximately $2.3 billion in Medicare EHR incentive payments that were
awarded to providers for 2011, a total of $1.3 billion was awarded to hospitals. The
amount of Medicare EHR incentive payments awarded to hospitals ranged from
$22,300 to $4.4 million, with the median amount being $1.7 million. About 61 percent
of hospitals that were awarded an incentive payment accounted for about 80 percent
of the total amount of incentive payments awarded to hospitals. Acute care hospitals
tended to receive larger incentive payments than critical access hospitals. (See
fig. 2.)




Page 20                                                            GAO-12-778R Electronic Health Records
Enclosure II

Figure 2: Distribution of Medicare EHR Incentive Payment Amounts Awarded to Hospitals for 2011, by
Selected Hospital Characteristics




Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. This analysis includes
incentive payments that were awarded to hospitals for 2011, including those that had not yet been disbursed, but were
approved and being processed by CMS.
a
 Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient
prospective payment system.


As illustrated in table 2, among hospitals that were awarded a Medicare EHR
incentive payment for 2011:

•    the largest proportion (44 percent) were located in the South and the lowest
     proportion (12 percent) were located in the Northeast;

•    about two-thirds (67 percent) were in urban areas;

•    more than four-fifths (86 percent) were acute care hospitals;

•    more than half (57 percent) were nonprofit hospitals;

•    more than half (54 percent) were not members of a chain; and

•    almost half (46 percent) were relatively large in terms of number of beds.




Page 21                                                                  GAO-12-778R Electronic Health Records
Enclosure II

Table 2: Selected Characteristics of Hospitals That Were Awarded a Medicare EHR Incentive Payment for
2011

 Characteristics                                                Categories                              Number (percentage)
 Geographic region                                              Midwest                                             218 (28.7)
                                                                Northeast                                             91 (12.0)
                                                                South                                               333 (43.8)
                                                                West                                                119 (15.6)
 Location                                                       Rural                                               252 (33.1)
                                                                Urban                                               509 (66.9)
                                                                                      a
 Hospital classification                                        Acute care hospital                                 652 (85.7)
                                                                Critical access hospital                            109 (14.3)
 Ownership type                                                 For-profit                                          172 (22.6)
                                                                Government-owned                                    163 (21.4)
                                                                Nonprofit                                           426 (56.0)
 Chain membership                                               Chain                                               343 (45.1)
                                                                Nonchain                                            409 (53.8)
 Total beds                                                     Low (39 beds or fewer)                              142 (18.7)
                                                                Middle (40-175 beds)                                271 (35.6)
                                                                High (176 or more beds)                             348 (45.7)
 Total                                                                                                               761 (100)
Source: GAO analysis of CMS and Health Resources and Services Administration data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the
number of hospitals that were awarded a Medicare EHR incentive payment includes hospitals that had a Medicare EHR
incentive payment for 2011 disbursed to them or had an incentive payment that was approved and being processed by CMS
but had not yet been disbursed. The sum of the number of hospitals listed by chain membership does not equal the total
number of hospitals due to missing data. The sum of the percentage of hospitals listed by geographic region does not equal
100 percent due to rounding.
a
 Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient
prospective payment system.


Among eligible hospitals, the percentage of hospitals that were awarded a Medicare
EHR incentive payment for 2011 varied substantially by certain characteristics, such
as total beds and location in an urban or rural setting. (See fig. 3.)




Page 22                                                                              GAO-12-778R Electronic Health Records
Enclosure II

Figure 3: Percentage of Eligible Hospitals That Were Awarded a Medicare EHR Incentive Payment for
2011, by Selected Hospital Characteristics




Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the
number of hospitals that were awarded a Medicare EHR incentive payment includes hospitals that had a Medicare EHR
incentive payment for 2011 disbursed to them or had an incentive payment that was approved and being processed by CMS
but had not yet been disbursed.
a
 Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient
prospective payment system.


Tables 3 through 6 below compare the characteristics of hospitals that were
awarded Medicare EHR incentive payments for 2011 to those of other eligible
Medicare hospitals that did not receive a payment for that year. Each characteristic
is divided into two or more categories. For example, the characteristic “geographic
region” is divided into four categories—Midwest, Northeast, South, and West
regions. As part of this analysis, we calculated relative risk ratios that indicate how
much more likely a hospital in each category was to have been awarded an EHR
incentive payment than a hospital in the category that was least likely to have been
awarded a payment. Hospitals least likely to receive an incentive payment are
labeled “ – ”. For example, as table 3 shows, under the characteristic “location,” the
relative risk ratio of 1.5 for the category “urban” indicates that hospitals in urban
areas were 1.5 times more likely to have been awarded an incentive payment for
2011 than hospitals in rural areas. A relative risk ratio of 1.0 indicates no difference
in the likelihood of having been awarded an incentive payment between the two
categories, and, as relative risk ratios approach 1.0, there is less and less difference
in the likelihood of having been awarded an incentive payment between the two
categories.



Page 23                                                                  GAO-12-778R Electronic Health Records
Enclosure II

Table 3 examines the relationship between hospitals receiving Medicare EHR
incentive payments for 2011 and characteristics of the regions in which the hospitals
are located. We found that

•   geographic location had a modest effect on the likelihood that hospitals were
    awarded an EHR incentive payment for 2011. For instance, hospitals in the
    South—the region with the highest level of program participation—were 1.4 times
    more likely to have been awarded a payment than hospitals in the West—the
    region with the lowest level of program participation; and

•   there was little association between the likelihood of having been awarded an
    EHR incentive payment for 2011 and whether the hospital was located in a
    county with a Beacon Community or in a county with high levels of electronic
    prescribing transactions per professionals who submit electronic prescriptions.




Page 24                                          GAO-12-778R Electronic Health Records
Enclosure II

Table 3: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for
2011, by Regional Characteristics

                                                                                                       Number (percentage)
                                                                                                  Awarded a               Not awarded a
                                                                               Number           Medicare EHR              Medicare EHR
                                                                             of eligible            incentive                  incentive  Relative
                                                                                       a                                                           b
    Characteristics                        Categories                        hospitals               payment                    payment risk ratio
    Overall                                                                         4,855               761 (15.7)             4,094 (84.3)
    Geographic location
        Geographic region                  Midwest                                  1,435               218 (15.2)             1,217 (84.8)                    1.2
                                           Northeast                                   610               91 (14.9)                519 (85.1)                   1.2
                                           South                                    1,866               333 (17.8)             1,533 (82.2)                    1.4
                                           West                                        944              119 (12.6)                825 (87.4)                       —
        Location                           Rural                                    2,070               252 (12.2)             1,818 (87.8)                        —
                                           Urban                                    2,783               509 (18.3)             2,274 (81.7)                    1.5
    County level of
    participation in selected
    health information
                           c
    technology initiatives
        Average county                     Low (130.99 or                           1,489               243 (16.3)             1,246 (83.7)                    1.0
        volume of electronic               fewer transactions)
        prescribing based on               Middle (131-182.58                       1,489               248 (16.7)             1,241 (83.3)                    1.1
        transactions per
                                           transactions)
        professional who
        submits electronic                 High (182.59 or                          1,487               232 (15.6)             1,255 (84.4)                        —
        prescriptions                      more transactions)
        Located in a county                Yes                                         296               44 (14.9)                252 (85.1)                       —
        with a Beacon
                                           No                                       4,559               717 (15.7)             3,842 (84.3)                    1.1
        Community
Source: GAO analysis of CMS, Office of the National Coordinator for Health Information Technology, Health Resources and Services Administration, and Surescripts
data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the
characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose
incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other
eligible hospitals that were not awarded a payment for that year. The sum of the number of hospitals listed by category may not
equal the overall number of hospitals due to missing data.
a
 We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of
whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access
hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the
Medicare program on or before January 2, 2011.
b
 The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive
payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative
risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two
categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded
an incentive payment between the two categories.
c
 These characteristics describe the level of participation in selected health information technology initiatives across all the
providers in a given county, rather than the level of participation associated with any particular hospital.




Page 25                                                                                      GAO-12-778R Electronic Health Records
Enclosure II

Table 4 examines the relationship between receiving a Medicare EHR incentive
payment for 2011 and hospital type. We found that hospital classification and chain
membership had a greater impact on the likelihood of receiving a Medicare EHR
incentive payment for 2011 than being a major teaching hospital or ownership type.
In particular,

•   among the two hospital classifications, critical access hospitals were 2.3 times
    less likely to have been awarded a Medicare EHR incentive payment for 2011
    than acute care hospitals; and

•   hospitals that were members of chains were 1.6 times more likely to have been
    awarded a Medicare EHR incentive payment for 2011 than hospitals that were
    not members of chains.




Page 26                                          GAO-12-778R Electronic Health Records
Enclosure II

Table 4: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for
2011, by Hospital Type

                                                                            Number (percentage)
                                                     Number of             Awarded a            Not awarded a
                                                       eligible        Medicare EHR             Medicare EHR    Relative
                                                               a                                                         b
    Characteristics        Categories                hospitals     incentive payment        incentive payment risk ratio
    Overall                                               4,855              761 (15.7)              4,094 (84.3)
                                                 c
    Hospital               Acute care hospital            3,524              652 (18.5)              2,872 (81.5)            2.3
    classification         Critical access                1,331               109 (8.2)              1,222 (91.8)             —
                           hospital
    Major teaching         Yes                              441               92 (20.9)                349 (79.1)            1.4
    hospital               No                             4,414              669 (15.2)              3,745 (84.8)             —
    Ownership type         For-profit                       833              172 (20.6)                661 (79.4)            1.5
                           Government-owned               1,217              163 (13.4)              1,054 (86.6)             —
                           Nonprofit                      2,805              426 (15.2)              2,379 (84.8)            1.1
    Chain                  Chain                          1,581              343 (21.7)              1,238 (78.3)            1.6
    membership             Nonchain                       3,027              409 (13.5)              2,618 (86.5)             —
Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the
characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose
incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other
eligible hospitals that were not awarded a payment for that year. The sum of the number of hospitals listed by chain
membership does not equal the total number of hospitals due to missing data.
a
 We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of
whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access
hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the
Medicare program on or before January 2, 2011.
b
 The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive
payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative
risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two
categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded
an incentive payment between the two categories.
c
  Acute care hospitals are hospitals described in Section 1886(d) of the Social Security Act, which are paid under the inpatient
prospective payment system.


Table 5 examines the extent to which the size of hospitals, measured in various
ways, is related to whether hospitals were awarded Medicare EHR incentive
payments for 2011. We found that large hospitals were generally more likely to have
been awarded a Medicare EHR incentive payment for 2011 than either small or
medium-sized hospitals. Specifically,

•      hospitals with the highest number of total beds were 2.4 times more likely than
       hospitals with the lowest number of total beds to have been awarded an incentive
       payment; and

•      hospitals with the highest number of total discharges were 1.4 times more likely
       to have been awarded an incentive payment than hospitals with fewer
       discharges.




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Enclosure II

Table 5: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for
2011, by Hospital Size

                                                                             Number (percentage)
                                                                                  Not awarded a
                                                      Number of         Awarded a Medicare EHR
                                                        eligible    Medicare EHR       incentive                      Relative
                                                               a                                                               b
    Characteristics Categories                        hospitals incentive payment       payment                     risk ratio
    Overall                                                  4,855              761 (15.7)       4,094 (84.3)
    Total beds           Low (39 beds or fewer)              1,619               142 (8.8)       1,477 (91.2)                —
                         Middle (40-175 beds)                1,616              271 (16.8)       1,345 (83.2)               1.9
                         High (176 or more beds)             1,620              348 (21.5)       1,272 (78.5)               2.4
    Medicare             Low (4,209 or fewer                 1,135              194 (17.1)         941 (82.9)               1.0
    inpatient bed        inpatient bed days)
    days                 Middle (4,210-18,525                1,138              187 (16.4)         951 (83.6)                —
                         inpatient bed days)
                         High (18,526 or more                1,135              267 (23.5)         868 (76.5)               1.4
                         inpatient bed days)
                                    c
                         Missing                             1,447               113 (7.8)       1,334 (92.2)               N/A
    Total                Low (2,442 or fewer                 1,137              190 (16.7)         947 (83.3)               1.0
    discharges           discharges)
                         Middle (2,443-9,045                 1,140              190 (16.7)         950 (83.3)                —
                         discharges)
                         High (9,046 or more                 1,137              269 (23.7)         868 (76.3)               1.4
                         discharges)
                                    c
                         Missing                             1,441               112 (7.8)       1,329 (92.2)               N/A
Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the
characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose
incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other
eligible hospitals that were not awarded a payment for that year.
a
 We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of
whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access
hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the
Medicare program on or before January 2, 2011.
b
 The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive
payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative
risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two
categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded
an incentive payment between the two categories.
c
 Data on Medicare inpatient bed days and total discharges from CMS’s Fiscal Intermediary Standard System were missing for
453 acute care hospitals (about 13 percent of eligible acute care hospitals) and 988 critical access hospitals (about 74 percent
of eligible critical access hospitals) because, at the time of our data extract, CMS had not yet populated the system with
information on those hospitals. We excluded an additional 6 hospitals from our analysis of Medicare inpatient bed days after
determining that the hospitals’ data were unreliable because the number of Medicare inpatient bed days exceeded the total
number of inpatient bed days.




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Enclosure II

Table 6 examines the relationship between receiving Medicare EHR incentive
payments for 2011 and the type and amount of hospital charges. We found that
hospitals with the highest charges were more likely to receive a Medicare EHR
incentive payment for 2011 compared to hospitals with lower charges. Specifically,

•      hospitals with high total charges were 1.5 times more likely to have been
       awarded an incentive payment than hospitals with middle-level total charges; and

•      hospitals with middle or high-level charity charges were 1.3 and 1.5 times more
       likely, respectively, to have been awarded an incentive payment than hospitals
       with low charity charges.

Table 6: Number and Percentage of Hospitals That Were Awarded Medicare EHR Incentive Payments for
2011, by Hospital Charges

                                                                                 Number (percentage)
                                                                       Awarded a                  Not awarded a
                                                           Number of Medicare EHR                 Medicare EHR
                                                             eligible    incentive                     incentive             Relative
                                                                     a                                                                b
    Characteristics Categories                             hospitals      payment                       payment            risk ratio
    Overall                                                      4,855          761 (15.7)            4,094 (84.3)
    Total charges        Low
                         ($118,590,920 or less)                  1,136          199 (17.5)              937 (82.5)                 1.1
                         Middle
                         ($118,590,921-$471,392,814)             1,139          184 (16.2)              955 (83.8)                  —
                         High ($471,392,815 or more)             1,136          266 (23.4)              870 (76.6)                 1.5
                                    c
                         Missing                                 1,444           112 (7.8)            1,332 (92.2)                N/A
    Charity              Low ($356,312 or less)                  1,136          169 (14.9)              967 (85.1)                  —
            d
    charges
                         Middle
                         ($356,313-$15,279,600)                  1,139          219 (19.2)              920 (80.8)                 1.3
                         High
                         ($15,279,601 or more)                   1,136          261 (23.0)              875 (77.0)                 1.5
                                    c
                         Missing                                 1,444           112 (7.8)            1,332 (92.2)                N/A
Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. We compared the
characteristics of the 761 hospitals that were awarded a Medicare EHR incentive payment for 2011, including those whose
incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of other
eligible hospitals that were not awarded a payment for that year.
a
 We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicare EHR program, regardless of
whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care hospitals, including those that were affiliated with a Medicare Advantage Organization, or critical access
hospitals; (2) located in one of the 50 states or the District of Columbia; and (3) not terminated from participating in the
Medicare program on or before January 2, 2011.
b
 The relative risk ratios indicate how much more likely a hospital in each category was to have been awarded an EHR incentive
payment than a hospital in the category that was least likely to have been awarded a payment, which is labeled “ – ”. A relative
risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between the two
categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been awarded
an incentive payment between the two categories.
c
 Data on hospital charges were missing from CMS’s Fiscal Intermediary Standard System for 453 acute care hospitals (about
13 percent of eligible acute care hospitals) and 988 critical access hospitals (about 74 percent of eligible critical access
hospitals) because, at the time of our data extract, CMS had not yet populated the system with information on those hospitals.
We excluded an additional three hospitals from our analysis of hospital charges after determining that the hospitals’ data were
unreliable because the amount of charity charges exceeded the total charges.
d
 Charity charges reflect the cost for providing inpatient and outpatient hospital services for which the hospital is not
compensated.



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Enclosure III

          Information on Professionals Who Were Awarded Medicare
                       EHR Incentive Payments for 2011

This enclosure provides information on the number and percentage of professionals
who were awarded Medicare EHR incentive payments for 2011, the amount of
incentive payments awarded to professionals, and the characteristics of
professionals who were awarded incentive payments. This enclosure also compares
different categories of eligible professionals to determine which were more likely and
which were less likely to have been awarded an incentive payment.

Of the estimated 600,172 eligible professionals, 9.4 percent or 56,585 professionals
were awarded a Medicare EHR incentive payment for 2011. The percentage of
eligible professionals who were awarded a Medicare EHR incentive payment varied
across states. For example, more than 20 percent of eligible professionals in New
Hampshire were awarded a Medicare EHR incentive payment for 2011, whereas
less than 5 percent of eligible professionals in New Mexico were awarded an
incentive payment. (See fig. 4.)




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Enclosure III

Figure 4: Percentage of Eligible Professionals Who Were Awarded a Medicare EHR Incentive Payment
for 2011, by State




Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the
number of professionals who were awarded a Medicare EHR incentive payment includes professionals who had a Medicare
EHR incentive payment for 2011 that was disbursed or had an incentive payment that was approved and being processed by
CMS but had not yet been disbursed. Our analysis does not, in general, include data on participating professionals who were
affiliated with Medicare Advantage Organizations.


Of the approximately $2.3 billion in Medicare EHR incentive payments that were
awarded to providers for 2011, $967 million was awarded to professionals. Among
participating professionals, about 80 percent were awarded an incentive payment of
$18,000, which was the maximum amount for most professionals. 1 Slightly less than
8 percent of professionals were awarded an incentive payment of greater than
$18,000, but less than or equal to $19,800. (See fig. 5.) Eighty-nine percent of the

1
 The amount of the Medicare EHR incentive payment for professionals who practice predominately in
a health professional shortage area could not exceed $19,800 for 2011. Health professional shortage
areas are areas designated by the Health Resources and Services Administration as having
shortages of primary medical care, dental, or mental health providers.



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Enclosure III

total amount of incentive payments awarded to professionals was awarded to
general practice and specialty practice physicians.


Figure 5: Percentage of Professionals Who Were Awarded Medicare EHR Incentive Payments for 2011,
by Amount




Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. This analysis includes
incentive payments that were awarded to professionals for 2011, including those that had not yet been disbursed, but were
approved and being processed by CMS. Our analysis does not, in general, include data on participating professionals who
were affiliated with Medicare Advantage Organizations. The amount of the incentive payment for 2011 cannot exceed $18,000
for most professionals. The amount of the incentive payment for professionals who practice predominately in a health
professional shortage area cannot exceed $19,800.


As illustrated in table 7, among professionals who were awarded a Medicare EHR
incentive payment for 2011:

•   the largest proportion (32 percent) were located in the South and the lowest
    proportion (17 percent) were in the West;

•   a significant majority (89 percent) were in urban areas;

•   half (50 percent) were specialty practice physicians, and over one-third
    (38 percent) were general practice physicians;

•   nearly three-quarters (71 percent) did not previously participate in CMS’s
    incentive program for electronic prescribing; and

•   about half had relatively high amounts of 2010 Medicare Part B charges
    (46 percent) and numbers of 2010 Medicare Part B patient encounters
    (51 percent).




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Enclosure III

Table 7: Selected Characteristics of Professionals Who Were Awarded a Medicare EHR Incentive
Payment for 2011

 Characteristics                                                   Categories                           Number (percentage)
 Geographic region                                                 Midwest                                     15,529 (27.4)
                                                                   Northeast                                   13,545 (23.9)
                                                                   South                                       17,805 (31.5)
                                                                   West                                         9,656 (17.1)
 Location                                                          Rural                                        6,108 (10.8)
                                                                   Urban                                       50,464 (89.2)
 Professional specialty                                            General practice physician                  21,588 (38.2)
                                                                   Specialty practice physician                28,446 (50.3)
                                                                   Chiropractor                                  1,265 (2.2)
                                                                   Dentist                                         18 (<0.1)
                                                                   Optometrist                                   2,340 (4.1)
                                                                   Podiatrist                                    2,893 (5.1)
 Received an incentive payment from CMS’s                          Yes                                         16,505 (29.2)
 Electronic Prescribing Program for 2010                           No                                          40,080 (70.8)
 Total amount of 2010 Medicare Part B                              Low ($27,117.01 or less)                     7,892 (13.9)
 charges (dollars)                                                 Medium ($27,117.02-$128,567.51)             21,265 (37.6)
                                                                   High ($128,567.52 or more)                  26,233 (46.4)
 Total number of 2010 Medicare Part B                              Low (615 or fewer encounters)                7,428 (13.1)
 encounters
                                                                   Medium (616-2,665 encounters)               19,402 (34.3)
                                                                   High (2,666 or more encounters)             28,560 (50.5)
 Total                                                                                                          56,585 (100)
Source: GAO analysis of CMS and Health Resources and Services Administration data.

Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. This analysis includes
professionals who had a Medicare EHR incentive payment for 2011 that was disbursed to them and professionals whose
payment was approved and being processed by CMS. Our analysis does not, in general, include data on participating
professionals who were affiliated with Medicare Advantage Organizations. The sum of the number of professionals listed by
category may not equal the total number of professionals due to missing data. The sum of the percentage of professionals
listed for each characteristic may not equal 100 percent due to missing data.


Among eligible professionals, the percentage of professionals who were awarded a
Medicare EHR incentive payment for 2011 varied by certain characteristics, such as
professional specialty and amount of Medicare Part B charges. (See fig. 6.)




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Enclosure III

Figure 6: Percentage of Eligible Professionals Who Were Awarded a Medicare EHR Incentive Payment
for 2011, by Selected Professional Characteristics




Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the
number of professionals who were awarded a Medicare EHR incentive payment includes professionals who had a Medicare
EHR incentive payment for 2011 that was disbursed to them and professionals whose payment was approved and being
processed by CMS. Our analysis does not, in general, include data on participating professionals who were affiliated with
Medicare Advantage Organizations.


While 8 percent of all specialty practice physicians were awarded a Medicare EHR
incentive payment for 2011, the percentage varied substantially by specialty. For
example, 17 percent of cardiologists were awarded a Medicare EHR incentive
payment, compared to 2 percent of psychiatrists. (See fig. 7.)




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Enclosure III

Figure 7: Percentage of Specialty Practice Physicians Who Were Awarded a Medicare EHR Incentive
Payment for 2011, by Selected Specialty




Note: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis of the
number of professionals who were awarded a Medicare EHR incentive payment includes professionals who had a Medicare
EHR incentive payment for 2011 that was disbursed to them and professionals whose payment was approved and being
processed by CMS. Our analysis does not, in general, include data on participating professionals who were affiliated with
Medicare Advantage Organizations.


Tables 8 through 10 below compare the characteristics of professionals who were
awarded Medicare EHR incentive payments for 2011 to those of other eligible
Medicare professionals who did not receive a payment for that year. Each
characteristic is divided into two or more categories. For example, the characteristic
“geographic region” is divided into four categories—Midwest, Northeast, South, and
West regions. As part of this analysis, we calculated relative risk ratios that indicate
how much more likely a professional in each category was to have been awarded an
EHR incentive payment than a professional in the category that was least likely to
have been awarded a payment. Professionals least likely to receive an incentive
payment are labeled “ – ”. For example, as table 8 shows, under the characteristic
“geographic region,” the relative risk ratio of 1.4 for the category “Midwest” indicates
that professionals in this census region were 1.4 times more likely to have been
awarded an incentive payment for 2011 than professionals in the West, who were
the least likely to receive an incentive payment. A relative risk ratio of 1.0 indicates
no difference in the likelihood of having been awarded an incentive payment


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Enclosure III

between the two categories, and, as relative risk ratios approach 1.0, there is less
and less difference in the likelihood of having been awarded an incentive payment
between the two categories.

Table 8 examines the relationship between professionals receiving Medicare EHR
incentive payments for 2011 and characteristics of the regions in which the
professionals are practicing. We found that geographic location had a modest effect
on the likelihood that professionals were awarded an EHR incentive payment for
2011. For example,

•   professionals practicing in health professional shortage areas were 1.4 times less
    likely to have been awarded a payment than other professionals; and

•   in contrast, professionals practicing in urban areas were no more likely to have
    been awarded an incentive payment than rural professionals.

There was an inconsistent relationship between the level of county involvement in
selected health information technology initiatives—such as Beacon communities—
and the likelihood that professionals in that location were awarded an EHR incentive
payment.




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Enclosure III

Table 8: Number and Percentage of Professionals Who Were Awarded Medicare EHR Incentive Payments
for 2011, by Regional Characteristics

                                                                                                     Number (percentage)
                                                                                                 Awarded a               Not awarded a
                                                                        Number of              Medicare EHR              Medicare EHR
                                                                           eligible                incentive                  incentive               Relative
                                                                                  a                                                                            b
    Characteristic                         Category                 professionals                   payment                    payment              risk ratio
    Overall                                                                    600,172             56,585 (9.4)           543,587 (90.6)
    Geographic location
                                   c
        Geographic region                 Midwest                              142,159           15,529 (10.9)            126,630 (89.1)                       1.4
                                          Northeast                            133,236           13,545 (10.2)            119,691 (89.8)                       1.3
                                          South                                197,703             17,805 (9.0)           179,898 (91.0)                       1.1
                                          West                                 121,715               9,656 (7.9)          112,059 (92.1)                           —
        Location                          Rural                                  65,684              6,108 (9.3)            59,576 (90.7)                          —
                                          Urban                                534,273             50,464 (9.4)           483,809 (90.6)                       1.0
        Located in a health   Yes                                                19,385              1,290 (6.7)            18,095 (93.3)                          —
        professional shortage No                                               580,580             55,283 (9.5)           525,297 (90.5)                       1.4
        area
    Level of participation in
    selected health
    information technology
                d
    initiatives
        Average county                    Low                                  202,811             18,196 (9.0)           184,615 (91.0)                       1.0
        volume of electronic              (117.83 or fewer
        prescribing based on              transactions)
        transactions per                  Middle                               192,988             16,864 (8.7)           176,124 (91.3)                           —
        professional who
                                          (117.84-152.53
        submits electronic
                                          transactions)
        prescriptions
                                          High                                 199,471           21,393 (10.7)            178,078 (89.3)                       1.2
                                          (152.54 or more
                                          transactions)
        Located in a county               Yes                                    38,853              2,993 (7.7)            35,860 (92.3)                          —
        with a Beacon                     No                                   561,112             53,580 (9.5)           507,532 (90.5)                       1.2
        Community
Source: GAO analysis of CMS, Office of the National Coordinator for Health Information Technology, Health Resources and Services Administration, and Surescripts
data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis does not,
in general, include participating professionals who were affiliated with Medicare Advantage Organizations. We compared the
characteristics of the 56,585 professionals who were awarded a Medicare EHR incentive payment for 2011 including those
whose incentive payment was disbursed to them and those whose payment was approved and being processed by CMS, to
those of other eligible professionals who were not awarded a payment for that year. The sum of the number of professionals
listed by category may not equal the overall number of professionals due to missing data.
a
 We use the term eligible professionals to refer to those professionals who were eligible for the Medicare EHR program,
regardless of whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible professionals are
those who (1) were permissible types of providers: doctors of medicine, dental medicine or surgery, optometry, osteopathy, and
podiatric medicine, and chiropractors; (2) were not hospital-based, and (3) had greater than $0 in Medicare Part B charges in
calendar year 2010.
b
 The relative risk ratios indicate how much more likely a professional in each category was to have been awarded an EHR
incentive payment than a professional in the category that was least likely to have been awarded a payment, which is labeled
“–”. A relative risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between
the two categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been
awarded an incentive payment between the two categories.
c
  Five thousand three hundred fifty-five eligible professionals practiced in U.S. insular areas, which are not included in the four
U.S. census regions. Of those, 46 (about 1 percent) were awarded a Medicare EHR incentive payment.
d
 These characteristics describe the level of participation in selected health information technology initiatives across all the
professionals in a given county, rather than the level of participation for any particular professional.




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Enclosure III

Table 9 examines the relationship between professional characteristics, such as
specialty, longevity, and involvement in other health IT initiatives, and receipt of a
Medicare EHR incentive payment for 2011. We found that

•   among general practice physicians and specialty practice physicians—the two
    specialty categories that together account for most of the eligible professionals—
    general practice physicians were 1.8 times more likely than specialty practice
    physicians to have been awarded a Medicare EHR incentive payment; 2 and

•   professionals who received an incentive payment from CMS’s Electronic
    Prescribing Program for 2010 were 3.7 times more likely to have been awarded a
    Medicare EHR incentive payment for 2011 than professionals who did not.




2
 To determine how much more likely a general practice physician was to have been awarded a
Medicare EHR incentive payment for 2011 than a specialty practice physician, we divided the
probability that a general practice physician was awarded an incentive payment (21,588/153,402 =
0.1407) by the probability that a specialty practice physician was awarded an incentive payment
(28,446/355,926 = 0.0799).



Page 38                                                 GAO-12-778R Electronic Health Records
Enclosure III

Table 9: Number and Percentage of Professionals Who Were Awarded Medicare EHR Incentive Payments
for 2011, by Professional Characteristics

                                                                                                    Number (percentage)
                                                                                               Awarded a           Not awarded a
                                                                      Number of              Medicare EHR          Medicare EHR
                                                                         eligible                incentive              incentive     Relative
                                                                                a                                                              b
    Characteristic                      Category                  professionals                   payment                payment    risk ratio
    Overall                                                                  600,172             56,585 (9.4)      543,587 (90.6)
    Professional specialty              General practice                     153,402            21,588 (14.1)      131,814 (85.9)         27.2
                                        physician
                                        Specialty practice                   355,926             28,446 (8.0)      327,480 (92.0)         15.4
                                        physician
                                        Chiropractor                           45,108              1,265 (2.8)      43,843 (97.2)           5.4
                                        Dentist                                  3,479                  18 (0.5)     3,461 (99.5)            —
                                        Optometrist                            27,745              2,340 (8.4)      25,405 (91.6)         16.3
                                        Podiatrist                             14,477            2,893 (20.0)       11,584 (80.0)         38.6
    Number of professionals             Solo practice                          54,938              4,234 (7.7)      50,704 (92.3)            —
    in practice                         2-10                                 101,315            12,266 (12.1)       89,049 (87.9)           1.6
                                        professionals
                                        11-50                                  70,297            7,103 (10.1)       63,194 (89.9)           1.3
                                        professionals
                                        51 or more                           159,056            17,893 (11.2)      141,163 (88.8)           1.5
                                        professionals
                                        More than one                        127,716             11,974 (9.4)      115,742 (90.6)           1.2
                                        group practice
                                                   c
                                        Missing                                86,850              3,115 (3.6)      83,735 (96.4)          N/A
    Signed an agreement to              Yes                                    65,029           12,155 (18.7)       52,874 (81.3)           2.3
    receive technical                   No                                   535,143             44,430 (8.3)      490,713 (91.7)            —
    assistance from a
    Regional Extension
    Center
    Received an incentive               Yes                                    59,575           16,505 (27.7)       43,070 (72.3)           3.7
    payment from CMS’s                  No                                   540,597             40,080 (7.4)      500,517 (92.6)            —
    Electronic Prescribing
    Program for 2010
    Years since degree                  Low                                  203,884            21,500 (10.5)      182,384 (89.5)           1.2
    awarded                             (18 years or fewer)
                                        Middle                               165,563            17,634 (10.7)      147,929 (89.3)           1.2
                                        (19-28 years)
                                        High                                 203,064             17,318 (8.5)      185,746 (91.5)            —
                                        (29 years or more)
Source: GAO analysis of CMS and Office of the National Coordinator for Health Information Technology data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis does not,
in general, include participating professionals who were affiliated with Medicare Advantage Organizations. We compared the
characteristics of the 56,585 professionals who were awarded a Medicare EHR incentive payment for 2011 including those
whose incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of
other eligible professionals who were not awarded a payment for that year. The sum of the number of professionals listed by
category may not equal the overall number of professionals due to missing data.
a
 We use the term eligible professionals to refer to those professionals who were eligible for the Medicare EHR program,
regardless of whether they were awarded a Medicare EHR incentive payment for 2011. Specifically, eligible professionals are
those who (1) were permissible types of providers: doctors of medicine, dental medicine or surgery, optometry, osteopathy, and
podiatric medicine, and chiropractors; (2) were not hospital-based, and (3) had greater than $0 in Medicare Part B charges in
calendar year 2010.




Page 39                                                                                     GAO-12-778R Electronic Health Records
Enclosure III
b
 The relative risk ratios indicate how much more likely a professional in each category was to have been awarded an EHR
incentive payment than a professional in the category that was least likely to have been awarded a payment, which is labeled
“ – ”. A relative risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between
the two categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been
awarded an incentive payment between the two categories.
c
 Our analysis of the number of professionals in eligible professionals’ practices includes only a subset of professionals. That is,
information on the number of professionals in the practice was missing for 86,850 professionals (about 14.5 percent).


Table 10 examines the extent to which the size of professionals’ practices under
Medicare, measured in various ways, is related to whether professionals were
awarded Medicare EHR incentive payments for 2011. We found that professionals
who saw the largest number of Medicare patients and billed Medicare the largest
amounts were the most likely to have been awarded a Medicare EHR incentive
payment for 2011. Specifically,
•    professionals with the highest total amount in 2010 Medicare Part B charges
     were 3.3 times more likely to have been awarded an incentive payment than
     professionals with the lowest amount of 2010 Medicare Part B charges; and

•    professionals with the highest number of 2010 Medicare Part B encounters were
     3.8 times more likely to have been awarded an incentive payment than
     professionals with the smallest number of encounters.




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Enclosure III

Table 10: Number and Percentage of Professionals Who Were Awarded Medicare EHR Incentive
Payments for 2011, by Practice Size

                                                                                 Number (percentage)
                                                                         Awarded a              Not awarded a
                                                             Number of Medicare EHR             Medicare EHR
                                                                eligible   incentive                 incentive         Relative
                                                                       a                                                        b
    Characteristic              Category                 professionals      payment                   payment        risk ratio
    Overall                                                     600,172        56,585 (9.4)      543,587 (90.6)
    Total amount of             Low                             199,460         7,892 (4.0)      191,568 (96.0)                —
    2010 Medicare               ($27,117.01 or less)
    Part B charges              Medium                          200,057      21,265 (10.6)       178,792 (89.4)               2.7
    (dollars)                   ($27,117.02-128,567.51)
                                High                            199,460      26,233 (13.2)       173,227 (86.8)               3.3
                                ($128,567.52 or more)
    Total number of             Low                             199,648         7,428 (3.7)      192,220 (96.3)                —
    2010 Medicare               (615 or fewer encounters)
    Part B encounters           Medium                          199,825        19,402 (9.7)      180,423 (90.3)               2.6
                                (616-2,665 encounters)
                                High                            199,504      28,560 (14.3)       170,944 (85.7)               3.8
                                (2,666 or more encounters)
Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicare EHR program through April 2, 2012. Our analysis does not,
in general, include participating professionals who were affiliated with Medicare Advantage Organizations. We compared the
characteristics of the 56,585 professionals who were awarded a Medicare EHR incentive payment for 2011 including those
whose incentive payment was disbursed to them or whose payment was approved and being processed by CMS, to those of
other eligible professionals who were not awarded a payment for that year. The sum of the number of professionals listed by
category may not equal the overall number of professionals due to missing data.
a
 We use the term eligible professionals to refer to those professionals who were eligible for the Medicare EHR program,
regardless of whether they participated in the program and were awarded a Medicare EHR incentive payment for 2011.
Specifically, eligible professionals are those that (1) were permissible types of providers: doctors of medicine, dental medicine
or surgery, optometry, osteopathy, and podiatric medicine, and chiropractors; (2) were not hospital-based, and (3) had greater
than $0 in Medicare Part B charges in calendar year 2010.
b
 The relative risk ratios indicate how much more likely a professional in each category was to have been awarded an EHR
incentive payment than a professional in the category that was least likely to have been awarded a payment, which is labeled
“ – ”. A relative risk ratio of 1.0 indicates no difference in the likelihood of having been awarded an incentive payment between
the two categories, and, as relative risk ratios approach 1.0, there is less and less difference in the likelihood of having been
awarded an incentive payment between the two categories.




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                  Enclosure IV

                            Comments from the Department of Health and Human Services



Note: Page
and footnote
numbers in the
draft report
may differ from
those in this
report.




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Enclosure IV




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Page 43        GAO-12-778R Electronic Health Records
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