oversight

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

Published by the Government Accountability Office on 2012-12-13.

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

United States Government Accountability Office
Washington, DC 20548



           December 13, 2012

           Congressional Committees

           Subject: Electronic Health Records: Number and Characteristics of Providers
                    Awarded Medicaid 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, 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). The Congressional Budget Office estimates that from 2011 through
           2019, spending for the Medicare and Medicaid EHR programs will total $30 billion,

           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 American
           Recovery and Reinvestment Act of 2009. 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 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-13-146R Electronic Health Records
with spending for the Medicaid EHR program accounting for more than a third—
$12.4 billion. This report focuses on the Medicaid EHR program.

Provisions in the HITECH Act define the types of hospitals and professionals that
may be eligible to receive Medicaid EHR incentive payments. Eligible hospitals
include acute care hospitals, critical access hospitals, children’s hospitals, and
cancer hospitals. 5 Eligible professionals include doctors of medicine, dental medicine
or surgery, and osteopathy; nurse practitioners; certified nurse midwives; and
physician assistants who work for a federally qualified health center or rural health
clinic that is led by a physician assistant. 6 To participate in the Medicaid EHR
program, providers must generally meet a patient volume requirement. This
requirement was established to ensure that providers that receive incentive
payments from the Medicaid EHR program serve a minimum volume of Medicaid
patients, or, for certain professionals, a minimum volume of needy patients. 7
Hospitals generally must have a Medicaid patient volume of at least 10 percent. 8
Professionals must have a Medicaid patient volume of at least 30 percent unless
they are pediatricians or practice predominantly in a federally qualified health center
or rural health clinic; pediatricians must have a Medicaid patient volume of at least
20 percent. 9

To qualify for incentive payments in 2011 or during the first year they participate in
the Medicaid EHR program, providers only need to adopt, implement, or upgrade to
a certified EHR system, and they do not have to demonstrate meaningful use. In
subsequent years, however, providers must demonstrate meaningful use of the EHR
systems in order to qualify for the program’s incentive payments. To demonstrate
meaningful use, providers must collect and report information on various measures
established by CMS.




5
 In this report, for the purpose of analyzing participation in the Medicaid EHR program, we use the
term acute care hospital to describe short-term hospitals that are not critical access or cancer
hospitals. However, in the Medicaid EHR program, the term acute care hospital refers to short-term
hospitals generally, which includes critical access hospitals, and cancer hospitals. The hospitals
classified as critical access hospitals typically are very small (25 inpatient beds or fewer) and operate
in rural areas.
6
 Federally qualified health centers are urban or rural centers that provide comprehensive community-
based primary care services to individuals regardless of their ability to pay. Rural health clinics
provide similar primary care services in underserved rural areas, but unlike federally qualified health
centers, rural health clinics are not required to provide services to all individuals, such as those who
are uninsured.
7
 Needy patients are defined by CMS as patients who are enrolled in Medicaid or the State Children’s
Health Insurance Program, receive uncompensated care, or receive care at no cost or on a sliding
scale determined by ability to pay.
8
 Children’s hospitals are the only hospitals that do not have to meet the 10 percent Medicaid patient
volume requirement.
9
 Professionals who practice predominantly in a federally qualified health center or rural health clinic
must have a needy patient volume of at least 30 percent. To be considered as practicing
predominantly in a federally qualified health center or rural health clinic, a professional must treat over
50 percent of his or her total patient volume over a period of 6 months in a federally qualified health
center or rural health clinic.



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States, the District of Columbia, and the U.S. insular areas administer and oversee
the Medicaid EHR program, with CMS providing additional oversight and funding.
Although states are not required to offer the Medicaid EHR program, 42 states
launched a Medicaid EHR program and disbursed incentive payments for 2011. 10
During 2011, the first year of the program, 2,700 hospitals and 66,663 professionals
registered for the Medicaid EHR program, which is a necessary first step to
participate in the program. 11 Under the Medicaid EHR program, incentive payment
amounts to hospitals and professionals are determined as follows. 12 Payments are
determined and awarded on a fiscal year basis for hospitals and on a calendar year
basis for professionals. 13

•    For hospitals, the amount of incentive payment in any given year is generally
     based on the hospital’s annual discharges and Medicaid share, which is the
     percentage of the hospital’s inpatient bed days that were attributable to Medicaid
     patients. The number of years over which incentive payments are awarded (from
     3 to 6 years) is at the discretion of the state. As a result, the payment amount
     awarded to hospitals for a certain level of discharges and Medicaid share in any
     given year, including 2011, can vary across states. Theoretically, the maximum
     possible amount a hospital could receive in total Medicaid EHR incentive
     payments is $15,926,000. 14

For most professionals, the amount of incentive payment that a professional
receives in any given year is, in general, a fixed amount, $21,250 in the first year
and $8,500 each year for up to 5 subsequent years. The total amount over a
6-year period cannot exceed $63,750. 15




10
  In addition to the U.S. insular areas and the District of Columbia, the following states did not offer
the Medicaid EHR program in 2011: Colorado, Hawaii, Idaho, Minnesota, Nebraska, New Hampshire,
Nevada, and Virginia.
11
 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.”
12
  The last year for which providers may begin receiving payments is 2016 and the last year for which
providers may be awarded Medicaid EHR incentive payments is 2021. Providers can maximize their
total payments by first participating in the Medicaid EHR program no later than 2016.
13
 As a result, year 2011 refers to the fiscal year—October 1, 2010, through September 30, 2011—for
hospitals and the calendar year for professionals.
14
  This amount assumes that all patients the hospital served were Medicaid patients and that the
hospital had at least 23,000 discharges each year, which is the highest number of discharges used in
the calculation of Medicaid EHR incentive payments. For more information see CMS, “Medicaid
Hospital Incentive Payment Calculations” accessed December 3, 2012,
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/MEDICAID_HOSP_INCENTIVE_PAYMENTS_TIP_SHEETS.PDF.
15
 Pediatricians who qualify with less than 30 percent Medicaid patient volume (but have at least
20 percent) may receive $14,167 in the first year and $5,667 in subsequent years, up to a total
amount of $42,500 over a 6-year period.



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The HITECH Act requires us to report on, among other things, the impact of its
provisions on adoption of EHRs by providers. 16 In response to this requirement, in
April 2012 we reported on CMS’s efforts to oversee the first year of the Medicare
and Medicaid EHR programs as well as challenges encountered by providers and
strategies they used to participate in these programs. 17 We recommended, among
other things, that CMS take steps to enhance its processes used to verify that
providers receiving incentive payments have met program requirements. On behalf
of CMS, the Department of Health and Human Services agreed with most of our
recommendations. In July 2012, we reported information on providers that were
awarded Medicare EHR incentive payments for 2011, including the number of award
recipients and their characteristics. 18

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 incentives provided by the HITECH Act.
Identifying the number and characteristics of providers that participated during the
first year of the Medicaid EHR program can provide important information on
whether certain types of providers were more likely than others to participate. As
discussed with the committees of jurisdiction, in this report we provide information on
providers that were awarded Medicaid EHR program incentive payments for 2011,
the first year of the program.

To provide information on providers—that is, hospitals and professionals—awarded
Medicaid EHR incentive payments for 2011, we analyzed data related to the 2011
program year that CMS collected from participating states as well as data from CMS
and other government and private sources on provider characteristics. 19 We used
these data to

•     determine the number of providers that were awarded a Medicaid EHR incentive
      payment,

•     estimate the percentage of eligible providers that were awarded a Medicaid EHR
      incentive payment,

•     determine the amount of Medicaid EHR incentive payments awarded to
      providers, and

16
    Pub. L. No. 111-5, § 13424(e), 123 Stat. 278-279.
17
  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.
18
  See GAO, Electronic Health Records: Number and Characteristics of Providers Awarded Medicare
Incentive Payments for 2011, GAO-12-778R (Washington, D.C.: July 26, 2012).
19
  In the Medicaid EHR program, states have the flexibility to establish the deadline by which providers
must submit the information needed to determine incentive payment eligibility. States also have the
flexibility to establish the deadline for completing the incentive payment awards. As a result, at the
time of our analysis, not all states had determined which hospitals and professionals would receive
incentive payments for 2011. We analyzed data related to the 2011 program year that CMS collected
from the states from January 3, 2011, through October 1, 2012.



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

Specifically, to determine the number of providers that were awarded a Medicaid
EHR incentive payment for 2011, we analyzed CMS data on providers that had an
incentive payment disbursed to them. We also used these data to estimate the
percentage of eligible providers awarded a Medicaid EHR incentive payment for
2011. To do this, we divided the number of providers awarded an incentive payment
by the estimated total number of eligible providers, that is, providers that were
eligible for the Medicaid EHR program, regardless of whether they were awarded an
incentive payment. To determine the total amount of Medicaid EHR incentive
payments awarded to providers, we summed the Medicaid EHR incentive payments
awarded to providers. To provide context, we compared these numbers to
participation levels and total award amounts made under the Medicare EHR
program for 2011. 20 We also examined the distribution of the Medicaid incentive
payments across providers. Specifically, for hospitals, we determined the minimum,
25th percentile, median, 75th percentile, and maximum Medicaid EHR incentive
payment amount. For professionals, we determined the percentage of professionals
who were awarded an incentive payment of various amounts.

To examine the characteristics of providers awarded Medicaid 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. 21 Examples of professional characteristics
included whether the professional had previously participated in CMS’s Electronic
Prescribing program or signed an agreement to receive technical assistance from a
Regional Extension Center. 22 As part of our analysis, we also compared the
characteristics of hospitals that were awarded Medicaid EHR incentive payments for
2011 to those of other hospitals that were eligible for the Medicaid EHR program but




20
 Information on participation in the Medicare EHR program in 2011 was obtained from
GAO-12-778R.
21
 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.
22
  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. 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).
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, participate in CMS’s EHR
programs.



Page 5                                                    GAO-13-146R Electronic Health Records
were not awarded a payment for that year. 23 Our comparisons included eligible
hospitals from the 50 states, the District of Columbia, and the U.S. insular areas.

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. As part of our efforts to
ensure the reliability of CMS data on providers that received a Medicaid EHR
program incentive payment for 2011, we reviewed information from states, which
submit the data to CMS, to assess the completeness of the CMS data. In general,
we found that total participation and amounts awarded for 2011 will likely increase
because some states had not completed their determinations of which hospitals and
professionals had met all the requirements to receive incentive payments for 2011.
We estimate that up to 4 percent more hospitals and up to 9 percent more
professionals may obtain 2011 incentive payments. 24 On the basis of these activities,
we determined that the data we analyzed were sufficiently reliable for our analysis. 25
Enclosure I provides additional information on our scope and methodology.

We conducted this performance audit from January 2012 to December 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, 1,964 hospitals and 45,962 professionals were awarded a total of
approximately $2.7 billion in Medicaid EHR incentive payments for 2011. These
1,964 hospitals, which represented 39 percent of the 5,013 eligible hospitals, were
awarded a total of $1.7 billion in Medicaid EHR incentive payments for 2011. 26 While
the amount of Medicaid EHR incentive payments awarded to each hospital ranged
from $7,528 to $7.2 million, the median payment amount was $613,512.
Participation rates, as well as total payments, were higher for hospitals in the
Medicaid EHR program when compared to the Medicare EHR program, though the
median payment amount in the Medicaid EHR program was less than half as large.
(See table 1.)


23
  It was not feasible to conduct a similar analysis of professionals that examined characteristics of
eligible professionals who received Medicaid EHR incentive payments compared to those who did
not. We lacked the data to be able to identify professionals who met the minimum Medicaid or needy
patient volume threshold—a key eligibility requirement in the Medicaid EHR program—but did not
receive a Medicaid EHR incentive payment.
24
   Most of the hospitals that had not yet been paid at the time of our analysis were concentrated in
Illinois, and most of the professionals that had not yet been paid at the time of our analysis were
concentrated in California, Illinois, and New York.
25
  The amount of missing data on provider characteristics was generally low; however, in instances in
which data were missing for 6 percent or more of providers, we noted this explicitly in tables
presented in encs. II and III, as appropriate. See enc. I for specific information on the extent of
missing data for the various provider characteristics we examined.
26
 In contrast to professionals, certain hospitals may receive an incentive payment from both the
Medicare and Medicaid EHR programs in the same year. Through October 1, 2012, 529 hospitals
were awarded an incentive payment from both programs for 2011.



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Table 1: Participation in the Medicaid and Medicare EHR Programs by Hospitals, 2011

                                                                         Medicaid                              Medicare
Number (percentage of eligible)                                          1,964 (39)                              761 (16)
Median payment                                                            $613,512                            $1.7 million
Total payments                                                          $1.7 billion                          $1.3 billion
Source: GAO analysis of CMS data.

Notes: Medicaid figures are based on data CMS collected through October 1, 2012, for the 2011 program year. Medicare
figures were reported in GAO, Electronic Health Records: Number and Characteristics of Providers Awarded Medicare
Incentive Payments for 2011, GAO-12-778R (Washington, D.C.: July 26, 2012). The total number of hospitals that receive
incentive payment awards from the Medicaid or Medicare EHR programs may increase.


About 50 percent of hospitals accounted for about 80 percent of the total amount of
Medicaid incentive payments awarded to hospitals. Among hospitals awarded a
Medicaid EHR incentive payment for 2011, we found that
•     the largest proportion (46 percent) were located in the South and the smallest
      proportion (15 percent) were located in the Northeast,

•     three-fifths (62 percent) were located in urban areas,

•     four-fifths (80 percent) were acute care hospitals,

•     more than half (57 percent) were nonprofit hospitals, and

•     more than half (57 percent) were not members of a chain.

Comparing the hospitals that received incentive awards to the eligible hospitals that
did not, we found that hospitals with certain characteristics were more likely to have
been awarded Medicaid EHR incentive payments for 2011. For example, acute care
hospitals were 1.7 times more likely and children’s hospitals were 1.6 times more
likely to have been awarded a Medicaid EHR incentive payment for 2011, when
compared to critical access hospitals. In addition, hospitals with the highest number
of total beds were 2 times more likely to have been awarded an incentive payment
than hospitals with the lowest number of total beds.

The 45,962 professionals awarded a Medicaid EHR incentive payment for 2011
represented 33 percent of the estimated 139,600 professionals eligible for the
program and were awarded a total of $967 million in incentive payments. Almost all
professionals (97 percent) were awarded the maximum incentive payment amount
generally available to professionals in 2011 ($21,250). Proportionally more than
three times as many eligible professionals participated in the Medicaid EHR program
in 2011 than in the Medicare EHR program, though the total payment amounts in the
two programs were nearly equivalent. 27 (See table 2.)




27
  Although the Medicare and Medicaid EHR programs both distributed a total of $967 million to
professionals for 2011 as of the dates we obtained the data from CMS, the aggregate amount
distributed is determined independently for the two programs.



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Table 2: Participation in the Medicaid and Medicare EHR Programs by Professionals, 2011

                                                                            Medicaid                          Medicare
Number (percentage of eligible)                                           45,962 (33)                        56,585 (9)
Median payment                                                                $21,250                           $18,000
Total payments                                                         $967.1 million                    $967.4 million
Source: GAO analysis of CMS data.

Notes: Medicaid figures are based on data CMS collected through October 1, 2012, for the 2011 program year. Medicare
figures were reported in GAO, Electronic Health Records: Number and Characteristics of Providers Awarded Medicare
Incentive Payments for 2011, GAO-12-778R (Washington, D.C.: July 26, 2012). The total number of professionals who receive
incentive payment awards from the Medicaid or Medicare EHR programs may increase.


Among the professionals who received a Medicaid EHR incentive payment for 2011,
we found that
•     the largest proportion (37 percent) were located in the South and the smallest
      proportion (20 percent) were located in the Midwest;

•     four-fifths (83 percent) were located in urban areas;

•     nearly three-quarters were physicians—either general practice physicians
      (23 percent) or specialty practice physicians (51 percent)—and the lowest
      proportion (1 percent) were physician assistants; and

•     almost half (47 percent) had signed agreements to receive technical assistance
      from a Regional Extension Center.

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

We provided a draft of this report to the Department of Health and Human Services
for comment. The department provided technical comments, which we have
addressed as appropriate.

                                                      –––––

We are sending copies of this report to the Secretary of Health and Human Services,
the Administrator of the Centers for Medicare & Medicaid Services, the National
Coordinator for Health Information Technology, and other interested parties. In
addition, the report is available at no charge on the GAO website at
http://www.gao.gov.




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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 Offices of
Congressional Relations and Public Affairs may be found on the last page of this
report. Major contributors to this report were Kristi Peterson, Assistant Director;
Julianne Flowers; Krister Friday; Melanie Krause; E. Anne Laffoon; Shannon Legeer;
Monica Perez-Nelson; and Eric Peterson.




Linda T. Kohn
Director, Health Care

Enclosures – 3




Page 9                                         GAO-13-146R 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 10                                     GAO-13-146R 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 (1) determine the number of providers that were awarded a Medicaid
electronic health record (EHR) incentive payment, (2) estimate the percentage of
eligible providers that were awarded a Medicaid EHR incentive payment, 1
(3) determine the amount of Medicaid EHR incentive payments awarded to
providers, and (4) examine the characteristics of providers that were awarded
Medicaid EHR incentive payments.

Number of providers that were awarded a Medicaid EHR incentive payment. To
determine the number of providers that were awarded an incentive payment, we
analyzed data on providers that were awarded Medicaid 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 October 1, 2012. 3
Specifically, we counted the number of providers that had an incentive payment
disbursed to them.

Estimate of the percentage of eligible providers that were awarded a Medicaid
EHR incentive payment. To estimate the nationwide percentage of hospitals that
were awarded an incentive payment, we divided the number of hospitals that were
awarded an incentive payment by the total number of eligible hospitals, that is,
hospitals that were eligible for the Medicaid EHR program, regardless of whether
they were awarded an incentive payment. We identified eligible hospitals as those
that met the following three criteria:
1
 We use the term eligible providers to refer to hospitals and professionals who were generally eligible
for the Medicaid EHR program, regardless of whether they were awarded a Medicaid 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
Medicaid EHR program, including information on providers that are registered for the incentive
program and the amount of incentive payments, if applicable. The National Level Repository also
contains information on providers pertaining to the Medicare EHR program, which we generally did
not include in our analysis.
3
  As part of our efforts to ensure the reliability of CMS data containing information on providers that
received a Medicaid EHR program incentive payment for 2011, we reviewed information from states,
which submit the data to CMS, to assess the completeness of the CMS data. In general, we found
that total participation and amounts awarded for 2011 will likely increase because some states had
not completed their determinations of which hospitals and professionals had met all the requirements
to receive incentive payments for 2011. We estimate that up to 4 percent more hospitals and up to
9 percent more professionals may obtain 2011 incentive payments. (Most of the hospitals that had
not yet been paid at the time of our analysis were concentrated in Illinois, and most of the
professionals that had not yet been paid at the time of our analysis were concentrated in California,
Illinois, and New York.) However, we also found that the data we obtained from CMS for 2011 may
have included some providers that were awarded payments for 2012 rather than 2011, and this would
reduce the extent to which our results underestimate the total number of providers that obtained
incentive payments for 2011. Specifically, we compared CMS and state records in the six states that
paid the largest proportion of total hospitals or total professionals and found no discrepancies
between CMS and state hospital data in four of the states. But in two of the states, CMS data listed
more hospitals awarded a payment for 2011 than the states reported having paid for 2011—6 percent
more hospitals in one state and 11 percent more in the other. Discrepancies between the NLR and
state data were much smaller for professionals, less than one percent in all 6 states.



Page 11                                                   GAO-13-146R Electronic Health Records
Enclosure I

•   were acute care, critical access, cancer, or children’s hospitals;

•   were located in one of the 50 states, the District of Columbia, or a U.S. insular
    area; and

•   were not terminated from participating in the Medicaid program on or before
    January 2, 2011. 4

We used a similar approach to estimate the percentage of hospitals that were
awarded an incentive payment in each state. To estimate the nationwide percentage
of professionals who were awarded an incentive payment, we divided the number of
professionals who were awarded an incentive payment by the national estimate of
the number of eligible professionals—139,600—that CMS developed in consultation
with the Congressional Budget Office. 5 We used CMS’s national estimate of eligible
professionals because we lacked the data to be able to identify professionals who
met the minimum Medicaid or needy patient volume threshold—a key eligibility
requirement in the Medicaid EHR program—but did not receive a Medicaid EHR
incentive payment. Because CMS’s estimate of the number of eligible professionals
was not available at the state level, instead of estimating the percentage of
professionals awarded an incentive payment in each state, we estimated the number
of eligible professionals awarded an incentive payment per 10,000 Medicaid
enrollees for each state (based on a CMS count of enrollment for each state as of
December 31, 2010).

Amount of Medicaid EHR incentive payments awarded to providers. We
determined the total amount of the incentive payments that were awarded to
providers by summing the Medicaid EHR incentive payments that had been
disbursed to providers. To provide context, we compared these numbers to
participation levels and total award amounts made under the Medicare EHR
program for 2011. 6 We also examined the distribution of the Medicaid incentive
payments for hospitals and professionals. Specifically, for hospitals, we determined

4
 In this report, for the purpose of analyzing participation in the Medicaid EHR program, we use the
term acute care hospital to describe short-term hospitals that are not critical access or cancer
hospitals. However, in the Medicaid EHR program, the term acute care hospital refers to short-term
hospitals generally, which includes critical access hospitals, and cancer hospitals. The hospitals
classified as critical access hospitals typically are very small (25 inpatient beds or fewer) and operate
in rural areas.
5
 CMS determined its estimate of the professionals eligible for the Medicaid EHR program as follows.
First, CMS estimated that 14 percent of the 553,200 professionals participating in fee-for-service
Medicare in 2011 were ineligible for an EHR payment for 2011 because they were hospital based. Of
the 477,500 remaining professionals, it estimated that 20 percent, or 95,500, would meet the
Medicaid patient volume requirements and choose to participate in the Medicaid EHR program
instead of the Medicare EHR program because the incentive payment in the Medicaid EHR program
is higher than that in the Medicare EHR program. Next, CMS estimated that there were about 44,
100 professionals who were not eligible for the Medicare EHR payment but were eligible under the
Medicaid program. These included pediatricians and eligible nonphysicians such as nurse
practitioners and certified nurse midwives. Together, these two groups totaled 139,600. See 75 Fed.
Reg. 44314, 44548 (July 28, 2010).
6
See GAO-12-778R for information on participation in the Medicare EHR program in 2011.



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Enclosure I

the minimum, 25th percentile, median, 75th percentile, and maximum Medicaid EHR
incentive payment amount. For professionals, we determined the percentages who
were awarded an incentive payment amount of (1) $21,250, which was the
maximum Medicaid EHR incentive payment amount for most professionals, and
(2) $14,167, which is the maximum Medicaid EHR incentive payment amount for
pediatricians who qualify with a Medicaid patient volume of less than 30 percent but
at least 20 percent. 7

Characteristics of providers that were awarded Medicaid EHR incentive
payments. To examine the characteristics of providers that were awarded Medicaid
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. 8 (See
table 3.) Each characteristic is divided into two or more categories. For example, the
characteristic “location” is divided into two categories—rural and urban. As part of
this analysis for hospitals, we also compared the characteristics of hospitals that
were awarded a Medicaid EHR incentive payment to those of eligible hospitals that
were not awarded such payments. 9 To do so, 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.




7
 Pediatricians with a 30 percent Medicaid patient volume or greater were awarded an incentive
payment of $21,250 for 2011.
8
 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.
9
 It was not feasible to conduct a similar analysis of professionals that examined characteristics of
eligible professionals who received a Medicaid EHR incentive payment compared to those who did
not. We lacked the data to be able to identify professionals who met the minimum Medicaid or needy
patient volume threshold—a key eligibility requirement in the Medicaid EHR program—but did not
receive a Medicaid EHR incentive payment.



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Enclosure I

Table 3: Data Sources Analyzed to Examine Characteristics of Eligible Providers

                                                                                                Date of extract,
    Agency or entity           Data source                                                      download, or release
    Centers for Medicare       National Level Repository                                        October 2012
    & Medicaid Services        National Plan and Provider Enumeration System Data               May 2012
    (CMS)                                         a
                               Dissemination File
                                                                                          a
                               Provider Enrollment, Chain, and Ownership System                 August 2012
                               Provider of Services File                                        June 2012
                               Online Survey, Certification, and Reporting System               May 2011
                                                                                                               b
                               Fiscal Intermediary Standard System                              August 2012
                               2011 primary care health professional shortage areas             November 2010
                               2010 recipients of incentive payments from CMS’s                 July 2011
                               Electronic Prescribing program
    Health Resources and Area Resource File                                                     March 2012
    Services
    Administration
    Office of the National Regional Extension Center Customer Relationship                      July 2012
                                                            c
    Coordinator for Health Management System extract file
    Information            List of zip codes serviced by a Beacon Community
                                                                           d
                                                                                                June 2012
    Technology (ONC)
    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
    We used data that we obtained from CMS in December 2011 for 110 hospitals for which we did not have August 2012 data.
c
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, participate in
CMS’s EHR programs.
d
 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.


Using the data obtained from the sources listed in table 3, we examined the
following provider characteristics:

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


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. We were missing zip code data for no hospitals and
17 professionals. 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. When there was a discrepancy in practice state between
those previously mentioned data sources and the state from which the provider received an incentive
payment, as reflected in the National Level Repository—which occurred for 3 hospitals and for
702 professionals—we used the payment state and generally excluded those providers from our
analysis of regional characteristics. However, for geographic region we were able to use state
information rather than zip code information.



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Enclosure I

     •   Geographic region. We used the Health Resources and Services
         Administration’s Area Resource File to identify the U.S. census region—
         Northeast, Midwest, 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. 12 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.

     •   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. 13 Using these
         aggregated data, we created three categories for hospitals: (1) low—less than
         or equal to the 33.3rd percentile, (2) middle—greater than the 33.3rd
         percentile but less than or equal to the 66.7th percentile, and (3) high—
         greater than the 66.7th percentile.

     •   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. 14

     •   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. 15


11
 Information on U.S. census region was available for all providers.
12
 Information on whether providers were located in urban or rural areas was missing for 5 eligible
hospitals (less than 0.1 percent) and 732 professionals (1.6 percent).
13
 Information on county volume of electronic prescribing transactions was missing for 35 eligible
hospitals (less than 1 percent).
14
  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. Information on whether a provider is
located in a county with a Beacon Community was missing for 3 eligible hospitals (less than
1 percent) and 732 professionals (1.6 percent).
15
  CMS’s list of zip codes for health professional shortage areas does not contain zip codes that were
only partially in a shortage area. Information on whether a professional practices in a health
professional shortage area was missing for 732 professionals (1.6 percent).



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Enclosure I

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

      •   Hospital classification. We determined whether hospitals were classified as
          acute care, critical access, cancer, or children’s hospitals by using data from
          CMS’s Provider of Services file and a list provided by CMS. 16

      •   Major teaching hospital. We determined whether hospitals were listed as
          having a major affiliation with a medical school in CMS’s Provider of Services
          file. 17

      •   Ownership type. We primarily used data on ownership type from CMS’s
          Provider of Services file to create three categories of ownership: (1) for-profit
          by combining private for-profit and physician ownership, (2) nonprofit by
          combining church and private not-for-profit, and (3) 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. 18

      •   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
          Provider Enrollment, Chain, and Ownership System were designated as not
          being a member of a chain. 19

•     Hospital size. We analyzed data on the following measures of hospital size from
      CMS’s Provider of Services file and Fiscal Intermediary Standard System: 20



16
  CMS provided a list of hospitals that were eligible for the Medicaid EHR incentive program, but not
the Medicare EHR incentive program, including children’s and cancer hospitals and hospitals located
in the U.S. insular areas. Information on hospital classification was available for all eligible hospitals.
17
    Information on hospital affiliation with a medical school was available for all hospitals.
18
  Information on hospital ownership type was missing for two eligible hospitals (less than
0.1 percent).
19
    Information on chain membership was missing for 212 hospitals (about 4 percent).
20
  Data from CMS’s Fiscal Intermediary Standard System were missing for 168 acute care hospitals
(about 5 percent of eligible acute care hospitals) because, at the time of our data extract, CMS had
not populated the system with information on those hospitals. These data were also missing for
837 critical access hospitals (about 63 percent of eligible critical access hospitals) because, in
general, CMS only populates the system with information for those hospitals after the hospital has
applied for an incentive payment from the Medicare EHR program and submitted documentation of
the reasonable costs associated with the acquisition of the EHR system. In addition, these data were
missing for most cancer hospitals, children’s hospitals, and hospitals in the U.S. insular areas
because CMS does not populate the system with information for those hospitals. Consequently, data
from CMS’s Fiscal Intermediary Standard System were missing for a total of 1,108 hospitals.



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Enclosure I

      •   Total beds. Using data from CMS’s Provider of Services file on the total
          number of hospital beds, we created three categories: (1) low—less than or
          equal to the 33.3rd percentile, (2) middle—greater than the 33.3rd percentile
          but less than or equal to the 66.7th percentile, and (3) 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: (1) low—less than or equal to the 33.3rd percentile, (2) middle—
          greater than the 33.3rd percentile but less than or equal to the 66.7th
          percentile, and (3) 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:

      •   Total charges. Using data on the total amount of charges, we created three
          categories: (1) low—less than or equal to the 33.3rd percentile, (2) middle—
          greater than the 33.3rd percentile but less than or equal to the 66.7th
          percentile, and (3) high—greater than the 66.7th percentile. 22

      •   Charity charges. Using data on charity charges, we created three categories:
          (1) low—less than or equal to the 33.3rd percentile, (2) middle—greater than
          the 33.3rd percentile, but less than or equal to the 66.7th percentile, and
          (3) high—greater than the 66.7th percentile. 23

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

      •   Professional specialty. We chiefly 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: (1) general practice
          physician, (2) specialty practice physician, (3) certified nurse midwife or nurse




21
    Information on total beds was available for all eligible hospitals.
22
 In addition to the 1,108 hospitals for which we were missing data on total charges and charity
charges, we excluded an additional 7 hospitals from our analyses of total charges and of charity
charges after determining that the hospitals’ data were unreliable because the amount of charity
charges exceeded the total amount of charges.
23
 Charity charges reflect the cost for providing inpatient and outpatient hospital services for which the
hospital is not compensated.



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Enclosure I

         practitioner, (4) physician assistant, (5) dentist, and (6) other professional. 24 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. 25 To examine variation among
         different types of specialty practice physicians, we used information from the
         CMS crosswalk to assign specialty practice physicians to 1 of 28 specialty
         categories, such as such as cardiology, surgery, and psychiatry.

     •   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. 26 We subsequently created four
         practice size categories: (1) solo practice, (2) practice of 2 to 10
         professionals, (3) practice of 11 to 50 professionals, and (4) practice of 51 or
         more professionals. We also created a fifth category for professionals who
         were associated with more than one group practice of different sizes.

     •   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. 27 We then categorized professionals as either having signed an
         agreement to receive technical assistance or not.




24
  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. “Specialty practice
physician” also includes optometrists because the Medicaid statute permits states to consider, under
the provisions of their state Medicaid plans, optometrist services as physician services; thus,
optometrist services may qualify for the Medicaid EHR program. “Certified nurse midwife or nurse
practitioner” also includes other registered nurses because CMS regulations permit states, in
accordance with the scope of practice defined under state law, to allow other types of registered
nurses who meet the regulations’ training and experience to qualify for the Medicaid EHR program as
nurse midwives or nurse practitioners. “Other professional”—531 professionals (1.2 percent)—
comprises 426 professionals for whom information on professional specialty was missing and
105 professionals who we could not confirm had specialty types that were eligible to receive incentive
payments. However, CMS officials told us that these 531 professionals had permissible professional
specialties.
25
  Professionals were not required to enroll in the Provider Enrollment, Chain, and Ownership System
in order to receive incentive payments from the Medicaid EHR program.
26
  Information on the number of professionals in the practice was missing for 14,747 professionals
(32 percent).
27
 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, participate in CMS’s EHR programs.



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Enclosure I

     •   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. 28 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
         each professional’s degree was awarded. 29 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: (1) low—15 years or fewer, (2) middle—16 to
         29 years, and (3) high—30 years or more.

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.

We conducted this performance audit from January 2012 to December 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.




28
  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. 2494,
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).
29
 Information on the number of years since the professional’s degree was awarded was missing for
12,848 professionals (about 28 percent).



Page 19                                                   GAO-13-146R Electronic Health Records
Enclosure II

                Information on Hospitals Awarded Medicaid EHR
                          Incentive Payments for 2011

This enclosure provides information on the number and percentage of hospitals that
were awarded Medicaid 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 5,013 eligible hospitals, 39 percent, or 1,964 hospitals, were
awarded a Medicaid EHR incentive payment for 2011. In contrast to professionals,
certain hospitals may receive an incentive payment from both the Medicare and
Medicaid EHR programs in the same year. As of October 1, 2012, 529 hospitals
were awarded an incentive payment from both programs for 2011. The percentage
of eligible hospitals that were awarded a Medicaid EHR incentive payment varied
across states. For example, more than 60 percent of eligible hospitals in Alabama
were awarded a Medicaid EHR incentive payment for 2011, whereas less than
20 percent of eligible hospitals in Montana were awarded an incentive payment.
(See fig. 1.)




Page 20                                         GAO-13-146R Electronic Health Records
Enclosure II

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




Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. Colorado, the District of Columbia, Hawaii, Idaho, Minnesota, Nebraska, Nevada, New Hampshire, Virginia, and
the U.S. insular areas did not participate in the Medicaid EHR program in 2011.


Of the approximately $2.7 billion in Medicaid EHR incentive payments that was
awarded to providers for 2011, a total of $1.7 billion was awarded to hospitals. The
amount of Medicaid EHR incentive payments awarded to hospitals ranged from
$7,528 to $7.2 million, with the median amount being $613,512. About 50 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 but smaller
incentive payments than children’s hospitals. (See fig. 2.)




Page 21                                                              GAO-13-146R Electronic Health Records
Enclosure II

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




Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. We excluded the 11 cancer hospitals from this analysis.
a
 For the purpose of analyzing participation in the Medicaid EHR program, the term acute care hospital refers to short-term
hospitals that are not critical access or cancer hospitals.
b
Critical access hospitals typically are very small (25 inpatient beds or fewer) and operate in rural areas.


As illustrated in table 4, among hospitals that were awarded a Medicaid EHR
incentive payment for 2011,

•    the largest proportion (46 percent) were located in the South and the smallest
     proportion (15 percent) were located in the Northeast,

•    three-fifths (62 percent) were located in urban areas,

•    four-fifths (80 percent) were acute care hospitals,

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

•    more than half (57 percent) were not members of a chain, and

•    more than two-fifths (43 percent) were relatively large in terms of number of
     beds.




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Enclosure II

Table 4: Selected Characteristics of Hospitals Awarded a Medicaid EHR Incentive Payment for 2011

    Characteristics                     Categories                                                      Number (percentage)
    Geographic region                   Midwest                                                                    437 (22.3)
                                        Northeast                                                                  295 (15.0)
                                        South                                                                      897 (45.7)
                                        West                                                                       335 (17.1)
    Location                            Rural                                                                      744 (37.9)
                                        Urban                                                                    1,217 (62.0)
                                                                   a
    Hospital classification             Acute care hospital                                                      1,570 (79.9)
                                                                        b
                                        Critical access hospital                                                   354 (18.0)
                                        Children’s hospital                                                           39 (2.0)
                                        Cancer hospital                                                                1 (0.1)
    Ownership type                      For-profit                                                                 413 (21.0)
                                        Government-owned                                                           434 (22.1)
                                        Nonprofit                                                                1,117 (56.9)
    Chain membership                    Chain                                                                      827 (42.6)
                                        Nonchain                                                                 1,114 (57.4)
    Total beds                          Low (40 beds or fewer)                                                     416 (21.2)
                                        Middle (41-175 beds)                                                       713 (36.3)
                                        High (176 or more beds)                                                    835 (42.5)
    Total                                                                                                        1,964 (100)
Source: GAO analysis of CMS and Health Resources and Services Administration data.

Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. The sum of the number of hospitals listed by category may not equal the overall number of hospitals because of
missing data. The sum of the percentage of hospitals listed by category may not equal 100 percent because of rounding.
a
 For the purpose of analyzing participation in the Medicaid EHR program, the term acute care hospital refers to short-term
hospitals that are not critical access or cancer hospitals.
b
Critical access hospitals typically are very small (25 inpatient beds or fewer) and operate in rural areas.


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




Page 23                                                                              GAO-13-146R Electronic Health Records
Enclosure II

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




Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. Hospitals located in the states, the District of Columbia, and the U.S. insular areas that did not offer the
Medicaid EHR program in 2011 are included in the category of eligible hospitals that were not awarded an incentive payment.
Hospital classification excludes the 11 cancer hospitals because so few hospitals belong to that category.
a
 For the purpose of analyzing participation in the Medicaid EHR program, the term acute care hospital refers to short-term
hospitals that are not critical access or cancer hospitals.
b
Critical access hospitals typically are very small (25 inpatient beds or fewer) and operate in rural areas.


Tables 5 through 8 explore the relationship of various factors to the likelihood of
hospitals receiving Medicaid EHR incentive payments for 2011 by comparing the
characteristics of hospitals that were awarded Medicaid EHR incentive payments for
2011 to those of other eligible Medicaid 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—Northeast,
Midwest, 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 5 shows, under the
characteristic “location,” the relative risk ratio of 1.2 for the category “urban”
indicates that hospitals in urban areas were 1.2 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 24                                                                   GAO-13-146R Electronic Health Records
Enclosure II

Table 5 examines the relationship between hospitals receiving Medicaid EHR
incentive payments for 2011 and characteristics of the regions in which the hospitals
are located. We found the following:

•   Geographic location had a modest effect on the likelihood that hospitals were
    awarded an EHR incentive payment for 2011. For instance, hospitals in the
    Northeast and South—the regions of the country with the highest level of
    program participation—were 1.6 times more likely to have been awarded a
    payment than hospitals in the Midwest—the region of the country with the lowest
    level of program participation.

•   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
    Beacon Community.




Page 25                                         GAO-13-146R Electronic Health Records
Enclosure II

Table 5: Number and Percentage of Hospitals Awarded Medicaid EHR Incentive Payments for 2011, by
Regional Characteristics

                                                                                                   Number (percentage)
                                                                                     Awarded a                        Not awarded a
                                                                         Number of Medicaid EHR                       Medicaid EHR
                                                                           eligible    incentive                           incentive            Relative risk
                                                                                   a                                                                         b
    Characteristics                          Categories                  hospitals      payment                             payment                    ratio
    Overall                                                                      5,013          1,964 (39.2)              3,049 (60.8)
    Geographic location
      Geographic region                      Midwest                             1,461             437 (29.9)             1,024 (70.1)                             —
                                             Northeast                              625            295 (47.2)                330 (52.8)                        1.6
                                             South                               1,904             897 (47.1)             1,007 (52.9)                         1.6
                                             West                                   965            335 (34.7)                630 (65.3)                        1.2
      Location                               Rural                               2,076             744 (35.8)             1,332 (64.2)                             —
                                             Urban                               2,932          1,217 (41.5)              1,715 (58.5)                         1.2
    County level of participation
    in selected health
    information technology
                c
    initiatives                                                                                                                                                    —
      Average county volume                  Low (126.2 or fewer
      of electronic prescribing              transactions)                       1,731             556 (32.7)             1,165 (67.3)                             —
      based on transactions per              Middle (126.3-176.9
      professional who submits                                                   1,568             663 (42.3)                905 (57.7)                        1.3
                                             transactions)
      electronic prescriptions
                                             High (177 or more
                                             transactions)                       1,679             723 (43.1)                956 (56.9)                        1.3
      Located in a county with               Yes                                   305             136 (44.6)                169 (55.4)                        1.1
      a Beacon Community                     No                                  4,705          1,825 (38.8)              2,880 (61.2)                             —
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 Medicaid EHR program through October 1, 2012, for the 2011
program year. In general, hospitals located in the states, the District of Columbia, and the U.S. insular areas that did not offer
the Medicaid EHR program in 2011 are included in the category of hospitals not awarded an incentive payment. However,
geographic region does not include the 58 hospitals located in the U.S. insular areas because none of those areas participated
in the Medicaid EHR program for 2011. The sum of the number of hospitals listed by category may not equal the overall
number of hospitals because of missing data.
a
 We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicaid EHR program, regardless of
whether they were awarded a Medicaid EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care, critical access, cancer, or children’s hospitals; (2) located in one of the 50 states, the District of Columbia, or a
U.S. insular area; and (3) not terminated 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
hospitals in a given county, rather than the level of participation associated with any particular hospital.


Table 6 examines the relationship between receiving a Medicaid EHR incentive
payment for 2011 and hospital type. We found that hospital classification had a
greater impact on the likelihood of receiving a Medicaid EHR incentive payment for
2011 than being a major teaching hospital, ownership type, or chain membership. In
particular, we found the following:




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Enclosure II

•       Among the three hospital classifications identified below, acute care hospitals
        were 1.7 times more likely and children’s hospitals were 1.6 times more likely to
        have been awarded a Medicaid EHR incentive payment for 2011 than critical
        access hospitals.

•       There was a more modest relationship between a hospital’s status as a major
        teaching hospital, ownership type, and chain affiliation with the likelihood of a
        hospital being awarded an EHR incentive payment for 2011; major teaching
        hospitals, for-profit hospitals, and chain hospitals were 1.3 to 1.4 times more
        likely than other hospitals to be awarded payments.

Table 6: Number and Percentage of Hospitals Awarded Medicaid EHR Incentive Payments for 2011, by
Hospital Type

                                                                                Number (percentage)
                                                                            Awarded a             Not awarded a
                                                          Number of       Medicaid EHR            Medicaid EHR
                                                            eligible          incentive                incentive      Relative risk
                                                                    a                                                              b
    Characteristics        Categories                     hospitals            payment                  payment              ratio
    Overall                                                    5,013          1,964 (39.2)           3,049 (60.8)
                                                 d
    Hospital               Acute care hospital                 3,576          1,570 (43.9)           2,006 (56.1)                 1.7
                   c
    classification                                    e
                           Critical access hospital            1,332            354 (26.6)              978 (73.4)                 —
                           Children’s hospital                    94             39 (41.5)               55 (58.5)                1.6
    Major teaching         Yes                                   493            244 (49.5)              249 (50.5)                1.3
    hospital               No                                  4,520          1,720 (38.1)           2,800 (61.9)                  —
    Ownership type         For-profit                            887            413 (46.6)              474 (53.4)                1.3
                           Government-owned                    1,222            434 (35.5)              788 (64.5)                 —
                           Nonprofit                           2,902          1,117 (38.5)           1,785 (61.5)                 1.1
    Chain                  Chain                               1,662            827 (49.8)              835 (50.2)                1.4
    membership             Nonchain                            3,139          1,114 (35.5)           2,025 (64.5)                  —
Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. Hospitals located in the states, the District of Columbia, and the U.S. insular areas that did not offer the
Medicaid EHR program in 2011 are included in the category of hospitals not awarded an incentive payment. The sum of the
number of hospitals listed by category may not equal the overall number of hospitals because of missing data.
a
 We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicaid EHR program, regardless of
whether they were awarded a Medicaid EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care, critical access, cancer, or children’s hospitals; (2) located in one of the 50 states, the District of Columbia, or a
U.S. insular area; and (3) not terminated 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
 This analysis excludes the 11 cancer hospitals because so few hospitals belong to that category.
d
 For the purpose of analyzing participation in the Medicaid EHR program, the term acute care hospital refers to short-term
hospitals that are not critical access or cancer hospitals.
e
    Critical access hospitals typically are very small (25 inpatient beds or fewer) and operate in rural areas.




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Enclosure II

Table 7 examines the extent to which the size of hospitals, measured in various
ways, is related to whether hospitals were awarded Medicaid EHR incentive
payments for 2011. We found that large hospitals were more likely to have been
awarded Medicaid EHR incentive payments for 2011. Specifically, we found the
following:

•      Hospitals with the highest number of total beds were 2 times more likely than
       hospitals with the lowest number of total beds to have been awarded an incentive
       payment.

•      Hospitals with the highest number of total discharges were 1.5 times more likely
       to have been awarded an incentive payment than hospitals with the lowest
       number of discharges.

Table 7: Number and Percentage of Hospitals Awarded Medicaid EHR Incentive Payments for 2011, by
Hospital Size

                                                                                Number (percentage)
                                                                             Awarded a Not awarded a
                                                          Number of        Medicaid EHR Medicaid EHR
                                                            eligible           incentive    incentive                 Relative risk
                                                                    a                                                              b
    Characteristics        Categories                     hospitals             payment      payment                         ratio
    Overall                                                      5,013         1,964 (39.2)        3,049 (60.8)
    Total beds             Low (40 beds or fewer)                1,674           416 (24.9)        1,258 (75.1)                    —
                           Middle (41-175 beds)                  1,662           713 (42.9)          949 (57.1)                   1.7
                           High (176 or more beds)               1,677           835 (49.8)          842 (50.2)                   2.0
    Total discharges       Low (2,216 or fewer
                           discharges)                           1,302           433 (33.3)          869 (66.7)                    —
                           Middle (2,217-8,845
                           discharges)                           1,302           610 (46.9)          692 (53.1)                   1.4
                           High (8,846 or more
                           discharges)                           1,301           660 (50.7)          641 (49.3)                   1.5
                                     c
                           Missing                               1,108           261 (23.6)          847 (76.4)                  N/A
Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. Hospitals located in the states, the District of Columbia, and the U.S. insular areas that did not offer the
Medicaid EHR program in 2011 are included in the category of hospitals not awarded an incentive payment.
a
 We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicaid EHR program, regardless of
whether they were awarded a Medicaid EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care, critical access, cancer, or children’s hospitals; (2) located in one of the 50 states, the District of Columbia, or a
U.S. insular area; and (3) not terminated 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 from CMS’s Fiscal Intermediary Standard System were missing for 168 acute care hospitals (about 5 percent of eligible
acute care hospitals) and for 837 critical access hospitals (about 63 percent of eligible critical access hospitals) because CMS
had not populated the system with information on those hospitals at the time of our data extract. In addition, these data were
missing for most cancer hospitals, children’s hospitals, and hospitals in the U.S. insular areas because CMS does not populate
the system with information for those hospitals. Consequently, we were missing data for 1,108 hospitals.




Page 28                                                                     GAO-13-146R Electronic Health Records
Enclosure II

Table 8 examines the relationship between receiving Medicaid 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 have been awarded a
Medicaid EHR incentive payment for 2011 compared to hospitals with lower
charges. Specifically, we found the following:

•      Hospitals with high total charges were 1.5 times more likely to have been
       awarded an incentive payment than hospitals with low total charges.

•      Hospitals with high charity charges were 1.6 times more likely to have been
       awarded an incentive payment than hospitals with low charity charges.

Table 8: Number and Percentage of Hospitals Awarded Medicaid EHR Incentive Payments for 2011, by
Hospital Charges

                                                                                  Number (percentage)
                                                                              Awarded a          Not awarded a
                                                           Number of        Medicaid EHR         Medicaid EHR
                                                             eligible           incentive             incentive              Relative
                                                                     a                                                                b
    Characteristics        Categories                      hospitals             payment               payment             risk ratio
    Overall                                                       5,013         1,964 (39.2)         3,049 (60.8)
    Total charges          Low ($111,593,929 or less)             1,299           448 (34.5)            851 (65.5)                  —
                           Middle ($111,593,930-
                           $478,030,437)                          1,300           571 (43.9)            729 (56.1)                 1.3
                           High ($478,030,438 or more)            1,299           683 (52.6)            616 (47.4)                 1.5
                                     c
                           Missing                                1,115           262 (23.5)            853 (76.5)                N/A
                      d
    Charity charges        Low ($828,462 or less)                 1,299           435 (33.5)            864 (66.5)                  —
                           Middle ($828,463-$10,937,135)          1,300           587 (45.2)            713 (54.8)                 1.3
                           High ($10,937,136 or more)             1,299           680 (52.3)            619 (47.7)                 1.6
                                     c
                           Missing                                1,115           262 (23.5)            853 (76.5)                N/A
Source: GAO analysis of CMS data.

Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. Hospitals located in the states, the District of Columbia, and the U.S. insular areas that did not offer the
Medicaid EHR program in 2011 are included in the category of hospitals not awarded an incentive payment.
a
We use the term eligible hospitals to refer to those hospitals that were eligible for the Medicaid EHR program, regardless of
whether they were awarded a Medicaid EHR incentive payment for 2011. Specifically, eligible hospitals are those that were
(1) acute care, critical access, cancer, or children’s hospitals; (2) located in one of the 50 states, the District of Columbia, or a
U.S. insular area; and (3) not terminated 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 from CMS’s Fiscal Intermediary Standard System were missing for 168 acute care hospitals (about 5 percent of eligible
acute care hospitals) and for 837 critical access hospitals (about 63 percent of eligible critical access hospitals) because CMS
had not populated the system with information on those hospitals at the time of our data extract. In addition, these data were
missing for most cancer hospitals, children’s hospitals, and hospitals in the U.S. insular areas because CMS does not populate
the system with information for those hospitals. Consequently, we were missing data for 1,108 hospitals. We excluded an
additional 7 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 Awarded Medicaid EHR
                            Incentive Payments for 2011

This enclosure provides information on the number and percentage of professionals
who were awarded Medicaid EHR incentive payments for 2011, the amount of
incentive payments awarded to professionals, and the characteristics of
professionals who were awarded incentive payments.

Of the estimated 139,600 eligible professionals, 33 percent, or 45,962 professionals,
were awarded a Medicaid EHR incentive payment for 2011. The number of eligible
professionals who were awarded a Medicaid EHR incentive payment varied across
states. For example, more than 15 eligible professionals per 10,000 Medicaid
enrollees in Mississippi were awarded a Medicaid EHR incentive payment for 2011
whereas less than 5 eligible professionals per 10,000 Medicaid enrollees in Utah
were awarded an incentive payment. (See fig. 4.)




Page 30                                         GAO-13-146R Electronic Health Records
Enclosure III

Figure 4: Number of Eligible Professionals Awarded a Medicaid EHR Incentive Payment per 10,000
Medicaid Enrollees for 2011, by State




Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. Medicaid enrollment data are based on enrollment, by state, as of December 31, 2010. Colorado, the District of
Columbia, Hawaii, Idaho, Minnesota, Nebraska, Nevada, New Hampshire, Virginia, and the U.S. insular areas did not
participate in the Medicaid EHR program in 2011. North Dakota did participate but had not reported to CMS on its payments to
professionals by the time of our analysis.


Of the approximately $2.7 billion in Medicaid EHR incentive payments that was
awarded to providers for 2011, $967 million was awarded to professionals. Among
participating professionals, 97 percent were awarded an incentive payment of
$21,250, which was the maximum amount for most professionals. The remaining
3 percent of professionals were awarded an incentive payment of $14,167, which
was the maximum amount for pediatricians that had a Medicaid patient volume of
20 percent or more but less than 30 percent.

As illustrated in table 9, among professionals who were awarded a Medicaid EHR
incentive payment for 2011,


Page 31                                                               GAO-13-146R Electronic Health Records
Enclosure III

•      the largest proportion (37 percent) were located in the South and the smallest
       proportion (20 percent) were located in the Midwest, and

•      four-fifths (83 percent) were located in urban areas.

Table 9: Regional Characteristics of Professionals Awarded a Medicaid EHR Incentive Payment for 2011

    Characteristics                                                                               Categories                      Number (percentage)
    Geographic location
      Geographic region                                                                           Midwest                                        8,946 (19.5)
                                                                                                  Northeast                                    10,079 (21.9)
                                                                                                  South                                        17,008 (37.0)
                                                                                                  West                                           9,929 (21.6)
      Location                                                                                    Rural                                          7,662 (16.9)
                                                                                                  Urban                                        37,568 (83.1)
      Located in a health professional shortage area                                              Yes                                              3,324 (7.3)
                                                                                                  No                                           41,906 (92.7)
    County level of participation in selected health
                                      a
    information technology initiative
      Located in a county with a Beacon Community                                                 Yes                                              3,604 (8.0)
                                                                                                  No                                           41,626 (92.0)
    Total                                                                                                                                       45,962 (100)
Source: GAO analysis of CMS, Office of the National Coordinator for Health Information Technology, and Health Resources and Services Administration data.

Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. The sum of the number of professionals listed by category may not equal the overall number of professionals
because of missing data. The sum of the percentage of professionals listed by category may not equal 100 percent because of
rounding.
a
 This characteristic describes 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.


As illustrated in table 10, among professionals who were awarded a Medicaid EHR
incentive payment for 2011,

•      nearly three-quarters were physicians—either general practice physicians
       (23 percent) or specialty practice physicians (51 percent)—and the lowest
       proportion (1 percent) were physician assistants, and

•      almost half (47 percent) had signed agreements to receive technical assistance
       from a Regional Extension Center.




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Enclosure III

Table 10: Professional Characteristics of Professionals Awarded a Medicaid EHR Incentive Payment for
2011

    Characteristics                                       Categories                                             Number (percentage)
    Professional specialty                                General practice physician                                    10,458 (22.8)
                                                                                                  a
                                                          Specialty practice physician                                  23,490 (51.1)
                                                                                                             b
                                                          Certified nurse midwife or nurse practitioner                  8,454 (18.4)
                                                          Physician assistant                                               545 (1.2)
                                                          Dentist                                                         2,484 (5.4)
                                                                                     c
                                                          Other professional                                                531 (1.2)
                                                    d
    Number of professionals in practice                   Solo practice                                                  5,200 (16.7)
                                                          2-10 professionals                                             5,569 (17.8)
                                                          11-50 professionals                                            4,257 (13.6)
                                                          51 or more professionals                                       8,387 (26.9)
                                                          More than one group practice of different sizes                7,802 (25.0)
    Signed an agreement to receive                        Yes                                                           21,374 (46.5)
    technical assistance from a
                                                          No                                                            24,588 (53.5)
    Regional Extension Center
    Received an incentive payment                         Yes                                                             1,783 (3.9)
    from CMS’s Electronic Prescribing                     No                                                            44,179 (96.1)
    Program for 2010
                                           e
    Years since degree awarded                            Low (15 years or fewer)                                       13,761 (41.6)
                                                          Middle (16-29 years)                                          11,800 (35.6)
                                                          High (30 years or more)                                        7,553 (22.8)
    Total                                                                                                                45,962 (100)
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 Medicaid EHR program through October 1, 2012, for the 2011
program year. The sum of the percentage of professionals listed by category may not equal 100 percent because of rounding.
a
 This category also includes optometrists because the Medicaid statute permits states to consider, under the provisions of their
state Medicaid plan, optometrist services as physician services; thus, optometrist services may qualify for the Medicaid EHR
program.
b
 This category also includes other types of registered nurses because CMS regulations permit states, in accordance with the
scope of practice defined under state law, to allow other types of registered nurses who meet the regulations’ training and
experience requirements to qualify for the Medicaid EHR program as nurse midwives or nurse practitioners.
c
  This category includes 426 professionals for whom information on professional specialty was missing and 105 professionals
who we could not confirm had specialty types that were eligible to receive incentive payments. However, CMS officials told us
that these 531 professionals had permissible professional specialties.
d
 Information on the number of professionals in the practice was missing for 14,747 professionals (32 percent).
e
 Information on the number of years since the professional’s degree was awarded was missing for 12,848 professionals (about
28 percent).


Of the specialty practice physicians who were awarded a Medicaid EHR incentive
payment for 2011, over half (52 percent) had a pediatrics specialty. (See fig. 5.)




Page 33                                                                                      GAO-13-146R Electronic Health Records
Enclosure III

Figure 5: Specialty Practice Physicians Awarded Medicaid EHR Incentives for 2011, by Type of Specialty




Notes: We analyzed data CMS collects pertaining to the Medicaid EHR program through October 1, 2012, for the 2011
program year. “Other specialties” includes specialty practice physicians belonging to 23 discrete specialties, none of which
makes up as much as 3 percent of the total.




(291042)



Page 34                                                                  GAO-13-146R Electronic Health Records
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