Psychiatrists and other clinicians could face pressure to provide federal incentive payments that they receive for the installation or use of electronic health records (EHRs) to the community health centers or other facilities for which they provide contract medical care.

Psychiatrists and other physicians may begin qualifying this year for the first payments of what can amount to as much as $63,750 in federal cash incentives based on their purchase or their employers' purchase of EHR systems (Psychiatric News, November 5, 2010). Physicians whose employer cannot directly apply for the payments have no obligation under the law (PL 11-5) that created the incentive system to turn those funds over to that employer—regardless of whether the physicians are full time or contract employees—but some employers are considering requiring the physicians to do so, Robert Plovnick, M.D., M.S., director of the APA Department of Quality Improvement and Psychiatric Services, told Psychiatric News.

However, not all medical facilities will need to depend on physicians to voluntarily turn over the federal payments. Most hospitals can apply directly to the federal government to receive the incentive payments, with the individual incentive amount multiplied by the number of staff physicians (and other types of qualifying staff) they employ.

But at least one community mental health center (CMHC) plans to request that physicians contracted to provide medical care there designate that facility as the recipient of their EHR incentive payments, said Amy Machtay, a health care consultant, during a December 2010 webinar on EHRs sponsored by the National Council for Community Behavioral Healthcare.

The CMHC, which she did not name, plans to charge any physicians who refuse to designate the facility to receive those payments—in lieu of the clinician receiving the funds—for each time those clinicians use that facility's EHR system.

The physician, "in order to qualify for the incentive payment, will have to get reporting information [on EHR use] from the entity that provides that [EHR] system," said Machtay, about the complicated EHR relationship the law established between clinicians and medical facilities (see Actions Required to Qualify for EHR Payment). "Clinics or especially hospital-integrated-delivery-systems go about this in different ways."

Community health centers (CHCs), which provide some mental health care, also are openly discussing adding a contractual requirement for outside physicians who provide medical care at those facilities to turn over EHR payments they receive to those facilities as a way to offset the facilities' costs for installing and operating an EHR system, according to Plovnick.

"If they are full-time employees, then that makes a lot of sense because the incentive is really meant to go to those who are paying for the [EHR system], so if it is the [employer] that is paying to install it, it makes sense that [the CHC] would be compensated for that," Plovnick said.

However, the EHR law and its recently completed regulations may have created a complicated situation for some contracting psychiatrists and other physicians who receive requests to turn over their entire payment.

"One of the unintended side effects of this [law] is if you are working for multiple [facilities], and they are all going to charge you a fee [for not turning over the payment], that's pretty lousy," Plovnick said.

The National Association of Community Health Centers (NACHC) takes a different view on the payment issue, according to Amy Simmons, its communications director, who said that the organization believes that "in the case of providers who practice predominately at a federally qualified community health center (FQHC), the health center should receive the Medicaid HIT incentive payments, because the health center has made the up-front investment in the health information technology. . . . Under this particular scenario, NACHC supports and encourages health centers to seek contract amendments that will formalize this reassignment process. However, in the case of a contractor who does not work predominantly at an FQHC, NACHC believes that this is an issue to be negotiated between the contractor and the health center."

Requirements that physicians turn over such payments also would be difficult to enforce if the physician does not apply or if the physician does apply but does not qualify for the payments. Additionally, there are concerns that such requirements would impact clinicians who provide only a few hours of contract work at a health care facility and want to keep the payments to offset the cost of implementing an EHR system in their own office, said Plovnick.

"These dilemmas do point out the problems with the way in which the incentive payments are structured in that they are based on a typical conceptualization of how an office-based practice functions, without accounting for other models of health care delivery," Laura Fochtmann, M.D., chair of the APA Committee on Electronic Health Records, told Psychiatric News.

The major concern of most psychiatrists who contract with CMHCs, according to member psychiatrists who have contacted APA, is whether those facilities would qualify to receive the physicians' incentive payments, because the law does not authorize CMHCs to apply directly for the funding. Physicians who provide contract medical care at any facility qualify for the payments based on the extent of their own use of qualifying EHRs, according to the law.

Details on how psychiatrists can qualify for the incentive payments based on the types of EHRs used, the types of patient metrics tracked, and the percentage of their patients who they include in their EHR use is posted at <www.psych.org/ehr>.