The Political Economy of Health Information Technology

Healthcare reform is arguably the hot-button political issue of our time. And with the Supreme Court locked and loaded to decide the fate of the Affordable Care Act this summer, it’s a safe bet the controversial two-year-old legislation will have a huge impact on the 2012 election and beyond.

But what about health IT? If “Obamacare” has been a lightning rod, sparking historically nasty partisan bickering – Congress vs. President Obama, Republicans vs. Democrats, Fox News vs. MSNBC, the Tea Party vs. MoveOn.org – Washington’s efforts to spur healthcare information technology have enjoyed much broader support, on both sides of the aisle.

Just last week, a Washington think tank whose healthcare wing is led by two erstwhile rival Senate Majority Leaders put its weight behind smarter and more widespread use of technology and data exchange in healthcare organizations nationwide.

“To deliver high-quality, cost-effective care, a physician or hospital needs good information,” said former senator Bill Frist, MD, upon the release of a report, on Jan. 27, from the Bipartisan Policy Center’s Task Force on Delivery System Reform and Health IT. “Data about patients has to flow across primary care physicians, hospitals, labs, and anywhere that patients receive care.”

“There is strong bipartisan support for health IT,” added Frist’s old senate colleague, Tom Daschle, and also for “moving away from a payment model that largely focuses on volume – rewarding providers for doing more – rather than on quality outcomes or value.”

Hard to argue with that. But is support for health IT – and the transformative potential to improve quality, lower costs and widen access it represents – really as bipartisan as so many in the industry say it is?

Especially when adoption of electronic health records and establishment of both health information exchanges (HIE) and the highly-contentious health insurance exchanges (HIX) are being spurred in large part by money from the very federal stimulus program against which the Tea Party rose up to protest?

Without question, we find ourselves living in a starkly polarized country.

“When we’re up on Capitol Hill, one of the big frustrations is this lack of bipartisanship in general,” said Dave Roberts, vice president for government relations at HIMSS. “How do you create bipartisan conversations? Unfortunately, the system has broken down so much that they’re not finding a lot of things they can talk about.”

Strikingly, however, health information technology is “one of the extremely few areas where there still does appear to be consensus,” he said. “I personally think one of the reasons is that you have people on both sides of the aisle who see its value.”

How the feds first met HIT

Healthcare got just cursory mentions in President Obama’s State of the Union address earlier this month. But in years past, both health reform and health IT have taken much more central roles.

In 2011, for example, Obama touted a new era where “patients will be able to have face-to-face video chats with their doctors,” and “Veterans can download their electronic medical records with a click of the mouse.”

But Obama’s predecessor, so different from him in so many ways (and still reviled by so many of his supporters), has also given the rhetorical nod to health IT – in no fewer than three separate State of the Union addresses.

“We will make wider use of electronic records and other health information technology to help control costs and reduce dangerous medical errors,” exhorted George W. Bush in his 2006 speech. These were more than just words, of course: President Bush having established the Office of the National Coordinator for Health Information Technology by executive order in 2004.

Moreover, one of the two remaining Republicans with a plausible chance of succeeding Obama is similarly a fan of health IT. Newt Gingrich, upon the founding of his Center for Health Transformation (CHT) think tank, declared that, “Widespread adoption of interoperable health information technology is a cornerstone of creating a 21st Century Intelligent Health system.”

In 2004, Gingrich delivered the keynote talk at the HIMSS annual conference in Orlando, Fla. He also corralled a group of health industry heavyweights to contribute to the CHT book Paper Kills – one of whom, Allscripts CEO Glen Tullman, has told the Wall Street Journal flatly that “healthcare IT is a nonpartisan issue.”

We recently asked National Coordinator for Health IT Farzad Mostashari, MD, whether he believes that.

His answer? “Yes.”

Even, potentially, with a Republican president and a Republican-controlled House and Senate? Does he think the meaningful use program will go forward, as envisioned when enacted by a Democratic President and Democratic majorities in both chambers?

“That is certainly my hope and belief,” Mostashari said.

So the National Coordinator is unconcerned that HITECH Act funding will be affected?

“I don’t have a crystal ball, but I see nothing to indicate that there’s a real partisan or ideological drive to diminish or roll back the advances we have made on health IT,” he said. “This has been for decades a bipartisan issue, and I think people recognize that we’ve made good progress and that we should keep pushing ahead.”

“I’ve spoken with many members of Congress about the success we’re having with healthcare IT,” Mostashari said. “What ended up in HITECH was drafted in a bipartisan way. I have not seen anything to indicate there is any partisan rancor around HITECH.” He added: “After all, this office (ONC) was founded by President Bush.”

Before the Storm

But President Bush created ONC in 2004 – a full five years before the Tea Party sprung to life, united in righteous rage at the $787 billion American Recovery and Reinvestment Act (ARRA), of which HITECH was a part.

Suddenly, thousands of people who didn’t much care about President Bush’s multi-trillion dollar deficits – his tax cuts, his off-book wars, his prescription drug entitlements – cared very, very deeply about President Obama’s spending habits.

The past three years have seen the Tea Party caucus wield a power – whether or not it’s commensurate with their actual numbers – that’s very real. Simply put: they hate government spending – whatever benefits might come from those investments.

The Tea Party’s attitudes are perhaps summed up best by Texas governor (and 2012 presidential also-ran) Rick Perry: “Washington’s insatiable desire to spend our children’s inheritance on failed stimulus plans and other misguided economic theories have given record debt and left us with far too many unemployed.”

One year ago, Rep. Jim Jordan (R-Ohio) filed a bill, The Spending Reduction Act of 2011, that sought to lower federal spending by $2.5 trillion over the next 10 years. Among the host of federal programs targeted for elimination were “certain stimulus provisions” – including the Medicare and Medicaid EHR Incentive Programs set up under HITECH.

A Democratic president, veto pen at the ready, all but ensured that Jordan’s bill would never become law. But as HIMSS’ Dave Roberts told me at the time, the concern was less the legislation itself than the uncertainty it sowed in a still-fledgling healthcare IT industry.

“We’ve heard from some CIOs, asking us, ‘What is this? We hear the House is going to rescind our money,'” Roberts said then. “It adds to the confusion in the whole marketplace. And providers and hospitals who want to purchase this [technology] are wondering, ‘Do I really want to start down this path?’

Roberts assured those people that the meaningful use program was something to count on. But he worried, back then, that “We’re leading up to the 2012 elections. The Senate’s majority is very reduced right now. And if this is a new way of thinking, that could be concerning.”

One year later, “it’s very quiet on that front,” Roberts said. “We have seen no legislation – absolutely nothing at all – perceived as trying to do anything” related to defunding HITECH.

In fact, “I don’t think we’ve heard in over a year from anybody really complaining about using federal funding to prime this area,” he said. “Elected officials know how important the medical community is – and it is a good voting community. I think they see this as a wise use” of money.

There’s more to HIT than EHRs

For all the sound and fury from anti-government conservatives about the stimulus package, it does sometimes seem surprising that ARRA’s $27 billion HITECH plank hasn’t attracted more flack from certain folks on the right.

But Chilmark Research analyst John Moore reasons that the EHR incentives are “such a small, small piece of that massive program” that it’s almost akin to “the flea on the back of the dog.”

Still, he said, “what I do think is in jeopardy is if HHS does not show strong adoption – some positive things coming out of the HITECH Act, and continued traction – then that might come back to haunt them.”

Luckily, “right now, CMS is posting some pretty good numbers with regard to adoption, growth, attestation,” Moore said. “So, with EHR adoption the lion’s share of the HITECH Act, I think that’s probably going to be pretty safe.”

On the other hand, with certain HITECH programs, such as the Beacon Communities and some of the state HIEs and HIXs, “there’s a little more reason for concern,” he said.

Indeed, sustainability will be a huge issue for state-level HIEs and HIXs in the coming years. A soft economy and fractious political landscape don’t do anything to help that issue.

Mariannette Miller-Meeks, MD, director of Iowa’s Department of Public Health (IDPH), says that, in her state, at least, “a great many people” see healthcare IT “as a bi-partisan issue.”

While certain factions might have their “concerns” about government-spurred initiatives, she told Government Health IT, “they also see the ramifications and cross-savings that can occur” by sharing data, preventing duplication of tests and services.

That said, there are lessons to be drawn, not just here but abroad. Just look at England’s massive, government-designed interoperability project, the National Programme for IT (NPfIT). Launched by the Labour party in 2002, it was essentially dismantled by the new Conservative party this past year after a disheartening, decade-long string of failures.

Politics weren’t the program’s biggest problem, but it’s hard to miss the rueful schadenfreude in this headline from website of the right-leaning Daily Mail: “£12bn NHS computer system is scrapped… and it’s all YOUR money that Labour poured down the drain.”

Will we be seeing similar news stories in the U.S. in the coming years? Marc Willard, CEO of San Jose, Calif-based Certify Data Systems – and an English expat – is no fan of the top-down NPfIT. But he doesn’t think so. “Whether Republicans or Democrats are elected in this year, I don’t think a lot is going to change around healthcare IT,” he said. “At the end of the day, health systems have to connect to their physicians.”

EHR momentum to continue apace

It’s going to be an exciting year on the campaign trail. Debate about the ACA “is really gonna stir the pot,” Moore said, noting that the potential timing of the Supreme Court’s healthcare decsision is “like whacking the hornet’s nest.”

By and large, however, he doesn’t think “the effort to provide incentives for EHRs is going to be brought under much heavy scrutiny” on the campaign trail in 2012. “In the grand scheme of things, the money being spent on it is not that significant compared to other budgets.”

And, of course, the potential ROI is enormous – presuming, that is, that the forthcoming stages 2 and 3 of the meaningful use program “can be done right.”

And even should the GOP take the White House this November, it’s unlikely that we’ll see any significant threat to meaningful use funding, Moore said.

Mitt Romney, he points out, “is a bit of a technocrat. So I don’t see him backing off HITECH. And if you look at New Gingrich, he’s a bit of a technocrat as well. So if those are the two front runners –  both of them have, by Republican standards, fairly progressive healthcare stances on policy.”

Roberts agrees. “I have not heard Gov. Romney or Speaker Gingrich say anything about this program,” he said. “I’ve actually heard Speaker Gingrich speak positively about the value of Health IT. And I think Gov. Romney, from his experience in Massachusetts, with state healthcare reform, knows that you have to have data, and the only way to have data is to have electronic health information.”

In Congress, too, “you have doctors who are members of the House now, on both sides of the aisle, that get it.” They see the HITECH Act as an “opportunity to get something in place to improve the quality of care for [their] constituents.”

And, not to put too fine a point on it, but a lot of the money is already spent. More than $2 billion has been disbursed from the incentive funds, and a couple billion more has been spent on other projects such as Regional Extension Centers and HIEs.

“The train in many ways has already left the station,” Moore said.

And it’s all been worth it so far, Roberts added. “My challenge, day in and day out, is to continue to help educate people about the value of this program,” he said. “I tell anyone who will listen: ‘You’ll probably never see a program like this in our lifetime again.'”

Mike Miliard  is a contributing editor of Government Health IT where this post first appeared. Follow Mike on Twitter @MikeMiliardHITN. Bernie Monegain and Tom Sullivan also contributed to this story.

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