Those of us who have spent years arguing in favor of standards based health information exchange (HIE) have just had a few good months. The federal government has asked IT vendors and providers what it can do to advance health information sharing across organizations. This has drawn new attention to “interoperable” health IT systems and the quality and economy of care delivered to Medicare and Medicaid beneficiaries.
In late March, the Office of the National Coordinator for Health IT (ONC) awarded cooperative agreement grants to two non-profit trade groups working to certify and credential electronic health records (EHRs) and health exchange service providers whose products are capable of secure data sharing — that is, of “talking to one another.” (Disclosure: I am the President and CEO of one of these alliances, DirectTrust.) The tone of the conversation has definitely changed.
My sense, though, is that most people still don’t have a firm grasp on the issues. They remain uncertain or confused about what interoperable health information exchange really means to providers and patients, how it can be achieved, the barriers that remain to be overcome, and who is making the decisions about these matters. So this seems like a good time for both an update and a refresher of sorts on the nature of health information exchange, and to explain why this is not a good time to reduce spending on health IT in America.
Let’s start with what is probably the most important thing to understand: we are very, very close to national deployment of a relatively simple standard, known as Direct, that enables secure Internet transport of health information between people, organizations, and software. Direct exchange permits users of any EHR to send and receive messages and files from any users ofany other EHRs, regardless of operating system or vendor. In fact, Direct facilitates secure messaging, with attachments, to and from anyone with Internet access. It makes EHRs interoperable with one another, but also facilitates secure communication with providers and patients using Internet devices of almost any kind.
These doctors are not asking for money, but for relief from the negative effects brought about by CMS’ twenty year reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC) for valuing doctors’ work. They are asking CMS to enforce the Federal Advisory Committee Act(FACA), which requires that regulatory agencies shield themselves from undue special interest influence. In the process, they are asking CMS to rethink Medicare’s approach to physician payment, with a mind toward recognizing and valuing primary care’s ability to treat the whole patient within a larger system of care. They are asking CMS to develop payment policy that supports the needs of patients over those of professional groups.
In a sense, the suit reflects the larger concerns of America’s increasing unrest: a general frustration with a system rigged to benefit the few at the expense of the many, privatizing profits while socializing losses. It calls into question an incentive structure that has resulted in half or more of all health spending providing no utility and translating to exorbitant cost but debatable value. In other words, the case is accompanied by a sense that the system, as it is currently constituted, is failing the American people.
Any simple examination of medical services payment reveals the systematic under-valuing of primary care services relative to procedural services, the direct result of the RUC’s valuation process. For example, in an earlier Health Affairs Blog post we compared a 99214 moderately complex established office visit with a routine cataract extraction and intraocular lens implant. The first has all of medicine as it’s palette. The second is a highly refined, low risk, repetitive procedure that is valued, on an hourly basis, at 12.5 times the first.
This week in a Maryland federal court, six physicians based at the Center for Primary Care in Augusta, GA filed suit against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick. The complaint, spearheaded by Paul Fischer MD with DC-based lead counsel Kathleen Behan, alleges that the doctors have been harmed by the Medicare payment structure developed through the agencies’ reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC).
The suit also claims that the agencies have functionally treated the RUC as a federal advisory committee. But they have not required the RUC to adhere to the Federal Advisory Committee Act’s (FACA) stringent management and reporting rules – e.g., balanced representation, transparent proceedings, and scientifically valid analytical methodologies – that keep the proceedings in the public interest. The plaintiffs request injunctive relief, which would freeze the relationship between CMS and the RUC until the advisory group complies with FACA’s requirements. Of course, compliance would drastically change the way the RUC conducts its affairs, something it is almost certainly loathe to do.
One of American politics’ most disingenuous conceits is that health care must cost what we currently pay. Another is that the only way to make it cost less is to deny care. It has been in industry executives’ financial interests to perpetuate these myths, but most will acknowledge privately that the way we value and pay for medical services is a deep root of America’s health care cost explosion.
When the Resource-Based Relative Value Scale (RBRVS) became the framework for Medicare payment nearly twenty years ago, it equated a medical service’s “value” with four categories of physician work inputs: time, mental effort and judgment, technical skill and physical effort, and psychological stress. The assessment process, handled from the outset by the American Medical Association’s (AMA) secretive, specialist-dominated Relative Value Scale Update Committee (RUC), delineates and quantifies a service’s inputs in terms of its Relative Value Units (RVUs) which, with a monetary multiplier, define its worth.
We found that physicians can rate the relative amount of work of the services within their specialty directly, taking into account all the dimensions of work. Moreover, these ratings are highly reproducible, consistent, and therefore probably valid.
In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.
Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.
So when patients come home from the hospital, there is a smooth handoff, and all the necessary information follows them. When they are seeing a specialist, that specialist is coordinating care with their primary care doctor.
This description probably resonates with most health care professionals as a better approach than the current paradigm’s fragmentation and lack of continuity of care. But as with many things in health care, it won’t be easy getting to a value-based health care approach in Medicare and Medicaid. Despite wide acknowledgement that fee-for-service perpetuates our health system’s most undesirable characteristics, the mainstream of American health care seems stuck. One wonders whether CMS can rise above the special interest lobbying, get beyond the interminable pilots and decisively act on payment reform with the conviction required to help save health care from itself.
Still, the idea of value-based reimbursement begs questions. What payment methodology will incentivize the best quality and most efficient care? What path can take us there?Continue reading…
Finally, we have a Final Rule on the Medicare and Medicaid EHR incentive programs. The rules and criteria are simpler and more flexible, and the measures easier to compute. But they are still an “all or nothing” proposition for physicians, who will have to meet all of the objectives and measures to receive any incentive payment. Doctors who get three-quarters of the way there won’t receive a dime. And a lot of uncertainty remains about dependent processes that CMS and ONC must quickly put in place, like accreditation of “testing and certifying bodies,” and the testing schemas for certification. All in all, we expect most physicians in small practices to sit on the sidelines until the dust settles, likely in 2012 or 2013.
Nevertheless, while it is good to get Meaningful Use behind us, it may be better still seeing beyond it. After all, the incentive payments for becoming a “meaningful user of certified EHR technology” are merely a small down payment on the savings that could be realized if health care supply, delivery and payment are affected by the changing policy and market environments over the next 5 years. The EHR incentive programs are meant to prime the pump by putting approximately $25 billion, give or take a few billion, into the hands of physicians and hospitals who adopt EHR technology during the 5 years between 2011 and 2016.
During that same time, by comparison, reductions in waste, duplication, and unnecessary procedures might mean savings of $100 billion to Medicare alone,# depending on whose estimate you believe and how effective you think the reforms will be in replacing payment for volume with payment for value. It might be a lot more. Conservative estimates are that 30% of our total national health care expenditure of $2.5 trillion, or over $800 million, is unnecessary and could be eliminated through real reforms. Some authoritative estimates argue that half or more of care costs are unnecessary, so the target jumps to $1.25 trillion a year.
By VINCE KURAITIS JD, MBA and DAVID C. KIBBE MD, MBA
Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?
Harvard Business School Professor Clay Christensen studied this issue. He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.
So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:
Defending Plan A to your dying breath?
Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?
We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.
In this essay we’ll discuss:
1) The Need for HITECH Plan B
2) Questioning Assumptions — Issues to Reconsider in Plan B
a) Rewarding Incremental Progress
b) Addressing Root Causes for Non-adoption of EHR Technology
c) Questioning Health Information Exchanges (HIEs) as Building Blocks for the Nationwide Health Information Network (NHIN)
d) Catalyzing Movement Toward Modular EHR Technology
e) Focusing Incentives on High Leverage Physicians
f) Recalibrating Expectations for EHR Technology Adoption
g) Getting Bang-for-the-Buck in Achieving Meaningful Use Objectives
h) Comprehensively Revamping Privacy/Security Laws vs. Tweaking HIPAA
i) Maximizing Sync Between HITECH and PPACA
j) Leveraging Potential for Patient-Driven Disruptive Innovation
k) Promoting EHR Adoption Beyond Hospitals and Physicians, e.g., long-term care, home health, behavioral health, etc.
l) Dumping CertificationContinue reading…
An article in the April 10, 2010 New York Times entitled “Doctors and Patients, Lost in Paperwork,” brought attention to what may be, in the near term, the Achilles heel of the plan to incentivize doctors for the “meaningful use of EHR technology.” The article cited a study published in the Archives of Internal Medicine this past February, which asked a large cohort of physicians in internal medicine training programs about the time they were spending on clerical work, most of which is documentation in patient charts, both paper and electronic. A stunningly large 67.9% of the respondents reported that they were spending “in excess of 4 hours daily” on documentation, while only 38.9% reported spending an equal amount of time in direct patient care.
Now, I am fully aware that practice in the inpatient, hospital setting is not the same as practice in the office, clinic, or ambulatory care environment. Patients tend to be sicker and require more consistent attention while in the hospital, which often means more documentation is necessary. However, the study and the NYT article point to a real world problem that crosses all medical care settings and impacts physicians and other professional providers of all kinds: the enormous burden of documentation, clerical work, and administrative forms completion that impedes real care giving and makes health care less and less efficient even as we add more and more technology.
It’s time to revive the discussion of electronic health record software in light of the new federal regulations that define criteria for meaningful use and also set criteria for the EHR technologies that must be implemented by doctors and hospitals in order for them to become, and be paid for being, “meaningful users of certified EHR technology.”
While most of the public commentary so far has been directed to the NPRM on meaningful use, the real news here relates to the de-construction of EHRs that is described in the interim final rule covering EHR standards and implementation specifications. Of course, the NPRM and IFR are by design tightly linked. But the NPRM on meaningful use is primarily a set of instructions for doctors and hospitals about how to participate in the incentive payment programs established statutorily under ARRA/HITECH. The rule on EHR technology certification criteria, on the other hand, is a playbook intended for vendors and developers who want to qualify their products to meet the expected demand by meaningful users in those programs.Continue reading…
Massachusett’s voters’ stunning rejection of Democrat Martha Coakley, in favor of a not-very-impressive Scott Brown, should be exactly the splash of cold water that the Democratic party – and Congress as a whole – needed. The defeat can be understood in two ways: one large and one fairly small.
First, the large one. This will probably send reform back to the drawing board. Health care is too much in crisis and too pressing to be pushed completely off the table until certain issues – including both access AND cost – are addressed.
Second, this election marks the loss of a single critical Senate seat, but it is also very loud warning shot. The mandate received at the end of 2008 was a resounding call to throw out the Republicans who for more than a decade had ridden roughshod over American values. Yesterday, the Democrats, in one of their most secure strongholds, received the same message. Whatever people in DC think, rank-and-file Americans – not those on the right or left, but the swing voters in the middle who actually determine election results – are very unhappy with the gaming that’s been vividly displayed over the last year under the guise of health care reform.
The distaste expressed yesterday probably has little to do with the specific provisions of the bills, except for the largest generalities: that they expand coverage while avoiding a commitment to changes that could significantly reduce cost. But along the way, voters have witnessed — with an immediacy and transparency that has only been available as a result of the Web — lawmaking in its worst tradition. There was the White House’s deal making with powerful corporate interests like the drug manufacturers even before the proceedings began. And the tremendous lobbying contributions by health care and non-health care special interests in exchange for access to the policy-shaping process. Or the outright bribery of specific Senators and Representatives in exchange for votes. Last week’s White House deal with the unions that exempted them from the tax on “Cadillac” health plans until 2018 must have seemed like a perfectly OK arrangement to the people in the center of all this activity, but to normal people who read the paper, it was emblematic of the current modus operandi: If you have power and support the party in power’s muddled agenda, you get a special deal.
The most tempting mistake now for the Democrats would be to dig in. President Obama’s most appealing characteristic — the one that got him elected — was his embrace, his embodiment even, of approaches that would revise the traditional kinds of politics we’ve seen for the last year throughout the health care reform process. Of late, the most telling complaint about this Presidency so far has been disappointment that, once in office, he seemed to cave in so easily.
Undoubtedly, many Republicans are now rejoicing over the Democrats’ loss and the possible defeat of any health care reform legislation. That’s unfortunate. The health care crisis is real and remains unaddressed. The pressures it creates, particularly for powerful interests like business, will force Congress to return to it and develop meaningful solutions. Hopefully (though probably unlikely), Congress and particularly the Democrats, will be chastened and wiser. There’s a big opportunity here to make lemonade.
There is a new, bipartisan movement in Congress, highlighted on NPR two weeks ago, that would revisit the rules around the relationships between special interests and lawmakers. This is an issue that trumps and is more important than all others, because if every policy is ultimately shaped by those with enough money to buy Congress’ favor, then our democracy will be unable to hold.
The silver lining in yesterday’s election was that it was a mild, if critical, reminder that, whatever DC thinks, America’s center is just as displeased with the current governance as it was with its predecessors. Faced with a much larger rejection in the 1994 elections, President Clinton went on TV, took full responsibility, and then spent his time rebuilding. The good news is that today is a new day, and that, if they’re interested in what’s good for America over the long term rather than simply themselves over the short term, Congress has the ability to start again in ways that could please the American people and actually work to our collective advantage.
Brian Klepper and David C. Kibbe write together about health care technology, market dynamics and reform.