I spend a lot of my free time reading healthcare information technology plans for state and federal government. I know, it’s not much of a pastime, but it’s probably a better use of my time than watching re-runs of Caddyshack. In the past, these HIT plans were heavy on vision and light on funding. But in the last year, they started swimming in dollars at every level. Generally speaking this is great: government can provide a ‘public good’ by creating standards, funding research, setting security and privacy standards, and initiating information exchange. Unfortunately, some of these ideas would require that physicians do more without addressing how to pay for more.
Let’s start with the good, and there’s a lot of it. If you like quality of care and transparency, check out ONC’s Draft Strategic Framework. If you’re more interested in regional data exchange, flip through the state reports. Minnesota eHealth Initiative’s report to the Minnesota Legislature provides leadership on Health Information Exchanges and the potential for increasing efficiency. Iowa’s strategic plan addresses creating security and trust in health information exchange – great responsibility for government to assume. And if you’re interested in access to care, many of the state plans address safety net clinics. Nebraska’s plan even tackles the lack of specialists in rural communities by promoting telehealth capabilities, the very definition of government leadership in action. All these plans have innovative, occasionally inspired visions for how state and federal government should be developing a healthcare information infrastructure.
But if this mix of government leadership, money and HIT results in a metaphorical pumpkin pie of public good, this pie is undercooked: These strategic plans call for physicians to do more – more reporting, more coordination, more exchange, more expenditures on technology – without explaining how physicians are going to be reimbursed for playing along.
Which takes us to the federal government’s HITECH Act, the county fair-winning pumpkin pie. Smarter people than I suggest that it is an incentive program that appropriately funds for reporting, healthcare IT adoption, connections to HIE and the rest. And I completely agree – but only in 2011-12. When you reach 2014-15, where physicians have to do the most reporting and maintain complex HIE connections, you’re looking at just $2,000 per provider – less incentive for more work! Go out another year and you’re looking at a one to two percent decrease to the fee schedule. In that case the financial incentives just don’t match, or incent, the work required. And while we can all dream, you can’t realistically ask the world’s largest industry to make significant investments in technology, processes or people without a serious indicator that the payment model is changing.
So is anyone doing it right? The patient-centered medical home (PCMH) model, which is being embraced by some states and payers, has a strong emphasis on payment reform to create a “reimbursement structure that supports and encourages this model of care”. And HITECH is doing some very good things in terms of transparency and information exchange in the beginning years. We at athenahealth are also running into more payers and governmental leaders who understand that payment alignment can turbocharge quality, efficiency and access improvements. A good example is BCBS-MA’s Alternative Quality Contract, through which organizations like Caritas Christi are leading the way to transparency and high quality care.
As we look for solutions in the coming years we need to keep in mind the importance of aligning reimbursements with requirements with the goal of a greater public good in mind.