The Users' Guide to the Health Reform Galaxy

From a doctor's point of view: making billing better, for better care

James E. Bailey, M.D., M.P.H., is a practicing internal medicine physician, director of the Healthy Memphis Data Center and a professor of medicine at the University of Tennessee Health Science Center.  In this post, he riffs on a topic covered by a recent RWJF-supported study, about how streamlining billing procedures will increase efficiency and help improve the quality and cost of health care.

Between the recession and new health reform law, Americans have been thinking a lot about what health care costs. I’ve heard many stories of patients and their families suffering because of the cost of getting care. I also know many primary care doctors and hospitals that do their best to provide everyone the care they need most are finding it difficult to keep their doors open. Again and again, I’ve seen how the health care people receive is often of poor quality, despite its high, and rising, cost. Sadly, Americans end up getting expensive, sometimes even dangerous procedures they don’t need while their most essential health care needs are overlooked.

The health reform debate tended to focus on big, divisive issues—and rightly so. Real change in our health care system will require hard choices to be made by everyone. But there is another big issue—not quite as divisive but nonetheless worth our attention—which is the system’s misuse of time.  Any physician can speak of large amounts of time—and frustration—spent dealing with administrative issues such as billing. As a doctor, I want most to spend my time with my patients. And so every minute I spend on administrative tasks is one less minute I have for seeing patients. And instead of an efficient system that empowers doctors to best do their work, we’ve created a time hog that dictates the priorities of our practices, inhibiting us from doing what we are called to do as physicians—provide care for those who need it.

This is why reform efforts must address issues like the simplification of billing and paperwork. A new study from RWJF's Changes in Health Care Financing and Organization initiative, “Saving Billion of Dollars—And Physicians’ Time—By Streamlining Billing Practices” suggests that it is possible to streamline the billing process, increase the quality of care and eliminate some unnecessary costs. The study examines the U.S. system of billing third-party payers for health care services, arguing that the system of third-party payment is excessively cumbersome, complicated and costly. We spend about twice as much on the billing bureaucracy in America than in any other country in the world.  While it is unlikely that we will be able to eliminate third-party middlemen from the system any time in the near future, there is much that can be done now.

Health Reformer’s Lexicon: Meaningful Use

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit. 

The term: Meaningful use – assuring that health information technology (HIT) is used in a meaningful way to provide better patient care.

Congress earmarked billions of dollars to spur investment in “health information technology” (HIT) and electronic health records technology by health care providers, but money came with a string attached known as “meaningful use.” To qualify for these subsidies, doctors and hospitals must put the HIT they purchase to “meaningful use,” to improve the quality, efficiency, safety and coordination of care, and reduce disparities and engage patients and families in their care.

Why it matters: There is a lot of money at stake. Estimates are that between $14.1 billion and $27.3 billion in subsidies could flow to qualifying providers. These funds will help providers invest in HIT infrastructure. As results from the 21st  annual Healthcare Information and Management Systems Society leadership survey indicate,

Asked to identify their single IT priority during the next two years, 42 percent of respondents identified meeting meaningful use criteria.

But as we’ve noted previously on this blog, HIT in and of itself will not improve health care, it is how we implement and use it to engage with providers and patients that truly matters.

Roots: The Health-e Information Technology Act of 2008 was introduced as a bill “to promote the adoption and meaningful use of health information technology.” But the term “meaningful use” was put on the map by the American Recovery and Reinvestment Act of 2009, aka the “stimulus bill” under the bill’s Health Information Technology for Economic and Clinical Health Act provisions.

Where the term appears:  The usage that has mattered most of late came just two days before the end of 2009 when the Centers for Medicare & Medicare Services and the Office of the National Coordinator for Health Information Technology issued proposed rules that can be read here and here to define “meaningful use.” At 700 pages, at least one wag at Modern Healthcare deemed them "meaningful obtuse.“

CMS expects to finalize its meaningful use rule later this year.

Where's the magic with electronic medical records?

Mike Painter writes about health information technology and when might be the right time to assess its impact on health care quality and cost.

Last week a new article from The American Journal of Medicine entitled, “Hospital Computing and the Costs and Quality of Care:  A National Study” by Himmelstein, et al. appeared in my Twitter stream.  In fact, Brian Ahier (@ahier), whom I and about 3300 other tweeps like me follow, sent me a DM asking for thoughts.  In that article the authors sort of breathlessly conclude that current hospital computing has minimal impact on quality and no impact on cost.  Shocking.   Actually, it’s the kind of gotcha article that really grates—the kind that isn’t particularly helpful to anyone as the authors seem intent on drawing sweeping conclusions from pretty limited data. 

For starters, how can we draw any conclusions about the impact of widely adopted, meaningfully used electronic records until they’re, well, widely adopted?   As research by  Ashish Jha et al. highlighted in Chapter One of the recently released 2009 RWJF HIT Adoption report (results from that research also published in April NEJM) show that only 1.5% of hospitals have a comprehensive EHR system—and only another 8% have a so-called basic system.  I’m not sure how one can draw important conclusions about national hospital computing given such an unbelievably low national rate of adoption. 

More importantly, though, most do not think that simply adopting, even widely, a technology would ever magically on its own improve quality or lower costs.  I’m not sure why these authors seemed to say otherwise.  The point as many have noted over and over again is for health professionals to adopt and then USE (remember our year long discussion regarding meaningful use?) the technology FOR improved quality, including improved efficiency.  As I discuss extensively in Chapter Five of the 2009 HIT Adoption Report, one important use of the technology will be, for instance, automation of performance measurement and public reporting.   The automation enabled by widely adopted, meaningfully used EHRs will hopefully accelerate the creation of results oriented information—information that will facilitate payment reforms as well as improvement.  We absolutely cannot do the kind of payment reforms that the nation needs without creating measures from the automated collection and aggregation of clinical data.  Bundled payment reforms, like the Prometheus model for example, will not work without this kind of automation—and to get to that automation we need widespread adoption and meaningful use of the technology.  But the adopted technology is only an important step.

We are still nowhere near that kind of use in an environment of ubiquitous electronic records.  Given that small fact, to conclude that there is “evidence” that hospital EHRs “don’t” improve quality or lower costs seems pretty silly.  That’s like saying a stethoscope should, but shockingly doesn’t, improve the quality and cost of care just because an intern buys one and hangs it around her neck. 

The authors end their article asserting that predictions about cost and efficiency improvements from widely adopted EHRs “are premature, at best”.  To me that statement is pretty disingenuous, at best.  What’s premature is expecting magic transformation when folks are just getting the tools out of the box—and trumpeting the lack of that magic transformation as if it’s evidence.

 

Where were you?

Mike Painter, senior program officer at RWJF, writes about the latest report released by RWJF on the adoption of electronic medical records.  He contributed a chapter in the report on quality measurement and how it relates to health information technology.

I distinctly remember the first time I heard the title, “National Coordinator for Health Information Technology”.  It was 2004.  That’s, of course, the year that RAND released its important national report card highlighting the overall mediocre state of health care quality.  You know the one that told us “it’s a flip of a coin.”  I was an RWJF Health Policy Fellow working on the Hill with then Majority Leader Bill Frist’s health policy staff.  There was a flurry of staff activity regarding the president’s pending executive order pushing adoption of the electronic health record and creating a new federal health information technology, dare I say, czar. . . . But what to call this new position?  To be honest, when I initially heard folks say the words, “national coordinator for health information technology,” my first thought was, “Well, that’s a mouthful.”  My second was “It sort of sounds like a character from that TV show, ‘The Love Boat’”.  But I kept those smart remarks to myself and quite quickly got on board—and, to be honest, never looked back. 

At RWJF in 2005, several of us worked with then National Coordinator, Dr. David Brailer, on a partnership effort between the Office of the National Coordinator and RWJF.  With this project we extended a grant to Dr. David Blumenthal, then in Boston, to create a series of national reports that would track the national adoption of the electronic health record over several years as the nation progressed toward wider and wider adoption.  This week we’re issuing our third report in that series. 

Of course, the news is sobering.  This third report highlights yet again that overall adoption of the electronic record is stubbornly, almost shockingly, low in virtually all clinical settings.  This current report also highlights that without focused attention, adoption of electronic health records might make disparities even worse.  Terrific. 

Last but not least, "meaningful use" for patients and consumers

This is the third and final post in a three-part series on the implementation of the health information technology (HIT) provisions in the stimulus package, which called for "meaningful use" of HIT for those who give and get care.  This series was written by David K. Ahern, Judith M. Phalen, and D. Matthew Brothers.

In Part I of this series, we argued that the definition of ‘meaningful use’ should go beyond the matrix of outcomes, goals, and objectives developed by the federal government’s HIT Policy Committee to address the specific behaviors needed by healthcare’s agents (e.g., providers, consumers/patients, payers) to achieve the stated goals.  In Part II, we discussed the ABCs of behavior change –antecedents, behaviors, consequences – that must be in place in order to move providers toward a 21st century healthcare system.  Here, we will examine the role of the ABCs for patients and consumers (words we will use interchangeably here) in making the meaningful use of HIT a reality.

Part II: Putting meaningful use into action for providers

This is the second in a three-part series of posts on the implementation of the health information technology (HIT) provisions in the stimulus package, which called for "meaningful use" of HIT for those who give and get care.  This series was written for us by a team of people at the Health Information Technology Resource Center (HITRC) at Brigham and Women's Hospital in Boston, which provides technical assistance to RWJF’s Aligning Forces for Quality program.  David K. Ahern, PhD is the Director, Judith M. Phalen, MPH is the Associate Director, and D. Matthew Brothers, BA is the Program Associate.

In Part I of this series, we argued that the definition of ‘meaningful use’ should go beyond the matrix of outcomes, goals, and objectives developed by the federal government’s HIT Policy Committee.  We believe it should also determine what those who get, give, and pay for care – healthcare’s agents – need to do in order successfully achieve better health outcomes for all.  In this post we examine these questions:  What behaviors must be adopted by healthcare providers (and how can we reinforce them?) so that they will move lock-step towards an evidence-based, effective, and efficient healthcare system? And, what interferes with the good intentions of those who are trying to do the right thing?

Reading tea leaves, and what could happen next

I jog a lot but have never once been inspired to run a marathon, basically because I think 26.2 miles is an awfully long distance to drive, let alone cover on my two little legs, but if I was a marathoner, I kind of think that this point, where we are right now on the prospect of health reform legislation, this point is maybe like the 20th mile or so of a person's first marathon.  Right now, the terrain still feels familiar--we've covered this ground before, in our training runs--but we are bracing ourselves for that last grueling slog to the finish line, the distance that has been heretofore far unknown to us, despite all of our preparation.  The President's urging us all to keep going, the August deadline for legislation from Senate Finance is all but shot, and his budget director has administered what appears to be a gentle admonishment to the CBO, a place that he, lest anyone need reminding, once managed himself.  I can't quite figure out if I'm reading too much or too little into this:  Orszag stated that the CBO might have overstepped because it estimated long-term savings without an analytical basis for doing so, even though it might be in his boss's interest to cite those savings while selling a health reform package that many are arguing is too expensive.  Does arguing against the long-term savings also mean, by implication, that the long-term costs estimated by the CBO should also be viewed dubiously? 

Again, this may just be muscle fatigue talking.

On another note, trying to make a 2009 deadline for health reform legislation leaves very little time for folks to wonder what the post-legislation world might actually look like.  The folks from Massachusetts have some experience to offer the rest of the country on what happens when you try to get nearly everyone covered, especially on the payment and delivery side of the equation, but there are also some important discussions about implementation that came out of the health information technology provisions in the stimulus package. 

So today we're going to start a series of posts on that subject, especially on defining "meaningful use" of health information technology for those who give care and get care.  This series was written for us by a team of people at The Health Information Technology Resource Center (HITRC) at Brigham and Women's Hospital in Boston, which provides technical assistance to RWJF’s Aligning Forces for Quality program. David K. Ahern, PhD is the Director, Judith M. Phalen, MPH is the Associate Director, and D. Matthew Brothers, is the Program Associate.

The State of Meaningful Use

By Mike Painter

Is it possible that the State Department is technologically bolder than the HIT Policy Committee?  On Tuesday, that committee convened by the Office of the National Coordinator as required by the American Recovery and Reinvestment Act released some initial recommendations on the definition of "meaningful use" of health information technology.  Then yesterday, the New York Times in an above-the-front-page-fold article reported that the State Department recognized an internet blogging service could change history—right now.  Compare that report about the State Department to the HIT Policy Committee’s recommended vision for the role of patients and families.  The committee envisions that someone would eventually “provide access for all patients” to populated personal health records and some self-management tools by 2015—about six years from now.  It’s not that this vision is bad; it’s just so underwhelming.  Let’s see—the State Department thinks that the Iranian people might be using Twitter today to regain control of their nation—and in our multi-billion dollar ultimate vision for the patient’s role with health information technology we’re still talking about “providing” a couple of interesting tools to patients by 2015.  Is it me, or are we possibly missing a powerful health reform player here—the consumer?

So, as you can see, I listened to this meeting on “meaningful use” and came away with some distinctly mixed impressions.