Inaugurating Health Care Reform: Will the EHR Crack the Crisis in Health Care? Cont'd (Part I-i)

March 10, 2009

Comprehensive Managed Care in 2010

The author of "Health Care and the American Recovery and Reinvestment Act," Robert Steinbrook, MD suggests that the "stimulus law should have major and immediate effects," But I am not sanguine about that as I stated last week.

Steinbrook summarizes the dilemma: "At present, perhaps only 17% of U.S. physicians and 8 to 10% of U.S. hospitals have at least a basic electronic health record system." Referring to Blumenthal's Jan. 26, 2009 Commonwealth Fund Report, Steinbrook continues: "Far fewer have—and routinely use—the types of comprehensive systems that would allow them to fully realize the potential of the technology. However, such technology will lead to improvements in the quality of care and savings on other health care costs only if the implementation is done right." Throwing money at the problem, recognizing without defining "'meaningful' use of health information technology" and penalizing those who are not onboard, will not, in my opinion get us to a durable health care information solution.

In sales, the mantra is “location, location, location.” In medical billing and in a court of law, it is: 'what isn't documented didn't happen'. But, we already have evidence of what doctors do—we have data from billing and encounter forms, from electronic prescribing and supply ordering, and from acuity-adjusted episodes-of-care groupers.* The challenge is to translate those and other data into information.

* For more information about how data become information, please see the reference to "3M" in Part XIII of this Series, scheduled for release, March 2009.

The advancement of management information systems (MIS) should follow a logical path:

a. Later providers will share a protected chart—it is inevitable.

1. As is customary, doctors submit data so that they can be paid and to document what they do, if not why (eg, paper and electronic billing and remittance forms for services rendered and why).

2. Researchers and medical managers mine the data, resulting in

3. Information about what works and what does not work.

4. By encouraging 'what works' and discouraging 'what does not work', there will be both cost savings and improved clinical outcomes.

5. 'Incentive Alignment'— The aforementioned information is confidentially shared and that encourages the patient, the doctor and the insurer to actually work together in the interest of achieving the same objectives.

6. In a recursive way, patients are educated about best practices, moving #4 and #5 to a higher level, and better outcomes for all.

Of course, the "devil is in the details," but isn't this is what medical management is supposed to be doing, anyway?

As an aside: If you are concerned about the inertia we see in the implementation of the electronic health record/computerized patient record (EHR/CPR), that paradigm paralysis will quickly dissipate when medical managers realize it is unaffordable not to have the right information technology in hand. (That is, the paper trail is no way to manage medical practices, assure follow-ups, schedule, report, document, or forecast.)

Physician/Practitioner Payment Reform

"The history of physician payments under Medicare has taken a rather different path. Though there was a time in the 1980s when the program considered using DRGs to calculate physician payments as well as hospital payments, so far there has been no serious movement in this direction. Bundled payments are used to reimburse physicians in some instances: surgeons receive a fixed payment that covers preoperative care, the procedure itself, and some postoperative care. In general, however, physicians are paid for providing discrete services, according to a disaggregated fee schedule that uses more than 7000 billing codes."

That schedule was replaced with the Resource-Based Relative Value Scale (RBRVS) in 1989, which is "based on relative values for physicians' work effort, physicians' practice expenses, and malpractice liability insurance expenses. Although the scale was intended to correct for a historical undervaluing of primary care and overvaluing of procedures (which it does not appear to have done very successfully) and for larger differences between urban and rural reimbursements than could be justified by differences in the costs of practice, it retained the use of a largely disaggregated fee schedule."

A brief synopsis of how methods to reign in physician compensation have always failed is that nothing has worked. Some of this history is available in "Reforming Medicare's Physician Payment System" by Gail R. Wilensky, PhD, where it says:

Paying healthcare practitioners fairly is the crux of healthcare payment reform. Recognizing and rewarding what the health care team does well, and the obverse-not rewarding what they do not do well is fundamental; the translation of data into information is the means, and the key data that should be analyzed in this regard include: the structure, processes, and outcomes of care. None of this, however, no matter how overwhelming it seems, is beyond our ken.

See: Donabedian A. Basic approaches to assessment: structure, process, and outcome. In: The Definition of Quality and Approaches to Its Assessment. Ann Arbor, MI: Health Administration Press; 1980:77-128. Donabedian, A. 1982. The Criteria and Standards of Quality. Ann Arbor, MI: Health Administration Press.

Readers: How well do you think doctors respond to report cards about their performance, especially if it affects their reimbursement?

For further discussion, please see Managed Care 101 in 2010 (Part XII): "One Cannot Manage What One Does Not Measure," and after our health care reform discussions are completed, “One Cannot Measure What One Does Not Manage": Managed Care 101 in 2010 (Part XIII).