Between Meaningful Use, the Affordable Care Act and the ICD-10 conversion, providers have spent a lot of their IT money and energy in the past few years trying to keep up with shifting government regulations. The next few years look like more of the same. The government is gearing up for value-based care, which will upend traditional health IT as providers strive to gather and analyze the new information that they'll need to survive.
Systems built around getting the bills out—a function that will eventually be obsolete and irrelevant—must be transformed into engines for tracking cost and quality.
Is it possible to put an IT plan in place for value-based care? Experts say that regardless of the ultimate details of regulations surrounding value-based care, the IT needs are clear enough now that providers can and should start planning to meet them. Those needs—many of which are new territory for most providers— include:
* Population health and risk stratification analytics
* Integration of clinical data and claims data
* Interoperability among all providers in a given healthcare community
* Ability to track expenses incurred outside an organization for each patient attributed to it
* Advanced cost accounting
* A patient engagement platform that covers both clinical information and administrative basics like appointment scheduling and online bill payment.
Change is coming
"You can look at the question in two ways," says Robert Tennant, M.D., health information technology policy director at the Medical Group Management Association. "One, I'm going to tailor all my IT to meet some mythical program that won't kick in until 2019, or two, I'm going to identify and deploy technology that will optimize current physician performance and lay the foundation for any value-based program. The latter approach makes a lot more sense."
Tennant acknowledges that the government doesn't always act logically, and that its deep involvement in specific IT details has made the Meaningful Use program problematic for many providers. Now that EHRs are close to ubiquitous, though, he's "somewhat optimistic" that regulators will step away from mandating every little feature and function, and allow the marketplace to determine at least some of what providers need.
The Meaningful Use program succeeded in spreading the adoption of EHRs, but may not be much help in moving the industry to value-based care, says Doug Fridsma, M.D., formerly of the ONC and now CEO of the American Medical Informatics Association.
"If you want to do value-based care, you can't do it in a paper world—it's just not scalable,” he says. “But you want the assessment of the quality to become a byproduct of the care that's delivered, so that it's easy to go back and measure quality rather than having that [measurement] become an end in itself. If the parameters are secondary to the care process, then you'll get the complaints that we've had about Meaningful Use Stages 2 and 3, where the docs have to flip to a screen of checkboxes that drive the billing process but are separate from care."
The Centers for Medicare and Medicaid Services is moving relatively quickly toward value-based care. The agency announced in early 2015 that it will tie 30 percent of its total provider payments to quality and value by the end of 2016, and 50 percent by 2018, through alternative payment models such as accountable care organizations and patient centered medical homes.
As of the beginning of 2015, CMS counted 424 ACOs participating in the Medicare Shared Savings Program and the Pioneer ACO program, covering 7.2 million beneficiaries. Commercial insurers are headed in the same direction: Healthcare consulting firm Leavitt Partners estimated that there were 744 total ACOs, public and private, in January 2015, covering 23.5 million lives.
Physicians are looking at big federal payment changes. By 2019, they will have to choose between two value-based approaches. One is the Merit-Based Incentive Payment System (MIPS), which is still based on fee for service but adjusts payments based on whether physicians meet certain quality goals. The other is an alternative payment model (APM) that involves receiving a lump sum and taking on financial risk for patients' health.
To encourage APM participation, CMS is offering a big carrot: physicians will be eligible for total payment boosts of as much as 5 percent annually between 2019 and 2024. In September, CMS put out a request for information to solicit input from the public on how best to implement the new payment models for physicians, including what role EHR certification should play. "The fact that CMS went out with this RFI is a good sign that they want to engage and not be heavy handed," Tennant says.
Hoangmai Pham, MD, director of ACO programs at the CMS Innovation Center, says that at least initially, the agency is not likely to have prescriptive requirements for IT related to accountable care.
"We need to be supremely confident in the connection between the expenditure and the outcome of care," she says. "There isn't a super tight evidence base yet" for specific IT functionalities that can help providers move to alternative payment models. As that evidence base grows, she says, CMS is likely to put the onus on vendors to include specific capabilities in their products in order to be certified by the Office of the National Coordinator, leaving it to the providers to decide whether and how to use those capabilities to fulfill the requirements of value-based care programs.
The federal HIT certification program that accompanied Meaningful Use will continue to play a role in the move to value-based care, but the ONC will likely move away from certifying EHRs and point-of-care applications and turn its attention to interoperability issues, says Kelly Cronin, ONC's director of care transformation. "We need to think about the critical tools and functionalities that won't be solved through innovation and competition," she says.
The ONC will focus on capabilities that require the adoption of common standards among all vendors: for example, managing referrals. "If we don't have good structured data going back and forth between the PCP and the specialist in an easy way, then they won't have the tools they need," Cronin says. "That's going to require a higher level of interoperability than the market has. No matter how innovative a product might be, it's going to be a challenge to get normalized data across disparate platforms so that a patient is well managed regardless of where they receive care."
AMIA’s Fridsma says the certification process should focus on “just the right amount of standards, rather than being overly prescriptive.” He cites the example of the Internet, which was created by a handful of very basic standards that enabled astonishing depth and breadth of innovation.
"We can't improve these systems in the abstract or in a pilot or in committees," he says. "We need to see what works in practice and what doesn't, and allow innovation without regulations getting in the way."
What are the best moves to make right now? Revamped accounting systems will be key, says Pam Jodock, senior director of healthcare business solutions at the Health Information and Management Systems Society, which is currently surveying its members about the state of their cost accounting systems and will unveil the results at the upcoming HIMSS annual meeting in Las Vegas.
Jodock hopes to discover how many hospitals and large group practices know, on a line-item basis, what it costs to deliver care, and what margin they need to be financially viable.
In previous accountable care pilots, all providers have billed CMS directly, Jodock says, but in the most recent bundled payment project, the provider in charge of a particular patient is responsible for submitting all the bills and disbursing payments to the other providers. "Traditional revenue cycle management systems and business processes don’t support this type of activity."
Moreover, value-based care will give the edge to providers who know their costs and are willing to make them public. If providers try to engage in price competition without fully understanding their cost structures, they risk losing money on the services they provide, and if they’re not transparent about their prices, they risk losing business to competitors who are.
For example, Jodock says, retail clinics offer less complex care and can predict their costs accurately enough to post a price list at the door. If a hospital outpatient center can't do the same—and most can't— the retail clinic may lure away cost-conscious individuals who have high deductible health plans.
One thing is certain: the IT transition to value-based care is going to be expensive. For providers who are already operating on a shoestring, Jodock recommends allowing early adopters to work out some of the bugs before investing in new systems. "You can't afford to ignore this, but you want to delay as long as possible.”
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