I wrote the following article for a business writing class I was taking but also to clarify things that are going on in the industry. I am an in the healthcare industry and I often feel it is confusing!
Pioneer the Change
Since 2010 a strong movement, with both an industry and governmental component, has begun picking up momentum within the healthcare industry. This movement is taking the industry away from the current model, fee-for-service, and bringing to the forefront a managed-care model that is more focused on the quality of care that providers are offering patients. Yet, the transition from one model to another is a much larger undertaking than one might imagine. This transition requires the implementation of new technology, the creation of federal and state policies to guide the use of this technology, a different reimbursement model between providers and insurance companies, and, the final component, physicians moving from symptom-based- care to wellness-based-managed-care. The healthcare industry has recognized these issues, but until recently there has been no way to make viable changes. My proposal to all healthcare stakeholders is to use their multitude of services and standing within the healthcare industry to be the instrument of change within the current system.
Yet to understand the need for change, it is important to understand the current model and the problems it presents. Fee-for-service has filled the need for insured patient care, but physicians have had no ability to oversee the complete picture of the patient’s health. As the system currently stands, a provider whether a primary care physician or a specialist has very little access to the entirety of a patient’s files and in turn the entire picture of their health and wellness. This further plays out when individuals become sick or injured while traveling; complete medical records, although being stored digitally, are not being shared. The fee-for-service model also leads to insurance reimbursement only being allocated when an appointment or a procedure has taken place. There are no financial incentives for physicians to have healthy patients. Providers have been forced to see a large number of patients in order to receive an average compensation and deals are often made between these same providers and medical vendors, such as pharmaceutical companies, imaging providers, and laboratories, to negotiate the best incentives for patients’ use of services. Although patients would often require these services regardless of whether incentives were in place, these incentives create a situation that could lead to extraneous bills being sent to insurance companies, that in turn leads to insurance premiums rising, and at the same time are beneficial to the physicians and their practices. We, as Americans, have already seen how this model plays out: insurance premiums continue to rise, we have the first generation that is predicted to have a shorter life expectancy than their parents, and technology is advancing rapidly, but policies and laws are delaying the full advantages it can offer.
Although fee-for-service is the most common model today, Americans have already had a taste of managed-care model in the form of the failed HMO offering of the 1980s and 1990s.
Julie Barnes, the director of health policy at the Bipartisan Policy Center, wrote the following in an article she submitted to the Atlantic:
During the years prior to WWII, fee-for-service originated as "traditional indemnity" health insurance--you get a service, submit your claim, and your insurer covers your incurred expenses. What we now think of as "managed care" emerged around the same time, as prepaid insurance plans. In a prepaid plan, beneficiaries pay a set premium in return for care from a defined network of providers.
Due to wage controls during WWII, employers began offering insurance benefits as a way to attract employees--a trend which continues to this day. Indeed, a number of key trends in health care emerged after WWII: medical and scientific technology advanced dramatically, and more people enrolled in health insurance coverage. As health care costs grew in subsequent years, managed care, which encourages greater control over the utilization of health resources and services, also increased in the 1970s and 1980s.
Unfortunately, managed care ultimately failed to control health care costs, and increasing restrictions on care led to a patient- and provider-driven political backlash in the late 1980s and 1990s. (1)
The concept of managed care in the 1980s and 1990s was destined to fail from its inception. There was no viable method to care for a greater population or track the health of patients from hospitals to the provider. Without the ability to monitor the transition of care between facilities, costs and the drain on resources were bound to increase exponentially. There have been many variations of the managed care movement from HMO’s in the 1980’s to today’s Accountable Care Organizations and Patient Centered Medical Homes. Managed care options have maintained a high probability to fail like the HMO’s of the 1980s, but now that the Supreme Court has upheld the federal governments Affordable Care Act which was signed in March of 2010, the healthcare industries model of business will ultimately be forced to change.
In March of 2010 the Affordable Care Act was signed and, when paired with the American Recovery and Reinvestment Act, opened new opportunities for managed care (2). The Affordable Care Act opened the opportunity for the creation of Accountable Care Organizations and Patient Centered Medical Homes. To understand the significance of the signings one needs to understand what they are. Accountable Care Organizations were created on the belief that the goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors (3). While a patient centered medical home integrates patients as active participants in their own health and well-being. Here patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute, and chronic needs of patients using the best available evidence and appropriate technology (4). Both of these organizations seem simple enough, but without the ability to access data and the complete transition of care from Hospital to Provider or Provider to Provider they are also destined to fail.
Yet the Supreme Court’s decision to uphold the Affordable Care Act in June of 2012 plays a major role in these areas of data access and transition. MTS Healthcare summarized it well in writing:
While the goal of the Affordable Care Act is to improve the quality of healthcare with a focus on reducing cost the American Recovery and Reinvestment Act allocated billions of dollars in incentives to providers and organizations that adopt Health Information Technology such as Electronic Medical Records systems and Health Information Exchanges. Both pieces of legislation share many of the same goals.
However, there are distinct differences on how each law will accomplish these goals. Namely, the Affordable Care Act focuses on changing the healthcare delivery system and physician payment reform while American Recovery and Reinvestment Act focuses on adopting Health Information Technology. (5)
The American Recovery and Reinvestment Act, signed in February of 2009, created a range of new possibilities for the healthcare industry. It allowed the collecting of “big data” from laboratories, diagnostic imaging companies, and pharmacies to begin. This will provide the opportunity to see the volume providers are billing, rank providers care against each other, and obtain a profile of population health by tracking where bills are submitted. The American Recovery and Reinvestment Act’s Meaningful Use Requirements are also now set to have two years’ worth of collected “big data” which can help to change how care is managed.
In spite of the laws and policies that have been put in place, bringing the collection of big data to the fruition of practical use is something that has yet to occur. In June of 2012, Dan Riskin, the CEO of Health Fidelity wrote:
The promise of big data in healthcare is revolutionary. Use of big data will ease the transition to authentic data-driven healthcare, allowing healthcare professionals to improve the standard of care based on millions of cases, define needs for subpopulations, and identify and intervene for population groups at risk for poor outcomes. To date, few healthcare professionals would claim that the promise of big data has been fulfilled. (6)
To reiterate, Mr. Riskin believes, “to date, few healthcare professionals would claim that the promise of big data has been fulfilled.” The collection and accessibility of big data is essential. The industry knows this, yet has been unsuccessful in achieving it at a national level, never mind a global level. Efforts have certainly begun with the utilization of Health Information Exchanges on city and state levels, but the “holy grail” will be the ability to access a patient’s medical records residing in California from a hospital in Spain. Although these information exchanges are being developed at the lower tier of healthcare, there are additional components that must come from government agencies and national community registries. These are only in their infancy and will need to be spearheaded by vested, non-government agencies.
When further exploring what needs to happen to bring data exchange to a global medical team, there are three major obstacles being faced: the varied patient rights between states, how to share information that is stored within an Electronic Medical Record to various Information Exchanges, and how to collect information into one master patient disease registry. Patient rights are always difficult to handle due to both federal and state laws that are already in place. The federal law is covered in the Health Information Portability and Accountability Act of 1996, which establishes a general protection of communicating with a patient and protecting their medical records (7). The states add additional privacy laws protecting patient information; yet this becomes a very interesting component when a resident of one state makes use of a medical facility in another state, but the home state’s laws must be observed. Concerns also extend into the lack of standardization when different medical record software and exchanges are brought into different states and even different facilities within the same state; depending on the forms and policies in place patients are asked to opt in, given the option to opt out, asked if pieces of information should be excluded, etc. Due to this complexity, many health information exchanges are hesitant to connect to different state exchanges.
The second issue of sharing the information between health information exchanges is a bit more complex. Databases are often set up using different fields to hold the data. Establishing common community mappings will be critical in order to share information effectively. Fortunately, some standards have been met and as long as the systems can transfer the following industry standard data fields, patient care can be managed. The fields that are needed to be transferred are: Allergies, Conditions (Problems), Encounters, Healthcare Providers, Immunizations, Information Source, Insurance Providers, Medications, Person Information (Demographics), Procedures, Results, Support, and Vital Signs (8).
The American Recovery and Reinvestment Act has begun to address some of the hurdles within the third obstacle. Aside from stimulating the use of Electronic Medical Records, the Act has established many guidelines for meeting and reporting Meaningful Use Requirements. In order for providers to receive the monetary incentives from implementing and using Electronic Medical Records, providers must currently submit reporting measures on a yearly basis. Beginning in 2014, reporting will be required to be submitted automatically by the providers’ electronic medical record. This step will be critical to the success of any form of managed care.
Collaboration is critical to succeed in this government mandated, industry supported move from fee-for-service-care to a national managed-care model. There have to be leaders to connect all the pieces, to bring the parties to the table in order to be successful in bringing managed-care to the nation. Insurers need to reach out to the government, hospitals, providers, and patients to clear the final obstacles. A push has to be made to create the common community data mappings, to form common rules in transferring information between health exchanges, and, most importantly, there needs to be common disease registries to research ailments and determine which provider’s best care for any given disease. To this point no one has stepped forward to pioneer the change, it is a daunting task, but the fact that the industry is being forced to change provides healthcare stakeholders the opportunity to take the lead and utilize their services to better enhance the lives of those they try to help.
(1) Barnes, Julie “Moving Away From Fee-For-Service” 7 May 2012 The Atlantic
(2) Healthcare.gov “Affordable Care Act” US Department of Health and Human Services
(3) CMS.gov “Accountable Care Organizations (ACO)” 4 May 2012 Centers for Medicare and Medicaid Services
(4) aafp.com “Patient Centered Medical Home, Definition of” May 2008 American Academy of Family Physicians
(5) mtshealthcare.net “The Supreme Court’s Ruling on the Accountable Care Act and It’s Impact Upon Healthcare Information Technology” © 2012 by medical technology solutions, llc
(6) Riskin, Dan “Big data: opportunity and challenge” 12 June 2012 Healthcare IT News
(7) HHS.gov “Health Information Privacy” US Department of Health and Human Services
(8) Office of Information Technology “C32/CCD Clinical Summary” June 2011 US Department of Health and Human Services Section 7, Page 17