Thursday, January 22, 2009

Would you like some sticks to go along with your carrots?

A few minutes ago, the House Ways and Means Committee, chaired by Rep. Charlie Rangel (D-NY), completed its work on provisions of the economic stimulus bill under its jurisdiction. Among these are the creation of Medicare payment incentives for physicians and other clinicians to acquire health information technology.

According to a summary of the Ways and Means package voted upon today, a "carrots and sticks" approach will be used to get doctors to buy health information technology. Physicians will be eligible for $40,000 to $65,000 for showing that they are meaningfully using health information technology, such as through the reporting of quality measures. The payment incentives start at $15,000 in the first year, calendar year 2011, phasing down to $2,000 in the fifth year, 2015.

After that, though, sticks will be used to beat the non-compliant into submission. The bill would decrease total Medicare Fee Schedule payments for physicians and other "providers" who don't use certified electronic health record (EHR) systems beginning in 2016 by one percentage point a year until 2018. Beginning in 2019, if the percentage of eligible EHR users is less than 75 percent, the HHS secretary would be able to lower the fee schedule amount for the non-compliant to 96 percent of the fee schedule and lower it again to 95 percent in 2020. Individuals could be able to be exempted by the Secretary for "significant hardships" on a case by case basis.

Other provisions of the bill will lead to the development of standards by 2010 to allow for the nationwide electronic exchange and use of health information technology (HIT) to improve quality and coordination of care; strengthen federal privacy and security law to protect identifiable heath information from misuse as the health care sector increases its use of HIT; provide funds to states for low-interest loans to help providers finance HIT and grants to regional health information exchanges to unite local providers.

From the federal government's standpoint, I understand why carrots would be followed by sticks. The argument being, that it is the taxpayers' money being used to help doctors acquire HIT, so there should come a point where taxpayers can reasonably expect that everyone will get with the program. If you don't, well, they'll just make you.

But what happens if the positive incentives aren't enough to make the "business case" for a small primary care practice? If the vendors really aren't able to produce systems that have the functions needed? If there isn't enough support - such as training and problem-solving help as inevitable implementation problems arise - available to practices from trusted sources?

For smaller primary care practices in particular, the HIT incentives need to be combined with broader payment reforms to help sustain the economic viability of their practices. Otherwise, large multi-specialty group practices, the ones who already are most able to afford to buy EHRs, will get most of the money. And smaller primary care practices, the ones who most need the help, might find that the incentives aren't big enough to get them over the digital divide, and the penalties for non-compliance so big that it puts them out of business.

Today's question: Do you support the Ways and Means Committee's "carrots and sticks" approach to HIT adoption?


Jay Larson MD said...

Rather than having physicians buy one of the hundreds of EHRs out there, it would be nice if the Feds spent the money to develop free shareware for physicians to use. The typical EHR is about $30,000 per MD. The $15,000 only gets a physician half way there. So the incentive is more like a string bean than a carrot. It is still an extra $15,000 for software and another $10,000 for hardware. For a primary care physician a $25,000 hit would hurt.

Personally, I find electronic medical records a blessing. Data can easily be shared in the office and pulling a chart only takes a few key strokes. Electronic Health systems, though, can be difficult to navagate and slow efficiency initially. I just started e-prescribing and lets just say it is not "Plug and Play".

John said...

I have yet to see evidence with robust, meaningful clinical endpoints (physician or patient satisfaction, outcomes, or cost savings) that convincingly supports the benefit of EMR's. I think the EMR is in some ways akin to electronic airline ticketing - sure it has some advantages, but a good flying experience is defined much more by a safe, on time flight in which bags were not lost than by whether you used an electronic or paper ticket. As a solo practitioner who spends 30 minutes with every patient and then dictates a narrative summary of our visit in my own words (not using a phrase suggested by the computer) I remain a skeptic of the value of the EMR in a small practice and would anticipate that the "medicare stick" of reduced payments would force me to eliminate or severely reduce the number of medicare patients I see.