Monday, February 7, 2011

Should Congress cut off EHR funding to doctors?

Maggie Mahar asks this provocative question in a recent Health Beat posting. She posits that the $27 billion in incentives for physicians and hospitals in the American Recovery and Reinvestment Act (ARRA a.k.a. the stimulus bill) is creating a worrisome “bubble” in the market for EHRs. She writes:

“I am hardly an IT expert. But I have spent enough years observing markets—stock markets, real estate markets, and most recently, our health care market—to recognize a big, bright Bubble when I see one. Eager to take advantage of fat federal subsidies, too many buyers, with too little information, are scrambling to purchase health IT. And, as is always the case, too many sellers are all too eager to satisfy the buyer’s desire to part with his money. But many vendors won’t have the resources to follow through on the services and training that they promise. Or, they will be too busy chasing the next customer to meet their commitments. More importantly, the majority of HIT vendors cannot fathom what it’s like to work in an ER or a busy primary care office, and so they cannot begin to grasp precisely what doctors and nurses need.”

The federal subsidies that she is referring to are incentive payments – up to $44,000 under Medicare or $63,750 under Medicaid – that physicians can receive over the next five years for adopting EHRs and meeting the federal government’s “meaningful use” rules. After five years, physicians who do not meet the requirements will be subject to Medicare pay cuts.

The question of whether the government should cut-off the incentive payments is not merely an academic one. House Republicans have introduced legislation to eliminate all “unused” stimulus dollars, which presumably would include the EHR incentive program since those funds have only started to be paid out to physicians and hospitals. (The Senate would have to go along, though, and President Obama likely would veto any cut-off.)

Mahar ends up deciding that the government should not eliminate the incentive payments because “it would be too hard to get that money back, and ultimately health care providers will need subsidies in order to purchase this much-needed technology. . .That said, I definitely would like to see the process of adopting HIT slow and perhaps the House [GOP] bill will generate a conversation about the mad rush to fund EHRs.”

I understand Ms. Mahar’s concern about the rush by EHR vendors to corner market share while the stimulus funds are available, and the pressure that this places on physicians to make a decision on acquiring or upgrading EHRs to qualify for the incentives. But, as she recognizes, pulling the plug out entirely on the incentive funding would be a big step backwards. “What is the alternative?” said one of ACP’s own staff experts on health information technology when I asked his reaction to the calls to eliminate the incentive program. He added “Our current paper system is more broken and more dangerous than the emerging health IT systems on their worst days.”

Good point. And it’s not like the goal of universal adoption of EHRs is a new one. Giving everyone access to electronic health records within 10 years was first set by a Republican president, George W. Bush, six years ago in his State of the Union address to Congress.

It is widely recognized that the costs to clinicians is a principal barrier, one that the ARRA incentive program is designed to help overcome. The possibility that the incentive program could be eliminated will have a chilling effect on physicians who are contemplating buying or upgrading their EHRs. I addressed this in my remarks at ACP’s briefing last week on the state of the nation’s health care, noting that, “The threat that Congress might cancel the incentive program will discourage physicians from moving forward on health information technology investments, and could pull the rug out on those who have already invested tens of thousands of dollars in the expectation that they will qualify for the incentive payments.”

In my mind, the government offered physicians a quid pro quo, invest in EHRs for meaningful use and we’ll help offset your costs. Reneging on that promise now would be harmful and unfair to physicians who are meeting their end of the bargain, and harmful to patients by setting back for many more years the goal set by President Bush that we’d all have access to electronic health records by 2015.

Today’s questions: What do you think about the possibility that Congress could cut off the ARRA incentives to doctors for electronic health records? What impact would this have on your decisions?


Arvind said...

Having operated a fully electronic practice for almost 9 years (way before HITECH and ARRA) I agree that this nonsensical way of providing incentives to adopt HIT should be stopped, or at least reviewed. This current rush towards EMR's is leading to IT adopting for the wrong reasons with the wrong incentives.

The only successful way of implementing IT is for clinicians to realize the type and scope of technology they need to adopt in order to provide higher quality of care to their community. The government has no role in deciding what makes up MU. Just allow us to pass on the costs of IT to our customers/payers, and we will be happy. This will unleash the innovation in health IT that current govt-mandated methods can never do. When will you learn this basic concept?

Steve Lucas said...

Doctors have a number of issues to deal with in selecting or not selecting an EMR system. First is that with the large number of vendors trying to win a portion of the large amounts of money being spent there is the question of qualifications and experience.

One hospital reported taking 10 years to develop an EMR system that matched their specific work flow.

The follow on question is: Will that vendor go out of business or be bought by another vendor. Doctors do not want orphan systems.

Of concern to me is the large number of front line doctors who are at or near retirement age. Will these doctors choose not to engage in an EMR system and leave medical practice when the penalty phase kicks in? The result will be chaos.

EMR’s have the potential to improve medical care, the problem is the state of current systems are not ready for wide spread distribution. Doctors are reporting IT failure putting patient’s lives at risk and system failure have brought entire hospitals record keeping function to a halt.

We need to learn from England and Australia as they have both tried and failed to implement nationwide systems. Let’s not reinvent the wheel.

Steve Lucas

Harrison said...

I find it interesting that many physicians want to be able to pass on costs of technology to our patients.
Our patients cannot or will not afford our pass on costs.
Medicare and insurance companies pay for them, and for the last 50 to 75 years that has been the case.
Without Medicare we would have fewer patients and fewer treatment options.

IT is a technology that we want to adopt and we want to pass on costs to our patients.
The payer source for the majority of our patients shares in the desire for us to upgrade our communication technology.
But it has set up cost control mechanisms over the years because of other cost inflation concerns that make it impossible for that technology to move forward without forethought.
And so we have the incentive program.

We can only hope that Congress will not renege on a promise.


DrJHO7 said...

"Should Congress cut off EHR funding to doctors?"

No, they shouldn't and they won't.
"Buyer beware" is reasonable advice for physicians who are considering a purchase of such systems, though. One needs to do one's homework and seek information on which cchit-certified ehr systems are being used and recommended
loco-regionally by physicians in their specialty.

They should take advantage of the services available through their local REC, also, and research about the vendor companies involved to be reasonably certain of their staying power. They should keep in mind which products will be certified by the ONC/HIT for meaningful use.

They should clarify the conditions by which the ehr they are considering can achieve electronic interfaces with local labs and hospitals and who is going to pay for those (will cost somebody about $5000 for each interface). Without such interfaces, the ehr is not terribly useful.

EHR's are the way of the future and will play an important role in transforming the american medical system into a safer, more effective and more affordable enterprise.

Alot of fault can be found with various aspects of the ARRA, (also the PPACA), but I think congress actually got it right in providing a financial catalyst to get the otherwise rather
slow-moving medical profession out of its retentive quagmire into a higher gear with regard to adoption of higher quality HIT.

I agree that some of the MU requirements are of dubious value (yes, that's being nice about it), and come from some politician's quid-pro-quo wish list, but i'll suffer through the process, take the money, and learn a few things about why some of the MU objectives are and are not important.

Jay Larson MD said...

I rather have the government spend the money developing a free shareware EHR that meets all the criteria that they require for "meaningful use". I have a problem with data being entered into proprietary fields.

ryanjo said...

There is already a well-tested EHR, introduced in 1996, used by hundreds of physicians and dozens of hospitals, and paid for by tax money. It is called VistA, the Veterans Health Information Systems and Technology Architecture (V IST A). But rather than building on this proven system, the President and the Congress rewarded the corporate healthcare IT hand that feeds them by throwing HITECH money to scattered and incompatible software vendors.