Symposium on Health Information Technology - July 2006
By Ken Ortolon
Have you done a Pap smear on all your female patients over 40? It probably would take a full weekend of culling paper charts to find the answer. If you maintain your medical records electronically, however, you could have the answer in a matter of seconds.
That, say physicians who are jumping on the electronic medical record (EMR) bandwagon, can be a powerful tool to help individual physicians improve the quality of care they deliver. And, it will be indispensable for survival of physician practices as health insurers move from paying for the quantity of services toward paying for the quality of the outcomes.
Physicians traditionally have been paid at the point of care, charging a fee for each service performed. But commercial health plans and government programs, such as Medicare, increasingly are looking at new payment systems to compensate physicians based on the results they achieve.
Experts say these payment systems, widely known as pay for performance (PFP), will become more prevalent as employers and the government seek to further control their health care costs.
Another new twist in the cost-containment arena is the use of "tiered networks" in which health plans rate physicians based on the quality and cost effectiveness of the care they provide. These tiered networks provide financial incentives, such as lower copayments, for patients who use physicians in the upper tiers.
Both of these schemes are gaining popularity across the country, so physicians must be prepared to demonstrate the quality of care they provide. The first step in doing that, the experts say, is adopting health information technology (HIT), namely EMR systems.
"Physicians need to start thinking about this now because, whether they like it or not, these programs are coming, out of simple cost reasons," said Plano family physician Christopher Crow, MD. "There's not enough money in the system to pay for everyone's health care in the current fashion."
Dr. Crow says having and being able to analyze the type of data that EMRs can provide will not only help physicians thrive in the new payment environment but also help them improve their quality of care and maybe even the bottom line for their practices.
Cost Versus Quality
Tiered networks and PFP programs have been cropping up around the country for years. The most widely known PFP initiative likely is Bridges to Excellence (BTE), launched about five years ago by a coalition of employers, health plans, and others. BTE pays per-patient performance bonuses to physicians who achieve certain benchmarks in error reduction and diabetes and cardiac care management.
Medicare also has gotten into the PFP game, launching pilot projects involving 10 large group practices across the country in 2005. The Centers for Medicare & Medicaid Services has just begun soliciting physicians to participate in its Physician Voluntary Reporting Program.
Tiered networks, meanwhile, have increased nationwide since the Center for Studying Health System Change reported in 2003 that nearly two dozen health plans in 12 different markets had launched or were planning to launch tiered provider networks.
While supporters of these coverage schemes claim the focus is on improved quality, physicians have been skeptical.
"The skepticism over pay-for-performance programs is well validated because right now they're based on only claims data, which doesn't give you a lot of information about actual quality of care," said Dr. Crow. "It can only look at what type of costs you're spitting out per disease. It doesn't really tell you how well you're doing at treating it, just how much money you're throwing at it."
The American Medical Association was so concerned about PFP initiatives, including one considered last year by Congress that one AMA official termed "absolutely unacceptable," that the organization drafted a set of principles that it believes all PFP programs should meet. They must ensure quality of care, foster the patient-physician relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair and equitable program incentives.
Physicians also have raised concerns that most tiered networks are nothing more than economic credentialing of physicians.
Be that as it may, the idea of rewarding cost effectiveness and quality is likely here to stay.
Roland Goertz, MD, chief executive officer of the McLennan County Medical Education & Research Foundation in Waco, says physicians eventually will have to face up to what he calls "health parameters."
"We do an excellent job creating new things with technology to poke and prod every orifice of the body. We pride ourselves on doing that, and there's nothing wrong with that," Dr. Goertz said. "But we have done very little to force ourselves to understand what is of highest value."
He says PFP should be an educational tool with incentives for physicians to improve their quality of care, rather than simply giving doctors a grade on their performance.
Data Tell All
Regardless of how these systems shake out, experts say physicians armed with electronic technology will fare much better than those who rely on traditional paper records.
"There is a relationship between the economic tools that drive medicine and health IT," said David Brailer, MD, PhD, who recently retired as national coordinator for health information technology at the U.S. Department of Health and Human Services. "We know from looking at data, most recently the data that come from the Integrated Healthcare Association's (IHA's) project in California, that doctors who have electronic health records perform markedly better on performance measures than doctors who don't."
IHA is a statewide collaborative of California health plans, physician groups, and health care systems, plus academic, consumer, purchaser, pharmaceutical, and new technology representatives that for several years has operated a PFP initiative involving 225 physician groups representing more than 35,000 doctors. In February, IHA released performance results that showed its physicians had shown substantial improvement in clinical results, patient experience scores, and HIT adoption from 2003 to 2004.
"Pay for performance has been a successful collaboration of physicians, health plans, consumers, and those who pay for health care. California's PFP program should serve as an inspiration for any group attempting to advance health care quality improvement," said Steve McDermott, chief executive officer of Hill Physicians, Inc., and chair of the PFP planning committee that produced the report.
PFP programs such as that of IHA actually provide incentives for physicians to adopt HIT, but Dr. Brailer says he does not think the same will be true of tiered networks.
"That's picking winners," he said. "You exclude people from networks, which might be better from the health plan's perspective, but it doesn't do anything to help doctors across the nation develop electronic health records."
Crunching the Data
Dr. Crow's three-physician practice adopted EMRs more than four years ago, and he sees tremendous value in it for physicians dealing with both PFP and tiered networks. For one, physicians with electronic records have access to much more data than health plans can mine out of claims.
"An EMR that has a clinical data repository gives you a database that has all your patients' blood pressures and lab results in it, whether you've told them to quit smoking or not, whether you're checking their cholesterol at certain intervals, and what the impact of your treatment has been," Dr. Crow said. That, he says, can help physicians refute what a health plan might decide about the quality or cost effectiveness of their care.
At the same time, Dr. Crow says EMRs can be a valuable tool for physicians who are interested in improving the quality of their care regardless of whether they're in a PFP program or tiered network.
"All the research shows that disease management and prevention in this country is happening at about 55 percent of the rate that it should," he said. If physicians have an EMR that allows them to run reports and identify patients that may have "fallen through the cracks" in terms of preventive care or disease management, that can be a boost to anyone truly interested in quality of care, he says.
"If I can rein those people back in and let them know that we need to do certain things to keep up with the standard of care, wouldn't that be something I would be interested in as a physician who's interested in providing quality care?"
Dr. Crow and his partners believe they have provided better quality care and patient satisfaction is higher since they adopted their EMR system. Plus, they are saving between $60,000 and $80,000 per year per doctor in overhead costs because of increased efficiency and improved quality.
That, he says, is a big boost to their bottom line.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
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