With the HITECH Act passed and the Dept. of HHS feverishly working to draft a clear definition of what “meaningful use” and “certified EHR” actually mean for reimbursement purposes, a far bigger question looms: Is the promise of $19B dollars dedicated to reimbursing those hospitals and physicians who adopt and meaningfully use an EHR enough?
Let’s take a quick look at the numbers. (For sake of simplicity, this post will look at physician reimbursement.)
For adopting and meaningfully using a certified EHR a physician may be reimbursed between $44K (Medicare) to $65K (Medicaid). This will not be a lump sum payment, but is parsed out over 5 years as the physician continues to demonstrate meaningful use of an EHR. Important points here, the physician pays up-front costs (sunk capital) and is reimbursed over time if he/she can demonstrate meaningful use and the solution adopted is “certified.”
As the latest Wal-Mart, Dell and eClincalWorks partnership shows, vendors looking to sell into this market opportunity are pricing their solutions at or near reimbursement levels, e.g., $25K year one and $4-6.5K for follow-on years in the Wal-Mart offering.
According to athenahealth CEO, Jonathan Bush, their customer, a physician, grosses $400k/yr.
Virtually every report we have seen and physicians we have spoken to who use an EMR/EHR today, readily admit that the upfont pain of implementation, training and becoming adept at using the solution was significant. The significance is most often felt in an average 30% productivity hit for the first 6 months that is compensated through longer hours or seeing less patients. The proactice does not return to pre-implementation state of operation till a year after go-live.
Combining the above and keeping calculations simple: (Note: we’ll assume productivity returns to previous state within first year and use a sliding scale for productivity hit in year one of, first 6 months 30% hit, second 3 months, 20% and and last 3 months 10%)
Year One Cost: ($25K) for EHR purchase + (0.30($400K/2) + .2($400K/4) + .1($400K/4)) = ($115K)
Year One Reimbursement: $25K (more generous Medicaid)
Total Cost to Physician: ($115K) + $25K = ($90K)
After Year One, the physician is already down $90K. Assuming practice returns to normal operations/productivity in years 2-5 and the physician is successful in getting full reimbursement from Medicaid, at the end of five years, that physician is still down $50K. Depending on how much business the physician derives from Medicaid, it will take many more years of avoiding the “stick,” the sliding decrease of Medicaid payments, before a physician recoups this initial, year one loss.
Bottom-line: Adopting an EHR to tap that $19B dollar Stimulus package does not make economic sense for the average physician.
Solving the Physician Adoption Problem
To drive EHR adoption we will need three things:
1) Low “meaningful use” thresholds to ease the pain that a physician has to go through to demonstrate that indeed they are meaningfully using an EHR. As a starting pointing, let’s target electronic exchange of labs, meds and vitals (including allergies) for care coordination combined with eRx. That should address care coordination, quality and eRx outlined in HITECH Act.
2) Very simple certification process for HIT. Do not burden the system with complex certification processes, ala CCHIT. Don’t get me wrong, CCHIT has done some good things in the past, but to apply CCHIT certification for “certified EHR” will create far too complex and onerous a process for truly new and innovation approaches to provide solutions that assist physicians in meeting meaningful use criteria.
3) Leverage the consumer to create an additional forcing function to drive physician adoption as reimbursement under the HITECH Act is insufficient. Getting the consumer engaged may prove challenging, but engage we must for at the end of the day, the value in a physician adopting and using an EHR must return to the end consumer/taxpayer as they are the one footing the bill.
Over the next few years we, as a nation will be extremely challenged to drive true healthcare reform, healthcare reform as President Obama stated that is “evidence-based.” A common refrain in the manufacturing industry is: “You can not improve what you do not measure.” Today, our healthcare system has absolutely no systematic way of measuring its performance. It truly is a travesty. Healthcare IT can, if effectively deployed and used, can play a critical role in collecting those measurements that we can begin to use to conduct true, evidence-based reform.
We need to articulate to the Joe the Plumbers of this country, what HIT adoption and use means to them. To date, the healthcare industry and government has done an extremely poor job of helping Joe understand that value. Without his/her support, no amount of money thrown at this problem will suffice.