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Mostashari to Health IT Doubters: Chill

By John Reichard, CQ HealthBeat Editor

January 16, 2013 -- A spate of recent press coverage raising doubts about different elements of the Obama administration's multibillion-dollar program to spur adoption of health IT has left the top government official in charge of that effort in a feisty mood and eager to push back against critics.

"Are you disappointed?" Farzad Mostashari asked a reporter who called last week after being offered an interview with the National Coordinator for Health Information Technology. "There is no cause for disappointment,'' he declared.

Launched under the 2009 economic stimulus law (PL 111-5), the program pays doctors and hospitals higher Medicare and Medicaid payments if they make "meaningful use" of the technology. And, starting next year, they'll get paid less if they don't meet the meaningful use standards, which aim to improve the quality, safety and efficiency of health care.

But the meaningful use program has been taking it on the chin lately. A Sept. 21 New York Times investigative piece concluded that the move to electronic health records may be contributing to billions of dollars in higher Medicare costs. A RAND Corp. study released Jan. 7 said that health IT is not yet fulfilling expectations of savings. And a Jan. 14 Washington Post editorial complained that "the rush to digitize patient records has not cut costs."

To which Mostashari says critics are jumping the gun.

He said the RAND study "actually did not say health IT increased costs." It said the cost savings that RAND had predicted in 2005 if health IT were widely adopted haven't come true. But "we didn't do anything in 2005 that you would expect to spur huge adoption," Mostashari said. "We did that in 2009. And, since 2009, I think there's been zero evidence that there's been any disappointment in cost savings. Because, for one thing, why would you expect to see cost savings within a year of the payments beginning to go out? These things take time."

The incentive program sets out three successive stages of two years each, he said. "You start to computerize so you can access the information, then you do some sharing of data in stage two, which we haven't gotten to yet. And then, in stage three, we hope that we will be able to see the outcomes on quality, safety and efficiency."

The RAND study "is actually very measured" in saying that before cost savings can occur, "it's going to take time to get adoption up to levels we see in the European countries, and we're making progress. You know, we doubled adoption in the last two, three years." RAND says "you have to be able to share information with patients in computable form, and the study gives a lot of credit for making that part of stage two meaningful use that hasn't started yet.

"I think their main finding that it's going to take time before the full benefits are appreciated and we need to work on interoperability, usability and payment reform is right," Mostashari added. "Health IT is a tool, so what you use that tool to improve is going to depend on your payment context." Under the health care overhaul (PL 111-148, PL 111-152), changes such as bundled payments, patient-centered medical homes and accountable care organizations are beginning to occur, and they are pushing providers to better manage and coordinate treatment. "That's the world where we can see electronic health records being an absolutely critical part of delivering lower cost" care that also is of higher quality, he said.

The Sept. 21 Times piece, however, laid out specific examples of hospitals that adopted health IT and a short time later sharply increased their Medicare billings. The story said providers were, thanks to the power of the new technology, better able to bill for more complex ER services and that in some cases they practiced "cloning" in which the results of more complex care reimbursed at a higher level were moved easily from one bill to another without actually performing the service involved. Donald W. Simborg, chairman of a federal effort to determine the potential of health IT to commit fraud, told the Times that the abuses are widespread. "It's like doping and bicycling," he said. "Everybody knows it's going on."

The Times analysis found that, overall, hospitals that received government incentives to adopt electronic records showed a 47 percent rise in higher-level Medicare payments between 2006 and 2010, compared with a 32 percent increase at hospitals that did not get any incentive payments.

But Mostashari says the systems in that analysis predated the meaningful use program and were focused on documentation and billing rather than on improving care.

The meaningful use incentive program encourages the adoption of systems that improve efficiency and quality, he said.

The health IT chief acknowledged, however, that health IT systems can be instruments of fraud. He said the Obama administration is launching a summit next month to address use of the technology to commit fraud and to develop counter measures.

He added that the meaningful use program requires health IT to be certified if a provider is to receive the bonus payments. And the certification process requires that systems contain certain elements designed to protect against fraud, he said. In addition, a number of recommendations Simborg made to control fraud have been adopted by HHS or are under consideration, Mostashari said.

One of the points of the RAND study was that cost savings aren't occurring because systems aren't interoperable, meaning that for example, a doctor in a private practice who is not affiliated with a hospital system can't access imaging results from tests performed in that system. Easy access to those records would avoid duplicative tests.

But Mostashari said that even before stage two and stage three of the meaningful use program begins and interoperability catches hold, providers are reaping rewards from health IT.

As an example, he pointed to a primary care physician he interviewed in New York City who was shocked to learn after adopting a health IT system that she gave flu shots to just 20 percent of her patients. She had assumed the figure was closer to 80 percent. That kind of tracking allows doctors to make improvements, he said.

As other examples he said that electronic prescribing of prescription drugs in outpatient settings has grown from 4 percent of prescriptions in 2009 to over 50 percent now, increasing the legibility of prescribing information and reducing medical errors.

And every example in which health systems have lowered costs while improving quality – at places like the Geisinger health system in Pennsylvania, the Mayo Clinic in Minnesota, and Denver Health in Colorado, has involved integral use as health IT.

But as long as spending keeps rising and there's no assurance that systemwide providers are using the technology in a meaningful way, questions about the incentive program will continue.

Those questions are premature, Mostashari suggests. "We need to take a longer view."

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