The right incentives would lower costs, improve EHRs, Mostashari says.
This article first appeared May 24, 2018 on Medpage Today.
by Joyce Frieden
WASHINGTON -- Whose fault is it that electronic health records (EHRs) still aren't fully interoperable? Not the government's, Farzad Mostashari, MD, said Thursday.
"People say, 'Surely it's [the fault of] the government -- they didn't put enough standards in,'" said Mostashari, co-founder and CEO of Aledade, a company that helps primary care physicians start up accountable care organizations (ACOs). "No, that's not the problem with interoperability. The problem is, people don't have a business model where they make more money sharing data." Mostashari spoke at a summit on healthcare costs sponsored by the Alliance for Health Policy.
"The reason we don't have interoperability is not because we don't have the technical standards to do it -- it's because we don't have the business case to do it, or people are feeling like in furtherance of their business model, they can block the flow of information," said Mostashari, who served as National Coordinator for Health Information Technology under President Obama.
He noted that in many states, hospitals aren't notifying physicians when their patients are discharged from the hospital. "One hospital [I know of] said to a primary care doctor, 'If you join our ACO, you can get access to this information.'" In fact, having an interoperable EHR should be a condition of a hospital's Medicare participation, Mostashari suggested.
Health IT also hasn't helped cut healthcare costs, despite all its promise in that area, he continued. "Health IT is not going to do anything [to control costs] unless the people doing health IT are using it to achieve that goal. If you don't have the right goal, the right tools aren't going to help you."
Another reason healthcare costs haven't come down is that no one has really figured out how to make lots of money off of prevention, he said. "How can you make money preventing people from [for example] going into the hospital and needing dialysis? We know how you can make money giving dialysis; how do you make money saving lives? That's the question."
One thing that will help is payment incentives, said Mostashari: "Set the right payment policies and the market will emerge." He noted that although providers seem hesitant to take two-sided risk -- that is, they aren't willing to risk losing money -- when they form an ACO, they have no problems doing so in the Medicare Advantage program. "I know of physician groups that are taking full capitation risk on Medicare Advantage," he said.
Why the hesitation with ACOs? "It's because of the unpredictability of the benchmarks" being used to determine financial rewards and penalties for ACOs, he continued. "If you made [that program] more [predictable] like Medicare Advantage, it would massively open up the amount of potential disruption."
Another way to control healthcare costs, at least in federal programs like Medicare, "is to put programs on a budget and no longer give them an unrestricted draw on the U.S. Treasury," said Douglas Holtz-Eakin, PhD, president of the American Action Forum, a right-leaning think tank here. "Doing that would have a beneficial impact of saying to entire provider/beneficiary sector that 'There is only so much money for this senior; take good care of them with it, and focus your attention on doing that instead of taking more money from the treasury.'"
Topher Spiro, JD, vice president of health policy at the Center for American Progress, a left-leaning think tank here, agreed that healthcare should be put on a budget, "but it should be structured very carefully."
Reducing healthcare costs involves reconstructing the healthcare cost drivers, said Spiro. "In Medicare, it's very clear -- [the cost driver is] the variation in spending on post-acute care ... For that problem, there is an easy solution: we need to have bundled payments that bundle together the cost of hospital care with costs up to 90 days after discharge. I would phase in the bundles so they'd [eventually] apply to up to half of Medicare spending."
As for healthcare that's reimbursed by private insurers, "a recent JAMA study compared the U.S. with other developed countries and found that price, not utilization, was the major difference" that explained why the U.S. spent so much more, said Spiro. "To address this issue, we're ultimately going to need some kind of regulation of healthcare prices or provider payment rates -- such as a system like Maryland's that has all-payer rate setting. I think that's going to be necessary in the long run."