Recently, National Coordinator for Health IT David Blumenthal sent a public message outlining progress toward defining "meaningful use" as it relates to health care providers qualifying for the financial incentives outlined in the Health Information Technology for Economic and Clinical Health Act of 2009.
In the open letter, he states that the Office of the National Coordinator for Health IT "has already engaged in a broad range of efforts to support the development of a formal definition of meaningful use. The HITECH Act designated a federal advisory committee, the [Health IT] Policy Committee, with broad representation from major health care constituencies, to provide recommendations to ONC on meaningful use. The [Health IT] Policy Committee has provided two sets of recommendations, informed by input from a variety of stakeholders. ONC and CMS have also conducted a series of listening sessions to solicit feedback from more than 200 representatives of various constituent groups and an open comment period where over 800 public comments were submitted and reviewed."
He continues that a formal definition from CMS is expected by Dec. 31, 2009, and that further public comments can be expected thereafter. A review of the official meaningful use Web site (yes, there is one) indeed shows a series of reports and lengthy documents detailing the lengthy discussions to date. Stakeholders were broadly represented, comments were inclusively collated and incremental feedback was given.
As well-intentioned as these efforts toward defining meaningful use may be, I can't help but wonder if we could be better spending our time or dollars elsewhere. If there weren't the potential for $19 billion in incentive payments, would we really care as much about what meaningful use means? Will tying payments to meaningful use actually result in higher quality, more cost-effective health care? Something tells me we've been down this road before.
Relative Value
It was just during our last health care crisis in the early 1990s when some Harvard researchers attempted to define and quantify something equally subjective as meaningful use: "relative value" or, specifically, the relative value of services provided by physicians and therefore what price should be paid.
In the setting of annual health care cost inflation as high as 18%, William Hsiao and his colleagues at the Harvard School of Public Health believed that a "resource-cost basis would reflect estimates of what relative values would be under a hypothetical market that functions perfectly. Under such a market, competition drives relative prices to reflect the relative cost of efficient producers."
Over a period of several years, the Harvard research group, working with the American Medical Association in the form of a technical consulting group and a cross-specialty panel, tried to define what "relative value" meant and developed the Resource-Based Relative Value Scale -- which after 1992 became the basis for most provider payments in the U.S.
Using the RBRVS formula, the federal government established a standardized physician payment schedule in which allowable fees for health care services would be determined by the resource costs needed to provide them. Specifically, costs were calculated based on estimates of physician work, practice costs and professional liability insurance. Payment then was calculated by multiplying the costs of a service by a conversion factor and adjusting for geographical differences in resource costs.
Though valiant in its attempt to appropriately attribute free-market value to provider services, it's fair to say that RBRVS has done anything but that. Most critics argue that payments are based on relative effort, rather than outcome, favoring the volume of complex procedures over more cost-effective, pragmatic solutions. Others cite the political nature of the reimbursement formulas, as managed by AMA's RVS Update Committee, resulting in under-reimbursement of primary care and cognitive services. Regardless, it appears quite evident that RBRVS hasn't significantly improved price transparency but rather only distorted it. And health care costs remain out of control.
The Hazards of Centralized Subjectivity
In attempting to define what is meant by "meaningful use" or "relative value," there are some inherent problems with the task itself. First, it's likely that no single definition or solution exists. As is often said, value is in the eye of the beholder. A worn-out mattress may be one person's piece of junk and another person's bounty. Similarly, meaningful use could mean different activities to different constituents, and even to different individuals within the same constituency. To presume that there is one answer for everyone is overly simplistic.
Second, it's unlikely that the target definition will remain the same, or even serve the same purpose, over time. This is particularly true if you want to foster a dynamic, entrepreneurial market. A quick review of ICD-9 codes (e.g. 780.4, the diagnosis code for dizziness and giddiness) is more than testament to that. Once the definition has been made, it only becomes obsolete over time, if not restrictive and calcifying, and it's difficult to keep current despite the best of efforts.
Importantly (and equally concerning) is the notion that the goal of centrally defining and measuring value is compelling and alluring, particularly to intelligent individuals who enjoy a challenge. For many academics, an ultimate goal is to discover and define a single unifying truth that solves market flaws. And to put those ideas in motion through federal incentives makes it that much more powerful -- and dangerous.
The reality, as we've seen more often than not, is that meaning or value is best determined not by centralized criteria or edict, but by free-market principles and personal accountability. Some individuals prefer privacy at all costs; other individuals may prefer convenient online tools; while still others may be most concerned about medication errors. Though much of the current draft criteria for meaningful use certainly make general sense to most constituents today, it's unrealistic to presume that these criteria will at all be comprehensive, adaptable or sustaining -- let alone create the ultimate goal of quality, cost-effective health care.
The proper role of government should not be to define actions and activity, but rather to foster competition and incentives toward goals that meet the public good. Only then can the market begin to behave more rationally.
Unfortunately, we're still trying to back out from the pre-planned, centralized roads already traveled over the last several decades. Are the proposed HITECH initiatives only going to make the situation worse? Or will the current efforts to define "meaningful use" lead us toward our primary goals? Perhaps we should form another central committee to figure that out next.