As the U.S. approaches 2009, it is a time of profound uncertainty. Financial markets have imploded on a global basis. GM is asking the federal government for money to cover its health care liabilities as the company fiscally bleeds. American citizens balance their households' basic needs for food, shelter, clothing and other essentials in a retail-challenged holiday season. Senator Kennedy, the lion of the Senate and health reform driving force, battles cancer with the best medical armamentarium on his side. Some 58 Democrats will be in the Senate -- one more than Congress had in 1993 under President Clinton.
Now, we've a new president's policies to consider.
Thus, my iHealthBeat editor asks me, "So what's health IT going to look like after this election?"
Going Back to The Future
Sometimes you have to go back to the future to have a light-bulb moment about an issue as seemingly intractable as fostering health IT adoption in health care. One of the historical moments that we should revisit is a report sponsored by Louis Sullivan, the HHS secretary under President George Herbert Walker Bush.
In 1991, Sullivan convened a work group to address the challenges of reducing administrative costs in the U.S. health care system. The group's report to Congress in 1993 identified $42 billion in cost savings that would accrue to the year 2000 by implementing electronic data interchange and the underlying standards to facilitate electronic transactions in health care.
While many recommendations from the Workgroup for Electronic Data Interchange were written into HIPAA during the Clinton administration, did the savings indeed "happen?" And if so, where did they go?
The sad fact remains that in the 15 years since WEDI wrote its groundbreaking report, paper claims continue to litter the system both literally and figuratively.
How can we break this logjam starting in 2009?
What Do We Know?
With Sullivan's 15-year-old advice in mind, let's account for what we know we know; what we know we don't know; and what we don't know we don't know.
First, what we know we know, from macro to micro:
The nation is experiencing a level of economic pain we haven't seen for at least a generation. According to the Motley Fool, "Maxed-out America is due for a debt diet." A new debt clock will be installed that goes up to one quadrillion dollars because the one we currently have maxed out at $10 trillion.
The jobless rate is at a 14-year high.
When unemployment increases, so does "uninsurance;" the Kaiser Family Foundation calculates that for every 1% increase in unemployment, there is a concomitant 1.1 million person increase in the number of people who lose health insurance.
The Medicare Trust Fund will be insolvent by 2019. State Medicaid rolls are under relentless pressure, strained by an increasing number of uninsured citizens and ever-increasing health costs. Governors are severely stretched to balance their budgets.
Moody's, the credit agency, published an analysis of the credit implications of Obama's health plans on Nov. 7, finding a mixed bag for the industry. Providers, Moody's said, would benefit due to enhanced access to Americans and a growing number of patients to be served; drug and insurance companies would lose based on cost-cutting proposals (according to Candidate Obama's Web site, a President Obama would, "Make Health Insurance Work for People and Businesses -- Not Just Insurance and Drug Companies").
What We Know We Don't Know
We know that Barack Obama and his pre-election advisers were bullish on health care IT. The campaign's Web site says that an Obama administration would:
"Lower Health Care Costs by Investing in Electronic Information Technology Systems: A key feature of Barack Obama and Joe Biden's health care plan is the use of health information technology to lower the cost of health care. Most medical records are still stored on paper, which makes them difficult to use to coordinate care, measure quality, or reduce medical errors. Processing paper claims also costs twice as much as processing electronic claims. Barack Obama and Joe Biden will invest $10 billion a year over the next five years to move the U.S. health care system to broad adoption of standards-based electronic health information systems, including electronic health records."
Thus, we know that President Obama would really and truly like to allocate $10 billion for each of the next five years to promote the adoption of information standards and EHRs.
What we don't know is whether (1) the $10 billion per annum will be available from 2009 to 2013, and, (2) whether Congress will get its act together to make this happen.
We know there are several specific health battles to sort out. These will be prioritized and negotiated between the executive and legislative branches. Two are immediate issues: the funding of SCHIP, which covers kids (a sacrosanct health issue); and dealing with Medicare (in the short-term, physician payments).
What We Don't Know We Don't Know
Now, for the wild cards, those events that could shake up the tectonic plates that underlie the stubborn situation of moving health from a paper-era into a digital era. There are many:
Will Senator Kennedy be front-and-center in the health reform effort? He returned to D.C. in October and has begun to consult with advisers on a health bill.
How high will uninsurance rolls go? Will there be a tipping point percentage where the middle class says, "enough"?
How long will the credit crisis continue, severely hampering hospitals' and providers' access to capital?
Calling The Muses of da Vinci, Buffett and Schmidt
With bipartisan support for health IT for the past few years, shepherding standards and EHR adoption is a no-brainer. If there was ever a time to think out of the proverbial box, it would be now.
That's the point in creative thinking: Now that we're essentially fiscally broke as a nation, we must analyze investment in health IT in light of the total value that connectivity brings in health care. Think creatively like Leonardo da Vinci; about value like Warren Buffett; and like Eric Schmidt when it comes to the connectivity of Google.
The value of connected information in health accrues in many ways across many stakeholders. Among them:
- Reducing medical errors, which leads to better care and lives saved;
- Being able to measure what works, what doesn't, and pay based on performance;
- Improving office efficiencies, saving providers costs for expensive labor that deals with dead trees-worth of paper (just ask Jonathan Bush to wax lyrically about the role of athenahealth in targeting paper in doctors' offices alone);
- Reducing redundant tests and exams by being able to unify data that sit in paper-based silos; and,
- Bringing just-in-time knowledge and alerts to physicians at the point-of-care that improve clinical decision-making -- again, positively affecting patient outcomes and provider quality.
There's hard ROI, and there's soft ROI.
John Halamka, CIO of the CareGroup Health System and dean for technology at Harvard Medical School, has smart ideas about gain-sharing and redistributing the wealth that accrues when providers use electronic records and payers benefit from that use.
Newt Gingrich of the Center for Health Transformation has an idea where EHR adoption can be funded through savings that are found in targeting health fraud -- which can be done only when electronic health systems are in place.
Here's one example of the hard ROI in using EHRs to fight health care fraud: The New York Times in 2005 estimated that Medicaid fraud in New York state was 10% of total Medicaid spending in the state. That would net out to $4.4 billion in New York state Medicaid fraud savings alone. Those freed-up funds could finance adoption of health IT for providers in the state.
These and other creative ideas are what it's going to take to get moving on electronic health information. Let's listen to Dr. Sullivan, for whom a favorite quote was, "We can do it." This time around, we must do it.
Or in the optimistic words of our next president …Yes, We Can.