Sitting in my K Street office in Washington, D.C., I can see the dust settling after the political earthquake that followed the election of Republican Scott Brown to the Senate from Massachusetts. "Turmoil" would be a fair way to describe the behavior of policymakers, stakeholders and journalists in the wake of this electoral seismic event.
Let me hasten to say that I am not analogizing the political turn of events in Washington, D.C., to the profound tragedy that has befallen Haiti and its people. The two are incomparable. But in a real sense, Brown's election has disrupted the order of things in Washington in ways that were unpredicted (or at least unexpected) and with lingering consequences that may not be felt for some time.
What we all know is that the Democratic majority in the Senate has been reduced to 59. With that, the ability of the majority party to overcome minority party filibusters has been lost (unless, of course, a Republican senator can be coaxed to the other side). And with that loss, the prospects for enactment of comprehensive health care reform, such as the bills passed by the House and Senate, are enormously diminished, if not extinguished.
In days immediately following the Massachusetts election, President Obama has suggested that Congress consider a less expansive health care reform bill. House Speaker Nancy Pelosi (D-Calif.) has indicated that she does not have sufficient votes to approve the bill passed by the Senate.
From the White House to meeting rooms of the majority and minority leaders in Congress to the offices of every member of Congress who must stand for reelection in November, federal policymakers are trying to figure out, "Where do we go from here?"
Health IT Marches on, Regardless
Health care reform might advance in a limited version (if at all), but it will have little direct consequence on health IT policy or funding. After all, as I asked in my July 2009 column: "Where's the HIT in HCR (Health Care Reform)?"
For the most part, the health IT aspects of health care reform were launched as part of the American Recovery and Reinvestment Act of 2009 and its HITECH provisions. As we all know, new programs, new structures and lots of new funds for health IT were authorized and are in the process of being built and distributed by the Office of the National Coordinator for Health IT and CMS.
But … what the administration does with health IT policy and funding can have enormous impacts on reforming health care, whether there is health care reform legislation or not.
One area of health reform that is widely supported by Democrats and Republicans, in Congress and the executive branch, is the urgent need to replace fee-for-service payment systems and disaggregated, uncoordinated care. Both the House and Senate health reform bills offered various strategies to encourage providers -- physicians and hospitals -- to organize systems of care and then to pay those providers in a fashion that incents high performance, both clinical and operational.
The strategies in the bills to achieve these changes include:
- Accountable care organizations;
- Medical home programs;
- Bundled payment demonstrations; and
- Broad authority to CMS to develop, test and implement new delivery system and payment models.
For many concerned with the need for fundamental health care system reform, these provisions offered the best hope for success.
Now, the political landscape for health care reform seems inhospitable to sweeping legislative strategies. Even piece-meal approaches limited to widely supported provisions may not achieve stable footing. And yet, the need for reforms has not diminished. Indeed, the need to control the growth of health care costs, to improve quality, to expand coverage is greater today than it was a year ago. And the need will likely be greater yet a year from now absent leadership and action by public and private policymakers.
Call for Health IT Leadership To Reform Health Care
As many have observed, the first steps toward federal health care reform can be found in the federal stimulus package. A foundational element of health care reform is an IT infrastructure that can collect, analyze, and share actionable health care data to support improved clinical decisions and outcomes, greater efficiencies and real care coordination. At the administration's request, Congress provided direction and significant funds -- more than $30 billion -- for just that purpose.
Much time has been spent by ONC, CMS and hundreds of stakeholders in sorting out the granular policies of "meaningful use," standards setting, certification mechanics, and other aspects of the HITECH program. All necessary and important, but perhaps not sufficient.
The challenge of leadership here is to stretch the limits of executive branch authority to maximize the inherent powers of regulation and funding in order to effectuate policy objectives that might otherwise seem beyond reach.
To be more precise, health IT policymakers in the White House and at HHS, ONC and CMS should be exploring how to leverage health IT policy and funding to achieve broader health care reform objectives including organizing physicians and other providers into systems of care, having those systems of care be responsible for a patient's broad health care needs and using reimbursement and other financial incentives to achieve high levels of administrative and clinical performance.
With the publication of CMS' interim final regulation defining meaningful use, a mechanism to apply that leverage exists. The regulation creates a three-stage process intended to raise the bar over a five-year period to increase the functionality of electronic health records. In stage 1, "improve care coordination" is a health outcomes policy priority for 2011. The goal for that priority is the "exchange of meaningful clinical information among professional health care team."
I hope that stage 2 and 3 criteria would include more ambitious goals to improve care coordination. Care coordination is not achieved and is not meaningful without clinicians and providers working in concert to address the needs of a patient. While exchange of clinical information is necessary, it is not sufficient.
The challenge to the administration, CMS, ONC and HHS is to go beyond tentative steps (exchanging data is not care coordination) to not just improve care coordination, but actually achieve care coordination.
Why not tie incentive payments to eligible professionals to their active participation in a system which coordinates care, such as an accountable care organization, a medical group or an independent practice association? Participation in a system that coordinates care could be a policy priority that is articulated now and fully implemented in 2013 as part of the stage 2 objectives.
There are, no doubt, many other strategies that federal health IT policymakers could execute with health IT policy and funding as the driver for a health care system that is coordinated and high performing.
As the dust settles and the health care reform landscape comes into focus, the one certainty is that the need for health care reform persists. Health IT policy and funding can shape a reformed health care system. I hope our health IT leaders will recognize this opportunity.