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Home / News & IndustryManaged Care Insight and Analysis
Updated: June 17, 2008
HIT Slow To Develop In Practices

Physicians and insurers are making for strange bedfellows these days, trying to fight off investment, each for their own reasons, in office computers for health information technology (HIT).

Consequently quality healthcare could take a hit.

Doctors in small practices don’t want to invest, or don’t have the money to invest, in HIT that could run in excess of $30,000 per physician. Virtually all multi-specialty practices have HIT, potentially placing small physician practices at the mercy of health plans.

Insurers don’t want to help physicians pay for the infrastructure, preferring to get their information from outdated claims data. Some physician groups and the Centers for Medicare and Medicaid Services (CMS) say claims data is basically worthless in determining the quality of care in the office setting, with only a 50 percent accuracy rate depending on the illness.

"Claims data can’t really tell how sick a patient is or if a doctor is good," said Dr. Michael Mirro, medical director, Clinical Research Center, Parkview Hospital in Fort Wayne, Ind. "Physician performance can’t be measured accurately because nomenclature and coding is very arcane, with laboratory and pharmacy codes the exceptions."

Existing claims data, with their general, vague answers also don’t adequately address where care is provided or adequately exclude inappropriate patients from the data set.

The insurance and medical communities would prefer to use computerized clinical data over administrative claims data as it is a better measure of physician performance. To analyze clinical data to measure performance, HIT is required.

Physicians can use claims data to extract vital quality information for insurers but the work is labor intensive, Mirro said.

Mirro, a cardiologist, is a member of the American College of Cardiology (ACC) that along with the American Medical Association (AMA) wants insurers to chuck claims data. He is chair of the ACC’s HIT committee.

Though supportive of office computerization, CMS has a volunteer program called Physician Quality Reporting Initiative (PQRI) that revolves around the very claims data it abhors, in a pilot program, as a means to develop a reimbursement system based on performance as revealed by HIT.

Medicare will reimburse physicians as much as 1.5 percent more at year’s end if they submit that claims data that addresses how the doctors treated certain illnesses, such as diabetes and heart disease.

PQRI "has some value as an initial foray into getting physicians to report data but it is cumbersome," Mirro said.

In 2006, the ACC released its "Principles to Guide Physician Pay-for-Performance Programs." The white paper strongly supports pay-per-performance (P4P) as the means to improve quality of care"… noting, that traditional approaches "have failed in part" because they don’t address problems entrenched in America’s "complex and fragmented systems of care." The ACC also said that the current system has few incentives to transform the status quo and reward performance.

Despite universal approval for and proliferation of P4P programs, there is little evidence that these programs are actually positively affecting patient health, the ACC said.

"There are essentially no randomized controls and very few reports in the literature that analyze the existing programs," it added. It wants to see established evidence-based performance measures anchored in valid and reliable measures of performance.

Blue Cross and Blue Shield of Michigan believes that "data supports reimbursement, but it sometimes doesn’t include information explaining what went into a care plan, or information about health outcomes," said Dr. Richard Ward, the Blues vice president of clinical programs and medical informatics, in a written statement. It encourages its participating physician organizations and healthcare facilities to invest in HIT.

Until that day arrives the insurer will continue to work with Michigan-based physician organizations participating in its Physician Group Incentive Program "to use claims data to support clinical practice improvement," Ward said. This will help doctors "understand and comply with national provider identifier standards that should make claims data more useful for provider performance measures and clinical practice improvement."

Regarding diagnosis codes and provider identifiers, the Blues want "complete and accurate data" that includes the provider who ordered or referred a service as well as the physician who delivered the care. All of which is called for in standardized claims transactions anyway, he added.

The Blues also provide "benchmark reports as well as actionable data sets that doctors can use to support their chronic disease registries to assure that patients receive evidence-based care needed for prevention and chronic disease management," Ward continued.

The AMA has said repeatedly that claims data won’t work and is telling doctors not to use them. It is working with CMS and the ACC and some insurers to develop appropriate methodologies

Currently most claims data is recorded on ICD-9 reimbursement codes that define illnesses and which all physicians submit to insurers. The AMA developed this code with Medicare and almost every physician practice uses the code, Mirro said.

A new claims data system requires "a whole new billing, claims nomenclature and is being developed and called ICD-10," Mirro said, adding that ICD-10 is still at least five years away.

"Physicians are very data-driven individuals but the thing is the data must be verified as accurate and they all know that claims data is not accurate," he said. "Most doctors won’t participate unless they have electronic health records" but many doctors won’t buy HIT, which is the physician’s Catch 22. How can they invest in practice infrastructure in an environment of declining reimbursement?

ACC is working with some insurers and CMS to help create "a dialogue of useful claims data and theimportance of linking it to clinical data sets," Mirro said, so insurers can measure physician performance in their offices.

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  This article was taken from:
The Executive Report on Physician Organizations

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