|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
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infrastructure, preferring to get their information from outdated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
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
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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