Assessing HITECH Implementation and Lessons: 5 Years Later.

POLICY POINTS: The expansive goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, generating points of vulnerability. While federal legislation can be a powerful stimulus for change, its effectiveness also depends on its ability to accommodate state and local policies and private health care markets. Ambitious goals require support over a long time horizon, which can be challenging to maintain. The future of health information technology (health IT) support nationally is likely to depend on the ability of the technology to satisfy its users that its functionalities address the interests policymakers and other stakeholders have in using technology to promote better care, improved outcomes, and reduced costs. CONTEXT: The Health Information Technology for Economic and Clinical Health (HITECH) Act set ambitious goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes. With HITECH's grant funding now mostly exhausted but statutory authority for standards remaining, this article looks back at HITECH's experience in the first 5 years to assess its implementation, remaining challenges, and lessons learned. METHODS: This review derives from a global assessment of the HITECH Act. Earlier, we examined the logic of HITECH and identified interdependencies critical to its ultimate success. In this article, we build on that framework to review what has and has not been accomplished in building the infrastructure authorized by HITECH since it was enacted. The review incorporates quantitative and qualitative evidence of progress from the global assessment and from the evaluations funded by the Office of the National Coordinator for Health Information Technology (ONC) of individual programs authorized by the HITECH Act. FINDINGS: Our review of the evidence provides a mixed picture. Despite HITECH's challenging demands, its complex programs were implemented, and important changes sought by the act are now in place. Electronic health records (EHRs) now exist in some form in most professional practices and hospitals eligible for HITECH incentive payments, more information is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more fundamental issues associated with using health information technology (health IT) to improve health care delivery and outcomes. In some areas, HITECH's achievements to date have fallen short of the hopes of its proponents as it has proven challenging to move meaningful use beyond the initial low bar set by Meaningful Use Stage 1. EHR products vary in their ability to support more advanced functionalities, such as patient engagement and population-based care management. Many barriers to interoperability persist, limiting electronic communication across a diverse set of largely private providers and care settings. CONCLUSIONS: Achieving the expansive goals of HITECH required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, some better positioned to move forward than others. To date, it has proven easier to get providers to adopt EHRs, perhaps in response to financial incentives to do so, than to develop a robust infrastructure that allows the information in EHRs to be used effectively and shared not only within clinical practices but also across providers. Effective exchange of data is necessary to drive the kinds of delivery and payment reforms sought nationwide.

Making sense of the change in how Medicare Advantage plans are paid.

The Affordable Care Act has altered payment policy for private Medicare Advantage (MA) plans, with the goal of lowering costs closer to the level in traditional Medicare. Using newly available information on 2009 MA plan costs, this analysis com­pares plans' estimates of per capita costs for providing Parts A and B benefits to their enrollees, on a risk-adjusted basis, against what government data show to be the same costs for traditional Medicare program beneficiaries residing in the same county. It finds that on average, risk-adjusted MA plan costs were 4 percent higher than traditional Medicare costs (104%). Among plan types, only HMOs had lower average costs than traditional Medicare. Among local PPOs and private fee-for service plans, over 75 percent had costs exceeding those in traditional Medicare. The wide variation seen in MA plan costs relative to traditional Medicare suggests there is room for greater efficiency in care delivery.

Identifying, monitoring, and assessing promising innovations: using evaluation to support rapid-cycle change.

The Center for Medicare and Medicaid Innovation (Innovation Center) was created by the Affordable Care Act to identify, develop, assess, support, and spread new approaches to health care financing and delivery that can help improve quality and lower costs. Although the Innovation Center has been given unprecedented authority to take action, it is being asked to produce definitive results in an extremely short time frame. One particularly difficult task is developing methodological approaches that adhere to a condensed time frame, while maintaining the rigor required to support the extensive policy changes needed. The involvement and collaboration of the health services research community will be a key element in this endeavor. This issue brief reviews the mission of the Innovation Center and provides perspectives from the research community on critical issues and challenges.

Understanding a collaborative effort to reduce racial and ethnic disparities in health care: contributions from social network analysis.

Quality improvement collaboratives have become a common strategy for improving health care. This paper uses social network analysis to study the relationships among organizations participating in a large scale public-private collaboration among major health plans to reduce racial and ethnic disparities in health care in the United States. Pre-existing ties, the collaborative process, participants' perceived contributions, and the overall organizational standing of participants were examined. Findings suggest that sponsors and support organizations, along with a few of the health plans, form the core of this network and act as the "glue" that holds the collaboration together. Most health plans (and one or two support organizations) are in the periphery. While health plans do not interact much with one another, their interactions with the core organizations provided a way of helping achieve health plans' disparities goals. The findings illustrate the role sponsors can play in encouraging organizations to voluntarily work together to achieve social ends while also highlighting the challenges.

Availability of data to measure disparities in leading health indicators at the state and local levels.

OBJECTIVES: Healthy People 2010 identifies the elimination of health disparities as a critical national goal. The article analyzes the availability of state and local data to support this work. METHODS: We assessed data availability for the 10 leading health indicators (LHIs), comprising a set of 26 measures. Our analysis is based on a mid-2007 review of federal and state Web sites. FINDINGS: Federal data sources allow aggregate state estimates for 24 LHI measures, although some either are not available for all states or vary from the federal definition. National sources capture some but not all of the subgroup characteristics, defined as national disparities priorities. Limited sample size is a barrier to generating state estimates for specific subgroups, and data by geographic subdivision within a state are often lacking. States also vary in how aggressively they use disparities data or make them available externally. CONCLUSIONS: Federal leadership has been critical to state capacity to assess LHI disparities. Although some relevant state-level disparities data exist, major gaps remain, local estimates are limited, and some states make better use of the data than others. Continued federal leadership and support is critical to states' abilities to address Healthy People 2010's disparities goal.

Regional Variations: The Use Of Hospitals, Home Health, And Skilled Nursing In Traditional Medicare And Medicare Advantage.

In the traditional Medicare program, the use of health care services-particularly postacute care-varies substantially across geographic regions. Less is known about such variations in Medicare Advantage (MA), which is growing rapidly. Insurers that are paid on a risk basis, as in MA, may have incentives and tools to restrain the use of services, which could attenuate geographic variations. In this study of fifty-four million Medicare beneficiaries in the period 2007-13, we found that geographic variations in the use of skilled nursing facility and hospital care in the MA population exceeded those in traditional Medicare, though variations in the use of home health care were greater in traditional Medicare. Within hospital referral regions, the correlations between the use of services in MA and traditional Medicare were moderate to strong. The findings suggest that regional variations in hospital and postacute care reflect local factors that influence beneficiaries' use of services irrespective of the way they obtain coverage.

Translating research to action: improving physician access in public insurance.

Policymakers continue to struggle with how to assure adequate access to physician services in public programs like Medicaid, State Children's Health Insurance Program, or other public coverage programs. In this article, we synthesize available research on this topic and provide a framework that policymakers may find useful in identifying and measuring barriers to care access, determining where and why problems exist, and identifying how to intervene. Using our experience constructing the framework, we also consider what observations can be drawn from this experience for those interested in the challenge of moving the insights from research to practice.

Quality improvement in Medicaid managed care: Experience of the best clinical and administrative practices initiative.

BACKGROUND: The Best Clinical and Administrative Practices (BCAP) initiative is part of the Medicaid Managed Care Program (MMCP) operated by the Center for Health Care Strategies. Work groups of 10-12 plans addressed quality of care in designated areas. METHODS AND INFORMATION SOURCES: The assessment of BCAP was part of a larger MMCP program evaluation funded by the Robert Wood Johnson Foundation. Case studies were developed for four BCAPs that focused respectively on improving birth outcomes, preventive care for children, asthma care, and care for adults with chronic illnesses or disabilities. They were based on document review and semistructured interviews. Medicaid managed care plans nationwide were also surveyed. FINDINGS: BCAP participants were overwhelmingly risk-based managed care plans whose enrollment was dominated by Medicaid. Participants said BCAP helped them enhance the way they approach quality improvement. As a result of work group participation, most plans made changes in their delivery of care, and more than half sustained and continued to build on these changes after the work group ended. DISCUSSION: BCAP participation helped Medicaid plans change the way they think about quality improvement and take sustainable steps to improve quality; the ultimate impact may be stronger once plans become more sophisticated users of such techniques.

Private plans in medicare: another look.

Previous efforts by Congress to expand the role of private plans in Medicare have met with limited success. Although the same fate may befall Medicare Advantage (MA), authorized by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the political environment has changed, and powerful political interests now support Medicare privatization. Only time will tell whether these interests--and the policies they are pursuing--will be sufficient to offset the barriers that historically have limited the role of private plans in Medicare.

Challenges in improving care for high-risk seniors in Medicare.

Despite strong interest in improving care for high-risk elders, demonstration projects typically show negative results. This paper examines one large foundation-sponsored initiative to gain insight on why success often is so elusive. The findings indicate that specific flaws in concept, design, and implementation each make it more challenging for demonstrations to achieve their intended goals, especially those involving cost and utilization reductions. We speculate that part of the reason for this is that organizational and political processes lead to fundamentally conservative demonstrations that assume that small amounts of resources directed at incremental change can be effective in generating substantial change in organizations and can do so rapidly.

Consumer Engagement in Health IT: Distinguishing Rhetoric from Reality.

RATIONALE: Policymakers want health information technology (health IT) to support consumer engagement to help achieve national health goals. In this paper, we review the evidence to compare the rhetoric with the reality of current practice. CURRENT REALITY AND BARRIERS: Our environmental scan shows that consumer demand exists for electronic access to personal health information, but that technical and system or political barriers still limit the value of the available information and its potential benefits. CONCLUSIONS AND POLICY IMPLICATIONS: There is a gap between current reality and the goals for consumer engagement. Actions that may help bridge this gap include: (1) resolving technical barriers to health information exchange (HIE); (2) developing more consumer-centric design and functionality; (3) reinforcing incentives that attract provider support by showing that consumer engagement is in their interest; and (4) building a stronger empirical case to convince decision makers that consumer engagement will lead to better care, improved health outcomes, and lower costs.

Can managed care and competition control Medicare costs?

Medicare+Choice (M+C) was conceived to bring managed care and competitive forces to bear on Medicare. Ultimately, M+C could not thrive under the conditions of the marketplace and the Balanced Budget Act of 1997. Here I review what went wrong and the lessons from the experience, concluding that M+C is a tool, not a strategy. While managed care in a multiple-choice environment may have the potential to generate limited savings, promoting managed care and competition alone will not preempt the need for a debate on Medicare's obligations and how to finance them.

Provider risk sharing in Medicaid managed care plans.

Provider risk sharing was common throughout the 1990s. Recent evidence suggests waning interest, although no information exists that is specific to Medicaid. This paper examines risk-sharing arrangements in Medicaid managed care through a survey of participating plans in eleven states conducted during 2001. Risk sharing is prevalent among Medicaid-participating plans and often involves traditional providers. The "flight from risk" that others describe is not yet apparent in Medicaid, but Medicaid's idiosyncrasies might mean that trends appearing in other lines of business do not apply.

Participation of plans and providers in Medicaid and SCHIP managed care. State Children's Health Insurance Program.

For Medicaid and SCHIP managed care programs to succeed, they must attract enough and the right kinds of plans and providers to meet access and care goals. In 2001 we analyzed practices and perceptions that bear on these goals by surveying managed care plans participating in Medicaid or SCHIP, or both, in eleven states. Participating plans appear supportive of both programs and are largely able to secure providers to participate, too. To date, SCHIP has not attracted many plans not already participating in Medicaid. While perceptions were positive in 2001, maintaining current plan and provider relationships in an environment that has become much more budget constrained will be challenging.

Do quality improvement strategies for Medicaid enrollees differ in Medicaid-dominant versus commercial managed care organizations?

OBJECTIVE: To examine whether it matters, in terms of quality improvement initiatives and access to commercial networks, whether states contract with Medicaid-dominant or commercial managed care plans. STUDY DESIGN: A 2001 telephone survey of Medicaid managed care plans in 11 states that together account for about half of the national Medicaid managed care enrollment. METHODS: The survey was developed in consultation with a panel of individuals knowledgeable about Medicaid managed care. Information on plan characteristics and network design was obtained from the plan CEO or person most knowledgeable about the topics. The rest of the data were obtained from the person the CEO named as most knowledgeable about quality improvement initiatives. RESULTS: Surveyed plans reported an extensive array of quality improvement initiatives. Programs are in many ways similar across Medicaid-dominant and commercial plans. Medicaid-dominant plans tend to specialize more in conditions of greatest priority to Medicaid beneficiaries. Commercial plans tend to develop programs for accreditation by the National Committee for Quality Assurance, and to limit measurement specific to the Medicaid population. They draw on their commercial networks to support the Medicaid product line, but how much they expand provider access is not clear. Both types of programs face barriers that limit the effectiveness of the plans' initiatives. CONCLUSION: This study shows extensive development of quality initiatives in Medicaid managed care plans, with limited differences across Medicaid-dominant and commercial plans.

Financial risk sharing with providers in health maintenance organizations, 1999.

The transfer of financial risk from health maintenance organizations (HMOs) to providers is controversial. To provide timely national data on these practices, we conducted a telephone survey in 1999 of a multi-staged probability sample of HMOs in 20 of the nation's 60 largest markets, accounting for 86% of all HMO enrollees nationally. Among those sampled, 82% responded. We found that HMOs' provider networks with physicians, hospitals, skilled nursing homes, and home health agencies are complex and multi-tiered Seventy-six percent of HMOs in our study use contracts for their HMO products that involve global, professional services, or hospital risk capitation to intermediate entities. These arrangements account for between 24.5 million and 27.4 million of the 55.9 million commercial and Medicare HMO enrollees in the 60 largest markets. While capitation arrangements are particularly common in California, they are more common elsewhere than many assume. The complex layering of risk sharing and delegation of care management responsibility raise questions about accountability and administrative costs in managed care. Do complex structures provide a way to involve providers more directly in managed care, or do they diffuse authority and add to administrative costs?

Employing health information technology in the real world to transform delivery.

OBJECTIVES: Strong leadership and a supportive culture are critical to effective organizational transformation, but organizations pursuing change also need the infrastructure and tools to do so effectively. As policy makers seek to transform healthcare systems-specifically the delivery of care-we explore the real-world connection between health information technology (HIT) and the transformation of care delivery. STUDY DESIGN AND METHODS: This study is based on interviews with diverse federal and health system leaders and federal officials. The work was funded by the Office of the National Coordinator for Health Information Technology as part of a global assessment of the Health Information Technology for Economic and Clinical Health Act. RESULTS: The functionalities supported by HIT are integral to creating the information flow required for innovations such as medical homes, accountable care organizations, and bundled payment. However, such functionalities require much more than the presence of electronic health records; the data must also be liquid, integrated into the work flow, and used for analysis. Even in advanced systems, it takes years to create HIT infrastructure. Building this infrastructure and transforming delivery simultaneously is difficult, although probably unavoidable, for most providers. Progress will likely be slow and will require creative strategies that take into account the real-world environment of organizations and communities. CONCLUSIONS: While the rapid transformation of delivery and infrastructure is appealing, both types of change will take time and will progress unevenly across the nation. Policy makers serious about transforming the delivery of healthcare can benefit by recognizing these realities and developing practical strategies to deal with them over a relatively long period of time.

How to provide and pay for long term care of an aging population is an international concern.

As populations age, most industrialized nations are seeking to review the structure for their long term care programs with the goal of allocating better limited public resources to meet expanding needs. In this Commentary, I examine critical questions that define the way individual nations provide for the long term care needs of their aging populations. As examined by Asiskovitch, Israel's programs appear, in cross-national context, to have a broader reach and rely more heavily on community based services. In the future, the challenge Israel may face involves maintaining aspects of its programs that probably account for its popular support and stability while it identifies better the extent of potential gaps in care for those with greater needs and how best to meet them.

Evolving vendor market for HITECH-certified ambulatory EHR products.

BACKGROUND: The ambitious goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act require rapid development and certification of new ambulatory electronic health record (EHR) products. OBJECTIVES: To examine where the vendor market for EHR products stands now and the policy issues emerging from the market's evolution. STUDY DESIGN: Descriptive study with policy analysis. METHODS: We had 3 main sources of information: (1) documents describing this evolving market, which is not well represented in peer-reviewed literature; (2) operational data on certified ambulatory EHR products and their use by Medicareeligible professionals attesting for meaningful use payments from January 2011 to October 2012; and (3) telephone interviews with 10 vendors that account for 57% of the market. RESULTS: Those attesting for Medicare meaningful use payments used ambulatory EHRs from 353 different vendors, although 16 firms accounted for 75% of the market. The Herfindahl-Hirschman Index showed the ambulatory EHR market to be highly competitive, particularly for practices of 50 or fewer professionals. The interviewed vendors and the external analysts agreed that stage 1 requirements set a relatively low bar for market entry, but that likely will change as requirements get more demanding. CONCLUSIONS: The HITECH Act met its initial goals to motivate growth of diverse ambulatory EHR products. A market shakeout may emerge, though current data reveal no signs of it. Policy makers can influence the shape and value of such a shakeout, and the extent of disruption, through their approach to certification and "usability" and "interoperability" strategies and requirements.