While the vast majority of the country currently is debating the Supreme Court’s decision to grant cert on the individual mandate provision of the Patient Protection and Affordable Care Act (PPACA), other acts passed by Congress are expected to have major consequences on our country’s ability to ensure affordable access to health care for all Americans as well. One such act is the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was signed into law in early 2009 as part of the American Recovery and Reinvestment Act. The main purpose (see p. 2) of the HITECH Act is to encourage physicians and hospitals to make the transition to electronic health records (EHRs) by 2015 in order to lower costs by cutting the waste of paper records while improving the quality of medical record keeping, which in turn will reduce preventable medical errors.
Making the transition to EHRs is not an easy or inexpensive task. Most notable among the obstacles for physicians and hospitals making the transition is compliance with the Health Insurance Portability and Accountability Act (HIPAA), which sets out patient privacy requirements for medical records. Compliance with HITECH and HIPAA privacy requirements require the purchase of expensive software, while use of EHR and noncompliance with HITECH and HIPAA privacy requirements runs the risk of heavy fines. Congress, realizing the large financial disincentive that this posed to the implementation of EHRs, included two components to the HITECH Act to encourage the transition. First, Congress developed an EHR Incentive Program for eligible physicians that demonstrate meaningful use of certified EHR technology (a discussion of who qualifies as “eligible physicians”, what “meaningful use” means, and what counts as “certified EHR technology” is beyond the scope of this post). Compliant physicians are eligible for up to $44,000 over five years for participation in the Medicare EHR Incentive Program and up to $63,750 over six years for participation in the Medicaid EHR Incentive Program. Compliant hospitals receive a $2 million award under both programs. The second component to induce compliance with the HITECH Act is essentially a disincentive program in which non-compliant physicians and hospitals will have their Medicare reimbursements cut if they haven’t made the transition to EHRs by 2015. This disincentive program will be the focus of the remainder of this post.
There is little debate that on paper the HITECH Act’s goal of transitioning to EHRs will be beneficial both financially and with respect to overall patient treatment quality; however, the disincentive program may in fact lead to an overall decrease in the amount and quality of care given to Medicare patients. As indicated by the main heading of Title I of the PPACA, “Quality, Affordable Health Care for All Americans,” an overarching goal of the Obama administration’s revision to our health care system is to provide care to all Americans. Implicit in this goal is to provide Americans with needed health care who otherwise would be unable to afford it. Among those patients are Medicare and Medicaid patients.
Reimbursement rates to physicians and hospitals for treating Medicare and Medicaid patients are already low, and some physicians even lose money each time they treat a Medicare patient. While a hospital may not refuse treatment to a patient that arrives at their Emergency Room under the Emergency Medical Treatment and Active Labor Act (EMTALA), there are no restrictions to the ability of private physicians or non-Emergency Room hospital physicians to refuse to treat Medicare patients. The current inability of physicians to financially afford to treat Medicare patients given the inadequate reimbursement rates results in less affordable quality care to those Medicare patients. Coupling the already inadequate reimbursement rates with a further reimbursement rate cut for those physicians and hospitals that don’t make the transition to EHRs by 2015 will only exacerbate the problem. Additionally, studies indicate that smaller physician groups (which account for nearly 60% of all physicians and 65% of all patient visits) and more rural hospitals are less likely to adopt EHRs. Therefore, these physicians and hospitals will be disproportionately affected by the Medicare reimbursement cuts from the HITECH Act and are likely to disproportionately cut or refuse treatment to Medicare patients. (Note: These studies don’t even take into account the expected difficulty that older physicians, who aren’t as likely to be familiar with new technology and who have grown accustomed to more traditional health recordkeeping, will have in making the transition to EHRs.) Further compounding the issue is the general lack of providers in rural areas. For Medicare patients in rural areas, not only will there be a general lack of physicians and hospitals to provide medical care for them, but the few providers that do exist are more likely to reject them because the providers can’t financially afford to treat Medicare patients with the HITECH Act disincentive.
It is imperative that our nation increase the usage of EHRs in order to decrease costs and increase the quality of care, but the HITECH Act’s disincentive to treat Medicare patients may not be the most effective means to go about it. The HITECH Act’s one size fits all approach to EHR implementation doesn’t take into account the realities of the health care system. By placing the treatment of Medicare patients at risk, the HITECH Act is not in keeping with the Obama administration’s goal of making affordable quality health care available to all Americans. While most will be preoccupied by the constitutional debate on the individual mandate, we can’t ignore seemingly more innocuous health care legislation like the HITECH Act.