Peter Basch, MD, FACP and Michael Zaroukian, MD, PhD, FACP, FHIMSS
Incorrect Assumptions Lead to Incorrect Conclusions That Misinform Policy
Please refer to Part 1 of this post for our comments on the recent Wall Street Journal op-ed questioning the policy behind the EHR incentive program, and Part 2 for our comments on the extent to which EHR use was associated with higher short term charges, as published in the Center for Public Integrity report and recently summarized in the New York Times.
As we left off in Part 2 of this post, the finding of the OIG that 0.38% of providers had aberrant billing profiles was somehow inferred to be related to EHR use (if the OIG found that to be the case, we cannot find that association in the source documents), with the further inference that this was unexpected and needed to be corrected. As we affirmed repeatedly in Part 2, where the EHR, billing software, or just deceitful practices lead to intentional fraud, we join the call of Attorney General Holder and Secretary Sebelius to bring such practices to an end. Indeed, at least some of those providers in the highest coding group of 1,669 physicians reported by the OIG are likely to be knowingly, deliberately and consistently documenting care that was not delivered or not necessary and then using the coding software in their EHR systems to ensure that the fraudulent documentation supported the E/M code that was used, making it harder to detect their fraud.
Let’s imagine that the OIG actually had reported out something very different (which they did not); that early data (let’s assume for a future report in 2014) showed that EHR users, particularly those in the fields of family medicine and internal medicine showed a higher level of charges than their colleagues still on paper records. This of course would be followed by comments from policy makers about the lack of foresight in scoring the HITECH Act, and the failure of EHRs to curb costs.
For those not familiar with the theory of how EHRs could curb costs, below are some of the ways (not an all-inclusive list):
(1) Widespread interoperability would make results available to authorized providers such that test and procedure redundancy could be greatly reduced.
(2) Decision support could be used such that overused, misused or unnecessary tests or procedures could be successfully discouraged from use.
(3) Secure messaging and other technologies that enable less expensive, non-visit based care could be used when appropriate.
(4) Clinical decision support to optimize care could help to prevent adverse drug events and other medical mishaps that lead to expensive emergency department visits, hospitalizations, prolonged hospital stays, re-admissions, long-term disability and deaths.
(5) More consistent use of medication formularies and use of generic medications could reduce drug spending.
(6) Clinical decision support, particularly for primary care providers, will increase the percent of patients getting appropriate and necessary preventive and chronic care services.
As we mentioned in Part 1, it is nonsensical to look for results (positive or negative) where there is no chance of seeing them; thus, if one were looking for cost reductions enabled by EHRs, one would conclude that many of the gains would not be seen in the short-term, except perhaps from formulary adherence or use of generic medication. If we then return to our hypothetical 2014 OIG report above and assume that OIG found that there were statistically more charges for EHR users than for physicians on paper records, particularly for those physicians in family and internal medicine, would this be a cause for alarm? Should it generate another call for the government to revisit the wisdom of its EHR incentive program? Absolutely not; it would more likely be an early indicator that EHRs were being used as more than documentation tools (which is of little direct value to the patient), and instead as tools to improve quality, safety and efficiency.
There is an abundance of evidence that primary care doctors in the US are systematically undertreating their patients. Most studies confirm that only about 50% of patients consistently receive appropriate and medically necessary preventive services, and somewhat less than 50% with chronic illness receive appropriate management of those illnesses. The implication of this lack of consistent application of preventive and chronic care services is that there is a price to be paid for underuse of services as well. The cost of inattention to appropriate and necessary preventive care and screenings, as well as failure to appropriately manage chronic illnesses, comes at a high cost – such as failing to find and/or manage cancers when they are more easily treatable or curable, or inadequate inattention to preventing or treating chronic diseases that are then more likely to result in serious, debilitating and costly sequellae for patients, their families, and payers.
In the primary care fields, one design approach to optimize the value of EHRs is to recast every opportunity with a patient as an opportunity to address all unmet care opportunities and goals. The concept is shifting from what we know now doesn’t serve patients well, a reactive system of care in which we only focus on patients when they perceive themselves as sick, and we only treat what they perceive as a problem. Thus, a patient who only went to the doctor for respiratory infections and other complaints may never get cardiovascular and cancer screenings. A more recent approach, not invented by the EHR but made more achievable with EHR systems, is what is called a “shared agenda visit.” This means that although patients still come to the physician as needed for sick care, the physician uses the EHR to identify specific care opportunities and unmet goals. When appropriate and feasible, the provider then expands the acute care visit to include whatever preventive and chronic care needs are indicated and when this is not practicable, recommends another visit in a timely manner. For example, a patient coming to the doctor for back pain may also have cancer screenings scheduled, as well as appropriate follow-up exams and testing for diabetes and hypertension. Depending on the number of chronic care conditions addressed and how they were managed, under the current coding guidelines, you would expect that shifting to an outcomes-focused shared agenda model will lead to short-term increased costs.
Another concrete and timely example can be seen with Million Hearts™. For those not familiar with Million Hearts™, it is a program developed by HHS (in conjunction with the American College of Cardiology and the American Heart Association) built on the premise that more consistent attention to four health concerns (aspirin use to prevent heart disease, blood pressure screening and control, cholesterol screening and control, and smoking cessation – collectively known as the “ABCs”) can help to prevent one million new heart attacks and strokes over five years. We know that within the US, only 47% of patients who may benefit from aspirin for primary prevention are taking it; only approximately 50% of patients with hypertension have their blood pressures controlled; and only about one-third of patients with high cholesterol levels have them controlled.
One of us (PB) is launching a Million Hearts™ program across all of his health system’s primary care sites. This means that every adult patient seen by our primary care doctors will have over the course of each year, all of his or her “ABCs” addressed. Over the short-term, will adherence to this program result in higher costs? Absolutely. We expect to have more visits, more testing where it was previously not done, and in at least some instances higher complexity visits. That said, the short-term cost increases would be more than made up if they indeed led to success in preventing our share of the estimated million new heart attacks and strokes that would otherwise occur.
Please continue to Part 4 for our discussion of repetitive or “boiler plate” documentation, and whether that should be considered as prima facie evidence of documentation fraud.