Decade-Defining Moments in Healthcare Innovation, Reform

HITECH lays the foundation for data-driven healthcare

The Health Information Technology for Economic and Clinical Health Act (HITECH), which became law in 2009, set in motion widespread digital transformation in healthcare through the EHR Incentive Programs.

While the federal program sputtered out in Stage 2 Meaningful, well short of its ambitious to support providers in achieving the goals of the triple aim, there is no question that it forever changed healthcare in modernizing provider IT infrastructure.

Before the start of the EHR Incentive Programs, 22 percent of office-based physicians and 12 percent of hospitals reported using a basic EHR. By 2017, 96 percent of hospitals and 80 percent of office-based physicians reported using certified EHR technology (CEHRT) that met health IT certified criteria set by the Office of the National Coordinator (ONC), according to the National Electronic Health Records Survey (NEHRS).

Despite tens of billions in incentive payments, the architects of meaningful use couldn’t build on the early successes of the program and use that momentum to push the industry beyond adoption to information sharing. Widespread interoperability — a necessary component for effective care coordination and population management — remains a way’s off. As of 2017, a mere 41 percent of hospitals and 46 percent of office-based physicians have the capability to send or receive patient health information with other providers.

That is to say nothing about EHR usability. The aggressive push to adopt new technology and receive incentives came at a cost to end user satisfaction. Some providers grew dissatisfied with their initial systems and worked to replace their EHR systems; meanwhile, others sought to improve their implemented systems through EHR optimization efforts. Improving EHR usability has become a key focal point for leading industry associations, namely the American Medical Association, and their goals to improve provider satisfaction as part of the quadruple aim.

With the enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, federal officials have transformed the EHR Incentive Programs into the Quality Payment Program for physicians and Promoting Interoperability for hospitals. Unlike their predecessor, these two programs are heavily tied to payment reforms that link health IT use to clinical improvements, patient outcomes, and care delivery costs. It's too soon to tell whether the change will pay off.

Meaningful use did not go as planned, and its fits and starts ultimately sunk the program. But without a doubt, the EHR Incentive Programs drove the healthcare industry to embrace technology and has laid a foundation for future development, which will ironically include freeing data from the very siloes meaningful use sought to eliminate.

—Kyle Stephen Murphy, PhD, EHRIntelligence.com

Data privacy, healthcare cybersecurity come to the forefront

When the HIPAA Security Rule was enacted in 2009, its security features centered around technical controls able to protect confidential patient health information. The security portion operationalized the privacy section of HIPAA, addressing technical and non-technical safeguards needed to secure health data.

“The Security Rule requires covered entities to maintain reasonable and appropriate administrative, technical, and physical safeguards for protecting e-PHI,” HIPAA reads.

“Covered entities must ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit; identify and protect against reasonably anticipated threats to the security or integrity of the information; protect against reasonably anticipated, impermissible uses or disclosures; and ensure compliance by their workforce,” it continues.

However, the technologies available and threats faced in 2009 have evolved to a point where many industry stakeholders have called for a HIPAA upgrade to reflect the modern digital age.

While there were several patient data breaches throughout the first half of the 2010s, those bigger breaches were far less common and much more shocking. However, the real tipping point hit in 2016 when healthcare cybersecurity received a steady onslaught of ransomware attacks that drove hospitals and health systems into EHR downtime, forcing patient care disruptions.

The increased sophistication of these threats drove a shift in the mindset from believing technology was the answer to solving some of healthcare's most significant cybersecurity challenges, to understanding that successful security banks on people and policies to ensure patient data remains protected.

Studies have shown, for example, that training staff on how to detect and respond to phishing attacks reduces the risk of a breach.

But throughout 2019 an even greater shift has occurred: Congress is calling for greater privacy protections of individuals, especially in healthcare as massive breaches continue to dominate the headlines.

Ransomware has once again wreaked havoc on the industry, with attacks able to delete data, cripple systems for several weeks, and disrupt critical patient care, causing patient safety risks. A report from Emsisoft shows nearly 800 healthcare providers were hit with ransomware this year.

The coming year will face heightened threats, problems with outdated platforms on which healthcare heavily relies, and IoT vulnerabilities that will highlight the need for improved procurement policies.

—Jessica Davis, HealthITSecurity.com

Affordable Care Act defines a decade of health policymaking

On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law.

The history of the ACA since that day has been characterized by industry and legal response.

In the healthcare industry, the ACA wrought significant alterations. The ACA formed exchanges—federal and state health insurance marketplaces that offer federally subsidized, low-cost health plans. In many cases, these exchanges increased access to private health insurance.

And where coverage gaps remained, the option for statewide Medicaid expansion helped close the gap for people whose incomes exceeded Medicaid eligibility thresholds but who do not meet the income level to qualify for marketplace plans.

Medicaid expansion rang in positive outcomes.  Medicaid expansion reduces mortality rates, improves coverage and quality of care, might lead to less racial disparities, increases access to care, improves behavioral healthcare access and quality, reduced overall uninsurance rate, and other effects that we have covered.

But the ACA has faced high costs, which drive away payers and consumers alike.

For the ACA to work, the exchanges needed strong representation from healthy populations. The premiums from the healthy would cover the sick.

However, in the first few years of the Exchange’s existence, premiums were cripplingly high and rising. Double-digit premium increases made healthy individuals flee the risk pools, and as consumers fled, so did payers who left in their wake bare counties with zero or only one payer present. Other payers attempted mergers, hoping to bind together the resources to cover the increasingly costly high-risk members.

Fortunately, this year large payers began tiptoeing back into the marketplaces and venture capital-funded payers expanded with gusto.

As the industry worked out the challenges of the new system, the ACA endured a drawn-out legal battle that continues today.

In 2012, the Supreme Court upheld the ACA as constitutional twice, in the Florida v HHS case and the National Federation of Independent Businesses (NFIB) v Sebelius case.

In 2017, the Tax Cuts and Jobs Act set the law's individual mandate tax — which penalized those who did not have health coverage — to $0.

Meanwhile, there have been constant efforts in Congress to repeal the law, thus far unsuccessfully.

In December 2019, the individual mandate has been ruled unconstitutional by an appellate court and the debate on the constitutionality of the entire law persists.

—Kelsey Waddill, HealthPayerIntelligence.com

From P4P to ACOs, the evolution of alternative payment models

Quality improvement and cost reduction efforts have been around since the beginning of modern medicine. But it wasn’t until 2010 that the US healthcare industry put pen to paper to spell out how providers are to achieve higher care quality and lower costs.

In addition to healthcare insurance coverage reforms, the ACA pushed for the development of alternative payment models that would reimburse providers based on the value of care provided, rather than the volume of services rendered.

Since the law went into effect in 2010, CMS established the Innovation Center and that team devised 90 alternative care delivery and payment models. The models range from pay-for-performance arrangements to bundled payments for episodic care to global budget payments for populations of patients.

In the past decade, payers and providers have tested a plethora of alternative payment models in efforts to improve care quality and/or reduce costs. But both groups are still very much in the thick of this transition to value.

According to the latest data from the Health Care Payment Learning & Action Network (HCP LAN), the healthcare industry may have hit the value-based reimbursement tipping point. Less than half of healthcare payments were paid via traditional fee-for-service in 2018.

However, only about one-third of the payments were part of an alternative payment model that year. The remaining payments were tied to value and/or quality of care but were still rooted in fee-for-service.

The healthcare industry has come a long way with value-based care and reimbursement since 2010. However, some experts argue that we haven’t come far enough.

“We have moved backwards rather than forwards,” Harold Miller, the president and CEO of the Center for Healthcare Quality and Payment Reform, recently told RevCycleIntelligence.com. Thus far, alternative payment models have not struck the right balance between protecting care quality and reducing costs, he explained.

Recent data supports this line of argument. Catalyst for Payment Reform recently reported that while 53 percent of commercial healthcare payments were tied to value by 2017, care quality improvements and cost reductions were modest.

These findings and many other data points indicate a new era of value-based care.

“It’s not enough just to pay healthcare providers fee-for-service and give them a little bonus or penalty for doing something we think we want them to do,” Mark McClellan, MD, PhD, HCP LAN’s co-chair and director of the Robert J Margolis Center for Health Policy recently said in an interview. The next stage of this transition will focus on refining alternative payment models to offer sustainable financing for population health management, patient and community engagement, and other value-adding activities.

—Jacqueline LaPointe, RevCycleIntelligence.com

Patients take on role as consumers

The healthcare industry has also seen a significant shift in how patients experience care, tipping further from a patient space to a consumer-centric space.

This trend has arisen mainly as a result of patients beginning to bear the load of their healthcare costs. In 2010, Medicare beneficiaries' out-of-pocket costs totaled to $4,734, and rose to $5,460 by 2016, according to the Kaiser Family Foundation.

And while KFF does not yet have data about out-of-pocket costs at the end of the decade, but separate reports from TransUnion Healthcare have suggested patient financial responsibility increased 11 percent in 2017.

Because of high-deductible health plans and other cost-sharing efforts that increase patient financial responsibility, patients are learning more about their care options and investing in ones that meet their needs. Patients have a choice, and they are making those choices based on cost, convenience, their needs, and their preferences.

And as such, organizations are retooling their service options to promote convenient access to care, positive experiences, and ease of access. Online appointment scheduling tools, strategic patient outreach, and single-stream digital tools and web portals have supported organizations’ efforts to drive a consumer-centered environment.

Healthcare payers are likewise reacting to the consumerism trend, using technology to help patients shop for care and find providers who meet their personal needs.

And in the technology space, partnership connecting the patient portal to other valuable patient-facing tools like online appointment scheduling and provider directories have emerged to serve patients as consumers.

But there is more work ahead, especially as healthcare continues to rank at the bottom of consumer-friendly industries. Heading into the next decade, organizations will continue to compete with the likes of Google and Amazon, as well as the hotel, airline, and banking industry, all of which seem to have tapped into consumer expectations at a faster rate than healthcare.

At the crux of this will be a robust suite of tools that make it easy for patients to access, manage, and pay for their care.

—Sara Heath, PatientEngagementHIT.com

mHealth, telehealth, and remote patient monitoring take hold

Telehealth and telemedicine have gained gradual but steady ground over the past decade, fueled by an improvement in technology and demand among consumers to access healthcare when and where it's convenient for them. And while the healthcare industry has been slow to embrace connected health, consumer-facing companies have jumped on the bandwagon with a wide variety of platforms, services, and devices.

Hospitals and health systems are coming around slowly. They’re doing so because they now see value in connecting with patients – current and prospective – outside the walls of the hospital, doctor’s office or clinic. These new technologies are giving them an opportunity to collaborate with the patient at home, and to see how one’s daily life – diet, sleep, activities, interactions – affect care.

That's where remote patient monitoring is, and will be, making an impact. Healthcare providers can use telehealth platforms as well as mHealth apps and connected devices to communicate with and keep tabs on their patients, improving care in between the visits to the doctor. They can better prepare patients for an upcoming hospital stay and monitor them post-discharge, or create a continual care management plan for those with chronic conditions rather than waiting for periodic in-person encounters.

The key to RPM's growth lies in data. The technology allows the provider and patient not only to communicate at any time but also to share information previously not tracked. Both sides can measure and monitor a wide variety of biometric signs, moods, activities, and social determinants of health, all of which can go into a more comprehensive care plan. The challenge going forward is to make sure the right information is tracked, and the caregiver isn't overwhelmed by data that doesn't matter.

Aside from the development of better devices and platforms for RPM, continued adoption will also hinge on reimbursement. Healthcare providers won't try the technology unless they're incentivized, at least until they become comfortable and RPM's value is proven in improved workflows, reduced stress, and better patient outcomes.

Medicare has been slow to embrace RPM, claiming that the services haven't yet proven their value. But as the decade comes to a close, some CPT codes and other allowances are creeping into the physician pay schedule to support RPM services. State-run Medicaid programs and private payers are more accepting and working with providers who see RPM as a means of improving care outcomes and reducing wasteful health expenses (and hospitalizations).

RPM holds the potential to be a big thing in the coming decade and beyond, as more and more providers look to the technology to help in the transition to value-based care. The episodic care defined by the current-and-fading healthcare ecosystem will shift to continuous care management as devices, platforms, and apps become commonplace.

—Eric Wicklund, mHealthIntelligence.com

Focus turns to the social determinants of health

Although public health has always been a critical factor, the latter half of the decade saw an increased focus on the social determinants of health and population health.

Many factors influence an individual’s health. In fact, only about ten percent of a patient’s health outcomes can be attributed to clinical care. 

A majority of an individual’s health is impacted by non-clinical factors, or social determinants of health. From housing to education and socioeconomic status, social determinants of health are repeatedly linked to myriad health outcomes, including heart disease, asthma, cancer, and diabetes. 

The healthcare industry previously viewed addressing these factors as outside of their responsibility. But throughout the past decade, the growing evidence base has made social determinants of health impossible for the industry to ignore. 

Private and public data to understand these challenges has become increasingly more accessible, allowing payers and providers to better understand their patients in a unique and holistic way. Addressing social determinants of health is no longer a luxury but a requirement of payers and providers. 

In recent years, many organizations across the industry have begun cross-sector partnerships to address the social determinants of health. Some have partnered with ridesharing companies to help improve the accessibility of healthcare, and others have integrated social workers into community-centers to cover wrap-around services for patients. Some payers have even invested in local community-based organizations and local non-profits to form coalitions that work to prevent common social determinants of health. 

While buy-in for these initiatives has become easier in the last decade, organizations across the industry will need to continue leveraging evidence and strong community partnerships in order to better patients’ health. Further addressing social determinants of health will require continued cross-sector partnerships and population health strategies that look at the whole patient.

—Emily Sokol, MPH, HealthITAnalytics.com