Why geeks should care about meaningful use and ACOs

How healthcare data reforms and incentive reforms are connected.

Healthcare reform pairs two basic concepts:

  • Change incentives: lower costs by paying less for “better” care not “more” care
  • Use software to measure whether you are getting “better” care

These issues are deeply connected and mostly worthless independently. This is why all geeks should really care about meaningful use, which is the new regulatory framework from the Office of the National Coordinator of Health Information Technology (or ONC for short) that determines just how doctors will get paid for using electronic health records (EHR).

The clinical people in this country tend to focus on meaningful use incentives as “how do I get paid to install an EHR” rather than seeing it as deeply connected to the whole process of healthcare reform. But any geek can quickly see the bottom line: all of the other healthcare reform efforts are pointless unless we can get the measurement issue right.

Health economists can and do go on and on about whether the “individual mandate” will be effective. Constitutional law experts fret about whether the U.S. federal government should be able to force people to purchase insurance. We are all concerned about issues like the coverage of pre-existing conditions. Hell, I am certainly in the 99%.

Make no mistake, the core problem with healthcare in the United States is that costs are out of control. Under the current system, absent better health information technology, any kind of major system change — like the individual mandate — will simply assure that you get lots more of what you already have. That would be a disaster.

The only way to make healthcare in the U.S. both better and cheaper is to use health information technology. I recently was able to have a whiteboard session with Dr. Farzad Mostashari, and he drew out his view of the whole reform system. It was nice to be able to have such an intimate explanation, but I can think of nothing that he told me that he does not also say in his frequent public appearances (he was awesome at Health 2.0). He talked about this issue as one of “levers.” His point was simple: pulling one lever alone does nothing.

One of the levers on his whiteboard was something called Accountable Care Organizations (ACO), which is term that any technologist who cares about government or healthcare needs to get familiar with. The ACO is a new twist on Capitation. The idea is simple: lets pay doctors for keeping people healthy rather than paying them to treat the sick. But capitation has a bad name in the U.S. because of its abuse by Health Management Organizations (HMOs).

The only differences between an HMO and an ACO are the quality of data systems they will be required to use and the level of detail they will be required to report as a result. You might think of an ACO as the organizational vehicle that healthcare reform will move forward in.

With all of that context, technologists can now intelligently read news regarding the changes in meaningful use requirements for ACOs. For those not wishing to delve further, the news is pretty basic: the rules for ACOs around meaningful use have been made a little easier in the final ACO rule.

The final rule gives more time for ACOs to achieve meaningful use in some cases, and that is generally a good thing. Meaningful use seems simple to technologists, but the real-world rural medical practices and small offices that will need to implement it have very inconsistent computer skills. One of the most important issues for meaningful use is to go at the right speed — and for the most part, that should be as fast as possible … but no faster. Don Berwick (a legend in patient safety circles) explained that the final ACO rule relaxed the meaningful use requirements in response to a “mountain” of comments.

Generally, this is another example of consistently reasonable policy decisions coming from the meaningful use team at ONC. I grew up Republican/Libertarian/Texan and so it seems pretty strange to admit this, but the meaningful use regulations are good government. It is a core component (the geek component) of healthcare reform, and that healthcare reform will be painful. There is just no way around it.

As geeks, we can all call our local congressional representatives and say “this meaningful use thing seems to be going OK.”

I’m pretty sure that’s not a call they get a lot.

Meaningful Use and Beyond: A Guide for IT Staff in Health Care — Meaningful Use underlies a major federal incentives program for medical offices and hospitals that pays doctors and clinicians to move to electronic health records (EHR). This book is a rosetta stone for the IT implementer who wants to help organizations harness EHR systems.


tags: , , ,
  • Erich

    I agree that using HIT is crucial to improving health care while driving down costs. The challenge, I think, will come in helping people overcome their fear that increased data analysis will undermine their privacy in healthcare. This may be a big obstacle in gaining public support.

  • In theory, ACOs could achieve savings while improving outcomes. However, all the data I’ve seen so far on ACOs is that none of them are achieving savings or improving outcomes. Not to mention they aren’t making any money.

    Another problem I see is that if ObamaCare doesn’t get implemented (or Obama doesn’t win re-elections) all this will just go away.

    Republicans have already made it clear that they don’t want any part of ObamaCare.

    • Good points brandon.

      The problem with Health IT is that is -never- separate from politics. Assuming Obama is elected again, we might see a path that is consistent for long enough that it becomes irrevocable. If he is not then things will be… different, and it will be difficult to know how.

      Republicans have at least given supporting talk to EHR technology in the past. While Republicans do not agree with the stimulus spending, most of the EHR money has already been allocated. Would they undo EHR stimulus as part of unraveling Obamacare? Who knows.


  • Anonymous

    “The only way to make healthcare in the U.S. both better and cheaper is to use health information technology.”

    What about single payer and getting rid of the insurance companies that are profiting off of this mess?

  • I dunno, Anonymous. Profits are most often a reward for either (a) providing what consumers want, or (b) making more efficient use of resources than competitors. Are those things we should try not to reward?

  • DocMD

    I am a physician, and am disappointed but not surprised that the author of this article has a viewpoint that is wholly inconsistent with advancing medical care. Yes, the cost of healthcare has gone up. Astronomically. Two and three decades ago, the number of dollars spent per US citizen on health care was less. That being said, the diagnostic and interventional technology and pharmacology were entirely inferior to what they are now, and were inexpensive to provide because they did not involve a tremendous amount of additional computer technology. My office now has EMR, digital XRay, and a host of other “state of the art” medical devices. I file my patients claims electronically, which also costs a premium. My medicare payments were cut more than 20% for a number of months in 2010 due to the Medicare bureaucracy and Medicaid payments in my state were cut over 25%. Simply put, a visit to your doctor’s office costs more than the $50 medicare or medicaid pays for it.
    Physicians who are concerned about providing the best care are doing the only thing they can to protect their patients, albeit with a great degree of sadness. We are ending our participation with Medicare and Medicaid. There will be doctors that follow along and create ACOs, but the care you get there will not be the care you get at an unaffiliated office.