Health experts grapple over best agency to lead paperwork reduction effort
At a panel discussion of a new report on reducing health care administrative costs put on by the Center for American Progress, disagreement also surfaced on whether the current movement to switch from paper medical records to a standardized electronic system is a feasible time-and-cost saver.
David Cutler, a professor of applied economics at Harvard University who in 2008 advised then-presidential candidate Barack Obama on health care, noted that administrative costs account for 14 percent of health care expenses, “twice what we spend on heart disease and three times what we spend on cancer,” he said. “Office support is the biggest occupation in the health care field,” and just as Wal-Mart is the big entity that sets information technology standards in the retail field, “the only comparable player in health care is the federal government.”
The problem, Cutler added, is “the federal government has left administrative simplification to agencies whose primary purpose is payments,” so the task falls between the cracks, despite two sections of the 2010 Affordable Care Act devoted to facilitating the transfer of data to electronic health records.
Zeke Emanuel, a physician and senior fellow at the center, said a consumer can “go to five ATMs and get the same smooth financial transactions with a swipe card, but if you look at five medical patients, they’d all go through different credentialing procedures.” Doctors won’t “jump in” to standardize their own procedures until there is a common platform that’s as easy as a Visa card,” he added. “You either need a big stick or a big carrot, or it won’t happen. There has to be someone with a telephone number at the other end” pushing to make it happen.
As to which entity should take on such responsibility, Emanuel mentioned the Health and Human Services Department’s Office of the National Coordinator for Health Information Technology and the HHS chief information officer. The Office of Management and Budget, he learned when he worked there, displays little interest in running such a project because the bulk of the potential savings would go the private sector rather than the government.
But Karen Ignagni, president and chief executive officer of America’s Health Insurance Plans, argued it would do no good for a single authority to try to standardize industry practices and simplify administrative procedures without addressing a host of related issues and “getting the private and public sectors in synch.” Questions of quality measures, adoption of the diagnostic coding system used by the World Health Organization and use of technology have to be combined in an integrated platform that involves all stakeholders, she said, referring to physicians, hospitals, insurers and software makers. “We have to get vendors and private practice management systems on the same page,” Ignagni said, noting that her industry for a decade “has put the pedal to the metal” to create back-end portals that would allow all players to access the same data while preserving carriers’ ability to offer patients a variety of choices in insurance products.
Relying more on industry’s existing tools is the approach favored by Dr. James Madara, executive vice president and chief executive officer of the American Medical Association, who noted that his organization’s master file of physicians was useful during the national response to Hurricane Katrina in 2005.
Doctors share the goal of reducing administrative costs -- he’d like to get them down to 1 percent -- given that other nations have achieved more in this area than the United States. But Madara cautioned that some variations in medical and billing record-keeping systems have value, reflecting the differences between cardiology and primary care, for example, and in demographics and geography.
“Many doctors are suspicious of electronic health records, Madara added, saying they give software vendors broad powers for quality standards and because of the “enormous expense.” Medical practices are “are not well-capitalized and they lack an individual” dedicated to shifting to standardized digital systems, he said. Doctors also hesitate to invest in the required technology for fear that the rule will change. Physicians don’t like having to use a computer while turning one’s back on the patient, he added. “We don’t want to go back, but we don’t want to through with it. So we’re looking to tomorrow for a new choice.”
Dr. Peter Basch, a senior fellow at the center and a medical director for MedStar Health who co-authored the new report titled “Paper Cuts: Reducing Health Care Administrative Costs,” said the topic of simplifying administration is not “sexy,” and doctors are frustrated by it so “they’re not a willing audience.” Each employer wants to have his own design of such procedures as electronic prior authorization for treatment, so standardization to reduce the administrative burden requires a “cultural shift.”
Basch agreed doctors have financial incentives to continue the status quo, but he would counsel them that while “data entry is the most painful part,” that data will be used in many ways. “I wouldn’t go back to paper again,” he said, “and we’ll see this shift unfold in the next couple of years.”