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The American Journal of Managed Care January 2019
The Gamification of Healthcare: Emergence of the Digital Practitioner?
Eli G. Phillips Jr, PharmD, JD; Chadi Nabhan, MD, MBA; and Bruce A. Feinberg, DO
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Rajesh Balkrishnan, PhD
The Health Information Technology Special Issue: New Real-World Evidence and Practical Lessons
Mary E. Reed, DrPH
Inpatient Electronic Health Record Maintenance From 2010 to 2015
Vincent X. Liu, MD, MS; Nimah Haq, MPH; Ignatius C. Chan, MD; and Brian Hoberman, MD, MBA
Impact of Primary and Specialty Care Integration via Asynchronous Communication
Eric D. Newman, MD; Paul F. Simonelli, MD, PhD; Shelly M. Vezendy, BS; Chelsea M. Cedeno, BS; and Daniel D. Maeng, PhD
Mind the Gap: The Potential of Alternative Health Information Exchange
Jordan Everson, PhD; and Dori A. Cross, PhD
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Karen Donelan, ScD, EdM; Esteban A. Barreto, MA; Sarah Sossong, MPH; Carie Michael, SM; Juan J. Estrada, MSc, MBA; Adam B. Cohen, MD; Janet Wozniak, MD; and Lee H. Schwamm, MD
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Sung J. Choi, PhD; and M. Eric Johnson, PhD
Organizational Influences on Healthcare System Adoption and Use of Advanced Health Information Technology Capabilities
Paul T. Norton, MPH, MBA; Hector P. Rodriguez, PhD, MPH; Stephen M. Shortell, PhD, MPH, MBA; and Valerie A. Lewis, PhD, MA
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Alternative Payment Models and Hospital Engagement in Health Information Exchange
Sunny C. Lin, MS; John M. Hollingsworth, MD, MS; and Julia Adler-Milstein, PhD

Alternative Payment Models and Hospital Engagement in Health Information Exchange

Sunny C. Lin, MS; John M. Hollingsworth, MD, MS; and Julia Adler-Milstein, PhD
Alternative payment models (APMs) introduce value-based incentives for greater hospital health information exchange (HIE) engagement. We find that APM participation is associated with lower HIE volume and greater HIE diversity, breadth, and depth.

Objectives: To assess whether hospital participation in alternative payment models (APMs) is associated with greater engagement in health information exchange (HIE) along 4 dimensions: volume of patients for whom information is exchanged, diversity of information types, breadth of partner types, and depth of technical approach.

Study Design: Pooled, cross-sectional analysis of data on US hospitals from 2014 to 2015.

Methods: APM participation came from Leavitt Partners data, Medicare public use files, and the American Hospital Association (AHA) Annual Survey. We used Medicare data to measure HIE volume for 798 hospitals attesting to stage 2 Meaningful Use and the AHA Information Technology Supplement to measure HIE diversity, breadth, and depth for 1730 hospitals. We used mixed-effects regression to estimate the association between participation in APMs and each dimension of HIE.

Results: Compared with nonparticipating hospitals, full-year APM participation was associated with lower HIE volume (data were sent for 11 percentage points fewer discharges; P = .003), greater HIE diversity (of 4 data types, 0.3 more were transmitted; P <.001), greater HIE breadth (of 3 partner types, data were sent to 0.3 more; P <.001), and greater HIE depth (the odds of using a push and pull approach were 1.68 times greater; P = .004).

Conclusions: Our finding that APM participation was associated with greater HIE diversity, breadth, and depth suggests that value-based payment may be spurring improvements in HIE infrastructure. However, our finding that APM participation is associated with lower HIE volume suggests that there may be an incentive to focus HIE investments on a limited number of partners.

Am J Manag Care. 2019;25(1):e1-e6
Takeaway Points

Under alternative payment models (APMs), hospitals are incentivized to improve health information exchange (HIE) engagement in order to facilitate better healthcare quality and reduce cost. However, even under value-based reimbursement, substantial challenges to improving HIE may still remain.
  • Hospital participation in APMs was associated with greater engagement in 3 of 4 HIE dimensions: diversity of data types, breadth of partner types, and depth of exchange approach.
  • APM participation was associated with lower HIE volume.
  • Our work suggests that under value-based reimbursement, indirect incentives may improve HIE infrastructure, but hospitals may be limiting HIE efforts to a few partner-specific connections, resulting in lower overall HIE volume.
Failures in information sharing between hospitals and postacute care providers following hospital discharge can result in higher-cost, lower-quality care.1-3 Electronic health information exchange (HIE) can improve the accessibility of information during hospital discharges, leading to cost savings and better outcomes.4,5 However, volume-based reimbursement does not create incentives for provider organizations to engage in HIE.4-8 Medicare’s alternative payment models (APMs) are expected to change this dynamic: By rewarding hospitals for improving the quality and cost-efficiency of care received across the care continuum, APMs create financial incentives for hospitals to engage in greater HIE.9 However, even under APMs, significant barriers, such as lack of technical standards across electronic health record (EHR) products, poor usability of HIE solutions, concerns about data security, and potential loss of profitable fee-for-service patients to competitors, may impede hospital pursuit of HIE.4,10

If hospitals participating in APMs are not engaging in greater HIE, it is an ominous sign about the potential for HIE growth, as it suggests that even aligned financial incentives are not strong enough to overcome these barriers. It is therefore important to not only assess whether APM participation is associated with greater hospital HIE, but to do so in a way that reflects the multiple ways that HIE can generate value under APMs. Given that avoiding hospital readmissions is a core performance metric under APMs, improving HIE between hospitals and postacute care providers is likely to be a prioritized use case for HIE.

The extent of hospital HIE engagement with postacute care can be measured along 4 dimensions: volume, diversity, breadth, and depth.11 Volume refers to the proportion of discharged patients for whom data are transmitted electronically. Diversity refers to the types of data that are transmitted electronically. Breadth refers to the types of trading partners to whom data are electronically transmitted. Finally, depth refers to the nature of the technical approach through which data are transmitted (ie, push and/or pull).

Prior research on the association between APMs and HIE suggests that HIE is perceived as valuable to the achievement of financial rewards under APMs.12-14 However, these studies have not systematically examined whether hospitals in APMs engage in greater HIE or whether HIE efforts focus specifically on supporting care coordination following discharges.

To assess whether participation in APMs is associated with greater HIE engagement with postacute care providers along 4 dimensions (volume, diversity, breadth, and depth), we used mixed-effects regression analysis on data on US hospitals from 2014 to 2015. We defined APM participation as the proportion of the calendar year that a hospital participated in at least 1 of the following programs: Medicare or commercial accountable care organizations (ACOs), the Medicare Bundled Payments for Care Improvement (BPCI) initiative, and any type of medical home. Results from this study are critical to informing policy efforts aimed at improving interorganizational care coordination—a national policy priority. In particular, this work sheds light on challenges that may exist in reaching that goal through greater HIE under value-based incentives, such as those initiated under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).


Setting and Data Sources

The study population includes all nonfederal acute care hospitals in the continental United States with HIE data for at least 1 year of the study period. Data for this study came from the Leavitt Partners ACO database (current as of 2016), 2014-2015 Medicare BPCI public use file, 2014-2015 American Hospital Association (AHA) Annual Survey, 2014-2015 Meaningful Use public use file, and 2017 Area Health Resource File.

Hospital Participation in APMs

Under MACRA, hospitals can participate in APMs that provide value-based incentives for hospitals to engage in HIE. With APM participation, hospitals are held accountable for the cost and quality of care provided by their outpatient partners. APMs include ACOs, the BPCI program, and medical homes. ACOs offer shared savings to participating hospitals if per-patient spending is lower than a targeted amount. The BPCI program bundles inpatient and outpatient services into single episodes of care. Lastly, hospitals can participate in medical homes as part of their hospital-based ambulatory care practices. Medical homes provide performance-based rewards, along with per-member-per-month fees for care management.15

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