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Congressional Intent for the HITECH Act
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Congressional Intent for the HITECH Act

Pete Stark

The HITECH Act will modernize the nation's healthcare system by advancing adoption and use of health information technology.

Provision of Incentives Through Medicare and Medicaid. HITECH made doctors, hospitals, and certain other providers eligible for incentive payments through Medicare and Medicaid for the meaningful use of EHRs certified by the process set up by ONCHIT and the National Institute of Standards and Technology. The incentives were not meant to cover the entire cost of adoption of health IT, but rather to improve a provider’s business case for doing so. More money is made available through Medicaid because Congress recognized that providers who care for underserved populations would need more resources. The incentive payments are time-limited and decrease over time. In Medicare, payments will eventually be adjusted downward for providers who do not demonstrate that they are using a certified EHR system. The legislation takes a carrot-and-stick approach, with incentives structured to provide a reasonable amount of time for providers to adopt and start using health IT systems. However, the legislation does not encourage providers to procrastinate indefinitely.

HITECH Incentive Program

Because I authored the Medicare incentive provision on which HITECH’s incentives are based and was most involved with developing that part of the final bill, I want to provide a little more detail about the thinking behind that part of the legislation.

I have long been convinced that health IT has the potential to transform American medicine for the better. A robust health IT system—used correctly—can improve the quality of care, facilitate care coordination, reduce redundancy and improve efficiency, increase patient safety, give patients tools to improve their own health, and provide data that can be used to better track public health and fuel clinical research. That is why I admire the health IT system used by the Veterans Administration, known as VistA. I have visited several VA facilities and believe that VistA is an example of a well-deployed health IT system that has been effectively used to improve the health of patients and provide data for important clinical research.

I am not the only member of Congress who thinks highly of VistA, and for years I thought the best way to ensure that every American had access to a good health IT system was to simply provide a free version of VistA to every doctor and hospital in America and mandate that they use it. I still think that is not a bad idea, but I also recognize that many providers

have now invested enormous amounts of time and money into their health IT systems and it would be disruptive to require them to use an entirely different system.

One important lesson from the VistA experience is that we needed to find a way around the balkanized maze of standards and protocols used by different health IT systems. We had to push the private sector to start speaking the same IT language, or at least get them to speak in a way that could be easily translated and understood by other health IT systems.

Another important lesson is that healthcare will not improve just because a health IT system is in place. Health IT is simply a tool, like a stethoscope or an X-ray machine. What is most important is how that tool is used.

Too often I heard from doctors who installed a health IT system, but its use was limited to a fancy scheduling program or digitizing paper records as a way of clearing space in the practice’s records room. I realized that simply handing out money to help providers pay for a health IT system was not good enough. Incentives should be provided only to those who use health IT in ways that markedly improve patient care.

These lessons formed the genesis of the Medicare incentive

program I proposed in the fall of 2008. Under my bill, doctors and inpatient hospitals would be eligible for payments from Medicare as long as they demonstrated that they were meaningfully using a health IT system that was certified as meeting certain technological standards.

This proposal, in turn, became the core of the Medicare and Medicaid incentive program in the economic stimulus bill that was drafted in the months immediately after Obama’s election. Tweaks were made, most of which worked to improve the original

proposal. For instance, in spelling out what it means to be a meaningful user, the final legislation places more emphasis on information exchange and reporting clinical quality measures.

The stimulus bill also clarifies that the meaningful-use criterion should be seen as an “elevator,” continuously adapting to changes in technology and raising the bar by challenging providers to become more sophisticated users of health IT. In the end, Congress wisely resisted the urge to spell out the meaningful-use criterion in detail, instead leaving that up to those with more expertise in medicine and technology.

Another important change to my proposal was the time frame for incentives. My original bill envisioned the first incentive payments going out the door in 2013 and penalties for providers who did not use health IT in meaningful ways starting in 2016. Although Obama indicated that the health IT provisions in the stimulus bill were more of a first step toward health reform than an economic stimulus, the incoming administration insisted incentive payments go out the door as soon as possible. Therefore, HITECH will make incentive payments available in 2011; penalties for nonusers will begin in 2015.

Some of us had reservations that the time frame was overly optimistic given the steep mountain that had to be climbed before any incentive payment could be made: agreeing on standards, implementing a certification process, vendors adapting their products to meet those standards, and getting those products into doctors’ offices and hospitals. Thus, HITECH builds in rolling start dates so that providers that need an extra year or two to get started still are eligible for some incentive payments. The Obama Administration has worked tirelessly to meet the ambitious time line established by HITECH, and I am now optimistic that providers will have a fair shot at getting the incentives if they are committed to doing so.

Debate Over HITECH

HITECH has been criticized by some as being an inefficient use of money because it makes payments available to providers who already have adopted sophisticated health IT systems. Frankly, I believe this is not a fair criticism. Providers should not be shut out of the incentives simply because they did the right thing by being early adopters of health IT. Kaiser-Permanente, for example, has spent billions of dollars on its health IT system and used that system to improve patient care. Presumably they will need to spend more to bring their existing system into compliance with the standards issued by ONCHIT. It should not make any difference whether a provider invested in a health IT system 10 years ago or 2 weeks ago. As long as that provider demonstrates that it is meeting the meaningful-use criterion, the policy goal has been achieved and the incentive payments should be available.

The legislation also has been criticized because it does not make money available up front to help pay for the initial installation of an EHR, and because the incentive payments do not cover total adoption costs. Again, I disagree. As stated earlier, the incentive payments are not meant to go toward adoption of an EHR system. Congress intended these payments to reward providers who meaningfully use an EHR to improve patient care.

Some have suggested that incentive payments could be made in advance to providers who promise to meaningfully use whatever system they purchase, and the government could recoup the money later if the provider failed to meet that promise. But such an arrangement would inevitably end up with thousands of pay-and-chase situations, turning Medicare into the healthcare version of the Internal Revenue Service.

Congress never intended for the payments to cover all costs associated with using a health IT system. Rather, the incentives are designed to offset a portion of the costs involved with adopting and using an EHR. As economies of scale grow because more providers are adopting the technology, it is also likely that prices for certified EHR systems will fall and the incentive payments will go further toward covering those costs.

Finally, some have faulted HITECH for not making incentive payments available to more providers, including nurses and physician assistants, nonphysician mental health professionals, facilities such as nursing homes, and other providers who do not currently qualify. Spending on health IT in the stimulus bill was limited to a total of $20 billion. Congress decided to focus first on physicians, because they drive the bulk of decisions about care, and hospitals, because they are where the largest share of healthcare dollars are spent. Furthermore, providing sizable incentive payments to a limited number of providers has a greater impact than spreading payments more thinly to a larger number of providers.

There are also legitimate questions about whether it is currently possible to establish a clear and effective meaningful-use standard for all these other providers. To the extent that patients could benefit from use of health IT in those settings, Congress should give consideration to providing incentives to additional providers.

Conclusion

The HITECH Act is a landmark law that will be seen as a turning point in the effort to modernize the nation’s healthcare system. In its estimate of the bill’s effects, the Congressional Budget Office projected that HITECH would reduce federal and private sector spending on health services during the next decade by tens of billions of dollars by increasing efficiency.2 The Congressional Budget Office also said that 90% of physicians and 70% of hospitals will be meaningfully using a comprehensive EHR system by 2019. In addition to its other benefits, health IT will help to maximize the effect of the payment and delivery reforms that are part of the health reform bill enacted earlier this year. Congress will continue to monitor progress toward these ambitious goals, but there is little doubt among my colleagues and myself that the HITECH Act is a monumental step forward in the effort to improve the way healthcare is delivered in the United States.

Author Affiliation: From Committee on Ways and Means, US House of Representatives, Washington, DC.

 

Funding Source: There was no external funding for this report.

 

Author Disclosures: Mr Stark reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 

Authorship Information: Concept and design; drafting of the manuscript; critical revision of the manuscript for important intellectual content.

 

Address correspondence to: Pete Stark, Chairman, Health Subcommittee, House Committee on Ways and Means, 102 Longworth House Office Bldg, Washington, DC 20515. E-mail: petemail@mail.house.gov.

1. Kohn LT, Corrigan JM, Donaldson MS, eds; Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

 

2. Congressional Budget Office. Letter to the Honorable Charles B. Rangel, Chairman, Committee on Ways and Means, U.S. House of Representatives. January 21, 2009. http://www.cbo.gov/ftpdocs/99xx/doc9966/HITECHRangelLtr.pdf. Accessed November 22, 2010.

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