Much ado has been made about Accountable Care Organizations lately, between the comments from AHIP, the AMA, CHIME, not to mention pundits criticizing the programs as ‘fiascos’. History may judge this turmoil as baby steps towards progress, but among the debate around patient centered medical homes, retrospective attribution, performance reporting and shared risk, is a connection that is under-discussed: The underlying criticality of reliable health information exchanges as a necessary, though not sufficient, condition of effective ACOs. Certainly, other causes of reluctant initial enrollment in the Medicare Shared Savings Program, such as reimbursement risk and consumer engagement, must be addressed to successfully transform care delivery. But even among ACO pilots with commercial payers, a connectivity arms race is amassing between providers and payers maneuvering to control a key lynchpin of accountable care: information.
After all, accountability can’t be established if capital-constrained organizations can’t track patients moving between providers and measure how services provided across settings of care contribute to cost and outcomes. Analytics and risk adjustment are well and good, but without access to the underlying data none of the fancy math or performance dashboarding has a chance of reflecting reality. The recent acquisitions of health information exchanges Axolotl and Medicity by Ingenix and Aetna indicate this recognition by two of the most powerful payers in the country. Conversely, recent alignment of large provider systems to state-sponsored health information exchanges, like Centura hospitals joining Colorado’s Health Information Exchange, exemplifies providers that are savvy to the power of connectivity. The guarded optimists are no doubt hoping that all this information sharing will enable the titans of managed care and integrated delivery to collaborate better around patient-centricity. The doomsayers are no doubt waiting for this information battleground to invade privacy, drive price collusion and generally make US healthcare even messier. I suppose I’m with the optimists, but only time will tell which side predicted the winds of US healthcare correctly.
Of course, the march toward health system connectivity, and the accountable care that it will enable, could be accelerated with a little less claim-jumping by the keepers of all this information. Beyond addressing stakeholder concern with a lack of clarity about how Meaningful Use and ACO performance inter-relate, regulators could take greater steps to enable the information transparency necessary for ubiquitous connectivity. It is understandable that data around privately contracted rates or claims represents competitive advantage and should be kept confidential. But public payer data is different. While sharing information like Medicare claims data around provider quality and safety recently released by CMS is an important step, it does not go far enough. These claims should be anonymized to ensure HIPAA compliance and made publicly available to any request, not just “qualified entities.” Since public claims are paid for with taxpayer dollars, every U.S. citizen has need-to-know clearance, making the cherry picking of who may see these data is philosophically anathema to the Open Government Initiative. Connectivity is critical for care transformation, and data is critical for connectivity, so until these public rates are transparent, Americans will continue to be shortchanged.
But let all the finger-pointing not be directed at policy makers. The Open Government Initiative is a groundbreaking measure of good faith. The interest of entrenched healthcare organizations in care transformation is a watershed event, even if the outcome remains uncertain. Progress is happening. What remains is to push these models from the drawing board into the operating room is consumer demand. Even if CMS made all data fully transparent, it would still be up to us to consult and behave consistent with where the data points to value. Until educated consumers refuse to see providers who lack clinical integration capabilities; until employers demand real-time cost estimates from their managed care vendors and physician networks; until patients are incentivized to seek out value, world-class healthcare will not materialize.
So let’s point a few fingers at ourselves, while we’re at it, and empower fellow consumers to require connectivity as the cost of entry for healthcare companies claiming to be focused on us. ACOs meandering towards value-centricity are keeping an eye on the consumer health IT market, and for good reason. With half of US consumers willing to pay for devices and apps monitoring vital signs, there is an increasing involvement by patients in their own health. Information transparency could enable markets for applications built “by consumers, for consumers” hunting for value. If apps like this exist for buying gas, there’s no reason they couldn’t be built for healthcare. Hyper-regulation, information asymmetries and perverse incentives are barriers to value, true, but in this climate of change, the guarded optimists among us may find ways of leveraging the power of the consumer market to bend the healthcare cost curve. Only by contributing to this foundational capability will we as consumers help to drive care delivery beyond meaningful use toward a connected health system that makes sense.
MBA/MPH Candidate 2012
Haas School of Business
University of California, Berkeley