Whose Cost?

As each state prepares to launch Health Information Exchanges (HIEs), it is important to keep in mind the goals of the effort.  I believe this is more difficult than one may think at first blush. But, trustees of these HIEs need to move beyond a “motherhood and apple pie” approach of saying the purpose of an HIE is to reduce cost and improve quality and safety.

The cost question is very complicated. After all, one stakeholder’s expense is another’s revenue. Is the goal to reduce the cost to the State? The Patient? The Payors? The Providers of healthcare?

Take duplicate testing. Certainly an HIE has the ability to enable the reduction of duplicate testing by giving providers instant access to results stored in other providers Electronic Health Records. That is a win for the Patients, States and Payors. But, that will have an impact on provider revenue. If the HIE requires all parties to mutually support initiatives there is a strong potential for stalemate.

To complicate this even further…just because a provider has access to the results from another provider does not prevent the provider from ordering a duplicate test. I have overheard other organizations leaders suggest that they should not trust results from other providers and that re-ordering expensive tests is the best care. Unless the HIEs tackle that concern they may not achieve the benefits that they seek.

9 thoughts on “Whose Cost?

  1. I agree with your later point about duplication of tests should not prevent good practice if a provider believes that the results from a previous test is dubious.

    however, I couldn’t disagree more with your sentence “that will have an impact on provider revenue”. You are correct, that will impact their revenue. however, this is taking this change with a conservative state of mind – as a car owner, would you or your insurance agree to pay for an oil check or a fumes control when it has already been done? if you go to a grocery store, and ask for a pound of meat, would you pay for a half more “just because”?

    The change in the industry will have impacts on all, there is no questioning of it. While not all revenues are clear to date, there are opportunities that will unravel as we move forward. and if the opportunity is just a healthier society at the cost of reduced benefits, where is the problem? that eventually does not mean that industry’s parties _profits_ won’t be satisfying for all.

    • Just to be clear…Payors (insurance companies, patients, and government run healthcare programs) do pay for duplicate testing. While it is waste, it is part of the healthcare providers revenue stream. That is reality. My point is that technology alone will not solve this. My healthcare organizations (not just our patients) want to be part of the solution. We want to reduce the cost of care to our patients. We want to competing organizations do the right thing too, and not use our good intentions as a competitive advantage over us.

    • Hello,
      I will be the first to say that I don’t think all the pitfalls or benefits are completely understood at this time. All we can do is speculate on the outcomes. My concern is illustrated here with Will and Florian’s comments. One side you are discussing the lose of revenue to the provider and the other side you discuss the need to have duplicated test and the benefit of those tests. I would like to see if I can provide some perspective. I like Florian’s car analogy – “pay for an oil check or a fumes control when it has already been done?” I like the argument but you forget one critical factor. Time…. Duplicate tests do seen useless unless you factor in time. You have your oil check or fumes control tested. Then take a long trip pushing your car to its limits, buying bad gas, adding wear and tear to the motor. A week later you are having issues with the car running. Where do you start? Oil check or fumes control… but you just had them done… Time and other factors weight in. That is my point with duplicate test. We cannot blanket the statement without considering all the outside factors. That is where I think Will brings up valid concerns. This change seems to “blanket” too much. Where is the wiggle room? Also at “Whose Cost?” now you are pushing the cost to the patient because if you don’t have duplicate test and only one centralized area to see information. You make the patient go to the facility that can do the tests. Why? Because you will no longer be able to pay the specialized staff on your facility to be there to handle the occasional duplicate test, or whose yet you need to schedule around the work schedule of that staff for the next time they are at your facility to take the patient in. All the while “TIME” has added more factors. Cost is not always financial but emotional as well. I believe we will see how this plays out, but again I see it as Will does. At “Whose Cost?”

  2. Good thought!

    And what was meant by the “find tackle that concern” piece of the last sentence? Is that a fishing, football or sailing metaphor?

    “Unless the HIEs find tackle that concern they may not achieve the benefits that they seek.”

  3. Bill many others have struggled with these questions and all I can say is don’t lose sight of the bigger win-wins that exist…the highest goal is to reduce the cost to the State, the Patient, The Payors and the Providers of healthcare.

    This (to varying degrees) is what has occurred wherever real progress has been made whether it’s across Kaiser, or across Norway. At times there will be adversarial spitting contests over ‘clinical autonomy’ vs. ‘fiscal accountability’ etc but to me it comes back to making sure people keep their eyes on the fact the primary purposeof the health industry & associated funding is to care for sick people and keep them well efficiently and effectively -ultimately as a society we all pay one way or another and there are consequences for us, our loved ones and our communities if we are successful or if we fail to care 🙂

  4. Great question, Will!

    Its not all about costs, that’s just one leg of the tripod. How well an HIE addresses the *value* proposition where value is defined as quality divided by total costs to all collective stakeholders is ultimately key.

    Implementing HIE’s where quality measures that represent both the suppliers and consumers (payers) of health care economics with accountability measures on benefits realization is core to HIE success, IMHO.

    • Specifically to your point regarding duplicate tests being performed due to lack of trust, a root cause analysis should be done as part of HIE implementation to find out why there is no trust. Is it because of quality issues in a given provider’s lab? Are these quality issues real or perceived? Differences in practice philosophy? Can you share what’s behind the example you stated, Will?

      Thanks, Will!

  5. The discussion of testing seems to take as a given that the duplicated tests are all benign, except for the associated costs. However, this is not actually the case. Test involving radation poses a clear cumulative danger for increased cancer risks, as an example. The US leads the world in the amount of imaging radiation we expose to our patients. Tests involving imaging dyes may also pose risks. Even a simple blood test creates discomfort and some slight risk of infection.

    If I am the patient getting stuck, dyed, or irradiated, I would hope the test is not redundent. This is safety issue, not just a fiscal one.

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