0 Another Study on Electronic Health Records Fails to Show Cost Savings

Like President Obamas search for the precise rhetoric that can finally turn Republican obstructionism into cooperation, as well as Governor Christies search for the one cure that turns girth into svelteness, electronic health record (EHR) advocates keep looking for that one EHR study that proves that their financial black holes are really sources of profitability.

News reports like this suggest that this just-published Annals paper is that study. Unable to help either President Obama or Governor Christie, the curious DMCB took a look at the EHR manuscript.

Alas, it came away disappointed. EHRs have yet to consistently "save money."

The DMCB explains.

The Massachusetts eHealth Collaborative (MAeHC) has been promoting the community-based installation of EHRs since 2006.  32 Bay State communities applied for their assistance.  Three were selected.  Thanks to MAeHAC, by January 2008, 167 outpatient physician clinics (86% of the total in these communities) were outfitted with one of several commercially available EHRs.

The cost  to MAeHC was a whopping $130,822 per provider.

Realizing a "natural experiment" outcomes study could be fashioned, considerable demographic analytics and statistical effort was used to identify which non-EHR communities most closely resembled the three winners described above. Six communities were selected as comparisons. Two (unnamed) commercial health insurers provided claims data for the patients in the three EHR communities and the six best-matched non-EHR communities.

Keep in mind that the health care system has an ongoing background rate of cost inflation. In this study, the baseline period ran from January 2005 to March 2006 (before the EHRs were installed anywhere), while the EHR-live period ran from January 2008 to June 2009. This allowed the researchers to compare the two community groups increases in health care claims expenses compared to baseline once the EHR went live.

After looking at more than 4.8 million patient-months worth of data, the researchers found:

Total health care costs increased over baseline by .78% in the EHR communities vs. 1.09% in the non-EHR communties.  This .31% difference was not only small, it failed to achieve statistical significance.

The per member per month (PMPM) costs went from $151 to $173 ($22 increase) in the EHR communities vs. going from $155 to $179 ($24 increase) in the non-EHR communities.  Once again, tests of statistical significant indicated these small shifts could have been the result of randomness. 

When categories of health care utilization were examined, there was no meaningful impact on inpatient or pharmacy utilization.  The two pieces of good news were that a) the trend for ambulatory (or outpatient) favored the EHR communities (.41% baseline to 1.12%) vs. the non-EHR communities (.14% baseline to 1.2%), and b) the trend for radiology studies favored the EHR communities (1.03% baseline to .6%) vs. non-EHR communities (-.25% baseline to .94%).

For the 25% of the study population with one or more chronic conditions, there was no impact on total or ambulatory cost trends.  Radiology, however, showed a statistically significant shift that favored the EHR.

The authors relied on trend calculations to calculate how the PMPMs would have compared in the intervention vs. control communities.  Even though the savings of $5.14 was not statistically significant, the authors projected a 7 year timeline "... to recoup the projected 5 year adoption cost in the (EHR) communities of $130,822 per provider."
 
The DMCBs take

Despite the pro-EHR spin, this Annals article falls far short of being a study that the medical-technological complex can use to justify its existence. The bottom line is that costs did not drop in statistically significant (p less than .05) or financially significant (a seven year return based on a faux $5 PMPM savings) manner.  Lets be honest: there is only one beneficiary of the MAeHC $100K per doc investment, and its not the patient, the providers, payers or government: its the vendors that sell these systems to a technology-addled health system with the collusion of too many naïve policymakers.

If ACOs really think their EHR systems are going to be the panacea that helps them tame health care costs, this study tells them that they may be in for a nasty surprise.

The good news here is that this research suggests that the EHR may have had an impact on ambulatory care and radiology claims expense.  The DMCB says "may" because it knows that multiple subgroup comparisons can generate statistically significant findings faster than med-mal plaintiff attorneys around a dollar bill.  Even if the impact is real, the miniscule savings were washed away by the tide of total costs and hardly meet the original vision of President Bush or HITECH.

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0 Spin and Innovation vs Savings and Disease Management

Spinning is hard work!

With the 2012 political theater season underway with a faux budget rejection and a re-energized President, The Disease Management Care Blog is reminded of an inconvenient truth: the nations unsustainable health care cost trajectory continues and is the single biggest threat to a bipartisan "grand bargain." 

So our pols response?  Spin.  For a hot-off-the-presses example, check out this press release from CMS Innovations Center lauding the creation of quality-boosting and cost-cutting health care "models." Theres also a "one year of innovation" monograph describing hundreds of millions of dollars worth of demonstrations, initiatives, programs, partnerships and sessions.

Impressive says the DMCB, but the bottom line is that these are ongoing and innovative experiments. There are no outcomes data, cost savings are far from certain and the mainstream FFS Medicare program in place today hasnt really changed its stultifying and high cost ways.

Sooner or later in the coming months, Congress will have to agree on some sort of budget. As that moves forward, the DMCB offers up some hard "un"spun facts for consideration:

• Just as effective governing is not a matter of selecting from a series of policy options, effective doctoring is not a matter of selecting from comparatively effective treatment options.

• There is no proof that the versions of the electronic health record being currently adopted nationwide save money. The savings argument remains anecdotal or theoretical with considerable room for doubt. What is clear is that installing an EHR costs money.

• The Patient Centered Medical Home is still a work in progress. The cost savings widely reported here did not achieve statistical significance and the real truth underlying North Carolinas medical home data is mired in actuarial debates outside the peer review process.

• While ACOs are ultimately modeled on the success of large integrated systems, we know that bigger is not necessarily better.  As this multi-year experiment gets ready to set sail into politically stormy seas and if (and thats a big "if") they are proven to save money, itll take years to expand them. Any real savings are more than a decade away.

• Commercial insurers profits, while high in absolute terms, have a relatively low return on investment and, compared to their administrative burdens, are not one of the major drivers of health care costs.

So where do the real cost savings lie? Former White House advisor Ezekiel Emanuel, in this just published JAMA Viewpoint, points out that the best answer is not any of the notions above but but controlling chronic illness with what essentially can be described in two words: disease management.

Heres the quote:

Successful efforts seem to entail instituting at least 4 common changes: (1) installing electronic health records and using them to track patients health status and physician performance, as well as using decision supports to increase adherence to treatment pathways; (2) using the information for more intensive interactions between patients, caregivers, and clinic staff, including use of care coordinators, 24/7 access, interventions to increase medication adherence, specialized clinic services for recurrent problems of patients with chronic disease such as anticoagulation clinics; (3) reducing use of specialists, and when specialists are involved using those who are more efficient; and (4) providing services not traditionally covered by fee-for-service reimbursement, such as e-mail, wireless monitoring to increase medication adherence, home evaluations to minimize falls, lifestyle interventions to improve nutrition and exercise, and transportation services for office visits. Cumulatively, the savings appear to occur through fewer hospitalizations, emergency department visits, and lower use of specialist services (bolding from the DCMB)

The DMCB couldnt have said it better itself.  Dr. Emanuel describes the ingredients of successful commercial disease and population health management programs in place today today: a later generation EHR that is coupled with decision support and registries, risk stratification to identify the patients at great risk, care coordination with expedited access to specialized services and support for preventive care. 

Hes right, and thats no spin.

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