How Quality Assurance Technology Can Help Pay for Health Care Reform

Nov. 10, 2009

As we all know, health IT is expected to play a large role in any eventual reform measures. And indications are that ensuring quality, medical necessity and the delivery of best practice medicine will be the centerpiece of the health IT strategy.

As we all know, health IT is expected to play a large role in any eventual reform measures. And indications are that ensuring quality, medical necessity and the delivery of best practice medicine will be the centerpiece of the health IT strategy.

One relatively simple way to advance this effort would be to use existing automated clinical criteria technology in the administration of Medicare and Medicaid; not in the traditional unpopular managed care sense, but positioned as a quality assurance mechanism. The automation would absolutely minimize the administrative cost for physicians’ and hospitals’ staffs and, ultimately, improve the quality of care and save us all money by ensuring the medical necessity of high-cost services. Medicare and Medicaid could be assured that about 85 percent of hospital admissions, surgeries and other procedures met best-practice guidelines through fully-automated computerized processes; the remainder would potentially require QIO physician discussions.

The biggest hurdle to this approach is the probability that some would mislabel it “utilization management” and, by association, “managed care.” Admittedly, it is managing care to some extent. But it’s not the managed care that has come to be met with such negative passion by some over the past two decades. The technology need not be used to determine network affiliations or adherence to some complex commercial benefit plan; it would merely support the use of best practice medicine to foster optimal treatment. We wouldn’t even have to issue denials of payment if a doctor chose to proceed in spite of the outcome of the analysis for an individual patient — we could focus on education instead. Marketing and communications efforts would need to clearly position the effort as a quality assurance process, and making it simply part of our national health IT strategy to promote evidence-based medicine (already on the agenda) and help foster the best outcomes from the outset would be a great start.

There is little doubt that some iteration of health care reform is coming and in order to pay for it, we must find ways to lower costs. The two current options for saving Medicare and Medicaid dollars are either lowering reimbursement rates or raising taxes. Either way, consumers will wind up footing the bill. But it certainly doesn’t have to come to that. Instead, we can rather simply and affordably implement existing technology to improve quality, lower waste and ensure better care. In the big picture, it would be a relatively small expenditure that would more than likely generate a sizable return on investment. Rather than relying on the American people to subsidize an economic bailout of government programs, we could invest in American innovation to solve one of our country’s most serious problems. It’s a plea the health IT industry has been making for some time and one of those incredibly rare circumstances where so much can be gained with virtually nothing to lose.

David St.Clair founded MEDecision, a leading provider of collaborative health care management solutions, in 1988 and has served as the chief executive officer since 1988. You can learn more about MEDecision at www.MEDecision.com and subscribe to an RSS feed at http://www.MEDecision.com/blog/. Contact David at [email protected] and follow the company on Twitter at @MEDecision.

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