Q & A

Payment reform encourages accountability and creates incentives for providers to consider costs of healthcare services. But information is needed to make it work. "We need to bring electronic clinical information together with claims data in a way that is credible to providers so they can find a low-cost pathway to the best quality care," says David Blumenthal, MD, former national coordinator for health information technology under President Obama. He recently talked with Richard L. Clarke, DHA, FHFMA, president and CEO of HFMA, about using information to drive value in health care.

Richard Clarke: How does accountable care fit in with the idea of curbing costs and improving value?

David Blumenthal: Accountable care is synonymous with encouraging the healthcare system to concentrate on producing value-to be accountable to the public, to purchasers, and to the profession. We've been moving in this direction for quite a while. Accountability has, of course, been encouraged by pressure to contain spending, because only when you have limits on what you can spend do you have the kind of incentives and pressures that force people to look for ways to get the most value for every dollar spent on health care. We've lived without a budget for many years, so there has been very little pressure to be accountable. Accountability actually occurs throughout our healthcare system. It occurs at the point of decision, and only with some of those decisions. Only if you sum those decisions up do you see whether you've accomplished value and whether you've achieved accountability.

In my previous role as the national coordinator for health information technology, what excited me most about that work was the opportunity for communication through electronic methods with physicians, among physicians, among healthcare professionals, and between institutions and healthcare professionals. The communication and information are key to front-line accountability, making decisions value-based, and changing the kinds of individual care decisions that determine how resources are used. Getting into the workflow of healthcare professionals every day and with every patient and giving them the resources they need to better allocate care is where accountability has to begin. That's the problem we're trying to solve. We're trying to create the supports to make those individual minute-by-minute, visit-by-visit, round-by-round decisions better.

There are three major influences on the efficiency and quality of care. The first is payment, the second is how care is organized, and the third is the information that's available for decision making. Payment sets the tone. It creates that spending limit. It creates the incentives to take cost into account at the margin and to create value. Without payment change, it will be hard to realize many of our ambitions, control the federal deficit, control the rate at which premiums rise, and make universal coverage affordable.

Clarke: HFMA's Value Project recently released a report called Value in Health Care. One of the major findings is the need to define value from the perspective of the purchaser of care. What could be done to better communicate the value of care by providers to purchasers?

Blumenthal: There are many valid perspectives in health care. The challenge is to find the sweet spot among them.

Purchasers think about populations-their insured populations, their employees, or their customers. Physicians and nurses think about the patient in front of them. If they are particularly innovative and farsighted, they may start thinking about a population of patients that they regularly care for, but that is still not common.

In addition to a fundamental difference of perspective, there is a difference in professional ethic. Physicians and nurses are taught that there is no more important value than the health and care of that one person who is sitting in their office or lying in the hospital bed. That is something that most citizens highly value. People want to know that their physicians and their nurses are in their corner.

I don't think anyone wants to give that up. The question is, how can we find a way to allow physicians and their patients to feel comfortable that they can continue to serve and be served in that individual way while stewarding societal resources and trying to get the most benefit to the largest number?

The way to reach that compromise is to disseminate and use the best information that's available on how to achieve quality of care at the point of care. If we could help caretakers to see their patients' care from the standpoint of evidence and with the best thinking that's available, we could cut through a lot of this difference in perspective, because in fact, high-quality care will be more efficient care. The problem is that it's hard for many caretakers to keep up with it and to service it.

Caregivers become more interested in optimal care when they know that resources are not limitless. They need to find the most efficient pathway for their patients, and that's where payment reform comes in. A recent paper reported that the management of stable coronary artery disease has not changed much in the past few years since the COURAGE study was published showing that invasive care using stents is no better for chronic stable angina than medical management, and medical management is a good deal cheaper.

There are financial motives for continuing to place stents, but without information about what the optimal approach is, primary care physicians can't pick the referral specialist who uses stents sparingly. Getting that information into the hands of primary care physicians so they have confidence picking among cardiologists for the efficiency and the quality of the care they provide is where we begin to bend the cost curve. Of course, having incentives available so they gain from making those correct decisions will spur that decision-making process along.

Clarke: How does that happen?

Blumenthal: First, you create the motivation to be interested in improving decisions. That motivation comes from payment reform and the opportunity for shared savings. Then you need organizational forms that promote systems of improved care, and that's where an accountable care organization will play a role. And third, you need ways of getting information into the hands of physicians and nurses at the point of decision. It isn't a matter of teaching better in medical school, because it's mostly practicing physicians who have to learn about it.

You can pump information out in a didactic form or through computerized decision support, which is going to be an increasingly important part of medicine in the future, where literally at the point of decision, physicians will be reminded of their choices for managing an illness. For example, at the point of referring to a cardiologist for stable coronary artery disease, the physician could be reminded of the results of the COURAGE study. Similarly, when cardiologists see patients, they could be reminded of that.

There's also an option for payers to track electronically patterns of stenting in patients with the diagnosis of stable coronary artery disease, see where stenting is common and where it's not, and then allow accountable care organizations to share that information with their providers of care. That kind of information can be powerful in changing care patterns, but it's much better delivered in close to real time, rather than waiting a year or two years for claims data to get processed and then fed back. Having monthly or even biweekly rates of stenting for a group of cardiologists that looks at the frequency with which they do that and compares primary care physicians' patients in terms of the frequency with which they're stented, and feeding that information back to the primary care physician, the cardiologist, and the director of the cardiology practice are all powerful ways to affect decisions. But they require a payment, organizational change, and information.

Clarke: Another major finding of the Value Project is that creation of value will depend in large part on clinician engagement and leadership. What do clinical leaders need to know about the payment/ cost side of the value equation to effectively enhance the value of care? On the other hand, what do finance and other administrative professionals need to know about the quality side of the equation to enhance value?

Blumenthal: Your members might have different viewpoints on this. Those who are working for payers might want to see accounting systems that lay out the cost of managing illnesses in alternative ways from the perspective of the purchaser of care, to help clinical decision makers find the least-cost pathway. Those who come from organizations that live off clinical payments will also want to know what the consequences are for their organization's bottom line.

I'm not convinced yet that the average hospital or practice has made this transition toward accepting that it is in its financial interest to find a low-cost pathway to the best quality care. Once that transition occurs, incentives will be aligned.

I don't think there are good prototypical systems for bringing together claims and administrative data with clinical data in ways that inform decisions in real time. There is an abstract commitment to moving clinical and claims data together, and payers have begun to develop systems where they use what they can discern from their claims data about clinical issues to look at cost information. Claims-based clinical data are not credible to clinicians for the most part. We have to engage the professions with payers using electronic clinical information in a new project to bring financial information together with clinical data in ways that are credible to decision makers.

The people who control the use of healthcare resources are healthcare professionals. You can throw things at them from every direction, but until you get the information to them in a way that they find intelligible and credible, they're going to stick to their traditional ethic, which is, "I'll do what I should for my patient, and the rest I don't care about." There may be someone who has merged clinical and administrative data in a really powerful way. I'm just not aware of it.

Clarke: You recently left your position as the national coordinator for health IT. What were some of the biggest surprises you found in that position? What lessons did you learn from them?

Blumenthal: I was pleasantly surprised at the bipartisan support for the IT agenda. Even now, with the amount of concern about the federal deficit and the conversations about reducing Medicare and Medicaid spending, I don't hear any real groundswell of interest in changing the HITECH Act or the incentives that are available for spreading IT. Many bills have been introduced to reduce the incentives, but none of them have gotten traction. My general sense is that it's not high on the list of any political party to get in the way of the spread of health IT.

In addition, I came away absolutely convinced that we cannot be successful in our healthcare reform agenda unless we're successful in using IT. A lot of what we've been talking about here has been about getting information into the hands of decision makers that will make them better at what they do. Paper is not capable of supporting that change. It takes too long and is too expensive. I would love to see purchasers who are supportive in theory of this change and have taken some small steps, often in particular communities, toward spreading electronic health information systems. I would love to see them come together on some more comprehensive program to build out and support the HITECH agenda.

Right now, the federal government is putting close to $30 billion on the table to reform the information systems that are critical to our collective success with the Medicare and Medicaid programs, but those programs cover only about half the care that's provided in this country. The other half is paid for by the private insurance companies, and I don't see any organized system or program to do the same thing on their side.


David Blumenthal, MD, MPP, is the Samuel O. Thier Professor of Medicine and Professor of Health Care Policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School. Until April 7, 2011, he served as the national coordinator for health information technology under President Barack Obama. In this role, he was charged with building an interoperable, private, and secure nationwide health information system and supporting the widespread, meaningful use of health IT.

Previously, Blumenthal was a practicing primary care physician and director, Institute for Health Policy at the Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School. He received his undergraduate, medical, and public policy degrees from Harvard University and completed his residency in internal medicine at Massachusetts General Hospital.

Blumenthal is a renowned health services researcher and national authority on health IT adoption. With his colleagues from Harvard Medical School, he authored the seminal studies on the adoption and use of health IT in the United States. He was the founding chairman of AcademyHealth and served previously on the boards of the University of Chicago Health System and of the University of Pennsylvania Health System. He is recipient of the Distinguished Investigator Award from AcademyHealth, and a Doctor of Humane Letters from Rush University.


Publication Date: Monday, October 03, 2011

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