Investment subsidies and the adoption of electronic medical records in hospitals

In February 2009 the U.S. Congress unexpectedly passed the Health Information Technology for Economic and Clinical Health Act (HITECH). HITECH provides up to $27 billion to promote adoption and appropriate use of Electronic Medical Records (EMR) by hospitals. We measure the extent to which HITECH incentive payments spurred EMR adoption by independent hospitals. Adoption rates for all independent hospitals grew from 48 percent in 2008 to 77 percent by 2011. Absent HITECH incentives, we estimate that the adoption rate would have instead been 67 percent in 2011. When we consider that HITECH funds were available for all hospitals and not just marginal adopters, we estimate that the cost of generating an additional adoption was $48 million. We also estimate that in the absence of HITECH incentives, the 77 percent adoption rate would have been realized by 2013, just 2 years after the date achieved due to HITECH.

Payer mix and EHR adoption in hospitals

Payers are known to influence the adoption of health information technology (HIT) among hospitals. However, previous studies examining the relationship between payer mix and HIT have not focused specifically on electronic health record systems (EHRs). Using data from the Nationwide Inpatient Sample and the American Hospital Association Annual Survey, we examine how Medicare, Medicaid, commercial insurance, and managed care caseloads are associated with EHR adoption in hospitals. Overall, we found a weak relationship between payer mix and EHR adoption. Medicare and, separately, Medicaid volumes were not associated with EHR adoption. Furthermore, commercial insurance volume was not associated with EHR adoption; however, a hospital located in the third quartile of managed care caseloads had a decreased likelihood of EHR adoption. We did not find empirical evidence to support the hypothesis that payer generosity and other indirect mechanisms influence EHR adoption in hospitals. The direct incentives embedded in the Health Information Technology for Economic and Clinical Health Act may have a positive influence on EHR adoption--especially for hospitals with high Medicare and/or Medicaid caseloads. However, it is still uncertain whether the available incentives will offset the barriers many hospitals face in achieving meaningful use of EHRs.

COBRA ARRA subsidies: was the carrot enticing enough?

OBJECTIVE

To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008-2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions.

STUDY DESIGN/DATA COLLECTION

Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate).

PRINCIPAL FINDINGS

Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending.

CONCLUSION

Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.

Rescued by the safety net

The recent recession had a significant impact on the nation and Minnesota both in terms of the number of jobs lost and the loss of employer-sponsored health insurance (ESI). In this article, we present national and Minnesota-specific data on the loss of ESI. We also explore how government-sponsored programs provided a safety net that enabled many people with low incomes to retain health insurance coverage, lessening the recession's impact in Minnesota. We conclude with general comments about the role of the safety net in a health care system in which the majority of people have health care coverage through voluntary employer-based programs.

Comparative effectiveness research: does the emperor have clothes?

With the recent allocation ofa $1.1 billion "down payment" to fund comparative effectiveness research (CER) from the American Recovery and Reinvestment Act of 2009 (generally referred to as the stimulus package) and with $300 million being allocated for the Agency for Healthcare Research and Quality (AHRQ), $400 million for the National Institutes of Health, and $400 million for allocation at the discretion of the Secretary of Health and Human Services and with the National Center for Complementary Alternative Medicine putting out a request for research proposals for Comparative Effectiveness Studies of Complementary and Alternative Medicine, it is safe to say CER has entered a new era. CER solves two historical concerns for complementary and alternative medicine (CAM) researchers; first it focuses on effectiveness not efficacy; second it tests holistic approaches to care. Because it allows the providers to give care in any way they choose, it avoids the problem of reductionism inherent in standard random controlled trials. In CER, the provider can continue to practice holistically and to use individualized medicine to treat the patient. However, amid the largely positive responses to this move among researches in CAM, a more critical evaluation might be in order. This article argues that while the move to effectiveness research is a positive move for CAM, CER as currently being talked about and funded may just be a new form of privileging certain forms of evidence at the expense of other equally important and perhaps more relevant evidence.

Characterizing brain tumor research: the role of the National Institutes of Health

The contribution of radiology to brain tumor research is unknown. We sought to determine how the proportion of neuro-oncologic publications generated by radiology departments has changed and if there is an association with NIH funding levels. Therefore we searched The National Library of Medicine's PubMed database for all articles published on brain neoplasms from 1996 to 2007. Country and department of origin and NIH grant support were noted for each article. Approximately 10% of brain tumor publications originated from radiology departments, ranking third among medical specialties. NIH funding for this research grew from less than 20% in 1996 to more than 50% in 2007. Overall NIH funding levels rose approximately 2.5 fold during this time. The U.S. was the dominant producer of brain tumor publications, and the gap between the U.S. and the rest of the world grew over the study period. Thus a substantial proportion of brain tumor publications originate from radiology departments, and the percentage of this research that is funded by the NIH has grown significantly during a period of increasing NIH budgets.

Administration Tech Trends 2010. Trend: data infrastructure

THE LANDSCAPE: CIOs are realizing that everything they and their fellow executive and clinician leaders want to accomplish in hospital-based organizations--improving patient safety and care quality; enhancing efficiency and clinician workflow; delivering evidence-based patient care; creating outcomes transparency for purchasers, payers, and consumers; and participating in value-based purchasing initiatives, not to mention snagging federal funding under the ARRA-HITECH legislation passed last year--will require robust data infrastructures. And as pioneers are learning, creating those infrastructures is challenging and complex, but immensely critical.

THE FUTURE

Experts say the need for robust data infrastructures to support performance improvement and transparency will only intensify. The time is now to put the needed technologies into place.