Healthcare Economy

It was but a year ago that everybody in the provider segment, and their aunts, were trying to figure out how to solve the dilemma posed by the P4P and similar mandates. People in power (vendors included) were shouting at top of their lungs about the injustice of it all. After all, how could anybody put a price tag on quality care. Once their throats got parched and eyes started watering, they got around to finding best ways to maximize their returns in face of the “unjust” restrictions imposed by a “tyrannical” CMS. And all of a sudden, the water went off the boil. Nobody, and I mean nobody, could care less about the P4P measures anymore. Programs were shelved, people reassigned, budgets slashed.

So what happened?

Did all the underlying data collection issues evaporate all of a sudden on a steamy July night? Or the clinical processes automatically became self-efficient? Or all the providers secretly swore an oath to trust each other’s findings and not order wasteful and redundant procedures? Or, for that matter, they found a new floor cleaner that ensures nobody slips on an ER floor. Just spray it and forget about all penalties arising out of involuntary falls. Maybe that is my path to richness, but I digress.

Well, the correct answer is …………….. US elections.

With the elections came a small matter of $20B for ARRA and all bets were off. Nobody could give a hoot about the piddly little 4% penalties associated with pilot KPIs. After all we are talking 7-8 figure dollars associated with ‘Meaningful Usage”. Everybody was (and I believe, still is) rushing to Washington. Out goes the attempt to reduce costs and increase care through enforced and standardized clinical pathways, and in comes the attempt to share the information among caregivers as the first baby step, which should have been the case to begin with. One first learns to crawl and then run, with possible exception of Mr. Usain Bolt.

So, back to the titular question…. Does US healthcare industry need EPM? The answer, in my opinion, is a resounding YES. ARRA or no ARRA, $20B or no $20B, the bottom line still remains that till the time the provider sector does not have a hard look at their clinical practices, there is not going to be much improvement in quality of care and neither would be there much reduction in cost of care. $20B can take you only so far.

Especially once the hoopla of the EMRs die down and most providers get connected electronically, it will be much easier to maintain a standardized way of doing things irrespective of whether the hospital is Mass General or Beth Israel, irrespective of whether the doctor is John Smith or Joanna Smith. In addition, it will be much easier to weed out the black sheep too. Not too many places (or should I say, files) to hide with the good old computer cranking out the reports on a remote printer in CMS’ offices. So then what? How does it impact my choice for using EPM or not?

Well, as a wise man once said, ‘You don’t wanna take a knife to a gun fight’. Would you, as a provider, not be interested in acquiring all proactive tools that you could lay your hands in your battle with regulatory bodies who are hell-bent on using some of their own tools to monitor you to the minute? You bet, you will be. And there my friends, comes the proactive EPM tools to the picture.

An EPM tool that can alert you within time for you to take corrective action for a potentially payment-impacting variance in pre-ordained clinical pathways would pay for itself the first time you submit a 100% compliant HEDIS report. Can anybody hear those bonus checks leaving CMS’ headquarters? An EPM tool that can weed out the chronic violators and procrastinators among your clinical staff, would be worth its weight in Gold, especially if it could be configured to be a behavioral modification tool rather than a simple punishment artifact.

So, my response to all those doubting Sams is, just wait. Wait for another year or so and then see if the whole EPM gravy train does not come around again.