Editor’s note: Healthcare IT News launches a new column today. Health Data Miner is conceived and written by Jack Beaudoin. Beaudoin digs deep into HIMSS Analytics data to derive insight and commentary on a wide range of healthcare IT topics.
Health Data Miner
Federal, state and local governments have long used tax deductions and credits as policy tools to direct individual and organizational behavior. We take it for granted that incentives work – the debates on government incentives tend to cluster around their ethical use or the economics involved (i.e. how much incentive does it take to effect change, and is the outcome worth it?).
And so it is with meaningful use, the engine of change in the HITECH Act. The data seem to suggest that the use of incentives has driven greater IT adoption and deployment since the act’s passage.
In mid-2013, about 67 percent of hospitals in the United States had met the requirements of meaningful use Stage 1 and another 16 percent qualified under the related Medicaid program. "For hospitals, just 9 percent had adopted EHRs in 2008, but today, more than 80 percent have demonstrated meaningful use of EHRs," HHS Secretary Kathleen Sebelius noted in a press release trumpeting the news.
That number had risen to 86 percent by November, the last month for which data is available. Hospitals had until the end of the year to meet the Stage 1 requirements in order to receive an incentive, and since mid-2011, nearly $11 billion of incentives have been paid to hospitals.
Data from HIMSS Analytics adds further color to the role of incentives. Speaking to Mike Miliard, Healthcare IT News' managing editor, HIMSS Analytics executive vice president John Hoyt said he had little doubt about the success of the incentives. Not only were the least automated hospitals adopting IT, but so were the more advanced.
[See also: EHR incentives climb to $19B.]
Since the incentives went into effect, "notice that we've had 100 percent growth in Stage 7, about 170 percent growth in Stage 6 and more than 200 percent growth in Stage 5," Hoyt told Milliard, referring the top levels of HIMSS Analytics' Electronic Medical Record Adoption Model. "The question is, does the stimulus program work? This tells us something's going on."
Something was going on, but it would be wrong to conclude that collecting the incentive is the only explanation for healthcare IT adoption rates.
As Miliard pointed out in his story, the percentage of hospitals at the bottom of HIMSS Analytics' EMRAM model (Stage 0) declined from 20.4 percent in 2006 to 6.9 percent in 2013. The delta is 13.5 percent. And the percentage of hospitals at the other end of the EMRAM model – Stages 6 and 7 – grew from virtually zero to 13.3 percent.
To be absolutely clear, these are two different groups of hospitals. The similarity in deltas did not result from hospitals moving from paper-based systems to fully paperless systems. Between Stage 0 and Stages 6 and 7 sit the bulk of the nation’s hospitals, at various waypoints of adoption.
But the similarity does raise a question about broad-based incentives. Assuming that hospitals that attained the highest levels on the EMRAM model were already likely to qualify for the MU Stage 1 incentives, what motivated them to continue and increase IT adoption at roughly the same rate as hospitals that needed IT adoption to receive the incentive payments?
One explanation is coincidence. Hoyt and Miliard may have chosen their data points randomly. But we can rearrange the pairings in the data differently in an attempt to see if it is possible to quantify the role of the incentives.
In fact, Margalit Gur-Arie has already done this. In a May 2013 "On Health Care Technology" blog post (http://onhealthtech.blogspot.com/2013/05/spinning-ehr-adoption-numbers.html), Gur-Arie placed hospitals into two groups: those in EMRAM Stages 0-2, and those in Stage 3 and above. Those in the latter group would qualify, presumably, for Stage 1 meaningful use. Those in the former group would need to invest in IT to qualify for incentive payments.
Using 2008 as a baseline – a time when hospitals wouldn’t yet know Stage 1 requirements – 41.5 percent of all hospitals fell into the EMRAM Stage 3 and above. In 2010, when the rules on Stage 1 were finalized, the percentage was already at 68 percent. By 2011, when the incentive payments first started, that percentage was at 73 percent. And by Q3 of 2013, the number had risen to 81.2 percent.
In other words, prior to even knowing what the MU Stage 1 requirements were, nearly 7 in 10 hospitals had the technology to qualify in place. In the following three years, the number had climbed to only 8 in 10 hospitals. One might well conclude that not knowing what the requirements were drove adoption (by 64%) far more dramatically than the actual requirements themselves (15%).
This doesn’t mean that the incentives weren’t effective – far from it. As Gur-Arie noted in her blog, the number of hospitals reaching EMRAM Stage 3 or better doubled, from about 40 to about 80 percent. And at least some of that can be credited to the incentives. And even more change, nor doubt, can be attributed to the looming threat of disincentives scheduled for 2015. As social scientists have demonstrated, the stick can be far more effective than the carrot at changing behavior.
[See also: Time for a new optimism.]
