Health IT and the Other Disparities

On October 18 2010, Dr. Blumenthal published a letter to EHR vendors titled "Health IT and Disparities"  urging them to “include providers who serve minority communities in their sales and marketing efforts”. Reiterating the assumed benefits of Health IT to both quality of care and efficiency of care delivery, the National Coordinator for Health Information Technology stressed the importance of EHR vendors working together “to provide EHR adoption opportunities for physicians and other healthcare providers working within underserved communities of color”. This is obviously an important and welcome appeal. Physicians who provide care for impoverished minority communities usually lack the means to purchase EHRs and perhaps some EHR vendors will heed Dr. Blumenthal’s request and make special arrangements for these doctors and their clinics. The stimulus incentives may also help. But how about those who serve equally impoverished populations and are practically barred from incentives?

In my home State of Missouri there are about 350 Rural Health Clinics (RHC) serving a state which with very few exceptions is one big Medically Underserved Area/Population (MUA/MUP) which is a geographical area or a population designated by the Health Resources and Services Administration (HRSA) as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. For the uninitiated, RHCs are designated by CMS and have to meet certain requirements. The practice has to be located in a rural area and it has to provide team care, which is all the rage now, meaning that a Nurse Practitioner or a Physician Assistant and a Certified Nurse Midwife have to be on premise and team up with the physician in providing patient care. RHCs can be independent practices or they can be owned by rural hospitals. Either way RHCs are paid by Medicare differently than a practice without RHC designation. RHCs are required to submit reports of their operational costs and their total number of visits. Based on these two parameters the reimbursable cost per visit is calculated by Medicare. The entire process is complex and subject to rules, regulations and caps. The main point here is that RHC providers are not reimbursed according to the regular Medicare physician fee schedule and therefore will be unable to receive EHR incentives under Medicare. A few RHCs may qualify for Medicaid incentives, but in most cases they don’t have the prerequisite 30% Medicaid patients.

It all started with the HITECH Act where Medicare incentives to Meaningful Users are calculated based on allowable charges for “covered professional services”, which are defined in Section 1848(k) of the Social Security Act as “services for which payment is made under, or is based on, the fee schedule established under this section”, i.e. RBRVS. RHCs are reimbursed for most services on a cost basis as explained above, effectively barring them from qualifying for meaningful incentive amounts. Several public comments to the CMS NPRM on Meaningful Use addressed this very issue, but all were dismissed in the Final Rule by simply restating that “RHC services furnished by an EP are not considered covered professional services for purposes of the Medicare EHR because they are not billed or paid under the physician fee schedule”. While I do understand the bureaucratic difficulty in differentiating between the RHC Medicare claim form (UB04) and the form used by other practitioners (CMS1500), I don’t quite understand how RHC services are not “covered”. The even more perplexing fact is that CMS went out of its way to incentivize providers practicing in Health Professional Shortage Areas (HPSA) by adding 10% to their Medicare incentives, but at the same time decided to exclude a large portion of those providers just because they are using a different form for submitting claims to Medicare. It is worthwhile remembering that these same clinicians were also excluded from PQRI incentives and later from e-Prescribing incentives for the same exact reason.

Like most rural providers, RHCs face serious obstacles in Health IT adoption. Health IT vendors find it difficult to reach rural providers and rather expensive to provide them with services mainly due to simple logistics such as distance from airports and lack of physical concentration of customers. Most rural providers are strapped for cash anyway and reliable IT support is not as easily found as in urban areas. In many rural counties broadband is not available and even when it is available, rural hospitals, pharmacies, labs and diagnostics centers are rarely using HIT and are almost never able to exchange clinical information making the immediate value of an EHR unclear. For those RHCs that are owned by rural hospitals the prospects are even less attractive. There is very little reason for the hospital to invest in ambulatory EHRs if no incentives are expected, particularly since more often than not the hospital itself is light years away from having a qualifying inpatient EHR.

According to the Kaiser Family Foundation, an average of 21% Medicare beneficiaries reside in rural areas, with 12 States having over 45% rural Medicare residents, many of whom are served by RHCs. In Colorado, for example, the estimates are that 40% of Medicare beneficiaries receive care in an RHC. When you combine all factors, there is a veritable digital abyss forming between elderly Americans residing in the countryside and the rest of us.
It’s not too late, and it shouldn’t be too difficult to fix this, but rural America, and its few remaining doctors, need a champion in Washington… Dr. Blumenthal?