One day soon, patients will routinely interact with doctors via remote telepresence. It’ll be common for people to take digital photographs of medical conditions and send them to health-care professionals for evaluation. And improvements in data capture and analysis will lead the way toward better, more cost-effective medical care.
In 2009, Medicaid costs accounted for an average of 15.7 percent of states’ general fund spending, according to Medicaid and State Budgets: Looking at the Facts, a publication of the Center for Children and Families. By 2011, that amount had risen to 16.8 percent, with no sign of slowing in sight. Medicaid as it exists today is simply not sustainable. A new model that meets the needs of an aging population is necessary. The Affordable Care Act (ACA) requires states to take a number of steps over the next several years to reform the system. And while the ACA’s future also is in question (Gov. Mitt Romney has promised to repeal all or part of it if he’s elected president), the need for significant reform still is evident, and technology will likely play a role in a number of areas, including enrollment and eligibility, pay-for-performance and electronic medical records.
Cheryl Camillo is a senior researcher with Mathematica Policy Research, a Princeton, N.J.-based research organization. Camillo focuses on ACA and Medicaid and is also the former executive director of the Maryland Office of Eligibility Services. Camillo said the ACA is motivating states to use technology to change the future of Medicaid application and enrollment processes.
“From 2014 through 2019 there will be a substantial transformation of Medicaid due to ACA,” said Camillo. “If it all works out, the Medicaid program in 2020 will be very different than it is today, especially in the eligibility and enrollment areas. The use of IT systems will be a significant part of that.”
Rather than apply to numerous programs to determine eligibility, future applicants would fill out one electronic application and be automatically routed to the most appropriate program with minimal interaction and paperwork — a scenario dramatically different than today’s complex, paper-driven process.
“Information technology is essential to making that happen,” Camillo said. “It will allow people to apply electronically, and the systems will interface behind the scenes. The data needed to determine eligibility would be pulled from sources where it already exists electronically.”
Technology could also play a significant role in changing how providers interact with and manage chronic care patients. According to Alain Enthoven, professor of public and private management at Stanford University and a founder of the Jackson Hole Group, a national think-tank on health-care policy, Medicaid’s open-ended, fee-for-service payment system is a major contributor to the high level and rapid growth of spending. In 2009, the Massachusetts Special Commission on the Health Care Payment System said that fee for service “rewards overuse of services, does not encourage consideration of resource use, and thus cannot build in limitations on cost growth.”
Moving to a fee-for-performance scenario would change how doctors are rewarded while also promoting better outcomes. “Medicaid as we know it is a 1950s-era concept based on acute, episodic care and built around a doctor making a living,” Enthoven said. “In the future it will be more about doctor performance, actually helping improve health, and reducing patient dependence on the doctor. Coaching and electronic exchange of information would replace many in-person visits, and patients would be encouraged to manage their own health.”
Aneesh Chopra, senior adviser of health-care technology strategy at the Advisory Board Co., envisions a similar scenario. “Once a doctor has all the data they need, they could begin to look at how to best engage the patient in newer ways to improve their overall health outcomes. Technology tools could be used to collect patient monitoring data, and doctors could text or call patients instead of having them travel to the office,” Chopra said. “I envision an iPhone App Store scenario where patients download and use tech tools that support behavior change and help them make better health decisions.”
Coordination of care will also be critical to Medicaid reform, and technology and electronic health records will play a significant role there as well. “Chronic care patients are likely to have several different providers,” said Enthoven. “Without a good system of electronic health records, a lot of time can be wasted and data can be lost. Errors are more likely. Teamwork is important in treating chronic care patients and electronic health records are at the heart of that.”
“Most complex care patients go many places — surgery centers, specialists, etc.,” Chopra said. “Today each of those places operates in a silo. More effective information sharing technologies are important because doctors can only manage patients better if they have all the data.”
Oregon is one state that is already taking steps toward better coordinated care. The Oregon Legislature, in a bipartisan vote, recently directed the state to create coordinated care organizations (CCOs). In July, the state officially launched the new CCOs with 260,000 patients. The goal is to coordinate mental and physical health care and focus on prevention. CCOs will also provide more support to patients with chronic conditions. Over time, officials said, patients with complex conditions can expect their doctors, nurses and therapists to coordinate their work and be better prepared to help them handle their treatment between visits to a clinic.
Overall, states are taking different approaches to working toward the ACA provisions. Some states, such as Maryland and Colorado, are integrating Medicaid reform and health insurance exchanges and moving them forward together. Others, like Montana and Wyoming, are moving forward aggressively with Medicaid provisions and new eligibility systems but are not focusing on health insurance exchanges yet. “Which approach is better really depends on the state,” Camillo said. “With either approach, coordination and communication are essential to success.”
Technology will also likely play a significant role in health-care delivery in the future. There are already numerous examples of how different types of technology can be used to deliver a faster diagnosis or to simplify doctor/patient interactions. Patients take photos with smartphones and email them to their care provider for evaluation; doctors use Skype to video conference with chronic care patients and monitor their conditions from home using computer-based medical devices; large monitors and video conferencing allow a surgeon to update a patient’s family from the operating room immediately after surgery rather than making them wait for the surgeon to clean up and change clothes to update them in person.
The use of technology in health-care delivery also has potential to reduce costs and improve care in underserved or remote areas. Dr. Rafael Grossmann Zamora is a trauma surgeon at Eastern Maine Medical Center in Bangor, Maine. Zamora and his team are using video over a Wi-Fi network utilizing an inexpensive iPod Touch to conduct consultations for acute trauma patients, thereby extending the virtual presence of a specialist over a vast area instantaneously at a very low cost.
“This is about improving patient care and increasing the efficiency of the trauma system,” said Zamora. “Technology is helping us overcome high demand for a shortage of specialists in rural areas.”
When a hospital needs advice or a consultation, staff members call Zamora and, via big screens and video conversations, Zamora examines the patient and consults with doctors on the best approach to the patient’s care. While the traditional approach of in-person consultations is time consuming and inconvenient, the mobile technology solution has proven fast and inexpensive.
“This is the optimal way to provide patient care,” Zamora said. “I believe the medical profession will be using video connections and remote presence on a large scale in the future. It will become almost the standard of care for many things we do. So many of the patients that visit doctors in their offices today don’t actually need to see the doctor in person. Using technology, we can save huge amounts of time and money.”
Some states are helping encourage technology innovation around health care. The New York Digital Health Accelerator, for example, is a nine-month program for early and growth-stage digital health or health IT companies that is being run by the New York eHealth Collaborative and the New York City Investment Fund. The program is designed to provide a vehicle for health-care providers and entrepreneurs to work together to develop innovative technologies that leverage patient health records to support collaborative care and coordination.
The program’s participating providers are actively looking for new technology products that will help them effectively implement the new Health Homes model, which is part of New York’s Medicaid redesign initiative. Approximately 975,000 patients with multiple chronic illnesses are being transitioned from fee-for-service to this new managed care model. Under the New York Digital Health Accelerator program, eight companies that are developing software applications for care coordination, patient engagement, analytics and message alerts for health-care providers were selected to receive up to $300,000 of funding per company from a syndicate of leading venture capital and strategic investors. The companies will have priority access to the Statewide Health Information Network of New York, the technology platform that’s connecting electronic health records across New York state.
“Providers were looking for new apps to help them meet their emerging needs as we move from Medicaid to a managed care model, but they didn’t have the technology tools to make that happen,” said Anuj Desai, director of business development at the New York eHealth Collaborative. “The New York Digital Health Accelerator program was developed as a way to bridge that gap.”
In addition to helping encourage health-care and technology innovation in the state, the program also has an eye toward economic development.
“The applicant companies must have an office in New York, so another angle here is we are looking to create jobs for the future of the state,” said Desai. “We want to make New York a health-care IT leader.”
Some federal programs are also helping encourage innovation. The Center for Medicare and Medicaid Innovation hosts an award program designed to empower states to test new payment and service delivery models that will help improve quality of care and reduce the costs of care for the nearly 9 million people enrolled in both the Medicare and Medicaid programs. To date, 15 states have been awarded design contracts of up to $1 million to develop new ways to meet the needs of the Medicare/Medicaid population.
The vast changes the health-care system is currently undergoing makes it difficult for even health-care experts to predict what the future will look like.
“Because there is so much uncertainty around health care at the moment, most people in the health-care arena only look as far as 2020,” Camillo said. “But I think technology is a key element to achieving the goals of the program, improving health coverage and quality, and reducing costs. A large part of that is the expansion of electronic health records and electronic medical records.”
Data analytics will likely play a large part as well. “With data analytics, it is now computationally possible to predict which 5 to 10 percent of patients are most at risk of getting sick or requiring coordination of care,” said Chopra. “If a doctor can identify those patients early, he or she can figure out who needs to be seen before the patient even calls.”
But Chopra and others warn that technology alone won’t be the “cure” to our health-care woes.
“Technology alone will not change the health-care industry,” Chopra said. “But technology paired with a new business model has the ability to make that change.”