In 2020 and 2021, the health system faced a public health catastrophe unlike any experienced since the polio epidemic 75 years ago. Last year, 2022, was, in many respects, worse, despite some surface-level improvements. While Covid-19 remained a persistent challenge for everyone, patients who took the vaccines and boosters were much less likely to become seriously ill and require hospitalization - but the immunocompromised and some others were left behind when many returned to some semblance of pre-pandemic life. Telehealth enabled more patients, especially those with behavioral health conditions, to access needed care - but many provisions providing telehealth, especially audio-only telehealth used by some of the more underserved communities were rolled back or discontinued by providers.
These generally positive changes pale in comparison to the more intractable disruptions to the health system that Covid-19 created and that today threaten the future of hospitals and health systems. The pandemic revealed inequities in care in stark detail, above and beyond those called out previously. Doctors, nurses, and allied health professionals left their jobs in droves, crippling the health system's ability to care for the enormous number of patients whose care was delayed by the pandemic. The demand for behavioral health supports quickly overwhelmed the health system's capacity to serve these patients. Hospitals and health systems could not place patients in post-acute settings where the same disruptions were wreaking havoc. Inflationary increases in supplies, equipment, drugs, and labor costs hammered hospital margins. Administrative burdens, such as the byzantine prior authorization process, added insult to injury.
Implementing solutions to these problems will take years and cost money. Most of the funding for healthcare in last year’s Inflation Reduction Act, December's $1.7 trillion omnibus bill, and other 2022 legislation is dedicated not to subsidizing a struggling delivery system but to preparing it for future pandemics and the radical redesign necessary to improve health in the 21st century. Physician professionals will take a pay cut, while the healthcare workforce, behavioral health, Medicaid, and the Children's Health Insurance Program, will receive added support. Historically disadvantaged rural and public-pay hospitals, telehealth, and hospital-at-home programs will receive extended funding support. Community hospitals and health systems were spared substantial reductions in Medicare reimbursement, but that is it.
It doesn't take an economist to recognize that central to this funding is the recognition that acute care as we know it – patients seeing doctors in hospitals - is unsustainable. For the next two years and probably longer, federal health funding will diminish the central role of the hospital in the delivery system. Market competition will increase for those health services that don't require hospitals. Private investment in primary care, health promotion, disease management, and chronic care services will follow the Federal dollars away from the hospital to services delivered where patients live and work. This shift will leave unprepared, asset-laden acute care health systems with fewer physicians, expanded EDs and ICUs, and those surgical services that require a hospital stay. Other services will be provided elsewhere, through other means.
The means to succeed in this complex transformation are in the 21st Century Cures Act. As outlined in HIMSS' 21st Century Cures Act summary, the Cures Act, for short, was passed in December of 2016 by a Republican House (392-26) and Republican Senate (94-5) and signed by a Democratic President. While the bill is known mainly for its efforts to fund precision medicine, it contains provisions to improve health IT — most notably, with nationwide interoperability and information blocking. Certain sections focus on "improving quality of care for patients," with the lack of interoperability a paramount concern. It also emphasizes providing patients access to electronic health information that is easy to understand, secure, and updated automatically.
Prior authorization is among the highest burdens on provider organizations. Many have been working to improve the process and reduce this burden. MHDC recently completed a prototype project with Blue Cross Blue Shield of Massachusetts and New England Baptist Hospital implementing the DaVinci CRD Implementation Guide using FHIR to automate inquiries about prior authorization requirements. We are also working with the Network for Excellence in Health Innovation (NEHI) to propose Massachusetts-wide automated prior authorization standards to the Health Policy Commission. We also intend to initiate an ongoing service to help payers and providers in our community stand up their own automated prior authorization services using FHIR, DaVinci, and other modern health technology and related data standards.
MHDC provides other health data services and content to inform, support, and accelerate the interoperability journey. The opportunities for healthcare providers and health plans to innovate and create more value for patients are rooted in sharing all health information between providers, payers, and patients. This democratization of health data will give patients and their caregivers the knowledge and tools to make the best choices for each patient based on each of their specific needs.