Although the American Recovery and Reinvestment Act allotted grants to encourage the establishment of HIEs, participating in an HIE still doesn't come free. Participants must have an EHR in place, and most HIEs ask participants to pay a fee to connect; that price can vary depending on an organization's size and the degree and complexity of the connectivity needed.
For instance, the fee for a hospital HealthBridge subscription includes a predetermined portion that management has allotted be covered by hospitals (a cost spread among all participating hospitals) and is based on the hospital's gross expenses. In addition to that amount, participants pay an EHR data exchange fee based on how much data a participant receives and sends.
"When HIE started in Cincinnati, it paid for itself for participants just in the elimination of fax and mail cost, but the technology has gotten better and it costs more," says Gravell. "The federal government is spending billions to digitize healthcare … and there's a renewed interest in capitation and population health. Whereas episodic care doesn't require data, population health does. HIE is the solution to community health."
As of 2010, HealthBridge began working to aggregate raw data from its participants to help its members pursue population health initiatives and related payment models. It's an effort that has led the HIE to connect to organizations beyond physician groups and hospitals, such as long-term care facilities and home-care agencies.
Gravell notes population health management is generally accompanied by incentive programs such as pay-for-performance or shared savings, which are designed to motivate doctors to make less costly treatment choices for patients and to manage the total cost and treatment of a patient beyond a single encounter.
However, these incentive programs shift a great deal of payment risk from the payers onto the providers. Reimbursement is based on data showing a patient's progress, which requires complete clinical data. Without that, physicians cannot fully and accurately treat a patient, and that can influence outcomes and decrease incentive payments. All of that makes participating in these programs less appealing to physicians.