Sunday, April 7, 2013

Searching for a Business Model for Public Health

Have you read the recently released report by the Trust for America’s Health, “Healthier America 2013”? It is an excellent attempt to summarize the opportunities for public health to transform itself during the roll-out of the Affordable Care Act. Over and over again the urgent need for public health to work hand-in-hand with health care systems is highlighted in the report. 

Public health departments must adapt to work with new entities and financing mechanisms in the reformed health system, such as by working with Accountable Care Organizations (ACOs) or within newly capitalized care structures and global health budgets, to help improve health beyond the doctor’s office.
A key component of this, obviously, will be the ability to exchange health information with other parts of the health care systems electronically. Let’s consider my health department’s Maternal and Infant Health Program (MIHP) as an example. This program coordinates care for pregnant women and their children, many of whom are facing serious risks in their pregnancies. Our health department has an electronic health record (EHR) system. We manage our MIHP cases using the EHR which works quite well. We are completely paperless—well, almost.

In managing these cases we collaborate with  the families' primary care providers. The providers refer patients to us, and we coordinate their care with the providers. Information going back and forth between us and them still goes by old-fashioned, messy faxes. Just this morning, I found two “lost” MIHP faxes floating around in our copy room.  We would love to join a Health Information Exchange (HIE) so we would be able to exchange this information directly out of our EHR and ditch the faxes.

In fact, last week we met with one of the two big HIEs in our state to talk about doing just that. This HIE offers a sweet product for managing referrals which is exactly what the MIHP program is looking for. Physicians’ offices in our area are starting to jump aboard the HIE.  We would love to go forward, but there is a snag: the cost.

Participating in the HIE would only cost a few thousand dollars. The problem is that our health department is looking at possible budget cuts next year of tens of thousands of dollars. Our state pays for part of public health out of a health fund that is going to take a big hit this year; there is sequestration; and some of the counties in our district are warning that their general funds are still underwater.
Another complicating factor is that our health department is between two large medical trading areas, each with its own HIE. In order to provide MIHP services electronically across our district, we would need to join two HIEs, at twice the cost. Most frustrating of all, the two HIEs only exchange information between themselves using a protocol called Direct, which is very limited.  It’s kind of like secure email. It would not permit the kind of exchange we really need to make MIHP referrals efficiently.

Yet not joining the HIE at this point poses a risk, too. As more and more physicians join the HIE more of them will be making referrals electronically using the HIE’s product. If the health department does not appear in their system because we haven’t joined, referrals for things like MIHP, family planning and the various testing and screening services we offer will start going elsewhere. Now, I don’t think government should be competing with the private sector to deliver these services. My concern is that medically complicated or vulnerable people who should be seen at a health department may miss that opportunity. Our services need to be sustainable so that we can be here for those who need us.
That’s the challenge we are wrestling with: We need to come up with a business model through which programs like MIHP can generate the revenue we need to be part of our local HIEs. If we are part of the HIEs we'll be part of the future. If not... Will we be able to do it? Our team is working like crazy on that problem now.