Hospital APM Participation Not Linked to Interoperability Improvement

Hospital alternative payment model (APM) participation was not associated with enhanced interoperability, according to a study published in JAMA Health Forum.

Using American Hospital Association Annual Survey responses, researchers measured interoperability progress for 3,928 hospitals from 2014 to 2018.

Interoperability progress was slow, with engagement increasing at an average of 5.7 percentage points per year. By 2018, less than half of hospitals reported that they engaged in all four domains of interoperability: finding/querying for data, sending data electronically, receiving data electronically, and integrating electronic patient data from external care delivery organizations.

The study authors noted it will take until 2027 to achieve nationwide engagement in all four interoperability domains at the current rate.

Congress promoted APMs as a policy mechanism intended to align financial incentives for enhanced interoperability, as described in the US Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) of 2015. APMs include accountable care organizations (ACOs), patient-centered medical homes (PCMH), and bundled payments.  

However, the cohort study revealed no association between APM participation and interoperable data sharing. The researchers presented several reasons as to why this may be the case.

First, they suggested that APM incentives may be too weak.

"Given that most APM payment is based on fee-for-service programs, with only upside rewards rather than more aggressive downside risk arrangements, APM incentives may not be strong enough to change hospital behavior substantially," the study authors wrote.

"It may also be that the incentives are too diffuse; even if APM participation affects hospital decision-making, hospital leaders may choose to focus on reducing costs in other ways, such as reducing utilization or shifting referrals to lower-cost care facilities," they added.

Additionally, the authors pointed out that APM hospitals were equally or more likely to face data sharing barriers related to technical and governance issues compared to non-APM hospitals, including difficulty exchanging across different EHR vendors.

"This suggests that value-based payment models aligned financial incentives for sharing data, but technical barriers hampered interoperability progress," the researchers said.

The study authors suggested that the new framework to encourage interoperability through the 21st Century Cures Act may address remaining data sharing barriers, including technical challenges and data governance issues.

The researchers noted several limitations to their work.

First, the researchers used self-reported survey data and could not verify the accuracy of responses. However, healthcare stakeholders have previously validated the AHA Annual Survey results against external sources.

Additionally, the study authors acknowledged that there are multiple ways to measure interoperability, such as participation, breadth, and volume.

"We focused on four federally prioritized domains of interoperability but were unable to observe variability in implementation and use. Future research should examine differences across exchange methods," they explained.

"For example, the process of integrating data into the EHR without manual intervention may be different between hospitals using different methods of data sharing," they wrote. Similarly, there are dimensions of APM participation that our data were unable to capture, such as whether a hospital participated in a Medicare or commercial ACO and the specific bundled payment services."