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Associations between Florida counties’ COVID-19 case and death rates and meaningful use among Medicaid providers: Cross-sectional ecologic study [1]

['Katherine Freeman', 'Division Of Biomedical Sciences', 'Charles E. Schmidt College Of Medicine', 'Florida Atlantic University', 'Boca Raton', 'Florida', 'United States Of America', 'Judith P. Monestime', 'Health Administration Programs', 'Management Department']

Date: 2022-08 

Background

Accurate reporting to public health agencies has never been more critical than during the COVID-19 pandemic. Communication of daily incidence rates and trends in COVID-19 cases and deaths promotes optimal utilization of existing resources by healthcare professionals and helps mitigate population risk by identifying communities with increased spread while emphasizing protective measures [1]. Quantification of these key epidemiologic markers provides evidence-based decision-making regarding economic recovery, school participation, and healthcare resource allocation for staffing, testing, and vaccine distribution [2]. The primary reporting mechanism to state, territorial and local public health agencies was revolutionized by implementing electronic health records (EHR) which improve efficiency and quality of care in the healthcare system by facilitating public health reporting and surveillance of infectious disease transmission [1, 3]. Public health agencies have found EHRs particularly useful in surveillance efforts to curtail bioterrorism and outbreaks [4]. Not only does linkage of patient health records among providers facilitate coordination of care [5] and promote more optimal clinical outcomes, [6] but it allows public health administrators to initiate custom queries within secure data environments [4]. Additionally, the use of EHRs has fostered change in health record formats toward standardized reporting. The Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in February 2009; its purpose was to encourage healthcare providers to convert paper records to electronic and utilize such technology in accordance with federal regulations, commonly referred to as Meaningful Use, to improve quality-of-care outcomes, promote public health reporting and reduce health disparities [7, 8].

The Promoting Interoperability Program has been operational since 2011 and is currently providing incentive payments to Eligible Professionals (EPs) for demonstrating Meaningful Use [9, 10]. The HITECH Act provided subsidy payments [11], about $21,250 during year 01 and $8500 each subsequent year, to Medicaid providers who were required to meet standards of advanced functions, thus achieving Meaningful Use [7, 9, 12]. HITECH’s overall goal was to improve population health outcomes through the timely and seamless transfer of health data [8, 13–17]. Despite the promising benefits of public health reporting, in 2014, only 6% of providers chose Meaningful Use objectives to submit syndromic data to public health agencies [18]. Furthermore, of the $6 billion investment to Medicaid providers nationally, only 56.2% had demonstrated Meaningful Use by 2018 [19]. Ultimately, expected gains from the Triple Aim to improve population health outcomes, part of the impetus behind public health reporting requirements for Meaningful Use, has lagged [20].

Significant investments through the HITECH Act, for the Medicaid Promoting Interoperability program, to implement EHRs and achieve Meaningful Use has greatly contributed to the uptake of a basic technology in clinical care settings [21]. The use of EHRs for public health surveillance and reporting holds promise to identity cases that meet certain criteria for automatic reporting to public health agencies [12]. EHRs can also facilitate efforts to respond to public health emergencies such as the COVID-19 pandemic, to bridge the gaps among clinical practices to promote more equitable outcomes. While EHRs by themselves are useful, certain advanced EHR capabilities which are required to achieve Meaningful Use are necessary to exchange health data with public health departments. However, the trend in achieving Meaningful Use has stalled among Medicaid providers, who serve a large population of traditionally underserved and marginalized patients [10, 22]. The Medicaid Meaningful Use rate for Florida providers (42.6%), is more than 13 percentage points below the national provider Medicaid Meaningful Use rate of 56.2% [22, 23]. Ultimately, examining the differences in reported incidence rates of COVID-19 cases and deaths between Medicaid providers who did and did not achieve Meaningful Use, can reveal barriers to public health reporting of COVID-19 outcomes which inform public health decision-making. Furthermore, according to the Commonwealth Fund, in 2018, Florida ranked 48th lowest among 50 states plus the District of Columbia regarding overall healthcare and 49th for access, quality, and use of healthcare [24]. Florida ranks third among states with the highest Medicaid enrollment, behind California and New York [25]. In 2020, one in five Florida residents was on Medicaid, comprising 3,716,747 Medicaid beneficiaries; of these, 27% were Black or African American, 29% Hispanic or LatinX, 34% White, and 11% Other [26]. Additionally, 3 of 7 children in Florida and 4 of 7 of those in nursing homes are covered by Medicaid [26]. At the time of writing, Florida ranked 11th among states with the fewest coronavirus restrictions [27] and was tied for the largest percentage of its population 65 years and older (20%) [28] who are most at risk of death or requiring hospitalization. As previously mentioned, Florida Medicaid Meaningful Use low achievement rate in comparison to the national rate [23], underscores the limited advanced reporting capabilities of most of the state’s Medicaid providers.

Due to increased COVID-19 risk among Floridians because of these factors and pronounced health disparities cited during the COVID-19 pandemic at the county, state, and national levels [29], the two-sided hypotheses alternative to the null hypothesis of no difference are: 1) COVID-19 death, case and case fatality rates are underreported (lower) among Medicaid providers not achieving Meaningful Use relative to those achieving Meaningful Use, and, 2) these reported outcomes are greater in counties with lower concentrations of this technology. Although researchers have begun to explore the associations between COVID-19 outcomes and demographic and economic risk factors that relate to health equity, these studies have not emphasized that Health Information Technology (Health IT) is an essential component of Social Determinants of Health (SDoH) [29, 30].

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[1] Url: https://journals.plos.org/digitalhealth/article?id=10.1371/journal.pdig.0000047

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