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Crashing Waves Hit Radiologists in a Time of Accelerating Change

November 8, 2016
by Mark Hagland and Heather Landi
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A combination of policy, regulatory, payment, business, and technological trends is leading to dramatic change in the practice of radiology and in imaging informatics

The world is changing rapidly, and with it, the U.S. healthcare system—and with the healthcare system, so, too, the world of radiology and imaging informatics. Among the most bracing trends, emerging out of a very broad range of different sources, that are affecting the practice of radiology and the use of imaging informatics:

A massive and unprecedented shift from volume to value in the policy and reimbursement area is taking place now. This shift had already been underway for several years because of the implementation of the mandatory value-based purchasing program and the avoidable readmissions reduction program for physicians and hospitals, under provisions of the Affordable Care Act (ACA); but that shift has been accelerated by the passage of the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) by Congress in April 2015, with the MACRA final rule being published on Oct. 14, and set to be implemented beginning Jan. 1, 2017, and with all Medicare-participating physicians then being pushed either into advanced payment models (APMs) or into the MIPS (Merit-based Incentive Payment System) program. And those changes only compound the policy changes facing radiologists, as referring specialists will soon be required to make use of appropriateness criteria when ordering diagnostic studies.

> Partly driven by policy and payment shifts, a massive consolidation of the healthcare provider sector is underway, with physicians, including radiologists, in the smallest practices, joining either larger radiology groups or large multispecialty groups, or choosing direct employment by hospitals, and with imaging centers also consolidating.

> A combination of advances in information and communication technology is making it far easier for radiologists to work remotely, and spurring a shift of many radiologists into virtual groups or working as individuals for remote-reading services.

> Advances in information technology and in interoperability are changing imaging informatics, with PACS (picture archiving and communications systems) systems increasingly being folded into VNAs (vendor-neutral archives), which are incorporating not only radiological images, but also images from such medical specialties as cardiology, pathology, dermatology, and gastroenterology.

> Changes in technology and business are accelerating an already vigorous pace of consolidation among imaging informatics vendors, resulting in a far smaller number of increasingly larger solutions providers, and, with electronic health record (EHR) products increasing in sophistication, a plummeting level of interest in standalone RIS (radiology information system) solutions, except at the smallest, non-networked radiology practices.

> At the very leading edge of technology, the Armonk, N.Y.-based IBM announced in June the creation of the new Watson Health Medical Imaging collaborative, a global partnership that is bringing together 16 vendor, health system, and academic partners to improve cognitive imaging for radiologists and referring providers in many specialties. That collaborative’s leaders are looking to leverage big data to improve clinical decision support for radiologists and for referring physicians. Other initiatives are aiming at bringing machine learning-based tools into radiological practice in earnest. And the implications of all such initiatives are major, in terms of how radiologists will work in the future.

All of these changes in U.S. healthcare are fundamentally changing the landscape of radiology practice and of imaging informatics, at a time of both innovation and uncertainty for radiologists, always historically among the most technology-embracing of medical specialists.

What Do Industry Leaders Think Will Happen Next?

Rasu Shrestha, M.D., the chief innovation officer at the 20-plus-hospital UPMC health system in Pittsburgh, and a practicing radiologist, says that the release of the MACRA final rule will be excellent for radiology and for radiologists, particularly as it replaces some of the quality-focused measures under the meaningful use program under the HITECH (Health Information Technology for Economic and Clinical Health) Act with a new set of measures that he believes will more accurately measure radiologists’ and other physicians’ contributions to the quality of care delivery. “MACRA really is about moving to a continuum of scoring versus an all-or-nothing system, as Farzad [Farzad Mostashari, M.D., the former National Coordinator for Health IT] said [recently], and I think that’s spot-on. Meaningful use has been about looking at quantity—the numerator-denominator game we’ve been playing. Now we’re actually looking at quality, so there’s a movement and a validation, and a push, for us to actually get to value. I think this is actually awesome for radiology and radiologists,” Shrestha adds. “This basically substantiates a lot of the discussion that radiology has been leading in the last couple of years, moving from volume-based to value-based imaging.” In fact, he says, “I think radiology has also been the bellwether for healthcare on this.”

Rasu Shrestha, M.D.

That doesn’t mean that the shift into value will be easy for radiologists; quite contrary, says Ezequiel Silva, M.D., a practicing interventional radiologist at the 71-radiologist South Texas Radiology Group in San Antonio, and, since April, the chairman of the Commission on Economics of the American College of Radiology (ACR). “The challenge we’re seeing with new payment models and paradigms is that the shift towards them is happening very quickly and evolving very quickly,” says Silva, who has been in clinical practice since 2001. “Most of us who have been practicing for 10 or more years have gotten used to the fee-for-service system, and we’ve been fully comfortable with those kinds of mechanisms. So now with the ACA and in particular with MACRA, we’re seeing more of a focus not just on quantity of CPT codes, but on quality and value within that.”

Ezequiel Silva, M.D.

Silva concedes that, “On one level, you want to say, well, we should always have been focused on quality. But most of the mechanisms around quality were based on giving bonuses, and then later on, based on minor little penalties around quality. But now, we’re seeing a wholesale shift towards value. And from an informatics perspective, we’re seeing more and more of a drive towards using information technology. And we’re even seeing the use of IT being a piece of new payment mechanisms. The challenge that practices are facing is that they don’t really have a playbook yet for doing what’s needed,” he adds. “And the regulations are evolving so quickly that it’s really hard to move forward and do what is being asked.”

Can Radiologists Play a Role in the New Population Health-Driven Healthcare System?

Indeed, Eliot Siegel, M.D., the chief of imaging for the VA Maryland Healthcare System, and vice chair of research information systems for the University of Maryland Department of Diagnostic Radiology and Nuclear Medicine, believes that radiologists can play a significant role in the emerging universe of population health management. “I really believe that finding some carotid plaques way earlier before you develop carotid stenosis then have to intervene with a stent, being able to find patients who are at-risk of coronary artery disease by looking at calcium scoring way earlier, that’s a way to save money,” Siegel says. “If we have a certain amount of money, we have patient populations to track, I believe if we use detection early on and end up intervening, imaging would actually result in saving some dollars. I think in 10, 15, 20 years, maybe five years from now, the emphasis is going to be on spending a lot of money to keep healthy people healthy for a longer period of time.”

Of course, that’s partly where the advance of information technology, and the adoption of new tools on the part of radiologists, especially clinical decision support (CDS) tools, will be so important. Asked what he thinks CIOs need to know about the current landscape around radiology practice, Siegel says, “I’d like to work with CIOs to figure out how we can extract information from the radiology images and reports. I’d like CIOs to know that radiology is becoming increasingly structured, and so there will be data that they can start to make machine intelligible and in their algorithms, when a patient gets submitted to a hospital with a stroke, you can use algorithms. There is data in radiology that they can discover; it’s not just dark matter, it doesn’t exist to answer just one question. There is a wealth of information, and that data, pixel data, should be thought of a great source of information in EHRs. And yet,” he says, “In the same way that EHRs currently don’t support the use of genomic information, we have to struggle to figure out how to do that, the same is true for radiology: we’ve got a lot of interesting, complex information, and it’ll be great to work with them to figure out how we make that information discoverable, actionable.”

At UPMC, Peering Into a New World of Machine Learning-Driven Medicine

At UPMC, Shrestha and his colleagues are already on the case. “As chair of the RSNA Scientific Program Committee for Informatics, I have insights into all the scientific papers and presentations that are submitted,” Shrestha says, referring to the Oakbrook Terrace-based Radiological Society of North America. “And one of the most important trends that’s emerging this year is specifically around machine learning; and the context here is leveraging pattern recognition.”

Explaining what the pioneers in that area are doing, Shrestha says, “Machine learning is all about looking at relationships that happen between Fact A and Fact B or Data Point A and Data Point B, and looking at patterns, and drawing conclusions. And what better place to really push with this notion, than in radiology? And that’s because you have so many different types of data elements in radiology. And you have capabilities to leverage machine learning to look at relationships between data and text—and imaging data as well. So progress is being made in leveraging machine learning in terms of correlating text-based data with meta data, and also in terms of looking at patterns around data itself. So we’re not just looking at images one image at a time—for example, prostate detection or lung cancer nodule detection, in CAD, or breast imaging detection—we’ve had that for the last ten years or so. But now with machine learning, we can look at countless images at once.”

The implications of these emerging capabilities are startling, Shrestha says. “What does it really mean for us to be able to mine through these immense amounts of data sets, and have machines learn patterns, so that it will then aid us in diagnosis and tell us, is this lesion increasing or decreasing? Is this a lesion we should consider, as an element in diagnosis? These are sort of the early stages of, say, Watson coming into radiology. I don’t think it means the radiologist will be displaced anytime soon,” he reflects. “But for sure, there is a role for machine learning and artificial intelligence in order to separate the signals and the noise; and also in terms of patient-related data and context around the specific pathology of the image; and last but not least, helping in the diagnostic process, based on not just one or two, but millions of similar images and studies.”

Changes in Technology are Changing the Business of Radiology

In that regard, how are changes in the business and technological landscapes impacting radiology practice? Joe Marion, principal at the Waukesha, Wis.-based Healthcare Integration Strategies, LLC consulting firm, says that a combination of technological, business, and payment trends is going to seriously upend radiological practice going forward. Not only are radiologists banding together to provide remote-read services all across the U.S.; those newer arrangements are changing the whole concept of proximity, as immediate geographical proximity is no longer a limiting factor for where and how radiologists practice. “I’m working with a group in New Hampshire,” Marion says, “where the radiology group serves five facilities in the area; but those radiologists recently hooked up with a group in Connecticut, and will be doing readings through that group in that state as well. Furthermore, people are realizing that they need backup capabilities, and want to own their own data.” So the whole concept of location is morphing now when it comes to the provision of radiological services nationwide, Marion says.

Joe Marion

“And,” he adds, “you’ve got hospitals signing up with other entities for larger integrated delivery networks. And the question is how you manage radiology services across all those facilities. So load-leveling, and managing services. We’ve got a major integrated health system here in southeast Wisconsin that recently created their own doc-in-the-box in the Brookfield area [west of Milwaukee], and all the main studies, except for interventional studies that have to be done on site, are done out of that doc-in-the-box in Brookfield.” All that activity is also being impacted by a move into the cloud on the part of radiology practices and multispecialty group practices, hospitals, and integrated health systems.

Meanwhile, he says, the growing universalization of VNA and other broader architectures will in turn change who delivers services and how those services are delivered, Marion says. “So, for example, a hospital is concerned about getting reports economically and smoothly. So if a vendor could provide such services, why not? I know that a major PACS vendor looked into this years ago, and it came down to a marketing issue—whether they might be perceived as competing with their customer—and that sort of put the kibosh on a lot of it. But the concept is there.”

Changing Radiologists’ Incentives

Meanwhile, the opportunities and challenges of federal and private-insurer reimbursement systems will both be significant in terms of radiologists in practice. “When you look at the quality buckets under the MACRA law, the practices that have the informatics tools in place to allow for reporting to qualified clinical data registries, will find themselves in a position to perform more successfully on quality,” says Silva. “And that involves two elements: first, you have to report satisfactorily enough to retain your payments. But second, you want to engage in benchmarking, to improve processes and outcomes. And it’s difficult to do that from a traditional claims-based standpoint. But if you’re improving radiation dose or predictive value around lung cancer screening or CT radiography, etc., then it becomes, how do you show your quality externally, to your hospital systems, to your patients, to larger payers? Because we’re talking about alternative payment models.”

UPMC’s Shrestha believes that this decisive shift towards quality will actually empower radiologists, many of whom have been stressing out over the increasing commoditization of radiology services in recent years. In many ways, until the automation and digitization of processes, images, and data, have only served to speed up processes for radiologists, not change them—or radiologists’ place in care delivery. “And what that has propagated is the reality of how radiology has become commoditized in the last few years,” he says. “The radiologist or radiology service who provides the quickest reads at a good price—that could be a guy in India or the Philippines, or wherever. But the next phase is about a focus on value—on these clinical quality metrics. We’re tying payment to outcomes, and using evidence-based medicine and tying that to quality of care. And in that context, we need more collaboration, not less, collaborating with the ordering physician, collaborating with the surgeon who’s going to operate on the patient the next day. So the radiologist becomes not just a service provider, but a consultant. That’s the evolution that is allowed by technology and payment changes.”

A Call for Technical Standards to Overcome Remaining Obstacles

Yet for all the talk of the future, healthcare IT leaders say that numerous obstacles remain in the present, and those are becoming more urgent as the new policy, regulatory and reimbursement changes sweep the industry. The simple fact of having to continue in many cases to rely on the use of CDs to transport diagnostic images rankles, says Kent Hoyos, vice president of information technology and CIO at the 437-bed Pomona Valley Hospital Medical Center, a freestanding community hospital located in the Los Angeles suburb of Pomona. “The sharing of images across images, via health information exchange or some kind of DropBox lite—it remains challenging to move images around, in many cases.”

Indeed, Hoyos says, “We were in a revenue cycle meeting, and we ended up talking about the process of care delivery around mammograms. We ended up having to change in our revenue cycle system the length of time it was acceptable for a bill to be paid, in cases in which a mammogram had been done outside the hospital, because the process” of acquiring the images and moving the billing process along around outside mammogram procedures “is still clumsy.” The reality, he says, is that “We need to have [technical] standards. That’s an easy answer but hard to actually do. We need standards that are transferable and that are collaborative in the truest sense. When you can have a diagnostic imaging procedure down the street at the imaging center, but we’re still relying on moving CDs around, that’s terrible.” What’s more, Hoyos says, he believes that health IT vendors are dragging their heels on achieving true, vendor-neutral interoperability, because “They’re protecting their revenue stream however they can, just as we are. You wouldn’t get an argument from anybody about what’s right for the patient. But it’s all about money, about protecting the revenue streams around our populations.” In his view, it will take federal government pressure in order to finally break the remaining logjams around the interoperability needed to birth a truly new era in imaging informatics across U.S. healthcare.

An “All-For-One Kind of Thing”

Certainly, healthcare IT leaders will need to be front and center in order to help radiologists—and everyone—optimally navigate the next several years in U.S. healthcare. “What we’re seeing a lot of at the physician level,” says Silva, “is that a lot of what MACRA drives is physician-driven payment metrics. Initially, what we’ll see physicians say” to CIOs and other healthcare IT leaders, “is, help us to score better on this metric by giving us information systems. And the IT people already have a lot on their plates. But by the next three years and certainly five years, you’ll see the need for physicians and hospitals to partner. So that’s an important message to communicate: that this is very quickly becoming a one-for-all kind of thing” for clinicians and everyone else in the patient care enterprise.

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CMS: 93% of Clinicians Get Positive Payment Adjustments for MIPS Year 1

November 8, 2018
by Rajiv Leventhal, Managing Editor
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Ninety-three percent of MIPS (Merit-based Incentive Payment System)-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment, according to a CMS (Centers for Medicare & Medicaid Services) announcement today.

The first year of MIPS under MACRA’s Quality Payment Program (QPP) was dubbed by CMS as a “pick your pace year,” which essentially enabled clinicians to avoid payment penalties as long as they submitted at least the minimum amount of quality data. As such, in its announcement, CMS did admit that the overall performance threshold for MIPS was established at a relatively low level of three points, and the availability of “pick your pace” provided participation flexibility through three reporting options for clinicians: “test”, partial year, or full-year reporting.

CMS said that 93 percent of MIPS-eligible clinicians received a positive payment adjustment for their performance in 2017, and 95 percent overall avoided a negative payment adjustment. CMS specifically calculated that approximately 1.06 million MIPS-eligible clinicians in total will receive a MIPS payment adjustment, either positive, neutral, or negative. The payment adjustments for the 2017 program year get reflected in 2019.

Breaking down the 93 percent of participants that received a positive payment adjustment last year, 71 percent earned a positive payment adjustment and an adjustment for exceptional performance, while 22 percent earned a positive payment adjustment only. Meanwhile, just 5 percent of MIPS-eligible clinicians received a negative payment adjustment, and 2 percent received a neutral adjustment (no increase or decrease).

Of the total population, just over one million MIPS-eligible clinicians reported data as either an individual, as a part of a group, or through an Alternative Payment Model (APM), and received a neutral payment adjustment or better. Additionally, under the Advanced APM track, just more than 99,000 eligible clinicians earned Qualifying APM Participant (QP) status, according to the CMS data.

CMS Administrator Seema Verma noted on the first pick-your-pace year of the QPP, “This measured approach allowed more clinicians to successfully participate, which led to many clinicians exceeding the performance threshold and a wider distribution of positive payment adjustments. We expect that the gradual increases in the performance thresholds in future program years will create an evolving distribution of payment adjustments for high performing clinicians who continue to invest in improving quality and outcomes for beneficiaries.”

For 2018, the second year of the QPP, CMS raised the stakes for those participating clinicians. And in the third year of the program, set to start in January 2019, a final rule was just published with year three requirements. Undoubtedly, as time passes, eligible clinicians will be asked for greater participation at higher levels. At the same time, CMS continues to exempt certain clinicians who don’t meet a low-volume Medicare threshold.

Earlier this year, CMS said that 91 percent of all MIPS-eligible clinicians participated in the first year of the QPP, exceeding the agency’s internal goal.

What’s more, from a scoring perspective in 2017, the overall national mean score for MIPS-eligible clinicians was 74.01 points, and the national median was 88.97 points, on a 0 to 100 scale. Further breaking down the mean and median:

  • Clinicians participating in MIPS as individuals or groups (and not through an APM) received a mean score of 65.71 points and a median score of 83.04 points
  • Clinicians participating in MIPS through an APM received a mean score of 87.64 points and a median score of 91.67 points

Additionally, clinicians in small and rural practices who were not in APMs and who chose to participate in MIPS also performed well, CMS noted. On average, MIPS eligible clinicians in rural practices earned a mean score of 63.08 points, while clinicians in small practices received a mean score of 43.46 points.

Said Verma, “While we understand that challenges remain for clinicians in small practices, these results suggest that these clinicians and those in rural practices can successfully participate in the program. With these mean scores, clinicians in small and rural practices would still receive a neutral or positive payment adjustment for the 2017, 2018, and 2019 performance years due to the relatively modest performance thresholds that we have established. We will also continue to directly support these clinicians now and in future years of the program.”

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HHS Secretary Azar: HHS Is Planning New Mandatory Bundled Payment Models

November 8, 2018
by Heather Landi, Associate Editor
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The Centers for Medicare & Medicaid Services (CMS) is revisiting mandatory bundled payment models, possibly for radiation oncology and cardiac care, according to Health and Human Services Secretary Alex Azar, which signals a strong about-face in the Trump Administration’s policy about bundled payment initiatives.

HHS is reexamining the role that mandatory bundled payment models can play in the transition to value-based care, Azar said in a keynote speech at the Patient-Centered Primary Care Collaborative Conference on Thursday. HHS published Azar’s comments.

In the published remarks, Azar said the Trump Administration is revisiting mandatory bundled payments and exploring new voluntary bundled payments as part of the Administration’s goal of paying for outcomes, rather than process.

“We need results, American patients need change, and when we need mandatory models to deliver it, mandatory models are going to see a comeback,” Azar said.

In his speech, Azar said, “Imagine a system where physicians and other providers only had to worry about the outcome, rather than worrying about their staffing ratios and the individual reimbursements for every procedure they do and every drug they prescribe. That kind of payment system would radically reorient power in our healthcare system—away from the federal government and back to those closest to the patient.”

He continued, “One way we can do that is through bundling payments, rather than paying for every individual service. This is an area where you have already seen testing from CMMI for several years now—and I want to let you know today that you are going to see a lot more such ideas in the future.”

Azar highlighted the Bundled Payments for Care Improvement (BPCI), which, he said, has shown significant savings in several common inpatient episodes, including joint replacement and pneumonia.

During his speech on Thursday, Azar said, “I want to share with all of you for the first time today: We intend to revisit some of the episodic cardiac models that we pulled back, and are actively exploring new and improved episode-based models in other areas, including radiation oncology. We’re also actively looking at ways to build on the lessons and successes of the Comprehensive Care for Joint Replacement model.

“We’re not going to stop there: We will use all avenues available to us—including mandatory and voluntary episode-based payment models,” he said.

One industry group, the American Society for Radiation Oncology (ASTRO), already has voiced concerns about a mandatory payment model. In a statement issued Thursday afternoon, Laura Thevenot, CEO of ASTRO, made it clear that the organizaiton strongly supports a radiation oncology alternative payment model (RO-APM). "ASTRO has worked for many years to craft a viable payment model that would stabilize payments, drive adherence to nationally-recognized clinical guidelines and improve patient care. ASTRO believes its proposed RO-APM will allow radiation oncologists to participate fully in the transition to value-based care that both improves cancer outcomes and reduces costs."

Thevenot said ASTRO has aggressively pursued adoption of this proposed model with the Center for Medicare and Medicaid Innovation (CMMI). However, Thevenot said the group has concerns "about the possibility of launching a model that requires mandatory participation from all radiation oncology practices at the outset."

Further, Thevenot said any radiation oncology payment model will represent "a significant departure from the status quo." "Care must be taken to protect access to treatments for all radiation oncology patients and not disadvantage certain types of practices, particularly given the very high fixed costs of running a radiation oncology clinic," Thevenot stated.

Back in January, CMS announced the launch of the voluntary BPCI Advanced model, noting that it “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value.” The BPCI Advanced model includes more than 1,000 participants that are receiving episode-based payments for over 30 clinical areas, Azar said.

“BPCI Advanced is a voluntary model, where potential participants can select whether they want to join. But we’re not going to stick to voluntary models. Real experimentation with episodic bundles requires a willingness to try mandatory models. We know they are the most effective way to know whether these bundles can successfully save money and improve quality,” Azar said.

The Obama Administration introduced mandatory bundled payment for care for heart attacks and for cardiac bypass surgery in July 2016.

In the past, CMS Administrator Seema Verma has said that she does not support making bundled payments mandatory, and former HHS Secretary Tom Price, M.D. had strongly opposed mandatory bundles, going so far as to direct the end of two mandatory bundled payment programs—one existing and one previously announced. In November 2017, CMS finalized a rule, proposed in August 2017, that cancelled mandatory hip fracture and cardiac bundled payment models.

As per that final rule, CMS also scaled back the Comprehensive Care for Joint Replacement Model (CJR), specifically reducing the number of mandatory geographic areas participating in CJR from 67 areas to 34 areas. And, in an effort to address the unique needs of rural providers, the federal agency also made participation voluntary for all low-volume and rural hospitals participating in the model in all 67 geographic areas.

On Thursday, Azar acknowledged that his statements signaled HHS was reversing course on its previous stance, noting that last year the administration reduced the size of the CJR model and pulled back the other episode payment models, including those on cardiac care, before they could launch.

Azar, who was confirmed as HHS Secretary earlier this year, signaled early on that he diverged from Verma and Price on his views about mandatory bundled payments. During a Senate Finance Committee hearing in January on his nomination for HHS Secretary, he said, on the topic of CMMI [the Center for Medicare and Medicaid Innovation] pilot programs, “I believe that we need to be able to test hypotheses, and if we have to test a hypothesis, I want to be a reliable partner, I want to be collaborative in doing this, I want to be transparent, and follow appropriate procedures; but if to test a hypothesis there around changing our healthcare system, it needs to be mandatory there as opposed to voluntary, then so be it.”

During his speech Thursday, Azar pointed to the Administration’s first mandatory model, which was unveiled two weeks ago, called the International Pricing Index (IPI) Model for payments for Part B drugs. Azar said the model is a “mandatory model that will help address the inequity between what the U.S. and other countries pay for many costly drugs.”

Further, Azar said CMMI also will launch new primary care payment models before the end of the year, with the aim of introducing a spectrum of risk for primary care providers, Azar said.

“Before the end of this year, you will see new payment models coming forth from CMMI that will give primary care physicians more flexibility in how they care for their patients, while offering them significant rewards for successfully keeping them healthy and out of the hospital,” he said.

“Different sizes and types of practices can take on different levels of risk. As many of you know, even smaller practices want to be, and can be, compensated based on their patients’ outcomes,” he said. “We want to incentivize that, with a spectrum of flexibility, too: The more risk you are willing to take on, the less we’re going to micromanage your work.”

Azar also noted HHS’ efforts to examine impediments to care coordination, such as examining the Stark Law, the Anti-Kickback Statute, HIPAA, and 42 CFR Part 2. CMS has already launched and concluded a request for information on the Stark Law, and the Office of the Inspector General has done the same on the Anti-Kickback Statute, he noted.

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Dr. Sanjay Gupta’s Heartening Speech at CHIME18 Should Inspire U.S. Healthcare Leaders

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The story of an Amazonian tribe could serve as a motivational lesson for U.S. healthcare stakeholders

It was inspiring to hear Sanjay Gupta, M.D., the well-known neurosurgeon and medical reporter, give the closing keynote at the College of Healthcare Information Management Executives (CHIME) 2018 Fall CIO Forum in San Diego last week. Dr. Gupta, who serves as associate chief of the neurosurgery service at Grady Memorial Hospital in Atlanta, while also best known as CNN's multiple Emmy Award-winning chief medical correspondent, discussed the fascinating balance that he strikes between medicine and media.

“Oftentimes, I see people at their best, and sometimes at their worst. I get to travel the world, where I learn so much, but also teach others. Sometimes the dance between medicine and media can be awkward and emotionally challenging. But almost always, the stories we do have a significant impact,” Gupta told the Fall CIO Forum attendees.

What was perhaps most captivating about Gupta’s speech was when he spoke about visiting a primitive Amazonian tribe that appears to have the best heart health in the world. The Tsimane people of Bolivia do not speak a language, live a simple existence, and are disease-free, explained Gupta. So he went to visit the tribe with the goal to understand its lifestyle and what led to its members having such healthy hearts.  

Sanjay Gupta, M.D.

“I went spearfishing with one [tribe member], who thought he was 84-years-old, but he really didn’t know for sure. His shirt was off, and he was ripped, balancing himself on the canoe, just looking at the water, spearing fish. His eyesight was perfect. The entire indigenous tribe was just like this,” Gupta recalled.

After examining the Tsimane tribe’s diet, Gupta noted it was a hunter-gatherer society, meaning there was nothing technological. “The most mechanical thing I saw was a pulley for the well,” he said. Seventy percent of what they eat is carbohydrates—unrefined and unprocessed—while 15 percent of their diet is protein, and 15 percent fat, he added. “You need farmed food because oftentimes you don’t have successful hunting days, so the farmed food was the food in the bank. And they would do intermitting fasting, too. These are the people with the healthiest hearts in the world,” Gupta exclaimed.

When it comes to activity, when hunters are hunting, they’re never outrunning their prey, but rather outlasting it, noted Gupta. “We found that they walked about 17,000 steps per day. But they didn’t run; they only walked. They are active, but not intensively active. They also hardly every sit—they are either lying or standing all the time. And they would get nine hours of sleep per night, waking up to the rooster’s crow. There are no devices. Again, these are the people who have the healthiest hearts in world. They don’t have a healthcare system and don’t spend a dollar on healthcare,” Gupta stated.

What’s even more interesting about this tribe is that each of its members lives with some degree of a parasitic infection, which they usually get it early in life, have a few days of illness, and then just live with these parasites in their bodies for their entire lives. “The belief is that so much of the disease we talk about—that leads to this $3.3 trillion price tag [the total cost of U.S. healthcare spending in 2016]—is actually ignited or worsened by our immune systems. So the parasitic infections could be part of the reason they are protected from all types of diseases,” Gupta offered.

Essentially, it’s living this basic, undeveloped life that “inadvertently provides them extraordinary protection against heart disease,” noted a report in HealthDay last year. “Thanks to their unique lifestyle, most Tsimane [members] have arteries unclogged by the cholesterol plaques that drastically increase the risk of heart attack and stroke in modern Americans,” Gregory Thomas, M.D., medical director of the Memorial Care Heart & Vascular Institute at Long Beach Memorial, in California, said in that report.

Tsimane tribe (source: University of New Mexico)

You might be asking what the story of the Tsimane tribe has to do with U.S. healthcare since its lifestyle would obviously never be replicated in a developed country. And while that is true, it’s tough to ignore the $1 billion per day that our healthcare system spends on heart disease—compared to the Tsimane tribe that doesn’t spend a single dime, yet has the healthiest hearts in the world.

In this sense, perhaps we can use the Tsimane story to push ourselves to develop a greater understanding of why we spend so much money on healthcare and don’t have the results to show for it. Gupta asked this $3.3 trillion-dollar question in his speech—why does healthcare in the U.S. cost so much and what do we get in return?

“If you look at the statistics, it’s not impressive. More people die from preventable disease in the U.S. than in 12 other nations. People live longer in 30 other countries compared to the U.S.—including places like Chile and Costa Rica. We still have tens of millions of people who don’t have access, and we still spend all this money on healthcare. Why?” he asked.

Gupta explained that the nation’s high healthcare costs come down to the following: high administrative costs, technology, new drugs and development, and the cost of chronic disease—the last which is incredibly self-inflicted. About 70 to 80 percent of chronic disease is self-preventable, he said.

Indeed, as most of us know, about 5 percent of the U.S. population accounts for 50 percent of the healthcare costs. These are folks who are defined by illness, not by health, Gupta stated. This is why the modern-day healthcare system has proactively taken to targeting that 5 percent to improve their chances of preventing disease and staying healthy. “Data shows that home visits, nutritional counseling, one-on-one coaching, and diligent follow-up care can go a long way in preventing someone from getting sick in the first place, and from turning a disease into something more chronic. Some of these interventions can actually reverse disease. The die is not cast,” Gupta said.

For me, Gupta’s keynote highlighted the need for efforts around value-based care, care management, and population health to be intensified. A big part of that, as noted in the speech, is addressing patients’ social and environmental factors. It’s not at all surprising to see studies such as this one from earlier this year, conducted by researchers at the University of South Florida (USF) College of Public Health, Tampa, and WellCare Health Plans, and published in Population Health Management, which found that healthcare spending is substantially reduced when people are successfully connected to social services that address social barriers, or social determinants of health, such as secure housing, medical transportation, healthy food programs, and utility and financial assistance.

And with that, there is also an enormous opportunity for data and IT to play a role. Information sharing, so that providers have access to the right information at the point of care—no matter where the patient is—will be critical to reducing unnecessary costs. As will the robust use of data analytics, so that patient care organizations can be proactive in predicting which patients are at highest risk, when they might need services, and how to intervene at the appropriate time.

But to this point, Gupta, who noted that our society can get too caught up in high-tech, also suggested that “medicine seems to play by slightly different rules when it comes to innovation as opposed to other sectors. Sometimes, innovation moves painstakingly slow in respect to medicine.” At the end of the day, he said, it will be “the innovations that make us, [as a society], healthier, happier, and connect us in frictionless ways, that will be the biggest winners.”

So, will the U.S. population suddenly turn off their iPhone alarms, wake up to the rooster’s crow, and become a hunter-gatherer society? No, I would say that’s quite unlikely to happen. But hearing stories such as the one of the Tsimane tribe might just serve as good enough motivation to bring down the astronomical and unsustainable costs of U.S. healthcare.

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