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Diving Into the Deep End of the Pool: A Look at Physician Groups and Risk

September 14, 2016
by Mark Hagland
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As physician group leaders move into risk-based contracting, the ability to capably leverage data and IS will be crucial to success

Just as with everything else in U.S. healthcare, the path forward towards mastering risk-based contracts is one filled with challenge and complexity for the leaders of physician groups. But industry pioneers aren’t letting themselves be daunted by the challenges involved; they’re plunging ahead to create the future for themselves, their patients, and their communities.

That is certainly true for the 650 providers (500 of them physicians) at the Summit Medical Group, based in the northeast New Jersey community of Berkeley Heights, and with 36 care locations across northeastern New Jersey. Summit Medical Group’s leaders have spent years putting into place the strategic, operational, clinical, and IT foundations to take on risk on a major scale, and they’re ready for the future. They’ve also grown tremendously through expansion. “In 1989, when I came, we had 45 doctors,” notes Jeffrey LeBenger, M.D., the group’s chairman and CEO. LeBenger, a head and neck surgeon, who assumed the group’s top executive role in 2000, has aggressively moved to grow the group numerically (there were about 70 doctors in the group when he assumed its chairmanship), and to expand its presence across its service area.

How were the Summit Medical Group physicians able to find their way forward into successful risk-based contracting in a rapidly changing environment? “What happened is that we knew for us to grow, we had to be in the network of the largest insurer in the state, Horizon Blue Cross Blue Shield New Jersey,” LeBenger says. “So I started to manage with my CFO the negotiations” with Horizon BCBS, and “we were able to construct the first shared-savings product, with upside and downside risk,” with that health insurer. “That was about four years ago. And then once I knew that we had gotten Horizon, with 3.8 million beneficiaries in the state, we were able to grow our model,” as well as grow the medical group’s physician staff. There was no small investment involved, he underscores: “We spent millions developing our care management program, with hospitalists and with extensivists. And now we have four high-acuity urgent care centers. That’s the model. With chest pain, belly pain, our patients go there. And our admission rate is only 2-3 percent from our urgent care centers, whereas at the average hospital, they’re admitting over 20 percent of those patients.”

There are layers of details, but among the keys for Summit Medical Group’s success so far, LeBenger notes, are compensating the group’s hospitalists based on quality metrics rather than “per-click” patient rounding, leading to a 30-day readmission rate for Medicare below 8 percent (when New Jersey’s statewide rate is 18 percent), and the close care management of all patients through their transitions of care, through the group’s care management department, with all patients leaving the hospital seen by a nurse practitioner within the next day after discharge. “So with that, we’ve found that our PMPM [per member per month] cost” for patients in its risk-based plans “is $60, whereas the benchmark in New Jersey is over $110.”

Meanwhile, IT infrastructure has been absolutely essential to Summit Medical Group’s success in risk-based contracts, LeBenger says, but he emphasizes that “Infrastructure does not drive medical care. You have to have the physician buy-in and the program that manages patient care, and your infrastructure has to support the care, but not drive it.” And, finally, he says this about why physician group leaders can in some cases achieve what hospital and health system leaders struggle to achieve: “Often, when hospitals manage medical groups, the problem is that they use the wrong paradigm. Our paradigm is to take everything to the ambulatory sector, and do what’s right for the patient on the ambulatory side.”

Shifting paradigms create a complex landscape

At a time of shifting paradigms across the U.S. healthcare system, the leaders of physician groups are finding themselves working to build foundations for the future in a dramatically changing policy and operating environment. With the internal healthcare system reforms emerging out of the Affordable Care Act (ACA) ramping up now every year (around such areas as avoidable readmissions, value-based purchasing, and healthcare-acquired conditions), and with newer mandates emerging (including those around mandated bundled payments to providers in many healthcare markets for total joint replacement and now cardiac care), as well as an entirely new set of requirements emerging out of the MACRA (Medicare Access and CHIP Reauthorization Act of 2015), including the new MIPS (Merit-based Incentive Payment System), the leaders of pioneering medical groups are breaking new ground, even as others are struggling just to keep up with developments in the news.

In fact, the medical group world’s pioneers have been busy moving forward into uncharted territory, says Don Crane, president and CEO of CAPG—“the voice of accountable physician groups”—a national association of medical groups involved in accountable care organization (ACO) development and other risk-based contracts. “Among the key learnings,” Crane says, “is that taking on higher levels of risk and moving to professional and not just institutional risk, is being seen as a good thing,” among the leaders of the most innovative medical groups in the U.S. “Doing so improves the quality of care, results in higher quality scores, and higher bonuses. And so moving up in risk is something that has grown in the CAPG membership.

On the flip side, one of the biggest challenges for the pioneers in accountable care, Crane says, is the unhappy realization that “Open networks really are a bear to work with, because the leakage is very high” among patients/plan members attributed to specific ACOs. “All of our groups have done what they can to create stickiness and patient engagement and such,” he adds, “but it’s difficult to do that against a backdrop that allows people to migrate everywhere.”

Meanwhile, Crane says, “Data and IT are of paramount importance. This movement from volume to value requires multiple competencies, all indispensable. One of them is IT: you just don’t take responsibility for a population and deliver care across the continuum without IT. You need a record with memory. And,” he continues, “interoperable IT becomes critically important, because of the need to measure and manage data. How do you do well in pay-for-performance, which is pretty much baked into all the programs?” excellent information systems and data analytics are essential “for those trying to deliver the Triple Aim,” the triple set of goals for improved patient experience, improved health status of populations, and reduction in the cost of care, that has been promoted for years by the Cambridge, Mass.-based Institute for Healthcare Improvement (IHI).

At the Alexandria, Va.-based American Medical Group Association (AMGA), John Cuddeback, M.D., the association’s chief medical informatics officer, says that “The biggest challenge is simply that you have to work under multiple financial models, because different payers are at different stages. Meanwhile, the recognition that analytics is a really important tool in pop health management, has been given a lot of attention, and caused people to be willing to actually invest in analytics, because they know they’ll need it.”

Further, Cuddeback says, “A lot of organizations understood the idea of an electronic health record and the benefits of having all the data in one place, and yet still hadn’t realized everything you can do… Figured out which patients out of all my patients with CHF or COPD are the ones you can focus on. Because you have to switch now from a reactive to a proactive model of care. So first is, we’ve got this data, let’s invest in analytics. And once you’ve done that, you still have to redesign the process of care, to take advantage of the analytics.”

Senior executives at medical groups agree that, once one gets “into the weeds” of developing the IT infrastructure for risk-based contracts, as well as establishing good It and data governance processes, things inevitably become complicated. In that regard, says Krishna Ramachandran, chief administrative officer of the DuPage Medical Group, a 560-doctor multispecialty physician group with 70 care locations, based in the Chicago suburb of Downers Grove, “I'd say that our biggest challenges and opportunities have been in creating the infrastructure and building the team (data scientists and developers collaborating with physicians and clinicians) needed to ingest and interpret the messy, new world of healthcare claims data. They have been a necessary part of creating actionable insights from the data.”

In that regard, Ramachandran says, it is absolutely essential go get physician buy-in around the sharing of data for clinical performance improvement at the individual and group levels. Fortunately, he says, “We’ve had an early start on this with the adoption of our unblinded dashboards starting 2010,” he adds. “It has certainly been a journey, but our physicians have enthusiastically embraced data and dashboards, and they are now an integral part of our culture. We continue to refine the data in new world of claims so that we can deliver more insights on a physician level as well.”

Building a new culture at UPMC

At the vast UPMC health system based in Pittsburgh, change—including the physician culture change needed for success in taking on risk—has been in the air for a long time. Just ask Francis X. (Fran) Solano, M.D., an internal medicine physician who is president of Community Medicine, Inc., the largest group (330) of employed primary care physicians within the UPMC system, and vice president of the Physician Services Division at the health system. While taking on potential downside risk has been years in the making—Dr. Solano is currently working to develop a risk-based contract between Community Medicine, Inc. and the UPMC Health Plan—he has spent 15 years helping to lead a quiet, data-facilitated revolution around improvements in care quality and utilization management.

At the core of that effort has been the program Template for Change, which has laid a firm foundation for the taking on of financial risk in contracting, even as Template for Change has focused on initial shared-savings goals between and among the medical group constellation, the hospital system, and the health plan. The program, which has been applied to medical care delivery across all insurance lines (Medicare, commercial, Medicaid), has been implemented across the 330 primary care physicians in the Community Medicine constellation of groups, as well as 30 PCPs at Renaissance Family Practice based at St. Margaret’s Hospital, and 60 internal medicine physicians in a third group. The focus, Solano says, has been on providing monthly performance metrics to every physician in the program, at the individual, practice, and specialty level, for the following core statistics: inpatient admissions per 1,000, inpatient days per 1,000, ED visits per 1,000, primary care visits per 1,000, specialty visits per 1,000, diagnostic imaging rates per 1,000, and medical expense ratio. The physicians in the program have also been receiving data on their “HEDIS gaps”—gaps in care conveyed by HEDIS (Health Effectiveness Data and Information Set) data. Solano himself and his team look at a monthly 400-page printout of data, but, he notes, he learned early on that sending out massive amounts of raw data to the physicians in practices only led to mass confusion and frustration. T

he key has been that providing the doctors with these data points has helped them find “the patients who are high utilizers but are not yet in care management.” He says he jokingly refers to some of those patients as “our Seagram’s 7&7, because these are the people with seven diagnoses, who are on seven medications, and are seeing seven specialists”—and they are some of the key patients who need to be identified and care-managed. More seriously, he notes that the monthly sharing of clinical performance data, along with coaching sessions for physicians who are struggling, has made a huge difference. Still, “The biggest contribution” to physician behavioral change has been the average $20,000 in physician compensation that has been tied to individual physician performance on the various metrics being measured. Also very big has been the fact that the shared-savings program has involved sharing savings with the hospital system, an important factor, given that intended reductions in inpatient admissions and ED visits inevitably will affect the hospitals’ bottom lines.

“Sharing savings between the physicians and hospitals helps align the hospitals with us, because the hospitals take the biggest hit when you reduce admissions and readmissions,” Solano offers. “So when you break down the silos by sharing money across the continuum, that helps. And now the passage of the MACRA law has everyone aware of where this is going. They had never had cost data until recently, and charge-based data is very hard for physicians to understand. But with actual cost data from our health plan, doctors can use that, and they will start looking at the cost differential between a hospital-based colonoscopy and an ambulatory surgery center-based one, for example. And they are starting to pay attention to which specialists are over-utilizers, in terms of whom they refer their patients to.”

They key breakthrough, as UPMC’s physicians move towards taking on dual-sided risk, Solano says, is the need to push ahead into true outcomes measures. “Right now, when you look at quality, we’ve been using lots of process measures, particularly at the primary care level. We don’t have a lot of true outcomes measures yet, but I’m having our analytics team start to give me data across populations around such factors as the morbidity and mortality around atrial fibrillation. For example, when we recently looked at people who got anti-coagulation versus those who didn’t, we found that those who didn’t get anti-coagulation experienced a three-times higher rate of mortality. There might have been a number of reasons for this, but we want to explore why. And,” he adds, “we have 55,000 diabetics right now, and 30 percent of them are driving the costs, and the rest of them have minimal costs. Can you develop an algorithm to try to change that? Are there blood pressure medications they’re not getting? Or are they just very old and in very poor health? And the beauty of having an insurance company, is that I can get health plan cost/claims data and line it up with our clinical data in the EHR.”

Getting a health system to think like a physician group

Coming at all this from a different perspective are the leaders of Mosaic Life Care, an integrated health system based in St. Joseph, Mo. Though Mosaic Life Care is anchored by a 352-bed community hospital, its leaders have determined strongly that they are forging ahead into the risk-based world both enthusiastically and without the shackles of thinking like hospital administrators who fill beds—so much so that their organization’s foray into the competitive Kansas City healthcare market is purposefully purely on the outpatient side, says Linda Bahrke, R.N., the health system’s population health administrator. Importantly, Bahrke says, she and her fellow senior executives at Mosaic are fully committed to taking on more risk over time; they welcome it. Right now, Mosaic is in year three of its participation in the Medicare Shared Savings Program (MSSP) for ACOs. It has been in Track 2 of the program, involving downside risk (60/40 split), but has applied to move into Track 3 of the program for next year, involving greater downside risk (75/25 split).

Mosaic’s ACO has been doing well, Bahrke says: the ACO received $5.013 million in shared savings from the Medicare program after year one, and $2.065 million after year two; but they missed the mark in year three, as the performance benchmarks have continued to ramp up in rigor. Still, she notes, the ACO’s overall quality score is running at 96.11, which puts it near the very top nationwide in the MSSP program overall.

“The most important thing that you need after simply establishing a care management program” to thrive in a risk-based environment, Bahrke says, “is to create an IT system that puts the data in the physicians’ and other clinicians’ hands real-time, that helps them transform their thinking from acute care to a more longitudinal approach. One of the first things we did was to update our EMR to flag that a patient is in the program, and also to identify their level of risk; and to then provide real-time information about some of the care that they have or are receiving. How many times have they been in the ER in the last six months? How many medications are they on, and have they filled all their prescriptions? And in terms of standards of care testing, if they have diabetes, have they gotten their hemoglobin a1c test recently? Typically, in the acute-care setting, the physician addresses the acute need. In our model, the physician has all that information, and so that we can address things upstream, more proactively, with a more longitudinal mindset.”

And, in terms of the thinking behind such work, Bahrke says it’s important to let go of thinking like a hospital-based organization that needs to fill beds. “We are a health system that’s reinventing ourselves,” she says. For instance, we entered the Kansas City market with only physician and outpatient services; we have no intention of offering inpatient services there; that market is already saturated.”

CIOs and CMIOs need to be transparent in data-sharing

All those interviewed for this article agree that CIOs and CMIOs will be key players in helping to move their organizations forward into the value-based, risk-based world. Asked what he would tell CIOs and CMIOs, UPMC’s Solano says, “I would tell them that you need to share data, you need to be transparent. We started giving transparency data six years ago to our doctors, where we publish by doctor and practice and performance, we rank each practice by size and by doctors’ individual performance. That was a bold step. Obviously, people don’t like to be #500 or so. When you’re at the bottom, you’re not really happy, but it does drive change.” But, he reemphasizes, sharing reams of raw data is not helpful. The data shared has to be small in its number of data points, meaningful, and actionable to physicians in practice.

Meanwhile, CAPG’s Crane says he believes that the full implementation of the MIPS program and all the requirements under the MACRA law, will be “transformative in terms of Medicare,” pushing all Medicare-participating physicians in the U.S. away from traditional fee-for-service payment. “We know that the vast majority of physicians will be in MIPS, and that will require them to manage and marshal data for pay for performance in ways they may never have in the past,” he says, noting that even those physician groups not yet taking on risk-based contracts per se are going to need to approach data in a whole new way. In that sense, he says, “Getting ready for MACRA is the biggest thing that CIOs, CMIOs, CEOs, and CMOs need to do”—and plunging ahead into risk-based contracting itself will require a gigantic, strategic leap into the future.


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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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