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LIVE from HIMSS17: Healthcare Organizations Should “Swim to Risk” When Moving into APMs

February 19, 2017
by Heather Landi
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In a rapidly changing healthcare landscape, payers are asking providers to shift from volume-based care, or fee-for-service, to a value-based reimbursement model and, faced with the challenge of improving care quality but lowering cost, many healthcare organization are considering implementing an alternative payment model or developing an action plan to do so. Yet, the move from fee-for-service to value-based payment models significantly impacts business operations.

During a pre-conference session at HIMSS17 Sunday as part of the Business of Healthcare and New Payment Models track, industry stakeholders representing three distinct segments—a prominent health system, a large physician provider group and a solo practitioner physician group—shared their insights about implementing alternative payment models (APMS) and risk-sharing in a value-based world. The panelists discussed the impact of changing payment models on their organization’s business operations and the strategies they are employing in response to these challenges.

The recommendation of all three panelists for organizations considering alternative payment models was to “go slow” as they detailed the operational and data governance challenges they have encountered in their practice transformation journeys.

Mark Martin, president, Florida Hospital Physician Network and vice president of development, Florida Division of Adventist Health System, said, “We use the term “swim to risk”—don’t just jump in, you’ve got to build the infrastructure and build a process to make sure you’re able to manage it.”

Adventist Health System, which operates 43 hospitals in nine states with 80,000 employees and serves just short of 5 million patients annually, is involved in a number of APMs, according to Martin. He said, “When we talk about alternative payment model methodologies or arrangements, it is risk, by definition; it’s a changing payment methodology, but somebody is getting risk shifted to it. Start with looking at shared savings opportunities, as opposed to shared risk or full risk.” He continued, “As a hospital system, we’ve had full risk for every uninsured patient, we have full risk for them, so we built care management around our community care effort. By looking at the uninsured and “frequent flyers” in the ED, it’s a great opportunity to build infrastructure and show value to the community and to the hospital from an economic perspective.”

The health system’s bundled payment initiatives include participation in the Bundled Payments for Care Improvement (BPCI) initiative and, additionally, 16 Adventist Health System hospitals are in the designated regions and will be participating in the Comprehensive Care for Joint Replacement (CJR) program. The Centers for Medicare & Medicaid Services (CMS) selected 67 U.S. geographic regions for the five-year pilot CJR program. Beginning last April, nearly 800 hospitals nationwide must participate in the CJR program, the first U.S. mandatory shared-risk, outcomes-based payment model, and the first initiative to make hospitals financially responsible for patient care, including recovery.

Further, Adventist Health participates in the Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) program in the North Carolina market, the Comprehensive Primary Care Plus program, a national advanced primary care medical home model, in the Kansas marketplace and, in central Florida, some Adventist Health hospitals participate in the Medicare Advantage program. Florida Hospital also developed a clinically integrated network (CIN), which is a partnership between Florida Hospital and its employed and independent physicians. In January 2016, the health system entered into a shared risk arrangement managing 20,000 lives.

“We are in our infancy in many, if not most, areas, “Martin said. ‘As a faith-based organization, our mission fits to the part of looking at the chronically uninsured through our community care program. From a mission perspective, it’s a no brainer for us. We’ve seen wonderful results by partnering and focusing on care management for the indigent and the uninsured to reduce visits, reduce cost and improve health. It’s a good way of transitioning in this area of APMs,” Martin said.

Other members of the panel included Paul Casale, M.D., a cardiologist and executive director of NewYork Quality Care, the ACO of New York-Presbyterian, Weill Cornell Medicine and Columbia University College of Physicians and Surgeons, and Barbara McAneny, M.D., a medical oncologist/hematologist from Albuquerque, N.M. In 2012, McAneny received a $19.8 million award from the Centers for Medicare & Medicaid Innovation (CMMI) to test how oncology private practices could provide cancer patients better care at a lower cost. This award, called COME HOME (for Community Oncology Medical Home), later helped form Medicare's Oncology Care Model. McAneny formed Innovative Oncology Business Solutions Inc., a company now assisting physician practices in developing the process changes needed for The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). McAneny also is a member of the American Medical Association Board of Trustees.

McAneny described the practice transformation required to shift from fee-for-service to value-based payment and care as “changing the tires while you’re driving 65 miles an hour down the freeway.” As a physician in private practice, McAneny says she continues to see 25 to 30 patients a day. “The first challenge for your practice to transform is that you can’t stop doing the patient care while you’re doing the transformation. If you aren’t seeing patients, you are not generating income and there’s no money to do practice transformation,” she said.

According to McAneny, one critical key to practice transformation was creating clinical pathways for physicians and nurses and then implementing those pathways into a decision support tool.

During the session, the panelists discussed the operational challenges of entering alternative payment models as well as the challenges related to data governance and

Martin said Florida Hospital faced a challenge of having disparate data systems within its CIN as less than one-third of the physicians are employed physicians who utilize a common electronic health record (EHR). “That’s two-third of the physicians representing 130 different versions of EMRs and there’s a challenge of how to get that data to manage, coupled with some of the insurance companies and third-party administrators not willing to share data back with us so we could understand the wholeness of our population,” he said. To this end, Adventist Health invested resources in a population health services organization to build the infrastructure to manage these APMs methodologies, he said. “I think the ROI will be there as we build scale and investing in those resources up front is key to what, I believe, will be our success,” he said.

Martin stressed that it’s necessary for healthcare organizations to dedicate resources to alternative payment model initiatives. “It’s not part-time project, and it’s not the same skill set. It requires dedicated focus.”

Martin also cautioned that technology “is a tool not a panacea or a magic bullet.” “Technology enables you to identify patients,” he said, but successfully participating in alternative payment models also requires the right processes and people. He also noted that it’s vital to educate stakeholders throughout the process. “With stakeholders, such as physician sand office staff, you have to paint the picture and connect the dots to what you are looking to have measured and have managed and connect back to them why that’s good,” he said.

Discussing data issues and data quality, McAneny advised, “The best way to measure quality is to put a system on top [of your EHR]. The oncology best practices give you the ability to do pathway compliance and drill down to the individual patients to see whether they are compliant,” she said.

She also highlighted the need to have a technology tool that allows practices of all sizes to query their own data. “So, how do I solve problem x that is impacting my specialty, my practice… We need these other structures so we can transform healthcare into something where we can use these electronic tools to work more efficiently,” she said.

Casale says the work NewYork Quality Care has done with claims data has been very helpful for its ACO work. “It’s eye-opening for doctors to see all the places that patients go, so they understand the need to coordinate care. The claims data has been particularly helpful in engaging physicians around this population health and care coordination need,” he said.

He continued, “From a data perspective, marrying that claims data with pharmacy and lab and clinical data from the EMRs really is the magic sauce to be able to understand patient populations.”

When asked what recommendations on where healthcare organizations should start if looking to enter alternative payment models, McAneny said funding was a significant consideration. “It takes a fair amount of money to do transformation,” she said. “Find a payer who is interested in working with you. I’d like to see us switch to a franchise model. The National Cancer Care Alliance is 120 oncologists that banded together to purchase expensive data people and other functions to have the bandwidth to do what needs to be done. Have your franchise and your practice in your community that’s right-sized to fit you. How do you start transforming? You have to think it through, what works for the patients, to provide that infrastructure that’s needed and how are you going to fund it?”

Martin said, “When you look at funding any initiative like this treat it like a capital investment in a new market; you’re investing in infrastructure, in people, in developing care management programs and people associated with that with member experience.”

Healthcare organization leaders should also think about partnerships that already exist or that they can working on establishing, such as with post-acute care facilities, Casale said. “That’s going to be a critical factor in being successful. Go slow on risk. We are going very slow on risk. All the financial investment, you need to be prepared for the future; it is significant dollars to go into care management.”

Shared savings programs, either Medicare or commercial insurance plans, represent an opportunity to “go slow” on risk, Casale said. “Start with shared savings, upside only. It takes a while to change the culture and figure out bumps in the road.”

Martin added, “From risk standpoint, I wish we could swim slower, but change is happening very faster than you would expect. There’s a way to be smart about it.”

 

 


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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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