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At the World Health Care Congress, a Search for Transformational Triggers in U.S. Healthcare

May 1, 2017
by Mark Hagland
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On the opening morning of the World Health Care Congress, a look at incentives towards transformational change in U. S. healthcare

While industry leaders agree that transformational change needs to take place in U.S. healthcare, exactly which elements of the healthcare system need to be fixed and how they can be successfully fixed, were questions in high relief on Monday morning at the Marriott Wardman Park Hotel in Washington, D.C., as the annual World Health Care Congress kicked off with its opening keynote session, “Policy and Market Forces Impacting Health Care,” on Monday morning, May 1.

Ceci Connolly, president and CEO of the Washington, D.C.-based Alliance of Community Health Plans, led a very robust discussion of the incentives in U.S. healthcare and how they can be modified to improve patient outcomes and community health, lower costs, and transform the system, to everyone’s benefit. She was joined on the panel by Robert Pearl, M.D., executive director and CEO of the Oakland, Calif.-based Permanente Medical Group, co-CEO of the Permanente Federation, and the author of the just-published book Mistreated: Why We Think We’re Getting Good Health Care—And Why We’re Usually Wrong; Chet Burrell, president and CEO of the Baltimore-based CareFirst BlueCross BlueShield; Charles Sorenson, M.D., emeritus president and CEO of the Salt Lake City-based Intermountain Healthcare, and founding director of the Intermountain Healthcare Leadership Institute; and Paul Grundy, M.D., chief medical officer and director, healthcare transformation, at the Armonk, N.Y.-based IBM.

“So, we’ve got a very crazy situation here in Washington,” Connolly said, referencing the ongoing drama over whether the Affordable Care Act might be repealed and replaced, or modified in some way or another. But, she pointed out, the percentage of insured Americans who receive their health insurance through the ACA-established health insurance exchanges is between 4 and 6 percent of the total insureds, whereas, she noted, the vast majority of Americans still receive insurance either through employer-sponsored insurance, or through the Medicare and Medicaid programs. Focusing the discussion on private health plan-paid healthcare, she asked each of her panelists, “What do you see in the private sector that’s working and that’s not working?”

panelists (l. to r.) Connolly, Pearl, Burrell, Grundy, and Sorenson at the WHCC on Monday

“Let me start with the reality that our American healthcare system is simply broken,” Kaiser Permanente’s Pearl began. “We spend 50 percent more than any other [national healthcare] system, yet our outcomes are half. The American healthcare system is broken—it’s fragmented—it’s a nineteenth-century industry; it’s paid on a piecemeal basis, with 20th-century technology. I wrote the book to help suggest solutions,” he said.

“In the book,” Pearl said, “I talk about the fact that what’s broken isn’t the doctors or the insurance industry per se; it’s simply the context. And context shapes perception, which changes behavior. Think back to the Stanford Prison Experiment. One half become the jailers and one half the jailees. Within 48 hours, the jailers saw the jailees as being dangerous criminals; they started to impose debasing treatments. The jailees saw the jailers as imposing wardens. It makes no sense, but It changes behavior. And we have to understand this as we’re trying to change the delivery system,” he said. “If you integrate care, horizontally among physicians and vertically among the pieces of the continuum of care, all of a sudden, the physicians start to coordinate and collaborate, and you get the results you need. As soon as you capitate, all of a sudden, prevention, and early care become more significant, and you can see the care gaps. So it is not about what we think, but how we see. And if you can change perceptions, you can change behavior.”

“Chet, from the perspective of a health plan?” Connolly asked. “I would build on what Robbie said,” Burrell responded. “We cover northern Virginia, D.C., and Maryland. And we see the health systems developing into a system of oligopolies, usually under an academic medical center. And that congealing has resulted in care that is increasingly focused on academic medical centers. And federal healthcare policy has been hospital system-centric. And that’s increased cost, usually with 250-300 percent higher costs than in community-based care.” The solution, he said, is for health plans to work in conjunction with primary care physicians to force changes to patient utilization of medical specialists and hospitals.

We have not found it to be true that ACOs [accountable care organizations] have created more community-centered care.” Instead, he asserted, hospitals have only consolidated their power and continued to increase costs to the overall healthcare system. Instead, in working to bring down utilization costs and improve care delivery, he said, “We thought, who are the most important players in the system? Primary care physicians, not because they do everything, but because they make the most value-laden decisions in the system—when to refer, and to whom. We were looking for independent primaries in the system who were free to shop the specialists. The result has been a profound effect, when the primaries become the buyers. They become fussy about what happens. They’re not locked into systems. The difference between the big-system costs and community-based costs, are something between 22 and 27 percent in this market,” he said. “And I’ll be glad to talk about how we structured incentives. I agree with Robbie that if you change the context, you change what you do. And we cover 1.7 million people in this market.”

Looking at the healthcare system as a whole, IBM’s Grundy said, speaking of transformational change in healthcare, “There are really three things that are driving this, and I have the privilege of seeing this globally. The fist is unsustainable cost. And that’s everywhere, but more here than anywhere. The second is data. The third thing is this,” he said, holding up a smartphone for the audience to see. “We’re going to be able to a lot remotely, and I’ve seen that globally. So there are two things going on globally, reformation and transformation,” he said. “Reformation is about who pays.”

Continuing, Grundy said that, with regard to transformation, “Most people agree they’d like better and more affordable care. I had the privilege of being on a couple of calls with Price,” he said, referring to Tom Price, M.D., who recently became Secretary of Health and Human Services, and who had served as a Republican congressman from Georgia before that, “and he reminded me that we did a couple of videos on the patient-centered medical home,” whose model he sees as an essential component in transforming care delivery. “It’s not just how you pay for it, but whom you’re paying,” he said. “I’ve had the privilege of traveling around the country, and what’s great is building on the kind of work that they’ve done at Kaiser; and building on the patient-centered medical home and robust primary care.”

What’s more, Grundy said, there are several key elements to transforming the delivery system from the ground up. First, he said, “Practices have to be redesigned so that primary care is at the base of it, and primary care is on your side, not the hospital’s side. Then there’s payment redesign: start paying for episodes of care. Capitation, outcomes, value, service level, they’re all dials we’ve put in place. We’ve done that in Denmark. So one dial is paying the specialists to answer the emails of the primary care physicians. I’ve also been in 12 communities across the country,” he said, “including Alexandria, Louisiana and Lynchburg, Virginia, where the local employers are gathering together and working with local primary care, and when they do that, all of a sudden, you have data, and good primary care on the side of the patient and not on the side of the hospital, and we’ve seen decreases in cost. We’re in year 10 in Alexandria, Louisiana,” in that experiment, he said.

“Frankly speaking,” Grundy continued, “I can only buy integrated care from Kaiser or Intermountain for about 6 percent of our lives, because we’re everywhere. So some of this has to be rebuilt. The last is really benefit redesign. How do you put skin in the game for patients? The worst is to have a high-deductible benefit plan where your patient has no incentive to get preventive care, such as a diagnostic scan. So, payment redesign, practice redesign, and benefit redesign, all have to happen. But all three have to happen at the same time. I’ve talked to employers across the country doing benefit redesign, but all three things have to happen at once.”

“I’d like to start with the question, what do we really want as individuals?” Intermountain’s Sorenson said. “I don’t think anyone wakes up  and says, I hope today is the day where I get great care for a ruptured  aneurysm; or great renal dialysis. We want to live healthy lives. And talking about healthcare sometimes gets us focused on the wrong thing. About 20 years ago, a hospital CEO said, we’re not in the business of healthcare, we’re in the business of sick care. So, the incentives need to change. The financial incentives in the fee-for-service system encourage us to wait and delay. So, changing the fee-for-service system, moving to population health management, where health insurers, providers, and patients, all benefit,” is going to be a key shift for U.S. healthcare.

“The good news that we’ve found at Intermountain over the past 20 years,” Sorenson went on, “is that physicians want to do the right things for their patients, cost and clinical outcomes, and if you can incentivize that, you get better clinical outcomes and lower overall costs. The problem in the fee-for-service system is, if you prevent renal failure, prevent a cancer, etc., the health system gets paid less in fee-for-service. So we’ve got to change those incentives and track the outcomes, both clinical quality and cost, so engaging the caregivers and the patients. The good news is that when people are informed properly, they make good choices both about treatment options and healthy behaviors. And that’s true in our health plan, which serves about 20 percent of our patients at Intermountain. And this urge to merge, it’s often stated that that’s done to achieve economies of scale, but really, that just aggregates into a larger health system that has bigger clout with payers, and it really focuses leadership, I think, away from the bigger and much more critical job of changing how we deliver care and changing from a system that only fixes problems to one that also prevents problems. And that can’t be done by Washington, D.C.; that has to be done by the healthcare system.”

Shifting care away from hospitals?

A segment of the discussion focused on the shift that all the panelists agreed needed to take place in terms of focusing on primary care-based interventions in order to improve patient outcomes and health status and reduce costs over time in the U.S. healthcare system. “I was thrilled that a few of you mentioned primary care. Tell folks about your patient-centered medical home-based initiative, Chet?” she said, turning back to CareFirst’s Burrell.

“Well, we’re in our seventh year,” Burrell said, “and our program covers about 1.2 million people, and about $5 billion flows through the system” every year. One key element in CareFirst’s program, he noted, was that while primary care physicians order and direct so much care delivery, “they only manage about 5 percent of services. So we created everything by contract, not employment. The average panel is about 10 primaries. And 10 primaries in this region, with our market share, deal with about 1,000 members. And we did a very simple thing,” he went on. “We looked at all the care by specialists, for example, repair of your meniscus. And the average range of cost was 100-200 percent. And was that correlated to quality? Not in the slightest. And we said to the primaries, why are you always going to the highest-cost specialists? And their jaws dropped. And now they become fussy, under our incentives. So that set into place a dynamic. If you are a primary who is owned and controlled by a [hospital-based] system, you’re hermetically sealed into your high-cost system. But by empowering the primaries, that was landscape-changing. We caused the panel as a whole to be accountable for the whole. And we gave them a complete profile of what the patients’ expenses looked like. And we shared the savings with the panels. And this has produced rewards on average—50 percent increases in income to the ‘winning’ panels.”

“I was about to ask you what was in it for the primary care docs? It seems like lots of extra work for them,” Connolly said.”

“It is extra work,” Burrell conceded. “They need to focus on multi-chronic patients. We paid them 12 percent more just to come into the program, but we also said, if you perform well as a panel, we will share it; and we included no downside risk. And the reason we chose that as incentive-only—this was a 50-percnet incentive. That’s the average award, 40-50 percent—is that, if you ever get that, you’ll be incentivized to do it again. We said that a primary care physician taking 5 percent on the dollar, shouldn’t be accountable for 100 percent risk. Because when we talked about their taking risk, it drove them into the arms of the health systems.”

With regard to incentives for primary care physicians, IBM’s Grundy said, “I was sitting recently in a primary care practice in West Virginia. And he said, you know, there’s one hospital in town. It’s in my interest to keep that hospital alive, even though it costs much more to do a CT scan there. There’s enormous variation in costs. But when you get the GP on your side things, change. Honestly, though,” he said, “if a hospital employs everything, you’re probably going to have to employ your own.”

“Shouldn’t we be closing more hospitals in America?” Connolly asked bluntly. “Yes,” Intermountain’s Sorenson responded. “We’ve looked at that for many years in our market, which is mostly Utah, with a few hospitals in southern Idaho. We’ve been very conscious to only grow based on population growth. And we need to recognize that anything built with bricks and mortar is at high risk financially.”

“Why are there still so many hospitals?” Connolly asked Kaiser Permanente’s Pearl. “I’ve heard some CEOs say that hospitalization is a failure of the system.”

“You’re asking exactly the right question, Ceci,” Pearl responded. “Let me start with the reality that if you lower costs, you’ll have fewer hospitals and fewer clinicians. Between San Jose and San Francisco, where I live in Silicon Valley, 10 hospitals do heart surgery; three of them do fewer than 300 cases a year. That means there are 50 days a year when those hospitals aren’t doing that surgery. What business would work on that model? Until there are fewer hospitals, and fewer specialists, we’ll still have high costs. Chet talks about the medical home being the base; that works on quality, but it’s harder to fix cost. The ACO does some things better. But how do you right-size it? You need to move to a fully integrated delivery system, paid on a capitated basis. You need the quality, the cost control.”

Indeed, some visits don’t need to be in-person visits at all, Burrell asserted. “We found that the majority of routine office visits are for follow-up visits for chronic disease,” he said. “And we’ve found you can do that much more effectively and productively through televisits. And it’s a more efficient use of physicians’ time. And more convenient for patients.”

The panelists went on to agree that precision medicine, information technology, and advances in care management, will all help to push the U.S. healthcare industry forward towards greater efficiency and cost-effectiveness, and towards improved patient outcomes, in the coming decade.




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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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