She couldn’t have picked a better moment, or a better venue: when Seema Verma, Administrator of the federal Centers for Medicare and Medicaid Services (CMS), got up to speak on Tuesday morning at HIMSS18, unfolding here in the Sands Convention Center in Las Vegas, she had the entire healthcare IT industry, and much of the U.S. healthcare industry more broadly, listening to her.
And what Verma had to say was substantive, announcing the launch of a new initiative called “MyHealthEData,” aimed at revolutionizing the relationship of U.S. healthcare consumers to their patient data. As the announcement, published on the CMS website at about the same time Verma was speaking at HIMSS18, said, “Last year President Trump issued an Executive Order to Promote Healthcare Choice and Competition Across the United States. In response the Administration is moving towards a system in which patients have control of their data and can take it with them from doctor to doctor, or to their other healthcare providers. The government-wide MyHealthEData initiative is led by the White House Office of American Innovation with participation from the Department of Health and Human Services (HHS) – and its Centers for Medicare & Medicaid Services (CMS), Office of the National Coordinator for Health Information Technology (ONC), and National Institutes of Health (NIH) – as well as the Department of Veterans Affairs (VA). The initiative is designed to empower patients around a common aim - giving every American control of their medical data. MyHealthEData,” the CMS announcement said, “will help to break down the barriers that prevent patients from having electronic access and true control of their own health records from the device or application of their choice. Patients will be able to choose the provider that best meets their needs and then give that provider secure access to their data, leading to greater competition and reducing costs.”
Verma spoke passionately about the need to give healthcare consumers/patients more control over their data and information, citing an experience she had had personally, when her husband suffered heart failure while she was traveling, and when as a result, a series of unfortunate developments took place that might have unfolded very differently had she, as the spouse of a patient in an emergency medical situation, been empowered to access her husband’s data to support his emergency care.
“The reality,” Verma said, “is that once the information is freely flowing from patient to provider, the advances in coordinated, value-based care, will be greater than anything we could imagine today. Things could have been different for my family if my husband could have authorized me to have his health records on his phone,” she said. “Or if he could have notified me that he was in distress. And better yet, maybe we could have predicted his cardiac arrest days before, if his watch could have tracked his health data, and sending that data to alert his doctor, and possibly prevent what happened. My husband is part of the 1 percent that survives his condition. We shouldn’t have to depend on chance” for that type of outcome, she emphasized.
Moving back to the federal policy level, Verma told her audience Tuesday that, “Through the MyHealthEData initiative, this administration is focused on putting patients first, truly first, by giving them the information they need to truly improve their health. This administration will pull every lever to create a health information ecosystem that tailors the health system” to improve outcomes. And she insisted that “Our administration is completely aligned”—including across the Veterans Administration healthcare system, the Department of Defense, and other healthcare-related federal agencies—to achieve this goal. And the time is now. Hospitals and doctors” have extensive access to electronic patient records, she noted, “and nearly everyone has access to a smartphone. And smartphones in particular create the portability needed to create mobility… Uniform standards being drafted in the 21st Century Cures Act that will allow for information-sharing. The technology and regulatory requirements are finally coming together,” she emphasized.
Azar reinforces Verma’s message, with one of his own
Meanwhile, Verma’s speech turned out to not have been an isolated event this week, as federal healthcare officials made comments that reinforced her points, in a variety of venues and situations. Alex Azar, the new Secretary of Health and Human Services, caused his own splash this morning with a speech given in Washington, D.C. for America’s Health Insurance Plans (AHIP). According to the transcript of the speech that HHS posted on its website this morning, Azar said, among other things, that “This administration and this President are not interested in incremental steps. We are unafraid of disrupting the system simply because it’s backed by powerful special interests.”
Indeed, Azar said in his prepared remarks at AHIP, “[T]oday, I want to lay out four particular areas of emphasis that will be vital to laying down new rules of the road, accelerating value-based transformation, and creating a true market for healthcare. The four areas of emphasis,” he said, “are the following: giving consumers greater control over health information through interoperable and accessible health information technology; encouraging transparency from payers and providers; using experimental models in Medicare and Medicaid to drive value and quality throughout the entire system; and removing government burdens that impede this transformation. The key theme uniting these four priorities,” he added, “is the recognition that value is not accurately determined by arbitrary authorities or central planners.”
Higher up in that speech, Azar had placed all of this into a policy context, saying, “This is no time to be timid. Today’s healthcare system is simply not delivering outcomes commensurate with its cost — President Trump knows it, and the American people know it, too. But there is a better way. Imagine a day when healthcare delivery in the United States functions the way other parts of our economy do. We as patients would pick providers with the level of information we have when using Amazon or Yelp. Consumers would drive quality and cost-effectiveness with information, competition and genuine choice. Some argue healthcare is simply different, that it is and should be immune from market forces. I simply disagree. Real competition—in the economic sense—has never really been fully tried in our system.” And he added that, “Upon taking office at HHS, I identified the value-based transformation of our entire healthcare system as one of the top four priorities for our department. The others are combating the opioid crisis; bringing down the high price of prescription drugs; and addressing the cost and availability of insurance, especially in the individual market.”
Azar had actually made many of the same points on Monday, when he addressed the 2018 FAH Public Policy Conference and Exposition in Washington, D.C., a gathering of the Federation of American Hospital Systems—the national association of for-profit hospital organizations.
How will all of this play out? Some implicit public policy contradictions
So the question naturally arises, how will all of this play out, in the real world? Some of what Azar and Verma said in their speeches at HIMSS and AHIP this week are “mom and apple pie” notions—the idea that healthcare consumers might be able to drive quality and cost-effectiveness through making informed choices; on the other hand, they are also implicitly marrying two arguably contradictory, or at least, strongly contrasting, concepts—the ideas of market-driven change and federal government-compelled healthcare industry transformation.
Certainly, administrations of both political parties in the United States have struggled to master the challenges facing the U.S. healthcare system, which is arguably easily the most complex healthcare system in the world, by far. U.S. healthcare is neither a true free-market economic system, nor is it a completely government-run one; it is the strangest kind of hybrid one could possibly imagine—a fact frustrating to those on the political right and on the political left, and everywhere in between.
So here’s the nub of the profound question facing Azar, Verma, and everyone else in this administration, at the highest levels of federal healthcare policy: can the precisely right combination of federal government interventions force the U.S. healthcare system to respond in a “market-driven” way? In a “consumer-driven” way? That’s the gamble these federal healthcare officials are taking, both rhetorically and strategically. It’s one thing to say that healthcare consumers, armed with more data and information, and in control of their own patient records, will force the nation’s health insurers, hospitals, physicians, and all the other types of healthcare entities, to provide higher-quality, more efficient, more cost-effective, more consumer-centric, more satisfying care delivery, care management, and the like. But will that be the reality?
There seem to be two things missing here. First is addressing the issue of universal, or at least near-universal, health insurance coverage. This is an administration whose stated goal remains to repeal the Affordable Care Act, still the only vehicle designed at the federal level to broadly expand health insurance coverage in this country. And if healthcare consumers lack insurance, they literally have virtually no power in a market-driven healthcare system. Second is the assumption that providing healthcare consumers with more data and information, in itself, will fully empower them. Lots of people—from across the political spectrum—would regard that justifiable skepticism. Even Verma herself seemed to acknowledge the point, when, in announcing the creation of “Blue Button 2.0,” she noted that under the initial version of the Blue Button program, Medicare beneficiaries have for a few years now had access to some of their Medicare claims via Blue Button functionality; but that that data has been in raw form, without any contexting that could make it truly useful for Medicare patients. Blue Button 2.0, she promised, will facilitate that needed contexting. “Currently,” she said, “we give our beneficiaries this data in Excel or PDF formats, without any help in helping them to understand the context of it. That’s useless if that’s hard to understand.”
In an ONC press availability on Wednesday, Donald Rucker, M.D., National Coordinator for Health IT, told assembled journalists that the idea that patients aren’t ready to understand their data is “nonsense.” But when Healthcare Informatics Managing Editor Rajiv Leventhal asked UPMC chief innovation officer Rasu Shrestha, M.D., about that point, Shrestha told him that, while patient empowerment is a nice phrase, and patients are certainly more engaged than ever before, “We need some more substance behind it.” Shrestha added, “You can’t just ‘free the data’ and say, Patient X, here is your data, because they might not know what to do with it. So we need to make sure we empower the patients, but also empower them by giving them the right set of tools, insights and guidance.”
Shrestha, who is also the executive vice president at UPMC Enterprises, said part of the solution is to “shift from paternalistic medicine to intelligent, active participatory medicine, and it’s not just about the doctor-patient relationship, but about the care collaborative, where the patient is leaning in, empowered, and engaged, and you have the entire care team working to improve outcomes and better satisfaction.” That, said Shrestha, is the whole paradigm behind value-based care.
Federal regulations—a stumbling block?
And I myself asked Dr. Rucker, at yesterday’s press availability, about the potential need to rework some federal regulations, in order to allow for data to flow more freely between and among health insurers, providers, and other entities, and publicly, around such areas as pricing and outcomes. Rucker and his fellow federal healthcare officials have been stressing over and over the idea that facilitating the creation of open APIs (application programming interfaces) would somehow liberate vast troves of information. But when I asked Dr. Rucker whether some elements of antitrust law might need to be changed as part of this broad move forward, he said, “There are some things on the Stark law,” referring to the federal self-referral laws; “I’ve heard that argument. I’m not personally convinced that that is a true factor. I’m not a lawyer, but I don’t believe that that will be a significant factor in the swirl of complexity that we’re talking about. What is correct legally is that some of these population-level things are all currently covered by HIPAA [the federal Health Insurance Portability and Accountability Act of 1996], and it requires a legal HIPAA contract to do. So how is that different from what’s going on now?” he said, referring to data-sharing considerations.
The question in mind is, however, broader. There is an entire level here involving not just data and information, but how the purchasers, payers, providers, and consumers of healthcare interact, and might interact going into the future—including with regard to sharing data and information among themselves to make business decisions affecting healthcare consumers. Will the current policy, payment, insurance coverage, and consumer landscape of healthcare in the United States be one that, with the tweaks proposed by federal healthcare officials this week, provide enough of a platform for profound, consumer-led change? And for payers and providers to also be “liberated” to make needed changes in how they operate…???
With regard to that, Verma had tweeted this just before she spoke at HIMSS on Tuesday: “The days of finding creative ways to trap patients in health systems is over. It is not acceptable to prevent patients and their doctors from seeing patients' health records outside of a particular health system #MyHealthEData #HIMSS18” But there is a complexity in how the healthcare system operates, that that tweet, and some of the thoughts underlying it, appear to not fully acknowledge.
And, with regard to the question of how actual healthcare system might be compelled forward into transformational change, the honest answer is that no one knows. And while much of what Verma and Azar said this week contained substance on which most people in healthcare could agree on, at least in principle (certainly, no one is advocating for consumer disempowerment!), whether or not what they’ve proposed, awaits the test of time—and of federal healthcare officials’ intentions and execution on those intentions.
One thing is clear: Seema Verma, at least, has made it clear that she wants to push forward the idea of data-empowered healthcare consumers forcing the U.S. healthcare system to transform itself towards improved care delivery quality, cost-effectiveness, and consumer responsiveness. And, in that, as the very old saying goes, the proof will most definitely be in the pudding.