Could the MedPAC Proposal Around MIPS End Up Being the Wrong Answer to the Right Question? | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Could the MedPAC Proposal Around MIPS End Up Being the Wrong Answer to the Right Question?

March 20, 2018
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Does the MedPAC proposal really make sense in the context of the current moment in Medicare policy and payment?

As Associate Editor Heather Landi noted in her report Monday about the latest developments around the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, and its component, MIPS (the Merit-based Incentive Payment System), the Medicare Payment Advisory Commission (MedPAC—an independent commission whose mandate is to advise Congress on Medicare payment and quality issues) this month issued its report to Congress, recommending that the MIPS program be eliminated and replaced with an alternative model of reimbursement. MedPAC submits two reports to Congress each year, in March and in June. Back in January, MedPAC voted 14-2 to recommend scrapping MIPS and replacing MIPS with a new clinician value-based purchasing program, called the Voluntary Value Program (VVP), and that proposal was included in the advisory group's recent report to Congress.

The members of MedPAC were quite explicit in their recommendations and assertions. In their March report to Congress, they wrote, “The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established a new framework for how traditional FFS [fee-for-service] pays for clinician services. The Commission supports the elements of MACRA that repealed the SGR [the sustainable growth rate formula for Medicare physician payment] and encouraged comprehensive, patient-centered care delivery models such as advanced alternative payment models (A–APMs). MACRA also created the Merit-based Incentive Payment System (MIPS), which measures individual clinicians in traditional Medicare on a set of measures that they choose.”

Among the things they assert: “MedPAC shares Congress’ goal, expressed in MIPS, of having a value component for clinician services in traditional Medicare that promotes high-quality care. However, the Commission believes that MIPS will not fulfill this goal and therefore should be eliminated.”

What’s more, they say in their report, “MIPS is premised on the assumption that Medicare can measure and pay for quality at the level of the individual clinician, but a system built on that assumption will be fundamentally inequitable for two reasons: (1) clinicians will be evaluated and compared on dissimilar measures, and (2) many clinicians will not be evaluated at all, because as individuals, they will not treat enough Medicare beneficiaries to produce statistically reliable scores. In addition,” they state, “MIPS imposes a significant reporting burden on clinicians (estimated by CMS as over $1.3 billion in the first year). MIPS scores are not comparable among clinicians because each clinician’s composite MIPS score will reflect a mix of different, self-chosen measures. MIPS is complex and inequitable, with different rules for clinicians based on location, practice size, and other factors, and in 2018 it exempts more clinicians than will participate.” And, “MIPS-based payment adjustments with be small in the first years, providing little incentive, and then arbitrary and possibly very large in later years, creating significant uncertainty for clinicians.”

As a result, they propose the following: “After a two-year deliberative process, the Commission recommends that the Congress eliminate MIPS and adopt an alternative approach for achieving the shared goal of promoting high-quality clinician care for beneficiaries in traditional Medicare.” What’s more, “To help improve the quality of care in Medicare, quality measures should be reliable, encourage coordination across providers and time, and promote change in the delivery system. Quality measurement should focus on population-based measures and give rewards or penalties based on clear, absolute, and prospectively set performance targets. In addition, quality measurement should not be overly burdensome for providers or divert resources needed for patient care.”

Provider leaders weigh in

As Landi notes in her report, “MedPAC’s approach to a new value-based purchasing program is to allow clinicians to self-organize into groups that collectively assume responsibility for their patients’ outcomes. Under the VVP, clinicians can elect to be measured as part of a voluntary group and clinicians in voluntary groups can qualify for a value payment based on their group’s performance on a set of population-based measures, according to the report. The VPP would measure all clinicians on the same set of measures—clinical quality, patient experience and value.”

But even some provider associations that have complaints over MIPS do not necessarily support dumping MIPS altogether and replacing it with something completely new. Anders Gilberg, senior vice president for government affairs at the Medical Group Management Association (MGMA), said in a statement, “MedPAC’s March Report is an indictment of MIPS as implemented. However, its conceptual ‘VVP’ alternative lacks details. MGMA believes there are steps that can be taken now to reduce clinician burden. CMS can begin by shortening the 2018 MIPS data reporting period from one-year to 90 days in the same way the Agency did for Meaningful Use in 2014, 2015, and 2016.”

Meanwhile, in a Healthcare Informatics podcast interview, which Landi conducted back in January, David Barbe, M.D., president of the American Medical Association (AMA), said that he believes it is “premature” to abandon MIPS at this point. “We do believe there are significant improvements and opportunities in the MIPS program, but we’re not quite ready to abandon it, we think that’s premature,” Dr. Barbe told Landi at that time. “We’re not that far along in to the second year of the program; it has not given us as an industry and as individual physicians time to acclimate to this program.” And, he added, “We’re concerned that the [MedPAC] proposal suggests that the primary way, if not the only way, is through group reporting, and while that has some advantages, forcing physicians into group reporting, or making that the only way one can participate in what I’ll generically call value-based programs, is probably not right. Our industry is not a one-size-fits-all industry. We have some reservations, but we’re waiting to see more details of the proposal.”

Indeed, in its report to Congress, MedPAC concedes that many have argued that MIPS should be given a chance to succeed and that considerable resources have already been invested in the program. However, MedPAC stated, “MIPS will continue to consume limited CMS and clinician time and resources, and the burden of MIPS will outweigh its value to Medicare beneficiaries, the Medicare program, and clinicians. Progress in a more useful direction is feasible. MIPS should be eliminated, and a VVP should be established to encourage clinicians to move in a more productive direction.”

The devil you (sort of) know…?

So, where does all of this leave us? Well, in something of a conceptual and policy pickle, to be honest. So let’s parse this a bit, shall we?

To begin with, MACRA and MIPS were created as a remedy to the ridiculous situation that we had for a decade with the SGR, which had been passed with bipartisan consensus by both houses of Congress, back in 1997, and which in turn had replaced the old MVPS (Medicare Volume Performance Standard) that had been in place before the SGR. The core problem, of course, was that the SGR was never fully enacted, because members of Congress from both political parties lacked the courage of their convictions, and feared the rage of organized medicine, and therefore, the physician pay cuts called for under the SGR legislation, were never enacted. By January 2013, those cuts were estimated at an eye-popping 27.4 percent; they were estimated to be 24 percent in April 2014. So the passage of MACRA, which had firm bipartisan support, finally eliminated that sword of Damocles that had been hanging over physician payment for 16 years.

The theory behind MIPS made a lot of sense, and, it must be stated once again, had very broad bipartisan support. Of course, the devil is always in the details, and in this case, the details ended up being particularly thorny. As already noted above, the MedPAC commissioners noted in their report that “MIPS imposes a significant reporting burden on clinicians (estimated by CMS as over $1.3 billion in the first year). MIPS scores are not comparable among clinicians,” they underscored, “because each clinician’s composite MIPS score will reflect a mix of different, self-chosen measures. MIPS is complex and inequitable, with different rules for clinicians based on location, practice size, and other factors, and in 2018 it exempts more clinicians than will participate.”

On a far more basic level, physicians in practice are simply finding MIPS too complex to work with, and therefore, are finding it to be too much of an administrative burden. The question is, would this “Voluntary Value Program,” or “VVS,” be any better? What’s more, even if were an improvement over MIPS, would the transition to it be worth the additional hassle? Or would it be better to gradually streamline the MIPS reporting requirements instead?

U.S. physicians in practice are feeling oppressed and beleaguered these days, and that fact is understandable. Do they deserve “relief”? Yes—in certain ways, and along certain dimensions. But that element needs to be parsed, too. For one thing, as much as they may hate it on a day-to-day practice, the reality on the policy and payment levels, is that pay for performance is here to stay in healthcare; there’s simply no way that the U.S. healthcare system, particularly the Medicare program, is going to go back to unfettered, non-directed fee-for-service payment, not with total U.S. healthcare spending set to increase 70 percent over the coming decade, to an annual total of $5.7 trillion, and 19.7 percent of GDP. Even the current 5.5 percent healthcare inflation rate is simply too high, given the cost trajectory we’re on as a national healthcare system. So value-based purchasing will only accelerate, not decelerate or reverse.

That said, physicians in practice do have four very legitimate complaints in this area: that there are too many quality measures overall; that they are not all aligned (for example, Medicare versus private-payer sets of measures); that they are far too often process-based, and don’t truly measure differences in actual care quality; and finally, that, too often, the measures reward or penalize doctors for things that are not truly within their scope of control.

In that context, no one has claimed that the initial set of measures within MIPS is the be-all and end-all, the final set of measures that will be valuable forever; quite the opposite, in fact. Federal healthcare officials, and all others, involved in the evolution of MIPS and MACRA, agree that the measures need to be refined, and in some cases, changed, over time.

The question is, how, in what ways, and when.

And my own instinct, in reading this broad, somewhat vague proposal by the MedPAC commissioners, is to say that one of the key elements in that proposal—to allow physicians to gather together in voluntary pods of some sort, to be measured in groups, according to quality, would actually add yet another element of complexity to this, as the vast majority of practicing physicians are just figuring out what to do about MIPS, versus attempting to participate in advanced alternative payment models. I just see a lot of chaos breaking out, at a time when practicing physicians need to move forward, very quickly, under MACRA.

So while the MedPAC commissioners have put forward some interesting ideas, and while some physicians in practice might leap up to endorse it, it’s difficult to embrace their proposal at this time and in this context; things are simply too unsettled right now. And, though it might not be popular to say so, in a way, this moment reminds me of the first year under the meaningful use program. That was difficult, too, but in the end, nearly all Medicare-accepting hospitals, and more than 90 percent of Medicare-accepting physicians, did implement electronic health records and move forward, under meaningful use.

So for right now, really, the only practical option seems to be to move forward with the admittedly flawed MIPS program and fix it as things move forward. Sometimes, in an imperfect world, working with an imperfect system is preferable to introducing more complexity to that system in an effort to make it more perfect. In other words, realism can at times lead to a better outcome than can perfectionism. But, stay tuned to see what happens next; this play has several more acts up ahead!



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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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