How the HIT Industry’s Dominant Annual Conference Became (At Least Partly) a Policy Conference | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

How the HIT Industry’s Dominant Annual Conference Became (At Least Partly) a Policy Conference

March 14, 2018
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As the U.S. healthcare IT landscape becomes more policy- and payment-driven, so too, will the discussions at HIMSS

I remember a time about 10 to 12 years ago when rumblings emerged about the annual HIMSS Conference. Some people—not a lot, but some—were saying that the annual conference of the largest association of healthcare IT professionals (the Chicago-based Healthcare Information and Management Systems Society) had simply become too big—the crowds were too big, it was becoming too difficult to engage in serious discussions, it was simply becoming a hassle to attend and participate, etc.

There were of course legitimate complaints. Indeed, with regard to the size of the conference, HIMSS 2008 had 29,179 attendees, according to a history of the association and the conference compiled by members of the HIMSS Legacy Workgroup; whereas attendance at this year’s conference, as of Tuesday, March 6, was 42,608—more than 68 percent more people attending. So, clearly, the HIMSS Conference has become gigantic—so much so that only three cities—Las Vegas, Orlando, and Chicago—can now fully accommodate it. Remember that the conference requires a vast constellation of physical spaces of different sizes (all the way from a main ballroom accommodating more than 8,000 attendees, down to several hundred smaller rooms, including classroom-sized rooms for meetings), as well as an immense set of exhibit halls; and enough hotel rooms to accommodate nearly 45,000 people; and airports with sufficient flight to fly all those people in and out essentially at the same time.

In any case, the murmur of grumblings a decade-ish ago was not purely about crude numbers. It was also about the feeling, in some quarters, that HIMSS’ focus had become too diffuse over time. Certainly, back in the 1990s and in the very early 2000s, there was a somewhat diffuse feeling around the HIMSS Conference in general. I remember back in the 1990s, the tenor of the conference, which was quite unfocused compared to these days. Walking the exhibit floor back then, one observed a kind of miscellaneous smorgasbord of vendor offerings, with vendors kind of all over the place in terms of the wares they had for sale, and most systems, particularly electronic health record (EHR) systems very closed and proprietary then (indeed, EHR vendors took pride in the closedness of their systems—really). There was also a lot of vaporware on display then (and that was one of the commonest complaints 10 to 20 years ago).

Well, everything changed in 2009, when the U.S. Congress passed, and President Obama signed into law, the ARRA (American Recovery and Reinvestment Act of 2009), one piece of which was the HITECH (Health Information Technology for Economic and Clinical Health) Act. Yes, Virginia, the HITECH Act changed everything. Certainly, HITECH’s passage changed the trajectory of EHR implementation, turbo-charging the forward advance of EHR adoption in both hospitals and physician practices. Prior to 2009, depending on who’s doing the counting, somewhere around 40 percent of hospitals had fully implemented EHRs (and that’s only the basic implementation, not more advanced clinical information systems development), and no more than 15 percent of physician practices (counting quite liberally) had done so. Fast-forward to 2018, and virtually every Medicare-participating hospital is live on an EHR, as are the vast majority of physician practices. And that changed the entire landscape of healthcare IT.

For one thing, once EHRs had become near-universalized, that opened the door to the adoption of more advanced solutions, including analytics tools and other technologies. The EHR has been foundational for so much of everything else that’s come along in the past decade.

But the impact of HITECH, and of its prescriptive meaningful use program, has been only one piece of this puzzle. The passage in 2010 of the Affordable Care Act (ACA) totally transformed the landscape of U.S. healthcare for the leaders of patient care organizations, and therefore, the operational landscape for healthcare IT leaders. Along with it came the value-based purchasing program under the Medicare program, the mandatory readmissions reduction program also under Medicare, and a mix of mandatory and voluntary bundled-payment programs, and voluntary accountable care organization (ACO) programs, also under Medicare. And every single one of those programs required transformed healthcare IT, including a new generation of data and analytics strategies and tools.

In short, policy and payment imperatives have increasingly been driving the U.S. healthcare system forward over the past several years, and that broad healthcare system change has forced change at the operational level at hospitals, medical groups, and health systems. And, of course, healthcare IT has been and continues to be, a key facilitator of all this transformation. And that has put healthcare IT leaders—most especially CIOs, CMIOs, and other senior healthcare IT leaders—in patient care organizations—in positions of both extreme importance and tremendous pressure. CIOs, CMIOs, and their senior-level healthcare IT colleagues are in a position to be more influential than ever, among their c-suite colleagues. But they’re also under more pressure than ever to help their executive teams figure out how to leverage data and IT in ways that will help transform those organizations as they go into the new healthcare.

Of course, one of the underlying challenges in all this is that very few senior-level healthcare IT leaders got to where they’ve gotten to, via public policy-related routes. Most CIOs started out as programmers, IT network managers, telecom managers, etc., while most CMIOs started out as clinicians in practice. Translating the nuances of federal healthcare policy mandates and directives into actual operational strategies and tactics is simply not anything that anyone learned how to do in computer science courses or in medical school.

And that gets back to the annual HIMSS Conference—both with regard to educational sessions and vendor exhibits. Things have been shifting strongly now for years, but one very noteworthy element at the annual HIMSS Conference has been what has happened in the past five or six years now, with federal healthcare officials—from the Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS), and the Office of the National Coordinator for health IT (ONC), increasingly using the platform that the annual conference provides, to make major healthcare and healthcare IT policy announcements at the conference. Farzad Mostashari, M.D. was the first National Coordinator to really make use of the HIMSS Conference platform; Dr. Mostashari was (and still is) articulate and charismatic, and saw a real opportunity to get in front of healthcare IT leaders and focus their attention on issues of importance to him. Subsequent federal healthcare officials have followed suit, and in the past few years, conference attendees have come to expect federal healthcare officials to drop major news at HIMSS.

CMS Administrator Seema Verma didn’t disappoint last week, with her major announcement of CMS’s “MyHealthEData” initiative last Tuesday morning. Not only was that announcement important in itself; it also spoke to the triumph of policy and payment developments in the healthcare IT operational landscape in the U.S. Because however the MyHealthEData initiative plays out, Verma has signaled to American healthcare IT leaders that she wants providers to help her to empower patients/healthcare consumers with their data and patient records. And of course, that means dramatically enhanced data exchange and interoperability, among other things.

So the annual HIMSS Conference really has changed dramatically; and really, that transformation has been inevitable, when one looks at the big picture here. Put very bluntly, the purchasers (including the federal, state and private purchasers) and payers of healthcare in the U.S. have been telling providers that healthcare simply costs too much, provides too little value for the money, and lacks transparency and patient-centeredness. And, inevitably, providers and vendors are being pushed more and more directly by the purchasers and payers of healthcare in the U.S., to develop and implement the IT and data tools that can help to transform the U.S. healthcare system, as it explodes from $3.1 trillion and 18 percent of GDP right now, towards $5.631 trillion and 20-plus-percent of GDP in the next several years.

What will be fascinating, will be to see how rapidly the healthcare IT landscape evolves, over the next several years. I can tell you that that landscape will become more policy- and payment-driven than ever before. So it will be fascinating to see what HIMSS19 (in Orlando) is like, because as much as buzzwords and buzz terms like population health, care management, predictive analytics, artificial intelligence, and interoperability dominated conversations at HIMSS18, there’s no question that they will be back again next year.

Put simply, as “here” as we were this year, expect us to be even more “here” next year. And good luck and godspeed to everyone in the intervening year!

 

 

 

 

 

 

 

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Check and Checkmate: Is the Debate Around the MSSP ACO Program About to Get Super-Heated?

September 12, 2018
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Will NAACOS’s just-published study turn the tables on senior CMS officials? Or will it be ignored?

Something really quite extraordinary happened this week: NAACOS, the Washington, D.C.-based National Association of Accountable Care Organizations, published, in the august journal Health Affairs, a study based on research that NAACOS leaders had commissioned from Dobson DaVanzo & Associates, a healthcare economics consulting firm. And, as Healthcare Informatics Managing Editor Rajiv Leventhal noted in his report, “Medicare’s largest ACO (accountable care organization) initiative—the Medicare Shared Savings Program (MSSP)—generated gross savings of $1.84 billion for Medicare from 2013 to 2015, nearly double the $954 million estimated by the Centers for Medicare and Medicaid Services (CMS),” according to the NAACOS/Dobson DaVanzo & Associates study.

And here’s what’s extraordinary about that: this is the first time in my memory that I’ve seen a national association of provider organizations commission independent research that directly contradicted federal government findings and statistics. Could this be the start of a major conflict over the direction of the MSSP program? The potential for actual conflict here is quite real. But first, let’s look at what NAACOS and Dobson DaVanzo found. As Leventhal noted, “The study, which used similar scientific methods as a 2018 peer-reviewed paper by Harvard researchers published in The New England Journal of Medicine, found that MSSP ACOs reduced Medicare spending by $541.7 million during the 2013 to 2015 timeframe, after accounting for shared-savings payments earned by ACOs.”

The MSSP is the largest value-based payment model in the U.S., growing to 561 ACOs with more than 350,000 providers caring for 10.5 million Medicare beneficiaries in 2018. Under current MSSP rules, new ACOs are eligible to share savings with Medicare for up to six years if they meet quality and spending goals but are not at financial risk for any losses. As such, CMS has been reiterating in recent months that these “upside risk-only” ACOs are costing the government money.

What’s more, as Leventhal noted, “To this point, in a recent proposed rule that has so far been met with varying degrees of scrutiny, CMS is proposing to shorten that glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years. This proposal, coupled with CMS’ recommendations to cut potential shared savings in half—from 50 percent to 25 percent for one-sided risk ACOs—will certainly deter new entrants to the MSSP ACO program. Importantly, CMS has essentially said they don’t mind if upside-only ACOs that are costing the government money leave the program if they aren’t willing to take on more financial risk. CMS Administration Seema Verma said in a press call following the proposed rule’s release that ‘[Upside-only] ACOs have no incentive, at all, to reduce healthcare costs while improving outcomes, as they were intended.’ Nonetheless, MSSP ACO participants seemingly performed quite well in 2017, despite CMS’ claims that they have been largely ineffective. In sum, the 472 ACOs that were in this model last year achieved $314 million in net savings to Medicare in 2017 after accounting for bonuses paid from the government, and $1.1 billion overall.”

For the NAACOS leaders, the key element here is that, as the authors of the Health Affairs article pointed out, “Despite the positive 2017 results, gauging MSSP performance based on calculations using administratively derived spending targets (benchmarks) is simply not an accurate way to measure overall program savings. In fact, the published academic research on MSSP performance points to much higher savings than are suggested by the benchmarks.”

Explained further by the researchers, for its analysis of Medicare ACOs, “CMS calculates an initial risk-adjusted spending benchmark for each ACO based on its historical spending for a group of attributed Medicare beneficiaries; it then trends this benchmark forward to the current program year based on the national average growth in Medicare spending per beneficiary.” The article’s authors further point out that if an ACO’s spending is less than the benchmark, and has a savings rate of at least 2 percent—and the ACO meets MSSP quality thresholds—it earns a shared savings payment that is typically 50 percent of the calculated savings. CMS then calculates total MSSP savings as the sum of total savings for ACOs with spending below the benchmark, plus the sum of spending above the benchmark for ACOs that exceeded it. Using this method, CMS estimated MSSP savings of $954 million between 2013 and 2015. During this period, ACOs that saved money earned $1.3 billion in shared savings payments. CMS concluded that on a net basis, the program increased Medicare spending by $344 million between 2013 and 2015, according to the NAACOS analysis and Health Affairs commentary.

At this juncture, there is an obvious issue here, because CMS’s calculation method implicitly makes it difficult for ACOs to show progress, since savings are benchmarked against administratively derived targets, rather than actual savings. Who came up with that method, anyway???

And the implications of using such a method are clear. As the press release that NAACOS issued upon the publication of the Health Affairs article noted, “Despite the growing ACO track record of improving quality and saving Medicare money, CMS, in an August 17 proposed rule, moved to shorten the time new ACOs can remain in the shared-savings-only model from the current six years to two years. Data show ACOs need more than two years to begin showing the benefits of forming an ACO. That proposal, coupled with CMS’s move to cut shared savings in half — from 50 percent to 25 percent for shared-savings-only ACOs — would deter new Medicare ACOs from forming.”

What’s more, the press release quoted Stephen Nuckolls, CEO of Coastal Carolina Quality Care in New Bern, N.C., which includes 63 providers caring for 11,000 Medicare beneficiaries, as stating that “It takes time and money to transform entrenched care delivery practices in local communities and build the critical mass to successfully integrate care, manage risk, and improve quality while reducing spending growth. Unfortunately, the proposed changes will hold up the move to value-based care by significantly undermining the business case to voluntarily form new Medicare ACOs.” 

I take Mr. Nuckolls’s charge very seriously. I interviewed him recently, and as he noted in our interview, when asked the secret of his ACO’s success so far in the six-plus years in which Coastal Carolina Quality Care has participated in the MSSP program, “[I]t takes time for some of these strategies, such as population health, to pay off. Another thing that’s going on is that our care management program, I give credit for keeping our costs low and getting things in place. And in addition,” he told me, “we really made a lot of strides in our first contract cycle, specific to our market. All of our annual wellness visits and preventive care, we made our marks there and that positioned us well in our second contract cycle. And it just takes time, when you focus on the quality of care, for… when a greater percentage of your patients have their blood pressure under control, you’ll have fewer adverse events. And when you work to lower a1cs, that will avert events over time. And annual wellness visits, vaccinations, screening services—it costs money for screenings; and once you get things set up, that’s then in place. And care management services—when you go into your second contract cycle, you have some of those costs worked into your contract cycle the second time; so it takes time to achieve shared savings, and to get the staff to focus on the sickest population.”

What’s more, what Nuckolls told me in our interview reflects what virtually every ACO leader I and my colleagues at Healthcare Informatics have heard from ACO senior executives—that it takes several years to lay the foundations for ACO success.

What’s more, Nuckolls told me, the results revealed in this data review-based study and article are important, as they speak to “the policy point—organizations are truly saving the government money, even if it doesn’t immediately show on paper. The evidence doesn’t support the idea that ACOs should be kicked out because they have a bad benchmark. The true savings to the Medicare Trust Fund will then be less. And that’s what they need to focus on, achieving true savings to the government.”

So, the obvious question now is, what will happen next? Will CMS Administrator Seema Verma lash out against NAACOS, denouncing this “rival” analysis of MSSP ACO savings? Will she ignore it? Or will she reach out to NAACOS’s leaders, and attempt to find common ground, as the “Pathways For Success” program potentially threatens the expansion of the voluntary MSSP program? It feels as though a lot is hanging in the balance right now, because if the national association representing ACOs has just come out with what is implicitly a denunciation of CMS’s method for calculating ACO progress and success, that is a fairly major “j’accuse” that Administrator Verma and her fellow senior CMS and HHS officials would do well to consider carefully. So the next move on this chessboard is Ms. Verma’s. And who knows what that move might look like?

 

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Seema Verma’s Big Picture: Tough Love, ACO Acceleration, Interoperability, and Consumer Empowerment?

August 29, 2018
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Will CMS Administrator Seema Verma’s strategy of pushing hard on providers around ACO development and interoperability help to accelerate the shift to value-based healthcare—or will it backfire?

Whatever may come, CMS Administrator Seema Verma is standing steadfast in her “tough-love” stances towards providers when it comes to ACO development. As Healthcare Informatics Associate Editor Heather Landi wrote on Monday, “During a webinar sponsored by the Accountable Care Learning Collaborative Monday morning, Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma reiterated the agency’s focus on pushing healthcare providers in accountable care organizations (ACOs) to take on two-sided risk while also addressing CMS’s commitment to try to remove barriers to value-based care.”

Further, Landi wrote, “During the 30-minute webinar sponsored by ACLC, a Salt Lake City-based accountable care collaborative, Verma discussed the sweeping changes that CMS is proposing for the Medicare Shared Savings Program (MSSP), noting that ‘it is time to take the next step.’ On August 9, CMS proposed a rule that included major changes to the existing MSSP ACO program, with the goal to push ACO organizations into two-sided risk models by shortening the duration of one-sided risk model contracts. Referred to as “Pathways to Success,” CMS’ proposal looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track and the ENHANCED track. Verma’s comments on Monday morning emphasized CMS’s firm stance on pushing healthcare providers to take on more risk, as well as CMS’s strategy of giving providers more flexibility—such as waivers around telehealth—as a reward to transitioning to value-based care.”

What’s more, Administrator Verma came to the webinar with data. As Landi reported yesterday, “For the 2016 performance year, the Next Gen ACO Model generated net savings to Medicare of approximately $62 million while maintaining quality of care for beneficiaries, according to CMS. Overall, that represents a net reduction of 1.1 percent in Medicare spending within that program, Verma said. The Next Gen ACO model began in January 2016 with an initial cohort of 18 participants. It should be noted that 15 out of the 18 NGACOs had prior Medicare ACO experience.

Verma was not shy about what she thought those metrics meant. “What this really shows is that these Next Gen ACOs are taking the highest levels of risk and they’ve managed to maintain quality while still lowering cost,” Verma said during the webinar. “Much of the savings achieved by the Next Gen ACOs were largely due to reductions in hospital spending and spending in skilled nursing facilities, and that’s very consistent with what we’ve seen with how other two-sided ACOs have achieved savings. We’re excited about this; we think it’s a very strong start.”

Good cop, bad cop?

I’m impossible not to contrast Verma’s statements about the Next Gen ACO program with how CMS characterized the proposal it released just three weeks ago, on August 9. On that date, as Managing Editor Rajiv Leventhal and Associate Editor Heather Landi reported, “The Centers for Medicare & Medicaid Services (CMS) is proposing a new direction for ACOs (accountable care organizations) in the Medicare Shared Savings Program (MSSP), with the goal to push these organizations into two-sided risk models.”

Further, they wrote, “Referred to as ‘Pathways to Success,’ CMS’ proposal, which has been expected for a few months, looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk; and the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.”

And, Seema Verma has made numerous comments now in numerous speeches to numerous different healthcare groups, making it very clear that she is becoming impatient with the pace of change in U.S. healthcare, and is determined to do something about it—with the support of Health and Human Services Secretary Alex Azar, her boss.

Indeed, Verma’s first in a series of speeches around interrelated topics of value-based payment and care delivery, patient/consumer empowerment, interoperability, and technology advancement, came as early as the HIMSS Conference in Las Vegas, where, on March 6, she “spoke of the need to move forward to empower patients with their data and information, in remarkably personal terms, recounting an episode in which her husband had collapsed while the two of them were not together, and was rushed to an emergency department, for what turned out to be heart failure,” as I reported at the time.  In the wake of her husband’s health crisis, she experienced the difficulty of accessing her husband’s health record, as an authorized family member. And that experience, she said, particularly animated the development of the MyHealthEData initiative she was unveiling on that date.

“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 she said back in March. 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.

The big picture: pushing on several levels at once?

It seems clear that Azar and Verma—certainly, with the help of Donald Rucker, M.D., National Coordinator for Health IT—are determined to acceleration the transition of U.S. healthcare providers into value-based healthcare, through a combination of different incentives, including a wide variety of carrots and sticks. And, not to mix too many metaphors here, but it also seems clear that her praise of the progress made by the Next Gen ACO program ACOs is evidently a “good cop” positioning, while she largely framed the relatively modest progress in the MSSP program in a “bad cop” sort of way, essentially telling MSSP ACO leaders that it was time to stop with upside-only risk, and move into two-sided risk as quickly as possible.

Of course, the risks in this kind of approach are significant. Not surprisingly, the National Association of ACOs (NAACOs) heaped scorn on the August 9 “Pathways to Success” proposal, with NAACOS CEO Clif Gaus saying in a statement released that evening, that “The administration’s proposed changes to the ACO program will halt transformation to a higher quality, more affordable, patient-centered healthcare industry, stunting efforts to improve and coordinate care for millions of Medicare beneficiaries.” According to Gaus, “The downside financial risk for patient care would be on top of the significant financial investments ACOs already make, jeopardizing years of effort and investment to improve care coordination and slow cost growth.” He continued, “CMS discusses creating stability for ACOs by moving to five-year agreements, but they are pulling the rug out from ACOs by redoing the program in a short timeframe with untested and troubling polices.”

So it seems to me that Azar, Verma, and Rucker, and their colleagues, are in a bit of a challenging place here, because even as the progress has been measurably stronger in the Next Gen ACO program compared with that in the MSSP program, even in Next Gen, it hasn’t been spectacular. Meanwhile, Verma’s attempts to push down harder on the levers of payment and regulation in order to turbocharge ACOs, could very easily backfire, causing more ACOs to leave the MSSP program than to switch to two-sided risk.

So this is a delicate, complicated moment. Will “tough love” and “good cop, bad cop” strategies at HHS and CMS really work? Only time will tell—but this feels like an important moment in the evolution of value-based healthcare, with no clear answers as to how HHS (the Department of Health and Human Services) and CMS officials might be successful in forcing transformational change forward, at a time when the coming U.S. healthcare cost cliff is looming more closely than ever before, just up a head. As Bette Davis said, as Margo Channing, in Joseph L. Mankiewiecz’s 1950 film “All About Eve,” “Fasten your seat belts—it’s going to be a bumpy night!”

 

 

 

 

 

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PODCAST: Dr. Rita Numerof on CMS’ New ACO Proposals: “It’s Been a Long Time Coming”

August 23, 2018
by Rajiv Leventhal, Managing Editor
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Earlier this month, the Centers for Medicare & Medicaid Services (CMS) proposed a rule that included major changes to the existing MSSP ACO (accountable care organization) program. As Healthcare Informatics reported, referred to as “Pathways to Success,” CMS’ proposal, which has been expected for a few months, looks to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years: the BASIC track and the ENHANCED track.

The broad takeaway from the proposal is that CMS has a clear goal to move ACOs more quickly into two-sided-risk models as the agency has noted that upside-only ACOs are not reducing costs and are costing Medicare money. “We project these changes will result in $2.24 billion in savings to Medicare program over next 10 years,” CMS Administrator Seema Verma stated at the time of the proposal.

Rita Numerof, Ph.D., co-founder and president of St. Louis-based consulting firm Numerof & Associates—and a recurring guest on the Healthcare Informatics podcast, notes that CMS has been trying to bend the cost curve for years. “They have been experimenting with different ways to ‘encourage’ providers to move in a direction to take on more risk. So I applaud CMS’ move to require ACOs to take on more risk, both upside and downside,” says Numerof on our latest podcast episode.

On the podcast, Numerof ponders, “Have ACOs been a good investment of taxpayer dollars? We are all paying for this. I would argue that they have been an expensive experiment. The intent was laudable…But the business model is fundamentally broken, and the underpinnings need to be changed.”

The podcast with Numerof runs about 20 minutes in length and keep in mind, you can listen to all Healthcare Informatics podcasts right here.

 


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