Datapalooza: MACRA, EHR Reform and Working with Doctors – Not Against Them

Screen Shot 2016-05-12 at 8.45.31 AMThere’s a bit of a checklist for speaking at Datapalooza. Thank Niall. Mention Todd Park. Remark at how big the event has gotten compared to last year. Recap how much progress has been made. Refer to yourself as a “data geek” . Also, have in my notes “Good not to follow Farzad or Aneesh” . Perhaps even make some news with an announcement or grant or contest. Several of my colleagues did this and I share their excitement.

But I’m not going to make news. Instead, I’m going to relay a bit of my personal experience with health care innovation and technology as my goal is to leave this job with nothing really left unsaid. Twitter, by the way, seems to be helping with that.

Lately, we’ve been contemplating a significant transformation of the Medicare program by implementing the bi-partisan MACRA legislation. Legislation to make a wholesale change in the Medicare payment system to pay for quality. This has caused me to begin an obsession with the plight of independent physicians, knowing as we all do that if we don’t invest in primary care, we’ll invest double or triple when people get unnecessarily sick. And as a steward of programs where people with the lowest incomes and in the most remote locations get care, I know that without access, it will be people that can afford it the least that suffer first and most.

Starting in January, we began an unprecedented effort to engage and listen to physicians and patients and close the gap between policy-making and front line care. We had more than 6,000 conversations with physicians, with patients, with innovators in local communities, in their office, in focus groups and in workshops — collecting stories and seeking criticism we could act on. I’ve listened to a number of stories of doctors who feel burned out and eager to retire, but who hang in there only for their patients.

We have had extraordinary learnings. Learnings that come only when you spend months and months listening to thousands of physicians, patients and other clinicians all over the country. With many hours of observations, what became clear was that the combination of technology, regulation and measurement took time away from patients and provided nothing or little back in return. Among other things, physicians are baffled by what feels like the “physician data paradox.” They are overloaded on data entry and yet rampantly under-informed. And physicians don’t understand why their computer at work doesn’t allow them to track what happens when they refer a patient to a specialist when their computer at home connects them everywhere.

Through these conversations, one thing became very clear. As we move to a system based on quality measurement, we need to radically simplify and support physicians and patients with technology that works for them. What we call “interoperability” at this point would not be considered an impressive achievement by physicians. At best, it would count as making the technology work. A specialist in Chicago told us, “I think that the one thing that this really could’ve added to patient care is the one thing that hasn’t happened. The systems don’t talk to each other. It’s actually the opposite. With one of the EMRs I used, I can’t even access it at the hospital because of the firewall. I can’t even get into the EMR at the hospital to look at patient records.”

Discouraging? I have a hopeful experience with technology that started out . . . discouraging.

I arrived in Washington two-and-a-half years ago and the occasion for my arrival was that technology was putting national health reform at risk. Health reform that we had waited so long for. Tens of millions of Americans needed health coverage and we waited for the technology ofHC.gov to deliver. Once again, technology was the problem.

Until it wasn’t. After a while, except for some aftermath stories, you never heard about the technology again and next thing you know, we had 20 million new people covered with health insurance.

What you didn’t hear was that within months after we had technology functioning, for the first time across the country, we were using technology to do things that had never been done before and redefining the very value proposition of health insurance.

  • Using complex analytics, and a real time data hub, we were signing people up for coverage in real time when up until then, in Medicaid, for example families and children had to wait months to find out if they were even eligible.
  • By last year, technology had redefined the way health care is offered and purchased in America. The easy comparison of plans has brought down prices and created more service offerings. People who shopped and switched plans saved an average of $500/month and many “direct services” are now offered outside of a deductible to lure consumers.
  • And consumers changed the way they shopped. On a daily basis, gov crawls the websites of all the health plans for their provider directories and formularies. So instead of looking for a health plan, consumer can search for a prescriptions drug they needed or a doctor or hospital they want to see and the technology will match them with a plan.
  • Last year, in a single day, we watched as 500,000 people, many using mobile devices, signed up for coverage.

Health insurance costs less and offers more services because information was put to work for people. Just like it has in so many areas of people’s lives, like buying a car or getting same day shipping, technology has made our lives better and made a system work better.

What was responsible for the shift? A relentless focus on getting the customer what they wanted and making it a clear national focus. 

I relay this as I stand here today with eight-and-a-half months left in Washington because I can’t help but reflect on the parallel set of circumstances as it relates to technology and innovation in care delivery. Like the major change we went through as we improved access to coverage, we are now on the cusp of an equally transformative change in quality and affordability– paying physicians and hospitals for providing the right care. Yet now, while technology supports us in getting coverage, it is failing us in the care experience.

Health care is actually full of the same tasks over and over– getting a referral, getting discharged from a hospital, scheduling a follow up appointment. Yet the system treats us as if we’re doing everything for the first time and seems remarkably surprised by our activities. Robots can perform your mom’s surgery. But reminding her to fill her prescription? No! Telling her primary care doc how the surgery went and arranging a follow up? Seems to be too hard.

And guess what we know: all those things that happen to her after the surgery can be just as important as what happens during the surgery. Technology isn’t doing the things we know it can– help us make smarter decisions, reduce our wasted time, help us communicate or understand what to expect next.

I have the same feeling we faced two-and-a-half years ago as we turned around healthcare.gov. Physicians may be more skeptical now about the promise of IT than anyone was at that time. But just as we did then, we must re-focus on our customer and we must rise above our proprietary interests to make this a national priority. Having seen it happen, I know we can get this right.

So what are we doing about it?

This leads back to the MACRA implementation and the opportunity it gave us to re-think Meaningful Use. We may have surprised people with the changes we began to discuss, but it wasn’t discouragement, but confidence, that caused us to make this move. Confidence that if we worked closely with patients, clinicians, and the private sector, we could change the focus from payments and measurements and programs and a fragmented experience back to supporting patient-centered care. We committed to taking a page out of the consumer technology playbook and taking a user-centered approach to designing policy.

What we learned in all of our listening reinforces our effort around five significant strategic steps we have been undertaking:

  1. The massive, unprecedented release of data which this conference has been all about.
  2. Changing incentives through the CMS Innovation Center to pay physicians and hospitals more for practicing quality and coordinating care.
  3. The creation of a single set of “core” quality measures across all payers so physicians can just do it one way for all their patients.
  4. Advancing interoperability, requiring Open APIs and exposing data blocking practices so data can follow a patient and new apps can become plug and play.
  5. And, a proposed replacement of Meaningful Use and streamlining of quality measures to put the needs of the users — clinicians and patients — back in the center.

These steps are designed to make it easier for you to innovate, to open up competition, and to move the focus from designing around regulations to allowing you to design around patients and physician’s needs. So, as I speak here for the final time as the CMS Administrator, the opportunity for you to transform health care into an information industry has never been more ripe… or more urgent. No new inventions needed. Just three things I ask you to think about.

  1. Take stock of where you are in history. 

It’s time to think bigger. If it’s true that change breeds opportunity, as we implement MACRA to fully change Medicare payments to pay for quality, we are in the midst of the biggest change in our health care system since the 1960s and the beginnings of Medicare and Medicaid. Twenty million new people are accessing coverage; a boom generation is turning 70 and the 85+ generation is set to double in the next few years, taxing families and the system like never before. The affordability of health care and prescription drugs in specific is a top-tier issue for consumers by almost any study. And disaffection among physicians is significant, overloaded by change, lacking in support and fearful that their profession and independence is under assault.

For all of these macro changes, very little technology has yet to be created to make this change work. In short, it’s the perfect time to be an innovator. You can help change the course of history. We must learn how to take care of people better in their own homes and communities. We need to empower physicians so that technology improves their morale, not saps it. An entirely new operating system for health care will be needed to support it.

  1. Second, find those out-ahead physicians that can define the needs for everyone else.

I sat down with a physician from Vanguard Medical Group, a primary care practice in New Jersey to listen to input on the roll out of the Quality Payment Program. Dr. McCarrick told me that since his practice became a medical home and was given the incentives and freedom to take care of patients the way they wanted to, his office has exploded with innovation. He told me that now that payments have caught up with the way they wanted to practice medicine, he can focus entirely on caring for his patients. He’s found new ways to reach his aging and increasingly lonely and isolated patients. He’s creating Skype “villages” for elder, disabled, homebound patients so they can now not only talk to their physician once a week, but their sister across the country, their granddaughter in college, and other people in their same situation.

Dr. Bevill in rural Arkansas, who is also an early participant in a payment model rolling out now across the country, told me that unlike most physicians he talks to, he has figured out how technology can help him spend more time with patients when they visit. All his patients are risk stratified and a care coordinator leaves an iPad in the exam room displaying everything he needs to know on it, including all prevention and screening recommendations. He says he leaves it lying flat so it doesn’t get in the way of the conversation with the patient.

These physicians that are already in medical home models and bundles are at the leading edge of a huge wave. Already roughly 11 million patients are in a Medicare ACO. We’ve just launched the largest medical home model in history. As of April, approximately half of all hip and knee replacements are being paid for in a bundled payment requiring inpatient and outpatient collaboration. And next year, as the new Quality Payment Program that is introduced by MACRA, every Medicare physician will be in a program that rewards quality and coordinated care in some form.

Physicians don’t need to get “pushed” into using technology with incentives to show they’re clicking. They are “pulled” in because they need collaboration tools. The purpose of new payment models is to give care providers the freedom to do what they think is right. Your opportunity is to allow it to happen. Go find them and talk to them– design for them.

  1. Finally, with respect to some important business practices: it’s time to lead, follow or get out of the way.

At CMS we oversee the care needs of 140 million Americans in Medicare, Medicaid, CHIP and Marketplace plans. When you microscope their lives, almost all have moderate or fixed incomes and face a fragmented, mystifying health care system at their most vulnerable time– finding a nursing home for a parent, waiting on a biopsy, traveling by bus to a dialysis center, caring for a child with a disability. All of the handoff points are where the avoidable complications kick in.

If you want to lead the way with innovations that help consumers, great.

If you want to follow by using established standards for data and measurement and technology, also great.

If you have a business model which relies on silo-ing data, not using standards, or not allowing data to follow the needs of patients, pick a new business model or pick a new business. What Vice President Biden said should stick with us– as taxpayers, we did not spend $35 billion so companies could build their own silos.

There are a set of patient-friendly business practices everyone should follow:

  • Eliminate language from contracts that slows down the ability of the system to plug and play.
  • Make all your data machine readable and put it on an edge server so it can be securely and easily called to answer questions.
  • Provide physicians with data on their patients in real time and with feeds into their workflow, not your portal.
  • Use open APIs to be sure your technology is plug and play and with that, break the lock that early EHR decisions have placed on the physician desktop.

At this stage, there is no room for business practices that don’t match the need of patients.

Without better connected and easier to use technology, I worry most about the people with the least access to care. I worry about the independent physician practice. I worry about our country’s Cancer Moonshot. But mostly I worry that the moral underpinnings of our public-private health care system won’t support where we need to go. And that will mean our chances of any meaningful success will be held up, not because we can’t do it, but because we won’t do it.

When we put our minds to it, I have seen how much technology can radically improve health care and how fast. MACRA is the burning platform for progress in care delivery, just as the ACA was in health care coverage. Together, we can make the system radically better.

My job, like all of yours is filled with moments. Moments of human interaction that stand out. Some have snapped me to attention and action, like the time I spent at a dialysis center with people whose kidneys were slowly failing. Or when I met with Denis Heaphy, a young man living with disabilities in Boston, but who flew down to meet with me in D.C. because there was something I could do to help make sure he could continue to live independently. Letters from people whose lives were saved because they got insurance for the first time.

I had a moment last week that I will always remember, especially with my drive to simplify for medical practices. It was the last few minutes I spent with Dr. Bevill from Sama Healthcare in Arkansas– the one with the iPad and the focus on prevention. He showed me a photo of the entire office staff who wear t-shirts that say “Team Sama” and patients coming in to see him who say “the atmosphere feels electric.” Then he leaned over and confessed to me that his partner had been planning to retire, but now that he was free to practice medicine, he plans to practice until at least 70. As I looked at the picture, I noticed a quote from the Sama practice manager Pete Atkinson that made it all make sense in a way I know Vice President Biden will appreciate. It’s simple– “We find a stage 1 cancer rather than a stage 3 cancer.”

Let’s go help everyone do that.

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11 replies »

  1. I attended Andy’s speech as well, at Datapalooza. It was a potent statement. What stuck out for me were his musings on the “plight of the independent physician.” He said he and the senior staff at CMS understand fully where the doc concern and criticism is coming from– the burn-out, the burdens, the extra work, less time with patients, data-entry overload, the cynicism born of the MU experience. But he also clearly wanted to deliver a message, which could be summarized as this:

    We hear you and we understand, but we have to keep moving forward to fundamentally change the nature of the way medicine is paid for, and in part, practiced. That can’t be put off. The status quo does not work and is not acceptable. MACRA represents the biggest change to Medicare since 1960s, and it’s just gonna take time to play out.

    Being CMS administrator is no easy job. Andy serves credit for keeping his eye on the long-term ball game.

  2. A colleague of mine returned from Datapalooza with literally 91 key points within 8 categories – I just recounted them – so maybe that’s an analogy of the healthcare delivery/health IT technology challenges seemingly so dizzying to caregivers. If MACRA is the administration’s culmination/swan song of value-based care, some care is in order. Yesterday I presented a MACRA proposed rule webinar to an anxious audience and a couple of themes emerged: get me out of here and what am I supposed to do now. As much as I emphasized alignment and reporting decreases and selection increases and the virtues of CPC+, for example, the Q & A included thoughts on whether providers should shift all patients to Medicare Advantage and how I felt about John Halamka’s nuclear option quote – also published in THCB. That and ongoing questions of whether it all means providers should attest to MU in 2016 or not made clear the confusion of 2017/2019. I think it’s a long way of saying the forest/trees of MACRA need to be better articulated by CMS, and that the proposed rule’s Table 32 featured a lot more “Nos” in column 1(if not in column 6) than my audience anticipated. They all may understand the movement to or rationale of risk-bearing models, but saw MACRA not as an invitation but as an obstacle course. Hence the comment phase, I noted. Crickets.

  3. The federal government can solve data blocking silos in one of two ways: they can mandate the technology or mandate the outcome. Through $35 B of HITECH, the federal government has chosen to mandate the technology through certification rather than mandating the outcome of first-class access to personal data as a right of the individual person. In effect, the federal strategy of HITECH, Meaningful Use, and now MACRA is to allow the data silos to both hold the data they have and to control who can use it. The fox is guarding the hen-house. The government’s own JASON reports called attention to this failed approach to interoperablility multiple times.

    Certification of technology will not solve data blocking because the federal government, patient advocates, and physicians cannot control the standards that are required for interoperability. Standards-making is the exclusive domain of vendors and institutions and no amount of FACA-driven certification can change that because the standards process is inherently a multi-party exercise by the economic participants. In the US, EHRs are not purchased by the patients or by the physicians so we have no market power in the standards process. The federal government does purchase a significant fraction of the EHRs for VA, DoD, and Medicare, but as we have seen, these purchases are not made with an eye to citizen-cantered interoperability but rather they reflect the political clout of the non-government economic participants.

    Data blocking will end when patients have the right to control uses of our personal data and full transparency of how our data is used by the institutions that hold it. At that point, the cost of interoperability and the corresponding standards will be baked into the cost of the service that a hospital or health plan provides.

  4. Just help get us develop an EMR that works efficiently across “silos” and is focused on easy access of patient information and medical care, not billing and meaningful use.

    Then ease administrative burdens on primary care, shift some of the RUC payments to “cognitive” services, and get out of the way

    It doesn’t have to be complicated, despite your best intentions to make it so.


  5. I approve this message whole-heartedly. But in the comments here, there seems to be a bit of a debate about how forceful the government should be in moving this nation’s healthcare system into true interoperability and beyond toward the myriad ways in which a wise and creative use of information can give us healthcare that is both far better and far cheaper.

    Paul calls the ” lead, follow or get out of the way” a “giveaway,” intimating that Slavitt and the Obama Administration are somehow hiding their true intentions to “impose massive changes to the nation that we hope will work.” Whereas Dr. Evil wants CMS to be far more forceful, using legal means to force vendors to heel (though his concerns seem to focus more on data security than patient care).

    I lean strongly toward the side of Evil. The business decisions of some major vendors to aid, abet, encourage, and in many cases contractually require the building of incompatible silos across healthcare is not just stupid and massively wasteful, in its impact on the actual lives and suffering of patients across the country it has been a major tragedy. I am no lawyer, but it sure looks like criminal activity to me.

    We don’t have to speculate about what will happen without strong leadership and indeed imposition of massive changes. It has already happened — a mess that kills people by the tens of thousands, wastes hundreds of billions of dollars, slows down change, and causes untold suffering across the land. Of course the government has to be careful and thoughtful about just how it does this and has to listen carefully to clinicians and patients about what works and what doesn’t. This is exactly what Slavitt is talking about. But somebody has to get the industry to change, and I don’t see anyone else around with the power, the incentives, the knowledge, and the right intentions to make that happen than the federal government.

  6. Bravo Dr. Slavitt: You speak our truth. Excellent insight into Moral Dilemma in USA

    via TweetBot

  7. The tone is pretty conciliatory, and the intentions are good, but the giveaway is this quote from the piece: ” lead, follow or get out of the way.”…..as we impose massive changes to the nation that we hope will work (even though all the previous experiments haven’t) and will only cost a few (hundred?) billion.

  8. This is a good post, but the reality on the ground is very discordant. The IT infrastructure is so polluted, it has made improvements and good ideas nearly impossible. Communication has deteriorated, and that is compared to paper! I am glad you are waking up to the nightmare that physicians have been enduring for the last decade. I hope you can help right the ship. I hope you are not too late. The corrupt influences are deeply entrenched.

  9. I was at Andy’s speech, and Biden’s and an interesting HHS convo on Wednesday. The money quote is “What Vice President Biden said should stick with us– as taxpayers, we did not spend $35 billion so companies could build their own silos.”

    via email

  10. Mr. Slavitt has clearly read the memo. But it will be hard to take CMS seriously until Washington does something to force the vendors to change. We need more than scolding and a “you need to think about the business models you folks are imposing on people.” Set up a phone call with the state attorneys general, Mr. Slavitt. Talk to them about the security risks involved for consumers, the costs to taxpayers and the clear violation of the spirit of HIPAA. Make this happen.

    via e-mail.