Tommy Thompson at the 2018 Population Health Colloquium: A Declaration of Healthcare Independence

The following are the prepared remarks delivered on March 20, 2018, by former Department and Health and Human Services Secretary and Governor of Wisconsin, Tommy G. Thompson at the 18th Annual Population Health Colloquium in Philadelphia, Pennsylvania.

Introduction: A Declaration of Independence

It’s an honor to be here in front of so many esteemed health care professionals, presenting at the 18th Annual Population Health Colloquium, stretching across so many industries. Only in the city of “Brotherly Love” could so many divergent health care professionals, from so many industries come together so harmoniously. 

You can’t help but be inspired by history when in Philadelphia. With all the bright people gathered here today—everyone—why don’t we take a page out of the history books and create a little of our own?

Let’s be a little disruptive & come together and get something done.

We may not be able to do something quite as historic as John Adams, Thomas Jefferson and Ben Franklin did when they drafted the Declaration of Independence in 1776, I tend to think our opportunity is massive to create a little history of our own. In the Spirit of 1776…

Today I am Here to Declare our Independence: Data Will Deliver Consumers Independence from Today’s Healthcare System.

I tend to be an optimist…Today, we can Declare that Data Will Deliver our Independence from Today’s Healthcare! Why am I so confident?

The reality is that those that doubt the power of data in this changing healthcare marketplace are doomed.

Why Hasn’t Data Delivered on its Promise?

I made the Declaration earlier, “Data Will Deliver Consumers Independence from Health Care.” While I believe this to be true—the record up until now is best described as spotty. The common complaints fall into three categories—and I think it helps to think of them in simple terms—like a farmer would, which I’ll explain in a minute. I’d describe them as follows:

First, Plenty of Ingredients, No Recipe—Today’s big data situation in healthcare is not unlike having a kitchen’s worth of ingredients sitting on the counter, and no recipe. Perhaps a Top Chef would like this situation—but right now, there are more weekend BBQ cooks than top chefs around. What does all of this data mean…What am I supposed to do with it? This is a complaint voiced by everyone: clinicians, healthcare systems, insurers and employers 

Second, More Work than Results—I’ll let you in on one of my passions, I am a farmer at heart and still farm 1500 acres in Elroy, Wisconsin—where I grew up. In Elroy, if you dial a wrong number, you end up talking to someone you know for 30 minutes.

Sometimes, it helps to think of big problems, in simple terms-like a farmer.   Farming, can at times—seems like more work than results with no shortage of challenges; hours, seasonal unpredictability—it never comes easy.   But when it all comes together—green fields full of bountiful harvests, top-dollar healthy cattle casually roaming the fields with their young offspring, there’s no greater reward.

Big data right now is more like farming, than going to the grocery store. Today, big data feels like: buying the raw materials (soy and corn, livestock), buying the equipment (tractors, combines and fencing); and then staring at it—not sure at all what to do with it.

The data entry burden on clinicians, physician assistants and nurses are a massive a point of contention—especially when the output doesn’t provide value-driven, actionable data.

Third, The Unavoidable Family Friction —Who here hasn’t experienced the challenge of family members that can’t get along…short term or long term? Family friction—which at best includes family members that barely talk to each other or at worst, can’t even be in the same room! While the rest of us watch, and think, “Why can’t they get along…there has to be a better way!”

Family friction is not at all unlike the challenges of stitching countless data sources together and with great frustration, we exclaim, “Why can’t we get along…there has to be a better way!”

I think of it this way…Crazy Uncle Roscoe and Cousin Sweeny—both unique in their own way, might not get along—but aren’t bad people and important family members. Clinical and Claims Data…it’s healthcare’s Family Feud.

Data Can Deliver our Independence

What will it take for data to deliver our independence from today’s healthcare? The reality is as long as there’s money flowing, and no one is completely sure where it is going and what it is paying for—change will be a challenge. 

Well-aware of the frustration…current Secretary of DHSS and longtime friend, Alex Azar said it best during a recent speech in front of America’s Health Insurance Plans:

“…I assure you: Change is possible, Change is Necessary and, Change is most-certainly coming.”

The bedrock of our current health care system is paying for procedures. Paying for procedures, the bedrock—compacted, hardened and protected over time with insurers and providers and countless other supporting industries reliant on this solid foundation, for their success.

How do you break apart bedrock—it begins with a little dynamite—and in this case, there’s only one dynamite with enough power—it’s data.

Channeling Big Data into Smart Data

How we channel big data into smart data will define next-generation healthcare? Data can be that positive agent of change—and I think for it to be effective it needs to focus on four key areas:

1. FIRST-- Demanding Transparency between Payers and Providers

2. SECOND--Using Medicare and Medicaid as Market-Leading Value Change Agents

3.     THIRD-- Giving providers, including; clinicians and supporting medical professionals, administrators the right tools to turn volume into value for patients, systems and ultimately population(s)

4.     FOURTH—And Perhaps Most Important Giving Consumers True Control

First of all, if we allow the data to be protected, we protect the unsustainable status quo, allowing bad actors to thrive. Perhaps the single greatest threat to health care change is an unwillingness to share data. Payers have built their self-created economies, designed to protect their markets. Economies reliant on shielding data, including negotiated fee-for-service discounts, controlling the transaction and rising rates.

These so-called data silos, in which: payers, providers and their electronic health records vendor(s)—go through great lengths to protect and not share data and it is a gross and inexcusable process failure that hurts consumers. There’s no shortage of harm delivered by protecting these payer and provider data silos, including but not limited to:

1. Inability to marry costs of procedures and services to outcomes—preventing quality and value determinations

2. Preventing medical professionals from understanding how their care relates to outcomes

3. Hiding high costs providers

4. Hiding the bad actors guilty of fraud, waste, and abuse

I want to talk for just a moment about the hidden cost driver within health care—and it’s something that the data silos and lack of transparency have fueled. I am talking about a problem the FBI has estimated accounts for 10-15% of all healthcare spending—a conservatively-estimated $300 billion a year. I am talking about fraud, waste and abuse, the secret health care cost burden that the FBI identifies as the single fastest growing form of white-collar crime.

No one; not payers, providers and even employers understand the myriad of health care payment systems, providing incredible confusion as to who owes what to whom.  Here’s what should be stopped…but currently isn’t:

· An insurer that is charged 4 or 5 times for the same vasectomy—all within a given week, billed per different providers—all meet basic criteria and paid without question

· A doctor prescribing pain medication in a dosage one would use for a horse

· A doctor, radiologist and a hospital…all charging for x-ray services and diagnostics

Honest mistakes, I can’t answer that—but I do know how to put an immediate end to it.

Maybe you are thinking, “How can this be, my insurer and TPA are watching out for this—and I see the occasional story in which a health care fraud ring is brought down?” The reality is insurers and TPAs have little incentive to stop fraud waste and abuse—as their profits rely heavily on volume, not protecting client dollars. 

Paying claims first, and then chasing down fraudulent and wasteful payments after the fact—with a success rate often in the single digits. If this seems improbable, let’s think for a moment about a similarly-sized industry and how they’ve effectively handled transactions for over 40 years. I am talking about the robust, adaptive and incredibly effective credit card processing industry. The credit card industry has won, by not letting the bad actors out the payment door.

The credit card processing industry long ago ended the ineffective “pay and chase” model of attacking fraud and abuse. The credit card payment processing industry moves similar volumes of dollars as does the healthcare industry—but has a less than .05% (half a percent) rate of fraud and abuse. The “why” is obvious, the regional banks couldn’t afford that money leaving their pockets. The “how,” is a lesson that inexcusably should have been applied to healthcare long ago. 

Back in the ‘70s, individual banks struggling with fraud and abuse. Remember the carbons and manual slide machines—enabling a rate of fraud that was quickly climbing to +15%. Banks combined resources and built an electronic payment system complete with robust algorithms that stopped a fraudulent payment before it happened.

VISA and its competitive cousins—MasterCard, American Express, Discover have built and maintained a cost efficient and extremely effective system. Who hasn’t been on vacation and received that call, text and/or email, after trying to purchase a cocktail or two at the bar, asking if you were in-fact in Mexico?

Why doesn’t healthcare follow the lead of the credit card processing industry? The answer is simple, “The current system protects their financial interests.”

Here’s where I believe data can deliver a quick and near-immediate easy win for consumers, both subscribers and plan sponsors—as the “Visa for Healthcare” does exist—courtesy of 4C Health Solutions, a company I am proud to be chairman of. 

To address a long-ignored industry need, 4C has:

1. Brought together leading industry experts in healthcare, banking, and analytics. This is a team with the experience to disrupt.

2. Taken a page from the history books, and built health care’s only system that:

First, Intakes--any and all claims—using a modern electronic platform.

Second, Harmonizes--near-instantly all claims in a single database—we can immediately connect 1000s of data points across:

1.    medical systems,

2.    dental,

3.    pharmacy

4.    and facilities

Third, Analyzes--Utilizing historical claims data, next-generation analytics, artificial intelligence and other proprietary tools...4C scores claims:

1.    Confidentially letting good claims out the door, and

2.    Stopping the questionable claims at the door—before they are paid

It’s not a stretch to say no other company has the ability to make the near-immediate bottom-line impact that 4C can by preventing fraud, waste, and abuse. 4C has the value-driven outcomes…tested and market-ready.

Does the 4C solution really work? Absolutely—with jarring examples of fraud, waste, and abuse:

One of the largest industrial manufacturers in the United States asked us to look at their recent claims data:

Looking at 600+ variables, we found 16% of their claims—representing $100s of millions of dollars—were questionable or fraudulent

 An eastern state asked us to look at five years of their employee claims data:

 With variables nearing 1000, we discovered 15% of their medical claims were of concern—the dollar amount, which I am not at liberty to discloses—was truly shocking

You might be wondering, “Who is not interested in the 4C solution.” First, companies that are 100% satisfied with what they spend on healthcare—and if you know of such a company, let me know—we’ll cross them off of our target list. Second, and this is obvious, the entrenched fee-for-service silo-protectors

Using Medicare and Medicaid as Value Change Agents

The time has long-passed, we need to begin using Medicare and Medicaid as market-leading value change agents. The healthcare market in the United States is a conservatively-estimated $3.3 trillion. Our healthcare marketplace is bigger than the entire GDP of France, The United Kingdom or India, or more than the GDP of the 127 smallest countries combined.

Within our system, the single largest health care purchaser is the taxpayers—through our funding of the Medicare and Medicaid programs at $1 trillion. One-third of our healthcare spending goes towards these two programs with a rate of growth that routinely exceeds the rate of inflation.

Any conversation regarding a value-driven system of care, simply cannot exclude Medicare and Medicaid and its $1 trillion cost to taxpayers.

I firmly believe you have to look no farther than Medicare and Medicaid to understand how entrenched—and thick the fee for service/data protection bedrock truly is. There are examples of progress within as highlighted by the Accountable Care Organizations as the early value-driven model and the Medicare Shared Savings Program (MSSP) presenting promise of reaping strong financial rewards. 

Figuring out the right balance of risk, savings, performance & quality and financial reward will take a more robust data-engagement. For success, the winning formula will need to include: claims, HER, Patient Generated Health-Data (PGHD) are combined, along with prescription and medication adherence data with socioeconomic data layered over. The right IT-analytics tool will bring these unique data sets together, and most importantly is able to produce discernable action-able results.

Are we there yet? I think it depends on whom you ask, a late 2016 HealthyAnalytics industry survey was split: with 20% believing clinical and data analytics were very effective; and, another 19% having the exact opposite opinion. The remaining 61% reflect the current market, very uncertain. We have work to do.

Data: More Benefit than Burden

How do we make sure the data burden doesn’t outweigh the reward for the provider community as we seek value? Simply stated--the great promise of data is only as good as the willingness coupled with the tools to collect and analyze. 

The problem as I see it is two-fold: physicians, physician assistants, and support professionals are spending a growing amount of time behind the keyboard…and not with the patient; and, providers are collecting massive amounts of data, across varied platforms….and are struggling to make actionable-sense of it.

Starting on the ground, we need to build better tools to more-easily gather data. I tend to think the market is beginning to and will continue to address this needed evolution. More importantly, we need our healthcare clinical professionals to have the right training to understand what the data means.  

As you know, I take great pride in my home state, with the outstanding University of Wisconsin Madison Medical School being another example of what Wisconsin gets right. UW Medical School has created joint MD/Master of Public Health Degree. Why? Thomas Van Gilder a faculty/adviser says it best:

“It’s becoming increasingly important to know how individual patient fits into the overall population…we now have growing analytic capabilities to make decisions on those pieces of data…this is where the population health and value proposition is going.”

Dr. Van Gilder is right and be it tomorrow’s generation of medical professionals or today’s—immediate and ongoing learning is essential and understanding data and population health isn’t an option.

As I discussed earlier, having the right data management tools to combine; EHR data, administrative data and socio-economic data is essential. Only with a strong population health team, can any provider break the fee-for-service bedrock and transition to a value-driven system of care?

An effective population health team can play a significant role in keeping patients healthy & away from the office. How do you build such a team?

1.    First and foremost, it requires strong and unwavering C-Level support

2.    Add a dedicated investment in data—collection, maintenance, housing and analytic tools

3.    And finally, strong and diverse professionals to staff this essential and growing component of care. 

What makes a good team, I think it important to look both within and outside the system, focusing on:

1.    Healthcare analytics specialists,

2.    IT professionals,

3.    Nurse practitioners and physician assistants

4.    Add in behavioral scientists

I am constantly asked, “Tommy, I am either going to school (or already am a medical professional) what is the best field to get into?” My immediate response, “Get your MD and add a data scientist degree…preferably at UW-Madison.” I think even beyond the high-dollar, high profile-specialists—this will be the most sought-after skill set looking ahead. If you’re walking into today’s healthcare world, with an MD/Data Science skill set I have no doubt you’ll be able to write your own ticket.

Data Must Deliver a Win for Consumers

How do You Empower Consumers? Here’s a radical idea: consumers have the right to know what their care will cost—before, not after they get that service?

If a Payer can send a consumer countless copies of those annoying EOB(s) (Explanation of Benefits) after a procedure, why can’t they get their act together beforehand, disclose cost?

DHSS Secretary Azar encapsulate the vision and the current state of affairs at last week’s AHIP meeting: 

“Putting the healthcare consumer in charge… letting them determine value, is a radical reorientation from the way that American healthcare has worked for the past century.

…Simply put, our current system may be working for many…But it’s not working for patients, and it’s not working for the taxpayer.”

Empowering Consumers—making sure we have a system that is: transparent, value-driven and puts them at the steering wheel of their own care--will be very uncomfortable, for many entrenched stakeholders.

Think of it this way: Amazon is considered a potential threat to the healthcare status quo, why? Why would that nearly $200B company want to touch healthcare?

There’s perhaps no greater data success story than Amazon. Amazon is now responsible for:

1.    44% of all U.S. e-commerce

2.    $177.8B in 2017 sales revenue

3.    And now, with partners, Warren Buffet and JPMorgan/Chase is threatening to upend health care

To the penny, Amazon tracks every dollar, which allows them to:

1.    Identify high-cost, low-value products, and services

2.    Leverage data to deliver the lowest possible product costs

3.    Further leverage data to disrupt once standard services, like:

a.    Delivery

b.   Entertainment

Amazon has ultimately redefined the retail supply chain. On the consumer side, Amazon’s data collection efforts allow better targeting—using predictive technologies and artificial intelligence—it can predict what you need and even want before you need or want it! When Amazon started—as a simple bookseller, no one was predicting it would use data to upend the retail industry. 

Amazon offers zero apologies and no excuses, to anyone including those entrenched status quo retailers. Does this all sound rather familiar—Here’s my advice, bet against Amazon at your own peril.

Data can…and must deliver solutions to key questions like these:

1.    Why don’t consumers have full access to their health records?

2.    Why can’t the growing at-home care industry….and the consumer-friendly health monitoring wearables…be integrated into a patient’s electronic health records?

3.    And then there’s the industry’s most favorite and feared word—transparency.

4.    Why doesn’t full-care coordination happen—improving outcomes…reducing redundancy…and unnecessary or overutilization of service?

5.    Why can’t consumers shop for care... considering both price and quality?

The answer is simple—the industry is rewarded for protecting and shielding data, not sharing.

In many ways, we’ve already started down the path of empowering consumers—with all of the cost yet none of the tools through increasingly-popular high deductible plans. We’re telling consumers to play a completely different game, with the same unfair rules. Soon, data will rewrite the rulebook.

Closing: Data as an Ally

I want to finish by talking about, “The Declaration of Independence that Data Will Deliver Consumers from Today’s Healthcare System.” In the great book, “Thinking in Bets” by Annie Duke, Duke makes an observation that caught my attention and I believe applies to our conversation. Duke’s credits include; a dual-degree from Columbia University, a Doctorate in Cognitive Psychology from Pennsylvania University and Annie Duke happens to also be a repeat World Poker Champion, with over $6.4M in career earnings. 

Duke talks extensively about how we form our beliefs—sharing detailed studies that consider how we think we form our beliefs and how we actually form our beliefs.  

I am going to paraphrase a bit to fit our conversation—but here’s how we tend to think we form beliefs:

First…We hear (or read) something

Then…We think about it, vet it, determine whether it is true or false—AND ONLY AFTER THAT

Finally…We form our Belief(s)

Affirmed by countless studies, here’s how we actually form our beliefs:

First…We hear something

Then…We nearly always instantly pass judgment, believing it to be true or false

Finally…later—on occasion--when and if we have the time…or are challenged, do we get around to vetting—determining if it is true or false

The lesson is that while we tend to think we are contemplative, analytical and research-driven…the facts prove otherwise. Our current fee-for-service, data-silo-ed system, is how we actually form our beliefs: we hear; we form a belief; and, maybe consider later. To change our core beliefs, we need a disruption.

I tend to think data upends both belief models, providing the blueprint for a new model of care, and I think it will look like this:

First--We hear something—consider this patient input

Second--The clinician thinks about it, utilizing both experience and actionable data—harvested from a variety of sources…enabling a clinician to prescribe the best course of care. 

Third--There’s a patient output—a result.

Fourth—The output, and the various components of achieving that output, are measured. 

Those points of data…are stitched together…and used to derive a value-driven care model. The belief becomes the reality…a new value-driven healthcare model.

With Data as our Ally…We Can Deliver Consumers Independence from Healthcare. Thank you.