When most people think of innovation within the health care system, the startup community first comes to mind.
Another important player in enabling this type of innovation to become a reality? The U.S. Department of Health and Human Services (HHS). HHS is at the nexus of a really powerful lever to advance health care innovation, as a large purchaser that can drive early adoption, as a steward of health care data and also as a funder of grants to startups as they build their companies.
In this HealthChangers episode, we share a fireside chat between Bruce Greenstein, former Chief Technology Officer for the U.S. Department of Health and Human Services (HHS) and Lee Huntsman, professor Emeritus at the University of Washington, recorded at Cambia Grove. Together they explore the ripple effect of government innovations on the quality and cost of health care throughout the industry and what this means for our future.
Bruce shares what HHS is doing to move the needle on health care innovation and how health care stakeholders can get involved.
Leslie Constans: Welcome to the HealthChangers Podcast, presented by Cambia Health Solutions, where we share real stories of health care transformation from those experiencing it and those helping to make health care more personalized. I'm Leslie, your host.
LC: If you had to list what groups are creating change and innovation in health care, you'd likely say startups and entrepreneurs. You probably wouldn't think that the (HHS) also belongs on this list. With 80,000 employees and agencies such as the U.S. Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC), under its umbrella, HHS is a large bureaucracy, for sure, but with its size comes tremendous influence. In this podcast, we'll hear from Bruce Greenstein, who at the time of this recording was chief technology officer for HHS. He's now left that role, but he recently visited the Cambia Grove, a center for health care innovation in Seattle, to talk about the drive to make data, technology, and innovation a core part of HHS's mission. He spoke with Lee Huntsman, professor Emeritus at the University of Washington.
Bruce Greenstein: In trying to address the opioid crisis ... Congress has given several billion dollars to this effort and allocated it to HHS, through the Substance Abuse and Mental Health Services Administration (SAMHSA), CDC, Health Resources and Services Administration (HRSA), and through the Centers for Medicare & Medicaid Services (CMS) in a variety of ways.
How do we make the best decisions? How do we allocate those investment dollars?
Our goal being the return on investment and how many lives we save, how many people we impact, how many families we keep together, how many communities don't unravel. And we make those best decisions, whether it is what therapies have the most effectiveness in a given time frame, what states need the most money ... not based on population but based on true need.
"Our goal being the return on investment and how many lives we save, how many people we impact, how many families we keep together."
BG: We don't know the answer to those questions because we keep these data separate. So, part of what we do is this enterprise data strategy. Also, who is here for open data? Who loves open data, right? Who wants it to keep in silos, in lockboxes? No one! So why is it so hard? Because they're governed specifically by data-use agreements, and then, maybe even more difficult to change is that they're impacted by culture.
There are specific data sets [managed by date-use agreements) who run data sets that have been there for twenty-four years and believes that data set is theirs. And the data-use agreement is about how protective they want to be. And changing this massive bureaucracy into a culture of open data, sharing, connecting for the purpose of secondary use instead of just primary use is where we're going.
Primary use is going to be exactly what the data is collected for. If you run the immunization program, your goal is to produce the chart, book, or the end-of-the-year report that says this percentage of this population in this place had this attainment. Well, that's great. So, do it and make it the best in the world. But, that's not the end of the game. Because now I need to run that data against enrollment data and claims data and health plan data so we know who's doing a great job and who should get rewarded. And those that aren't doing a great job need to learn from those that are doing better or incented differently.
When it comes down to opioids, same thing. When it comes down to therapies, we don't know, unless we look at in-patient admissions, deaths, overdoses, and nonfatal overdoses to learn which [program] is better. It's one thing to look at the literature, which could be qualitative, but we need to see quantitative results. And that's what we're doing right now with these cases.
"When we think about health data, we tend to think about medical records. But ... your medical history is only a quarter of it. Your genomics is a big part of it. Your environmental factors and history is a part of it."
LH: Well, that makes a lot of sense why data is one of the pillars of where you're trying to go. But let's talk about that a little bit more. It's clear that there are a need and a potential to dramatically better utilize the data that's there. But when we think about health data, we tend to think about medical records. But if you think about what determines the health of the individual ... sort of that pie chart of health risks that they talk about ... your medical history is only a quarter of it. Your genomics is a big part of it. Your environmental factors and history is a part of it. And your lifestyle choices ... these are all big sectors of ... and there are more data to be had here. When you talk about this immediate challenge in HHS, which is huge and very valuable, is there a longer-term vision? Or is that part of the baton you're going to hand off? Or where's this going to go?
BG: When I think about the data that we make available, we make no data available that's from an electronic medical record. We make plenty of claims data available, but we do a lot with the rest. A company that was very interesting came to say, "We need access to more data." I said, "Give me the business problem you're trying to solve." And they said, "For people in your Medicare program if they are a low-income and have access to the subsidized drug program ... so-called low-income subsidy ... and they have access to either free or subsidized energy, (the heating assistance program), we show 29% decrease in hospital inpatient admissions for those that get it."
And I thought, all right, now this is interesting.
So that's really a good example of something that influences somebody's health outcome. But in this case, it's very targeted, it's very well thought through and there's evidence behind it and so we move forward on it. And this is the case as we do our Women Infant Children program (WIC), which is Women, and Infant, and children ... to be able to bring food and the ability to prepare food that gets paid for in programs in health care so we have healthier babies, healthier kids, and lower health care costs. We try to get both sides on each of these, but we'll typically take one or the other as wealth, it's just healthier or a less spend. But the idea is to get them both together and the best way to do that is to target the programs on the interventions that actually work. And that's what we're trying to do.
"Why is it that innovation somehow evades this piece that's so large in what we pay for?"
LH: Clarify a little bit. When you say chief technology officer and you say technology and innovation and data, what do you mean technology? Is it all databases, or are there other technologies in your toolbox, or how are you thinking about that?
BG: We apply technology in many different ways, I'll give you a few examples. One of my favorite programs that we're doing right now is around clinical innovation. And we talk about where kidney dialysis started for people with end-stage renal disease. And in the United States, almost all of the kidney dialysis services we buy from Medicare. And there are really two providers that supply almost 85% market share in this market; we spend a lot. It's 1% of the entire federal budget. This one service line ... we spend more on kidney dialysis in a year than we do on the entire NASA program plus the whole Department of Commerce put together. It's kind of interesting when you think about that.
And in the last sixty years, we've had ... I'll say zero innovation in this area. People from the industry will tell me how great they've done and they've cut four minutes off of dialysis and they have so much more effectiveness and people are more comfortable. It's basically the same. My mom died of kidney disease in 2008 and she was on dialysis for fifteen years. The first day she was on dialysis to the last day there was no difference. And that's fifteen years. Think about if somebody had cancer during those time periods, dramatically different approaches. If people needed arthroscopic surgery, just something as basic as that, dramatic differences. Dialysis: none.
Now, keep in mind, it does still keep people alive, so that's good. But in an area, that we spend so much there's been no innovation. That's one piece. We went out to the market to say, "Why is it that innovation somehow evades this piece that's so large in what we pay for?" And what we heard back was, "We think the government likes it the way it is. Because FDA and CMS and NIH haven't really paid attention to it. And we go ahead and you pay us a little less and we get more efficient and everything seems to be about right." And I thought, wow, that's kind of a crazy message that we're sending to the market.
"We bring our technology know-how and help business problems that we have in the department. "
BG: So, we teamed up with the American Nephrology Society, and we designed a program that would really kickstart innovation in this area. We brought FDA and CMS together for approvals and payment. We paralleled to compress the timeframe. If you are an investor, you can see your time to market will be shorter and your return on investment will come sooner. We also know that now we're asking for it. We're making this overt ask in the marketplace. We raised a $25,000,000 fund. We're making non-dilutive investments in novel approaches that will ... you can imagine what we're looking for. We're hoping for maybe an external and wearable or an implantable miniaturized dialysis machine that operates full time. Something that allows people to untether from. We're also interested in diagnostics and earlier-phase treatment to avoid end-stage renal disease.
We've done this really by reorganizing the market. So that's one piece. A couple other pieces that we do to technology internal to HHS, we won't call them failures because we try to intervene early so we have just troubled areas. Whether we're going to move from one Electronic Medical Record System to another in the Indian Health Services. They need help in understanding what is available in the market, how to diagnose their own needs, and so our team goes in to help them out.
In Medicare, dealing with appeals. There are millions of appeals from providers that don't get paid and we view this as sort of a supply chain of information problem that we bring our technology know-how and help business problems that we have in the department.
"As we start to think about things like autonomous vehicles and drones, information from the government is going to be important to establish and regulate those markets."
LH: You're at the nexus of a really powerful lever here to advance health innovation. And clearly, one thing is to capture that innovation to make better decisions inside of HHS. But if you look back, my impression is the federal government has been astonishingly important in health and health innovation over the decades; in other kinds of innovation, too. They not only are a big purchaser but they ... you mentioned non-dilutive funding. Well, non-dilutive funding from most of our enterprises is federal. That's the number one source, right? And it's hugely important. The other thing, though, is the federal government and its agencies have been early adopters of most, where did the internet come from, right? That's a direct path through Department of Defense (DoD), right?
And now we're talking about how do we innovate in health. We've spent a lot of time in this room agonizing over the fact that health care is not only a three trillion-dollar enterprise, and a lot its waste, and dramatically needs innovation, but that it is constipated, if you will, by the fee-for-service structure. And so, there's a huge role for HHS in advancing technology in both early-stage funding, non-dilutive support, but also early adoption. And is that part of the agenda here? And what can you point us to?
BG: Your question is perfectly illustrative. I could not even answer it and everybody would've learned because your question was so filled with content. It was great. And now you've got me thinking about it a different way. Let me approach the answer in two ways.
One is, when the government unlocks information that is either unique or at least unusual, economic activity can grow. Think about back to the '90s, we unlocked GPS data and I don't know how many industries benefited and were created from it, but it's enormous.
There will be more and more companies that are using claims data from CMS on Medicare fee-for-service and from managed care using that information to identify areas that are inefficient, ineffective, opportunities for better health outcomes and lower costs. I view that is in the supply of information side. And that's incredibly important and as we start to think about things like autonomous vehicles and drones, information from the government is going to be important to establish and regulate those markets.
Now, in terms of non-dilutive funding, we in the health system, you could think about National Institutes of Health (NIH) and Veterans Affair (VA) that run their systems, those providers are owned and operated by the payer and so you have complete alignment there. And no one likes anybody to go outside the network when that happens. There's probably a lot we can do better and things that we could learn. VA does some really incredible things in their system and the Indian Health Service been shifting over more in-patient intensive to more out-patient visits. And that's a function of how productive we can be, given our finite resources.
"It's an expression of humility on the government's side, no matter what administration it is, it says, 'Listen, we're not fast enough.'"
But I think the real key, especially for this audience is, the investments that we make in Medicare Advantage plans. So now we're at 35% of all the Medicare spend goes into Medicare Advantage plans. Every Medicare Advantage plan has an incentive to be able to produce their service at a lower cost and get better outcomes.
What does that mean? If you can assist the provider that is taking Medicare Advantage patients or you can assist the payer, the plan, in a way to reduce costs - overall medical expense - or to shrink the administrative costs, there's an incentive that is perfectly aligned there; and it's what we want to see.
It's an expression of humility on the government's side, no matter what administration it is, it says, "Listen, we're not fast enough. This isn't our sweet spot, but we're smart enough to know that if we shift risk from a fee-for-service payer environment to a market that is incented properly, we'll get better outcomes and more efficient operations from it.”
We've increased our commitment to the Medicare Advantage program. We've organized the quality structure, organized the payment structure better, and I think that is going to be where the locus of activity is in terms of innovation from the payer to provider space for a very long time to come.
"We want to bring HHS to the innovation startup and entrepreneur community around the country, not just Washington, D.C."
LH: Very important and most of us wouldn't have thought of Medicare Advantage as a potential customer. This is very good. You've made a very compelling case about the big picture and where HHS is going and the relevance to all of us. But most of the people here are in the startup community or closely allied to it. I know you had something to say about what HHS is doing this year that impacts them.
BG: On June 27th we're going to hold an event here called Startup Day. It's kind of a funny story how it all got started. At the end of a day in Washington, D.C., when we're kind of around the water cooler, so to speak, in the office and people said, "What's going on with you? How was your day?"
And I said, "I had three friends that came by, Congressmen that came in to see me."
"What were they doing here?"
"Well, they were ex-Congressmen."
"Well, what were they doing here?"
"They brought companies in."
"Why does a company need a Congressman to come see you?"
And I thought, man, that was a punch in the gut. I just enjoyed the conversation but really no one needs a Congressman. I put my email address out, there, you can see our Twitter handles, it's very easy to get in touch with me. First dot last name at HHS.gov. And it struck me that there is a great opaque barrier between startups and understanding how to engage HHS. And in my private equity days, even in my own companies that we were funding, I couldn't get them to address the federal health care market. And there were four areas that came up every time. Too long a sales cycle, unclear priorities, byzantine process, and don't know who to call. Every time it was the same four ... maybe a couple of others, but those four remained the same.
We wanted to design a program that has two benefits. One is for the startup community. We want to bring HHS to the innovation startup and entrepreneur community around the country. Not just Washington, D.C., one day a year, but really go around the country and get ourselves embedded in each of these communities where innovation is happening. We're doing that and usually we bring people from Federal Transit Administration (FTA), CMS, sometimes NIH. We try to focus who we bring to really explain how to engage with HHS, what the opportunities are, what we're going to go out to bid with soon. What are some of our programs that they could take advantage of? That's the main goal.
But really there's another part, and that is to teach HHS to get out of Washington, D.C., or get out of your office and go see real people that are struggling to understand how to help fix the health care system, how to address the health care economy, what it takes to grow a company, how hard it is to penetrate the federal government, whether it's understanding who to call or how to get in. So that's my little sneaky way of trying to address the cultural issues within HHS.
LH: Please join me in thanking Bruce.
LC: Thanks for tuning in for this episode of HealthChangers. You can find more information on all of our episodes at cambiahealth.com. You can also follow us on Twitter at @cambia. Please subscribe to HealthChangers on iTunes or Stitcher and leave a review. Thank you for listening.