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Policy Considerations for the Secretary of Health and Human Services

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Healthcare is an area ripe for innovation. Overspending in a financing system too far removed from the doctor-patient relationship, inefficiencies in the lack of integrated data, ineffective identity management, and disparate IT systems that do not support personalized medicine are just some of the problems that contributed to the projected $3.35T spent on healthcare last year in the U.S.[i] 

Market-based innovation can help transform healthcare to be an efficient, personalized, option-based quality system, with the patient and doctor relationship at the center of care.

IBM is committed to enhancing the patient-doctor relationship and sees an informed patient as critical to its success. Further, an empowered patient can be a powerful agent of change throughout the healthcare ecosystem. We believe that: 

  • Patients should have access to their data, and have confidence that their data are protected. 
  • Patients should have the flexibility to use products and services across different healthcare systems, and have confidence that they all are working seamlessly for their care.
  • Providers – doctors, insurers, case managers, etc. – should have access to information, insights, and the tools and support needed to provide high quality, accessible, and affordable care.

To achieve this vision, we suggest that the Secretary of Health and Human Services (HHS) take early action in three key areas.

Watson Health1. Enable secure, trusted data access and sharing – a lynchpin to deliver more efficient, effective and personalized care.

Studies show that the more patients can access their electronic health records, the better they trust their doctors.[ii] Key to this trust is engaging with patients in a secure manner that protects their identity and ensures the accuracy of their information. 

Further, by timely connecting disparate data across care venues and using advanced analytics technologies, the private sector has demonstrated that we can curate information and provide meaningful data back with insights to drive more informed, personalized decision making. With IBM Watson for Genomics, for example, oncologists can use advanced analytics and cognitive technologies to help them quickly translate DNA data into recommendations for personalized treatment options for patients, by helping doctors identify potential cancer-causing mutations and mapping those mutations to evidence-based therapeutic options.[iii]

We recommend that HHS —

  • Quickly implement provisions from 21st Century Cures on interoperability and data blocking. 
  • Promote policies that would help to ensure the accuracy of patient information and identifiers and the security of data and applications, and provide decision makers with confidence that their information has not been compromised. 
  • Consider using blockchain to protect data in transit and at rest, rethinking the way in which records are kept and therefore the way in which doctors, hospitals, post-acute care givers, and patients securely access patient-specific data.[iv]

2. Use advanced technologies to improve program quality for our most vulnerable populations, including rural communities, the elderly, and other health disparate groups. 

Advances in technology coupled with the explosion of data – from medical records, journal articles and genomics, to wearables, social determinants and the weather – are helping clinicians take better care of their patients, government program leaders efficiently care for their clients, and consumers take better care of themselves.  Science has shown that health is much more than healthcare (including genomics), which typically only represents 30 percent of health outcomes. The remaining 70 percent is connected to these other key determinants of health: environmental, social, and behavioral.[v]

We recommend that HHS, in collaboration with states: 

  • Implement policies that promote access to use and integrate data related to these key non-health factors that impact health.
  • Apply advanced data analytics to enable informed decisions on new models for benefits and delivery, and to ensure the effective and efficient management of taxpayer dollars spent on Medicaid, Medicare and other social programs.
  • Advance a streamlined, quality measurement and reporting system that is transparent and rewards performance based on measures that matter to each patient and family.
  • Expand programs that develop algorithms to identify individuals at risk for chronic diseases (e.g., heart disease, cancer, and diabetes) and addiction, to determine unmet needs, to help manage treatment, and to monitor whether individuals are receiving high value care.

3. Ensure program integrity – use advanced data analytics to reduce fraudulent claims. 

Studies show that three to ten percent of payments in health care are fraudulent.[vi],[vii] Healthcare fraud costs the federal government billions each year.[viii],[ix] With the recent expansion of Medicaid and insurance coverage, we anticipate the risk of eligibility fraud rising. 

We recommend that CMS —

  • Continue to improve the accuracy and integrity of eligibility verification and provider screening to ensure only qualified individuals and providers are in the program. 
  • Focus on identifying and closing holes in the payment process including before claims are paid.
  • Apply advanced analytics, including cognitive analytics and machine learning to detect and support identification and prosecution of perpetrators of complex fraud schemes (which has produced effective results such as CMS recovering $6.10 for every dollar spent on antifraud activities.[x])

Now is time to transform healthcare with these market-based approaches. We stand ready to work with the HHS Secretary to improve cost-effective health outcomes for all Americans. 


Media Contact:
Adam R. Pratt
Ph: (202) 551-9625

[i]  U.S. Centers for Medicare and Medicaid Services (CMS). National Health Expenditure Trends and Projections, 1960-2025.
[ii]  National Partnership for Women and Families. Engaging Patients and Families: How Consumers Value and Use Health IT, 2014.
[iii] Dr. Ned Sharpless of UNC’s Lineberger Comprehensive Cancer Center explains the value of Watson for Genomics in the fight against cancer on a 60 Minutes special.
[iv]  The FDA and IBM have partnered to explore how blockchain can provide benefits to public health by enabling the secure,  efficient and scalable data exchange of patient-level data from several sources, including electronic medical records, clinical trials, genomic data, and health data from mobile devices, wearables and the Internet of Things.
[v] Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Reports. 2014;129(Suppl 2):19-31.
[vi] U.S. Department of Health and Human Services. (2015, November 13). Fiscal Year 2015 Agency Financial Report (p. 193).
[vii]  Morris, Lewis. Combating Fraud In Health Care: An Essential Component Of Any Cost Containment Strategy, Health Affairs 28, no.5 (2009): 1351-1356. doi:10.1377/hlthaff.28.5.1351
[viii]  U.S. Government Accountability Office, Medicare Program: Additional Actions Needed to Improve Eligibility Verification of Providers and Suppliers, GAO-15-448 (Washington, D.C.: June 25, 2015).
[ix]  Berwick, Donald M. and Andrew D. Hackbarth, “Eliminating Waste in US Health Care,” JAMA 307, no. 14 (2012): 1513–6, doi:10.1001/jama.2012.362. 
[x] Department of Health and Human Services and the Department of Justice Health Care Fraud and Abuse Program Annual Report for FY 2015.
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