Dr. Oz describes a reimagined, technology-driven healthcare ecosystem

A rapid acceleration of digital healthcare applications and a sharpened focus on fraud, waste and abuse will be central to the looming transformation of the U.S. healthcare system, Mehmet Oz, MD, administrator of CMS, told a healthcare audience Wednesday.

Oz spoke May 21 in Manhattan at the Not-for-Profit Healthcare Investor Conference, sponsored by HFMA, Barclays and the American Hospital Association. He sought to explain to an audience of industry stakeholders why big changes to the healthcare system are necessary.

“I came to recruit you to help,” Oz said. “The magnitude of the challenge that we’re facing is scary, but you never want to waste a crisis. This is a generational opportunity for people to come and help play a role in whatever way possible.”

The impetus for change can be seen in several aspects, he said, including the increasing strain of Medicaid on federal and state budgets, the much-publicized disparity between spending and population health outcomes, and the prevalence of medical errors.

“We need more sophisticated, multifactor approaches to many of the challenges that we’ve [discussed],” Oz said. “I actually think they’re doable because the political will to make some of these seismic shifts exists now.”

A digital revolution

Oz hopes to drive improvement in areas such as bureaucratic overreach and prior authorization, but he said the industry needs to think bigger than that.

One example can be seen in a request for information (RFI) that recently went out to stakeholders on ways to create a healthcare technology ecosystem for Medicare beneficiaries.

The day is fast approaching, conceivably within a year, when Medicare beneficiaries get messages on their phones prodding them to take action on a basic health issue or holistic issue such as exercising or staying connected to their social networks, Oz said.

That interaction also will allow beneficiaries to describe symptoms or concerns they’re experiencing to a customized AI avatar, tailored to a beneficiary’s specific demographic and circumstances. If needed, the avatar can make an appointment with the patient’s physician, including finding patients a physician if they lack a primary care relationship. Full details of coverage terms and out-of-pocket costs are conveyed.

“When these kinds of more sophisticated tools exist and they can talk to you, and it’s not confusing and it cuts through the morass of seemingly bureaucratic phraseology, it actually becomes something that’s actionable,” Oz said.

The idea is for the new system to be more consumer-centric than the healthcare system traditionally has been.

For example, one predictor of high-cost Medicare cases is a beneficiary’s struggle to understand medical information, whether because the beneficiary speaks a language other than English or just because the information is complex and jargon-filled.

“We want to try to deal with those issues in ways that is hard normally for a system to address,” Oz said. “But we’re blessed to be in an era where we’re starting to wander into tips and tools that might work there.”

What it means for providers

When the patient in that new ecosystem arrives for the appointment within a day or so of the initial prompt, the physician already has had time to review the issue in the medical record.

“Now you can take that information and begin to act on the patient pretty quickly,” Oz said. “In fact, in the beginning, you may not have your staff talk to the patient. You may have the same AI avatar collate everything and deliver it in a fashion that’s much more accessible. So you don’t have to be Columbo searching for information. It’s all delivered to you.”

Follow-up information about medications and recommended imaging or lab appointments is at the physician’s fingertips as well.

“The physician’s not spending a lot of time, nor the nurse practitioner, to do all these efforts,” Oz said. “This stuff gets wrapped back in and is delivered, and the decision support is there.”

Paperwork, coding and charting are deemphasized in that scenario.

“If we can breed mediocrity in coding, it’ll be a good thing for the healthcare system,” Oz said. “If coding is not all critical, it will be nice.”

A role for big health systems that can optimize the technology, Oz suggested, potentially will be to support nearby under-resourced institutions through formal partnerships.

A sprint for solutions

The need to better leverage technology is why Oz is open to welcoming private equity as a healthcare stakeholder rather than trying to keep PE interests at arm’s length due to concerns about unintended consequences.

“Private equity is a way of supporting insurgents with really good ideas to compete against the big boys,” Oz said.

The idea is for CMS to create the infrastructure where such ideas can flourish and then allow innovators to race to develop solutions in what would be a competition of sorts.

“Part of the goal is to empower massive companies and the itty-bitty little insurgents to create data lakes with all the information that’s out there,” Oz said. “Or use a federated retrieval process where they go to the clinic, they go to the hospital, they go to the doctor’s office, they go to the pharmacy, they gather your data and you [as providers] give them permission, you don’t have to [formally] participate.

“We gather that data, we have open APIs, and app developers bring solutions based on those big data sets. And then we [at CMS] are going to make sure the financial model works.”

Targeting big savings

It’s unclear how expensive such a vision would be to implement, but Oz also has goals for slashing healthcare costs.

The Trump administration has described weeding out fraud, waste and abuse as a priority across the government, and Oz said the issue is critical in healthcare.

The issue is with abuse even more than billing fraud, he noted.

“You have the reality of Medicaid beneficiaries being registered in multiple states,” Oz said. “That’s about $4 billion a year. But even worse is within a state, being on Medicaid and being on an Affordable Care Act [ACA] exchange [health plan]. That’s about $10 billion a year.”

He added, “There’s almost a quarter of a million people who last year were signed up for the ACA [and] didn’t know it” due to the actions of insurance brokers. “It’s very destructive to the infrastructure of the system because the federal government’s paying money out, but we’re not getting any money’s worth, not value for the American people. And because we don’t pursue these things, people do it more and more.”

Oz supports the Medicaid work requirement contained in the budget reconciliation bill currently being negotiated among Republicans in Congress. Able-bodied adults would lose Medicaid eligibility if they do not spend at least 80 hours a month in some combination of working, volunteering, caring for a family member, and getting education or training.

“How we track it and make sure that the wrong people are not taken off the [Medicaid] rolls, I get all that, and that’s important,” Oz said. “That’s our challenge. But if we can do this correctly, and I believe we can, that should be a reasonable series of [expectations of beneficiaries].”