The Healthcare Policy Podcast ® Produced by David Introcaso (David Introcaso, Ph.D.)

Listen Now

In this 38 minute interview Dr. Reischauer defines what's meant by the "fiscal cliff" and what's problematic about it near and long term.   He discusses what the Congress can possibly achieve during the lame duck session concerning unemployment insurance, the AMT (Alternative Minimum Tax), the so called "doc fix" and how sequestration might likely be addressed by the Congress and/or the administration. The sunsetting Bush-era tax cuts, Medicare and Medicaid reforms, the "absurdity" of the debt ceiling and social security are also all examined.

Dr. Reischauer is one of the two Social Security and Medicare trustees.  Up until recently he was President of the Urban Institute, a nonpartisan social and economic policy research institute.  Presently he serves as Urban's Distinguished Institute Fellow and President Emeritus and as well Senior Fellow of the Harvard Corporation.  Among other positions, Dr. Reischauer was Director of the Congressional Budget Office (1989-1995) and a member and vice-chair of the Medicare Payment Advisory Commission (MedPAC) (2000-2009).  He was graduated from Harvard and Columbia universities.

Listen Now

In this 35 minute podcast Ms. E. Diane Champé discusses the prevalence of child abuse and her personal experience as a victim and a survivor.  She explains how and why the issue receives little attention, for example, responses she has received on Capitol Hill and elsewhere in attempting to draw attention to the subject and the inadequacies in abuse reporting and data collection, in federal research in the dissociative disorders and in ADA (the Americans with Disabilities Act) accomodation for employees with mental health diagnoses.  Also too she discusses time limits, due to statutes of limitations, survivors face in suing their abusers in civil court. 

Ms. Champé's work on behalf of adult survivors includes hosting a survivors' website at www.edcinstitute.org and speaking publicly about the long-term effects of child abuse and neglect.  Ms. Champé is also a member of Maryland’s Victim Services Professional Network.  Her more recent work includes participation in a national trauma campaign for SAMHSA (a division of the U.S. Department of Health and Human Services) and in the State Public Systems Coalition on Trauma.  She's presented before the US Congress, state and local officials and institutions of higher learning.  Ms. Champé recently established a 501(c)(3) social service agency, the E. Diane Champé Institute, which will provide safe havens for adult survivors of child abuse and neglect.  Her autobiography Conquering Incest: My Life as a Trauma Survivor was published in 2011. 

Listen Now

In preparation for further federal health care policy reform anticipated next year several plans are floating around Washington, D.C., all promising, among other things, to "bend the cost curve" or improve health care affordability.  In this 33 minute podcast Mr. Rother briefly defines National Coalition on Health Care's goals and how and why its health care affordability reform proposal, "Curbing Costs, Improving Care: The Path to an Affordable Health Care Future" was created.  He moreover discusses options in the plan beginning with several "game changers" identified in the report, i.e., reforms that pay for value or outcomes instead of services or volume, reforming how Medicare pays doctors, options for limiting the tax exclusion employers receive in providing employee health benefits, and taxing sugar-sweetened beverages.  He outlines reforming chronic disease care, improving medication adherence and lowering drug costs and reforming the private insurance markets via value based insurance designs.  More thematically he discusses market competition, active purchasing and transparency.  Finally, John describes what has been Congressional leadership's reception to the plan and chances next year for legislating any number of these affordability reforms.

John Rother is President and CEO of the NCHC, America's oldest and most diverse group working to achieve comprehensive health system change.  Prior to NCHC, Mr. Rother was for over 25 years the Executive Vice President for Policy, Strategy, and International Affairs at the AARP (formerly the American Association for Retired Persons).   From 1981 to 1984, Mr. Rother was Staff Director and Chief Counsel for the U.S. Senate Special Committee on Aging.  From 1977 to 1981 he served as Special Counsel for Labor and Health to Senator Jacob Javits.  Mr. Rother was graduated from Oberlin College and the University of Pennsylvania Law School.

Listen Now

During this 30 minute interview Dr. Zuckerman discusses the long-standing and widespread overuse or misuse of anti-psychotics in medicating nursing home residents.  She identifies some of the more commonly known and used anti-psychotics, why their inappropriate usage poses serious dangers and consequences for patients and how they are being over-prescribed despite FDA "black box" warning lablels.  She notes too the similar  misuse in medicating children.  She offers a sobering perspective regarding efforts by the Congress, CMS and the FDA to curb excessive use.   Finally she makes suggestions on how family members can protect their nursing home resident relatives from being administered anti-psychotic medications.

Since 1999 Diana Zuckerman, Ph.D., has been the President of the National Research Center for Women and Families, a nonprofit, nonpartisan research and advocacy organization promoting adult and child health and safety.  After academic careers at Yale and Harvard, Dr. Zuckerman worked for many years as a Senate, House and Department of Health and Human Services staffer and as well serving as a senior policy advisor for First Lady Hillary Rodham Clinton and the White House Office of Science and Technology Policy.  Presently, Dr. Zuckerman is also a fellow at the University of Pennsylvania Center for Bioethics and serves on the board of directors for two nonprofit organizations: the Congressionally mandated Reagan-Udall Foundation; and, the Alliance for a Stronger FDA. 

Listen Now

This 35 minute interview begins with Dr. Lynn describing the work of her Center in addressing how to improve care for the frail elderly.  Dr. Lynn then explains in some detail a three-year quality improvement intervention undertaken by 14 QIOs (Medicare Quality Improvement Organizations) that reduced hospitalizations and re-hospitalizations by almost six percent, i.e., she summarizes today's JAMA-published article she co-authored, "Association Between Quality Improvement for Care Transitions in Communities and Re-hospitaliations Among Medicare Beneficiaries."  Dr. Lynn explains what is "quality improvement" research or moreover how/why it differs from more traditional clinical practice improvement research.  She addresses generalizability in context of QI research, how hospitals may reconcile reduced hospitalizations and rehospitalizations and how this improved care transitions work is being extended via several other federal programs.  Finally, Dr. Lynn discusses how and why we need  to re-engineer health care delivery to create reliable, supportive services, not necessarily medical services, to assist and support an ever increasing population of frail elderly that will experience lenghty periods of disability.  

Dr. Joanne Lynn leads the Center on Elder Care and Advanced Illness for the Altarum Institute.   She previously has served as a consultant to the administrator of the Centers for Medicare and Medicaid Services, as a faculty member of the Institute for Healthcare Improvement, and a clinical expert in improvement for the Care Transitions project at the Colorado Foundation for Medical Care.  She has also been a senior researcher at RAND and a professor of medicine and community health at Dartmouth Medical School and at The George Washington University. 

Dr. Lynn has published more than 250 professional articles. Her dozen books include The Handbook for Mortals, a guide for the public; The Common Sense Guide to Improving Palliative Care, an instruction manual for clinicians and managers seeking to improve quality; and, Sick to Death and Not Going to Take it Any More!, an action guide for policymakers and advocates.  She is a member of the Institute of Medicine and of the National Academy of Social Insurance, a fellow of the American Geriatrics Society and The Hastings Center, and a master of the American College of Physicians.  She received her MD from Boston University.

Listen Now

In this 34 minute podcast Dr. Paul Van de Water explains the Center on Budget and Policy Priorities' recent call for an additional $1.5 trillion in budgetary savings to stabilize the federal debt at 73% of the GDP.  He discusses the revenue option of limiting individual tax deductions.  On the spending side, savings from Medicare drug pricing and greater beneficiary means testing are discussed and more generally whether Medicare cost growth, comparatively modest over the past three years, will pesist as the national economy recovers.  Dr. Van de Water explanis the merits of applying chained CPI (Consumer Price Index) to index Social Security benefits (to generate additional federal savings) and raising Social Security taxes without limit on annual earnings (currently annual income is taxed up to $113k).  Finally, Dr. Van de Water discusses the problem/s with applying "dynamic scoring" to Congressional Budget Office scoring.            

Dr. Paul N. Van de Water is a Senior Fellow at the Center on Budget and Policy Priorities where he specializes in Medicare, Social Security, and health coverage issues.  Previously he was Vice President for Health Policy at the National Academy of Social Insurance and from 2001 to 2005 served as Assistant Deputy Commissioner for Policy at the Social Security Administration.  Dr. Van de Water worked for over 18 years at the Congressional Budget Office in a variety of capacities.  He was graduated from the Massachusetts Institute of Technology with a Ph.D. in economics.

Listen Now

During this 28 minute podcast Dr. Gruman explains briefly the mission of the Center for Advancing Health.  She then defines what is patient engagement or patient participation by identifying ten categories that add up to 43 specific patient engagement behaviors.  Dr. Gruman then explains why patients are all too frequently unengaged in their own health care due to, for example, low literacy or health literacy, disability, etc.  She discusses how patients can actively engage in their own care using her own experiences as a cancer survivor as an example and what health care providers and regulators are doing to improve patient decision making and patient engagement measurement.  The interview concludes with comments on the work of the ACA-mandated Patient Centered Outcomes Research Institute (PCORI) and the role of family or informal caregivers.  

Dr. Jessie Gruman is President of the Center for Advancing Health, a nonpartisan, Washington-based policy institute dedicated to advancing patient engagement in health care delivery, i.e., the Center advocates for policies and practices to overcome the challenges people face in finding good care and getting the most from it.   Dr. Gruman is also a Professorial Lecturer in the School of Public Health and Health Services at The George Washington University.  She serves on the board of trustees of the Center for Medical Technology Policy and the Technical Board of the Milbank Memorial Fund.   She too is a fellow of the Society for Behavioral Medicine and a member of the Academy of Arts and Sciences, the Council on Foreign Relations and the NY Academy of Medicine.  Among other works, Dr. Gruman is the author of The Experience of the American Patient: Risk, Trust and Choice (Health Behavior Media, 2009).  She was graduated from Columbia University with a Ph.D. in Social Psychology.   

Listen Now

Since the remedy to the "fiscal cliff" did not include structural reforms to Medicare and Medicaid and since Congressional Republicans will call for entitlement savings during the upcoming debt ceiling debate and beyond, Ms. Sarah Kliff, Health Reporter for The Washington Post and Ms. Amy Lotven, Editor/Reporter for Inside Health Policy, discuss what reforms to Medicare and Medicaid are on the table during this session of the 113th Congress. During this 32 minute podcast raising the Medicare eligibility age from 65 to 67, Medicare means testing, the Medicare Independent Payment Advisory Board, the Medicare Sustainable Growth Rate (the "doc fix"), reforms to the Medicaid program and other related issues to reduce federal health care spending are discussed.

Sarah Kliff covers health policy for the Washington Post. Previously, Sarah wrote for Politico, where she authored Politico Pulse. Prior to Politico, Sarah was a staff writer at Newsweek covering national politics. She is the recipient of fellowships from the Kaiser Family Foundation and USC Annenberg School of Journalism.

Amy Lotven has been for the past five years a health policy editor and reporter at Inside Health Policy.  She has worked previously for newspapers in New Mexico, New York and North Carolina. She did her journalism training at Baruch College.

Listen Now

Heart disease is the leading cause of death for women (and men) in the US, accounting for one in every four deaths, however, among women, only 50% recognize heart disease is their #1 killer.  Additionally, almost two-thirds of women who die suddenly of coronary heart disease have no previous symptoms.  (February is American Heart Month.) 

During this 27 minute podcast Dr. Bennett discusses the prevalence of heart disease particularly among women and what are primary prevention measures - that if achieved cardio vascular disease (CVD) could be reduced by over 80 percent.  She explains what accounts for women's limited awareness of CVD, the benefits of cardio protective drugs and statins (to lower cholesterol), female versus male symptomology and the lack of adequate CVD research specific to women.  Dr. Bennett notes the varying reasons why cardio rehabilitation, despite its substantial benefits, is woefully under utilized at rates under 30 percent and what can be done to improve patient utilization or participation.  The interview concludes with bottom line recommendations to avoid CVD and mention of federal programming efforts to reduce CVD via the "Million Hearts" campaign (www.millionhearts.hhs.gov) as well as related work by the American Heart Association (www.heart.org) and WomenHeart (www.womenheart.org).  (The interview failed to discuss or note the association between CVD and mental health or mental illness.  For example, depression even in mild forms can increase CVD risk and that depression is twice as common in women as in men.) 

Dr. Bennett is a Consulting Cardiologist of the Women's Heart Program at the MedStar Heart Institute.  She is the past Director of the Women's Heart Program at The George Washington University Hospital.  Prior to that she was an Assistant Professor in the Division of Cardiology at the U. of Maryland.  Dr. Bennett is on the Scientific Advisory Board of WomenHeart: The National Coalition for Women and Heart Disease, served as Chair for the National Heart, Lung and Blood Institute's Advisory Panel on Women and Heart Disease, she is Past-President of the Greater Washington Area American Heart Association (AHA), a national spokesperson for the AHA and is the author of numerous clinical publications.  She earned her MD degree from the Eastern Virginia Medical School.

Listen Now

In January 2013 the Institute of Medicine released "Shorter Lives, Poorer Health" a 404-page report that found Americans die sooner, experience higher rates of disease and injury than people in 16 other like high-income countries and that these health disadvantages exist at all ages from birth to age 75. 

During this 22 minute podcast Dr. Steven Woolf, the chair of the IOM panel that authored the report, discusses the pervasiveness of problem or the diversity of health problems that exist across our entire lifespan, how social factors contribute to poorer health and the fact that higher educated and higher income Americans are also too in poorer health compared to their peer group overseas.  Dr. Woolf discusses worse birth outcomes in this country, the importance of antecedents for good health and possibly why the only subpopulation of Americans, those over 80, do comparatively well.  Finally, Dr. Woolf outlines the report's three policy recommendations and identifies a few foreign health care policies, that if adopted, might prove effective in the US.  

Dr. Woolf is Professor at the Departments of Family Medicine, Epidemiology and Community Health at  Virginia Commonwealth University.  In 2001 he was elected to the Institute of Medicine.  He has published more than 100 articles that have focused on evidence-based medicine with a special focus on preventive medicine, cancer screening, quality improvement and social justice.  He is the associate editor of the American Journal of Preventive Medicine and served as North American editor of the British Medical Journal.  He received his MD from Emory and his MPH from Johns Hopkins.

Listen Now

One of the most discussed provisions of the Affordable Care Act promising to "bend the cost curve" are Accountable Care Organizations (ACOs).   CMS has now selected over 250, moreover physician-led, organizations as ACOs coverning four million Medicare beneficiaries.   ACOs offer the promise of improved coordinated care, care quality and reduced Medicare costs.  During this 27-minute interview Dr. Patel explains the impetus for and creation of Accountable Care Organizations, how rapidly ACOs are growing in number and what are some of the barriers limiting participation in the “shared savings” program.  She explains further how Medicare reimburses ACOs (Type 1 and 2) and the concern among providers regarding the freedom Medicare beneficiaries have in seeking care outside their ACO.  What ACO activity is occurring beyond Medicare or among large physician groups and private insurers, how and why ACOs might be successful and how and why ACOs serve as a catalyst for provider integration (and the downside risks involved with accelerated consolidation) are all also discussed.  The interview concludes with a brief summary of the Brookings-Dartmouth ACO learning network (www.acolearningnetwork.org).

Dr. Kavita Patel is a Fellow in the Economic Studies program and Managing Director for clinical transformation and delivery at the Engelberg Center for Health Care Reform at the Brookings Institution.  She is also a practicing primary care internist at Johns Hopkins Medicine. She served previously in the Obama Administration as Director of Policy for the Office of Intergovernmental Affairs and Public Engagement in the White House.  Dr. Patel also served as Deputy Staff Director for the late Senator Edward Kennedy.  She too has an extensive research and clinical background having worked as a researcher at the RAND Corporation and as a practicing physician in both California and Oregon.  She earned her medical degree from the University of Texas and her masters in public health from the UCLA.

Listen Now

Dr. Linda Randolph, President and CEO of District of Columbia's Developing Families Center (DFC),  discusses DFC's unique maternal and child health care model that has drawn international attention for its comprehensiveness and its high quality outcomes.  

During this 23 minute interview Dr. Randolph offers her explanation for the causes of worse maternal outcomes among minority populations, including higher income African American women.  For example, she notes inter-generational factors, the effects of toxic or chronic stress and racism.  She explains the DFC's services beyond nurse midwifery, i.e., pediatric care, the DFC's breastfeeding education and peer support program (African American women are the least likely to breast feed) and the DFC's infant and todler (newborns-to-three-year-olds) child development center or early head  start.  Dr. Randolph defends this programming against criticisms that Head Start program benefits fade as children reach the first and second grades.  Finally, Dr. Randolph emphasizes the importance of a continuum of maternity to early child development care, one that is more holistic emphasizing primary prevention - that is the mission of the DFC.  

(This discussion compliments the Dr. Lubic interview.) 

Dr. Linda A. Randolph is a public health pediatrician with over thirty years of experience serving in Federal, state and local governments, academia, private philanthropy and not-for-profit organizations.  Dr. Randolph, a native Washingtonian and a 20 year resident of Harlem and Albany, NY, is known for her work to eliminate racial/ethnic disparities in health and building upon the strengths of families and communities to effect health policy.  Dr. Randolph was elected to the Institute of Medicine in 2008, she is the recipient of numerous awards in the field of maternal and child health including the American Public Health Association’s 2001 Martha May Eliot Award.  In February Dr. Randolph and Dr. Lubic co-presented the Association of Maternal and Child Health Program's John C. MacQueen Memorial Lecture.  She earned her MD from the Howard University College of Medicine and her MPH from the University of California at Berkeley.

Listen Now

In 1997 the Congress reformed how it pays physicians under Medicare.  The new formula was termed the "sustainable growth rate" (SGR).   The impetus for the reform was to control better Medicare cost growth.   (Medicare physician payments now exceed $100 billion annually).   Largely because of the concern physicians would limit seeing Medicare patients if their Medicare reimbursement rates were cut, the Congress has not enforced the SGR since 2002.   Despite the realization the SGR is unalterably broken, the Congress has been unable or unwilling to amend the law.  Though the upaid SGR tab is presently $138 billion this amount is substantially less than previous calculations that approached  $300 billion (due to a recent decline in Medicare utilization).  With debt and deficit reduction talks expected to re-emerge over the next few months will the Congress finally find the wherewithal to fix the docs?    

The podcast begins with Dr. Berenson addressing the genesis of the SGR and then proceeding to explain why Congress has routinely ignored enforcing the SGR since 2002.  The discussion proceeds to explain why/how doing away with the SGR would currently cost $138 billion.   What effect the SGR has (still) had and what recent MedPAC and a bipartisan House proposal (Reps. Schwartz and Heck) call for in creating a new payment method while offsetting the accumulated $138 billion.  Dr. Berenson next discusses his recent Congressional testimony where he identified ways to improve or mend Medicare fee for service payments, e.g., reducing distortions in, or improving the accuracy of, physician service relative value units (RVUs), improving payment for evaluation and management services.  He argues in sum for global payment or partial capitation.  Dr. Berenson concludes by noting current Congressional bi-partisan support for SGR reform though noting reform proposals would have to identify some mechanism/s to control for volume growth and an indication that quality and efficiency would be improved.           

Dr. Robert Berenson is currently a Fellow at the Urban Institute where his research work concerns health care policy, particularly Medicare.  From 1998-2000, Dr. Berenson was in charge of Medicare payment policy and private health plan contracting in the Centers for Medicare and Medicaid Services (CMS). Previously, he served as an Assistant Director of the Carter White House Domestic Policy Staff.  Dr. Berenson became a Commissioner of the Medicare Payment Advisory Commission (MedPAC) in 2009 and in 2010 became MedPAC's Vice Chair.  Dr. Berenson is a board-certified internist, for the last twelve years practicing in Washington, D.C.  He is Fellow of the American College of Physicians and the author of numerous research publications.  He is a graduate of the Mount Sinai School of Medicine and on the faculty at the George Washington University Schools of Medicine and Public Health and the Fuqua School of Business at Duke.

Dr. Berenson's February 2013 Energy and Commerce Committee testimony can be found at:  http://democrats.energycommerce.house.gov/sites/default/files/documents/Testimony-Berenson-Health-SGR-Medicare-Payment-2013-2-14.pdf

Dr. Berenson's (et al.) March 2013 Urban Institute paper, "Can Medicare Be Preserved While Reducing the Deficit?" is available at:http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/03/can-medicare-be-preserved-while-reducing-the-deficit-.html

Listen Now

For decades the US has experienced the highest infant mortality rate of high income countries.  The US also ranks poorly on other birth outcomes such as pre-term births, low birth weight and Caesarean sections.  Infant mortality rates for non-hispanic blacks is twice that of the national average.  In sum, about 25,000 infants die each year in the United States.  During this 37 minute interview Dr. Lubic explains briefly nurse midwifery and its peri-natal goals, she discusses at some length the gradual acceptance of nurse midwives from the 1930s through the 1960s, the Family Health and Birth Center's "care in a social context" and birth outcomes its achieved, i.e., a 66% reduction in both pre-term births and Caesarean sections and a 75% reduction in low birth weights.  

For more on midwifery outcomes see this recently published article in the Journal of Midwifery & Women's Health:  http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full

Dr. Lubic's midwifery career began in 1962 when she was graduated from the country’s first nurse-midwifery program, the Maternity Center Association in NYC.  In 1970, Dr. Lubic became General Director of the Association (now called Childbirth Connection) and opened the first state-licensed birthing center in the country in 1975.  Eventually the Morris Heights Childbearing Center opened in the South Bronx, bringing quality obstetric care to underserved, low-income women.  The moneys she received from a MacArthur Foundation genius award enabled her to replicate her NYC midwifery model in 2000 by opening the Developing Families Center in Washington, D.C.  Among other numerous credits and awards Dr. Lubic was elected to the National Academy of Sciences’ Institute of Medicine and is the recipient of its Lienhard Award.  The American Academy of Nursing, also in 2001, named her a Living Legend.   The American College of Nurse-Midwives honored her with the Hattie Hemschemeyer Award.   In 2006, the American Public Health Association conferred its Martha May Eliot Award and she also is the recipient of eight honorary doctorate degrees.  Dr. Lubic was awarded a nursing degree from the U. of Pennsylvania and was graduated from Columbia University with a Ph.D. in applied anthropology.

Listen Now

Family caregivers are the most ignored providers of health care delivery despite the fact they constitute 30 percent of the adult population, or are 65 million Americans.  Caregivers are more typically women, over fifty, spending 20 hours a week (over an average of five years) providing care most frequently for a family member typically a parent with dementia.  They are literally the backbone of health care.   Professionally, caregivers, half of whom work full time, incur lost wages, promotions, health insurance, retirement savings and frequently suffer deleterious physical and mental health effects.  Nearly 80 percent of caregivers report needing more help and information with at least 14 specific topics related to caregiving. 

During this 31 minute interview Ms. Mintz discusses the varied and substantive contributions caregivers make and how their efforts can be better supported.

Ms. Suzanne Mintz is the cofounder of the nonprofit the Caregiver Action Network (formerly the National Family Caregivers Association), an organization that provides both direct support for caregivers and advocates for legislative reform  and other policy changes.  Currently Ms. Mintz also serves on the board of National Patient Safety Foundation, the advisory council of the National Transitions of Care Coalition and the advisory board of the Partnership to Fight Chronic Disease.  She was honored for her work in 2006 as one of the first 15 winners of the Purpose Prize.  She has written several books, the latest is A Family Caregiver Speaks Up: It Doesn't Have to Be This Hard and has published numerous articles on and for family caregivers.   She holds a BA in English from Queens College, City University of New York and a MS in Human Ecology from the University of Maryland.

For more on the Caregiver Action Network, see: http://caregiveraction.org/

Listen Now

Over 80 percent of Americans take at least one medication, nearly 30 percent take five or more. That translates to more than 3.5 billion prescriptions written every year making drugs the third highest health care delivery cost after hospital and physician services - amounting to over $250 billion annually. While the benefits of medication therapy are or can be substantial medication errors are among the most common medical error. According to the IOM an estimated 450,000 preventable adverse drug events (ADEs) occur each year in hospitals and another 800,000 preventable ADEs occur in long term care facilities – though these numbers are believed to be under estimates. According to the CDC fatalities from medication errors in 2010 accounted for 35,000 deaths, or more deaths than caused by auto accidents. Medication harm is so pronounced per the Dartmouth Institute for Health Policy there is nearly a 1:1 ratio of drug spending to spending on unintended mediation harm.

Dr. Isetts begins this 20-minute podcast by noting the importance of rethinking or reframing the problem of medication harm by emphasizing the utility developing a true medication use system, i.e., medication therapy management (MTM) and imbedding MTM into all health care delivery settings.  He emphasizes the importance of understanding first why patients do not appropriately follow their medication regimes.  He discusses the pluses and minuses of physician computer order entry systems.  He defines MTM as primarly insuring patients understand the intended uses for their medications, identifying each patient's goals of therapy and insuring patients understand all relevant drug safety issues.   Dr. Issets describes the work that's been done to improve the Medicare drug benefit by aligning it with Medicare hospital and physician care delivery and what can and is being done to reduce drug-related fatalities.                 

Dr. Brian Isetts is Professor of Pharmaceutical Care and Health Systems at the University of Minnesota.  For the past two years he has been a Health Policy Fellow at the Centers for Medicare and Medicaid Services (CMS) working to improve medication adherence.  Dr. Isetts' field of expertise concerns studying the outcomes of medication therapy management services (MTMS) provided within the practice of pharmaceutical care.  Beyond CMS, Dr. Isetts has worked with the American Medical Association, et al. to ensure MTMS by pharmacists.  He was graduated with a BS from the University of Wisconsin School of Pharmacy and with a Ph.D. from the University of Minnesota College of Pharmacy.

Listen Now

It's estimated the Affordable Care Act will add another 16-17 million lives to the 60 million Americans already receiving Medicaid.  Of these current 60 million Medicaid enrollees, two-thirds receive their health care via managed care companies and over half of Medicaid managed care enrollees are in for profit plans.  Concerning the quality of care for profit plans deliver, a 2011 study published by the Commonwealth Fund found for profit Medicaid plans did significantly worse than non profit plans at ensuring members receive preventive care and managing members chronic disease.  Also too, for profit plans had comparatively higer administration costs than non profit plans.

Ms. Alker begins this 24-minute interview discussing reasons for ever-growing Medicaid managed care plan enrollment and the issue of access to, or provider participation in, Medicaid and in Medicaid managed care plans.  She assesses the state of quality data collection and explains why data is generally lacking, spotty and/or not uniformly collected.  She makes comment on for profit  interest in expanding to cover additional Medicaid sub-populations, what relevant ACA reforms promise, the challenges and opportunities for reducing costs since the Medicaid program as already an efficient payer, findings from her recent study of a five-county managed care demonstration in Florida and lastly provides comment on the recent decision in Arkansas to use federal Medicaid subsidies to purchase insurance in 2014 via their state exchange for citizens otherwise eligible for Medicaid under the ACA's expanded coverage provision.             

Ms. Joan Alker is the Co-Executive Director at the Center for Children and Families (CCF) and for the past ten years a Research Associate Professor at the Georgetown University Health Policy Institute.  Her work focuses on health coverage for low-income children and families, with an emphasis on Medicaid, the Children’s Health Insurance Program (CHIP) and the Affordable Care Act (ACA).  She has authored numerous reports and studies on a range of issues including Medicaid waivers, child and family coverage, premium assistance and is the principal investigator of a multi-year study on Florida’s Medicaid program.  Ms. Alker holds a Master of Philosophy in politics from St. Antony’s College, Oxford University and a Bachelor of Arts with honors in political science from Bryn Mawr College.

Listen Now

Tooth decay affects US children more than any other chronic infectious disease.  It is five times more common than asthma and almost entirely preventable.  Between 41% and 55% of children age 2 to 11 suffer tooth decay and upwards of 34% of this decay is untreated.  Disparities in dental health, the CDC has termed, "profound."  This is explained in part by fact that one-third of the population (over 100 million Americans) lack dental health insurance.  That means uninsured children are 2.5 times less likely to receive dental care than insured children.  All this matters because oral health is an integral part of both overall physical (systemic) health as well as nutritional health.

Dr. Edelstein begins this 31-minute podcast assessing children's oral and dental health status including how and why oral health effects overall health status and the relationship between obesity and oral health.  He discusses the level of adequacy of dental care financing or coverage and the subsequent adequacy of (and barriers to) access to dental services particularly under Medicaid.  How relevant provisions of the Affordable Care Act may change care delivery approaches are discussed, the relevant work anticipated by MACPAC and the work of the Children's Dental Health Project.         

Dr. Edelstein is a Board Certified pediatric dentist and the 1997 founder of the Children’s Dental Health Project.  Dr. Edelstein practiced pediatric dentistry in Connecticut while teaching at both Harvard and UCONN for 21 years.  He is currently Professor of Dentistry and Health Policy at Columbia University where he chairs the Department of Social and Behavioral Sciences at the College of Dental Medicine.  Edelstein has authored over 100 publications on topics related to pediatric oral health, dental education and health policy.  He presently serves as a Commissioner of the Congressional Medicaid and CHIP Payment and Access Commission (MACPAC).  He is a graduate of Harpur College, SUNY Buffalo School of Dentistry, the Harvard School of Public Health, and the Boston Children's Hospital pediatric dentistry residency program.

Listen Now

The health care sector has substantially lagged all other major industries in the adoption and use of information technology.  For example, per the CDC, in 2011 still slightly more than half of physicians (54%) used an electronic health record (EHR) (though compared to 17% in 2008), among of solo practitioners only 29% and among specialities only 48% of surgeons.  However, since 2009 the federal government has made substantial financial investments in incenting the adoption and use of heath information technology (HIT) such that by the end of 2013 it's anticipated 80 percent of hospitals providing Medicare or Medicaid (ostensibly all hospitals) will be using EHRs (compared to 9% in 2008). 

During this 27-minute podcast, Ms. Christine Bechtel discusses the 2009 ARRA's HITECH provision that incented hospitals, physicians and others to adopt HIT.  She addresses the law's policy and standards' committee activities, specifically the law's "meaningful use" provision, what meaningful use stages 1, 2, 3 are intended to accomplish and the extent to which HIT adoption has succeeded over the past four years.   She explains Health Information Exchanges (HIEs and what level of success they've achieved to date.  The interview concludes with her assessment of the extent to which HIT has produced cost savings.        

Ms. Christine Bechtel is President of the Bechtel Health Advisory Group, an organization that advises clients on how to implement patient- and family-centered, IT-enabled health care and policies.  Among other clients are the National Partnership for Women & Families, where she previously served as Vice-President and the Casey Health Institute, a new non-profit primary care practice in Gaithersburg, MD.  Ms. Bechtel also served previously as vice president of the eHealth Initiative (eHI), a Washington D.C.-based non-profit organization dedicated to improving the health care quality via information technology.  Prior to eHI, Ms. Bechtel worked with American Health Quality Association, she also served as senior research adviser at AARP, worked as Director of Community Development for Louisiana's Medicare Quality Improvement Organization and served on the staff of Senator Barbara Mikulski (D-MD).  Her BS is in politics and public policy from Goucher College and her master's is in political management from George Washington University.

Listen Now

Since the 1970s Medicare beneficiaries have had the option of receiving their Medicare benefits via private health insurance plans.  Today 27% of Medicare beneficiaries, or 13.3 million seniors, are enrolled in these private plans.  MA program growth in the past few years has been rapid, enrollment almost tripled between 2003 and 2012 and the program is estimated to add another 1.5 million beneficiaries this year.  Medicare, which pays MA plans a capitated rate rather than on a FFS basis, reimbursed MA plans $136b. in 2012.  The program has not been without controversy largely due to payments or over payments made to MA-participating plans.   For example, just prior to the 2010 passage of the Affordable Care Act the CBO estimated equalizing payments between Medicare Advantage programs and the traditional fee for service Medicare program would generate $170 billion in savings over the ten year budget window.   Despite ACA reforms to MA, MedPAC (the Medicare Payment Advisory Commission) estimated in 2013 overall payments to plans will equal $6 billion more for MA enrollees than would have been paid to cover the same enrollees in Medicare fee for service.  

Dr. Biles begins this 27-minute interview by explaining how private insurance plans participte in the MA program including how they bid for services against county benchmark rates.  He explains why MA participation has nearly tripled over the past decade, what MA payment and quality incentive reforms were included in the Affordable Care Act including the star bonus program, MA risk adjustment, the quality of care provided by MA plans and possible future reforms to the MA program are also all discussed.       

Since 2000 Dr. Brian Biles has been a Professor in the Health Policy Department at The George Washingtion University and is also a Senior Vice President at the Commonwealth Foundation. Previously Dr. Biles served for seven years as staff director of the House Ways and Means Subcommittee on Health, served later as Deputy Assistant Secretary for Health at the Department of Health and Human Services in the Clinton Administration and also served as Deputy Secretary for Maryland's Department of Health and Mental Hygiene.  Among other professional activities, Dr. Biles chairs the Medical Administrators Conference and is a Fellow of the New York Academy of Medicine and an Invited Lecturer at the Kennedy School of Government at Harvard University.  Dr. Biles received his Doctor of Medicine and Bachelor of Arts with honors from the University of Kansas and he holds a masters degree in public health from Johns Hopkins University.

Listen Now

After the doubling of the National Institutes of Health's (NIH) budget between 1998 and 2003, federal funding for medical research and more widely federal R&D has been falling or stagnate over the past several years.  Most recently, the federal budget sequester slashed NIH funding by 5.5  percent leading to a $1.6 billion funding reduction in 2013, the largest cut in the agency’s history.    (The president's proposed 2014 budget calls for a repeal of sequestration and a slight increase in the NIH budget of 1.6 percent or $471 million over the 2012 budget.)   The decline in federal research funding is particularly concerning in light of the growing importance of knowledge-based industries in a global economy.   If current trends in biomedical research investment continue the US government's investment in life sciences research over the ensuring half decade is likely to be barely half that of China's in current dollars and one-quarter of China's level as a share of its GDP.  (China already has more gene sequencing capacity than the US.)   Korea, Singapore, Taiwan, the UK and France also fund more as share of their economies.  

This 27-minute podcast begins with a brief description of AAAS's work.   Mr. Hourihan discusses next federal R&D funding generally and NIH funding specifically compared to other developed countries, the recent history of federal NIH funding, proposed White House and Congressional NIH FY'14 funding  (or moreover how Democratic and Republican proposals substantially differ), the effect of budget sequestration on the FY'13 NIH budget and sequestration's effect on NIH funding should sequestration persist through 2021, the consequences funding restraints have had on life sciences research and the economy and the prospects for future NIH funding over the next five to 10 years.     For more on Mr. Hourihan's NIH analysis (and federal R&D funding more generally) see: http://www.aaas.org/spp/rd/.

Mr. Matt Hourihan has been Director of the R&D Budget and Policy Program at the American Assocation for the Advancement of Science (AAAS) since 2011.  Prior to joining AAAS, he served as a Clean Energy Policy Analyst at the Information Technology & Innovation Foundation (ITIF).   Previous to that, Mr. Hourihan served as Jan Schori Fellow at the Business Council for Sustainable Energy, a coalition of energy firms and utilities working to engage policymakers for market-based solutions to sustainable energy development and climate change and prior still he worked as a journalist at the Ocean Conservancy.   Mr. Hourihan earned a masters degree in public policy with an emphasis on science and technology policy at George Mason University and a undergraduate degree in journalism from Ithaca College.

Listen Now

The lowlight during the 2009-2010 ACA debate was Governor Palin's invention of "death panels" (PolitiFact's 2009 "Lie of the Year") in response to a proposal to allow Medicare to pay physicians whom voluntarily counsel patients about advanced care planning or directives.   The fear mongering was so convincing the proposal was dropped by the Congress and later, via rule making, by the White House.  The facts remain that while far and away most Americans die of a long term chronic, eventually fatal ilness/es, according to AHRQ, Pew and others only approximately twenty to thirty percent of Americans have an advanced directive or a living will including those severely or terminally ill.  

During this 28-minute discussion Mr. Sabatino discusses the importance and benefits of advanced care planning and the various types of advanced care directives (living wills, durable power of attorney, POLST, and others), reasons for our hesitancy in planning for advanced illness and completing directives, limitations (e.g., portability problems) and operational challenges.  He notes specifically advanced care planning is not a one time conversation or a check the box exercise.  He describes what steps are being taken to improve advanced care planning, for example through opportunities presented via the movement towards electronic health/medical records.       

Charlie P. Sabatino is the Director of the American Bar Association’s Commission on Law and Aging where he is responsible for research and education in health law, long‑term care, guardianship and capacity issues, surrogate decision‑making, legal services delivery for the elderly and professional ethics.  He has written extensively on capacity issues, surrogate decision-making and advance care planning.  Mrs. Sabation is also an Adjunct Professor at Georgetown University Law Center, currently serves as a legal consultant to the National POLST Paradigm Task Force and is a board member of the Coalition to Transform Advance Care.  Mr. Sabatino is a Fellow and former president of the National Academy of Elder Law Attorneys.  He received his A.B. from Cornell, his J.D. from Georgetown and is a member of the Virginia and D.C. bars.

For ABA information on advanced care planning and directives see:  http://www.americanbar.org/groups/law_aging/resources/consumer_s_toolkit_for_health_care_advance_planning.html and for Respecting Choices information see: http://www.gundersenhealth.org/respecting-choices.

Listen Now

The homeless of course suffer substantial health problems.  The CDC estimates nearly half have one or more chronic health condition (e.g., heart disease, diabetes, cancer), two in five have a mental health diagnosis/es, one-fourth suffer substance abuse, one-third are alcohol addicted.  One 2005 study showed shocking mortality rates, the median age of death was 45.  Over half do not have health insurance - though homeless adults will become eligible in 2014 for Medicaid coverage in states that agree to expand their Medicaid program under the ACA (about half the states) to 133 percent of the federal poverty level ($15,200). 

During this 24-minute podcast, Dr. Rogers explains how/why he became involved in caring for the homeless.  He discusses the magnitude of the problem, explains the purpose and evolution of the Carpenter's Shelter, the services he provides its patients (as well as care he provides for other homeless Alexandria residents), his frustrations when attempting to find provider for patients needing more intensive care, e.g., surgeries, expectations for Virginia in expanding Medicaid coverage under the ACA in January 2014 and what that would mean for Carpenter's.    Dr. Rogers operates a free medical clinic at the Carpenter's Shelter for the homeless in Alexandria, Virginia.  Dr. Rogers is also the Director of the Physicians Regulatory Issues Team at the Centers forMedicare and Medicaid Services (CMS) and is also a member of Georgetown University ospital medical staff working in the Emergency Department and teaching residents and medical students.  He too holds the rank of Colonel in the US Air Force and is the Operational Medical Director for the National Park Service, National Capital Area.  Before joining CMS, Dr. Rogers served as the Regional Director for an ED staffing company responsible for four EDs in Virginia employing 50 physicians.  Dr. Rogers is a member of the American College of Emergency Physicians (Fellow) and the federal Emergency Care Coordinating Committee.   Dr. Rogers received his medical degree from the University of Virginia. 

Listeners with an interest in Carpenter's Shelter see: http://www.carpentersshelter.org/.

For more general information see, for example, the National Healthcare for the Homeless Council's website at: http://www.nhchc.org/. 

Listen Now

In 2009, or the year before the Affordable Care Act passed, the Herfindahl-Hirschman Index (used by the FTC and the DoJ) defined hospital ownership as "highly concentrated" in over 80% of the 380 MSAs (Metropolitan Statistical Areas).  Since passage of the ACA, a law that among other things strongly encourages care continuity and coordination between/among providers, hospital mergers and acquisitions continued unabated with over 100 in the past year alone (and over 500 between 2007 and 2012).  This matters because studies commissioned by the Robert Wood Johnson Foundation and others show hospital market consolidation generally results in higher prices. 

During this 27-minute podcast, Dr. Ginsburg discusses the current state of hospital market concentration and what effect this has on hospital pricing and quality.   He describes the impetus for the ACA encouraging care integration, what effect this has on hospital as well as physician group practice consolidation (both horizontally and vertically), what upsides there are to a less silo-ed industry, effects of similar consolidation within the payer/insurance industry and what are or should be appropriate federal efforts to best regulate mergers and acquisitions within the healthcare industry.   

Dr. Paul Ginsburg is President (and Founder) of the Center for Studying Health System Change (HSC).  The HSC conducts research to inform policymakers and other audiences about changes inorganization, financing and the delivery of health care.  Prior to HSC Dr. Ginsburg served as the founding Executive Director of the Physician Payment Review Commission (now the Medicare Payment Advisory Commission).  Dr. Ginsburg was a Senior Economist at RAND and served as Deputy Assistant Director at the Congressional Budget Office (CBO). Before that he served on the faculties of Duke and Michigan State universities.   He has been named to Modern Healthcare’s “100 Most Influential Persons in Health Care” eight times.  He is founding member of the National Academy of Social Insurance, a Public Trustee of the American Academy of Ophthalmology and serves on Health Affairs’ editorial board.  He earned his doctorate in economics from Harvard University.

Listen Now

Recently the French government fined Sanofi $53 million for what it called a smear campaign against a competitor drug manufacturer.   Ranbaxy was fined $500 million, in part, for making false statements to the FDA.   Last year the pharamaceutical industry in sum paid out $5.5 billion to resolve fraudulent marketing practices.  These included $3 billion in fines against GlaxoSmithKline (GSK) and $762 million against Amgen.   When these settlements were reached eight of the top 10 global pharmaceutical companies were under "corporate integrity agreements"  (that require companies to report compliance activities via an independent monitor for five years).   With governments recouping only a portion of drug company profits via these marketing practices many say pharma simply views the fines as a cost of doing business.  (The day the GSK fine was announced, the largest of its kind in history, GSK's stock price actually closed up).

During this 23-minute interview Dr. Fugh-Berman discusses the types and pervasiveness of pharmaceutical marketing abuses, the public health consequences thereof, the adequacy of corporate integrity agreements and other efforts that promise to curb abuse (e.g., the Physician Payment Sunshine Act), her views regarding direct to consumer advertising, Pharmed Out's efforts to better educate (or insulate) physicians, patients and other consumers from marketing manipulation.    

Dr. Adriane Fugh-Berman is an Associate Professor in the Department of Pharmacology and Physiology and in the Department of Family Medicine at Georgetown.   She is also Director of PharmedOut a research and education project that promites rational prescribing and exposes the effect of pharmaceutical marketing on prescribing practices.  Previously, Dr. Fugh-Berman was a medical officer in the Contraception and Reproductive Health Branch of the National Institute for Child Health and Human Development at the NIH.  Dr. Fugh-Berman is the former chair of, and currently writes a column for, the National Women’s Health Network and she has appeared on 20/20, the Today Show and every major news network.  Dr. Fugh-Berman graduated from Georgetown University School of Medicine and completed a family medicine internship in the Residency Program in Social Medicine at Montefiore Hospital in the Bronx.

For information regarding PharmedOut see: http://www.pharmedout.org/.

Listen Now

The centerpiece of the Affordable Care Act are the state health insurance exchanges where individuals beginning October 1st will be able to buy health care insurance with coverage beginning January 1st.   There are numerous questions regarding how and how well the exchanges will function.  For example, how may insurance plans will participate in each state, how competetive will these marketplaces be or what premiums participating plans will charge and how many individuals will purchase health insurance through the exchanges. 

During this 28-minute telephonic interview Professor Jost describes generally how the exchanges will operate, what challenges they face including, for example, adequate participation (particularly among young adults), concern regarding employers self-insuring to avoid ACA mandates, the status of the SHOP exchanges, how related ACA coverage provisions may have been/might be improved and expectations for how well the exchanges will operate in their first year.  

Professor Tim Jost holds the Robert L. Willett Family Professorship of Law at the Washington and Lee University School of Law.  Prior to Professor Jost taught for twenty years at Ohio State University where he held appointments in the law and medical schools.  He is a coauthor of a casebook, Health Law, used widely throughout the US.  He is also the author or editor of Health Care at Risk, A Critique of the Consumer-Driven Movement; Health Care Coverage Determinations:  An International Comparative Study; Readings in Comparative Health Law and Bioethics; Medicare and Medicaid Fraud and Abuse; and, Regulation of the Health Care Professions.   Professor Jost blogs regularly for Health Affairs, i.e. he has analyzed virtually every rule and guidance issued by the departments of Health and Human Services, Labor, and Treasury implementing Title I of the Affordable Care Act.  These can be found at: http://healthaffairs.org/blog/author/jost/.   Professor Jost is an elected member of the Institute of Medicine, the American Law Institute, and the National Academy of Social Insurance.  He is a member of the American Society of Law and Medicine, the American Health Lawyers Association, the American Society of Comparative Law, and the American Bar Association.   

Listen Now

While the vast majority (70%) of people turning 65 will need long term care services for an average of three years, only 7 million Americans own a long term care insurance policy.  Medicare does not provide for long term care and Medicaid only covers long term care costs for those with very limited financial means.   The CLASS Act, a provision within the ACA, would have created a voluntary and public long term care insurance policy for employees but the ACA provision, as written, was unworkable such that the Obama adminstration abandoned its efforts to implement the CLASS Act in late 2011.  (The Congress offically repealed the provision in early 2013.)     

During this 25-minute interview Ms. Garner discusses the need for long term care insurance (both for the elderly and younger disabled), the origins of the CLASS Act and why the provision was ultimately unsuccessful and the continuing need for related reforms to both entitlement programs, i.e., Medicare and Medicaid, and the long term care insurance market.

Ms. Connie Garner is currently the Executive Vice President for Public Policy at United Cerebral Palsy.  Previously, Ms. Garner worked at Foley Hoag where she served as Policy Director in the Government Strategies Practice Group and as Executive Director of Advance CLASS, Inc., a position she still holds.  For 17 years prior she was Policy Director, Disability and Special Populations, to the U.S. Senate Committee on Health, Education, Labor and Pensions Committee.  In that role, she was the lead Democratic Committee architect for the CLASS Act, the major long-term care legislation that was a part of the ACA.  Ms. Garner also served in the U.S. Department of Education.  She received her B.S. in Nursing from the University of Pennsylvania, a M.S. in Nursing form George Mason, and an Ed.S. in Special Education from George Washington.  She is certified as a Pediatric and Neonatal Nurse Practitioner and is the mother of seven children.

For a primer on long term care insurance see this DHHS Assistant Secretary for Planning and Evaluation (ASPE) research brief: http://aspe.hhs.gov/daltcp/reports/2012/ltcinsRB.shtml. 

Listen Now

The most expensive Medicare beneficiaries are not those with multiple chronic conditions.  They are those with chronic conditions AND functional impairment (i.e., those needing help with routine life activities).  For example, the 15% of Medicare enrollees with both chronic conditions and functional limitations disproportinally account for one-third of Medicare spending.  Alternatively, Medicare enrollees with three or more chronic conditions but no functional impairment (48%) account for roughly the same percent of spending (51%).  The challenge therefore both in improving quality care for the chronically ill and reducing costs (via, for example, reduced hospitalizations) is in improving long term care supports and services (LTSS). 

During this 26-minute podcast Dr. Alkema defines "functional limitation" and "care coordination", explains the current lack of care coordination for Medicare patients with chronic conditions and functional limitations, describes three exemplary models of care coordination and what Medicare can or should do to improve care for these patients.

Dr. Gretchen Alkema currently serves as Vice President of Policy and Communications for The SCAN Foundation.  Prior to joining SCAN Dr. Alkema was the 2008-09 John Heinz Health and Aging Policy Fellow serving in the office of Sen. Blanche Lincoln.  Dr. Alkema earned her PhD at the University of Southern California’s Davis School of Gerontology and and completed her post-doctoral training at the VA Greater Los Angeles Health Services Research and Development Center of Excellence.  Her academic research focused on evaluating innovative models of chronic care management and translating effective models into practice.  She is a Licensed Clinical Social Worker and has practiced in government and non-profit settings including community mental health, care management, adult day health care, residential care and post-acute rehabilitation.

For background information concerning this topic see this paper by Georgetown's Harriet Komisar and Judy Feder: http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf  See also too SCAN's "10 Conversations to Plan for Aging with Dignity and Independence" at: http://www.thescanfoundation.org/10-conversations-plan-aging-dignity-and-independence.

Listen Now

In 2009 the Congress overwhelmingly passed landmark legislation (commontly termed the "Tobacco Control Act") that included banning flavored cigarettes - except menthol.  Instead, the Congress called upon the FDA to first study the use of menthol before taking action.   In 2011 the FDA released an initial report, the conclusions of which were widely interpreted.  Two weeks ago the FDA released a subsequent report again finding the menthol/mint flavor helps people acquire the tobacco/nicotine addiction but did not increase the risk of disease compared to smoking non-menthol cigarettes.  Neither report recommended banning or restricting the use of menthol. 

During this 24-minute podcast Andrea Villanti and Diane Canova discuss why menthol was exempted in the 2009 legislation, the findings of the 2011 Tobacco Products Scientific Advisory Committee, why the FDA chose to follow up with a report of their own (released July 23rd) and what it found, various confounding factors including an international trade dispute concerning the importation of clove cigarettes and ultimately their take on whether and when the FDA will either ban or regulate menthol's use.       

Dr. Andrea Villanti is an Associate Director for Regulatory Science and Policy at the Schroeder Institute for Tobacco Research and Policy Studies at Legacy Foundation and holds an adjunct faculty appointment in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health.  Her work concerns translational research to improve tobacco control policy and program decision-making with a specific focus on young adult cessation.  Since the passage of the 2009 Family Smoking Prevention and Tobacco Control Act, she has been actively engaged in research on the impact of menthol cigarettes on tobacco use behaviors.  Dr. Villanti received her doctorate in Social and Behavioral Sciences the Johns Hopkins Bloomberg School of Public Health and she received both her Master’s in Public Health and BA in Medical Ethics from Columbia University.

Ms. Diane Canova is currently Vice President of Government Affairs at the Legacy Foundation. Previously, Diane served as Vice President of Policy and Programs with the Partnership for Prevention.  Prior still she served as Vice President of Advocacy for the American Heart Association and as Director of Government Relations for the American Red Cross.  Ms. Canova is a founding board member and immediate past chair of the Center for Lobbying in the Public Interest (CLPI) and frequent lecturer on nonprofit leadership and advocacy.  She received her JD from the Brandeis School of Law at the University of Louisville and her BS in Education from Kent State.  

Listen Now

Today nearly all large employers offer a workplace wellness programs and most small employers that offer health benefits also offer at least one wellness program.  Typically these programs consist of health risk assessments, biometric screenings, health coaching and lifestyle management education.  Program popularity is not surprising considering the epidemic in what's termed "lifestyle diseases" due to, in part, poor nutrition and tobacco use.   To encourage employee participation in these programs the Affordable Care Act will allow beginning in 2014 employers to discount up to 30% of successfully participating employee's insurance premiums and up to 50% if the additional 20% is due to a reduction in employee tobacco use.  However, do these programs work and more pointedly do they shift health care costs from healthier employees to those considered less healthy? 

During this 22-minute podcast, Ms. Darling briefly describes workplace wellness programs, their rationale, funding, program incentive payments (including loss aversion policies) and the difficulties in determining wellness programming effectiveness.  She also addressess cost shifting criticisms of wellness programs and other related issues.  The interview concludes with her thoughts concering whether employers will begin to drop employee benefits in 2014.         

Ms. Helen Darling is President of the National Business Group on Health, a national non-profit, representing large employers' perspective on national health policy issues.  Its over 300 members, including 64 of the Fortune 100, purchase health and disability benefits for over 55 million employees, retirees and dependents.  Ms. Darling also currently serves on numerous boards including the Institute of Medicine's Roundtable on Evidence-Based Medicine, the Board of the National Quality Forum, the VHA Health Foundation Board and the Board of the Congressionally-created Reagan-Udall Foundation.  She is widely quoted in The New York Times, Wall Street Journal, The Economist, Washington Post and numerous other periodicals.  Previously, Ms. Darling worked at Watson Wyatt Worldwide, the Xerox Corporation, at William W. Mercer and served as an advisor to Senator David Durenberger.  Ms. Darling received her Master's and Bachelor's of Science fom the University of Memphis.

For more on the debate regarding the effectiveness of wellness programs see, for the example, the debate between Ron Goetzel and John DiNardo via the Health Affairs Blog, at: http://healthaffairs.org/blog/. 

Listen Now

During this 21-minute interview, Professor Nichols discusses the reasons for the decline in health care cost growth and whether its slowing will persist, alternative payment models (to fee for service) that contribute to this decline, how worrisome or not health care market consolidation is as well as the prospect of employers dropping employee health care coverage, why Congressional Republicans (moreover House Republicans) oppose the ACA, ways of improving the law via moroever price transparency provisions and whether states, specificallly Virginia, will take advantage of the ACA and expand its Medicaid coverage in 2014.

Since 2010 Dr. Len Nichols has been Professor of Health Policy and the Director of the Center for Health Policy Research and Ethics at George Mason University.  Previously, Dr. Nichols served as the Director of the Health Policy Program at the New America Foundation, as Vice President of the Center for Studying Health System Change, as a Principal Research Associate at the Urban Institute, as a Senior Advisor for health policy at the Office of Management and Budget during the Clinton Administration's health reform effort, and as Chairman of the Economics Department at Wellesley College. He has advised the World Bank and the Pan American Health Organization, as well as various state governments and departments of the US Government.  Because of his reputation as an honest and knowledgeable health policy analyst, Dr. Nichols has testified on numerous occasions before Congress and is frequently interviewed by major media outlets including The New York Times, The Washington Post, The Wall Street Journal, Congressional Quarterly, National Public Radio, the British Broadcasting Service and ABC, CBS and the NBC's nightly news.  He received his Ph.D. in economics from the University of Illinois at Champaign-Urbana.

Professor Nichols most recent Congressional testimony was before the US Senate Budget Committee this past July 30th, see: http://www.budget.senate.gov/democratic/index.cfm/files/serve?File_id=4dd8a8b5-c123-44e6-b13e-34b6e825c3f0

Among other noted publications Prof. Nichols co-authored (with John Bertko) in 2009 "A Modest Proposal for a Competing Public Health Plan".  See: http://www.newamerica.net/files/CompetingPublicHealthPlan.pdf

Listen Now

As part of last year's "fiscal cliff" agreement the Congress created a Long Term Care/LTC Commission tasked to make recommendations to improve LTC delivery.   (The Commission was created largely as a result of the demise of the ACA's CLASS Act.  See the related August 5th interview with Connie Garner.)  Today more than 12 million Americans rely on LTC services and this number will grow dramatically as baby boomers age.  Currently however only impoverished older Americans and the disabled are covered via state Medicaid programs and because few companies offer LTC policies (and because annual premiums are expensive), only about 8 million Americans have private LTC insurance.  As a result LTC services are provided moreover informally by 42 million Americans at an AARP estimated out-of-pocket cost of $450 billion annually.  In mid-September the 15-member LTC Commission voted 9-6 in approving 28 recommendations.  The six dissenting votes were largely due to Commission's failure to address the most substantive LTC issue, how best to pay for LTC services. 

During this 22-minute interview Prof. Feder discusses the Commission's findings generally.  Moreover she details how/why the Commission failed to address structural financing for LTC.  She also discusses the views of the six Republican-nominated commission members, how/why private insurance policies are limited and/or inadequate, what a publically funded LTC insurance policy would look like and prospects for future work conducted by a subsequent national committee and the Congress.                

Judy Feder is a Professor of Public Policy at the Georgetown Public Policy Institute.  Prof. Feder began her career at the Brookings Institution, continued at the Urban Institute, and, since 1984 has worked at Georgetown University.  She served as Staff Director to the Congressional Pepper Commission in 1989-90, served as Principal Deputy Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services in President Bill Clinton’s first term; as a Senior Fellow at the Center for American Progress and today as an Institute Fellow at the Urban Institute.  Prof. Feder is an member of the Institute of Medicine, the National Academy of Public Administration, the National Academy of Social Insurance, she's a former chair and board member of AcademyHealth, the Hamilton Project’s Advisory Council and a senior advisor to the Kaiser Commission on Medicaid and the Uninsured.  She received her B.A. from Brandeis University and her master's and Ph.D. from Harvard University.

The Commission's report can be found via: http://www.ltccommission.senate.gov/.  Prof Feder, et al., recommendations can be found at: http://www.medicareadvocacy.org/wp-content/uploads/2013/09/LTCCAlternativeReport.pdf.

Listen Now

This past October 1st uninsured Americans who qualify for coverage under the Affordable Care Act could begin choosing a health care insurance plan offered via their state's healthcare insurance marketplace or exchange.  The CBO estimates about 14 million Americans will buy health care insurance for 2014 and about 25 million will do so by the end of the decade (still leaving about 20 million Americans uninsured).  Those that make more than the Federal Poverty Level/FPL but less than four times that level, or $94,000 for a family of four, can buy subsidized insurance and for those making less that 133% of the FPL ($15,000 a year for a single adult or $31,000 a year for a family of four) can sign up for Medicaid if their state is participating in the ACA's Medicaid expansion program - currently 24 states.   Many American who can reasonably afford health care insurance do not buy it and approximately 40% of Americans who qualify for Medicaid do not subscribe.  Since policy is what policy does, the relevant question is how many Americans will sign up for health care insurance under the ACA.

During this 22-minute interview, Ms. Barba Brown discusses Enroll America's mission, its various activites, moreover in 10 states, to advocate for coverage and to educate the uninsured about obtaining either private insurance or Medicaid coverage and how and why she believes Americans will substantially sign up for health care insurance under the ACA.

Ms. Jessica Barba Brown currently serves as National Communications Director for Enroll America.  Previously she was Vice President for Program Development at Faith in Public Life and prior still Communications Director for former U.S. Representative Tom Perriello.  Ms. Barba Brown began her career managing communications and branding efforts for nonprofit social service organizations such as City Year New York and CancerCare in New York City.  She holds a B.A. in Gender and Sexuality Studies from New York University. 

Listen Now

US medical malpractice policy is considered to be substantially flawed.  Only a small percent of patients harmed file claims, awards even for similar injuries vary widely, and "defensive" medicine that leads to over-testing and treatment inflate health care costs by as much as $55 billion annually.  What reforms can be made to "medmal" policy to improve patient safety, reduce health care costs and create greater trust between the public and the health care industry. 

During this 22-minute interview Ms. Mulligan explains why there's actuallly been a recent downward trend in medical tort claims, she discusses the meaning and merits of "defensive medicine" and other alleged medmal-driven adverse affects on health care delivery, she critiques several proposed reform solutions including "safe harbors," "sorry works" and "health courts" along with state reforms in California and Texas, finally she offers her own prescriptions in improving medical malpractice policy.      

Ms. Janice F.Mulligan is a partner with the San Diego law firm of Mulligan and Banham.  Ms. Mulligan's particular expertise is in medical malpractice and personal injury.   Previously to forming her own practice, Jan worked in the California Attorney General's Office prosecuting physicians for malfeasance.  Jan has served in leadership positions in the American Bar Association, is a former President of the San Diego Inn of Court and a former Board member of the San Diego County Bar Association.   In addition to her full time law practice, Jan regularly teaches at the University of California San Diego, School of Medicine.  Jan attended the University of San Diego and St. Anthony's College at Oxford University and graduated with honors from the University of San Diego School of Law.

Listen Now

For nearly four decades, Maryland's “all payer” system has set hospital prices for the state's 53 hospitals.  The state regulates prices for every insurer including Medicaid, Medicare and patients who pay their own bills.  Last week the state proposed to substantially alter how it pays state hospitals by creating over time a capitated payment system (a hard cap) that would increase overall spending using a ten year rolling average.  Maryland would save a minimum projected $300 million over the first three years of the program if the state managed to keep the pace of hospital costs commensurate with the state's economic growth.  If successful, Maryland would join one other state, Massachusetts, in tying hospital spending to the growth of the state's economy. 

During this 21-minute interview Mr. Cohen explains why Maryland's all payer system remains unique, why the state is now proposing to reform its all payer system, he explains how specifically it intends to revise its reimbursement formula, how it will work practically, how it will generate cost savings (largely through health care quality improvements) and what challenges the state will face should the federal goverment approve its proposal to revise its payment system.    

Mr. Robb Cohen is currently Senior VP of Public Policy with the Gorman Health Group.  Prior to Robb founded XLHealth, a Special Needs Plan (SNP), and served as their Chief of Goverment Affairs.  Prior still Robb was the Founder and President of Phoenix Healthcare Consulting.  Robb graduated from the Wharton School of the University of Pennsylvania, the Leonard Davis Institute in Health Economics with an MBA in Finance and Healthcare Management.  Among other community activites Robb has served on a number of State of Maryland Department of Health & Mental Hygiene workgroups and task forces.

To learn more about the Maryland proposal go to: http://dhmh.maryland.gov/SitePages/Medicare%20Waiver%20Modernization.aspx.

Listen Now

In 1999 the Institute of Medicine published "To Err Is Human," a report that shocked the medical establishment because it concluded as many as 98,000 Americans die annually from hospital caused medical errors.  In 2000 the highly respected scholar Dr. Barbara Starfield estimated medical errors or adverse events actually amount to 225,000 deaths annually making them the 3rd leading cause of death after heart disease and cancer.   Most recently a study published this past September in the Journal of Patient Safety estimated medical errors cause between 210,000 to 440,000 deaths annually.  Added to these sobering estimates is the fact there's never been an actual count of how many patients have been killed by medical errors and what progress that has been made in reducing errors, or at least the growth in the number of errors, has been charterized as "frustratingly slow" and "agonizingly slow."

During this 23 minute intereview Ms. Gibson discusses the prevalence of medical errors and why she believes the rate of medical harm is actually getting worse.  She explains why she believes both the medical community's response as well as federal and state government responses have been inadequate and what is needed to reverse this extraordinary number of medical-related deaths.       

Ms. Rosemary Gibson is a Senior Advisor at the non-profit Hasting Center, a research organization dedicated to addressing ethical issues in health, medicine and the environment.  Ms. Gibson is also an editor for JAMA Internal Medicine.  Previously, Ms. Gibson was a Program Officer at the Robert Wood Johnson Foundation where she addressed safety and quality issues particularly in palliative care.  Among other books Ms. Gibson is the author of "Wall of Silence, The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans."  Ms. Gibson serves on numerous boards including the Consumers Union Safe Project and among others she received the Lifetime Achievement Award from the American Academy of Hospice and Palliative Medicine.  Ms. Gibson is a graduate of Georgetown University and the London School of Economics.

To learn more about Ms. Gibson's work go to: http://www.amazon.com/s/?ie=UTF8&keywords=rosemary+gibson&tag=googhydr-20&index=stripbooks&hvadid=18834377909&hvpos=1t1&hvexid=&hvnetw=g&hvrand=187281419643604594&hvpone=&hvptwo=&hvqmt=b&hvdev=c&ref=pd_sl_6ynacw5hh2_b

Listen Now

According to Information Week there are now approximately 100,000 mobile medical applications (double the number from last year) and the market for these applications is expected to grow from $500 million in 2010 to $8 billion by 2018.  These applications promise to provide the consumer with everything from health and wellness information to cancer diagnoses.  What do we know about who uses mobile medical applications or digital therapeutics, why and to what effect?    

During this 22 minute interview Ms. Marchibroda describes four general categories of mobile medical applications, their parochial uses by the public, healthcare providers, employers and insurers, what's known about their effectiveness, potential downsides and why the FDA is regulating these (and future federal regulation of health information technology more generally).  

Ms. Janet Marchibroda is currently the Director of the Health Innovation Initiative and the Executive Director of the CEO Council on Health and Innovation at the Bipartisan Policy Center in Washington, DC.  Ms. Marchibroda also serves as a board member for Doctors Helping Doctors Transform Health Care.  Ms. Marchibroda previously led stakeholder engagement activities for the National Coordinator for Health Information Technology at DHHS, served as the Chief Health Care Officer at IBM, served as the founding Chief Executive Officer for eHealth Initiative (eHI) and also served as the Chief Operating Officer of the National Committee for Quality Assurance.  Among other awards she's been recognized as one of the Top 25 Women in healthcare by Modern Healthcare magazine.  Ms Marchibroda was graduated from the University of Virginia with a BS and from The George Washington University with an MBA.

Listen Now

It's estimated in the next few years the Affordable Care Act will add 25 million Americans to the health care insurance rolls.  In addition, 10,000 Americans age into Medicare every day.  Current estimates by the Health Resources and Services Administration and others show the country already has a shortage of health care providers, particularly primary care physicians, and the shortage is projected to grow substantially worse by 2025.   Since we can neither meet the demand nor improve supply without changes or improvements to medical workforce training what then can be done to reform federally-funded graduate medical education (GME), particularly since GME policy has been frozen since 1997.   

During this 17 minute interview Dr. Goodman discusses the adequacy of the current health care workforce, what can be done in the near term to improve supply particularly to reduce the maldistribution of providers, policy alternatives he is recommending to improve (or incent) provider supply via changes to federal funding of GME and how (any) reform to GME can avoid the consequence of more physicians simply accelerating health care spending without improving healthcare outcomes or population health.  (Please note: Dr. Goodman's comments are his own.)     

Dr. David C. Goodman is a Professor of Pediatrics, the Co-Principle Investigator of the Dartmouth Atlas of Health Care and leads the Institute for Health Policy and Clinic Practice at Dartmouth.  His primary research interest is the relationship of outcomes to health workforce supply and its implications for health workforce policy.  He also leads and mentors a wide range of projects investigating the causes and consequences of variation in health care capacity and utilization. Dr. Goodman is the co-founder of the Wennberg International Collaborative, a research network that advances the study of unwarranted medical practice variation.   He is the author of numerous research publications and serves on several editorial boards.  Dr. Goodman was graduated from SUNY, Syracuse with a MD degree, he did his medical training at Johns Hopkins and earned a MS in epidemiology from Dartmouth.

Listen Now

Conservative estimates show hospital-acquired infections (HAIs) sicken two million Americans, directly kill 23,000 and contribute to a total of 100,000 deaths each year.  The bacterial infection C. diff (Clostridium difficile) alone causes 250,000 people to be hospitalized annually.  Healthcare costs associated with these infections are estimated at over $50 billion.  These illnesses and deaths are largely the result of an overuse or misuse of antibiotics that causes bacteria to become over time drug or anti-microbial resistent.  (Fifty percent of all antibioticis prescribed for people are not needed.)  The CDC has recently termed these "nightmare bacteria." They pose, the CDC has stated further, a "catastrophic threat" to the public's health. 

During this 23 minute interview Ms. Jezek explains why antimicrobials are overused both in human and food animal populations, why drug companies have been pulling out of doing research in this area, what's being done to spur researchers to develop new anti-bacterials including the IDSA's 10 x 2020 program, what IDSA is doing regarding bacterial transplants, what's being done by the FDA under 2012 GAIN Act and what the Congress has tried to do, or is trying to do, to address this substantial public health problem.

Ms. Amanda Jezek is the VP for Public Policy and Government Relations at the Infectious Diseases Society of America (IDSA) which represents over 10,000 physicians and scientists.  In her position Amanda is responsible for policy development and advocacy on IDSA priority issues including antimicrobial resistance, antimicrobial and diagnositcs development, preparedness and federal funding.  Prior to joining IDSA, Amanda was the Deputy Director for Federal Affairs at the March of Dimes Foundation.  Amanda has lobbied for Mental Health American and worked as a Legislative Assistant and Press Secretary for Rep. Grace Napolitano (D-CA).  Amanda received her BA from Dartmouth College.

Listen Now

Human physiology or biological functioning exhibits fractal or irregular patterns.  When heart rate, (or respiration rate, blood pressure, brain waves and even walking stride length) begins to lose its fractal dimension or there is a loss of heartbeat variability, this is an indication of illness.  In order to respond best to environmental circumstances, adaptative variability (not homeostasis) is what organisms strive toward.  Measuring therefore the decline in heart rate variability over time can serve as a clinically effective biomarker for the onset of disease, for example, the onset of chronic obstructive pulmonary disease (COPD), one of the leading causes of hospitalizations and re-hospitalizations.  

During this 20 minute interview Professor Palmer explains briefly the science behind what explains heart rate variability and variability more generally in biological functioning, what are the clinical or health care or clinical applications for this research, his research to avoid COPD hospitalizations and the onset of infection for leukemia patients, the larger implications of this research work and receptivity toward this different paradigm in understanding biological functioning and disease progression.

Dr. James Palmer is an Assistant Professor in Family Medicine at the University of Colorado's Anshuyltz Medical Campus in Denver.  His research concerns testing and developing the use of heart rate interval dynamics as an actionable prognostic biomarker for earlier detection and diagnosis COPD exacerbation.  Dr. Palmer also has an independent professional practice that designs applications of complexity sciences to improve clinical care processes and outcomes.  His work has helped to develop and implement healthcare improvement projects both in the US and Canada.  Dr. Palmer completed his Doctor of Management in 2007 at the Complexity and Management Centre, University of Hertfordshire, UK.  He was also educated as an economist at the University of Chicago (MA) and Texas Christian University (BA).

For a review of the theory behind and applications for monitoring variability see, for example, Andrew JE Seely, et al. "Continuous Multiorgan Variability Monitoring in Critically Ill Patients - Complexity at the Bedside," at: http://www.therapeuticmonitoring.com/files/IEEE-CIMVA-paper_Boston_Sep-2011.pdf 

Listen Now

Of the two and a half million Americans that die annually, less than half, or 45%, die under hospice care. About one-third of these deaths are cancer related the remainder are moreover from heart and lung disease and dementia.  Of the over 5,000 hospice providers nearly two-thirds are for profit.  Over 80% of all hospice care is paid for by Medicare.  While hospice care is ever-increasingly becoming accepted by the public, the program's benefits are compromised largely due to the fact that over one-third of hospice enrolled decedents were enrolled in the program for too short a period of time, or less than seven days.  

During this 21 minute podcast, Dr. Doblin discusses why he became a hospice physician, what makes for good hospice care, why the benefit remains under-utilized, what constitutes a "good death," how might hospice and palliative care be improved and how these services might better fit  in ever-evolving changes in the health care industry.     

Dr. Bruce H. Doblin is currently a Physician in the Department of Internal Medicine at Northwestern Memorial Hospital.  He also serves as an Instructor of Clinical Medicine-Internal Medicine at the Northwestern University Feinberg School of Medicine.  Previously, Dr. Doblin served for over ten years as the Medical Director for Seasons Hospice and Palliative Care in Chicago.  Dr. Doblin earned his BA in Economics at Williams College and his MD and Masters in Public Health from Northwestern University.  He completed fellowship training at UCLA in health services research and at the University of Chicago in Clinical Medical Ethics.

Listen Now

 Transcendental Meditation (TM) has long been studied as an approach to improving health status generally and lowering blood pressure specifically.  For example, the American Heart Association published research in 2012 that found African Americans who practiced TM regularly over five years were almost half as likely to have a heart attack or stroke or die from all causes compared to African Americans who attended health education classes due to lowered blood pressure and improved anger management.  Among other applications, TM has also shown to be effective in reducing PTSD and polytrauma among active military service members and veterans.  

During this 21 minute podcast Dr. Schneider discusses what's meant by the "mind-body-heart" connection, what role can/does TM play in influencing these connections, the research evidence for TM's use in reducing hypertension and more generally stress and anxiety for a wide variety primary and secondary disease prevention purposes and the level of acceptance for TM within the medical community.     

Dr. Robert Schneider is currently the Director and Senior Investigator of the Center for Natural Medicine and Prevention at the Maharishi University of Management Research Institute.  Over the course of his career Dr. Schneider has been awarded more than $20 million in grants from the NIH for his pioneering research on natural approaches to reducing heart disease.  Dr. Schneider is a Fellow of the American College of Cardiology, a former member of the White House Commission on Complementary and Alternative Medicine Policy and has has served on numerous commissions and expert panels for the Congress, the CDC and others.  Dr. Schneider is the author of Total Heart Health and over 100 medical research articles.  He has been featured in numerous media reports including CNN, The New York Times, and Time magazine.  He received his MD from the University of Medicine and Dentistry of New Jersey and did his residency training at the University of Michigan Medical Center.

Listen Now

(This podcast is a companion to the November 13th interview with Infectious Diseases Society of America's Amanda Jezek.)  

As previously noted, conservative estimates show hospital-acquired infections (HAIs) alone sicken two million Americans, directly kill 23,000 and contribute to a total of 100,000 deaths each year.  The bacterial infection C. diff (Clostridium difficile) alone causes 250,000 people to be hospitalized annually.  The US has some one of the highest infection resistant rates among developed countries and within the US infection rates are highly variable.     

During this 25 minute conversation Dr. Anthony Harris discusses why comparatively US infection resistance rates are high, why hand hygiene compliance rates remain persistently high (despite the fact hand contamination contributes substantially the the spread of infections), what acute care providers can do to reduce infections, what activites SHEA is pursuing to help reduce infection rates and what more can be done nationally, specifically regarding quality metrics, to lower rates. 

Dr. Anthony Harris is currently a Professor of Epidemiology and Public Health at the University of Maryland's School of Medicine and is the President-Elect of SHEA.  His research interests include emerging pathogens, antimicrobial-resistant bacteria, hospital epidemiology/infection control, epidemiologic methods in infectious diseases and medical informatics.  He has published over 100 research papers and currently receives funding from the NIH, CDC and AHRQ to study antibiotic resistant infections and hospital epidemiology.  Dr. Harris received his medical degree from McGill Univesity and his MPH from Harvard. 

For information on SHEA's compendium of strategies to prevent health care associated infections see:  http://www.shea-online.org/HAITopics/CompendiumofStrategiestoPreventHAIs.aspx

For information on SHEA's research network of 200 hospitals see:  http://www.shea-online.org/Research/SHEAResearchNetwork/SRNStudiesandResources.aspx

Listen Now

 The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 under the Reagan administration to help prevent patient dumping.  The law requires hospitals to provide emergency medical treatment to anyone regardless of citizenship, legal status or ability to pay.  In recent years however hospitals have begun to impose upfront emergency room fees.  Today approximately half of all hospitals do so.  Hospital executives claim these fees reduce ER overcrowding by diverting patients with non-emergency needs.  Patient advocates claim the fees undermine EMTALA's intent and causes patients' health conditions to worsen.  For example, in 2011 one large national hospital chain saw 80,000 patients leave their emergency rooms untreated when faced with a $150 use fee.  

During this 17 minute podcast Professor Rosenbaum explains what generally EMTALA requires, when ER fees can be legally solicted or collected, the negative effects of fee collection, she questions the legitimacy of the industry's argument that fees help to encourage more appropriate site of care use and what can be done to provide better oversight and enforcement of EMTALA.     

Professor Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy and Founding Chair of the Department of Health Policy at The George Washington University School of Public Health and Health Services.  Professor Rosenbaum is best known for her work on the expansion of Medicaid and community health centers, patients' rights in managed care, civil rights and health care, and national health reform.  She is the lead author of Law and the American Health Care System, a landmark textbook that provides an in-depth exploration of the interaction of American law and the U.S. health care system.  She has received numerous national awards for her work, serves on governmental advisory committees, private organizational and foundation boards, and is a past Chair of AcademyHealth. She is a member of the CDC Director's Advisory Committee, the CDC Advisory Committee on Immunization Practice and a Commissioner on the Medicaid and CHIP Payment and Access Commission (MACPAC).  She received her BA from Wesleyan and her JD from Boston University.

Listen Now

The term "medical home" was first introduced in the 1960s by the pediatric profession.  Still to date this model of care emphasizes team-based comprehensive, continuous and coordinated care.   The care model is intended to improve primary care generally via improved patient communication, care quality, safety and outcomes.  In several ways the ACA encouraged the adoption of the, now termed, Primary Care Medical Home/PCMH for both the Medicaid and Medicare programs and among private health insurers.   (In some ways the PCMH is seen as a precursor for providers interested in becoming an Affordable Care Organization (ACO), i.e., taking on reimbursement risk.)  Over the past few years PCMHs have become widely adopted.  Over forty state Medicaid programs are experimenting with the model along with 90 commercial health plans and three federal initiatives. 

During this 23 minute discussion Dr. Nielsen discusses the PCPCC's purpose and goals, more specifically what is the PCMH model of care, the varying ways PCMH's are reimbursed, what does the research to date show regarding PCMH effectiveness and challenges in adopting this new model of care.

Dr. Marci Nielsen currently serves as CEO of the Patient Centered Primary Care Collaborative (PCPCC), an organization dedicated to advancing an effective and efficient health system built on a foundation of primary care.  Prior to the PCPCC, Dr. Nielsen served as Vice Chancellor for Public Affairs and Associate Professor at the University of Kansas School of Medicine’s Department of Health Policy and Management.  Dr. Nielsen was appointed by then-Governor Kathleen Sebelius as first Executive Director and Board Chair of the Kansas Health Policy Authority (KHPA).  She worked as a Legislative Assistant to Senator Bob Kerrey and later served as the health lobbyist for the AFL-CIO.  Dr. Nielsen is a board member of the American Board of Family Medicine and also a committee member for the Institute of Medicine’s Leading Health Indicators for Healthy People 2020 and Living Well with Chronic Illness: A Call for Public Health Action.  Early in her career she served as a Peace Corps volunteer in Thailand and served for six years in the US Army Reserves.  Dr. Nielsen earned her MPH at The George Washington University and her Ph.D. from the Johns Hopkins School of Public Health.

The PCPCC's 1/14 PCMH impact on cost and quality report can be found at: http://www.pcpcc.org/newsletter/annual-report-pcmhs-impact-cost-quality-2012-2013.

Listen Now

In late January in a case involving a Catholic charity, the US Supreme Court issuesd a ruling temporarily exempting religious-affiliated non-profits from providing ACA-required contraceptive coverage.  (The ACA coverage requirement was based on an IOM recommendation that found birth control is "medically necessary."  The requirement took effect January 1st).  While churches and houses of worship are exempt, owned or controlled religious organizations can opt out of the contraceptive coverage requirement by completing and signing a form explaining their objection.  However, opponents say by opting out - that then allows the employee to obtain contraceptive coverage through a separate insurance policy - they are complicit in immoral conduct, i.e., they too should be exempted outright.  In addition, the Supreme Court has agreed to hear two cases that involve for-profit companies similarly objecting to the requirement.  

During this 20 minute conversation Mr. Sonfield discusses the specifics of the ACA contraception coverage requirement and why it was included as an "essential health benefit, exemptions to it including how religiously affiliated non-profits can avoid providing coverage and moreover, in light of the recent legal challenges to the contraception mandate, what the research shows regarding the benefits of women's contraception.              

Adam Sonfield joined the Guttmacher Institute in Washington DC in 1997.  (Guttmacher is a non-partisan reproductive health and rights research and policy shop.  Its goal is to "ensure the highest standard of sexual and reproductive health for all people worldwide.")  Adam currently serves as a Senior Public Policy Associate.  He is the managing editor and a regular contributor to the Institute’s public policy journal, the Guttmacher Policy Review.  Mr. Sonfield’s portfolio includes research and policy analysis on public and private financing of reproductive health care in the United States, the rights and responsibilities of health care providers and patients, and men’s sexual and reproductive health. He also writes a quarterly Washington Watch column for Contraceptive Technology Update.  Mr. Sonfield earned an A.B. with honors in social studies from Harvard and a Master of Public Policy, focusing in health policy, at Georgetown University.

The Guttmacher Institute's Supreme Court amicus brief can be found at: http://www.guttmacher.org/media/inthenews/2014/01/31/index.html,

Listen Now

Concierge medicine (also termed membership medicine, direct pay or cash only practice) has become a rapidly-growing care model moreover among primary care physicians.  In concept, physicians charge patients a monthly or annual fee that can vary widely from approximately $50 per month to $25,000 per year (or accept cash only per visit).  In exchange patients are promised greater access, longer appointment times and possibly services not typically reimbursed by payers.  The current number of physicians practicing concierge medicine is today small, approximately 5,500 nationwide, however, concierge practices are expected to continue to grow at a healthy rate, currently estimated at 25% per year.  While these fees enable physicians to reduce patient panel size and presumably improve physician satisfaction, the model by definition posses access problems for the sickest patients, typically those least able to afford a concierge fee.  For example, among Medicare beneficiaries, in 2012 half of all had annual incomes less than $22,500 and for African American and Hispanic Medicare beneficiaries annual income was less than $15,000. 

During this 21 minute discussion Ms. Schwarz explains the intersection between concierge medicine and the Medicare program, related investigative efforts by CMS and the DHHS Office of the Inspector General, whether there is any data showing improved care quality and/or reduced health care system costs, whether the practice of concierge medicine constitutes patient abandonment and what would the Medicare Rights Center tell a beneficiary if they called the Center inquiring about the appropriateness and merits of concierge medicine.    

Ms. Casey Schwarz is currently the Policy and Client Services Counsel at the Medicare Rights Center in Washington, DC.  Among other duties Ms. Schwarz represents individuals in appeals and directly counsels individuals with complicated Medicare questions.  She works closely with the Medicare statute, regulations, and guidance on a daily basis, including drafting responses to proposed regulatory changes.  She also provides trainings for legal and other professionals working with Medicare clients.  Prior to her Rights Center work Ms. Schwarz served as a Court Attorney in the New York County Supreme Court.  Ms. Schwarz is a graduate of Brown University and the New York University School of Law.  She is a member of the New York  and Maine State Bars.

Listen Now

 Corporate Owned Life Insurance are life insurance policies corporations buy on their employees whereby the corporation is the named beneficiary.  This practice, at least initially, was adopted as a way of insuring a company against the loss of a limited number of key executives.  These policies also became attractive because both premium returns and benefits paid were not taxed.  Over time large companies, like Walmart, purchased these policies on millions of employees increasingly for the tax advantages and, industry executives argued, to provide or afford employee and retiree medical benefits.  Beyond the moral objection of profiting from an employee's death, even in instances where the person dies years after they left their employer, these polices perversely incent companies to compromise on insuring employee health and workplace safety.  While regulatory limitations have been placed on these policies, in 2007 dead peasant's insurance was estimated to account for 30% of the life insurance market. 

During this 22 minute podcast Peter explains what is an "insurable interest," whether we know how corporations use the income derived from these policies, whether  employee consent is required, the outcome of law suits filed by surviving family members against corporations for this practice, reforms made in 2006 to better regulate this practice and whether these policies do indeed on balance undermine insuring worker safety and health status.   

Professor Peter Kochenburger is the Executive Director of the University of Connecticut's Law School’s Insurance Law Center.  He also serves as Director of the Law School’s graduate program, is a Consumer Representative for the National Association of Insurance Commissioners and is an Associate Editor for the ABA Tort Trial & Insurance Practice Law Journal.  Before joining UConn. in 2004 Professor Kochenburger spent eleven years as Counsel at Travelers Property Casualty, where he managed coverage and bad faith litigation, as well as legislative and regulatory affairs across such subjects as workers compensation, OSHA, guaranty funds, tort reform, antitrust, and environmental issues.  His professional experience also includes serving as an Assistant Attorney General in the Consumer Protection Division of Iowa’s Department of Justice and from 1986-1988 he served as Special Assistant to the dean of the Harvard Law School.  He is a graduate of Yale University and Harvard Law School.

Related articles

'Dead Peasant Insurance' Still Alive in Corporate America

Listen Now

The 2010 Affordable Care Act created the Center for Medicare and Medicaid Innovation at CMS with $10 billion in funding to test innovation and service delivery models to improve health care delivery and outcomes and reduce costs.   To date the CMS Innovation Center has funded one round of innovation awards throughout the US (a second round of awards are expected to be announced this summer).  In DC, Mary's Center was awarded in 2012 a three-year $15 million grant to create the "Capital Clinical Integration Network" (CCIN).  The CCIN promises to save $17 million over three years by implementing and testing an integrated clinical network to improve care for chronically ill DC residents whom typically rely on emergency room visits for health care.  To do this Mary's Center will, in part, train and hire 44 health care workers to serve as care managers and community-based care coordinators.  

During this 18 minute discussion Dr. Pistulka discusses Mary's Center's work generally, how the CCIN is organized, the clinical care and social service support work CCIN is doing via care coordinators and others and results they've been able to achieve now two years into the three year CMMI award.   

Gina Pistulka joined Mary’s Center in 2006.  During her 17 years in nursing, she has also worked as a rural public health nurse and as an urban health nurse educator in Minnesota.  She has also done nursing work overseas in Central America.  Her research background includes having done cross-cultural intervention research.   She has also served on boards to further nurse training through Catholic University of America and via the nonprofit organization Truth About Nursing.   Gina was graduaged from Johns Hopkins with a duel Master’s in Public Health and Community Health Nursing and in 2007 received her Ph.D. in Nursing also from Johns Hopkins. 

To learn more regarding CMMI's innivation awards see: http://innovation.cms.gov/initiatives/map/index.html.

Listen Now

Since 1992 use of the RBRVS (Resource Based Relative Value Scale) has been the prevailing method by which physician procedure prices are determined.  The method or formula for determining prices is managed by the AMA's RUC (or the Relative Value Update Committee).  In recent years the RUC has come under increasing criticism largely because their work perversely incents the use or overuse of higher priced medical procedures. The RUC has been a topic of Congressional hearings over the past few years and just this past week the Congress included a provision in the so called "doc fix" bill to have the DHHS Secretary begin to collect information on physician services to better determine relative values in setting physician fees.  

During this 23 minute conversation Kavita discusses how the RUC determines prices, the AMA's defense of the RUC process, what effect price skewing has on the practice of primary care and how the RBRVS might be reformed.   

Dr. Kavita Patelis a Fellow in the Economic Studies program and Managing Director for clinical transformation and delivery at the Engelberg Center for Health Care Reform at the Brookings Institution.  She is also a practicing primary care internist at Johns Hopkins Medicine.  She served previously in the Obama Administration as Director of Policy for the Office of Intergovernmental Affairs and Public Engagement in the White House.  Dr. Patel also served as Deputy Staff Director for the late Senator Edward Kennedy.  She too has an extensive research and clinical background having worked as a researcher at the RAND Corporation and as a practicing physician in both California and Oregon.  She earned her medical degree from the University of Texas and her masters in public health from the UCLA.

Listen Now

Since the 1960s Community Health Centers (CHCs) have been providing health care services to moreover minority populations, the poor and the uninsured.  Today there are approximately 1,200 health centers providing health care to over 20 million Americans in all fifty states.  They our the nation's true safety net.  The Affordable Care Act created the CHC Fund that provided $11 billion over five years for the expansion of health centers and services throughout the country.   

During this 20 minute discussion Michelle Proser discusses the work of the National Association of Community Health Centers, how CHCs work to reduce health care disparities, what work CHCs have been doing with ACA's $11 billion in  funding and the potential effect should CHC Fund moneys not be renewed when they expire later next year. 

Michelle Proser is the Director of Research at the National Association of Community Health Centers where she conducts research and policy analysis on a variety of topics used to empower health centers and educate policymakers and the public.  Michelle also directs NACHCs’ efforts to build health center capacity for community-directed translational research.   Previously, Michelle served as a research analyst at the Center for Health Services Research and Policy at The George Washington University.   Michelle received her MPP from George Washington and is presently a Ph.D. candidate at GWU.

Listen Now

 The ACA's open enrollment period ended this past March 31st. Over eight million Americans signed up for health care insurance.  Of these 2.2 million, or 28 percent, were young adults or between the ages of 18 and 34.  In 26 states and the District of Columbia approximately 15 million adults with income below 138 percent of the poverty level became eligible for Medicaid coverage.  (19 states are not participating in the ACA's Medicaid expansion program and five states remain undecided).  

During this 21 minute discussion Brian explains the National Association of Insurance Commissioner's (NAIC) work, what we know about the 8 million individuals that signed up for health care insurance under the ACA marketplaces, the most popular plan, what "effectuated enrollment" means, how many individuals already had insurance and prospects for 2015 enrollment.

Brian Webb is the Manager of Health Policy and Legislation for NAIC. The NAIC represents the insurance regulators in all 50 states, DC and the five U.S. territories.  Previously, Brian worked on Medicare and Medicaid policy for the BlueCross BlueShield Association and prior still was the Assistant VP for Legislation for the then-Federation of American Health Systems (FAHS).  Brian began working in DC in 1988 as a legislative aide for Congressman Bill Thomas.  After six years with Mr. Thomas, Brian worked for five years in California Governor Pete Wilson’s Washington office as health and welfare aide and Deputy Director.  Brian was graduated with a MPA from The George Washington University and his Bachelor's degree is from Biola University in California. 

Listen Now

This past April 24th the FDA announced a proposed rule to regulate e-cigarettes.  The FDA is, in part, proposing to ban the sale of e-cigarettes to minors, require manufacturers to disclose e-cigarette ingredients and prohibit manufacturers to claim e-cigarettes are less harmful than tobacco cigarettes without submitting scientific proof.  The proposed rule did not forbid TV advertising and does not ban flavorings such as cotton candy and Gummi Bear.   Are these regulations adequate, or alternatively, even necessary since some claim e-cigarettes are a lifesaver since they can prevent smokers from consuming harmful tobacco.  

During this 23 minute discussion Dr. Abrams, in part, provides a brief overview of the Schroeder Institute's work, evaluates the efficacy of e-cigarettes as an aid to smoking cessation (are they a lifesaver), assesses the FDA's proposed regulations and how they might be improved.   

David B. Abrams is the Executive Director of the Schroeder Institute for Tobacco Reseach and Policy Studies at the Legacy Foundation.  He is also a Professor in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health and an Adjunct Professor at Georgetown Univeristy Medical Center, Lombardi Comprehensive Cancer Center. Previously, Dr. Abrams directed the Office of Behavioral and Social Science Research at NIH.  He has published over 250 scholary articles and monographs, served as President of the Society for Behavioral Medicine and is the recipient of numerous awards including the Joseph W. Cullen Memorial Award from  the American Society for Preventive Oncology.    He was graduated from the University of Witwatersrand, South Africa with a BS in Computer Science and from Rutgers University with a Ph.D. in Clinical Psychology.

For more on the FDA's proposed rule, see: www.fda.gov/TobaccoProducts/default.htm

Listen Now

In May 2011 Vermont passed legislation signed by Governor Peter Shumlin creating a single-payer, publicly financed, universal health care system termed Green Mountain Care.  The law recognized health care as a public good much like electricity.  The program, not expected to go into effect until at least 2017, will be defined by an independent board, the Green Mountain Care Board, created to oversee all aspects of the program including rate setting, hospital budget authorization and the regulation of insurance carriers.  The single payer system is expected to increase insurance claims costs but the savings derived from lower administrative costs are expected to result in net savings.

During this 19 minute discussion Joshua discusses how politically Green Mountain Care came about, where presently the state is in rolling out the plan, how the state's insurance marketplace will enable the program, what role private insurance plans will play, how will the program be financed, what skeptics are saying and how Vermont's effors may inform the on-going natonal health care policy debate. 

Joshua Slen served as Vermont's Mediciad Director from 2004-2008.  Presently, or since 2011, Joshua has been an Executive Account Director with Molina Healthcare.  He was a Senior Consultant to Bailit Health Purchasing from 2009-2011 and prior to serving as Medicaid Director he was a Deputy (Budget) Commissioner and a Budget and Management Analyst for the State of Vermont.  Joshua began his public service career working in several Ohio state budget offices from 1991-1999.  He earned his MPA at Ohio State University and his BA in political science at Wittenberg University.    

To learn more about Green Mountain Care go to: http://gmcboard.vermont.gov/. 

Listen Now

Primary care is considered the bedrock of healthcare delivery.   Primary care services promotes wellness, prevents disease onset, progression, exacerbation and premature death and moderates the need for higher-cost specialty services.   However, as the recent news about wait times at VA health care facilities demonstrated, the US suffers a shortage of primary care providers.  The current shortage, estimated at approximately 8,000 primary care physicians, is anticipated to grow to 50,000 or more by 2020. 

During this 21 minute discussion Dr. O'Malley explains why primary care is becoming more team based and why that is important, the adoption and use of electronic medical records in the primary care practice setting and the emergence of retail health clinics over the past 15 years and her assessment thereof.    

Dr. Ann O’Malley is a Senior Fellow in the Health Research Division at Mathematica, a social policy research organization.   Her research focuses moreover on primary care and quality of care.  Dr. O’Malley has also held faculty positions at Georgetown University Medical Center where she worked on research funded by the NIH's National Cancer Institute and foundations examining the use of evidence-based preventive services in primary care settings.  She serves as a reviewer and has published in the New England Journal of Medicine, Health Affairs, and the Annals of Internal Medicine.  She is a member of AcademyHealth and a fellow of the American College of Preventive Medicine.  Ann earned her MD from the University of Rochester School of Medicine and her MPH in Health Policy and Management from Johns Hopkins. 

For more on retail health clinics see this 2013 Center for Studying Health System Change publication titled "Despite Rapid Growth, Retail Clinic Use Remains Modest," by Ha T. Tu and Ellyn R. Boukus at: http://www.hschange.org/CONTENT/1392/.

Listen Now

As is well known Congressional Republicans have vehemently opposed the Affordable Care Act (the ACA or Obamacare). House Republicans, for example, have voted an estimated 50 times to replace the law.   Despite their criticisms over the past four years only recently has the party presented anything that approaches a substantive alternative to the ACA. Earlier this year an alternative proposal was presented by Republican Sentors Burr, Coburn and Hatch titled the Patient Choice, Affordability, Responsibility and Empowerment (CARE) Act. 

During this 21 minute podcast Jim discusses several provisions of the CARE plan, i.e., auto-enroll and continuous coverage, coverage limits and mandates, limitations on the tax exclusion, reforms to Medicaid and other issues.          

James C. Capretta is a Senior Fellow at the Ethics and Public Policy Center in Washington, DC, where he provides research and analysis on a wide range of public policy and economic issues with a focus on health-care and entitlement reform, US fiscal policy and global population aging.  He also is presently a visiting fellow at the American Enterprise Institute.  Mr. Capretta previously served in senior positions in the executive and legislative branches of the federal government for sixteen years.  For example, from 2001 to 2004, he was an Associate Director at the White House Office of Management and Budget (OMB), where he had responsibility for health care, Social Security, education, and welfare programs.  He received his MA in Public Policy Studies from Duke University and was graduated from the University of Notre Dame with a BA in Government.

Details regarding the CARE Act can be found at: http://www.coburn.senate.gov/public/index.cfm/rightnow?ContentRecord_id=7ef8f0d5-bf56-4ea3-80fe-7f86765a00ca&ContentType_id=b4672ca4-3752-49c3-bffc-fd099b51c966.

Listen Now

A few years ago the federal Agency for Healthcare Research and Quality sponsored billboard ads that stating simply "this year thousands of men will die from stubbornness."  The message was intended to encourage moreover middle age men to seek preventive health screening since they are 25 percent less likely than women to visit a doctor in any one year and 30 percent more likely to be hospitalized for a preventable condition.   While prostate cancer is largely survivable, aside from non-melanoma skin cancer, it is the most common cancer among men (most prevalent among African Americans) particularly men over age 50, it usually presents without any symptoms and men "stubbornly" ignore being (routinely) tested.   Nearly 200,000 cases are diagnosed annually causing over 28,000 deaths.  While the value of PSA testing is debated, a digital rectal exam, while incomplete, evaluates the back of the prostate where 85% of prostate cancers arise.   

During this 21 minute discussion Guido shares his personal experience, i.e., how he came to be diagnosed, his treatment (still ongoing) and his efforts to public raise awareness.   Another prostate cancer survivor,  Howard Topel, comments on his treatment and survival - that he owes to hearing Guido's "get screened" presentation.        

For the past 30 years Guido Adelfio has managed his family's custom travel business (Bethesda Travel Center, LLC) in Bethesda, Maryland.  After a happenstance conversation with a friend about preventive health screening, Guido scheduled a prostate screening exam.   The exam determined he had Stage IV metastatic prostate cancer.   His diagnosis was determined to be fatal.   Fortunately Guido was able to enroll in a NIH experimental treatment therapy program that saved his life.

Howard Topel is a 66 year old retired communications attorney.  He represented radio and television station owners for 38 years.  Through the early detection of a PSA test, he was diagnosed at the age of 55 with highly aggressive form of prostate cancer.  The early detection saved his life, and he now fully enjoys retirement with his wife Andria and watching his children Fred and Melanie and infant granddaughter Celia grow and thrive.

For more on prostate cancer and screeing see the related CDC information at: http://www.cdc.gov/cancer/prostate/. 

Listen Now

Late last year Gilead Sciences received FDA approval for its Hepatitis C drug Solvaldi.   Hepatitis C (Hep C) affects three to four million Americans and can have serious health consequences.  Gilead priced the drug at $1,000 a pill or between $84,000 and $168,000 for the full, curative treatment (effective in approximately 90% of patients).   However as priced if every Hep C patient received Solvaldi the cost would equal the combined annual spending amount for all drugs sold in the US.

During this 21 minute podcast Chris discusses how and why this drug's pricing effects all of health care financing and delivery, the work the DC-based Campaign for Sustainable Rx Pricing is doing to try to mitigate Solvaldi's cost, when and if similar Hep C drugs entering the market will force Gilead to lower its price and why past efforts to moderate pharmaceutical drug pricing, e.g., authoring Medicare to negotiate drug prices it pays, have proved unsuccessful.   

Through this past April Chris Dawe was the Health Care Policy Adviser for the White House National Economic Council.  Previously, Chris served as Director of Delivery System Reform at the US Department of Health and Human Services.  Before joining the administration in 2011 Chris served as a Professional Staff member for the US Senate Finance Committee under Chairman Max Baucus. From 2007 to 2008, Chris served as Health Policy Adviser to Senator John Kerry. Prior still Chris was a Legislative Analyst at Jennings Policy Strategies in DC, while there he served in 2006 as the Deputy Director for Global Health at the Clinton Global Initiative.   Before coming to Washington, DC, Chris was a Market Analyst at Partners Healthcare, Massachusetts' largest hospital system.  Chris is a Massachusetts native and a magna cum laude gratudate of Bowdoin College.  

Listen Now

Medicare billing fraud is pervasive.  It's estimated at $50 to $60 billion annually or approximately 10% of all of Medicare spending.   While billing fraud is committed in numerous ways from never performed procedures to fake patient care, it's possibly no more prevalent than in home health care, an industry of 12,000 providers whom bill Medicare $18 billion annually.  For example, a 2010 DHHS Office of the Inspector General report found one in every four home health agencies had unusually high billing.   In one example, federal officials in 2012 arrested a Texas-based home health provider accusing him and his colleagues of running a $375 million home health scam.   

During this 21 minute interview Sherill Mason defines home health, discusses how home health is reimbursed, how fraud or improper billing is committed via for example upcoding and over utilization, where, the prevalence of the problem, what CMS is doing to try to curb fraudulent behavior, rule making solutions and whistle blower (qui tam) suits.   

Sherill Mason is currently Principal, Mason Advisors, where she provides strategic planning, program development and operations analysis for post acute care providers including senior living and nursing home facilities, home health, hospice, long term acute care hospitals, in patient rehabilitation facilities, and long term care pharmacy.  Previously, Sherill she served as a Vice Presient to the Marwood Group, a healthcare industry consultant, as Senior Vice President at Sunrise Senior Living and as a Director at KPMG.   Among other current professional activities Sherill currently is a Guest Lecturer at the University of Pennsylvania School of Nursing.  She received her RN diploma and training at the Englewood Hospital School Nursing and a BA in American Studies from Eckerd College.  

Listen Now

Health care insurance plans and policy makers are constantly working toward improving cost management.  Recently two techniques to do so have reemerged in this effort: narrow networks and reference pricing, techniques that have enjoyed success in the past.  Likely the largest (de facto) user of narrow networks is the integrated health plan Kaiser and CalPERS (the California Public Employees's Retirement System) has saved millions in its use of reference pricing.   What are these practices, to what extent are they successful in saving money (and improving health care quality) both for payers and patients and what are the real and/or potential downside risks associated with these practices.  

During this 21-minute interview Dan Mendelson defines these two cost savings techniques, i.e., how do they work or why they are attractive to plans, do they improve health care quality both within and beyond the ACA insurance marketplaces and how or why these techniques might not be in the best interests of patients (and possibly providers as well).   

Dan Mendelson is CEO of Avalere Health, a DC-based health care research and policy consulting firm.  Dan leads the organization's operations and engages in strategic advisory work for major clients in life sciences, managed care and in many provider segments.   Prior to founding Avalere in 2000, Dan served as Associate Director for Health at the White House Office of Management and Budget.  Dan also presently serves on the board of two public companies: HMS Holdings; and, Champions Oncology.  He previously served on the boards of Coventry Healthcare and Pharmerica.  Dan is also on the faculty at the Wharton School of Business at the U. of Penn.  He holds a BA in Economics and Viola Performance from Oberlin College and a MPP from the Harvard Kennedy School of Goverment.   

Listen Now

Half of the US adult population suffers one or more chronic illnesses and two-thirds of the Medicare population suffers three or more.  Largely for this reason, i.e., the prevalenece of chronic conditions, health care delivery, by necessity, is becoming ever increasingly more team based.   Providing care particularly for the chronically ill therefore places a premium on enhanced relational coordination between and among clinicians of all types (and as well those providing social support services) and by all-too-typically siloed provider organizations.    

During this 22 minute interview Professor Gittell discusses how she developed the relational coordination model or tool, what are its seven elements, how it's applied in improving coordination and communication in health care delivery and patient outcomes, how it's measured and examples of its application both in US health care delivery and health care overseas. 

Jody Gittell is a Professor at Brandeis University's Heller School for Social Policy and Management and an expert on relational coordination and organizational performance.  She founded the Relational Coordination Reserach Collaborative in 2011 and co-founded Relational Coordination Analytics Inc. in 2013.  Her most recent work is "Transforming Relationships for High Performance (Stanford University Press, forthcoming).  Before joining Brandeis, Professor Gittell taught at Harvard for six years.  She has published widely in numerous scholarly journals and among other awards was the winner of the Best Book Award from the Alfred P. Sloan Foundation.  Professor Gittell serves on several boards including the Academy of Management Review's editorial board.  She earned her Ph.D. from MIT Sloan School of Management and her MA from The New School.   

For more on relational coordination go to: http://rcrc.brandeis.edu/.

Listen Now

Despite recent efforts to improve care delivery for mental health and substance use conditions, for example, passage in 2008 of the Mental Health Parity and Addiction Equity Act, mental health and substance use conditions remain both woefully under-diagnosed and treated.  For example, one recent study of emergency department patients showed psychiatric illnesses were under-diagnosed in 75 percent of patients.   Compounding under diagnosis is the fact that these conditions are highly correlated with common chronic conditions such as heart disease and diabetes - making successful treatment for these illnesses far more difficult and costly.  With major healthcare delivery and financial reforms now being tested under the Affordable Care Act, for example the Primary Care Medical Home and the Accountable Care Organization, there exists today an opportunity to improve substantially diagnosis and treatment for these conditions. 

During this 22 minute interview Joyce Wale discusses the prevalence of mental and substance use conditions and the extent to which they're undiagnosed, efforts (motivated largely by ACA reforms) currently underway to improve care (moreover in the primary care setting) for these patients and what good mental and behavioral healthcare looks like.           

For the past 18 years Ms. Joyce Wale has served as Chief Behavioral Health Officer and Senior Assistant Vice President of New York City's Health and Hospitals Corporation where she is responsible for behavioral health services at over 10 acute care hospitals and numerous diagnostic treatment centers and long term care facilities throughout New York City.  Prior to Joyce served as the Regional Director to the Bronx Mental Health Center and prior still worked for the Bureau of Children's Services at the New Jersey Division of Mental Health and Hospitals.  Joyce has received numerous awards over her thirty-five year career as well as has served on an equal number of professional boards and committees related to mental and behavioral health.  Ms. Wale is a Licensed Clinical Social Worker having been graduated from the University of Louisville with a Masters of Social Work.    

Listen Now

Despite signifcant press coverage over the past four and a half years many provisions of the Affordable Care Act remain largely unknown to the American public.  Polling data shows slightly less than half of Americans know the ACA is still law, over half said they've heard nothing about the state marketplaces and over a third do not know there's a penalty for not having health insurance.  More generally, researchers have found Americans have a low health insurance literacy rate.  Less than half of those polled were unable to describe an insurance deductable.   None of this is surprising when you realize how complicated health care financing and delivery is.  For example, the recently published final rule that describes changes to how Medicare will pay physicians in 2015 was well over 1,000 pages.  

During this 20 minute interview Dr. Moore discusses the reasons he and Dr. Askin wrote the book, some of their findings, what he was surprised to learn and how health care is delievered in the US, how research and writing the volume changed his practice, reaction to, and use of, the work and changes in the soon-to-be-released second edition.       

Nathan Moore is an resident physician in internal medicine at Barnes-Jewish Hospital in St. Louis. When he and his colleague Elisabeth Askin were in medical school at Washington University, they wrote The Health Care Handbook, A Clear and Concise Guide to the United States Health Care System. To date, approximately 60 medical schools and hospital residency programs have incorporated this handbook into their core curriculum.  Dr. Moore has been a featured speaker at dozens of medical schools, universities and health professions conferences and is currently working on the 2nd edition of the Handbook.  The 2nd edition is anticipated to be released this month. 

To learn more about "The Health Care Handbook" go to: http://healthcarehandbook.wustl.edu/

Listen Now

Beyond the problem of an estimated 600,000 Americans being homeless each night (and 1.5 million in any given year), homelessness or unstable housing is strongly correlated with high rates of chronic illness, unmet healthcare needs and mortality. Inadequate housing impedes access to health care and  an ability to stay healthy such as caring for injuries or disease and taking medications. For the chronically homeless mortality is four to nine times higher than for the general population.   Though current federal Medicaid rules do not allow states to provide supportive housing, it appears the health care industry is nevertheless beginning to close the gap between health care and housing by recognizing and addressing the fact it is a key social determinate of health.

During this 20 minute interview Ms. Morely discusses the work of the National Center for Healthy Housing, the magnitude of the housing "famine," how housing serves as a health care "vaccine," why health care providers have been slow to recognize its importance as a key social determinate of health and opportunities to better intergrate supportive housing and health care.     

Rebecca Morley is the Executive Director of the National Center for Healthy Housing (NCHH), a national non-profit dedicated to creating healthy and safe housing for children. Among other things Rebecca spearheaded NCHH's recovery work in the Gulf Coast after hurricanes Katrina and Rita and she led the development of the National Health Homes Training Center. She is the author of numerous publications including the new book, "Healthy & Safe Homes: Research, Practice and Policy." Before joining NCHH, Ms. Morley worked with ICF Consulting on affordable housing and related issues, at HUD as a Presidential Management Fellow and as a Legislative Fellow for Senator Jack Reed.  She serves on numerous boards and commissions including Health Housing Solutions. Ms. Morley was graduated from Nazareth College (in Rochester, NY) with an undergraduate degree in environmental science and from the Georgia Institute of Technology with a master's in public policy.   

For more on the National Center for Healthy Housing go to: http://www.nchh.org/

Listen Now

While it appears obvious a person's health status is directly related to their life circumstances the health care industry has been slow to recognize an individual's bio-psycho-social factors or characteristics in planning and delivering an individual's care.  This critcism is typically phrased as clinicians being over attentive to the "patient" and under attentive to the "person".  For various reasons having in part to do with utilization/cost, reimbursement and population health concerns this is changing.  That is the health care industry is developing a greater appreciation and more sophisticated understanding of the non medical predictors of health care risk.  

During this 21 minute interview Dr. Alkema discusses why the health care industry has been slow to adopt socioeconomic factors in care planning and delivery, non-medical factors that correlate with higher care utilization, how these factors or characteristics can be used for predictive purposes and related related issues.  

Dr. Gretchen Alkema currently serves as Vice President of Policy and Communications for The SCAN Foundation.  Prior to joining SCAN Dr. Alkema was the 2008-09 John Heinz Health and Aging Policy Fellow serving in the office of Sen. Blanche Lincoln.  Dr. Alkema earned her PhD at the University of Southern California’s Davis School of Gerontology and and completed her post-doctoral training at the VA Greater Los Angeles Health Services Research and Development Center of Excellence.  Her academic research focused on evaluating innovative models of chronic care management and translating effective models into practice.  She is a Licensed Clinical Social Worker and has practiced in government and non-profit settings including community mental health, care management, adult day health care, residential care and post-acute rehabilitation.

Listeners will recall in August 2013 Dr. Alkema discussed the relationship between Medicare utilization and cost and beneficiary (declining) functional status.  

For more on predictive analytics related to high-risk Medicare beneficiaries see: http://www.thescanfoundation.org/sites/thescanfoundation.org/files/identifying_high_cost_benefits_fact_sheet_1_1.pdf

Listen Now

Medical tourism has been defined moreover as people traveling from less developed to more developed countries to receive medical treatment.   Today, well over one million Americans travel both within the US and worldwide to receive a wide variety of medical interventions.  Medical tourism originating in the US is growing dramatically, it is today considered one of the fastest growing segments in our health care industry.  The primary reason for its popularity is of course cost or cost savings (though wait times can play a factor as well).  A recent NYT poll found for example 46% of respondents describe paying for health care as a "hardship".  Both self-employed companies as well as private insurance plans have offered tourism coverage for certain procedures for several years.  However, like all medical care, procedures received abroad are not without risk.

During this 22-minute interview Ms. Stephano provides a brief overview of her organization, the range of medical services sought, typically where and at what cost savings, its increasing use among self-insured employers, the quality of care received and what recourse patients have in the event of an error.  

Ms. Renee-Marie Stephano is the President and Co-Founder of the Medical Tourism Association and editor-in-chief of the Medical Tourism Magazine.  She works closely with governments, hospitals, business leaders and travel and tourism entities to develop sustainable medical tourism/international patient programs and strategies throughout the world.  She has authored and co-authored several books, has been a keynote speaker at hundreds of international conferences and is a resource regarding medical tourism initiatives for media outlets worldwide.  She earned her JD degree from the University of Pennsylvania.

For more onthe Medical Tourism Assocation see: http://www.medicaltourismassociation.com/en/index.html, 

Listen Now

Over the past few years the lines between health care payers and health care providers have been blurring.  Some say these health care industry silos, insurance companies and acute and post-acute providers, will eventually merge.  For cost purposes, health care plans are ever-increasingly interested in improving their relationship with patients in order to provide more efficient and effective care.  Health care providers want to better control their revenue streams and be more competitive.  CareConnect, formed last year by North Shore-Long Island Jewish Health System, is New York State's first provider-owned commercial health insurance plan.  

During this 21-minute interview Mr. Alan Murray discusses the reasons CareConnect was formed, how it's structured, its patient population, how its physicians deliver care within the CareConnect network and what it is doing to improve its patient and service community's population health.  

Mr. Alan Murray is the Co-Founder, President and Chief Executive Officer of North Shore-LIJ CareConnect, the first provider owned health plan in New York State.  Mr. Murray is also currently President and CEO of North Shore-LIJ Health Plan whose offerings include a managed long-term care plan for Medicaid recipients.  Previously, Mr. Murray was VP of Managed Care for North Shore-LIJ Health System.  Mr. Murray also served for five years as a Vice President for UnitedHealthcare in New York and previously still as at WellPoint/Empire BlueCross BlueShield).  Mr. Murray's background also includes serving for over five years as a Second Officer in the British Merchant Navy.

For more on CareConnect see: http://www.nslijcareconnect.com/

Listen Now

Over 20 million immigrants live in the US, approximately half of whom, or 11 million, are undocumented.  Because immigrants are frequently employed in low-wage jobs they largely lack health care coverage.  Legally residing residents are able to acquire coverage via the ACA's state marketplaces however they are typically required to wait five years to apply to qualify for Medicaid. Undocumented immigrants are neither able to buy marketplace coverage even if they pay the full premium nor are they typically allowed Medicaid coverage.   Last November the President announced a pathway to citizenship for undocumented immigrants but whether this will improve their ability to obtain health insurance is unclear.

During this 23-minute discussion Mr. Padilla explains the genesis of the five-year waiting period for legal immigrants to apply for Medicaid, why undocumented immigrants are unable to purchase marketplace insurance at full cost, where (and how) immigrants typically get health care services and moreover what, if any, effect will the President's executive order actions announced last November have in providing health care coverage for undocumented immigrants.      

Angel Padilla is a Health Policy Analyst at the National Immigration Law Center (NILC) where he works to develop and implement NILC's federal immigrant health policy agenda.  Prior to joining the NILC in 2014 he was an immigration policy consultant at the National Council of La Raza.  Prior still he served as a Legislative Assistant to Rep. Luis Guiterrez (D-IL).  Mr. Padilla also interned at the Department of Homeland Security.  He holds an undergraduate degree from the University of California at Berkeley and a graduate degree form the Princeton University's Woodrow Wilson School of Public and International Policy.

The National Immigration Law Center website is at: http://www.nilc.org/.

Listen Now

Health care payment is solidly moving, or moving once again, toward pay for value or value-based contracting.  This means a health care provider's reimbursement is incented or tied to a predetermined (typically annual) financial amount and/or is based on attaining certain quality care metrics.   The Medicare Shared Savings Program and private sector "accountable care organizations" are both endeavoring to lower health care cost growth and improve quality and patient outcomes via these value or performance-based contracts.  

During this 21-minute discussion Dr. David Muhlestein describes the various types of pay for value contract arrangements including use of quality metrics, what types of providers sign these contracts, what have the results been to date, the keys to success or what are the challenges in succeeding under these agreements and potential downsides for providers and/or patients .   

David Muhlestein is the Senior Director of Research and Development at Leavitt Partners (LP).  He directs LP's study of pay for value and accountable care contracting through LP's Center for Accountable Care Intelligence and leads the firms' quantitative evaluation of health care markets. He is an expert in using policy analysis, predictive modeling and applied analytics to understand the evolving health care landscape.  His insights have been quoted by publications including The Wall Street Journal, The Seattle Times and Modern Healthcare.  David earned his Ph.D. at Ohio State University and his JD at Ohio State's Moritz College of Law.   

For information regarding Leavitt Partners' related work see: http://leavittpartners.com/solutions/.

Listen Now

Visiting nurse services have been delivering home-based health care since the late 19th century providing everything from maternal and child health to geriatric care.  Today their services are more frequently being sought due to an ever-increasing emphasis on keeping patients out of the hospital (and emergency department), improving care coordination, comprehensiveness and patient satisfaction and paying for care that improves quality and care outcomes and that is more cost efficient.  

During this 19 minute discussion Ms. Moorhead discusses the goals of VNAA and its members, services its visiting nurses and other home health providers deliver, health care outcomes achieved and a range of federal Medicare policy options currently under discussion to improve care in the so called "post acute" care setting.   (One factual correction: Medicare spending on post-acute care in 2013 was $59 billion.)

Tracey Moorhead is President and Chief Executive Officer of the Visiting Nurse Associations of America (VNAA).  VNAA educates, advocates and promotes nonprofit providers of home-based care services including home health, palliative care and hospice. Previously,  Tracey served as CEO of the Care Continuum Alliance.  Prior roles also include serving as Executive Director of the Alliance to Improve Medicare (AIM), a bipartisan coalition advocating comprehensive Medicare improvements through the Medicare Modernization Act of 2003 and Vice President, Government Relations for the Healthcare Leadership Council (HLC). She was graduated from The George Washington University.  

For more about the VNAA go to:  www.vnaa.org.

Listen Now

Street Sense is a tabloid newspaper that has been sold biweekly by the District of Columbia's homeless residents for the past 12 years.  The publication's focus is on homelessness and related issues confronting the poor.  DC has one the highest rates of homelessness in the country with over 2,000 individuals and families sleeping on the streets on any given night, a quarter of whom are veterans.  Unemployment, obviously a major cause of the problem, is 7.8 percent in the nation's capital or one and a half times the national average.  For DC's African Americans unemployment is 10 percent. Nearly 20 percent of DC's residents live in poverty.  Beyond homelessness, Street Sense vendors typically face a long list of health issues.  Recently however a city inter-agency council on homelessness unanimously endorsed a plan, that DC's new mayor supports, to end homelessness over the next five years.

During this 18 minute discussion Brian Carome discusses the purpose and success of Street Sense to date, it's vendors, the health and social issues they confront and his outlook for finally solving DC's homelessness problem.

Brian Carome has served as Executive Director of Street Sense since 2011.  Previously he was Executive Director at Housing Opportunities for Women, Project Northstar and A-SPAN.  He has also worked at new Hope Housing, Sasha Bruce Youthwork, the Washington Legal Clinic for the Homeless and the Father McKenna Center.  He has lectured on homelessness and at risk populations at the Catholic University of America's School of Social Service and Georgetown University Law School.  Brian was graduated from Boston College with a BA and earned an Executive Certificate form the Georgetown University's Center for Public and Non-Profit Leadership.  

To learn more about Street Sense go to streetsense.org.

Listen Now

Risk adjustment is a statistical method by which payers can reasonably predict how much a patient's care needs are expected to cost in any given year.  In so called Fee-For-Service Medicare this matter is essentially moot since since providers are simply paid for the reimbursable services they provide their patients.  However, health care payment is rapidly moving towards fixed or pre-arranged reimbursement models.  For example, Medicare Advantage plans are paid a pre-determined or fixed per member per month fee and ACOs are incented to spend less annually than a pre-determined benchmark that amounts to an ACO's patients' historical costs risk adjusted.  Therefore, risk adjustment, or getting risk adjustment right, becomes critically important.  

During this 23 minute discussion Dr. Book explains the theory behind risk adjustment, how it's calculated for Medicare Advantage plans using hierarchical condition categories (HCC) codes and demographic data, the phenomenon known as "up coding," what CMS has done to address the issue and whether predicted costs tend to be lower than actual costs for high cost beneficiaries is a problem.

Dr. Robert Book is a Health Economist and Senior Research Director at the Health Systems  Innovation Network.   (His paper discussed during this interview was authored via his work with the American Action Forum.)  Dr. Book's work primarily focuses on modeling of the effects of the ACA.   He has also expertise in a wide variety of related issues including Medicare and Medicare Advantage pricing, provider incentives, employer-sponsored insurance, drug regulation and the economics of medical research.  Dr. Book earned his Ph.D. in economics and his MBA at the University of Chicago, an MA in computational and applied mathematics at Rice and his undergraduate in mathematics at Duke.     

Dr. Book's primer on Medicare Advantage risk adjustment is at: http://americanactionforum.org/research/primer-medicare-risk-adjustment.

For a discussion on Medicare Advantage pricing more generally see the May 6, 2013 interview with Dr. Brian Biles.   

Listen Now

Shortly before the Supreme Court recesses in early July the Court will rule on David King v. Sylvia Burwell, the case where the plaintiffs argue the Affordable Care Act only allows for tax credit subsidies via state-run exchanges or only those, as the ACA states, "established by the state."  If the court rules in favor of the plaintiff an estimated 5 to 8 million newly insured will lose their coverage absent a subsidy because to date only 16 states plus the District of Columbia have set up state health insurance exchanges or marketplaces.  If this is the Court's ruling how might the Republican-controlled Congress react?   Regardless of the Court's decision the health care reform likely becomes a 2016 presidential campaign issue for the Republican party.  

During this 21-minute discussion, Dr. Tevi Troy outlines possible responses by the Republican controlled Congress to a Court's decision in favor of the plaintiffs, how Republican presidential candidates may shape the race's health care reform debate (moreover if the Court rules in favor of Burwell) and he addresses major aspects of the ACA that remain contentious, i.e., the employer mandate, the Cadillac tax and Medicaid reform.

Dr. Tevi Troy is currently President of the American Health Policy Institute and Adjunct Fellow at the Hudson Institute.  Previously he served as Deputy Secretary at the Department of Health and Human Services under President George W. Bush, as Deputy Assistant and Acting Assistant to the White House Domestic Policy Council, as Policy Director for Senator John Ashcroft and as Senior Domestic Policy Adviser and Domestic Policy Director for the House Policy Committee.  Still previously he was a Researcher at the American Enterprise Institute.  His numerous writings include,"What Jefferson Read, Eisenhower Watched and Obama Tweeted, 200 Years of Popular Culture in the White House," and "Intellectuals and the American Presidency," Philosophers, Jesters or Technicians?"  Dr. Troy earned his Ph.D. in American Civilizations from the University of Texas as Austin.     

Information on Dr. Troy's latest book, ""What Jefferson Read, Eisenhower Watched and Obama Tweeted, 200 Years of Popular Culture in the White House” can be found at: http://www.amazon.com/What-Jefferson-Watched-Obama-Tweeted/dp/1621570398/ref=sr_1_1?ie=UTF8&qid=1437409023&sr=8-1&keywords=what+jefferson+read+ike+watched+and+obama+tweeted.

Listen Now

Alzheimer's Disease accounts for approximately 70% of all dementia diagnoses.  The disease affects over five million Americans or upwards of 35 million worldwide.  Disease burden is currently estimated to grow to 16 million patients in the US by 2050 with projected costs estimated at over $1 trillion.  Patients diagnosed with Alzheimer's survive three to nine years. The disease kills 500,000 deaths annually, making it the 6th leading cause of death.  The risk of the disease is believed to be largely genetic.  There are currently no treatments or medications to stop, reverse or modify its progression - the only major disease with this distinction.  

During this 23 minute discussion Mr. Egge discusses the work of the Alzheimer's Association, the current state of curative research and the development of a blood test to diagnose Alzheimer's before symptoms appear, the adequacy of federal funding to fight the disease, the federally-legislated "National Alzheimer's Plan" and what's being done to improve care for patients currently suffering from Alzheimer's and other forms of dementia.   

Robert Egge is the Chief Public Policy Officer and Executive Vice President of Government Affairs for the Alzheimer's Association.  Mr. Egge also serves as the Executive Director of the Alzheimer's Association's sister organization, the Alzheimer's Impact Movement.  Prior to joining the Alzheimer's Association Mr. Egge served as Executive Director of the Alzheimer's Study Group.  Prior still he served as a Project Director for the Center for Health Transformation and as Vice President for Government Affairs for the JC Watts Companies.  Mr. Egge's writings have appeared in The New York Times, the Financial Times, in Health Affairs and he has provided testimony to both US House and Senate health care committees.

For more on the work of the Alzheimer's Association go to: www.alz.org.

Listen Now

The use of community health workers (CHW) dates back to the 1800s.  The impetus for these workers today is to provide peer support largely in poor or under-served communities since these communities typically suffer disparities in health care access, in the quality of health care delivery and consequently experience higher morbidity and mortality rates.  The ACA via the Center for Medicare and Medicaid Innovation is supporting CHW demonstration projects, states are testing their use via Medicaid programming and various providers are using CHW to improve self management support among high health care service utilizers.   

During this 20 minute conversation, Dr. Fisher discusses the reasons why the use of CHW is increasing, who they are and how they're trained, in what provider setting they work, their level of success, how they're accepted by clinicians and patients and how their services are reimbursed.      

Dr. Edwin Fisher is a University of North Carolina Gillings School of Global Public Health Professor and serves as Global Director for the American Academy of Family Physicians Foundation's Peers for Progress program.  Peers for Progress promotes peer support in health, health care and prevention around the world.  From 2002 to 2009 Dr. Fisher served as National Program Director for the Robert Wood Johnson Foundation's Diabetes Initiative.  Dr. Fisher has published widely in prevention, chronic disease management and quality of life addressing asthma, cancer, cardiovascular disease, smoking and weight management.  He is past-president of the Society of Behavioral Medicine and has served as a board member for the International Society of Behavioral Medicine and the American Lung Association.  He was graduated from the SUNY, Stony Brook with a Ph.D. in Clinical Psychology.       

Information on Peers for Progress is at: peersforprogress.org. 

Listen Now

With the health care industry now accounting for 18.5 percent of the nation's GDP, or a far greater percentage than any comparable nation, combined with ever continuing access, coverage (now possibly moreover the issue of under-insurance) and quality (including the frequency of patient or iatrogenic harm) health care policy students are left to wonder to what extent has health care delivery or legitimate health care delivery been compromised or even undermined by medical commerce.    

During this 27 minute conversation Ms. Gibson explains what's meant by the Eisenhower-inspired "medical industrial complex" and her use of the phrase "privatized gains and socialized losses" in this context.  She discusses the unwarranted influence of the health care industry in part by noting pharmaceutical industry behavior and the advent of so called "consumer directed health plans.  Ms. Gibson also evaluates to what extent the ACA will strike a better balance between health care and medical commerce or again the "medical industrial complex."  

Ms. Rosemary Gibson is a Senior Advisor at the non-profit Hasting Center, a research organization dedicated to addressing ethical issues in health, medicine and the environment.  Ms. Gibson is also an editor of JAMA Internal Medicine.  Previously, Ms. Gibson was a Program Officer at the Robert Wood Johnson Foundation where she addressed safety and quality issues particularly in palliative care.  Among other books Ms. Gibson is the author of Wall of Silence, The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans.  Ms. Gibson serves on numerous boards including the Consumers Union Safe Project and among others she received the Lifetime Achievement Award from the American Academy of Hospice and Palliative Medicine.  Ms. Gibson is a graduate of Georgetown University and the London School of Economics.

Information on Rosemary Gibson's book, noted during this interview (and coauthored by Janardan Prasad), The Battle Over Health Care, can be found at: http://www.amazon.com/The-Battle-Over-Health-Care/dp/144221449X. 

Listen Now

Health care analytics has typically referred to modeling insurer or payer risk or to predict patient utilization or to segment patient populations.  However, because of advances in personal or wearable medical devices, supporting software applications and the increasing use of electronic health records, individuals or patients now have the opportunity to gather their own health and medical data and information and use it to better manage their health status and/or medical needs.  This opportunity is what's become termed the democratization of health care or alternatively the emancipation of the patient.  

During this 25 minute conversation Dr. Dwight McNeill provides an overview of his recently published work, "Using Person-Centered Health Analytics to Live Longer," i.e., he unpacks four domains he identifies ("knowing me," "protecting health," "minding illness," and "managing data") that can empower, enable and equip an individual to manage their health and medical needs.  Dwight also discusses barriers to the adoption to "person-centered" analytics  and near future potential of these tools.          

Dr. Dwight McNeill is Lead Faculty for the International Institute for Analytics.  He is also President of WayPoint Health Analytics which provides consultation to organizations on health and healthcare analytics.  During his 30-year career, he has worked in corporate settings, most recently as global leader for business analytics and optimization for the healthcare industry for IBM and previously as director of healthcare information at GTE Corporation (Verizon).  Earlier, Dwight worked for the federal Department of Health and Human Services and the Commonwealth of Massachusetts, for information companies, and in provider settings.  Dwight has published two related books on healthcare analytics in 2013: A Framework for Applying Analytics in Healthcare: What Can Be Learned from the Best Practices in Retail, Banking, Politics, and Sports; and, Analytics in Healthcare and the Life Sciences: Strategies, Implementation Methods, and Best Practices.   He has also published frequently in Health Affairs and other related journals. Dwight earned his PhD from Brandeis University in Health and Social Policy and his MPH degree from Yale University in Public Health and Epidemiology.  

For more on "Using Person-Centered Health Analytics to Live Longer" see: http://www.amazon.com/Dwight-McNeill/e/B00DC26RXW. 

Listen Now

For the past eight years the federal government has been working to create a unique medical device identification (UDI) number that would identify a medical device's manufacturer, the device's make and model, its expiration date and other information for the purposes of improving or ensuring patient safety and product improvement.   While progress has been made in establishing a UDI tracking system, we have still not implemented the use of UDIs in medical claims forms and in electronic health records (EHRs).  A UDI is particularly important since it would allow health care providers, researchers and others to track particularly implantable medical devices.   For example, annually over one million Americans receive an artificial hip or knee.  These devices can and do fail and can cause serious cognitive and neurological impairment, bone deterioration and in severe cases, amputation.  

During this 19 minute conversation Mr. Ben Moscovitch discusses the development of a UDI over the past eight years, current efforts to include a UDI data field on the medical claims form and in EHRs, why UDI adoption has not, or still not, been achieved and chances it will be achieved.    

As Officer of The Pew Charitable Trust's medical devices project, Ben Moscovitch works on federal initiatives to enhance the data available on product performance to support medical device innovation and quality improvement.   Prior to joining Pew, Mr. Moscovitch worked on public policy communications at the National Association of Chain Drug Stores and was previously a journalist covering medical product regulation and legislation.   Mr. Moscovitch received his Master of Arts degreee from Tel Aviv University and his Bachelor's from Georgetown University.

For more on Pew's work regarding medical devices see: http://www.pewtrusts.org/en/search#q=medical%20devices.

Listen Now

This past July 13th the White House convened its sixth Conference on Aging.   The meeting's purpose is to identify elder care needs over the next 10 years.  More specifically the meeting is, or is typically, held to discuss improvements to the Older Americans Act (OAA).  The OAA was  signed into law in 1965 by President Johnson and has historically enjoyed Congressional support having been amended over ten times.   This Conference, the 6th, however was held despite the fact the Congress has failed to reauthorize the OAA over the past four years.  The OAA expired in 2011 though the Congress has appropriated funding since then to continue to fund OAA programming.   Among other purposes the OAA established the federal Administration on Aging and provides moneys to state agencies on aging that in turn fund health care services including nutritional programming, social service support programs (termed Long Term Services and Supports) and employment and legal protection programs.  

During this 21 minute discussion  Ms. Montgomery discusses what issues President Obama discussed during the meeting, other or additional meeting discussion topics, what was not or insufficiently discussed, the future/near future health and social service support needs for this country's rapidly growing senior (and frail elderly) population (10,000 Americans age into Medicare every day) and what are the prospects for Congressional renewal (with adequate funding) of the OAA this fall or going into the 2nd session of Congress in 2016.    

Anne Montgomery is a Senior Policy Analyst at Altarum Institute’s Center for Elder Care and Advanced Illness and is a Visiting Scholar at the National Academy of Social Insurance.  From 2007 to 2013, Ms. Montgomery served as Senior Policy Adviser for the U.S. Senate Special Committee on Aging.  She has also served as a Senior Health Policy Associate with the Alliance for Health Reform in Washington, as a Senior Analyst in public health at the U.S. Government Accountability Office and as a Legislative Aide for the House Ways & Means Health Subcommittee.   As an Atlantic Fellow in Public Policy based London in the early 2001-2002, Ms. Montgomery undertook comparative policy analysis of the role of family caregivers in the development of long-term care in the United Kingdom and the United States.  During the 1990s, she worked as a health and science journalist covering the National Institutes of Health and Congress.  Ms. Montgomery earned her MS at Columbia and her BA  at the University of Virginia.

For information about the Altarum's Center for Elder Care and Advanced Illness go to: http://altarum.org/research-centers/center-for-elder-care-and-advanced-illness

Listen Now

Bundled or episodic health care payment for a clinically defined medical episodes of care has been used since at least the 1980s.  However, recently CMS has initiated two bundled payment demonstrations, the Bundled Payment for Care Improvement Demonstration (BPCI) that bundles care for 48 (DRG) episodes of care began in 2013 and more recently CMS proposed the Chronic Care for Joint Replacement (CCJR) demonstration this past July.   Considered the middle ground between fee for service reimbursement and capitated payment the jury is still out whether bundled payments can be designed to reduce cost growth and improve care quality and patient outcomes.      

During this 22 minute conversation, Mr. Miller addresses five aspects of bundled payment and how well or not these aspects are addressed in CMS's recent CCJR proposal to mandate bundled payment for hip and knee replacement surgeries in 75 markets nationally.  Theses aspects are: how well or not bundled payment addresses the underlying problems of fee for service reimbursement and whether bundled payments incent or not care innovation; what types of patients are best served under bundled payment arrangements; how best providers can organize to be effective and efficient under these arrangements; how well bundled payments address over-utilization; and, how episodic payments can be integrated with wider care coordination and whole person care.   

Harold D. Miler is the President and CEO of the Center for Healthcare Quality and Payment Reform.  He also serves as Adjunct Professor of Public Policy and Management at Carnegie Mellon University.   From 2008 to 2013, Mr. Miller served as President and CEO of the Network for Regional Healthcare Improvement, the national association of the Regional Health Improvement Collaboratives.   From 2006 to 2010, Mr. Miller serves as the Strategic Initiatives Consultant to the Pennsylvania Governor's Office of Policy Development, Associate Dean of the Heinz School of Public Policy and Management at Carnegie Mellon, Executive Director of the PA Economy League, Director of the SW PA Growth Alliance and the President of the Allegheny Conference on Community Development.   Mr. Miller has worked in more than 30 states and metropolitan regions to help physicians, hospitals, employers, health plans, and government agencies design and implement payment and delivery system reforms.  He assisted CMS with the implementation of its Comprehensive Primary Care Initiative in 2012.  Mr. Miller also serves on the Board of Directors of the National Quality Forum.

For more on bundled payment see Mr. Miller's, "Bundling Better, How Medicare Should Pay for Comprehensive Care" published September 2015, at: http://www.chqpr.org/index.html.

Listen Now

This past July CMS announced a proposed demonstration that would either reduce or increase a Medicare home health agency's reimbursement based on quality performance.   With a rapidly aging and growing Medicare population home health utilization and costs have risen significantly over the past decade.  Per MedPAC, between 2000 and 2012 total Medicare home health spending increased 64 percent.  However, home health agency quality performance has been limited.  For example, again per MedPAC, less than half of all Medicare home health patients in 2013 showed improvement in medication management and only 65 percent showed improvement in pain management.    

During this 22 minute discussion Ms. Mason explains the several, if not numerous reasons, why CMS announced this demonstration, how it will work, e.g., how quality will be measured or what quality metrics will be used, what are the specific financial incentives, in what states the demo will be conducted, when it will begin and for how long, and what are some of the perceived pros and cons of the demonstration as proposed.   

Sherill Mason is currently Principal, Mason Advisers, where she provides strategic planning, program development and operations analysis for post acute care providers including senior living and nursing home facilities, home health, hospice, long term acute care hospitals, in patient rehabilitation facilities, and long term care pharmacy.  Previously, Sherill she served as a Vice Presient to the Marwood Group, a healthcare industry consultant, as Senior Vice President at Sunrise Senior Living and as a Director at KPMG.   Among other current professional activities Sherill currently is a Guest Lecturer at the University of Pennsylvania School of Nursing.  She received her RN diploma and training at the Englewood Hospital School Nursing and a BA in American Studies from Eckerd College.  

For information regarding CMS's proposed value-based home health demonstration go to: https://www.cms.gov/center/provider-Type/home-Health-Agency-HHA-Center.html

Listen Now

Beyond numerous other benefits derived by genetically modifying foods is herbicide resistance. This allows farmers the ability to control for weed growth without killing their crop, for example, corn and soybeans.  While a foreseeable unintended consequence, the increasing or intensive use of the herbicides, specifically glyphosate, the primary ingredient in the widely used product Roundup, has caused weeds to develop resistance.   As a result glyphosate is now beginning to be used in combination with another herbicide, 2,4-D, a component of the defoliant Agent Orange, under the product name Enlist Duo.  The question begged is to what extent do these herbicides, used independently and in combination, pose a public health risk.

During this 30 minute discussion Dr. Benbrook discusses in part the evolution of the use of these herbicides, the federal governments efforts to risk assess their use, the IRAC's (International Agency for Research on Cancer) recent finding these products are probable or possible human carcinogens, the pending National Academy of Sciences' report (scheduled to be published next year) and his thoughts regarding what can be done to safeguard exposed populations.

Dr. Charles (Chuck) Benbrook, Benbrook Consulting, is a recognized expert in pest management sytsems, pesticide use and regulation and the environmental and  public health consequences of farming system choices.  Dr. Benbrook worked in Washington, D.C. on agricultural policy issues for nearly twenty years as the agricultural staff expert on the Council for Environmental Quality, as Executive Director of the Subcommittee on Department Operations, Research and Foreign Agriculture for the House of Representatives and as the Executive Director for the Board on Agriculture at the National Academy of Sciences.   He also served for six years as Chief Scientist of the Organic Center and for three years as a Research Professor at Washington State University.  Dr. Benbrook holds a Ph.D. in agricultural economics from the University of Wisconsin at Madison, an undergraduate degree from Harvard and is the author of nearly three dozen peer-reviewed articles.        

The New England Journal of Medicine essay noted during this conversation, co-authored by Dr. Benbrook and Dr. Philip Landrigan and titled "GMOs, Herbicides and Public Health," is at:  http://www.nejm.org/doi/full/10.1056/NEJMp1505660

Listen Now

January 1st will mark the Affordable Care Act's (ACA) third health insurance expansion year.  Under the ACA individuals with income below 400% of poverty are eligible for insurance subsidies and individuals with incomes below 138% of the federal poverty level are eligible for state Medicaid coverage (or in the 31 states that have to date chosen to expand Medicaid coverage).  As of 2015 the ACA has expanded coverage to approximately 12 million Americans.   Medicaid expansion has added another 14 million lives.   Despite significant gains in the number of insured approximately 25 million non-elderly adults or about 11% remain without coverage.  Roughly half of these are undocumented immigrants whom are ineligible for coverage under the ACA.   Despite subsidies the cost of insurance remains the reason individuals go without coverage that frequently results in individuals going without needed care.      

During this 24 minute conversation, Ms. Corlette discusses expected 2016 enrollment numbers, premium prices, the impact pharmaceutical cost growth has had on premium costs, to what extent individuals comparative shop for plans, the number of and reasons for the un-enrolled, insurer participation and the issue of risk corridor funding (recently a presidential campaign issue). 

Sabrina Corlette is a Senior Research Fellow and Project Director at the Center on Health Insurance Reforms (CHIR) at Georgetown University's Health Policy Institute.  Prior to joining the Georgetown faculty, Ms. Corlette was Director of Health Policy Programs at the National Partnership for Women and Families.  From 1997 to 2001, Ms. Corlette worked as a professional staff member for the Senate Health, Education, Labor and Pensions (HELP) Committee.   After leaving the Hill Ms. Corlette also served as an attorney at Hogan Lovells.  She received her JD with high honors from the University of Texas and earned her undergrad degree also with honors from Harvard. 

For more on CHIR go to: http://chir.georgetown.edu/.  

Listen Now

Telehealth and remote monitoring services generally enable physicians to treat patients and monitor their health status remotely.  Because of advances in wireless communication and biosensor technology these services are increasingly being used in the commercial health care market and as well in the Medicaid program and the VA because research shows these services can reduce acute care visits and lengths of stay, iatrogenic harm and improve patient adherence to care.  Nevertheless, the Medicare program restricts reimbursement for these services largely because CMS (the Congress and the CBO) see them moreover as duplicative (v. substitutive) services.   For example, in 2014 Medicare spent just $14 million on telehealth service reimbursement.  (Total Medicare spending in 2014 was well north of $500 billion).    

During this 18 minute conversation Ms. Drobac discusses in part how and why reimbursement for telehealth and remote monitoring services are limited under Medicare, how other payers and providers are using telehealth and remote monitoring, what the research literature suggests regarding clinical effectiveness and cost efficiency, proposed Congressional legislation and related regulatory action to broaden Medicare coverage and chances for legislative and regulatory success. 

Krista Drobac leads the Alliance for Connected Care, a 501(c)(6) coalition formed to create a statutory and regulatory environment in which providers are able to deliver and be adequately compensated for providing telehealth and remote monitoring services regardless of delivery location or technological modality.   Ms. Drobac was previously Director of the Health Division at the National Governors Association's Center for Best Practices.  Prior to that she was senior adviser at CMS, Deputy Director of the Illinois Department of Healthcare and Family Services and spent five years on Capital Hill where she was a Health Adviser to the Senate Majority Whip Senator Richard Durbin and served as a John Heinz Senate Fellow for Senator Debbie Stabenow.  Ms. Drobac earned her BA from the University of Michigan and her MPP from the Kennedy School of Government at Harvard. 

For information on the Alliance for Connected Care go to: http://www.connectwithcare.org/ 

Listen Now 

In 2011 a 78 year old blind, amputated Vermont woman, Ms. Glenda Jimmo, was denied physical therapy services under Medicare because her condition was determined to not likely improve. Because Medicare therapy services via skilled nursing, home health and outpatient care never required the patient "improve" in order to receive services and because thousands of other Medicare beneficiaries along with Ms. Jimmo had been denied therapy the Center for Medicare Advocacy and Vermont Legal Aid filed a class action suit against the federal government, i.e., Jimmo vs. Katheleen Sebelius.  After 11 months of negotiations, a settlement agreement was reached in late 2012 that affirmed there is no "improvement standard" required to be met for beneficiaries to receive therapy services.  That is care would no longer be denied due to a Medicare beneficiary's lack of restoration potential. 

During this 18 minute discussion Ms. Murphy explains the impetus for the case, speculates why DHHS did not act on its own in resolving the problem, how well or effectively CMS has implemented the terms of the settlement agreement (not very well) and why the decision has received so little attention over the past three years.   

Margaret Murphy is the Associate Director of the Center for Medicare Advocacy where she works to develop the Center's legal policy and litigation strategies.  Ms. Murphy has been counsel or co- counsel in several of the Center's federal class action suites.  She serves on the Steering Committee of the Complex Care Committee of the Connecticut Medicaid Medical Assistance Program Oversight Council.  She has also been appointed by the Connecticut probate courts to represent incapacitated adults. She has also taught as an adjunct professor at Quinnipiac University Law School.   Prior to joining the Center Ms. Murphy worked for more than 20 years a a trust and estate attorney.   She is a member of the Connecticut Bar Association, serves as the Secretary of the Executive Committee of the Elder Law Section and is a member of Swift's Inn in Hartford.  Ms. Murphy earned her JD degree from the University of Connecticut School of Law and her BA from Mt. Holyoke College.  

Listen Now

Much of the health care industry's effort to improve health care payment and delivery centers around improving primary care. This is largely because Americans suffer more disease/disease burden throughout their life spans compared to individuals in other industrialized countries.   This therefore makes obvious sense since primary care is the foundation upon which an effective and efficient health care/medical care program is built.  When done well primary care promotes wellness, prevents disease onset, progression, exacerbation and prevents premature death.  Primary care also moderates the need for higher cost specialty care and improves population health.  For numerous reasons, not least of which is inadequate reimbursement, primary care delivery has been sub-optimal.   New models of primary care are emerging, one termed direct primary care (noted in the ACA under Section 1301 (A) (3) and now recognized in 13 states) is showing promise in improving quality, improving patient satisfaction and lowering cost growth.      

During this 21 minute conversation Dr. Judge discusses moreover the impetus for the creation of Iora Healh, how Iora's primary care delivery model works or how it is different from traditional primary care delivery, how Iora's model is staffed, IT supported and reimbursed, with whom and how it contracts and what Iora's performance data demonstrates to date. 

Dr. David Judge serves as Iora Health's Chief Medical Officer.  Dr. Judge joined Iora in 2014 to continue his work in improving and redesigning of primary care.  Priorto , he helped found and was the Medical Director of the Ambulatory Practice of the Future at Mass. General Hospital.  David received his undergraduate degree in biomedical engineering and public health studies at Brown University and attended University of  Mass. Medical School.  He completed his residency training in internal medicine at Columbia Presbyterian Medical Center in New York City. 

For more on Iora Health go to: http://www.iorahealth.com/

Listen Now

The Medicare program, now in its 51st year, still does not cover oral/dental health care such as exams, X-rays, cleanings, fillings, tooth extractions and dentures.   (Medicare will cover an oral health procedure if it is incent to a serious accident or disease, for example, for surgery to treat fractures of the jaw or face or if you have oral cancer and need dental services necessary for radiation treatments.)  This is unfortunate when you consider for example: poor oral/dental health worsens overall health; less than five percent of older Americans have dental insurance of any kind; one-third of adults over 65 have untreated dental caries and over 40 percent have periodontal disease; the Affordable Care Act did not name adult oral/dental benefits as an "essential health benefit"; an overwhelming majority of adults believe dental coverage should be part of overall health coverage; for all of CMS's "innovation" demonstrations (now numbering well over 50) there are none that address improving oral/dental health for seniors; and, oral/dental health disparities are, according to the CDC, "profound."  

During this 20-minute conversation Dr. Vujicic provides his assessment of the oral/dental health of American seniors, his understanding of why the Medicare program still does not cover routine oral health care and what can be done to improve access and (insurance) coverage of oral health for seniors or Medicare eligible individuals.

Dr. Marko Vujicic is the Chief Economist and Vice President of the Health Policy Institute at the American Dental Association (ADA).  Prior to joining the ADA Dr. Vujicic was a Senior Economist at The World Bank and also a Health Economist with the World Health Organization in Geneva, Switzerland.  Dr. Vujicic is the lead author of the book, "Working in Health" and has authored additional essays and book chapters on various health policies.  He is published in the New England Journal of Medicine, Health Services Research, Health Affairs and other policy and scholarly journals.  Dr. Vujicic is also a visiting professor at Tufts University in Boston.   Dr. Vujicic earned his Ph.D. in Economics from the University of British Columbia and his undergraduate degree at McGill University in Montreal.

For more on the work of the ADA's Health Policy Institute go to: http://www.ada.org/en/science-research/health-policy-institute

Listen Now

California has been long known for health care delivery and payment reform (think, for example, Kaiser Permanente).   With efforts nation-wide to better align health care quality and patient outcomes with reimbursement or savings efficiency, related efforts in California are carefully watched and studied.     

During this 23 minute conversation Dr. Jill Yegian briefly outlines the work if the California Integrated Healthcare Association (IHA), provides an overview of the California healthcare payment reform landscape, discusses specifically IHA's value-based pay for performance work involving 10 health plans, 200 physician organizations and nine million Californians, discusses quality measurement including "resource use" and "total cost of care" and identifies lessons learned from IHA's activities.     

Dr. Jill Yegian, is the Senior VP for Programs and Policy at the California Integrated Healthcare Association where she oversees IHA's work regarding care integration, performance measurement and reporting and payment innovation.   Previously, she co-directed the American Institutes for Research Health Policy and Research Group, a team of over 70 health services research professionals.   Prior still Dr. Yegian worked with the California Healthcare Foundation where her focus was on improving the state's healthcare financing and delivery system.  Dr. Yegian is the author of numerous peer-reviewed articles and is a frequent conference speaker.  She was graduated from the University of California at Berkeley with a Ph.D. in health services and she earned her undergraduate degree in human biology at Stanford. 

For more on IHA's work go to: www.iha.org

Listen Now

As a follow up to my April 1st conversation with Jim Gera concerning bundled payments, during this podcast Dr. Richard Morel discusses Medicare's other major payment reform program, Accountable Care Organizations (ACOs), or WESTMED Medical Group's three year experience as a Track 1 ACO.   The Medicare ACO program is a creation of the 2010 Accountable Care Act and participation in the program began in 2012.   Currently, there are 434 ACOs (over 90 percent participating in the "no risk" Track 1) caring for approximately 7.5 million Medicare beneficiaries.  The program to date has been a mixed success.  After two performance years (2013 and 2014) only 25 percent of participants have been successful, i.e., have earned shared savings.  (Performance year three or 2015 performance will be made known this September.)  CMS is currently in the process of revising how the agency calculates an ACO's reset financial benchmark.  It is anticipated these changes will improve program performance, or improve both provider interest in participating (or continuing to participate) in the program and participant success in earning shared savings.   

During this 21-minute conversation Dr. Morel provides an overview of WESTMED, explains the organization's interest in becoming a Medicare Shared Savings Program or ACO participant in 2013, WESTMED's experience under their first three year agreement, what explained their success, challenges they've found with the program, how the program could be improved and their expectations now as a second agreement period Track 1 ACO.

Dr. Richard Morel is the Co-Medical Director of WESTMED Medical Group in Yonkers, New York.  Prior to joining WESTMED in 2008 Dr. Morel was in private practice affiliated with Columbia-Presbyterian Riverdale Hospital for 12 years.  Dr. Morel is board certified in internal medicine.  He received his medical degree from Columbia University College of Physicians and Surgeons, did his postgraduate training at Columbia-Presbyterian Medical Center and  received his masters of medical management from Carnegie Mellon.  He is a fellow of the American College of Physicians and a member of the American College of Physician Executives.  

For information regarding WESTMED go to: http://www.westmedgroup.com/.

Listen Now

Since, in part, April is recognized by DHHS as National Minority Health Month (this year's theme is "Accelerating Health Equity in the Nation") it is thoroughly appropriate to discuss Professor Daniel Dawes's recent work, "150 Years of Obamacare."  Professor Dawes's work begins with a discussion of efforts since the Civil War to reform national health care policy beginning with the 1865 Freedmen's Bureau Act.  The work moreover provides an accounting of his and others efforts to lobby successfully for health equity provisions in passing the 2010 Affordable Care Act ( ACA).  

During this 31-minute conversation, Professor Dawes discusses passage of the ACA, i.e., "Obamacare,", e.g., Republican opposition to the legislation and moreover the importance of the sixty plus health equity-related provisions in the legislation and what are his priorities for furthering health care equity or reducing disparities in health care delivery and outcomes - that sadly remain pronounced.   

Attorney and Professor Daniel E. Dawes is the Executive Director of Health Policy and External Affairs at the Morehouse School of Medicine and a Lecturer within Morehouse's Satcher Health Leadership Institute and the Department of Community Health and Preventive Medicine.  He founded and chairs the Working Group on Health Disparities and Health Reform and is the co-founder of the Health Equity Leadership and Exchange Network (HELEN).  Previously, Professor Dawes held positions with the Premier Healthcare Alliance, the American Psychological Association and served on the Senate HELP (Health, Education, Labor and Pensions) Committee under Senator Edward Kennedy.   He is the recipient of numerous award including the Congressional Black Caucus Leadership and Advocacy Award.  He earned his JD from the University of Nebraska and his BS from Nova Southeastern University.

For more information concerning Professor Dawes's work, go to: https://jhupbooks.press.jhu.edu/content/150-years-obamacare.  

Listen Now

Today, CMS launched the agency's second bundled payment demonstration, a mandatory five-year initiative in approximately 800 hospitals nation-wide.  It's titled, the Comprehensive Care for Joint Replacement (CJR).  The CJR essentially reimburses hospitals a predetermined amount for a 90-day hip or knee surgical and rehab episode of care.  CMS is emphasizing hip and knee replacement surgeries because they account for the single largest Medicare dollar amount and highest percent of annual 30 day episode spending.  This demonstration follows CMS's voluntary Bundled Payment for Care Improvement (BPCI) demonstration that provides bundled payments for 48 care episodes (including hip and knee replacements) via four care model designs.  How successfully hospitals, orthopedic surgeons and various post acute providers manage these care episodes will be important if CMS is to better control Medicare spending growth.   (Listeners will recall I discussed moreover the theory of bundled payment arrangements with Harold Miller this past September 23rd.)  

During this 29 minute conversation Mr. Gera provides and overview of Signature Medical Group and their orthopedic bundled payment work under both CMS's BPCI and CJR demos.  More specifically, he discusses how hip and knee replacement surgical patients are identified, how the bundled payment care team is assembled, how the care episode is manged, how quality is measured, profit sharing conducted and moreover principles his organization has developed to succeed under these capitated payment arrangements.  

Mr. Jim Gera is the Senior Vice President of Business Development for Signature Medical Group, Inc., a multi-specialty group of physicians located in St. Louis and rural Missouri.   Among other related activities Mr. Gera co-authored an Advanced Payment Medical Accountable Care Organization application and a successful CMS Strong Start for Mothers and Newborns grant award.   Recently he has also served as a Chair for several CMS innovation grant reviews.  Mr. Gera's previous experience includes working with other physician group practices, in outpatient facilities and in managed care both in Medicare Advantage and Special Needs Plans.  Mr. Gera received his MBA from Southern Illinois University at Edwardsville.

For more on CMS's CJR demonstration see:  https://innovation.cms.gov/initiatives/cjr

For more on Signature Medical Group see: http://www.signatremedicalgroup.com/ 

Listen Now

What accounts for so called patient compliance or adherence or why is it the case physicians and other providers are frequently unable to successfully engage their patients.  Why is it the case, for example, that patients adhere to highly toxic regimens of such as chemo therapy and not to more tolerable drugs such as statins.  What explains adherence or non-adherence?         

During this 22-minute conversation Dr. LaFountain explains why, using her phrase, the "epidemic of non-adherence" persists. She discusses the "importance of differentiation," the application of "cognitive profiling" or "cognitive restructuring," and provides examples using treatments for ADHD, breast cancer and diabetic patients at the Cleveland Clinic.

Dr. Andrea LaFountain is CEO of Mind Field Solutions Corporation, a firm specializing in the application of cognitive neueroscience to health behavior and patient engagement.   Prior to establishing Mind Field, she worked for AstraZeneca Pharmaceuticals leading consumer research and analytics for their oncology portfolio.   Before moving to the US, Dr. LaFountain was a Lecturer at The University of Liverpool.   She is a fellow of the American Psychological Association and the British Psychological Society and a scientific reviewer for the International Society of Pharmaco-economic Outcomes Research.  Dr. LaFountain earned her Ph.D. in pre-frontal cortex executive functioning at Imperial College, London.  

For information concerning Dr. LaFountain's work go to: http://www.amazon.com/How-Patients-Think-Science-Based-Engagement/dp/069266095X.

Listen Now

In an extremely busy year for Medicare delivery and payment reform,  regulatory implementation of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) stands out.   This past April CMS published the agency's 960-page proposed rule to implement the law.  The proposed rule, that will go final this fall, will change the way Medicare physician payments (Medicare Part B) are annually updated beginning in payment year 2019.   Payment updates, either at the individual provider or at the group level, will be calculated either by the Merit-based Incentive Payment System (MIPS), a composite score based on four, differently weighted, component scores, or via provider participation in what CMS defines as an "advanced" Alternative Payment Model (APM) pathway, e.g., Track 2 and 3 ACOS and Patient Centered Medical Homes that meet certain financial risk criteria.

During this 22-minute discussion Ms. Mara McDermott evaluates how CMS proposes to define APM nominal risk, how the agency has defined the MIPS composite score, the effect MACRA will have on small practices, how Medicare Advantage plans and physicians can be included in MACRA, and several inter-related issues.   (While the introduction to this discussion provides some brief explanatory information, our conversation assumes the listener has some familiarity with Title I of the MACRA law.)    

Mara McDermott is the Vice President of CAPG (formerly the California Association of Physician Groups) where she leads the organization's federal legislative and regulatory activities in Washington, D.C.  Prior to joining CAPG, Mara was Counsel in the health industry practice of Akin Gump Strauss Hauer and Field.  Mara received her JD with high honors and her MPH from George Washington University School of Law in 2007.  She received her BA in 2003 from the University of California, Davis.

The CMS MACRA proposed rule is at: https://www.federalregister.gov/articles/2016/05/09/2016-10032/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm

 Information concerning CAPG is at: http://www.capg.org/

Listen Now

Measuring health care quality and outcomes effectively and efficiently remains a daunting task.  Quality measures are largely seen as too process versus outcome focused, substantially irrelevant to patients and insufficiently aligned between and among payers.  Measuring care or care quality, ironically, can and does detract from actual care delivery, can have no relationship to spending efficiency and on its own is costly.  A recent article published in Health Affairs found physician practices spent over $15 billion in 2014 in reporting quality measures.  Concerning the Medicare program's quality measurement activities, MedPAC in a 2014 report to the Congress went so far as to state, "Medicare's current quality measurement approach as gone off the rails." 

During this 23 minute conversation Dr. Burstin briefly describes the work of the National Quality Forum (NQF), the work done by the CMS-led Core Measure Collaborative, quality measurement under the CMS proposed MACRA (Medicare Access and CHIP Reauthorization Act) rule, risk adjusting measures for socio-demographic factors, the role of PREMS and PROMS or patient reported experience and outcome measures and correlating care quality and spending or measuring for healthcare value.  

Dr. Helen Burstin is the Chief Scientific Officer at the NQF.  Prior to serving in her current position, Dr. Burstin was NQF's Senior Vice President for Performance Measurement.  Prior to NQF Dr. Burstin was the Director of the Center for Primary Care at the DHHS Agency for Healthcare Research and Quality (AHRQ).  Prior to AHRQ, Dr. Burstin was an Assistant Professor at Harvard Medical School and the Director of Quality Measurement at the Brigham and Woman's Hospital in Boston.  Dr. Burstin has published more than 80 articles and book chapters on quality, safety and disparities.  She was recently selected as a 2015-2016 Baldridge Executive Fellow.  She currently is also is a Professorial Lecturer in the Department of Health and Policy and a Clinical Associate Professor of Medicine at George Washington University and serves as a preceptor in internal medicine.

For information concerning NQF go to: http://www.qualityforum.org/Home.aspx

Listen Now

The 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will sunset three current Medicare performance measurement and incentive payment programs in 2018.  (This year, 2016, will be the last year these programs will be measuring and rewarding Medicare physician performance.)  These are: the Physician Quality Reporting System (PQRS); the HIT Meaningful Use (MU) program; and, the Value-Based Modifier (VM) Program.  The VM Program, modified under the 2010 Affordable Care Act, is designed to incent Medicare physician performance by updating annual Part B physician payments based on their quality and cost (or spending) performance.  (The performance and payment years are two years apart, e.g., the 2016 payment year is based on 2014 performance.)     

During this 23 minute conversation Ms. Cleary explains how the VM program is designed, how physicians have performed to date under the program, the extent to which physicians use VM data to inform or improve their practice, how the program will be translated, or continue, under the MACRA Merit-Based Incentive Payment System (MIPS) and quality and value performance expectations under MIPS beginning in 2017, the first MACRA performance year.   

Ms. Kelly Cleary is a DC-based health care attorney with the firm Akin Gump.  Her work primarily concerns health care related legislative and regulatory initiatives, matters involving state and federal fraud and abuse laws and cybersecurity, privacy and data protection issues.  Prior to joining Akin Gump, Ms. Clearly clerked for the Honorable Claude M. Hilton in the US District Court for the Eastern District of Virginia.  She was graduated from Catholic University's School of Law.  While there she served as editor-in-chief of the Catholic University Law Review.   

For more on the CMS VM program go to: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeedbackprogram/valuebasedpaymentmodifier.html

Listen Now

Since the passage of the Affordable Care Act in 2010 CMS has been working to reform Medicare reimbursements from "fee for service" to "fee for value."  (Earlier this year Secretary Burwell noted 30% of traditional or "fee for service" Medicare reimbursements are now tied to quality or value.)  The Medicare Access and CHIP Reauthorization Act (MACRA) passed in 2015 accelerates this transition by incenting Medicare providers to participate in "fee of value" or pay for performance agreements, termed Alternative Payment Models (APMs) under MACRA, with a 5% annual bonus.  To date, commercial Medicare Advantage (MA) plans (Medicare Part D) have been immune from these reforms.   However, under MACRA beginning in performance year 2019 MA plan providers can potentially count their MA reimbursements and MA beneficiaries toward qualifying for the 5% MACRA APM bonus - if they meet the financial risk and other qualifying MACRA APM criteria.  To what extent MA plans, that now account for nearly one-third of all Medicare beneficiaries, will work with their provider partners to meet the MACRA APM qualifying criteria is unknown.      

During this 23 minute conversation Ms. Turco discusses expectations for MA plan participation under MACRA as qualifying APMs, how MA stakeholders are thinking about moving the program outside of MACRA toward improved value or reduced spending growth, CMS's MA Value Based Insurance Design (VBID) demonstration scheduled to begin in January and anticipated MA reforms under a new White House administration next year.   

Ms. Molly Turco is presently Director of Policy and Research at the Better Medicare.  Previously, Ms. Turco was a Senior Healthcare Policy Analyst with the Marwood Group.   Ms. Turco also worked as a Healthcare Policy Researcher in the State of Vermont Office of Health Reform, within the University of Pennsylvania Health System and at Dartmouth Hitchcock Medical Center and the Geisel School of Medicine at Dartmouth.  Ms. Turco holds a MPH from the Dartmouth Institute for Health Policy and Clinical Practice and a BA from Middlebury College.  

Listen Now

Excluding from taxable income the moneys employers spend in providing employees with health insurance dates back to WWII-era wage and price controls.  Today, this tax policy, that amounts to over $250 billion in lost federal tax revenue, effectively constitutes the third largest federal government expenditure on health care after Medicare and Medicaid.  Few tax experts would disagree that the tax exclusion constitutes bad policy.  Beyond lost tax revenues, the policy is, among other things, highly regressive, causes lower or stagnant wage growth, reduces health plan competition, contributes to excessive health care spending, incents the over-utilization of health care services, limits job mobility and negatively influences retirement decisions.   

During this 25 minute conversation Dr. Antos discusses the extent to which the tax exclusion is responsible for employers providing employees with health care insurance coverage, what effect would capping or phasing out the exclusion have on coverage, how best can the policy can be reformed via a Cadillac tax or otherwise, what might be done to reform the tax exclusion under a Secretary Clinton administration and how the exclusion may play into future tax reform may legislation.   

Dr. Joe Antos is the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute (AEI).  Before joining AEI,  Dr. Antos served as the Assistant Director for Health and Human Resources at the Congressional Budget Office (CBO).  Dr. Antos has also held senior positions in the US Department of Health and Human Services, the Office of Management and Budget and the President's Council on Economic Advisers.  He recently completed a seven year term as Health Adviser to CBO and two terms as a Commissioner of the Maryland Health Services Cost Review Commission.  In 2013 he was named Adjunct Associate Professor of Emergency Medicine at George Washington University.   Dr. Antos earned his Ph.D. and MA in economics at the University of Rochester and his BA in mathematics from Cornell University.   

For more background information about the exclusion and micro-simulation data on reforming the exclusion, see Jonathan Gruber's 2011 article in the National Tax Journal, at: http://www.ntanet.org/NTJ/64/2/ntj-v64n02p511-30-tax-exclusion-for-employer.pdf. 

Listen Now

For this, my 101st interview, I discuss with the author, Daniel L. Hatcher, his new work, "The Poverty Industry, The Exploitation of America's Most Vulnerable Citizens."  The work is aptly summarized by Columbia University Professor Jane Spinak.  She notes on the book's dust jacket, "In the tradition of great muckracking, Hatcher has exposed how states and localities misdirected and misused public funds envisioned to benefit the most vulnerable among us." 

During this 26 minute conversation Professor Hatcher discusses his motivations for writing the book, defines "poverty's iron triangle," explains how state foster care and Medicaid agencies, with the help of private contractors, monetize poverty for state financial gain, explains how states attempt to reason this behavior and offers solutions for how this malfeasance can be "reeled in."  

Daniel L. Hatcher is Professor of Law at the University of Baltimore School of Law, teaching a civil advocacy clinic and other classes.  Before joining the faculty in 2004, Hatcher was with the Maryland Legal Aid Bureau, serving as the assistant director of advocacy for public benefits and economic stability.  He previously worked as a staff attorney for Legal Aid representing abused and neglected children, and he represented adult clients all poverty law matters – including public benefits, housing, consumer and family law issues.  He was also a senior staff attorney with the Children's Defense Fund.  Hatcher has testified before Congress, the Maryland General Assembly and in other governmental proceedings regarding several issues affecting children and low-income individuals and families.  Professor earned his law degree at the University of Virginia and his undergraduate degree at the University of Texas at Arlington. 

For more on Hatcher's work go to: https://www.amazon.com/Poverty-Industry-Exploitation-Americas-Vulnerable/dp/1479874728. 

Listen Now

UnitedHealth Group and other major health care insurers' participation in state health insurance marketplaces has caused increasing concern Affordable Care Act-created state marketplaces are becoming unstable.  Moreover, this means health care insurance consumers will have little or possibly no choice in selecting an insurance provider.  For example, in 2016 30 percent of counties throughout the US had only two insurers participating in state marketplaces (10 percent of counties had one). Beyond consumer choice, the absence of marketplace competitors threatens premium affordability.   Creating new and stable insurance marketplaces, that is by definition challenging to accomplish, has been made additionally difficult by Congressional Republican opposition to the ACA's risk corridor program, that along with risk adjustment and reinsurance, is designed to mitigate unavoidable plan financial losses in trying to appropriately price premiums for a population with an unknown health history.             

During this 25 minute conversation Professor Hoadley discusses contributing factors to state marketplace instability andmoreover four methods by which the insurance marketplaces can be stabilized: a "fall back plan;" state participation requirements; extending risk corridors and reinsurance; and, methods to improve marketplace enrollment. 

Dr. Jack Hoadley is a Research Professor at Georgetown University's Health Policy Institute where he studies health financing topics including drug pricing, out-of-pocket costs and the dynamics of insurance making decisions.   In 2015 Professor Hoadley was reappointed to a second, three-year term as a Medicare Payment Advisory Commissioner (MedPAC) member.  Prior to his work at Georgetown, Dr. Hoadley held staff positions at DHHS, i.e., within the Assistant Secretary for Planning and Evaluation (ASPE) office, at MedPAC, the Physician Payment Review Commission and at the National Health Policy Forum.   Professor Hoadley has published widely on health care financing and pharmaco-economics topics and has provided testimony to numerous federal Congressional and other government panels.  He earned his Ph.D. in political science. 

Jack Hoadley and Sabrina Corlette's August 2016 paper, "Strategies to Stabalize the Affordable Care Act Marketplaces: Lessons from Medicare," is at: http://www.rwjf.org/en/library/research/2016/08/strategies-to-stabilize-the-affordable-care-act-marketplaces.html.

Listen Now

Section 1332 of the Affordable Car Act allows states to propose Affordable Care Act-comparable state insurance programs.   Programs would need to meet certain criteria in order to win federal waiver authority.   One state currently considering a wavier is Colorado, i.e., Colorado voters will be asked to approve a state constitutional amendment that would create in part, a financing plan that would provide universal health care to all eligible Colorado residents.       

During this 20 minute conversation Dr. Butler discusses the genesis of Section 1332, why states (blue and red) would be motivated to submit a waiver, the benefits of such waivers, how the next administration might revise current 1332 regulations and state efforts to date, for example, Colorado under its ColoradoCare initiative. 

Dr. Stuart Butler is a Senior Fellow in economic studies at the Brookings Institution.   He is also currently an AdjunctProfessor at Georgetown, a Visiting Fellow at the Convergence Center for Policy Resolution, a member of the editorial board of Health Affairs, a member of the Board on Health Care Services of the Institute of Medicine and of the Advisory Group for the Academy of Medicine's Culture of Health program.   Prior to Dr. Butler spent 35 years at the Heritage Foundation.   Among other previous positions he was an Institute of Politics Fellow at Harvard and a member of Housing Secretary Jack Kemp's Advisory Commission on Regulatory Barriers to Affordable Housing.  Dr. Butler was educated at St. Andrews University in Scotland where he received his undergraduate degree in physics and mathematics, his Masters of Arts in economics and history and his Ph.D. in American economic history.  

Dr. Butler's JAMA Forum essay, noted during this conversation, is at: https://newsatjama.jama.com/2016/09/14/jama-forum-action-on-the-aca-next-year-maybe/

See also Dr. Butler's most recent November 30th JAMA Forum essay titled, "Repeal and Replace Obamacare: What Could it Mean?"  At: https://newsatjama.jama.com/2016/11/30/jama-forum-repeal-and-replace-obamacare-what-could-it-mean/.