The Healthcare Policy Podcast ® Produced by David Introcaso

Listen NowDuring this 30-minute interview Professor Engel discusses moreover why, as he notes, US healthcare is "uniquely dysfunctional," and "laden with profit taking" largely due to induced demand, provides an overview of efforts to contain spending growth via HMOs both in the commercial and the Medicare market, the success of Medicaid HMOs, and discusses his disappointments with the Affordable Care Act (ACA) actually making healthcare more affordable.    Jonthan Engel is Professor of Health Policy and Management at the Marxe School of Public and International Affairs at Baruch College, CUNY.  He has taught previously at Seton Hall University, Mailman School of Public Health at Columbia University and the School of Public Health at the University of Massachusetts.  He has been a consultant to the White House's President's Advisory Committee on Human Radiation Experiments, the lead author on multiple HIV needs assessments for the City of Newark and director of research at the Local Area Board for Health Planning for Essex and Union counties in New Jersey.  His published works include: Doctors and Reformers: Discussion and Debate of Health Policy 1025-1950; Poor People's Medicine: Medicaid and the US Charity Care Since 1965; The Epidemic: A History of AIDS; American Therapy: The Rise of Psychotherapy in the US; and, Fat Nation, forthcoming.   He is currently writing a book on Cold War science and policy in the US.  Professor Engel received his BA from Harvard, an MBA from the Yale School of Management and his PhD in the history of medicine from Yale.  For more information on "Unaffordable" go to: https://uwpress.wisc.edu/books/5682.htm. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowThis past January 9th CMS announced Bundled Payment for Care Improvement (BPCI) Advanced.  This five-year Medicare bundled or episode-based payment demonstration, that begins this October 1st, will succeed the agency'a five-year BPCI demonstration that sunsets this September 30th.  BPCI Advanced, also voluntary, will be considerably less expansive than its predecessor in that, among other things, it will include just 32 clinical episodes (29 inpatient and three outpatient), and offer only a single, 90 day retrospective bundled payment under one risk track.During this 28 minute interview Mr. Dave Terry briefly defines Archway's business model/s, posits what attributes describe successful bundled payment providers, summarizes the findings from a recent study, he coauthored, of BPCI reimbursed total hip arthroplasty surgeries, how CMS has improved bundled payments under BPCI Advanced, or moreover in financial benchmarking and in quality measurement, the legitimacy of criticisms regarding care fragmentation and competition with other pay for performance models and likely success of the demonstration.Mr. Dave Terry is currently CEO of Archway Health.  Previously, at Partners Healthcare in Boston, Mr. Terry negotiated global cap and pay for performance contracts with managed care plans.  Prior still at Harborside Healthcare, he led a home care agency that managed Medicare and commercial episodes of care within a single payment.  As a partner with The Chartis Group, Mr. Terry developed provider networks and risk sharing models for Medicare Accountable Care Organizations (ACOs).  Mr. Terry holds an MBA from the Harvard Business School and a BA from Columbia University.  He currently serves on the board of Bottom Line, a national educational non-profit, and is a past board member of the Harvard Business School Health Industry Alumni Association.For information on BPCI Advanced to go: https://innovation.cms.gov/initiatives/bpci-advanced. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowIn a letter last March to state Medicaid directors by then DHHS Secretary Tom Price and CMS Administrator Seema Verma telegraph the administration's intent to radically redefine the Medicaid program.  Believing the ACA's expansion of the Medicaid program was, per the March letter, a "clear departure from the core, historical mission of the program,"  administration officials telegraphed they were preparing to reinvent the program by, in part, requiring work or community engagement for abled-body adults as a precondition for Medicaid coverage.  Historically, the Medicaid program was intended to strengthen and increase coverage for the poor.  In a nine-page, January 11 letter to state Medicaid directors, Ms. Verma announced, "a new policy to assist states in their efforts to improve Medicaid enrollee health and well-being through incentivizing work and community engagement."  That there is no evidence that work improves health status, the January 11th letter stated "work . . may improve health outcomes," on January 12th CMS approved a Kentucky waiver to require employment as a prerequisite for Medicaid coverage despite state officials recognizing through the course of the waiver's implementation 15 percent of abled-body Kentuckians would lose coverage.    During this 20 minute interview, Professor Sara Rosenbaum briefly explains Medicaid 1115 waivers, the administration's intent to, in addition to requiring employment, refashion the Medicaid program to more resemble commercial insurance, what evidence the administration posits to justify the policy change, the details of the Kentucky waiver (the first of likely several, if not many work requirement waivers), the anticipated effects of the Kentucky waiver and the legal bases for litigation already filed to challenge the Kentucky waiver. Professor Sara Rosenbaum is the Harold and Jane Hirsh Professor of Health Law and Policy at the Milken Institute School of Public Heath at George Washington University.  She also holds professorships at GWU's Law and Medical Schoold and at the Trachtenberg Schoolf of Public Policy and Public Administration.  Professor Rosenberg worked in the Clinton Administration where she directed and drafted the Health Security Act and designed the Medicaid's Vaccines for Children program.  She currently advises states, foundations and others on health policy and has served as a testifying expert in landmark litigation to enforce children's rights under Medicaid.  She is the lead author of Law and the American Health Care System.  Professor Rosenbaum is the Past Chair of AcademyHealth and a member of the National Academies of Sciences, Engineering, and Medicine.  She also has served on the CDC's Director's Advisory Committee and Advisory Committee on Immunization Practice.  She was the founding Commissioner of the Congress's Medicaid and CHIP Payment and Access Commission (MACPAC) and served as its Chair from January 2016 through April 2017.Recent related writings by Professor Rosenbaum, i.e., "The Trump Administration Re-Imagines Section 1115 Medicaid Demonstration - and Medicaid" (Health Affairs Blog, 11/9/17) and "Experimenting on The Health of the Poor: Inside Stewart v. Azar (Health Affairs Blog, 2/5/18) are at: https://www.healthaffairs.org/do/10.1377/hblog20171109.297738/full/  and https://www.healthaffairs.org/do/10.1377/hblog20180204.524941/full/. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowIn early February the Human Rights Watch (HRW) published, "'They Want Docile': How Nursing Homes in the US Over-medicate People with Dementia."  The inappropriate or misuse of antipsychotics, e.g., Haldol, Seroquel and Risperdal, in nursing facilities to chemically restrain nursing home patients, moreover frail and elderly seniors, has been practiced for decades.  The HRW report found in 2016-2017 "massive use" or abuse, i.e., the report estimated in an average week over 179,000 long-stay nursing facility patients were administered antipsychotic drugs without a diagnosis for which the drugs are indicated or approved.  Despite efforts to reduce the abuse of these medications, in part via a CMS voluntary initiative (a link to which his provided below), the practice persists, in part, because the federal government has nominally enforced regulations and enforcement measures to remedy the problem.  The use of these drugs can and does cause serious patient harm.  In testimony before the Congress in 2007, the FDA's Dr. David Graham stated, "15,000 elderly people in nursing homes [are] dying each year form the off-label use of antipsychotic medications for an indication that the FDA knows the drug doesn't work."  Listeners may recall I initially discussed this topic in December 2012 with Diana Zuckerman.   During this 36 minute discussion Ms. Flamm explains what prompted the HRW study, the study's methodology, how widespread is the practice of misuse of antipsychotics in nursing facilities, how and why they are used inappropriately, that includes the the failure to obtain free and informed consent, the federal government's inadequate enforcement of federal laws and regulations to police the problem and how this practice violates not just US laws but international human rights agreements. Ms. Hannah Flamm is currently an immigration lawyer at The Door's Legal Services Center in New York. In 2016-2017, Ms. Flamm was New York University's School of Law Fellow at Human Rights Watch where she researched and wrote, "They Want Docile."  She interned with the Southern Poverty Law Center, South Brooklyn Legal Services and Schonbrun DeSimone, an international human rights and civil rights firm.  She is a graduate of NYU's School of Law and the Harvard University Kennedy School of Government.  As a student she participated in NYU's Family Defense Clinic and the Harvard International Human Rights Clinic.  Prior to attending law school, Ms. Flamm worked for the International Rescue Committee in Haiti. The Human Rights Watch report is at: https://www.hrw.org/report/2018/02/05/they-want-docile/how-nursing-homes-united-states-overmedicate-people-dementia.Two related 2012 and 2011 DHHS Office of the Inspector General reports are at: https://oig.hhs.gov/oei/reports/oei-07-08-00151.pdf and https://oig.hhs.gov/oei/reports/oei-07-08-00150.pdf.Information on CMS' "National Partnership to Improve Dementia Care in Nursing Homes" is at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve-Dementia-Care-in-Nursing-Homes.html. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowFatalities related opioid use now account for over two-thirds of all drug overdoses annually, over 60,000, in the US.  Approximately 115 Americans die every day from an opioid overdose.  This number represents a five-time increase over the past two decades.  Opioid-related fatalities have become so prevalent, according to the National Center for Health Statistics, they have caused a decrease in US life expectancy for the past two consecutive years.  (The last time life expectancy dropped was in 1993 due to the AIDS epidemic.)  While the amount of prescription opioids sold to pharmacies, hospitals and doctors has quadrupled in the recent past, Americans are reporting on reduction in the amount of pain they suffer.  (Ironically, we are over prescribed and under treated.)  To date the federal government's response to the epidemic has been poor although this past week, the Congress appropriated $6 billion, an amount experts believe beyond inadequate, over a two year period to address the crisis.   During this 28 minute interview Dr. Passik discusses the numerous causes contributing to the opioid epidemic, policies and practices in pharmacology that may be contributing to the problem, strategies used in pharmaceutical prescribing, or in the use of abuse deterrent formulations, to reduce addiction or abuse and the role other reforms in the clinical practice setting and in reimbursement can play in reducing harm and opioid-related fatalities.  Since 2017 Dr. Steven Passki is currently the Vice President of Scientific Affairs, Education and Policy at Collegium Pharmaceuticals.  Prior to joining Collegium, Dr. Passik was Director of Clinical Addiction and Education at Millennium Laboratories.  Prior still, he spent 25 years in academia and clinical care at Memorial Sloan Cancer Center, at the University of Kentucky and at Vanderbilt University.  His research has focused on the psychiatric aspects of cancer and non-cancer pain and symptom management and the interface of pain management and addiction.  He has served as on the editorial board of the Journal of Pain and Symptom Management and as a reviewer for multiple journals including The Clinical Journal of Pain.  He has been a member of several scientific and medical societies including the American Psychological Association and the American Society of Psychiatric Oncology/AIDS.  He has written extensively on the interface of pain management and addiction. He is a clinical psychologist and has areas of expertise include the general psychological aspects of cancer including palliative care and symptom management with an emphasis on pain, depression, nausea and fatigue.  Dr. Passki was named a fellow of Division 28 of the American Psychological Association (Psychopharmacology & Substance Abuse) and awarded a Mayday Fund Fellowship in Pain and Society. An author of more than 120 journal articles, 60 book chapters and 59 abstracts, he speaks nationally and internationally on pain, addiction and the pain/addiction interface.  Dr. Passik received his doctorate in clinical psychology from the New School of Social Research in New York City.I noted during the interview Dr. Passik will be keynoting a DC-area abuse deterrent formulations meeting in March, information on the meeting is at: http://www.cbinet.com/conference/pc18298. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowA year ago last week the President Trump signed an executive order reinstituting the so called global gag rule (more formally termed the Mexico City policy).  The policy was first implemented by President Reagan and has gone in and out of effect depending on whether a Republican or Democrat holds the White House.  The initial policy only applied to abortions, i.e., in order to obtain US family planning funding aid, not for profits or non-governmental organizations (NGOs) had to certify they would not use non-US funding, including private funding, to perform or promote (i.e., they are gagged) abortions overseas.  Beginning in 2001, the policy was expanded to cover other forms of contraception.  Under President Trump the policy was substantially expanded.  Under this administration's global gag rule, NGOs can neither use US family planning funding aid (at $575 million annually) nor any US global health funding aid (that totals $8.8 billion) even if it is used to prevent or treat other public health issues, for example, HIV or malaria, unless, again, the NGO certifies it is not using other funds in performing or promoting abortion as a method of family planning.         During this 21 minute conversation, Jonathan Rucks briefly explains PAI's mission, the Trump administration's significant expansion of the global gag rule, what effects the global gag rule has had in the past and what expected results an expanded policy will have going forward, what work PAI is doing to address the current global gag rule and past and present efforts by the Congress to prohibit the implementation of the rule via executive order. Jonathan Rucks is the Senior Director of Advocacy at PAI (formerly the Population Action International) where he is responsible for the development and management of advocacy strategies to inform and influence public policy in the US and overseas in moreover developing countries to increases support for sexual and reproductive health and rights.  Prior to PAI, Mr. Rucks worked for Pathfinder International, prior still he spent eight years working for Congressional Representative Jan Schakowsky (D-IL) and Representative Jim Oberstar  (D-MN).  Mr. Rucks holds a master's degree in Strategic Security Studies from the College of International Security Affairs at the National Defense University in Washington, DC.   For information regarding PAI go to: pai.org. President Trump's January 23, 2017 global gag rule memorandum is at: https://www.whitehouse.gov/presidential-actions/presidential-memorandum-regarding-mexico-city-policy/. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowThis past November 16 CMS published the agency's final 2018 MACRA (Medicare Access and CHIP Reauthorization Act) rule (at 661 federal register pages).  MACRA, authorized in 2015, formulates how approximately 1.5 million Medicare Part B physicians and other eligible clinicians are reimbursed.  Annual MACRA proposed and final rule making is closely monitored since the law's MIPS (Merit-Based Incentive Payment System) and Advanced Payment Model (APM) pathway are the two formulas CMS uses to annually update Fee for Service Medicare Spending (Part A and Part B) and how eligible clinicians under Medicare Advantage (Part C) can participate in MACRA's payment updates or rewards.    During this 24 minute conversation Ms. O'Brien discusses the MIPS two threshold exclusions, MIPS quality and cost components, the composite performance score (CPS), the Advanced APM (AAPM) pathway, the anticipated 2018 Medicare Advantage (MA) AAPM demonstration and criticisms of MACRA implementation, specifically MedPAC's.  Ms. Kristen O'Brien serves as Counsel at the law firm, Olsson, Frank and Weeda (OFW), in their Health Industry and Regulatory Practice.  Prior to OFW, she served as Senior Legislative Counsel with the American Medical Association and prior still worked in private practice.   Ms. O'Brien's experience also includes serving as professional staff for the Senate Finance Committee under Former Committee Chair, Senator Max Baucus (D-MT), where she worked on health and environmental issues as well as financial reform.  Ms. O'Brien received her J.D. cum laude from Georgetown University Law Center and her undergraduate from Cornell University that included study at the London School of Economics.The 2018 final MACRA rule is at: https://www.federalregister.gov/documents/2017/11/16/2017-24067/medicare-program-cy-2018-updates-to-the-quality-payment-program-and-quality-payment-program-extreme. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowCMS has been experimenting with Medicare bundled payment arrangements, where the provider is reimbursed a total fee (either prospectively or reconciled retrospectively), for three decades.  Under ACA authority CMS' Center for Medicare and Medicaid Innovation (CMMI) has launched several five-year bundled payment demonstrations, most notably BPCI that began in 2013.  The BPCI demo allows providers to voluntary accept a bundled payment for any one of 48 Diagnosis Related Groups (DRGs), for example a heart attack, under three care models.  Model Two is the most popular.  It begins with an anchor acute hospital stay followed by 30 to 90 days of post acute care.  The most common Model Two bundle is for hip or knee replacement surgery.  Recently, the Lewin Group completed its third evaluation of the BPCI.  Regardless of the demonstration's performance to date, has it moreover reduced spending and/or improved care quality and outcomes, it is anticipated CMS will renew the BPCI demo in the very near future since the current demo times out this September. During this 25-minute discussion Mr. Clay Richards discusses naviHealth's BPCI's efforts, the company's BPCI financial and quality results to date, Lewin Group's most recent BPCI evaluation and how the demonstration can be improved under a reauthorized BPCI demonstration.  Mr. Clay Richards is CEO of naviHealth, a post-actue care transition company and one of the nation's largest BPCI convenors.  The company, founded in 2012, partners with approximately 50 hospitals in 25 states, collectively they account for over 40,000 BPCI care episodes  annually.  Prior to joining naviHealth, Mr. Richards served as Senior Vice President of Healthways, Inc.  Mr. Richards' community service includes serving on the Martha O'Bryan Center Board, the Oak Hill School Board and on the Vanderbilt Owen Graduate School of Management Board of Visitors.  Mr. Richards was graduated from Washington and Lee University and from the University of Mississippi School of Law.Information on naviHealth is at: https://www.navihealth.com/.Information on the BPCI demo and the Lewin Group's evaluation can be found at: https://innovation.cms.gov/initiatives/bundled-payments/.   This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowDespite the fact an estimated 100 million Americans suffer from chronic pain costing approximately $640 billion annually in medical expenses and lost productivity, the disease remains widely under treated.  This is all the more true for ethnic and racial minorities independent of age, gender, education, wealth and pain intensity.  Despite recent efforts by the Institute of Medicine, the DHHS, i.e., its 2016 "National Pain Strategy," and new payment models designed to improve care quality, for example, Accountable Care Organizations and Patient Centered Medical Homes, under treatment persists.  Addressing the problem has become all the more difficult over approximately the past decade due to the opioid epidemic that has blurred, if not erased, the line between effective treatment and drug abuse.  We face the nearly impossible situation where Americans are simultaneously under treated and over medicated.     During this 29-minute conversation Ms. Christopher discusses why chronic pain continues to be under treated, to what extent, if any, chronic pain measurement and data collection has improved, the work of the Center for Practical Bioethics' PAINS Project and the extent to which the opioid epidemic is undermining chronic pain treatment. Ms. Myra Christopher is currently the Director of the PAINS Project and as well the Kathleen M. Foley Chair at the Center for Practical Bioethics.   She served as President and CEO of the Center from its inception in 1985 through 2011.  From 1998 through 2003 she served as National Program Officer at the Robert Wood Johnson Foundation's National Program Office for State-Based Initiatives to Improve End-of-Life Care.   She has consulted with numerous organizations including the Joint Commission on the Accreditation of Healthcare Organizations, at CMS in developing the Community State Partnerships to Improve End-of-Life Care initiative, participated in drafting the IOM's 2011 "Relieving Pain in America" report discussed during this interview, as a reviewer on the IOM's 2014 report, "Dying in America" and the DHHS committee that produced the  "National Pain Strategy." She has also consulted with the CDC, AARP and other organizations to promote pain and palliative care as public health issues.  She is s a founding member of the Coalition to Transform Advanced Illness (CTAC), has served on numerous boards including the Duke University Institute for Care ad the End of Life and has received as well numerous awards including the American Society for Bioethics + Humanities Lifetime Achievement Award in Bioethics.   For more information on the PAINS Project go to: http://painsproject.org/The IOM's "Relieving Pain In America" is at: https://www.ncbi.nlm.nih.gov/pubmed/22553896.The DHHS' "National Pain Strategy" is at: https://www.hhs.gov/ash/about-ash/news/2016/national-pain-strategy-outlines-actions-improving-pain-care/index.html. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com

Listen NowThis, my 125th interview, will discuss Oregon's Coordinated Care Organizations (CCOs) that have received considerable attention nation-wide for their ability to provide Medicaid beneficiaries with coordinated care, moreover primary care services integrated with mental/behavioral and oral health.  The Oregon CCO model has also demonstrated over the past five years an ability to improve care quality while keeping spending below a targeted 3.4 percent annual growth rate via a capitated payment arrangement.  Oregon's CCO success is the subject of Dr. Jim Rickards recent work, "Our Health Plan, Community Governed Healthcare That Works.  The work details the experience of one Oregon CCO, Yamhill Community Care.     During this 29-minute discussion Dr. Rickards provides a brief description Yamhill County, how the Yamhill County's CCO, Yamhill Community Care, was formed, what initial decisions or steps it took, how it organizes or coordinates care moreover between and among primary care providers, dentists, behavioralists, community health workers and a community paramedicine program.   The role Health Information Technology (HIT), or Oregon/Washington's Health Information Exchange (HIE) or EDIE, and quality measures play, what beneficiary spill over effects have resulted from the CCO's care delivery and how might Oregon's CCO model be adopted elsewhere.  Dr. Jim Rickards is currently the Senior Medical Director at Moda Health in Portland, Oregon.  Previously, Dr. Rickards was the Chief Medical Officer of the Oregon Health Authority, where he provided clinical and policy leadership in managing Oregon's Medicaid population.  He received his B.S. from Indiana University Bloomington, MBA from Oregon Health and Science University, M.D. from Indiana University School of Medicine.  He completed his residency and fellowship training in radiology in Chicago at Cook County Hospital and Rush University Hospital.  Dr. Rickards currently resides in Mcminnville, Oregon.For more information on Our Health Plan go to: https://www.prnewswire.com/news-releases/new-health-care-delivery-book-asks-is-community-healthcare-the-future-300501810.html.For information on the Oregon Health Authority go to: http://www.oregon.gov/OHA/Pages/index.aspx.A thorough review of 2016 CCO performance results is at: http://www.oregon.gov/oha/HPA/ANALYTICS-MTX/Documents/CCO-Metrics-2016-Final-Report.pdf.  This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit www.thehealthcarepolicypodcast.com