The Healthcare Policy Podcast ® Produced by David Introcaso

Listen Now A 2012 National Academy of Sciences (Institute of Medicine) study titled, "Best Care and Lower Cost," found about one quarter of all medical spending is wasted, much of this excessive spending going to pay for treatments that are of unknown effectiveness.   With medical spending now accounting  for one-sixth of the nation's GDP, or over $3 trillion annually, how do we limit spending to treatments that are proven effective or are of high value.  How do we increase the use of evidence-based medicine.  While this issue or problem has been, or is being, addressed by several federal health care agencies including the Agency for Healthcare Research and Quality (AHRQ) and the the ACA-created Patient Centered Outcomes and Research Institute (PCORI), progress has been frustratingly slow.   (For example, a day prior to this interview a Health Affairs blog post discussed the persistent use, despite clinical evidence to the contrary, of pre-cataract surgery blood analysis and EKG testing.)      During this 23-minute conversation Dr. Feinman discusses how his background as a hospitalist led to his co-founding Doctor Evidence, what explains the variation in the use of evidence based medicine, how Doctor Evidence is working to improve the timely collection, dissemination and use of evidence-based medicine, how his work is related to the Cochrane Collaborative, and how work by Doctor Evidence can influence quality measurement and drive or improve health care value, or patient outcomes achieved relative to spending. Dr. Todd Feinman is the Chief Medical Officer and co-founder of Doctor Evidence where he works to create evidence technologies that will lead to improved care, better health care outcomes, greater patient satisfaction and reduced spending growth.  Among other partnerships, Doctor Evidence works with the USC Center of Body Computing and with several medical associations and pharmaceutical companies.  Dr. Feinman began his career as a hospitalist, developing the first such programs in Southern California.   He is a board certified internist.   Dr. Feinman earned his medical degree at UCLA's David Geffen School of Medicine and did his residency work at Cedars-Sinai Medical Center in Los Angeles and at Huntington Memorial Hospital in Pasadena. For information on the firm Doctor Evidence go to: http://drevidence.com. 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 NowApproximately 8,700 Americans die annually awaiting a kidney donation or become too ill to receive one.  This is half the number of those who annually receive a kidney, or 17,000.   Over 100,000 at any time are awaiting a kidney.  The median wait time is over three and a half years.  One-third of kidney donations are live donations typically from a child, parent, sibling, spouse or other relative.  However, an increasing number of live donations are made by strangers voluntarily choosing to donate. The number of these donations while small, at less than 400 annually, has doubled in recent years.  The benefits of receiving a donated kidney are pronounced, the expected benefits to the recipient are estimated at 100xs the expected costs to the donor. During this 26 minute conversation Professor Marsh explains why she became interested in altruism particularly extraordinary altruism, what her and her colleagues' research has found that explains donor reasoning in providing a kidney, how "social discounting" and other factors play into their decision making, how brain development, or the size of a donor's amygdala (the part of the brain responsible for decision making and emotional reactions including compassion), plays a factor and to what extent normalizing voluntary kidney donations may over time reduce or eliminate the shortage of kidney donations.Professor Abigail Marsh is an Associate Professor in the Department of Psychology and the Interdisciplinary Program in Neuroscience at Georgetown.  Prior to Georgetown, Dr. Marsh conducted post-doctoral work at the National Institute of Mental Health at the National Institutes of Health from 2004 to 2008.   Her areas of expertise include social and affective neuroscience, particularly understanding emotional processes like empathy and how they related to altruism, aggression and psychopathy.   Her work has appeared in the Proceedings of the National Academy of Sciences, Psychological Science, the American Journal of Psychiatry, JAMA Psychiatry and Nature Human Behavior.  Dr. Marsh was graduated with a BA in Psychology from Dartmouth and a Ph.D. in Social Psychology from Harvard.   Professor Marsh's June 2016 TED talk, "Why Some People Are More Altruistic Than Others," is at: https://www.ted.com/talks/abigail_marsh_why_some_people_are_more_altruistic_than_others.A 10-page, footnoted discussion weighing the pros and cons of voluntary donating a kidney can be found on the Effective Altruism Forum website, at: http://effective-altruism.com/ea/ay/kidney_donation_is_a_reasonable_choice_for/.  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 May 4, US House or Representative Republicans passed the American Health Care Act (AHCA).  The bill, defined by Republicans as a repeal of the Affordable Care Act (ACA), is now under debate among Senate Republicans. (Neither any House Democrat voted for the AHCA nor are there any Senate Democrats expected to vote for related Senate bill should it make the Senate floor.)  Per the Congressional Budget Office's (CBO) estimate of the AHCA's spending and revenue effects, published May 24, the AHCA would cause 14 million Americans to lose their health insurance in 2018 and 23 million by 2026, 14  million of this latter total would be Medicaid recipients.  This is because the AHCA would cut $834 billion from the Medicaid program over the ten year budget window, or by 2026.  The cuts in Medicaid spending, along with substantial reductions in tax credits, would allow for ACA taxes, approximately $600 billion, to be rescinded.  For example, the ACA's 3.8% tax applied to capital gains for family incomes over $250,000 and a 0.9% Medicare surtax on wage income in excess of $250,000 per year, i.e., tax cuts that would benefit the comparatively wealthy.           During this 25 minute conversation Dr. Silverstein provides, among other things, his assessment of the AHCA, i.e., legislation moreover as tax relief for the wealthy, the likely effect it would have one women's health and on disparities in care and alternatively how the ACA could be improved. Dr. Jason Silverstein is a Lecturer and Writer-in-Residence at Harvard Medical School in the Department of Global Health and Social Medicine. He is also currently an Instructor at the Harvard T. H. Chan School of Public Health.  He is also a faculty affiliate of the Science, Religion and Culture Program at the Harvard Divinity School.  He is a regular contributor to VICE's health channel, Tonic.   He has written for The New York Times, the Atlantic, The Guardian, Slate, The Nation and others and has provided commentary for, among others, MSNBC, NPR, HuffPost Live and BET.   His previous experience includes conducting research at Children's Hospital Boston, the Dana-Farber Cancer Institute, Harvard Law School's Program on Disability, and Stony Brook's HIV Treatment Development Center. Dr. Silverstein holds a Ph.D. and Master's in Anthropology from Harvard, a Master's in Religion, Ethics and Politics from Harvard Divinity and an undergraduate degree in philosophy from Penn. State. Dr. Silverstein's Tonic writings are at: https://tonic.vice.com/en_us/contributor/jason-silverstein.  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 NowConsidering the debate over the past five months about repealing the ACA (and more generally reforming the Medicare program via premium support),  it is worth remembering that approximately 55% of non-elderly Americans, or 155 million, still receive their health care coverage via their employer.   In addition, as of 2016 the ACA requires employers with over 50 employees to either offer health benefits or face a financial penalty.   The question remains what is the future of employer based insurance coverage, both for employees and retirees) if, for example, the ACA's "employer shared responsibility" provision and/or the employer tax exclusion (addressed in the ACA by the so called "cadillac tax") is repealed. During this 25 minute discussion Mr. Gelband briefly describes ERIC's mission/work, identifies what methods large employers are using to continue to offer employee coverage, how retiree coverage is being addressed, how employers are incenting providers to deliver quality care, ERIC's view of much debated HRAs (Health Risk Assessments) and wellness programs and his organization's position on the employer tax exclusion.  (Listeners may recall I interviewed Dr. Joe Antos last August 5th on the tax exclusion.)Mr. James Gelfand is Senior Vice President of Health Policy at ERIC where he works to develop and advance public policies to support the ability of employers to design and administer health plans.   Previously, Mr. Gelfand was the Director of Federal Affairs at the March of Dimes Foundation.   Prior to, he served as Associate Director for Luntz Global Partners.  He served on Capital Hill as Counsel to Senator Olympia Snowe, on the Senate Small Business Committee and to Senator Tom Coburn.   Mr. Gelfland also was for four years a lobbyist for the US Chamber of Commerce.   Mr. Gelfand received his JD from the George Washington University Law School and his undergraduate degree from Northwestern. For more information on ERIC go to: http://www.eric.org/. 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 Now As former DHHS Secretary Louis Sullivan wrote in support of this work, "Mary Otto brings history, policy and painful personal realities together in this compelling and engaging book about our nation's highly preventable epidemic of oral disease.  Teeth should be read by every policy maker and health professional who believes we can and must ace to reduce the current barriers to dental care."  (Listeners of this podcast may be also interested in related interviews with Burton Edelstein, DDS, from April 2013 and my interview with the American Dental Association's Dr. Marko Jujicic from January 2016.) During this 22 minute conversation, Ms. Otto discusses the impetus for her work, i.e., the 2007 death of a 12-year old Maryland resident, Deamonte Driver, from an abscessed tooth, she discusses efforts to integrate oral health with overall physicial health, the problems of substantial racial/ethnic disparities in oral health in light of the industry's increasing financial interests in provided cosmetic dentistry, the battle between dentists and mid-level providers, e.g., dental hygienists, over the latter's efforts to improve oral health primary and secondary prevention and the possibilities for improved oral health coverage moreover for adults under both Medicare and Medicaid.   Ms. Mary Otto is the oral health topic leader for the Association of Health Care Journalists.  She began writing about oral health at The Washington Post, where she worked for eight years covering social issues, including health care and poverty.  Ms. Otto is a resident of Washington, DC.  Ms. Otto's volume is available via Amazon at: https://www.amazon.com/Teeth-Beauty-Inequality-Struggle-America/dp/1620971445.   A review of her work appeared in the March 23rd issue of The New York Times, at: https://www.nytimes.com/2017/03/23/books/review/teeth-oral-health-mary-otto.html?_r=0.   An executive summary of Surgeon General David Satcher's 2000 report, "Oral Health In America," noted during this conversation, is at: https://www.nidcr.nih.gov/datastatistics/surgeongeneral/report/executivesummary.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 NowIn mid-January the CDC abruptly canceled a three-day "Climate and Health Summit" the Center had been planning for months.  The meeting was intended to discuss public health risks caused by the climate crisis and steps being taken to reduce the emissions of carbon dioxide and other greenhouse gases or its adverse consequences on human health.   (It was speculated the meeting was canceled because the CDC did not want to run afoul of the incoming president who has repeatedly called climate change a “hoax” perpetrated by the Chinese.)   The American Public Health Association (APHA) and others however went ahead and held a one-day meeting on February 16 titled,"Climate and Health" at the Carter Center in Atlanta.  The meeting was keynoted by former Vice President Al Gore.   Dr. Jonathan Patz, the Director of the Global Health Institute at the University of Wisconsin-Madison, was one of the meeting's organizers and participants.    During this 24 minute conversation Dr. Patz discusses how the meeting came about and what was accomplished, e.g., he summarizes the afternoon's panels that discussed what's being done to reduce green house gas emissions.  He also discussed how to better involve the professional medical community  and how to effectively communicate the reality of the climate crisis. Dr. Jonathan Patz is the Director of the Global Health Institute at the University of Wisconsin-Madison.  He is a professor and the John P. Holton Chair in Health and the Environment with appointments in the Nelson Institute for Environmental Studies and the Department of Population Health Sciences.  For 15 years, Dr. Patz served as a lead author for the United Nations Intergovernmental Panel on Climate Change (or IPCC)—the organization that shared the 2007 Nobel Peace Prize with Al Gore.  He also co-­chaired the health expert panel of the U.S. National Assessment on Climate Change, a report mandated by the Congress.  Dr. Patz has written over 90 peer-reviewed articles, a textbook addressing the health  the health effects of global environmental change and co-edited the five volume Encyclopedia of Environmental Health (2011).  He has been invited to brief both houses of Congress and has served on several scientific committees of the National Academy of Sciences.  Dr. Patz served as Founding President of the International Association for Ecology and Health.  He is double board-­certified, earning medical boards in both Occupational/Environmental Medicine and Family Medicine.  He received his medical degree from Case Western Reserve University (1987) and his Master of Public Health degree (1992) from Johns Hopkins University.A webcast of the February 16 meeting is at: https://www.climaterealityproject.org/health.  Listeners are particularly encouraged to listen to Vice President Gore's 30 minute keynote address.  For more information concerning the Medical Society Consortium on Climate and Health go to: https://medsocietiesforclimatehealth.org/.Since I mention during the discussion the Obama administration's 2016 "The Impacts of Climate Change on Human Health in the US: A Scientific Assessment," a review of the paper is, again, at: http://altarum.org/health-policy-blog/nature-bats-last-a-warming-earth-will-exact-adverse-health-effects-but-our-responsibilities-are.    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 NowOver approximately the past decade the health care industry has become increasingly committed to financially incenting physicians and other clinicians, or tying performance to reimbursement.  Commonly termed "pay for performance"(P4P), these arrangements are increasingly employed in the Medicare (i.e., under the Medicare Access and CHIP Reauthorization Act, or MACRA) and Medicaid programs and by commercial insurers, most notable accountable care models and bundled payment arrangements.   One might assume because P4P models are now common there is research evidence that demonstrates they are effective in, again, improving care quality, patient outcomes and lowering spending growth.  That is not the case.  For example, a systematic review published by Cochrane in 2011 found "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."  Among other examples, for all the attention the Massachusetts' Alternative Quality Contracts (AQCs) have received since they were launched in 2009, it remains unclear if they have reduced spending or spending growth.   Because P4P models have not proved out, payers and providers, for example, England's National Health Service and in the US the integrated, 12 hospital system, Geisinger Health, have substantially reduced incentive payments or are returning to paying providers straight salaries.            During this 27 minute conversation, Professor Soumerai discusses his interest in the P4P topic, describes P4p arrangements, summarizes his and others' review of the research evidence relative to the effectiveness of P4P arrangements and suggests model designs that may be more effective.  Stephen B. Soumerai is Professor of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute.  He also co-chairs the Statistics and Evaluative Sciences concentration within Harvard University’s health policy Ph.D. program.  Dr. Soumerai recently served as International Trustee for the Canadian Health Services Research Foundation.  Dr. Soumerai has published more than 250 original scientific articles in leading scientific journal, such as the New England Journal of Medicine and the Journal of the American Medical Association.  He is well known nationally and internationally for his work on the impacts of health policies and methods to improve the quality of medical practice.  He frequently advises Congress, state legislatures and federal and international agencies on the design of drug cost containment, coverage and quality-of-care policies, evidence-based health policy and his research has been used extensively to support expanded economic access to medications in Medicaid and Medicare. He is the recipient of numerous honors including numerous article of the year awards from national and international scientific societies, named lectureships, and is the recipient of the Everett Mendelsohn Excellence in Mentoring Award from the Harvard University Graduate School of Arts and Sciences.Professor Soumerai's 2015 and 2016 CDC articles noting in this discussion are at: https://www.cdc.gov/pcd/issues/2015/15_0187.htm and https://www.cdc.gov/pcd/issues/2016/16_0133.htmA summary of these works can be found at: http://www.vox.com/the-big-idea/2017/1/25/14375776/pay-for-performance-doctors-bonuses 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 NowLate today, or within a few hours after this interview was completed, the House Republicans proposed ACA repeal or reconciliation legislation.  The legislation includes repealing Medicaid expansion under the Affordable Care Act (ACA).  More specifically, House Republicans propose repealing the  federal enhanced match rate for eligible beneficiaries on December 31, 2019 though states can keep the enhanced match rate for those Medicaid eligible before January 1, 2020 but only for those that do not have a break in Medicaid eligibility for more than one month after that January 1, 2020..  Moreover, the proposed legislation would reform federal Medicaid funding by creating a per capita cap model starting in 2020.  This means federal funding would be benchmarked to 2016 for the five Medicaid enrollee categories: the elderly; blind and disabled; children; non-expansion adults; and, expansion adults.  Year- over-year federal spending increases would be pegged to the medical care component of the Consumer Price Index (CPI).   While there is not yet a Congressional Budget Office (CBO) score for the proposed legislation, that's schedule for mark up on Wednesday, estimates by the Center for Budget and Policy Priorities (CBPP) project that if the 32 states that expanded Medicaid coverage under the ACA wanted to keep it, the cost to these states would be approximately $280 billion over the next decade.  CBPP also estimates that per capita caps will  increase the state's share of Medicaid costs, excluding expanded coverage, by another $280 billion also over 10 year budget window.   During this 25-minute interview, Executive Director of the National Association of Medicaid Directors (NAMD), Matt Salo, discusses the mission of NAMD, his understanding of House Republican legislation to fundamentally reform the Medicaid program, the challenges with either Medicaid block grants or per capita caps, and other related policy issues the NAMD is working to resolve.  Mr. Matt Salo has served as Executive Director of NAMD since 2011.  NAMD is a non-partisan association representing all 56 of the nation's state and territorial Medicaid Directors.    Prior to NAMD, Mr. Salo spend 12 years at the National Governors Association where he  worked to forward the Association's health and human services policy agenda.   Prior still Mr. Salo worked for five years as a health policy analyst at the American Public Human Services Association.   Mr. Salo also spent two years as a substitute teacher in the Alexandria, VA public school system. Mr. Salo holds a BA in Eastern Religious Studies from the University of Virginia.For more on the NAMD go to: http://medicaiddirectors.org/For more on House ACA repeal or reconciliation legislation go to: https://energycommerce.house.gov/hearings-and-votes/markups/markup-committee-print-and-h-res-154https://waysandmeans.house.gov/event/markup-budget-reconciliation-recommendations-repeal-replace-obamacare/ 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 his recent work, The Case Against Sugar, Gary Taubes argues not all calories are alike.  Sugar, or the consumption of sugar, causes elevated levels of insulin, or hyperinsulenema, and high levels of insulin drives fat accumulation.  Rather than obesity causing diabetes, Taubes argues, hyperinsulinemia causes both.   That there's been an 800% increase since 1960 in the consumption of sugar and approximate doubling of diagnosed cases of diabetes since 1990 cannot be a coincidence.  (Per the CDC, over the past 25 years the age-adjusted prevalence of diabetes increased by ≥50% in 42 states and by ≥100% in 18 states.)   Not only does sugar consumption drive the diabetes epidemic, Taubes argues it can also be correlated to hypertension, cancer, stroke and dementia.        During this 35 minute conversation Mr. Taubes discusses the impetus for the book, sugar's relationship to elevated insulin levels and obesity and diabetes, the problem/s with the accepted belief that a "calorie is a calorie," the FDA's determination that sugar is GRAS (Generally Accepted as Safe), the role the Sugar Association has played in encouraging and defending sugar's consumption, the difficulty in scientifically proving sugar consumption is correlated to diabetes, hypertension and cancer among other prevalent serious and fatal illnesses, how much sugar do we consume and how much is too much, or how much sugar can we tolerate safely.    Mr. Gary Taubes is the co-Founder of the Nutrition Science Initiative, and a science and health journalist. He is the author of Why We Get Fat and Good Calories, Bad Calories. Gary has been a contributing correspondent for the journal Science since 1993, and has contributed articles as a freelancer to The Atlantic Monthly, The New York Times Magazine, Esquire, Slate, and numerous other publications.  His 1997 book, Bad Science was a New York Times Notable Book and a finalist for the Los Angeles Times Book Awards.  He is the only print journalist to be a three-time winner of the National Association of Science Writers Science-in-Society Journalism Award.  He is the recipient of a Robert Wood Johnson Foundation Independent Investigator Award in Health Policy Research.  Gary received his B.S. in physics from Harvard University, his M.S. in engineering from Stanford University, and his M.S. in journalism from Columbia University.For more information on The Case Against Sugar go to: http://www.penguinrandomhouse.com/books/213737/the-case-against-sugar-by-gary-taubes/9780307701640/.To learn more about the Nutrition Science Initiative go to: http://nusi.org/.  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, voters in seven states legalized marijuana either for medical or for recreational use.  Twenty-nine states have now legalized cannabis for medicinal use (and of these eight, along with the District of Columbia, for recreational use).   Despite growing state legalization, the debate concerning marijuana's health effects continues.  Recently, the National Academy of Sciences (NAS) published an extensive scientific review of research literature published since 1999 to reach nearly 100 conclusions about its therapeutic benefits including in the treatment for chronic pain in adults, chemotherapy-related nausea and vomiting and Multiple Sclerosis-related spasticity.  Despite state approval and demonstrated health benefits, at the federal level, marijuana is still classified as a Schedule I controlled substance (along with, e.g., heroin), and its use illegal.  Mr. Paul Armentano is the Deputy Director of NORML, the National Organization for the Reform of Marijuana Laws.  He is also a faculty member at Oaksterdam University in Oakland, California.  His is the author of over 200 publications including more than a dozen contributions to textbooks and anthologies.  His most recent book-length work is, The Citizen's Guide to State-by-State Marijuana Laws (2015) and he is co-author of the 2013 volume, Marijuana is Safer: Why Are We Driving People to Drink?  Mr. Armentano was the principle investigator for the defense counsel in US v Schweder, the first federal evidentiary hearing since 1973 to challenge the constitutionality of cannabis as a Schedule I controlled substance.  He also served as an expert in a successful Canadian constitutional challenge, Crown v. Allard, preserving qualified patients right to grow cannabis at home.   Among other awards Mr. Armentano was the 2013 Freedom Law School Health Freedom Champion of the Year.  The National Academy of Sciences' report, The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research is at: http://nationalacademies.org/hmd/reports/2017/health-effects-of-cannabis-and-cannabinoids.aspx.For more information regarding NORML go to: http://norml.org/. 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