The Healthcare Policy Podcast ® Produced by David Introcaso

Listen NowOver the past 20 years Dr. Ronald Epstein has published on the topic he terms "mindful practice."  "Mindful practice," he argues, enables physicians and other clinicians to have heightened self-awareness that allows in turn for greater attentiveness or greater presentness in caring for patients.  It is what makes good providers, he says, great.  During this 26-minute conversation Dr. Epstein discusses his recent work, Attending: Medicine, Mindfulness and Humanity, or moreover what mindfulness is, how it improves patient care and outcomes by, in part, better addressing patient suffering and how it improves as well physician or provider satisfaction.    Dr. Ronald M. Epstein is Professor of Family Medicine, Psychiatry & Oncology at the University of Rochester Medical Center, and board-certified in Family Medicine and Hospice and Palliative Medicine.  He is also the Director of the Center for Communication and Disparities Research and he directs the Dean's Teaching Fellowship program to promote excellence in medical education.  Among other accomplishments, he was named the first George Engel and John Romano Dean's Teaching Scholar at the University of Rochester. National honors include the Lynn Payer Award from the American Academy on Communication in Healthcare for lifetime achievement in research on communication and health and the Humanism in Medicine Award from the New York Academy of Medicine.  Dr. Epstein has been a Fulbright scholar at the Institute for Health Studies in Barcelona, Spain and a visiting scholar at the University of Sydney.  He is a frequent keynote speaker at major national and international conferences on medical education, communication, and mindfulness in health care.  He has published over 200 research articles.  Dr. Epstein graduated from Wesleyan University and Harvard Medical School.  For information on Attending go to: http://www.ronaldepstein.com/.For a complete list of related literature go to: https://www.urmc.rochester.edu/family-medicine/mindful-practice/publications-research.aspx. 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 NowElectronic Health Records (EHRs) were largely adopted after 2009, or after the Congress passed the HITECH Act that appropriated $30 billion in financial incentives for hospital and physicians to migrate from paper to digital records.   In theory the policy made/makes perfect sense.  Adopting information technology/IT would over time create efficiencies, drive better care coordination and overall improve care quality and reduce unnecessary spending or reduce spending growth.  However, for numerous reasons moving to widespread use of EHRs has presented/continues to present numerous challenges and problems, some anticipated and some not, that meant putting patients at risk of medical harm, or essentially swapped out one set of problems (associated with paper records) for another set of problems (associated with EHRs).    During this 29-minute conversation Dr. Troxel offers his view why the medical industry comparatively lagged in adopting digital records, what are the more common EHR design flaws and what kinds of medical errors they cause, how prevalent are EHR-related errors or what did his report, cited below, conclude, why EHR-related errors or harm occur, what is the current status of a proposed federal Health IT Safety Center and what can patients do to improve the safety of their EHRs. Dr. Troxel is Secretary of the Board of Governors and Medical Director of The Doctors Company, a physician-owned medical malpractice insurer.  Dr. Troxel is also Clinical Professor Emeritus at the School of Public Health at the  University of California at Berkeley.  He is past president of the American Board of Pathology and the California Society of Pathologists.  He serves as Chairman of The Doctors Company Foundation and as a member of the Patient Safety and Technology Committees at The Doctors Company.Referenced during the discussion the report, "Electronic Health Record Closed Claims Study," is at: http://www.thedoctors.com/ecm/groups/public/documents/print_pdf/con_id_013553.pdf.The 2011 IOM report, "Health IT and Patient Safety: Building Safer Systems for Better Care," also referenced during the discussion is at:  http://www.nationalacademies.org/hmd/Reports/2011/Health-IT-and-Patient-Safety-Building-Safer-Systems-for-Better-Care.aspx.Information on the Doctors Company is at: http://www.thedoctors.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 NowMr. Eric Weinberg is co-author with College of New Jersey Journalism Professor, Donna Shaw, of the recently published work,  Blood On Their Hands, How Greedy Companies, Inept Bureaucracy, and Bad Science Killed Thousands of Hemophiliacs (Rutgers University Press).  The book details how beginning in the late 1970s through the mid-1980s tens of thousands of hemophiliacs in the US (and tens of thousands more around the world) became infected with HIV via the use of life-saving plasma-based blood clotting medicines.  Manufactures knew plasma-based products transmitted disease, for example, it was well known clotting medicines had infected countless hemophiliacs with hepatitis.  Nevertheless, neither did they cleanse or purify their blood clotting products, technology that was also well known, nor warn patients of adverse side effects.  Federal regulators, similarly, did nothing.  As a result, by the late 1980s the mean life span of a hemophiliac declined by over fifteen years.  While (civil) financial settlements were reached with approximately 6,000 victims or their families and the Congress passed in 1998 legislation, the Ricky Ray Hemophilia Relief Act, that provided additional compensation, the Justice Department chose not to criminally prosecute anyone.      During this 35 minute conversation Mr. Weinberg discusses among other issues how blood plasma was obtained in the 1970s and 1980s, the position manufactures held on the safety of their clotting medicines, a (failed) federal class action effort to compensate hemophiliacs and their family survivors, the influential Institute Of Medicines 1995 report on HIV transmission through blood products, eventual civil settlement with the major manufacturers of these products and how his work representing hundreds of hemophiliac patients and their families over more than a decade affected him.  Mr. Eric Weinberg is the principal of the Weinberg Law Firm, based in New Brunswick, New Jersey, since 1984.  Since founding the firm, Mr. Weinberg has tried approximately thirty jury trials and over two hundred bench trials to verdict.  He has also served as a Visiting Lecturer at Cook College, Rutgers University and has taught Ph.D. candidates at the Rutgers School of Management and Labor Relations.  Previously, Mr. Weinberg worked for the law firm Franchino, Lenahan and Cross and prior still served as Chief of Juvenile Prosecutions and Assistant County Prosecutor in Somerset County, New Jersey.   Mr. Weinberg has been an invited speaker in many forums on topics relating to the prosecution and settlement of serious injury cases, including mass torts and catastrophic injury cases.  Mr. Weinberg is the recipient of numerous awards for his years of community service. He was graduated from Rutgers College in 1977 and from Boston University School of Law in 1980. He is admitted to the Bar of the States of New Jersey and New York as well as numerous federal courts.   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 NowEarlier this year St. Martin's Press published Dr. Haider Warraich's Modern Death, How Medicine Changed the End of Life. As the dust jacket notes, "the mechanics and understanding" of dying, "the whys, wheres, whens and hows are almost nothing like what they were mere decades ago."  Today, eight in ten Americans die at an advanced age, or under Medicare, die in a medical setting after suffering for some while from a chronic, eventually fatal disease or diseases.  If lucky, how Americans die will have been determined, or at least informed, by an advanced directive or like document.        During this 27 minute conversation Dr. Warraich discusses what characterizes "modern death,"  how the 1970s Karen Ann Quinlan case redefined death or dying, the role family caregivers play and the unintended consequences for them in providing a family member care, the limitations of advanced directives and living wills, euthanasia, physician assisted suicide and terminal or palliative sedation and whether "how medicine changed the end of life" has made "modern death" comparatively better. Dr. Haider Javed Warraich is currently fellow in cardiology at Duke University Medical Center.  He was graduate from medical school in Pakistan in 2009 and did his residency in internal medicine at the Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School   He is a regular opinion page contributor to The New York Times, The Atlantic, The Guardian, The Wall Street Journal, the LA Times and has contributed to several academic publications such as The New England Journal of Medicine, the Journal of the American Medical Association, Lancet and Circulation.  During the interview mention is made of a November 28, 2016 Fresh Air (NPR) interview titled, "The Debate Across the Nation Over Death With Dignity Laws," that featured Dr. Warraich along with Dr. Ira Byock.  The interview is at: https://dianerehm.org/shows/2016-11-28/aid-in-dying.  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 NowRecently the National Academy of Medicine (NAM) (formerly the Institute of Medicine) released it's "Effective Care for High-Need Patients, Opportunities for Improving Outcomes, Value and Health."  The report attempts to address a long-standing problem in health care delivery, e.g., five percent of patients ("high-need" patients) account for, or consume, 50 percent of health care resources.  That is if these patients were identified in a more timely manner and better managed overall health care spending could be substantially reduced.   Beyond the complexities involved in managing care for these highly co-morbid patients, the US does a comparatively poor job of coordinating or blending clinical care with non-clinical social service supports these patients need to mitigate their functional status limitations.     During this 28 minute conversation Ms. Abrams discusses among other things the NAM work group's efforts to calculate methods for identifying high-need or super utilizers, or more generally developing patient categorization schemes, the importance of accompanying clinical care with social service supports for those patients with functional status limitations, how/why the 14 profiled providers in the report are able to provide comprehensive quality care for these patients, and the need for improved reimbursement models to allow for or support such care. Ms. Melinda Abrams is currently Vice President at The Commonwealth Fund.  Since 1997 she has worked on, among other projects, the Fund's Task Force on Academic Health Centers, the Child Development and Prevention Care Program and most recently has led the Patient-Centered Coordinated Care Program.  Ms. Abrams has served on numerous national boards and committees for federal agencies and private organizations and as a peer-reviewer for several health care journals.  She is the recipient of the Champion Award from the Primary Care Development Corporation and a Primary Care Community Research Leadership Award from the Patient Centered Primary Care Collaborative.  Ms. Abrams earned her undergraduate degree from Cornell and her M.S. in health policy and management from the Harvard School of Public Health. The NAM report is at: https://nam.edu/effective-care-for-high-need-patients/For more on the Commonwealth Fund's work go to: http://www.commonwealthfund.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 NowApproximately three weeks ago New York Magazine published David Wallace-Well's 7,500 word essay "The Uninhabitable Earth, Famine, Economic Collapse, A Sun That Cooks Us: What Climate Change Could Wreak - Sooner Than You Think."  The article has to date been downloaded over 4.5 million times.  It is the most read essay the magazine has ever published.  The essay begins with, "If your anxiety about global warming is dominated by fears of sea-level rise, you are barely scratching the surface of what terrors are possible, even within the lifetime of a teenager today."  The work goes on to discuss worst case effects by the end of this century should carbon emissions or global warming not be successfully addressed.   During this 36 minute conversation Mr. Wallace-Wells discusses what prompted him to write the essay.  He summarizes his findings, discusses Jim Hansen's concern climate scientists may be undermining their ability to effectively communicate the threat via what Hansen terms "scientific reticence," what, if any, edits he would make after learning the scientific community's response to the essay, and how hopeful he is whether carbon tax, carbon capture and other policies will avoid atmospheric warming by four, five or more degrees Celsius over the next several decades.David Wallace Wells is deputy editor at New York Magazine.  His 2015 cover story about the epidemic of honey bee deaths, the first magazine story to put the blame on neonicitinoid pesticides, is now accepted science.  He joined the magazine as literary editor in 2011 and became features director in 2016.  Before joining the magazine he was deputy editor at The Paris Review where he edited and published writers including Ann Beattie, Werner Herzog and Jonathan Franzen.  Previously Mr. Wallace-Wells served as The New York Sun's books editor.  Mr. Wallace-Wells graduated from Brown University with a degree in history.    Mr. Wallace-Wells essay is at: http://nymag.com/daily/intelligencer/2017/07/climate-change-earth-too-hot-for-humans.html.   The noted Popovich and Pearce article, "It's Not Your Imagination Summers Are Getting Hotter," in the July 28 issue of The New York Times is at:  https://www.nytimes.com/interactive/2017/07/28/climate/more-frequent-extreme-summer-heat.html.Listeners may recall my March 31 interview with Professor Jonathan Patz regarding this past February's "Climate and Health Conference" at the Carter Center and links to two related essays by me posted this past June 13 concerning the medical community's non-response to the the Trump administration withdrawal from the Paris climate accord and one posted May 25, 2016 reviewing the Obama's administration's, "The Impacts of Climate Change on Human Health in the US."   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 NowDuring this 20 minute discussion Dr. Halee Fischer-Wright discusses her recently published work, "Back to Balance, The Art, Science and Business of Medicine."  As the title suggests, Dr. Wright argues the practice of medicine has become dominated by the business and science aspects of care delivery both to the detriment of both the patient and the physician.  Dr. Halee Fischer-Wright is currently President and CEO of MGMA (the Medical Group Management Association).  Prior to, Dr. Wright was a practicing pediatrician and management consultant in multiple industries. Immediately prior to accepting the MGMA position,  Dr. Wright  served as a Chief Medical Officer within Centura Health.  Prior to that she was President of the 680-physician Rose Medical Group in Denver for 12 years. She is the recipient of several national awards for leadership in innovation, healthcare, business and women's leadership.  She is also co-author of the work, "Tribal Leadership."  Dr. Wright earned her bachelor's and medical degree from the University of Colorado and holds a a master's in medical management from USC.  She completed her internship/residency as president of the Pediatric Residency at Phoenix Children’s Hospital/Maricopa Medical Center Program.For information on "Back to Balance," go to, e.g., https://www.amazon.com/Dog-Complex-Bringing-Balance-Backwards/dp/1633310140. 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 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