The Healthcare Policy Podcast ® Produced by David Introcaso

Listen NowIt'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. 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 NowConservative 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. 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 NowUS 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. 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 NowFor 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. 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 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.  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 NowAs 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. 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

Medical devices, everything from tongue depressors to pace makers and defibrillators, are regulated by the FDA.  How competently or effectively the FDA regulates these products has been questioned for several years in part due to the substantial increase in recent years in product recalls, for example the recall of certain hip implant devices.  More specifically is the question whether the FDA's 510(k) process, that reviews or “clears for the market” medical devices, is adequate.  An IOM study of the topic released in July 2011 reached the unanticipated and controversial conclusion that since, in part, 510(k) determines only “substantial equivalence” in clearing devices for the market, i.e., it does not evaluate device safety and effectiveness, the process should be scrapped and replaced.  (Listeners will recall Dr. Zuckerman was interviewed last December about the excessive use of anti-pshychotics in nursing homes.) During this 26-minute discussion, Dr. Diana Zuckerman defines what's meant by "substantial equivalence" and the three FDA classes of medical devices, she assesses what assurance the public has in knowing approved devices are safe, comments on her 2011 findings published in the Archives of Internal Medicine (see the link below) and the IOM report and what progress the FDA has made over the past two years in improving its medical device review process particularly in post-market surveillance.  Diana Zuckerman, Ph.D., has since 1999 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.Dr. Zuckerman's article noted above, "Medical Device Recalls and the FDA Approval Process," can be found at: http://archinte.jamanetwork.com/article.aspx?articleid=227466. 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 NowToday 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/.  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 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-34b6e825c3f0Among 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 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 NowThe 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. 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