The Healthcare Policy Podcast ® Produced by David Introcaso

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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