The Healthcare Policy Podcast ® Produced by David Introcaso

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Over 80 percent of Americans take at least one medication, nearly 30 percent take five or more. That translates to more than 3.5 billion prescriptions written every year making drugs the third highest health care delivery cost after hospital and physician services - amounting to over $250 billion annually. While the benefits of medication therapy are or can be substantial medication errors are among the most common medical error. According to the IOM an estimated 450,000 preventable adverse drug events (ADEs) occur each year in hospitals and another 800,000 preventable ADEs occur in long term care facilities – though these numbers are believed to be under estimates. According to the CDC fatalities from medication errors in 2010 accounted for 35,000 deaths, or more deaths than caused by auto accidents. Medication harm is so pronounced per the Dartmouth Institute for Health Policy there is nearly a 1:1 ratio of drug spending to spending on unintended mediation harm.

Dr. Isetts begins this 20-minute podcast by noting the importance of rethinking or reframing the problem of medication harm by emphasizing the utility developing a true medication use system, i.e., medication therapy management (MTM) and imbedding MTM into all health care delivery settings.  He emphasizes the importance of understanding first why patients do not appropriately follow their medication regimes.  He discusses the pluses and minuses of physician computer order entry systems.  He defines MTM as primarly insuring patients understand the intended uses for their medications, identifying each patient's goals of therapy and insuring patients understand all relevant drug safety issues.   Dr. Issets describes the work that's been done to improve the Medicare drug benefit by aligning it with Medicare hospital and physician care delivery and what can and is being done to reduce drug-related fatalities.                 

Dr. Brian Isetts is Professor of Pharmaceutical Care and Health Systems at the University of Minnesota.  For the past two years he has been a Health Policy Fellow at the Centers for Medicare and Medicaid Services (CMS) working to improve medication adherence.  Dr. Isetts' field of expertise concerns studying the outcomes of medication therapy management services (MTMS) provided within the practice of pharmaceutical care.  Beyond CMS, Dr. Isetts has worked with the American Medical Association, et al. to ensure MTMS by pharmacists.  He was graduated with a BS from the University of Wisconsin School of Pharmacy and with a Ph.D. from the University of Minnesota College of Pharmacy.

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In 1997 the Congress reformed how it pays physicians under Medicare.  The new formula was termed the "sustainable growth rate" (SGR).   The impetus for the reform was to control better Medicare cost growth.   (Medicare physician payments now exceed $100 billion annually).   Largely because of the concern physicians would limit seeing Medicare patients if their Medicare reimbursement rates were cut, the Congress has not enforced the SGR since 2002.   Despite the realization the SGR is unalterably broken, the Congress has been unable or unwilling to amend the law.  Though the upaid SGR tab is presently $138 billion this amount is substantially less than previous calculations that approached  $300 billion (due to a recent decline in Medicare utilization).  With debt and deficit reduction talks expected to re-emerge over the next few months will the Congress finally find the wherewithal to fix the docs?    

The podcast begins with Dr. Berenson addressing the genesis of the SGR and then proceeding to explain why Congress has routinely ignored enforcing the SGR since 2002.  The discussion proceeds to explain why/how doing away with the SGR would currently cost $138 billion.   What effect the SGR has (still) had and what recent MedPAC and a bipartisan House proposal (Reps. Schwartz and Heck) call for in creating a new payment method while offsetting the accumulated $138 billion.  Dr. Berenson next discusses his recent Congressional testimony where he identified ways to improve or mend Medicare fee for service payments, e.g., reducing distortions in, or improving the accuracy of, physician service relative value units (RVUs), improving payment for evaluation and management services.  He argues in sum for global payment or partial capitation.  Dr. Berenson concludes by noting current Congressional bi-partisan support for SGR reform though noting reform proposals would have to identify some mechanism/s to control for volume growth and an indication that quality and efficiency would be improved.           

Dr. Robert Berenson is currently a Fellow at the Urban Institute where his research work concerns health care policy, particularly Medicare.  From 1998-2000, Dr. Berenson was in charge of Medicare payment policy and private health plan contracting in the Centers for Medicare and Medicaid Services (CMS). Previously, he served as an Assistant Director of the Carter White House Domestic Policy Staff.  Dr. Berenson became a Commissioner of the Medicare Payment Advisory Commission (MedPAC) in 2009 and in 2010 became MedPAC's Vice Chair.  Dr. Berenson is a board-certified internist, for the last twelve years practicing in Washington, D.C.  He is Fellow of the American College of Physicians and the author of numerous research publications.  He is a graduate of the Mount Sinai School of Medicine and on the faculty at the George Washington University Schools of Medicine and Public Health and the Fuqua School of Business at Duke.

Dr. Berenson's February 2013 Energy and Commerce Committee testimony can be found at:  http://democrats.energycommerce.house.gov/sites/default/files/documents/Testimony-Berenson-Health-SGR-Medicare-Payment-2013-2-14.pdf

Dr. Berenson's (et al.) March 2013 Urban Institute paper, "Can Medicare Be Preserved While Reducing the Deficit?" is available at:http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/03/can-medicare-be-preserved-while-reducing-the-deficit-.html

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Family caregivers are the most ignored providers of health care delivery despite the fact they constitute 30 percent of the adult population, or are 65 million Americans.  Caregivers are more typically women, over fifty, spending 20 hours a week (over an average of five years) providing care most frequently for a family member typically a parent with dementia.  They are literally the backbone of health care.   Professionally, caregivers, half of whom work full time, incur lost wages, promotions, health insurance, retirement savings and frequently suffer deleterious physical and mental health effects.  Nearly 80 percent of caregivers report needing more help and information with at least 14 specific topics related to caregiving. 

During this 31 minute interview Ms. Mintz discusses the varied and substantive contributions caregivers make and how their efforts can be better supported.

Ms. Suzanne Mintz is the cofounder of the nonprofit the Caregiver Action Network (formerly the National Family Caregivers Association), an organization that provides both direct support for caregivers and advocates for legislative reform  and other policy changes.  Currently Ms. Mintz also serves on the board of National Patient Safety Foundation, the advisory council of the National Transitions of Care Coalition and the advisory board of the Partnership to Fight Chronic Disease.  She was honored for her work in 2006 as one of the first 15 winners of the Purpose Prize.  She has written several books, the latest is A Family Caregiver Speaks Up: It Doesn't Have to Be This Hard and has published numerous articles on and for family caregivers.   She holds a BA in English from Queens College, City University of New York and a MS in Human Ecology from the University of Maryland.

For more on the Caregiver Action Network, see: http://caregiveraction.org/

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Dr. Linda Randolph, President and CEO of District of Columbia's Developing Families Center (DFC),  discusses DFC's unique maternal and child health care model that has drawn international attention for its comprehensiveness and its high quality outcomes.  

During this 23 minute interview Dr. Randolph offers her explanation for the causes of worse maternal outcomes among minority populations, including higher income African American women.  For example, she notes inter-generational factors, the effects of toxic or chronic stress and racism.  She explains the DFC's services beyond nurse midwifery, i.e., pediatric care, the DFC's breastfeeding education and peer support program (African American women are the least likely to breast feed) and the DFC's infant and todler (newborns-to-three-year-olds) child development center or early head  start.  Dr. Randolph defends this programming against criticisms that Head Start program benefits fade as children reach the first and second grades.  Finally, Dr. Randolph emphasizes the importance of a continuum of maternity to early child development care, one that is more holistic emphasizing primary prevention - that is the mission of the DFC.  

(This discussion compliments the Dr. Lubic interview.) 

Dr. Linda A. Randolph is a public health pediatrician with over thirty years of experience serving in Federal, state and local governments, academia, private philanthropy and not-for-profit organizations.  Dr. Randolph, a native Washingtonian and a 20 year resident of Harlem and Albany, NY, is known for her work to eliminate racial/ethnic disparities in health and building upon the strengths of families and communities to effect health policy.  Dr. Randolph was elected to the Institute of Medicine in 2008, she is the recipient of numerous awards in the field of maternal and child health including the American Public Health Association’s 2001 Martha May Eliot Award.  In February Dr. Randolph and Dr. Lubic co-presented the Association of Maternal and Child Health Program's John C. MacQueen Memorial Lecture.  She earned her MD from the Howard University College of Medicine and her MPH from the University of California at Berkeley.

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For decades the US has experienced the highest infant mortality rate of high income countries.  The US also ranks poorly on other birth outcomes such as pre-term births, low birth weight and Caesarean sections.  Infant mortality rates for non-hispanic blacks is twice that of the national average.  In sum, about 25,000 infants die each year in the United States.  During this 37 minute interview Dr. Lubic explains briefly nurse midwifery and its peri-natal goals, she discusses at some length the gradual acceptance of nurse midwives from the 1930s through the 1960s, the Family Health and Birth Center's "care in a social context" and birth outcomes its achieved, i.e., a 66% reduction in both pre-term births and Caesarean sections and a 75% reduction in low birth weights.  

For more on midwifery outcomes see this recently published article in the Journal of Midwifery & Women's Health:  http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12003/full

Dr. Lubic's midwifery career began in 1962 when she was graduated from the country’s first nurse-midwifery program, the Maternity Center Association in NYC.  In 1970, Dr. Lubic became General Director of the Association (now called Childbirth Connection) and opened the first state-licensed birthing center in the country in 1975.  Eventually the Morris Heights Childbearing Center opened in the South Bronx, bringing quality obstetric care to underserved, low-income women.  The moneys she received from a MacArthur Foundation genius award enabled her to replicate her NYC midwifery model in 2000 by opening the Developing Families Center in Washington, D.C.  Among other numerous credits and awards Dr. Lubic was elected to the National Academy of Sciences’ Institute of Medicine and is the recipient of its Lienhard Award.  The American Academy of Nursing, also in 2001, named her a Living Legend.   The American College of Nurse-Midwives honored her with the Hattie Hemschemeyer Award.   In 2006, the American Public Health Association conferred its Martha May Eliot Award and she also is the recipient of eight honorary doctorate degrees.  Dr. Lubic was awarded a nursing degree from the U. of Pennsylvania and was graduated from Columbia University with a Ph.D. in applied anthropology.

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Heart disease is the leading cause of death for women (and men) in the US, accounting for one in every four deaths, however, among women, only 50% recognize heart disease is their #1 killer.  Additionally, almost two-thirds of women who die suddenly of coronary heart disease have no previous symptoms.  (February is American Heart Month.) 

During this 27 minute podcast Dr. Bennett discusses the prevalence of heart disease particularly among women and what are primary prevention measures - that if achieved cardio vascular disease (CVD) could be reduced by over 80 percent.  She explains what accounts for women's limited awareness of CVD, the benefits of cardio protective drugs and statins (to lower cholesterol), female versus male symptomology and the lack of adequate CVD research specific to women.  Dr. Bennett notes the varying reasons why cardio rehabilitation, despite its substantial benefits, is woefully under utilized at rates under 30 percent and what can be done to improve patient utilization or participation.  The interview concludes with bottom line recommendations to avoid CVD and mention of federal programming efforts to reduce CVD via the "Million Hearts" campaign (www.millionhearts.hhs.gov) as well as related work by the American Heart Association (www.heart.org) and WomenHeart (www.womenheart.org).  (The interview failed to discuss or note the association between CVD and mental health or mental illness.  For example, depression even in mild forms can increase CVD risk and that depression is twice as common in women as in men.) 

Dr. Bennett is a Consulting Cardiologist of the Women's Heart Program at the MedStar Heart Institute.  She is the past Director of the Women's Heart Program at The George Washington University Hospital.  Prior to that she was an Assistant Professor in the Division of Cardiology at the U. of Maryland.  Dr. Bennett is on the Scientific Advisory Board of WomenHeart: The National Coalition for Women and Heart Disease, served as Chair for the National Heart, Lung and Blood Institute's Advisory Panel on Women and Heart Disease, she is Past-President of the Greater Washington Area American Heart Association (AHA), a national spokesperson for the AHA and is the author of numerous clinical publications.  She earned her MD degree from the Eastern Virginia Medical School.

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In January 2013 the Institute of Medicine released "Shorter Lives, Poorer Health" a 404-page report that found Americans die sooner, experience higher rates of disease and injury than people in 16 other like high-income countries and that these health disadvantages exist at all ages from birth to age 75. 

During this 22 minute podcast Dr. Steven Woolf, the chair of the IOM panel that authored the report, discusses the pervasiveness of problem or the diversity of health problems that exist across our entire lifespan, how social factors contribute to poorer health and the fact that higher educated and higher income Americans are also too in poorer health compared to their peer group overseas.  Dr. Woolf discusses worse birth outcomes in this country, the importance of antecedents for good health and possibly why the only subpopulation of Americans, those over 80, do comparatively well.  Finally, Dr. Woolf outlines the report's three policy recommendations and identifies a few foreign health care policies, that if adopted, might prove effective in the US.  

Dr. Woolf is Professor at the Departments of Family Medicine, Epidemiology and Community Health at  Virginia Commonwealth University.  In 2001 he was elected to the Institute of Medicine.  He has published more than 100 articles that have focused on evidence-based medicine with a special focus on preventive medicine, cancer screening, quality improvement and social justice.  He is the associate editor of the American Journal of Preventive Medicine and served as North American editor of the British Medical Journal.  He received his MD from Emory and his MPH from Johns Hopkins.

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One of the most discussed provisions of the Affordable Care Act promising to "bend the cost curve" are Accountable Care Organizations (ACOs).   CMS has now selected over 250, moreover physician-led, organizations as ACOs coverning four million Medicare beneficiaries.   ACOs offer the promise of improved coordinated care, care quality and reduced Medicare costs.  During this 27-minute interview Dr. Patel explains the impetus for and creation of Accountable Care Organizations, how rapidly ACOs are growing in number and what are some of the barriers limiting participation in the “shared savings” program.  She explains further how Medicare reimburses ACOs (Type 1 and 2) and the concern among providers regarding the freedom Medicare beneficiaries have in seeking care outside their ACO.  What ACO activity is occurring beyond Medicare or among large physician groups and private insurers, how and why ACOs might be successful and how and why ACOs serve as a catalyst for provider integration (and the downside risks involved with accelerated consolidation) are all also discussed.  The interview concludes with a brief summary of the Brookings-Dartmouth ACO learning network (www.acolearningnetwork.org).

Dr. Kavita Patel is a Fellow in the Economic Studies program and Managing Director for clinical transformation and delivery at the Engelberg Center for Health Care Reform at the Brookings Institution.  She is also a practicing primary care internist at Johns Hopkins Medicine. She served previously in the Obama Administration as Director of Policy for the Office of Intergovernmental Affairs and Public Engagement in the White House.  Dr. Patel also served as Deputy Staff Director for the late Senator Edward Kennedy.  She too has an extensive research and clinical background having worked as a researcher at the RAND Corporation and as a practicing physician in both California and Oregon.  She earned her medical degree from the University of Texas and her masters in public health from the UCLA.

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During this 28 minute podcast Dr. Gruman explains briefly the mission of the Center for Advancing Health.  She then defines what is patient engagement or patient participation by identifying ten categories that add up to 43 specific patient engagement behaviors.  Dr. Gruman then explains why patients are all too frequently unengaged in their own health care due to, for example, low literacy or health literacy, disability, etc.  She discusses how patients can actively engage in their own care using her own experiences as a cancer survivor as an example and what health care providers and regulators are doing to improve patient decision making and patient engagement measurement.  The interview concludes with comments on the work of the ACA-mandated Patient Centered Outcomes Research Institute (PCORI) and the role of family or informal caregivers.  

Dr. Jessie Gruman is President of the Center for Advancing Health, a nonpartisan, Washington-based policy institute dedicated to advancing patient engagement in health care delivery, i.e., the Center advocates for policies and practices to overcome the challenges people face in finding good care and getting the most from it.   Dr. Gruman is also a Professorial Lecturer in the School of Public Health and Health Services at The George Washington University.  She serves on the board of trustees of the Center for Medical Technology Policy and the Technical Board of the Milbank Memorial Fund.   She too is a fellow of the Society for Behavioral Medicine and a member of the Academy of Arts and Sciences, the Council on Foreign Relations and the NY Academy of Medicine.  Among other works, Dr. Gruman is the author of The Experience of the American Patient: Risk, Trust and Choice (Health Behavior Media, 2009).  She was graduated from Columbia University with a Ph.D. in Social Psychology.   

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This 35 minute interview begins with Dr. Lynn describing the work of her Center in addressing how to improve care for the frail elderly.  Dr. Lynn then explains in some detail a three-year quality improvement intervention undertaken by 14 QIOs (Medicare Quality Improvement Organizations) that reduced hospitalizations and re-hospitalizations by almost six percent, i.e., she summarizes today's JAMA-published article she co-authored, "Association Between Quality Improvement for Care Transitions in Communities and Re-hospitaliations Among Medicare Beneficiaries."  Dr. Lynn explains what is "quality improvement" research or moreover how/why it differs from more traditional clinical practice improvement research.  She addresses generalizability in context of QI research, how hospitals may reconcile reduced hospitalizations and rehospitalizations and how this improved care transitions work is being extended via several other federal programs.  Finally, Dr. Lynn discusses how and why we need  to re-engineer health care delivery to create reliable, supportive services, not necessarily medical services, to assist and support an ever increasing population of frail elderly that will experience lenghty periods of disability.  

Dr. Joanne Lynn leads the Center on Elder Care and Advanced Illness for the Altarum Institute.   She previously has served as a consultant to the administrator of the Centers for Medicare and Medicaid Services, as a faculty member of the Institute for Healthcare Improvement, and a clinical expert in improvement for the Care Transitions project at the Colorado Foundation for Medical Care.  She has also been a senior researcher at RAND and a professor of medicine and community health at Dartmouth Medical School and at The George Washington University. 

Dr. Lynn has published more than 250 professional articles. Her dozen books include The Handbook for Mortals, a guide for the public; The Common Sense Guide to Improving Palliative Care, an instruction manual for clinicians and managers seeking to improve quality; and, Sick to Death and Not Going to Take it Any More!, an action guide for policymakers and advocates.  She is a member of the Institute of Medicine and of the National Academy of Social Insurance, a fellow of the American Geriatrics Society and The Hastings Center, and a master of the American College of Physicians.  She received her MD from Boston University.