The Healthcare Policy Podcast ® Produced by David Introcaso

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Reforming the Physician Self-Referral Law (Stark Law): A Conversation with Amy Hooper Kearbey (July 31st) Aug 01, 2018

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Over the past several years the Congress and Medicare regulators have discussed reforming the 1989 Ethics in Patient Referral Act. Otherwise known as the physician self-referral or more commonly termed Stark law (named after the former California House member, Pete Stark, the initial sponsor of the bill). Stark law is today widely viewed as an impediment to care coordination or payment models that financially incent providers to improve care, care coordination and reduce spending growth, or moreover Accountable Care Organizations (ACOs) and bundled payment arrangements, because as implied the law prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or immediate family member has a financial relationship. Beyond the complexity of the law, its strict liability provision, potential substantial fines imposed under the law, exposure to False Claims liability and Medicare exclusion, there has been increasing sentiment the law generally does not have a place in today's pay for performance or pay for value world. Most recently, this past June 25th DHHS published a Request for Information (RFI) soliciting stakeholders to offer comments on improving Stark law and most recently, or on July 17th, the House Ways and Means heard related testimony.

During this 27 minute conversation Ms. Hooper Kearbey discusses her work related to Stark law, the numerous current problems with the law and areas where the law can be improved. She notes the current DHHS Stark RFI, e.g., to what extent improved transparency about a physician's financial relationships could help improve the law and and makes comment on the use of gainsharing in current pay for performance arrangements.

Ms. Amy Hooper Kearbey is a attorney and partner with the DC-based law firm, McDermott Will & Emery. Her practice focuses on providing Medicare regulatory coverage, coding, reimbursement and compliance as well as advice regarding federal fraud and abuse regulations and clinical research compliance. She is a member of the District of Columbia Bar Association, the American Health Lawyers Association and the National Blood Clot Alliance. She earned her law degree from the Duke University School of Law and her AB from Dartmouth.

The Stark RFI is at: https://www.gpo.gov/fdsys/pkg/FR-2018-06-25/pdf/2018-13529.pdf and related July 17 testimony by four witnesses before the House Ways and Means Committee is at: https://waysandmeans.house.gov/event/hearing-on-modernizing-stark-law-to-ensure-the-successful-transition-from-volume-to-value-in-the-medicare-program/.

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

HCCI's President, Mr. Niall Brennan, Discusses Employer-Sponsored Insurance (July 19th) Jul 18, 2018

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While coverage under the Affordable Care Act (ACA), Medicare and Medicaid enjoy, deservedly, a great deal of discussion and debate, employer-sponsored insurance (ESI) insures approximately 55% of the non-Medicare eligible population, or approximately 152 million Americans. (Medicaid insures 19.5% of the population and Medicare 16%). Larger employers, or those with over 500 employees, are moreover (82%) self insured, 26% of smaller employers are as well. What we know about ESI and what further we can learn is therefore of substantial importance.

During this 25 minute conversation among other comments Mr. Brennan outlines HCCI's research, he explains what drives ESI spending growth, what employers are doing to control prices, he provides an overview of his recent testimony before the Senate HELP Committee and makes comment on data transparency and the employer health insurance tax exclusion.

Mr. Niall Brennen is the President and Executive Director of the Health Care Cost Institute (HCCI) since June 2017. Immediately previously, he served as the Chief Data Officer at CMS. He has also worked at the Brookings Institution, the Medicare Payment Advisory Commission (MedPAC), the Congressional Budget Office (CBO), the Urban Institute and Price WaterhouseCoopers. He has published widely in leading academic journals including The New England Journal of Medicine and Health Affairs. Mr. Brennan received his MPP from Georgetown University and his BA from the University College Dublin, Ireland.

For more on HCCI go to: http://www.healthcostinstitute.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

"Integrating Behavioral Health Into the Medical Home: A Rapid Implementation Guide," A Conversation with the Lead Author, Dr. Kent Corso (June 27th) Jun 28, 2018

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As listeners may be aware well over 50 million Americans suffer from a mental or behavioral health disorder. Less than half of these individuals actually receive treatment. This reality is substantially worse for minorities. For example, African Americans and Hispanic whites are half as likely as non-Hispanic whites to receive treatment. Primary care practices, more than any other setting, are the cite for behavioral health treatment. Despite federal parity legislation to improve coverage for behavioral health diagnoses and improvements under the Affordable Care Act, for example, payment models intended to provide more comprehensive and coordinated care, or to better integrate behavioral with physical healthcare, behavioral health patients remain under-diagnosed and under-treated and primary care practice settings too frequently remain un- or ill-equipped to provide behavioral health services.

During this 26 minute conversation Dr. Corso begins by defining the difference between mental and behavioral health, he explains why there is a shortage of behavioral health clinicians (it's a distribution problem) and moreover provides an overview of his 2016 work, Integrating Behavioral Health Into the Medical Home: A Rapid Implementation Guide, including summarizing healthcare outcomes and spending reductions associated with six IBH examples provided in work. He concludes the conversation by explaining why IBH helps address or mitigate the stigma (still) associated with a behavioral health diagnoses.

Dr. Kent Corso is a licensed clinical health psychologist and a board certified behavior analyst. He is the President of National Capital Region Behavioral Health. He is also an Adjunct Assistant Professor, Department of Family Medicine, at the Uniformed Services University of Health Sciences (USUHS). Dr. Corso has co-authored over 25 peer-reviewed papers on primary care behavioral health. He is, again, the lead author of Integrating Behavioral Health Into the Medical Home: A Rapid Implementation Guide.

For information on Integrating Behavioral Health go to: https://greenbranch.com/store/index.cfm/product/1470/integrating-behavioral-health-into-the-medical-home-a-rapid-implementation-guide.cfm.

For information on National Capital Region Behavioral Health go to: http://ncrbehavioralhealth.com/about.php.

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

The Contributions Made and Challenges Faced By Foreign-Trained Physicians: A Conversation with Mr. Neal Simon (June 12th) Jun 13, 2018

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Research published by the Association of American Medical Colleges (AAMC) this past April estimated the US could see a shortage of up to 120,000 physicians by 2030. AAMC estimates the shortage would be particularly acute in primary care, i.e., upwards of 50,000 primary care physicians would be needed. The primary care shortage is already acute. The federal Health Research and Services Administration (HRSA) estimates there are currently over 5,900 Primary Care Shortage Areas (PCSAs) in the US. The current and future physician shortage would be dramatically worse if not for the approximately 250,000 foreign-trained physicians currently practicing in the US, a disproportionate percent of whom are primary care practitioners and work in under-served communities. Despite the critical role these physicians play (and the quality of care they provide), foreign-trained medical school graduates face substantial barriers, particularly under the current administration, in obtaining residencies, qualifying academically to train and practice in the US, and in obtaining requisite visas.

During this 25 minute conversation Mr. Simon discusses, in part, AUA's programming and student demographics, the contribution foreign-trained students make in the US health care market, again, particularly in primary care and in under-served areas, and the barriers foreign-trained students, moreover foreign-trained and non-US citizens, face in obtaining medical residencies and licensing, moreover in obtaining visas, in order to train and practice in the US.

Mr. Neal Simon is the President and C0-Founder of American University of Antigua (AUA) College of Medicine. After graduating from New York School of Law in 1978 Mr. Simon worked as Assistant Counsel at the New York Department of Education and worked as well in private practice specializing in medical licensure. He taught at the Ross University College of Medicine in the 1990s and served as President of the Ross University from 1992 to 2003. Mr. Simon has been recognized for his work in medical education by the American Association of Physicians of Indian Origin and by Sungshin Women's University. Mr. Simon has served as Ambassador at Large for Antigua and Barbuda and is presently serving on the advisory board at Florida International University and at Manipal University.

For information on AUA's College of Medicine go to: https://www.auamed.org/.

The report by the American Immigration Council's "Foreign-Trained Doctors Are Critical to Serving Many US Communities," noted during this podcast is at: https://www.americanimmigrationcouncil.org/research/foreign-trained-doctors-are-critical-serving-many-us-communities.

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

Oral Health America's Latest "State of Decay" Report: A Conversation with Beth Truett (June 4th) Jun 05, 2018

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Recently, Oral Health America (OAH), published the fourth volume in its series, "State of Decay." The current volume, is subtitled, "Are Older Americans Coming of Age Without Oral Healthcare?" (The series dates back to 2003.) Among other findings, the current report again concludes the state of oral health in this country is, in a word, poor. For example, one-third of older adults have lost six or more teeth, one in five have lost all their teeth (or are edentulous), disparities in oral health remain substantial, and the Medicare program still does not provide routine oral health care despite overwhelming public support and the fact studies show that compared to seniors with chronic conditions do not receive dental care, seniors with chronic conditions that do receive dental care would reduce Medicare program spending.

During this 24 minute conversation, Ms. Truett summarizes OAH's fourth "State of Decay" report, discusses what factors or performance measures explain the variation in oral health care by state (MN, WI and IA score at the top, LA, TN and MS at the bottom), disparities in oral health and oral health care, oral health care work force shortages, and OAH's advocacy efforts to include oral health coverage under the Medicare program.

Ms. Beth Truett is President and CEO of Oral Health America, a non profit dedicated to improving the oral health of all Americans. Ms Truett's has spent the majority of career working with consumer products, pharmaceutical, technology and defense clients to design global business solutions. Ms. Truett holds a Masters of Divinity from McCormick Seminary, a BS from Valparaiso University, and earned her Certificate in Non-profit Management from the Indiana University School of Philanthropy. She is an honorary Fellow of the American College of Dentists and was recognized as an Outstanding Advocate of the Year by Friends of NIH's National Institute of Dental and Craniofacial Research (NIDCR) for her work on older adult oral health issues.

Oral Health America's fourth "State of Decay" report, "Are Older Americans Coming of Age Without Oral Healthcare?" is at: https://oralhealthamerica.org/astateofdecay/.

The Surgeon General's 2000 report, "Oral Health In America," cited during this podcast is at: https://www.nidcr.nih.gov/research/data-statistics/surgeon-general.

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

CMS Proposes Direct Provider Contracting: A Conversation with Mara McDermott (May 30th) May 31, 2018

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This past week public comments were due in response to a CMS Request for Proposal (RFI) that would potentially lead to the agency fielding a Medicare a direct primary care (DPC) demonstration. The demo would pay Medicare physicians directly a predetermined fixed per-beneficiary-per-month fee to provide primary care services to participating beneficiaries. The demo would try to replicate private, commercial DPC contracts physicians have with individuals or through self-insured employers.

During this 27 minute conversation Ms. McDermott discusses, in part, both the potential positives and pitfalls should CMS field a DPC demonstration, whether the model would qualify as an Alternative Payment Model (APM) and whether fielding a DPC model would move the Medicare program closer to premium support.

Ms. Mara McDermott is currently Vice President at McDermott + Consulting, a subsidiary of the DC-based law firm McDermott Will and Emory. (Ms. McDermott is no relation to the McDermott partner.) Previously, Ms. McDermott was employed as Senior Vice President of Federal Affairs at America's Physician Groups (formerly the California Association of Physician Groups, CAPG). Previously still, Ms McDermott was counsel in the health care industry at a firm in Washington, DC. Ms. McDermott received her JD with high honors from George Washington School of Law, her MPH from George Washington University and her BA from the University of California at Davis. (Listeners may recall Ms. McDermott discussed the proposed MACRA rule via a June 14, 2016 podcast.)

The DPC RFI is at: https://innovation.cms.gov/Files/x/dpc-rfi.pdf.

For more on Qliance, the former DPC provider group based in Seattle mentioned during this discussion go to: https://www.seattletimes.com/business/qliance-closes-after-10-year-effort-at-new-approach-to-basic-medical-care/.

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

The Current State of Nursing Care: A Conversation with Dr. Barbara Ihrke (May 16th) May 18, 2018

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Nurses, today numbering over four million, represent the largest segment of the healthcare workforce and deliver the majority of direct patient care. Their role in determining care quality (and safety) cannot be under-estimated. Absent adequate nursing care patients can face a long list of nonfatal and fatal outcomes. The profession however suffers a number of challenges due in part to both an aging population and one that is increasingly co-morbid. For example, not only are hospital patients more sick (i.e., have higher acuity) but because of financial pressures their lengths of stay have decreased. Among other issues facing the profession are the increasing demand for nurses (there's presently a nurse shortage that is only expected to grow worse), the increasing demand for higher educational attainment, increasing administrative burdens (that takes away from their ability to provide direct care), an aging nurse population, career burnout, long standing/persisting scope of practice issues that limits their ability to "practice to the top of their licence" and the lack of nurses in organizational leadership positions.

During this 27 minute conversation Dr. Ihrke discusses nursing education, the nurse shortage, nurse job satisfaction, scopes of practice issues and the under-representation of nurses on hospital and related health care institution boards.

Dr. Barbara Ihrke is currently Vice-President for Academic Affairs, School of Nursing, at Indiana Wesleyan University. She has been on faculty at Indiana Wesleyan University (IWU) since 1994 as Professor, Division Chair, and Executive Director before serving as Dean of the School of Nursing in 2010. Dr. Ihrke's research focus includes trans-cultural experience and spiritual care. Her writings have also covered nursing education, clinical informatics and nurse leadership. Dr. Ihrke overseas work includes serving on an IWU research team that studied Zika on the Island of Gonave, Haiti. Dr. Ihrke received her doctorate from Purdue, her Masters in community health nursing from IWU and her undergraduate in nursing from St. Cloud School of Nursing. She earned another under graduate degree in Missions from Crown College and a certificate in Tropical Medicine.

Cited during this interview are research findings, in part, by the National Academies of Science, see, for example, "The Future of Nursing: Focus on Education (2011): : http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Brief-Education.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

Dr. Tim Williams Discusses the Use of Patient Reported Outcome Measures (PROMs) in the United Kingdom: May 8th May 09, 2018

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Healthcare payment models have been increasingly evolving to include quality performance in determining reimbursement. For example, the Medicare program, including Medicare Advantage, is today littered with quality performance measurement. Measuring quality in healthcare is, however, not as simple or straight forward as frequently assumed. Among other challenges, measures developed to date overwhelming measure healthcare process, not outcomes. Providers typically report on measure sets unique to each payer causing them undue collection and reporting burden, which measure is attributed to which provider can be or is an inexact and under pay for performance agreements comparatively higher quality scores does not always translate to comparatively greater financial reward. Because of these problems and related others, Patient Reported Outcome Measures (or PROMs) are increasingly seen as a solution. They reduce provider reporting burden, they are largely outcome based, are more responsive to patient care goals, help to better engage or activate the patient, PROMs data can be, or is, reported real time and can enable more efficient and more timely care delivery.

During this 27 minute conversation Dr. Tim Williams discusses how/why My Clinical Outcomes was formed, how PROMs measures are used in the clinical practice setting and for primarily what disease conditions, what opportunities or advantages they present to improve care delivery and outcomes, the extent to which they've been adopted in the UK, and what might American payers and providers learn from My Clinical Outcomes' PROMs experience.

Dr. Tim Williams is currently CEO (and cofounder) of My Clinical Outcomes a London-based, an IT company that automates for health care providers, via a web-based platform, the collection and analysis of Patient Reported Outcome Measures (PROMs). He founded My Clinical Outcomes in 2011 to help bridge the gap in patient-centered care data available to inform clinical care. Previously, Dr. Williams worked as a physician for the UK's National Health Service and as a healthcare management consulting also for the NHS.

For more information on My Clinical Outcomes go to: http://www.myclinicaloutcomes.com/.

See also this recent April 19 essay by Dr. Williams and myself in The Health Care Blog, "Patient Reported Outcome Measures: Progress Across the Pond," at: http://thehealthcareblog.com/blog/2018/04/19/patient-reported-outcome-measures-progress-across-the-pond/.

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

Kip Sullivan Discusses the Flaws and Future of the Medicare ACO Program (April 17th) Apr 18, 2018

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The Medicare Shared Savings Program's Accountable Care Organization (ACOs), created by Section 3022 of the 2010 Affordable Care Act constitutes the flagship Medicare pay for performance (P4P) program. Though there are other P4P (also termed pay for value) models, for example two bundled payment models (Bundled Payments for Care Improvement and Comprehensive Care for Joint Replacement), they are short-lived CMS demonstrations. If the federal government is to bend the Medicare spending curve or make the program more financially sustainable it will likely be due moreover to the success of ACOs. Though provider participation in ACOs is substantial, this year there are 561 ACOs providing care to 10.5 million Medicare beneficiaries, the program has to date achieved marginal success. Over four performance years (2013-2016), ACOs have saved substantially less than one percent of annual Medicare spending (now over $700 billion) - which is why the DHHS Secretary Alex Azar recently admitted candidly ACO performance has been "underwhelming" and "lackluster." Even before the Medicare ACO program formally began there have been questions and criticism about the model's design. Perhaps no one has written more about the model's flaws than Kip Sullivan.

During this 32 minute conversation Mr. Sullivan discusses the genesis of ACOs including results from its predecessor, the Physician Group Practice demonstration, assumptions made in the the design of the model, e.g., the relationship between cost and quality and the effectiveness of financially incenting physicians, and moreover the problem of addressing care quantity instead of pricing. In sum, Mr. Sullivan argues the Medicare ACO model is fatally flawed and will not achieve meaningful success.

Mr. Kip Sullivan is currently a member of the board of the Minnesota chapter of Physicians for a National Health Program. Mr. Sullivan began his career as a staff attorney for the New York Legal Aid Society and as a researcher for Citizens Action League in California. Form 1980 through 2000 he researched universal health insurance and a single payer system for Minnesota COACT (Citizens Organized Acting Together). He also served as a consumer representative on the Minnesota Governor's Health Plan Regulatory Reform Commission in the 1980s. From 2000 to 2007 Mr. Sullivan was a health system analyst for the Minnesota Universal Health Care Coalition. Mr. Sullivan has written over 150 health policy articles for the American Journal of Public Health, the Journal of Health Politics, Policy and Law, the LA Times, The Nation, The New England Journal of Medicine, The New York Times, and others. He published 2006 "The Health Care Mess: How We Got Into It and How We'll Get Out of It." Mr. Sullivan earned his undergraduate degree from Pomona College and his law degree the Harvard School of Law.

Mr. Sullivan's latest essay, "Curb Your Enthusiasm," is at: http://thehealthcareblog.com/blog/2018/04/16/curb-your-enthusiasm/.

The Lawton Burns and Mark Pauly essay titled, "Transformation of the Health Care Industry: Curb Your Enthusiasm," in the the recent Milbank Quarterly, that is noted during this discussion is at: https://onlinelibrary.wiley.com/doi/full/10.1111/1468-0009.12312.

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

Pediatrician Dr. Niran Al-Agba Discusses Gun Violence (Via In Part Her Columbine Experience) (April 12th) Apr 13, 2018

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Including the February 14th shooting at Marjory Stoneman HS in Parkland Florida that killed seventeen students and teachers, there have now been over 130 shootings in elementary, middle and high schools in 43 states since 2000 and another 58 shootings in US colleges and universities. Gun violence in this country is in a word, obscene. It is, for example, 96 times higher than in Japan and 55 times higher in the UK. It is largely explained by gun prevalence. The US accounts for approximately five percent of the worldwide population, however, Americans own 42 percent of the world's guns. What also explains gun violence is a federal policy that has persisted since 1996, the so called Dickey amendment, that prohibited federal funding to conduct gun violence research. (Since 1996 there have been approximately 600,000 gunshot victims.) The recently passed omnibus spending bill (that funds the federal government through this fiscal year) included accompanying report language stating the Dickey Amendment does not prevent federal agencies, moreover the CDC, from conducting gun violence research. However, the spending bill included no money to conduct gun violence research.

During this 28 minute conversation Dr. Al-Agba discusses her experience treating survivors of the 1999 Columbine High School shooting (that killed 13 and wounded 21), why the physician community has been hesitant to discuss gun safety with their patients and what can be done by the physician community to reduce gun violence, e.g., participating in student threat assessments.

Dr. Niran Al-Agba is an a board certified pediatrician in private practice in Silverdale, Washington and is affiliated with multiple hospital in the region including Harrison Medical Center and MultiCare Mary Bridge Children's Hospital and Health Center. She is a her family's third generation physician practicing in the Kitsap County. She is also an Assistant Professor on at the University of Washington School of Medicine and is a lead instructor at Seattle Children's Hospital for the past 15 years. She has been voted the Best Doctor in Central Kitsap for three of the last six years. She is the independent practice editor for the Health Care Bog, published on KevinMD and RebelMD, and pens a monthly column for her local newspaper, The Kitsap Sun. Dr. Al-Abga received her medical degree from the University of Washington School of Medicine, did her residency at the University of Colorado School of Medicine/Denver Children's Hospital.

Dr. Al-Abga's March 10th essay titled, "I Treated the Columbine Kids, I Have Not Spoken Before," noted during this discussion is at: http://thehealthcareblog.com/blog/2018/03/10/i-treated-the-columbine-kids-i-have-not-spoken-out-before/.

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

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