The Healthcare Policy Podcast ©

Matt Hourihan Discusses the NIH Budget (May 23, 2013)

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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.

Dr. Brian Biles Discusses the Status of Medicare Advantage (May 6, 2013)

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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.

Joan Alker Discusses What's Known About the Quality of Care Provided by For-Profit Medicaid Managed Care Plans (April 18, 2013)

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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.

Dr. Burt Edelstein Discussess Tooth Decay, the Most Chronic Infectious Disease Among Children (April 10, 2013)

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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.

Dr. Brian Isetts Discusses Ways to Improve Medication Therapy (April 3, 2013)

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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.

Dr. Bob Berenson Discusses Possible Remedies for the Infamous Medicare "Doc Fix" (March 26, 2013)

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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

Ms. Suzanne Mintz Discusses the Work of Family Caregivers and the Caregiver Action Network (March 12, 2013)

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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/

 

Dr. Linda Randolph Discusses the Developing Families Center's Maternal and Child Health Care Model (March 7, 2013)

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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.

Dr. Ruth Lubic Discusses Midwifery's Contribution to Improving Healthy Births (March 5, 2013)

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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.

Dr. Susan Bennett Discusses the Prevention and Treatment of Heart Disease, the #1 Killer of Women (and Men) (February, 21, 2013)

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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.