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10/13/2014

Improving Mental/Behavioral Health Services: A Conversation with Joyce Wale (October 14th)

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Despite recent efforts to improve care delivery for mental health and substance use conditions, for example, passage in 2008 of the Mental Health Parity and Addiction Equity Act, mental health and substance use conditions remain both woefully under-diagnosed and treated.  For example, one recent study of emergency department patients showed psychiatric illnesses were under-diagnosed in 75 percent of patients.   Compounding under diagnosis is the fact that these conditions are highly correlated with common chronic conditions such as heart disease and diabetes - making successful treatment for these illnesses far more difficult and costly.  With major healthcare delivery and financial reforms now being tested under the Affordable Care Act, for example the Primary Care Medical Home and the Accountable Care Organization, there exists today an opportunity to improve substantially diagnosis and treatment for these conditions. 

During this 22 minute podcast, Joyce Wale discusses the prevalence of mental and substance use conditions and the extent to which they're undiagnosed, efforts (motivated largely by ACA reforms) currently underway to improve care (moreover in the primary care setting) for these patients and what good mental and behavioral healthcare looks like.           

For the past 18 years Ms. Joyce Wale has served as Chief Behavioral Health Officer and Senior 0[1]Assistant Vice President of New York City's Health and Hospitals Corporation where she is
responsible for behavioral health services at over 10 acute care hospitals and numerous diagnostic treatment centers and long term care facilities throughout New York City.  Prior to Joyce served as the Regional Director to the Bronx Mental Health Center and prior still worked for the Bureau of Children's Services at the New Jersey Division of Mental Health and Hospitals.  Joyce has received numerous awards over her thirty-five year career as well as has served on an equal number of professional boards and committees related to mental and behavioral health.  Ms. Wale is a Licensed Clinical Social Worker having been graduated from the University of Louisville with a Masters of Social Work.    

09/13/2014

What are "Narrow Networks and "Reference Pricing" and Do They Work?: A Conversation with Dan Mendelson (September 12th)

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Health care insurance plans and policy makers are constantly working toward improving cost management.  Recently two techniques to do so have reemerged in this effort: narrow networks and reference pricing, techniques that have enjoyed success in the past.  Likely the largest (de facto) user of narrow networks is the integrated health plan Kaiser and CalPERS (the California Public Employees's Retirement System) has saved millions in its use of reference pricing.   What are these practices, to what extent are they successful in saving money (and improving health care quality) both for payers and patients and what are the real and/or potential downside risks associated with these practices.  

During this 21-minute podcast Dan Mendelson defines these two cost savings techniques, i.e., how do they work or why they are attractive to plans, do they improve health care quality both within and beyond the ACA insurance marketplaces and how or why these techniques might not be in the best interests of patients (and possibly providers as well).   

Dan Mendelson is CEO of Avalere Health, a DC-based health care research and policy consulting firm.  Dan leads the organization's operations and engages in strategic advisory work for major clients in 1375133683_Mendelson_Dan_233x161life sciences, managed care and in many provider segments.   Prior to founding Avalere in 2000, Dan served as Associate Director for Health at the White House Office of Management and Budget.  Dan also presently serves on the board of two public companies: HMS Holdings; and, Champions Oncology.  He previously served on the boards of Coventry Healthcare and Pharmerica.  Dan is also on the faculty at the Wharton School of Business at the U. of Penn.  He holds a BA in Economics and Viola Performance from Oberlin College and a MPP from the Harvard Kennedy School of Goverment.   

08/07/2014

Medicare Fraud in Home Health: An Interview with Sherill Mason (August 6th)

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Medicare billing fraud is pervasive.  It's estimated at $50 to $60 billion annually or approximately 10% of all of Medicare spending.   While billing fraud is committed in numerous ways from never performed procedures to fake patient care, it's possibly no more prevalent than in home health care, an industry of 12,000 providers whom bill Medicare $18 billion annually.  For example, a 2010 DHHS Office of the Inspector General report found one in every four home health agencies had unusually high billing.   In one example, federal officials in 2012 arrested a Texas-based home health provider accusing him and his colleagues of running a $375 million home health scam.   

During this 21 minute interview Sherill Mason defines home health, discusses how home health is reimbursed, how fraud or improper billing is committed via for example upcoding and over utilization, where, the prevalence of the problem, what CMS is doing to try to curb fraudulent behavior, rule making solutions and whistle blower (qui tam) suits.   

Sherill Mason is currently Principal, Mason Advisors, where she provides strategic planning, Sherill-mason[1]program development and operations analysis for post acute care providers including senior living and nursing home facilities, home health, hospice, long term acute care hospitals, in patient rehabilitation facilities, and long term care pharmacy.  Previously, Sherill she served as a Vice Presient to the Marwood Group, a healthcare industry consultant, as Senior Vice President at Sunrise Senior Living and as a Director at KPMG.   Among other current professional activities Sherill currently is a Guest Lecturer at the University of Pennsylvania School of Nursing.  She received her RN diploma and training at the Englewood Hospital School Nursing and a BA in American Studies from Eckerd College.  

 

07/27/2014

"Get Screened" or Surviving Prostate Cancer (the 2nd Most Deadly Cancer Among Men): A Conversation with Guido Adelfio & Howard Topel (July 24th)

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A few years ago the federal Agency for Healthcare Research and Quality sponsored billboard ads that stating simply "this year thousands of men will die from stubbornness."  The message was intended to encourage moreover middle age men to seek preventive health screening since they are 25 percent less likely than women to visit a doctor in any one year and 30 percent more likely to be hospitalized for a preventable condition.   While prostate cancer is largely survivable, aside from non-melanoma skin cancer, it is the most common cancer among men (most prevalent among African Americans) particularly men over age 50, it usually presents without any symptoms and men "stubbornly" ignore being (routinely) tested.   Nearly 200,000 cases are diagnosed annually causing over 28,000 deaths.  While the value of PSA testing is debated, a digital rectal exam, while incomplete, evaluates the back of the prostate where 85% of prostate cancers arise.   

During this 21 minute discussion Guido shares his personal experience, i.e., how he came to be diagnosed, his treatment (still ongoing) and his efforts to public raise awareness.   Another prostate cancer survivor,  Howard Topel, comments on his treatment and survival - that he owes to hearing Guido's "get screened" presentation.        

For the past 30 years Guido Adelfio has managed his family's custom travel business (Bethesda 0[1]Travel Center, LLC) in Bethesda, Maryland.  After a happenstance conversation with a friend about preventive health screening, Guido scheduled a prostate screening exam.   The exam determined he had Stage IV metastatic prostate cancer.   His diagnosis was determined to be fatal.   Fortunately Guido was able to enroll in a NIH experimental treatment therapy program that saved his life.

 

Topel

Howard Topel is a 66 year old retired communications attorney.  He represented radio and television station owners for 38 years.  Through the early detection of a PSA test, he was diagnosed at the age of 55 with highly aggressive form of prostate cancer.  The early detection saved his life, and he now fully enjoys retirement with his wife Andria and watching his children Fred and Melanie and infant granddaughter Celia grow and thrive.

 

For more on prostate cancer and screeing see the related CDC information at: http://www.cdc.gov/cancer/prostate/

07/08/2014

Policy Options to Mitigate Gilead's $1,000 Hepaitis C Pill: A Conversation with Chris Dawe (July 10th)

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Late last year Gilead Sciences received FDA approval for its Hepatitis C drug Solvaldi.   Hepatitis C (Hep C) affects three to four million Americans and can have serious health consequences.  Gilead priced the drug at $1,000 a pill or between $84,000 and $168,000 for the full, curative treatment (effective in approximately 90% of patients).   However as priced if every Hep C patient received Solvaldi the cost would equal the combined annual spending amount for all drugs sold in the US.

During this 21 minute podcast Chris discusses how and why this drug's pricing effects all of health care financing and delivery, the work the DC-based Campaign for Sustainable Rx Pricing is doing to try to mitigate Solvaldi's cost, when and if similar Hep C drugs entering the market will force Gilead to lower its price and why past efforts to moderate pharmaceutical drug pricing, e.g., authoring Medicare to negotiate drug prices it pays, have proved unsuccessful.   

Through this past April Chris Dawe was the Health Care Policy Adviser for the White House Dawe headshotNational Economic Council.  Previously, Chris served as Director of Delivery System Reform at the US Department of Health and Human Services.  Before joining the administration in 2011 Chris served as a Professional Staff member for the US Senate Finance Committee under Chairman Max Baucus. From 2007 to 2008, Chris served as Health Policy Adviser to Senator John Kerry. Prior still Chris was a Legislative Analyst at Jennings Policy Strategies in DC, while there he served in 2006 as the Deputy Director for Global Health at the Clinton Global Initiative.   Before coming to Washington, DC, Chris was a Market Analyst at Partners Healthcare, Massachusetts' largest hospital system.  Chris is a Massachusetts native and a magna cum laude gratudate of Bowdoin College.  

 

06/24/2014

A Republican Alternative to the Affordable Care Act: A Conversation with James Capretta (June 27th)

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As is well known Congressional Republicans have vehemently opposed the Affordable Care Act (the ACA or Obamacare). House Republicans, for example, have voted an estimated 50 times to replea the law.   Despite their criticisms over the past four years only recently has the party presented anything that approaches a substantive alternative to the ACA. Earlier this year an alternative proposal was presented by Republican Sentors Burr, Coburn and Hatch titled the Patient Choice, Affordability, Responsibility and Empowerment (CARE) Act. 

During this 21 minute podcast Jim discusses several provisions of the CARE plan, i.e., auto-enroll and continuous coverage, coverage limits and mandates, limitations on the tax exclusion, reforms to Medicaid and other issues.          

James C. Capretta is a Senior Fellow at the Ethics and Public Policy Center in Washington, DC, where he provides Untitled-8-300x300-150x150[1]research and analysis on a wide range of public policy and economic issues with a focus on health-care and entitlement reform, US fiscal policy and global population aging.  He also is presently a visiting fellow at the American Enterprise Institute.  Mr. Capretta previously served in senior positions in the executive and legislative branches of the federal government for sixteen years.  For example, from 2001 to 2004, he was an Associate Director at the White House Office of Management and Budget (OMB), where he had responsibility for health care, Social Security, education, and welfare programs.  He received his MA in Public Policy Studies from Duke University and was graduated from the University of Notre Dame with a BA in Government.

Details regarding the CARE Act can be found at: http://www.coburn.senate.gov/public/index.cfm/rightnow?ContentRecord_id=7ef8f0d5-bf56-4ea3-80fe-7f86765a00ca&ContentType_id=b4672ca4-3752-49c3-bffc-fd099b51c966.

 

06/11/2014

How Can We Improve Primary Care: A Conversation with Ann O'Malley (June 10th)

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Primary care is considered the bedrock of healthcare delivery.   Primary care services promotes wellness, prevents disease onset, progression, exacerbation and premature death and moderates the need for higher-cost specialty services.   However, as the recent news about wait times at VA health care facilities demonstrated, the US suffers a shortage of primary care providers.  The current shortage, estimated at approximately 8,000 primary care physicians, is anticipated to grow to 50,000 or more by 2020. 

During this 21 minute discussion Dr. O'Malley explains why primary care is becoming more team based and why that is important, the adoption and use of electronic medical records in the primary care practice setting and the emergence of retail health clinics over the past 15 years and her assessment thereof.    

Dr. Ann O’Malley is a Senior Fellow in the Health Research Division at Mathematica, a social policy AOMalley_bio[1] research organization.   Her research focuses moreover on primary care and quality of care.  Dr. O’Malley has also held faculty positions at Georgetown University Medical Center where she worked on research funded by the NIH's National Cancer Institute and foundations examining the use of evidence-based preventive services in primary care settings.  She serves as a reviewer and has published in the New England Journal of Medicine, Health Affairs, and the Annals of Internal Medicine.  She is a member of AcademyHealth and a fellow of the American College of Preventive Medicine.  Ann earned her MD from the University of Rochester School of Medicine and her MPH in Health Policy and Management from Johns Hopkins. 

For more on retail health clinics see this 2013 Center for Studying Health System Change publication titled "Despite Rapid Growth, Retail Clinic Use Remains Modest," by Ha T. Tu and Ellyn R. Boukus at: http://www.hschange.org/CONTENT/1392/.

 

05/22/2014

Vermont's Move to Single Payer, Universal Health Care: A Conversation with Joshua Slen (May 29th)

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In May 2011 Vermont passed legislation signed by Governor Peter Shumlin creating a single-payer, publicly financed, universal health care system termed Green Mountain Care.  The law recognized health care as a public good much like electricity.  The program, not expected to go into effect until at least 2017, will be defined by an independent board, the Green Mountain Care Board, created to oversee all aspects of the program including rate setting, hospital budget authorization and the regulation of insurance carriers.  The single payer system is expected to increase insurance claims costs but the savings derived from lower administrative costs are expected to result in net savings.

During this 19 minute discussion Joshua discusses how politically Green Mountain Care came about, where presently the state is in rolling out the plan, how the state's insurance marketplace will enable the program, what role private insurance plans will play, how will the program be financed, what skeptics are saying and how Vermont's effors may inform the on-going natonal health care policy debate. 

Joshua Slen served as Vermont's Mediciad Director from 2004-2008.  Presently, or since 2011, SlenJoshua has been an Executive Account Director with Molina Healthcare.  He was a Senior Consultant to Bailit Health Purchasing from 2009-2011 and prior to serving as Medicaid Director he was a Deputy (Budget) Commissioner and a Budget and Management Analyst for the State of Vermont.  Joshua began his public service career working in several Ohio state budget offices from 1991-1999.  He earned his MPA at Ohio State University and his BA in political science at Wittenberg University.    

To learn more about Green Mountain Care go to: http://gmcboard.vermont.gov/

 

05/12/2014

Enrollment Results Under the Affordable Care Act: A Conversation with Brian Webb (May 15th)

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 The ACA's open enrollment period ended this past March 31st. Over eight million Americans signed up for health care insurance.  Of these 2.2 million, or 28 percent, were young adults or between the ages of 18 and 34.  In 26 states and the District of Columbia approximately 15 million adults with income below 138 percent of the poverty level became eligible for Medicaid coverage.  (19 states are not participating in the ACA's Medicaid expansion program and five states remain undecided).  

During this 21 minute discussion Brian explains the National Association of Insurance Commissioner's (NAIC) work, what we know about the 8 million individuals that signed up for health care insurance under the ACA marketplaces, the most popular plan, what "effectuated enrollment" means, how many individuals already had insurance and prospects for 2015 enrollment.

Brian Webb is the Manager of Health Policy and Legislation for NAIC. The NAIC represents the Photoinsurance regulators in all 50 states, DC and the five U.S. territories.  Previously, Brian worked on Medicare and Medicaid policy for the BlueCross BlueShield Association and prior still was the Assistant VP for Legislation for the then-Federation of American Health Systems (FAHS).  Brian began working in DC in 1988 as a legislative aide for Congressman Bill Thomas.  After six years with Mr. Thomas, Brian worked for five years in California Governor Pete Wilson’s Washington office as health and welfare aide and Deputy Director.  Brian was graduated with a MPA from The George Washington University and his Bachelor's degree is from Biola University in California. 

 

05/06/2014

The FDA's Proposal to Regulate E-Cigarettes: A Conversation with David Abrams (May 5th)

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This past April 24th the FDA announced a proposed rule to regulate e-cigarettes.  The FDA is, in part, proposing to ban the sale of e-cigarettes to minors, require manufacturers to disclose e-cigarette ingredients and prohibit manufacturers to claim e-cigarettes are less harmful than tobacco cigarettes without submitting scientific proof.  The proposed rule did not forbid TV advertising and does not ban flavorings such as cotton candy and Gummi Bear.   Are these regulations adequate, or alternatively, even necessary since some claim e-cigarettes are a lifesaver since they can prevent smokers from consuming harmful tobacco.  

During this 23 minute discussion Dr. Abrams, in part, provides a brief overview of the Schroeder Institute's work, evaluates the efficacy of e-cigarettes as an aid to smoking cessation (are they a lifesaver), assesses the FDA's proposed regulations and how they might be improved.   

David B. Abrams is the Executive Director of the Schroeder Institute for Tobacco Reseach and DBA_s.jpgPolicy Studies at the Legacy Foundation.  He is also a Professor in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health and an Adjunct Professor at Georgetown Univeristy Medical Center, Lombardi Comprehensive Cancer Center. Previously, Dr. Abrams directed the Office of Behavioral and Social Science Research at NIH.  He has published over 250 scholary articles and monographs, served as President of the Society for Behavioral Medicine and is the recipient of numerous awards including the Joseph W. Cullen Memorial Award from  the American Society for Preventive Oncology.    He was graduated from the University of Witwatersrand, South Africa with a BS in Computer Science and from Rutgers University with a Ph.D. in Clinical Psychology.

For more on the FDA's proposed rule, see: www.fda.gov/TobaccoProducts/default.htm