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04/24/2019

Are Federal Regulators Panicked Over the Increased Use of E-Cigarettes Among Adolescents: A Conversation With Prof. David Abrams (April 23rd)

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The e-cigarette market, or what the FDA formally terms Electronic Nicotine Delivery Systems or ENDS, has grown since 2004 to approximately 11 million American consumers.  Recent survey data published in February in JAMA has shown use of e-cigarettes (or vaping) among underage youths or middle and high school students has increased significantly since 2011.   Beyond potentially serving as a gateway to the use of combustible or tobacco cigarettes, there is research to suggest nicotine can harm developing adolescent brains and the exhaled aerosol can also pose a public health threat.   Beyond the significant increase in under age use there is also concern recent investments in the e-cigarette industry by tobacco manufacturers, specifically Altria's December investment in e-cigarette manufacturer, JUUL, will result in e-cigarette users transitioning to tobacco cigarettes.  Recently resigned FDA Commissioner, Scott Gotlieb, made e-cigarette regulation a priority throughout his two-year tenure.  The question begged is will FDA's e-cigarette regulatory actions prove productive, will they prevent or inhibit current and future consumers of nicotine from taking up of combustible/tobacco cigarettes and/or allow or encourage current tobacco cigarette consumers to transition to e-cigarettes a far safer product.    

During this 30 minute conversation Professor Abrams critiques the evidence to date that rising use of e-cigarettes among middle and high school students is necessarily a cause for concern, i.e., that e-cigarettes or vaping is a gateway to use of combustible or tobacco cigarettes.  We briefly discuss how underage youths are able to acquire e-cigarettes.  Moreover our discussion focuses on related regulatory actions under the FDA, i.e., is limiting access and use of e-cigarettes or youth addition to nicotine commensurate with the potential massive public health gain.  Are these actions commensurate with the potential to reduce adult combustible cigarette use that remains the leading cause of preventable death in the US at nearly half a million deaths per year (and estimated to kill 1 billion throughout the world this century).  We also discuss Altria (manufacturer of Marlboros) recent $13 billion investment in JUUL, the leading e-cigarette manufacturer or what it may mean, reducing nicotine content in cigarettes, raising the minimum age requirement from 18 to 21 to buy tobacco cigarettes and related issues.    

Dr. Abrams is currently Profess of Social and Behavioral Sciences at New York University.  Dr. Abrams was a professor and founding director of the Centers for Behavioral and Abrams-David-Center
Preventive Medicine at Brown University Medical School.  He then directed the Office of Behavioral and Social Sciences Research at the National Institutes of Health (NIH).  Until 2017, he was Professor of Health Behavior and Society at Johns Hopkins Bloomberg School of Public Health and the founding Executive Director of the Schroeder National Institute of Tobacco Research and Policy Studies at Truth Initiative (formerly the American Legacy Foundation).  Dr. Abrams has published over 250 peer reviewed scholarly articles and been a Principal Investigator on numerous NIH grants.  He is lead author of The Tobacco Dependence Treatment Handbook: A Guide to Best Practices.  He has served on expert panels at NIH and National Academies of Sciences, Engineering and Medicine on Obesity, Alcohol Misuse and Ending the Tobacco Problem: A Blueprint for the Nation. He has also served on the Board of Scientific Advisers of the National Cancer Institute (NIH-NCI) and was President of the Society of Behavioral Medicine.

For information concerning the FDA's regulation of tobacco products go to: https://www.fda.gov/TobaccoProducts/default.htm  

The JAMA studied discussed during this interview, "The Association of Electronic Cigarettes Use with Subsequent Initiation of Tobacco Cigarettes in US Youths," is at: 

04/16/2019

Ann Neumann Discusses Mercy Killings or Suicide-Homicides (April 15th)

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In 2017 more than 47,000 Americans committed suicide.  While suicide rates decreased during the 1980s and 1990s, they have increased by 33% over the past two decades.  Today they are one of the top ten causes of death.  Suicide or suicide-homicides, where the spouse or partner kills their loved one and frequently and immediately themselves, are unsurprising for several reasons.  Among others, the US has no universal long term care policy.   (The ACA attempted to create a voluntary long term care provision, termed the CLASS Act, but it was never implemented having found to be financially non-viable - some would say intentionally so.)  Medicare does not provide long term coverage.  The Medicare hospice benefit is de facto time limited (Medicare hospice providers have an annual per beneficiary reimbursement cap, the only Medicare program to impose a spending cap), one has to meet a poverty threshold to qualify for long term care under Medicaid and commercial long term care insurance, if available, is unaffordable for many seniors.  This last fact is largely explained by the reality that a quarter of Medicare beneficiaries have annual incomes below $15,000 and an equal percent have savings totaling less than $15,000 and over half of these have no savings or are in debt.   Concerning medical aid in dying laws, that present their own limitations, currently only eight states (NJ as of this past week) and DC allow for it. 

During this 27 minute conversation, Ms. Neumann discusses her recent  Harper's Magazine essay titled, "Going to Extremes, Are Homicides Among the Elderly Acts of Mercy or Acts _50A9718_HR_4of Malice?"  The conversation begins with Ms. Neumann's account of Philip Benight and Becky Golden's experience around which the essay is focused.  Ms Neumann moves on to discuss how these acts are addressed by prosecutors, what explains a not uncommon precipitating event, that is terminally ill patients being held in acute or in-patient settings against their will, how and why the health care industry fails to meet the needs of seriously/terminally ill individuals and whether mercy killings can be defined as rational suicides or whether they are acts of mercy or malice.        

Ms. Ann Neumann is the author of The Good Death: An Exploration of Dying in America and a nonfiction contributing editor at Guernica magazine.  Ms. Neumann was a visiting scholar at The Center for Religion and Media at New York University until 2018 and has written about religion and health care for Harper's Magazine, The New York Times, The Washington Post, Virginia Quarterly Review, The Baffler and other publications.  Ms. Neumann is currently working on a book about grief and travel. 

Ms. Neumann's February Harper's Magazine essay is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/

The Kaiser Health News April 9th report noted in the introduction of this podcast and titled, "Lethal Plans: When Seniors Turn to Suicide in Long-Term Care," is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/

04/10/2019

Harold Miller Discusses Improving Medicare's Alternative Payment Models (April 9th)

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Medicare's Fee for Service Alternative Payment Models (APMs), a creation of 2015 MACRA legislation, currently 12 in number with participation largely voluntary, requires Medicare providers to assume financial risk, based on historical spending and quality measurement performance, beyond a "nominal amount."  The flagship APM is the ACA's Medicare Shared Savings Program, more commonly termed Accountable Care Organizations (ACOs).  Though in its 8th year, the ACO program, that currently provides care to over 10 million assigned Medicare beneficiaries, has not produced meaningful savings (estimates are 1 to 2% annually).  Nor have other APMs, largely bundled payment arrangements, produced substantial savings.  The Medicare Advantage program (with one-third of Medicare beneficiaries), defined as administrative pricing, does not formally score savings.  Over the past few years per capita Medicare spending has been limited, however, program growth or beneficiary enrollment (via the aging baby boomer population) is causing Medicare spending, in sum, to increase substantially.  In addition, the soon-to-be-published annual Medicare Trustee's report will show the program will become insolvent within the next few years. 

During this 26 minute discussion, Mr. Miller provides an overall assessment of APM performance to date.  He moreover discusses the shortcomings in APM design or the barriers APM providers face in improving care, e.g., as ostensibly Fee for Service APMs are not reimburse for valuable non-medical services such as social service supports and ways to improve these models.  We conclude the discussion with his views on the ACA-created PTAC (the Physician-Focused Payment Model Technical Advisory Committee), that has reviewed to date over 30 submitted APM proposals, none of which have been chosen by Secretary Azar for testing as a Medicare demonstration.    

Mr. Harold D. Miller is the President and CEO of the Center for Healthcare Quality and Payment Reform.  In this role he has worked in more than 40 states and metropolitan regions to help physicians, hospitals, employers, health plans, and government agencies design and implement payment and delivery system reforms.  He is also currently one of eleven HaroldMillermembers of the PTAC.  He also serves as Adjunct Professor of Public Policy and Management at Carnegie Mellon University.  Mr. Miller has written a number of widely-used papers and reports on health care payment and delivery reform.  He has assisted numerous professional organizations in developing alternative payment models designed to support better care for patients at lower cost.  From 2008 to 2013, Mr Miller served as the President and CEO of the Network for Regional Healthcare Improvement (NRHI), the national association of Regional Health Improvement collaboratives.  He served as a member of the Board of Directors of the National Quality Forum from 2009 to 2015.  From 2006 to 2010, Mr. Miller served as the Strategic Initiatives Consultant to the Pittsburgh Regional Health Initiative (PRHI).  In 2007, he served as the Facilitator for the Minnesota Health Care Transformation Task Force.  In previous positions, Mr. Miller served as the Director of the Pennsylvania Governors Office of Policy Development, Associate Dean of the Heinz School of Public Policy and Management at Carnegie Mellon University, Executive Director of the Pennsylvania Economy League - Western Division, Director of the Southwestern Pennsylvania Growth Alliance and President of the Allegheny Conference on Community Development.

For information on the Center for Healthcare Quality and Payment Reform, go to: http://www.chqpr.org/ 

 
Per my mention of Dr. Robert Berenson's recent (February) essay concerning improving the Medicare Fee for Service schedule, go to: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05411

 

03/20/2019

Interview with America's Health Insurance Plans' (AHIP) CEO Matt Eyles (March 19th)

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Despite gains made under the ACA, health insurance coverage in the US remains fraught with problems.  Over 28 million non-elderly remain uninsured.  Health care spending is extreme.  Health care coverage is the most expensive worldwide in absolute terms and relative to average incomes – despite the fact Americans consume no more or fewer health care resources than our comparative peers.  In 2018, an insurance premium for a family of four was $19,616 or almost one-third of median household income of $61,372.  Several factors explain this.   Among others, while Medicare spending per capita decreased by 1.2% between 2007 and 2014 however for private insurance spendingincreased per capita by 16.9%.  Rapidly rising drug prices, that account for 17% of all national health spending, are two times as much as comparative countries.  Americans also pay substantial health care administrative costs that equaled $259 billion in 2017, or nearly four times average of other developed countries.  (We spend more on health care administration the UK spends on all of health care.)  Relative to outcomes, US life expectancy at birth, that has declined for the past three years (for the first time in a century), is exceeded by 79 countries.  Per a recent Bloomberg health efficiency study, the US ranked 54th out of 56 countries.  Hong Kong, Singapore and Spain ranked 1 through 3, the US fell between Azerbaijan and Bulgaria.

During this 29 minute conversation Mr. Eyles answers whether health care coverage is a right or a privilege, notes AHIP's position on Texas v. Azar, discusses the problem of consolidated insurance markets, i.e., lack of market competition and what can be done about it.  He responds to questions concerning the health care sectors efforts at measuring for value (outcomes achieved relative to spending), the Medicare Advantage (Part C) program, the future of the insurance industry, what it is doing to address or prepare for the health effects of climate change and we conclude with his brief comment regarding Medicare for All. 

Matthew (Matt) Eyles has served as President and CEO of America's Health Insurance Plans or AHIP (the national trade association representing commercial health insurance Downloadproviders) for one year.  Mr. Eyles joined AHIP in 2015 to lead its Policy and Regulatory team and served as Chief Operating Officer just prior to his current position.  Just previously, he served in several senior positions at Coventry Health Care (now an Aetna company) and with Wyeth (now a subsidiary of Pfizer).  He also was employed by Avalere Health, a DC-based consulting firm, where his worked moreover concerned pharmaceutical industry issues.  Mr. Eyles began his career at the Congressional Budget Office where he examined an array of health care policy topics.  Mr. Eyles serves on the Board of Directors of the National Health Council and previously on the Board of the Network for Excellence in Health Innovation (NEHI).  He earned his undergraduate degrees in history and political science from The George Washington University and a graduate degree in public Policy from the University of Rochester. 

For information on AHIP go to: https://www.ahip.org/.

03/01/2019

David Wallace Wells Discusses His Just-Published "The Uninhabitable Earth, Life After Warming" (February 28th)

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For this, my 168th interview, David Wallace Wells discusses his just-published book, "The Uninhabitable Earth, Life After Warming."  Listeners may recall I interviewed Mr. Wallace Wells on August 2, 2017 shortly after his published his July 2017 New York Magazine article by the same title, "The Uninhabitable Earth."  (At: http://nymag.com/intelligencer/2017/07/climate-change-earth-too-hot-for-humans.html.)   (In the recent past, or since last October, I've also interviewed Jessica Wolff, Kris Ebi and Jeremy Hess all on climate change.)   Currently, the earth has warmed to approximately 1 degree Celsius (1.8 F).  Our atmosphere presently contains over 400 parts per million of CO2, more than anytime over upwards of the past 15 million years.  According to the United Nations we are on course to pass 1.5C by 2040.  We learned last October the difference between 1.5C and 2.0C, per the UN Intergovernmental Panel on Climate Change (IPCC), is cataclysmic.  (We are after all the Goldilocks planet.)  As one commenter of Wallace's Wells work has noted, "the impacts of climate change will be much graver than most people realize and he is right." Another stated, Wallace Wells " doesn't sugarcoat the horror."  As I note in the introduction to this interview, younger listeners (say under 40) are particularly encouraged to listen since you will inherit the full consequences of climate change.     

During this 35-minute conversation Mr. Wallace Wells begins by describing what explains the planet's five great extinctions and what effect they had on species survival.  (Scientists believe we are presently experiencing our sixth great extinction.)  Based on his intensive study he offers the most likely
scenario relative to the current and near-term emissions of global warming greenhouse gas emissions.  He discusses current science on global warming feedback loops, e.g., the albedo effect, James Hansen's "scientific reticence" critique, the value of exploiting hope versus fear in addressing global warming, the promise of carbon capture technology or negative emissions technology and creating hydrocarbon fuels from carbon capture and a general assessment of current US politics, including the recent "Green New Deal," in re: remedying climate change/global warming.       

David Wallace-Wells is deputy editor at New York Magazine, where he also writes about science and SWVjwzZE_400x400his  recurring “Tomorrow” column on the future of science and technology, e.g., his 2015 cover story about the epidemic of honey-bee deaths (the first magazine story to put the blame on neonicitinoid pesticides, which is now accepted science).  He joined the magazine as literary editor in 2011, became features director in 2016, and has overseen the magazine’s family of podcasts in addition to his writing and editing.   Before joining New York magazine, David was deputy editor at The Paris Review, where he edited and published writers such as Ann Beattie, Werner Herzog, Jonathan Franzen, Janet Malcolm, among others, and interviewed William Gibson as part of the magazine’s “Writers at Work” series.  He previously served as "The New York Sun’s" book editor.  Mr. Wallace Wells was graduated from Brown University.

Listeners are again encouraged to read the IPCC's recent, "Global Warming of 1.5C," a 32-page summary of the report is at: https://report.ipcc.ch/sr15/pdf/sr15_spm_final.pdf

02/19/2019

ATAP's Dr. Robert Levin Discusses Reforming Drug Pricing Policy (February 18th)

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The administration and the Congress are currently discussing various proposals to reform drug pricing policy.  Drug prices, as listeners are likely well aware, have risen substantially over the past two decades.  For example, between 1997 and 2007 they tripled and currently year-over-year Medicare Part D drug spending is expected to grow through 2026 at twice the 2007 through 2013 growth rate.   The administration formally began its effort last May with the announcement of its drug pricing "blueprint."  The Congress is currently holding hearings, e.g., the Senate Finance and House Oversight committees, on drug pricing.  The administration currently is proposing two drug pricing reforms that would address both Medicare Part B and Medicare Part D drug pricing and the Congress has already introduced several bills to curb drug price growth.     

During this 28 minute conversation Dr. Levin discusses ATAP's mission and funding and ATAP's position on the administration's current proposal to reform Medicare Part B drug pricing via reference pricing or via the use of an international price index.  Dr. Levin discusses moreover the administration's current proposal to reform Medicare Part D drug pricing by eliminating or prohibiting drug manufacturers from paying a rebate to pharmaceutical benefit managers (PBMs) and Part D plan sponsors.  Our conversation concludes with Dr. Levin's comments concerning the long standing debate whether the Secretary of DHHS should be allowed to negotiate Part D drug prices with manufacturers.   

Dr. Robert Levin is the President of the Alliance for Transparent and Affordable Prescriptions (ATAP), President of the Florida Society of Rheumatology and is a practicing physician Levinin Tampa Bay.  He teaches medicine at the University of South Florida and has served as a principal investigator in dozens of clinical trials involving rheumatoid arthritis, osteoarthritis, osteoporosis, lower back pain and fibromylagia.    Dr. Levin is board certified in Internal Medicine with a sub-specialty in rheumatoid arthritis and is a fellow with the American College of Rheumatology and the American College of Physicians.  He earned his medical degree at Hahnemann University in Pennsylvania, did his residency at the Medical College of Pennsylvania and earned his undergraduate degree in chemistry from Oberlin College in Ohio.   

For information on ATAP go to: https://atapadvocates.com/

Concerning the proposed Medicare drug rebate proposal go to: https://www.govinfo.gov/content/pkg/FR-2019-02-06/pdf/2019-01026.pdf.

For an overview of drug pricing issues, see, for example, Hopkins Professor Gerald Anderson's recent Senate Finance Committee testimony, at: https://oversight.house.gov/legislation/hearings/examining-the-actions-of-drug-companies-in-raising-prescription-drug-prices

02/01/2019

Remote Area Medical's Free Health Care Clinics: A Discussion with RAM CEO Jeff Eastman (January 31st)

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Over 40 million Americans live in poverty or upwards of 14% of the population.  Those living in extreme poverty number 18 million and over 5 million live in absolute poverty.  The US also has the highest youth poverty rate among OECD countries.  This reality is made worse by the fact the US is the only highly developed country in the world that lacks universal health care coverage.   Despite passage of the ACA in 2010 that reduced the number of non-elderly uninsured from 44 million to 27 million by 2016, last week Gallup survey data indicated over the past four years seven million fewer Americans have health care insurance.  This finding is not unsurprising considering the administration's ACA regulatory actions over the past two years.  With a significant number of Americans impoverished and a recent decline in those covered, it is no surprise that Americans are forced to seek charity care.   

During this 21 minute interview, Mr. Eastman explains why RAM was founded by Stan Brock in 1985, he describes RAM's upcoming clinic or "expedition" (RAM's 1,000th) this weekend in Knoxville.  More specifically he provides an overview RAM's patient population, the types of medical care RAM provides and who provides RAM care.   He also discusses how clinic sites are selected in the US and overseas and how the organization is funded.   (Over the past 34 years, RAM has served over 785,000 patients, via the volunteer efforts of over 135,000 clinicians and other volunteers, providing an estimated $785 million in free health care.) 

Jeff Eastman is currently the CEO or Remote Area Medical (RAM).  Previously, he spent 28 years employed by Altria sales Eastmanand distribution.  He began volunteering with RAM in 2008 and in 2014 became a full-time employee.  In 2015 he was voted RAM's first ever CEO.  Jeff earned an Associate’s Degree from the State University of New York at Canton, a Bachelor’s Degree from the University of Tennessee at Chattanooga, and a Master’s of Business Administration from Lincoln Memorial University.  Jeff lives in Athens, Tennessee with his wife, Debbie.

For more on RAM go to: https://www.ramusa.org/

01/18/2019

The Current Ebola Outbreak in the Congo: A Conversation with Joseph Lafave (January 17th)

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This past summer the the Democratic Republic of the Congo (DRC) began experiencing its 10th Ebola outbreak.  (The virus, with a mean mortality rate of 50 percent, is endemic in that country.)  To date, the current outbreak has claimed approximately 400 lives.  The World Health Organization (WHO) expects the outbreak to persist for another six months, in part, because current political turmoil in the DRC is effecting the ability of health officials to contain the spread of the disease to neighboring Rwanda, the South Sudan and Uganda.  Listeners may recall the last Ebola outbreak in 2014-2016 in West Africa infected over 28,000 and killing over 11,000.  While vaccines are in development and currently in use in the Congo there is currently no approved or licensed vaccine.

During this 21 minute conversation Joseph Lafave discusses the status of the current outbreak, the role political instability resulting from a disputed December 30th DRC presidential election is playing in containing the outbreak, what support the US is currently providing, how the US's current response compares to its 2014-2016 efforts, what related actions the Congress has taken, progress in developing an Ebola vaccine and the difficulty in fighting a major public health problem in context of political unrest.

Joseph Lafave is a journalist with NewRep and covers infectious disease outbreaks along with military and finance issues.  LafavePrior to is journalism work that included work at the Shreveport News, Mr. Lafave worked as an Environmental Safety and Health Engineer for Lockheed Martin as a Emergency Medical Technician in Leon County, Florida, and as a Safety Administrator for University Health Shreveport.  Mr. Lafave holds a Masters of Science in Healthcare Management from the University of Southern New Hampshire and an undergraduate degree in criminology from Florida State University.      

For more information on Ebola go to, e.g., https://www.cdc.gov/vhf/ebola/index.html.   

Also, please see this January 22nd JAMA viewpoint/editorial, "Ebola and War in the Democratic Republic of the Congo, Avoiding Failure and Thinking Ahead," at: https://jamanetwork.com/journals/jama/fullarticle/2717586?guestAccessKey=c668402c-2993-40a9-95aa-eefd1a0c47f1&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=012219

01/14/2019

After Conceding Health Care Market Consolidation, What's Left is Exploiting Pricing Power (January 14, 2019)

The Trump administration published a lengthy report in December outlining its solutions for creating higher quality health care at more affordable prices.   

This editorial, titled, "The Necessity of Exploiting Pricing Power in a Post-Consolidated Health Care World," by myself and my colleague, John Rother,  is essentially a rebuttal.  It appears today in "The Morning Consult" and is at: https://morningconsult.com/opinions/necessity-exploiting-pricing-power-post-consolidated-health-care-world/

The Trump administration's report, "Reforming America's Healthcare System Through Choice and Competition," is at: https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf.

 

12/19/2018

Essay: "Climate Change Is the Greatest Threat to Human Health in History" (December 19th)

Listeners may be aware this has been a long standing interest/concern of mine, e.g., over the past few months I've posted several related podcast interviews and another essay.  Today, Health Affairs published my essay titled, "Climate Change Is the Greatest Threat to Human Health in History."  Since this simply is a summary of existing report findings, it's largely or only noteworthy in that it is, sadly, the first discussion on this topic by the journal in its 37 year history.  The essay is at: https://www.healthaffairs.org/do/10.1377/hblog20181218.278288/full/.