Dr. Thomas Lee, CEO of Partners Community Healthcare, discusses reforming the health care delivery system.

Mark Masselli: This is Conversations on Healthcare. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, the healthcare debate is anything but tame these days.
No one thought it would be easy, but I don’t think anyone expected it to get so heated.
The President is trying to move past the heat and shine the light on finding a bipartisan
solution. He has invited Democratic and Republican leaders to a summit on February 25,
there is a hope he can find a solution for our nation’s crisis.

Margaret Flinter: Well Mark it does sound hopeful, but I also think it's a pretty high
stakes meeting. In preparation for it last Friday, the President’s Chief of Staff Rahm
Emanuel and Secretary of Health and Human Services Kathleen Sebelius published the
invitation they have sent to attendees of the bipartisan meeting and they said in their
letter, look when it comes to healthcare the status quo is unsustainable and acceptable.

Mark Masselli: Speaking of unsustainable, they cite Anthem Blue Cross of California’s
proposed 39% rate increase. It certainly underscores what advocates of Health Reform
have been saying, we can't sustain the current cost structure.

Margaret Flinter: Even while they are looking at those issues in trying to push reform
forward, it seems like the retrospective analysis has already begun. I was really
impressed by a piece in the New York Review of Books by Elizabeth Drew titled “Is
There Life in Health Care Reform.” She points to the poor planning on the part of
Democrats leading up to Scott Brown winning the Massachusetts Senate seat which was
a huge blow for Democrats and for Health Reform. And she said at the point that that
happened the bills were more than 95% alike after the intense negotiations of early
January, we were that close and it slipped away.

Mark Masselli: I really like Drew’s article and she is a great writer and thinker on these
issues of politics, but I wonder if they were really 95% close to finishing this. And she
laid there the Republicans’ strategy of denying, delaying, and ultimately killing the bills.
Negotiations continued after it was clear Republicans didn’t want to enter into anymore
discussions, but the White House thought the bipartisan support would gain some public
backing, so Senate Chairman Max Baucus spent the entire summer trying to get
Republicans on board. And by the time the Senate finally passed the bill on Christmas
Eve, no one seemed to have noticed that race in Massachusetts to fill Senator Ted
Kennedy’s seat was slipping out of their reach as Senator Brown’s opponent Martha
Coakley’s campaign was imploding.

Margaret Flinter: Mark, I think there will be an enormous list of what-ifs this one. And
Drew said that a senior democratic house strategist told her, “if we have known that

Massachusetts was in play, we would have worked right through the Christmas break and
we might well have been done before that election ever happened.

Mark Masselli: You know we are feeling the effects of not having former Senate
Majority Leader Tom Daschle in charge. We are going to rule the day that he was not
appointed to his position as the _______3.00. And there is a lot of blame to go around for
that including Senator Daschle himself, but we have to move forward and find a way to
th
achieve some bipartisan support and let's hope they can do it on the 25 .

Margaret Flinter: While we are waiting to see what each camp proposes for discussion
during that live debate next Thursday, let's shift our focus away from politics and turn
towards some innovations in healthcare that are really making progress. Our guest today
is Dr. Thomas Lee Professor of Medicine and Health Policy at Harvard University and
CEO of Partners Healthcare, the largest healthcare system in New England. He is also a
cardiologist. Dr. Lee has applied his research and quality patient outcomes to Partners,
where his mission is on organizing healthcare information and the healthcare providers
into one team base. Dr. Lee is also going to talk about the reality of Health Reform in
Massachusetts. The plan is getting more attention as a model for state healthcare as
national reform is put on hold.

Margaret Flinter: And no matter what the story, you can hear all of our shows at our
website www.chcradio.com . You can subscribe now to iTunes to get our show regularly
downloaded or if you want to hang on to our every word and read a transcript of one of
our shows, come visit us at www.chcradio.com .

Mark Masselli: And speaking of every word, as always, if you have feedback, send us an
e-mail online at www.chcradio.com , we would love to hear from you. And before we
speak with Dr. Lee, let’s check in with our producer Loren Bonner with headline news.

Loren Bonner: I am Loren Bonner with this week’s headline news. Anthem Blue Cross
has agreed to postpone their 39% rate hike for insurance policies. The increase that was
st
supposed to take effect on March 1 is now being delayed until May. Nearly 700,000
Anthem customers in California receive notices of increases that average 25%. About a
quarter of them are seeing leaps of 35% to 39% the company said, at least four times the
rate of medical inflation. Democrats are using the grim news to push their stance that
Healthcare Reform must move forward. It's good timing on their part leading up to the
televised bipartisan conference on healthcare next Thursday, when 20 Democrats and 17
Republicans from the House in Senate will discuss Healthcare Reform. In a letter the
attendees of the meeting Health Secretary Kathleen Sebelius and the President’s Chief of
Staff Rahm Emanuel noted that when it comes to healthcare the status quo is
unsustainable and unacceptable. In particular, they cited the case of Anthem Blue Cross.
The situation with the Californian insurer has no doubt shifted the focus in Washington
from the need for universal coverage to the need for serious cost control. The letter also

said that the text of a proposed Health Reform package will be posted online before the
meeting on February 25. They write in the letter, this legislation will put a stop to
insurance company abuses, extend coverage to millions of Americans, get control of
skyrocketing premiums and out-of-pocket costs and reduce the deficit.

The new February edition of Health Affairs looks into e-health and highlights some
interesting communication technologies that are being used to transform healthcare in
developing nations. Some important findings include the only fully electronic touch-
screen system in Malawi for more than 35,000 HIV patients. Patient tracking has been
beneficial for HIV patients in Africa since 76% of them don’t make a follow-up visit.
The Malaysian systems that texted patient reminders showed a significant decrease in
missed visits. Studies have shown through and through that texting is a great way to
harness new communication technologies for a greater good, especially when it comes to
daily medication reminders. Dr. Sanjay Jain from the John Hopkins Hospital said that
this technology is especially perfect for patients with tuberculosis. TB patients usually
have to take medication for months to cure their condition. Dr. Jain notes that most cases
of TB worldwide are found in developing nations that’s also where texting is most
popular.

Today, we are happy to have Dr. Thomas Lee as a guest on our show. Dr. Lee is a
Professor of Medicine and Health Policy at Harvard and CEO of Partners Healthcare, an
integrated healthcare delivery system founded by Brigham and Women’s Hospital and
Massachusetts General Hospital. Dr. Lee has applied his research on patient outcomes
and the development of improving the quality and efficiency of care in a profound way.
Partners, a unique team-based network of primary care physicians, community health
centers and community hospitals as well as specialty facilities has been a successful
example of effective organized healthcare. A book Dr. Lee co-authored last year called
Chaos and Organization in Health Care argued that this kind of organization is key to
improving healthcare systems overall. He says that in order to make sense of continuing
medical advances, doctors, hospitals and other providers need to form large tightly
integrated clinical groups. Some of the solutions Dr. Lee proposes include electronic
medical records and information systems for sharing knowledge and disease management
programs to coordinate care for the sickest patients. Dr. Lee can also speak from
experience as a practicing cardiologist and internist, he brings relevant knowledge from
the clinical side of medicine into managing a healthcare organization. He knows what
doctors are up against, yet he remains positive that improvement will happen down the
road.

Mark Masselli: This is Conversations on Health Care. We are speaking today with Dr.
Thomas Lee, Professor of Medicine at Harvard Medical School and Professor of Health
Policy and Management at Harvard School of Public Health. He is also CEO of Partners
Community Healthcare. Welcome, Dr. Lee. Dr. Lee, you are practicing cardiologist and
your research interests have focused in on improving quality care. A recent article on the

Wall Street Journal argued that comparative effectiveness research part of both the House
and Senate Reform Bills are yielding findings that are not always easy to incorporate into
the practice of medicine. The article gave the example of the COURAGE Study which
found that one of the most common cardiac procedures, stenting, and I think our Former
President Bill Clinton just had two of those stents put in the other day, but they did not
yield the additional benefit to the standard cocktail of medications. And after all the news
of the study die down, the use of the procedure soon began to rise again, what’s the
problem there? Is there a problem with the comparative effect in this research or with
changing long established habits?

Dr. Thomas Lee: Well, the Wall Street Journal might have been upset about the stents
going to a Democrat instead of a Republican, but that’s one of speculations. I think that
it's a very important question. I actually think that we know a lot about what works and
doesn’t work, our problem is how we use that information and I think that patients as
well as physicians are overwhelmed with a flood of progress and the result is we are not
that reliable about matching patients to resources because very often, there are so many
options, we don’t know what to do.

Margaret Flinter: Dr. Lee, virtually every state is looking at how to evaluate quality and
patient outcomes. But what are those key measurements of quality and patient outcomes
that you think are most important, particularly in primary care, but also for hospitalized
patients and how do states get that data given that most of it seems to reside with a
variety of different insurance payers?

Dr. Thomas Lee: You know I think the irony is that, well not the irony, the harsh reality
is we are not there yet with any of these measures, we are not really capturing the things
that really matters to patients yet, I think we will get there. But we are defining our
current measures by what our fragmented healthcare system can do was under the control
of a hospital, was under the control of a doctor and very often that’s not what matters to
patients. What matters to them are their outcomes and their outcomes include what are
the chances of survival, what are chances they will feel better, but also what are the
chances they will be re-admitted, what are the chances that they will have an infection,
what are the chances that their informational needs will get met. Those kinds of
outcomes aren’t captured right now. I think we will get there, but it will take providers
getting organized, so they can get the information and then reporting it and managing
their performance so that they actually get better.

Mark Masselli: You are also the CEO of the Partners Community Healthcare, the
integrated healthcare delivery system established by Brigham and Women’s Hospital,
Mass General, and their parent company Partners Healthcare System. It seems like your
organization is the accountable-care organization that's focusing much attention. How do
you see accountable-care organization making a contribution to both improved quality
and controlling cost in United States?

Dr. Thomas Lee: Well you know I have been working all day long about this and
working toward it. The question that we should be asking is, are these organizations
going to be greater than the sum of their parts. I think that doctors already work hard in
their offices and hospital personnel do their best, but can these accountable-care
organizations create value for patients that the pieces cannot. So the kind of things that
we are interested in at Partners are, can we say to patients you know there aren’t going to
be any drop-balls as you move among our various provider entities and physicians that
they will know what each other have said you, you know we are not going to have
confusion of what drugs you are allergic to and what medications you should be on.
What we want to be able to say is that we won’t have bounce back, you won’t be
readmitted unnecessarily or bounce back to the emergency department because of lack of
coordination of care. And what we really want to is you know if you are sick, we are
going to get give you to someone who can help you reliably and quickly. Now I am
being honest with you, I can’t say that now because we are only beginning to work on
measuring these things and then managing them, but I think we can. It takes hospital and
doctors and other providers working together though to make real progress on those kinds
of goals

Margaret Flinter: We are speaking today with Dr. Thomas Lee, Professor of Medicine at
Harvard Medical School and Professor of Health Policy and Management at the Harvard
School of Public Health. Dr. Lee maybe you could tell us a little bit about the program
launched by Partners called High Performance Medicine, you have specifically addressed
areas as I understand that where improvement and performance was needed maybe some
of those that you spoke about a moment ago, but tell us about those areas, how they have
been improved and can you share with us a little bit of the strategies and the resources
that you needed to make this happen.

Dr. Thomas Lee: Sure, you know I think that we do have a nice program that I am proud
of called High Performance Medicine and it was aimed at trying to get our system in this
to really come to life, that is not just rely upon people working harder and longer, but to
try to improve the way they work together. So one of the most fundamental steps was,
well before the President made it a focus, we made electronic record adoption a focus,
because you have got to get everyone on the same information platform so they know
what each others are doing. And first we use carrots and then we you use sticks, I mean
first, we offer financial bonuses to people who would adopt our electronic record. But
then at a certain point when we pass the tipping point, we went to sticks, we said you
know what, you are not going to be in our network, you are not going to be on our
contracts anymore after a certain date, if you haven’t adopted the record. So we actually
threw about 180 doctors, because they just didn’t want to go there, but we had to use
more than bonuses more than peer pressure to get to where we need to be, which is
everyone using a platform where we know what each others are doing.

Mark Masselli: You know you have been talking about the way the parts of the system
work together, you have also stated the plan to focus your research more in the coming
years in the community setting or across the continuum of care as opposed to within the
hospital, why that focus?

Dr. Thomas Lee: Well you know fortunately people are outside the hospital most of the
time and we want them to stay healthy and stay outside the hospital, but to do that, it
actually requires you know the continuum to work as one system. Like an example of
something that’s both fun and difficult, but, we set up a nice heart failure program to try
to keep heart failure healthy from being readmitted. But our doctors they just didn’t think
of it. We would send them e-mails saying this is Jones who is a good candidate for the
heart failure program, can we refer her and only 20% of the time would they answer the
e-mails because they are overloaded like everyone else in society. So what we went to a
couple of years ago is, I think you may know the book Nudge by Richard Thaler and
Cass Sunstein about to choice architecture. You know we took their advice and we made
it an opt-out program which is we would just send doctors a message saying, we think
your patient is right for the heart failure program, let us know if you disagree. And if we
hadn’t heard from them in a couple of days, they were referred into the heart failure
program. And with that, we have kind of real drop in our readmissions and admissions
for heart failure. So this kind of, it’s not so much community, it's really system-wide
choice architecture and creation of systems. This is both the really fun and exciting part,
but you know it’s difficult change at the same time.

Margaret Flinter: Dr. Lee, it's not everyday that a cardiologist has an award for
excellence in primary care named after them and there is the Thomas Lee Award for
Excellence in Primary Care at Harvard. And certainly the experience in Massachusetts
with universal coverage has been instructive to all of us and we are very aware of all of
the cost control issues you face. Do you have any data from your work that looks at the
issue of cost control where you have really been able to quantify the impact of excellent
primary care or high performance primary care and controlling cost?

Dr. Thomas Lee: Well you know I think I have got good news and bad news for you,
which is that, we really have been working at cost and organization of care to lower cost
a lot here in Massachusetts. I mean I can tell you that I have like 400 active patients, I
am part-time clinician, every single one has insurance now, and I take care of patients
from Roxbury and Mattapan, poor patients, so we are delighted and we are proud of
Massachusetts Healthcare Reform. But we are really worried about the cost, so we can
make it sustainable. I think that payment reform can make healthcare better, but it is not
going to solve all of our problems financially. We will provide more value, but I think
that cost can be reduced by payment reform models by only 3% or 4%. I might be
wrong, I hope I am wrong, I hope it is more, but I don’t think we should expect better
care alone to solve our financial challenges, so they are going to have to be other policy
issues that get addressed to definitely address cost issues.

Mark Masselli: You know it’s excited to hear that your entire panel has a health
insurance. Do you think the Massachusetts Health Reform has been effective and do you
think other states could do something on a similar level if Healthcare Reform Legislation
is not passed at the federal level?

Dr. Thomas Lee: You know I think it can and I think that the Massachusetts way is, I
think the good one, and I think that you have got to have the individual mandate, because
otherwise you know people are going to move in and out of the insurance pool, whenever
they feel sick, and that will make insurance very expensive for the people who are staying
in the pool. And I think you have got to have the employers brought in and you have got
to reduce cost shifting from commercial to government insurers, but then you have all got
to work on cost. And I can tell you, I think people should be realistic in there is no
solving to cost problem, it's a problem you manage, not a problem you solve. You know I
always say to my colleagues costs are the headaches that we are going to wake up to
everyday for the rest of our careers, the pounding headache and we are never going to
solve it, but we just have to struggle to deal with it. One thing we feel in Massachusetts,
which I think is very important for people to know is that we don’t think you can deal
with cost until you’ve got everyone covered, because otherwise it's too easy to deal with
cost the lazy persons way, which is you un-insure people and under-insure people. But
once you basically committed yourselves to covering everyone then with the gun held to
your head, you start dealing with the very difficult issues of, okay how are we going to
make healthcare affordable.

Margaret Flinter: Dr. Lee you have your finger on the pulse of healthcare here in the
United States and I am betting around the world as well. What do you see when you look
around the country in the world that excites you in terms of innovation in healthcare and
who should our listeners at Conversations be keeping an eye on?

Dr. Thomas Lee: Well you know I am Chinese and you can tell that, but I am and there is
a Chinese saying, from Confucius where, if there are three people on the street in front of
you, any two of them could be your masters, your teachers. And so what I really believe
is that there is something to learn from all sorts of organizations around the world. I
mean to give you a couple of things I am jealous of, like if you go to websites on the
National Health Service in UK, you can look at the percentage of patients with breast
cancer who are beginning treatment within one month of diagnosis. You can look at the
percentage of patients who have less than two weeks from referral from their general
practitioner to a cancer specialist for breast cancer and every other type of cancer. Now, I
have no idea how quickly patients with cancer get connected to treatment specialists in
our system and I don’t think anyone else does in United States, but that’s the kind of
saying that I think patients care about. So there are many examples like that out there,
where we have things to learn from other healthcare systems that have been addressing
the system challenge more quickly than we have.

Mark Masselli: We’ve been speaking today with Dr. Thomas Lee. Thank you for joining
us today.

Dr. Thomas Lee: My pleasure.

Mark Masselli: Each week, Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. This week’s bright idea focuses
on a group that has some innovative ideas about how increasing the communities’ social
cohesion can have a positive health effect for its members. It sounds almost intuitive, a
closer community is happier and healthier, but Robert D. Putnam, a Professor of Public
Policy at Harvard University has devoted the last two decades to exploring the nuance of
this phenomenon. In 1995, Putnam founded the Saguaro Seminar to study the ways
people make connections or fail to do so within their communities and social economic
and health affects of those interactions. This project emerged at a time when Putnam felt
as though interpersonal connections were breaking down among Americans in the advent
of the more individualistic internet age. The seminar’s findings illustrate that increased
civic engagement from instituting a weekly family game night to volunteering at the local
food pantry has tremendous positive affect for the individual in the community. These
benefits include increased safety and education and decreased crime and socioeconomic
disparity and by and large civic health means physical health. When a community has a
strong sense of connectivity, its members are more likely to organize to take care of each
other and their physical environment. This can mean everything from cooking a meal for
a sick neighbor to creating a cancer patient support group from renovating the town’s
bike pass to creating a running club, all of which has proven positive health benefits for
community members. In an effort to encourage this positive civic engagement and
community cohesion, the Saguaro Seminar commuted the Better Together Project in the
late 1990s. The “What You Can Do” section a Better Together’s website has a list of 150
actions that will connect people with their communities. These recommendations include
Ten-to Town meeting, joining a gardening club, cut back on television and take a walks
with friends or family. Listeners who are interested in learning more about the Saguaro
Seminar and Better Together can visit www.bettertogether.org for more information. As
the Saguaro Seminars findings show small actions like these can go a long way to
promoting community wellness. Improving civic and physical health, now that’s a bright
idea.

Margaret Flinter: This is Conversations on Health Care. I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, Peace and Health.

Conversations on Health Care broadcast from the Campus of Wesleyan University at
WESU, streaming live at wesufm.org and brought to you by the Community Health
Centre.