A futurist perspective on health care with Dr. Ed O’Neil, Director of the Center for the Health Professions, and Professor in the Departments of Family and Community Medicine and the School of Nursing at the University of California, San Francisco.

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, I am worried about those grand lands across the
countryside who are wreaking havoc by blaming everything on Health Care
Reform. I am a little worried about those insurance companies over the next few
years who might unrealistically increase our insurance premiums and certainly
those increases will surely be laid at the doorstep of reform. Currently, I am not
the only one with this concern.

Margaret Flinter: I think the country should be worried about this. There is
always something to worry about with Health Reform, but the possibility of major
rate increases is a big one. Meanwhile, one of the things we are going to try and
do is not just help keep our listeners’ pulse on both public opinion and what’s
happening with the unveiling of Health Reform, but also to pay attention to what’s
missing. Senate Democrats seem to recognize that one thing that’s missing is
federal oversight of insurance rate increases. Senator Dianne Feinstein of
California has now introduced a bill that would allow the Health and Human
Services an opportunity to make sure that rate adjustments are justified and fair.

Mark Masselli: She lit into WellPoint, a health insurance company, who used a
special computer program to target breast cancer patients and terminate their
health coverage. She was so angry and she said it on the floor of the senate,
“We have a duty to protect the American people from the corporate greed of
these for-profit publicly-traded health insurance companies. Left to their own
devices, companies like WellPoint will throw paying customers to the shark for
the sake of profit.” And that’s why she introduced the Insurance Rate Authority
Act of 2010.

Margaret Flinter: Well, the stories like that of which we heard a lot in the past
several years that I think ultimately sway the country in the direction of the Health
Reform we now have. But Mark, I want to touch on Medicaid for a moment. The
experts are estimating that of the 30 million people who’d be newly insured,
about 20 million, 2/3rds of them will be insured by Medicaid. That’s a huge
expansion of Medicaid and it's a fulfillment of its original role to ensure that low-
income Americans have access to health care. But while is it going to test the
capacity of Medicaid and the health care safety net for poor and lower-income
families likely to be a challenges all the down the line from infrastructure at the
state Medicaid offices to overcoming the tendency of private providers to not sign
up for Medicaid at all.

Mark Masselli: Margaret, we talked about Massachusetts stress. When they
introduced their reform bill, they just didn’t have enough primary care providers in
place. That’s why the framers of this Health Care Reform bill committed

themselves to expanding the Community Health Center network with an $11
billion investment over the next four years to help ensure that there will be
delivery points all across the country. They also provided 1.5 billion in funding for
the National Health Service Core which pays for the education of health care
providers. As long as they do some service in medically underserved areas or to
Community Health Center, they were thinking about the problems.

Margaret Flinter: Mark, I think it's about time for us to do a show both on our
Community Health Center and on the system of care known as Community
Health Centers across the country, one of America’s best kept secrets in health
care. But for now, I am going to turn our attention to today’s guest Dr. Ed O’Neil
who’s got a handle on creating the future of health care. Dr. O’Neil is Director of
the Center for the Health Professions, a research, efficacy and training institute
dedicated to educating a health care workforce that can lead the improvements
in health and well-being of people and their communities. Dr. O’Neil is a
Professor in the Departments of Family and Community Medicine in the School
of Nursing at the University of California, San Francisco. And we are delighted,
he is here to speak with us today.

Mark Masselli: No matter what the story, you can hear all of our shows on our
website Chcradio.com. You can subscribe to iTunes to get our show regularly
downloaded. Or if you would like to hang on to our every word and read a
transcript of one of our shows, come visit at Chcradio.com.

Mark Masselli: And as always, if you have feedback, email us at Chcradio.com,
we would love to hear from you. Now, before we speak with Dr. O’Neil, let’s
check in with our producer Loren Bonner for the headline news.

Loren Bonner: I am Loren Bonner with this week’s headline news. After Reuters
reported that the insurance giant WellPoint had been intentionally dropping
coverage for patients recently diagnosed with breast cancer, Health and Human
Services Secretary Kathleen Sebelius made a point to highlight the wrong doing
in a lengthy reply to WellPoint executives that was also made public. Insurance
companies have used the practice known as Precision for years, but under the
new law that goes into effect later this year, insurance companies will be banned
from dropping coverage for people who become sick. Reuters said WellPoint
used a computer algorithm that automatically targeted patients recently
diagnosed with a breast cancer. WellPoint CEO Angela Braly responded to
Secretary Sebelius in a letter saying that the Reuters report was inaccurate and
misrepresented the insurance company’s efforts to help patients to tack and treat
cancer. In any case, the situation signaled the administration’s aggressive
approach toward insurers who unlawfully deny health care to Americans. This
news is also a chance to talk about how women will benefit under Health Care
Reform. In 2009, The National Women’s Law Center, an advocacy group that
worked hard to get the new law passed, found that insurance companies charged
women up to 84% more for individual and small group policies than men, even

without coverage for maternity care. In other cases of unfair practice, some
women simply can't find an insurer to cover them. And for women who have
insurance, sometimes it just doesn’t cover certain scenarios like pregnancy.
Secretary Sebelius says women being charged more for being pregnant will
change in the new marketplace.

Kathleen Sebelius: They won't be able to charge women two and three times
what you can charge their male counterparts because they might get pregnant.

Loren Bonner: Provisions in the new law will help women in several other ways.
Midsized employers will be required to provide a place and time for nursing
mothers to lactate. New insurance plans that start up five months from now and
later will have to allow women to go directly to an OB/GYN without a referral from
a primary care doctor and insurers won't be allowed to charge co-payments and
other upfront costs for preventative services like mammograms and pap smears.

This week, we are discussing the health care workforce and its importance in
moving the country toward meaningful health care reform. Our guest today, Dr.
Ed O’Neil, is the Director of the Center for the Health Professions at the
University of California, San Francisco, an organization that has done a
tremendous job to ensure that the current workforce as well as the next
generation can lead the way forward. One way this center achieves this goal is
through numerous leadership programs for nurses. Certainly, a lot of attention
has been focused on initiatives to address the nursing shortage. Since 2005,
Governor Schwarzenegger has been funding the California Nurse Education
Initiative to provide funding for a nurse training that can directly help the critical
shortage of registered nurses. The nurse leadership programs at the center for
the health professions aim to do more and draw on the larger role that nurses
play and can play in our health care system. Mary Dickow is the Deputy Director
for the Robert Wood Johnson Foundation Executive Nurse Fellows Program at
the center, an advanced leadership program for nurses with the overarching goal
to lead and to shape the health care system for the future. She says, “Nurses
have an important role in Health Care Reform.”

Mary Dickow: The nurses are primarily the ones delivering the care or in the
______ 8:11, the ones really shaping those that will deliver the care. So in the
case of nursing education, they have a direct impact on how the curriculum is
shaped or what the student’s experience is. And in the hospital systems, they
would have of course an impact on what the role of that nurse on the frontline is.
And in public health, they are out delivering the care to a great extent in the
community.

Loren Bonner: All of the nurses in the program work on a project that actually
influences the way care is delivered. And just to highlight how such a program
can influence Health Care Reform, our very own Margaret Flinter, a Robert Wood
Johnson Executive Nurse Fellow herself, refined her idea for a family nurse

practitioner residency program during her work as a fellow. The first such
residency program of its kind in America started here at the Community Health
Center and it's now a model for a National Training Demonstration Program and
the Health Care Legislation that was just passed in March. Let's listen now to the
interview with Ed O’Neil to learn more about meaningful Health Reform for our
future.

Mark Masselli: This is Conversations on Health Care. Today, we are speaking
with Ed O’Neil, Director of the Center for Health Professions and Professor in the
Departments of Family and Community Medicine and the School of Nursing at
the University of California in San Francisco. Welcome, Ed.

Dr. Ed O’Neil: Thank you.

Mark Masselli: You are both historian and a futurist, a great combination of
perspectives as we move forward to the implementation phase of the National
Health Reform. You stress the importance of finding a midpoint between
government and the marketplace recognizing that health care can’t be left to the
sole province of either and you have talked about the genius of American middle
where the pragmatists come together to create good policy that leaves enough
room for individual action and responsibility. How does that middle way translate
to the future of health care in the context of this national legislation?

Dr. Ed O’Neil: We have to reinvent the practice models in a way that builds in
that kind of public support when necessary, but individual accountability and
engagement involvement throughout. And that’s going to require us to think
differently about how we understand the professional role, what we finance, how
we regulate, how we educate beginning in the earliest years so that there is this
sort of expectation of responsibility on the part of the consumer. And we are also
going to have to think about policies that shift some of that responsibility back to
the patient, consumer, public as well. But the kind of responsibility that looks at
behavior, that looks at contribution, that looks at material effect, and then prices
your share of health care accordingly. So continued substance use, tobacco,
alcohol and someone refuses to seek any kind of assistance to change that
behavior, all of those things are things that we are going have to reconsider and
how we think about individual responsibility. But we also then, backing it up,
have to be prepared to have a public system, whether it's delivered privately or
publicly, it's kind of unimportant, but we have to have a publicly supported system
that will help those individuals be more accountable.

Margaret Flinter: The kind of health care system transformation that you are
talking about obviously requires leadership and maybe at a level we just haven’t
seen before in health care. Now, you have done a lot of work both with emerging
and season leaders in California and also nationally, and you have identified
these three core domains and you can tell that we do redo work that you see as
the task of our leaders in our new reality, coherence, efficacy and community.

Can you elaborate on those domains and how do we train the next generation of
leaders in them?

Dr. Ed O’Neil: The health care in the U.S. is the sixth largest economic
undertaking on the base of the globe and it’s complicated. But it's complicated in
part because that’s how we have made it. So to change that means that we
have to be able to say, with some very clear first principle, this is what we are
trying to achieve, this is what success will look like, and it's got to be coherent to
the providers, it’s got to be coherent to the public. But we need broader public
discussion around that to give that kind of coherence. One of the concepts that I
have been trying to push for a decade is this idea of health commons. What I
mean is that tradition in America of communities coming together to do things in
common, whether it's raising a bar or it’s building and supporting a public school
system, but we need that same kind of ethos for health care in which I have
taken the responsibility as a citizen, as a consumer, as a patient to actually learn
what I need to do to take care of myself. Efficacy means that it's got to work, it's
really got to be able to demonstrate that we are using the resources wisely, that
we are selecting the treatments that have the greatest probability of a positive
return. And it’s also being candid about what we can and cannot do. And then
on the community, we do need broader definition of how we participate in health
care. We actually know that that kind of engagement actually produces health in
and of itself. That’s not what I am advocating for, but it's that community
engagement and involvement that I think is just essential. It's a system that is
understood and valued by the entire community.

Mark Masselli: Speaking of promoting health and things that have to work, the
primary care setting is really where the focus is in the Reform Legislation and
there are many incentives in the bill that reward primary care providers, those in
practice and those who are applying to the field. Do you feel these incentives are
aligned with our goals for prevention?

Dr. Ed O’Neil: I do think that. I don’t think there is a last word in it but it's the
beginning of a redirection of our health care system. A Dutch M.D. physiologist,
a guy named Bernard De Vries, wrote an article many, many years ago called
Unraveling the Mystery of Health. What De Vries said was “You know why don’t
we look up from the tissue in the organ to the system, to the human, to the
human in relations and the broader community, and look for health there, not just
in correcting the chemistry.” So primary care gives us the beginning to move
care back to prevention and management. And management is probably just as
important in primary care as prevention. In fact, in some ways, prevention really
is the domain, the responsibility of the individual assisted by the professional.
But once we have the onset of disease, managing that disease, keeping that
person out of the hospital, out of the treatment modalities is really an important
part of what we need to do for the future.

Margaret Flinter: So, Ed, let’s stay on the health care cost for a minute and
certainly there has been lots of criticism that the Reform Bill won't lower cost
quickly and they are probably justified. But the point wasn’t made strongly
enough I think that one person’s cost is another person’s income. So we see
options like curtail access or cut the prices, neither of them very popular. So let
me just ask you a bit of the futurist’s perspective. Do you think there really are
significant cost savings that we can achieve by covering the uninsured,
managing those chronic diseases, and investing in prevention as you just said?
Or if you are making a prediction, will we still see runaway cost at least for
another decade?

Dr. Ed O’Neil: So the only option really is to reengineer or redo or refocus, re-
imagine the way we organize and deliver care. I think there is some money to be
saved long term in prevention but that’s a very long term, that’s a couple of
decades before I think we begin to see big material returns. I think that the
bigger and more readily available, accessible option for us to save money is to
look at this large burden of chronic care, so diabetes, arthritis, congestive heart
disease. Today, what we do predominately is we tell somebody they have this
chronic disease and then we manage that care in the old acute care setting, a
visit to the physician for 15 minutes every six months or so, a hospitalization
when things get out of control. So, the option, Margaret, is to actually say now
how do we use these resources, and there are a lot of resources once we look at
how much all that acute care treatment costs, how do we use those resources to
manage that care a different kind of way. Maybe we need new kinds of
professionals, promotoras, and community health workers, or medical assistants
working in an extended fashion. We need to think about changing behavior once
the diagnosis is in. We need to think about wraparound supports. And while
some people look at those and say well, that sounds very costly, the few studies
that have been done in these different areas would indicate that yes, it's a
different kind of expenditure but it's a lower expenditure. The only thing is we
have 20 years of research from the Agency for Healthcare Quality and Research
that would point to all of these well-established evidence-based ways to manage
that care differently. And we need to incentivize people’s movement to those.

Mark Masselli: Today, we are speaking with Ed O’Neil, Director of Center for
Health Professions and Professor in the Departments of Family and Community
Medicine in the school of nursing at the University of California in San Francisco.
I want to sort of pick up on that theme about managing things a little differently.
There is no doubt that the big question out there over Health Care Reform
concerns health care workforce. Covering more people means that we need to
find a cure for our health care workforce shortage and I am sure this was on your
mind well before the Health Care Reform Legislation passed. It was certainly the
experience out of the Massachusetts Reform Effort. Can you break down for our
listeners how critical this issue of health care workforce shortage is and what
initiatives have you been promoting to provide access to better training and
education in health care?

Dr. Ed O’Neil: It’s important for us to think about what are the resources that we
have currently, not just do we staff with our personnel to the old model of care but
how do we think about the resources that we have, institutions and professions,
what do we want to achieve for the future, that’s why this Health Commons idea
is so important, and then how do we staff that, what do we have in abundance of,
what do we have too few of, and how can we make up that difference in some
creative and different kind of ways not just building new capacity, not just taking
what we have done in the past and projecting a straight line into the future.

Margaret Flinter: So, Ed, one more factor I would lay into that is the
demographics of the workforce we have got and let’s just say the average age of
physicians and nurses is up there, somewhere in the high 40s. But equally
important, it seems to me, we have a generation of young adults and kids who
are not likely to want to get their health care the same way that their parents did.
Instead, we see a push for they want it electronically, virtually, using lots of
different media than coming into the office. So maybe we have a gap in
expectation that we need to bridge. Who is doing that successfully? Have you
seen any examples out there of this?

Dr. Ed O’Neil: I think two places that are doing it a nice job of that. One, in the
spectrum, is Kaiser Permanente. They have been the largest organized system
in the country and they don’t operate across the country. But in those places
where they do operate, they have instituted a medical record. And they have not
only used that medical record to administer health resources more efficiently and
then to provide clinical information to the professionals more efficiently and
effectively, most importantly, they have rather aggressively used that information
tool to change the way the consumer thinks about and interacts with their own
health, their own health information, and their practitioners. It's almost like
banking 25 years ago when banks made these all own tellers and now we do a
whole array of financial services using those online resources. And the other
place, the other end of the continuum I would say, is in community clinics where
we are actually seeing, in part because they don’t always have every resource
available to them, beginning to think about how that practice model can change
using paraprofessionals, using community members, having individuals help
each other in self-help groups and group visits to the clinic, and thinking about
health within the community contact.

Mark Masselli: Let me pull on this right of innovation. When you look around the
country and the world, what do you see that excites you in terms of innovations
and who should our listeners of Conversations be keeping an eye on?

Dr. Ed O’Neil: The State Medicaid Program in Colorado has been one of the
tremendous thoughts of innovation in terms of hospital care. Virginia Mason up
in Seattle has been particularly outstanding. I think Virginia Mason has very
aggressively pursued the route of changing itself with unflinching courage, that is

to say, change what we do even if in the short run, it negatively impact our
bottom-line and hospitals are going to have to confront that and live with that
reality but much better to lead it I think than that to have it push back on you.
And then in terms of medical group out our way, the Palo Alto Medical
Foundation has demonstrated, to me, a kind of consistent fairly strong set of
innovations.

Mark Masselli: Today, we have been speaking with Dr. Ed O’Neil, Director of the
Center for the Health Professions, and Professor in the Departments of Family
and Community Medicine in the School of Nursing at the University of California,
San Francisco. Thank you for joining us today.

Each week, Conversations highlights a bright idea about how to make wellness a
part of our communities into everyday lives. In past weeks, we brought you
stories about walking school buses and trayless cafeterias. Today, the bright
idea focuses on a broader initiative to make schools healthier places for our
children to learn and develop. After spending years working to make their three
daughters’ schools in Illinois healthier and safer, Chevy Chase and his wife Jayni
founded the Green Community School Initiative with the goal of using their
personal experience to improve schools around the country. Although their
chosen name more readily aligns them with traditional environmentalist, the main
impetus behind the initiative is children’s mental and physical wellness. The
Green Initiative focuses on several environmental factors, both inside and
outside the classroom, that frequently compromise or endanger students’ health,
such as transportation students to and from the school, indoor air pollution,
reduction in recess and PE time, as well as limited food choices in the cafeteria.
Green Initiatives are powered by students’ research in designing and
implementing plans with teachers’ assistance. For example, this year, students
at Al Raby High School in Chicago have taken on the task of making their school
healthier and safer. They organized a community trash pickup day for school’s
playground and surrounding streets. They have begun to research their school’s
air quality with the help of science teachers. Green Community School Initiative
programs have begun to make a real difference in students’ health. Children
whose schools are part of the Green Initiatives are less likely to be overweight or
to experience pollution-related respiratory illnesses. The Green Initiative has
also succeeded in improving the social atmosphere in schools. Instead of sitting
in class all day without interacting with each other, the students are taking charge
of their school environment and working together to implement projects of their
own design. This increased sense of community and purpose has led to
decrease levels of violence and aggression by students. The Green Initiative has
worked to make these changes long lasting by partnering with the Marilyn G.
Rabb Foundation which works to reduce socioeconomic and educational barriers
for low-income students. The Foundation conducts violence prevention
workshops in participating schools. All of these changes mean that students are
better able to focus in class and retain what they learn. The Green Community
School Initiative is now active in several Chicago and Detroit schools and

programs elsewhere in the United States are on their way to becoming a reality.
With its comprehensive approach to student wellness and its use of student
input, the Green Community School Initiative is helping communities take control
of their children’s health by making their school safer places to learn and grow.
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.