Dr. William Kassler, chief medical officer for the New England region of the Centers for Medicare and Medicaid Services.

(Music)

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, today we are going to focus in on practice redesign
and payment reform but also at the heart of these transformations it's a focus in
on prevention. The health reform legislation requires that all new health plans
cover recommended preventative services like mammograms and vaccines with
no deductibles or co-payments eliminating financial barriers for people to get
these services.

Margaret Flinter: And Mark, the White House is making sure that the country
knows about it. Prevention is near and dear to the hearts of this administration
and finds its way into almost all aspects of health reform. Secretary Sebelius,
Surgeon General Regina Benjamin and Nancy-Ann DeParle from the White
House hosted two back-to-back national call and conference calls to talk about
the preventive service change for the health plans and also how it specifically
affects women and girls just a continuing thrust to involve people in the changes
and in the positive ways that can impact America’s health.

Mark Masselli: And today we are going to hear from somebody from CMS who is
going to tell us a little bit about not only the private health plans but the new
directions that CMS is headed. We have with us Dr. Bill Kassler who is the Chief
Medical Officer for the New England Region of the Centers for Medicare and
Medicaid Services. Dr. Kassler also serves on the board of the Foundation for
Healthy Communities which is helping to improve health and health care in New
Hampshire.

Margaret Flinter: New Hampshire being one of the states that's really doing
some very innovative work. And no matter what the story you can hear all of our
shows on our website www.chcradio.com . Subscribe to iTunes and get our show
regularly downloaded or if you would like to hang on to our every word and read
a transcript of the show, come visit us at www.chcradio.com .

Mark Masselli: And as always, if you have feedback, Email us at
www.chcradio.com we would love to hear from you. Before we speak with Dr.
Kassler let’s check in with our producer Loren Bonner with Headline News.

(Music)

Loren Bonner: I am Loren Bonner with this week’s Headline News. The Obama
Administration rolled out another benefit under health care reform that give
patients the right to appeal health plan decisions like insurance claims denials.

Last week, the administration issued rules for new health plans in every state that
guarantee a consumer the right to appeal a denial to the insurance company and
then to an external board if necessary at the same time many consumers don’t
know that they can appeal on insurer’s decision, determinations like claims
denials and rescissions made by their health plans. In addition to the new
regulations, the administration is providing $30 million and grants to states to
strengthen consumer assistance offices. President Obama also wants to
regulate any erroneous government spending from Medicare and Medicaid. Last
week, he signed the Improper Payments Elimination and Recovery Act that
requires agencies to spend at least one million dollars on audits to identify
potential overpayments, produce plans to cut such overpayment errors and set
penalties for agencies that fail to comply.

Obama: We have begun an unprecedented effort to put an end to a problem
known as improper payments which is the purpose of the bill that I am signing
into law today. Now, these are payments sent by the government to the wrong
person or for the wrong reasons or in the wrong amount.

Loren Bonner: The Office of Management and Budget says the majority of
improper payments come from Medicare and Medicaid.

Nancy Pelosi: We will have what we need to hold the insurance companies
accountable. I contend that whatever we have coming out of this bill will hold
them accountable and they will be crying out for a public option one of these
days.

Loren Bonner: That was speaker of the house Nancy Pelosi talking about the
public option during the health care debate last year. The subject is back on the
table. More than 120 democrats in the house are pushing a new bill to
reintroduce the debate arguing that it would help reduce federal spending.
Democrats say that the CVO estimates that the public option could save the
government $68 billion between 2014 and 2020. It was a contentious issue in
the health care debate leading up to the reform legislation and the potential bill
has a slim chance of passing in this Congress. In any case democrats wanted to
remain a viable option down the road.

This week on Conversations on Health Care, we are exploring the patient-
centered medical home concept. The current and planned medical home pilot
projects around the country are designed to make primary care practices more
effective, more efficient and more satisfying for both patients and providers alike
and perhaps even more cost effective. Right now the National Committee for
Quality Assurance or NCQA is the primary vehicle for practices and providers to
be recognized as medical homes. The NCQA in collaboration with a number of
professional groups such as the American College of Physicians have defined
the criteria with practices able to achieve certain levels based on the degree to
which they meet the criteria. These include making sure that a patient has a

personal relationship with a specific provider, the use of guidelines and reminders
for chronic and preventative care, extended hours and ways to communicate
electronically between patient and provider. Practices that qualify must have an
effective way to manage health information both in practice and when the patient
receives care outside of the practice. Ideally, this would be an electronic health
record but in cases where a full EMR is not available, practices might use a
registry for chronic disease and an electronic prescribing system. Contrary to
popular belief, practices in poor neighborhoods with a high percentage of racial
and ethnic minorities are more likely than others to have a medical home
structure in place. A recent Commonwealth Fund study that surveyed around
300 primary care practices in Massachusetts that serve poor neighborhoods
found that these practices were more likely than others in the state to qualify as
medical homes. They were significantly more likely than others to have onsite
language interpreters, clinicians who spoke multiple languages, frequently used
multi-functional electronic health records, staff who assisted patients in self-
managing chronic illnesses and physicians who were aware of the patients’ rating
of their health care experiences. Transforming primary care practices require
substantially large investments in time, money and technological support. In
some ways, this study gives hope to what is possible as we strive to make the
patient-centered medical home a standard for delivering care. Let’s turn now to
our interview with Dr. Bill Kassler who can tell us more about one of these
medical home pilot projects, the multi-payer demonstration project as well as
some other innovation highlights from CMS around health care delivery.

Mark Masselli: This is Conversations on Health care. Today, we are speaking
with Dr. William Kassler, Chief Medical Officer for the New England region of the
Centers for Medicare and Medicaid Services. Welcome Dr. Kassler.

Dr. William Kassler: Thank you.

Mark Masselli: The appointment of Dr. Don Berwick to head CMS is a very
significant move forward both because CMS has been without a head since 2006
and because Dr. Berwick’s stature as a physician leader in driving change in
health care. There has been a widespread support in the health care community
for his appointment but also a recognition that CMS is an enormous agency and
creating and driving change, the hallmarks of his career since he founded the
Institute for Health Care Improvement will be easy at CMS. What do you think
the immediately challenges will be for Dr. Berwick in assuming to fill this long
unfilled position?

Dr. William Kassler: Well, Dr. Berwick is going to have to hit the ground running.
We have a number of responsibilities at CMS given the implementation of the hi-
tech aspects of the stimulus plan. We have a tremendous amount of work to do
to make sure that the doctors and hospitals get the incentives that they need for
a meaningful use of health information technology. And then of course right on
the heels of the stimulus was the Affordable Care Act called Health Care Reform

and that’s such a massive act and there are so many responsibilities that we
have to implement so many provisions of that act and we will certainly look
forward to his leadership in terms of making sure that CMS implements that well.

Margaret Flinter: Dr. Kassler, you have spent most of your career in public
health, seven years as State Medical Director for New Hampshire, 17 years as
an officer in the Public Health Service at CDC. And it seems from what we have
read about your work that a lot of your efforts have focused on collaboration
within communities, integrating population based public health strategies and
preventative services into clinical care and making a priority of doing that with the
public health insurances Medicare and Medicaid. And it seems to me in
Medicare over the last few years we have seen a move in the direction of
preventative services for sure but we need to do more. What are the prevention
priorities for CMS now from your viewpoint and what innovations and prevention
might we see in the coming years?

Dr. William Kassler: We are in a very fortunate position with respect to Medicare
being able to take on more preventative services. And with the recent legislation,
we are now authorized to give not only preventative services that 10:31______
those really work but we are also authorized to do that in a way that doesn’t have
beneficiary have a co-pay associated with it. So we are really looking forward I
think to the golden age of prevention in Medicare.

Mark Masselli: It's been only a few weeks since Congress voted a reprieve on
the scheduled cuts in Medicare fees to physicians. We understand the history
about this legislation and I think everyone expected the late reprieve but it
creates an uproar every time that scheduled cut comes around mostly around
fears that physicians will ould drop out of the Medicare program. What’s CMS
doing to ensure that physicians continue to enroll as Medicare providers?

Dr. William Kassler: Well, first and foremost, the cuts that you are referring to,
the so-called sustainable growth rate, is an active Congress and CMS has
absolutely no authority to change that. So the so-called Doc Fix must happen at
the legislative level, Congress and the senate needs to act and CMS can’t. What
we can do is we can make sure that every time that this expired and that the
doctors were threatened with a cut, we can try that 10 claims, full claims, wait
until congress acts and then of course retroactively make docs hold if Congress
does that. In terms of what we can do overall to make Medicare more provider-
friendly, we have to do a better job in terms of making sure that we have good
customer service, that we are not an awful bureaucracy to deal with.

Margaret Flinter: Dr. Kassler, let me talk about the next generation of health care
professionals for a minute. Today, as our listeners probably know, physicians
complete their residency training in a specialty area whether that’s family
medicine or neurosurgery in a hospital based residency program funded by
something called GME or Graduate Medical Education legislation that sets

forward a payment mechanism by Medicare to pay hospitals for the cost of their
training. Now there have been so many calls for changes in the way GME is set
to prioritize primary care, increase diversity to recognize the importance of
training outside of the hospital where most care takes place. What do you see
that’s innovative coming up either in terms of changes to GME or just training the
next generation of health professionals in general in the United States?

Dr. William Kassler: Once again, GME is a creature of Congress so I don’t think
CMS is going to on its own change the way in which we pass through federal
funds to support medical education. I think medical education is a very
conservative beast. It takes a long time for these sorts of trends to percolate
down into the medical school and residency program. But I do think that some of
the areas in which we are working on in CMS might help. In particular we are
standing up a whole center for innovation in which we are going to be looking at
innovative ways, at demonstration projects, at creative ways in which we can pay
docs, in which we can align incentives for physicians to deliver higher quality,
more effective and more efficient care. And finally, I think one of the most
exciting innovations on the horizon is what’s called the Medical Home Concept.
And I am happy to talk about that more if you want but I think that’s where the
innovation is and that’s where the national efforts are to reinforce and help save
primary care.

Mark Masselli: Today, we are speaking with Dr. William Kassler, Chief Medical
Officer of the New England region of CMS. I think we share the same belief
about the importance of community to build healthy infrastructures and support
systems for health. You practice in a community health center yourself in New
Hampshire and you also currently serve on the board of the Foundation for
Healthy Communities which is helping to improve health care in New Hampshire.
At our health center we believe that every state in America represents a
laboratory for innovation. What are some of the advances in innovations that
New Hampshire has made?

Dr. William Kassler: Well I think you are correct. I think that the federal
government being so large can only do so much but I think the states really are
_____15:12 for innovation. Particularly in New England, some of the small states
I think have the ability to be very, very creative in ways that larger states that may
be more stuck in political rivalries can’t do. In the state in which I live in, New
Hampshire, there have been number of innovations. First of all the state works
together with every single health plan and payer including Medicaid in New
Hampshire to come up with a medical home project in which primary care docs
are paid more for counseling and for coordinating care and for more effectively
serving the needs of patients. As well, the State of New Hampshire through
what’s called the Citizens Health Initiative is developing another model called an
Accountable Care Organization in which groups of doctors and other providers
stand together and are accountable for the outcomes that we care about such as
better quality, more efficient care, lower cost and better patient outcomes.

Margaret Flinter: And Dr. Kassler I am going to take you up on the offer to talk a
little bit more about the patient-centered medical home or health care home as
some call it. It strikes me that I can hardly remember a development in health
care delivery that’s gotten more across the board support as a concept than this
concept. And so the advanced primary care practice or the patient-centered
medical home concept, and I think those are being used somewhat
interchangeably, now has a major champion in Medicare through the new
demonstration project, the Multi-payer Advanced Primary Care Practice
Demonstration if I have said that long title correctly. Can you tell us what really
drove this for CMS? This is really CMS getting involved in a level of care delivery
on the ground that’s a little bit unusual in our experience. So tell us more about
CMS’s goal for this project.

Dr. William Kassler: Well first of all this is a project that is really developed and
advocated by the providers, by the family docs, by the pediatricians, by the
primary care internals. So what the medical home model says is that patients do
best when they have a medical home, when they have a primary care doctor who
serves basically as a conductor of this very, very complicated orchestra and that
primary care doctor can refer to a specialty care, can do the counseling, can do
the care coordination and deliver high quality cost effective care. But the
payment system has to change. So rather than simply being reimbursed for
procedure and the more procedures one indulge, the more money one gets, this
demonstration project, this concept will reimburse doctors extra for coordinating
care, for having the technologies in place to do preventive services, having better
hours, being more patient centered, having health records that reduce medical
errors. So docs will be paid for performance, they will be paid for counseling and
for care coordination things that typically now they are not.

Mark Masselli: That’s quite interesting. It seems like there is this intersection of
practice redesign and payment reform that’s going on and New England seems
to be leading the way certainly. You have the group that you are working with in
New Hampshire, the Foundation for Healthy Communities and you have got
Vermont Blueprint for Health and also you have got in Hanover Dartmouth and
they are very engaged in their many initiatives, the clinical microsystems. Tell me
though outside of being in New England what needs to be in place for states who
want to implement medical home models or payment redesigns. Is there sort of
a ____ 19 11 going on here that they have to have before they take this leap?

Dr. William Kassler: Well first of all I want to point out in your neck of the woods,
the Middlesex Health Care System is one of those innovators as well. They have
been involved for quite a while in our primary care demo and have really
demonstrated high quality cost effective care through innovation and through
some of these techniques that we are talking about. So don’t discount what’s in
your own backyard

Mark Masselli: It's still New England though, I am trying to--

Dr. William Kassler: There you go. So that being said, I do think that the
successes in Maine, New Hampshire, Vermont, Massachusetts around some of
these projects have to do with putting aside the differences and bringing all the
stakeholders to the table, bringing the competing health plan, Medicare,
Medicaid, the different doctors and hospitals and the different systems that they
represent to get together to figure this out. And so states that are successful
really try to transcend this very vulcanized and fractured system and develop a
vision across all the players.

Margaret Flinter: Dr. Kassler, we all recognize that how we pay providers needs
to change and that’s part of that concept of the patient centered medical home.
But I think HHS Secretary Kathleen Sebelius said it thoroughly when she said
that advanced primary care practices are the most promising model for bringing
down health care costs across the country and certainly CMS will be monitoring
this very closely in terms of cost. What is the potential for saving cost with the
patient centered medical home or the advanced primary care practice model and
what are you looking for in terms of cost savings, what are the areas where you
think that really can be accomplished?

Dr. William Kassler: One of the ways is using technology to reduce medical
errors. Apart of being a medical home and getting paid that extra amount is that
an office and a practice has to develop transformed set of standards, they have
to adhere to a higher level of practice and a higher level of standards than
previously in order to qualify for these extra payments. So that generally means
having patient registry so that they can keep track of who is getting the
preventive services and who is not and can reach out to those who aren’t getting
the preventive services, they have health information technology that can
effectively share information and reduce the redundancy across all the different
specialty systems, they have electronic health records that can reduce
medication error and clearly document all of the various different tests involving
patients from provider to provider.

Mark Masselli: Dr. Kassler, when you look around the country and the world
what do you see in terms of innovation and who should our listeners of
Conversations be keeping an eye out for?

Dr. William Kassler: We have to have innovation around how health care gets
delivered at the system level, how it gets financed and paid for, what are the
disparities. And frankly the next step really needs to be at the policy and political
level in order to be able to diffuse all that wonderful biomedical research out into
the public. I mean right now we have areas of the country and certain
populations that aren’t benefiting from all of the wonderful health care that we
have and we need to develop those systems in order to make sure everybody
benefits.

Margaret Flinter: Today, we have been speaking with Dr. William Kassler, Chief
Medical Officer for the New England region of CMS. Dr. Kassler, thank you so
much joining us today.

Mark Masselli: Each week Conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives.

Speaker: This week’s bright idea focuses on a new program called Open Notes
which is seeking to increase access to doctors’ notes on patients medical
records. According to the 1996 federal Health Insurance Portability and
Accountability Act, patients are legally permitted to view doctors’ notes but they
rarely do. The creators of the Open Notes program want to change that. The
program is still in its pilot stage with about a 100 primary care doctors currently
signed up for a 12 month trial period in Massachusetts, Maryland, and
Washington State. Participating patients will be able to access their medical
records and doctors’ notes on a secure online portal. Researchers will interview
these patients and their doctors both before and after the trial to track the
program’s success. The Open Notes Initiative is part of a larger movement to
increase access to medical information by creating digital reserves of medical
records online. Proponents hope that the increased availability of this
information will strengthen doctor-patient communication, reduce medical errors
and improve overall quality of care. Although patients are excited about the
project’s potential, not all doctors feel the same way. They worry that access to
their notes will lead to an increase in patient questioning, they will overwhelm
their already busy schedules. However, experts are hopeful that these possible
challenges will motivate doctors to find solutions that will further improve doctor
patient communication. For example, rather than using confusing shorthand
terminology such as anorexia to mean reduced appetite, doctors will be
encouraged to clarify their notes or include a guide to abbreviations and terms.
Improvement such as these will actually save doctors’ and patients’ time since
patients medical records and doctors notes on them will eventually be available
online, patients will simply look up information such as their latest cholesterol
level or blood pressure reading instead of calling their doctor’s office to ask. By
streamlining the process through which patients access their medical records
and doctors’ notes, Open Notes is helping to improve doctor-patient relationships
and cut down on time consuming communication problems. 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 www.wesufm.org and brought to you by
the Community Health Center.