Dr. Lisa Dulsky Watkins, associate director of the Vermont Blueprint for Health, discusses Vermont’s medical home project.

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

Margaret Flinter: I am Margaret Flinter.

Mark Masselli: Margaret, Medical Home Concept should be familiar to our
listeners by now. We have talked about it on the show most recently with Dr.
Paul Grundy, who leads the Patient Centered Primary Care collaborative – a
coalition group that’s advancing and advocating this model and pilot
demonstrations around the country. The concept is emerging as a leading model
for efficient management and delivery of quality care, probably care at its best, a
team approach with patients at the center.

Margaret Flinter: And like so many things in healthcare people who deliver
healthcare may have a very different perspective than our patients. Knowing
about the Medical Home Concept may not be the case for everybody. The New
York Times article a few weeks ago really hit it on the head. It spoke of how
much providers are embracing the model but patients they are kind of in the dark
saying what’s a Medical Home, a Nursing Home.

Mark Masselli: These things do time Margaret. Hopefully, our guest today can
offer some insights, Dr. Lisa Dulsky Watkins from the Vermont Blueprint for
Health, is here with us today. The Blueprint is an integrated health service pilot
program in Vermont that includes the Patient-Centered Medical Home. It's been
operating for several years now and is successfully expanding its mission and
reach. Dr. Dulksy Watkins can hopefully answer many of the questions that still
linger about the Medical Home Pilots for apparently many of our listeners.

Margaret Flinter: Well, Vermont has really been a leader in healthcare innovation
and reform for the past several years now. I think they are pretty close to
achieving universal coverage. Their healthcare reform commission recently
voted in support of a team that’s going to craft three possible single payer system
plans that will be considered by the legislature. But no matter what the story, you
can hear all of our shows on our website chcradio.com, subscribe to iTunes to
get the 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 chcradio.com.

Mark Masselli: And as always, if you have got feedback, email us at
chcradio.com, we would love to hear from you. Before we speak with Dr. Lisa
Dulsky Watkins, let's check in with our producer Loren Bonner with headline
news.

Loren Bonner: I am Loren Bonner with this week’s headline news. A Federal
Judge in Virginia ruled that the state can proceed with its lawsuit to challenge the
healthcare overhaul. The state is claiming that it's unconstitutional to require
citizens to buy health insurance or pay a penalty. Virginia is the first state to have

their lawsuit go before a judge and a hearing on the case is scheduled for
th
October 18 . Florida, joined by 19 other states, filed a separate lawsuit arguing
that the healthcare reform law is unconstitutional because it puts a physical
burden on its cash drop budget by expanding state run Medicaid programs.
Cornell University Law Professor Robert Hockett says he doesn’t expect the anti-
federal cases to make it all the way to the High Court.

Robert Hockett: I tend to find that this huge drop by the states against the
Healthcare Act so surprisingly lacking in there that I really I am rather doubtful
that it will ever get up if filed in Supreme Court.

Loren Bonner: A judge hasn’t scheduled a hearing in the Florida case until
September. The Department of Health and Human Services announced two key
steps that will help states begin establishing health insurance exchanges. HHS
will offer $51 million in grants to help states to get started creating state based
health insurance exchanges, which will be operational in 2014 under the new
law. The temporary exchanges in states just began coverage for people with
st
preexisting conditions on August 1 . In a second move, the department also
issued a notice requesting public comment on standards needed to create a
successful exchange. Each state and the District of Columbia are eligible for up
to $1 millions in grant money to establish their exchange. HHS said this first
round of grant money will give states resources for research and planning
needed to build and manage a strong health insurance marketplace. Money for
this critical piece of healthcare legislation comes as states struggle with their
budgets. In the coming weeks HHS plans to host governor staff from across the
country to begin navigating the road ahead. The White House unveiled a new
report by the centers for Medicare and Medicaid services that predicts the new
healthcare law will save Medicare about $8 billion by the end of next year and
$575 billion during the rest of the decade. Senior citizens have been the most
skeptical of the new law and the administration hopes this news will build
support. This week on Conversations on Healthcare we are looking to the State
of Vermont as a laboratory for healthcare reform and innovation. Vermont has
been a leader in efforts to ensure access, affordability, and quality. The Vermont
Blueprint for Health Pilot began in 2003 and the state passed its own healthcare
reform in 2006. Right after the Patient Protection and Affordable Care Act was
signed into law this spring the Vermont House of Representatives passed a bill
establishing a new commission called the Healthcare Reform Commission, which
gives the state permission to experiment with different methods to achieve a
more efficient and accessible but less expensive healthcare system. The
Healthcare Reform Commission authorizes the state to hire a team of
consultants to create implementation plans for three different design options for a
new statewide healthcare system that will provide coverage for all Vermonters.
One must be a government finance system or single payer and another must
include a public option for health coverage along with private insurance. A third
design is to be determined by the consultant. However, Vermont’s efforts to
create either a public option or a single payer insurance system could run into

some road blocks. The reform legislation of our states from experimenting with a
public healthcare system until 2017 and Vermont would need approval by the
federal government for the measure. It comes as no surprise that Vermont
Senator Bernie Sanders an independent who is one of the strongest proponents
of including a public option in federal health reform will fight to win permission
from the federal government. Sanders believes state should be able to take the
lead in demonstrating that single payer healthcare is the best method of
providing quality affordable care to all Americans. If implemented in Vermont, he
believes the single payer approach will prove to be the most cost effective and
will expand nationally. All this week Sanders is holding a series of town halls and
rallies in his home state to support single payer and healthcare as a human right.
Let’s turn now to our interview with Dr. Lisa Dulsky Watkins who will tell us more
about how Vermont has already begun reforming its healthcare delivery system
through the Vermont Blueprint for Health Pilot Program.

(Music)

Mark Masselli: This is Conversations on Healthcare. Today we are speaking
with Dr. Lisa Dulsky Watkins, Associate Director of the Vermont Blueprint for
Health in the Integrated Health Service Pilot Program in Vermont that includes
patient centered medical homes, community health teams and health IT
infrastructure. Welcome Dr. Dulsky Watkins.

Dr. Lisa Dulsky Watkins: Thank you very much.

Mark Masselli: You know Vermont has been serious about reforming healthcare,
especially the delivery system I believe. Vermont passed its own Health Reform
Legislation about four years ago. So let’s start with some background. This
commitment to comprehensive health reform that includes universal coverage is
largely the result of the visionary leadership from Governor James Douglas, a
republican and a democratic legislature, a bipartisan effort if you will. Can you
talk to us in more depth about Vermont’s vision for healthcare reform and how
this leadership has been critical to that goal?

Dr. Lisa Dulsky Watkins: Absolutely and I think you really can underscore that
statement enough. We really are incredibly fortunate to have bipartisan support
for the cutting edge work we are involved in. The legislation that you referred to
that passed in 2006 was really landmark healthcare reform legislation. But the
Vermont Blueprint for Health precedes that by a couple of years. It was kicked
off by Governor Douglas and our former commissioner Paul Jarris, the
commissioner of health in 2003. And, that was clearly a response to the
overwhelming burden of chronic disease and related illnesses to ageing and
obesity that appears still to this day to be very concerning in terms of the looming
cost, in terms of human health and the financial impact. The program at the time
was very much modelled on something called the Chronic Care Model which is
designed by Dr. Ed Wagner out in Seattle at the MacColl Institute in the

University of Washington. And that’s a holistic approach to health looking at a
person who not only goes to the doctor’s office but actually lives at home and
works and lives in the community and goes to school or goes to church I mean
this is a very comprehensive look at a person who lives in their world. And how
do you support people staying well if they are well or certainly not getting secure
if they are unfortunate enough to have a chronic disease. And so what the
information that you need about what happened to the doctor’s office is only one
part of that. What happens when you get home, what kind of opportunities do
you have to make choices that will keep you well. While we were focused on
chronic disease specifically diabetes but other chronic diseases initially that has
changed very significantly over the last several years guided by the legislature
and the governor as well whose work is going on here at the department of
health. So we really are much more about prevention, health maintenance,
comprehensive approach to people’s health and wellness and not just about
chronic disease.

Margaret Flinter: We are big fans of Dr. Wagner’s chronic care models and
certainly appreciate that benefit it provides, but you know, one of the things that’s
really striking about the work that you have done in Vermont is that while clearly
the incidents of chronic disease and particularly diabetes and the cost associated
with that and the suffering was a major motivator for you all. You seem to have
accomplished something quite remarkable which is to bring together the public
health people and the private practice people in a joint goal towards making an
impact there. Can you tell us a little bit more about that partnership?

Dr. Lisa Dulsky Watkins: It has always been the case with the Blueprint being
here at the department of health. In state government that we have reached out
and had to establish very strong working relationships with many areas in the
private sector. And that includes the University of Vermont which actually is a
public school but really you know is not state government are various colleagues
in the insurance industry both in the private insurance career role as well as
Vermont Medicaid and also with obviously all the people who provide care. We
have really had it remarkable opportunity perhaps because Vermont is a small
place and people tend to know each other, not everybody obviously but there is
an intimacy in being in a relatively small environment that allows four people to
literally be at the same table at meetings, you know so there are opportunities we
are very lucky on some level that we had that in place.

Mark Masselli: Today we are speaking with Dr. Lisa Dulsky Watkins, Associate
Director of the Vermont Blueprint for Health program. Little curious about how
your progress has been made on Health IT across the board. You have been
working on establishing central registry for patient records. What kind of
infrastructure needs to be in place first established this as well as the expansion
of the electronic medical record and what kind of challenges are you facing now
in anticipation of the meaningful use standards being set up by the office of the
national coordinator.

Margaret Flinter: I think I can safely say that IT has been one of our greatest
challenges and I think there are multiple reasons for that. One is that pure and
simple the cost of any sort of transition to an electronic or medical record or to
the use of a as you mentioned a centralized registry, which I can describe in
some detail has, it's a big change in terms of our practice functions and it's a
huge undertaking in terms of cost. Vermont has been seeking out and fortunate
in some decisions that have been made at the legislative level as well as I think
very deservedly receiving significant funding for the implementation both at the
registry and the electronic medical record in practices around states. I think that
we have had tremendous partners in many different parts of the states in terms
of the practices in hospitals and we have a non-profit organization called the
Vermont Information Technology Leaders that has really taken the lead in
creating a health information exchange, structure that is starting to be used and
working as partners with us as we try to move this ahead both for individual
practitioners as well as for the state.

Mark Masseli: Sounds like not everyone is leaping though.

Dr. Lisa Dulsky Watkins: There is tremendous interest. If you had looked back
two years ago, you would have seen something like 11% or 13% of primary care
practices in the State of Vermont using electronic medical record. That number is
much, much higher now and that’s not even counting practices that are in
transition. You know we are looking at more like 40% to 50%. It's a huge change
and I do think that is a function of interest of some very enticing programs that
actually are you know grant to practices to both purchase electronic medical
records and also to have the support that they need in terms of practice
transformation and IT support plain and simple who do you call from the help
desk.

Margaret Flinter: Yeah right, exactly, and we are expecting over the next year or
two as the office of the national coordinator releases funds at that rate of
acceleration is going to speed up even more which is a good thing.

Dr. Lisa Dulsky Watkins: Absolutely but you need people on the ground who
really hand troubleshoot, not just technically too. I mean I couldn’t emphasize
enough the need for support for practices looking at their processes, looking at
their workflow, looking at how they interact with each other and with their patient.

Margaret Flinter: One of the things we were curious about is that Vermont is one
of not so large number of states that’s been successful in getting the insurance
companies, the payers to the table paying for some of these reforms at the
practice level and when I say payers in Vermont that includes Medicaid as well,
correct. So I think a big challenge from beginning was getting the payers on
board and we would assume that they were interested in better care but certainly

interested in controlling cost. Any early data on whether they have seen a
realization of return on that investment?

Dr. Lisa Dulsky Watkins: We do not have hard numbers to state whether or not
there has been a return on the investment in infrastructure of the Blueprint. That
will be available in the next 6 to 12 months and we have a tremendous resource
that we are just starting to be able to pull reports from which is a multipayer
claims database that allows us to actually flag the patients who are involved in
our integrated patients in a Medical Home Pilot and compare them to matched
cohorts in other practices.

Mark Masselli: Now, are you practicing physician right now?

Dr. Lisa Dulsky Watkins: I am not in practice right now. I am a general
pediatrician and I was in practice for ten years.

Mark Masselli: And how are your colleagues embracing this model as it rolls
out? What are you hearing directly from them? What's their reaction in the
communities not only from the providers but their medical staffs as well as you
roll this out?

Dr. Lisa Dulsky Watkins: Well, I think first of all you have to be careful not to
make generalization, certainly there is a spectrum of opinion but overall I would
say you have tremendous interest and enthusiasm for this type of work. People
who have been in primary care have been feeling like they are on hamster wheel.
They get paid for the perverse incentive of seeing as many patients as possible.
And people understandably were in practice and not just the physicians but
people who are in the practice and work in the practice which is a multi-
disciplinary team by definition are very interested in both taking better care of
patients as well as being compensated more fairly and compensated for the
things that really do matter in terms of keeping people well such as patient
education, self-management opportunities, coordination of services so that you
don’t have redundancy.

Mark Masselli: Does that really fall under the sort of Patient Centered Medical
Home Concept that’s both supported in the current federal legislation? Medicare
is now doing, starting some demonstration projects on it. Are you using some of
that in terms of reimbursement or the private companies in Vermont using that
model for reimbursement that sort of gets away from just the productivity based
model but more really around outcomes?

Dr. Lisa Dulsky Watkins: We have, based on the recognition of scoring if you will
from NCQA, established a patient centered medical home there if you will of
each of our pilot practices. And our insurers are covering per attributed patient in
each of these practice a certain amount of money per month based on that
score, so it's like a multiplication factor. So it really is paying for the quality of the

services that are delivered, the experience that the patient will have, not the
number of patients that were seen but the patients that are actually in the
practice. It’s a very different model and it’s also in star contrast to a more
traditional pay for performance mechanism, which is saying okay how you know
perfect can you get these blood tests, which of course doesn’t take into account
all the other human factors that have nothing to do with you know the actual
number.

Margaret Flinter: You know doctor one of the innovations that I think is being
watched most closely in Vermont because it's so applicable across the country to
communities where you largely have physicians and other healthcare providers
and small independent practices of one or two or three people is the
development of this community health teams that can serve a number of
practices and sort of share that resource. Do you think that that is a sustainable
model? Has that been a particularly successful effort in Vermont and something
that the rest of the country can build upon?

Dr. Lisa Dulsky Watkins: Right. I completely agree with that, yes. And it's
actually my favorite part of the program I have to say. The teams are, as I said,
multi-disciplinary. They are locally based. Every insurer in the country including
Vermont Medicaid has a telephone type of service that is a Remote Disease
Management Program. In Vermont, and I suspect this is probably true in many
other part of the country, people don’t really want to be called at home by
someone they don’t know and ask personal question for their diabetes. People
just don’t like that sort of intrusion and it doesn’t feel at all personal or may be a
little too personal with that sort of the background. The teams are designed at
the local level for people who work in the teams, work in the community in which
they are providing service. And they are multi-disciplinary as I said, so you will
typically have you know a nurse coordinator and a behavior health specialist,
may be a dietician and you know there are all kinds of roles that people fill and
those positions are paid for as a shared responsibility by the insurance
companies as well as the state kicking in as if we were Medicare, at least for the
pilot program.

Margaret Flinter: So now to get too deep into the details but this is really an area
that I hear so much interest and excitement about, so who do this community
health teams work for? They are not working for the practice, they are not
working for the State of Vermont or are they?

Dr. Lisa Dulsky Watkins: The way the money has sort of funneled through is that
they typically are working either for the hospital that is at the center of a hospital
service area and in Vermont the state is divided into a 12 different hospital
service areas or they might be working directly for the practice. The grant goes
out to the community and then it gets spent the way the community wants to
spend.

Mark Masselli: When you look around the country and the world, what do you
see in terms of innovations that excite you and that our listeners at
Conversations on Healthcare should keep an eye out for?

Dr. Lisa Dulsky Watkins: One of the opportunities we have had is to be part of
the Institute for Healthcare Improvement’s Triple Aim, which is an international
organization. My personal bias around this is that the construction of
multidisciplinary teams and as a link with community involvement and public
health measures and programs that I think are badly under-utilized is where the
key is. I think we are going to get to cost containment through prevention. I can
get a lot of other issues around cost containment obviously in terms of utilization
of expensive resources, but I really do believe that if people are baseline
healthier and have access to important preventive services that we will be
dealing with less morbidity and less bill population over time, it is not a quick fix
and that’s one of the very important take on messages around this whole
process. We are not talking about savings that will happen in a 6, 12 or 24
month period. I do think it’s going to take time.

Margaret Flinter: So excitement and patience both, today we have been
speaking with Dr. Lisa Dulsky Watkins, Associate Director of Vermont Blueprint
for Health, doctor thank you so much for joining us today.

Dr. Lisa Dulsky Watkins: You’re quite welcome, thank you.

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

Margaret Flinter: This week’s bright idea comes in response to a White House
led challenge from the Community Health Data Initiative. The company MeYou
Health recently released a new interactive game called Community Clash at the
initiative launch earlier this summer. Community Clash is an online card game
that picks cities against each other on the basis of public health data and it aims
to teach people about their city’s health and encourage them to take everyday
action to create a healthier community. Chris Carter, General Manager at MeYou
Health said they wanted to create a fun way for people to interact and get
motivated.

Chris Carter: We designed Community Clash to really be for anybody who wants
to engage with the health data as it pertains to their community. The real fun in
the game comes from that comparison of your community to another community
in the head to head clashes at the game.

Dr. Lisa Dulsky Watkins: The data used in the game combines information from
Twitter conversations, the Community Health Data Initiative, the Healthways
Well-Being Assessment and the Gallup-Healthways Well-Being Index. Side note,
MeYou Health is a subsidiary of Healthways. To begin the game, a player selects

their city and a rival city to compare. Then four cards are randomly dealt per
location, each card contains a datapoint for a Community Health Indicator such
as obesity, smoking diabetes and homicides. The fifth card contains the Gallup
Healthways Well-Being Index score for each city. A player can exchange up to
two of the cards before play begins by reviewing a list of matrix and deciding
which ones might improve their odds of winning in the clash. Players can also
choose to use their own Well-Being score instead of their cities by completing a
scientifically validated assessment. Community Clash provides several ways for
different players to interact with one another as well, including comparing their
personal Well-Being scorecards and sharing health related Twitter posts. In this
technological age games like Community Clash are proving to be an increasingly
effective way to communicate information by making complex public health data
easier to understand and fun to access, MeYou Healths Community Clash card
game is helping people learn about their city’s health and find tangible ways to
make themselves and the people around them healthier. Now that’s a bright
idea.

Margaret Flinter: This is Conversations on Healthcare, I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Healthcare, broadcast from the campus of Wesleyan University
at WESU, streaming live at wesufm.org and brought to you by the Community
Health Center.