Dr. Kavita Patel, Brookings Institution and Bipartisan Policy Center

(Music)

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, we’re just around the corner from that great time of year
when kids are heading back to schoo l of all ages. We’re excited for them and wishing
them best in the New Year.

Margaret Flinter: Well I cannot believe that once again summer has flown by. It seems
to go faster every year but this is a great time to remind our listeners that this is the time
of year to remember to schedule those back to school checkups, update your children’s
vaccines and immunizations and while you are at it , don’t forget to update your own.

Mark Masselli: It's also started school for folks pursuing careers in medical professions.
It's a good time to know that two new medical schools are opening around the country,
one in our home state Quinnipiac University ’s new medical school is going to be
focused in on primary care.

Margaret Flinter: Well we’re excited about th at and a shout out to them and
congratulations on their big effort and this comes at a time when we’re seeing that
millions of Americans will be gaining access to health coverage under the Affordable
Care Act and that means we’re also acutely aware that we simply don’t have enough
primary care providers, no r enough in the pipeline. I think we’re seeing a trend towards
more medical students choosing careers in primary care that’s a very good thing and it
can happen soon enough .

Mark Masselli: And Margaret you know well because you are the founder of our Nurse
Practitioner Residency Program. We have eight new residents coming in very shortly
and we look forward to them joining in the movement to increase primary care all across
America.

Margaret Flinter: And a shout out to those who are graduating this year, they are going
to all corners of the country to serve as primary care providers and we’re very excited
for them. Now , our guest has done significant analysis on the need for a better national
policy to direct resources towards filling that primary care need across the United
States . Dr. Kavita Patel is an internist at Johns Hopkins and is the Managing Director of
Delivery System Reform and Clinical Transformati on at the Brookings Institution.

Mark M asselli: She’s also a c o - c hair of the Bipartisan Policy Center's Health
Professional Workforce Initiative . Dr. Patel will be discussing the reports which examine
the need for better national planning strategies for projecting health care workforce
needs in the future.

Margaret Flinter: She’s a terrific guest Mark and we will also be hearing from
Factcheck.org ’s Lori Robertson who we can always count on to be out there uncovering
untruths about health reform in the public arena.

Mark Masselli: But no m atter what the topic you can hear all of our shows by Googling
CHC Radio and as always, if you have comments, email us at www.chcradio.com or
find us on Facebook or Twitter because we would love to hear from you.

Margaret Flinter: Now we’ll get to our in terview with Dr. Patel in just a moment.

Mark Masselli: But first, here is our producer Marianne O'Hare with this week’s
Headline News.

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Marianne O'Hare: I am Marianne O'Hare wi th these Healthcare Headlines. Electronic
Health Records and meani ngful use, the Healthcare Information and Management
System Society is looking for more time. They’ve asked the Health and Human
Services Secretary Katherine Sebelius for a six month extension for hospitals,
physicians and other health care professionals, to be federal guidelines for stage two
meaning use criteria for the federal electronic health record incentive payment program.
Under the current rules providers who have met stage one requirements for two years
must step up to stage two level requiremen ts by the end of the year to remain compliant
with the stimulus package money supporting the switch to EHRs. Healthcare
information leaders asked the Feds to leave the stage t w o starting dates alone but to
give providers 18 months instead of one year to a chieve 90 days of stage two
meaningful use compliance. The E HR Incentive Program has thus far paid out more
than 15.5 billion dollars to over 4 , 000 hospitals and more than 305,000 physicians and
other eligible professionals.

America’s obesity rates holdi ng steady but we’re still fat. According to a recent study
conducted by the Trust for America's Health and the Robert Wood Johnson Foundation ,
statistics have been released on the nation’s obesity rates and it's been found that after
three decades of stea dy increases rate held steady in the last year. The report if as in
fact how obesity threatens America's future, it show s that obesity rates v a ry region by
region with the south again leading the charge in obesity rate s . Louisiana has knocked
Mississippi out of the long held top spot with just under 35% obesity among adult s in
that state and they vary by ages well. The obesity rate for boomers in Alabama and
Louisiana is over 40% and sadly this is one area where there is gender parity. Men
have conned u p to women and now have roughly equal obesity rates. There’s also a
direct correlation between income and obesity, the lower the education and income, the
higher the obesity rates.

One rate has gone up dramatically over the past decade though. The numbe rs of
morbidly obese with Body Mass Index is over 40% that number has risen by 350%
since the beginning of 2000. The report issues guidelines for tackling the problem,

calorie labeling at restaurants, the report cautions more efforts are needed for obesit y
prevention that obesity related health cost stand poise d to cripple the nation’s economy.

Medical residencies , a gateway to practicing medicine through a gauntlet of sleep
deprivation experiments . Well at least it used to be. A pair of recent studies looked at
the impact of regulations restricting the number of hours first year residents could work
at a stretch during their on the job training. Critics of the new model limiting their shifts
to 16 hours warned they would negatively impact the flow of t heir training especially as
it would limit interns’ actual exposure to patient overtime. Researchers at UPenn and
the Boston VA among others looked at mortality rates after the new restrictions were put
in place limiting residents to 80 hour work weeks no more than 24 hours per shift.
Mortality rates stayed relative flat the first three years then started to decline. Another
study at Johns Hopkins looked at the breakdown of how interns spen t their time with a
limited hour restrictions access to and actua l time with the patients did drop slightly but
they also collaborated more away from the patient communication more through
electronic devices suggesting they were keeping one another up to speed remotely. It
suggests that well these students had less fac e time with patients. They increase their
team approach to care by some 20%.

And speaking of sleep deprivations America’s got an insomnia problem. A new study
shows instead of knocking yourself out with drugs try running it out but you’ll have to
slog i t out too. Study posted in the Journal of Clinical Sleep Medicine found that for
those who added at least three to four days of intense 30 minute cardio improved their
sleep each night by 45 minutes which is significant but the study found it took up to f our
month of that steady practice cardio for that sleep benefit to kick in.

I am Marianne O'Hare with these Healthcare Headlines.

(Music)

Mark Masselli: We’re speaking today with Dr. Kavita Patel, Managing Director of
Delivery System Reform and Clinica l Transformation at the Engelberg Center for Health
Care Reform at the Brookings Institution . Dr. Patel is also c o - c hair of the Bipartisan
Policy Center's Health Pr ofessional Workforce Initiative and co - author of two just
released reports, the C omplexity of National Health Care Workforce Planning and Better
Health Care Worker Demand Projections. She worked in the Obama A dministration as
well as a committee led by Senator Ted Kennedy in drafting of the Affordable Care Act.
She’s a practicing primary care physician at John Hopkins University. Dr. Patel
welcome to the Conversations on Health Care .

Dr. Kavita Patel: Thank you so much for having me. Please call me Kavita.

Mark Masselli: Kavita, great. So we’re just months away from the implementation of
the Affordable Care Act in January 2014 and we’ll see t e ns of millions of uninsured
Americans added to the system. So tell us a little bit about why workforce projections
are so complex in health care and why your reports are so important in helping us

u nderstand why the lack of relevant health care workforce date is, obvious you’ll
equipped to meet the coming needs.

Dr. Kavita Patel: Let me just start by telling you that when we were surprised , it was
sobering to myself that when you look for supply es timates just how many health care
professionals they have in this country, you’ll find such a variation from one stores to
another and it's because of how we count health professional so in some cases
physicians are counted only as primary care doctors and don’t necessarily include the
specialists and then in some cases nurses are people with just an RN but if you go to
some of the nursing societies they also include people with RNs as well as other
advanced degree s like PhDs and so there were such a wide v ariety of our estimates
that we thought okay, we need to first do deeper dive and what are the sources o f data,
what are the differences sources of the data and then we can start to talk about how do
we look at a model for what kind of health care workers we might need or for example
the demand of health care and it was -- as I mentioned very sobering to try to
understand all the differences between some of these number s which made it even
more complex.

Margaret Flinter: It seems to me Kavita that one of the challenges you have and I
thought you made this point really compellingly and one of your reports is that we keep
piling lots of new data on the top, when you've made the case we really have to change
the underlying assumptions if we want to make use o f the new data. Can you talk a talk
a little bit more about that for our audience?

Dr. Kavita Patel: Sure. Let's just take a very basic example. A lot of our data
assumptions about what kind of workforce we need are modeled on our current system
or ol d systems of team patients in office visits and having always be a physicians who
leads that office visit and we also have used other assumptions about how many
doctors you need for a thousand patients and we’ve used that model for years in fact
decades an d in all -- in the meantime we since had all these models at Care Patients
Center Medical Homes, Accountable Care Organizations, we’ve seen a great
proliferation of community health workers, lay health workers the use of nurse
practitioners and physicians assistance in practices. But our model and the way we
think about how much care we need still hinges on this very cottage like industry with a
doctor in charge. Those are the assumptions we use when we start to say, well there’s
a shortage and I think th at, that’s part of what we try to tackle was, wait a minute let’s
not just talk about how we might need one doctor for every, you know, 5 , 000 people in
the country. Let’s actually think about what kind of care do 5 , 000 people need, and then
what are the s kill sets of the various members of the healthcare team that best suit
those needs, that’s almost fourth in the equation and saying what is this that we want to
get to a nd how do we work backwards to figure out what we need to fulfill that.

Mark Masselli: You know, you’re seeing the fast rise of retail clinics, lot of different
ways that people are delivering and caring. You really look at the distinction between
patient demand and true healthcare need, how are these needs differing in the different
soci al economic groups as well?

Dr. Kavita Patel: We really thought long and hard about how you deal with especially
the needs of high risk populations, take for example the 11 million Medicare dual
eligibles and Medicare and Medicaid dual eligibles for this country really high
concentration of need. And one thing that we found is that in modeling our demand
side, so we talked about so far a little bit and I kind of alluded to the demand that’s
where the information about some populations really comes to pla y. What we found
was that instead of looking at those location or site of care, we really need to
understand how could care delivery to special populations look differently we must
agree on some standardize data reporting, and then -- and these means not just on
supply side but we have to have some standardize reporting on the demand side
especially for populations of special interest.

Margaret Flinter: One area seems to -- me from working at the state level anyway is,
we don’t have any uniformity across states in terms of the kind of data we collect.
What’s your approach as really a national research group looking at this, what’s your
approach to trying to get states to agree on how to collect data in common and
electronically and what the critical elem ents of data are to collect?

Dr. Kavita Patel: So, this is a perfect question because we actually reached out to a
National Governors Association who has been very interested in this exact issue. What
are the minimums state data reporting requirements ? And we canvassed across the
state to try to understand what is it that they currently do a nd then who can we
effectively give them some recommendations and they are actually more than willing to
ad o pt a little bit more of standard approach. But, I was su rprised people said look we
are overwhelmed, we have no idea what to do about this, we want you to tell us what to
do. So, what we actually did is we went back and then went to our federal colleagues in
the Health Resources and Services Administration, wh ich is tasked with doing some of
these work a nd through the Affordable Care Act, we actually went back to them and
said listen can you tell us what you’re coming up with in terms of minimum data
elements, and how you’re recommending those be collected. An d then we will take
those back to the state s and that’s -- that’s exactly the process that we’re in right now,
we’re actually taking what HRSA has been doing and recommending and saying to the
states, we’re not telling you, you have to do this. Here’s wha t the Federal Government
is trying to, here is how we could recommend you do this, and the timing could not be
better because they already updating their data collection infrastructure to meet the
needs of the expanded Medicaid enrolment, and health insura nce exchanges. So
they’re willing to do this, but they just need help, I mean these are really great people
inside the state who are trying to do everything at the same time. So we found that it
was best to pair the work going on at the federal level and say here’s the minimum and
Health IT plays a big role in this . We’re trying to explore right now how to get the best,
how we can try to understand some health work force staffing information based on the
Health IT systems that are currently deployed acros s the countries.

Mark Masselli: We’re speaking today with Dr. Kavita Patel, Managing Director of the
Delivery System Reform and Clinical Transformation at the Engelberg Center for Health

Care Reform at the Brookings Institution. Dr. Patel served in the Obama Administration
as the Director of Policy for the Office of Intergovernmental Affairs and Public
Engagement. So lot’s of exciting opportunities arise out of the Affordable Care Act, it’s
created many new incentives and innovations in health care, it’ s also created some new
challenges, you know what through for our listeners some of those challenges in how
you think we might best meet them.

Dr. Kavita Patel: I do think that we are really at a precibus of how can we leverage the
data that we have and then these emerging models of care. And, so one thing I would
say that we walk through this as we’re thinking about restructuring care differently, and
we’re thinking about trying to decrease the cost of health care and then we’ll also
looking our patient s in the eyes and saying, you know what I’m going to try to make sure
that I give you the best information in a small amount of time as possible, but I will also
hope that you take that information and make better decisions from it. So I see this is
like a narrative of a -- kind of a cycle -- life cycle, and then we also have to look at some
of these emerging innovation models and say , what are we learning about the kinds of
training, the skill sets , and the response from our patients. And then how do we see
that back, I mean we have a massive infrastructure of education in our country and we
don’t talk about it a lot. We talk about health reform a lot, we don’t talk about going in
and opening up our classrooms and saying, wait a minute are we actually tr aining the
types of people that we actually want o n the receiving end ? A nd I would say to you
there’s a great disconnect there, so I see this as a great life cycle and a true biological
sense. We need to cycle it back and I think that to me that’s the na rrative, not just the
workforce study but the Bipartisan Policy Centers doing the work on cost containment,
they’re doing work on Health IT , t hose things have to marry together.

Margaret Flinter: You know the Affordable Care Act had a number of important
provisions that have not yet come to past and I noted in your report, you addressed or
you listed one of them which we actually authored around the demonstration grants for
family and nurse practitioners training programs which are in there but not yet
ap propriated but -- funded but much larger than that really is the creation of the National
Health Care Workforce Commission that would have address this need from more
centralized data and I think probably would have gone at that connection between
educatio n, training not just the clinical care but to models of care and what’s your
expectation about what will happen with that National Health Care Workforce
Commission?

Dr. Kavita Patel: If I start getting brought down and what Congress can and can’t do I
th en just having worked on the inside, it can get pretty depressing. I am optimistic that
all the things we’re talking about and by the way I’m a fan of your program because I
think you all do a great job of bringing this complex concept to people in a very kind of
digestible way. I think everything you’ve been talking about for months now quite
honestly is going to come to ahead when we’ve got headlines in 2014 that say, you
know, in certain parts of the country it’s hard to find a primary care doctor, etc etera,
etcetera. And I think that will force the issue for people to say wait a minute we have
this provision in health reform what happen to it, and then we’re really talking about two

to three million dollars for the workforce commission to be funded. But in the big picture
and the impact it could have it’s a great investment, so I’m optimistic that in the next
year we’re going to see enough demand for the information that the commission will
have. In the meantime though, we have got to figure out how to leverage the private
sector and I know we say that a lot in health care, but I’m serious . We are seeing the
big insurance companies , big integrated systems like guys in Kaiser we sees them
come forward with their own creative data set solutions models of care and estimates. I
think we need to go back to some of these leaders in the private sector and say listen,
let’s actually think about what the needs could be and what you can teach the rest of the
country in terms of what you found and then actually let’s take that out and show how
states like Texas can think about Medicaid expansion and workforce models in a
different way.

Mark Masselli: I really liked it when you took us back to that big picture looking at the
triple aim of the Affordable Care Ac t to increase access improve outcomes and reduce
cost. And questioning how they come back to the educational system. So there’s other
--

Dr. Kavita Patel: Great.

Mark Masselli: -- there are so many different models happening and I just really worry
t hat the educational system in our leadership for th at next generation of nurse
practitioners, physician assistance, physicians , all the allied health providers just aren’t
ready for primetime and we are at a point of reinvention and redefinition of how pri mary
care could operate in an optimal setting, what should we be looking out for rays of hope
from you?

Dr. Kavita Patel : So let me tell you that I always look for rays of hope in a lot of different
pair settings. So we often talk about, you know, Virgi nia M ason G roup H ealth , Kaiser
they’re incapacitated settings, they ’ve got kind of a lovely bubble around them so to --
so I look for things that could actually take advantage of really amazing care in a
steeper service setting. Let me give you two exampl es in Medicare, one is a program in
Florida called ChenMed they take care of pretty much a 100% Medicare patients and
they do it in Florida, one of our costliest states and they do the following, they send out
a town car to pick up patients and they do aut o reminders for patients and they have
elderly patients but we think the elderly don’t use technology they do -- they got
grandchildren that they talk to on Skype and Facebook more than I do. So they meet
the needs of patients that generally cost the syst em a lot of money but they meet the
needs by dealing with things that don’t get reimburse by Medicare, but what they found
is they can actually make money, meaning they’re not losing money on this and they do
this kind of wrap around in text reminders abou t preventive services that are due, and I
think that, that’s an amazing accomplishment in the Miami area.

The second one I’ll tell you about is you may have heard of because he was profiled in
one of the toggle and as I says Rushika Fernandopulle started Iora Health and they take
what you’re talking about a little bit mark with kind of the pot design. But they take the

hot spotters and design a clinic around hot spotters needs and they’re doing this in
Massachusetts and Atlantic City, New Jersey and they’ ve just opened all in a Medicaid,
Medicare setting mostly dual eligibles and they s a t in looked at what hot spotter’s needs
are when they do come to clinic and they basically structured an entirely different flow of
work to address those needs. And so I t hink that those are rays of hope because
they’re entrepreneurial, they’re in our current system which in a large r way is somewhat
broken financially but they’re doing something and they’re making it work financially.
And what I hope is that I really want Rushika and ChenMed to give us the data on how
they’ve understood the staffing needs for their health care and how we can actually go
back to some of the top medical schools and nursing schools and Allied Health Workers
Schools in the country and say how a re we training people to engage in work in this
environment.

Margaret Flinter : We’ve been speaking today with Dr. Kavita Patel Managing Director
of Delivery System Reform in Clinical Transformation at the Engelberg Center for Health
Care Reform at the Br ookings Institution. Dr. Patel is also the co - chair of Bipartisan
Policy Centers Health Professional Workforce Initiative and the co - author of two just
released reports “The Complexities of National Health Care Workforce Planning and
Better Health Care Wo rker Demand Projections” . You can access these reports and
learn more about her work by going to bipartisanplolicy.org. Dr. Patel , thank you so
much for joining us today on Conversations on Health Care.

Dr. Kavita Patel : Thank you for having me.

(Musi c )

Mark Masselli: At Conversations on Health Care we want our audience to be truly in the
know when it comes to the facts about health care reform and policy, Lori Robertson is
an award winning journalist and Managing Editor of FactCheck.org a non partis an, non
profit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori, what have you got for us this week ?

Lori Robertson: Well, Mark and Margaret we receive several questions from readers
about online reports that c laim the IRS said the cheapest health insurance plan for
families under the Federal Health Care Law would cost $20,000. But that’s not what the
IRS said at all . Instead this number comes from a hypothetical example in an IRS
document about how it would c alculate the tax penalty for a family that doesn’t obtain
health insurance as required by the Affordable Care Act. The Treasury official told us
that the $20,000 figure was quote not in estimate of premiums. Like many viral claims
this figure was taken o ut of context and then embellish, the IRS wasn’t estimating the
cost of premiums at all, the fact is no one knows exactly how much insurance plan sold
on state and federal run exchanges will cost. Back in January 2010 shortly before the
law was passed, th e Nonpartisan Congressional Budget Office estimated that the
cheapest plan would cost between $12,000 and $12,500 for family policies. But CB O
hasn’t updated that estimate since.

CB O did say that about 80% of the 25 million people getting insurance on th ese
exchanges by 2023 will receive federal subsidies to help cover the cost. And the
average subsidy would be $8 , 290 for the year . For those who are interested the Kaiser
Family Foundation has a subsidy calculator on its website that gives a sense of who is
eligible for subsid ies and how much those subsides might be. And that’s my Fact
Check for this week . I’m Lori Robertson Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country’s
major poli tical players, and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you’d liked checked, email us at
CHCradio.com we’ll have FactCheck.org’s Lori Robertson check it out for you here on
Conversat ions on Health Care.

(Music )

Marianne O’Hare: I’m Marianne O’Hare with this tech report.

Imagine the future where any object you need even in organ or on layer of skin could be
grown in front of your eyes in a 3D printer. The future, it’s here . 3D pr inting is exactly
what it says, three dimensional objects are produced via any number of materials in a
mechanized back and forth, back and forth layering system. And through basic
computer animated design, they program to build well, just about anything.

David Flanders: 3D printing will change everything and more to the point because it’s
physical reality I think it’s especially going to change the way we think about money and
also all the opportunities for making money from these objects.

Marianne O’H are: It’s become a hot topic at the world’s many head thought gatherings
and implications for health care could be limitless in their potential. At a recent TEDx
event in Homburg Germany, 3D expert David Flanders shared what is already being
tested in ti ssue growth using 3D printing technology.

David Flanders: There’s already several universities in the S tates who are actually
starting to be able to graph skin cells from you, cultivate those skin cells put them in a
syringe type mechanism be able to put your hand down or other body part, lay the
printer over the top and actually print a new layer of skin on you this is actually
happening.

Marianne O’Hare: Since technology is already working hard in generating the growth of
new organs to all kinds of bi ological means and thousands of people die each year
waiting for organ donations. There could be a time but not too distant future where you
could grow your own new liver in a 3D printer from your own cells.

David Flanders: And this is where I think thi s can really change lives full stop, is the fact
that wait for us has already demonstrated the ability to actually cultivate your liver cells,
cultivate those and then print you a new liver. And that doesn’t mean you shouldn’t stop

signing your organ dono r cards, this technology is not fully capable yet but it’s well on its
way and it’s starting to get there.

Marianne O’Hare: There are far reaching implications for building everything from a
better implant of all medical device to exact specifications to a person’s own body type
chemistry and shape, better prosthetics design to fit perfectly the dimensions of one’s
owns specific injury or the foundation for growing new body parts like ears in a matter of
hours. 3D printers are being created in desktops s ize unit, they could be built and
assembled for a few $100, expect to see a lot more technological breakthroughs in
medicine and it’s exciting world of 3D printing . I’m Marianne O’Hare with this tech
report.

(Music )

Mark Masselli: Each week conversatio ns highlight ’ s a bright idea about how to make
wellness apart of our communities and to everyday lives. When Jennifer Staple C lark
was a sophomore at Yale and the internship at the Ophthalmology office turn out to be a
life transform ing exper ience she rea lize that many of the patients who had limited
access to medical care were coming into the office with serious eye conditions that had
gone past the point of reversing leading to unnecessary blindness. What she launched
from her dorm room 11 years ago was a local initiative to improve access to preventive
eye care to the neediest population in her local community. Her vision quickly gr e w
within two year she took her organization Unite for Sight worldwide and has since
turned it into one of the leading pro viders of global eye care in hundreds of communities
around the world. Unite for Sight bring social entrepreneurs , public health experts, local
eye surgeons and volunteers together to bring eye care into some of the most
underserved areas of the world. T he motto at Unite for Sight is that local problems
need local solutions, so they use each countries existing pools of ophthalmologist to
treat their local patients, they also trained community health workers in each area they
served, thus removing traditio nal barriers and also ensure in a continuum of care for all
of the patients they served . The community health workers provide education and
transportation to get doctors to the patient’s communities and patients to the hospital as
surgery is indicated. S ince its inception Unite of Sight has served 1.4 million patients
worldwide and restored eye sight to roughly 55,000 people. Restoring not only their
sight but their dignity and ability to be productive members of their communities as well,
identifying an d pressing medical need and improving the quality of life by offering basic
preventative eye care to those who had previously gone without. Now, that’s a bright
idea.

(Music )

Margaret Flinter: This is Conversations on Health Care, I’m Margaret Flinter.

Mark Masselli: And I’m Mark Masselli, peace and health.

Conversations on health care broadcast from the campus of WESU at Wesleyan
University s treaming live at wesufm .org and brought to you by the community health
center.