Dr. Rishi Manchanda, Founder and President of HealthBegins

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

Margaret Flinter: And I am Margaret Flinter.

st
Mark Masse l li: Well Margaret, we are inching ever closer to October 1 , the day
that the online insurance exchanges in the Affordab le Care kicks off.

Margaret Flinter: Well, it's a day we have waited for, for a long time. And a lot of
states are still scrambling to get online for the first customers who will be w anting
to purchase insurance in the new online marketplace .

Mark Mass el l i: New York State is ready for business with its exchanges. They
even have a catchy marketing campaign with a little help from Billy Joel . We are
in New York s tate of h ealth , has a nice ring to it.

Margaret Flinter: I wish we could find a song like that in our state. And of
course , they have also made their insurance rates available for review as have
all the states , and it appears that there will be some bargains for New Yorker s
shopping for insurance under the Affordable Care Act .

Mark Masselli: Indeed , several states are boasting insurance rates that are far
lower in some cases than the going commercial rates.

Margaret Flinter: And speaking of insurance rates , Mark, for the second year in a
row, the growth in insurance rates has slowed consid erably on a national level.
We were seeing almost double digit increases in recent years ; in fact, health
insurance premiums were up 196% since 1999. But last year, the increase was
a modest 4% and I am hearing we are going to see that again this year.

Mark Masselli: Margaret, you are absolutely right. Insurance premiums for job -
based family coverage rose a relatively modest 4% reflecting slowed health
spending , but that’s not necessarily the rosiest of pictures. For the first time,
average health ins urance cost for a family plan has topped $16,000 . That’s a lot
of money for health coverage.

Margaret Flinter: It is. And of course , there is huge concerns about the out - of -
pocket expenses not just the premium. So still so much work to do to contain
h ealth care costs . That’s going to require transformation in how we deliver care,
how we make it more efficient and more e ffective in terms of the outcomes for
everybody.

Mark Masselli: That’s something our guest today is working hard to do. Dr. Rishi
M anchanda is the Founder and President of HealthBegins, a startup using
innovative technologies to improve care for patients with social as well as
medical needs.

Margaret Flinter: He has written a really interesting book , The Upstream
Doctors , in which h e promotes the growth of an upstreamist movement treating
the social determinants of health that are so associated with poor health
outcomes.

Mark Masselli: We have got another visit from Lori Robertson, managing editor
of FactCheck.org.

Margaret Flinte r : And no matter what the topic, you can hear all of our shows by
Googling CHC Radio.

Mark Masselli: And as always , if you have comments , email us at
www.chcradio.com or find us on Facebook or Twitter; we would l ove to hear from
you.
Margaret Flinter: We will get to our interview with Dr. Rishi Manchanda in just a
moment.
Mark Masselli: But first , here is our producer Marianne O'Hare with this week’s
Headline News.
(Music) Marianne O'Hare: I am Marianne O'H are with these Healthcare Headlines .
Doctors and Medicare patients, the numbers are up. According to our report
from the Department of Health and Human Services, the number of physicians
accepting new Medicare patients rose by 1/3

rd
between 2007 and 2011 . It's now
higher than the number of physicians accepting new private insurance patients.
It's p artly reflection of the aging population . We are only weeks away from the
st
October 1 start date when Americans will be able to purchase health insurance
onl ine in those insurance exchanges setup by the Affordable Care Act . And
California is one of the states who got into the act early. But a poll out shows the average Californian knows little to nothing about the state exchange s. The field
poll found only 25% of Californians had heard anything about the state ’s
exchange called Covered California , and only 18% of the uninsured population ,
those who are most likely to be users of th is system , had any knowledge i f all of
how it works. The poll ’s findings sugg est much more needs to be done to
educate consumers in California .
And what about the National Health Insurance scene which will be covering the
needs of more than 30 states across the country ? A couple of national surveys
are making some predictions. T he average health care costs across the board
are expected to rise a little over 5% in the next few years. And most analysts are
predicting an increase in high deductible plans being offered to employees as
well as incentive programs for wellness activiti es like increasing exercise and
losing weight. But workers don’t have much to cheer as the increases are still

double the rate of wage increases and four times the rate of inflation. I am
Marianne O'Hare with these Healthcare Headlines .

(Music)

Mark Ma sselli: We are speaking today with Dr. Rishi Manchanda , a physician,
public health entrepreneur , and f ounder and p resident of HealthBegins , a startup
implementing innovative technologies to improve care for patients with social as
well as medical needs. Dr. Manchanda is also Founder of Rx Democracy, a
national nonpartisan coalition to promote health equity through civic and voter
participation. He is a board member of the National Physician s Alliance , and Dr.
Manchanda is also author of the Upstream Doct ors in which he calls for the
upstreamist movement to transform health care by addressing the social
determinants of health care. Dr. Manchanda , w elcome to Conversations on
Health Care .

Dr. Rishi Manchanda : Thank you for having me .

Mark Masselli: You have been a long time activist , seeking better health
outcomes for tac kling social determinants of health. In your recently released
book, you coin ed the phrase upstreamists . Tell us about this upstreamist
movement you are trying to generate in health ca re and who are the
upstreamists in the health care system .

Dr. Rishi Manchanda : In the book, The Upstream Doctors, I argue that the future
of health care depends quite simply on growing and supporting more
upst reamists. And these upstreamists are the ra re innovators who are on the
frontlines of health care. They are the ones that see th at health like sickness is
more than a chemical equation . They are the ones that see rather that our health
begins in our ever yday lives , in the places where we live , wh ere we work, eat and
play , what the exper ts call the social determinants of health. They can be
doct ors, nurses or other clinicians. They are the ones who know that asthma for
instance can start in the air around us . They understand that obesity and hea rt
disease originate partly in the way that we have constructed our busy modern
schedules , in the way that our neighborhoods are designed. Now the last point
about the upstreamists is that the upstreamists move beyond just having this
understanding of hea lth where it begins but really translate that knowledge to
meaningful action and they do so not just as advocates in the community but as
really transformers of their clinical care delivery.

Margaret Flinter: Dr. Manchanda , you had an early introduction into the
upstream concept of health care . You were a student at Tufts, working with the
underserved population in Boston and you have worked in rural communities in
Africa, South America and India. And I am really curio u s to ask you , in so many
ways the touch points are similar to the development of the Community Health
Center Movement in the United States with Tufts and the work of Dr. Geiger and

others. I know you have been involved in Community Health Centers in your
career, and so tell me where does the upstreamist movement take off from those
concepts of community - oriented primary care and being of and in the community
and responding to the social determinants of health.

Dr. Rishi Manchanda : I think it's a great point and in fact in the book I talk about
the lineage of upstreamists that dates back to e ven further back beyond Jack
Geiger , to the (07:09 inaudible) of course in South Africa where Geiger himself
received his own inspiration , and then even further back to Rudol ph Virchow, the
father of m odern pathology as well as the father of social medicine. So the
upstreamist movement has been part of medicine from the get - go in terms of
modern medicine. And I think COPC, the Community - Oriented Primary Care
movement here in the U.S. , the Community He alth Center Movement, certainly
the upstreamists who are out there o n the front - lines of health care today are all
part of the same l ineage. There is a lot to be learned I think from the lessons of
upstreamists , pioneers . It's vital for us to think about the ways in which we orient
the health care system to treat health where it begins.

Mark Masselli : And I want to pull the thread a little on the concept of
upstreamists. In your book , The Upstream Doctors , you give a very illustrative
example of why he alth care industry is failing so many . And you talk about a
patient Veronica who had been su ffering for over a year with progressively
worsening headaches and other debilitating ailments and the use of specialist
and numerous test s didn’t really have any e ffect on her situation. So tell us
about the upstreamist approach you took to focusing on her disease causality
and how things were turned around .

Dr. Rishi Manchanda : This wa s a patient who came into a clinic I was working in ,
in South Central Los Ang eles and when I first met her , she had her head in her
hands in the exam room and she had been suffering from headaches that had
come and gone for a number of years . She had gone to three different
emergency rooms trying to get relief or care. In months and years prior, she had
tried to get relief in going to the fragment ed primary care system in that
community and was still unable to kind of get a diagnos i s. Prior month s before I
had seen here , she had received a dozen blood tests, a spinal ta p or a lum bar
puncture, and it's the whole host of interventions that represent in some ways the
best of modern medicine.

But for Veronica , each visit t o the emergency room ended the same way. She
was told that her test results were “normal.” One of the hospital visits led to a
$1200 bill, her own rent was about $850 a month so already she was
experiencing stress financially. She was fighting bac k tears as she described the
toll this situation was tak ing on her family. But I do think there is something in
Veroni ca’s story that ’s also more illustrative of the upstreamists scenario , and we
did things slightly differently . And the difference was that our medical assistant
not only recorded vital signs as part of the normal operating procedure in a clinic

but she al so asked her some simple questions about her housing. Veronica
indicated that she had problems with mold and water leaks . That data helped to
tailor my care ; that social data was critical. It allow ed me within 15 minutes to
feel pretty confident in my d iagnosis after talking with her and doing a targeted
physical exam. Veronica in fact had migraines related to chronic nasal allergies
and si nus congestion and these conditions are often made worse by dampness
and the very things that were marke rs of such housing in her home.

So I ended up giving her some treatment but then I also referred her as part of
my treatment plan to a program run by our clinic in partnership with some local
organizations to help make her housing healthier. And so one of our partn er
organizations sent a community health worker to her home and assessed her
situation, provided her with new techniques for controlling some of the dampness
in her home, and even connected her to resources so that she c ould advocate
more clearly with her landlord. Veronica follow ed this advice. A f ew months
later, she came back in the clinic and she hadn’t been to the emergency room
anymore , h er home was healthier , her headaches were gone and she and her
family had gotten better. That’s a glimpse as I c all it in the book of a slightly
better standard of care and I think that’s illustrative of what we can all strive for
with the upstreamist approach.

Margaret Flinter: I think you have a stated goal of promoting the development of
a national task force o f at least 24,000 upstreamists in the American health care
system by the year 2020 and you have said that we don’t just need to cultivate
the upstreamists but the comprehensivist s and the partialist s and the integrated
medicine also plays a vital role. So tell us how you are going to develop,
cultivate, inspire this national task force.

Dr. Rishi Manchanda : The upstreamist really comes from that simple story that
many of us know in public health which is the story of friends who approach a
river and see a child pleading for help and the three friends jump in to try to help
that child to safety , only to find that there are more children in the water , and
eventually overtime those friends start to take care of those children . One of
them focuses on the chi ldren who are at most risk of drowning right away. Those
are what I would call the partialists or the specialists in our system today. They
are the ones who are trained and are vital parts of our system. The other person
becomes the comprehensivist , the one who can coordinate a raft so that they can
avoid falling over the waterfall . But that’s the e r a that we are in right now , the e r a
of the comprehensivist . As we have seen with the Affordable Care Act , we have
a moment right now where the Patient - Cent ered Medical Home is on the rise , t he
idea that everybody deserves a personal physician and a team of providers.

The story though , that parable also includes a third person and that is that person
who starts to swim upstream and she shouts back I am going to find out who or
what is throwing those children in the water. By the year 2020, many expert
organization s estimate we will need about 460,000 partialists. Expert s estimate

that we will require certainly more comprehensivists and we will need around
2 50,000 primary care comprehensivists by the year 2020 . That’s about 45,000
more than we have currently as well . While we stri v e for that goal that we also
again get 24,000 upstreamists in the system and these are people specifically
task ed with the oppor tunity to redesign their health care system to build bridges
to other sectors to improve the quality of care and the social determinants of
health .

Mark Masselli: We are speaking today with Dr. Rishi Manchanda , a physician,
public health entrepreneur , an d founder and president of HealthBegins , a startup
implementing innovative technologies to improve care for patients with social as
well as medical needs. And Dr. Manchanda is also author of The Upstream
Doctors , in which he calls for the upstreamist move ment to transform health care
by addressing the social determinants of health. So there is a lot of providers
coming into the practice w ho are going to end up being upstreamists and so it
doesn’t seem that there is currently an infrastructure in place to support the
outreach that you envision. So let’s look at your new startup HealthBegins and I
understand it's a portal for upstreamists in health care to connect and share
solutions to address patient and social and community needs. So what are the
new in novative technologies you are deploying with HealthBegins ?

Dr. Rishi Manchanda : So the work of HealthBegins is to use to try to work in
both addressing some of those specific problems head - on and find partners to
address the ones that we are not able to address head - on. So , for instance, the
first thing we did in terms of our work with HealthBegins , we decided to take on
the first challenge of the lack of a network . There simply isn’t at this point a
space for upstreamists to come together as there is f or the comprehensivists and
the partialists . And we decided to create that both in the real world as well as
online several months ago . We started an online platform and now it's invite - only
platform ; people can visit the site at HealthBegins .org and sig n up.

But the other work that we are doing is around training and across the country
not only are we giving presentations to residen ts and practicing clinicians b ut we
are also taking that content, give specific information about how we can connect
the do t s within health care to the social determinants . We are moving our
content into online modules, moving content into a format that’s accessible by
learners at all levels. And so by deconstructing the infrastructure problem into
addressable pain points , w e can really make a dent in this movement.

Margaret Flinter: Dr. Manchanda, I know from what you have said and what you
have written that you are interested in data, big data sets that really help you
understand populations. A t our home state here, the health directors have
worked very hard over the past several years to develop a health equity index,
which looked at every single city and town and the state, of the social
determinants of health , really able to create an index down to the block level.
Ar e there any points of li ght around the country where that level of availability of

data on the social determinants of health likely to be a ffecting that individual or
that family are incorporated into the primary care system?

Dr. Rishi Manchanda: Yeah. The great news is you are talking about
Connecticut and around the country that there are some glimpses of better care
on the horizon and of specifically the applications of Big Data, of Health
Information Technology, and bridging this divide between clini cal care and the
social determinants. So I think of examples in the State of Vermont where the
blue print for health that has been adopted there as part of their statewide
implementation of the Affordable Care Act has not only called for a medical home
an d the formation of Affordable Care Organizations b ut really the inclusion of
community health workers and there is going to have to be a data infrastructure
in place in that state. There is examples of organizations out in as far as Hawaii
that I profile in the book about a clinic called KKV for short and w hat they do is
collect information about their patients’ food habits and access to food , and
based on that data , we are able to not only provide better care in the clinic walls
but then advocate for the institution of a community farm.

The Institute of Medicine released a report outlining opportunities to improve the
integration of primary care in public health. And as that report indicated ,
widespread adoption of electronic medical re cords represents a major
opportunity . Many clinics are well - position ed to collect data from their patients on
the social determinants of health . We are going to have the ICD - 10 that updated
classification list developed by the WHO that’s in the next few years going to
com e online and require clinicians in the US to code for diseases and signs and
symptoms of course b ut also for social circumstances to a level of specificity
that’s been unprecedented.

Mark Masselli: You know , I want to talk a little bit about the t ech sid e because
health care industry has been very slow to adapt and adopt into new
technologies. You say you have been looking at the (16:5 2 inaudible) like
roadmap for health care and you say it's been done in other industries and
obviously it's not been done in health care and it should be a way finding tool.
Tell us about your idea for a six - step roadmap that can help us better map out
the social determinants that are impacting population health.

Dr. Rishi Manchanda: Yeah. I think it's important because there is a rise of
technology solutionism and for us not to fall into a trap that many technology
enthusiasts sometimes report which is that there is an app for everything. In
some ways, technology can only make us better and more efficient but it enables
the real work of the upstreamists which is to leverage that technology and data to
move the needle on the social drivers a nd that means the work of face - to - face
organizing . While there is an app for a lot of things, there is not an app for the
important work o f reorganizing our health care system. So the six - step roadmap
within HealthBegins is design ed to help the people who might be listening to this

right now and thinking well if I want to be an upstreamist , that sounds great but
how do I do this.

So we walk people through those six steps and make it attainable. The first step
is of course to define the population and then to move on to define the social
determinants of that community a nd to use technology to do so to then develop a
very specific inte rvention and then to use the best knowledge of quality
improvement to think about moving the needle on that social determinant , not
only taking the data from that pilot but then of course celebrating that spread and
using specific tools that come from the social movement and business
community to spread that knowledge .

So the specific example of where the tool of the (18:22 inaudible) comes in i s we
started working on the education side with high school students and over the
past year, so many high school students have participated in the educational
curriculum where they learn about the social determinants of health . Every
week , as they learn about housing or nutrition or whatnot , they also map the
resources that can address those drivers. And when I say map it, they literally
are going online and looking for the resources that can address the needs of their
parents and their neighbors. And that mapping exercise results in a resource
listing database that we then turn over to the clinical partners to say now use this
resource listing database, this (18:54 inaudible) service to now more easily
connect a patient with a social need to the resource that these students have
mapped. We called this model Community Health Detailing 2.0 , the idea of
taking exerci se of detailing th at the pharmaceutical industry has used for so long
and bringing it to using the expertise and the power of community mapping to
help detail the prescribing behaviors and the practices within a clinic. So the
community itself is saying h ere are the resources doctor that exist outside your
clinic w alls and here are the ways in which you can help a patient that walks in
your door to find them through a simple, easily accessible online tool. That’s our
vision, we have built the prototype of it and are proud to be in the midst of a beta
right now with some clinic partners here in Los Angeles to make that app.

And right now, doctors and case managers and others in the health care system
are looking at when they find a patient coming in with a social need , they are still
looking at b inders full of tattered papers to find that number for the housing
agency or the (19:53 inaudible) provider or the food stamp or the legal aid
th
foundation. So it's incredible that we are still using 12 Century too ls to t ackle
st
21 Century problems.

Margaret Flinter: We have been speaking today with Dr. Rishi Manchanda, a
physician, public health entrepreneur , founder and president of HealthBegins,
and author of the Upstream Doctors : Medical Innovator Track Sickne ss to its
Source . You can learn more about his work by going to www.healthbegins.org or
follow him o n Twitter by going to Rishi Manchanda. Dr. Manchanda, thank you
so much for joining us o n Conversations on He alth Care today.

Dr. Rishi Manchanda: Thank you for having me here.

(Music)

Mark Masselli: At Conversations on Healthcare, 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 nonpartisan, nonprofit 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: President Obama r ecently made a sweeping claim about the
Affordable Care Act , saying that all of the uninsured would be able to get
insurance o n the exchanges “at a significantly cheaper rate than what they can
get now on individual market even , without federal tax credit s .” But experts
including Health and Human Services Secretary Kathleen Sebelius have said
that younger Americans would likely pay more on the exchanges while those who
are older would likely pay less. Much will depend on the individual. If you have a
med ical condition , you will likely pay less on the exchanges than what you would
have paid on the individual market , and perhaps you weren’t even able to get
coverage at all . But not everyone will pay lower rates.

The law requires a minimum set of benefits which will make some plans more
generous and more extensive. The law also changes how insurers can calculate
rates , and experts have long predicted that will cause a shifting in premiums.
Right now , insurers can charge more based on health status or gend er. They
won’t be allowed to do that in 2014. They will also be limited to varying
premiums based on age to a 3:1 ratio , meaning older folks can't be charge d more
than three times the rate for the young. This change fr om medically underwritten
policies to community rating , which limits premium variation , will bring better
deals to some and worse deals to others. About 90% of the uninsured will qualif y
for Medicaid or subsidies to help them buy insurance , but Obama said they
would pay less even without a c counting for subsidies . And that’s my fact check
for this week. I am Lori Robertson, Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com . We will have FactCheck.org’s Lori
Robertson check it out for you here on Conversations on Health Care.
(Music) Mark Masselli: Each week, Conversations highlights a bright idea about how to make wellness a part of our communities and everyday lives. Lo w literacy rates

have been linked to poor health outcomes around the g lobe so Nicholas
Negroponte decided he should do something about that. The Chairman
Emeritus of the MIT Media Lab has been on a mission since 2005 , the year he
launched One Laptop p er Child whose mission is exactly that. Negroponte
figured his organizati on could meaningfully change the lives of about a 100
million children living in world without access to education. He felt that this sturdy
child - friendly laptop relying on solar power could change that statistic.

Nicholas Negroponte: What if we go to these parts of the world where there are
no schools. We can try and experiment where the kids teach themselves .

Mark Masselli: Negroponte was so inspired that he tried an experiment in an
Ethiopian village, no schools, no literacy , that brought boxes of computers to the
village , left them there with no one to instruct the children in any way.

Nicholas Negroponte: Within five days, they were using 47 apps per child per
day. Within two weeks, they were singing ABC songs and within five months,
they had hacked Android.

Mark Masselli: Negroponte says this could enable a whole new way of teaching
around the globe that effectively has the power to eliminate illiteracy , and one
hopes , improve the economic and health figures of these children as well . The
O ne Laptop p er Child organization now has deployed three million computers in
40 countries and 25 languages . Distributing a simple, durable laptop into the
lives of children who would have otherwise been left illiterate , and offering a
promise of brighter future, now that’s a bright idea.

(Music)

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

Mark Masselli: And I am Mark Masselli , p eace and health.

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