Dr. Ardis Hoven, President of the American Medical Association

(Music)

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masse l li: Well Margaret, what a wild set of weeks before October . The
exchanges are up and running. But who knows wh at’s going to go bump in the
night . But folks are starting to shop online for health insurance across the
country.

Margaret Flinter: That’s right. And October 1 was the date that the exchanges
opened and now we are hearing that the expert industry take is that business
won’t really pick up significantly in the se first few weeks, maybe not even until
November. But the analysts are still predicting that at least seven million
Americans will find insurance coverage on the exchanges during this first open
enrollment period , which runs from now until the end of March. So I think some
good news also , premiums are coming in generally below expectations around
the country.

Mark Massel l i: You are absolutely right, Margaret. We know that rates are going
to va ry from state to state and the federal exchange is going to cover folks in
some 36 states either partially or fully . But the last check with the Department of
Health and Human Services , the average monthly insurance premium is coming
down around $320 per month for the midlevel silver plan.

Margaret Flinter: And Mark, that’s the figure before you factor in the tax
subsidies for folks who buy on the exchanges. So there will be more savings to
add to those savings when the calculations are done.

Mark Mass elli: I think it's really important to remind folks who are entering these
online insurance marketplaces to seek assistance from a trusted navigator .
Some of these plans may seem reasonable until you factor in things like high
deductibles and higher co - p ays for services . Make sure you investigate the fine
print to make sure it fits your family’s budget and needs.

Margaret Flinter: So Mark, looking across the country, still some surprises to
note in states like Texas where there has been a pre tty vocife rous opposition to
the health care law. The premium rates on their exchange are coming in lower
than the national average , which is interesting. And some of the proactive states
like Connecticut well they are showing premium rates that a re among the high est
in the nation. So politics aside , there are of course local and regional factors that
impact rates.

Mark Masselli: But the Congressional Budget Office has determined that of the
seven million individuals and small business es , who will purchase insur ance on

the exchanges by next year , over six million will qualify for subsidy under the
Affordable Care Act . That’s going to a mount to significant savings for folks
struggling to gain coverage.

Margaret Flinter: And of course , we expect a significant nu mber of people will be
covered by Medicaid in the states where Medicaid expansion is taking place. So
with all of these newly insured Americans comes the question that many have
been asking , who will care for all of these additional patients ? And that’s a
question that our guest today has been mulling over for some time. Dr. Ardis
Dee Hoven is the President of the American Medical Association . Since tak ing
that position in June, she has been urging her membership to embrace the
Health Care Law and the r eforms and the innovations that are coming about as a
result of this really huge shift in how we manage our health care system.

Mark Masselli: She will be talking about the policies and practices they are
advocating now at the AMA to improve the work env ironment for medical
professionals as well as protecting the rights of patients .

Margaret Flinter: And we will hear from Lori Robertson, the Managing Editor of
FactCheck.org . She is always on a mission to correct falsehoods about health
policy that are spoken in the public domain.

Mark Masselli: But no matter what the topic, you can hear all of our shows by
Googling CHC Radio. Or if you have comments, please email us at
www.chcradio.com or find us on Facebook o r Twitter because we love to hear
from you.
Margaret Flinter: And we will get to our interview with Dr. Hoven 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'Hare with these Healthcare Headlines. Health care and politics , inextricable bedfellows and contentious ones at that with
threats of government shutdowns over the Health Care Law and the looming debt ceiling creating another potential for fi scal disaster , the health law march e s
on. Insurance exchanges went live across the country October 1

st
and residents
in all 50 states are now looking into how they can access health insurance
policies in these new online insurance marketplaces and how muc h of a tax
subsidy they will qualify for as well.

The re are fits and starts in the various exchanges around the country. The
insurance exchange in the District of Columbia was experiencing some

technological difficulties. In fact, it's expected to be on e of the main problems
nationwide . The Affordable Care Act is supported by a matrix of computer
technology in Washington that provide s the state exchanges with a flood of
information about each insurance applicant including his or her income. This
data h ub also is supposed to allow states to check with the Department of
Homeland Security to ensure that applicants are citizens or legal residents. And
because all systems across the country were at varying degrees of readiness
st
October 1 , the federal gover nment has waived the income verification
requirement for a year for those applying for health insurance subsidies.

Meanwhile the need to rein in health care costs is impacting how some major
corporations view their health care policies. UPS is changing t heir policies to
discontinue spousal coverage if the employee’s spouse has access to coverage
in their own work plans. They will not, as some pundits have suggested, be
eliminating policies for all employee spouses. Walgreens , which employs
thousands of Americans, is resorting to a private insurance exchange, not the
government run one, although it’s less a move to control employee health care
cost, more to stimulate competition among those insurers vying for the insurance
business Walgreens offer.

Meanw hile, the Feds have given approval to the request by the State of
Arkansas to take a different approach to Medicaid expansion. The state had
requested a plan that would allow them to extend Medicaid expansion by giving
some 200,000 residents vouchers to p urchase insurance on health exchanges.
Other states are looking to the Arkansas compromise for a possible option in
their own states.

And menopause and insomnia, unfortunately the two go hand - in - hand for a large
number of middle aged women. Hormone ther apy is the only FDA - approved
treatment for reducing symptoms, but a recent study published in the publication
Menopause may have found a new solution for some , yoga . A study of
menopaus al wom e n who took a 12 week yoga course showed their insomnia
improved . Yoga had no impact however on hot flashes. Well if you can’t beat
them, just go do hot yoga and have a t it . I am Marianne O'Hare with these
Healthcare Headlines .
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Mark Masselli: We are speaking today with Dr. Ardis Dee Hoven , the 168
President of t he American Medical Association, and the third wom a n to hold that
position in the nation ’ s oldest and largest physician organization. Dr. Hoven
serves as the AMA representative on the board of directors of the National
Quality Forum, which seeks to improv e health care delivery in this country. Dr.
Hoven is an internist , and infectious disease specialist , focusing on HIV AIDS in
Kentucky , where she also served as President of the Kentucky Medical
Association . She is a member of the American College of Phy sicians and
Infectious Disease Society of America. Dr. Hoven , welcome to Conversations on
Health Care .

Dr. Ardis Dee Hoven: Thank you.

Mark Masselli: You know, we are in a new phase of the implementation of the
patient protection and Affordable Care A ct with opening this month of the online
insurance exchanges . And your organization, the American Medical Association ,
has over 200,000 members but not all of them support the health care law . But
since taking office in June , you have said that it's time for the medical profession
to embrace the Affordable Care Act and start to exploit the law ’ s potential for
improving public health and the health care profession , including informing
patients about the on line exchanges so that they might access health cov erage .
So can you give our listeners an assessment of where your membership stands
with Obama care?

Dr. Ardis Dee Hoven: Well a s you are aware , the AMA’s position at the time of
activity around the Affordable Care Act actually had to do with our position on the
uninsured , making sure that uninsured Americans in this country would have
access to high quality health care in a meaningful way. And that has been the
driver for much of our work in the Affordable Care Act as well. We knew at the
f ront end that the Affordable Care Act was not a perfect piece of legislation but in
fact it had some very important elements that we thought very important to
support. Having said that , the physician community has actually been lea d ing in
much of the change in some wa ys out there , if you think about what is happening
now and work a round model s of care , delivery of care, looking at ways to do
enhance d care coordination. So the physician community has taken up a
significant lead here in helping to enact many of these ch anges.

Margaret Flinter: Well Dr. Hoven , the mission statement of the American Medical
Association , as you know so well, is to promote the art and the science of
medicine for the betterment of the public health . And I think we would all
probably agree t hat art and science of medicine are undergoing some significant
changes in the way we are delivering it to the public and not just due to the
Affordable Care Act of course but so many factors these unbelievable advances
in science and technology that we ar e witnessing and changes in the way
consumers and patients expect to get the ir care , aging population , all sorts of
thing . So what do you think the most dramatic changes for the medical
profession are going to be and particularly for physicians on the fro nt lines?

Dr. Ardis Dee Hoven: W ell w hat we see is that we know we have to innovate
and change the way we deliver care in this country . It's not just about delivering
care , it's also about the cost of care , the quality of care and the health of our
pati ents . And so to do that , we see one of the most important pieces of this is
looking at how health care is being delivered . And when I talk about delivery
change , I am talking about various models of care . For example , we have seen
work around something called ac countable care organization s, which are people
and practices integrating to provide care and control cost. We talk about the

primary medical home model, another way in which particularly folks with chronic
diseases are well - managed to their bette rment and improving the quality and
cutting down on the cost. So there are lot of different models in play out there ,
many of them are being tested right now . This is where the big change is going
to take place and the physician community is ready to emb race this. So w ill it
happen overnight ? No. Will it require resources and education ? Yes. Will it
require changes in how our patients access care ? And the answer is yes. So
those changes out there are underway and we will direct our attention to the m
and be appropriate in our responses to them.

Mark Masselli: Dr. Hoven , let’ s take a look at the work the AMA does in
advocating for growth in the medical profession . And as we move forward with
the implementation of the health care law, one of the b y p roducts I think in
Massachusetts was the large demand for primary care providers . And we are
going to see millions of more Americans entering the health care arena where
there is predicted to be shortages in the tens of thousands , and there have been
mixe d reviews in the past over policies governing the number of medical school
positions there are available in this country . But the ti de seems to be turning and
I know the AMA’s Liaison Committee o n Medical Education has advocat ed
strongly for an increase i n medical schools and there are a number of new
medical schools opening up across the country and the y are very much focused
in on training primary care clinicians . What vision does the AMA have for
responding to the growing health care needs and making t he ground more fertile
for enticing medical students to choose the path of primary care?

Dr. Ardis Dee Hoven: Well we have got to address that a s a nation but
specifically , the AMA’s work has been directed in many ways around one of our
new strategic dir ections , as you alluded to, which is medical education reform .
And we know that in this country we have more medical students , we have more
medical schools , we have more patients to be seen and yet , we have an
obstruction if you will in the whole concept of graduate medical education , which
is that training piece which occurs between graduating for medical school and
then going out into practice. And so the AMA has been very specific in looking at
GME funding, how that’s going to take place , but it's also now looking as part of
its strategic focus on ways of changing educational innovation . So it's something
that’s going to take multiple levels of activity . It's going to take work at the
graduate medical education level , it's going to take work at our me dical school
level, and it's going to involve funding as well. So it's a complex issue . Team -
base d care is going to be taught in medical schools ; it's being taught now , t eam -
base d care being physician - led care but at the same time allowing all health car e
professionals to function at their highest level of training and expertise . And it's
that team care that’s going to afford u s the ability to manage the care that we
want to provide in this country in a more efficient and timely manner.

Margaret Flinter : Well Dr. Hoven , you talked about team care . Are there other
changes in terms of distribution or investment of resources o r strategies to get
things right in this country that you expect to see or to at least be considered?

Dr. Ardis Dee Hoven: I thin k it's probably all of the above . What we are looking
at now a s we look at these various innovation models , and there have been 11
schools that we have awarded grant money to look at this, so that we have
competency - based training as o pposed to just calen dar training , that we are
looking at pathways that are more efficient in the use of educational time and
exposure to the types of education that young men and women need , and most
importantly , being able to develop amongst these young men and women their
e xcitement and enthusiasm about doing primary care for example.
th
Mark Masselli: We are speaking today with Dr. Ardis Dee Hoven , the 168
President of the American Medical Association . Dr. Hoven is a n internist
specializing in infectious disease . Dr. Hov en , the AMA has been very active in
promoting a better system for Medicare r eimbursement and the so - called SGR
formula , which stands for Sustained Growth Rate. Can you tell us the efforts that
are underway and what do you think would be the ideal solution for fixing the
broken Medicare reimbursement system?

Dr. Ardis Dee Hoven: Over the last 10 years , we have had 15 patches to the
SGR . Now what we mean by that is threaten ed cuts based on a formula that
doesn’t work anymore . It's based on the GDP not on providing care and it's
threaten ed many practices . And it's very disconcerting for our seniors out there
th
every year to see Congress debate this and then at the last minute , at the 11
hour , patch it , kick the can down the road and wait un til one more ye ar appears.
This year , things are different . This year , the AMA along with our physician
colleagues in the state and specialty societies throughout the United States
collaborated together and came up with a plan , and it's not only to repeal the
SGR which is the first step but it is then the second part of this which is to
provide five years of stable reimbursement of physician practices throughout the
country s o that they could then begin to work on the infrastructure to moving
towards innovative models o f health care delivery as we were talking about
earlier. It's these models of delivery of care which are going to be best for
patients, improve health outcomes in this country , and at the end of the day ,
going to save on the cost of health care . We have been very pleased with the
positive uptake , bipartisan , both sides of the a isle looking at this and saying yes
this is something we should do, we must do and I am much more optimistic than I
have ever been in years past about our ability to see this change .

Margaret Flinter: Well Dr. Hoven , it sounds to me like change is something that
you get up and embrace everyday in your role a s the president of the
organization . But there is a law of change for people to embrace . I am sure with
200,000 members and in states all across the country , these things have to be
met with equal parts of enthusiasm and resistance . And I w onder from where

you sit, how you work with the different regions and the states and the
stakeholders , what’s your structure to try and bui ld a consensus . And I guess the
second part of that would be do you see a generational shift kicking in ; are we at
another point where a new generation is sort of rising up within medicine that
sees things differently in how the world of health care works ?

Dr. Ardis Dee Hoven: W ell the AMA actually represents about 185 states and
specialty organizations , so all 50 states and then the balance being the rest of
the specialty and sub - specialty societies in the United States are represented by
delegates to t he House of Delegates at the AMA which is the policy setting body
of the organization. The AMA then takes that policy and advocate s on behalf of
physicians and patients in this country . So we have very good representation
and very good working relationsh ip s throughout the country. Young men and
women coming into this arena now actually come with great passion and
enthusiasm and I am very optimistic they will continue to be our leaders . They
bring a view of health care which reflects change and supportiv e of change and
they are going to be those taking care of us in the future , not only politically but in
policy setting and at the bedside . And I am very optimistic about their
enthusiasm and their knowledge and I will tell you they are the brightest and t he
best we have ever seen.

Mark Masselli: You know, I wanted to get back to reimbursements and you
talked on Medicare and the need to probably stabilize those rates . We know the
private physician community also does a tremendous job in this are a . And a s
part of the Affordable Care Act , the rates were increased ; they a re often times
the lowest that a practitioner will receive . But all across the country , states were
allowed to sort of nationalize their Medicaid rates by going up to the Medicare
levels , which is an exciting prospect given where the rates were before . This is a
two year experiment . Any sense of how the adoption has gone and whether or
not physicians across the country are adding more Medicaid patients to their
ro les or has there been dis cussion about trying to do , as you are doing with
Medicare, a five year stabilization also to try to stabilize those rates so we can
encourage the great work that happens in so many private offices across the
country ?

Dr. Ardis Dee Hoven: I don’t have go od numbers at my fingertips . I will tell you
t his, the sense in the country right now amongst physicians is they are very
concerned about Medicaid expansion only because they are worried about
obviously the reimbursement part of it but are they going to b e able to handle the
volume . And I say that only because that’s what I keep hearing , what are we
going to do with these people , these folks , these patients . And my response to
this frequently is these a re patients that a re already in the health care deli very
system, they are getting their care at the wrong place at the wrong time by the
wrong person and we need to flip that formula and make it work better. Having
said that, I find amongst my physician colleagues a willingness to see Medicaid
patients , a willingness to work with the system and a willingness to work with

their states to help make Medicaid delivery in their states the best it can possibly
be. It isn’t easy sometimes . It's a fiscally troubling issue for many states as you
know . But our phy sician colleagues out there work at the state level with
Medicaid programs and are trying to be very creative and helpful in getting
access improve d for these patients.

Margaret Flinter: Well Dr. Hoven , we appreciate that and I want to appreciate the
fac t that you , in your practice c areer, chose to specialize in HIV AIDS care and
became and are just a tremendous advocate for the underserved and very well
aware of the health disparities in our country . You know we just had Dr. Jack
Geiger on our show rece ntly . I am sure you know his work , launching the
Community Health Center Movement back in the 1960s . And really , as he
always reminds us, a movement that was created out of an understanding that
health is much more about what happens outside of health ca re and much more
about what we think of as those social determinants of health , and if we want to
improve health in our communit ies and our p atient populations that we have got
to be very focused on addressing those social determinants and tackling still t he
huge and persistent health disparities in our country. I know that ’s something
that the AMA is concerned with as well . Perhaps you can share with us a little bit
about the AMA’s initiatives to address health disparities and how do you see that
work re flected in training and practice and research across the country.

Dr. Ardis Dee Hoven: Great question . And obviously the social determinants for
us in this country are significant , and I recently had the opportunity of listening to
Sir Michael Marmot , w ho actually i s the gentlem a n from the United Kingdom ,
who really brought to the forefront this conversation. But the AMA actually has
done several things and continues to do it over the last decade . One of the most
important has probably been the AMA’s M inority Affairs Section , which serve s as
a grassroots forum if you will for increasing the voice of minority physicians in the
AMA itself. This is important because it's an important link to the minority patient
population .

So what it does is it brings t o the AMA a very important perspective to our
discussions around all the critical issues in health care delivery , in population
issues around disparity and professional concerns . So it provides us real life,
real time information that enables us as an org anization to be much more
appropriately reactive to the issues. The Commission to End Health Disparities,
another entity , is co - chaired by the AMA and the National Medical Association ,
again recognizing that health care disparities exist due to multiple f actors
including race and ethnicity . And this group works together to increase
awareness amongst physicians.

You know the other thing we have been very active in is our Doctors Back to
School Program . And I am not sure whether you are aware of it , but p hysicians
and medical students across the country , visit schools and community
organizations to help young minority children realize that they can pursue a

career in medicine. And it's an exciting thing ; the feedback is wonderful . This is
not only Africa n - Americans but Hispanics , American Indians . And so we are
trying to look and get the percentage of the physician population to represent the
people they serve , and so this is something we talk about and work about.

Mark Masselli: We have been speaking today with Dr. Ardis Dee Hoven ,
President of the American Medical Association , and the third woman to hold the
position in the n ation ’ s oldest and largest physician organization where she has
been a member of the AMA Board of Trustee s since 2005 . You can learn more
about her work and the work of the A MA by going to www.ama - assn.org . Dr.
Hoven , thank you so much for joining us today on Conversations on Health Care .

Dr. Ardis Dee Hoven: Thank you . I have enjoyed i t.

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 nonpart isan, 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: Well, Senator Ted Cruz spen t about 21 hours on the senate
floor railing against Obama c are. We here at FactCheck are still going through
the pages and pages of the transcript but we found several false and misleading
claim s so far. For instance , Cruz , the freshman senator from Texas , wrongly
said that the spouses of 15,000 UPS employees will be "left without health
insurance and forced into an exchange with no employer subsidy ” . That's not
true . UPS announce d that it was dropping coverage for spouses only if they
could get insurance with their own employer. A company memo said that since
the A ffordable Care Act required businesses to provide insurance , "we believe
your spouse should be covered by their own employer" . UPS estimated that of
th e 33,000 spouses it currently covers , 15,000 can get insurance through their
own workplace.

Cruz also s aid that the IRS Employees Union has been asked to be exempted
from Obama c are . That's not the case either. The union , the National Treasury
Employees Union , which represents agency and department employees
including workers at the IRS , oppose s a Republic an bill that would move federal
employees out of their current health insurance program and into the exchanges
setup by the Affordable Care Act. The union isn't oppose d to Obama c are ,
instead it says this bill goes against the very intent of the law. The union says
the law ’ s goal was "not to take average away from employees who already
receive it through their employers ”. And that’s my fact check for this week . I am
Lori Robertson , managing editor of FactCheck.org .

Margaret Flinter: FactCheck.org is co mmitted 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) Margaret Flinter: Each week, Conversations highlights a bright idea about how to make wellness a part of our commun ities and everyday lives. When Chef Karl
Guggenmos grew up as a kid in post - war Germany , he lived on a diet of organic
and locally grown foods. Now he is the Dean of the Culinary Arts Programs at Johnson & Wales University in Rhode Island and he realize d that he has
responsibility to teach the next generation of chefs how vital natural and simple ingredients are , not just to creating good food but to the health of the population
as well. He watch ed the obesity epidemic take hold in this country and decid ed
to use his platform to create a new approach to chef training. He teamed up with a professor of medicine at Tulane University Medical School in New Orleans , and
together , they created what they believe is the first course in culinary medicine in
the Un ited States , t eaching chefs and fo u rth year medical students how to
understand the synergy between healthy eating , good food and good health.

Karl Guggenmos : Our graduates from Johnson & Wales , or any cooking school ,
really have to take responsibility fo r the health and wellness of the people that they serve food to. So we created this program where our students are actually going to Tulane Medical School for an internship and they work side - by - side with
medical students and physicians , working in the co mmunity , doing research ,
using an evidence - based approach to this whole idea of culinary medicine rather
than anecdotal.
Margaret Flinter: So , in addition to learning knife skills , sauté and poaching
techniques , fo u rth year medical students are given a l esson in food pairing s,
learning which foods are most poise d to foster good health , and to combat
obesity in their future patient s ’ lives.
Karl Guggenmos : The medical students at the Center for Culinary Medicine,
they have their own coursework th at we he lp them develop and they identify ingredients as to their relationship to health . They then start basic introduction to
cooking from knife skills to basically how to sauté, how to poach , how to other
roast and then they do recipe conversions and then they have to do research .
And our students , they are helping and they are engaged working , writing
articles , being part of this whole program , working side - by - side with the medical
students and learning and exchanging information and techniques from each othe r. The results and the responses are incredible . We are hoping to continue
that . Dr. (28:59 inaudible) and I have been out speaking about this a s a joint
collaboration between the chef and the physician . It’s really unique and it's one

of its kind and I think it's the first around the world and we are getting more and
more traction about this.

Margaret Flinter: He strongly believes in the idea that chefs will be the
pharmacist s of the future . A d ean of a reputable culinary program , teaming up
with a medical school , to train future doctors , armed with the skills and
information to assist their patients in healthier eating , f ostering the development
of health conscious chefs who are train ed to feed the next generation well, with
foods that can prevent o besity , 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, peace 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.