Dr. Darshak Sanghavi, Engleberg Center for Health Care Reform, Brookings Institution

(Music)

Mark Masselli: This is Conversations on Health Care, I’m Mark Masselli.

Margaret Flinter: And I’m Margaret Flinter.

Mark Masselli: Well, Margaret we’re seeing a number of veteran members of
congress choosing to leave Capitol Hill at the end of their terms. We’re losing some
real champions of Health Care reform with these announced departures .

Margaret Flinter: 87 ye ar old, Michigan democrat John Dingell is stepping down at
the end of this term after close to 60 years in congress. He has been a champion of
Health Care for all Americans, he was there when Medicare was created back in the
60s. Of course he was promine nt and supporting the Affordable Care Act.

Mark Masselli: He’s had a lifetime of service, he was an advocate for Universal
Health Insurance from the beginning of his service, as far back as 1955. And has
worked tirelessly on behalf of Americans througho ut his career.

Margaret Flinter: And he follows a host of other veteran law makers who sight the
current climate in congress as unworkable and unfair to the American people has
been impetus to move on. But, in this particular case, congressman Dingell s ays he
simply wants to enjoy his remaining years at a more relaxed pace around by his
family.

Mark Masselli: And just a few weeks ago another highly respected long term veteran
of congres s also announce the departure at his end of his term. Henry Waxman of
California stepping down after almost 40 years of congress. He too has been a
career long advocate for Health Care rights for all Americans, he does a point to the
partisan bickering and the gridlock as the primary reason for not seeking to run for
re election.

Margaret Flinter: Well both are leaving congress with the Affordable Care Act intact.
It’s been a lot based on good intentions and good policy Mark, but still has left many
confused. Our guest today is here to talk about an initiative to help shed more light
on the Health Care Law and particularly for those in the Health Care professions.
Dr. Darshak Sanghavi is Managing Director of Economic Studies at the Engelberg
Centre for Health Care at the Brookings Institution.

Mark Masselli: They’ve launched a campaigning conjunction with the free online
learning service Khan Academy to produce a series of videos aimed at educating
medical professionals as well as the public on some of the basic aspects of the
Health Care Law in America and how the A ffordable Care Act might impact them.

Margaret Flinter: And Lori Robertson checks in from FactCheck.org looking at false
claims about health policy spoken in the public domain.

Mark Masselli: But no matter what the topic you can hear all of shows by go ing to
CHC Radio and always if you have comments please contact us at chcradio.com or
find us on Facebook or Twitter, we’d love to hear from you.

Margaret Flinter: We’ll get to our interview with Darshak Sanghavi in just a moment.

Mark Masselli: But fi rst here is our producer Marianne O’Hare with this week’s
headline news.

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Marianne O’Hare: I’m Marianne O’Hare with these Health Care Headlines. The
Health Care Law in health premiums according to a report from the Centers for
Medicare and Medicaid Services insurance premiums could rise for 11 million small
business employees under the Affordable Care Act. Well lowering premiums for
another 6 million Americans. It’s based on the provision that premiums can no
longer be set based on a perso n’s age or preexisting conditions. So younger folks
that are healthier will likely find themselves paying a little bit of higher premiums,
while older workers will be paying lower than what they did before.

Meanwhile, health insurers were swimming in som e positive territorium Wall Street
last week after assessing that government cuts to privately run Medicare programs
we come in lower than original projections for 2015. Analyst have been expecting
cuts of 7% or more to Medicare advantage plans, but it lo oks like it’s closer to 3.5%.
working out the glitches on the state based health exchanges, California’s exchange
covered California was down for five days due to software problems causing
frustrations and delays for navigators and insurance pros across t he state. They’ve
been averaging 7000 signups per day in California. And the state within entirely
different sort of exchange experience is taking it show on the road, Connecticut
exchange launched with few of those major problems plaguing the other heal th
insurance exchanges.

AccessHealthCT President Kevin Counihan has put together a program to take the
states considering setting up their own exchanges in the next few years. Counihan
saying they will license the state’s technology and essentially sell it as exchange in a
box. Connecticut is already talking to several states who’ve expressed interest. I’m
Marianne O’Hare with these Health Care Headlines.

(Music)

Mark Masselli: We’re speaking today with Dr. Darshak Sanghavi, Managing Director
of the Engelberg Center for Health Care Reform at the Brookings Institution where
he’s also the Merkin F ellow for F inance R eform in C linical L eadership. Dr. Sanghavi
is an Associate Profess or of Pediatrics and the former Chief of Pediatric Cardiology
at the University of Massachusetts Medical School. Dr. Sanghavi is award - winning
medical educator and has been a frequent contributor to NBC and NPRs all things
considered. He writes on Health Care Reform for the New York Times slate and
Washington Post. Dr. Sanghavi, welcome to Conversations on Health Care.

Dr. Darshak Sanghavi: Hi, it’s great to be with you.

Mark Masselli: You know, we hear all the time from people about how complicated
and confusing the reforms are within the Health Care Law and the Brookings

Institution initiated a program to help people better understand exactly what these
health reforms really mean and how they can participate in the process of approving
health care i n. You recently assembled a number of clinicians at the form at the
Brookings to discuss reform and its many complexities, it sounds like there’s still a
great deal of confusing in the medical community about the rules governing payment
reform. So can yo u give our listeners an idea on how systemic that confusion is?

Dr. Darshak Sanghavi: Sure, so I mean I think that as one of the panel has said at
our event, clinicians are confused because health care reform is confusing. So it’s a
complex topic to be honest, so a lot of clinicians just are as much in the dark as
ordinary Americans are. And in fact, you know, several survey have shown that –
that this confusion really starts even early in their careers, many medical students
have residence or never rea lly taught the basics of how, you know, insurance works
or what Medicare really is and how it works and how Medicaid works. And so, I think
this is a complicated problem that’s been present for quite a while. And I think that,
you know, if you told someb ody about the Affordable Care Act and told them that
only about 20% of it really deals with health insurance reform, 80% of it really deals
with health care delivery reforming, changing how we pay for care and sort of
reorganizing how we deliver to make it better, most people would be really surprised
to hear that. And that’s sort of what we’re trying to bring to light, and trying to in a
way that’s little bit more innovative kind of talks to clinicians in a way they can
understand, which is to be honest t he same way you talk to anybody who’s trying to
understand this stuff.

Margaret Flinter: Well – we’re going to come to back to that in a few minutes, but I
know that one of the reasons that you assembled that recent panel at the Brookings
Institution was to examine ways to empower the clinician community to become both
more aware of just what the reform changes are. But you also looked at some
emerging tools that you’ve identified as potentially empowering to health care
professionals in their engagement and reform processing, using social media and
maybe using (inaudible 7:23 ) massive open online courses that have so wildly
gained a popularity around the globe. Tell us about the initiatives that you’ve
launched at Brookings to expand access to these and other tools for clinicians who
are really working to understand these very real changes under health care reform.

Dr. Darshak Sanghavi : Well I thought it was, well you know, this – this is to a some
extents not really a rocket science. But how can we harness this type of education
to teach people about health care reform. And one of the things we realize is that
clinicians today, they wa nt to learn on their own time, they want to learn flexibly, they
want to learn in small bites, and they want to learn through cases and through stuff
that’s actually practical to them delivered in a way they can understand. And when
we survey the landscap e if you look at how we typically describe health reform
they’re in this kind of slum somewhat upscale journals and they’d say written in a
way that’s very alienating it presumes that you already understand all the stuff about
the ten titles of the Afforda ble Care Act and you know what a medical home is and
so forth. And so we decided to sort of scale that down to a more basic level and
then create a stepwise progression. And so what we were most excited about first of
all was a partnership that we launch ed with the Khan Academy, which is really a
terrific organization based in California, started by a young man who works in a
finance industry and trying to figure out how to teach math to his nieces. And he

created this online tutorials that are very simp le, you know, start with addition,
subtraction, you know, they’re five minutes course but then stepwise work up to
doing multi variable calculus. And we thought that’s a really good model for who we
should teach health care, you know, we want to explain w ell what is Medicare and
what’s Medicaid and then stepwise work our way up to how exactly do you calculate
a bundle for a payment and look at how you transform a larger system practice. And
so we partnered with the Khan Academy to create these stepwise tu torials clinicians
can learn on their own time in the small little bytes and work their way up. And just
last week our first set of tutorials just went live.

Mar k Masselli : Well let me just say as a parent of an 11 year old who’s home
schooling Salman K han’s work is really just extra ordinary. You know starting back
in 2006 when he created this with the ambition to provide world class education to
anyone, everywhere. So I want you to pull a little thread on that because, you know,
it’s so amazing to us still even in the health profession they get Medicare and
Medicaid confused all the time. I am shocked by it, but it is a reality and if we don’t
address it upfront this is going to be a real problem. So tell us a little more about that
work with the Kh an Academy, taken it’s also something that’s available for just
people, laypeople who are interested in the process of understanding this better as
well as the health professions.

Dr. Darshak Sanghavi: That’s right so to be clear anybody can log on, you can go
right now to the khansacademy.org website click on learn, and then partner content
go to Brookings Institution. And anybody can see these tutorials and we’ve just
really started off on a pretty straightforward way of just kind of explain the basics of
the health care system. So we currently – what we did, we developed it around ten
videos each one lasting about 15 minutes or so. And that starts with saying well
what is the health care system, how does it work, what is Medicare, what is
Medicaid, w hat’s up with private health insurance and so on. And so once our
learners potentially whether they’re clinicians or general public, they get that
material. Then there’s also sort of self guided exercise, you can sort of answer these
quiz questions and i t gives you a hint to figure this stuff on. And then the next pack
of tutorials were going to deliver are, what is health care delivery reform and again
it’s one of our favorite panelist that joked at our event last week. When most people
think about del ivery reform they wonder about the – what the postal services are
doing on Saturdays. But the next type of insurance we’re going to explain well what
is a bundle payment, what is this thing we call a medical home. So that’s sort of the
idea behind these tutorials.

Margaret Flinter: You know, again as you said the coverage is just a small piece and
you talked more about some of the payment reform. But there’s a few other titles
that we have found are health care providers to be particularly interested i nto
certainly the – the thought of the deals with public health and prevention and also the
title dealing with workforce and I wonder if you’ve found this as well in your
conversations, so people are really interested not just in what happens within our
do main of the delivery of care to individuals, but what happens in the world of
prevention public health and how are we going to use health reform to train the next
generation. I wonder if you have any comments on that.

Dr. Darshak Sanghavi: The first is well how do we explain what this law is to the
broader public. And I do think that the law tries to so many different things in so
many different ways that, you know, as a policy enthusiast one can’t help but marvel
it how much was packed int o it. But at the same time as somebody who’s trying to
garner political support, you know, create consensus and get people interested in it,
it’s really double lives worth because it’s so complicated that you can’t really explain
what it does to be honest very easily that obviously works against the line, where I
think we can see this tension being played out nationally. We will try to make this
narrative, we think that people learn to the stories and we would try to think of ways
either through our Khans Academy platform or see some of our other work. I’m
trying to make this work very personal. So with population health for example,
there’s clearly a lot of stuff in the Affordable Care Act about improve nutrition, you
know, there’s calorie labeling of m enus to really deal with obesity, and then sort of
building a frame around that to see well how can the Affordable Care Act be used to
look at population health. You know that might the simple way and then you build it
out because through the founding of the innovation center they do have a population
health entire area that’s building around that, maybe we’d get there as well and even
community based ACO. So there is a way to get there but I think that we’re starting
at such a low bar in terms of public knowledge that I think that we should focus
maybe on the stuff that’s a little easier and then build out from that.

Mark Masselli: We’re speaking today with Dr. Darshak Sanghavi Managing Director
of the Engelberg Center for Health Care Reform at the Broo kings Institution where
he’s also the Merkin F ellow for F inance R eform in Clinical Leadership. You know,
you mentioned just a moment ago that we learn from stories and it seems also true
that we share through social media which is playing a big role in th e empowerment
of medical professionals as well as the patient community. But it’s an area, it’s also
froth with proprietary concerns when looking to protect the interest of patient privacy,
where do you see social media playing the biggest role in empower ing frontline
clinicians in their patient populations?

Dr. Darshak Sanghavi: It’s important to explain that when people talk about patient
privacy that sort of proxy for the confusion around (inaudible 14:21 ) the health
insurance portability and privacy law, you know, the default way that people
understands is that we as clinicians can’t talk about patients because we’re going to
get sued and getting in trouble. I feel that, that actually is not as much of a concern
because many of these conversations around health care where they’re initiated by
patients they themselves are willing to share their stories. One of the panelist last
week at our event was Elizabeth Rosenthal of the New York Times, who is been
w riting really extraordinary articles on the cost of medical care. When they just
posted a request on one of their blogs to say, can you please share your stories
about paying for medical care, that post is only up for two hours and yet they were in
in - dat ed with hundreds of emails with detailed stories people who are willing to share
their experience and in fact that served as a basis for the series of articles it later
became her series. And that’s been tremendously influential in getting people to
think in a very concrete way about the cost of medical care. So I think in that way
social media really does allow people to tell their stories in a way and sort of get their
message out and these are people that may not have been able to be reached any
other way. And it also to some extent lets clinicians communicate with each other, if
you’re interested in health policy and you’re a physician to be honest it will be a little

bit unusual. You know, most clinicians are not really as interested but through soc ial
media the ideas that you can find other people who are likeminded and one of the
organizations who did that was doctors for America, you know, these are physicians
that all found each other through social media. They now play a role and important
advo cacy around health care reform, for a physicians and patients as well. So we
feel that there is certainly a great deal of work that can be done without necessarily
getting to the issues of patient privacy.

Margaret Flinter: Well Dr. Sanghavi you’ve note d that many clinicians still kind of left
out of the discussions around payment reform and the Affordable Care Act certainly
puts forward new models around the accountable care organizations and bundle
payments. But for practicing providers where pediatri cians as you were, pediatric
surgeons as you were or primary care providers in private practice community health
centers. The kind of transformation they might be looking for things that really help
them get a handle on the enormous work that needs to be done, that people need to
be taking care of without that fee for service driven reimbursement system remains
somewhat illusive. Maybe you could share with us you r view as Merkin F ellow for
F inancial R eform in Clinical Leadership at Brooking, what kind of leadership is going
to be need to help really drive meaningful health payment reform and what do you
see evolve and go for the next decade or so?

Dr. Darshak Sanghavi: When one talks about changing the ways in which we deliver
health care, people instinc tively worry about that. They think that health care reform
is anonymous with making things cheaper and making things cheaper means taking
things away from people. And I think that because that’s a dominate way putting the
general population confuse of h ealth care reform they look to clinicians and
physicians as their protectors. And so I think that’s sort of the – and it’s hard the
reason that I believe clinicians have a very important part to play in health care
reform. Not only because they understan d how to transform health care because
they work in it, but they also to some extent are some of the most trusted folks by
patients and even politicians. So I think probably the one everybody should know
about and the one that I feel the most optimistic a bout is there will be a permanent
repeal of the sustainable growth rate formula for Medicare. As many people may be
aware the ways in which we’ve stopped Medicare from growing don’t make a lot of
sense, we do it sort of willy - nilly there’s a 25% cut in Me dicare fees to physicians
that’s been on the books for several years, and this year for the first time there’s
political movement that, that might stop. But at the cost, physicians will have to
move away from fee for service reimbursements and start to no w offer measures of
quality and participate in other payment models. So no matter what happen if that
sort of ship is leaving the harbor now and my hope is that physicians once they
realize that can then take the lead to then reorganize how they organize their
practices. If you don’t need to worry about seeing somebody in person to get paid,
you’re going to be creative, you’re going to say well hey maybe I’ll answer those
emails or make those calls or better yet I’ll sort of think about how I can use my
n urses to really meet the needs of a patients in a way we did do before. Once
they’re freed of the perverse economic incentives, their natural impulse to do what’s
right for patients will shine through. Now the second part I would say there’s a much
more radical approach, if you’re freed of the conventional fee for service maybe a
small number of physicians will say, you know, we should completely change, you
know, go to a direct pay model where we essentially act like medical home without

steroids, you kn ow, we assume all the kinds of care of patients we’re really going to
completely radically redesign care. There will be a small number of people that
maybe free to do that as well and I think that, that innovation will be good over time.

Mark Masselli: We’ve been speaking today with Dr. Darshak Sanghavi Managing
Director of the Engelberg Center for Health Care Reform at the Brookings Institution.
Where he’s also the Merkin Fellow for Finance Reform in Clinical Leadership, you
could learn more about his work by following him on Twitter at darshakshanghavi.org
or to Brookings study DU. Doctor thank you so much for joining us today in
Conversations on Health Care.

Dr. Darshak Sanghavi: It’s been a pleasure speaking with you both.

(Music)

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
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: We’re starting to see democrats and Senath races repeat old and
misleading claims about representative Paul Ryan’s Medicare plan. Ryan’s
proposed budget in recent years included changing Medicare to a premium support
system in which private insurers and traditional Medicare would be offered on a
Medicare exchange. Democrats have been attacking the plan for years, and now in
the Arkansas Senath race and from democratic Senator Mark Pryor criticize his
republican challenger Tom Cotton for supporting Ryan’s plan. Two prior adds claim
that seniors would pay thousands more each year under the plan Cotton supported,
but the nonpartisan congressional budget office said the plan could lead to higher
cost of beneficiaries without offering any specific estimate. One prior adds says the
higher cost would affect every senior in Arkansas, but Ryan’s plan wouldn’t pertain to
those 55 and over, and another plan that Cotton backed wouldn’t pertain to those 60
and older. And second add says that plan would allow insurer s to cut benefits, but
the plan requires policies sold to seniors to include a minimum level of benefits.
Under the Ryan plan seniors in the future would chose a plan from the Medicare
exchange but the subsidy being sent to the policy of choice, these sub sidies would
be tight to the full cost of the second cheapest private plan or traditional Medicare
whichever is less, the growth of that second cheapest plan would be kept at GDP
plus 0.5%. Critics argue health care cost would go faster and eventually
ben eficiaries would have to pay more out of pocket, but that’s speculation.
(inaudible 21:53 ) any guide we’ll see more of these claims in 2014 races, and that’s
my fact check for this week, I’m Lori Robertson Managing Editor of FactCheck.org.

Margaret Flint er: 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
www.chcradio. com, we will have FactCheck.org’s Lori Robertson check it out for you
here on Conversation on Health Care .

(Music)

Mark Masselli: Each week, conversations highlights a bright idea about how to make
wellness a part of our communities and to everyday lives. Dieting is a numbers
game but as anyone with midriff bulge nose, it’s hard to win a game of losing. But
researchers at Miriam Hospital at Rhode Island have found a fun interactive tool that
could help improve the odds of dieters seeking to shed po unds. Dr. Trisha Leahey is
the lead researcher at Miriam Hospital’s weight control and diabetes research center.
They wanted to see if the introduction of social media gaming and placing a bet on
one’s own weight loss would have an impact on dieter succe ss. So they looked at
the weight loss social media site diet bet, participants engaged in a four week weight
loss challenge.

Dr. Trisha Leahey: Everybody has four weeks to lose 4% of their initial body weight.
And in the very beginning of the program b efore the game begins, you can bet how
every much money you want. And all of their bets get polled and then those folks
who lose at least 4% of their initial body weight in four weeks then gets a split pot of
money that was bet at game start. And during the game they interact with one
another via social media platform.

Mark Masselli: Dr. Leahey says they were also encouraged by the success of
participants in the diet bet study.

Dr. Trisha Leahey: So on average using this conservative approach folks loss about
2.5% of their initial body weight. I mean that’s in just for a weeks and that’s actually,
you know, quite good and those folks who actually loss the 4% and won the game
and were allowed to split the pot of money loss about 4.5, 5% of their init ial body
weight.

Mark Masselli: She says they were so encouraged by the success of the
participants in the diet bet study. They are expanding their research to include more
participants, with longer term experiments. The company has a follow - up to diet bet,
diet better which engages participants in a six month diet goal on the social media
site. Diet Bet an online social media site that encourages dieters to bet on their own
diet success winning both cash prices and a healthier body mass index, 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 Wesleyan University
at WESU, st reaming live at www.wesufm.org and brought to you by the Community
Health Center .