Dr. Harry Greenspun, Deloitte Center for Health Solutions

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret interesting report out of Kaise r Health news last
week , in spite of the dire predictions to the contrary in the run up to the
healthcare loss addition of millions of Americans gaining insurance coverage , the
primary care system in America has not been crushed u nder the weight of these
new enrollees .

Margaret Flinter: Oh Mark you remember a policy (inaudible 00:27 ) been
predicting that new patient populations would inundate the healthcare system
causing delays and backlogs in the primary ca re space , but the Kaiser report that
shows the system is doing a pretty job of absorbing the new healthcare
con sumers with a largest exp ansion of healthcare in 50 years . A quick survey of
health systems around the country show that for the most part systems have
been able to handle the influx of the some 13 million newly insured individuals
either through the priv ate insurances or the Medicaid expansion , so a p rediction
that did not come to pass.

Mark Masselli: It should be noted Margaret there are some parts of the country
where there have been higher utilization from those new patients , Washington
state , Califo rnia , Kentucky , all who had successful enrollment efforts . T here
have been some delays in getting Medicaid ’ s cards out to people but there is a
sense that folks are feeling empowered to utilize the healthcare system in our
learning to navigate it as well.

Margaret Flinter: Well I think everybody would agree that the country is still in a
bit of a learning curve but you know I think compared to years going by our
healthcare system , may be is a little more adaptable and a population that has
much better ac cess to getting information about what to do and how to use it in
all that boats well I think.

Mark Masselli: Our guest today is someone who has had his eye on
transformation of the healthcare system moving fo rward. Dr. Harry Greenspun is
a senior advis or to the Deloitte center for healthcare transformation and
technology at the Deloitte center for health solutions . H e is also working at the
intersection of health information in healthcare delivery and has examined how
healthcare systems are being trans formed?

Margaret Flinter: Lori Robertson will be checking in from FactCheck.org's . She
is always on the hunt for misstatements about health policies spoken in the
public domain.

Mark Masselli: But no matter what the topic, you can hear all of our show s by
Googling CHC Radio. And as always if you have comments please email us at
www.chcradio.com or find us on Facebook or Twitter , we would love hearing
from you .

Margaret Flinter: We will get to our interview with Dr. Harry Greenspun 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 with these Hea lthcare Headlines. The
VA coming out of more scrutiny in the wake of several dozen deaths due t o
delayed treatment at a VA hospital in Phoenix , Arizona. While the director of that
VA hospital has been replaced , the secretary of Veteran’s Affairs Administration
has come under a mirage of criticism. Defense secretary Chuck Hagel has said
he supports secretary Eric Shinseki , but add s the care of veterans are receiving
is simply not good enough recently report service that as many as 40 veterans
may have died while waiting for medical care from the VA hospital in Phoenix .
V eterans have also waited yea rs in some cases to collect benefits from the
administration. The American region and some in congress have called for
Shinseki’s ouster . Hagel admitted many of these issues were long standing and
plague d of the department since long before Shinseki took to helm. T he matter
continues to be i nvestigated and while we grab over the concept of access to
care for all in this country one - third rural country is seeing dramatic results in one
year from a concerted health policy shift. Thailand has seen the 13% d rop in one
year with it s 3 0 - B art program which essentially makes about $35 per capita
available for folks to access healthcare in that country especially in more
impoverished provinces. A Harvard MIT study showed the biggest increase in
patient usage was young women of child bearing age and infants and children .
T he survey revealed then the sharp decrease in infant death was a result of
parents feeling they had a right to hospital intervention and most of the diseases
were highly treatable , pneumonia , inf ection , MLI. I am Marianne O'Hare with
th ese Headline s News.

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Mark Masselli: We are speaking today with Dr. Harry Greenspun senior advisor
of healthcare transformation and technology at the Deloitte center for health
solutions which is addressin g key health information technology in clinical
transformation prior to that Dr. Greenspun was chief medical officer for De ll Inc.
He writes extensively on healthcare co - author of reengineering healthcare or
manifesto for radically re - thinking healthcare d eliveries serves on the world
economic form global agenda counsel and digital health and was named one of

the 50 most influential physician executives in healthcare by modern healthcare,
Dr. Greenspun welcome to Conversations on Healthcare .

Dr. Harry Gree nspun: I am great to be here.

Mark Masselli: We are in this incredible transformational shift in the healthcare
system and while we had a few bumps on the road of rolling out the Affordable
Ca re Act things seem to be moving forward the number of enrolle es finally
exceeded the administrations initial hopes but your book 2012 co - written by Jim
Champy re engineering healthcare suggests that something else needs to be
done to really radically transform healthcare for the better can you talk to us
about this r adical redesign and how there is any interplay between the efforts of
the Affordable Ca re Act and the direction you see the country moving.

Dr. Harry Greenspun: Well sure when you think about a lot of what healthcare
has done to improve itself has been m ake sort of like small incremental changes
you know how can you get a physician to see you know a couple of more
patients per hour how do you move people more efficiently for the hospital and if
you really want to transform the system you have to really do things differently
you have to have different models of care have different types of people,
providing those kinds of care and you also have to change the focus on what you
are caring for are you focusing on doing sick care or acute care treatment or you
are going to focus more on prevention and wellness. Now what’s interesting
when we look at the Affordable Care Act we are moving from a reimbursement
model of paying physicians and hospitals for the volume of what they do to the
value of work that they do , sort of the outcomes they achieve and that creates a
lot of different types of behavior and a lots of new opportunities to provide
innovation where if physicians of hospitals are responsible for not just doing a
good job when you in front of them but als o making sure you stay healthy and
you help make good choices and when care gets transferred from person to
person or facility to facility , that they gets ineffectively.

Margaret Flinter: with for this show we spend a lot of time speaking with
innovators in the healthcare space who have really tempted to do what your
describing reinventing the wheel by rebuilding systems from the ground up and
always with those three pillars that you talk about in your work technology
process and people what does that ree ngineering process look like and who in
the country do you think is really got your right so far.

Dr. Harry Greenspun: You know you see a lot of people coming in from other
industries trying to fix healthcare, and you have a lot of technology companies
a re specifically trying to do this. But the problem that exalt is the technology
problem which is usually not the hard problem to solve so you know they come
up with the better way of presenting information or some full app for your phone
but they really h aven’t done much, and you think there has been a lot of
technology around for quite sometime Telehealth being an example of that and

where it really wasn’t for a lack of good technology that didn’t catch on. It was a
reimbursement problem that they were d istance centers of physicians to use that.
So you know unless these technological improvements can you know some of
these other issues, I really like to help much, the lots of places around the county
where you see some really interesting innovations and it occurs in some smaller
pockets, you we are seeing you emergency rooms, create you know smaller in
care centers on the side we are seeing lot of work with that integrated delivery
system like Kaiser and Atlantic care another where they are able to provid e
different types of outreach and different types of communication with their patient
and to give them information when they needed.

Mark Masselli: You know technology is important and on the clinical side but
proved to be one of the difficulties in the roll out of trying to get technology
related to enrolment to work successfully and now we are from Connecticut and
then we had Kevin Counihan who was the CEO of the Connecticut exchange on
which had a really remarkable success story to tell, they also had an intersection
with Deloitte was part of that, success but talk to us a little bit about that
technol ogy platform around enrollment because we are going to see a big shift
over the next half a dozen years where the employer based insurance policy
might ch ange really to these large exchanges are they equipped to manage them
what you see out that’s good, news around technology platforms.

Dr. Harry Greenspun: Well you know I think the lesson we have learned is that
large IT projects are hard. And you know in this first round what we saw many
exchanges were just helping people to sign up and the key issue that were going
to be looking forward to in the future is helping people actually make better
decisions of what kind of coverage they need it's very often that the choices
people make and how they get covered don’t necessarily align with their
particular need so and you know it's really about getting appropriate coverage for
the right conditions that you have and that’s complicated and we see individuals
as consumers and consumers only needs stuff when they need stuff. Right so
and same thing with consumers and healthcare is that you often think about
catastrophic coverage or different medication coverage until those needs actually
arise for you.

Mark Masse lli: Well Dr. Greenspun the Deloitte 2013 survey of healthcare
consumers showed a really kind of decided l ack of trust in the healthcare system
and is value to the healthcare consumer with over half of those questions and
this really surprise me rating th e healthcare system with the D or an F and half
reporting that they pay more out of pocket cost for their healthcare than in
previous years what are your thoughts on how do we educate people how to
engage people and get them to plan in advance. What are y ou saying around
the country what are the strategies is it a social Media campaign education
campaign we would love to hear your thoughts on that.

Dr. Harry Greenspun: the number one is that as you mentioned most consumers
give our healthcare system at pretty low rating. But what’s also interesting about
that is in that extent you have a view quality when you ask individuals about the
quality of care that they get, the response back usually get our things related to
with the people nice that they listen to you, but you are getting appointment when
you wanted to and you know all this people who have stayed with a doctor
despite of that outcome and it's not until they have a problem with the office staff
or you know doctor upsets them or something like tha t, that they actually
consider shifting. We have to help them understand how they interpret quality
and outcome information .

And I think what we are going to see as we push more of a cost of care and to
consumers that’s going to have to start thinking mo re about the value who has
got the outcomes that are looking for, but also the service experience are looking
for and safety considerations and other things that are important to them.

So you know if I need a knee arthroscopy and I find out this is going to cost me
you know x amount of dollars to go to a particular position that they have done,
but I don’t simply skip care that I am able to understand how can I find a
physician who fits the budget I can afford with outcomes that are high end type of
servic e that I want to get.

Mark Massel li: We are speaking today with Dr . Harry Greenspun senior advisor
of the Deloitte Center for health solutions, Harry let’s look at that proliferation of
HIT technology and renew you talk about what’s really needed is this big secure
system in the cloud where all health records can be safely accessed but you say
that really remains a distant dream so what’s needed to help achieve that kind of
seamless flow of information.

Dr. Harry Greenspun: consumers are very concerned about how their
information get shared, where they get shared, you know unlike other areas of
your life like Fina ncial Services most healthcare consumers and 50% are
concerned about losing individual pieces of their medical information and if you
think abo ut long medical history , there is tough that you just don’t want other
people to know about and you want some pretty tight control over that. One of
the other things so you know talk about the seamless aspect is that one of the
big problems we have is you know starting with you know sort of traditional
health information technology and electronic health records, real permanent
inoperability and that only getting more complicate d and we are addressing it to a
degree but to think about the number of things o ut there whether it's you know
infusion pumps in a hospital or the (inaudible 13:04) managing wear, we have all
these new devices out there, you know that are in us or around us that are
putting out data and we have to find ways of making the data inoperab le so
induced because frankly that helps the IT industry has not done a great job of
pushing inoperability and that cannot happen.

Margaret Flinter: Well Dr. Greenspun when CMS released a data from closed to
900,000 physician and co unters they are now i n sort in the word of Todd parks
the data has been liberated and lots of researchers and data analyst are minding
it we think we will start to see some insights inter casting outcomes what are we
going to do with all that information to really drive change s in our understanding
of outcomes and price?

Dr. Harry Greenspun : This first data I mean it's a fascinating one, because it
contains a tremendous amount of data in that, and now we are showing some
explanations around well you know in some places a sing le provider code we use
for multiple providers or drugs or devices are rolled up to so it's getting
complicated so you know using any single database is very, very challenging to
get meaningful information about but it's important first that for us to unde rstand
what’s going in cost and quality because as you see and study after study then
what people charge and the outcomes they achieve are often unrelated. And so
we want to be able to help people make you know better decisions and when I
say people I am not only patients that’s employers and that’s payers and for
government. You know to understand are they actually achieving the sorts of
outcomes they are supposed to achieving for the price that people are paying for
it.

So you know it's important that we get this data out, I mean again I reference the
cardiac surgery in cardiology outcomes database in New York, can you marry up
the outcomes information it's available with some of the cost information that’s
coming out, you know to h elp folks make better decisions. And you know
unfortunately you know isolated pockets of data are not going to get us all the
way there but it's certainly an important first step. You also mentioned the
pioneer ACOs and I think we seen some interesting things that you know t he
early experience of the ACOs has been time and I think it shows that you know
and some sense places that were early adaptors of the ACO model many of
them actually were well prepared to be adaptors of the ACO model their
integrated delivery systems or t hey had already invested heavily an IT so they
are capable doing that so they may have not have achieved this sort of
remarkable new results that we expect them to achieve the other thing we see is
you know changes are as I mentioned before and it's going to be while before we
figure out what’s the right model what’s best way to make these what can be
effective .

Mark Masselli: Talk a little bit about the youth population it seems that there is a
digital divide if you well by age and this younger generatio n millennial and the
some of the generalized certainly been raised in this digital age and you would
call them digital armed force and owners of many different types of devices and
sort of thinking back to your comment about trust this is a group of consum ers
who post what we would s ay our HIPAA violations on their face book all the time
very comfortable about sharing information how are they going to drive sort of the

redesign of how the healthcare industry thinks about sharing information and
using techno logy.

Dr. Harry Greenspun: Well I think it will be very interesting time since that when
you -- years a go we talked about when the barriers of Health IT adoption was
you know getting physicians to (inaudible 16:58) doctors, to adopt these
compute r things and you can draft that with you know most younger physicians
and those coming out of school, you know they grew up these as you mentioned
and some working without them, is really unthinkable and you are seeing a lot of
practices where you providers really can’t recruit new physicians unless they
have pretty extensive electronic health records and other type systems. One the
consumer side you know it's not as the people’s need have changed but their
expectations have changed pretty dramatically and you thi nk about banking
several years ago where the half the people would use from the bank on your
phone when may be help you find an ATM. Now people can deposits checks
with their phones they can do all their banking and their phone, and so when they
look at h ealthcare they compare the kind of service they get in healthcare
compared to how they make restaurant reservations or you know how they travel
as you have been gapped and as I mentioned earlier now when consumers give
the service experience of as the qual ity they are going to start looking at this gap
i n service as a gap in quality.

And I think that’s what going to drive a lot of demand and it's not only going to be
for their own healthcare it's going to be as you know children taking care of their
elderl y parents or as they are taking care of their kids is going to become more
important for them to have these sort of support and it's going to drive a lot of it. I
think the other things talking about the social Media aspect of it, I just put out a
paper o r four dimensions of them help and one of the key things we talked about
is as much as healthcare can lend itself to social media and vice versa you know
that you see great work being done in cancer and diabetes and other areas of
real engaging people with each other. You know that a lot of other conditions
don’t really lend themselves to that either because they are not fun or more
importantly there is a real privacy concerns for people concerned about having
the information shared.

I think we will start to see this as people start using these variable devices which
they have been you know competing against each other in the fitness and
wellness kind of area. As they start moving into healthcare that people may be
more and more reluctant suddenly, to sha re some of this information as it
proceeds in towards the healthcare round.

Margaret Flinter: We have been speaking today with Dr. Harry Greenspun senior
advisor for healthcare transformation and technology at the Deloitte Center for
health solutions. Y ou can learn more about his work by going to deloitte.com/US
Harry Greenspun or follow him on twitter by going to @Harrygreenspun. Dr.

Greenspun thank you so much for joining us on conversations on healthcare
today.

Mark Masselli: At Conversations on He althcare, we want our audience to be
truly in the know when it comes to the facts about Healthcare 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 U.S. politics. Lori, what have you got for us this
week?

Lori Robertson: Well, during this 2014 election cycle we have seen several ads
that makes the claim that the Affordable Care Act is hurting families . I t's a very
general claim and its misleading some who brought their own insurance on the
individual market could end up paying more. It would depend on what kind of
coverage they had before health conditions and whether they qualify for
subsidies. But no ends of uninsured families will gain coverage under the law,
many of them through free or low cost Medicaid or children’s health insurance
program coverage and millions of insured families will get those federal subsidies
to help pay for coverage . The no n - partisan congressional budget office projects
there will be 25 million fewer uninsured due to the law as soon as 2016 , and 12
million are expected to gain free or low cost Medicaid with children’s health
insurance program - I nsurance. We have seen the h urting families claim and
adds in Louisiana , Mississippi , and Nebraska which were among the 19 states
that have decided not to expand Medicaid, but even those states the non
partisan Kaiser family foundation estimates that a 135 , 000 residents total would
n ewly join Medicaid because of the law. User folks you would have been eligible
previously but are expected to sign up now prompted by news about the
Affordable Care Act or the individual mandate. Statements about struggling or
hurting families , attempt t o paint a law in black and white when reality isn’t so
clear cut. And that's my FactCheck 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 po litical 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 Chcradio.com, we will have FactCheck.org's Lori Robertson
check it out for you here on Co nversations on Healthcare .

Dr. Harry Greenspun: All my pleasure thanks for having me.

Mark Masselli: Each week, Conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives. Asthma is one of
the leadi ng causes of trips to the emergency room for children , and there are
often a correlation between high density low income neighborhoods and more
trips to the hospital for treatment and intervention. When officials at Boston
Children’s Hospital noticed a sp ike in Asthma outbreaks and certain

neighborhood clusters , they decided to do something about it . They launched
the community asthma initiative. Triggers for Asthma are well known dust , mold ,
pest , mice , and even overuse of certain cleaning products can cause trouble .
T hey realize d that if you could treat the environments in the patient ’s home that
might reduce the need to treat the patient in the emergency room.

Dr. Elizabeth Wood: The home visiting efforts work with children and families
that have be en identified through their hospitalizations and emergency room
visits as an identification of having poorly controlled asthma and also it's a
teachable moment when families are open to making changes in terms of care
and environment within the home.

Mark Masselli: Dr. Elizabeth Wood heads the program and says the first step is
to identify the frequent fliers . T hose kids who mak e repeated trips to the
emergency room . T hen they match with the community health worker who visit
their home several times and assess the home for asthma triggers.

Dr. Elizabeth Wood: And they work on three areas understanding a sthma itself,
understanding the medications , and the need for control medications and then
working on the environmental issues within the home.

Mark Ma sselli: Families were given everything from HEPA filter vacuum cleaners
to air purifiers. They are told not to clean with certain toxic products and the
homes are monitored for the presence of pest or rodents. T he result says Dr.
Wood has been pretty dr amatic.

Dr. Elizabeth Wood: What’s remarkable is that there was a 56% reduction in
patients with NA emergency department visits and 80% reduction in patients with
NA hospitalization.

Mark Masselli: And while this program expensive about $2400 per famil y there is
a return on investment in reduced hospital costs and healthier children. The
program has been so successful, it's being deployed in other hospital
communities around the country. The community asthma initiative a simple
reshifting of resources aimed at removing the cost of disease outbreaks in the
community leading to healthier patient populations - now that’s a bright idea.

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

Mark Masselli: And I am Mark Masselli. Peace and health.

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