Dr. Elizabeth Bradley, Yale Global Health Initiative

(Music)

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret there is a new person at the helm of the
departmen t of health and human services, Sylvia Mathew s Burwell sailed with
relative ease through the confirmation process receiving accolades from both
sides of the isle.

Margaret Flinter: It's a daunting task that you faces , HHS has a trillion dollar
budget , 80,000 employees and they are really still on t hose first throws of the
launch of the Affordable Care Act.

Mark Masselli: Not to mention the myriad other areas she must have received
Margaret. She has the authority over drug regulation disease monitoring as well
as medical research , all issues relat ed to population health.

Margaret Flinter: Most recently she was the president ’ s director of the office of
management and budget before that she was president of the Wal - Mart
foundation chief operating officer of the Bill and Melinda Gates Foundation and
deputy chief of staff to President Bill Clinton’s. So obviously no stranger to high
stress , high profile jobs.

Mark Masselli: And let’s say she needs to hit the ground running and that she
must act quickly to set standards in place for 2015 open enroll ment which
technically speaking is just around the corner.

Margaret Flinter: She really has to just imbue confidence in the department ’ s
abilities to marshal its forces arou nd the continued roll out of the Affordable Care
Act but she seems to have inspir ed confidence in some of the nation ’ s top
politicians and corporate entities thus far , so I think her 10 year holds promise.

Mark Masselli: (Inaudible 1:18) secretary Kathleen Sebelius did spend some
time recently thanking cohorts and supporters at the r ecent healt h data (inaudible
1:25) gathering in Washington. She noted that HHS will continue to focus on
reforms that optimize health outcomes and help us really reduce the cost.

Margaret Flinter: That’s something our guest today has spent a tremendous
amount of her scholarly energy examining mark Dr. Elizabeth Brad ley is the
director of the Yale Global Health Initiatives and also the co - author of the
American Healthcare Paradox by spending more is getting us less.

Mark Masselli: She examines why healt hcare cost are so expensive in this
country and why outcome still rank poorly compared to other industrialized

countries, we will also hear from Lori Robertson managing editor of
FactCheck.org . But no matter what the topic, you can hear all of our shows b y
googling chcradio.com

Margaret Flinter: And as always, if you have comments, please e - mail us at
www.chcradio.com or find us on Facebook or Twitter , we love hearing from you. .
We will get to our interview with Dr. Elizabeth Bradley 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 Hea lthcare Headlines. The
V eterans Affairs healthcare scan dal has done something that few other issues
have achieved in this hyper partisan congress unite members of opposing parties and supportive swift action to reduce veteran ’ s weights for care and whol e VA
officials accountable from mis - re presenting waiting t imes. The house
overwhelmingly approved a bill , they would love veterans facing long waits for VA
care to see private doctors to spend VA bonuses and require an outside assessment that this year ’ s American Medical Association meeting discussion
with fear surrounding yet again another failure by congress to fix the sustainable
growth rate formula that reimburses physicians for treating Medicare patients .
T here had been a bipartisan solution ready to sales through congress but it
wasn’t acted upon in time b efore the end of the session. (Inaudible 3:15) so high
over this in a long line of attempts to repeal the SGR that a decision was made to
have an annual review of the AMA’s lobbying efforts. A number of trade groups
and accountable care organizations hav e sent letters to HHS secretary Sylvia
Mathews Burwell urging her to take swift action. On improving impediments to
implementation of telemedicine protocols such as remote patient monitoring and
tele health consults currently telemedicine is governed by a patch work quilt of
restrictions on use and payment models which is in many cases hindering
adoption those signing the letters comes from across the spectrum (inaudible
3:50) The American Telemedicine Association , large ACO organizations like
Geisinger . S ecretary Burwell has the power to overwrite some of those
restrictions. I am I a m Marianne O'Hare with th ese Healthcare Headlines .
(Music) Mark Masselli: We are speaking today with Dr. Elizabeth Bradley , director of the
Yale Global Health Initiatives a nd faculty director of the Global Health Leadership Institute , and she is co - author of the book the “ American Healthcare Paradox -
Why Spending More Is Getting Us Less” which examines reasons for America’s
extremely high health cost and relatively poor out comes Dr. Bradley is a
professor of public health policy at Yale School Public Health . S he has earned

her bachelors at Harvard or MBA at the University of Chicago and her PhD at
Yale. Dr. Bradley welcome to Conversations on Healthcare .

Dr. Elizabeth Bra dley: Thank you so much Mark.

Mark Masselli: Betsy it's a great book first of all . I t was wonderful to read the
American Healthcare paradox, you explore how much we are spending per
capita in healthcare in this country and how we rank relative to othe r industrialize
nations in terms of outcomes and your focus at Yale is on Global Health Initiative
so you are well positioned to comment on which country has the best healthcare
system in the world so can you explain to our listeners that paradox and help us
understand how we actually stack up relative to other countries around the world.

Dr. Elizabet h Bradley: The paradox in the American Healthcare System is as
you said we spend about one and half times to two times as much per capita any
other country in the world any of our health outcomes or among some of the
worst actually for instance our maternal mortality rate as six times that of Sweden
or life expectancy is six years less than the best countries life ex pectancy is and
these differences these dis parities go on and on across diabetes heart disease
teenage pregnancy it goes on how can we spend so much and get so little we do
however get some things for that of course we do have tremendous access to
high technology equipment kidney transplant knee re placements etc are some of
those very, very technical pieces but when you look over all to the big health
outcomes we are just not doing as well as countries that actually spend less than
we do.

Margaret Flinter: So to do this work Betsy you took a deep dive all around the
world and examined health data from some 30 countries and it came to the at
this conclusion that while we spend close to 20% our GDP and healthcare in the
United State s and I think that’s roughly three trillion dollars per year. We are
spending far less than other countries on social services which goes long ways in
those countries to improving population health , can you give us some examples
of how other countries are off setting healthcare across by investing in social
programs on the front end.

Dr. Elizabeth Bradley: For every one dollar , the United State s spends on
healthcare we spend another 90 cents on social services. But in western Europe
for every one dollar spend on healthcare another two dollars is spend on social
services s o although we are all spending about the same amount of the total
GDP when you look at both of these together we just favor heavily the medical
care and the healthcare side and we are less favorable on the social service
side. The place that we were most impressed with is really spending a moderate
amount of money and getting honestly the best health outcome is Scandinavia
we wanted to go there to understand what could we learn we know we can’t do
the identical same thing we are much bigger we are much mor e diverse but what
is that any mechanisms they are using that we could learn something from and

one of their collaborate ways in which they deal with us is they do at a county
level they do joint budgeting and planning, for all the social services and the
medical care services. Somebody in the county government could say we are
going to put a little more in housing then we won’t have to spend quite so much
money in the emergency room and it's the same system that benefit from that
offset which we really do n’t have in the United States to try to use our scarce
dollars to make the greatest health outcome we possibly could.

Mark Masselli: You know that seems to be another one of the paradox is that
everybody is talking about the social determinants of health but we don’t see a lot
of real activity happening in the ground is you are suggesting and you have the
opportunity to sit with thought leaders for your book who figured out the foreign
so can you highlight some of those organizations that are really impro ving care
on that front end the support services, and what sort of healthcare savings on the
back end have been achieved if any as yet.

Margaret Flinter: It's interesting because we f ound the home grown innovations
in the United States across diverse sec tors, so one of the learning was for us is
just echoing our countries way where extremely diverse and we saw many
different small level innovations. But a couple of programs I would turn to one is
important Oregon called C - Train and it's a collaboration b etween the Oregon
Health and Science University and Central city concern which is community
center and the community center almost act as the hinge between what is a high
tech medical care system and what is really housing immigration support legal
suppor t education nutrition cooking support, they establish a joint governance
structure in which the hospital and health system actually provided support to the
central city concern by placing and guaranteeing thoughts with primary care
coordinators basically i n the central city and any patient that was at risk for really
post discharge readmissions or having intense sort of social service needs and
they identified early and they called they put them on the C - Train and they got
the full case management and then this community center really was engaged
and help them be sure that they could access services that were already paid for
often the hospitals may not even realize to connect people in but if you can just
get the connection the resources is there and someti mes underutilized. The
other piece we saw in this is when the healthcare system got involved with some
of these community state and local social services there was an automatic okay
we are going to track things, now we are paying attention , there was a ce rtain I
think rigger that came to the management of both of these kinds of services to
make them both bet ter.

They did randomize trial they found their patients at lower mortality better quality
of care and the hospital is actually funding expansion to o ffer this service to even
their high income and donor population that’s coming in as patients.

Margaret Flinter: So Betsy when we are talking about health and healthcare and
social spending we are inevitably going to talk a little bit about politics or t he

political climate and what are your thoughts about the kinds of political incentives
that might be deployed to improved social program spending specifically a s a
hedge against higher healthcare c ause and also the degree which you think the
Affordable Ca re Act addressed any of these issues along with the issue of un -
insurance.

Dr. Elizabeth Bradley: I think the first thing that is important implication of our
book is the idea really in the book is can we use as we intimated the healthcare
dollar which i s as you said almost 20%of our GDP can we use that significant
investment. And make it in the best intere sts of those providers to also address
some of the social determines of health and get involved with the services that
are already funded at state lev el , our incentives now are still for the most part to
provide more medical care and that’s an incentive from the supply side
physicians in hospitals do better financially from that, but also from the demand
side patients and families we see ourselves as me eting medicine and that’s a
whole another thing that’s quite different in the United States from for instance
Scandinavia so from both sides we have an incentive system that asks us and
pushes to put more and more in medical care. I think the ACA does hol d some
potential for us it does create a platform on which providers can collaborate they
can take set part of money for a group of population and they can be held
accountable for some of the health indic ators not just the healthcare indicators.
That is p ossible it would be legal it's regulatory supported through the ACA
however in the early roll out of the ACA most of the indicators on which these
provider groups getting together are being evaluated on are still not health
indicators. They are still serv ices so we haven’t yet gone to the place, where the
organization is actually rewarded for what percentage of their patients are obese
what percent of their patients are housed, what percentage of their high school
patients are on track to finish high schoo l this would be an extreme forwardness
and I think it will be decades before we think this way thinking a little bit more
holistically about all the things that can make their patients healthy not just
medical care.

Mark Masselli: We are speaking today w ith Dr. Elizabeth Bradley with Dr.
Elizabeth Bradley director of the Yale Global Health Initiatives and she is co -
author of the book the American Healthcare Paradox why spending more is
getting us less you know so we are spending a lot of money we are spen ding
20% of the GDP, and so what’s the concern about the diminishing of health
spending so you have got part of it is you are going to shift some of those dollars
but there is a big drive in this country to reduce costs second unravel all these
initiatives if we start to undermine the economic underpinnings of the country in
some ways by starting to reduce cost what are your thoughts on that?

Dr. Elizabeth Bradley: One thing we might look at is may be we are spending
that what’s right, but we haven ’ t real ly thought through how to spend it as
efficiently as we can allocating it in a way that truly will get us this spending but a
much healthier po pulation that would be the goal.

Margaret Flinter: The best accountable care organizations which are generally
described as organizations of group to providers that hopefully more effectively
coordinate healthcare for large populations of patients in how effective have
these organizations been at improving health outcomes while seeking to contain
costs what are you r thoughts on that?

Dr. Elizabeth Bradley: The accountable care organization s the evidence on their
impact is very mixed, if you would never look at the body of evidence coming out
of our last three four five years of experimentation on this and say that is going to
transform healthcare. You just wouldn’t, you know on the margin with the right
case management model and the proper navigation model in their right
communities they are finding modest savings so that’s just not something that I
think we can h an g on our hat on and assume that’s finally going to get us out of
this conundrum as you said. How do we as a public how do our communities
first understand health what do we demand when we have a hurt back what do
we want when we hurt our shoulder in the American world a lot of what the first
thing happens is try to get in line for an orthopedic who will get you and MRI who
will likely land in surgery. We have story after story in the book of places where
people chose a different path to try to look at a I would say more holistic more
behaviorally focused way to deal with that pain they may have in their shoulder
but that concept of how the community understands what healthcare can do for it
that’s really cor e to solving and addressing this problem. Okay health that’s a
collective good, but how to get a governance structure around that where people
can reall y collaborate.

Mar k Masselli: Talking about it -- talk a little bit about the American Solution a
new focused lot on the Scandinavian countries Norw ay and Sweden , tell us
about those and the challenge of sort of cross walking those over to our unique
culture here.

Dr. Elizabeth Bradley: Yeah well I think the challenges of really cross walking
some of what we have learned in Scandinavian too the Unit ed States has a lot to
do with what our phase is in our government and what we would delegate to our
government to do and we use the world value survey to compare the United
States to Scandinavian and that basically characterizes people the rude values
abo ut what they feel about their government income and in a quality whole set of
measures one of which is trust and Scandinavian is a very high on trust and
Americans not so much but we have tremendous amount of innovation and
localism when you get i nto the l ocal, local communities amazing things are
happening like C - Train but we saw things throughout the country that were at a
very local level where trusted high and that I think unlike perhaps Scandinavia
our pace of change is very fast our freedom to make a new ideas is very fast, I
think in some ways we may come up with more innovative things than we see
around t he globe, that’s where we are out to really be looking at and even at the
employer level.

Margaret Flinter: That’s when we will continue the move from the global to the
local and I have read your analysis and your thoughts on the community health
center move overtime legislation funding initiatives all well intended had perhaps
a unanticipated consequence of shifting the focus back much more heavily to
investment in the healthcare part of it and less and in addressing the social
determinants. And what a loss that’s when I wonder to you think that the
community health center movement 20 million patients expected to grow to 40
million has the potentia l to be one of these local community based and very
diverse communities strategies for beginning to shift some of the investment from
healthcare to social services .

Dr. Elizabeth Bradley: yes I absolutely think it is central there are a couple of
pieces that I think have to fall into place to get that locus to really flourish looking
at the social determinants and what happened in the early days in the 60s that
really shifted things was putting the community health center movement under
allowing it's reve nue stream to be fully dependent on Medicaid and Medicare,
which could only pay for medical care things. When that happened you know it
changed the incentive system it changed the psyche, not of the people but just of
what really was possible with an orga nizational constraint. Today we may see
loosening of that it's possible I don’t know how far the country will go but states
are starting to be quite innovative with their Medicaid programs there are lot of
more wavers that can happen for do eligible or fo r Medicaid only recipients in
which the dollar could be used to do the combination that a community health
center might tell you is going to be the most effective. Not only the medical care
not only the referrals of the hospital but potentially looking at housing and I call
our attention to this, I attempt I will project in LA which worked with hospitals to
identify the top 10% of homeless people and basically use Medicaid dollars to
work on the homelessness and other social support services through commun ity
centers first before the referral the hospital and they just had tremendous savings
I mean only a couple of years but they are quoting healthcare cost decreasing by
72%.

So I feel like the provider group of community health centers is exactly where it
could be but we do need the payer piece of it to align with health not healthcare
in order to allow the centers to really I think flourish and what their vision has
already been.

Margaret Flinter: We have been speaking with Dr . Elizabeth Bradley directo r of
the Yale Global Health Initiatives and faculty director of the Global Health
Leadership Institute she is co - author of the book the American Healthcare
Paradox why spending more is getting us less you can learn more about her
work by going to ghli .yale .edu or you can follow her on twitter at EHBL. Betsy
thank you so much for joining us in Conversations.

Dr. Elizabeth Bradley: Thank you both very much.

Mark Masselli: At Conversations on Healthcare, we want our audience to be
truly in the know when i t 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, do the Affordable Care Act increase income tax brackets
capital gains and state taxes and 2014, that’s what our viral e - mail says but it's
not true, the unanimous message claims that several taxes went up on January
st
1 , 2014 because of the Affordable Care Act but none of the taxes listed had
anything to do with the healthcare lot, most of were part of the fiscal cliff [PH]
st
package that congress passed on January 1 , 2013 for instance the to p income
tax rate did go back up to 39.6% for singles making more than $400,000 a year
and couples earning more than $450,000 that increases part of the fiscal cliff in
2013. Capital gains and dividend tax rates also went up under that deal, and not
as mu ch as the viral message claims the top capital gains rate dividend rates are
both now 20% for those who are earning more than $400,000 or $450,000 a
year. The e - mail wrongly says that t he estate tax went from 0% to 55%. The tax
is still 0% for anyone who dies this year and has in a state worth less than $5.3
million. The top rate is next to the fiscal cliff deal 40% this message goes on to
claim that the tax increases it list were “passed with only democratic votes” not
true at all, the fiscal cliff deal passed by a vote of 89 to8 in a senate with 40
republicans in favor. In the house 85 republicans voted in favor. The ACA does
include some tax increases such as a 3.8% tax on net investment income and
additional Medicare tax of 0.9% for those earning mo re than $200,000 a year or
$250,000 for couples but that increase is no where to be found in this bogus viral
message and that 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 Chcradio.com, we will have FactCheck.org's Lori Robertson
check it out for you here on Conversations on Healthcare . Each week,
Conversations highlights a bright idea about how to make wellness a part of our
communities into everyday lives. Primary care providers have their work for
seeing patien ts after patients all day in brief visits it can be difficult to cover all the
important basis and often signs alcohol dependence can get overlooked and
many patients are put off by lengthy questionnaires that are aimed to determining
whether you have a pr oblem with drinking or using drugs. Researchers at the
Boston University School of Public Health have determined that asking one
simple question could actually determine the level of a patient’s possible drug or
alcohol dependency. For alcohol use partic ipants were asked how many times in
the past year they had consumed five or more drinks in a day for other substance

use they are asked how many times in the past year have used illegal drug or
used a prescription medi cation for non medical reasons.

The r esearchers compared alcohol screening responses with alcohol
dependence reference standards and drug screening questions with drug
dependence standards. The single alcohol screening questions detected 88% of
those with alcohol dependence the drug question detected 97% of those with
drug dependence. Lead researcher Dr. Richard states say this could provide a
valuable rapid assessment for primary care providers to help patients and get
them to the treatment options they need a single simple question aimed a t
revealing drug or alcohol dependency that could primary care providers
diagnosed the problem more readily getting patients sooner to the help they need
now that’s a bright idea.

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

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.