Dr. Erica Frank, CEO of NextGenU.org

( Music)

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

Margaret Flinter: A nd I am Margret Flinter .

Mark Masselli: Well Margaret, it's been a busy couple of weeks in the courts with
the Health Care La w continuing to undergo legal challenges from a number of
sectors with some recent decisions in several district courts for many more
controversial interpretations of the Affordable Care Act .

Margaret Flinter: There were lower court rulings on some challenges to the
Health Care Law’s tax subsidies for people who are seeking to buy health
insurance on the exchanges.

Mark Masselli: The U.S. Circuit Court of Appeals for the District of Columbia
rule d that based on a lit eral interpretation of the language in the Affordable Care
Ac t , states that did not setup their own exchanges are not allowed to provide
subsidies to those residen ts gaining coverage on the federal exchange.

Margaret Flinter: Well, this is far from the final word, Mark Masselli, b ut that
r uling could have devastat ing consequences. I think it needs to be noted though
that a second ruling on the matter in the U.S. District Court in Virginia upheld the
same thing, the legality of the tax subsidies saying that the IRS does have with in
its purview the ability to author ize subsidies for government - mandated programs.
So essentially, we h ave a diametrically oppose d view . We are kind of use d to
those diametrically oppose d views coming out of Washington these days.

Mark Masselli: We are, and it's left quite a lot of conf usion though, Margaret.
Millions of Americans have gained coverage during the first open enrollment , and
at least 75% of those Americans are receiving some sort of tax subsidy to offset
the purchase of that insurance . So majority of those who gained cove rage could
be im pacted by these decisions . Americans s t a nd to lo se some $36 billion in
premium subsidies if the DC court de cision is upheld.

Margaret Flinter: And the Urban Institute paints a pretty grim picture.
Essentially, the Affordable Care Act , I hate to say it this way, but people are
saying it becomes a blue state law in which only those folks in sta te s who setup
their own insurance exchange can take full advantage of the law ’ s promise , s o
lots more to follow on this incredibly fascinating story .

Mark Masselli: Another story that’s unfolding is the ongoing crisis with the tens of
thousands of immigrant refugee children being dispersed around the country
while they awa it some kind of immigration he aring. It's a humanitarian crisis
that’s unfold ing right within our borders , and there is no simple solution to this
problem either though I read with great interest that George Will, the

conservative columnist said, “Just let them in, we can manage that here in
America.”

Margaret Flinter: And so muc h political discussions , some backlash across the
country over what to do with these children , but the fact remains they are here,
they are children , th ey need to b e treated in a humanitarian way, and from what
we are reading , many of them have escaped jus t unimaginable violence and
threat in their home countries.

Mark Masselli: So another unfolding story that we are keeping our eye on,
Margaret.

Margaret Flinter: And our gues t today has her eye on global public health issues
as well . Dr. Erica Frank i s the Canada Research Chair in Preventive Medicine
and Population Health, and a professor in UBC School of Population and Public
Health. She is also the Founder of NextGenU.org , a free global online university
that ’s been developed to meet the growing need in the health sciences, an
interesting approach to the need to train more health care workers around the
globe.
Mark Masselli: Lori Robertson will also be checking in from FactCheck.org .
Margaret Flinter: And no matter what the topic , remember , you can hear all of
our shows by g oing to CHC Radio .
Mark Masselli: And as always , if you have comments , please e - mail us at
www.chcradio.com

; we love hear ing from you .
Margare t Flinter: We wi ll get to our interview with Dr . Frank 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 Health Care Headlines .
H ouse and Senate negotiators announced an agreement on legislation that
would allocate $17 billion to overhaul the Department of Veterans Affairs’ sprawling and beleaguered health care system, a legislation (inaudible 03:51)
sometimes rancorous standoff ove r how much to spend to begin to fix the department, and it would help ensure that veterans who face long waits to see doctors at the department’s facilities could get appointments more quickly with private physicians. The agreement came about from some ra re haggling across
party line s , something not seen much in Capitol Hill these days.

Medicare ’ s Hospital Insurance Trust Fund which finances about half the health
program for seniors and the disabled won’t run out of the money till 2030, four
years later t han projected just last year, and 13 years later than projected the
year before the passage of the Affordable Care Act . Unlike Medicare however ,
the part of Social Security that pays for people getting disability benefits , is in far
more immediate jeopard y. The Disability Insurance Trust Fund is projected to
run out of money in 2016. On Medicare, the news was mostly positive , Medicare
considerably stronger than it was four years ago according to Health and Human
Services Secretary Sylvia Burwell. She no ted the recent slow growth of the
program spending will likely mean that Medicare Part B premium charged to
beneficiaries will remain the same for the third year in a row.

But whatever reason, no one contests the slowdown has been dramatic .
Medicare , whi ch covered an estimated 52.3 million people in 2013 , spen t $582.9
billion on how we train our doctors. An expert panel recommended completely
overhauling the way government pays for the training of doctors saying the
current $15 billion system is failing to produce the medical workforce th e nation
needs. The federal government mostly via the Medicare Program currently
provides more than $11 billion per year in payments to support the training of
doctors . Most of that goes to the hospitals that sponsor in t e rns or residents .
There are persistent problems with uneven geographic distribution of physicians ,
too many specialists and not enough primary care providers.

HPV, the virus that causes most forms of cervical cancer, there is a vaccine for
that, but yo u wouldn’t know it from the number of teens receiving it . Though the
vaccine against human papillomavirus is highly effective in preventing certain
forms of cancer, the number of pre - teens getting the vaccine is still dismally low
according to the Centers for Disease Control and Prevention. One of the top five
reasons parents listed they hadn’t vaccinated their children was that it hadn’t
been recommended to them by a doctor or a nurse. Dat a from the national
survey released shows only 57% of young women ages 13 to 17, and only 35%
of young men have received one or more of the dose.

I am Marianne O'Hare with these Health Care Headlines .

(Music)

Mark Masselli: We are speaking today with Dr . Erica Frank , Professor at the
University of British Columbia’s School of Population and Public Health where
she is Canada Research Chair in Preventive Medicine and Population Health.
She is also Founder, President and Research Director at NextGenU.org , the
world’s first onlin e portal that free accredite d higher education in health science
as well as in other disciplines. Dr. Frank has been the Co - Editor in Chief of
journal of Preventive Medicine, and served as the U.S. President of Physicians for Social Responsibilit y, and sh e earned her Master ’ s i n Public Health from
Emory University , her Medical Degree from Mercer University , and her residency

at Yale School of Medicine. Dr . Frank , welcome to Conversations on Health
Care .

Dr. Erica Frank: Thank you so much.

Mark Masselli : We are in this midst of radical transformation in health care and
how we deliver it, how we teach it and disseminate it . You have been
instrumental in creating the world’s first online university focusing on health
sciences, and this is a n area not gen erally associated with online learning by
traditionalists in the health industry although we are seeing this proliferation of
MOOCs Massive Open Online Courses being generated from a host of
prestigious universities around the world. So tell us what’s dif ferent about
NextGenU and what was the genes i s for the idea?

Dr. Erica Frank: We are essentially the world’s first free university . We are the
first portal to free accredit higher education , so the first place you can go to and
get credit from an univer sity for taking a course for free , which is different from
MOOCs, right. They give courses for free, but don’t give credit. And then we
also have a lot of other characteristics that are different from MOOCs , some
shared with traditional education . For e xample , we provide mentor ed activities
and peer activities , especially important of course in the health sciences where
there are lot of skills that you need to practice, and we have evaluation built - in
both in a qualitative and quantitative way ; we are ad - free ; we are free of other
barriers as well like time and place. So we like to refer to ourselves actually as a
doohickey , a democratically open online hybrid of Internet - aided, computer - aided
and human - aided education . So for your radio listeners, that does indeed have
the acronym spell out the doohickey.

Mark Masselli: I love it.

Margaret Flinter: You know , Dr. Frank , it seems to me for all sorts of kind of
immediately obvious reasons this has the potential to be a global game changer
in terms of t he democratization of access to education , and I am intrigued by the
massive level of cooperation that must have been required to pull this enterprise
together . I understand you have government agencies from different countries.
So I wonder if you would share with our listeners some of the primary
stakeholders that you have engaged and involved in this project, the agencies
and countries you are working with, what are these global collaborations, and
how are you marshalling and pulling together all of the se resources?

Dr. Erica Frank: We noticed like , lots of people did , that there are all these
remarkable free learning objects that have been posted on the web by
government s, specialt y societ ies, peer - reviewed organizations and universities.
Those are o ur four sources, and we pair them with competencies that have also
already been established by expert organizations. So that’s pretty inexpensive to
do that pairing, and then we work in partnership as you said with lots of

organizations, governments, univ ersities and specialty societies to accredit and
fund these trainings. So for example , in Sudan, we have just launched a Family
Medicine Residency Program which we have a Memo of Understanding with the
Government of Sudan and University of Gezira, the lar gest of their 30 medical
schools, to train 10,000 family medicine residen ts over the next five years. We
work in partnership with the university , and we work with the Government of
Sudan. One other example to give might be in Ecuador where we are working
with the Accreditation Council for Graduate Medical Education International and
the American College of Preventive Medicine to create a globally available
prevent ive medicine residenc y . And we are doing similar kinds of initiatives in
over a 100 other co untries including in the U.S. and Canada.

Mark Masselli: And you know, may be a few more details about the size
currently of how many registered users you have, and I am sure there is this
conflict that goes on with the traditionalist in terms of how eff ective this training
will be so you might want to walk our listeners through some of the battles that
you have had to fight and how those have been resolved .

Dr. Erica Frank: So I am a Canada Research Chair as you pointed out, and this
is a lot of what I spend my research time doing is examining the efficacy of this
new kind of educational model. And we have done multiple pilots . The three that
we have done in North America having been trained and taught in North
America, and having that the gold standa rd for many people for training in
medicine and public health in the world, that’s where we wanted to do our proof
of concept. So we did two substantive pilots , one at the Uniformed Services
University of the Health Sciences in Bethesda, Maryland and at U niversity of
Missouri with our emergency medicine training, and we demonstrated at both
Bethesda and at Mizzou that NextGen users do as well as or better than
traditionally trained medical students . That was very encouraging. And then we
also did a flipp ed classroom at Simon Fraser University with our Environmental
Health Course , one of the core MPH courses, and found that students again
performed identically on knowledge test, but reported liking the course even
better , substantially higher , like 20% hig her course evaluation s . So we have
been very pleased in terms of the proof of concept that it ’s perform ed
magnificently in North America , and it's performing quite wonderfully at our pilot
site in less developed countries as well .

The main foundation of our sustainability is generosity in terms of learning
objects, course creators who assemble the courses, books with expertise in the
area who are willing to spend about a month worth of time over whatever time
period they are willing to give , b ut we also h ave more traditional academic
sources. We just received a $15.5 million endowment from the Annenberg
Physician Training Program . We have gotten three grants from Grand
Challenges Canada, one from WHO. So because our burn [ph] rate i s so low for
our core expenses , about a third of a million dollars a year, that’s the equivalent
of a couple of fairly fancy faculty members at most academic institutions , and we

are able to run all of NextGenU with that kind of funding . And we don’t have a
whole lot of maint enance cost s o we are pretty sustainable at this point.

Margaret Flinter: Well Dr. Frank , I wanted to maybe draw a little analogy to one
of our innovations . Our organization launched the first in the country
postgraduate formal residency training progra ms for new nurse practitioners back
in 2007 and training not just to clinical complexity but really training people to a
model of transformative care which means you really need to be in settings which
have embraced transformation and innovation . And I am curios how are you
managing that tricky area of making sure that the students get the mentoring
experience or the clinical practice experience in organizations that really have
embraced that level of innovation and transformation that we are looking to se e
going forward .

Dr. Erica Frank: So I ran the Preventive Medicine Residency program at Emory
University for a dozen years before I came here, and we used the ACGME
competencies, Accreditation Council for Graduate Medical Education
competencies to form t he structure of our residency program and identify
learning objects and activities that our residents needed to do. We do the same
thing with NextGenU , and there are competencies that require mentored
activities . Our highest use of NextGenU is indeed as you are suggesting , the
institutions adopting the courses and using them for their students. So the
institutions , as they always do, identify mentors and have collected a cohort of
peers, other students, and so that’s how those pieces end up getting assem bled.
We essentially hand an institution or a learner a course in a box and they have to
identify someone who will let them shadow them , have typical clinical
experience s with them, and evaluate them at the end. We provide the
evaluations.

Mark Masselli : We are speaking today with Dr. Erica Frank, Professor at the
University of British Columbia’s School of Population and Public Health. She is
the Founder, President and Research Director at NextGenU.org , the worl d’s first
online portal to free accredit higher education in health science s. Dr. Frank, in
addition to NextGen, you have focused much of your professional attention on preventive medicine and you have a particular focus of study on how practitioners ’ own prevention behaviors impact their patients , how important it is
do as I do in getting patients to practice better prevention in health care?

Dr. Erica Frank: My main research for the last couple of decades ha s been on
this link between physicians’ perso nal and clinical health practices, and we found
an extremely strong and consistent link between what docs do ourselves and
what we talk to our patients about . So this is the kind of thing that if a physician
manages to overcome barriers and to figure out how to do it for themselves , it
makes them more believable and more motivating to their patients. So that research has been on identifying that link between what doctors do ourselves

and what we talk to our patients about, and then trying to encourage phy sicians
to have healthier habits so that we can have a healthier population as a result.

Margaret Flinter: Well Dr . Frank , among all of the things you have done, you are
also a past President of Physicians for Social Responsi bility, a winner of the
Nobel Prize for Peace, and of course , a pioneer in the area of tackling the social
determinants of health. I would love to link the work that you are doing now with
NextGenU.org and the mission of Physicians for Social Responsi bility. What’s
the synergy in the mission of these two organizations?
Dr. Erica Frank: Well for me, as a specialist in preventive medicine and
population heath, they are pretty inseparable actually. This is both true in
practical terms. We hav e a climate change and health course as well as our
environmental health course with NextGenU that PSR is a co - sponsor of, and
both NextGenU and Physicians for Social Responsi bility are interested primarily
in addressing the greatest threats to humanity, a nd in trying to redress them
through health sciences education and through rational approaches to dealing
with the terrible problems now and increasing problems that are going to be
coming from climate change. So that’s one of the areas where we have a gr eat
deal of overlap , b ut yes, generally, both philosophically and practically, there is
an enormous amount of overlap between Physicians for Social Responsibility
and NextGenU.
Mark Masselli: And you talked a little bit about your passion for climate cha nge
and its impact o n global health , and tell us a little bit about how you have
integrated this into any of your core struct ures for people . Is that sort of a side
passion that you have? Dr. Erica Frank: Unfortunately both in Canada and in the United S tates there
have been varying to the rational acknowledge ment of and dealing with climate change. It's just another one of perhaps one of the most important ones, but
another one of the rational set of facts that people need to consider and make
decisions based on if they want to live a healthy life and if they want for future
generations to have that opportunity too.
Margaret Flinter: We have been speaking today with Dr. Erica Frank, Professor
at the University of British Columbia’s School of Population and Public Health,
and the Founder of NextGenU.org

. You can find out more about her work by
going to NextGenU.org . Dr. Frank , thank you so much for joining us on
Conversat ions on Health Care today.
Dr. Erica Frank: Thank you. It's my great pleasure.
(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: Well , the Urban Institute is out with a new report that looks at
how the Affordable Care Act has affected the number of un insured. Its survey
data showed that the number of uninsured adults dropped by 8 million between
September and June. The open enrolment period for the ACA marketplaces
st
began October 1 . The percentage of uninsured in the United States was an
estimated 13.9% in June compared with 17.9% in September, the survey found.
The drop in the percentage of uninsured was more pronounced in states t hat
expanded Medicaid under the ACA. In those states, the rate of uninsured was
10.1% in June, a 6% point drop from September. Meanwhile, the states that
haven’t expanded Medicaid, there are currently 24 of them, have an uninsured
rate of 18.3%, down sli ghtly from a 20% rate in September.

These are of course only estimates from a survey taken a few months after the
first open enrolment period under the Health Care Law. The data don’t include a
break down of the sources of insurance for the previously un insured. They do
however show that the insurance gains overwhelmingly occurred in families
whose incomes were below 400% of the federal poverty level. That’s $95,400 for
a family of four this year making those families eligible for subsidies on the
insur ance marketplaces or Medicaid coverage. The survey, which has been
taken quarterly since 2013, is funded by the Robert Wood Johnson Foundation,
the Ford Foundation and the Urban Institute. And that’s my fact check for this
week. I am Lori Robertson, Man aging Editor of FactCheck.org .

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major political players, and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com . We will have FactCheck.org ’s Lori
Robertson check it out for you here on Conversations on Health Care.
(Music) Mark Masselli: Each week, Conversations highl ights a bright idea about how to
make wellness a part of our communities and everyday lives. Medical errors are believed to be responsible for about 100,000 deaths per year. The medication errors play a big part in that number. In a study just released in the Journal of American Medical Informatics Association, showed that a newly designed
electronic medication alert system had a significant impact on the reduction of prescribing errors.

Dr. Alissa Russ : We focused on alerts that are presented to physi cians during
the medication ordering process so when they are in electronic health record how
the alerts are displayed to them that save them time and reduce prescribing
errors.

Mark Masselli: Dr. Alissa Russ is a human factors engineer, focusing on how
clinicians and patients interact with the health care system. She conducted a
study at Roudebush Veterans Affairs Medical Center in Indianapolis . She notes
that the overworked clinicians can have trouble discerning subtle differences in
medications in th e electronic medical systems so they decided to change the
design of the alert system in the electronic medical records of patients creating a
simpler, more easy, readable alert system for clinicians.

Dr. Alissa Russ: So errors that might be that they co uldn’t see the alert because
they (inaudible 23:27). The other errors in terms of reducing prescribing errors
really just get back to providing the key information at the right point in time and
not overloading the providers with information.

Mark Massel li: The clinical trials showed a marked reduction in medication
errors, and a better handle on understanding potential adverse drug interactions
ahead of time, noting that a good alert design may offer better cognitive support
for clinicians during busy p atient encounters.

Dr. Alissa Russ: So in this study we focused on three basic types of alerts, those
for adverse reactions where provider is ordering a medication that the patient’s
had an allergic reaction to; we also looked at drug - drug interactions; then we also
warned providers about cases where patients have low creatinine clearance or
impaired kidney function.

Mark Masselli: The results were so convincing. They are expanding the trial to
further test design ideas that make the process even more seamless for
clinicians prescribing multiple medications everyday. A simpler clinician - based
approach to reducing all - too - common prescribing errors, yielding better
outcomes for patients and their health practitioners, 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
Wesleyan University, streaming live at www.wesufm.org and brought to you by
the Community Health Center.