Dr. Harvey Fineberg, President of IOM

Mark Masselli: This is Conversations on Healthcare, I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margaret we've been getting some interesting numbers from
around the country on the drop in the rate of uninsured Americans in the wake of the
Affordable Care Act. Of course those numbers rate differently from state to state here
on o ur home state in Connecticut we've seen some terrific numbers after just one
season of open enrollment our uninsured rate is down to around 4%.

Margaret Flinter: Overall the national uninsured rate as of July of this year is 13.2%
that's down from around 18% before open enrollment began and that is the lowest since
mid 2008.

Mark Masselli: But if -- if factor in those states that chose not to expand Medicaid for
more of its citizens not only have their uninsured numbers remain high so have their
insuranc e rates of the individual insurance market. All these changes in health policy
are effecting the medical profession as well. And our guest today has a keen insight
into that side of the equation.

Margaret Flinter: Dr. Harvey Fineberg has presided over t housands of public health
studies in his role as the President of the Institute of Medicine. And he will share some
unique insights into the progress that they have made at the Institute of Medicine and
developing evidence based recommendations for polici es that will improve healthcare
delivery training and public health.

Mark Masselli: Lori Robertson, managing editor of FactCheck.org stops by uncovering
misstatement spoken about health policy in the public domain.

Margaret Flinter: And no matter what th e topic you can hear all of our shows by
Googling CHC Radio.

Mark Masselli: And as always if you have comments email us at chcradio.com of find
us on Facebook or Twitter we'd love hearing from you.

Margaret Flinter: We'll get to our interview with Dr. Ha rvey Fineberg in just a moment.

Mark Masselli: But first hear is our producer Marian ne O'Hare with this week's headline
news.

Marian ne O'Hare: I'm Marian O'Hare with th ese Healthcare headlines. Todd Park is
stepping down but not out the nation's chief t echnology officer who has been
st
spearheading a move to bring government and the White House into the 21 century
technology zone is leaving that post and he's returning to his roots. The one successful
tech entrepreneur is going back to home turf Silicon Valley in an effort to recruit more

top tech talent to lend expertise to Washington. Park whose mantra was release the
data when he was chief technology officer for health and human services has since
broadened his influence in government to make more fed eral data accessible via
technology.

Birth control is supposed to be free to all American women under the Affordable Care
Act but the recent Supreme Court hobby lobby decision added a great degree of
confusion to the law's regulations. The White House is since responding with a
modified rule on the subject that women who work for religious nonprofits oppose to
providing birth control on religious grounds can seek full coverage under the federal
government, under a procedure the Obama Administration said bu t also relieve their
employers of any moral obligations.

Back to school to learn the golden rule but according to the American academy of
pediatrics that return should come later in the day. Study show American teens most in
need of a decent night sleep a re sleep walking through a large portion of their day due
to sleep deprivation. They are recommending high school days begin later than the
typical 7 AM hour, 8:30 in the morning instead and keep them in longer through the day.
The typical teenagers gett ing an estimated six to seven hours of sleep per night when
pediatricians agree it should be eight to ten ideally. Pediatric health experts see their
sleep deprivation as a major unaddressed health issue. School districts are not quick to
catch on though currently only 15% of the nation's middle and high schools begin after
8:30 in the morning. I'm Marian ne O'Hare with this Healthcare Headlines.

Mark Masselli: We're speaking today with Dr. Harvey Fineberg, President of the
Institute of Medicine the heal th branch of the National Academy of Sciences an
independent nonprofit organization that works to provide unbiased and authoritative
advice to decision makers in the public on matters of public health. Dr. Fineberg served
as the provost at Harvard Univers ity from 1997 to 2001 following 13 years as dean of
the Harvard School of Public Health. Dr. Fineberg is an author of several books
including clinical decision analysis in innovators in physician education. Dr. Fineberg
earned his MD and PhD at Harvard a nd he's a recipient of several honorary degrees in
numerous awards including the Frank A. Calderon Prize which is the highest prize in
public health. Dr. Fineberg thanks so much for joining us on Conversations on
Healthcare.

Dr. Harvey Fineberg: My pleas ure to be with you.

Mark Masselli: You oversee the efforts of nine boards and 15 standing forms and
roundtables managing some 3000 volunteers all engaged in (inaudible 4:58 ) quest to
improve public health in this country. Could you give us some insight i nto the work your

task with the IOM and highlights of what you think some of the most important areas of
research are.

Dr. Harvey Fineberg: The institute of medicine is the nation's advisor to improve health.
We are the health firm of the National Academ y of Sciences an independent non -
government organization dedicated to improving decision making and helping policy
makers, professionals and the public come to better choices about health. We work on
the needs of disadvantage populations on children on el derly, we work on the problems
of prevention of disease and population health. We're deeply immersed in the
challenges of healthcare and improving the practice of medical care. And we have
groups working on health science and policy as it relates to all manner of activities that
bear on health whether it's nutrition so the rate of the institute of medicine is quite broad.
It's domestic, it's also global but all of it is focused on the goal of improving health.

Margaret Flinter: But Dr. Fineberg you realize that maybe there's been no time in the
history of healthcare in our country where the potential at least for transformation is so
great. And you've said that to achieve greater public health we have to align the
incentives for all the stakeholders . So in this moment in time you're someone who is
scrutinize the creation and the implementation of public health policies for the better part
of your career. Share with us and our listeners what's your take on the Affordable Care
Act and its potential f or this transformation.

Dr. Harvey Fineberg : The Affordable Care Act is one step along a long trajectory in the
United States about increasing access to healthcare. Literally this goes back to before
the Great Depression of the 1930s in the early discuss ions about widening access to
health insurance there were proposals that President Roosevelt made, President
Truman, President Kennedy, President Nixon, President Regan all put forward various
proposals. And President Obama and the administration did succ eed in putting forward
and having enacted our current extension of insurance through the Affordable Care Act.
It's core contribution (inaudible 7:25 ) it does increase access to services for millions of
Americans who otherwise lack insurance and it also ha s provisions it strengthen the
preventive services in our country including for example mandating the certain
preventive care be available without co - payment. It's a step forward it will continue to
be politically controversial. And I believe that we wil l continue to see in our country
efforts to intensify and expand availability of healthcare to everyone in the country.

Mark Masselli: Dr. Fineberg you focus much of your work on prevention which you see
is critical to creating a high functioning healthca re system and a healthy society.
However you've noted in the past that there are seven deadly sins that impact public
health everyday that you think pose a real challenge to those tasks with creating
sustainable public health policies. And tell our liste ners what they are and what you see
he solution's to be.

Dr. Harvey Fineberg: It's inspired obviously by the original seven deadly sins that were
th
first annunciated by Pope Gregory the first back in the 6 century.

Mark Masselli: That's great.

Margaret F linter: Haven't changed much.

Dr. Harvey Fineberg: Well, you know, lust, loss (inaudible 8:40 ) envy and pride, you
know, the seven deadly sins. So for public health I adopted some of them I said well,
you know, sloth blocks us from doing the things ever yday that would keep us healthy.
Gluttony cajoles us into eating more even when we're not hungry and contributed to the
obesity problem. Greed is certainly a driver in some corporate settings to market and
profit from things that are bad for health such a s cigarettes. So I adopted additional sins
I say well ignorance is an important deadly sin for public health. There are always
colors judgment and leads to poor decision making. Complacency I thought was
responsible for so much of accepting as normal, t hings what we really should be
struggling to prevent. And then timidity which prevents us from demanding those
changes in policy and practice that would actually improve our health.

Now for the seventh deadly sin of public health I chose obstinacy which i s the refusal to
accept evidence on what would actually be best for our own health. Interestingly I did a
little exercise with the community here at the institute of medicine our staff and I ask
them what would they chose as the seventh deadly sin of publ ic health if they had a
choice. And we got some very interesting answers for example arrogance, hypocrisy,
denial, procrastination and selfishness. And then someone suggested the deadly sin of
silence and I thought these are really quite suggestive. I m ight add that we decided to
do a little exercise on what would be the seven living virtues of public health that could
counteract these deadly sins. I started out with suggesting moderation, prevention,
science and then asked our staff what would they sug gest as the seven living virtue and
they came up with collaboration, leadership, partnership and someone said if only we
could adopt the golden rule.

Margaret Flinter: So Dr. Fineberg the institute of medicine has produce so many
seminal reports on so man y areas within healthcare. But your most downloaded report
in the history of issuing these reports is the report publish in 2010 on the future of
nursing. Take us to the future of nursing what were the recommendations aimed at
transforming nurse educatio n and training.

Dr. Harvey Fineberg: The key recommendation was to enable nurses to practice up to
the full extent of their training and ability. Many states still had on the books limitations
that restricted the ability of nurses to contribute in the wa ys that they should. In primary
care settings for example, in nurse practitioner roles in a variety of settings, every state
and the district of Col umbia establish what we call action collaborations that are

intended to help foster the adoption of changes in regulation and rule and to establish
the principles for nursing practice. And in the (inaudible 11:57 ) several years, at least
seven states have actually modified their rules and regulations that give wider latitude of
practice for nursing. This repo rt three years after its release continues to be actively
downloaded from the institute of medicine website but what's more gratifying than the
readers of the report is the actions that have adopted the recommendations.

Mark Masselli: We're speaking today with Dr. Harvey Fineberg, President of the
Institute of Medicine. Dr. Fineberg has served as provost of Harvard University and
dean of the Harvard School of Public Health. Dr. Fineberg one of your specific areas of
study over the years has been in clini cal decision making. And let's look at the decision
making on the policy side for a moment, what might politicians learn from your work in
clinical decision making that might help them make more decisive policies aimed at
improving the public health.

Dr. Harvey Fineberg: One of the things that you learn as you study decision making
that feeling to decide is also a decision. The case of an individual in clinical decision
making, the choices about that one person whereas policy makers are choosing and
deci ding for a nation or for a state or for the whole body politic. One of the key features
of all these decisions is that there's uncertainty about the future and the second feature
of all decisions is that they take account of our values and preferences. I n the case of
individual in a clinical setting it's the patient's values and preferences, in a body politic in
a legislature you've got many values and contending preferences that are obviously
working sometimes jointly but often against one another. So t he key I think for policy
making is really the notion of compromise, everyone has to be willing to participate in
the give and take that results in an agreement where each side gets part of what they
want and gives up part to the other side so they get wha t they want.

Margaret Flinter: Dr. Fineberg and I wonder if you'd share maybe your vision for this
recalibration of the education and training of healthcare professionals as we move into
the future.

Dr. Harvey Fineberg : Well health education is fundament al if we're going to have the
future workforce to meet the health needs. There was a very interesting report of the
lancet commission about three years ago on the future health workforce that emphasize
the idea of learning across the disciplines and team base learning. And when you
coupled that with reports like our recent nursing report I think you can identify certain
key principles that are going to be very, very important going into the future as any
practitioner begins their career the knowledge base that they have is going to be turning
over multiple times if they're going to remain current. And so the capacity for
continuous learning has to be built into learning from the beginning. We know that
patients with chronic disease particularly require t eam base care to have optimal

management of their conditions. Learning together across the professions is a really
good way to help reinforce the kind of practicing team work that is needed and is
important preparation.

A third really important challenge I think for the future is going to be the combination of
information technology and maintaining the personal touch contact and relationship that
healing requires. So practitioners of the future going to have to be adapt simultaneously
with a more technolo gical world and at the same time retain the capacity to establish
promote and strengthen those personal relationships that are the heart of clinical care
and healing. I think it's going to be very important for everyone to keep patients
centered as the he art of our focus and attention because it's more than just a moment
when an individual is a patient it's about their needs at every stage in relation to their
health and (inaudible 16:04 ) health system the public health system served to reinforce
positive aspects of health. And on top of all this we are going to have to find ways to
make education like everything else ever more efficient and cost effective if we're going
to have a sustainable system. And all of it will help us shape a health education sys tem
that will prepare the clinician leaders for delivery of better care in the future.

Mark Masselli: You recently gave a very popular tad talk about the ear of new evolution
we're entering. So in many ways the future is here but you're also concerned that the
institute of medicine with insuring that these technologies are studied for the potential to
do harm as well as to do good. So how do we accelerate the pace of research in these
areas and talk to us about how we bring about this power to healthca re and while we're
still protecting the population.

Dr. Harvey Fineberg: When it comes to the data explosion I think we need to be able to
apply that data but in an interpreted way to give us the knowledge base and ultimately
the most sensible choices for the benefit of people. The power of patients to take more
control of their own lives, to have more mastery of available knowledge to be more
actively engaged in the management of their own conditions, to give a voice to their
preferences and every stage of life and illness including the end of life. When it comes
to specifically this problem of the long delay between discovery and availability of new
technologies we do have I think a very serious policy and technological task ahead of
ourselves. We do n eed to find ways to continue to reinforce invention to harmonize
regulations and make it possible for innovators to produce their new ideas and convert
those into technologies that will benefit patients. So this can only be accomplish if we
develop and op timize regulatory science as well as basic and clinical science we need
to focus on translation. And from a policy point of view we need to find ways to provide
better incentives for investors and entrepreneurs in this critical period when the
technology is promising but not yet a product so that it's advantageous to develop
genuinely novel advances and not simply work on the meet two substances that make
only marginal improve.

Margaret Flinter: We've been speaking today with Dr. Harvey Fineberg Presiden t of the
Institute of Medicine and former provost and dean of the School of Public Health at
Harvard University. You can learn more about his work by going to IOM.EDU or by
following the Institute of Medicine on Facebook or Twitter. Dr. Fineberg thank yo u so
much for joining us on Conversations on Healthcare today.

Dr. Harvey Fineberg: It's been my pleasure to talk with you.

Mark Masselli: At Conversations on Healthcare 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 we ek?

Lori Robertson: Well (inaudible 19:38 ) some republican senath candidates want to ban
birth control that's the claim we're seeing in the few races across the country and it's a
reference to the issue of personhood. For instance in Colorado where a per son whose
initiative is on the ballot in November democratic senator Mark Udall has been saying in
TV that his challenger republican representative Cory Gardner embarked on an eight
year crusade that would ban birth control. That's a reference to Gardner support for the
state personhood initiative which were also on the ballot in 2008 and 2010. These anti -
abortion measures don’t explicitly call for a ban on birth control but they could lead to
some forms birth control being illegal, why? Well these measur es generally say that the
rights of people would apply to the unborn from the moment of fertilization. And while
the birth control pill the most common form of contraception and IUDs mainly prevent
pregnancy by preventing ovulation, they also can stop a f ertilized egg from implanting in
the uterine wall.

So it's questionable whether these hormonal forms of birth control would still be legal.
No personhood measure has passed in a court case would likely determine the impact.
Representative Gardner meanwhi le says he has changed his mind and no longer
supports the initiative in Colorado precisely because it could ban some forms of birth
control. However he still backs a federal bill which also would make a ban of some
contraception of possibility. Gardner announced his change of position in March eight
months after he had signed on as a cosponsor to the federal Life At Conception Act
which Gardner's camp says wouldn’t effect contraception. But it has the same language
th
about extending the rights of people i n this case under the 14 amendment to the pre -
born from the moment of fertilization. That's the language that raises the birth control
concerns. So neither side is telling the full story. Udall's adds fail to explain that the
references to the personh ood initiative and anti - abortion measure that could ban some
birth control. Gardner has changed his mind on the state measure but he still supports

a federal bill that prompts the same question over birth control. And that's my fact
check for this week I 'm 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 y ou 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 c are.

Mark Masselli: Each week conversations highlight some bright idea about how t o make
wellness a part of our communities and to everyday lives. The US boast among the
highest rates of teen births in the world's industrialize nations. And while those numbers
have been declining in recent year it still a significant health issue in t his country.
According to a recent study the decline in teen birth rates in this country can be
attributed in part to the launch of the popular MTV show 16 And Pregnant and the
subsequent teen mom. MTV launch the series in 2009 to show the challenges and
harsh realities of teen pregnancy and teen parenthood.

Researchers at the University of Maryland and Wellesley College conducted an
empirical study to determine what if any impact the show's had on the decline of teen
pregnancy and birth. Wellesley Colle ge economist Phillip Levine decided to utilize
Google data tracker and Twitter activity around the airing of the shows which develop a
loyal following and consistently high ratings since the show begin in 2009.

Phillip Levine: You know it's remarkable how people respond to the show do things like
tweet and search about things that they're watching on TV as they're watching. You
see these enormous spikes and activity about 16 And Pregnant the day the episode
airs. And that also tends to correlate with peo ple doing things like searching and
tweeting about birth control.

Mark Masselli: More interestingly where the social media conversation surrounding
themes explored on the show, loss of freedom, the fathers of the baby often removing
themselves from the pi cture. Themes that really drove the challenge of teen
motherhood home to billions of young vulnerable views.

Phillip Levine: It really illustrates the life choices that these girls have made in a way
that the reality TV show can do that a public service announcement or etcetera
education teacher or some other form of communication can't really accomplish.

Mark Masselli: Based on the data they compiled, they determine the show led to a
5.7% drop in teen births from 2009 to 2012 a significant number in a r elatively short
period of time. A media outlet utilizing airwaves to reveal the risk of teen pregnancy

that's creating a platform for dialogue for teens to address this potentially life changing
event leading to a significant reduction in teen pregnancy n ow that's a bright idea.
Margaret Flinter: This is Conversations on Healthcare, I'm Margaret Flinter.
Mark Masselli: And I'm Mark Masselli, peace and health.
Conversations on Healthcare, broadcast from the campus of WESU at Wesleyan
University, streaming live at www.wesufm.org and brought to you by the Community
Health Center.