Dr. Fitzhugh Mullan, Milken School of Public Health at George Washington University

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Mark Masse ll i: This is Conversations o n Health Care . I am Mark Masselli.

Margaret Flinter: And I am Marg a ret Flin ter .

Mark Masselli: Well , Marg a ret , interesting report from the Centre for Medicare
and Medicate Services , CMS reported that healthcare spending held at the
modest rate of 3.6% growth in 2013. That’s the lowest rate of increases since
1960 when CMS kept records on the rate of inflation.

Margaret Flinter: Spending indeed has slowed across a number of areas, p rivate
health insurance, medicare, hospitals, physicians and clinical services , and out of
pocket spending by consumers , which I think might be the key to all the other
ones.

Mark Masselli: And let’s start looking at those numbers , and the causes for them
including the recession , and changes in spending for things like medicare due to
the Affordable Care Act.

Margaret Flinter: As more Americans rely on high deductible insurance plans,
one in three American families report that the y have put off seeking medical
attention due to out of pocket cost and that’s got to have an impact on spending
as well.

Mark Masselli: Analysts say now that the economy is improving that might send
healthcare spending higher in the coming years. Also , the market is shifting so
dramatically with millions of Americans now buying health insurance on online
markets , and it’s not so clear yet how those things will effect healthcare spending
moving forward.

Margaret Flinter: Well , we spent $ 2.9 trillion on healthcare in 2013, that was
roughly 18% o f the National GDP and at least when we look comparatively at
other developed countries that’s too big a chunk of the economy.

Mark Masselli: The cost of medical education is also rather high in this country ,
and the cost of training one physician can run into millions. It's making health
policy officials rethink new approaches to fill in the gaps in healthcare workforce
using some creative ideas.

Margaret Flinter: Well , that is something that our guest today is quite informed
about. Dr. Fitzhugh Mulan is a pediatrician, writer, health policy expert, also an
expert on graduate medical education and training in this country , and has some
insights into what kinds of change s might be called for , and how best to prepare
the healthcare workforce for the future.

Mark Masselli: Lori Robertson , managing editor of FactCheck.org. looks at more
false claims spoken about health policy in the public domain . But no matter what
no ma tter what the topic, you can hear all of our shows by going to chcradio.com.

Margaret Flinter: And as always if you have comments, email us at
[email protected] or find us on Facebook, Twitter at CHC Radio. We wo uld
love to hear from you. We will get to our interview with Dr. Fitzhugh Mul a n in just
a moment.
Mark Masselli: But first here’s our producer Maria n n e O’ Hare with this week’s
headline news.
(Music) Maria n n e O’ Hare : I am Maria n n e O’ Hare with these healthcare headlines. What
a difference healthcare law makes, in the past five years the Department of Health and Human Services has become the third largest payer to outside contractors after the Defense Industry dominated this space for deca des. Well automatic spending, cuts and a shrinking military presence in Iraq and Afghanistan have led to some sharp declines in defense spending on private contractors. Conversely the Affordable Care Act has lead to increased g overnment spending on healt h related contractors. Health spending from HHS
has increased to a 147% since 2009. Change in the wind of the Office of National Coordinator for Health IT , ONC is emphasizing two directions continued
momentum and adoption of EHR technology , and better in terface of that data as
well. Ninety four percent of eligible hospitals and close to 80% of eligible physicians have received payment for either purchasing or meaningfully using a tested certified EHR. But the program left gaps by not extending payments to behavioral health, long - term care and other providers. The ONC and other
federal agencies are looking at ways to help these excluded providers cover the cost of buying electronic health records. Giving birth in America, fewer women are heading down th e maternity road. Statistics show a 6 - year decline in
birthrates in this country. In 2013, there were 3.93 million births down 9% from
the high in 2007. The economy is largely to blame . And a recent analysis of the
significant decline in teen births h as been attributed in part , according to a study ,
to the reality show ‘ 16 and pregnant’ , which depicts the lives of teen mothers ,
and the struggles they face daily to stay in school while caring for a child. The study showed a dramatic uptake in Google se arches for things like birth control which spiked nationally every time an episode aired . The reality of watching their
peers struggle with lots of freedom abandoned by the baby’s fathers , and
challenges involved with raising a child really sending that m essage home. I am
Maria n n e O’ Hare with these healthcare headlines.
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Mark Masselli: We are speaking today with Dr. Fitzhugh Mulan of the Murdock
Head Professor of Medicine and Health Policy at the Milken Institute School of
Public Health at George Washington University . Dr. Mulan is also Professor of
Pediatrics at the George Washington School of Medicine. Dr. Mulan served as
Assistant US Surgeon General , was the Director of the National Health Service ,
coined as a member of the Council of G raduate Medical Education , an editor at
Health Affairs. He has written numerous articles and books on the subject of
healthcare including ‘White Quote Clenched First.’ Dr. Mullan welcome back to
Conversations o n Health Care.

Margaret Flinter: Thank you Mark. Glad to be here.

Mark Masselli: Yeah, yeah, it’s been four years since you have been on our
show , and much has changed in the Healthcare landscape . And, you know , at
last count some 10 million uninsured Americans have gained coverage . And we
are on track hopefully for millions more in the second round of open enrollment.
But much of your career has been focusing on closing the health disparity. So ,
could you illustrate for our listeners the fundamental importance of giving millions
of previously uninsured Americans access to healthcare , and what’s the potential
impact of that one fundamental change of access in the nation’s health policy?

Dr. Fitzhugh Mulan : Well , once upon a time in the year 1900, it probably didn’t
matter if you had access to healthcare. In fact you may have suffered ill effects
in the hands of physicians . As the 20 th century progressed, medical science
improved. Antibiotics were invented. Diagnostic tools such as x - rays came
along , and it did matter whether you had healthcare . And people without money
had to rely on charity care of some sort , which was in short supply. By the mid
20 th century, we had health insurance that stepped in as a vehicle to allow
people , and their employers to pu t money aside, so that when they got sick, they
had access. In 1965, Medicare was enacted , because old people didn’t work ,
and didn’t have coverage . The g overnment stepped in , and provided what has
become a very popular program. It also provided Medica i d or also an enacted
Medicaid at that time , which has been a spo t ty effort to cover the poor. Every
state runs it differently, levels of eligibility vary , and that’s where we found
ourselves at the beginning of the 21 st century with some 40 or 50 million
Americans about 15% of the population without access to the healthcare system .
And the Affordable Care Act has been a principled effort to get at that. It’s a
complicated issue to begin with , with the terrible fractiousness in general , and
Republicans by and large not subscribing to the notion that there was a public
role in trying to assure access for those who weren’t covered. It adopted health
insurance, which is not a terribly efficient way to provide access, but that was one
of the compromises neede d to be made. And we have the bill that we have
before us , which is a huge step ahead morally , and it’s a huge step in terms of
beginning to fill in the system. But it has made considerable progress . And we
know that there are millions of folks now who are covered who wouldn’t be , and
more to come . And it’s only as more people get on over a period of time that we

will be able to measure the full impact . And in fact I believe in many that the full
impact will be greatly appreciated by the population as a whole , and you will have
a huge constituency for what will then w e look back on , I suppose as Osama
Care , and I think it will be as popular as Medicare a few years down the road.

Margaret Flinter: Well Fitz you’ve -- as often as we talked about bringing millions
of people into the ranks of the insured . We also talked about and who will take
care of these individuals ? And so the whole question of the capacity of the
primary care provider , and the health profession workforce generally was huge .
And you’ve commented on this question of , is there a shortfall of primary care
providers , and the degree to which our way of training future physicians in
particular through Graduate Medical Education might have to be a just of course
The Institute of Medicine just released this report , and Graduate Medical
Education called for the establishment of a transformation fund , which might look
at can we do somethings in a new way? So maybe you could comment on that
area for us?

Dr. Fitzhugh Mul an: Sure ly, Margaret. There are really two questions here. One
is the question of adequacy. Do you have a shortage , and where are we headed
in terms of numbers of providers ? And the second is since -- for medicine for
medical practitioners , Graduate M edical Education is the final common pathway
into practice. The US Medical School graduates are joined by US Osteopathic
School g raduates , who are joined by International Medical graduates , and then
the International Medical g raduates who are non - US citizens. So , all of those
candidates for practice come together in GME (Graduate Medical Education) ,
because in order to get a license you need to have Graduate Medical Education.
So , how we manage and fund and subsidize d Graduate Medical Education is
t erribly important , which why that report is long overdue and very welcome. So ,
the first question, shortage. So , there is fair amount of flexibility in the system .
And a lot of what happens is local convention. Primary care is the bedrock of a
system . That needs to be robust , and all kinds of studies have demonstrated
this , in terms of outcomes , in terms of costs , and in terms patient satisfaction .
The more robust the primary care situation is in a community , the better the
outcomes in general , the lo wer the cost , and higher the patient satisfaction will
be. In practice primary care physicians make roughly half on an average as
specialists do . And their work li v es are generally less controllable than certain
specialties. So , we have a long standing unlevel pl a nning field in this country of
primary care , and then what medical students choose. That problem is with us.
We are definitely short and (inaudible 11:01 ) be shorter as we have more people
arriving in the system. But if the system a s a whole short , and the answer is
probably not, more people will be insured under the Affordable Care Act. And as
we are an aging population , our demographics are moving to the elderly , who
clearly consume more health services , including importantly primary care , which
can sort out the problems the elderly more effectively th a n sending everybody to
cartload of specialist s . Does that mean we need to put a lot more doctors into
the field? My own thought is we need to grow as the population grows . But we

have good evidence that putting doctors in does not necessarily distribute them
better , and there’s a notion that if you graduate more , they will distribute to areas
of the country that are in shortage. We have good evidence they don’t distribute
well. They tend to well up in the already well served areas. So , if have shortage
problems, the first answer is not, there are many people , for example, just put
more doctors out and they to tend to stay as many of us would in areas where
the living is easier. And that’ s where there is money. Secondly, as things get
tighter, we need other solutions. The doctor solution is an expensive one. Other
solutions calling on our creativity whether it is minute clinics at one end or nurse
practitioners , and TAs at another , ther e are many other ways to deal with , and
increasing demand . And simply using the model that we have now and I will call
it 20 th century model , it tends to use a lot of specialists, and that’s one of the
major reasons we are an out liar in the world in terms of the enormous amount
that we pour into our system without terribly good results. In 21 st century , we
need to think through that , and work through that . And a tightness in the system
will lead to creativity . And what you are seeing now particular ly with the ACA are
enormous burgeoning of other solutions or other approaches ranging from
accountable care organizations. A great emphasis on population health, much
more emphasis on data use , early intervention, the use of other providers such
as nurse practitioner and PAs. So , there are many ways to treat this issue to
skin this cat . And the old way which is simply pour more doctors on it , many of
us feel will be very expensive , and not very effective . And our job, the job o f the
(inaudible 13:29 ) r eport was to talk about , how you manage this GME system ,
addressing the new kinds of competencies , and the new kinds of locations ,
where our doctors need to work , and they proposed a transition plan that is
transform of a nature , and really is the first comprehensive alternative to the
current plan that has been put forth . And finally and unfortunately , the leadership
group in the medical education community is very much w ed to the current
system , which is quite remunerative to p articularly leading large teaching
hospitals , and has been reluctant to take seriously this question of
transformation.

Mark: We are speaking today with Dr. Fitzhugh Mulan of the Murdock Head
Professor of Medicine and Health Policy at the Milken Institut e School of Public
Health at George Washington University . And he was the Assistant US Surgeon
General and served as Director of the National Health Service cor p . You know, I
think , yours was maybe in Mississippi, you certainly brought you face to face with
huge disparities faced by Americans in terms of access to care . And th e
Affordable Care Act is putting in a number of measures in place at addressing
such disparities , and access , as well as , trying to build a more diverse workforce.
Can you talk to our listeners about some of those measures in ACA that is
impacting the workforce diversity?

Dr. Fitzhugh: The ACA puts a great deal of more money into the National Health
Service c or p . There are now about 10 , 000 health professionals in the field in
sh ortage areas , compl e ment to the National Health Service Cor p, and that’s

good. That’s double the size it was previously. But that sun sets at the later part
of this year , and it isn’t clear that the congress is going to re - up anything ne ar the
level of s upport that currently is there , a huge problem . Secondly, community
health centers, fed erally qualified health centers, the core of the safety net
ambulatory system in this country . And again it got a big bump up , and that sun
sets , and it’s unclear what’s happening there. There are modest investments in
Medicare payments , increasing primary care pay a bit . And those are the
provisions , there is one important one that also sun sets teaching health c e nters
where there are now 60 com munity - based organizations that have applied for
and 1 grant to do residency training. These residence train at local hospitals , but
their primary identit y , and their primary clinical training sight is a community
based organization , and they learning med icine from a non - hospital perspective
while working , and getting their clinical skills in a local hospitals. This changes
the par adigm a bit . And that’s been a very good experiment . So, that ACA has
put ideas on the table in terms of developing the workforce , but those are less
than we might have , and most of them are at risk as AC A moves forward.

Margaret: I know that your connection to the community health center movement
has sta yed stronger over the years , and I have had the pleasure of visiting the
Upper Cardoz o Community Health Center . I know that you work there as a
pediatrician for many years . And certainly represent not just access to care
about innovation and care in serving a population that is overwhelmingly at lower
income members of r acial and ethnic minority groups . And this ideas of the
community health c e nters as a locus of innovation in the redesign ed of health
care is something near and dear to our hearts. So , I wonder if you might want to
just take a moment to talk about some o f the key innovations that you see either
a rising out of health centers of or being adopted by the health centers and then
taken to scale .

Dr. Fitzhugh: Well , health centers have long had a mandate. They sit in
communities , and by definition , and by law they are community institutions. They
require to have community boards, they are required to serve all regardless of
ability to pay . So, they are dealing with population s who have a community
sense often are disadvantage d in the sense of bein g poor , and that this notion of
community oriented primary care delivery, which h as been a kind of hypothesis,
they have actually been practicing. In today’s policy discussion , this notion of
population health of trying to prevent illness from deteriorati ng is very much at
the center of the debate about how do we modernize , and make our system
more effective both in preventing illness from a system point of view. And health
centers have been out there struggling with that for a long time when nobody was
e ven talking about it. Community based training really has been a very much of
a sidebar of our standard system back to this notion of a teaching health center.
All doctors are hospitalized in their training. They spend most of their working
hours, most of their educational hours in large institution . But most patients are
ambulatory most of the time . And we seek help at doctor’s office or community
clinics , and our training really does not go on there in any appreciable degree.

Deinstitutionalizing tr aining particularly for primary care docs, but for others as
well . Surgeons at the operating room is their big tool, but more and more
ambulatory surgery is being done to help the push to develop teaching and
training , and role modeling in communities is very important. It’s very hard to
move that -- some of it out into the community. Community health centers , they
are really pioneering a new kind of training . But will certainly put new
competencies , and new values into the practice of medicine, nursing, dentistry
right through the health professions, which are more community oriented
population focused, hopefully economic and efficient.

Mark: We have been speaking today with Dr. Fitzhugh Mulan the Murdock Head
Professor of Medicine and Health Policy at the Milken Institute School of Public
Health at George Washington University. You can learn more about his work by
going to publichealth.gwu.edu. Dr. Mulan thank you so much for joining on
Conversat ions on Health Care.

(Music)

Mark: 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 U . S . politics. Lori, what have you got for us this week?

Lori Robertson: Well, President Obama’s executive actions on immigration
include a $ 3 , 000 .00 bonus to employers for each immigrant they hire , instead of
a US citizen, not exactly. But that’s what some Republicans and Conservative
media outlets are saying , and it has to do with the Affordable Care Acts employer
penalties . Under the ACA , employers may be required to pay penalties if their
employees are eligible for tax credits to purchase health insurance through the
la rge new market places. But those who gain provisional legal status under the
President’s Immigration Plan wouldn’t be eligible for the tax credits. Does that
create an incentive to hire immigrants over citizens? Perhaps , but healthcare
experts say it would be in rare circumstances. Employers hiring or firing they
have done healthcare credit eligibility would be subject to discrimination
provisions in the law. Most firms wouldn’t even face the potential ACA penalties ,
because they are either too small, fewer than 50 full time employees or already
offer health insurance as 96% of firms with 50 or more employees do. The White
House estimates that less than 0.2% of all firms could face the employer
requirements. An employer could incur the $ 3 , 000 .00 penalty if the firm offers
insurance , but doesn’t meet minimum coverage standards or is deemed
unaffordable for some employe es , and an employee gets a market place plan
with the help of tax credits. But again immigrants a ffected by Obama’s actions
aren’t eligible for the tax credits. One health law professor told us that if only a
few employees qualify for the tax credits, it could be worth h iring such
immigrants. But it would require some manipulation to get the m ath right to both

incur costs for offering substandard insurance , and still save money on the
penalties . And that’s my FactCheck for this week. I am Lori Robertso n
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, w e will have FactCheck.org's Lori Robertson
check it out for you here on Conversations on Health Care.

(Music)

Margaret Flinter: Each week , Conversations highlight s a bright idea about how
to make wellness a part of ou r communities and everyday lives. It’s a known fact
that the current generation of American children is more obese than any previous
generation . And at the Washington DC Community Health Centre, Unity Health
Care, a pediatrician was in a quandary over how to tackle this growing health
scourge. He began with a unique solution targeted to a teen patient whose body
mass index or BMI had already landed her in the obese category. What he did
was write a prescription for getting off the b us one stop earlier on the way to
school , which made her walk the equivalent of 1 mile a day. Dr. Robert Zarr of
Unity Community Health Centre understood that without motivation to move more
kids just might not do it. The patient complied with the prescr iption , and has
moved from the obese down to the overweight category, certainly an
improvement. He then decided to expand this program by working with the DC
Parks Department , mapping out all the potential walks and play area kids have
within the city’s p arks, mapping 380 of them so far.

Dr. Robert Zarr: How to get there. Parking is parking available, if someone is
going to drive bike racks. There is a section on PED’s, park safety.

Margaret Flinter: Dr. Zarr writes park prescriptions on a special prescription pad
in English and Spanish with the words RX for outdoor activity , and a schedule
slot that asks when and where would you play outside this week.

Dr. Robert Zarr: I like to listen and find out what it is my patients like to do and
then gauge the parks I prescribe based on their interests, based on their
schedule, based on the things they are willing to do.

Margaret Flinter: Ultimately Dr. Zarr says with some 40% of his patient
population grappling with overweight or obesity, he wants to mak e the
prescription for outdoor activity adaptable for all of his patients , and adaptable for
pediatricians around the country. He has pl anned to create an App for his park’s
database where providers and patients alike can use it . And one day he would
lik e to be able to track his patient’s activities in the parks. RX for outdoor activity,

partnering , clinicians, park administrators, patients , and the families to move
more yielding fitter, healthier young people. Now that’s a bright idea.
( Music )
Margaret Flinter: This is Conversations on Health Care . I am Marg a ret Flin t er.
Mark Masselli: And I am Mark Masselli . Peace and health.
Narrator: Conversations on Health Care, broadcast from the campus of WESU
at Wesleyan University, streaming live --