Dr. Darshak Sanghavi, Director at the Center for Medicare and Medicaid Innovation

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

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margaret, some promising numbers regarding smoking rates in this
country. Smoking rates are down from 19% of the population in 2013 to 15% this year.
That large drop represents hundreds of thousands of former smokers, and that's good
news.

Margaret Flinter: Then if you look back to smoking rates in 1965 and astonishing 42%
of American smoked. And as the old cigare tte ad used to say we've come a long way
baby but we're not there yet.

Mark Masselli: And according to the CDC's survey the nation tougher smoking laws
have had an impact laws banning indoor smoking even smoking in public spaces
outdoors have marginalized smokers in public settings many of whom say they were
simply tired of feeling like social pariahs. These public health laws really do have an
impact Margaret.

Margaret Flinter: The CVS pharmacy chain is claiming some of the responsibility for the
drop. They stop selling cigarettes at all of their thousands of stores nationwide earlier
this year. And they believe that measure has had impact a number of their customers
who quit.

Mark Masselli: As we know it's the leading cause of preventable deaths in t his country
about 450,000 Americans die each year from smoking related causes in within a few
years of quitting the risk of early death decreases significantly.

Margaret Flinter: And we know the cardiovascular disease is a leading cause of death
in this c ountry something that cigarette contributes enormously to, and that's something
that our guest today is quite focused on. Dr. Darshak Sanghavi is the Director of the
Preventive and Population Healthcare Models Group at the Center for Medicare and
Medicaid Innovation. They've launched the Million Hearts Model to work towards the
goal of eliminating a million heart attacks and strokes.

Mark Masselli: We'll also have Lori Robertson come by, she's the Managing Editor of
FactCheck.org. She's always on the hu nt for misstatements spoken about health policy
in the public domain. But no matter what the topic you can hear all of our shows by
going to chcradio.com.

Margaret Flinter: And as always if you have comments please email us at
[email protected] or find us on Facebook or Twitter at CHC Radio, we'd love to hear
from you. Now we'll get to our interview with Dr. Darshak Sanghavi 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'm Marianne O'Hare with these Healthcare Headlines. It would
appear all those willingly chilled participants in last year's ice bucket challenge have
paid off. What began as a social media campaign to rai se awareness and funds for
ALS better known as Lou Gehrig's D isease which cripples and eventually kills its
suffers. It's far more successful than anyone anticipated, the tens of millions of dollars
raised went straight to scientist long working on resear ch to find a cure. And it seems
there's been a breakthrough because of that funding specifically on the research
focused on a protein called TDP - 43 that in some cases is linked to cell death in a brain
or spinal cord of patients. And that by inserting co stume design protein it allow the cells
to return to normal.

Lead author of the study Dr. Jonathan Ling of Johns Hopkins says the therapy could
also work for a common cause of mental deterioration frontotemporal dementia . The
ALS association managed to ra ise a 150 million dollars with that campaign.

A Colorado program that is led to a 50% reduction in unintended pregnancy since 2009
especially among teens will live to see another year, the program which provides free
long term contraception such as IUDs to young women and low income women had
been funded by private donation. When the legislature was approached to pick up the
funding after the promising study, it was rejected by conservative law makers. Not only
were pregnancies reduced dramatically, the n umber of Colorado residence seeking
public assistance was also reduced.

Prep does the trick apparently and experiment in San Francisco has led to some very
promising results participants who are HIV negative who took a daily prophylactic dose
of Truvada a virus inhibiting drug remained HIV free after a year in the program.
(inaudible 4:15 ) one pill a day experiment worried less condom use would lead to higher
infection rates, the data showed while some participants did catch other STDs none of
the 600 plus participants contracted HIV. Even those with HIV positive partners,
conversely in an English study some participants were given Truvada and others
received a placebo. In that group nine cases of infection for a hundred participants
were reported. With 50,000 new HIV cases per year in this country alone mostly among
young men of color this is could be a powerful new tool in preventing infection. I'm
Marianne O'Hare with these Healthcare Headlines.

(Music)

Mark Masselli: We're speaking today with Dr. D arshak Sanghavi Director of the
Preventive and Population Healthcare Models Group at the Center for Medicare and
Medicaid Innovation, Dr. Sanghavi recently served as the Managing Director of the
Engelberg Center for Health Reform at the Brookings Instituti on. And he's also served
as the Chief of Pediatric Cardiology at the University of Massachusetts Medical School.
Dr. Sanghavi is an award winning medical educator and author with numerous scientific
studies and publications including his critically claim ed best seller A Map of the Child, A
Pediatrician's Tour of t he Body . Dr. Sanghavi earned his medical degree from Johns
Hopkins and completed his residency in cardiology fellowship at Harvard Medical
School in Boston Children's Hospital. Dr. Sanghavi welcome back to Conversations on
Healthcare.

Dr. Darshak Sanghavi : Pleasure to talk to you.

Mark Masselli: Yeah and you are on the show when you're at the Brookings Institution
and discussing the campaigned informed the American public about the dramatic
changes under the Affordable Care Act. Now you're at the center for Medicare and
Medicaid innovations overseeing something is quite exciting the Million Hearts
Cardiovascular risk reduction model. And it's a very ambitious effort to prevent
cardiovascul ar disease. And I wonder if you could tell our listeners about the goals of
the Million Hearts program, who you're targeting and why it turn out to be so
revolutionary.

Dr. Darshak Sanghavi : We know that prevention is a nobel thing for us, clinicians to all
be doing. Now we know that simply by enhancing access to care, in other words that is
part of the solution but it turns out it's really not enough. We still believe for example
that about 90% of heart attacks and strokes could be prevented by better use of
prevention currently. So the question is how do we make that better? And, you know,
traditionally the way Medicare's handled it you clinicians out there you report to us on
whether you're doing all of these things. Are you checking people's blood pressure?
Are you checking cholesterol? Here is the target we'll pay you more.

But clearly many doctors also feel that that's to some extent removing a little bit of
clinical judgment from them. And we feel that's not the best approach to prevention and
t hat's where this Million Hearts model is so revolutionary. The bottom line is rather than
sort of piecemeal looking at all of these different preventive pieces we are going to
assist clinicians really essentially make it easy for them to simply calculate a ten year
cardiovascular risk. Every person who comes in will be told hey over the next ten years
giving your particular risk profile, you know, I'm going to put in there, age and ethnicity
and (inaudible 7:35 ) cholesterol whether they are smokers do the y have diabetes. This
is the risk you're going to have a heart attack or stroke in the next ten years.

And then the clinician going to work with that patient to say well did you know if you do
any of these things for example (inaudible 7:49 ) blood pressur e stop smoking, you'll
reduce your risk to this amount. And it's a really concrete way that encourage the
patients and doctors to talk together saying well hey this is the individualized plan I'm
going to come up with. And we will then pay providers to d o that screening and then we
will pay additionally depending on how much that overall risk across the practice. And
there's no downside to this. So it's really in other words if you have trouble with it, it
doesn’t work for you, you're off no worse than you are before on the other hand if you're
succeed you can make more money.

Margaret Flinter: Well Dr. Sanghavi what are you looking at in terms of the patients, are
clinicians reporting data on what the individual risk factors are. I guess how granular is
the data that you'll be able to look at the end of the project?

Dr. Darshak Sanghavi : Great question because it's (inaudible 8:36 ) this is model test,
it's actually one of the largest test that (inaudible 8:40 ) for prevention and Medicare has
ever done . If you sign up for it each practice will then be randomize to be (inaudible
8:46 ) intervention or control group. And we really try to make it simple, again realizing
that there's nothing clinicians hate more than having to sort of report more thing.

An d so the way we're going to try to address that, we will provide practices a simple
online tool into which you input this sort of few pieces of data, it will give you the risk or
the decision support and then it will handle all the billing on the backend. So you don’t
need to do additional data reporting on top of that. The other thing we'll do is we're
going to make what's called an API ideally available to other vendors. So if you have
(inaudible 9:21 ) medical record and you want to built this in you can do that as well and
(inaudible 9:26 ) report that (cross talk). And we're developing those tools so that
hopefully that won't be too big of an issue.

Mark Masselli: Well you do have a lot of really ke y partners, the American College of
Cardiology, The American Heart Association and also The US Surgeon General's
Offices also promoting the campaign. Talk to our listeners about how these
organizations are assisting and what roles will others play to achi eve this vision?

Dr. Darshak Sanghavi : So I think that we really want to rely on the existing clinical
expertise in the community. And so if we're going to be developing this ten year risk for
I mean that's a pretty big scientific risk, you know, we got to make sure that the -- we
have all that right. And the way we thought that we should do it and the (inaudible
10:09 ) was simply to use what the American Heart Association and American College of
Cardiology have essentially endorsed for the past two year s. So I think that moving
forward as this model test continues which will be plan for five years we may tweak the
model as the years go by in repose to sort of feedback from our clinical partners and

those professional association. And maybe they say the y're -- their model needs to be
adjust in this way, there's a new medicine that's come out, we've heard about new
inhibitors. That maybe incorporate and we'll have an annual review we'll try to
incorporate that as well.

Margaret Flinter: (inaudible 10:42 ) put ourselves in the locus of the project in the
primary care office where we all recognize that the underlying causes of poor cardio
vascular health are obviously the huge factors. And so you calculate this risk score for
your patient, is the Million H earts campaign helping providers at that level in primary
care with what happens (inaudible 11:02 ) reducing those risk factors?

Dr. Darshak Sanghavi : Yeah I just want to make sure I emphasizes this model test
voluntary but we are currently recruiting prac tices. So it take only about five minutes to
sign up and again there's essentially no downside risk. We do think that awareness and
having a new way to talk to patients is a side benefit here. How do we have that
conversation about well, what does it me an to quit smoking and how much will it really
help me. And can I actually visually see the benefit, you know, several folks like the
Mayo Clinic and others have already developed really cool sort of visualization that say
well if you quit smoking you'll risk the heart attack is going to go from say 30% down to
20% over the next 10 years, what does that really mean? Well, you know, out of a 100
people 10 of them are going to get to see their child graduating from high school or
college. And so we think th at giving clinicians that language maybe helpful.

And I know (inaudible 11:57 ) underemphasize how important that is, one of the great
successes of modern medicine our clinical partners right now, every doctors out there
said we have dramatically already re duce the number of people who are dying of heart
attack and stroke. So, they're already doing a wonderful job and this is going to ideally
continue and hopefully accelerate that decline.

Mark Masselli: We're speaking today with Dr. Darshak Sanghavi Direc tor of the
Preventive and Population Healthcare Models Group at the Center for Medicare and
Medicaid Innovation. Dr. Sanghavi recently served as the Managing Director of the
Engelberg Center for Health Reform at the Brookings Institution. He also served as a
Chief of Pediatric Cardiology at the University of Massachusetts Medical School. So
let's talk a little more about payment reform and that's in your (inaudible 12:41 ) that you
will focused in on your research when you are at Brookings and one of the ultimate
goals of the Million Hearts model is to reduce cost. And I really like this rolling analysis
every year you sort of taking a look at the model and how effective it is. What are you
seeing around the world in terms of models of reimbursement that excite you around
prevention and I think we always know that there are sort of an American solution, so
we have to be very cognizant of that. So I'm just wondering is it informed by other work
elsewhere?

Dr. Darshak Sanghavi : The solution that we're try ing to propose is basically two fold.
The first is that we want to sort of create a national environment and we believe that
where Medicare goes ideally your singles other insures hopefully will follow. One of the
key things we're finding at the innovati on center is that the models of payment that really
tend to succeed are once where, you don’t just have one payer working in isolation. So
accountable care organizations and others, we are strongly trying to encourage multi
payer participation. Because, you know, that sort of eliminates that wrong (inaudible
13:46 ) hey if I pay for preventive care now and my colleague down the street doesn’t,
he's going to get make more money and he's going to reap the benefit of my
investment. So I see the first thing i s that sort of recognition that we need to focus on
making sure our payers are sort of integrated up front.

And in the second they need to say well we need to also rethink how we value
prevention in the long term. With our Million Hearts (inaudible 14:10 ) we're saying well
look we're going to pay for this predicted future outcome and reducing that because we
know that data is really, really good. And so we're essentially paying for prevention and
finding a new way to do that, so the more you reduce a long term risk maybe the more
you can get pay. And those are sort of the paramount we're exploring at this point.

Margaret Flinter: You know, Dr. Sanghavi I know that you are a pediatrics person at
heart and in your clinical practice and this initiative is w eighted towards the older adult
but I wonder if you comment on what we can be doing what more we can be doing with
the adolescence in particular and the kids about trying to keep them from turning into
our cardio vascular disease ridden adults of the futur e.

Dr. Darshak Sanghavi : So let me start by saying I'm actually very optimistic on this
front. We are at historically low tobacco use rates among young people now due to this
consorted of partnership not only between clinicians but between public health
organization and even broader into our media. And really it's a cultural shift that we've
seen, but it's difficult to tell and I think sort of the parts of the questions well what role
does a payer like Medicaid or Medicare have and what role does the tra ditional medical
system have there as well. And probably the simplest way to sort of phrase the solution
is that we have the president's increased emphasis both on primary care as well as
public health. Because we believe that within those areas why the fruits of reaching a
large number of people. And traditionally we're going to public health authorities
because they are out of the fee for service system are getting paid for visit. I believe
that the way we're also getting there now was by broadly movi ng away from fee for
service to accountable care organization and sort of this alternate payment model
strategy. And then looking at broad based health indicators but I think that those are
the ways we're going to try to address it's only by breaking the cycle of sort of fee for
service that we can then start to recognize and reward broad based community
improvements and exactly these types of long term preventive areas.

Mark Masselli: And along with that the sort of cultivation of the -- of empowering
st
pa tients which has been called sort of the block buster drug of the 21 century. And,
you know, there's a lot of movement in that area, you certainly mention that the
enormous reduction of tobacco usage by young people serve a cultural change. And a
lot g oing on in technology wearing health tracking devices as growing telemedicine
remote monitoring also getting momentum and more people were educating themselves
about health and wellness and solutions. In fact while you are at Brookings your
partnered with Khan Academy so tell our listeners how successful that campaign was
and how do you see these other technologies really coming to play as we shift focus
from sort of sick care to well care and prevention?

Dr. Darshak Sanghavi : Right, it's a great question . I would like to think that the work we
did with a Khan Academy and more broadly with public engagement has completely
demystified health reform for the American public. And I am sad to report I -- we've only
be partially successful but -- those efforts were a start, you know, thousands of people
have used those educational materials we developed. And clearly we were not alone
many others are out there as well. I think that health reform is complicated, it's deep
and it's politically fraud and so we st ill have a fair amount of work to do in educating
people about this kinds of issues.

But again having said that I want to come back to sort of this optimism I feel, I realize
that every time I go to this pharmacy the people who make toothpaste have an
enor mous degree of faith that I can understand, you know, the differences between 50
different kinds of toothpaste evaluate different (inaudible 18:08 ) and make approaches.
And well that's a little funny, you know, I think that we can do the same thing in
hea lthcare, you know, Americans have an enormous appetite to know more. And I think
that one of the ways we're getting there is although we are sort involved in this broad
based strategy to improve the transparency of how much we charge for the services as
w ell as making electronic medical records more freely available to people. And in that
way that is exactly sort of empowering patients understand, you know, where is my
money going? What's going on with my health? And how can I participate in that kind of
care.

Not only that, in addition to just the information with the move towards high deductable
health plans, I mean that's a complicated politically challenging thing. However when
you know your own money as a risk to some extent, you are going to start a sking
questions and engaging in ways that perhaps you didn’t before. It' s our job to make
sure that we give people the tool so they can make decision if they're going to be taking
some of that risk. But that's the other way, I think that market is going to be continually
expanding, hopefully we'll be playing at CMS and other places -- a part and sort of
making sure that we help patients navigate that well.

Margaret Flinter: We've been speaking today with Dr. Darshak Sanghavi Director of the
Preventive an d Population Healthcare Models Group at the Center for Medicare and
Medicaid Innovation. You can learn more about their work by going to
Millionhearts.hhs.gov or follow him on Twitter by going to @Darshak Sanghavi or
@CMS Innovates. Dr. Sanghavi thank yo u so much for your optimism, your work and
for joining us on Conversations on Healthcare today.

Dr. Darshak Sanghavi : A great pleasure thank you.

(Music)

Mark Masselli: At Conversations on Healthcare we want our audience to be truly in the
know when it c omes 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 US
politics, Lori wh at have you got for us this week?

Lori Robertson: Jeb Bush claimed that Plant Parenthood shouldn’t receive federal
funding because, quote, they're not actually doing women's health issue, that's simply
false. In 2013, Plant Parenthood Clinics provided ne arly 10.6 million services to 2.7
million women and men including contraception, test and treatment for sexually
transmitted diseases, cancer screening, abortions and several other women's health
services, that's according to the organization's most recent annual report.

Politicians who are against abortion have pushed to defund Plant Parenthood after
undercover videos showed Plant Parenthood officials talking about aborted fetal tissue
being collected and used for research. According to Plant Parenthood figures abortions
represent 3% of the organization's total services and about 12% of its clients received
an abortion. Its services for 2013 also included 4.5 million test and treatmen t for
sexually transmitted infection, 3.6 million contraception services, more than 900,000
cancer screenings and 1.1 million pregnancy test and prenatal services.

Plant Parenthood received 528.4 million dollars in federal and state government money
in 201 3. Federal money cannot be used for abortions except in cases of rape, incest
and to save the life of the mother. And that's my fact check for this week, I'm Lori
Robertson Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed t o 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 c are.

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and to everyday lives. Of the 6.6 million birth per
year i n this country over half are unintended. And among teens those rates are even
higher, Colorado has been conducting an experiment for several years to examine what
might happen if sexually active teens and poor women were offered the option of long
term bi rth control such as IUD's or implants, the first questions to answer would they
take the offer.

Dr. Larry Wolk: The word of mouth amongst these young women to each other and the
network of support that was built to access this program through these clinic s to help
the tens of thousands of women over the course of the four to five years really did then
result in the significant decreases in unintended pregnancies and abortion.

Mark Masselli: Dr. Larry Wolk Medical Director of the Colorado Department of Hea lth
and Environment. He says the results were nothing short of astounding.

Dr. Larry Wolk: The result in decrease is 40% plus or minus in both categories
pregnancy and abortion preliminary data for 2014 looks like those reductions maybe
even more dramati c to more than 50 even approaching 60% reduction.

Mark Masselli: There was a significant economic benefit to the state as well.

Dr. Larry Wolk: We've seen a significant decrease in the number of young moms and
kids applying for and needing public assista nce than longer term this will translate into
better social and economic outcomes for these folks and for us as a state and in our
state's population.

Mark Masselli: And in spite of what conventional wisdom might lead one to assume the
incidence of sexual ly transmitted diseases dropped in this population as well.

Dr. Larry Wolk: And amongst young women 15 to 24 we've seen a decrease in sexually
transmitted infections.

Mark Masselli: Many other state health departments are already consulting with
Colorado on the successful outcome of their experiment, a free long term contraception
program offered to at - risk teens and women trying to avoid the economic hardship of
unplanned pregnancies leading to a number of positive health and economic outcomes
for all in volve, now that's a bright idea.

(Music)

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
Unive rsity, streaming live at www.wesufm.org and brought to you by the Community
Health Center.