Dr. Joshua Seidman, Former Director of Meaningful Use at ONC, Analyzes Healthcare Landscape Under GOP

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

Mark Masselli: This is Conversation on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well, Margaret, we just returned from the annual gathering of the
nation’s Community Health Center Organizations, the Na tional Association of
Community Health Centers represents thousands of care delivery organizations,
which serve the health needs of some 25 million Americans. It was an energized
gathering this year as healthcare providers come together to share best
prac tices, but also to embrace themselves for some of the challenges that lie
ahead.

Margaret Flinter: Boy, you are right ; there is so much concern about what’s to
come next from the health policy perspective. While the GOP Health Plan failed
to get off the ground, there is still so much uncertainty about what is likely to
happen next and that’s very challenging for people.

Mark Masselli: And looming over all of us is the President’s budget cuts to
significant chunk of money from the Department of Health a nd Human Services
and HHS secretary Tom Price has indicated that he will seek to roll back
Medicaid Expansion across the country, which could significantly impact the
nation’s Community Health Centers, which provide care to a large sector of the
Medicaid p opulation.

Margaret Flinter: Well, that is something that our guest today is keeping a close
eye on Mark. Dr. Joshua Seidman is the Senior VP of Payment and Delivery
Innovation at Avalere Health, but of note he served as the Director of Meaningful
Use a t the Office of the National Coordinator for Health IT. So, we are looking
forward to hearing from him.

Mark Masselli: And we are also looking forward to hearing from Lori Robertson,
the Managing Editor of FactCheck.org, but no matter what the topic, yo u can
hear all of our shows by going to www.chcradio.com .

Margaret Flinter : And as always if you have comments, please email us at
[email protected] or find us on Fa cebook or Twitter , because we love
hearing from you. Now, we will get to our interview with Josh Seidman in just a
moment.

Mark Masselli: But first, here is our producer Marianne O’Hare with this week’s
Headline News.

Marianne O’Hare: I am Marianne O’ Hare with these Healthcare Headlines. The
setback for one State that it saw to expand Medicaid for more residents living
close to the poverty line, Kansas law makers failed to produce enough votes to
override Governor Brownback’s Veto of the Medicaid Expa nsion, which would

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

have provided health coverage to 180 thousand uninsured residents. Governor
Brownback has been a staunch opponent of Government spending and viewed
the Medicaid Expansion as too costly for the state, although the Medicaid
Expansion is l argely covered by the Federal Government for the initial few years
of expansion. Meanwhile, those who received subsidies to help underwrite the
cost of purchasing health insurance on the online exchanges are concerned
about the outcome of a case launched by House Republicans. They sued the
Obama administration last year challenging the legality of the subsidies, saying
the funds were not appropriated by Congress. Meanwhile, Congressman Greg
Walden, a Republican from Oregon and Chairman of the House Energ y and
Commerce Committee vowed to protect those subsidies at least for the rest of
2017. President Trump took his Healthcare Diplomacy approach to the links
inviting Libertarian Senator Rand Paul to Mar - a - Lago for some golf and
conversation over healthcar e. Members of the Republican Freedom Caucus
were vehemently opposed to the GOP Healthcare proposal, saying it didn’t go far
enough to eliminate provisions of Obama care. Trump publicly vilified the
Freedom Caucus on Twitter saying if they refuse to negot iate, the President
would “make a deal with the Democrats.” While the President has said he has
moved on after the defeat of the AHCA, he is still carrying on talks with the new
approach. In the wake of the anti - vaccination movement, some once thwarted
c hildhood infections have made quite a comeback, whooping cough once a
th
scourge of the 19 Century has become a persistent foe once again.
Researchers at California’s Kaiser Permanente examined data on almost 149
thousand infants born in California, they f ound babies whose mothers got the
Tdap booster vaccine for Tetanus, Diphtheria, and Pertussis were 91% less likely
to get whooping cough during the first two months of life, a critical period before
U.S. infants typically get their first dose of the vaccin e. I am Marianne O’Hare
with these Healthcare Headlines.

Mark Masselli: We are speaking today with Joshua J. Seidman, PhD, Senior
Vice President of Payment and Delive ry Innovation at Avalere Health, a
Washington D.C. based consulting firm dedicating to solving challenges in the
healthcare system. Dr. Seidman also served as Director of Meaningful Use at
the Office of the National Coordinator for Health IT at the Department of Health
and Human Services. He earned his Bachelor’s degree in Political Scienc e from
Brown University and Masters and PhD in Health Service Research from Johns
Hopkins University. Josh, welcome to Conversations on Healthcare.

Josh Seidman : Good to be with you.

Mark Masselli: Yeah, so you are somebody who is very familiar with W ashington
and also health policy and I am sure you’ve been quite busy in the recent days
with the GOP version of health reform, the American Healthcare Act failing to
make it through even the House. Well, President Trump and House Speaker
Ryan have said t hey are moving onto other issues. There’s much talk on the hill
of another attempt at health reform of some kind and I am wondering if you could

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

share with your listeners, were you surprised by the swift derailment of the
legislation.

Josh Seidman : It w as not a surprise to me that they had a lot of challenges in
actually implementing something or actually agreeing on legislation. It is much
harder to actually craft legislation than to critique legislation. Once a law is
established and embedded into ho w healthcare is done in the country, it
becomes very difficult to take things away from people. I mean of course there
would have been CBO said 24 million people who would have lost health
insurance over the next decade and you know that becomes an issue for
members of Congress, who are trying to get reelected by who so might be losing
coverage. When the CBO score came out with those numbers, it definitely
reinforced in a very real way for members of Congress what they were facing and
then of course, ther e is a polarization even within the Republican party right now
over how far to go.

Margaret Flinter: Well, Joshua, the Affordable Care Act, we certainly agree has
some flaws. There really isn’t a lot of doubt that it has done an enormous
amount to expan d coverage and also to positively impact population health, but
still we have this very entrenched disconnect between the two competing political
parties on what health reforms should look like, but we’ve paid attention to this
kind of slowly rising course of Republican policy makers, who are calling for a
more bipartisan approach to reform. What’s the likelihood we’ll see some kind of
bipartisan solutions coming forward?

Josh Seidman : I think it’s actually going to be very difficult to do that. First o f all,
it is a very polarized environment and I think that, as I said, it’s just very
complicated to do this kind of thing and it becomes a question of how you are
going to change things that for a lot of people are working reasonably well. They
are going to have to make some decisions about how much time and how much
political capital to spend on this one issue. Obviously, there are lot of things that
the Congress and the new administration want to accomplish and they are
beginning to realize how time in tensive and resource intensive it’s going to be to
get things done on any kind of changes to the ACA.

Mark Masselli: So Secretary Tom Price seems pretty determined to make
changes in the Medicaid Program, as well as other population health and issues.
I am wondering if you could talk about some likely scenarios for changes to the
Affordable Care Act and what aspects of the health law do you view as
vulnerable.

Josh Seidman : Yeah, there are certain things that they in a sense have already
begun. You kn ow, we saw in the last open enrollment period that they really
pulled back on a lot of the active efforts to try to get people signed up, but there
is certainly the issue of the subsidies right now, where there is a law suit the
house had filed against the administration and it is going to be very interesting to

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

see what happens there because, the subsidies, obviously are a huge part of this
excess of getting people signed up along with the Medicaid Expansion and so
without the subsidies, that would potenti ally unravel a lot of the coverage in the
marketplaces. I think it is pretty clear that both the current secretary, secretary
Price, as well as the new CMS Administrator Seema Verma have a lot of interest
in using Medicaid to experiment with a number of t hings and how to manage
Medicaid. So I think we are going to see this administration approve a lot of
Medicaid waivers and those could you know test out a lot of the things that they
wanted to do with the AHCA, per capita caps or block grants, and I think we’ll see
them pushing some of the limits there.

Margaret Flinter: Well, Joshua, I am going to let us take a breath from the AHCA
for just a moment and ask about some of your time at the office of the National
Coordinator for Health IT, where you tasked with advancing what we came to
know as the Meaning Use of Health Information Technology. Certainly, that first
big grand challenge which is to shift the health industry from paper to electronic
health records was well executed, but the requirement to use that technology has
been a harder lift. Talk with us about your experiences advancing the Meaningful
Use throughout the industry and the progress that has been made.

Josh Seidman : Yeah, there is no doubt that the transition to digitization of health
re cords has been mostly accomplished, so you know, it just didn’t happen until of
course 2009, when the stimulus by the American Recovery and Reinvestment
Act passed and the high tech part of that actually did simulate the digitization,
where you know, it wa s less than 10% of hospitals in 2009 and now more than
90% of hospitals are electronic. You know, that bill did focus, not just on
digitization, but as you said, on the Meaningful Use of EHR and we were very
concerned at that time that just focusing on mo ving to electronic might just make
the same bad processes happen faster and I would say that we have you know
achieved pieces of that, but we still have a long way to go. The high - tech Act
was constructed with a series of carrots and sticks. All those ca rrots were the
tens of billions of dollars of incentive payments to providers and those of course
are now all gone and what’s left really are the sticks. I think that we are in a
place, where there is this bill challenge in this balancing act. Certainly that we
face d when we implemented, you know, from the beginning stage one
Meaningful Use all the way to the present, which is that we wanted to provide
enough direction that people were driven to Meaningful use by doing more than
just a check - the - box activ ity, trying not to be overly prescriptive and that
balancing act is you know one the most challenging things of writing legislation or
implementing regulation and I think that that is still a challenge that is being
faced. We have a lot of the infrastruct ure now to make it possible.

Mark Masselli: We are speaking today with Joshua J. Seidman , PhD, Senior
Vice President of Payment and Delivery Innovation at Avalere Health.
Dr. Seidman also served as Director of Meaningful Use at the Office of the
Nationa l Coordinator for Health IT at the Department of Health and Human

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

Services. Josh, you know, changes in administration always bring policy,
uncertainty, and we still need to focus in on what will move the healthcare system
forward in. Your work at Avalere Health is specifically focused on Innovations in
Payment and Care Delivery, trying to move the country from volume to value, but
the table for that was really set with the passage of MACRA and that’s the
Medicare Reimbursement and CHIP Reauthorization Act . A recent study found
that 20% of smaller physician practices are ready to meet the MACRA
requirements, but with so much uncertainty around policy directors, what kind of
forces do you see moving these policy and issues forward and how should the
healthc are stakeholders be preparing for MACRA?

Josh Seidman : We, definitely, I think are in a place, where we have set in motion
this movement from fee for service, basically a place where we historically have
paid providers for doing things to people. Now, t rying to think about we actually
pay for helping people to be healthier and I think that we are very much in a
transition and it is something that is going on in both public and the private
sector. Certainly, the ACA helped to stimulate a lot of that as w ell, but it is
something that is now very much embedded both publicly and privately in the
healthcare system. So, MACRA certainly is reshaping how physicians will be
paid under Medicare, but there clearly is a long way to go for them to be
prepared as you say. It also is again a question of this balancing act of making
sure that they are accountable for more than just check - the - box activity, but also
trying to make sure that the measures that we are using to asses whether we are
getting value, actually do measure things that matter to patients and I think that
that is a big challenge. But, I think it is also important to keep this mind this was
a bipartisan bill, one of the very few healthcare bills passed on a bipartisan basis
and we can expect to see co ntinuation of the basic tenets of it, whether the new
administration tinkers to create more flexibility for physicians, I think is something
that we will be watching because there are other levers in ACA that they can use
and you know, there is the Center for Medicaid and Medicaid Innovation, which
has been testing out new payment delivery models, but there may be again some
tweaks; one of things that the secretary has been critical of in the past is
mandatory bundle payments. The last administration has p ut in place for
comprehensive joint replacement, which is already in place and then a final rule
was finalized at the end of the last administration on some cardiac bundles and
hip and femur fractures and those bundled payments are mandatory for fifth to a
quarter of all hospitals. It is now something that I think is a little bit in question as
to whether that will continue to move forward. If it does not, it means that those
hospitals that have been sitting on the sidelines would be able to continue sit ting
on the sidelines as the new payment methodology will swerve it.

Margaret Flinter: I know you recently participated in a political panel with former
White House Chief Technology Officer Anish Chopra and VA Secretary Dr. David
Shulkin, both of whom I would note were former guests on the show and you
know, it seems we heard so much about the VA and it’s need to grapple with an
address to the wait - time issue, but it is also important to remember they’ve made

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

very significant inroads in telehealth, as wel l as widespread use of data that is
mined from their very longstanding electronic health records, so it seems like a
lot to be learned from their experience as well.

Josh Seidman : They really have done a lot of important things that we can learn
from. W hat they certainly did, I think were probably three things, one is that, you
know, very early on, they did make a commitment to electronic health information
and figuring out ways to use that and not just ways to digitize, but actually to do
things to actu ally help Veterans get better healthcare. So that, you know, that
was the first that commitment to this to early on means that they were really
ahead of the curve in that respect. The second is that they applied that to their
quality improvement efforts and you know demonstrated very high quality on a
number of performance measures. Certainly in areas like diabetes care and
cardiovascular care, the VA has performed very well and in part because they
have made Meaningful Use and some of those systems thro ugh Vista and then
the third thing I would say is they made a commitment early on to engaging
patients in the use of that technology. You know they implemented something
called My Healthy Fad, which was a personal health record or PHR or a pool for
patien ts to get into their records and to be able to engage electronically with their
clinical teams. I think that is you know something that now we see it all over, but
they were again definitely ahead of the curve and that is something that we
should be tryin g to replicate elsewhere and similarly, they were one of the
leaders in the Federal Government with the use of something called Blue Button,
which allows for download of information and over a million Veterans have made
use of that Blue Button to download their information.

Mark Masselli: Speaking of great places and your old stumping ground, the
Office of National Coordinator will have a new lead, Dr. Donald Rucker was just
named to the position at HSS, a former Medical Director at Siemens, recently a
Pr ofessor of Bioinformatics at Ohio State School of Medicine. Any thoughts on
the appointment and what direction he is likely to take at ONC and obviously lot
of important dates coming up in terms of Meaningful Use in the like and there is
certainly lot of political pressure to slow things down, but what are your thoughts?

Josh Seidman : I think that what confronts Dr. Rucker now is some of the
challenges we were talking about before. There is this issue of not having a lot
of carrots and trying to figure out how to use the sticks that do exist under
MACRA to continue to move forward, particularly around health information
exchange, removing barriers to interoperability, trying to crack down on any
information blocking that is going on and you know maintain ing strong
certification standards while trying to allow for flexibility. You mentioned earlier
one of the other changes that could happen from the current administration in
healthcare, is what they do on the budget and if the current proposed budget
from the administration were to move through, it would obviously constrict the
funding for most agencies, you know that was one of the things that certainly was
very helpful in advancing the cause of electronic health records, was having

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

sufficient resources t o be able to support providers and the industry in making
that kind of progress, I think that it will be interesting to see what happens with
the budget and what kinds of resources Dr. Rucker has to move forward.

Margaret Flinter: We’ve been speaking tod ay with Dr. Joshua Seidman, Senior
VP of Payment and Delivery Innovation at Avalere Health. You can learn more
about his work by going to Avalere.com or you can follow him on Twitter at
Jseidman. . Josh , thank you so much for joining us on Conversations o n
Healthcare today.

Josh Seidman: You are welcome.

Mark Masselli: At Conversations on Healthcare we want our audience to be truly
in the know when it comes to the facts about healthcare reform and policy, Lori
Robertson is an award - winning journalist a nd Managing Editor of FactCheck.org,
a non - partisan, 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: In seeking to repeal and replace the Afford able Care Act, Health
and Human Services Secretary Tom Price has said “one out of every three
physicians in this nation aren’t seeing Medicaid patients. It is the common
criticism of the Medicaid Program that the doctor participation rate is lower than
th e rate for Medicare beneficiaries or the privately insured. We looked at why
that is and what this means for patients. There are no continuous measures on
Medicaid participation, but Federal statistics gathered over recent years show
that the percentage of physicians accepting new Medicaid patients has remained
around 70%. We found no support for the idea that the rate has declined under
the ACA. The participation rate varies by State. In 25 States, the rate was
significantly higher than the nationwide figure of about 70% and in 5 states it was
significantly lower. That variation largely reflects reimbursement rates. For
example, Montana pays primary care doctors the same rates for Medicaid and
Medicare and has a Medicaid doctor participation rate of 90%. If a State
expands eligibility, it may have to cut the reimbursement rate to limit spending.
While doctors who take no or only some Medicaid patients overwhelmingly cited
low payment as the reason. Three - fourths also cited delayed payments and
bill ing requirements; what does this mean for access to care? Well, participation
rates are limited measures in that the supply of doctors and their geographic
distribution are important factors. Studies show Medicaid beneficiaries fare as
well as the privat ely insured on key measures of access to care. 74% of adults
with Medicaid coverage have seen a doctor in the previous 12 months, while
69% with private insurance have done that’s my FactCheck for this week, I am
Lori Robertson, Managing Editor of FactChe ck.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

Josh Seidman, Former Director of Meaningful Use at the Office of the National
Coordinator

checked, email us at www.chcradio.com , we will have FactCheck.org, Lori
Robertson, check it out for you, here on Conversations on Healthcare.

Margaret Flinter: Ea ch week conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives. Stanford based
bioengineer Manu Prakash has a simple goal. He wants to create a portable
medical lab small enough to fit in a backpack and has already developed a tool
that fits the bill. Whil e sitting under a tree in Uganda, he noticed that the local
medical clinics door was propped open by an expensive centrifuge machine, now
broken and no longer in use and he wondered how could he create a portable
centrifuge that would be inexpensive to mak e, easy to operate, and easy to
replace. His inspiration came from a simple ancient childhood toy, the whirligig.

Manu Prakash : Before us, nobody had actually understood how this fully works.
So we spent a significant portion of his time truly understa nding the mathematical
phase for how you can convert linear motion into rotational motion and there is
some beautiful mathematics hidden inside this object.

Margaret Flinter: So he took this simple toy idea to another level, creating a
human power centri fuge made from simple components, paper, twine, and
plast ic, all together each Paperfuge, as he calls it, can be constructed in under 2
minutes and costs only 20 cents and yet, remarkably it works extremely
efficiently.

Manu Prakash : We were able to make essentially make a centrifuge that’s spins
all the way to 120,000 RPM. In the lab, we can separate and pull out malaria
parasites from blood, separate blood plasma.

Margaret Flinter: It is currently being tested for malaria diagnosis, but is being
read ied for fare more complex diagnostic challenges.

Manu Prakash : This is a too l that requires no electricity; you can carry them
around in your pockets for a price point of 20 cents.

Margaret Flinter: The Paperfuge, a cheap, but highly effective field to ol for
clinicians creating a quicker pathway to diagnosis and treatment. Now, that’s a
bright idea.

Margaret Flinter: This is Conversations on Healthcare, I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations o n Healthcare broadcast from the campus of WESU at Wesleyan
University , streaming live at wesufm.org and brought to you by the community
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