Dr. Ashish Jha, Professor of Health Policy at the Harvard School of Public Health

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

Margaret Flinter : And I am Margaret Flinter

Mark Masselli : Well, Margaret the summer is really heating up and things are also
heating up around the Affordable Care Act a s well.

Margaret Flinter : Well that is right Mark and the White H ouse issue that there was a
bombshell recentl y when they announced that the implementation of the so called
employer mandate in the Health Care Law is going to be delayed as long as 2015 an d
that was big news.

Mark Masselli : Well administration officials say that the delay is needed to ensure that
the proper reporting infrastructure is in placed but I think it is wise to and get it right but
it does not delay when it started the insurance exchanges which seem to be on target
for October.

Margaret Flinter : And let us take a look at some of the statistics of more than 200,000
small businesses in the United States, only about 10,000 of them don’t offer health
insurance to their employees and technically these employees could enroll in the
insurance exchange on their own where they can get the tax subsides and the premium
discussed so it is not like there is no options for those employees.

Mark Masselli : I think it is important Margaret that we continue to communicate with
people about the Affordable Care Act and what it means to them, for instance many
folks don’t know that in addition to tax subsides they help to free the cost of purchasing
insurance, there is also a cost sharing provision for those gaining health coverage on
the exchanges.

Margaret Flinter : Because that really reduces the out of pocket expense in health care
which can be significant. So depending on income and what plan you purchase, you
got additional assistance in meet ing your true cost of health care with co - pays and the
like.

Mark Masselli : There is also a great website where people can go for information, it is
healthcare.gov.

Margaret Flinter : Well our guess today has spent a lot of time analyzing systems of
car e around the country and ways that that care can be improved. Dr. Ashish Jha is a
practicing internist at the VA Boston Health Care System and professor health policy in
the Harvard School of Public Health.

Mark Masselli : He has got some interesting ins ights into the current state of health care
in this country and how it can be improved in the future.

Margaret Flinter : And in fact checked that out where he managing editor Lori
Robertson, looks at claims about federal employees health care plans being impacted
by the Affordable Care Act but no matter what the topic, you can hear all of our shows
by googling CHC radio.

Mark Masselli: And there is always if you have comments, e - mails at chcradio.com or
mine is on Facebook or twitter because we love to h ear from you.

Margaret Flinter : Now we will get to our interview with Dr. Ashish Jha in just a moment.

Mark Masselli: But first here is our producer Marianne OHare with this week’s headline
news.

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Marianne OHare : I am Marianne OHare with the healthcare headlines. Obama care
and the employer mandate, the twain shall take more time to meet in a stunning
announcement before the July 4th holiday began, the Obama administration announced
the so called employer mandate would be postponed for a year to 2015. The provision
in the Affordable Care Act that required companies with more than 50 employees to
provide health coverage for their full time staff or pay a penalty. Health of human
services secretary Kathleen Sibelius saying there needs to be mo re infrastructure put in
place to handle the law’s verification technology, nine pioneer ACEO’s, those newly
formed accountable care organizations are opting out of a program set up by the
healthcare law, leaving instead for a more manageable medicare alte rnative test of the
payment module, the shared savings program which allows ACEOs to opt for a
payment arrangement, it does not include the risk of financial losses. Scientist in
Yokohama Japan are over the mood about something they have developed growing a
rudimentary liver in a petri dish . Scientist around the world are making some significant
success growing less complex organs in the lab using foundational scaffolding from
stem cells to grow on. The Japanese experiment decided to look at harvesting t he stem
cells and programming them without scaffolding would yield the same results, within 5
days they have grown a small rudimentary but functioning liver which they implanted in
a mouse. Well much refinement of the technique and promise for human trial s is years
away. These scientist say they were “gobsmacked” by their discovery . I am Marianne
OHare with these healthcare headlines.

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Mark Masselli: We ’re speaking today with Dr. Ashish Jha practicing internist at the VA
Boston Health Care Syst em and professor of health policy at the Harvard School of
public health for the past five years, Dr. Jha has served a special advisor for quality and
safety to the department of veteran’s affairs. He is a frequent contributor to health
affairs to the jou rnal of American Medical Association and is founder of his own blog
and ounce of evidence. He is the senior editor on a new health industry journal Health

Care the Journal of Delivery Science and Innovation . Dr. Jha is a senior research fellow
at the Wes t Health Policy Center where his focus is on improving health care delivery in
lowering cost. Dr. Jha received his medical degree from Harvard School of medicine
and his masters in Public and health at the Harvard School of Public Health. Dr. Jha
welcome to Conversations and Health Care.

Dr. Ashish Jha : Oh t hank you so much for having me, I’m glad to be here .

Mark Masselli: We are so happy that you are with us and you are a prolific observer of
health care deliver and public policy in this country but you are particular focus is on
gathering and showing data that has the power to improve delivery of care in fact your
blog and ounce of evidence is propagated on the idea that an ounce of evidence is
worth a 1000 pounds of opinion, I love that. Your focu s on the health care debate has
been bringing data into the discussions so may be you can share with our listeners your
vision about how technology and data can help us improve health care.

Dr. Ashish Jha : Sure, you know the health care system obviously is extremely complex
and we often get into trouble because we have very simple answers to these very
complex questions. Most of the times when I look at the complex problems that are
facing our health care systems around cost and quality, each way that I feel like I have
the right solution and I really think the solutions are out there but technology I think will
have a really important role to play but how do we actually get technology to start
helping us deliver better care at lower cost and how do we ac tually get data to help us
make better decisions, that is the challenge and that is what I work on. If we can use
these and other tools, I think we can really begin to have an impact that is sustainable
up in the long run.

Margaret Flinter: Well Dr. Jha you have a unique approach I think by being at the VA
and example of a health care system that you know may be was thought of us having
some serious flaws in the past but it has really transformed itself into what is recognized
as a very high quality syst em of care and what you did was seemed to marry up the use
of technology and information with culture change to achieve some real breakthroughs
and quality of care, may be you could share with our listeners how did the VA do that,
how did they use health d ata to achieve significant improvements in the quality of care
and get people to change their behaviors along with it.

Dr. Ashish Jha : Yes really for 60 some odd years, it had a reputation for being an
organization that you know that really did not deliv er top notch health care and in the
mid 1990s under the Clinton administration the VA put in a new health care leader, a
guy named Ken Kaiser and Ken was a former navy seal and when he came in his task
was really very simple which was transform the health care system that delivers care to
the VA to veterans in a way that really both improves outcomes and improves quality
and lowers cost but what Ken Kaiser and the leadership of the organization did at the
time was they took what I think of are as a series o f very free market principles. First
and foremost, they said look it is too hard to make all the really important decisions in
Washington DC, we think the key decisions about the cost and quality and really should

be done much more locally but alon g with that came accountability and so for
accountability they said we need data and so they started collecting data nationally on a
series of quality metrics and said we have to hit these benchmarks and holding
government employees accountable for metrics not al ways the easiest thing and then
during this entire time period to put in an electronic health record across the country. I
think the combination of accountability incentives, all of this stuff was publicly reported
to congress and other key stakeholders a nd IT; the combination of all of that stuff really
transformed the organization in a few short years and what it has taught me is that it is
unlikely that any one thing could have done it, if they had just put in technology, I doubt
it would have done very much, if they had just had accountability and incentives,
probably wouldn’t have worked, it is really putting them all together with the right mix
that had such a big impact on the VA Health Care System.

Mark Masselli: You know let us talk a little bit about some of the data you have been
examining and particularly you have writing about the organ experiment which basically
had a state wide lottery that allowed the uninsured to gain coverage to medicate and it
was written that after a number of years tha t the data suggested that patient’s did really
fair much better in terms of things like management of cardiovascular disease or type II
diabetes but you said the data was misunderstood and that they are many aspects of
the organ experiments that really did work to help us better understand what the real
story is there.

Dr. Ashish Jha : I think there are two or three lessons from organ that I think are
unmistakable. So the first thing that I learnt from the organ experiment is that health
insurance works. Insurance is meant to be something that protects you from financial
catastrophe. You know we have insurance on our house because if my house burnt
down tomorrow, it would be a financial disaster for me, unless I have home owner’s
insurance. In the same way, if I got sick tomorrow and I did not have health insurance,
it could potentially bankrupt me and what we saw in the organ experiment was that
people who went on Medicaid, you know there were far less likely to go bankrupt
because of health care issues and so from an insurance point of view, given what
insurance is supposed to do it really does work and so for people who try to make the
argument that insurance doesn’t matter, I think the organ experiment has really put that
to rest so that is the side t hat the democrats love and the people on the left love. Let’s
flip to the other side which has been the issue around, well does insurance improve
health outcomes and I personally think that is a very tall order to expect that health
insurance alone will i mprove the health of the population because of course insurance
gives you better access to doctors and nurses and hospitals but to actually improve
health that health care that you get now has to be of really really high quality and our
health care system fails to deliver high quality health care in any consistent fashion and
so what we see in the organ experiment is patients who went to the doctor many many
times and yet they still had really high blood pressure and they still had really poorly
controlled diabetes and that is not an indictment of insurance or Medicaid, it is an
indictment of our health care system and that is unable to really deliver on effective
chronic disease management and so I basically have made the argument, let us not
over sell the value of health insurance, very important for bankruptcy protection and

very important for its financial protections but from a health outcomes point of view it is
necessary but it is not sufficient, we are really going to have to improve the health care
d elivery system if we wanted to actually improve patient outcomes.

Margaret Flinter: Well actually we have talked a little bit about organ on the west coast
but let us bring it east where you are in Massachusetts, certainly the focus of a lot of
study and interest since the passage of landmark reform in 2006 and there both
legislation and action on the ground to control cost but in that middle, in that experience
of what did happen in terms of health from either a utilization or a outcome point of view,
an d I wonder if you would like to comment being right there in Massachusetts what data
do we have any measurable changes in the health of the population.

Dr. Ashish Jha : It is a really good question and you know what Massachusetts again
has taught us is no t unlike what organ is teach ing us which is when you give people
insurance it does have huge financial benefits and f inancial protections for people. You
know what we saw is in the early days, people were hoping for some substantial decline
in util ization , we really didn’t see that four or five years in, actually in the first couple of
years we saw an increase in ER use, that stabilized and it has come down and now I
think in some ways we are back to baseline, there is some preliminary studies that I
have seen that suggest that for people who are uninsured getting health insurance
really did make a big difference in their health and you know in the last five years health
care costs in Massachusetts have continued to rise at a pretty fast clip. So if you ta ke a
step back and say what has Massachusetts taught us, I would say two or three things,
one is it is certainly possible to get to universal access without any major major you
know disruptions to the healthcare systems, second work that we have done says you
know asked the question when you give a whole bunch of people health insurance do
you make things much worse off for every one else because you are flooding the
system we new people and it turns out from the work that we have done and other
people have done, the answer is not really , the capacity of the health care system to
absorb new patients is pretty amazing and the system is resilient but don’t expect,
again, the insurance alone to do much for you on either cost or on patient outcomes and
that is t he part that we really need to work on. We need to figure out how to make the
health care delivery system work better in terms of quality and as well as efficiency.

Mark Masselli: We are speaking today with Dr. Ashish Jha practicing internist at the VA
Boston Health Care System and Professor of health policy at Harvard School of public
health and for the past five years Dr. Jha has served as special advisor for quality and
safety to the department of veteran’s affairs. Dr. Jha writes extensively for num erous
medical journals including his own blog, an ounce of evidence, and is senior editor at
the New Health Industry Journal, Health Care the Journal of Delivery Science and
Innovation. Ashish tell us a little more about the work that you are doing with t his new
journal and tell us a little bit of why you decided to go forward with this and who are
some of the contributing editors to it and what do you hope the impact will be.

Dr. Ashish Jha : So you know when we first started talking about this and reall y the
driving force behind the new journal are these two young folks Sachin Jain and Amol

Navathe who are both physicians at Brigham and Women’s Hospital and when they first
sort of came to me with this idea and you know the first question I asked myself a nd
other people have asked this, do we really need yet one more health care journal and I
think we pretty quickly concluded as we look at the landscape and the answer was yes
for the following reasons. There are very few really arguably no other journals that we
could identify that were focused on the science of health care delivery. There are lots of
terrific journals out there and one of the my favorites health affairs and very focused on
health care policy, very focused on kind of how do things that we do in Washington or in
state capitals that really impact health care delivery but if you are the leader of a health
care system and you are trying to think about well how do I actually make improvements
in let us say infection rates, right across my hospi tals. There are surprisingly few places
where you can turn to get vigorous thoughtfully described data driver recommendations
and that is the niche that we thought was really important to begin to attack. How do we
help clinical leaders and organizationa l leaders and policy makers to think about
improving the health care delivery system and so our first issue is out, we had two
terrific people Melinda Benton and Rachel Warner, Melinda is at the congressional
budget office, soon heading off to (16:05 inaud ible) and Rachel Warner is at the
University of Pennsylvania. They edited the first issue, it was about payment innovation
and how can new payment modules really help improve health care delivery. We are
going to have issues on quality improvement , on he alth information technology. The
patient centered innovation. These are some of the themes and again we have a lot of
very good people who are going to be leading the efforts but as we published off and as
we get stuff out, we will get feedback from the market place about what kinds of things
are getting traction and are useful, what kind of things are really redundant with other
things that are out there and I am confident, we will make changes along the way but
that is the vision right now, is that ther e is this important gap to fill and we want to play a
helpful role in that area.

Margaret Flinter: Ashish you are currently a research fellow as well at the West Health
Policy Center whose state of goal is to greatly reduce costs in health care while at the
same time improving quality and outcomes and in fact we have had your colleague on
the show West Health’s chief medical officer Dr. Joseph Smith who spoke about that
mission very eloquently, may be you could share with us what specific area of cost
con tainment are you focusing on in your work at the west health institute?

Dr. Ashish Jha : Yeah you know I obviously can’t do the west health institute, the kind of
justice that Joe, he really is the intellectual and I think sort of passionate leader behind
it. I will describe our project and we actually just published a paper on this three days
ago in JAMA ( Journal of the American Medical Association ) , but here is the notion, so
when I am speaking to audiences about health care spending, I mentioned that y ou
know 10% of Medicaid beneficiaries account for about 60 or 70% of all the health care
spending and everybody knows this and everybody kind of nods and so we know that
health care spending is very concentrated a small number of people really count for
mo st of the spending. The second thing we know is that people who are tend to be
these high cost patients they tend to have more chronic illnesses, they tend to be sicker,
they tend to be older, well you would say of course they are, I mean completely not

s urprising that people who are older and sicker are going to end up using more health
care resources, that makes total sense. The logical leap that people make next is they
assume that most of that spending among these high costs patients is for the ir chro nic
illnesses, it is for their diabetes, it is for their hypertension, it is for their heart failure and
so that is the question that we thought was really important; is it the chronic illness that
is driving most of the spending, what exactly is it and so that was the project that West
supported and we just finished and we published our first paper on this, we have a lot
more work to do but I will give you the highlights, what we found basically was among
high cost patients, you know most of their spending is in hospital care and then we said
what proportion of that hospital care is really preventable and we use AHRQ as a
definition of preventable hospitalizations and we found that about only 9.5% of the total
inpatient spending for these high cost’s patien ts were these preventable things. So that
is really interesting and I think it surprised a lot of us, what it told us their expensive
because they get major procedures, they get defibrillators, they get hip replacements,
they go to the hospital and then e nd up getting sepsis and end up being in the ICU for
four weeks. These very very expensive episodes, that is what drives the other 90% and
things like chronic disease management, nurse manager, or sort of better care
coordination, very very important but it isn’t going to get us nearly far enough, it is not
going to safe us the kind of money that we would ideally like, we are going to have to
have very different strategies for saving money on these very expensive patients.

Mark Masselli: We have been spe aking today with Dr. Ashish Jha internist at the VA ’s
Boston Health Care System and professor of health policy at the Harvard School of
Public Health, you can follow his writings at his blog site, an ounce of evidence, and
follow him on twitter. Ashish th ank you so much for joining us on Conversations on
Health Care today.

Dr. Ashish Jha : Oh it has been my pleasure thank you for having me.

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Mark Masselli : At Conversations on Health Care we want our audience to be truly and
to know when it comes to the facts about health care reform and policy, Lori Robertson
is an award winning journalist and managing editor of fact checked out org, a non
partisan, non - profit consumer advocate for voters that aim to reduce the level of
deception in US politics. Lori what have you got for us this week.

Lori Robertson : Well Mark and Margaret, this week we will talk about a democratic
talking point about republicans and congress who want to repeal the Affordable Care
Act . The line is that these republicans were “voting congress, tax payer funded health
care for life” but the truth is no one has voted to give congress health insurance that
they don’t already have. Here is where this distorted talking point comes from,
members of congress have long received health insurance through the federal
employees health ben efits program which much like ly soon to be launched health care
exchanges offers the choice of private health plans. Eight million federal employees
and retirees get their health insurance this way. But a republic amended to the

Affordable Care Act requires numbers of congress and their staff to get insurance
through the exchanges instead. If the law were to be repealed, congress would simply
go back to getting health insurance the same way they had been . The federal plan is
generous. The government pays an average of 72% of the cost of premiums just as
lowest work based coverages largely paid by the employer. We recently saw this claim
in an add from a democratic political action committee attacking r epublican
representative Tom Cotton a potential senate candidate in Arkansas. But Cotton didn’t
vote for some new tax payer funded health care for himself and other law makers for
life, instead he voted to repeat the Affordable Care Act and that is fact c heck for this
week. I am Lori Robertson, managing editor of factcheck.org . F actcheck.org is
committed to factual accuracy from the countries major political players and is a project
of the A nnenberg Public Policy Center at the U niversity of Pennsylvania . If you have a
fact that you would liked check, e - mail us at chcradio.com, we will have factcheck.org.
Lori Robertson, check it out for you here on Conversations on Health Care.

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Margaret Flinter : Each week Conversations highlights a bright ide a about how to make
wellness a part of our communities and every day lives. Right now there are about
three and a half million people living in refugee camps around the world whether
displaced by wars or natural disasters, the fate of these people is ofte n the same, living
in squalled conditions, intense cities that provide little protection from harsh elements
and these conditions pose serious threats to their health and well being. The IKEA
F oundation has taken the parent companies wildly successful do it yourself approach to
home furnishings and applied it to the problems of inadequate housing for displaced
refugees, they have created a do it yourself dwelling that can shipped and assembled
anywhere.

Mark Masselli : So first and foremost there is the v ery well known flat tach a pproach that
IKEA has pioneered, secondly the materials and the product itself so it is a shelter, it is
not a tent.

Margaret Flinter : Jonathan S pampinato is the head of communications and strategic
planning at the IKEA Foundatio n , they are working closely with the United Nations
organizations working on the ground trying to assist refugees in Somalia and other parts
of the world.

Mark Masselli: We extended that to also include funding for an innovation unit within
the UNCHR so they could think more long term so providing that funding allowed them
to start the refugee housing shelter looking at how to design a better shelter.

Margaret Flinter : S ince on average a person is likely to spend up to 12 years in a
refugee camp these IKEA structures have some unique properties that can make the
experience more bearable, the walls and the roof are made out of a new fancy version
of basically a plastic material that is much more durable but very very light weight and
still it is insulate d. The IKEA foundation currently has prototypes being tested in various

refugee camps on a scale of production once refinements are made and true to IKEA,
the price point is going to come in under a $1000 per structure, a deliverable,
affordable, do it yo urself dwelling that can provide some sense of dignity, privacy, and
protection for families who are struggling as refugees; now that is a bright idea.

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Margaret Flinter : This is Conversations on Health Care. I am Margaret Flinter .

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

Announcer: Conversations on Health Care broadcast from the campus of WESU at
Wesleyan University streaming live at wesufm.org and brought to you by the community
health center.