Dr. Christine Cassel, President and CEO of the National Quality Forum

Dr. Christine Cassel

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

Margaret Flinter: And I’m Margaret Flinter.

Mark Masselli: Well Margaret another year has flown by, 2015 was action packed in the
health care arena. It's a good time to look back at some of the year’s industr y’s
highlights.

Margaret Flinter: The Health Care law survived an other Supreme Court challenge in
June that upheld the legality of the Affordable Care Act’s premium subsidies and
averted a health insurance market meltdown real ly.

Mark Masselli: The high cost of pharmaceuticals top the list of health industry stories
this year whether it's the $85,000 price tag to treat just one patient with Hep C it's
indicative of a much larger problem. Drug costs are skyrocketing and its le ading cost of
inflation in the health care sector.

Margaret Flinter: Lawmakers, health industry activists, providers, payers all are jumping
on the bandwagon of transparency calling for something to be done to contain this
extreme high cost to pharmaceuti cals. And I think that’s the trend that’s likely to
continue into 2016 as we see more transparency around health care cost, not just in
pharmaceuticals but across the board.

Mark Masselli: And Margaret another big story that actually was a non - story. It 's the
long awaited switch to ICD - 10 billing codes, the switch was dubbed Health Care ’s Y2K
and indeed that’s how it played out the new coding going into effect in October and for
the most part the transition has been a smooth one.

Margaret Flinter: 2015 was also a year of mergers and acquisitions among many health
systems and insurance companies around the country , and I also note that more
medical schools have been announced, Kaiser Permanente is leveraging its integrated
high quality care model to creat e a new kind of medical school they are focused training
next generation clinicians to be able to advance population health and promote
sustainable health cost at the same time.

Mark Masselli: You know Kaiser CEO Bernard Tyson says creating a medical scho ol to
prepare clinicians for the Kaiser method of care delivery makes sense, especially as the
US health system shifts towards value based coordinated care.

Margaret Flinter: And Dr. Christine Cassel , CEO of the National Quality Forum has
announced that s he will leave her poster run this new Kaiser Permanente School of
Medicine because of that recent announcement we thought we would revisit her
conversation with her from earlier this year.

Dr. Christine Cassel

Mark Masselli: And also we hear from Lori Robertson, she always is on the hunt 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 because we love to hear from
you. We will get to our interview with Dr. Christine Cassel 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 health care headlines. Opioids and
overuse is reached crisis level proportions in this country with 250 million opioid
prescriptions being doled out in the past 10 years. And more than a 150,000 opioid
overdoses reported is a growing call for the medical profession to curb those
prescriptions and the Centers for Medicare & Medicaid is getting involved.

CMS plans to more closely track the use of opioids by adults and antipsychotics among
children and adolescents. About 28,600 people died in 2014 alone. The CDC says the
figure is the highest on record and is tripled since the year 2000. The measure is
intended to indicate inappropriate prescribing or fragmented care. The American
Pharmacist Association said, the new Medicaid measures could help identify patterns of
opioid misuse.

2015 also saw a dramatic rise in cyber security issues and health industry hacks with
millions of Americans’ health information having been compromised. The Health Care
information technology sector is haling health care specific cyber security provisions
that have made their way into the massive Omnibus legislation congress recently
passed. The $1.1 trillion spending in tax extender b ill includes language that closely
follows the recommendations from HIMSS, the Health Care Information and
Management Systems Society as well as other groups pushing for greater government
support to combat cyber threats, the legislation creates a health c are industry cyber
security task force.

Concussions are a real health threat in this country House and Energy Commerce
Committee chair Fred Upton is proposing an initiative to study the depth of the
prevalence of concussion and whether the current treatmen t protocols are sufficient
enough to mitigate the aftermath of concussion, Upton calling concussion a true public
health threat.

Dr. Christine Cassel

Meanwhile $16 million grant has been given to brain researchers to seek a way to
diagnose chronic traumatic encephalopathy whic h currently can't be determined until
the patient has died. The new study aims to develop ways to spot the disease in the
living. The National Institutes of Health is fully funding the CTE study saying it didn’t
want NFL money influencing the outcome of the research in anyway. I am Marianne
O'Hare with these health care headlines.

(Music)

Mark Masselli: We are speaking today with Dr. Christine Cassel , P resident and CEO of
the National Quality Forum, a non profit membership organization that works to help
improve health and health care quality through measurement, an internist and specialist
in geriatric medicine Dr. Cassel served as president and CEO of the American Board of
Internal Medicine. She serves o n the President’s Council of Advisors on Science and
Technology. Dr. Cassel is a former president of the American College of Physicians
and has published extensively her most recent book is Medicare Matters. She is
consistently named on Modern Health Car e ’s 100 most influential list. Dr. Cassel,
welcome to Conversations on Health Care .

Dr. Christine Cassel: Thank you Mark. It's a pleasure to be here.

Mark Masselli: Yeah. And the quality forum was set out to create a best in class
standards and metric s that could be used to improve the nation’s quality of health care ,
could you share with our listeners about how far we have actually come since the
National Quality Forum was established?

Dr. Christine Cassel: Well if you think back to 1999, it was a ti me where we had very
little open information for consumers or even for providers about the quality of care. If
you think about it even Google had just barely been created around that time, so --

Mark Masselli: Hard to believe.

Dr. Christine Cassel: Yeah . It's hard to imagine but that’s how long ago it was. So we
have come a long way and NQF has been right at the center of helping to set standards
for what measures are actually accurate but I would say we have a long way to go. But
NQF’s role has been all along to one place that includes all the perspectives from
stakeholders’ public and private as well as a very strong voice of consumers and
purchasers.

If you look at just the last four years we have seen a dramatic reduction almost 20%
reduction in ho spital acquired conditions like infections, 50,000 lives saved and $12
billion. So that would now have happened if we hadn’t been able to measure those
things and then report back to people and allow them to find ways to reduce those kinds

Dr. Christine Cassel

of events. Sam e kinds of level of improvements actually even more dramatic in
maternity care and reducing unnecessary hospitalizations and readmissions so I think
the place to really look for results in this area is within the hospitals and community
based institutions where people now are able to look at the quality of care and the
patient experience and collaborating regionally or even nationally to figure out how to
reduce problems and improve quality.

Margaret Flinter: You know Dr. Cassel you have said that to create a truly gold
standard for quality measures you have got to have all stakeholders at the table, how do
you arrive at quality measures in a way that satisfies all the stakeholders that are at the
table?

Dr. Christine Cassel: Well it's actually what m akes NQF so unique, there really isn’t
another organization like this. The NQF is the really only place that comes together
around an open transparent process, particularly having the strong consumer voices at
the table. So we have roughly 12 to 14 diffe rent ongoing standing committees. We
have 850 plus volunteers on all these experts and multi - stakeholder committees, so
helping us come to consensus . We are seeing more and more controversial measures
now because payment is so strongly attached to so man y of them, and that’s not
surprising. One of the things we are able to do through our consensus process is get to
the most practical results.

Mark Masselli: You have talked about these tensions that weigh heavily on the industry
we had Dr. Steven Stack w ho is the president of the AMA describing that his
membership is drowning in reporting requirements, could you talk to our listeners about
these industry challenges and the need for better science behind the measurements?

Dr. Christine Cassel: It is reall y true that the demand for better information is kind of
hitting the doctors with all these different requirements and there really is a need to align
the measures, to get all of the different people who are using similar measures but not
exactly the same together and try to reduce the redundancy, it's interesting you know
when I first came to NQF literally 50% of the people I talked to said that that we are
drowning in measures. The other 50% are saying we don’t have enough measures.
From the doctors’ pe rspective if you are a neurosurgeon we actually don’t have good
measures to measure what you do.

And if you are a patient and you have an unusual condition or actually not an unusual
like let's say multiple sclerosis, you want to know about that and we don ’t have good
measures for that. So I called this a Goldilocks problem, we have too many measures
and not enough measures and we don’t have the right measures. So we need just the
right measures, and that’s where measurement science comes in.

Dr. Christine Cassel

Margaret Fli nter: Well Dr. Cassel, what kind of system changes have come about
because of having access to better data because of these quality measures, give us
maybe some examples of the system changes within that led to the better outcomes
and also if you have exa mples of some health systems across the country that you
really think are getting this data sharing right.

Dr. Christine Cassel: I can point to Mayo Clinic, Cleveland Clinic, Geisinger , Denver
Health , Kaiser, Intermountain , Mass General and Partners and each of them, they
report these national metrics to the federal government and to state payers Medicaid
and the private payers as well and lot of people are just literally learning from one
another the science of quality improvement. And that includes put ting in place
reminders, checklists that for safety and every single time they go into the operating
rooms because that’s how you prevent errors from happening.

So recently a number of hospitals have done amazing things in reducing readmissions
by followin g up with their patients and some even giving the patients an iPad to take
home with them that reminds them to take their medication, has them able to
communicate seamlessly with a nurse at the hospital, lots of sort of creative ideas like
that.

Mark Masse lli: We are speaking today with Dr. Christine Cassel president and CEO of
the National Quality Forum, national collaboration of stakeholders indeed improving
health and health care quality through measurement. Dr. Cassel also served as
president and CEO of the American Board of Internal Medicine. Dr. Cassel let's talk
about the incentive movement and we are seeing this shift from volume to value. HHS
and secretary Burwell recently announced some very ambitious goals for the coming
year including ensurin g that 90% of Medicare outcomes are tied to quality, is the
National Quality Forum engaged in conversations with them about this reach?

Dr. Christine Cassel: We are very definitely Mark engaged in conversations with them
and with the private payers as wel l because they are moving down this road too, they all
are part of a national if we call the learning and action network that’s trying to align the
efforts of the private sector and the public sector. NQF has been very clear in our
measurement science wor k to say, you are not going to be able to just use cost alone
and still have consumers know that they are getting value because value is cost plus
quality. It's really about getting rid of the waste and the necessary cost in health care
and paying for wha t really does benefit the patient.

Some physicians and some health care systems and hospitals are way far along, they
have been doing this for a long time and they know how to think about patient centered
care in a way that doesn’t ask every time, is this going to get paid for or not. But for
many providers it's the whole new way of thinking about how you collect information and

Dr. Christine Cassel

how you organize your teams and how you interact with your patients providing really
good quality data that both providers and th eir own patients can understand and that
they really believe in is dramatically motivational. If they are using data that they
believe they will say, I never realized that I wasn’t checking lipids in my diabetics
because we didn’t have the data systems to make that visible to folks before.

Margaret Flinter: Well Dr. Cassel let's maybe take a moment to look at some areas of
interest to you personally prior to heading the National Quality Forum, you were the
CEO of the American Board of Internal Medicine an d the ABIM Foundation and three
years ago ABIM launched the Choosing Wisely campaign that call for providers as well
as patients to curtail the overuse of dozens of costly often unnecessary common
procedures and medications, share with us what kind of impa ct has the Choosing
Wisely campaign had.

Dr. Christine Cassel: It was in a way something that came from the profession itself
who were beginning to look at all of the concerns about the rising costs of care and say,
you know we own a piece of this, and we can be helpful by identifying areas in our own
practice that are overused often because patients had those expectation too.

Margaret Flinter: Right.

Dr. Christine Cassel: I think the insight that we had at ABIM Foundation was so often
when you began tal king about cost of care and reducing overuse people are worried
about rationing and so let's just have them the medical experts and patients groups we
were so fortunate to have a robust partnership with consumer reports and I think that
was the magic of Ch oosing Wisely. And now, as you have seen it's kind of entered the
vernacular this is coincided in interesting way with the rise of more high deductible
insurance programs. So I think it came just at a time when consumers needed this
because often that fi rst dollar payment is actually something that comes out of their
pockets.

Mark Masselli: There is certainly a world renowned expert at geriatric medicine and
th
Medicare as we know celebrated its 50 anniversary, your book Medicare Matters - What
Geriatric Me dicine Can Teach American Health Care you note that the Medicare is
perhaps the most important health care program of our time and I wonder if you can
share with our listeners a little bit about what we learned about the evolution of
Medicare as well as th e evolving discipline of geriatric medicine.

Dr. Christine Cassel: People are living longer and staying healthier as they age but part
of the price of getting old is that you do develop a number of age related conditions.
The specialty of geriatrics is u nique because it understands the science behind aging.
The distinction between treating a disease and treating a patient with multiple, multiple
chronic conditions and all of it is patient focused which is of course something we want

Dr. Christine Cassel

all health care to be now. And that’s why geriatric medicine can teach American Health
Care because looking at what are our patient’s values but let's have a partnership
between the patient and their family and organize the care around that set of values
which frankly might s ometimes be putting different priorities in place than a standard
medical guideline would have. It's also totally committed to coordination of care so
having multiple specialists very interactive with one another so everybody knows what
everybody else is doing. And trying to keep people out of nursing homes, out of
hospitals but when they are in nursing homes and hospitals being able to communicate
and organize the care to be the best care it can be so geriatricians work very closely
with nurses and socia l workers and physical therapists and others. But I think the
innovations you know Medicare has also been an innovator in terms of data for
reporting. So I think that all of the creative approach is to driving care that’s more
coordinated in some ways co me from those roots within the early days of Medicare and
the specialty of geriatric medicine.

Margaret Flinter: Well Dr. Cassel, I know that in your role at the National Quality Forum
the issue of inter - professional practice must arise but also you must have represented
the other clinical professions in particular that played important role in the health care
delivery system; the PAs and the nurse practitioners and the health psychologists and
others. Tell us maybe just a little bit about how the Nationa l Quality Forum has really
transformed who is at the table in terms of inter - professional perspective.

Dr. Christine Cassel: Well we have a large number of medical specialty societies who
are members of NQF but we also have a very large number of nursing organizations,
pharmacy is huge I mean when we think about how the world of pharmacy uses data
and make sure that they deliver the accurate medication to the right patient at the right
time we have tended to focus on the doctor measures because that’s who gets paid.
But in fact more and more everybody is recognizing that the quality of the care that is
given is can be attributed to a team, either a small team or a larger system and more
and more I think we should be recording team outcomes and system outco mes rather
than the individual. And that’s going to of course depend on changing of payment and
models and things like that.

Mark Masselli: We have been speaking with Dr. Christine Cassel president and CEO of
the National Quality Forum. You can learn mo re about their work by going to
qualityforum.org or you can follow them on Twitter @NatQualityForum. Dr. Cassel,
thank you so much for joining us on Conversations on Health Care today.

Dr. Christine Cassel: You are most welcome, I have enjoyed it.

(Music)

Dr. Christine Cassel

Mark Masselli: 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
non partisan, nonprofit 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: What is the coming year mean for those who don’t purchase health
insurance, higher penalti es under the Affordable Care Act, the Health Care law called
for penalties for those who don’t have health insurance with some exemptions mainly
based on income or economic hardship. And the amount of the penalty was phased in
over three years beginning i n 2014. That means the penalties hit their highest point
next year.

For 2016 the penalty will be either a flat fee or a percentage of family income whichever
amount is greater. The flat fee is $695 per adult plus another $347.50 per un - insured
child that maximum penalty per family is $2,085. For those paying a greater amount
under percentage of income that penalty is 2.5% of family income above the certain
threshold that’s about $10,000 for an individual and about $20,000 for a family. So for
instance a n individual earning a $40,000 a year would pay about $750 for not having
health insurance based on the percentage fee but an individual earning $30,000 would
pay the flat $695.

The increase for 2016 means a doubling of the flat fees and a bump up of a hal f of the
percent in the percentage penalties. The nonpartisan Kaiser Family Foundation
estimates that the average household penalty in 2016 for those who could have
purchased insurance on the ACA marketplaces would be $969 and the average
household penalt y for those who could have purchased such a plan but not with the
help of subsidies would be $1,450. The penalty is prorated if you had insurance for part
of the year and that’s my fact check for this week, I am Lori Robertson Managing Editor
of FactCheck .org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact, that you would like checked, e mail us at
www.chcradio.com . We will have FactCheck.org's Lori Robertson check it out for you
here on Conversations on Health Care .

(Music)

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Of the 6.6 million births per year
in this country, over half are unattended and among teens those rates are even hig her.
Colorado has been conducting an experiment for several years to examine what might

Dr. Christine Cassel

happen if sexually active teens and poor women were offered the option of long term
birth control such as IUD s or implants. The first question to answer, would they t ake the
offer?

Dr. Larry Wolk : What was striking was 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 clinics really did result in the significant decreases in uninten ded pregnancies and
abortion.

Mark Masselli: Dr. Larry Wolk medical director of the Colorado Department of Health
and Environment he says the results were nothing short of astounding.

Dr. Larry Wolk : The results in decrease is 40% plus or minus in both c ategories
pregnancy and abortion those reductions maybe even more dramatic when you extend
this out over an additional year to more than 50 even approaching 60% reductions.

Mark Masselli: And the results showed not only a dramatic decrease in unintended
p regnancies there was a significant economic benefit to the state as well.

Dr. Larry Wolk: We have seen a significant decrease in the number of young moms
and kids applying for and meeting public assistance whether that’s public insurance,
whether that’s t hrough the WIC program you know we hope that in longer terms this will
translate into better social and economic outcomes for these folks.

Mark Masselli: And in spite of what conventional wisdom might lead one to assume the
incidents of sexually transmitt ed diseases dropped in this population as well.

Dr. Larry Wolk: We have seen a decrease in sexually transmitted infections and the
rates are now below the national averages.

Mark Masselli: A free long term contraception program offered to at risk teens a nd
women trying to avoid the economic hardship of unplanned pregnancies leading to a
number of positive health and economic outcomes for all involved, now that’s a bright
idea.

(Music)

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

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

Conversations on Health Care , broadcast from the campus of WESU at Wesleyan
University, streaming live at www.wesufm.org and brought to you by the Comm unity
Health Center.