Dr. Patrick Conway, Deputy Administrator for Innovation & Quality and Chief Medical Officer at CMS

Dr. Patrick Conway - Centers for Medicare and Medicade Services

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret Puerto Rico has reported th e first death from the zika
virus an indicator that the mosquito population is moving north at a steady pace.

Margaret Flinter: Mark , we should note that HHS Secretary Sylvia Burwell went there
last week to meet with our partner scientist on the ground . Their epidemiologist will be
doing a lot to inform public officials here in the US as we prepare for the arrival of zika
on the shores.

Mark Masselli: As Congress didn’t approve the President’s funding requ est for zika
preparedness here in the United States so any rel e vant information we can gain from
Puerto Rico ’s front line experience will help us understand the depth of the threat to the
population in this country . Zika exposure has been linked to some d evastating birth
defects.

Margaret Flinter: And public health officials in the gulf states are already galvanizing
resources to get the word out about potential threats from zika so that people can take
extra precautions and certainly particularly pregna nt women. As we both know Mark
funding underlies so much of what we can do in public health and the funding of
healthcare in America is at the very core of the work our guest today is responsible for.
Dr. Patrick Conway is Deputy Administrator and Chief Medical Officer at the Centers for
Medicare and Medicaid Services .

Mark Masselli: And we are really looking forward to hearing about the new rules aimed
to transforming the American healthcare system.

Margaret Flinter : Well Lori Robertson will be checking in as she does every week , the
managing editor of FactCheck.org , always on the hunt for misstatements spoken about
health policy in the public domain.

Mark Masselli : But no matter what the topic , you can hear all of our shows by going to
chcradio.com or you can email us at [email protected]

Margaret Flinter: Or , f ind us on Facebook or Twitter ; we love to hear from you. So w e
will get to our interview with Dr. Patrick Conway in just a moment.

Dr. Patrick Conway - Centers for Medicare and Medicade Services

Mark Masselli: But first here is our producer Marianne O'Hare with this week's headline
news.

(Music)

Marianne O'Hare: I am Marianne O'Hare with these healthcare headlines. Hundreds of
scientific researchers and activities gathered in the Holy See to discuss ways to
advance global research for cancer and other deadly diseases . Vice President Joe
Biden who is leading the president’s Moonshot for Cancer was joined by other s toiling
[PH] on the frontlines of disease research. The gathering at the Vatican called Cellular
Horizons was organized by the US based Stem for Life Foundation. Vice President
Biden saying cancer is a n international problem and we are on the verge of major
breakthroughs but not enough is being done to coalesce that research. The vice
president lost his son Beau to cancer last year.

Speaking of profits, executives from the pharmaceutical company Valea nt were in the
hot seat in Congress defending the jacking up of prices of a number of commonly
prescribed drugs. The Senate Special Committee on Aging one of two US
congressional panels investigating the skyrocketing price increases of certain decades -
old drugs acquired by companies including Valeant . A major Valeant shareholder
appeared Wednesday alongside the company’s outgoing Chief Executive Michael
Pearson , Valeant had hiked prices of some of their drugs by several thousand percent
the outgoing CE O saying he will urge the company to drop those prices back down.

Drugs on the black market a counterfeit opioid produced in China has hit the Pacific
Northwest with a vengeance , the counterfeit versions of fentanyl a hundred times more
potent than morphi ne . Fentanyl is purchased from China shipped to Mexico and
transported to the US across its southwest border. In 2014 alone, there were 47,000
overdose deaths in this country and those numbers from 2015 and beyond are
expected to be much higher. I am Ma rianne O'Hare with these healthcare headlines.

(Music)

Mark Masselli: We are speaking today with Dr. Patrick Conway , Acting Principal Deputy
Administrator at the Centers for Medicare and Medicaid and CMS Deputy Administrator
for Innovation and Quality as well as CMS’ Chief Medical Officer. He oversees Access
to Care for the hundred million Americans receiving health cov erage through Medicare
and Medicaid and the Children’s Health Insurance Program or CHIP . A pediatric
hospitalist Dr. Conway received numerous distinctions including the induction into the
Institute of Medicine and the HHS award for Distinguished Service . He earned his

Dr. Patrick Conway - Centers for Medicare and Medicade Services

medical degree from Baylor College of Medicine and he completed his pediatric
residency at Harvard Medical School’s Children’s Hospital in Boston. Dr. Conway ,
welcome to Conversations on Healthcare.

Dr. Patrick Conway: Thank you, happy to be here.

Mark Masselli: Well you have the distinction of being called the most powerful doctor in
America and yet as Chief Medical Officer of the Centers for Medicare and Medicaid
Services you manage a trillion dollar care delivery sy stem . And you are also at the
helm of the Centers for Medicare and Medicaid Innovation and key figure in guiding the
transformation of the nation’s healthcare system b ut at heart you are a clinician and you
are still practicing medicine on the weekends, c ongratulations . And I wonder if we could
just start off thematically what should our listeners be keeping an eye on around the
crucial transformations that are going on?

Dr. Patrick Conway: Yeah. So first, not sure about the most powerful doctor in America
but yeah --

Margaret Flinter: That’s good.

Dr. Patrick Conway: -- you know it had been a great to serve the last you know five plus
years in the chief medical officer role and then expa nding roles as you described . On
the high level goals and what this means for patients and people across America , we
are focused on Better Care , Smarter Spending and Healthier People . And it really is
transformation that tries to put patients at the center of care delivery , have well
coordinated care and the best possible patient outcomes. To get there , we are trying to
create change in three major areas: One is , payment, how do we pay for better
outcomes and higher quality and not the volume of care delivered. So right now our
fee - for - service system you know pays for 15 Minute Office Visits for surgeries in volume
but we are really trying to align it with what matters to patients and peop le which is
better outcomes and care coordination.

Then Two, we are focused on care delivery , integration in mental and behavioral health
and also prevention of disease , helping incentivize, keeping people healthy in and out of
the hospital. And then the Third area is, information, so this transparency through
comparing websites and star ratings and other systems around the quality and cost of
care and also electronic health information both for patients and for providers. So I
think at the critical poin t over the last five years I think we have seen significant
transformation in the health system but we have got much more work to do to make
sure we achieve the best health outcomes as possible for people across the nation.

Dr. Patrick Conway - Centers for Medicare and Medicade Services

Margaret Flinter: Well Dr. Con way you have certainly been able to observe this
evolution of healthcare and health reform from within the federal bureaucracy for some
time now, and you were first appointed by Michael Leavitt as a White House Fellow
during the Bush Administration , Dr. Berwick appointed you chief medical officer at CMS
in 2010 . And now you are presiding over a sp a d e of new directives and regulations
around how people on healthcare are paid, moving from that fee - for - service system to
something else, how much they ar e paid and for what, what are the big difficulties you
face in changing how we pay for healthcare in this country and why the changes are so
essential ?

Dr. Patrick Conway: Yeah. So first I have served in a Republican Administration and
now on a Democrat ic Administration, I think the delivery system reform and health
system improvement I think is truly bipartisan . The first challenge I would call out is
really dealing with the diversity of medicine, so in Medicare we have to think about
different special ties , rural providers, small practices you know other diverse practice
settings we often are creating national programs and payments and policies. The way
we have tried to address that is, to have different options for people as they make this
transition different on ramps if you will as people transition their practices and really
focused on supporting especially those small and rural practices . Two, and I think this
burden issue , and physician clinician burn out is real, both my own family members , and
as I practice in the clinical setting I think we need to simplify whenever possible , lessen
burden on physician and clinicians, really try to align requirements across the public and
private sector . And we have done work with private health plans to try to improve there ,
you know at the end of the day focus on what matters most to clinicians and doctors
and patients which is better patient outcomes.

So as we make this migration I do think doctors and clinicians fundamentally want to
provide high qual ity to their patients so how do you enable the system that support s
that. The Third and last one I call out is really just allowing people to innovate you know
whether it's Accountable Care Organizations or bundled payment s w e try to outline the
outcomes we want to achieve for patients both quality and smarter spending a nd then
really let providers and communities and people innovate . If it's telehealth and bundled
payment initiatives or care managers or community health workers and Accountable
Care Organ izations we don’t want to dictate the how if you will, we want to let providers
and people innovate on how they improve care.

Mark Masselli: Dr. Conway I want to pull the thread a little more on both payments and
care delivery and you started off by saying that we are on the payment side moving
from volume to value based . And as the Deputy Administrator of the Centers for

Dr. Patrick Conway - Centers for Medicare and Medicade Services

Medicare and Medicaid Innovation you are also looking at a number of care delivery
models that ai m to achieve sort of both of thes e ends of better integrated care and
potentially better payment models. And we have heard over the years of Accountable
Care Organizations PCMH, the Patient Centered Medical Homes, the SIMs – the State
Innovation Models so we have got all these experiment s going on, right?

Dr. Patrick Conway: Yeah.

Mark Masselli: And so One, we are trying to figure out how do those relate and then
you have got your new 962 page CMS proposed rule changes for payments and you
have clinicians you are going to choose , sort of two different pathways, the Merit - Based
Incentive payment systems or the alternative payment models, how do I put together all
of these?

Dr. Patrick Conway: So One, I think they are all connected with the high level point of
incentivizing Better Care , Smarter Spending and Healthier People and really moving our
system to alternative payment models where the provider is accountable for quality and
total cost of care for a population that can be in an Accountable Care Organization or
Primary Care Medical Home it could for you know in a bundled payment might be a 90
day episode around a hip and knee replacement but they all have the high level
principle of increasing accountability for care coordination and better outcomes for
patients.

In Accountable Car e Organizations we are seeing that grow , w e have got about 9
million Medicare beneficiaries in ACOs and last [Inaudible 00:11:26 ] from the private
sector is you know over 27 million people in various ACOs across the country . And we
are seeing improved qua lity, better patient experience and lower cost in bundled
payments which is one of the next big models. Our voluntary bundled model has 48
various episodes like hip and knee replacements or cardiac surgery or medical
conditions and we have got over 1500 hospitals , physician groups and post acute
facilities volunteering to take on two - sided financial risk because they know , they think
they can improve quality in lower cost for whole episode of care . And at the end of the
day that’s how patients think about it , if my mother has a hip and knee replacement, she
wants better outcomes over that whole episode . And then lastly with MACRA , with the
Proposed Rule on the new physician payment system you know physicians and
clinicians will have choices on the Merit - Based program essentially paying for value but
adjusting based on quality and cost to really take on accountability for caring for their
patients preventing disease and improving outcomes.

Dr. Patrick Conway - Centers for Medicare and Medicade Services

Margaret Flinter: Well Dr. Conway when I think that the lofty goal of reducing fee - for -
service payment for Medicare by 15% is the goal for the year 2018 which is already like
on my cal e nd a r. So we have talked about alternate payment models, but when we think
about alternative care models the aging and place f or seniors , more extensive use of
telehealth, how does all that figure into the equation with achieving the kind of changes
that we want to see?

Dr. Patrick Conway: You know we talked about a number of the payment models
telehealth , we are increasingly b oth in our Accountable Care Organizations and our
Primary Care Medical Homes seeing doctors and care teams manage patients when
and where and how patients want to interact with the health system which is often at
home through telehealth , or remote monitori ng , or email or other technologies. We
have a model is literally home based primary care for very frail elderly patients saved
over $3,000 for beneficiary like a person who has been hospitalized 19 times the year
before and wasn’t hospitalized at all in t his model so really preventing those kind of
hospitalization and things that no one wants to go through. The palliative care issues ,
our biggest model there is Care Choices which you are either in hospice and you are
forgoing curative care services or you are getting curative care whereas most people
including my own father and patients I have taken care of, it's a much more trajectory
that’s not that black and white. And so we have a model that allows now patients to get
hosp ice and palliative care services at the same time as so called curative care
services. So we think this is a much more patient centered care model.

Mark Masselli: We are speaking today with Dr. Patrick Conway , Acting Principal Dep uty
Administrator at the Centers for Medicare and Medicaid and CMS ’ Deputy Administrator
for Innovation and Quality as well as Chief Medical Officer , Dr. Conway is also
responsible for all quality measures at CMS . And Dr. Conway let's talk about the
Cente rs for Clinical Standard s and Quality and yet oversee quality measures and
controls in all 50 states ensuring that health providers are properly certified , as quality
outcomes become more incentivize d at CMS, how are you going to oversee those
measures and to ensure as you would say that we are getting better care and the best
outcomes.

Dr. Patrick Conway: So really focusing on outcome oriented measures things like
patient reported outcomes after hip and knee surgeries, readmissions to hospital,
hospitali zation. Two, really being transparent about those results, so whether it's
nursing homes or home health or in the physician setting you know publicly posting the
results often typically with star ratings that we learned are more understandable for
consume rs. And then the last thing, we do survey and certification and partnership wit h
the states so nursing homes, hospitals, home health agencies etc. I unfortunately get

Dr. Patrick Conway - Centers for Medicare and Medicade Services

reports everyday of what we call Immediate Jeopardy which are major quality and
safety issues in a given provider and there you know we work with the states to enforce
those regulations including terminating providers from the programs . So you got to go
back to first principle , and our first principle is ensuring the quality and saf e ty of, over
100 million, we are getting close to a 140 million total beneficiaries if you add up
Medicare Medicaid CHIP and market place so huge responsibility to try to ensure safety
in all these healthcare settings for all Americans.

Margaret Flinter: Well Dr. Conway it's no s e cret that providers are feeling just
enormous pressure to embrace all of the changes that are out there to meet the
benchmarks that we are setting . And I think, we have read that you have even taken
some heat from your own sister who is a physician about the concerns of many [PH]
that you are just trying to do too much too fast, what are your thoughts on how we both
maintain this culture of innovation and forward progress while not alienating and burning
out the front line clinici ans delivering that care ?

Dr. Patrick Conway: You know we had heard from physicians and clinicians you know
too rigid, not flexible. So we really try to simplify, try to make it much more flexible but I
think these principles around simplification , flex ibility, less burden are critical. You are
right I have a number of family members and my sister is actually solo practitioner you
know these physicians and clinicians they want to improve care but they need support .
So we launch ed this initiative we cal l the Transforming Clinical Practice Initiative but we
are funding over $650 million over four years and supporting these entities we call
Practice Transformation Networks . But they are basically entities that have
relationships with physician and clinicians practices they now exist in every state across
the county and the whole point is to help these physicians and clinicians , measure
progress on quality . And it's peer to peer to learning this is critical, this is peer to peer
learning where one practice will teach another practice how to improve care and there is
good evidence that this kind of peer to peer learning is much more effective.

Mark Masselli: Recently CMS offered new guidelines for the Medicaid population I think
I have lost track of the numbers of folks in Medicaid is somewhere between 60 million
and 70 million people but recently the Obama Administration released new rules
governing Medicaid services to ensure th at coverage they are being given meet specific
guidelines , and I wonder if you could talk to our list e ners about these new rules an d how
you anticipate they will improve the experience.

Dr. Patrick Conway: Yeah. So Medicaid is growing substantially and then nationally
over two - thirds of Medicaid beneficiaries now receiving their benefits through Medicaid
managed care . That finalization, that rule for Medicaid managed care was the first

Dr. Patrick Conway - Centers for Medicare and Medicade Services

complete overall and over two decades so really focusing on quality of care so
everything from quality rating systems to quality improvement. Two, it really does align
with out care transformation goals , so for example incentivizing Medicaid managed care
to pay providers based on accountability. At the end of the day it' s all about aligning
Medicaid requirements with commercial and Medicare whenever applicable and really
continuing to update and improve Medicaid and Medicaid managed care over time and
we want that care to be as high quality and best the possible outcomes as possible.

Margaret Flinter: Well Dr. Conway just so that our listen er s have good understanding
the Medicare Access and CHIP Reauthorization Act has created such a buzz and I
understand your office is offering Final Rules this week, can you talk about the new
guidelines provided in MACRA , the acronym that you believe will promote more value
based models for care delivery ?

Dr. Patrick Conway: It's the biggest change in physician and clinician payment probably
in Medicare history. It takes a whole bunc h of different quality and value systems that
were created and different laws over time and it puts them into one program. It gives
physicians and clinicians basically two paths: One is, so called Merit - Based incentive
you know we want you to improve quality how you use technology and clinical practice
improving activities a nd if you do well in those areas we are going to pay you more for
doing well.

And then the second pathway is these advanced alternative payment models so thi ngs
like some of our Accountable Care Organizations or some of our Primary Care Medical
Homes we are saying, you know if you are wil ling to really invest and take on
accountability for these populations of patient you know there is a 5% bonus payment
by la w. My mother is a Medicare beneficiary she had to receive care through an ACO,
at the end of the day I think her experience i s not that different than many you know
now her physician and clinician and various specialists and others they are focused on
coo rdinative care and making sure that she goes to the appropriate follow up
appointments , that her medications are managed and you know that’s what we want for
all the people in the system.

Mark Masselli: We have been speaking today with Dr. Patrick Conway Principal Deputy
Administrator Chief Medical Officer and CMS Deputy Administrator for Innovation and
Quality at the Centers for Medicare and Medicaid Service . You can learn more about
his work by going to cms.gov or following @CMSinnovates on Twitter. D r. Conway,
thank you so much for joining us on Conversations on Healthcare today.

Dr. Patrick Conway: Thanks for having me.

Dr. Patrick Conway - Centers for Medicare and Medicade Services

(Music)

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 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 what have you got for us this week?

Lori Robertson: In late April 2014, the city of Flint began using the Flint River as its
water source, b ut the Flint River has particularly corrosive water which led to high levels
of lead leaching into the water from many of the city’s dated pipes. In July 2015 the
Michigan Department of Health and Human Services claimed the elevated blood lead
levels in c hildren followed a normal seasonal trend. The link between Flint’s water
switch and elevated blood lead levels in children wasn’t confirmed until two independent
researchers put forth their own analyses in September 2015.

At an April US House hearing, Re p. Gene Green asked Nick Lyon, Director of the
Michigan Department of Health and Human Services, Why the department had
conclude d that the spike in blood lead levels wasn’t related to the water supply? Lyon
said that, the initial July 2015 department anal ysis showed seasonal fluctuations that
were comparable to years before , but the analysis showed the opposite. The state
analys e s aim to answer whether the July , August and September 2014 blood lead
levels in children under 16 fell within the normal seasonal range compared with previous
years. It was more than two months after that July 2015 analysis that the County Health
Department declared a public health emergency and told residents not to drink the
water. And that’s my fa ct 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
Univer sity of Pennsylvania. If you have a fact, that you would like checked, email us at
www.chcradio.com . We will have Fa ctCheck.org's Lori Robertson check it out for you
here on Conversations on Healthcare.

(Music)

Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. Depression is extrem ely
common among adolescents in this country but it's often hard to differentiate between
teen angst and a clinical condition that requires more immediate intervention. Suicide is

Dr. Patrick Conway - Centers for Medicare and Medicade Services

the third leading cause of death among 10 to 24 year olds, a population that almost
ubiquitously uses texting as a form of communication

Nancy Lublin: So if you are someone who is in pain, you text us , and the counselor on
the other side is not workin g from a phone.

Mark Masselli: Nancy Lublin is founder and CEO of Crisis Text Line , an instant texting
service designed to encourage teens in crisis to reach out for help. All they have to do
is text the numbers 741 - 741.

Nancy Lublin: When messages co me in with certain keywords in them , they
automatically get tagged as high risk. So if you are at risk for suicide , you are
automatically bumped up in the queue and you are like a code red.

Mark Masselli: They receive an average of 15,000 texts per day from kids experiencing
everything from typical teen dilemmas to kids contemplating suicide. Crisis Text Line,
an instant age appropriate intervention, free of charge and 24x7 to give kids in crisis a
lifeline and lead them to help they need , now that’s a bright idea.

(Music)

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

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

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