Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and High Cost of American Health Care

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

[Music]

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

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret , it seems transforming healthcare isn’t as easy as
some of the nations most successful business leaders would hope . The latest
news from the Amazon , Berkshire Ha tha way , JP Morgan Chase p artnership to
transform healthcare , t hey had been having a tough go of finding the right person
to lea d that initiative.

Margaret Flinter: Amazon’s Jeff Bezos, Ber kshire’s W arren Buffet and Chase’s
Jamie Dimon , reportedly they started looking out for CEOs months ago, first in
the health policy and insurance sectors, but have since switched to looking for
someone who is more of an entrepreneur.

Mark Masselli: Word is that former CMS administrator, An dy Slavitt , and former
White House c hief t echnology o fficer, Todd Park , both who we re on our show
removed themselves from consideration and are starting their own entities .

Margaret Flinter: Well, they have a challengi ng mission [Inaudible 00:00:54 ]
healthcare from the outside and there is an opportunity to leverage Amazon’s
d irect m arket d elivery s ystem to give patients more access to meet their medical
needs as well as more affordable prescriptions which is certainly on people’s
mind these days.

Mark Masselli: Cost and access is something our guest t oday has been quite
focused on , Dr. David Bl umenthal is the President of the Commonwealth Fund .

Margaret Flinter: L ongstanding philanthropy dedicated to ensuring access to
quality healthcare for all Americans, their work helps provide a global view of the
American Healthcare System compar ed to other countries.

Mark Masselli: And he was also quite instrumental in the passage of the
HITECH act, which paved the way for Am erican hospitals a n d practices to switch
from paper to electronic health records . We are really looking forward to hearing
his insights .

Margaret Flinter: A nd Lori Robertson will stop by, the managing editor of
f act c heck.org, but no matter what the topi c, you can hear all of our shows by
going to chcr adio.com or go to iT unes.

Mark Masselli: And as always, if you have comments, please email us at
chcr adio.com or find us on Facebook or Twitter , we love hearing from you.

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

Margaret Flinter: And we will ge t to our interview with Dr. David Blumenthal in
just a moment.

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

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Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines.
Health cover age remained fairly steady in 2017 in spite of efforts by the
President and G OP leadership to derail the Affordable Care Act.

A ccording to a survey conducted by the Centers for Disease C ontrol and
Prevention, the ra te of uninsured Americans held roughly s teady at 9.1% in 2017
down from 16% uninsured when the ACA was passed in 2010 . But there are
discrepancies, the uninsured rate is much higher in the 18 states th at did not
expand Medicaid. T he Congr essional Budget Office predicts the removal of the
indiv idual mandate and the recently passed tax law will lead to far more people
choosing not to purchase cover age in the coming year.

One of the key drivers of high health cost is prescription drugs . A ccording to
recent study, kids are being prescribed fewer of them comparing prescription
rates from 1999 to 2002 t o rates from 2011 to 2014, number of overall
prescriptions drop from 25% down to 22%, antibiotics saw the biggest drop while
prescriptions for things like asthma, ADHD , and contraception have gone up.

Teen suicide on the rise , the study showing almost 116,000 hospitalizations for
suicide ideation or attemp t s , s tudy also showed some interesting data on when
these cases spike, mid autumn and mid spring suggesting school pressures are
weighing heavily on teens . The American Acade m y of Pediatrics has recently
issued a directive that all 12 - year - olds are screened for depression as part of
their routine primary care protocol. I am Marianne O'Hare with these healthcare
headlines.

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Mark Masselli: We are speaking today with Dr. David Blumenthal , P resident of
the Commonwealth Fund a National Philant h ropy now on its 100 th year ,
dedicated to creating independent research on h ealth a nd social policies. Dr.
Blumenthal was the Samuel O. Thi e r Professor of Medicine at Harvard Medical
School and served as c hief h ealth i nformation and i nnovation officer at Partners
Health c are in Boston . H e served as the National Coordinator for Health IT from
2009 to 2011 . H e earned his undergraduate medical and public p o licy degrees
from Harvard and did his residency at Massachusetts General. Dr. Blumenthal ,
welcome back to Conver s atio n s o n Healthcare.

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

Dr. Blumenthal: Great to be here.

Mark Masselli: The last time you joined us, it was in 2009, you’ve been tapped
by President Obama to be the National Coordinator for H ealth IT to develop and
manage the infrastructure needed to support the roll - out of HITECH act. Tens of
billions of dollars are put into this, I am wondering if you could share with our
listeners about t h at deployment of the HITECH act.

Dr. Blument h al: This was a big new program . I t was intended to correct a
market failure which was the tardiness of our health industry in moving from
paper to th e electronic world when the rest of the world was moving w ith great
rapidity into using electronic information. When I became national coordinator in
2009, slightly fewer than 1 in 5 physicians used a n electronic health record i n 1 in
10 hospitals, our rates of use now are well over 90%, so we’ve made that
trans ition.

Mark Masselli: Uh - huh .

Dr. Blumenthal: Virtually every patient in America who sees a physician, has
electronic information stored about them and that amounts to a huge, what I
would call reservoir of information that is a natural resource that c an be tapped
for human gain . W e have not found ways to move that dat a to connect
electronically between institutions, on the whole it doesn’t happen , and it is
getting much better as we speak because of strong efforts by the F ederal
G overnment and also so me technical breakthroughs . But we haven ’ t gone to
where we want to be and we also haven’t implemented what I call decision
support and that is decision aids for doctors at the point of care that help them be
smarter about caring for patients.

Margaret F linter: Well Dr. Blumenthal, we are seeing a growing number of non -
health entities like Apple, like Google, like Amazon to the health arena . And so
we ’d be really curious how all of these entities somewhat new to healthcare will
help us to min e the poten tial of this growing body of the natural resource of
electronic health data.

Dr. Blumenthal: Well , t his is something that we tr y to lay the ground work for,
there are complaints about the requirements associated with federal funding for
those records , th at too much information was required of physicians and other
healthcare professionals to enter . But that information is now part of that huge
natural resource , and we hope that the private sector would find this an
irresistible opportunity . And we are no w beginning to see that because of
requirements that ha d been placed on physicians in hospitals to adopt certain
technologies that enable outside organizations with proper authentication to get
access to that data . And the technical term for these gateway s are APIs or
Application Programming Interfaces i nterlocking technical software patches that
enable Apple , or enable Google, or enable IBM Watson to get it out in a de -

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

identi fied form so that no privacy can be compromised . And it has liberated the
pr ivat e sector to be really involved in combing through that data and using it for
research , and I hope for services to patients who want to see their data used to
make them smarter.

Mark Masselli: And Dr. Blumenthal, we recently had Dr. Ashish Jha join ed us
s haring his findings from research h e conducted on America’s o utside h ealthcare
c ost based in part of the data generated by the Commonwealth Fund . And I’m
wondering if you could talk about the goals of your research protocol s and some
of the collaborated e fforts.

Dr. Blumenthal: Yeah . We not only used our data, but we also support his
research and we are committed to creating a high - performing health system in
the United States, and one of the ways we do that is through development of
evidence and develo pment of policies toward improving performance. We are
probably the only foundation in the United States that works to bring insights from
abroad to the United States . The Commonwealth Fund s u pported the first
demonstration of hospice in the United State s w hich was from the UK.

Margaret Flinter: Right.

Dr. Blumenthal: And we are constantly in the business of lookin g for the next
innovation that could improve the functioning of our healthcare system. There i s
a lot to learn from other countries that f ace the same h ealthcare problems, the
same kinds of patients, use electronic health records because virtually everybody
does around the world , that we can learn something from them is something that
we are very committed to , is ha ve been through our 100 ye ars and continue to
work very harder .

Margaret Flinter: Well D r. Blumenthal, we really appreciate your missi o n at the
Commonwealth Fund and the credo of Affordable Quality Healthcare for
everyone. We’ve lived through the planning and the implementation of the
Affordable Care Act which moved us closer to th at goal and the fund has done an
excellent job of charting the impact . You have an ACA tracking survey which has
shown that unfortunately coverag e is slipping in the country , and the 2018
scorecard sho ws great disparities in coverage, maybe you could share some of
the revelations and insights from the 2018 state scorecard , both good news, but
also what you find most concerning.

Dr. Blumenthal: Well, the good news is that on our 37 indicators of state health
systems, we see almost all states show progress on more of those indicators
than they show regression and either indicators of quality, access, cost -- by the
way also smoking rates are falling -- so there is some good news . But we are
seeing probl ems ; death rates are rising and life expectancy is falling in the United
States. We are virtually unique in the developed world for showing that pattern ,
t h e opioid epidemic is clearly one important reason, nowhere else in the

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

developed world is there an epidemic like we have here.

There are also high and rising levels of obesity in the United States. We have
a mong the least functional primary care systems and the lowest levels of
coverage. Now, there are big differences among states ., w e have some very
high - performing states, Minnesota is one, Massachusetts is another, but we also
have some that are really not doi n g very well, and they tend to be concentrated
in the American South [PH] . Many states are seeing the misuse of effective
healthcare services , so 30% of back pain patients are getting inappropriate
imaging studies , t here is still a lot of unnecessary care being provided, so good
news, but there is also sobering news.

Mark Masselli: We are speaking today with Dr. David Blumenthal, President of
the Commonwealth Fund dedicated to quality a ffordable h ealthcare for all
Americans . T he Commonwealth Fund just recently released an analysis that
indicat e d that Americans are paying far more for prescription drugs than any
other industrialized nation and offers several tactics , and maybe share with our
listeners what tools you think would have the greatest potential to drive down
drug prices.

Dr. Blumenthal: Well, the future would be almost intolerable if we can ’ t find a
way to manage these drug prices. We are producing miraculous new therapies
though pricing the m at a level w here only a tiny fraction of Americans would be
able to afford them or else we are going to have to devote virtually our entire
gross national product to the s e new drugs, probably the best solution to reducing
drug prices is to enable competition. There are many type s of drugs that are sold
in the generic market which is the market where pate nts have expired and there
is pretty much free entry to anybody who can make the drug to a quality that
meets FD A standards . But we have seen a very rapid rise in generic drug prices
because of lack of competition and there are a bunch of things that FDA can do
that can make it easier for competitors to enter the market by reducing the length
o f time to a pproval of new generic drugs. There are also some abus es that
traditional drug companies have used to prevent the emergence of competitors
and the FDA is in fact I think moving to eliminate those abuses . And t here are
some tactics th at drug co mpanies engage in to extend their pat ent protections,
very minor tweaks in drugs, for example taking a drug that was in a pill form and
putting it in a capsule form t hat then enabl e s them to prevent competition from
entering the market. There is also a se ries of special treatment s for drug s that
are called orphan drugs , and the orphan drug protections have been abused to
get protection again st competition . So we are right now paying exorbitant
amounts of money, unconscio nable a mount s of money for some old and new
drugs . A nd public is angry about it and I think we are getting to the point where
we are going to break this long chain [PH] .

Margaret Flinter: You know, we are concerned about a lot of things and whi l e
C ongres s failed to repeal the Affordable Care Act , we’ve certainly seen some

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

significant changes to the l aws’ protections, we know the repeal of the individual
mandate will lead to fewer Americans being covered. Could you talk with us a
little bit about hits to the ACA, the potential impact that they will have on
American h ealth, I am sure that the Commonwealth Fund has many research
and evaluation studies underway to monitor these impacts?

Dr. Blumenthal: The A ffordable Care A ct remains a law of the land, but the
current administration is usin g its executive discretion to interpret the law in ways
that reduce the effectiveness of many other provisions of the law . So some of
the things they are doing relate to the Affordable Care Act individual market
places, either run by the state themselves or run by the Federal Government.
Every market in the country has an individual health insurance market, those
plans are now governed or regulated in terms of their generosity and their
requirements to accept people who have preexisting conditions by Affo rdable
Care Act requirements . And a number of the proposals that the administration is
advancing would allow insurance companies to market plans that do not meet
those requirements . So do not cover drugs, cover maternity benefits or do not
cover mental h ealth benefits, things that are required to be covered under the
rules of the Affordable Care Act or could be sold for six months or a year rather
than continuously available to the person .

W hat this will do is cause healthy people who feel they don’t rea lly need
comprehensive coverage to take less generous coverage because they can pay
less and mostly these are young people . And as they exit from the market
places, they will leave 50 - year - olds, 60 - year - olds, who have multiple illnesses,
high blood pressu re, high cholesterol, diabetes, and those people are the people
who use a lot of health services and they are going to c ost a lot more and the
premiums are going to go up because they will be supporting only sick people.
So, that’s going to take us back t o where the individual market was before the
Affordable Care Act where people were paying very high premiums, it is as
though we are willing ourselves to repeat history where if you were self - employed
or unemployed, you couldn’t find insurance you could af ford, that is where we are
heading, not so much into market where states run things, but w here the current
executive br anch is in charge of those markets .

T he Affordable Care Act made it possible for states to expand their Medicaid
programs to cover indiv iduals with incomes up to 138% of poverty, even people
who were working . And the administration is putting additional requirements
around those expansion states, one of which is to require th at a ble - bod ied
people either work or do some kind of community s ervice or go back to school .
Most of the individuals who got Medicaid through the expansion either are
working already or are unable to work, it would be much more complicated to
sign up and we will discourage people from en rolling, so we do expect that t here
would be a drop in enrollment. O ne of the most important changes in the
Affordable Care Act was part of the most recent budget act which repe a led the
penalty for not having insurance in the United States.

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

Mark Masselli: Which takes effect, I guess next year.

Dr. Blumenthal: 2019.

Mark Masselli: Yeah . And we had on the show Dr. Francis Collins obviously
mapping the human genome and we had Eric Dishman who walked us through
this All of Us initiative, and R ecently we just had Dr. Aviv Regev and Dr . Sarah
T e ichman n talking about this really exciting Human Cell Atlas that they are about
to engage in, and so lot s of people doing good things, but what are you optimistic
about?

Dr. Blumenthal: Well, one of the things that keeps my energy and hopes hig h is
the fact that we have fewer uninsured Americans tha n we ever have in history, so
despite all the efforts to reverse the progress that was made over the last 8
years, we still are at 15% uninsured which is very, very low. I am also
encouraged that we are seeing reductions in the number of safety problems that
occur in hospitals , that 50,000 lives were saved between 2011 and 2017
because of the reduction in occurrence of hospital - acquired conditions, then
enormous progress has been for decades now – I a m a primary care physician I
spent most of my time career at a eminent teaching hospitals, so I w as constantly
surrounded by cutting - edge r esearchers in the biomedical sciences and their
work is very exciting . And the availability of this digitized data r esource will be
enormous potentiating factor in accelerating that work and in the Precision
Medicine Initiative that Francis Collins has been pioneering . So having my data,
your data, artificial intelligence , and humans will make care better for us and
mu ch more precise. Having said all that, precision does not come free to totally
individualize medicine means to reverse the process of mass pro d uction.

One of the things that makes drugs cheaper is when you can prescribe them for
million people, you can r educe the cost of producing the pills because you make
it up in volume. If everybody’s care is completely different from everybody else’s
care, it may be more expensive , and that worries me, it means we’ll live longer,
but at a higher price for our care.

Margaret Flinter: We’ve been speaking today with Dr. David Blumenthal,
President of the Commonwealth Fund and it ’s now celebrating its 100th
anniversary . You can learn more about their work by going to
commonwealthfund.org or follow him on Twitter @ Davi dBlumenthal or
@commonwealthfnd . Dr. Blumenthal, we want to thank you so much for your
very significant contributions to health and healthcare and for joining us on
Conversations on Healthcare today.

Dr. Blumenthal: My pleasure.

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Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

Mark Masselli: At Conversations o n Healthcare, we want our audience to 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 red uce the
level of deception in U S politics. Lori, what have you got for us this week?

Lori Robertson: The Centers for Disease Control and Prevention has released
its latest national health interview survey, which measu res insurance coverage in
the population . I n 2017, 9.1% of Americans or 29.3 million people were
uninsured at the time they were interviewed, that ’s about the same as the rate for
2016 which was 9%. For adult s age d 18 to 64, 69.3% had private insurance
c overage, 4.3% of those aged 18 to 64 had coverage through the Affordable
Care Acts , health insurance exchanges. There was a drop in the percentage on
exchange plans from the fourth quarter of 2016 to the same quarter of 2017, it
amounted to nearly 1 milli on, a fewer people on those plans . Those most likely
to be uninsured were aged 25 to 34, nearly twice as likely to be uninsured as
adult s aged 45 to 64.

Adults in states that expanded Medicaid under the ACA wer e also less likely to
lack health insurance than those in states that didn’t expand Medicaid. While the
percentage of the uninsured adult s age d 18 to 64 in Medicaid expansion state
was 9.1% in 2017 , the percentage was more than doubled at 19% in non -
expansion states. In fact, in non - expansion stat es, the uninsured rate crept up
from 17.5% in 2015 to 17.9% in 2016 to 19% in 2017. Adult s aged 18 to 64 are
mo re likely to be uninsured in states using the Federal Government ’s market
place compared with states running their own exchanges or using the hy brid
partnership , w ith Texas having the highest uninsured rate of 26.4% and
Massachusetts having the lowest at 5.4% , and that ’s my FactCheck for this
week. I am Lori Robertson, Managing Editor of FactCheck.org.

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Margaret Flinter: FactCheck.org i s 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, email us at chcradio.com , we’ll have FactCheck.org’s Lori Robertson
check it out for you here on Conversations on Healthcare.

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Mark Masselli: Each week, conversations highlight s a bright idea about how to
make wellness a p a rt of our communities an d everyday lives. When Le anne
Brown was a graduate student in nutritional s cience at NYU, she came to
understand the enormous challenges of eating healthy foods while doing field
work with some of New York City’s more impoverished populations. She

Dr. David Blumenthal of the Commonwealth Fund on the HITECH Act, ACA and
High Cost of American Health Care

though t, why not write a cookbook of health recipes aimed at the millions of
Americans living on food stamps or SNAP stipends a four dollars a day.

Le anne Brown: Four dollars a day is sort of explain s like a budget range, we are
saying this is a SNAP cookbook without actually saying , getting so many words.

Mark Masselli: So , she crafted Good and Cheap, a c ookbook aimed at not only
teaching these families how to shop for affordable produce, but how to get an
entire family to cook in a more healthy way.

Le anne Brown: I really want ed to arm people with the ability to walk in to a
grocery store, and say like, okay, this is on sale, I can totally make something
delicious out of that, I know how to do that , instead of find the deals and find the
value in order to r eally get buy on such a small amount of money.

Mark Masselli: She wants to kick start her campaign to raise enough money to
make the book available at Soup Kitchen s , Women’s Shelters and Community
Health Centers. She has made her book available as a fre e PDF download to
anyone who wants it, G ood and C heap, a cookbook aimed at the food stamp
population teaching them how to shop for healthy produce , helping to positively
influence their diets, obesity, and well - being , now that’s a bright idea.

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Ma rgaret 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 WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health
Center.

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