Vaping Crisis, Public Health Heroes and Open Notes: A Look Back at the Best of 2019

Best of 2019

[ Music ]

Female : Welcome to Conversations on Health Care with Mark Masselli and
Margaret Flinter , a show where we speak to the top thought leaders
in health innovation , health policy , care delivery and the great minds
who are shaping the health care of the future. This week in our best
or 2019 show Mark and Margaret look back at a year of policy giants,
innovators in the health care space, clinicians turned to activists
against public health and justices , and our luminary guests who are
making a true differe nce across the health care spectrum. They
highlight their conversation with Dr. Mona Hanna - Attisha, the Flint,
Michigan pediatrician who sounded the alarm on the Flint Water
Crisis , and Matthew Meyer, CEO of C ampaign for Tobacco - Free Kids
with chil ling inf ormation on the industry driven vaping crisis . Policy
giants like House Majority with James Cl y burn, and policy activist like
former CMS administrator Andy Slavitt. If you have comments, please
email us at chcradio@ chc1.com or find us on Facebook, Twitter, or
wherever you listen to podcast . Y ou can also hear us by asking Alexa
to play the program Conversations on Health Care . Now stay tuned
for our Best of 2019 edition here on Conversations on Health Care .

Mark Mass elli : Welcome to Conversations on Health Care , I’m Mark Masselli .

Margaret Flinter: A nd I am Margaret Flinter .

Mark Masselli : Well , Margaret 2019 we're almost at the end of it .

Margaret Flinter: How about that .

Mark Masselli : 10 years on the radio.

Margare t Flinter: Amazing.

Mark Masselli : It was great to celebrate with all of our various luminaries that we've
had on the show and to realize that we had done 500 shows in that
time. T his time of the year we always like to take a moment and
reflect on the gues t that we had on the show this year.

Margaret Flinter: There were definitely moments that stood out this year and certainly
one for me was one of our true public health heroes, Dr. Mona
Hanna - Attisha . She's the pediatrician who first really observed the
sp ike in lead poisoning and elevated lead levels that she was seeing in
children in her practice in Flint . S he made the connection to a change
that was brought about by city leaders , changing the source of the
water supply . I n the process really set off just a public health and I
would say a humanitarian social justice crisis in that community. S he
organized leadership and she brought that community together really
stands as a marker for people of how they can organize when there's
a public health crisis in a community , s o very powerful.

Best of 2019

Dr. Mona : From the moment that we recognize that we had this population wide
lead exposure, we knew that our next step was secondary prevention.
W e failed at preventing this exposure , but we were working around
the clock to ma ke sure that we didn't see the consequences of this
exposure. We also had an outbreak of Legionnaires disease, we had
massive skin issues , but by and large it was a crisis of betrayal and loss
of trust. All of those emotions as we know as clinicians also c an lead
to poor outcomes.

Science was denied in this crisis. U ltimately it was our science that
spoke truth to power and we have been committed to using the
science of child development of brain plasticity of resilience to buffer
the impact of this crisis. T hat's what this P ediatric Public Health
Initiative is all about , i t's this holistic approach to mitigating the
impact of this crisis and using everything we know to promote the
development of children. Things like expansion of home visiting
programs, lit eracy promotion, breastfeeding services, Medicaid
expansion .

W e have also just launched something called the Flint R egistry. The
goal of this registry is to identify those exposed but most importantly
to get them connected to these development promoting
in terventions to improve their outcome. T his is one of the ways where
we hope to share what we are doing with other communities ,
b ecause the story of Flint is not isolated . There are kids everywhere
waking up to the same toxicities of le ad exposure or povert y or
injustice or lost democracy or austerity or violence. Wh at we want to
share is how we've been able to turn the story around and improve
the outcomes of our children.

Mark Masselli : Speaking of public health crises , this year the vaping crisis really t ook
hold. We had Matthew Myers who join ed the show, CEO for the
C ampaign for Tobacco - Free K ids talking about the spike in nicotine
addiction due to the vaping craze . C ompani es are selling candy
flavored e - cigarettes , I think we've heard a couple of people have
started to ban it , v ery interesting , conversation. Let's hear a little of
Matthew Meyers.

Matthew Meyers : In the last two years, we've seen 135% increase in the number of kids
who u se e - cigarettes. Now , over 5 million kids are using e - cigaret tes.
The newest generation of e - cigarettes deliver such a powerful impact
of nicotine that kids are becoming addicted to the product more
rapidly , and in many cases , more intensely. W e face a real public
health threat. 28% of high school kids currently use e - cigare ttes , and
what the data doesn't show the kids who are currently using e -
cigarettes are kids who never would have smoked cigarettes. We have
more kids addicted to nicotine today than we've had in the last two
decades.

Best of 2019

This wasn't an accident. This came abou t because the e - cigarette
industry read and implemented the tobacco industry's old playbook.
They introduced products with sweet flavors that the industry is
known for decades appeal to kids. They packed it with massive
amounts of nicotine. They made it co ol among kids by engaging in the
kind of social marketing that didn't exist when the Marlboro Man
existed. T hen when the public health scare became widespread, they
hired more lobbyists than we can count to try to undermine efforts at
reasonable thoughtful government regulation. We're not helpless ,
virtually every kid who starts using an e - cigarette uses one of those
flavored products, whether it ’d be mango or gummy bear or cotton
candy . I f we prohibit the sale of any flavored e - cigarette, we can
dramatical ly cut the number of young people who star t , we can cut
off that on ramp.

Margaret Flinter: We still don't know enough about the potential harm that these
products are capable of. If you want more information on this topic,
visit the website tobaccofreekid s.org . We also have what we will call
another epidemic in the unmet demand for mental health services.
Lack of access to mental health in this country is huge. We had Dr.
Ken Duckworth, the Medical Director of NAMI the National Alliance
on Mental Illness , and he talked about their efforts to improve access
around the country.

Dr. Ken Duckworth: Yeah, NAMI advocated very intensely to get m ental h ealth p arity, and
it has shown an increase in accessibility and availability and attitudes
have improved towards h elp seeking . There has been no
corresponding public health response to create more practitioners,
more psychiatrists , more loan forgiveness plan s that w ould enable
people to participate. There are millions of people right now who
didn't get the Medicaid ex pansion in their state. The people who have
the Medicaid expansion are doing better per square person than the
states who don't have the Medicaid expansion. Many psychiatrists are
choosing not to take insurance.

My experience here in Massachusetts is that masters level clinicians
are very happy to take insurance , and so w e have more people getting
assessments and evaluations and being seen by social workers ,
l icensed m arriage and f amily t herapist than ever before. What I would
encourage people to do is work with their health plan. The health plan
has an obligation to give you the help you've paid for , and the health
plan will pay out of network benefits , i f there isn't anyone in their
network . I think that's a secret that people don't really know.

Mark Masse lli : You know, pulling the thread on that conversation w e also really had a
wonderful conversation with Dr. Steven Woolf who was out of
Virginia Commonwealth University School of Medicine . H is research
showed market decline in life expectancy in America, a nd especially

Best of 2019

for working families and really focused in on that 25 to 64 year old
group . B ut then he talked about the D e a ths of D espair , a nd boy that
phrase just grabs your heart. It's the loss of so many lives to the
opioid crisis, alcoholism, and suicid es that really have reached an
incredible tipping point. Let's hear a little from Dr. Wo o lf.

Dr. Steven Woolf : Well, it might be helpful to start just by unpacking what's behind this
increase in working age mortality. D rug overdoses fueled by the
opioid ep idemic are the leading contributor for that increase , by far .
There's also been an increase in deaths from alcoholism and suicides.
It was not me actually , but other researchers who coined this term
D eaths of D espair in an attempt to try to weave together some
explanation for those three causes . B ut our study found increases in
35 causes of death in this age group , and it extended well beyond
substance abuse and suicides to include a variety of chronic diseases.
W hile clearly opioids and drug addiction are major priorities in trying
to solve this problem, it's actually more pervasive.

Margaret Flinter: Well, we really apprec iated having him as the wrap up year in the
darkest and shortest days of the year coming in December. We hope
it pr estigious a brighter tomorrow.

Mark Masselli : Yeah , a nd speaking of brighter tomorrow s.

Margaret Flinter: Brighter tomorrow s .

Mark Masselli : We had our good friend .

Margaret Flinter: Tom Bodenheimer, that is always a cause -- that is always cause for a
smile .

Mark Masselli : He brought light.

Margaret Flinter: Tom has inspired generations of people in health care to rethink how
we think about health care , how we think about the role of people in
health care , and how we think about teams and teaching people to
work together in te ams, and perhaps most importantly, to go
upstream to prevention wherever we can. He is really a legendary
person in our circle of admired heroes, and we were thrilled to have
him on.

Tom Bodenheimer : L et's just take a particular issue like say, let's take colorectal cancer
screening, which we know reduces the rate and increases the
longevity of people who are going to get colon cancer. I t's a very, very
important thing that all primary care practice s should pay attention
to . All of their patients over the a ge of 50 get regular colorectal cancer
screening. T he first thing you have to do is to measure it to see how
you're doing. I f you have a good IT system as you do, you can measure
that for all your patients a nd you can see how you're doing over time .
B ut th en you also have to drill it down not just to your whole

Best of 2019

organization, but to each team s o you can compare how different
teams are doing. Y ou have to drill it down to each clinician and see
how their patients are doing.

W hen we talk about data in the build ing blocks, which is one of the
foundational building blocks, we don't just say data we say data use
for improvement. H ow do you use th e data for improvement? Well,
you talk about it in the team , s o, okay, are colorectal cancer screening
rates only 45% ? Ou r goal is 80% by like the end of this year, how are
we going to get from 45% to 80%? One organization that does data
better than any other I’ve seen is University of North Carolina Family
Medicine Residency C linic in Chapel Hill, North Carolina. T hey have
data on all these things. They've drilled the data down to the teams ,
they’ve drill ed the data down to each provider and they have all the
data up on the walls. Everyone knows what everyone else's data is ,
it’s all transparent , s o you know what all the oth er physicians, how
their continuity ra te is , how their access is, how they’re colo rectal
cancer screening, how their diabetes rates are .

B ut the other thing is they want to make sure that all of their patients
are offered to get colorectal cancer screening . E ach team has a
whiteboard right above where the team is working. T he whiteboard
says today the re are six patients coming in who are overdue for
colorectal cancer screening. These are their names so make sure that
medical assistants who do this, make sur e that you really work with
those six patients , a nd then at the end of the day they say we got five
out of the six , but we still have one more to get. I t's really taking the
data and like making it very patient specific to really make sure that
every singl e patient has all of these things that they should do to keep
healthy.

Mark Masselli: Well, Tom speaks for himself. What a n incredible professional and as
you said earlier, a great friend and we were so glad to hear from him.
While we had that joy, we a lso had some sadness this year.

Margaret Flinter: We did , and you can't wrap up a year without thinking about the
people who are no longer with us. C ertainly the list of heroes that we
admire was Dr. Fitzhugh Mullan , a really be loved friend, mentor,
colleague , and source of inspiration certainly for myself and so many
of us in health care. Fitz hugh passed away recently. He actually had
lived with a diagnosis of cancer in his 30s , lived well into his 70s ,
didn't slow down . B ut he had made his work in the last d ecade or so
of his life to restore social mission particularly in medicine but invited
in people from all the disciplines and professions to help him with that
work, and we will remember Fitzhugh and honor his legacy for years
to come.

Mark Masselli: Absol utely. Indeed, Margaret, we will miss Fitzhugh and we also were
honored to have some real important health t ransformers on our

Best of 2019

show, and one was Dr. Tom Delbanco, who is our primary care expert
at Harvard Medical School . He opened something called OpenNote s a
decade ago, it was a pretty radical idea that he had -- [Crosstalk]

Margaret Flinter: Everyone said it wouldn't work .

Mark Masselli: Everyone said it wouldn’t work and he thought what if primary care
provider notes were made available to their patients , letting them
have access to their full record . H e began this experiment with lots of
pushback as we said from the industry .

Margaret Flinter: Oh yeah, patients could not be trusted to look at their own notes.

Mark Masselli: They could not be trusted with their own information even though
they own it. But it really blossomed into this great global movement. I
think now some 40 million patients including ours at Community
Health Center are available to our patients, they can go home and go
through the porta l and see their notes and make comments on it.
Also, I think one of the things he said was, people's outcomes
improve, because oftentimes you walk out of that engagement, that
conversation, don't remember anything that happened, but you can
go back , look a t the notes and follow the plan that you've agreed on
with your primary care provide r. T hat was really exciting.

Dr. Delbanco: Very few studies yet , and we may never have studies that show
differences in clinical ou tcomes. What we do have is much, much
mor e data replicated from many centers now. We have 200 centers
more than 200 centers involved with OpenNotes , extraordinarily
similar reports from patients and d octors about their experiences
with Open N otes. We did do one study in which we were able to
compa re patients with Open Notes to patients without OpenNotes in
the way that they refill their medicines if they had high blood
pressure . W e were gratified to see that those who actually ha d access
to their notes, we don't know whether they read them or not ha d
higher refill rates of their medicines than those who did not have
access. That's the only really formal outcome study that we have so
far.

On the other hand, we have institutions trying things, trying little
pilots and saying we're going to do this , i t' s the right thing to do and
it's useful for our patients and it's useful for us. We have many, many
anecdotes about patient safety, two eyes on one chart are better than
two eyes on a 1000 charts. When you've got a patient reviewing his or
her record and s aying there's a mistake here, it's the left knee not the
right knee, I missed that lump or the doctor missed that lump I was
supposed to follow through on it, or that lesion on my back which
may be precancerous , we have many rather exciting and sobering
an ecdotes now in the patient safety arena, which says this really
increases safety. We think it 's a very important part of it.

Best of 2019

We also with medications and adherence to medications, we just
published a paper in the last few weeks in the Annals of Internal
Me dicine, showing that patients say very firmly that they're
understanding their medicines better and that 15% to maybe 40% of
patients say they're taking their medicines more effectively . It cost
our nation $300 billion a year to have poor adherence to medi cations.
I f you do a little bit of math and you extrapolate to more patients
reading their notes that to me as a doctor is maybe the most exciti ng
finding we have so far.

Margaret Flinter: For all those people who've ever gone home and their partner said t o
them, what did your provider say ? T hey said, I don't know . W e think
we solve d that problem. But you know, Mark, I go back to the early
days of the show and I remember the unbelievable excitement,
optimism, energy that there was around feeling that we wer e finally
on the precipice of achieving and really did achieve a giant step
forward towards making health care a right and a privilege . T hat was
through the creation and then the legislating and the implementation
of the Affordable Care Act that was going o n right at that very
beginning.

It was a pretty extraordinary time and has accomplished so much and
we wanted the smartest people that we could find to come help us
understand. We had so many people who played a role in creating the
Affordable Care Act c o me and join us. Just as we speak , literally,
mandates are again under fire , there ’s worries that the whole
Affordable Care Act could really be --

Mark Masselli: Fifth Districts ’ ruling is -- yeah

Margaret Flinter: The Fifth Districts’ ruling c ontinuing to take those big hits . But one of
the law ’s champion s, former CMS administrator Andy Slavitt joined us
recently to talk about where the law stands now.

Mark Masselli: Yeah, but one thing we do know is that millions of Americans have
received coverage because of the expansion of insurance on Medicaid
and through the exchanges , and that's made a profound difference in
people's health and well bein g and also economic well being.

Margaret Flinter: That's right.

Mark Masselli: S o many people were put into bankrupt cy without having a health
insurance. L et's hear from -- [Crosstalk]

Margaret Flinter: That’s not opinion that’s fact evidence based.

Mark Masselli: Let's hear from Andy now.

Andy Slavitt: What's different about asking the question now, five years after th e
ACA is rolled out is we actually had a data , we actually ha ve facts that

Best of 2019

we can point to . W hat we've seen across the country in pretty large
numbers is reduction to premature deaths in the tens of thousands ,
reductions in cancer, early diagnosis of cance r , reductions in heart
rate, reduction in disparities between African - Americans and whites,
which is just sort of amazing , increase in homeownership, reduction in
payday lending, increase in rural hospital ownership. A lot of these big
broad outcomes which shouldn't be surprising to us if what we're
really doing is saying that there are people who are of marginal
income who were not able to afford insurance before . L et's face it,
insurance is expensive , h ealth care is expensive. O nce they get it, they
get a measure of protection. W e know the number i s 20 million more
people are insured and all that , and there are all those good
outcomes.

On another level I think, there's been a psychological change as well in
this country. The bargain for the American public used to be if you get
sick or if you can't afford coverage that's just too bad. That has
changed to it doesn't matter if you've ever been sick before , if you've
got a preexisting condition , if you lose your job, if you change jobs,
you'll still be able to get health care coverage. That's a dramatic
change . I use the wor k designed to work for insurance companies and
people ha d to wrap their lives around it. Now, it's supposed to work
for people, insurance companies are supposed to wrap their life
around it.

Now, it's not perfect , a ny major piece of legislation we wou ld hope
should get it about 80% right then the next responsible thing to do is
you say, o kay, well, after a few years, what are the things that
worked? What are the things that didn't work? Let's take the things
that didn't work, and let's adjust them. I think the major political
disappointment with the ACA is just Congress just refused to act on
any of the things th at it saw that could have fixed. Not only that, it
actually tried to make politica l hay out of anything it found that was
wrong and tried to use that to repeal the entire law, including the
good parts. T hat's just not the way we've historically governed in this
country because we're not going to get it perfectly right.

There are people who health insurance is too expensive for , and it's
un affordable . T here are bills that are in the Congress right now if
Congress chose to act and I will point to one by R epresentative Lauren
Underwood that would actually cut premiums in half for people who
are making up to $ 1 50,000 and it would cover 3 or 4 million more
people. It's a really good bill , it’s common sense b ill.

Mark Masselli: Well, as you said, we'll be continuing to watch what happens in 2020
with the Affordable Care Act and all the legal is sues around it. But we
really had somebody who just reminded us about the longevity of
battles that go on when we had Congressman James Clyburn who is

Best of 2019

the House Majority Whip from South Carolina who came on and
talked about his long career in health and in Civil Rights and the
impact that it's had on who he is as an individual. He talked about the
st
Affordable Care Act as a Civil Rights Act of the 21 century . He really
just shared an incredible amount of wisdom , and I would say joy . F or
all the struggles th at he has, he has such a positive outlook. Let's hear
from our good friend Representative James Clyburn.

James Clyburn: The best thing about the Affordable Care Act, a lot of people say it's
bec ause of [ inaudible 00:22:09] people with pre existing condition s ,
t hat's not the best thing to me . The best thing to me was not being
able to kick people off the health care policies once they got sick.
There's another one that I think is very important, the 80 / 20 rule that
you must return in the form of benefits to y our [Inaudible 00:22:26] at
least 80% of the premiums, and if you don't you have to send them a
refund check. These are things about the Affordable Care Act that
never get talked about , and I think it is the most important thing that
we did. What we have t o do is to stay engaged and be vigilant and
make sure that the country doesn't go too far left or too far right. I tell
people where the tunnel is going left to right or right to left it ’s
passing through the center, which means that we spend twice as
much time in the center as we do to the left or to the right. To me
that ’s what we have to do, be vi gilant .

Margaret Flinter: H ere we go. We're launching into 2020 and the presidential election is
likely to have a huge impact on health policy and the future of health
care along with so many things in our country . M any hats in the ring ,
been really impressed with some of the debates and the attention
that health care is getting whatever your position is, and we had been
honored to welcome some of the candidates to our show. I hope we
get everybody over the coming months. We also welcome d experts to
help us understand when people say Medic are for all, what do they
mean?

Mark Masselli: That's right. I think you're absolutely right , i t was important to hear
every in dividual's voice and we hope to have conversations with
people from all over the country from all walks of life. We hope our
show can bring vision, its 20 20, to the issues that Americans struggle
with all the time and we've had some really illuminating gue st who
help ed break down the issues and really you only do that when you
have a conve rsation with some of them .

Margaret Flinter: That’s right. T hank you for listening. Thank you for watching when we
move d to a video format . We think we have a lot of great opportunity
in the next year to continue to bring thought leaders and innovators
to the show and to share their ideas with you , so until then --

Mark Masselli: Peace and Health.

Best of 2019
Margaret Flinter: Happy New Year.
[ Music ]
Mark Masselli: You've been listenin g to Conversations on Health Care. I'm Mark
Masselli.
Margaret Flinter: And I'm Margaret Flinter.
Mark Masselli: Peace and Health.
Female : Conversations on Health Care is recorded at WESU at Wesleyan
University, streaming live at www.chcradio.com , iTunes, or wherever
you listen to podcasts. If you have comments, please e - mail us at
[email protected] , or find us on Facebook or Twitter. We love
hearing from you. This show is br ought to you by the Community
Health Center.