Climate denial remains rife in the US. For example, in Washington, D.C., nearly 25% of the current members of Congress are, via their public statements, climate denialists. As for Health and Human Services (HHS), the department has steadfastly refused to promulgate any regulations to mitigate the healthcare industry’s massive carbon footprint that, for example, amounts to well over four times the annual cumulative greenhouse gas emissions of Exxon, Marathon Petroleum, Phillips 66, Chevron and BP.

In his just-published book Tad Delay provides an unsparing assessment of “the vast arsenal of denial that we rarely ever talk about,” i.e., “the scams, lies and misinformation that sustain the degradation of people and planet.” As I note during the discussion, Delay’s work can be read in context of Wainwright and Mann’s 2018 work, “Climate Leviathan” also published by Verso.

See: https://www.versobooks.com/products/2857-future-of-denial?srsltid=AfmBOoqF3FkLO1Aa5HBJhDrdFBE2ssKju6LOOjW0Og1x4l0YOE59Cup3

In the recent past, hunger, food insecurity and malnutrition have (re)gained policymakers’ interest largely due to the COVID pandemic and accelerating climate breakdown – that has among other things reduced the growth of global agricultural production by 30-35%.  As a result, last year 2.8 billion of the world’s population could not afford a healthy diet.  In the US, over 40 million Americans receive food assistance via the federal Supplemental Nutrition and Assistance Program (SNAP) in large part because grocery prices have increased by over 20% since 2021.  Poor diet has long been known to be responsible for innumerable causes of disability and death.  For example, the number of states with an obesity rate at or above 35% doubled over the past five years to 19.  One in 10 Americans have diabetes and one in three will be diagnosed with cancer, both of which are related to poor diet.  Diet-related diseases also help explain high US COVID morbidity and mortality rates.   

Information concerning West Side Campaign Against Hunger’s efforts is at: https://www.wscah.org/.

Recently published research regarding the association between food security, health and dietary factors discussed during this interview is at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10857290/.

Sepsis presents an enormous public health threat. There are for approximately 1.7 million hospital cases and 270,000 deaths per year. Sepsis is consistently in the top five for hospital case volumes and is the most expensive and resource intensive medical inpatient condition, representing approximately 15% of total hospital costs despite accounting for less than 4% of hospital stays.  Various studies estimate sepsis is present in 30% to 50% of hospitalizations that culminate in death.  Because two-thirds of sepsis cases are paid for by Medicare, beginning this January 1, HHS will add sepsis care Medicare’s Value-Based Purchasing/VBP program. Meaning, Medicare hospital reimbursement will be determined in part on adherence in meeting a multi-step sepsis treatment protocol focused on timely diagnosis and treatment.  Dedicated listeners of this podcast may recall ten years ago this week I interviewed Dr. Jim Palmer regarding the use of heart rate variability to identify the onset of infection.

During this 23-minute interview Dr. Scoggins begins by explaining why timely diagnosis of sepsis has remained challenging and why the Medicare program will now tie reimbursement to meeting a sepsis quality measure or protocol. He explains the SEP-1 measure, addresses concerns regarding the sepsis measure driving antibiotic overuse and administrative burden, whether paying for sepsis performance will unduly penalize hospitals serving poorer communities, how the Medicare rule will impact his program, comments on emerging technology improving sepsis diagnosis, the extent to which commercial payers will adopt a similar sepsis pay for value payment rule and finally why we are seeing more sepsis infections and mortality.

Robert Scoggins, MD, PhD, has been a practicing medicine for over twenty years as a pulmonary and critical care physician. He currently is Chief of Staff and ICU Medical Director at Kootenai Health in Northern Idaho. He earned his undergraduate degree in Molecular Biology from Vanderbilt University and his MD and a Ph.D. in Microbiology at the University of Virginia. Dr. Scoggins completed his residency in Internal Medicine and a fellowship in Pulmonary and Critical Care at Vanderbilt University.

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Since I've received and answered questions via email concerning podcast interviews and related health care policy questions over the past eight years, I thought it might be it might be useful to attempt answering listeners via a podcast program.  This podcast addresses questions I received via my solicitation a few months ago.  Joe DiLauro, the gentleman whom introduces the podcast and thanks listeners after each interview, and moreover my audio engineer, poses the questions.

During Part II of this discussion, 24 minutes length , I address questions concerning differences between the two presidential candidates, expectations for the next Congress, the relationship  between economic inequality and health, additional comments regarding the climate crisis, what I've learned over the course of 200 plus podcast interviews and advice I'd give those interested in pursuing a health care policy career.   Part I of this conversation was posted May 27th.   

As for my bio . . . , over approximately the past 25 years I have done health care delivery, financing, policy research and evaluation in Washington DC.  My bio includes having served as Health Policy Adviser to the U.S. House of Representatives Majority Leader, Rep. Steny Hoyer.  I also spent eight years working in the US Department of Health and Human Services serving as the Evaluation Officer for the Agency for Healthcare Research and Quality (AHRQ) and as a Public Health Analyst in the Office of Assistant  Secretary for Planning and Evaluation (ASPE).  I have acute care experience having worked at DC General and post-acute experience having worked with the National Hospice and Palliative Care Organization.   My consulting clients have ranged from the American Heart Association and the American Public Health Association to UnitedHealth Group.  Among other awards I received a three-year W. K. Kellogg National Leadership Fellowship.  I have taught as a adjunct at Georgetown and at George Washington universities and over the past eight years, beyond producing over 200 interviews via this podcast, have authored over 50 health policy-related essays.  My BS, MA and Ph.D. degrees were earned at Rutgers and Arizona State.  

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The COVID-19 pandemic has had particularly fatal effect on seniors or the frail elderly residing in Long Term Care (LTC) facilities, e.g., in a Skilled Nursing Facility (SNF_ or in assisted living.  As of last week approximately four in ten COVID-related deaths had occurred in these residences.  For example, in Virginia, as of mid-May approx. 60% of all COVID 19 related deaths have occurred in a SNF, among other states, in Minnesota , 80% of deaths have occurred in SNF and residential care homes.  Beyond LTC residents being immuno compromised, federal regulations concerning SNFs have, again, proven to be inadequate.  The question begged here is what can family caregivers, or those who have Power of Attorney or serve as Medical Proxy, do to protect their family members living in LTC - particularly if the facility is locked down or preventing family visits.

During this 30-minute conversation, Ms. Powers discusses among other related questions: what family members should know about the LTC facility in which their relative resides; beyond LTC facility’s precautions, what added/additional safety steps can the family caregiver take, e.g., if they've not should they pursue obtaining legal Power of Attorney (POA) and health care proxy authority; considering the extent to which the pandemic has adversely affected their family member's LTC facility, should, or how should, family caregivers evaluate proactively relocating their family member; can family members refuse to have their relative tested for COVID-19; if the relative tests positive for COVID 19 is the family caregiver, POA, medial proxy required to tacitly accept their relative being transferred to a hospital; and, if not, what are appropriate, proactive options can they take or what de facto dvanced care plans/planning should family caregivers make? 

Ms. Mary Paier Powers has been practicing law since 1984. Her practice focuses primarily on Estate Planning, Probate matters and Elder Law. She is a native of the Pioneer Valley where she was born and raised,  Ms. Powers began her career as a trust officer for Bank of New England West.  She next worked at Monarch Life Insurance Company, where she provided legal support and documentation on various life and disability income plans.  In 1993, she opened her own estate planning, probate and elder Law practice.  In 2019, Ms Powers formed Powers Law Group with her husband and son in West Springfield and Springfield, Massachusetts.  Ms. Powers graduated from Trinity College in Vermont and received her Juris Doctorate from Western New England University School of Law. 

Per my mention, the CDC guidance, "COVID-19 Guidance for Shared or Congregate Housing," is at: https://www.cdc.gov/coronavirus/2019-ncov/community/shared-congregate-house/guidance-shared-congregate-housing.html. 

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Since the federal government's response to the COVID-19 pandemic remains, as the The New England Journal of Medicine termed last week, laconic, the US response continues to be best understood at the state level.  California immediately comes to mind for obvious reasons.  Among others, it has a population of 40 million or 12% of the nation’s total (and if it was its own nation, would constitute the world’s fifth largest economy).  To date, California has limited COVID-19 related deaths to 4,250 or 4% of total COVID-19 related US deaths - notwithstanding having a substantial homeless population (approximately 20% of the nation's total). 

During this 28 minute podcast Ms. Kent discusses moreover the state's actions in response to the pandemic, especially concerning those most vulnerable including seniors, the poor or the states Medicaid, termed Medi-Cal, population and the homeless.  She also discusses the state's efforts at addressing related mental health and those with substance use disorders as well as whether the COVID-19 infection rate has peaked in the state and the state's predicament in funding its Medi-Cal program going forward. 

Ms. Jennifer Kent is currently CEO of the Sacramento-based Kent Group.  Previously she served as Director of the California Department of Health Care Services.  As Director, she oversaw the second largest public healthcare system in the nation with an annual budget of over $100 billion and serving approximately 13 million Californians.  She oversaw the administration of twenty-four managed care plans as well as 56 county behavioral health plans.  Ms. Kent has also held leadership roles in the state's Health & Human Services Agency and Governor’s office.  Her previous experience also includes working in the private sector as a lobbyist, consultant and association executive.  Ms. Kent earned her undergrad degree at Saint Mary's College of California and her MPA from the University of Southern California. 

Per my mention of California Governor Newsom's response to the pandemic see, for example, https://www.gov.ca.gov/california-takes-action-to-combat-covid-19/.  

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It should go without saying that we interact with the environment constantly.   It should also go without saying a degraded environment compromises our health and leaves us less resilient.  This explains why Black Americans, disproportionately suffering from chronic conditions resulting from, e.g., poor air quality, are suffering COVID-19 mortality rates upwards of three time that of White Americans.  According to the National Academies of Science, the environment is responsible for 30% of premature mortality while health care is only responsible for, or prevents, 10%.  Despite formally admitting via, e.g., Environmental Impact Statements, the Trump administration has gutted the nation’s environmental protections.  According to the Sabin Center, the administration has unwound, or intends to unwind, approximately 100 environmental regulations ranging from power plant and car and truck CO2 emissions, mercury and hydroflurocarbons emissions, rules protecting wetlands from oil and gas leasing, rules regarding pesticide use, drilling, fracking and coal leasing rules, off shore oil and gas drilling rules, Arctic exploration rules, rules governing natural gas pipeline construction and logging rules and the US’s commitment to the Paris climate accord.  Concerning the climate crisis, as I've noted previously research published in 2016 concluded that the adverse health affects resulting from health care industry’s greenhouse gas emissions is commensurate with upwards of 98,000 deaths annually in the US alone. 

During this 30 minute discussion, Professor Burger explains the Sabin Center's mission, provides an overview of the administration's efforts to moreover unwind air quality standards, discusses related procedural rules the EPA has/is unwinding, e.g., restrict the use of scientific research, and discusses the Juliana decision in light of related climate crisis-related court decisions world wise.  

Profess or Michael Burger is the Executive Director of the Sabin Center for Climate Change Law.  He frequently collaborates with researchers across Columbia's Earth Institute, and with local and national environmental groups, government representatives, and international organizations.   Previously,  he was an associate professor at Roger Williams University School of Law.  Previously still he taught in the Lawyering Program at New York University School of Law, served as an attorney in the Environmental Law Division of New York City’s Office of the Corporation Counsel.  He has also lead short courses on climate change and human rights in the Hague.  He is also a co-founder and member of the Environmental Law Collaborative, and is the incoming chair of the New York City Bar Association International Environmental Law Committee.  Professor Burger is a widely published scholar, a frequent speaker at conferences and symposiums, and a regular source for media outlets, including The Washington Post, Newsweek, Time, Forbes, The Guardian, Bloomberg, and Vox.com.  Michael is a graduate of Columbia Law School and of Brown University and also holds a Master of Fine Arts degree from the Creative Writing program at NYU.

Though not noted during the interview, listeners are encouraged to read, Climate Change, Public Health and the Law (Cambridge University Press), edited by Michael Burger and Justin Gundlach.  At: https://www.cambridge.org/core/books/climate-change-public-health-and-the-law/D2DED4C703EBD2F8CBD5B302E0B7AA3B.

Concerning the administration's attack on air quality, see, e.g., S. William Becker and Mary D. Becker, "The Devastating Impacts on the Trump Proposal to Roll Back Greenhouse Gas Vehicle Emissions Standards, "The Untold Story," at http://blogs.edf.org/climate411/files/2019/05/FINALGHGREPORT.pdf.   

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Since I've received and answered questions via email concerning podcast interviews and related health care policy questions over the past eight years, I thought it might be it might be useful to attempt answering listeners via a podcast program.  This podcast addresses questions I received via my solicitation a few months ago.  Joe DiLauro, the gentleman whom introduces the podcast and thanks listeners after each interview, and moreover my audio engineer, poses the questions.

During Part I of this discussion, approximately 22 minutes, I address questions concerning the current COVID-19 pandemic and questions concerning health care policy specifics related to Republican and Democratic party approaches to health care reform, Congressional functioning and policy management by Medicare program regulators.    

As for my bio . . . , over approximately the past 25 years I have done health care delivery, financing, policy research and evaluation in Washington DC.  My bio includes having served as Health Policy Adviser to the U.S. House of Representatives Majority Leader, Rep. Steny Hoyer.  I also spent eight years working in the US Department of Health and Human Services serving as the Evaluation Officer for the Agency for Healthcare Research and Quality (AHRQ) and as a Public Health Analyst in the Office of Assistant  Secretary for Planning and Evaluation (ASPE).  I have acute care experience having worked at DC General and post-acute experience having worked with the National Hospice and Palliative Care Organization.   My consulting clients have ranged from the American Heart Association and the American Public Health Association to UnitedHealth Group.  Among other awards I received a three-year W. K. Kellogg National Leadership Fellowship.  I have taught as a adjunct at Georgetown and at George Washington universities and over the past eight years, beyond producing over 200 interviews via this podcast, have authored over 50 health policy-related essays.  My BS, MA and Ph.D. degrees were earned at Rutgers and Arizona State.  

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Considering how the COVID-19 pandemic has been addressed by federal policy makers, e.g., the US, with 4.25% of the world's population, accounts for approximately 30% of worldwide deaths, the question arises to what extent do we value life - literally.  As Professor Friedman notes in his work, lives undervalued are lives unprotected since they are exposed to greater health and safety risks and enjoy far fewer legal protections. 

During this 33-minute conversation, Prof Friedman discusses his motivation or intent in writing the book, what in theory is intended in calculating a monetary value for a life, how value is calculated or the "Value of a Statistical Life," why valuations vary widely, examples of why and when they're employed, for example, the 9/11 Victims Compensation Fund (VCF), the infamous Ford Pinto example and others including employer insurance policies on employees (commonly termed "dead peasants" insurance") and lives threatened by the climate crisis and relevance today in context of the COVID-19 pandemic.

Professor Howard Friedman teaches at the Columbia University Mailman School of Public Health and Columbia's Data Science Institute. He also provides statistical analysis for the United Nations Populations Fund.  Previously, Dr. Friedman served as a Director at Capital One where he led teams of statisticians, analysts and programmers in various areas of operations.  He has authored and co-authored over 70 scientific articles and book chapters in areas of applied statistics, health economics and politics.  His recent publications have appeared in the American Journal of Gastroenterology, Current Medical Research & Opinion, Clinical Therapeutics, Inflammatory Bowel Disease, Journal of Managed Care Pharmacy, Clinical Drug Investigation, American Journal of Cardiovascular Drugs and Value in Health. Professor Friedman is also the author of the 2012 work, Measure of a Nation and the 2013 work, A Modest Proposal for America.  Professor Friedman Friedman received his Bachelor’s degree from Binghamton University in Applied Physics, earned a Masters in Statistics and Ph.D. in Biomedical Engineering from Johns Hopkins. 

Information on Ultimate Price is at: https://www.ucpress.edu/book/9780520343221/ultimate-price. 

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Listeners may be aware that up until recently the Medicare program strictly limited provider use of telehealth services via originating site and other numerous other regulatory rules despite its much wider adoption by other payers and the VA.  (E.g., see my previous interview/discussion with Ms. Drobac.)  Annual Medicare reimbursement for telehealth services equaled approximately 0.003% of annual Medicare spending.  With the onset of the COVID-19 pandemic, the Congress and CMS regulators, recognizing the emergency or dire need to maintain a Medicare beneficiary's ability to access to clinical care in a timely manner, markedly expanded telehealth coverage.  Both the Congress's March 27th CARES Act and CMS' April 6 interim final rule made sweeping reforms to Medicare telehealth policy.   

During this 22 minute conversation Ms. Drobac begins by explaining why the Medicare program significantly restricted use of telehealth.  Moreover, she outlines telehealth policy reforms noted in recent COVID-19-related legislation, moreover the CARES Act, and in CMS' interim final rule.  She discusses take-up or utilization by the provider community subsequent to these reforms, related Stark law issues, the need or persistence of integrity guard rails, and whether telehealth reforms will persist beyond the COVID-19 public health emergency.

Ms. Krista Drobac is the Executive Director of the Alliance for Connected Care, an organization that advocates for telehealth policy reform.  She is also a Partner at the DC-based Sirona Strategies, a health policy consulting firm.  Previously, Ms. Drobac  was Director of the Health Division at the National Governors Association’s Center for Best Practices.  Prior to NGA, Ms.Drobac spent five years on Capitol Hill as a health advisor.  Prior still, she was a Senior Advisor at the Center for Medicare & Medicaid Services (CMS) working in Medicaid and private insurance regulation and also served as Deputy Director of the Illinois Department of Healthcare and Family Services.    Ms. Drobac holds a BA from the University of Michigan and an MPP from the Harvard University Kennedy School of Government.

The Alliance for Connected Care is at: http://connectwithcare.org/.

Telehealth reform policies detailed in CMS' April 6th interim final rule  are at: https://www.govinfo.gov/content/pkg/FR-2020-04-06/pdf/2020-06990.pdf

The CARES Act is at: https://www.congress.gov/bill/116th-congress/senate-bill/3548/text. 

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Now, exactly one month after President Trump declared a national emergency, the federal government's response to the COVID-19 pandemic has been largely inept.  As of April 12th, the pandemic has infected over 560,000 Americans constituting slightly more than 30% of the world’s total number of infections. The US accounts for 5% of the world’s population, however, it has suffered 20% of worldwide deaths, more than 22,000 (a number that is substantially underestimated), or more than any other country.   Comparatively, Germany has suffered far fewer infections and deaths per capita due in part to early and widespread testing, a capable health care model (Germany has even been accepting COVID-19 patients from Italy, Spain and elsewhere), a population that has uniformly observed social distancing guidelines (and is advantaged by having a chancellor with a Ph.D. in chemistry).   Among other failures, the federal government has not taken leadership in acquiring necessary Personal Protective Equipment (PPE) and medical supplies forcing states to competitively bid, i.e., pay inflated prices, for the them.  Still fewer than 1% of the US population has been tested, in part because the president failed to deliver on  his March 13th promise to establish drive-through testing sites, causing former CMS Administrator, Dr. Don Berwick, to conclude, “we’re in a lot more trouble than we need to be" because "we are flying blind unless we find a way to find the people who are infected.”  Concerning Congressional efforts, this past Friday HHS Secretary Alex Azar announced he was awarding $30 billion of the $100 billion in grant moneys authorized under the March 27th CARES Act to support provider response to the COVID-19 pandemic.  Despite noting in his press press release theses monies were being distributed in a “fair” manner, Kentucky, the home of Senate Majority Leader Republican Mitch McConnell, received $311,000 per COVID-19 case, while New York, the home state of Senate Minority Leader Democrat Chuck Schumer, received $11,800 per case. 

During this 27 minute conversation Dr. Rishi Desai discusses where we are on the infection curve, mortality projections, success to date in practicing social distancing, uniquenesses associated with COVID-19, the development of a vaccine and antibody tests, supply and demand of PPE, the pandemic's disproportionate effects on minority communities and the poor, mental health effects, what lessons have we or will we learn as a result of the public health emergency and what these lessons suggest for necessary health care policy reforms going forward. 

Dr. Rishi Desai (MD, MPH) is a pediatric infectious disease physician with a public health background who currently serves as the Chief Medical Officer at Osmosis, an online medical learning platform developer.  He also recently led Khan Academy Medicine.  Dr. Desai had an accelerated education, completing high school and receiving his BS in Microbiology and Molecular Genetics from UCLA by the age of 18.  He completed his medical training at UCSF and went on to work at medical centers including Boston Children's Hospital, Boston Medical Center, Children's Hospital Los Angeles, and Stanford University.  He earned his MPH in epidemiology at UCLA and then spent two years at the Centers for Disease Control and Prevention as an Epidemic Intelligence Service Officer investigating disease outbreaks before beginning his work in online medical education.  Otherwise, Dr. Rishi spends his time taking his 3-year-old son to the park - when allowed, eating raspberries and learning Mandarin.

For information on Osmosis go to: https://www.osmosis.org/. 

The CARES Act is at: https://www.congress.gov/bill/116th-congress/senate-bill/3548/text. 

CDC information on COVID-19 is available via the agency's home page at: https://www.cdc.gov/. 

Stay well. 

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It is altogether appropriate to discuss the political determinants of health since this past Monday we marked the ten year anniversary of the Affordable Care Act (ACA).   The law was intended, in part, to reduce health inequities.  Research published earlier this month in Health Affairs concluded, “the ACA produced broad gains in insurance coverage,” and “that coverage increased most among groups whose members were mostly likely uninsured before the reforms,” i.e., racial and ethnic minority groups.   We would do well to remember the 19th century German physician Rudolph Virchow whom argued, we should think of medicine as a social science - meaning medical care requires collective action to address social inequality’s contribution to ill health.  (Concerning social inequities, I encourage listeners will to listen to my March 10th conversation with the Center for Budget and Policy Priorities' Mr. Joseph Llobrera regarding the administration's treatment of SNAP.)

During this 33 minute conversation, Daniel Dawes begins by providing historical context, i.e., early efforts in our nation's history to address population health and health inequities, e.g., creation of the (short lived) Freeman's Bureau in 1864.  He identifies and discusses three over-arching political determinants of health, possible reasons why the ACA (and again its health inequity provisions) have been so polarizing and current progress in political determinants addressing inequities, e.g., as related to the climate crisis.      

Mr. Daniel Dawes is the Director of the Morehouse School of Medicine’s Satcher Health Leadership Institute and Associate Lead for Government Relations.   Among previous positions he founded and chaired the advocacy group, the National Working Group on Health Disparities and Health Reform and was the co-founder of the Health Equity Leadership and Exchange Network (HELEN).  He has worked to shape federal health equity policies including the Mental Health Parity Act, the Americans with Disabilities Act Amendments Act, the Genetic Information Nondiscrimination Act and the Affordable Care Act.  He is the author of the 2017 work, 150 Years of Obamacare.  He is an elected fellow of the New York Academy of Medicine and has served on several boards, commissions, and councils focused on improving health outcomes and elevating health equity in the United States.  He is an adviser to international, national, regional, state, and municipal policymakers, as well as think tanks, associations, foundations, corporations, and nonprofit organizations.  Mr. Dawes obtained his Juris Doctorate from the University of Nebraska. 

For more information on The Political Determinants of Health go to: https://jhupbooks.press.jhu.edu/title/political-determinants-health. 

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Increasing social isolation and loneliness have been recognized for several decades.  The issues was the topic of Harvard’s Robert Putnam’s much publicized research three decades ago, i.e., his 2000 publication "Bowling Alone."   More recently, the Pope has observed “radical loneliness,” caused by a consumer culture is subverting social relationships.  In Japan, loneliness deaths among the elderly have become so common the Japanese have named the phenomenon, kodokushi (lonely death).  In the UK, former Prime Minister Theresa May in 2018 created the new cabinet position, Minister of Loneliness.   In the US, former US Surgeon General Vivek Murthy called loneliness a “growing health epidemic.”  

During this 32-minute conversation, Dr. Blazer begins by defining social isolation and loneliness or collectively social connections.  He then discusses the numerous associated adverse health effects including cardiovascular disease and dementia.  He discusses the current state of play regarding the extent to which the health care sector is addressing, social isolation in context of the ongoing COVID-19 pandemic, he notes several recommendations the report makes, discusses programming, and the scientific evidence for, that attempt to address these issues and potential problems associated with some of these interventions moreover use of technology.        

Dan G. Blazer II, M.D., M.P.H., Ph.D., is the J. P. Gibbons Professor of Psychiatry Emeritus and a professor of community and family medicine at Duke University as well as adjunct professor in the Department of Epidemiology, School of Public Health, University of North Carolina.  He is the author or co-author of more than 180 books chapters, more than 220 published abstracts, and nearly 500 peer-reviewed articles.  He is also the editor or author of 40 books.  Many of the book chapters and scientific articles are on the topics of late life depression, epidemiology, consultation liaison psychiatry, the interface between religion and psychiatry, and the epidemiology of substance use disorders.  Most of his research projects have focused on the prevalence of physical and mental illness in the elderly.  He has served as the principal investigator (PI) of the Duke University Established Populations for Epidemiologic Studies of the Elderly, the Piedmont Health Survey of the Elderly, and the MacArthur Field Studies of Successful Aging.  He also was the original PI of the Duke Clinical Research Center for the Study of Depression in Late Life.  Dr. Blazer is an elected member of the National Academy of Medicine from which he received the Walsh McDermott Award for Distinguished Lifetime Service to the Academy.

The NAS report is at: https://www.nationalacademies.org/our-work/the-health-and-medical-dimensions-of-social-isolation-and-loneliness-in-older-adults.

In part because there are over 10,000 known human diseases and symptoms thereof may have numerous possible explanations, frequently diagnostic tests can be in-determinative or less informative than observing (termed: watchful waiting) a suspected disease’s clinical course over time.  Because of diagnostic complexities population level diagnostic errors represent a significant public health problem.  Nevertheless, despite the progress made in treating cancer - as Ropeik writes in his introduction two-thirds of nearly 200 types of cancer are either treatable as chronic diseases or entirely curable - cancer today remains the emperor of nosophobias that in turn leads to over-screening, over diagnosis and false positives, over treatment, potentially harmful side effects, death and excessive healthcare budgeting and wasteful spending.  As one reviewer of the book wrote, “Ropeik details how the gravity force of cancerphobia warps risk perception, leading to personal and societal harms and legislative misdirection.” 

During this interview Mr. Ropeik begins by clarifying the book’s discussion is at the population level, disputes the belief cancer always needs be diagnosed as soon as possible and describes the US Preventive Services Taskforce’s (USPSFT’s) work upon which his book is based. He next discusses USPSTF’s (evolving) mammography screening recommendations for breast cancer, the prevalence of associated false positive diagnoses particularly related to DCIS (ductal carcinoma in situ). He discusses his chapter regarding environmental agents as cancer agents or contributing to the fear of cancer, the lack of a relationship between federal funding and the burden of disease, e.g., breast v pancreatic cancer funding. He concludes by discussing policy solutions that can simultaneously reduce cancer phobia and improve the effectiveness and cost cancer care.

Mr. David P. Ropeik is a retired Harvard University Instructor, author, and international consultant on risk perception, risk communication, and risk management. He worked as a television reporter for WCVB-TV in Boston from 1978 – 2000 specializing on environment and science issues, wrote a science column for The Boston Globe, taught journalism at Boston University, Tufts University, and MIT, was a Knight Science Journalism Fellow at MIT and a member of the Board of Directors of the Society of Environmental Journalists. Mr. Ropeik previously published “How Risky Is It, Really? Why Our Fears Don’t Always Match the Facts,” (2010, McGraw Hill), and co-author of “RISK, A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World Around You,” (2002, Houghton Mifflin). Mr. Ropeik has also authored more than 50 articles, book chapters, and other essays on risk perception and risk communication published in The New York Times, The Washington Post, The Los Angeles Times, USA Today, Scientific American, The Atlantic Monthly, Health Affairs, Issues in Science and Technology and elsewhere. He writes a blog for Psychology Today and blogged at Big Think and The Huffington Post. Among numerous awards Mr. Ropeik is a two time winner of the DuPont-Columbia Award and seven regional EMMY awards.

Information on “Curing Cancer-Phobia” is at: https://www.press.jhu.edu/books/title/12956/curing-cancerphobia.

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Despite the fact the US is a net food exporter, the country suffers a significant food security problem (defined as uncertain of having or unable to acquire enough food).  Per the USDA, over 11% of Americans, or over 37 million(including 12 million children), are food insecure or worse.   In addition, the US ranks first among OECD countries in obesity, a primary indicator of a poor or low nutritional diet.  (Many Americans also suffer from "hidden hunger" or micro-nutrient deficiency.)  What explains this includes the fact 42% of American workers are paid $15 an hour or less – causing the US to have one of the highest poverty rates among developed/wealthy countries.   The US, unlike 158 other countries, is not a signatory to the 1966 International Covenant on Economic, Social and Cultural Rights which recognizes “the fundamental right of everyone to be free from hunger.”  In addition, health care ironically contributes to hunger in America.  If health care cost what it does, for example in Switzerland or 30% less per capita, median income growth over the past 30 years would have grown to twice what it is.  Phrased another way, medical expenses push millions of Americans below the poverty line, including 7 million who earn 150% of the poverty level.  (Devoted listeners may vaguely recall I interviewed the CBPP's Dr. Paul Van de Water in January 2013 regarding Medicare and Social Security reform.) 

During this 32-minute conversation Dr. Llobrera begins by providing an overview of the SNAP program and its benefits.  He then explains the Trump administration's proposed FY 2021 SNAP budget that would, like the administration's previously proposed budgets, cut SNAP spending by $182 billion over ten years, or by over 25%, he discusses administration regulatory reforms currently being implemented that will cut SNAP by $50 billion and remove approximately 4 million from the program, how or what rationale the administration uses to explain these budget cuts/program changes, the Congress's response to these policies and what the health care industry/health care providers are doing programmatically to address the reality that food is medicine.     

Dr. Joseph Llobrera is the Director of Research for the Food Assistance team at the Center on Budget and Policy Priorities (CBPP).   Previously, Dr. Llobrera served as Research Associate at the Center between 2002 and 2007.   Before returning to the Center, he served as an Associate Director of Learning and Improvement at Insight Policy Research, providing technical assistance and training to federal, state, and local human service agencies that administer the Supplemental Nutrition Assistance Program and the Temporary Assistance for Needy Families program.  He also also employed as a researcher at IMPAQ International and the Urban Institute, focusing on food assistance policy, workforce development, and health policy.  Dr. Llobrera received his Ph.D. in Nutrition from the Friedman School of Nutrition Science and Policy at Tufts University, his master’s degree from the University of Washington (Seattle), and a bachelor’s degree in Mathematics and Urban Studies from Brown University.

The CBPP's February 18 memo providing an overview of the president's proposed 2021 SNAP budget is at: https://www.cbpp.org/research/food-assistance/presidents-2021-budget-would-cut-food-assistance-for-millions-and-radically

CBPP's November 2019 SNAP Chartbook is at: https://www.cbpp.org/research/food-assistance/chart-book-snap-helps-struggling-families-put-food-on-the-table

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CMS' efforts, via the Centers for Medicare and Medicaid Innovation (CMMI),  to develop episode-based bundled payment models in Medicare is now it its eight year.  This work is currently being pursued under the 2018-initiated Bundled Payments for Care Improvement (BPCI) Advanced (that succeeded the BPCI demo, begun in 2013, now concluded) and the Comprehensive Care for Joint Replacement (CJR) and the Oncology Care Model demonstrations, both began in 2016.   These models are designed to pay a specified or target price for a discrete episode of care, in CJR for a hip or knee replacement.   Assuming quality performance is met, if spending is below the target price the provider recoups the savings, if above the target they owe the difference.   Recent evaluations, discussed here, show these programs are on balance demonstrating savings, though modest, to the Medicare program.  Listeners may recall I interviewed Archway's Founder and CEO, Dave Terry two years ago this  month.     

During this 37 minute interview (lengthy but worth it), Ms. Macmillan begins by providing an overview of Archway Health.  She then discusses Archway's results to date regarding participation in BPCI Advanced relative to financial performance, quality and utilization - that she unpacks by discussing what accounts for savings, what quality is being measured and how measuring quality can be improved and steps CMS is taking to more accurately target price episode payments via peer groupings.  We discuss CMS' latest evaluation of the agency's CJR demonstration and other evaluation findings, participation by MA and commercial plans in episode based bundled payment arrangements, how best these demonstrations or models can be evolved, i.e., how better episode and population-based models can be better integrated, the inclusion of Part D spending, whether bundled payments should be made mandatory and what explains Archway's success in participating in these payment  models.      

Ms. Keely Macmillan is currently Senior Vice President of Policy and Solutions management at Archway Health where she oversees all aspects of Archway’s involvement CMS' Bundled Payments for Care Improvement (BPCI) Advanced demonstration.   She is an expert in alternative payment models including bundled payments and ACOs, value-based purchasing, and MACRA’s Quality Payment Program.  Previously, Ms. Macmillan was manager of government payment policy at Partners HealthCare, the largest health system in Massachusetts, where she managed public payer financial forecasting and led the government payment policy team in the analysis of performance-based reimbursement models.   Ms. Macmillan earned her master’s degree in Health Policy and Management from the Harvard T.H. Chan School of Public Health and a Bachelor of Science from Yale University.

Information on Archway Health is at: https://www.archwayhealth.com/.

Mentioned during this discussion:

CMS' January 2020 8-page overview of episode based bundled payment results to date is at: https://innovation.cms.gov/Files/reports/episode-payment-models-wp.pdf. 

The Lewin Group's second CJR evaluation published last June is at: https://innovation.cms.gov/Files/reports/cjr-secondannrpt.pdf.

Evaluations of BPCI published in the January issue of Health Affairs are by Amol Navathe, et al. and Rajender Agarwal, et al., are at: https://www.healthaffairs.org/toc/hlthaff/39/1 (subscription is required).

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This past January 17 the 9th Circuit Court of Appeals ruled in Juliana v the US.   Filed in 2015 by 21 children and others, the plaintiffs argued health harm caused by the federal government’s long support or promotion of the fossil fuel industry violates their Constitutional right to life and liberty, i.e., their right to a survivable climate.  The plaintiffs argued further the court should redress this harm by issuing an injunction requiring the federal government  to prepare a plan for judicial review and approval that would draw down green house gas emissions.  In its defense the federal government argued there is no fundamental constitutional right to a stable climate system, or that the state of the climate has no connection to personal life and liberty.  The court ruled 2-1 in favor of the US government, arguing the plaintiffs complaint was not redressable or was nonjusticiable, despite admitting "climate change was occurring at an increasingly rapid pace," "will wreak havoc on the Earth if left unchecked" and "may hasten an environmental apocalypse."  The dissent argued the Constitution's perpetuity principle, that life and liberty is secured for both ourselves and posterity, does not "condone the Nation's willful destruction."  

During this 30 minute discussion, Ms. Rodgers begins by describing the physical and mental health harm experienced by the Juliana plaintiffs.  She notes organizations that contributed amicus briefs.  She explains the majority opinion's reasoning (authored by Justice Andrew Hurwitz) that ruled in favor of the defense and the minority opinion authored by Justice Josephine Staton.  She discusses media coverage of the case, related cases, moreover the December Urgenda decision by the Supreme Court of the Netherlands that ruled in favor of the plaintiffs, and the Juliana plaintiffs intent to appeal the January decision or petition the 9th Circuit Court for a rehearing en banc.   

Ms. Andrea Rodgers is Senior Litigator Attorney at Our Children’s Trust, an Oregon-based public interest law firm, that represents the Juliana plaintiffs.  In her role at Our Children's Trust she also is lead counsel on the constitutional youth climate lawsuits against the state of Washington, Aji v. State of Washington, and the state of Florida, Reynolds v. State of Florida.  Previously, Ms. Rodgers served as an Honors Attorney for the U.S. Department of Transportation, In-House Legal Counsel for the Snoqualmie Indian Tribe, and Staff Attorney for the Western Environmental Law Center.  After graduation from the University of California, Santa Barbara in 1998 and the Arizona State University School of Law in 2001, where she served as co-executive editor of Jurimetrics: The Journal of Law, Science and Technology, she clerked for the Hon. John C. Gemmill on the Arizona Court of Appeals.  In 2016, Seattle Met Magazine recognized her legal work representing youth in the Washington climate change case in King County Superior Court against the Washington Department of Ecology (Foster v. Ecology).  

The 9th Circuit Court's January decision is at: http://cdn.ca9.uscourts.gov/datastore/opinions/2020/01/17/18-36082.pdf. 

For complete information on the Juliana case go to: https://www.ourchildrenstrust.org/juliana-v-us. 

Information on the Urgenda case decided this past December in the Netherlands is at: https://www.urgenda.nl/en/themas/climate-case/. 

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Considering the frequent favorable assessment of Canadian health care of late, by, for example, several presidential candidates and (surprisingly) the Trump administration via its recent decision to propose a regulatory pathway for US entities to import drugs from Canada, the question is begged how or how well do the Canadians deliver universal health care and at what expense.

During this 30-minute interview Dr. Cram begins by providing a general overview of population health in Canada.  He goes on to discuss moreover how care is organized and budgeted (or how spending is managed) in Canada, how care is designed (via an emphasis on primary care), the extent to which providers enjoy autonomy and patients suffer lengthy appointment/referral wait times and the prospects of Americans importing drugs from Canada.  

Dr. Peter Cram, an American citizen (a Connecticut native), is currently the Director of General Internal Medicine and Geriatrics at Sinai Health System and the University Health Network and Professor of Internal Medicine at the University of Toronto.  Previously, he was on faculty at the University of Iowa from 2002 to 2013.  Dr. Cram has published more than 180 research papers and is the co-founder of the International Health System Research Collaborative (IHSRC).  He earned his medical degree at the Wake Forest School of Medicine and completed his medical training at the University of Michigan.  

During this interview mention was made of Cram, et al., "Trade-Offs: Pros and Cons of Being a Doctor and Patient in Canada," it is at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400751/. 

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Professor Andrea Freeman's recently published, Skimmed: Breastfeeding, Race and Injustice, explains how and why Non-Hispanic Black women are significantly less likely to breastfeed their newborn than White, Non-Hispanics and Hispanics.  Black, Non Hispanics are, instead, significantly more likely to feed their newborns formula milk.  That formula, manufactured by Pet, Mead Johnson, Abbott Labs, Nestle and others and consisting of corn syrup and among other ingredients enzymatically dydrolyzed soy protein isolate (Freeman terms junk food for babies) does not compare to breast milk (that consists of living human cells, active hormones, antibodies and hundreds of other unique components ideal for infant health) helps explains why Black infant (and maternal) mortality remains twice that of White, Non-Hispanics.  Why Black women use formula, Professor Freeman explains, is due to a myriad of reasons that include targeted Black marketing, Professor Freeman details Pet's use of the Fultz quadruplets (born in North Carolina in 1946), federal policies that support and endorse formula use by Black women and a web of other laws, polices and practices that obstruct the ability of Black women to initiate or sustain breastfeeding. 

During this 30 minute interview, Professor Freeman discusses Dr. Fred Klenner's contract with Pet to market the Fultz children and numerous other variables that explain why Black women are less likely to breastfeed.  Among others, she discusses the effect 350 years of slavery has played, stereotypes of Black women, formula milk industry motivations, federal policies that reinforce/subsidize these motivations, limited legislative and regulatory oversight and limited efforts by the medical profession to contain or prohibit marketing formula milk and encourage breastfeeding.

Andrea Freeman is an Associate Professor at the University of Hawaii's William Richardson School of Law.  She has also taught as a visiting professor at the University of California, Berkeley, School of Law, at the University of Denver Strum College of Law and has a Distinguished Scholar of Sustainable Agriculture and Food Systems at Vermont Law School. Before joining the faculty at the University of Hawaii, she taught at Santa Clara University School of Law, University of San Francisco School of Law, and California Western School of Law.  Professor Freeman is an active community member serving on the Litigation Committee of the ACLU Hawaii chapter.  She volunteers with the Kokua Hawaii Foundation, makes legal presentations to the Hawaii Judiciary History Center and Hawaii State Judiciary, and writes op eds on topics including Hawaiian sovereignty and race and health.  In 2015, Professor Freeman received the Community Faculty of the Year award from Richardson's Advocates for Public Interest Law.  Professor Freeman is the Chair of the AALS Section on Agriculture and Food Law and Treasurer of the AALS Section on Constitutional Law.  She is co-chair of the Law and Society Collaborative Research Network for Critical Race and the Law and a Founding Member of the Academy of Food Law and Policy.  After graduating from UC Berkeley School of Law, she clerked for Judge Jon O. Newman of the U.S. Court of Appeals for the Second Circuit and former chief Judge José A. Fusté of the U.S. District Court for the District of Puerto Rico.  Prior to attending law school, she worked in Toronto as a counselor for women and children who experienced domestic violence and in New York as a production manager in the independent film industry.   

Information on Skimmed is at: https://www.sup.org/books/title/?id=28151. 

The related CDC August 2019 Morbidity and Mortality Weekly Report (MMWR) report noted during this interview is at: https://www.cdc.gov/mmwr/volumes/68/wr/mm6834a3.htm. 

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The 2019 Lancet Countdown on Health and Climate Change (subtitled, Ensuring That the Health of a Child Born Today is not Defined by a Changing Climate), released in mid-November, identifies 41 indicators in five domains: climate change impacts, exposures and vulnerability; adaption, planning and resilience for health; mitigation actions and health co-benefits; economics and finance; and, public and political engagement.  Since this interview focuses on the first three domains, concerning the latter two, a few take-aways: in 2018 investment in fossil fuels increased slightly while investment in low-carbon energy slightly decreased; fossil fuel subsidies increased to $427 billion in 2018 or were 50% higher than in 2016; carbon pricing instruments in 2018 covered just 13% of global greenhouse gas emissions; in the US carbon prices averaged just $1/ton of CO2; regarding fossil fuel divestment, since 2008 investment funds committed to divestment equaled nearly $8 trillion with health institutions accounting for only $42 billion.  Concerning public engagement, in 2018 only 12% of health care companies referenced health in context of the climate crisis – however this was consistent with media and government communication that also does not typically connect the climate crisis with health.  Listeners may know I interviewed Dr. Jeremy Hess a year ago this week regarding 2018 Lancet Countdown report.   

During this 28-minute conversation Dr. Salas discusses moreover the Countdown's 2019 findings moreover regarding health impacts, exposures and vulnerabilities including heat-related illnesses, those related to greenhouse gas emissions/ambient air pollution, vector borne diseases and the disproportionate effects they have on children and the elderly.  Dr. Salas also discusses adverse effects the climate crisis is having on food security and nutrition, what, or what more, health care providers can do to respond to the crisis (including relevant changes in clinical training) and efforts during the just-concluded UN COP 25 (Conference of the Parties related to the UN's Framework Convention on Climate Change) meetings just held in Madrid - that Dr. Salas attended.

Dr. Renee N. Salas is an Assistant Professor of Emergency Medicine at Harvard Medical School and an Emergency Medicine Physician at the Massachusetts General Hospital (MGH). She received her Doctor of Medicine from the innovative five-year medical school program to train physician-investigators at the Cleveland Clinic Lerner College of Medicine. She concurrently obtained a Master of Science in Clinical Research from the Case Western Reserve University School of Medicine.  Subsequently, she received a Master of Public Health from the Harvard T.H. Chan School of Public Health with a concentration in environmental health while completing a Fellowship in Wilderness Medicine at MGH.  She now has a sole academic concentration on climate change and health. As a 2018 Burke Fellow, she is addressing the current research gaps in this field.  She served as the lead for the 2019 Lancet Countdown on Health and Climate Change US Brief and is a nationally recognized leader on this subject.

The 2019 Lancet Countdown report is at: http://www.lancetcountdown.org/2019-report/.  

The Lancet Countdown US Policy Brief is at: https://www.lancetcountdownus.org/2019-lancet-countdown-us-brief. 

Information on Juliana v the US, noted in the podcast introduction, is at: https://www.ourchildrenstrust.org/juliana-v-us. 

Information on Naomi Klein's work, On Fire, The (Burning) Case for a Green New Deal, mentioned during this podcast, is at: https://naomiklein.org/on-fire/.  

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Twenty years ago last month the National Academy of Sciences published the landmark report, “To Err Is Human, Building a Safer Health System.”  The report found upwards of 98,000 people die each year in hospitals alone as a result of medical errors.  One specific medical error, diagnostic error, was, and remains today, a substantial contributor.  Defined as a wrong, delayed or missed diagnosis, misdiagnoses continue to constitute a major public health problem, adversely affecting more than 12 million annually.  Approximately one-third of whom are seriously harmed and an estimated 40,000 to 80,000 die each year from diagnostic failures in hospitals alone.  Resulting costs are estimated over $100 billion annually.  Despite the problem's pervasiveness and dire effects, the federal government spends less than $10 million annually researching the problem.  (For perspective, the 2019 NIH budget was $39 billion.)   

During this 30 minute conversation, Mr. Epner briefly describes the Society to Improve Diagnosis in Medicine's activities, discusses the use/non-use of autopsies in reducing diagnostic errors, the extent to which improved imaging technology is reducing errors and the extent to which this issue is a disparities problem.  He, moreover, discusses efforts to increase funding to address the problem, needed payment reforms, efforts to identify related quality performance measures and recently introduced legislation to improve funding and research.   

Mr. Paul L. Epner, MBA, is the Chief Executive Officer and Co-founder of the Society to Improve Diagnosis in Medicine (SIDM).  He is also Chair of the Coalition to Improve Diagnosis, a collaborative with more than fifty of the country’s leading healthcare societies, health systems, patient organizations, and organizations focused on improving quality.  He recently was named to the National Steering Committee for Patient Safety.  Mr. Epner is a Past President of the Clinical Laboratory Management Association (CLMA) where he also created the Increasing Clinical Effectiveness (ICE) initiative.  He was recently a member of the CDC’s “Clinical Laboratory Integration into Healthcare Collaborative” and a consultant to their Laboratory Medicine Best Practices program (an evidence-based practice initiative).  Mr. Epner is an Associate Editor for the peer-reviewed journal, Diagnosis.

Information on SIDM is at: https://www.improvediagnosis.org/. 

The 2015 National Academy of Sciences expert committee report noted during this interview, "Improving Diagnosis in Health Care," is at: http://www.nationalacademies.org/hmd/Reports/2015/Improving-Diagnosis-in-Healthcare. 

Recently introduced legislation to address misdiagnoses, i.e., the "Improving Diagnosis in Medicine Act of 2019" (HR 5014), is at: https://www.congress.gov/search?q=%7B%22congress%22%3A%22116%22%2C%22source%22%3A%22legislation%22%2C%22search%22%3A%22HR%205014%20%22%7D&searchResultViewType=expanded. 

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On October 31st, the FDA released the agency's Congressionally-mandated report titled, “Drug Shortages: Root Causes and Potential Solutions.”  The 124-pg report found drug shortages are increasing, persistent, i.e., the duration longer, with both the intensity and public health impact high.  These shortages can, the FDA found, “have a devastating effect,” by prolonging patient suffering, contributing to disease progression & increased morbidity.  Concerning root causes, the FDA found market consolidation has caused current contracting practices to constitute in sum a “race to the bottom.”   The FDA also found the market also fails to recognize or reward manufacturers for mature quality management systems and found a market that is unable to quickly recover after a disruption in either manufacturing or supply chain distribution.  Despite the worsening drug shortage problem, and the Congress’ considerable focus on drug pricing legislation this year, not a single drug shortage committee hearing was held this Congressional session or this year.  (Listeners may recall I posted in August a related essay I wrote on this topic for STAT).  

During this 28 minute conversation Captain Jensen begins by providing an overview of her day to day efforts managing the FDA's drug shortage efforts.  She moreover discusses the details of the FDA's report to the Congress, principally the report's recommendations, potential other related solutions including improving risk management planning, stockpiling and lengthen expiration dates, efforts by Civica Rx and Provide GX,  forthcoming FDA drug shortage guidances and potential for Congressional action. 

Captain Valerie Jensen is the Associate Director of the Drug Shortage Staff at the Food and Drug Administration.  She previously worked as a clinical pharmacist for Indian Health Service hospitals in Arizona and New Mexico for nine years before joining FDA.  She has been with the FDA for the past 19 years leading FDA efforts to work with manufacturers to mitigate and resolve shortages of medications for the patients who depend on them.  Captain Jensen received a B.S. degree in Pharmacy from the University of Iowa in 1990 and upon graduation was commissioned as an officer in the U.S. Public Health Service.  She completed an American Society of Health-System Pharmacists Specialized Residency in Ambulatory Care at the White River Indian Health Service hospital in White River, Arizona in 1991. 

The FDA's report is at: https://www.fda.gov/drugs/drug-shortages/report-drug-shortages-root-causes-and-potential-solutions

A related and recent Civica Rx report is at: https://civicarx.org/wp-content/uploads/2019/10/Civica-Rx-White-Paper-FINAL-10.01.19-1.pdf

Again, my related August STAT essay is at: https://www.statnews.com/2019/08/09/drug-shortages-presidential-candidates-policy/

(In my opening statement, I misspoke.  The drug shortage problem adds at least approximately over half a billion (not half a million), dollars annually to healthcare spending.)  

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As has been widely reported the US spends upwards of twice what other OCED countries on medical care however with worse or similar outcomes.  What explains this is in part the fact the US spends about one-third of what other OECD countries spend on social services such as food aid, housing assistance and transportation.  This despite knowing research shows basic measures of health are more closely and positively associated with social service spending.  “It’s hard to escape the conclusion,” a 2016 Brookings Institute op-ed concluded, “that we should gradually be redirecting a lot of money from medical series to so-called upstream factors [or social factors] that are associated with health.”  This was precisely the same conclusion drawn by a recent/September National Academies of Science’s (NAS) consensus study titled, “Integrating Social Care Into the Delivery of Health Care.”  The NAS report concluded health care be redesigned to integrate social care into health care and that financing of health care integrate social care spending. 

During this 30 minute conversation Mr. Palmieri briefly discusses CCA's business lines, moreover its One Care its Senior Care Options health plans that serve Medicaid-Medicare  beneficiaries (so called "Duals") and Medicare beneficiaries under a a Special Need Plan (SNP) designation.  He discusses how his patient population is recruited and moreover CCA's  whole person care approach, accomplished in part via care navigators, that includes providing CCA's patients with social service supports, e.g., CCA's medically tailored meals plan and its mobile integrated health program.  He also discusses how CCA care is financed and the spending efficiency CCA care achieves.  He concludes with a brief description of CCA's WinterStreet Ventures, a CCA affiliate that pilots/develops innovations in care delivery. 

Mr. Chris Palmieri has served since 2015 as President and Chief Executive Officer of the Massachusetts' Commonwealth Care Alliance (CCA).  Immediately prior, Mr. Palmieri served as the CEO of Remedy Partners, a bundled payment organization.  Prior still, Mr. Palmieri worked for ten years with Visiting Nurse Service of New York (VNSNY), as President and Chief Executive Officer of VNSNY Health Plans where he developed a $2 billion safety-net insurance organization.   Mr. Palmieri has also held senior positions with Amerigroup Corporation, Metropolitan Jewish Health System, Inc., and Faxton-St. Luke’s Health Care/Mohawk Valley Network.  In 2012, Chris was named one of Crain’s New York “40 Under 40,” a distinction for the top business leaders.  Mr. Palmieri currently serves as the Chair of the Association for Community Affiliated Plans (ACAP), and the Vice Chair of the national Managed Long-Term Services and Supports (MLTSS) Association.

For more information on CCA go to: http://www.commonwealthcarealliance.org/. 

The Brookings' op-ed is at: https://www.brookings.edu/opinions/social-spending-not-medical-spending-is-key-to-health/.

The National Academy of Science report, again titled, "Integrating Social Care in to the Delivery of Health Care," is at: http://nationalacademies.org/hmd/Reports/2019/integrating-social-care-into-the-delivery-of-health-care. 

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On November 1st, the Centers for Medicare and Medicaid Services (CMS) published the agency's final 2020 Quality Payment Program (QPP) rule that announced beginning in 2021 CMS will begin instituting MVPs, or Merit-based Incentive Payment System Value Pathways.  These value pathways will be created to financially incent and reward, as CMS states, “high value clinicians.”  This means CMS will begin to measure and financially reward Medicare physician performance based on value or spending efficiency defined as outcomes achieved relative to spending.  MVPs may prove to be a significant Medicare payment policy reform.   This is because while Medicare program officials have implemented numerous "value-based payment" programs and demonstrations since the passage of the 2010 Affordable Care Act, these arrangements financially reward either quality - or - reduced spending growth, they do not reward “value” or spending efficiency.  In addition, as recently noted by Harvard’s Ashish Jha and his colleagues in a October 9th JAMA "Viewpoint" essay, these current "value-based payment" programs have not had large effects on quality improvement.   (Listeners may recall I discussed measuring for health care value or spending efficiency with University of Michigan Professor Andrew Ryan this past May 11th and in later May posted on the podcast website a related essay I wrote for Bloomberg Law.)

During this 30 minute conversation Dr. Goodrich discusses in sum CMS' proposal to implement beginning in 2021 Merit-based Incentive Payment System Value Pathways (MVPs).  She explains the rationale for using of global and population health measures and patient-reported outcome measures (PROMs) and how the agency will measure or evolve its MVP-related cost measures.  She discusses MVPs potential to increase provider productivity, the potential MVPs have in helping to harmonize Medicare three payment silos: fee for service, Accountable Care Organizations (ACOs); and, the Medicare Advantage (Part C) program, in influencing commercial insurance plans' payment policies through CMS' HCPLAN (the Health Care Payment Learning Action Network), and discusses the relevance or importance of social determinates or measures thereof in driving Medicare value. 

Dr. Kate Goodrich is currently the Director of the Center for Clinical Standards and Quality (CCSQ) and CMS Chief Medical Officer (CMO).   This Center is responsible for 18 quality measurement and value-based purchasing programs including the Quality Payment Program, quality improvement programs in all 50 states, clinical standards and survey and certification of all providers across the nation, and coverage decisions for treatments and services for CMS.  The Center budget exceeds $1.2 billion annually. Prior to being CCSQ director and CMO, Dr. Goodrich served as the director of the Quality Measurement and Value-based Incentives Group in CCSQ from 2012 through 2015. She graduated from the Robert Wood Johnson Clinical Scholars Program at Yale University in 2010.  From 1998 to 2008, Dr. Goodrich was on the faculty at the George Washington University Medical Center (GWUMC) and served as division director for Hospital Medicine from 2005 to 2008.  She went to medical school at Louisiana State University in Shreveport, Louisiana, and completed her internal medicine residency and chief medical resident year at GWUMC.  She continues to practice clinical medicine as a hospitalist and professor of medicine at GWUMC.

The Quality Payment Program final 2020 rule that discusses MVPs is at: https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other. 

Information on the HCPLAN is at: https://hcp-lan.org/. 

The Bloomberg Law essay is, again, at: https://news.bloomberglaw.com/health-law-and-business/insight-containing-health-costs-requires-measuring-rewarding-spending-efficiency. 

According to the non-profit Mapping Police Violence, since 2013 when experts first starting tracking police shootings, last year was the deadliest year on record with 1,176 law enforcement gun deaths, or more than three people per day and nearly 100 per month.  In 2022 Blacks were three three times more likely to be killed by police than Whites.  However in, for example, MPLS and Chicago, Black shooting deaths were respectively 28 and 25 times more likely than White.   In her recently published book by Viking Press, Prof. Schwartz explains how the corruption of the 4th amendment and Civil Rights law, the creation of the legal fiction “qualified immunity” and other reasons make it nearly impossible to police the police.  

During this 38-minute interview, Prof. Schwartz begins by discussing the case of Ornee Norris. She in turn explains the courts’ undermining of 4th amendment’s protection from unreasonable searches, civil rights protections, specifically section 1983 of the 1871 Civil Rights Act, and the Supreme Courts 1967 creation of, in Pierson v. Ray, of qualified immunity, discusses the case of systematic violence by Vellejo, CA, police, the failure by governments to learn from these cases, efforts by states to pass laws ending qualified immunity, notes the value of Freedom of Information Act (FOIA) requests, and finally comments on the issue of the militarization of the police.

Joanna Schwartz is Professor of Law at UCLA School of Law and the Faculty Director of the David J. Epstein Program in Public Interest Law and Policy.  She was a recipient of UCLA's Distinguished Teaching Award in 2015 and served as Vice Dean for Faculty Development from 2017-2019. Beyond Shielded, her recent scholarship has been published in the Yale Law Journal, Stanford Law Review, University of Chicago Law Review, Columbia Law Review, New York University Law Review, Michigan Law Review, Northwestern Law Review, Georgetown Law Journal, UCLA Law Review, and elsewhere. She has also written for The New York Times, The Washington Post, The Los Angeles Times, USA Today, The Atlantic, The Boston Review, and Politico, and has appeared on NPR’s Fresh Air, CBS Sunday Morning, PBS NewsHour, ABC News, CNN, MSNBC, and elsewhere. Professor Schwartz is also co-author with Stephen Yeazell and Maureen Carroll of a leading casebook, Civil Procedure (11th Edition). Professor Schwartz was graduated from Brown University and Yale Law School. She clerked for Judge Denise Cote of the Southern District of New York and Judge Harry Pregerson of the Ninth Circuit Court of Appeals.  

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Dr. Azra Raza's recently published book, The First Cell and the Human Costs of Pursing Cancer to the Last, has been described as a "searing account of how both medicine and our society (mis)treat cancer, how we can do better, and why we must."  It has been termed "a clarion call . . . [that] repudiates the approach . . . that biomedical science has taken to attempt to find new treatments and curers."  The lack of progress in treating cancer is "an embarrassment" and "equally embarrassing is the arrogant denial of that embarrassment."  We spend over $150 billion annually on treating cancer and a patient diagnosed today is as likely to die from the diagnosis as a patient diagnosed 50 years ago.   

During this 35 minute conversation Dr Raza begins by discussing what causes cancer (we do not know or know completely).  She moreover discusses the urgent need for a new cancer research paradigm, i.e., the current use of tissue culture cell lines and mouse models have proven to be inadequate.  She also argues cancer researchers need to spend less time chasing the last cancer cell and instead ID the first cancer cell, i.e., we should place greater emphasis on early detection.  She explains her criticisms of the pharmaceutical industry and the federal government funding in researching effective cancer treatments.  Dr Raza also explains her relationship with her patients, her belief treating oncologists need to develop empathic relationships with their patients and she notes her view regarding palliative sedation. 

Dr. Raza is the Chan Soon-Shiong Professor of Medicine and Director of the MDS Center at Columbia University in New York.  She started her research in Myelodisplastic Syndromes (MDS) in 1982 and moved to Rush University, Chicago, Illinois in 1992, where she was the Charles Arthur Weaver Professor in Oncology and Director, Division of Myeloid Diseases.  The MDS Program, along with a Tissue Repository containing more than 50,000 samples from MDS and acute leukemia patients was successfully relocated to the University of Massachusetts in 2004 and to Columbia University in 2010.  Before moving to New York, Dr. Raza was the Chief of Hematology Oncology and the Gladys Smith Martin Professor of Oncology at the University of Massachussetts in Worcester.  She has published the results of her research and clinical trials in numerous, peer reviewed journals such as The New England Journal of Medicine, Nature, Blood, Cancer, Cancer Research, British Journal of Hematology, Leukemia, and Leukemia Research. Dr. Raza serves on numerous national and international panels as a reviewer, consultant and adviser and is the recipient of a numerous of awards including the First Lifetime Achievement Award from APPNA, Award in Academic Excellence twice (2007 and 2010) from Dogana and The Hope Award in Cancer Research. 

For more on The First Cell go to: https://www.basicbooks.com/titles/azra-raza/the-first-cell/9781541699526/. 

Dr Raza's related 2006 3 Quarks Daily post, "Rx: Reductionist Vs.. Pluralist Views of Cancer," is at: https://www.3quarksdaily.com/3quarksdaily/2006/01/rx.html.

Per my mention of Thomas Kuhn's seminal, The Structure of Scientific Revolutions, the Wiki overview is at: https://en.wikipedia.org/wiki/The_Structure_of_Scientific_Revolutions. 

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Psychedelic agents or drugs, for example Lysergic Acid Diethylamide or LSD (a cereal fungus and first synthesized in 1938), were widely researched for their therapeutic potential through the 1950s.   Among other noted users of these agents was the actor, Cary Grant.  However, when these drugs escaped the research lab in the 1960s, moral panic set in.  America's youth would, it was feared, "turn on, tune in and drop out" (a phrase popularized the Berkeley/Harvard psychologist Timothy Leary) and social upheaval would ensue.  By 1970 LSD, psilocybin and other psychedelic agents were banned for both research and recreational use purposes.  Beginning in the 1990s the FDA began giving limited approval to conduct psychedelic-related efficacy studies.  Two decades later it appears the US has now, finally, turned the corner on researching the potential wide spread therapeutic benefits of psychedelics.  This was again made evident last month when by Johns Hopkins announced opening its Center for Psychedelic and Consciousness Research.  This announcement was preceded in April by the Imperial College in London announcing the opening of its Centre for Psychedelic Research.  

During this 26 minute interview, Dr. Doblin begins by describing what effect these agents have on the brain or what parts of the brain are stimulated to what effect.  He discusses moreover his organization's MDMA (methylenedioxy-methamphetamine) research, currently a Phase 3 trial to study the effects on patients suffering from PTSD (oddly not supported by the DoD or VA), and a wide range of other current research efforts concerning treating, among other diagnoses, addiction, depression, eating disorders, phobias, OCD, schizophrenia and terminal illnesses.  He also weighs in on the future legal status of these drugs, again currently illegal or banned as Schedule I controlled substances. 

Rick Doblin, Ph.D., is the founder and executive director of the Multidisciplinary Association for Psychedelic Studies (MAPS).  He received his doctorate in Public Policy from Harvard's Kennedy School of Government, where he wrote his dissertation on the regulation of the medical uses of psychedelics and marijuana and his Master's thesis on a survey of oncologists about smoked marijuana vs. the oral THC pill in nausea control for cancer patients.  His undergraduate thesis at New College of Florida was a 25-year follow-up to the classic Good Friday Experiment, which evaluated the potential of psychedelic drugs to catalyze religious experiences.  He also conducted a thirty-four year follow-up study to Timothy Leary's Concord Prison Experiment.  Rick studied with Dr. Stanislav Grof and was among the first to be certified as a Holotropic Breathwork practitioner.  His professional goal is to help develop legal contexts for the beneficial uses of psychedelics and marijuana, primarily as prescription medicines but also for personal growth for otherwise healthy people, and eventually to become a legally licensed psychedelic therapist.  He founded MAPS in 1986.

For information on MAPS go to: https://maps.org/.

Information on Michael Pollen's 2018 work noted during this discussion, How to Change Your Mind,What the New Science of Psychedelics Teaches Us About Consciousness, Dying Addiction, Depression and Transcendence, go to: https://www.penguinrandomhouse.com/books/529343/how-to-change-your-mind-by-michael-pollan/.

For a recent personal account of a psychedelic experience, see, for example, Helen Joyce, "My Adventures in Psychedelia," at: https://www.3quarksdaily.com/3quarksdaily/2019/10/my-adventures-in-psychedelia.html.  

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Though difficult to accurately calculate for obvious reasons, the Department of Housing and Urban Development's (HUD's) 2018 point-in-time survey identified over 550,000 individuals living in emergency shelters, transitional housing or were unsheltered.  One-third were families, a disproportionate number were African American and/or veterans and a growing number were victims of wildfires or a severe climate event (think: Hurricane Florence or Michael).  The homelessness problem is worsening for numerous reasons including growing income inequality and the lack of livable wages, failed federal policy, an insufficient stock of affordable housing, the criminalization of poverty and health care that leaves nearly 30 million non-elderly uncovered and/or is ill equipped to diagnose and treat a homeless population that bears a heavy disease burden that includes psychotic and affective disorders.  

During this 30 minute conversation Mr. Watts and Dr. DePietro begin by briefly explaining how NHCHC is organized and its mission.  They discuss moreover upstream or systemic causes of homelessness, the inadequacy of affordable housing and the failure of related federal policy, the criminalization of homelessness and its effects,  the prevalence and largely unmet physical and behavioral health care needs, associated health care costs and what some health care institutions are doing to recognize the necessity of combining medical care with social service supports including housing. 

Mr. G. Robert (Bobby) Watts is the CEO of the National Health Care for the Homeless Council.  Mr.Watts has more than 25 years of experience in administration, direct service, and implementation of homeless health services. He began his work with people experiencing homelessness as a live-in staff member of the New York City Rescue Mission in Manhattan.   Previously he served as the ED of New York City’s Care for the Homeless where he significantly expanded the organizations FQHC and constructed a women’s shelter.   Mr. Watts is also the former Finance Officer of the New York City HIV Health and Human Services Planning Council.   He has served on the Steering Committee of the New York City Medicaid Managed Care Task Force and a member of the New York State Interagency Council on Homelessness and numerous other related committees, task forces and work groups.  He earned his undergraduate degree at Cornell University, his a MPH and Master's of Science in epidemiology from Columbia University and holds a Certificate of Theological Studies from Alliance Theological Seminary in Nyack,

Barbara DiPietro, Ph.D.,  directs the policy and advocacy activities for the National Health Care for the Homeless Council. This includes conducting policy analysis, providing educational materials and presentations to a broad range of policymakers and other stakeholders, coordinating the Council’s policy priorities with national partners, and organizing staff assistance to the Policy Committee and the National Consumer Advisory Board.   Previously, she worked for the State of Maryland in the Governor’s Office as well as the Department of Health.  Dr. DePietro holds a Master’s Degree in Policy Sciences and a Doctorate in Public Policy, both from the University of Maryland, Baltimore County.  Her dissertation research focused on the impact of homelessness on emergency departments in Baltimore City. 

For information on NHCHC go to: https://nhchc.org/  

Per my mention of the 2018 UN report on poverty in the US, i.e., "Statement on Visit to the USA, by Professor Philip Alston, United Nations Special Rapporteur on Extreme Poverty and Human Rights" go to: https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=22533&LangID=E

Per my mention of Amazon's opposition last year to a Seattle tax that would have helped the homeless, see: https://www.nytimes.com/2018/06/12/technology/seattle-tax-amazon.html

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Largely with the exception of the 2010 passage of the ACA, federal legislative (and regulatory) efforts to reform health care over the past few decades has lagged.   This is the result of an increasingly dysfunctional Congress.  For example, Congressional productivity, measured by the number of enacted laws, has decreased every decade since 1990 by over 20 percent.  For this reason and because states are required to balance their annual budgets (with the exception of Vermont and possibly North Dakota and Wyoming as well), health care policy innovation has shifted substantially to the states.  For example, the 2019 legislative session resulted in 29 states passing Medicaid-related legislation, 13 states passing health insurance legislation and 10 states passing health care assignment and billing legislation. 

During this 24 minute conversation, Dr. Delbanco begins by briefly explaining the Catalyst for Payment Reform's mission and members.  She moreover discusses state policy reforms related to data (i.e., All Payer Claims Databases) and price transparency, efforts to improve state market competition, delivery and payment reforms, for example, reference pricing or benchmarking to Medicare reimbursement and she identifies states that are particularly noteworthy in their efforts to improve care delivery and lower spending growth.

Dr. Suzanne F. Delbanco is the Executive Director of Catalyst for Payment Reform (CPR), an independent, non-profit corporation working to catalyze employers, public purchasers and others to implement strategies that produce higher-value health care and improve the functioning of the health care marketplace.  In addition to her duties at CPR, Suzanne serves on the advisory board of the Blue Cross Blue Shield Institute.  Previously, Suzanne was the founding CEO of The Leapfrog Group.  Suzanne holds a Ph.D. in Public Policy from the Goldman School of Public Policy and a M.P.H. from the School of Public Health at the University of California, Berkeley. 

For information on CPR go to: https://www.catalyze.org/. 

Dr. Delbanco (and colleagues') recently published article, "The State of State Legislation Addressing Health Care Costs and Quality," is at: https://www.healthaffairs.org/do/10.1377/hblog20190820.483741/full/.

Per Dr. Delbanco's reference to The Source, U. of CA Hastings College of Law's recently posted online database of state laws impacting health care cost and quality, go to: https://sourceonhealthcare.org/legislation/. 

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In CMS' proposed hospital outpatient rule published in the Federal Register in early August, the agency proposed requiring hospitals to make public a list of its negotiated rates for common items and services.   The proposed rule is based on two White House executive orders and is an expansion of a related regulatory rule that went into effect this past January 1st that requires hospitals to make publicly available a list of current standard hospital charges (on their so called chargemaster list).  Despite the administration's enthusiasm for price transparency (and state's - approximately half have passed price transparency legislation) the evidence to date demonstrates that price transparency has not led to or enabled patients to lower their out of pocket costs, lower health care prices, improve market competition creating greater care value.   

During this 24 minute conversation Professor Michael Chernew begins by discussing related anti-trust enforcement.  He moreover discusses his research findings concerning price transparency, alternative practices providers have or can exhibit that have demonstrated success in lowering patient out of pocket spending and potential unintended negative consequences, e.g., hospitals may demonstrate less willingness to make price concessions for fear of having to extent them to all payers, should CMS' rule go final as proposed in November. 

Professor Michael Chernew is the Leonard D. Schaeffer Professor of Health Care Policy and the director of the Healthcare Markets and Regulation (HMR) Lab in the Department of Health Care Policy at Harvard Medical School.  Professor Chernew is a member of the Congressional Budget Office’s Panel of Health Advisors and of the Institute of Medicine’s Committee on National Statistics (CNSTAT).  He is also a research associate at the National Bureau of Economic Research.  In 2011, he served on the Institute of Medicine’s Committee on Determination of Essential Health Benefits and in 2010 was elected to the Institute of Medicine of the National Academy of Sciences.  Prof. Chernew is the former Vice Chair of the Medicare Payment Advisory Commission (MedPAC).  In April 2015, Massachusetts Governor Charlie Baker appointed Professor Chernew to the Massachusetts Health Connector Board of Directors.  Dr. Chernew is currently a co-editor of the American Journal of Managed Care and editor of the Journal of Health Economics.  He is a former senior associate editor of Health Services Research.  Professor Chernew earned his undergraduate degree from the University of Pennsylvania and his PhD in economics from Stanford University.

The two White House Executive Orders noted are at: https://www.whitehouse.gov/presidential-actions/executive-order-improving-price-quality-transparency-american-healthcare-put-patients-first/ and at: https://www.whitehouse.gov/presidential-actions/presidential-executive-order-promoting-healthcare-choice-competition-across-united-states/ 

The White House's related, "Reforming America's Health System" paper is at: https://www.hhs.gov/sites/default/files/Reforming-Americas-Healthcare-System-Through-Choice-and-Competition.pdf

CMS' current proposed rule discussing expanding hospital price transparency regulations is at: https://www.govinfo.gov/content/pkg/FR-2019-08-09/pdf/2019-16107.pdf . See pages 39571, ff. 

The summary of Prof. Chernew, et al. April 2018 New England Journal of Medicine price transparency research article noted during this podcast is at: https://newsatjama.jama.com/2019/08/22/jama-forum-price-transparency-in-health-care-has-been-disappointing-but-it-doesnt-have-to-be/ 

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Medical aid in dying is now legal in nine states and the District of Columbia or is available to approximately one-fifth of the US population.  State medical societies allow physicians to provide treatment that comports with their conscience, survey data shows the practice enjoys substantial public support and the option is available in numerous foreign countries including the Netherlands where it is available to children with their parents' consent.  Nevertheless, the practice remains controversial.  Listeners may be aware I've discussed end of life care during several previous podcasts dating back to June 2013 when I discussed advanced care directives with the American Bar Association's Charlie Sabatino.  

During this 35 minute discussion, Dr. Cohen begins our discussion by explaining how suicide became defined as a mental illness and life insurance coverage in instances where aid in dying has been exploited.  the problems associated with medical aid in dying for patients with disabilities and those suffering with Alzheimer's or related cognitive impairments and whether aid in dying should be restricted to the terminally ill.  He discusses several case histories including the aid in dying deaths of Admiral Chester J. and Joan Nimitz, Jack Kevorkian's work and efforts by the Hemlock Society, Caring Friends and the Final Exit Network.  

Dr. Lewis Cohen is a Professor of Psychiatry at the University of Massachusetts-Baystate School of Medicine, and an Adjunct Professor of Psychiatry at the Tufts University School of Medicine.  He is the recipient of a Guggenheim Fellowship for Medicine and Health, two Rockefeller Foundation Bellagio Residency awards, and a Bogliasco Fellowship for the Arts and Humanity, as well as the Eleanor and Thomas Hackett Award from the Academy of Consultation-Liaison Psychiatry.  He is the author or co-editor of several previously published books, including No Good Deed.  Dr. Cohen earned his MD at the State University of New York Upstate Medical University and is board certified by the American Board of Psychiatry and Neurology.

For more information on A Dignified Ending go to: https://rowman.com/ISBN/9781538115749/A-Dignified-Ending-Taking-Control-Over-How-We-Die.

For information on Compassion and Choices and Final Exit Network (successor organizations to the Hemlock Society) go to: https://compassionandchoices.org/ and http://www.finalexitnetwork.org/.

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In late June, Professor Philip Alston, the UN's Special Rapporteur on Extreme Poverty and Human Rights, published "Climate Change and Poverty."  The 20-page report is unsparing in its criticism of the response, or lack thereof, by corporations, governments, NGOs and the human rights community to the climate crisis, moreover their response concerning the effect the crisis will have on the poor - whom will disproportionately bear the burden of climate emergency.   "Government, and too many in the human rights community," he wrote, "have failed to seriously address climate change for decades."  "Most human rights bodies have barely begun," he stated, "to grapple with what climate change portends for human rights."  "There is no recognition of the need for seep social and economic transformation."  As a result, "Climate change threatens to undo the last 50 years of progress in development, global health and poverty reduction."  Professor Alston concludes his report by writing, "The human rights community, with a few notable exceptions, has been every bit as complacent as most governments in the face of the ultimate challenge to mankind represented by climate change. The steps taken by most United Nations human rights bodies have been patently inadequate and premised on forms of incremental managerialism and proceduralism which are entirely disproportionate to the urgency and magnitude of the threat.  Ticking boxes will not save humanity or the planet from impending disaster."  (This discussion is my 10th concerning the climate crisis over the past 2 plus years.)  

During this 27 minute conversation Professor Alston describes the role of the Special Rapporteur on Extreme Poverty and Human Rights, discusses the genesis of his report and provides an overview of its findings.  He comments what he terms the "patently inadequate" response to date by the human rights community including the UN's Human Rights Council, in response to the climate crisis.  He also discusses how the growing climate crisis refugee crisis is being addressed, as an international criminal law professor his view regarding prosecuting corporations and their CEOs for having devastated the environment, the Juliana and related court cases seeking climate justice, and the upcoming UM climate summit this September 23rd.   

Philip Alston has served as the United Nations' Special Rapporteur on Extreme Poverty and Human Rights since 2014.  In forwarding his work he has reported on Chile, China, Mauritania, Romania, Saudi Arabia and the US.  He was previously UN Special Rapporteur on extrajudicial, summary, or arbitrary executions from 2004 to 2010.  He was a member of the Group of Experts on Darfur appointed in 2007 and served as special adviser to the UN High Commissioner for Human Rights on the Millennium Development Goals.  He has also served as UNICEF's legal adviser.  In the field of international law, Professor Alston was editor-in-chief of the European Journal of International Law from 1996 through 2007.  He was a co-founder of both the European Society of International Law and the Australian and New Zealand Society of International Law.  As a UN, he worked in Geneva on human rights issues from 1978 to 1984.  He has worked as a consultant to the ILO, the UNDP Human Development Report, the Office of the UN High Commissioner for Human Rights, UNESCO, OECD, UNICEF, and many other inter-governmental and non-governmental organizations.  Professor Alston is also presently the John Norton Pomeroy Professor of Law at New York University's Law School where his teaching focus is on international law, human rights law, and international criminal law.  He also co-chairs the NYU Center for Human Rights and Global Justice.  During the 1980s Professor Alston taught at the Fletcher School of Law and Diplomacy and at Harvard Law School.  Afterward, he became Professor of Law and Foundation Director of the Center for International and Public Law at the Australian National University, a post he held until 1995.  From 1996 to 2001 he was Professor of International Law at the European University Institute (EUI) in Florence, Italy, where he was also head of department and co-director of the Academy of European Law.  Professor Alston received degrees in law and in economics in Australia and a JSD from Berkeley.  

Professor Alston's report is at: https://chrgj.org/wp-content/uploads/2019/06/UNSR-Poverty-Climate-Change-A_HRC_41_39.pdf.

In May 2018 Professor Alston published a related report on extreme poverty in the US, it is at: “Report of the Special Rapporteur On Extreme Poverty and Human Rights on His Mission to the United States."  My summary of this report is at: https://thehealthcareblog.com/blog/2018/08/22/the-uns-extreme-poverty-report-further-evidence-us-healthcare-is-divorced-from-reality/.

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The news is grim.  Our planet has just experienced its hottest June in recorded history and likely the hottest July.  This year will likely join ten others since 2000 as the warmest ever recorded.  Several studies just published in Nature and Nature Geoscience have concluded there has never been a period over the past 2,000 years when temperatures have changed as fast and extensive as in recent decades.  To make matters worse, the climate crisis substantially explains the fact our planet is currently experiencing its 6th mass extinction – 4 of the previous 5 were also caused by high atmospheric CO2 concentrations, the worst of these extinguished 90% of all planetary life.  Despite the increasingly dire evidence, the federal leaders continue to do nothing.  The White House and the Republican Party not only refuse to admit reality but argue Americans have no fundamental right to a climate system capable of sustaining human life.  Congressional House Democrats refuse to move any meaningful legislation - even if that means simply putting Republicans on record for opposing maintaining life on earth and the health care industry, in sum, is neither working to reduce its own carbon emissions nor lobbying for requisite federal policy reforms.  Listeners may be aware this is my 8th climate crisis-related interview since last October.

During this 29 minute conversation Dr. Benjamin assesses the current stay of play relative to federal action concerning the climate crisis, he discusses the challenges the climate crises poses relative to achieving health equity and moreover the work of APHA's Center for Climate, Health and Equity (and how individuals can become involved in the APHA's climate crisis work). 

Dr. Georges Benjamin has served as Executive Director of the American Public Health Association since 2002.  He also serves as publisher of APHA's nonprofit's monthly publication, The Nation's Health, the association's official newspaper, and the American Journal of Public Health. Previously, Dr. Benjamin served as Secretary and Deputy Secretary of the Maryland Department of Health.  Dr. Benjamin began his medical career in 1981 in Washington State where he served as Chief of the Acute Illness Clinic at the Madigan Army Medical Center.  He subsequently moved to Washington, D.C. to serve as Chief of Emergency Medicine at the Walter Reed Army Medical Center.  After leaving the Army, Dr. Benjamin chaired the Department of Community Health and Ambulatory Care at the District of Columbia General Hospital, was promoted to Acting Commissioner for Public Health for the District of Columbia and later served as Interim Director of the Emergency Ambulance Bureau of the District of Columbia Fire Department.  He is the author of more than 100 scientific articles and book chapters.  His most recent book is, The Quest for Health Reform: A Satirical History is an exposé of the nearly 100-year quest to ensure quality affordable health coverage for all through the use of political cartoons.  Dr. Benjamin is a member of the National Academy of Medicine of the National Academies of Science, Engineering and Medicine and also serves on the boards for several organizations including Research!America and the Reagan-Udall Foundation.  In April 2016, President Obama appointed Dr. Benjamin to the National Infrastructure Advisory Council.  Dr. Benjamin is a graduate of the Illinois Institute of Technology and the University of Illinois College of Medicine.  He is board-certified in internal medicine and a Fellow of the American College of Physicians, a Fellow of the National Academy of Public Administration, a Fellow Emeritus of the American College of Emergency Physicians and an Honorary Fellow of the Royal Society of Public Health.

For information on the APHA's Center on Climate go to: https://apha.org/topics-and-issues/climate-change/center  

The APHA's 2016 "Climate Change and Health Strategic Plan" (noted during this interview) is at: https://www.apha.org/-/media/files/pdf/topics/climate/apha_climate_change_strategic_plan.ashx?la=en&hash=03D148BBD2A45E2A2B98BC4C98D33F32118244E1 

Phillip Alston's (United Nations' Special Rapporteur on Extreme Poverty and Human Rights) report, "Poverty and Climate" (also noted or quoted during this interview - and must reading) is at: http://www.guninetwork.org/files/unsr-poverty-climate-change-a_hrc_41_39.pdf

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One way to increase the value of insurance coverage is to eliminate or lower a patient's out of pocket costs (OOP), i.e., their co-pays and/or deductables, for health care services that are of high value, for example, vaccines and/or alternatively increase OOP costs for low value service, for example, certain imaging tests.  The concept is based on the straight forward rationale that, based on clinical evidence, certain health care products or services are proven to be more effective than others.  (This is the rationale for the Choosing Wisely program, at: https://www.choosingwisely.org/.)  OOP costs therefore should not be uniform for all services and medications, particularly when non-adherence rises along with rising health care OOP spending.  This largely explains the problem of medication non-adherence.  Phrased another way, we need need to solve for the increasing problem of under consuming high value care.  This idea was recognized in the 2010 Affordable Care Act, specifically Section 2713 [c] that eliminates patient cost sharing for specific preventive care services.  For example, OOP costs for significantly under-utilized breast and colorectal screenings, for which approximately only 72% and 60% of patients, respectively, are screened.  The value-based idea was furthered by the ACA-created CMS Innovation Center that in 2017 the launch the MA VBID demonstration - that was recently extended to 2024.  (This discussion is related to or can serve as a follow up to my May 11th conversation with Professor Andrew Ryan concerning measuring for value or spending efficiency.)

During this approximately 30 minute conversation, Dr. Fendrick discusses moreover the creation of the University of Michigan's VBID Center, provides his assessment of the current CMS Medicare Advantage VBID demonstration, the U. of MI Center's just announced V-BID X insurance design, VBID efforts at the state level and the Treasury Department's just-announced guidance allowing Health Savings Account/High Deductible Health Plans to practice VBID.   

Dr. A. Mark Fendrick is the Director of the Value-Based Insurance Design Center at the University of Michigan.  He is also Professor of Internal Medicine in the School of Medicine and a Professor of Health Management and Policy in the School of Public Health at the University of Michigan.  He has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design.  Dr. Fendrick is an elected member of the National Academy of Medicine (formerly the Institute of Medicine or IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the U.S. Senate Committee on Health, Education, Labor and Pensions, the U.S. House of Representatives Ways and Means Subcommittee on Health, and the U.S. Senate Committee on Armed Services Subcommittee on Personnel.  Dr. Fendrick is the co-editor in chief of the American Journal of Managed Care and is an editorial board member for three additional peer-reviewed publications.  He is also a member of the Institute for Healthcare Policy and Innovation at the University of Michigan, where he remains clinically active in the practice of general internal medicine.  Dr. Fendrick received a bachelor’s degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School.  He completed his residency in internal medicine at the University of Pennsylvania where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program.

For information about U. of Michigan's Center for Value-Based Insurance Design to go: https://ihpi.umich.edu/center-value-based-insurance-design-v-bid.

A summary of the V-BID X proposal is at: https://www.healthaffairs.org/do/10.1377/hblog20190714.437267/full/.  The more complete white paper is at: http://vbidcenter.org/wp-content/uploads/2019/07/VBID-X-Final-Report_White-Paper-7.13.19.pdf.  

For information concerning Dr. Fendrick's mention of the just-released US Treasury guidance allowing HSA-HDHP plans the flexibility to cover specified medications and services prior to meeting the plan deductible go to: https://ihpi.umich.edu/center-value-based-insurance-design-v-bid . 

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Nine in 10 prescriptions are today filled using a generic drug saving Americans tens of billions annually.   A significant amount of generic drugs, along with active ingredients in all drugs, are manufactured overseas.  However, how safely or to what quality standards are these ingredients and generics produced?   Bottle of Lies, published in May, tells the story of appalling practices foreign generic manufacturers use to produce these drugs at the most minimal cost.  The work moreover provides a detailed account of Ranbaxy, the former India-based generic manufacturer that after eight years of investigation was fined a then record amount,$500 million, for significant fraud.  The work questions or brings to serious doubt the FDA's ability to adequately inspect overseas generic manufacturers ensuring these drugs are safe for consumption in the US or around the world.  Listeners may recall I interviewed coauthor Paul Weinberg in September 2017 concerning his related work, Blood On Their Hands, How Greedy Companies, Inept Bureaucracy and Bad Science Killed Thousands of Hemophiliacs and Rosemary Gibson this past December concerning her related, China Rx, Exposing the Risk of America’s Dependence on China for Medicine. 

During this 37 minute interview. Ms. Eban provides an overview of Ranbaxy's manufacturing practices revealed by former employee and whistleblower, Dinesh Thakur.  She explains the mindset, termed "Jugaad," used in India to produce generics.  She discusses the adequacy of the 2013 US settlement with Ranbaxy , the role the Japanese firm, Daiichi Sankyo, a  major Ranbaxy stakeholder, the FDA's ability to adequately inspect Ranbaxy and other generic manufacturers around the world, e.g., Cipla and Mylan, recent and future related Congressional action, how poor or inadequate manufacturing practices complicate remedying the drug shortage problem and what precautions consumers or patients can take before consuming generic drugs.  

Katherine Eban, an investigative journalist, is a Fortune magazine contributor and Andrew Carnegie fellow. Her articles on pharmaceutical counterfeiting, gun trafficking, and coercive interrogations by the CIA, have won international attention and numerous awards.  She has also written for Vanity Fair, The New York Times, Self, The Nation, the New York Observer and other publications. Her work has been featured on 60 Minutes, Nightline, NPR, and other national news programs.  She lectures frequently on the topic of pharmaceutical integrity.  Her first book, Dangerous Doses: a True Story of Cops, Counterfeiters and the Contamination of America’s Drug Supply, was named one of the Best Books of 2005 by Kirkus Reviews and was a Barnes&Noble Discover Great New Writers pick.  Her account of reporting on 9/11 was anthologized in At Ground Zero: 25 Stories From Young Reporters Who Were There. Her work has also been awarded grants from the Alfred P. Sloan Foundation, the Fund for Investigative Journalism, the Alicia Patterson Foundation and the McGraw Center for Business Journalism at CUNY’s Craig Newmark Graduate School of Journalism.  Educated at Brown University and Oxford, where she was a Rhodes Scholar.   

Information on Bottle of Lies is at: https://www.harpercollins.com/9780062338785/bottle-of-lies/.  

Ms. Eban's FAQ regarding how to learn about generics or best to consume is at: https://www.katherineeban.com/faqs. 

US healthcare emits a massive amount of carbon pollution at approximately 600 million tons annually or roughly 9% of total US greenhouse gasses.  Because of the rapid increase in climate crisis-related harms projected economic losses worldwide over the next few years are estimated in the trillions.  Consequently, the US is beginning to follow Brazil, Canada, France, Japan, Switzerland and the UK in mandating GHG emission and climate-risk disclosures.  Most noteworthy, in April 2022 the Security Exchange Commissions (SEC) issued a proposed rule, anticipated to go final this month, that will require publicly traded companies to disclose information about climate-related financial risks and financial metrics to inform investors in making corporate investment and voting decisions.  Just recently the California governor signed a “Climate Accountability Package,” the White House in late September charged the OMB to work with fed agencies to measure GHG emissions in order to calculate impacts on fed programs and the European Union has moved related reporting regulations that will impact American companies doing business overseas.

During this 34 minute interview Ms. Hanawalt begins by outlining the proposed SEC climate disclosure rule. She next outlines CA’s “Climate Accountability Package (S253 and S261) that address CA reporting for different sized private and public companies and discusses related European Union regulatory rules.

Ms. Cynthia Hanawalt is the Director of the Sabin Center’s financial regulation practice. Her work supports regulatory and policy responses to climate-related financial risk at the federal and state level and includes a focus on the complex intersections of ESG and antitrust law with sustainability goals and climate resiliency measures. Ms. Hanawalt is affiliated with Columbia Climate School and the Initiative for Climate Risk & Resilience Law. Prior to joining the Sabin Center, Ms. Hanawalt served as Chief of the Investor Protection Bureau for the New York State Office of the Attorney General and was a litigation partner at the firm Bleichmar Fonti & Auld. She was graduated from Columbia Law School where she was a Harlan Fiske Stone Scholar and Duke University where she received the William J. Griffith University Service Award.

For more information regarding climate disclosure see these Sabin Center writings:

https://blogs.law.columbia.edu/climatechange/2023/08/08/new-california-legislation-would-be-a-major-step-forward-for-climate-disclosure/

https://blogs.law.columbia.edu/climatechange/2023/03/28/global-consensus-is-emerging-on-corporate-scope-3-disclosures-will-the-sec-lead-or-lag/

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US gun violence is, in one word, obscene.  It is widely considered an epidemic, even the always cautious AMA termed it a "public health crisis" in 2016.  Through the first five months of this year there were 148 mass shootings that killed or wounded nearly 750 individuals.   It is worth repeating comments I made in April 2018 to introduce Dr. Al-Abga (whom treated victims of the 1999 Columbine High School shooting).  US gun deaths are 96 times higher than in Japan, 55 times higher than in the UK, 32 times higher than in Germany.  Gun violence is particularly common in schools.  Since 2000 there have been over 200 shootings in over 40 states at elementary, middle, high schools and at colleges and universities. Research suggests gun violence is explained largely by one fact: gun prevalence. The US makes up less than 5% of the world's population but owns nearly 45 percent the world's guns, or 300 million that one-third of Americans’ possess.  Ownership is, for example, 150 times higher than in Japan.  This fact largely explains why guns used to commit homicides far exceeds other developed countries.  US gun homicides are 471 times more prevalent than in the UK.  As for whether mental health issues explain US gun violence, the rate of severe mental disorders in the US is no greater than in comparative countries. 

During this 26 minute conversation Ms. Brown discusses Brady United's mission or work activities including its legal efforts relative to the 2nd amendment.  Moreover, she explains current efforts in the Congress to appropriate moneys for federal gun violence research (that has not been conducted for over 20 years) and recently House-passed bills that include regulating gun sales via extending background checks to private fire arm sales.  Ms. Brown also discusses policy plans by Democratic presidential candidates including Sen. Cory Borker to curb gun violence and she discusses the State of Virginia's upcoming special session next month in the wake of the May 31st Virginia Beach shooting that left 12 dead.  

Ms. Kris Brown is the President of Brady.  Ms. Brown began her career working on Capitol Hill for (now former ) Rep. Jim Moran (D-VA), advocating for the bill that would eventually become the Brady Act requiring background checks on federally licensed gun sales.  At Brady, she led the lunch of the organization’s safe storage campaign to End Family Fire and formed Brady’s “Team Enough” youth initiative after February 2018 Marjory Stoneman Douglas High School massacre in Florida.  A noted media commentator, Ms. Brown was, for example, featured in the November 2018 TIME magazine cover article titled, “Guns in America.”  Ms. Brown has also served as the Chief Legal Officer to a publicly traded company based in Switzerland and as a lawyer practicing at the law firm Weil, Gotshal & Manges.  She earned her law degree at George Mason University. 

For more on Brady go to: https://www.bradyunited.org/  

For information on the Enhanced Background Checks Act of 2019 go to: https://www.congress.gov/bill/116th-congress/house-bill/1112/text 

The recent debate sparked by FiveThirtyEight regarding the accuracy of CDC's gun injury statistics and titled, "The CDC is Publishing Unreliable Date on Gun Injuries, People Are Using It Anyway," is at: https://fivethirtyeight.com/features/the-cdc-is-publishing-unreliable-data-on-gun-injuries-people-are-using-it-anyway/

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This past June 4th the 9th Circuit Court heard oral arguments concerning Juliana v. the US, a case filed in 2015 by 21 children seeking a jury verdict on whether the US government, by failing to address the climate crisis, is protecting the plaintiff’s rights to life, liberty and the pursuit of happiness.  In its defense the US is arguing these children, now young adults, have “no fundamental constitutional right” to a “climate system capable of sustaining human life.”  In a May 30th essay published in The New England Journal of Medicine Dr. Salas and two colleagues agreed with the plaintiffs concluding , “As the Juliana plaintiffs argue - and we agree - climate change is the greatest public health emergency in our time and is particularly harmful to fetuses, infants, children and adolescent.” (Listeners may be aware this is my 7th climate crisis related interview since October.)

During this 26 minute interview Dr. Salas discusses her related research work, the amicus brief she and her colleagues forwarded in support of Juliana plaintiffs and other related litigation filed world wide.  Moreover, Dr. Salas explains the numerous adverse health effects children are suffering via the climate crisis including various birth defects, heart, lung and neurodevelopment illnesses, vector-borne diseases, harms from high heat and wildfire exposure, cognitive, behavioral and mental health effects, contaminated water, and numerous others.  She discusses what parents need to know or can do to protect their children and the extent the health care industry needs to (better) address its own contribution to greenhouse gas emissions/pollution or global warming. 

Dr. Renee Salas is Affiliated Faculty and a Burke Fellow at the Harvard Global Health Institute.   Her research addresses how climate change is impacting the healthcare system and developing evidence-based adaptation.She is also a practicing physician in the Department of Emergency Medicine at Massachusetts General Hospital and on faculty at Harvard Medical School.  Dr. Salas served as the lead author on the 2018 Lancet Countdown on Health and Climate Change U.S. Brief and will again in 2019.   She lectures on climate and health nationally and internationally, has published in numerous scholarly journals and is the founder and past Chair of the Climate Change and Health Interest Group at the Society of Academic Emergency Medicine.  Dr. Salas received her Doctor of Medicine from the Cleveland Clinic Lerner College of Medicine with a Master of Science in Clinical Research from the Case Western Reserve University School of Medicine.  She also holds a Master of Public Health from the Harvard T.H. Chan School of Public Health with a concentration in environmental health.

Renee Salas, Wendy Jacobs and Frederica Perera's New England Journal of Medicine essay, "The Case of Juliana v US - Children and the Health Burdens of Climate Change," is at: https://www.nejm.org/doi/full/10.1056/NEJMp1905504 

The video of the 9th Circuit Juliana v the US oral argument is at: https://www.ca9.uscourts.gov/media/view_video.php?pk_vid=0000015741&fbclid=IwAR3K3vnHCO4M2KlcMZ1NSQ4ua1ZZhpdyA-hONwyj6N7uS0u1X5ojmuVVkCc

The amicus brief filed in support of the Juliana plaintiffs by 13 medical societies and over 65 medical professionals is at: http://clinics.law.harvard.edu/environment/files/2019/03/Juliana-Public-Health-Experts-Brief-with-Paper-Copy-Certificate.pdf. 

Again, my related essay, "Can the Climate Crisis Continue to Go Begging?" is at: https://www.3quarksdaily.com/3quarksdaily/2019/06/can-the-climate-crisis-continue-to-go-begging.html.

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Americans spend over $3.5 trillion or 6% of the GDP annually on health care.  One third, or over $1 trillion, of that spending is considered waste, i.e., health care that does not improve our health status.  Despite substantial efforts to improve health care value or spending efficiency via so called pay for value, performance based and alternative payment models, for example ACOs and bundled payment arrangements, health care providers, Medicare and other payers, do not generally measure for value - defined as outcomes (the numerator) achieved relative to spending (the denominator).   For example, the MACRA MIPS  program, that reimburses Medicare physicians, measures quality and spending separately, not simultaneously.  They are not correlated.  As a solution the government has been over the past few years advocating increasingly health care price transparency, specifically here price transparency.  If prices were transparent patients, less those riding in an ambulance, could shop for value. The problem is even if patients could intelligently shop for value, a big if, they would not get far because prices do not necessarily reflect value.  As I note in my Bloomberg Law essay posted as a run up to this interview, former Princeton economist, Uwe Rinehardt, use to explain this reality, or the fact that the same health care service can dramatically vary in price between/among provides, via the quip, "the finest health care in the world costs twice as much as the finest health care in the world."    

During this 28 minute conversation Prof. Ryan outlines his research interests, provides background on how measuring for quality, cost and spending efficiency has evolved, explains various methods of how spending efficiency is currently being measured (e.g., conditional and unconditional), to what extent pay for value or pay for performance arrangements have proven successful to date, what value-based payment models likely offer the most promise and what the patient can or should know about pay for value arrangements.  

Professor Andrew Ryan is United Healthcare Professor of Healthcare management and Professor or Health Management and Policy at the University of Michigan, Ann Arbor.  Professor is also the Director of the Center for Evaluating Health Reform, the co-Director of the Center for Health Outcomes and Policy and the Associate Director of the Institute for Healthcare Policy and Innovation’s Data and Methods Hub.  Prior to coming to Michigan, Professor Ryan was an Associate Professor of Public Health in the Division of Outcomes and Effectiveness Research at Weill Cornell Medical College.  Among other awards he is the recipient of the 2009 AcademyHealth Dissertation Award for "The Design of Value Based Purchasing in Medicare: Theory and Empirical Evidence."  Professor Ryan earned his Ph.D. in social policy with a concentration in health policy from the Heller School of Social Policy and Management at Brandeis University. 

Professor Ryan's publications can be found at: https://sph.umich.edu/faculty-profiles/ryan-andrew.html.

The Bloomberg Law essay is again at: https://news.bloomberglaw.com/health-law-and-business/insight-containing-health-costs-requires-measuring-rewarding-spending-efficiency.

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It should go without stating "nature's contribution to people are vital to human existence."  Nevertheless, this was the third line in the May 6th report by the UN Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES).  As the report notes, "70% of drugs used for cancer are natural or are synthetic products inspired by nature, four billion people reply primarily on natural medicines for their health and, among other examples, 70% of global food crops rely on animal pollination.   "Nature underpins," the report states, "all dimension of human health."  Duly noted, noted, the UN report goes on to detail at great length the fact nature is being "significantly altered by multiple human drives" including anthropogenic global warming that among other things is presently threatening approximately 25% of species of assessed animal and plant groups "suggesting that around 1 million species already fact extinction unless action is taken to reduce the intensity of drivers of biodiversity loss."  As of 2016 over 9% of 6,190 domesticated breeds of indigenous mammals used for food and agriculture had become extinct.  (Despite the UN report's devastating findings and/or dire warning), the head of the Democratic Party (the only major party to recognize climate change), House Speaker Nancy Pelosi, did not bother to release a press release commenting on the IPBES report's findings.)  One way to substantially mitigate nature's collapse are via natural climate solutions, largely reforestation.   As it relates to greenhouse gas emissions, forests act as carbon sinks.      

During this approximately 25-minute discussion Ms. Tabola explains how the The Nature Conservancy's (TNC's) Natural Climate Solutions initiative was born or its rationale.  She moreover explains how and why "natural" climate solutions present a substantial opportunity to mitigate the adverse effects of global warming.  I.e., re-greening the planet via net zero deforestation and reforestation, related re-vegetation of coastal habitats (think: mangroves, salt marshes, sea grass beds) and several other changes in land use, e.g., use of cover crops on crop lands, in sum nature-based solutions, are estimated to potentially provide 37% of climate change mitigation until 2030 needed to meet the Paris climate accord goal of keeping warming to no greater than 2 degrees Celsius.  

Ms. Tabola is currently TNC’s Acting Director of its Climate Strategy programming that addresses forest and soil carbon science, forestry, communications, carbon finance and policy, and works to connect global, regional and local climate work across TNC.  Previously, Ms. Tabola served as TNC’s Deputy Managing Director for Global Lands.  Prior to TNC, she was the Senior Director for Health and Climate Change at ecoAmerica, leading a national strategy across the health sector to elevate climate solutions as a top health priority.  Ms. Tabola has also been the Senior Director of Education at the National Environmental Education Foundation, leading national strategy, programming and partnerships to advance K-12 climate change and environmental literacy.  Ms. Tabola also worked in the U.S. federal government within the Corporation for National and Community Service as the Education and Training Director for the National Civilian Conservation Corps and as one of the first national AmeriCorps Program Officers.  As a Peace Corps Volunteer in Ecuador, Ms. Tabola collaborated with international and local NGOs to develop the country’s first urban environmental youth service corps.  Ms. Tabola holds a Bachelor Degree in Social Ecology from the University of California, Irvine, and a Masters in Policy from Harvard University.  She is a Board Member of the Green Schools National Network, the Climate for Health Leadership Circle, and is a member of her city’s local Environmental Services Council.

Since Ms. Tabloa is presently serving in an acting role re: TNC's Natural Climate Solutions, her comments are her own. 

TNC's Natural Climate Solutions web page is at: https://global.nature.org/initiatives/natural-climate-solutions

The UN IPBES report's 39-page summary, see particularly "key messages" at pgs. 1-9, is at: https://www.ipbes.net/system/tdf/spm_global_unedited_advance.pdf?file=1&type=node&id=35245  

The October 2017 National Academy of Sciences Proceedings' paper, "Natural Climate Solutions," also mentioned during this discussion, is at: https://www.pnas.org/content/pnas/114/44/11645.full.pdf

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After the food industry health care is considered this country's second largest emitter of green house gas (GHG) pollution.  With emissions equal to approximately 655m metric tons of CO2 equivalents annually, if the health care industry was its own country it would rank 13th worldwide in GHG emissions.  Yale researchers have estimated the industry's GHG emissions alone are “commensurate with” the 44,000 to 98,000 annual hospital deaths the Institute of Medicine estimated from preventable medical errors nearly 20 years ago.  In addition, more recent research has shown that compared to similarly sized organizations, very few health care organizations make the effort to report their GHG emissions via the Carbon Disclosure Project or by other means.  

During this 29-minute conversation Ms. Gerwig discusses the climate change related adverse health effects Kaiser providers are currently treating.  In California, these result largely from air quality compromised by wildfires.  Moreover, she discusses the specifics concerning Kaiser's recent purchase of 180 MW of clean/renewable energy (wind and solar) along with battery storage, the expected return on this investment, patient and employee reaction to Kaiser's carbon neutral efforts,  related state efforts via the newly-formed CA Health Care Climate Alliance, Kaiser's 2017 issuance of $1 billion in green bonds and additional efforts to reduce KP's carbon footprint via improvements in supply chain management, transportation, water consumption and waste management.   Kaiser anticipates they will be carbon neutral (Katy defines as Scope 1 and 2) by next year. 

Ms. Kathy Gerwig is currently Kaiser Permanente's VP of Employee Safety, Health and Wellness and also serves as KP's Environmental Stewardship Officer.  She is responsible for organizing and managing KP's nationwide environmental initiative.  In forwarding this work Kathy has testified twice to Congress on the need for federal chemical policy reform, and she has appeared at numerous hearings on environmental issues.  Ms. Gerwig is also KP's national leader for Employee Safety and Health and Wellness, responsible for eliminating workplace injuries and reducing health risks for the organization.  Prior to joining KP 1993, Ms. Gerwig was an environmental and economic development consultant to businesses and public agencies in the United States and Europe.  Prior still she worked for nonprofit environmental organizations in California.  Ms. Gerwig holds a MBA with honors, from Pepperdine University and a bachelor’s in geography and environmental studies from San Francisco State University.  She is a certified professional health care risk manager, a certified professional environmental auditor, and a certified health care environmental manager.  Her 2014 book published by Oxford and titled, Greening Health Care: How Hospitals Can Heal the Planet, examines the intersections of health care and environmental health both in terms of harmful impacts and the revolution underway to address them.

The Kaiser press release noted is at: https://about.kaiserpermanente.org/community-health/news/kaiser-permanente-finalizes-agreement-to-enable-carbon-neutralit

Information on Greening Health Care is at: https://global.oup.com/academic/product/greening-health-care-9780199385836?cc=us&lang=en&

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The e-cigarette market, or what the FDA formally terms Electronic Nicotine Delivery Systems or ENDS, has grown since 2004 to approximately 11 million American consumers.  Recent survey data published in February in JAMA has shown use of e-cigarettes (or vaping) among underage youths or middle and high school students has increased significantly since 2011.   Beyond potentially serving as a gateway to the use of combustible or tobacco cigarettes, there is research to suggest nicotine can harm developing adolescent brains and the exhaled aerosol can also pose a public health threat.   Beyond the significant increase in under age use there is also concern recent investments in the e-cigarette industry by tobacco manufacturers, specifically Altria's December investment in e-cigarette manufacturer, JUUL, will result in e-cigarette users transitioning to tobacco cigarettes.  Recently resigned FDA Commissioner, Scott Gotlieb, made e-cigarette regulation a priority throughout his two-year tenure.  The question begged is will FDA's e-cigarette regulatory actions prove productive, will they prevent or inhibit current and future consumers of nicotine from taking up of combustible/tobacco cigarettes and/or allow or encourage current tobacco cigarette consumers to transition to e-cigarettes a far safer product.    

During this 30 minute conversation Professor Abrams critiques the evidence to date that rising use of e-cigarettes among middle and high school students is necessarily a cause for concern, i.e., that e-cigarettes or vaping is a gateway to use of combustible or tobacco cigarettes.  We briefly discuss how underage youths are able to acquire e-cigarettes.  Moreover our discussion focuses on related regulatory actions under the FDA, i.e., is limiting access and use of e-cigarettes or youth addition to nicotine commensurate with the potential massive public health gain.  Are these actions commensurate with the potential to reduce adult combustible cigarette use that remains the leading cause of preventable death in the US at nearly half a million deaths per year (and estimated to kill 1 billion throughout the world this century).  We also discuss Altria (manufacturer of Marlboros) recent $13 billion investment in JUUL, the leading e-cigarette manufacturer or what it may mean, reducing nicotine content in cigarettes, raising the minimum age requirement from 18 to 21 to buy tobacco cigarettes and related issues.    

Dr. Abrams is currently Profess of Social and Behavioral Sciences at New York University.  Dr. Abrams was a professor and founding director of the Centers for Behavioral and Preventive Medicine at Brown University Medical School.  He then directed the Office of Behavioral and Social Sciences Research at the National Institutes of Health (NIH).  Until 2017, he was Professor of Health Behavior and Society at Johns Hopkins Bloomberg School of Public Health and the founding Executive Director of the Schroeder National Institute of Tobacco Research and Policy Studies at Truth Initiative (formerly the American Legacy Foundation).  Dr. Abrams has published over 250 peer reviewed scholarly articles and been a Principal Investigator on numerous NIH grants.  He is lead author of The Tobacco Dependence Treatment Handbook: A Guide to Best Practices.  He has served on expert panels at NIH and National Academies of Sciences, Engineering and Medicine on Obesity, Alcohol Misuse and Ending the Tobacco Problem: A Blueprint for the Nation. He has also served on the Board of Scientific Advisers of the National Cancer Institute (NIH-NCI) and was President of the Society of Behavioral Medicine.

For information concerning the FDA's regulation of tobacco products go to: https://www.fda.gov/TobaccoProducts/default.htm  

The JAMA studied discussed during this interview, "The Association of Electronic Cigarettes Use with Subsequent Initiation of Tobacco Cigarettes in US Youths," is at: 

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2723425

Concerning Prof Abrams recent related research see: https://www.clivebates.com/documents/AbramsFeb2019.pdf and https://www.sciencedirect.com/science/article/pii/S0091743518301981?via%3Dihub

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In 2017 more than 47,000 Americans committed suicide.  While suicide rates decreased during the 1980s and 1990s, they have increased by 33% over the past two decades.  Today they are one of the top ten causes of death.  Suicide or suicide-homicides, where the spouse or partner kills their loved one and frequently and immediately themselves, are unsurprising for several reasons.  Among others, the US has no universal long term care policy.   (The ACA attempted to create a voluntary long term care provision, termed the CLASS Act, but it was never implemented having found to be financially non-viable - some would say intentionally so.)  Medicare does not provide long term coverage.  The Medicare hospice benefit is de facto time limited (Medicare hospice providers have an annual per beneficiary reimbursement cap, the only Medicare program to impose a spending cap), one has to meet a poverty threshold to qualify for long term care under Medicaid and commercial long term care insurance, if available, is unaffordable for many seniors.  This last fact is largely explained by the reality that a quarter of Medicare beneficiaries have annual incomes below $15,000 and an equal percent have savings totaling less than $15,000 and over half of these have no savings or are in debt.   Concerning medical aid in dying laws, that present their own limitations, currently only eight states (NJ as of this past week) and DC allow for it. 

During this 27 minute conversation, Ms. Neumann discusses her recent  Harper's Magazine essay titled, "Going to Extremes, Are Homicides Among the Elderly Acts of Mercy or Acts of Malice?"  The conversation begins with Ms. Neumann's account of Philip Benight and Becky Golden's experience around which the essay is focused.  Ms Neumann moves on to discuss how these acts are addressed by prosecutors, what explains a not uncommon precipitating event, that is terminally ill patients being held in acute or in-patient settings against their will, how and why the health care industry fails to meet the needs of seriously/terminally ill individuals and whether mercy killings can be defined as rational suicides or whether they are acts of mercy or malice.        

Ms. Ann Neumann is the author of The Good Death: An Exploration of Dying in America and a nonfiction contributing editor at Guernica magazine.  Ms. Neumann was a visiting scholar at The Center for Religion and Media at New York University until 2018 and has written about religion and health care for Harper's Magazine, The New York Times, The Washington Post, Virginia Quarterly Review, The Baffler and other publications.  Ms. Neumann is currently working on a book about grief and travel. 

Ms. Neumann's February Harper's Magazine essay is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/

The Kaiser Health News April 9th report noted in the introduction of this podcast and titled, "Lethal Plans: When Seniors Turn to Suicide in Long-Term Care," is at: https://khn.org/news/suicide-seniors-long-term-care-nursing-homes/

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Medicare's Fee for Service Alternative Payment Models (APMs), a creation of 2015 MACRA legislation, currently 12 in number with participation largely voluntary, requires Medicare providers to assume financial risk, based on historical spending and quality measurement performance, beyond a "nominal amount."  The flagship APM is the ACA's Medicare Shared Savings Program, more commonly termed Accountable Care Organizations (ACOs).  Though in its 8th year, the ACO program, that currently provides care to over 10 million assigned Medicare beneficiaries, has not produced meaningful savings (estimates are 1 to 2% annually).  Nor have other APMs, largely bundled payment arrangements, produced substantial savings.  The Medicare Advantage program (with one-third of Medicare beneficiaries), defined as administrative pricing, does not formally score savings.  Over the past few years per capita Medicare spending has been limited, however, program growth or beneficiary enrollment (via the aging baby boomer population) is causing Medicare spending, in sum, to increase substantially.  In addition, the soon-to-be-published annual Medicare Trustee's report will show the program will become insolvent within the next few years. 

During this 26 minute discussion, Mr. Miller provides an overall assessment of APM performance to date.  He moreover discusses the shortcomings in APM design or the barriers APM providers face in improving care, e.g., as ostensibly Fee for Service APMs are not reimburse for valuable non-medical services such as social service supports and ways to improve these models.  We conclude the discussion with his views on the ACA-created PTAC (the Physician-Focused Payment Model Technical Advisory Committee), that has reviewed to date over 30 submitted APM proposals, none of which have been chosen by Secretary Azar for testing as a Medicare demonstration.    

Mr. Harold D. Miller is the President and CEO of the Center for Healthcare Quality and Payment Reform.  In this role he has worked in more than 40 states and metropolitan regions to help physicians, hospitals, employers, health plans, and government agencies design and implement payment and delivery system reforms.  He is also currently one of eleven members of the PTAC.  He also serves as Adjunct Professor of Public Policy and Management at Carnegie Mellon University.  Mr. Miller has written a number of widely-used papers and reports on health care payment and delivery reform.  He has assisted numerous professional organizations in developing alternative payment models designed to support better care for patients at lower cost.  From 2008 to 2013, Mr Miller served as the President and CEO of the Network for Regional Healthcare Improvement (NRHI), the national association of Regional Health Improvement collaboratives.  He served as a member of the Board of Directors of the National Quality Forum from 2009 to 2015.  From 2006 to 2010, Mr. Miller served as the Strategic Initiatives Consultant to the Pittsburgh Regional Health Initiative (PRHI).  In 2007, he served as the Facilitator for the Minnesota Health Care Transformation Task Force.  In previous positions, Mr. Miller served as the Director of the Pennsylvania Governors Office of Policy Development, Associate Dean of the Heinz School of Public Policy and Management at Carnegie Mellon University, Executive Director of the Pennsylvania Economy League - Western Division, Director of the Southwestern Pennsylvania Growth Alliance and President of the Allegheny Conference on Community Development.

For information on the Center for Healthcare Quality and Payment Reform, go to: http://www.chqpr.org/ 

For information on the PTAC, go to: https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee

Per my mention of Dr. Robert Berenson's recent (February) essay concerning improving the Medicare Fee for Service schedule, go to: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05411

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Despite gains made under the ACA, health insurance coverage in the US remains fraught with problems.  Over 28 million non-elderly remain uninsured.  Health care spending is extreme.  Health care coverage is the most expensive worldwide in absolute terms and relative to average incomes – despite the fact Americans consume no more or fewer health care resources than our comparative peers.  In 2018, an insurance premium for a family of four was $19,616 or almost one-third of median household income of $61,372.  Several factors explain this.   Among others, while Medicare spending per capita decreased by 1.2% between 2007 and 2014 however for private insurance spendingincreased per capita by 16.9%.  Rapidly rising drug prices, that account for 17% of all national health spending, are two times as much as comparative countries.  Americans also pay substantial health care administrative costs that equaled $259 billion in 2017, or nearly four times average of other developed countries.  (We spend more on health care administration the UK spends on all of health care.)  Relative to outcomes, US life expectancy at birth, that has declined for the past three years (for the first time in a century), is exceeded by 79 countries.  Per a recent Bloomberg health efficiency study, the US ranked 54th out of 56 countries.  Hong Kong, Singapore and Spain ranked 1 through 3, the US fell between Azerbaijan and Bulgaria.

During this 29 minute conversation Mr. Eyles answers whether health care coverage is a right or a privilege, notes AHIP's position on Texas v. Azar, discusses the problem of consolidated insurance markets, i.e., lack of market competition and what can be done about it.  He responds to questions concerning the health care sectors efforts at measuring for value (outcomes achieved relative to spending), the Medicare Advantage (Part C) program, the future of the insurance industry, what it is doing to address or prepare for the health effects of climate change and we conclude with his brief comment regarding Medicare for All. 

Matthew (Matt) Eyles has served as President and CEO of America's Health Insurance Plans or AHIP (the national trade association representing commercial health insurance providers) for one year.  Mr. Eyles joined AHIP in 2015 to lead its Policy and Regulatory team and served as Chief Operating Officer just prior to his current position.  Just previously, he served in several senior positions at Coventry Health Care (now an Aetna company) and with Wyeth (now a subsidiary of Pfizer).  He also was employed by Avalere Health, a DC-based consulting firm, where his worked moreover concerned pharmaceutical industry issues.  Mr. Eyles began his career at the Congressional Budget Office where he examined an array of health care policy topics.  Mr. Eyles serves on the Board of Directors of the National Health Council and previously on the Board of the Network for Excellence in Health Innovation (NEHI).  He earned his undergraduate degrees in history and political science from The George Washington University and a graduate degree in public Policy from the University of Rochester. 

For information on AHIP go to: https://www.ahip.org/.

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For this, my 168th interview, David Wallace Wells discusses his just-published book, "The Uninhabitable Earth, Life After Warming."  Listeners may recall I interviewed Mr. Wallace Wells on August 2, 2017 shortly after his published his July 2017 New York Magazine article by the same title, "The Uninhabitable Earth."  (At: http://nymag.com/intelligencer/2017/07/climate-change-earth-too-hot-for-humans.html.)   (In the recent past, or since last October, I've also interviewed Jessica Wolff, Kris Ebi and Jeremy Hess all on climate change.)   Currently, the earth has warmed to approximately 1 degree Celsius (1.8 F).  Our atmosphere presently contains over 400 parts per million of CO2, more than anytime over upwards of the past 15 million years.  According to the United Nations we are on course to pass 1.5C by 2040.  We learned last October the difference between 1.5C and 2.0C, per the UN Intergovernmental Panel on Climate Change (IPCC), is cataclysmic.  (We are after all the Goldilocks planet.)  As one commenter of Wallace's Wells work has noted, "the impacts of climate change will be much graver than most people realize and he is right." Another stated, Wallace Wells " doesn't sugarcoat the horror."  As I note in the introduction to this interview, younger listeners (say under 40) are particularly encouraged to listen since you will inherit the full consequences of climate change.     

During this 35-minute conversation Mr. Wallace Wells begins by describing what explains the planet's five great extinctions and what effect they had on species survival.  (Scientists believe we are presently experiencing our sixth great extinction.)  Based on his intensive study he offers the most likely scenario relative to the current and near-term emissions of global warming greenhouse gas emissions.  He discusses current science on global warming feedback loops, e.g., the albedo effect, James Hansen's "scientific reticence" critique, the value of exploiting hope versus fear in addressing global warming, the promise of carbon capture technology or negative emissions technology and creating hydrocarbon fuels from carbon capture and a general assessment of current US politics, including the recent "Green New Deal," in re: remedying climate change/global warming.       

David Wallace-Wells is deputy editor at New York Magazine, where he also writes about science and his  recurring “Tomorrow” column on the future of science and technology, e.g., his 2015 cover story about the epidemic of honey-bee deaths (the first magazine story to put the blame on neonicitinoid pesticides, which is now accepted science).  He joined the magazine as literary editor in 2011, became features director in 2016, and has overseen the magazine’s family of podcasts in addition to his writing and editing.   Before joining New York magazine, David was deputy editor at The Paris Review, where he edited and published writers such as Ann Beattie, Werner Herzog, Jonathan Franzen, Janet Malcolm, among others, and interviewed William Gibson as part of the magazine’s “Writers at Work” series.  He previously served as "The New York Sun’s" book editor.  Mr. Wallace Wells was graduated from Brown University.

Listeners are again encouraged to read the IPCC's recent, "Global Warming of 1.5C," a 32-page summary of the report is at: https://report.ipcc.ch/sr15/pdf/sr15_spm_final.pdf. 

US healthcare spending is extreme currently at approximately $4.3 trillion.  The single largest payer of healthcare services is Medicare at roughly $900 billion annually or 21% of total healthcare spending.   In this edited volume, recently published by Johns Hopkins University Press, Dr. Moffit along with eleven other contributors including Joe Antos, Douglas Holtz-Eakin, Brian Miller, Mark Pauly and Gail Wilensky, lay out the conservative version of Medicare reform.  In sum, the authors argue federal policymakers reinvent Medicare as a defined contribution or premium support program or at minimum substantially expand the Medicare Advantage program (Medicare Part C), or Medicare coverage provided by private insurance companies. 

The interview begins by Dr. Moffit commenting on whether healthcare services can be defined as a market commodity. He discusses the problem of healthcare pricing, measuring for value in healthcare, improving Medicare Advantage benchmarking, remedying Medicare Advantage coding intensity via retrospective risk adjustment and risk transfer pools and competing fee for service Accountability Care Organizations (ACOs) against Medicare Advantage.

Dr. Robert Moffit is a Senior Fellow in Domestic Policy Studies at The Heritage Foundation specializing in health care and entitlement programs, moreover Medicare. Dr. Moffit also serves on the Maryland Health Care Commission as an appointee of Gov. Larry Hogan and he is a member of the advisory board of the Buckley School of Public Speaking in Camden, South Carolina. He brings to the reform effort experience as a senior official of the U.S. Department of Health and Human Services (HHS) and the Office of Personnel Management (OPM) during the Reagan administration. Dr. Moffit is a co-author of “Why Obamacare Is Wrong for America,” (Harper Collins, 2011). He was a contributor to “A Time for Governing: Policy Solutions From the Pages of National Affairs” (Encounter Books, 2012) and “Controversial Issues in Social Policy” (Allyn and Bacon, 2003), a university textbook on public policy. He has published in numerous professional and specialty journals among them Health Affairs, Health Systems Review, Harvard Health Policy Review, Inquiry, Journal of Law, Medicine and Ethics, National Affairs, New England Journal of Medicine, Postgraduate Medicine, and Journal of Medicine and Philosophy. His analysis and commentary have been cited or published by The New York Times, The Wall Street Journal, The New York Post, The Washington Post and The Washington Times. He holds a master's degree and a doctorate in Political Science from the University of Arizona. He received his bachelor's degree in Political Science from LaSalle University in Philadelphia.

Information on “Modernizing Medicare,” is at: https://www.press.jhu.edu/books/title/12839/modernizing-medicare.

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The administration and the Congress are currently discussing various proposals to reform drug pricing policy.  Drug prices, as listeners are likely well aware, have risen substantially over the past two decades.  For example, between 1997 and 2007 they tripled and currently year-over-year Medicare Part D drug spending is expected to grow through 2026 at twice the 2007 through 2013 growth rate.   The administration formally began its effort last May with the announcement of its drug pricing "blueprint."  The Congress is currently holding hearings, e.g., the Senate Finance and House Oversight committees, on drug pricing.  The administration currently is proposing two drug pricing reforms that would address both Medicare Part B and Medicare Part D drug pricing and the Congress has already introduced several bills to curb drug price growth.     

During this 28 minute conversation Dr. Levin discusses ATAP's mission and funding and ATAP's position on the administration's current proposal to reform Medicare Part B drug pricing via reference pricing or via the use of an international price index.  Dr. Levin discusses moreover the administration's current proposal to reform Medicare Part D drug pricing by eliminating or prohibiting drug manufacturers from paying a rebate to pharmaceutical benefit managers (PBMs) and Part D plan sponsors.  Our conversation concludes with Dr. Levin's comments concerning the long standing debate whether the Secretary of DHHS should be allowed to negotiate Part D drug prices with manufacturers.   

Dr. Robert Levin is the President of the Alliance for Transparent and Affordable Prescriptions (ATAP), President of the Florida Society of Rheumatology and is a practicing physician in Tampa Bay.  He teaches medicine at the University of South Florida and has served as a principal investigator in dozens of clinical trials involving rheumatoid arthritis, osteoarthritis, osteoporosis, lower back pain and fibromylagia.    Dr. Levin is board certified in Internal Medicine with a sub-specialty in rheumatoid arthritis and is a fellow with the American College of Rheumatology and the American College of Physicians.  He earned his medical degree at Hahnemann University in Pennsylvania, did his residency at the Medical College of Pennsylvania and earned his undergraduate degree in chemistry from Oberlin College in Ohio.   

For information on ATAP go to: https://atapadvocates.com/. 

Concerning the proposed Medicare drug rebate proposal go to: https://www.govinfo.gov/content/pkg/FR-2019-02-06/pdf/2019-01026.pdf.

For an overview of drug pricing issues, see, for example, Hopkins Professor Gerald Anderson's recent Senate Finance Committee testimony, at: https://oversight.house.gov/legislation/hearings/examining-the-actions-of-drug-companies-in-raising-prescription-drug-prices. 

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Over 40 million Americans live in poverty or upwards of 14% of the population.  Those living in extreme poverty number 18 million and over 5 million live in absolute poverty.  The US also has the highest youth poverty rate among OECD countries.  This reality is made worse by the fact the US is the only highly developed country in the world that lacks universal health care coverage.   Despite passage of the ACA in 2010 that reduced the number of non-elderly uninsured from 44 million to 27 million by 2016, last week Gallup survey data indicated over the past four years seven million fewer Americans have health care insurance.  This finding is not unsurprising considering the administration's ACA regulatory actions over the past two years.  With a significant number of Americans impoverished and a recent decline in those covered, it is no surprise that Americans are forced to seek charity care.   

During this 21 minute interview, Mr. Eastman explains why RAM was founded by Stan Brock in 1985, he describes RAM's upcoming clinic or "expedition" (RAM's 1,000th) this weekend in Knoxville.  More specifically he provides an overview RAM's patient population, the types of medical care RAM provides and who provides RAM care.   He also discusses how clinic sites are selected in the US and overseas and how the organization is funded.   (Over the past 34 years, RAM has served over 785,000 patients, via the volunteer efforts of over 135,000 clinicians and other volunteers, providing an estimated $785 million in free health care.) 

Jeff Eastman is currently the CEO or Remote Area Medical (RAM).  Previously, he spent 28 years employed by Altria sales and distribution.  He began volunteering with RAM in 2008 and in 2014 became a full-time employee.  In 2015 he was voted RAM's first ever CEO.  Jeff earned an Associate’s Degree from the State University of New York at Canton, a Bachelor’s Degree from the University of Tennessee at Chattanooga, and a Master’s of Business Administration from Lincoln Memorial University.  Jeff lives in Athens, Tennessee with his wife, Debbie.

For more on RAM go to: https://www.ramusa.org/. 

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This past summer the the Democratic Republic of the Congo (DRC) began experiencing its 10th Ebola outbreak.  (The virus, with a mean mortality rate of 50 percent, is endemic in that country.)  To date, the current outbreak has claimed approximately 400 lives.  The World Health Organization (WHO) expects the outbreak to persist for another six months, in part, because current political turmoil in the DRC is effecting the ability of health officials to contain the spread of the disease to neighboring Rwanda, the South Sudan and Uganda.  Listeners may recall the last Ebola outbreak in 2014-2016 in West Africa infected over 28,000 and killing over 11,000.  While vaccines are in development and currently in use in the Congo there is currently no approved or licensed vaccine.

During this 21 minute conversation Joseph Lafave discusses the status of the current outbreak, the role political instability resulting from a disputed December 30th DRC presidential election is playing in containing the outbreak, what support the US is currently providing, how the US's current response compares to its 2014-2016 efforts, what related actions the Congress has taken, progress in developing an Ebola vaccine and the difficulty in fighting a major public health problem in context of political unrest.

Joseph Lafave is a journalist with NewRep and covers infectious disease outbreaks along with military and finance issues.  Prior to is journalism work that included work at the Shreveport News, Mr. Lafave worked as an Environmental Safety and Health Engineer for Lockheed Martin as a Emergency Medical Technician in Leon County, Florida, and as a Safety Administrator for University Health Shreveport.  Mr. Lafave holds a Masters of Science in Healthcare Management from the University of Southern New Hampshire and an undergraduate degree in criminology from Florida State University.      

For more information on Ebola go to, e.g., https://www.cdc.gov/vhf/ebola/index.html.   

Also, please see this January 22nd JAMA viewpoint/editorial, "Ebola and War in the Democratic Republic of the Congo, Avoiding Failure and Thinking Ahead," at: https://jamanetwork.com/journals/jama/fullarticle/2717586?guestAccessKey=c668402c-2993-40a9-95aa-eefd1a0c47f1&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=012219