Tom Bodenheimer – Building Blocks of High-Performing Primary Care and the Quadruple Aim

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Dr. Tom Bodenheimer is one of the world’s foremost experts in primary care re-design, having recently written about high-performing primary care clinics and the Quadruple Aim, which are articles consistently in the most-read list for the Annals of Family Medicine and among his most cited work.  We focused much of our conversation on his work visiting 23 high-performing primary care practices, what he and co-authors learned, how resident teaching sites can also be high-performing, and why we should be seeking a fourth aim in addition to IHI’s famed Triple Aim.

A general internist who received his medical degree at Harvard and completed his residency at the University of California-San Francisco, Dr. Tom Bodenheimer spent 32 years in primary care practice in San Francisco’s Mission District, a primarily low-income, Latino community—ten years in community health centers and 22 years in private practice.  He is currently Professor of Family and Community Medicine at UCSF and Founder and Co-Director of the Center for Excellence in Primary Care.  He has written extensively in journals such as the New England Journal of Medicine, JAMA, Annals of Family Medicine, and Health Affairs, on health policy and health care delivery for chronic disease management, including patient self-management, health coaching, and team-based care. He is also co-author of the books Improving Primary Care: Strategies and Tools for a Better Practice, and the health policy text book Understanding Health Policy.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.

Joshua Freeman – Designing a Fair & Equitable Healthcare System

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Dr. Joshua Freeman is a family physician, health policy researcher, social justice activist, and writer.  He publishes a widely-read blog, “Medicine and Social Justice”, and in 2015 published a book, Health, Medicine and Justice: Designing a fair and equitable healthcare system (Copernicus Healthcare press), which is available on Amazon and other sites, in both softcover and electronic versions.

This week, Thomas Kim chats with Dr. Freeman about some of the major themes of the book: why the US health care system fails to produce a healthy population, the role of profit in American medicine, why he uses social justice to frame his analyses and commentary, and how the American health care system could become more primary care-centered.

Dr. Freeman is Professor Emeritus at the University of Kansas Medical Center in Kansas City, where he served as the Alice M. Patterson MD and Harold L. Patterson MD Professor and Chair of the Department of Family Medicine from 2002-2016, and was also Professor in the Departments of Preventive Medicine and Public Health and of Health Policy and Management. He was a Fulbright Scholar in São Paulo, Brazil in 2003 and served nationally as Treasurer of the Society of Teachers of Family Medicine and the Association of Departments of Family Medicine. He received STFM’s highest honor, the Recognition Award, in 2006. He served as a member of the board of trustees of Roosevelt University in Chicago, as assistant editor of the journal Family Medicine, and also on the board of Southwest Boulevard Family Health Center in Kansas City, KS.

Dr. Freeman is a graduate of the Loyola-Stritch School of Medicine, family medicine residency at Cook County Hospital in Chicago, and faculty development fellowship and Preventive Medicine residency at the University of Arizona.

This interview was lightly edited for clarity.

David Himmelstein – Blending Research & Advocacy

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Our guest this week is David Himmelstein. He is a distinguished professor of public health and health policy in the CUNY School of Public Health at Hunter College, adjunct clinical professor at Albert Einstein College of Medicine, and lecturer in medicine at Harvard Medical School. He has served as chief of the division of social and community medicine at Cambridge Hospital.

David has authored or co-authored more than 100 journal articles and three books, including widely cited studies of medical bankruptcy and the high administrative costs of the U.S. health care system. His 1984 study of patient dumping led to the enactment of EMTALA, the law that banned that practice. He is also a co-founder of Physicians for a National Health Program and is a principal author of PNHP articles published in the JAMA and the New England Journal of Medicine in conjunction with Dr. Steffie Woolhandler.

We talk about how he got his start in research by looking at patient dumping practices as a trainee, and how he views advocacy as a natural outgrowth of his research findings. We also talk about his work as a leader in advocacy for a national health insurance program and talk about a few common arguments against such policy changes. Lastly, he gives some advice for folks early in their career who would like to follow his model of research blended with advocacy.

If you like the show, please rate and review us on itunes, google play, or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you, and thanks for listening.

Gail D’Onofrio, Initiation of Suboxone Treatment for Opiate Use Disorder in the ED

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This week we are again looking at the opioid crisis, but this time from the perspective of an emergency room physician. Gail D’Onofrio, MD, MS is Physician-in Chief of Emergency Services at Yale-New Haven Hospital; she and her colleagues published a randomized controlled trial in JAMA in April 2015 looking at an intervention initiating suboxone treatment for patients with substance use disorders in the ED.  Gail is Professor and Chair of the Department of Emergency Medicine at Yale University and is internationally known for her work in substance use disorders, women’s cardiovascular health, and mentoring physician scientists in research careers, and she is a founding board member of the American Board of Addiction Medicine.

We talk about her perspective on the opioid epidemic as an ED physician; her RCT; how people could set up a similar program in their local ED and community; and her thoughts on ED utilization for primary care complaints, which is the subject of a recently issued report from the Massachusetts Health Policy Commission.

Please rate and review us on iTunes or Stitcher and share us on social media. Tweet us your thoughts @RoSpodcast and check out our Facebook page at www.facebook.com/reviewofsystems. Or, you can email us at contact@rospod.org. We’d love to hear from you.

Harold Pollack – ACA and AHCA Update

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This week we are joined a few days early by Harold Pollack to bring you a timely update on the Affordable Care Act (ACA) repeal and American Health Care Act (AHCA) legislation that is moving quickly through congress.

Harold has published widely at the interface between poverty policy and public health including the effects of health reform and the ACA. Today we talk about the current state of the repeal and replace effort in the Senate and what effects their bill would have in terms of individuals who would lose coverage or find it much more expensive should the bill pass. We also discussed the very dramatic changes the bill would likely make to Medicaid and how that might affect the poor and vulnerable people that the program serves, and in particular how it might impact the raging opiate epidemic. Lastly, we talk about what a bipartisan solution to many of the very real problems of the ACA might look like, and what impact individuals can have on policy by calling congress. You can find more information about the unusual legislative process here, and the lack of information available on the bill here. Read about the effects that changes to Medicaid might make for disabled individuals here, and listen to Matt Broaddus of the Center on Budget and Policy Priorities discuss block granting and per capita caps on Medicaid here. If you would like to reach out to your Senator to talk with him or her about the legislation and how it might affect you or your patients, you can find your Senator’s contact information here.

Harold is the Helen Ross Professor at the School of Social Service Administration, an Affiliate Professor in the Biological Sciences Collegiate Division and the Department of Public Health Sciences and Co-Director of The University of Chicago Crime Lab and a committee member of the Center for Health Administration Studies (CHAS) at the University of Chicago. He tweets @haroldpollack.

If you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

Lauren A Taylor – Integration of Healthcare and Social Services

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Today we’re joined by Lauren A Taylor, a health services researcher based at Harvard Business School, where is she is earning her doctorate in health policy and management. Prior to joining HBS, Lauren co-authored The American Health Care Paradox, which has become required reading at a variety of medical and public health schools across the country. Our discussion spans a range of topics and should excite clinician and policymaker listeners alike, especially those interested in addressing upstream factors that affect health in our American society.

We start with reviewing the initial research paper that lay the groundwork for her book and what other countries show us about how government spending on social services can affect health outcomes, as well as what she learned interviewing caregivers and social services workers in the US.  We also talk on how American sociopolitical factors influence our discourse on the distribution and allocation of resources as well as how research is done in her field. We discuss whether health systems are moving in the right direction addressing social determinants of health through ACOs, why management gets overlooked and undervalued as a key ingredient in healthcare delivery, and why it’s just so hard to get all of this right.

Lauren’s work focuses on organizational theory and strategy in health care, with a particular emphasis on the integration of health and social services. She holds a BA in the History of Medicine and a Master in Public Health from Yale University. She has also worked as a health care chaplain and studied ethics as a Presidential Scholar at Harvard’s Divinity School.

If you like the show, please subscribe on our website www.rospod.org, and rate us on iTunes and Stitcher and share us on social media. Get in touch via twitter @RoSpodcast or drop us a line at contact@rospod.org. Thanks for listening!

Dennis Dimitri – Supervised Injection Facilities

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Today we are joined by Dr. Dennis Dimitri, the immediate past-president of the Massachusetts Medical Society (MMS) and current chair of the society’s Task Force on Opioid Prescribing and Physician Communication, to discuss supervised injection facilities, or SIFs. A SIF is a location where individuals may use illegal drugs under the supervision of a medical professional ready to assist in case of an overdose requiring treatment.

Later this month, the MMS will vote on whether to advocate for a task force to assess the feasibility of a pilot SIF in the state of Massachusetts. If the proposal is approved, the MMS will become the first statewide physician organization in the Bay State to advocate for such a pilot program.

We discuss with Dr. Dimitri what it would mean should the MMS advocate for SIFs. We review the evidence on the effect of SIFs on rates of fatal overdoseuptake of Substance Use Disorder treatment, and rates of transmission of HIV and HCV. We talk about the ethical considerations of such a program, whether SIFs enable behaviors harmful to people’s health or they represent harm reduction, and the complex legal considerations involved with a potential pilot program.

Major events of the opioid epidemic in the last few years, such as business owners planning for the possibility of overdose in bathrooms and a recent HIV outbreak stemmed by a needle exchange program in Indiana, raise the potential benefits of SIFs. If you’re interested in reading more, check out recent guest Dr. Sarah Wakeman‘s compassionate and evidence-based case for SIFs in this recent NEJM article. You can also listen to our past episode Dr. Jessie Gaeta on the SPOT program (supportive place for observation and treatment) when she also gave her thoughts on SIFs.

Dr. Dimitri is a family physician and Vice Chair of the Department of Family Medicine at University of Massachusetts and the UMass Memorial Medical Center.

What do you think? In the face of the opioid epidemic, could pilot SIFs in the US also reduce overdose deaths as in Canada and Australia? Tweet us your thoughts at @rospodcast or leave a comment on our facebook page at www.facebook.com/reviewofsystems.  Or, drop us a line directly at contact@rospod.org. We’d love to hear from you – and thanks for listening.

Graphic from of Centers for Disease Control, Opioid Overdose.

Emma Sandoe – Update on the AHCA & ACA

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This week, we are publishing the show a few days early to bring you a timely AHCA and ACA update. We are joined once again by Emma Sandoe, a PhD candidate in Health Policy & Political Analysis at Harvard University, for a discussion of the AHCA, the most recent attempt to repeal the ACA. You can find our prior episode with Emma, about the ACA, here. Prior to starting her PhD program, Emma spent six years in Washington, DC working on the passage and implementation of the ACA. She served as the spokesperson for Medicaid and HealthCare.gov at the Centers for Medicare & Medicaid Services and worked on ACA coordination at the HHS Budget Office.

We start with a summary of what happened this week and what were key factors in the ACHA’s demise (2:45), in particular the key Essential Health Benefits (9:00), talk about the future of the ACA (14:05), and ways that opponents of the law may try to sabotage it’s success over the next few years (15:25), and finally how lawmakers might address some of the very real problems with the law (16:57).

It turns out that healthcare reform is complicated, and advocacy does work as this Washington Post article shows. Listen to a show all about block grants and per capita caps on Medicaid featuring Matt Broaddus of the Center on Budget and Priorities here.

If you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

David Buck – Caring for High Need, High Cost Patients

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This week, Thomas Kim hosts the show and interviews Dr. David Buck, a family physician and professor of family and community medicine at the Baylor College of Medicine.  He is the founder and president of Patient Care Intervention Center (PCIC), an organization that uses advanced population health methods to target super-utilization of the health care system and intervenes through intensive care coordination and case management. It’s based in Houston, Texas and recently opened a branch in Dallas, and they were recently featured on PBS NewsHour. Prior to Dr. Buck’s work at PCIC, he founded Healthcare for the Homeless – Houston (HHH), now a federally qualified health center for over 7,000 homeless in Harris County, as well as the associated Houston Outreach Medicine Education and Social Services (HOMES) clinic, a student-managed clinic at HHH in conjunction with BCM and the University of Texas Health Science Center. He is a co-founder of the Houston-based physician advocacy group Doctors for Change, and founded the Houston-Galveston Albert Schweitzer Fellowship. He helped found the international street medicine institute, and was appointed to the 15-member Consumer Operated and Oriented Plan Program advisory board created as part of the Patient Protection and Affordable Care Act in 2012.
You can find some CDC resources about Adverse Childhood Experiences, or ACEs here, and a New Yorker article about the effects of ACEs on health here.
Dr. Buck is a graduate of the Baylor College of Medicine and the University of Texas School of Public Health, as well as family medicine residency at the University of Rochester.

Matt Broaddus: What are Medicaid Block Grants?

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This week we are joined by Matt Broaddus to talk about block granting Medicaid, which is a major health policy change that the Trump administration plans to pursue in the coming months. Matt is a Research Analyst in the Health Division at The Center on Budget and Policy Priorities, a non-partisan research and policy institute in Washington DC. His policy, research, and analytical work is conducted in the areas of Medicaid and the State Child Health Insurance Programs.

We start with an overview of the Medicaid program, the largest insurance program in the US. We touch on the possible benefits of block granting (19:00), and how it may affect other industry stakeholders such as health systems, hospitals, community health centers, and insurers that offer Medicaid managed care products (23:20). Lastly we discuss another block granted program, CHIP and why many see it as a successful block grant program (29:00), and one other suggestion that has been made for Medicaid reform, per-capita funding (32:45).

You can find the article we mentioned by Sara Rosenbaum here, as well as some additional resources on block grants from Kaiser Health News and The Commonwealth Fund.

If you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

Photo: President Lyndon B Johnson surrounded by supporters and advisors signing Medicare into law.