Dr. Sanjeev Arora, founder of the Project Extension for Community Healthcare Outcomes (Project ECHO).

(Music)

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, was there any surprise to the news that the super
committee made up of equal number of democrats and republican law makers
did not approve the plan to reduce the deficit by at least $1.2 trillion, now am I
right, the majority, they only need it seven out of 12?

Margaret Flinter: That’s what I understand. And I’m getting the feeling that our
leaders like to keep us on the edge because they do a lot of it these days. As
usual, the two sides cannot bridge the taxes versus the entitlements divide and
without an agreement or some sort of postponement worked out a set of
automatic cuts are going to kick in to reduce the deficit over the next 10 years
and we’ve introduced a new word to the vocabulary “sequestration” not one that I
think the American public was familiar with before this debate.

Mark Masselli: Well, there is the old adage that ‘less is more’. I have heard the
analysis that if Congress doesn’t act either in this case or on the Bush tax cuts
there will be about $6 trillion in savings or new revenues brought into the system.
One hopes that these cuts aren’t in the healthcare area but I have a feeling that
it's on the top of many people’s list.

Margaret Flinter: I think so. And some people believe a way to avoid having
healthcare cost cut is to transfer those costs from the federal budget on to
individuals, insurers and healthcare providers but I think we’ve already been
there and tried that. Others suggest this just fails to address the underlying
healthcare cost issues. But you know back to this resolution, I heard some
members of Congress saying, ‘well, those automatic triggers maybe they aren’t
so automatic and we can put those aside.’ But the president has been pretty
clear. He is going to hold those triggers in place if they fail to reach an
agreement.

Mark Masselli: And hold their feet to the fire. But well, there are a lot of dismal
thoughts happening in Washington, it is the time of celebration. Thanksgivings is
right around the corner. It's a day of ‘thanks’ and we hope everyone is
surrounded by family and friends and good food, not too much of that food.

Margaret Flinter: That’s right. And I think today’s guest can also set an optimistic
tone for us today about real people solving real problems. Dr. Sanjeev Arora is
the founder of Project Extension for Community Healthcare Outcomes or Project
ECHO. It's an innovative model of care that links primary care providers with
specialists in both rural and underserved areas of the country as a way of
eliminating barriers to specialty care and improving health outcomes. And I think

he has the potential to be a game changer for the way primary care providers
can treat patients with complex illness.

Mark Masselli: We are very excited to learn more about Project ECHO. But no
matter what the story, you can always find out more about our shows and hear
more about us by googling chcradio.com.

Margaret Flinter: And as always, if you have feedback, e-mail us at
chcradio.com, we love to hear from you.

(Music)

Mark Masselli: Today Margaret and I are speaking with Dr. Sanjeev Arora,
founder of the Project Extension for Community Healthcare Outcomes known as
Project ECHO, a model of care that’s linking primary care providers with
specialist to improve healthcare in rural and underserved areas. Welcome, Dr.
Arora.

Dr. Sanjeev Arora: It's a pleasure to be here.

Mark Masselli: You know, the New England Journal of Medicine published your
study about Project ECHO describing how primary care providers can treat
patients with complex illnesses, usually managed by specialists and you’ve
established a very innovative model some would say a disruptive innovation, one
that takes advantage of technology to provide expert consultation and support via
video conferencing. Tell me, what’s the story behind the start of Project ECHO
and what are your outcomes to date?

Dr. Sanjeev Arora: So Project ECHO was started about seven and a half years
ago and the problem we were facing at that time in New Mexico as your
audience is probably aware that New Mexico is a very rural state. And about
28,000 patients with in the State of New Mexico had this very common disease
Hepatitis C. And there were very few specialists in rural areas to treat these
patients. So most of these patients didn’t have access to treatment, in fact, less
than 5% have been treated and they would be -- have to travel 200-250 miles
each way to see me. And so there was so much pressure on my schedule.
There was an eight-month wait to see me in my clinic. Now, Hepatitis C is a very
serious disease and it can cause liver cancer, it causes cirrhosis. The Center of
Disease Control has recently estimated that in the United States with the current
rate of – rates of treatment for Hepatitis C about 890,000 patients would die from
this disease in the U.S. alone. So, this was the problem we were trying to tackle
and there weren’t enough specialists in the rural areas to manage this disease.
So, we developed a new model and the goal of the model was to bring access to
best practice care for Hepatitis C to all the patients in New Mexico wherever they
lived. And we felt that if we could do that then we would have a model that could
treat Hepatitis C everywhere but not only that be applicable to many, many other

chronic diseases for which patients didn’t have adequate access to specialists.
And as you mentioned, we set up this program and we have been able to
demonstrate in the New England Journal Medicine article that you were
mentioning that after participating in the ECHO Project these rural clinicians can
manage Hepatitis C as good as we do with – as well, sorry, as we do in the
University of New Mexico and get similar outcomes. In fact the outcomes that we
got in our study were significantly better than other community-based trials for
treatment of Hepatitis C even by specialists.

Margaret Flinter: Dr. Arora, I want our audience to fully appreciate just how
valuable Project ECHO is and also what the potential of the model. And it's
important to understand those gaps in access to specialty care that patient’s
facing, you certainly talked about the rural issues where distance is the problem.
But certainly even in urban areas we see people without insurance or with the
wrong kind of insurance with just a lack of numbers of specialists in the field to
treat. But Project ECHO goes beyond just access to A specialist and I have
sighted on several of your sessions and you can see it's really giving the primary
care providers access to an entire team of specialists to help them manage their
patient. I’ve seen you with us, you’re a gastroenterologist, hepatologist, but I’ve
seen you with psychiatry, with the nurse care coordinator and addiction medicine
specialist, also around the table to weigh in on the problem. So, tell us about this
team consult approach and how did that come up about?

Dr. Sanjeev Arora: So Project ECHO is based on four key ideas. The first is, as
you saw in our clinic is the interactive video conferencing technology where
many, many primary care clinicians join simultaneously. They not only learn from
us at the university but they learn from each other. The second idea there is best
practices and that relates to the question. Best practice for a disease involves
knowledge from variety of different sources. So, we said, we would bring this
team-based best practice approach to the primary care clinicians. So, the
training and the expertise is developing is along multiple domains as opposed to
just one expert’s opinion. And the third key idea in Project ECHO is case-based
learning. That these primary care clinicians we’ve shown in our research over
time become absolute experts and they need that less and less, I hope you got
the idea when you were listening how these doctors had become quite expert in
this disease. This is not a disease typically that primary care treats, in fact when
we started Project ECHO in New Mexico not a single primary care doctor was
ever treating -- had ever treated Hepatitis C. And the fourth is we measure
outcome, so it’s a combination of all these three things. And in order to do these
well having a multidisciplinary team at the University is essential.

Mark Masselli: Dr. Arora, assured goal in healthcare today is to increase quality
while reducing cost and I think we first became aware of your work through our
relationship with the Dartmouth Institute and I know you’re paying close attention
to the two outcomes. You’ve talked about having good understanding of its
effectiveness in terms of quality, what would you say about cost and if it is

effective in both of these areas doesn’t it make sense to have this as a
fundamental approach to linking primary care and specialist versus just its
current application in rural and underserved areas.

Dr. Sanjeev Arora: So certainly that’s I hope and thank you for articulating it so
well. We think our Project ECHO saves cost in multiple different ways. So first,
it’s an obvious and simple way it saves cost in rural area that saves travel costs.
So when I used to treat Hepatitis C before I started Project ECHO, patients would
have to travel 200 miles each way. And if I was treating Genotype 1 infection
which accounts for two thirds of all patients in the United States, they would have
to make about 18 trips of 250 miles each way to see me and you could imagine
the amount of economic loss that resulted in, there is of course the gas mileage
but the time off work, and then they were feeling sick so they often had to bring
relatives with them, that was one aspect of cost saving, the travel cost. The
second is that when you bring best practice care you reduce errors in the
healthcare system because you bring coordinated care in our healthcare system
typically one party is not often aware, one physician is not aware or what the
other persons are doing. But when you all are in a room conversing together you
reduce errors and improve quality. And error reduction is a very important
component of cost reduction. Third key way Project ECHO saves costs is if you
treat disease early then you prevent downstream cost of emergency room visits,
of hospitalizations, also of end-stage liver disease, liver cancers in the future,
liver transplants, Hepatitis C is the number one reason why people get liver
transplants in the United States right now. So, there is this preventable cost of
disease that happens. The fourth is that there is a desegregation in our health
care system between the prevention arm of our health care system and the
therapeutic arm. So the Departments of Health do something different from
others from the doctors who treat patients whereas from a patient’s perspective
this care needs to be integrated. So what we do in Project ECHO is we bring this
together and we essentially rebalance because right now the therapeutic arm or
our health care system is very heavy, where as we don’t do enough prevention
etcetera. So you can have a rebalancing of this system when you bring public
health principles back into a knowledge network. And lastly, I think that doctors
typically have to travel large distances to get continuing medical education
credits that they need to keep their licenses. And, in our case, we don’t really
need to do that because they can sit in their offices as you’ve seen on the video
conferences. And they can get their educational credits while taking better care
of their patients at the same time. And we certainly hope that we can integrate
some of these ideas into the health care system of the United States for more
cost effective again.

Margaret Flinter: Dr. Arora, you’ve spoken to so many compelling outcomes that
we’re seeing and I would add to that list may be we haven't expressed it
specifically, the increased satisfaction with their primary care practice that the
physicians and nurse practitioners who are sitting in on your sessions have from
being able to manage these conditions for their patients with their patients and

their own practice. But, of course, there is one problem which is our payment
system hasn’t really caught up with this at all, and neither at the time the primary
care providers spend on their video conferences with Project ECHO nor the
extended time it may take to treat patients with these complex issues is readily
reimbursed. Are you engaged in policy efforts to try and remedy this
disconnecting? And have you been able to accomplish any of that in your home
State of New Mexico?

Dr. Sanjeev Arora: So I think that -- I think you hit on the absolute soft spot of
Project ECHO, which is really the issue of our payment when you said when you
sat in the Connecticut Community Health Center Clinic those people who are
volunteering their time to learn and treat and better have to help their patients --
the patients better. And so the reason why Project ECHO works is because
doctors are extraordinarily interested in doing that. But I think for a long term
sustainable solution we have to start thinking differently about what we
reimbursed in healthcare. And I think that this kind of team work gaining
knowledge producing a more efficient health care system should be reimbursed
in some way. And we are in policy discussions with the state government here
and we are initiating some policy discussions with the federal government to try
and understand what would be the mechanism for a primary care clinician to be
reimbursed for this kind of work that they do, which is very meaningful. It
improves the health care system and it helps patient reduce his cost. But
currently in a fee-for-service system, the major value accrues only when a doctor
sees a patient in person and also there isn't adequate compensation for
complexity. This remains a challenge for Project ECHO that we are trying to
overcome. But I think that we are getting relatively good reception from the
payers because they understand the limitations of the current fee-for-service
system as it is designed today. But I think we are hopeful that we will be able to
make effective change in the future.

Mark Masselli: This is Conversations on Health Care. Today, we’re speaking
with Dr. Sanjeev Arora, founder of Project ECHO. I want to pull the thread on
that conversation a little and it seems to me that this disruptive innovation you
have will also change the role of specialist into much more of a real time
consultant helping direct other healthcare providers and how best see patients.
Can you talk a little bit about the emerging role of specialist in your project as
well as the primary care provider?

Dr. Sanjeev Arora: Sure. The principle goal in project ECHO is what we call a
force multiplier. The force multiplier is based on one simple fact that there is a
worldwide shortage of specialists. It’s much worse in developing countries but
even in the United States in rural and underserved areas and urban underserved
areas of the kind you talked about this is a shortage of those specialists. So the
underlying premise is that if we can create knowledge network where primary
care clinicians can do work, which is as good as a specialist then you get force
multiplication that is you get a logarithmic improvement and capacity, you get a

10 times in expansion and capacity. So what does this do to the role of primary
care clinician? The role of a primary care clinician changes is the traditionally
primary care clinicians see themselves as generalists with an expertise and
everything. And what ECHO is saying is that, yes, that’s a wonderful goal but
add something to it. Now you are a generalist with a special interest in Hepatitis
C, and one of your colleagues is a generalist with a special interest in
rheumatology, another one is a generalist with a special interest in HIV and so on
and so forth, so that now you have embedded within your own primary care
practice various kinds of expertise which creates self-supporting organizations in
these underserved areas. So, that’s the role of the primary care clinician. We
see the role of a specialist changing too because traditionally the federal
government funds graduate medical education. What they do is they provide
large amounts of funding to academic medical centers to train residents and
fellows, these are people in training. But with the knowledge explosion that is
occurring in the world, we need -- these doctors need training throughout their
life, but there is no mechanism right now for that. We believe that a specialist at
academic medical center should have dual roles, one is, one role is to actually
treat patients and train trainees that reside in academic medical centers like
residents and fellows etcetera, but then also assume the responsibility for
continued training of the rest of the workforce which graduated many years ago,
but in order to be effective and actually deliver best practices they do need to be
connected to knowledge networks. And we believe that the ECHO model could
be one effective way to make that happen.

Margaret Flinter: Now, Dr. Arora, I look back in may be 15 months and I was
hearing about project ECHO for the first time and since then I have to say in the
last few months especially I hear it just about everywhere I go in healthcare and I
probably tell everybody about it wherever I go, as well. So it seems to me and
when we think about the range of issues that project ECHO has organized itself
to address the behavioral health issues chronic pain which is such an enormous
issue rheumatology, HIV aids all of these things, it seems to me that we really
have reached a tipping point where replication and spread of the model is
absolutely lined up to happen, but as we know from, you know, creating some
innovations of our own, to ensure that you preserve the quality the robustness of
your model, the standards of how you’ve done it is challenging. May be you
could share with us who are your partners across the country who you’re working
with on the replication and spread of this well maintaining that fidelity to the
things that make ECHO work so well which you’ve I think laid out very well for
us?

Dr. Sanjeev Arora: I think that you -- I’m sort of amazed how well you understand
our project and challenges. A nd so, currently we have replicated project ECHO
at the University of Washington and we have a very effective replication going on
there for chronic Hepatitis C, for chronic pain and for substance use disorder.
So, we have three programs in full swing there. We have also replicated project
ECHO for HIV with the University of Florida. We’ve replicated it for chronic pain

Hepatitis C, congestive heart failure and diabetes and the VA system of the
United States, not in the entire system but in seven regions. We are in
negotiation with several states, to put ECHO program there. So, essentially
there is a rapid spread going on and of course as you pointed out that, you know,
we’ve had a lot of learning occur in the last seven and a half years and we don’t
want everybody to have to start from scratch and then spend years to get to
where we are. So we would -- we are trying to set up a system where we can be
-- provide effective technical assistance to a very broad range of replicators so
that they can replicate project ECHO with high fidelity, maintaining outstanding
patient outcomes, ensuring that primary care clinicians have high satisfaction.

Mark Masselli: Today, Margaret and I, in speaking with Dr. Sanjeev Arora
founder of Project Extension for Community Health Care Outcomes known as
project ECHO, a model of care that’s linking primary care providers with
specialists to improve healthcare outcomes. Thank you so much for joining us
today.

Dr. Sanjeev Arora: Thank you.

(Music)

Mark Masselli: Each week, Conversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives. This week’s bright
idea focuses on creative solutions to feed the hungry especially during this
thanksgiving holiday season. For several years the relief group feeding America
has been helping underserved communities in the United States access fresh
healthy food. The concept is simple, if a community can organize a food pantry,
it will come to them. Mobile food pantries are managed by local food banks or
agency staff volunteers bring into action once the truck arrives on site to unload
and distribute the food. A nd the food brought by the food bank or donated is free
to those who come; no proof of need is required. Since many underserved areas
lack grocery stores, the priority for many mobile food pantries has become not
just access but getting quality food to these deserts. Mobile units permit food
pantries to mobilize a much larger circle of players into supplying food to the
needy. This not only increases the number of people who receive the service but
expands food pantry distributions into communities they haven’t been able to
reach before according to feeding America there are over a 130 members
operating mobile pantries throughout their national network supplementing the
regular offering of a local food pantry while at the same time bringing fresh food
to food deserts. Now, that’s a bright idea.

Margaret Flinter: This is Conversations on Health Care; I am Margaret Flinter.

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

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