Former CMS Administrator Dr. Mark McClellan Examines Trump Health Policies, Community Health Centers, Pharmaceutical Industry, and Innovation

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Mark Masselli: This is Conversations on Health Care, I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well Margaret after eight years of the Obama presidency, President
Trump is taking over the reign in Washington in what looks like to be an entirely new
approach to health reform.

Margaret Flinter: Well Mark we've seen many changes in the health care industry over
the years but I wonder if any have been as dramatic as the changes that we've seen
over these last yea rs of the Affordable Care Act. Really a lot of improvements in health
quality, so we are fervently hoping to maintain some of these positive progressions.

Mark Masselli: We thought it would be a great time to bring in a highly respected health
policy ana lyst Dr. Mark McClellan the former administrator for the Centers for Medicare
and Medicaid under President George W. Bush.

Margaret Flinter: And hopefully we'll bring some unique insights to this evolving
landscape in health reform as we move forward from this point on.

Mark Masselli: And we also have Lori Robertson, Managing Editor of FactCheck.org
who's always on the hunt for misstatements spoken about health policy in the public
domain. And no matter what the topic you can hear all of our shows by goi ng to
chcradio.com.

Margaret Flinter: And as always if you have comments email us at [email protected]
or find us on Facebook or Twitter because we love hearing from you. Now we'll get to
our interview with Dr. Ma rk McClellan in just a moment.

Margaret Flinter: But first here our producer Marianne O'Hare with this week's headline
news.

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Marianne O'Hare: I'm Marianne O'Hare with these Health Care Headlines. Health and
Human Services Secretary nominee Dr. T om Price took a grilling at his confirmation
hearing, largely surrounding his investment portfolio and plans for replacing the
Affordable Care Act. Price had reportedly had made several investments in medical
device and pharmaceutical companies who then b enefited from legislation he
introduced claimed he didn’t know what investments were being made by his broker.
Congressmen Price said he would work to ensure the vulnerable still had access to
health care after the law was repealed, though impressed for d etails he didn’t indicate
how that would happen. Meanwhile a majority of Americans gain health coverage

through their employers and they're also likely to see some changes to that coverage
under repeal of the Affordable Care Act. A number of ACA driven b enefits could go
away including what's known as essential benefits. All preventive screenings are
covered with no co - pay, no annual caps on insurance payouts, no lifetime limits on
payouts for catastrophic illness, all of those are at risk.

The world's ec onomic influencers gathered in Davos, Switzerland for the world
economic summit, a coalition of government and health leaders and philanthropist from
around the world has launched a preemptive strike against the next global pandemic.
They form the coaliti on for epidemic preparedness the goal to outsmart future epidemics
with a fund to develop new vaccines. Bill Gates saying the Ebola and Zika virus
outbreak showed how "woefully ill prepared the world is to tackle the emerging threat."
Also from Davos a l ook forward health forecasters seeing continue growth in the digital
health arena some trends that will likely gain traction, financial innovations for funding a
sustainable future global health economy including greater reliance on sugar and
tobacco tarif fs, encouraging accountability for a more open and transparent health
system which should lead to better outcomes. And more advanced applications of new
personalized and genomic medicine technology, 3D printing and robotic surgery also
look to see tremend ous growth in the health sector moving forward. I'm Marianne
O'Hare with these Health Care Headlines.

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Mark Masselli: We're speaking today with Dr. Mark McClellan Director of the Robert J.
Margolis Center for Health Policy at Duke University. Dr. McClellan served as the
former administer at the Centers for Medicare and Medicaid as well as Commissioner of
the Food and Drug Administration under President George W. Bush. Also a senior
fellow and director of Health Care and Value Initiative at the Brookings Institution, board
certified in an internal medicine Dr. McClellan earned his MD from the Harvard MIT
division of Health Science and Technology. Dr. McClellan welcome to Conversations
on Health Care.

Dr. Mark McClellan: Mark, Margaret great to talk to you.

Mark Masselli: As someone who know the interworking of the federal government and
the process of advancing tough policy initiatives like health reform, what do you believe
are the most significant changes we're likely to see coming from the Trump
Administration in congress?

Dr. Mark McClellan: It's probably no accident that health care is continue to be very
important policy issue that area where the federal government is spending the most
money and on the other hand medical care can do more and more to extend lives and
really add a lot of value for our economy as well. So where we are likely to see things

head in this next round is more of approaching in the direction towards less of a role
and requirement set by the federal government wher e it's a big role for states. But I
would emphasize that there is some common ground among democrats and republican
for example Dr. Price although strong critique of the Affordable Care Act, secretary
Health and Human Services will be implementing a bipar tisan law that he sponsored to
significantly reform the way physicians are paid in Medicare and have implication
throughout the health care system with the goal trying to create more value. So areas
where there is a lot of disagreement but also there will be other policy reforms taking
place that have more bipartisan support.

Margaret Flinter: Dr. McClellan if we polled most Americans today we probably find that
they had tended to focus more on things which had a direct impact on them today from
the Affor dable Care Act, but there were so much more. One of the important areas
were payment reform initiatives within the ACA that some would say have led to some
real savings whether within Medicare or the growth of accountable care organizations.
Help our aud ience understand some of these payment reform initiatives that we saw
under the ACA.

Dr. Mark McClellan: When I was starting in CMS I have lots of meetings with health
care providers around the country, we're trying to do the right thing for their patient
answering emails by setting up teams to take care of their patients hiring nurses, social
workers who could do things that physicians don’t have time to do. And what a lot of
these efforts have in common was that they led to better outcomes for their pat ient and
they led to lower cost for Medicare but Medicare didn’t pay for any of that stuff. So
instead what we set up was an early version of what became something like the
accountable care organizations today where you made a deal with a pilots of health
care providers which was that if they could track who their population of Medicare
beneficiaries were doing on things like controlling your diabetes and they were
preventing avoidable hospitalization. And at the same time the overall Medicare cost
were l ower, those kinds of programs have evolve with bipartisan supp ort and legislation
like MACRA into much more widespread use of new kinds of payment models today.
And that was part of the affordable care act. I do think in the new administration and
what' s more of a -- I want to call it a republican flavor you might see more efforts to build
on what CMS has done already to align with things going on the private sectors and I
also think more of an emphasis on payment reforms that get to the consumer side of
things. If patients choose less costly ways to get their cares, more ways for them to
share in savings as well.

Mark Masselli: Dr. McClellan, President Trump recently said that everyone would have
insurance, house speaker Paul Ryan has a different view about how to repeal and
replace creating high risk pools eliminating the Medicaid expansion. And what type of
advice would you give to the nation's network of community health centers which care

for some 24 billion Americans on how they should think strate gically and prepare
themselves for the changes that are afoot?

Dr. Mark McClellan: Well community health centers in the program grow steadily over
the last couple of decades with I would add this another whether it is some
bipartisanship -- bipartisan support for community health centers and increase funding,
because their role is really important from primary care type services towards now
playing integral roles in some cases leading true population care management
approaches like being part of accountable care organizations and being a medical home
for a network of care in conjunction wi th specialist in their region particularly for
vulnerable patients and -- and states that haven't expanded Medicaid. The health
centers are developing more efficient network to deliver care best they can in the
ambulance service much insurance coverage. I those kinds of steps are going to
continue to get bipartisan support and attention if there is for example, more shift
towards state flexibility and how they provide care for lower income and the vulnerable
residence. One might expect greater reliance o n efficient on our community health
center base network and similarly if some of that reforms have take place in the
exchanges are really kind of pushing towards more efficient ways of delivering care, that
too may feature a bigger role for community healt h centers in that re form health plan.
So I think the future is both challenging but also bright in some ways. For community
health centers the more they're able to expand from focusing only on what happens
when the patient's in your office to what's real ly going on with helping the patient to
prevent complications and get the best health outcomes and avoid unnecessary cost,
that set up our constructive direction for -- for health centers too.

Margaret Flinter: Well Dr. McClellan there is a recent report from the congressional
budget office that predicted in a large jump in the number of uninsured Americans and a
rise in uncompensated care. What do you think governors and state legislatures should
be doing or considering as they plan for potential changes in their policies and budgets?

Dr. Mark McClellan: Well I think as far as what the congressional budget office recently
reported was that if all that happened in congress was repealing the funds for Medicaid
expansion like payment of the Affordable Care Act, lots of people will do out coverage,
the insurance markets will become unstable and we'd end up with very high rates of an
insurance. I think the republicans has very pointedly emphasize that that is not their
plan, their plan is repeal and replace, but we are right now just at the beginning of that
legislative process with just the first steps towards real repeal happening, what that
needs to happen at more clarity around how proposals like big alliance would work at,
they have continue to have a tax credit for people to buy insurance with more
competition and bigger role for states and assisting low income individuals, people with
high healthcare needs that proposal is not yet completely flushed out into legislative
language to not just repeal key pr ovisions of the Affordable Care Act but to replace with

a model that depends on steps like thing continuously enrolled and having a support
available for people who have higher health care need. And I know that president elect
is -- talk about how he want s this to happen sooner rather than later, encouraging the
two sides in congress to come together. This is an issue that very important topic that
will continue to be debated for all the foreseeable future.

Mark Masselli: We're speaking today with Dr. Ma rk McClellan Director of the Robert J.
Margolis Center for Health Policy at Duke University. Dr. McClellan served as the
former Administrator at the Center for Medicare and Medicaid as well as Commissioner
of the FDA under President George W. Bush. He al so served on the President's council
of Economic Advisors. And Dr. McClellan I would like to pull on your expertise around
economics as you know health care constitutes about one fifth of the nation's GDP and
the American Hospital Association has warn tha t the industry could suffer up to 160
billion dollars in setbacks in the short term. And other analyst estimate a complete
repeal of the ACA could lead to three million jobs lost in health and I'm sure that both
the Trump Administration and congress are g oing to take these economic impact into
consideration as they think through health reform.

Dr. Mark McClellan: Well one thing we can say for sure the numbers are big there are a
lot of people effected that even though it's only around 10% of the US popula tion 21
million people with coverage related to the ACA. Republicans have been stressing that
this is not just about taking away funding and destabilizing current insurance markets
and but rather about replacing it with something it does provide a good le ss costly
alternative. What we're talking about though in terms of job growth from the -- the
hospital side is really about slowing the growth rate. So even through the recession, so
the great recession the biggest slowdown in the economy hospitals and t he health care
sector continue to add job it was one of the bright spots over the years following the
2008 market crash. So a reform would affect our hospitals but some of the reforms
have behind them the idea of changing the way that care is delivered so cial services
and supports. Mental and behavioral services that could had off emerging room visits
for patients with poorly controlled dental illnesses or care coordination services that
might involve a nurse practitioner or a pharmacist. I feel pretty c onfident about the
overall future of the health care industry but I do think that's a new direction for hospitals
and for health care employment are probably good for the economy in terms of creating
new kinds of jobs and also good for the wellbeing of Americans.

Margaret Flinter: Dr. McClellan one aspect of the high cost of health care that got a lot
of attention in the past over months was drug prices. You served as the commissioner
of the FDA so you know perhaps better than anyone in the country the complexity of
drug pricing and certainly the intricacies of the pharmaceutical industry. How can we
meaningfully bring drug cost down without harming research and development
pipelines?

Dr. Mark McClellan: It's important to remember that there are stat of different issues
going on that are contributing to our high drug cost. Some of the drugs that have made
the most news like EpiPen and others are generic drugs where there really isn't a
reason why other drug manufacturers couldn’t come in make it some more drug and
have some real price competition. And there is actually bipartisan legislation now in
congress to try to encourage steps that would do that, steps like giving the FDA more
support to approve new competing drug and make it easier for generic drug
manufacturers to get that quick and predictable approval to market drugs where there is
a need for -- for more competition to improve the availability of low cost generic
alternatives where we're not seeing good competition now. There are also opport unities
coming for biologic drugs and the most expensive drugs that are much more complex
the manufacturers so called buy a similar drugs are starting to come on the marketing in
United States and there are opportunities for perhaps by some estimates 50 bi llion
dollars in savings of very similar medication, some real opportunities for bringing cost
down.

I think we're going to see in the coming months and years more attention the same kind
of reforms that we were talking about earlier primary care doctors, oncologist hospitals
others are moving into payment models where they pay more for actually getting b etter
results for patient. So far those models have more or less excluded prescription drugs
and also medical devices even though the incremental cost of producing another pill is
quite low and the real value is in the -- intellectual property in the mole cule itself and
then knowing how to us it in particular occasion. So drug seem to me to be a good
opportunity for new payment models that are more aligned with this shift to greater
values. Imagine a drug manufacturer would pay more for getting better re sults and let
the population that using the medication.

Mark Masselli: Dr. McClellan we recently hosted your former Duke colleagues Dr.
Victor Dzau on our show who is the now the director of the National Academy of
Medicine he's very complimentary about n ot only your work that you've been doing in
value driven health approach, but that you're a great example of health bipartisan
approach can actually work to advance good policy and I'm wondering where you see
that steam of opportunity and collaboration.

Dr . Mark McClellan: Well I think it is hard to get health care right, again the biggest
component of the federal budget now and -- and even though there are some
disagreements on very important issues like how the Medicaid program should work for
low income American. Some of this is reflected in the recent report that Victor Dzau
and I worked on at the National Academy of Medicine on bridal directions for health
care. This report had recommendations in three major areas steps to improve
population's health bringing traditional health care more into population health improving
long term outcomes at a lower cost. Second area is changing the way that we pay and

finance health care, but at least payment models that are less burdensome
administratively on provi ders, paying for things like send it off with hours or converting
their office visits to telemedicine or just remote patient monitoring. And then the third
area is in our education and research programs, most of our training dollars right now
goes into th e traditional ways of running a lab of delivering care in hospital, not as part
of a team there are some good educational models and margin taking advantage of big
data, large scale research network team base approaches to health care all of these
areas ha ve considerable bipartisan support but do require policy changes but there are
also a lot of opportunities for bipartisan legislation to get to better health for the country
and to help get health care cost down.

Margaret Flinter: We've been speaking toda y with Dr. Mark McClellan Director of the
Robert J. Margolis Center for Health Policy at Duke University. You can learn more
about his work by going to healthpolicy.duke.edu, Dr. McClellan thank you so much for
joining us on Conversations on Health Care t oday.

Dr. Mark McClellan: Thank you all great to talk to you Mark, Margaret about this
important topic.

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Mark Masselli: At Conversations on Health Care we want our audience to be truly in the
know when it comes to the facts about health care refor m and policy. Lori Robertson is
an award - winning journalist and managing editor of FactCheck.org a nonpartisan,
nonprofit consumer advocate for voters that aim to reduce the level of deception in US
politics. Lori what have you got for us this week?

Lori Robertson: As President Obama leave the office we looked back at fact checking
th
the 44 president and health care headlined the biggest falsehood of Obama's tenure.
Back in 2009 he promised quote, if you like your health care plan you keep you keep
your health care plan. We wrote then that Obama couldn’t keep that promise for
everyone and in 2013 reality caught up with the president after the minimum benefit
standards were set the ACA market place open for business on October first 2013.
Almost immedia tely some individual market policy holders began to receive cancelation
th
notices from their insurance company. By November 14 2013 Obama announced a
temporary fixed to address the problem and admitted that he had made some
assumptions about the law that were incorrect.

Also in 2009 Obama claimed in a speech to congress that an insurance company was
responsible for the government Illinois cancer patient, it wasn't. Insurance company did
briefly canceled the man's coverage but his sister said the interrupt ion lasted a few
weeks and shortly after the man was able to get a successful stem cell transplant that
extended his life by three and a half years. And another Obama anecdote turned out

not to be true in 2011, Obama had long told the story about his moth er's battles with her
health insurance carrier, he claims that she was nearly denied health insurance
coverage for a preexisting condition while she was dying, but in 2011 author Jenny
Scott published a biography on Obama's mother and in it she wrote that Dunham's fight
was over disability coverage which was not affected by Obama's health care law and
not over medical insurance coverage. Scott had, had access to Dunham's letters to her
insurance company. For more on our eight years of fact checking Obama see our
website, I'm Lori Robertson Managing Editor of FactCheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players and is a project of the Annenberg Public Policy Center at the
University of P ennsylvania. If you have a fact, that you would like checked, email us at
www.chcradio.com. We will have FactCheck.org's Lori Robertson check it out for you
here on Conversations on Health Care.

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Mark Masselli: Each week Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. A lbuquerque oncologist D r.
B arbara McAneny didn’t like the trend she saw in her 3500 patients that she treats
every year. When her cancer patient suffered illness and side effects those who are
hospitalized or even treated in the emergency room came out sicker.

D r. B arbara McAneny : If a cancer patient walks into the emergency room studies have
shown that they have between a one third and two third chance of getting a dmitted
because ER doctors are used to taking care of people with heart attacks and having
babies and gunshot wounds and car accidents, and our patients come in and they're
skinny and they're bold and they don’t look healthy and they take one look at them and
go my gosh you look like you need to be in the hospital.

Mark Masselli: She realize that a problem was in the hospital themselves. Far more
lethal to those with compromised immune systems like cancer patients. She thought
what if I offer weekend sup port for all of my patients allowing those patients to avoid a
trip to the emerg ency room. She launched the COM Home model which stand s for
Community Oncology Medical Home offering weekend office hours where cancer
patients can be seen and treated immediately by clinicians familiar with their case. She
found those patients were often admitted to the hospital when they really didn’t need to
b e.

D r. B arbara McAneny: So I wrote the triage pathways, so that we could discern which
patients really did need to go to the emergency room, you sound like you really are
having a heart attack so you really need to go to the ER. But you sound like you're

having chest pain because you have bronchitis and you're coughing now your ribs are
kind of sore. We can fix that you can come here.

Mark Masselli: She said cancer patients are already under pressure of massive medical
bills and lose of income unnecessa ry hospitalizations were creating enormous cost.
The COM Home model has saved her patient population some 18 million dollars in
medical cost.

D r. B arbara McAneny: We started with a triage pathways coming up with a systematic
way that sends people to the right side of service for what they need.

Mark Masselli: The program has been loaded by former CMS Administrator Mark
McClellan who says it provides a robust framework for better care to Medicare patients.
The American Society of Clinical Oncology recent ly announced the collaboration with
COM Home to help other oncology practices lower cost and improved quality of care at
cancer facilities around the country. The COM Home model treating cancer patients
suffering symptoms from treatment with timely and ta rgeted care that is sensitive to their
unique health challenges, saving money while improving the patient care now that's a
bright idea.

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Margaret Flinter: This is Conversations on Healthcare, I'm Margaret Flinter.

Mark Masselli: And I'm Mark Mass elli, peace and health.

Conversations on Healthcare, broadcast from the campus of WESU at Wesleyan
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