California Health Care Foundation CEO Dr. Sandra Hernandez Says Tackling Big Public Health Issues Like Opioids and HIV Benefited from Expanded ACA Coverage

Sandra Hernandez - CHCF

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Mark Masselli: This is Conversations on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well Margaret, some interesting healthcare news has come out
of this week. Tech giant Apple has launched a un ique heart study in partnership
with Stanford University and the Telehealth Company American Well. It's a first
of the kind study using a free app downloaded to the Apple Watch which can
detect subtle hints of the presences of atrial fibrillation or irreg ular heart beat. It's
a really interesting idea if the watch detects irregular heart beat it notifies the
wearer then connects them swiftly to clinician the American Well’s Telehealth
Service and a treatment protocol could be quickly ordered.

Margaret Fl inter: Certainly atrial fibrillation is not that uncommon, and many
people are unaware of their status, so this early morning system could potentially
be of real value. It's going to be interesting to see what kind of data comes out of
the study. Certai nly a lot of buzz in the healthcare industry because there are
millions of people who already own that Apple Watch.

Mark Masselli: Meanwhile speaking of buzz, another industry announcement is
garnering quite a lot of attention. The proposed merger betwe en the insurance
giant Aetna and the drug store chain CVS could have some far reaching
implications if approved.

Margaret Flinter: An emulous [inaudible 00:01:16] say that the merger has the
potential to bring down drug prices for consumers overtime. It could also spur a
new wave of walk - in clinics and on - demand care using the pharmacy as the point
of delivery of healthcare services. So a deal that still has to be approved by anti -
trust regulators certainly being viewed as a potential disruptive innovat ion in
healthcare.

Mark Masselli: Our guest today is very committed to the idea of delivering quality
care, Dr. Sandra Hernandez, is President and CEO of the California Health Care
Foundation, really looking forward to that conversation, Margaret.

Marga ret Flinter: Lori Robertson will stop by, the Managing Editor of
FactCheck.org. No matter what the topic, you can hear all of our shows by going
to www.chcradio.com .

Mark Masselli: And as always if you have comme nts, please e - mail us at
[email protected] or find us on Facebook or Twitter, we love hearing from you.

Margaret Flinter: And we will get to our interview with Dr. Sandra Hernandez in
just a moment.

Sandra Hernandez - CHCF

Mark Massell i: But first, here is our producer Marianne O’Hare with this week’s
Headline News.

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Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines.
Forward motion on the Aetna CVS merger, CVS’s $69 billion deal to purchase
Aetna Insuranc e would mark a significant opportunity for the new partners to
negotiate pricing. Beyond the 9,600 retail outlets, CVS also runs more than a
thousand walk - in clinics and is also a large benefits manager provider for drug
prescriptions. The jury still out on the exact outcome such a deal would yield.
But industry analysts see the CVS Aetna merger as a marriage of two verticals
and they might actually be in a position to create a new sort of healthcare
business model. The move could be good for consumers in two ways, CVS
Caremark access one of the largest pharmacy benefits managers in the country
and could negotiate lower drug prices. The proposed deal still must pass
scrutiny by anti - trust regulators.

Open enrollment is barreling towards the finish unde r the Affordable Care Act
and while the federal government has greatly reduced the outreach budget for
those seeking help and navigating the online insurance marketplaces there is a
flurry of activity in many parts of the country so far three million Ameri cans have
signed up for coverage. Analysts predict that there will be a flurry of sign up
activity in the final days.

The first American woman has given birth to a healthy baby from a transplanted
uterus. The successful birth was announced at Baylor Med ical Center in Texas.
Eight women have received uterine transplants in the Baylor study. One woman
is also pregnant of the group and others are attempting to conceive. There have
been several successful births from transplanted uteruses in Europe. I am
Marianne O’Hare with these Healthcare Headlines.

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Mark Masselli: We are speaking today with Dr. Sandra Hernandez, President
and CEO of the California Health Care Foundation, independent nonprofit
organization dedicated to improving health care f or all Californians. Previously,
Dr. Hernandez served as CEO of the San Francisco Foundation and as the
Commissioner of Public Health for San Francisco. Dr. H ernandez was Assistant
Clinical Professor at the University of California, San Francisco School of
Medicine and was a long time Clinical Practitioner at the San Francisco General
Hospital AIDS Clinic. She earned her BS at Yale, her medical degree from Tufts
School of Medicine and study public health at the John F. Kennedy School of
Government at Har vard. Dr. Hernandez, welcome the Conversations on
Healthcare.

Sandra Hernandez - CHCF

Dr. Sandra Hernandez: Thank you. It's nice to be with you.

Mark Masselli: Yeah, you know the foundation founded on the principle that
healthcare is a right. California, a champion of stat e - based innovation, I wonder
if you could share how you’ve connected the dots back to the mission of the
foundation with these various initiatives?

Dr. Sandra Hernandez: Well, you know, I think the biggest opportunity that the
foundations has had in term s of the policy environment to reach the many, many
low - income folks throughout the State of California really was the passage of the
ACA and the opportunity and really statewide effort that philanthropy and the
State of California joined together to expan d the Medicaid program under the
ACA as well as to standup what I think most would agree is the most well run,
most accessible, state run insurance exchange in the country. The foundation
really played a pivotal role in both of those to get the exchange a nd Medi - Cal, it's
enrollment functions actually allow easy enrollment Medi - Cal in the State of
California reaching now a third of all Californians was an extraordinary uplift to
get people actually aware that they were eligible because for many people who
live in rural areas often come from communities where there are many social
issues that contribute to healthcare needs. So the effort to expand coverage the
foundation has had just a long track record in policies. And then really making
sure that the del ivery system itself was using the best evidence and the best
care.

Our maternity initiative falls into this category of care that is often not evidence -
based and a case of maternity there were wide variations. In C - section rates,
most of it was really trying to develop tools in the hands of clinicians to drive
change in a delivery system and change the practice pattern such that clinicians
who are practicing according to good evidence all of the work are deeply focused
on what does evidence tells to do and really important example is work that
we've done opioid prescribing through state agencies, the Medicaid program, all
came together and said what are the conditions in which there is overuse of care,
and so CHF has a very large statewide effort with mo re than 30 regional
coalitions all working at the opioid overuse problem trying to understand what the
prescribing patterns are, or how to use data to really redress what has been an
overprescribing scenario of opioids for many, many years.

Margaret Flint er: Well Dr. Hernandez, as 2017 is winding down, we find
ourselves in just another period of great uncertainty around healthcare and
health policy across the country. Certainly the open enrollment period for the
Affordable Care Act being cut in half, but in California, you took a very different
tack, you vastly outspent the federal government in enrollment and outreach
efforts, talk about the gains that you have seen because of the expansion of
coverage and insurance and why that was so important in drivi ng your state to
maintain this level of promotion for open enrollment?

Sandra Hernandez - CHCF

Dr. Sandra Hernandez: One of the many important insurance tenants that were
part of the ACA was the individual mandate. So of course tax bill now would
back that mandate and one of t he reasons California has stood out as an
effective exchange is because the concept of having a broad [inaudible 00:08:41]
to enroll everybody who is eligible. With a court tenant of keeping the premiums
within the coverage, affordable helped California b uild a exchange with more
than a million and a half members in it, and by virtue of the risk spread in that
also allowed it offer very affordable premium. And to enroll populations that have
had very little experience or exposure to health care that upfro nt investment was
a critical part of the success of the exchange. California has an uninsured rate
today of south of 7% -- I think it's 7.5% at this point we also know that it was
going to try be effective with our public dollars that you need to have eve rybody
in.

Mark Masselli: We had the opportunity to meet with one of your stars out there
Dr. Mitch Katz on the show recently who is wrapping up his time at LA County
Health Commissioner and he is talking about spending public health dollars on
housing t he homeless to improve health outcomes and reduce costs and you
were in San Francisco and you oversaw some innovative approaches to treating
HIV and AIDS. And I’m wondering if you could talk about these innovations and
what made them so effective and how the foundation is working to scale up these
programs?

Dr. Sandra Hernandez: One of the things that we learned very early on during
the HIV epidemic in San Francisco was how important it was to establish
evidence and clinical practice patterns that was ba sed on the best evidence at
any one time, but also that care needed to be fully integrated. So one of the
things we did very early on was make sure that all of our federally qualified health
centers and all of our community clinics were able to provide fu ll scope testing
counseling early treatments and literally utilize the primary care setting as the
optimal setting for care management for patients who had HIV. The way I see
that translated today and in the work very much that CHCF is doing is patients d o
not do well when we take a particular disease code and create a segregated
delivery system to provide that care.

Mental health care, for example, we care for people who are incarcerated in a
certain way while they’re incarcerated and then when they’re released should
they go to primary care or should they go to behavioral health specialist and so I
think the opportunity that we have to learn from the HIV epidemic is to think
about how to best holistically provide care and California is going on 24, Who le
Person Care Pilots where counties themselves are innovating about how to deal
with patients who have very complex conditions, how do we best serve
populations that have very complex care where we create a system where there
is no wrong door through tele medicine and through technologies and in some
cases maybe even through private companies we funded for example who

Sandra Hernandez - CHCF

provide substance use treatment in rural communities, these are all ways in
which in California we are continuing to try to evolve our delive ry system that
patients in particular who have complex issues and needs can get their care in a
holistic way, so if you are already in a mental health clinic we want to make sure
you easily can get primary care.

We want to be able to provide that care i n the most coordinated efficient way and
so we're supporting evaluation of helpers and care pilots across the state. We're
trying to create the evidence and understand what works and scale it in other
places or whether it's through telemedicine capability or whether it's through
some electronic consultation between specialists. We have great centers of
academic excellence and then we have places that have significant workforce
shortage. And so we're trying to really understand how do we utilize and devel op
the workforce for the future using new technology with the idea that we're trying
to reach the most complex patients in the most efficient way possible. HIV in
San Francisco had a very active consumer base and that very much influenced
the program desi gn. We recognize we need that same kind of feedback loop
coming from Medicaid and Medi - Cal enrollees so that systems that we're
designing work best for that. So, we have many opportunities in California to
innovate and to scale.

Margaret Flinter: Well, Dr. Hernandez I wonder if I could get you to zero in on
the Opioid crisis maybe highlight a few initiatives that you think stand the
possibility of really making a difference?

Dr. Sandra Hernandez: Response in epidemic like this not unlike HIV really
r equires a very multidisciplinary response. We are working with public health
institute to provide all kinds of technical support across the state who are working
with their local data, with their pharmacies, with their emergency rooms and
really broad sec tor of folks that have come together in the coalition, physicians
over a long period of time were sort of told two things one we were under
prescribing pain medications and under managing pain and two, we were really
led to believe by a few very, very poor ly run articles early on that these high dose
opioids were somehow not addictive that is clearly not the case. The use of very
high dose opioids has a very limited scope and really the only place for any sort
of long - term opioid use is in people who have terminal condition. Now we’ve got
a whole population that’s significantly addicted to the opioids that we’ve
prescribed in the past and so for that population it's really important to make
Narcan which is the drug that reverses the narcotic affect, if it was widely
available in our community it has a very short acting, it is not addictive, and it is
absolutely lifesaving.

We should think about Narcan as we do people knowing [Inaudible 15:26] and
medication assisted treatment and it should be on demand, we should be able to
take anybody who today is addicted and be able to at any point that they are
ready to get treatment, be able to get them into Medicare assisted treatment, we

Sandra Hernandez - CHCF

both need to train more addictionologists, and we need to bring more primary
care physician in doing MAT that is a path that we're certainly supporting along
with many others.

If you do not carefully manage people who have chronic addictions and get them
off opioids in a thoughtful way these are individuals who get quite despera te and
if they come across fentanyl or other drugs that are even of higher potency those
drugs are very hard to manage and control, and that I think is one of the reasons
it's been so hard to see mortality began to decline with opioids, but what I would
sa y about California it's a partnership effort, epidemics of complex issues and
you really need everybody in the community looking at real time data, there is a
fantastic tourist [PH] database that the state set up that allows absolute real time
prescription s who has gotten what when was it last prescribed and that is really
helping with the information sharing that’s necessary.

Mark Masselli: We're speaking today with Dr. Sandra Hernandez, president and
CEO of the California Health Care Foundation, dedicat ed to improving health
care for all Californians. And Dr. Hernandez you gave a wonderful keynote at the
Health 2.0 Conference in San Francisco and you outline the ways technology will
help fill the growing gaps and challenges in the health system and but just a few
of them certainly the shortage of clinicians in primary care there are 10,000 baby
boomers a day who are aging into Medicare. I wonder if you could share with
our listeners your vision of a technology enabled healthcare system of the future.

D r. Sandra Hernandez: You know if we think about technologies and the kinds of
capabilities that we can readily foresee and that are already being studied today
and you recognize that we have this immense silver tsunami that’s occurring in
California. I t hink that you have got to be able to see the opportunity for
technology to help with helping people stay in homes and be able to be
monitored from afar and to support issues with medication management. There
are many, many technology companies now that ar e looking at how we even
build in a build environment via a phone or via an iPad be able to communicate
with their providers. I don't think we're going to be able to address all of our
healthcare need both as the age as a population and as we think even b etter
investment and workforce I think increasingly we need to think about how
technology can give us leverage in meeting some of the needs that people would
have in order to help them a little bit home for as long as possible.

You know telemedicine is an area that it's quite extraordinary in terms of what its
capabilities are, people don't have to leave work to be able to go you know and
assess whether their child has an otitis or not. They could you use the telephone
will be able to assess whether in fact there's pus in the ear or not. The way that
technology could transform and really fully leverage the workforce of the future.
We are really excited of them really thinking about monitoring capabilities that we
have allow us to envision a time when o ur workforce might be to be much more
focused on wellness and use the more scaled up, more expensive centers only in

Sandra Hernandez - CHCF

the circumstances in which you had no other choice. If you think about predictive
analytics and artificial intelligence all of those capab ilities potentially have health
wellness healthcare delivery implications and opportunity. We think about the
workforce of the future. We think about it in complement the technology and then
we not try to build the workforce for the way we used to provid e care. We should
be able to use technology and virtual capabilities and all of those things I think
will help us figure out those what the workforce should look like in the future and
how it uses technology by the way the workforce of the future are goin g to be
millennial and younger and they are so tech native that you can imagine the way
that they will deliver care and how they will use technology will be quite different
than we have used it in the past.

Margaret Flinter: We have been speaking today w ith Dr. Sandra Hernandez
President and CEO of the California Healthcare Foundation. You can learn more
about her work by going to chcf.org or follow them on Twitter @chcfnews. Dr.
Hernandez thank you so much for the work they do and for joining us on
Con versations on Healthcare today.

Dr. Sandra Hernandez: Thank you it's a real pleasure.

Mark Masselli: At Conversations on Healthcare, we want our audience to be
truly in the know when it comes to the facts about healthcare reform and policy,
Lori Robert son is an award - winning journalist and Managing Editor of
FactCheck.org, a non - partisan, nonprofit consumer advocate for voters that aim
to reduce the level of deception in U.S. politics. Lori, what have you got for us
this week?

Lori Robertson: Republi can Senator Bill Cassidy wrongly claimed that he has a
way to prevent the senate tax plan from raising health insurance premiums on
the individual market. The senate tax bill contains a provision that would
eliminate the penalty on Americans who don’t buy health insurance. The
nonpartisan Congressional Budget Office and the joint committee on taxation
have said in a joint report that repealing individual mandate would increase
average premium on the individual market by about 10% for most years over the
n ext decade but Cassidy said that concurrently passing the tax bill and the
bipartisan healthcare stabilization act would result in “net” lower premiums it
wouldn’t.

The bipartisan bill was introduced by Senators Lamar Alexander a republican
and Patty Mu rray a Democrat. Cassidy claimed that the CBO said the bill would
quote lower premiums by 25%. That’s not correct. Instead the CBOs said the
bipartisan bill would prevent premiums from going up by 25% by 2020. The bill
would continue to provide cost sh aring subsidies for those who earn between a
100% and 250% of the federal poverty level. Subsidies of the Trump
administration had ended, ending the subsidies would cost premiums to rise so
the bipartisan bill stops a future potential increase from happen ing.

Sandra Hernandez - CHCF

Meanwhile eliminating the Affordable Care Act penalty for not having health
insurance would increase average premium on the individual market because
healthier people would be less likely to purchase insurance that would lead to a
less healthy risk pool for the individual market and higher premiums. And that’s
my factcheck for this week, I am Lori Robertson, Managing Editor of
FactCheck.org.

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Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country’s major politic al players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com , we will have FactCheck.org’s, Lori
R obertson, check it out for you, here on Conversations on Healthcare.

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Mark Masselli: Each week Conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives. Currently about 2
million people arou nd the world are suffering from end - stage renal disease.
There are basically two options for these patients kidney transplants or dialysis
requiring patients to undergo blood filtering treatments at medical facilities lasting
up to five hours per treatmen t a Montréal team science project just may pave the
way for another solution. Anya Pogharian developed a portable home dialysis kit
that cost about $500 to produce far less than the $30,000 dialysis machines
currently in use inspired by her high school in ternship working at a dialysis center
in Montréal.

Anya Pogharian: You wouldn’t have to make a way to the hospital which is a
problem for a lot of patients.

Mark Masselli: Pogharian says hundreds of hours of research led her to build a
prototype of the dialysis machine which is about the size of a typical gameboard
but pumps and purifies blood just as large - scale dialysis machines do. She
hopes this device can be developed throughout the world.

Anya Pogharian: 10% of patients living in India and Paki stan who need the
treatment cannot afford it, so that’s really what motivated me to continue.

Mark Masselli: A relatively cheap portable easily assembled dialysis machine
allowing them to be treated at home, now that's a bright idea.

[Music]

Margaret F linter: This is Conversations on Healthcare, I am Margaret Flinter.

Sandra Hernandez - CHCF

Mark Masselli: And I am Mark Masselli, peace and health.
Conversations on Healthcare broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health
Center.