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33 posts categorized "Podcast"

April 13, 2015

Get Social Health: David Harlow Podcast Interview with Janet Kennedy


I recently had the pleasure of speaking with Janet Kennedy of Get Social Health about health care uses of social media, with a focus on HIPAA and other privacy concerns and other legal issues that may apply to uses of social media by health care organizations for marketing purposes and otherwise.

Check out her post, and her entire podcast: David Harlow IS @Healthblawg. Stick around and listen to some of the other interviews she has conducted, too.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting

December 15, 2014

Farzad Mostashari on the Proposed ACO Regulation: The future of the Medicare Shared Savings Program examined in an interview with David Harlow

Mostashari_Farzad_ORIGINALThe Accountable Care Organization regulations were first promulgated under authority of the ACA's Medicare Shared Savings Program in 2011. Three years later, the regs are in the shop for a tune-up. Farzad Mostashari MD was one of the authors of the Brookings Institution ACO issue brief released in the spring, suggesting some changes to the program that would keep current ACOs engaged past the end of their three-year contract term, and improving the program overall. Dr. Mostashari, former National Coordinator for Health IT, is now the founder and CEO of Aledade, a startup focused on helping physician organizations develop ACOs. With a level of excitement shared only by a small coterie of health wonks -- and usually reserved for video recordings of unboxing the latest hi-tech toy -- Farzad livetweeted his reading of the 429-page typewritten version of the proposed ACO rule when it was released late last Monday. (See the CMS Fact Sheet on Proposed Changes to the MSSP and the Aledade post on the proposed reg.

The rule was published officially on December 8, with a 60-day comment period. I had the opportunity to interview Dr. Mostashari about the new rule. As he noted in our conversation, CMS is calling for input on a variety of issues, so don't be shy, especially if you have some data to back up your suggestions on the choices that remain to be made in this rulemaking process.

(Read or listen to the full interview after the jump.)

Continue reading "Farzad Mostashari on the Proposed ACO Regulation: The future of the Medicare Shared Savings Program examined in an interview with David Harlow" »

October 14, 2014

Apple HealthKit - Epic Integration at Ochsner Health System - David Harlow Interviews Dr. Richard Milani

Apple-healthkitThe first health system to announce that it had integrated HealthKit into its Epic EHR is Ochsner Health System in Louisiana. It is a 12-hospital, 40-clinic operation with over 900 physicians. I spoke recently with Dr. Richard Milani, Ochsner's Chief Clinical Transformation Officer. He was enthusiastic about the improvements in clinical outcomes realized to date through homegrown integrations of things like Withings scales, and sees significant expanded potential using the Epic-HealthKit integration including dissemination of data to clinicians for more efficient and effective management of care and presentation of data to patients in a way that may motivate behavior change to improve health status.

Continue reading "Apple HealthKit - Epic Integration at Ochsner Health System - David Harlow Interviews Dr. Richard Milani" »

August 07, 2014

Solving Sovaldi: David Harlow Talks Value-Based Payment with Cyndy Nayer

6793824321_398d881757_mWe have been deluged with stories about the $100-a-pill medication for Hepatitis C. Is it really worth $87,000? (Well, it's cheaper than a $600,000 liver transplant.) I had the opportunity to speak with Cyndy Nayer, of the Center of Health Engagement, about the issues surrounding this drug and its use, value-based approaches to payment, and the question of whether we are able to solve this problem in our current environment at all.

Continue reading "Solving Sovaldi: David Harlow Talks Value-Based Payment with Cyndy Nayer" »

June 06, 2014

Telehealth: Roy Schoenberg, CEO of American Well, Speaks with David Harlow

5669123427_4ab5769ecf_oI had the opportunity to speak with Roy Schoenberg about the model policy recently adopted by the Federation of State Medical Boards (FSMB): Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine. The model policy is offered as a means for state medical boards to get up to speed quickly and to access standards of care that are both protective of patients' interests and, frankly, are baselines against which physician behavior may be judged by an individual board. Roy distinguishes between telemedicine (doc-to-doc communication) and telehealth (patient-to-doc communication). The latter, particularly using a secure live video platform is a disruptive innovation in a way that the former is not: it allows patients to access medical advice at their convenience, without the need for an office visit or a trip to a specialist.

Continue reading "Telehealth: Roy Schoenberg, CEO of American Well, Speaks with David Harlow" »

September 24, 2013

Doximity: An online physician network hits 200,000 members, and co-founder Nate Gross speaks with David Harlow

Nate grossI recently caught up with Nate Gross (@ng), co-founder of Doximity (@Doximity), to hear about how the company is building out the social graphs of physicians. Earlier this year, Doximity hit a milestone -- doc #200,000 -- and Nate filled me in on where the company has been, and where it's going.

Nate will be speaking at Connected Insight Summit, the annual conference presented by Activate Networks, taking place October 8-9, 2013, in Cambridge, MA (use discount code: HARLOW50 for 50% off registration).

Have a listen to our entire conversation, and see the transcript below.

Nate Gross Doximity Interview HealthBlawg 09172013

Continue reading "Doximity: An online physician network hits 200,000 members, and co-founder Nate Gross speaks with David Harlow" »

August 13, 2013

The RUC (again): Is there a light at the end of the tunnel? A conversation with Brian Klepper

Tunnel of Light TJ Blackwell Flickr CC Recently, there were a couple of breathless articles about the RUC (Relative Value Scale Update Committee) published in The Washington Post and The Washington Monthly, reporting as news the state of affairs that has prevailed for years in the realm of re-setting the relative values of physician services annually for purposes of the RBRVS -- which is at the heart of the Medicare Physician Fee Schedule (MPFS) and which affects physician reimbursement well beyond Medicare, since the RBRVS is used as a touchstone in determining payment levels under commercial payor agreements as well.

I thought this confluence of publications was a good excuse to call up Brian Klepper, who is an expert critic of the RUC, to discuss the latest stories and talk about the prospects for meaningful reform.

Have a listen to our conversation (about 30 minutes long):

Brian Klepper on RUC HealthBlawg Interview with David Harlow 07262013

Brian Klepper - RUC - HealthBlawg

A transcript is appended to this post.

Continue reading "The RUC (again): Is there a light at the end of the tunnel? A conversation with Brian Klepper" »

July 29, 2013

Diabetes Innovation: We Get to "Ask Manny" a Few Questions

Manny HernandezI spoke with Manny Hernandez (@askmanny) about the diabetes online communities he founded at TuDiabetes (Engligh) and EsTuDiabetes (Spanish) -- which include tens of thousands of people with diabetes and their family members -- as well as his experience attending the Diabetes Innovation conference last year, and his thoughts on communications regarding diabetes.

Manny was a keynote speaker at last year's conference and will take part in a social media panel discussion this year.

I am working with the Joslin Diabetes Center to get the word out about Diabetes Innovation 2013, October 3-5, 2013 in Washington, DC. Follow the link for the best rate available on conference registration. This interview first appeared on the Diabetes Innovation blog,

I asked Manny whether social media can play a role in effecting clinical improvements in diabetes management, and he pointed to the Big Blue Test, an initiative of his Diabetes Hands Foundation. He's presented data from this project at the American Diabetes Association annual meeting: Folks who participate by posting their blood glucose readings before and after 15-20 minutes of exercise, and engaging in online conversation, see long-term benefits in terms of better management of their conditions. (The before-and-after glucose readings showed a 20% drop on average.) Over 40,000 PWD have participated to date. Look for a social media campaign this fall to promote participation in the Big Blue Test in the month leading up to World Diabetes Day.

Continue reading "Diabetes Innovation: We Get to "Ask Manny" a Few Questions" »

May 07, 2013

Ponemon Institute study finds outdated communications technologies cost U.S. hospitals $8.3 billion a year

I spoke with Sean Kelly, CMO of Imprivata, a health IT company with single sign-on and secure SMS solutions that commissioned the study, entitled The Economic & Productivity Impact of IT Security on Healthcare (PDF).

The audio file of my interview with Sean Kelly (about 20 minutes long) is available for download/podcast, or may be played here:

Sean Kelly - Imprivata - Cost of Outdated Technology

Sean Kelly - Imprivata - Cost of Outdated Technology

A full transcript is available as a PDF (Sean Kelly - Imprivata - Interview) and is reproduced below. 

From the presser:

Economic and Productivity Impact of Outdated Communications Technology

  • Clinicians estimate that only 45 percent of each work day is spent with patients; the remaining 55 percent is spent communicating and collaborating with other clinicians and using EMRs and other clinical IT Systems.
  • According to the study, clinicians waste an average of 46 minutes each day due to the use of outdated communications technologies. The primary reason is the inefficiency of pagers (as cited by 52 percent of survey respondents), followed by the lack of Wi-Fi availability (39 percent) and the inadequacy of email (38 percent).
  • The Ponemon Institute estimates that this waste of clinicians’ time costs each U.S. hospital $900K per year, and based on the number of registered hospitals in the U.S., this translates to a loss of more than $5.153 billion annually across the healthcare industry.
  • Similar deficiencies in communications lengthen patient discharge time, which currently averages 102 minutes. About 37 minutes of this is due to waiting for doctors, specialists or others to respond with information necessary for the patient’s release. The Ponemon Institute estimates that this lengthy discharge process costs the U.S. hospital industry more than $3.189 billion annually in lost revenue.
  • Sixty-five percent of respondents believe secure text messaging to communicate with care teams during the discharge process can cut discharge time by 50 minutes. 

Effects of Regulations on the Delivery of Patient Care and Technology Adoption

  • Fifty-one percent of survey respondents say HIPAA compliance requirements can be a barrier to providing effective patient care. Specifically, HIPAA reduces time available for patient care (according to 85 percent of respondents), makes access to electronic patient information difficult (79 percent) and restricts the use of electronic communications (56 percent).
  • Additionally, 59 percent of survey respondents cite the complexity of compliance and regulatory requirements as the primary barrier to achieving a strong IT security posture.

While health IT did not create the need for clinicians to spend time reviewing and updating patient records, the promise of health IT -- to make things easier for clinicians, better for patients and more efficient and cost-effective for all of us -- is a matter for the future.  As the saying goes, "The future is already here -- it's just not evenly distributed." Kelly makes the case for SSO and secure SMS, and the Ponemon study provides a snapshot evoking the scope of the opportunity.

David Harlow
The Harlow Group LLC
Health Care Law and Consulting


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Sean Kelly
Chief Medical Officer, Imprivata

May 7, 2013

David Harlow: This is David Harlow with HealthBlawg and I have with me today Sean Kelly, the Chief Medical Officer of Imprivata, which is providing some interesting new services and has news about a recent study which was conducted regarding communications systems that are in place in hospitals today and how that helps or hurts our healthcare system. Sean, thank you very much for speaking with us today.

Sean Kelly: My pleasure, David.

David Harlow: So Sean in an nutshell what can you tell us about this new study and what it may mean for folks looking at this from the hospital perspective?

Sean Kelly: Sure, the study was conducted by the Ponemon Institute and it’s entitled Economic and Productivity Impact of IT Security on Healthcare. It explores essentially the impact of security in people’s perception of how their workflow happens in the hospital both with regard to HIPAA compliance and security issues as well as with efficiency and convenience and the ability to take care of patients. Some of the higher level points that came out of the study are that doctors and other caregivers including nurses and other people who have direct patient contacts feel like they spend really less than 45% of their time actually caring for patients and in direct patient care, face-to-face contact. They also feel that outdated technology leads to at least 45 minutes a day of wasted time. The economic impact of this amount of time being wasted with outdated technologies can amount to a significant amount per hospital -- probably close to $1 million per hospital per year in the United States, and when you add all that up that over $8.3 billion per year in the US alone. This is probably a problem with economic impact around the globe as well although this study was conducted on participants in the United States alone.

There is a lot of subjective information that came back as far as people’s information and opinions about what the cause of some of these delays were. Specifically they cited the inefficiency of pagers, the lack of WiFi availability and inadequacy of e-mail as well as the fact that text messaging wasn’t allowed. They felt that a lot of these things led to the inefficiency and inconvenience at work as opposed to what they’re used to in their consumer life.

I’m a practicing emergency physician as well as the Chief Medical Officer at Imprivata and I can tell you that there is a lot of promise and potential that comes with technology and there is also a lot of difficulties with it as well. Traditionally in healthcare we’ve seen a lot of tension between security concerns and convenience and we see this at Imprivata since we provide a single sign on solution addressing some of the pain points around the fact that providers are required to log on and authenticate just about every time they touch protected health information. This is a reasonable thing to ask providers to do because you really want to have an audit trial – it’s required by HIPAA to be compliant it’s very necessary and proper to have good security barriers in place because you really want to make sure patients’ private information is protected and it’s really the right thing to do.

The problem is a lot of these systems inherently can be difficult. In my life as a practicing doctor on a typical shift in the emergency department I might log on and off of systems hundreds of times per shift for multiple patients and try to navigate back and forth between my electronic medical record and the PACS system to look up X-rays and other radiologic findings I might go to other clinician applications such as Up-to-Date or epocrates or other websites and for every one of these jumps between and navigating around the system I might need to log in or log out or try to boot something up or close it down and every one of those points can cause delay -- not just in the time but also in cognitive disruption of my thought process, and so it’s really important to make sure that we have sort of a latest and greatest technology to allow us to do our jobs as physicians.

David Harlow: Right -- so it sounds like the single sign on solution would address something like that, that problem that you describe in the emergency department. And my understanding is that you’re talking also about another solution in terms of trying to ease the pain and reduce the time that’s spent on these various tasks in the day in the life in the hospital, is this a texting solution?

Sean Kelly: Yeah, I think it’s important for people to understand that healthcare is still reliant on some outdated technology -- specifically pagers -- and just to give you an example of what a typical workflow might be in a hospital, is that to page a colleague, whether it’s a nurse that you need to try to find out something or order not necessarily something you do through the EMR but if you just want to find out Room 7 has had a recent vital sign performed or oxygen saturation level or something you might page the nurse and the pager system as it currently exists might be unidirectional and so I would go to a desktop, have to log on, open up an application, look at what nurse is on call for a patient that’s on duty at that time, send the page out to that person who may or may not contact me back and that unidirectional message flow can get lost out there, it’s hard to know, there is no read receipt, I’m not sure if it’s delivered or read -- there is no easy way to just text me back and say well, yes, that was performed or no, it was not performed but I’ll do it, or actually the result is 97% on room air.

And that kind of inability to just quickly send a message out, have it come back, complete the workflow in the current state of affairs in most places makes it difficult, especially when I walk into the hospital and in my pocket is this very efficient tool that I’m used to using all the time in my consumer life, where I can text message back and forth and get a quick reply, finish my thought process, move on to the next step. When I’m trying to discharge a patient from the hospital or from the emergency department there are many, many different points in that workflow that can lead to delay and in this study for example they found that it may take over 100 minutes to get a patient discharged from a hospital of which 37 minutes or more might be spent just trying to contact physicians and hear back from them that it’s okay to discharge a patient, or there might be one last minute thingthey need to clear up and this kind of operational flow issue would be very ideally solved with the text messaging platforms.

David Harlow: Right. So these issues aren’t new but I guess what you’re suggesting is that there is a solution just beyond our reach or maybe now just within our reach, but the problem as you state it is not a new problem. There has always been a need for people to be reviewing records, consulting with colleagues in the course of caring for an inpatient and it’s been traditionally a paper process but now with Meaningful Use starting to take hold, do you see an improvement on that front? Are these numbers based on a recent survey? Is there an older survey to compare these against? It just seems to me that there has been some improvement over time and perhaps things are better than they were but not quite as good as they could be.

Sean Kelly: Yes it’s a very good point you raised. I think it is a double-edged sword there are lot of things that have certainly improved with the advent of electronic medical records and computers are good at a lot of things. For example, when we’re about to discharge someone home, it’s very nice to be able to take their current medication list and when you write a new prescription the computer is very good at cross checking the drug- drug interactions or looking up their past listed allergies or reminding me that they’re due for their flu vaccination, and so from a population health standpoint and even from a patient care standpoint there are a lot of things that technology does for us, and you’re right, though, that the problem has been in existence for a while where we’re trying to figure out all these different moving parts and be as efficient as possible -- that problem has been around.

Now we have tools that we can use to help solve those problems so that we can bring technology to bear. The issue in the past couple of years with acceleration of adoption of a lot of different technologies, as healthcare starts to finally catch up to a lot of the rest of the world, the issue is this again this tension between security and convenience or efficiency, and the problem is that since we’re required to make sure that we’re absolutely compliant from a HIPAA standpoint we traditionally haven’t been able to use things like SMS texting because it’s not HIPAA compliant or secure and above all else we have to make sure we hit that threshold. So the solution we created was really due to feedback from hospitals saying we want this tool but it needs to be ironclad secure, and so we as a healthcare security company set about working on this as a solution to help address the pain that’s out, to say doctors and nurses want security and efficiency. If there is a tool that works they will do the right thing and use it, but it has to actually work and it has to actually be secure enough to satisfy the security officer at the hospital in order to be enabled on a hospital-wide basis and okayed for use by endpoint clinicians.

David Harlow: My readers and I are at varying levels of sophistication when it comes to the technical details behind this but I wonder if you could delve in a little bit and explain how the product or service achieves this level of security?

Sean Kelly: Sure, and my specific role is Chief Medical Officer and so I’m also not a security officer, I’m a workflow person and I understand workflow from the clinician’s perspective, but what we have done is we’re in conjunction with a lot of our partner hospitals to work with their security officers to make sure that we are compliant with their needs to be HIPAA compliant, and the long and the short of that is that instead of using just an SMS text platform where messages and pictures and everything else lives on the server or on the phone itself and is not HIPAA compliant what we’ve done is create a protected area within an app. So this is essentially an app that you download to the phone, users are enabled by the hospitals it syncs to their active directory and you can immediately enable or disable users on to the system and it’s configured in such a way that everybody that the hospital wants to be visible to each other on this network within this app can be visible to one another but if you’d like to remove somebody you can erase them immediately and all the Protected Health Information or PHI along with their conversations just go away -- no longer visible for that person, it lives within the app.

David Harlow: And then do the conversations reside on a hospital server of some sort?

Sean Kelly: So the conversations reside in the cloud on a server that is accessible only to the hospital. It’s encrypted so that the hospital is the only one who can see the protected health information within it. We will see usage stats and we will know messaging information about how much is being used and by whom in the hospital but we won’t see any of the information within that -- that’s encrypted and only visible to the hospital users themselves -- to the admin and to the end users within the hospitals, and for greater detail on the security measures involved I’d be happy to let readers or you hook up with people on our end that are experts, but our basic strategic process has been: let’s pick the information security officers that we know around the country and the world that are the most strict, make sure it meets their needs because if it meets their needs as to hospital IT then it will certainly meet the needs of the others who are less stringent out there and as long as it meets their needs and we’ve gone through that due diligence and we sign business agreements stating that we’re HIPAA compliant as a vendor, then hospitals are comfortable as per their policy to enable users on this, and then on the other end we want to make sure that we are creating the best user experience and the user satisfaction in a very healthcare centric way for the end users specifically physicians, nurses, administrators, other caregivers within the hospital.

David Harlow: Okay. You mentioned earlier that you’re focused on this from a workflow perspective and I’m wondering if there are other changes to workflow in your typical hospital - if there is such a thing - that could be looked at in order to alleviate some part of this problem that you’re trying to solve?

Sean Kelly: Yeah, I think the possibilities are certainly exciting. Once you have a platform in place that allows for control of your desktop and easier access in and out of systems throughout the desktop -- which is part of our core offering with single sign on and authentication and sort of a trust fabric of authentication -- and you have endpoints involved where you’re reaching out and those messages that get out sent out to endpoints like mobile devices and you’ve got providers within the network able to now have secure messaging back and forth now things get really interesting because you can really accelerate the provider’s ability to provide good care because you’re making their workflow much more efficient, and so this is where we’re actually the fun just gets started once people start to use it because then they realize, okay well there are these Meaningful Use guidelines or there are these problems as an Accountable Care Organization where we need to really enhance communication between our facilites when we do interfacility transfers, or we really need to make sure we prevent congestive heart failure readmissions and we think that the best way to do that is to facilitate communications between our case managers and our primary care doctors and our cardiologists so here is a package of communications that we could enable using CorText which is the secure messaging platform, along with some of our ability to automate which applications pop up when someone signs on in the cardiology unit and you could picture a hospital now structuring because they have just enough of these different secure collaboration communication tools to really create an interesting package that can be used as a template by different hospitals to address a particular clinical problem and just like someone comes up with a really good stethoscope and then it’s up to the caregivers to figure out how they’re going to best use it to care for a patient -- technical tools in a way are similar. We’ve created a very secure way of communications I don’t know that we’re going to try to tell doctors and nurses and hospitals this is how you should use it -- we can say here are examples of how we think it can be used work with us to tell us how it could be the most valuable to make your jobs easier and make your patients lives better so that’s sort of the goal.

David Harlow: Right - sounds good. Well it’s an exciting time and that’s a very interesting tool, set of tools that you’re developing. I thank you for taking the time to share with us today. This is David Harlow and I’m speaking with Sean Kelly, Chief Medical Officer of Imprivata. We’ve been talking about CorText, their secure texting service and related products as well. Thank you for listening on HealthBlawg.

April 04, 2013

Medicaid Expansion Under the Affordable Care Act - A New Look at the "Before" Picture, with Tim Waidmann, Senior Fellow in the Health Policy Center at the Urban Institute

Financial Burden of Medical Spending by State and the Implications of the 2014 Mediciaid Expansions is the latest report from the Affordable Care Act implementation monitoring and tracking initiative funded by the Robert Wood Johnson Foundation. (Direct link to PDF of report.) I spoke with Tim Waidmann, Senior Fellow in the Health Policy Center at the Urban Institute, an author of the report. Please listen in:

The audio file of my interview with Tim Waidmann (about 20 minutes long) is available for download/podcast, or may be played here:

Tim Waidmann - Urban Institute - Medicaid Expansion

A full transcript is available as a PDF (Tim Waidmann interview) and is reproduced below.  

The Census Bureau has made these researchers' lives easier by collecting data that allows for the running of a natural experiment that answers the question: How will implementation of the ACA affect the percentage of household income spent on health care by low-income Americans? One of the interesting points highlighted by Waidmann is that the state in which the highest proportion of low-income household income is spent on health care (surprise: Nevada!) is not the state in which Medicaid coverage is least comprehensive, the state in which health care is most expensive, or the state with the greatest prevalence of poverty (though some of those states show up in the top ten).

All of the states with health care access and payment problems for low-income residents would be well-advised to consider the opportunities to expand coverage under the ACA Medicaid expansion provisions. Some -- including a couple at the top of Waidmann's list, as of this writing -- remain dead-set against the Medicaid expansion program (though most of the states that challenged the ACA are more than willing to accept the increased FFP for the Medicaid expansion to cover residents at up to 133% of the Federal poverty level, to the relief of the membership of their local hospital associations and other providers, which have been providing free care to folks who will be the beneficiaries of the Medicaid expansion). Some are exploring opportunities for creative alternatives to Medicaid expansion per se: Consider the Arkansas premium support plan, which will use Medicaid expansion dollars to buy private health insurance for those who would otherwise be eligible to enroll in an expanded Medicaid program.

If you're looking for a scorecard, you can follow state-by-state Medicaid expansion activity at 

David Harlow
The Harlow Group LLC
Health Care Law and Consulting   


HealthBlawg :: David Harlow’s Health Care Law Blog

Interview of Timothy Waidmann, Senior Fellow, Health Policy Center, Urban Institute 

April 3, 2013 

David Harlow:  This is David Harlow at HealthBlawg.  Today I’m speaking with Timothy Waidmann at the Urban Institute and with Kyle Caswell as well.  Tim is a senior fellow in the Health Policy Center at the Urban Institute, where Kyle is a Research Associate.  They are co-authors of a report on Medicaid released yesterday funded by the Robert Wood Johnson Foundation as part of the Affordable Care Act Implementation, Monitoring and Tracking Initiative.  The report is titled, Financial Burden of Medical Spending by State and the Implications of the 2014 Medicaid Expansions.  Welcome Tim and Kyle and thank you for speaking with us.

Tim Waidmann:  Thank you.  It’s a pleasure. 

Kyle Caswell:  Thanks. 

David Harlow:  So, the title of the report you’ve just released is a bit dense and I wonder if you could unpack it a bit for us before diving in. 

Tim Waidmann:  Let me look at the title again. 

David Harlow:  The Financial Burden of Medical Spending by State and the Implications of the 2014 Medicaid Expansions. 

Tim Waidmann:  Right.  So, the basic idea of this report is that we study how much income the non-elderly population devotes to medical spending and we look at that state-by-state.  And the idea is by looking at this variation and then focusing in on a low income population in particular, we hope to learn what state’s decisions about whether or not to expand their Medicaid programs as part of the Affordable Care Act.  What implications those decisions might have for their own populations.  So, this is, if a state has a particularly high level of burden of medical care spending, it’s likely that expanding Medicaid will have a larger beneficial impact than a state that has relatively low level of financial burden, so that’s kind of the – what we are trying to tease out of the data was a comparison along those lines. 

David Harlow:  Are there other takeaways from the report?

Tim Waidmann:  Well, the first cut of this was just to look, I mean, this is relatively new data source with which we can do this kind of study.  The Current Population Study is a nationwide large survey that has samples in every state and it allows us to look down at even small states and say, to get some idea of population characteristics and a couple of years ago they added to the survey a question or a couple of questions on how much people spend out of pocket on premiums and other expenditures for their healthcare, so whether co-pays or co-insurance, payments, deductibles, those kinds of things.  And so, the first cut at this was just to look overall, the whole population -- and we focused on non-elderly because Medicare is just sort of different word for medical spending.  But, excluding that population, we’re able to see of quite a bit of variation from state-to-state in how burdensome medical care is to the typical family and to the typical person.  So, for example, a typical person in New York say, in the State of New York spends about 2% of their total family income on medical care.  But in Idaho, the typical person spends more than twice as much as a share of their income and they spend about 5% of their annual income on healthcare.  So, that’s just, you know, the typical person in the middle of the distribution. 

David Harlow:  So, that’s in the general non-elderly population? 

Tim Waidmann:  Yeah.

David Harlow:  And is the spread the differential as pronounced for the Medicaid population? 

Tim Waidmann:  So, in fact, it’s even greater for the low-income population, which we focus in on later, but when you look, you know, if staying with the general population, if you look at, if you say well, the typical person doesn’t really use a lot of medical care, what about the sort of higher-spending group and these differences that we see at the median persist and even grow, if you look at the top half of the spending – of the burden distribution.  And again, you just compare typical -- the 75th percentile -- think about the typical person in the top half of the burden distribution.  In Idaho that person spends 11% of income, while in New York they spend around 6, 6.5%.  So, these differences that appear in one part of the distribution seem to carry through the rest of the distribution as well, that indicates… 

David Harlow:  And by the higher percentile of the burden distribution you’re referring to someone who is making greater use of the healthcare system? 

Tim Waidmann:  Well, it’s sort of relative to income.

David Harlow:  Yes.

Tim Waidmann:  So that if you think of, what someone can expect to spend out of their take home pay or out of their total income, this suggests that someone in Idaho should expect to spend about twice as much of their income as someone in New York would spend. 

David Harlow:  So, would you characterize these data as surprising? When we think of New York, California, a couple of other locations, Massachusetts where I am, as being high cost centers for healthcare.  Are you saying that they may be high cost, but they’re not necessarily high cost relative to income? 

Tim Waidmann:  So that’s right, you pick up on a very important point that this measure of financial burden has both the spending component and an income component.  And a state could appear to be a very high burden state just because it’s a low income state.  And, if people have the same medical care needs, but lower income, their burden would appear to be higher.  And so, that – those same differences that would be apparent between individuals who show up across the states, so low income states are more likely to show high burden than high income states.  But then, the other factor that matters and varies from state-to-state as you mentioned is that health care costs more in some states than it does in others.  And so, two states that have similar levels of income, but different levels of medical care costs will also show up as having different levels of financial burden.  

David Harlow:  So, let’s look at perhaps some of the states that we think of as having particular problems in this area -- and whose Governors had at least initially said that they would not buy into the Medicaid expansion.  I’m thinking off the top of my head of places like Louisiana, Mississippi, where also traditional state level Medicaid coverage is rather slim. 

Tim Waidmann:  Right. 

David Harlow:  So that there is probably a higher burden now for lower income folk in those states. 

Tim Waidmann:  So, if you look specifically at the low income population, which is where we wanted to get to, the differences across states just seem to grow quite a bit.  But, in every state the average amount that a low income household spends on healthcare is going to be higher as a percentage of income than high income households.  But, the sort of range that we see between low income folks in some states and other states is quite dramatic.  And then, if you then further focus in on, you know, the population who doesn’t have Medicaid, the low income population that doesn’t have Medicaid -- that’s kind of where I think the policy implication is strongest and you mentioned Louisiana, Mississippi as two examples and they happen to be, you know, if you look at the top five states nationwide in terms of the share of their population who is low income and doesn’t have Medicaid and has high medical care burden, those two are among those top five. 

Nevada is actually the state with the highest fraction of its population, who is not covered by Medicaid, has high burden and low income.  But Nevada has decided that it’s going to go ahead with the Medicaid expansion.  So, what we would expect is that, you know, among these states that currently have – appear to have – a large portion of population who would be affected by the expansion, some of these states who go ahead with the expansion, we expect them to reduce their place on this ranking.  So, Nevada, we expect to fall -- once it expands its Medicaid program -- out of this top five, while Louisiana and Mississippi we expect will likely stay as high burden states for their low income population. 

David Harlow:  Right, unless they do accede to some pressures from the hospital industry and others, who would like to see some of their free care get reimbursed, which they would do if they had the Medicaid expansion in place. 

Tim Waidmann:  And so, I mean, it’s interesting among these top five states that we have found.  There were two, Nevada and Montana, who have agreed to expansion, two have said no to expansion so far, and one -- in Arkansas -- that has said yes to an expansion sort of, that would like to use a private, use the exchange system to expand coverage to this low income population.  And so, you could sort of think of this as an intermediate case, you know, it would be interesting to see what happens to a measure like this.  If the private version of the Medicaid expansion looks like Medicaid in that it has very low or zero cost-sharing requirements of its beneficiaries, I would expect that it will – what will happen in Arkansas will look very much like what happens in states that have full public expansion in Medicaid. 

David Harlow:  And so that would be private pay, in the Arkansas model? 

Tim Waidmann:  If what happens is that beneficiaries are fully subsidized to join private plans, you could imagine that they’ll see very little difference between that and in public sector Medicaid expansion.  But if they’re required to – if what happens is that they get some subsidies for enrolling in a private plan that doesn’t fully cover their expenses then it may well be that they don’t reduce this burden. 

David Harlow:  Right.  I had understood that there were not a whole lot of waivers available in order to reconfigure the way in which the Medicaid expansion would work, so that federal dollars would not necessarily be available for private premiums versus reimbursement of additional Medicaid expenses.

Tim Waidmann:  Yeah, I mean, I think that, I was a little surprised that how quickly they seemed to – the federal government quickly seemed to agree to a private version of covering this population in some form.  So, it will be interesting to see what happens there. 

David Harlow:  Sure … 50 laboratories, as they say. 

Tim Waidmann:  Yeah, that’s true. One of the key takeaways for us, I think was that, you know, we see where the world or where the states line up now before the ACA is fully implemented and this is kind of an ideal from a social science perspective experiment that we have 50 different approaches and we’ve got the state of the world before implementation and it’ll be a good sort of natural experiment to see what happens. 

David Harlow:  Sure.  And, you have a good level of confidence in the data source that you are using in terms of the sort of self-reported statements that you described? 

Tim Waidmann:  Well, you know, Kyle actually is one of the people who did a study comparing this data source to other established sources and I think the Census Bureau folks, which is where Kyle was before he joined us, are fairly satisfied with the quality of this data.  And it was a boon to us in the health services research world that CPS added this question.  And I think we’re beginning to see the usefulness of it in some of these research projects we have undertaken. 

David Harlow:  Sure. I imagine you have a cache of some other questions that you’d love to see added to that questionnaire as well.

Tim Waidmann:  We have endless sets of questions that we would like to see added, but the Census Bureau is very careful with expanding that survey. I think they are worried about burdening their respondents too much and I think rightly so. This has been a great source of information even before this, even before these questions were added, especially on estimating coverage differences across states.  But, we’re just happy that they were able to add this most recently.

David Harlow:  Great.  So, how does this piece of work fit in with the other work that you have been doing about the roll-out of the Affordable Care Act?

Tim Waidmann:  Well, you know, I think that we’ve also, using other data sources, looked at differences in access to care across states and differences in coverage across states, and kind of also trying to get a sense of where the world is before the ACA gets into full swing.  And, you know, I think that we find similar amounts of variation in the use of – in access to basic healthcare and in the use of preventive services, I think that these findings here -- I think, from what I remember other members of our staff here have worked on that, but preventive care differences have been a little less dramatic, but certainly access to basic care does appear to have a bit of variation from state-to-state.  And we expect as coverage is expanded through both Medicaid and the exchanges and other methods, we expect some of those differences and access to care to shrink, but we’ll see what happens.

David Harlow:  Right. Well again, Tim and Kyle, thank you very much for joining me today.  It’s been a very interesting conversation for me and I hope for our listeners and readers.  And again, this is David Harlow at HealthBlawg.  Thank you very much.

Tim Waidmann:  Thank you, it’s been pleasure.