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"The Poverty Industry, The Exploitation of America's Most Vulnerable Citizens," A Conversation with the Author, Daniel L. Hatcher (September 22nd)

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For this, my 101st interview, I discuss with the author, Daniel L. Hatcher, his new work, "The Poverty Industry, The Exploitation of America's Most Vulnerable Citizens."  The work is aptly summarized by Columbia University Professor Jane Spinak.  She notes on the book's dust jacket, "In the tradition of great muckracking, Hatcher has exposed how states and localities misdirected and misused public funds envisioned to benefit the most vulnerable among us." 

During this 26 minute conversation Professor Hatcher discusses his motivations for writing the book, defines "poverty's iron triangle," explains how state foster care and Medicaid agencies, with the help of private contractors, monetize poverty for state financial gain, explains how states attempt to reason this behavior and offers solutions for how this malfeasance can be "reeled in."  

Daniel L. Hatcher is Professor of Law at the University of Baltimore School of Law, teaching a civil advocacy clinic and other Hatcherclasses.  Before joining the faculty in 2004, Hatcher was with the Maryland Legal Aid Bureau, serving as the assistant director of advocacy for public benefits and economic stability.  He previously worked as a staff attorney for Legal Aid representing abused and neglected children, and he represented adult clients all poverty law matters – including public benefits, housing, consumer and family law issues.  He was also a senior staff attorney with the Children's Defense Fund.  Hatcher has testified before Congress, the Maryland General Assembly and in other governmental proceedings regarding several issues affecting children and low-income individuals and families.  Professor earned his law degree at the University of Virginia and his undergraduate degree at the University of Texas at Arlington. 

For more on Hatcher's work go to:


How Providers Will Respond to MACRA Implementation (September 14th)

For those interested in how providers will likely respond to MACRA, today the Better Medicare Alliance posted my essay, "How Will Providers Respond to MACRA and What Does It Mean for Provider Participation in Medicare Advantage?"  The essay is at:

The proposed MACRA (the Medicare Access and CHIP Reauthorization Act) rule was the subject of my June 14th interview with CAPG's Mara McDermott on June 14th. 


Medicare Advantage Program Reforms Within and Beyond MACRA: A Conversation with Molly Turco (August 15th)

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Since the passage of the Affordable Care Act in 2010 CMS has been working to reform Medicare reimbursements from "fee for service" to "fee for value."  (Earlier this year Secretary Burwell noted 30% of traditional or "fee for service" Medicare reimbursements are now tied to quality or value.)  The Medicare Access and CHIP Reauthorization Act (MACRA) passed in 2015 accelerates this transition by incenting Medicare providers to participate in "fee of value" or pay for performance agreements, termed Alternative Payment Models (APMs) under MACRA, with a 5% annual bonus.  To date, commercial Medicare Advantage (MA) plans (Medicare Part D) have been immune from these reforms.   However, under MACRA beginning in performance year 2019 MA plan providers can potentially count their MA reimbursements and MA beneficiaries toward qualifying for the 5% MACRA APM bonus - if they meet the financial risk and other qualifying MACRA APM criteria.  To what extent MA plans, that now account for nearly one-third of all Medicare beneficiaries, will work with their provider partners to meet the MACRA APM qualifying criteria is unknown.      

During this 23 minute conversation Ms. Turco discusses expectations for MA plan participation under MACRA as qualifying APMs, how MA stakeholders are thinking about moving the program outside of MACRA toward improved value or reduced spending growth, CMS's MA Value Based Insurance Design (VBID) demonstration scheduled to begin in January and anticipated MA reforms under a new White House administration next year.   

Ms. Molly Turco is presently Director of Policy and Research at the Better Medicare.  Previously, Ms. Turco was a Senior Healthcare Policy Analyst with the Marwood Group.  Turco Ms. Turco also worked as a Healthcare Policy Researcher in the State of Vermont Office of Health Reform, within the University of Pennsylvania Health System and at Dartmouth Hitchcock Medical Center and the Geisel School of Medicine at Dartmouth.  Ms. Turco holds a MPH from the Dartmouth Institute for Health Policy and Clinical Practice and a BA from Middlebury College.  


What Can Be Done About Reforming the Employer Health Insurance Tax Exclusion: A Conversation with Dr. Joe Antos (August 5th)

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Excluding from taxable income the moneys employers spend in providing employees with health insurance dates back to WWII-era wage and price controls.  Today, this tax policy, that amounts to over $250 billion in lost federal tax revenue, effectively constitutes the third largest federal government expenditure on health care after Medicare and Medicaid.  Few tax experts would disagree that the tax exclusion constitutes bad policy.  Beyond lost tax revenues, the policy is, among other things, highly regressive, causes lower or stagnant wage growth, reduces health plan competition, contributes to excessive health care spending, incents the over-utilization of health care services, limits job mobility and negatively influences retirement decisions.   

During this 25 minute conversation Dr. Antos discusses the extent to which the tax exclusion is responsible for employers providing employees with health care insurance coverage, what effect would capping or phasing out the exclusion have on coverage, how best can the policy can be reformed via a Cadillac tax or otherwise, what might be done to reform the tax exclusion under a Secretary Clinton administration and how the exclusion may play into future tax reform may legislation.   

Dr. Joe Antos is the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute (AEI). Img-joeantosheadshot300x225_145016424575 Before joining AEI,  Dr. Antos served as the Assistant Director for Health and Human Resources at the Congressional Budget Office (CBO).  Dr. Antos has also held senior positions in the US Department of Health and Human Services, the Office of Management and Budget and the President's Council on Economic Advisers.  He recently completed a seven year term as Health Adviser to CBO and two terms as a Commissioner of the Maryland Health Services Cost Review Commission.  In 2013 he was named Adjunct Associate Professor of Emergency Medicine at George Washington University.   Dr. Antos earned his Ph.D. and MA in economics at the University of Rochester and his BA in mathematics from Cornell University.   

For more background information about the exclusion and micro-simulation data on reforming the exclusion, see Jonathan Gruber's 2011 article in the National Tax Journal, at:


What Does Performance Under Medicare's Value-based Modifier (VM) Program Suggest Concerning Physician Performance Under MACRA: A Conversation With Kelly Cleary (July 20th)

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The 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will sunset three current Medicare performance measurement and incentive payment programs in 2018.  (This year, 2016, will be the last year these programs will be measuring and rewarding Medicare physician performance.)  These are: the Physician Quality Reporting System (PQRS); the HIT Meaningful Use (MU) program; and, the Value-Based Modifier (VM) Program.  The VM Program, modified under the 2010 Affordable Care Act, is designed to incent Medicare physician performance by updating annual Part B physician payments based on their quality and cost (or spending) performance.  (The performance and payment years are two years apart, e.g., the 2016 payment year is based on 2014 performance.)     

During this 23 minute conversation Ms. Cleary explains how the VM program is designed, how physicians have performed to date under the program, the extent to which physicians use VM data to inform or improve their practice, how the program will be translated, or continue, under the MACRA Merit-Based Incentive Payment System (MIPS) and quality and value performance expectations under MIPS beginning in 2017, the first MACRA performance year.   

Ms. Kelly Cleary is a DC-based health care attorney with the firm Akin Gump.  Her work primarily concerns health care related legislative and Cleary_Kelly_highres regulatory initiatives, matters involving state and federal fraud and abuse laws and cybersecurity, privacy and data protection issues.  Prior to joining Akin Gump, Ms. Clearly clerked for the Honorable Claude M. Hilton in the US District Court for the Eastern District of Virginia.  She was graduated from Catholic University's School of Law.  While there she served as editor-in-chief of the Catholic University Law Review.   

For more on the CMS VM program go to:


"Where's The Value In MACRA?" (June 24th)

Students of the Medicare program are well aware in late April, CMS dropped its proposed Medicare Access and CHIP Reauthorization Act (MACRA) rule.  Specifically, the rule addresses MACRA Title I.   At 424 Federal Register pages the rule will make considerable changes to how CMS will, beginning in 2019, annually update Medicare Part or physician payments.  For all the Strum and Drang surrounding MACRA and regulatory implementation thereof, the proposed rule represents conventional thinking.  Despite the considerable rhetoric about moving Medicare payments from volume to value, remarkably, value goes undiscussed, i.e., value as the relationship between care outcomes and spending.  If we're serious about "bending the Medicare cost curve" and/or expecting providers to accept downside financial risk via ACOs and other models or CMS demonstrations, we'll not get there by continuing to ignore measuring for value.  

If you're interested please feel free:


Recent Efforts to Improve Quality Measurement: A Conversation with Dr. Helen Burstin (June 15th)

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Measuring health care quality and outcomes effectively and efficiently remains a daunting task.  Quality measures are largely seen as too process versus outcome focused, substantially irrelevant to patients and insufficiently aligned between and among payers.  Measuring care or care quality, ironically, can and does detract from actual care delivery, can have no relationship to spending efficiency and on its own is costly.  A recent article published in Health Affairs found physician practices spent over $15 billion in 2014 in reporting quality measures.  Concerning the Medicare program's quality measurement activities, MedPAC in a 2014 report to the Congress went so far as to state, "Medicare's current quality measurement approach as gone off the rails." 

During this 23 minute conversation Dr. Burstin briefly describes the work of the National Quality Forum (NQF), the work done by the CMS-led Core Measure Collaborative, quality measurement under the CMS proposed MACRA (Medicare Access and CHIP Reauthorization Act) rule, risk adjusting measures for socio-demographic factors, the role of PREMS and PROMS or patient reported experience and outcome measures and correlating care quality and spending or measuring for healthcare value.  

Dr. Helen Burstin is the Chief Scientific Officer at the NQF.  Prior to serving in her current position, Dr. Burstin was NQF's Senior Burstin PhotoVice President for Performance Measurement.  Prior to NQF Dr. Burstin was the Director of the Center for Primary Care at the DHHS Agency for Healthcare Research and Quality (AHRQ).  Prior to AHRQ, Dr. Burstin was an Assistant Professor at Harvard Medical School and the Director of Quality Measurement at the Brigham and Woman's Hospital in Boston.  Dr. Burstin has published more than 80 articles and book chapters on quality, safety and disparities.  She was recently selected as a 2015-2016 Baldridge Executive Fellow.  She currently is also is a Professorial Lecturer in the Department of Health and Policy and a Clinical Associate Professor of Medicine at George Washington University and serves as a preceptor in internal medicine.

For information concerning NQF go to:




How CMS Proposes to Annually Update Medicare Physician Reimbursement Under MACRA: A Conversation with Mara McDermott (June 14th)

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In an extremely busy year for Medicare delivery and payment reform,  regulatory implementation of the 2015 Medicare Access and CHIP Reauthorization Act (MACRA) stands out.   This past April CMS published the agency's 960-page proposed rule to implement the law.  The proposed rule, that will go final this fall, will change the way Medicare physician payments (Medicare Part B) are annually updated beginning in payment year 2019.   Payment updates, either at the individual provider or at the group level, will be calculated either by the Merit-based Incentive Payment System (MIPS), a composite score based on four, differently weighted, component scores, or via provider participation in what CMS defines as an "advanced" Alternative Payment Model (APM) pathway, e.g., Track 2 and 3 ACOS and Patient Centered Medical Homes that meet certain financial risk criteria.

During this 22-minute discussion Ms. Mara McDermott evaluates how CMS proposes to define APM nominal risk, how the agency has defined the MIPS composite score, the effect MACRA will have on small practices, how Medicare Advantage plans and physicians can be included in MACRA, and several inter-related issues.   (While the introduction to this discussion provides some brief explanatory information, our conversation assumes the listener has some familiarity with Title I of the MACRA law.)    

Mara McDermott is the Vice President of CAPG (formerly the California Association of Physician Groups) where she leads the Mara McDermott_smorganization's federal legislative and regulatory activities in Washington, D.C.  Prior to joining CAPG, Mara was Counsel in the health industry practice of Akin Gump Strauss Hauer and Field.  Mara received her JD with high honors and her MPH from George Washington University School of Law in 2007.  She received her BA in 2003 from the University of California, Davis.

The CMS MACRA proposed rule is at:

 Information concerning CAPG is at:



"About Hastert’s “Known Acts:” The Indifference Is as Disturbing as the Crime" (June 6th)


This past April 27th former US House Speaker, Denise Hastert, was convicted of violating federal banking laws resulting from his efforts to buy the silence of a high school student he sexually molested several decades ago while Hastert was employed as the school's wrestling coach.  Since Hastert's sentencing no Congressional leader nor the White House has bothered to condemn Hastert's "known acts" much less recognize the adverse life time health effects survivors' suffer, nor has the health care media, nor leading health care associations.  This behavior is the status quo.   If your interested in the Hastert case and non-response to it, here is the link to: "About Hastert's "Known Acts:" The Indifference is as Disturbing as the Crime."

See also this related January 2013 Health Affairs blog post:

My podcast interview with Diane Champe, noted in the above THCB blog post, is dated December 7, 2012. 



Andrea LaFountain Discusses Her Recent Work: "How Patients Think: A Science-based Strategy for Patient Engagement and Population Health" (May 26th)

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What accounts for so called patient compliance or adherence or why is it the case physicians and other providers are frequently unable to successfully engage their patients.  Why is it the case, for example, that patients adhere to highly toxic regimens of such as chemo therapy and not to more tolerable drugs such as statins.  What explains adherence or non-adherence?         

During this 22-minute conversation Dr. LaFountain explains why, using her phrase, the "epidemic of non-adherence" persists. She discusses the "importance of differentiation," the application of "cognitive profiling" or "cognitive restructuring," and provides examples using treatments for ADHD, breast cancer and diabetic patients at the Cleveland Clinic.

Dr. Andrea LaFountain is CEO of Mind Field Solutions Corporation, a firm specializing in the application of cognitive LaFountain Photoneueroscience to health behavior and patient engagement.   Prior to establishing Mind Field, she worked for AstraZeneca Pharmaceuticals leading consumer research and analytics for their oncology portfolio.   Before moving to the US, Dr. LaFountain was a Lecturer at The University of Liverpool.   She is a fellow of the American Psychological Association and the British Psychological Society and a scientific reviewer for the International Society of Pharmaco-economic Outcomes Research.  Dr. LaFountain earned her Ph.D. in pre-frontal cortex executive functioning at Imperial College, London.  

For information concerning Dr. LaFountain's work go to: