A Second Opinion with Cara James | A Second Opinion Podcast

A Second Opinion with Cara James

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In today’s episode, I’m excited to have Dr. Cara James of the Centers for Medicare and Medicaid Services joining us. But before we get started, I wanted to thank our sponsors. A Second Opinion is powered by Tivity Health, lifestyle brands that transform healthy living for adults through nutrition, fitness, and social connection. We’re also brought to you by Jarrard, Phillips, Cate, and Hancock, the preeminent, trusted, strategic communications firm devoted to healthcare providers.

Now let’s turn to the episode. Dr. Cara James is the director of the Office of Minority Health at CMS, the Centers for Medicare and Medicaid Services, where she is also co-chair of the Rural Health Council. She’s a nationally recognized expert in health disparities, in health equity, and improving health outcomes for vulnerable populations. Under her leadership, CMS developed it’s very first CMS Equity Plan to improve quality in Medicare, as well as it’s first formal Rural Health Strategy. And she continues to think creatively to move federal levers that make a difference in health and well being of the underserved. Cara and I are old friends, having both worked together a decade ago at the Kaiser Family Foundation. In our conversation, you will find her thoughts on maternal health to be particularly compelling. And now, please join me and our guest for A Second Opinion.

Jarrard - Sponsor for A Second Opinion Podcast with Senator Bill Frist. MD

Sen. Bill Frist:               Cara, health care disparities, a vulnerable population, minority issues, the underserved, that’s what you do.

Dr. Cara James:             Yes.

Sen. Bill Frist:               That’s what you do every day. You wake up and you have now for years. Tell us a little bit about the nature of your position right now, one that I know very well, and I have huge respect for both the position, but also especially for you. Because you’re on the road, you’re collecting information, you’re listening to people, you’re sharing with others. Take us, walk us into this world of the vulnerable population.

Dr. Cara James:             Okay, sure. I’m the director of the Office of Minority Health at the Centers for Medicare and Medicaid Services, and in that role, we try to, as I say, make sure that the voices and the needs of the populations we represent are present as the agency is developing, implementing, and evaluating it’s programs and policies. That’s really, from start to finish. Not just, we put a policy out, we’re communicating to the community what’s happening. But we’re also thinking about the unique needs that communities face.

Sen. Bill Frist:               Now just to put it in perspective, the CMS, the Centers for Medicare and Medicaid Services, it is huge. It is big.

Dr. Cara James:             It is big.

Sen. Bill Frist:               I don’t know how many people it is or even what the budget is now, but it is everywhere and obviously is responsible. The government entity most responsible for true health and health care. Do you get inserted in all of the policies there, and if so, that’s impossible to do yourself. It is cross department, and then you have your own department, and it’s your responsibility to go out and get involved in those issues as you can have an impact on them?

Dr. Cara James:             Absolutely. As you said, CMS is huge. CMS, we run Medicare, Medicaid, the health insurance marketplaces or what people call Obamacare, we work on Medicare fraud, we have innovation, and so those are kind of our big bucket areas that the work is organized. We as an office work across all of those as well as our Center for Clinical Standards and Quality to try and be at as many tables as we can. We cannot be at every one because that is impossible as you said. Trying to work with each one in certain ways. We do some things in quality, we do some things in Medicare, we do some things in Medicaid. Not as many as I would like, but we’re doing those and trying to work across to be a little strategic in our focus. It’s a big mission. It’s one of the things that keeps me excited about the work, because it’s almost not a question of what to do. It’s a matter of, where to start?

Sen. Bill Frist:               And you’ve been there how long?

Dr. Cara James:             I’ve been there seven years, and it’s been really interesting because this is a new office that was established as part of the Affordable Care Act, along with several other offices within different parts of Health and Human Services such as FDA, the Food and Drug Administration, and SAMSA as well. We work collectively across those offices and we also work with other partners in the department to make sure that we are reducing disparities and achieving equity.

Sen. Bill Frist:               Fantastic. At A Second Opinion podcast, we focus on issues at the nexus of policy, government, which obviously you’re a part of, with health and health care. With health being much more than just health care delivery. And the third area being innovation and creativity and entrepreneurship and change and transformation. Let’s start with the policy. When you’re in these meetings in Washington DC, that I’ve been in many of them. When you walk in the door, what do people start thinking in terms of expectations? They know what you’ll be talking about. How do people react when you come in the door?

Dr. Cara James:             I would say people react differently depending on which door I walk in. There are some doors where I walk in and it’s, “Welcome, so glad you’re here.” There are some doors where people will actually reach out and say, “We need to make sure you’re here.” There are other doors where people are a little more skeptical and kind of, “Why are we here?” Policy is the same for everybody. It’s not necessarily that policy is different, but the implications and the impact can be different. And there are ways that we don’t even think about sometimes. And so, that’s part of the reason we want to be there and share. We start with our work, and our process is a three part path to equity. That starts with data. How do we increase our understanding and awareness of data? Disparities and their causes. We bring that information to the table to kind of highlight problems. The magnitude of the problems, what may be some of those causes.

Sen. Bill Frist:               Are people surprised by the data? Because usually policies start at this big, big level. And then all of a sudden they start going deeper and deeper and deeper. And then you walk in, and that’s probably the first time they’ve looked at the disparity, the equity data. Tell me a little bit about that.

Dr. Cara James:             It is, in many cases it may be the first time. Part of that is, an agency as large as we are, we cover one in three Americans through our programs in Medicare, Medicaid, and the marketplace. We’re thinking big policy. But not necessarily thinking about what the impact may be for the one in five rural Americans that we have. Or what it may be for the one in three people of color in our communities. Lifting that up to say, let’s just even start by looking at the data across these different population groups. There are some times where it is the first time that we’re putting out data. For example, last year for the first time, we put out a report looking at quality data by rural and urban, in Medicare Advantage through our health plans. That was the first time we’ve done that. It can be the first time that we look at that because, again, our colleagues were so focused on the broad program and the impact. We don’t often have the time.

Sen. Bill Frist:               Is data, compared to seven years ago when you started, is it easier? Are people collecting data in a more disciplined way? By the time it gets to you, it can be trusted and collected? It’s been 12 years since I was in the Senate, and I worked with David Satcher a lot who was a wonderful physician who ran Meharry here and been a huge advocate for healthcare disparities over the years. The data was hard to get because of inadequate collection, inadequate attention. Has that gotten better?

Dr. Cara James:             It has gotten better, and there are some places where we still struggle. Data quality is a so important issues because if you get garbage in, you’re going to get garbage out. We have put in place a number of places where we’re standardizing the data collection to make sure that we are able to compare apples to apples. So, making sure that we’re using the new HHS data standards around race/ethnicity, language for example. We have so many people, 60 million Americans who speak a language other than English at home. We don’t often capture that information to know, how would they like to be served when they enter the healthcare system?

Dr. Cara James:             We also have some challenges with legacy systems. As you know, states and even at the federal government, it’s hard to change those systems to adapt to some of those changes. In some cases, we are doing patchwork and trying to do statistical methods to make sure that we are able to capture that information. Data is much better. I think people recognize the importance of that data. And there are still areas where we have data gaps. Everyone is talking about the social determinants of health. There aren’t many places in our health data where we capture social determinants of health. There’s still a need to collect some data.

Sen. Bill Frist:               So it’s in progress. Because that’s number one. Sort of the data [inaudible 00:10:02]. What’s number two?

Dr. Cara James:             Number two is our developing and disseminating solutions. So how do we find those best practices, lift them up, and share them across the community? Because we often find that most of the people we talk to actually want to address and close their disparities. It’s not a matter of, I don’t want to do that. It’s, I don’t know what to do. How can you help me?

Sen. Bill Frist:               Is there an example? What would be an example of that, in terms of an issue?

Dr. Cara James:             Oh, let’s take one that’s really important right now in a lot of conversation. Maternal mortality. If you want to talk about the racial disparities, particularly for high rates among black women and tribal women for maternal mortality, infant mortality. Long standing issues, a lot of people are very interested in reducing those disparities. And I would say, if we had a magic wand, we probably would have waved it, but these are issues that are complicated. There are some things that we can do immediately, and there are some other things that are going to be longer term.

Sen. Bill Frist:               And tell me about the data there in terms of … probably surprising to people because people haven’t thought that much about it. But maternal mortality is something that appeals to people because of moms and it involves kids eventually. But does the data itself speak loudly when you introduce the disparities that are there?

Dr. Cara James:             I think it does. When you say that the maternal mortality rate for African American women is four times that of non-Hispanic white women, that’s a powerful statement. And when you add to that that a lot of the maternal mortality is preventable. It’s not like these aren’t things we can prevent. So what’s going on with that rate? That’s a powerful number to be able to say. On the flip side, it’s a small population that we’re talking about. Fortunately, even though our numbers in the US are not quite going in the right direction, they’re not nearly as bad as some other countries. And so, how do you grab that attention in the context of, maybe some other issues that are having a greater impact on the community?

Dr. Cara James:             If you think about heart attacks and smoking and people who are dying from cardiovascular disease, the sheer number is larger for that than the number of mothers who are dying, and maternal mortality. But it’s preventable. It shouldn’t be happening. So how do we use that and then develop those solutions to close those gaps and to improve health outcomes for everyone? One of the challenges is that, often we think about quality improvement, but we’re not necessarily thinking about closing the gap. To borrow a phrase from our friends in the UK, we want to mind the gap. Because quality improvement, we’ve seen with the national health care disparities and national health care quality reports that have been coming out since before you left, for more than 12 years, thankfully quality is improving for everybody. But those gaps are largely remaining the same.

Sen. Bill Frist:               And in the reports that are coming out today, is the reporting sufficient to shine that light? Or do you find yourself coming in and saying, well, when you do your reports coming out of the government, just go ahead and put this in as a sort of correlating issue? Once you see the data, it is powerful data.

Dr. Cara James:             Yes, so there are a couple of things. One of the things that you said is, putting that in as part of the process. That’s some of what we try to do is to get our colleagues who are working on other reports to, again, look at the data for vulnerable populations. Because it can be a powerful tool to just shed light on an issue that may have been invisible.

Sen. Bill Frist:               On the private sector side, we’re talking mainly government now and the collection of data, and the identification of policies to advance. Do you find the payers receptive, and do they have a role outside of government? Again, a lot of our listeners aren’t like you and I. We’ve spent more than our fair share of time in Washington. But the private sector themselves, how should they be looking at the whole issue of, again, disparities and vulnerable populations and reporting of data?

Dr. Cara James:             That’s another really good question and it’s a good point. A lot of the private sector, the philanthropy, local, state, are looking at these issues. And sometimes they may be a little bit further along than we are in their data. Hospitals are collecting data on the social determinants. Health plans are looking at these things. Where we have some challenges is sometimes, data sharing, that might not be happening as much as we would like or need. These problems were not created by just the federal government, or just the health plan, and they’re not going to be solved by just the federal government or just another. So every level of our health care system, from the beneficiary on up to the federal government, state, local health plans, hospitals, providers, community health workers, everyone needs to come together to address these issues.

Sen. Bill Frist:               Well said. And the third big bucket?

Dr. Cara James:             And the third big bucket is implementing sustainable action. So through ourselves and our partners, how do we implement that sustainable action? What I mean by that is, making it standard operating procedure, so that health disparities and health equity isn’t viewed as that work done by that office over there. But it’s baked into our programs and the way in which we run them.

Sen. Bill Frist:               Fully integrated.

Dr. Cara James:             Fully integrated so that, as we like to say, long after I retire, the work continues.

Sen. Bill Frist:               And how do you convince people to do that? You want it, almost a forgettable thing that you do. Instead of saying, I’ve got to go in that room, pull this person in and take care of it. How do you do that? And both incentivize it or set the pathway and reduce the barriers for it to happen?

Dr. Cara James:             So, slow and steady work. Starting again with showing that there is an issue with the data, is the first thing. And then we also, one of the things that has been important for us is to be able to run that data ourselves. So it’s not always coming to our colleagues to say, could you do this for us? If we come as a partner, I find that we are able to get further along than coming and asking for something. And then coming again with that solution with, here’s what we could do to address this issue. And working with them to figure out how to implement that. It’s so critical that we have those partnerships because our office doesn’t run Medicare, our office doesn’t run Medicaid. It’s our colleagues who are running it through our Center for Medicare, through our Center for Medicaid, or our innovation models. And so we have to work with them in order to do that. And I find that we’ve got some really great partners.

Dr. Cara James:             And the other thing is, going back to the many tables that are happening, and conversations. We try to create what I like to call health equity ambassadors. So that it becomes part of their lexicon to think about, oh, maybe we should do this. Or maybe we should reach out to the Office of Minority Health and see if they have something so that we don’t have to try and be at every table.

Sen. Bill Frist:               The equity issue is so important. We do an initiative here in Music City USA, Nashville Tennessee, called Nashville Health. It’s a population health initiative. Interesting, here, we have all these great tremendous health services with the hub of these huge both hospital chains and acute service chains and preventive chains and disease management. But our population health is just not what it should be. I’ve come to really begin every conversation with the words of either a disparity or equity. They mean different things to different people and some people turn off immediately. But I think, and this is where the Robert Wood Johnson Foundation has gone, it’s really this cultural of health. If you’re talking about the culture of health, you’re never going to change it or improve it or have an impact unless you … even if you don’t lead, as part of natural business, have these issues. But what is the role of the philanthropic non profit world overlapping and marrying with government as partners, as accelerators?

Dr. Cara James:             The philanthropic role is critical. I think about, I’ve had the pleasure of traveling across Tennessee these last couple of days going east to west. I will say, I was surprised in just the sheer number of states that abut Tennessee. Eight states, and what that means for partnership and collaboration. What we saw in the places that we visited, whether it was Ballad Health, Hancock County, or others. The community and the resources that people are tapping into and how they’re coming together to work and address these issues. And philanthropic is right at the center of a lot of that.

Dr. Cara James:             A lot of the communities are applying to grant programs, getting funding to be able to implement a mission to address opioids. Or working to fill the transportation gap that they see in the community. Or to start a new food program to help address those needs. A lot of this is happening through philanthropic means. Also, though, there are some great state programs. When you talk about what’s happening people are … one of the programs, the state transformation grants, to think about, how do we transform rural hospitals to be more sustainable? And to be able to provide the services?

Dr. Cara James:             So we learned about a hospital that was able to apply to that grant and is now getting the feedback and thinking about, how do they change their services so that they can be there much longer to meet the needs of the community? And so, it’s pulling people together in every single level of the health system to address these needs. And when you get to that culture of health, where we need to do more is to pull in those social programs and the others. Because as we talk about the social determinants of health, how do you pull in the Department of Transportation? The Department of Housing, or Food Programs? Because that’s really how we’re going to address these needs.

Sen. Bill Frist:               I think getting them in the same room. If we look at the social determinants or the non-medical drivers of health care, whether it’s food or transportation or access to the internet or housing, many have not been in the same room before. I think that coalescing, convening, collaboration, collaborative approach is going to lead us very quickly to address a whole range of issues. But issues just surrounding equity where the range is so broad.

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Sen. Bill Frist:               And now, back to the episode.

Sen. Bill Frist:               You mentioned your trip across Tennessee. It’s also a long state, 560 miles. Having been the former senator here, all 95 counties, I’m familiar with them all. Let’s talk a little bit about rural health and the equity issues. Tennessee is a rural state. You mentioned the hospitals, we’ve had 17 rural hospitals close. And these are the centers of healthcare for many, many people. Lots of change and lots of transformation coming on. What sort of issues, and we could use some examples, in rural health are you addressing through the department?

Dr. Cara James:             In terms of rural health, at CMS, rethinking rural health is a strategic initiative of ours. It started last year with the release of the first CMS Rural Health Strategy, where we really wanted to think about, how do we apply a rural lens to our programs and policies? Again, going back to that, many millions of Americans that we serve through our programs, one in five live in rural communities. How do we put their needs at the forefront of our conversation? As I like to say, when we’re successful with that, I get fewer angry letters from rural stakeholders who are telling us we got something wrong. And so, putting that at the forefront and making that part of our conversation is critically important.

Dr. Cara James:             We’ve made some strides in expanding access to telehealth, thinking about how to be creative within the bounds of the statute to make sure that people can get the services that they need, remote access to care. Also, some of the more recent changes that we had around the Hospital Wage Index. And thinking about, how does that, local wage has typically been where lower wage hospitals haven’t been able to be as competitive to some of the higher wage, which disproportionately tend to be rural communities. How do we adjust that a little bit so they can be more competitive? So we’re pleased with that.

Dr. Cara James:             And also thinking about, how do we leverage our payment models and other innovation programs to spur some of that transformation in rural communities? Those are a couple of the things that we’re doing. But we also work very closely with the federal Office of Rural Health Policy, who have been in this space for a very long time and have a wealth of information. So we have them on speed dial, and have been part of our partners traveling through the state this week.

Dr. Cara James:             And seeing the programs that they’re fostering around transformation. Opioids, they have a rural maternal health care program, around how do you provide access to maternal health services in rural communities? Because as you mentioned, those hospital closures have implications for so many services in the community, and particularly, maternal health one is a big one. So they have a new grant program, we got to visit one of the applicants out in Hancock County, who is applying to see how they can pull together to meet the needs of the community and the rural women who live out there.

Cara V. James, PhD

Dr. Cara James:             I would say one of the other things that we all know. I should say, we know, but we don’t always think about it and keep it at the forefront, not every rural community is the same. And not all problems are the same. We visited, in some communities, where opioids is a very big problem. And others where, it’s not opioids, it’s meth. Or it’s a smaller issue of opioids and a bigger issue around COPD because of the high rates of smoking for some of the communities. So how do we create those flexibilities at the federal and state level to allow communities to address their specific needs, rather than prescribing that everybody work on this issue. Is something that we also are looking at at the federal government.

Sen. Bill Frist:               I’m thinking of success. If you think back over the last couple years or three years, give me an example or a couple of examples of, where you feel like you. You meaning your whole division and teams of people working in partnership. Have been effective. It can be in the data or the execution, implementation, or the sustainable, moving head? A few examples.

Dr. Cara James:             I’ll give you two examples. One example of a success that we have is, when we think about individuals who may be new to health insurance. Or new to a particular health insurance program. Maybe the first time they’ve had Medicaid, or they’ve aged into Medicare and trying to figure that out. We all know our health system is a little complicated. But we also know that a lot of people have questions about, what is a formulary? What is network? What’s the difference between co-pay or co-insurance?

Dr. Cara James:             So our office started an initiative called From Coverage to Care, or as we jokingly like to call it, the “So You Got Health Coverage, Now What?” Project. How do you understand your health coverage to be able to leverage that to get primary care and preventative services that you need? And we’ve developed a number of resources to help in that space around prevention, finding a provider and preparing for that visit, understanding what to do next if you get an explanation of benefits, and the difference between a bill.

Dr. Cara James:             We worked with community groups to translate those materials into a number of languages including Spanish and Chinese and other ones that are very common, or more common. And then we worked with community groups to share those resources. One of my highlights of the last couple of days was, we went to the Cherokee Health System in Morristown, Tennessee, and walked in the door, and one of our resources, or two of our prevention resources were hanging up. So to see that reach-

Sen. Bill Frist:               In the field.

Dr. Cara James:             In the field has been great. And we are not a large office. Don’t have massive resources. But to see that getting into a community that really needs that. I talked to the CEO there and they were saying that part of their mission was to help consumers understand their coverage. That was a nice one.

Sen. Bill Frist:               It is so important. Again, having been a physician, or a nurse or any healthcare provider, you can give the care and you can give the prescription, but if it’s not understood by the individual or the family, you might as well not have seen them. The empathy is good, but in terms of the real treatment and turning the disease around. It’s so overlooked today. It’s got to be a challenge. But again, if you have the materials there, which takes nobody else’s time, that has that sort of last mile of the care to make sure that it is as effective, and it effective in the sense that it’s actually carried out, is hugely powerful.

Dr. Cara James:             And I’m sure from your experiences working with patients, that the patients who are more engaged in their care, and the families who are engaged, tend to have the better outcomes. And that’s part of, how do we empower patients and their families to be that active participant and partner in the healthcare? Because it’s not just what the provider is doing for them. There’s the recovery. There’s the rehab and every piece of it that they need to be part of in changing that way.

Dr. Cara James:             The second example was one that, again in the social determinants, it is in the data side, but we are very pleased that working with our colleagues, we just finalized that for the first time in our Medicare program in the post-acute care setting, we will begin collecting some standardized data around some of the social determinants of health. This will really help us in an apples to apples comparison, do a couple of things. One, be able to see, what is the relationship between some of these social determinants and health outcomes? Quality of care, resource utilization. But also help us quantify the magnitude of some of these challenges, to be able to know among our Medicare beneficiaries who are going through the post-acute care setting, what percent of them have transportation needs? Or what percentage of them are feeling socially isolated? And help us think about how that then can be used to leverage that conversation around additional resources, community partners, other philanthropic issues to be able to address those needs.

Sen. Bill Frist:               It is so fundamental. So fundamental. You said it so beautifully I can’t restate it, but to be able to have that basic understanding of, not just what social determinants are. But what the impact is. Social determinants, we all run through our list of what they are. We know they are what predominantly, not the doctor, not the hospital, not the Obamacare, not the Nixoncare or whatever we have, it is these social determinants of the housing and how people live and the education and access to the internet. One of the problems we have at the community level is a lack of organization. The bucket in which to insert them to collect that data. And therefore in the aggregate, unless you have some consistent way of reporting and of identifying and sharing, you never get the full impact. So I love the fact we’re making that progress today.

Dr. Cara James:             Yes. And it’s a stepping stone. Because as you just said, that path of collecting, sharing, the sharing is huge. And that’s an area where we still have a long way to go. Because it’s not just sharing as a patient moves from hospital to post-acute care back to the community. But it’s also thinking about sharing as we’re doing through the accountable health communities model, sharing with those social programs who may also be able to fill that gap and address the actual social need that the individual has.

Sen. Bill Frist:               I think this dialogue is so important. The sharing dialogue. Because health data is so personal, the people have not, especially putting it on the internet or in the cloud, people haven’t wanted to share it. And people can hide behind that and say, well, we just can’t share in the health field. Or even in the social determinant field. I do think, as people understand the power of this information and data, obviously not about individuals in the sense of identification. But depersonalized data. The power of understanding what the needs are, defining them clearly, and then what the resources are that are available, is huge. And it’s untapped. And if we really want to change health and well being, it’s probably not going to be more hospitals and more doctors. It’s going to be through further understanding with clarity and with discipline, what the problems are in terms of social determinants, the resources that are out there, and as you said, how to take them to scale. I’m glad to hear that progress is, again, just starting. But is being-

Dr. Cara James:             And one of the things you mentioned that’s so important as well is the, explaining to consumers why we’re asking these questions. We find that, in some cases, we don’t have complete race/ethnicity data or language data because the person asking the question is uncomfortable asking the question. And we’re finding, as we’re getting into more people who are asking about social determinants of health, that there’s also uncomfortableness about asking the question. In part because some people feel disempowered to be able to actually address it if there is a need that’s been identified. There’s work on both sides that needs to happen to help the consumer understand why we’re asking. Because we have seen data around, with race/ethnicity, sexual orientation and gender identity, that if you explain why you’re asking it, and ask it in a way that is culturally sensitive, people will give you the information.

Dr. Cara James:             And then on the other side, making sure that the person who’s asking the information feels like they’re empowered to be able to do something about it, rather than just recording a problem. And helping them feel comfortable with how to ask the questions. So, we have actually developed some resources around building an organizational response to health equity that include some of these tools and resources around how you can ask some of these questions. Create a more welcoming environment in which to help individuals share data around some of these sensitive issues.

Sen. Bill Frist:               And that comes back to, this role of government in many ways. But the role of government interacting, partnering with the private sector, the philanthropic world, the business leaders, the hundreds of nonprofits, for example, in Nashville who are working together. Haven’t fully been aligned, just that coming together as partnerships and as collaborators, that’s going to have a huge, huge impact. As we look forward over the next couple of years, you mentioned a couple of the initiatives in maternal health, what other initiatives will you be focusing on? What would you like for the vision to be focusing on?

Dr. Cara James:             As I said, I’ll go back to one of the things that excite me is almost not what to do, it’s just where to start.

Sen. Bill Frist:               Exactly.

Dr. Cara James:             I think that we will continue our work in the social determinants. We are looking at, around the ICD-10 codes. There are some Z codes around social determinants. We’ve analyzed some of our data in Medicare to see that, there’s an opportunity to do more in that space. And already begun engaging with stakeholders, the health plans, the providers, some of the EHR vendors around, how do we utilize that a little bit more? Again, getting that standardized collection.

Dr. Cara James:             I think we are anxious and interested in how we can further advancing our rural health and rethinking rural health. As I like to say, rural health is the new black. Everybody’s doing rural health. It’s a great opportunity. It’s also a little concerning because as we have so many people coming into the space, it’s hard to identify all the dots, let alone collect all the dots. So we want to think about how we can maximize our impact and work together and not duplicate efforts. I think there’s a real opportunity to truly advance our rural health.

Dr. Cara James:             And then I think the other piece is continuing to look at, how do we embed a focus on equity into our programs in quality improvement and payment models and things like that, to really make that part of our standard operating procedures. Those are-

Sen. Bill Frist:               Exciting times. Exciting times. And the progress, again, going back two years with the Kaiser Family Foundation, looking at similar issues. And the last seven years in government, it sounds like there’s been huge progress. Would you look at the challenge that’s out there, as a huge mountain for us to continue to climb?

Dr. Cara James:             Yes. As I said, health equity and reducing health disparities, you always know it’s an uphill battle. And every now and then you get a glimpse of how steep the gradient is.

Sen. Bill Frist:               That’s right. Sometimes you want to look the other way.

Dr. Cara James:             Exactly.

Sen. Bill Frist:               I do find in our national health care, again we have 700,000 people. We’re trying to raise up the health and well being of every Nashvillian here in a collective way. Some people just don’t believe that the average population health is as challenging or as bad, to put it bluntly, even compared to our brother and sister cities. And as I look more and more at the data, I find, at least in my own mind, my sort of uneducated way of addressing it. The earlier you address the issues around disparities, the greater the collective impact.

Sen. Bill Frist:               And part of it’s the systems that you put into place. Part of it is bringing people together and looking at all the issues in the different light. But the more time I spend with raising the health up of all 700,000 people, if you lead, in that first 15% of the time you have, you lead with the discussion on vulnerable populations, the disparities that are out there, the equity issues. People seem to say, I get it. Let’s focus on it. And we focus there. Again, under your leadership, I get educated and it makes me want to go right back out in the field.

Sen. Bill Frist:               One final thing, what other message … again, we’ll have thousands of people listen to this conversation. And you’ve been out crossing Tennessee the last five days, on the ground, looking at programs. I’m sure it’s uplifting to see, many things we talked about. But also, you see how big that mountain is. Is there any final message that you’d give to the entrepreneurs listening, or the innovators, or the business people, or the policy people in the statehouses around that you’d like to say?

Dr. Cara James:             Yes. First, I will just say, this is a great state, and I’ve enjoyed every moment that I’ve spent here crisscrossing the state. And the opportunities, what excites me, is the work that’s happening here. You’re seeing people come together to address these issues, as I said, tapping into state programs. Collaborating with businesses. Collaborating with community groups. And I think, to the extent that everyone here can reach out of their orbit a little bit, to see whom else they might be able to partner with. Because again, no one entity, organization, or person is going to be able to address these issues.

Dr. Cara James:             But there’s a lot of wealth in the community, and even just on our trip, we were traveling with some of your colleagues from the Department of Health. And they were making some of the connections to say, we need to follow up with them, in learning about other programs. And in organizing these meetings, some of the communities were connecting up with each other and saying, oh, I didn’t know you did that. But I think, really how we lift up and disseminate those solutions. Because there’s a lot of work that’s happening in the community in bridging those gaps. People are creative with funding, they’re creative with programs to be able to expand those. There’s a lot that’s happening, and the answers often are here, and not in Washington. How do we support that? I think one, it would just be a word of encouragement for everyone to keep going. And to think about, what can you do to help support some of what’s already happening, or to share that with another community?

Sen. Bill Frist:               And then, if you do it at the community level, it can go to scale. As it goes to scale, the entire country and even beyond that.

Dr. Cara James:             And the last thing I would say is, which was often … sometimes doesn’t always happen as well. There are people such as myself and our office and other offices of minority health, the federal office of rural health, who are working on these issues. If you have questions, if you have concerns, let us know. That is our job, to help take those in. If you have ideas, let us know. We get no shortage of ideas from some folks, but I think oftentimes, some of our communities or vulnerable populations, so focused on keeping the lights on. Which is critically important. But we also need them to let us know how we can help. Because we are here to help. And I think that hearing those voices is so important, making sure that our policies really do apply a rural lens, or address health equity and health disparities.

Sen. Bill Frist:               Beautifully said. Thank you so much for being with us.

Dr. Cara James:             Thank you for having me.

Sen. Bill Frist:               Thank you so much.

Dr. Cara James:             Great.

Sen. Bill Frist:               This episode of A Second Opinion was produced by Todd Schlosser, the Motus Creative Group team, and Snapshot Interactive. You can subscribe to A Second Opinion on Apple Podcast, or wherever you are listening right now. And be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show, it’s guest, and sponsors, at asecondopinionpodcast.com. That’s asecondopinionpodcast.com. Thank you again to our sponsors Tivity Health, and Jarrard, Phillips, Cate and Hancock. Be sure to join us for our next episode with Dr. Josh Umber. Josh is a Kansas based family practitioner, who’s direct primary care model is getting national attention. A Second Opinion broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services, where we engage at the intersection of policy, medicine, and innovation.