A Second Opinion with Dr. Anand Parekh – A Second Opinion Podcast

A Second Opinion with Dr. Anand Parekh

Today’s episode is brought to you by Medhost, a trusted EHR for healthcare facilities. And now I’m excited to be joined by my good friend, Dr. Anand Parekh, who serves as chief medical advisor for the Bipartisan Policy Center. We’ve worked together since he joined the BPC in 2015, formulating policies related to the obesity epidemic and nutrition, domestic and global HIV/AIDS, business and public health collaboration, social isolation, rural health, and so many more issues. Anand is a board-certified internal medicine physician, a Fellow of the American College of Physicians, and an adjunct assistant professor of medicine at Johns Hopkins University. He previously served for a decade at the U.S. Department of Health and Human Services, including as an HHS deputy assistant secretary for health from 2008 to 2015. There he played an instrumental role in the implementation of the Recovery Act’s Prevention and Wellness Fund, the Affordable Care Act’s prevention initiatives, and HHS Multiple Chronic Conditions initiative.

His new book, Prevention First: Policymaking for a Healthier America, was released in December, 2019. It argues that prevention must be our nation’s top health policy priority.

Senator Bill Fr…:           So Anand, let’s jump right in. The Bipartisan Policy Center. I have been involved for a long time. You’ve been involved for a long time, but for our listeners, the word bipartisan is something you don’t hear very much about these days, and then…

Anand Parekh:              That’s right.

Senator Bill Fr…:           … And then especially in policy, and then especially in Washington, D.C., so tell us just real quickly about the Bipartisan Policy Center, and then follow a little bit into how in the world you, a physician, a doctor by training and practice, flowed into government into the highest sort of levels of our government, and now to the Bipartisan Policy Center.

Anand Parekh:              Sure. Well, Senator, first, thank you for having me on the podcast. The Bipartisan Policy Center is a nonprofit organization in Washington, D.C. It was founded actually 12 years ago by four former Senate majority leaders, as you know, Tom Daschle and Bob Dole, George Mitchell and Howard Baker, and the idea was really to take the best ideas from both political parties to promote health and security and opportunity, and so for the last 12 years, BPC, and it’s the only entity in town that’s got the word bipartisan in its title, is trying to do just that, bring all sides together. It works on a wide variety of issues. Health is probably the largest program, the most robust program, and it’s trying really in Washington, D.C. to do something unique and come up with the best ideas for Congress, for the executive branch, for states and localities.

Anand Parekh:              It has a sister organization as well, a 501(c)(4) called BPC Action. We try to tell ourselves when we write a report or we issue recommendations, we’re only halfway there. We then try to advocate for them. Jason Grumet is the president. It’s just a wonderful place, great people, a great mission. I think bipartisanship is something that resonates with most Americans. They may be surprised that actually an entity like this exists, but I think we need more bipartisanship, so for me, being someone who’s very mission-driven, I was inspired to join that cause.

Anand Parekh:              Many years ago, maybe 25 years ago, I actually started in political science. That’s where my first love was. I went to medicine, went to public health, went to public service. Coming to the Bipartisan Policy Center really makes me come back full circle. It puts it all together, and the reason I took all of those different paths, Senator, is I really enjoyed, like you, seeing patients for so many years. It’s just that what was getting me up in the morning was the idea that instead of helping one individual at a time, I could try to have a bigger impact and try to impact the lives of not just one person at a time, but hundreds or thousands or millions. That’s what started getting me up and that’s how I gravitated towards my career path.

Senator Bill Fr…:           Well, the BPC has been very active, and sort of disclosure just to our audience, I’ve been involved as the co-chair of the Health Initiative there, and I found it really one of the most powerful things that I can do because it’s a rare place that you can go. It’s safe, secure, bringing ideas from the left, from the right, Republican, Democrat, Independent, into a room, discuss them, formulate policy, get consensus as much as consensus can be obtained, but that safe environment for open discussion is really unique, so thank you for everything that you do there.

Senator Bill Fr…:           A Second Opinion, this podcast, we look at things from the policy arena, a lens very important, and one that you do with your history at the Department of Health and Human Services. How long were you there?

Anand Parekh:              10 years.

Senator Bill Fr…:           So you were there 10 years.

Anand Parekh:              Yes.

Senator Bill Fr…:           So a little bit like me, spent 12 years sort of in the government end of things, and that takes care of that. It doesn’t take care of it, that’s that perspective of policy we’ll come back to, and the second big arena and overlapping field is health and healthcare, and again, your being a doctor and a physician and that lens is just a little bit different, and then that third lens we like to look through things is innovation and creativity and the white papers that you generate, and so let’s touch upon several areas there to share with our listeners and our viewers how the BPC works, which I think will give kind of an optimistic view on some of the things going on in Washington, D.C.

Senator Bill Fr…:           So let’s start with rural health. It’s an area that over the last 48 months is getting increasing attention in that people realize that rural health is different than suburban and urban health. I mean, health is health. Healthcare is healthcare, but it’s a little bit different entity. What has the BPC done, and are there any specific recommendations that they or we have put on the table?

Anand Parekh:              Well, you’re exactly right. I think many listeners may not realize that one in five Americans or 60 million Americans live in rural America. It’s 97% of our land in this country, and rural America is unique. The population is unique. It’s a bit older. It’s a bit sicker in the sense they have higher rates of chronic disease risk factors and are more likely to die of chronic diseases. They have higher poverty levels, higher uninsured rates, but geographically, many rural Americans are in remote places. That makes transportation harder. There are barriers there. There are broadband issues as well.

Anand Parekh:              And then from a provider perspective, we hear about hospital closures, but also there are physician shortages as well. So I think there are many unique aspects of rural America, and Senator, we just released a poll recently, the Bipartisan Policy Center with the American Heart Association, and it found that access to care in rural areas is an issue. More than half of rural Americans have difficulty finding a specialist. More than a quarter of rural Americans are having difficulty finding a behavioral health specialist.

Anand Parekh:              So I think we’re hearing more about this, and actually this is now translating into a 2020 Presidential election issue. Over 90% of Republicans and Democrats think access to healthcare in rural areas is a critical issue. Three in five say that they’d actually vote for a candidate that prioritizes it, so I think it’s in this backdrop, that’s where BPC works. We try to take a really important healthcare issue that’s topical, that there are lots of different viewpoints, and we try to bring people together, and what we’re trying to do now with the launch of a new rural health task force, which you’re a part of, is to come up with actionable recommendations to Congress and the executive branch and stakeholders, and some of this work will build upon an effort that we engaged in over the last two years.

Anand Parekh:              We did a case study. We went up to the upper Midwest and we focused on seven states, North Dakota, South Dakota, Nebraska, Iowa, Minnesota, Wyoming and Montana to better understand… Get out of the beltway and understand what are the challenges in rural America, and what are the opportunities. And very briefly, there were four critical findings of that work. The first is, many rural communities are defined by the services they have, as opposed to the way it should be, which is the reverse, which is really community needs driving the services that they need.

Anand Parekh:              So take, for example, a community with a critical access hospital. Some communities may absolutely need a critical access hospital. Other communities may decide based on the needs and the health status of their population, they need an outpatient center, an emergency department, an ambulance service, but they don’t need a full scale hospital.

Senator Bill Fr…:           And who determines that?

Anand Parekh:              And it should be the population.

Senator Bill Fr…:           The community itself.

Anand Parekh:              It should be the local needs that determine that, but to transform from what you have to what you need takes tools, resources. And that’s where the public sector and the private sector come together to help communities transform the set of services they have to the set of services they need based on community health needs.

Senator Bill Fr…:           I want to get to the other three points, but I think this idea of the grass roots, people coming together in communities, they don’t have to be healthcare experts either. It’s not the doctors that come, the hospital administrators or the local city. It is real people with real issues coming together collectively in their small… Whether it’s a dinner type or the town store or the filling station, and coming up with what do we need. And that dialogue is critically important. So that’s number one.

Anand Parekh:              Yes, yes.

Senator Bill Fr…:           And number two?

Anand Parekh:              So number two is we can’t leave rural America behind when it comes to value based healthcare transformation. And that’s where healthcare is going where it needs to go. Hopefully, it’ll get there faster. What is happening is many rural healthcare entities have had challenges engaging in value-based healthcare transformation. Either the number of patients they have is low. Some of the quality metrics are not as applicable. So we need to help these entities engage in value-based healthcare transformation.

Senator Bill Fr…:           And value-based in the rural community, how do you describe that?

Anand Parekh:              Yeah, so, again, it is based on payments based on improvements in the quality of care. I think that’s the best way to put it. Metrics are really the currency that drives value-based healthcare transformation. The challenge is how do you help many of these entities that may not have the information technology or the infrastructure or the quality measurement capability engage in many of these areas. What we have found that some of the alternative payment models that provide some upfront investment, so rural healthcare entities can do some of this, those entities actually end up doing quite well, even better than their urban counterparts when it comes to sharing savings and reducing preventable healthcare costs and improving outcomes. So the message is it can be done, we just need to be conscious of how we engage rural healthcare entities in value-based healthcare transformation.

Senator Bill Fr…:           And the backdrop trends and an example is here in Tennessee where we’ve had seventeen important rural hospitals, important to those communities or similarly important, close. Financially driven in large part because to have a ten bed hospital with only two beds used…

Anand Parekh:              That’s right. That’s right.

Senator Bill Fr…:           …Simply does not make sense. It takes the resources.

Anand Parekh:              That’s right.

Senator Bill Fr…:           So the value-based end of things.

Anand Parekh:              That’s right.

Senator Bill Fr…:           So where you have a ten bed hospital and only two beds being used, so the backdrop of hospitals closing, sad and hard and challenging. On the other hand, it gives a real opportunity, a teachable moment to bring people together.

Anand Parekh:              Absolutely. And better understand what are the needs of that community and what do they really need? Do they need that facility that only has an average census of two. For example, are there some services that can be shared between communities? So I think it starts that dialogue.

Senator Bill Fr…:           So, number two, value-based. That’s a bigger trend coming through, and it gives an opportunity to pull people together.

Anand Parekh:              Absolutely.

Senator Bill Fr…:           What is value? We need to measure outcomes and determine what’s provided for each dollar. And where would you move? Number four.

Anand Parekh:              Yeah, I’ll just say, too, a really innovative model, I want to cath on the innovation piece. In rural Pennsylvania is now a model that’s looking at an all-payer global budget model. And what this is doing to really I think rural facilities, we’ll see over the next few years whether the results pan out. Instead of the constant pressure of filling beds at the fee for service reimbursement, payers are providing an upfront global budget, monthly payments. This is what you get. And so now it flips the whole script in healthcare. It’s no longer about increased healthcare utilization driving reimbursement. It’s now about how do you keep people healthy, so you can reduce healthcare utilization.

Senator Bill Fr…:           And is that reimbursement for a population or for a region and is it from a payer or is it from the government?

Anand Parekh:              It’s a all-payer. So Medicare plays in there, Medicaid plays in there. All the private payers, and they provide monthly payments to the hospital and there are many hospitals right now in rural Pennsylvania that are part of the model.

Senator Bill Fr…:           I love the model and in health services in this country, again, thinking about our Second Opinion podcast view of looking things through innovation and creativity. Health services, there hasn’t been a lot of innovation over the last 20 years, but that’s a perfect example of the new way of thinking, and if we think a little bit outside the box in an innovative, entrepreneurial way, we can transform a whole community.

Anand Parekh:              That’s right.

Senator Bill Fr…:           And go… As we know, we’re going from a fee for service to a much more value-based system. And that’s what gives me optimism and hope, this sort of change, of transformation, this innovation that’s going on. And I think that’s a perfect example.

Anand Parekh:              And we get the incentives right finally.

Senator Bill Fr…:           Yeah, and aligned.

Anand Parekh:              And aligned.

Senator Bill Fr…:           And aligned. Yeah, around the patient.

Anand Parekh:              Absolutely.

Senator Bill Fr…:           Around the patient and their family in their local community, and not the traditional model of people having to drive, get in the car and drive and go to a hospital usually in a more urban area. All right, number three.

Anand Parekh:              Number three is we need to build pipelines at an early age. We’re talking students, young students, young professionals to engage them in the health professional workforce so they can stay in rural America to really tackle that issue of shortages. I’ll tell you, one innovative example, the University of Washington’s medical school, they have a program called the WWAMI. So it’s for Wyoming, Washington, Alaska, Montana, and Idaho. And there are slots, dedicated slots, to medical school students from several of those states because they don’t have a medical school.

Senator Bill Fr…:           Yeah, yeah.

Anand Parekh:              And many of these students ultimately end up going back to these areas to provide. So we need those types of programs not just for medical students, but also for mid-level providers, for nurse practitioners, physician assistants. They need to also be able to provide at the top of their license, so practice is important. Community health workers are a piece of this. We need to engage young people and individuals in these regions, particularly rural America because they’re more likely to go back there and practice.

Senator Bill Fr…:           And that’s a huge point because the people… If we have, I don’t know, 120 medical schools in the country? I’m not even sure.

Anand Parekh:              Yeah. Yeah.

Senator Bill Fr…:           But about 120 medical schools.

Anand Parekh:              Yeah.

Senator Bill Fr…:           Many people think you go to the medical school, and then when you go to the medical school, you just sort of decide where to go. What we know today is that if people come from a rural community or an underserved community and then they go to a medical school, they are much more likely to come back and be involved in that community in primary care in family practice. But it’s hard because you need to reach the rural community and inspire people, and not just inspire them, but give them a track. And I think that’s a perfect example. And I think the whole human capital end of it is interesting in that it’s not just doctors, and it’s not even just nurses. But as you said, there are these extended ancillary fields that come down to social workers, community service type individuals who can be doing activities and jobs and careers that center around health and healthcare that we need to encourage as well.

Anand Parekh:              Absolutely. Absolutely.

Senator Bill Fr…:           All right, then, number four.

Anand Parekh:              And the four is really telehealth. And I think the finding there was not just that telehealth can have a dramatic positive impact on health outcomes, but it can actually be a powerful force for the recruitment and retention of healthcare providers. So I traveled out to Sioux Falls, South Dakota and visited with Avera Health System, the largest dental health provider in the country. And they had a E-hub there in South Dakota staffed by board certified healthcare professionals. And that E-hub is connected to dozens of regional healthcare entities as well as hospitals. So if there’s a case in the ICU, a case in the emergency department where a provider in these remote regions don’t quite know exactly what the next step is, they link into this E-hub and you have board certified clinicians to provide that peer to peer support.

Anand Parekh:              And I can tell you, if you’re in a remote area, and you’re the only person there, having that support… We talk about provider burnout, we talk about social isolation from the patient perspective, but provider isolation is also an issue. So the power of telehealth to provide that peer to peer consultation, that support, is also I think critical in ensuring that you can recruit providers to rural areas but also retain them.

Senator Bill Fr…:           Yeah. I think that’s great. Human capital is going to be a challenge no matter where you are in urban areas, but it’s especially difficult in rural areas in part because people who are physicians, they have their families, they’re exposed to cities and the cultural aspects. And they’re less likely to move unless they’ve had the previous exposure to rural areas. But through telemedicine or telehealth or the broader term virtual health delivery, you can still have physicians talking to physicians, a specialist in Nashville, Tennessee at Vanderbilt talking to somebody 150 miles away with the video or just on telephone in a coordinated way and care just as good. We used to think the virtual care was not as good, not as effective. Today it’s been proven. It’s been proven that if used effectively, virtual care, telehealth, it does bring up the whole social determinant of access, Internet access as a social determinant. And, again, that’s something in the rural health community that you and I and others have discussed, the policy of Internet access, which people say, “What does that have to do with healthcare?” It comes right back to that fourth point of virtual care.

Anand Parekh:              That’s right.

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Anand Parekh:              That’s right. And I would probably add if I think about rural aging, tech is a critical piece of that but I think it’s high tech and high touch.

Senator Bill Fr…:           Yeah.

Anand Parekh:              And I think you really need both because the human touch element I think is critical. When I think of some of the innovative models out there today focused on older adults out of Vermont that support seniors at home, the SASH model, that’s essentially a wellness coordinator and a nurse coming to an assisted living facility, affordable housing complex, and providing that social service support, that care coordination support for that beneficiary. Outcomes have been shown to improve. Medicare costs potentially coming down as well. Another model out of Johns Hopkins called the CAPABLE model. That’s Communities Aging in Place. In that model, you have a nurse, an occupational therapist, and a handyman to fix up the home to promote aging in place. Again, outcomes shown to be improved, potentially Medicare costs coming down. Both of those models, you have sort of this team-based, high touch just sort of touching human lives. And I think that combination of touching human lives potentially with technology, I think that is probably going to be the combination for matching those health outcomes.

Senator Bill Fr…:           Yeah, that integration. And when you were trained, and then fifteen years before when I was trained, we used to think it was all touch.

Anand Parekh:              That’s right.

Senator Bill Fr…:           And culturally, you had to see a patient… This could apply to a nurse or a doctor, but you’d have to see them, examine them, touch them, hold their hand, and that still is my image, and it’s what I still think is best, but with technology, and it has been demonstrated again and again, and it can be video, it can be telephone, it can even be text, it’s just incredible today, but that combination of that human touch and empathy and compassion and understanding and trust with appropriate use of technology leads me to be very optimistic about the future especially in rural communities where we know that human capital is short, resources are short. And healthcare then has no address. And that needs to be the goal, and I think can be the goal.

Senator Bill Fr…:           It does come to… Because there more team-based approaches, both of those that you just described where you’re bringing in community health workers and a social worker and access to physicians and nurses does take payment models that are very different than a fee for service model. What do you see going on there in terms of changing for a more wholistic payment mechanism which allow those models to flourish?

Anand Parekh:              I think you need sufficient reimbursement that goes towards a capitated model where you get a fixed sum to take care of a set of patients. And then there are certain performance bonuses based on reaching quality metrics, but I think that will really promote sort of the team-based orientation. Physicians aren’t always trained like that, and I think…

Senator Bill Fr…:           Yeah, culturally…

Anand Parekh:              And I think that’s a culture change. But the best results we’re seeing in an outpatient setting are in a team-based setting.

Senator Bill Fr…:           And is government going to take the lead there or the payer’s going to the lead there or is it going to be individual practices that take the lead. I know the answer is all of them, but since you’re sitting in a policy arena and you have access to the left and the right and everybody coming up for discussions, if you had to sort of boil it down and make it easy for me to understand, who is taking the leadership role?

Anand Parekh:              I think you’re seeing both public and private payers now investing particularly in primary care and that team-based care and trying to identify ways to increase payments to facilitate team-based care. Going much beyond fee for service, but really look at overall payments, capitated payments, performance bonuses as well. And what that’ll do, that’ll increase the pool to allow primary care providers in these teams to have the time to wholistically take care of patients. So I think you’re seeing the innovation and the incentives by both the public sector as well as the private sector, and I think you have more and more practices that are getting engaged. I think it’s going to take a little bit more time for some of the solo practitioners to get engaged, but I think that’s where the trends are moving.

Senator Bill Fr…:           And I think as the outcomes are generated of this sort of more value-based wholistic appropriately aligned but reimbursed almost as a bundle, as the outcomes are demonstrated to be improved, there’s a lot of anecdotal evidence, and there’s some good emerging data, but that I think this whole cycle will speed up more and more and more.

Anand Parekh:              Agreed. Absolutely.

Senator Bill Fr…:           And it’s cultural change, because physicians, as you said, are not trained… We were trained up until very recently to have all that knowledge in our head that we needed to command and control and that’s just not the way the world works most effectively.

Anand Parekh:              That’s right. Yeah. Yeah.

Senator Bill Fr…:           There is a fantastic book coming out and the book is Prevention First: Policymaking for a Healthier America. And what I love about it is in that book are the specific recommendations you make for healthcare, healthcare delivery, and broader health issues in America. But why the book? What’s most exciting to you that’s in the book in terms of messaging, and a little bit more about when it’s going to come out?

Anand Parekh:              So the book is really a summary of my last fifteen or twenty years in clinical practice, then as a public servant in Health and Human Services, and now at the Bipartisan Policy Center. The motivation is the realization that hundreds of thousands of Americans are dying every year because of preventable deaths, and this should be unacceptable to all of us. And what we need to do is make prevention the centerpiece of all of our healthcare policy discussions, our debates, as well as our actions. And so the book tries to identify ways within the healthcare system and then outside the healthcare system where prevention can be integrated, elevated, and placed at the center. There are ultimately five recommendations, one to different types of stakeholders. Heavy lifts, but that’s why you write a book to really try to inspire people.

Anand Parekh:              The first is that the next Administration, be it Republican, be it Democrat, and even this current Administration, make prevention the top priority for the U.S. Department of Health and Human Services. And now as policy makers, we’re often reactive. Crises come and we have to react. But this is truly making a prevention as a top priority. And all scientific agencies and agencies within the department make prevention a priority.

Senator Bill Fr…:           And does that have to come from the President of the United States or does it come from the leader of HHS or does it come from the American people? Because prevention, we know it’s going to have the greatest incremental impact of anything. We just know that. You know that as a physician. We know it as population health specialists and the like. But where does that leadership come from? Who sets that priority?

Anand Parekh:              I think the leadership has to be from all of the above. Certainly, the President and our elected leaders and policy makers. I think it’s critical. But prevention starts at the home. It’s individuals, it’s families, it’s communities, it’s faith-based organizations, it’s a nonprofit organization, there’s the media. Everyone has a role in prevention. The purpose of this book is to say, “Policy makers, you too have a role. And there is something that you can do, policy makers, to support all the other sectors that are playing a role in prevention and here are a couple of ideas for you.”

Senator Bill Fr…:           Yeah, number two?

Anand Parekh:              Yeah, so number two really focuses on public and private payers. And as we talked about, value-based healthcare transformation, measures are the currency. We have a lot of measures to try to incentivize providers to manage chronic diseases. We need metrics to help them focus on preventing chronic diseases. So the recommendation is healthcare and they ought to be accountable not just for the management practices but the incidents, new cases of diabetes or heart disease, the prevalence of tobacco use or obesity. And only then will we really help build the clinical community linkages that are necessary to improve health status and health outcomes. So we really need to take the current set of metrics and really push the outcome up to…

Senator Bill Fr…:           It’s a real shift. It’s a real shift in thinking.

Anand Parekh:              It’s a real shift. It’s an absolutely…

Senator Bill Fr…:           Because you’re exactly right. When people think of outcomes measures, quality measures, initially it was processed. Now we’re looking a little bit more of outcomes. But to move that back in the timeline to prevention is a shift of thinking.

Anand Parekh:              Absolutely. Yeah. Yeah. So third recommendation focuses on our regulatory agencies in this country. Senator, as you know, if we have a drug, a novel drug, or a novel device, there is a clear pathway. There is the FDA that looks at safety and efficacy, and then we have CMS that looks at reasonable and necessary, and then private payers follow. There is a pathway. But if you’re a community-based prevention program outside the healthcare setting, sometimes even led by laypersons, there are all sorts of evidence-based programs out there. There is currently no pathway.

Senator Bill Fr…:           Yeah.

Anand Parekh:              And so the recommendation calls for a parallel pathway, just like you have the FDA on the drug and device side. You could task CDC, you could task the Administration on Aging. Have an entity look at the safety and effectiveness of these prevention programs, and then once they’re approved, they go to CMS just like a drug or device would be for reasonable and necessary. Right now there is no pathway to reimburse or support or scale evidence-based prevention programs that are occurring in the community.

Senator Bill Fr…:           And to create that pathway, is that a legislative change, is it a regulatory change? But if you had to snap those fingers and have the pathway there, what has to be done?

Anand Parekh:              Well, it’s a legislative change because if you go through the current regulatory approach, just take the example the Diabetes Prevention Program. Landmark NIH clinical trial in 2002. It took sixteen years for CMS to start paying for that, and that was only through the innovation center authorities from the Affordable Care Act which said that it had to save money. Now it’s great that it does save money, but we don’t use that standard for any drug or device or anything out there. FDA doesn’t ask, “Hey, did you save money?” CMS doesn’t do that. So we have all of these archaic structures that don’t facilitate prevention. So that’s really the third recommendation.

Senator Bill Fr…:           Yeah, that’s fantastic. And number four?

Anand Parekh:              Fourth recommendation is in our four trillion dollar budget, which you know also well, we need to, Senator, find more money for public health. Only two and a half percent of healthcare expenditures in this country go to public health. We know the enormous public health has had over the last 100 to 150 years in this country in terms of dramatically increasing life expectancy.

Senator Bill Fr…:           And so public health, again, for our listeners and our viewers, public health, what do we mean today? Because public health, traditionally people think of just clean water and clean over time, but public health, what do you mean by that?

Anand Parekh:              Yeah, so public health really assures the conditions for individuals and communities and populations to be healthy.

Senator Bill Fr…:           In this whole ecosystem.

Anand Parekh:              In this whole ecosystem. And you’re right. About 100 years ago, it was about water. It was about sanitation. And then it was about infectious diseases. And now it’s about chronic diseases and environmental health. But public health really does surveillance and really tackles all of those problems from a population lens and tries to create partnerships to really tackle the social determinants as well as partner with the clinical community to improve health outcomes. So that is traditionally public health. There’s a governmental public health perspective. There are also others in the private sector who are engaged in public health, but that’s what we mean by public health. And in fact, as you know well, it has been really public health which dramatically with advances in modern medicine of course, it’s really the two of them together and particularly public health that has led to dramatic increases in life expectancy.

Senator Bill Fr…:           And I agree. And I think for our listeners, they know it, but because public health is still a vague concept, but they hear it from you and be reinforced by me with my Second Opinion is public health is the primary driver of health and well-being in America. And the challenge that we have… And this is why through this podcast, we look at things through the policy lens, the health and medical lens, and the innovation lens. The policy lens, and it’s predominantly government here, has to step forward. Nobody else owns public health. Individuals don’t. Communities without government support cannot. But it shows why looking at issues through policy is critical because the policy itself and government itself is who is going to be supporting public health.

Anand Parekh:              That’s right.

Senator Bill Fr…:           And then we got to four?

Anand Parekh:              Yeah. And number five is research. We have a 50 billion dollar medical research enterprise in this country. We need to promote prevention and make sure that there’s enough research ongoing in prevention. That’s in basic sciences, that’s in clinical sciences, that’s in health services research. We need a cohort of young investigators who are engaged in prevention research so we know what works and what doesn’t work. And I think this will also help, and you’ll remember from your Senate days, this’ll help entities like the Congressional Budget Office when they score legislation to know the impact of prevention interventions can do. But we need much more of a focus in a research enterprise in this country on prevention. There ought to be a HHS trans NIH prevention or a trans HHS prevention council. So I think there are a lot of things we can do on the research side. We don’t usually think about prevention in research. We got to put them together, and we got to get results out there so people know how we can prevent illness in the best possible way.

Senator Bill Fr…:           I love it. I love it. The book is Prevention First: Policymaking for a Healthier America. If there’s one place that you could have the single greatest incremental impact in changing health and the health of America, we know it’s prevention. And it is underserved, in part because people don’t fully understand it and then there’s no real advocates for it. And I think… I know that your book, having read it, that your book addresses that head on, so congratulations with that.

Anand Parekh:              Thank you, Senator. Well, thank you for leadership in that area for so many years.

Senator Bill Fr…:           So let’s close with, again, thinking about listeners and our conversation today, and we could go on forever, and I look forward to talking more, but in all of your experience, because you sat in an unusual perch at the BPC, the Bipartisan Policy Center, conferences, collectivity, Democrats, Republicans, Independents coming in from all over America formulating policy, making recommendations, hugely respected. Is there one issue that we can kind of leave with that our listeners may not have thought about in terms of either a solution or addressing a challenge that’s in health or healthcare you’d like to share with them?

Anand Parekh:              I think a lot of the political debate right now is about the Affordable Care Act, and certainly this next election is going to be consequential in 2020, whether you continue to build on the Affordable Care Act or not. And I think universal health coverage has become the key issue of our time, and I think that’s a really, really important issue. I would say a subset of that, and we touched upon it a little bit earlier, is the need in this country for universal primary care. I’m biased, Senator, but I think that universal primary care, we know the data. Primary care is associated with better health, better care, and lower costs. And I really think primary care can be the great connector to the upstream elements that we just talked about the social determinants of health, public health, the prevention, as well as the connector to the rest of the healthcare system. And primary care, team-based care compensated well, supported well, done the right way with enough time can take all of those upstream elements and ensure people remain healthy and well but also reduce a lot of the preventable healthcare utilization and costs that come from suffering that is preventable in the first place. And so all 320 plus million Americans, yes, they should have universal health coverage. We’re 90 percent there. We’ve got to get to 100 percent.

Anand Parekh:              But universal primary care, which is a usual source of care, I would even divorce that, and many experts would argue, from health insurance coverage. Health insurance as a concept is you purchase it, any kind of insurance, car insurance, health, it’s a risk. Primary care shouldn’t be a risk. This is what we ought to be engaged in if we want a society that’s predicated upon health, health and wellness. And so when I look at this country, I’m optimistic about the future. But I say our challenge is that we have a country where right now this is the best country in the world to be in if you’re sick, and if you have the means. And we got to move to this being the best country in the world if you’re sick, but also to be well and healthy irrespective of means. And that’s where we have to go. So not just sickness but health and wellness, and not just if you have means but irrespective of means. And I think that’s going to take a lot of work.

Anand Parekh:              But what makes me optimistic is over the last fifteen years, Senator, traveling as a public servant, now at the Bipartisan Policy Center, I’ve seen trailblazers all over the country that are putting the power of prevention in practice, that are designing new care models, and that gives me hope. And I wonder at the end of the day how much is about new innovation? We need innovation, but how much is also about just scaling and replicating what is working in pocket so that we can help not just hundreds of people but thousands and millions. And so I think what gets me up in the morning, to come back full circle, is the ability to just play a small role, to be a small part. That’ll make this sort of journey worth it from my perspective.

Senator Bill Fr…:           Well I think unbelievably perfectly said. To take things to scale that we know that work, they’re out there in these little pockets all across America. And when you do that, and you couple it with, as you said, in your five recommendations, great research and alignment of incentives, you can’t help but to be optimistic. And it’s great to be optimistic when we have so many other things going on in Washington now where I know in our divided world that people are down and pessimistic and say, “Where are we going?” But the opportunity we have through the principles that you’ve outlined both in your book and the discussion earlier in our conversation gives me great hope and optimism as well. And I thank you so much both for your service in government, your service in the private sector, your service now with a commitment of bringing people together. You’re making a huge difference. I’m a huge fan. Thank you so much for being with us.

Anand Parekh:              Thank you, Senator, for your leadership. Thank you.

Senator Bill Fr…:           Thank you.

Anand Parekh:              Thank you. Great to be on.

Senator Bill Fr…:           This episode of A Second Opinion was produced by Todd Schlosser, the Modus Creative Group, and Snapshot Interactive. You can subscribe to A Second Opinion on Apple Podcast or wherever you’re 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 and our our guests and sponsors at ASecondOpinionPodcast.com. 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.