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Q&A: Dr. Joanne Conroy and Karen Fisher discuss health policy and academic medicine

Q&A: Dr. Joanne Conroy and Karen Fisher discuss health policy and academic medicine


– Hello and welcome to Facebook
Live from Dartmouth-Hitchcock. I’m Joanne Conroy, the CEO and president of Dartmouth-Hitchcock and
Dartmouth-Hitchcock Health. And I’m here today with a
very good friend of mine, Karen Fisher, who is the
chief public policy officer for the Association of
American Medical Colleges in Washington, DC. She is here for a visit to
give the health policy lecture that’s sponsored by
Wayne Granquist tomorrow, but she’s also here visiting the campus and learning a little bit
about Dartmouth-Hitchcock. Karen actually spent almost a decade at the double-AMC as senior
director in healthcare affairs. And that’s where I met Karen, when I went to the double-AMC in 2008. She left and went to serve
as senior health council for the Senate Finance
Committee for four years and she has a real
commitment to public service and that is public
service with a capital P, and worked very diligently
with that committee for the next four years,
but then came back to the double-AMC in
2016, where she is now the chief public policy officer. So thank you for joining us, Karen. – Glad to be here. – So I wanted to talk to
Karen and interview her on Facebook Live because
of your career path. When I went to Washington, number one, I was impressed by how many young, really bright people there were that went to Washington just to get
a taste of public policy and it is the place for
people to learn about policy, so how did you get into policy? – Well that’s a good question. My background is a little bit different than a lot of people’s background. I actually went to pharmacy school first at the University of Pittsburgh. My father was an independent pharmacist and I really loved what he did. But I was really bitten by the policy bug because of the University of Pittsburgh. They’re an academic medical center and I sort of saw the interactions between the education and
the clinical settings. And I had some good mentors there who said, well, if you’re
interested in policy you should go to law school. And why not go to law school and stay here at the University of
Pittsburgh, which I did, and so I got a law degree at
the University of Pittsburgh. I then moved to Washington wanting to do policy, never
wanting to go to Congress or spend time in Congress, but I wanted to sort of be outside of that space. But I ended up working for
a healthcare commission that advised Congress
on healthcare policies, predominantly the
Medicare program policies. And after that, as you
mentioned, I then moved to the double-AMC which represents all of the major teaching hospitals and all of the medical
schools in the country, and focused on the health policy issues that affect academic medical centers and found that very interesting, and then had a chance to
work with you and spend time and really get to see from
an operational standpoint about representing and working as someone who works in an academic medical center. And it was during that time that the Affordable Care Act passed, and it was also during that
time that Medicare and Medicaid were also going under
financial challenges. And I feel very strongly about healthcare and the role of the federal
government in healthcare, and found an opportunity to go and work at the Senate Finance Committee. I sort of hate the name of the committee because it doesn’t really
have the word health in it, but the Senate Finance
Committee for the Senate is the committee that
does all the legislation for Medicare, the Medicaid program, as well as the Affordable Care Act. It also, interestingly,
does the tax legislation, which is why it’s the Finance
Committee in that arena, but had, as you mentioned,
that opportunity to spend time and actually work with a lot of great people and work on some important issues
during that period that I was there, 2011 to 2016. – So what advice would you
have for a young person. The Dartmouth Institute
here actually trains a lot of graduates that
are really interested in health policy, so what
should they think about when they graduate from
a program like that? What next steps should they take? I think we do get a lot of people that come to Washington, and I’m not sure they’re always fulfilled
in what they end up doing, even though it’s a exciting place to be. What recommendations would
you have for young students that wanna get into health policy? – Well, I think Washington’s
a good place to come and I think sometimes people
see a lot of partisanship, but there’s a lot of
bipartisanship that also occurs when you’re actually in Washington in the federal government. But there’s a lot of places besides being in the Senate or working for the Senate or working for the House
of Representatives. There’s healthcare commissions, there’s an agency called the Government Accountability Office
that does a lot of reports for Congress; they are
a nonpartisan entity. There are the agencies
themselves that run the programs. For example, the Centers for
Medicare and Medicaid Services, that operate the Medicare
program and work with states on the Medicaid program, so
there’s a lot of opportunities beyond just saying, well,
I wanna be a staffer in the Senate or a staffer in the House. And I do think some
young policy people come and think that’s where they need to be, and you can learn a lot at these agencies about how programs work, and then you can still
have the opportunity to work on the legislative
side if you want. And I’ve found that some of
the people came from agencies and then came to the
legislative branch, brought a lot of great experience with them to that legislative
side rather than coming cold from that front. But I’m a big encourager of
people coming to Washington. I think healthcare and healthcare policy is only going to get more important so we want good and bright people, Joanne, coming to Washington, so please come and bring your talents to there because the American people
and the government needs it. – You know, it’s interesting;
I think the first time I had kind of real insight in terms of how legislation was crafted was, maybe building up to
the Affordable Care Act but there was some legislation
that was floating around, and I remember a feeling that
it was very poorly written and realizing that a lot of young staffers actually are told to kind of
craft the framework of it. But then they send it to
agencies like the double-AMC and a lot of other stakeholders where we kind of hammer
it into some semblance of kind of a working legislation that may actually result in working regulations. – Yes, I would say that
often they will reach out to stakeholders and say,
look, this legislation’s going to impact you;
tell us what you think will work and what won’t work. But they also work very closely, again, with those agencies who will
implement the legislation, and those agencies have
staff who are very adept at reading legislation and saying, hey, we’re gonna have trouble operationalizing what you want us to do, Congress, and there would be a
give-and-take, a back-and-forth where they say, well, what
is possible for you to do? I also have to give kudos
to the legislative councils for both the House and the Senate. There are experts there who
write and finalize legislation so that if a staffer, and
particularly, their boss, the senator or representative
says, I have an idea; this is where I’d like to go forward with, they will go to that
legislative staff person and they will put it
in that fine-tuned way of making sure it works within the statute and then again the offices
have to work with the agencies to say, if this legislation would pass, can you actually put
regulations, operationalize it, and then they talk to, as you mentioned, the stakeholders like
the double-AMC and say, how will this legislation impact you? Will it help? What problems do you see? What unintended consequences do you see? ‘Cause the ultimate
goal is to have a piece of legislation that passes
and the president signs that is workable and that
will make a difference and won’t have unintended consequences, because as I think a
lot of people have seen, it’s hard enough for
Congress to pass legislation. It’s even more difficult if
they made a technical mistake and wanna go back and clean that up and pass another piece of legislation. So you like to get it as right
as you can the first time. – So how long have you
lived in Washington? – I have lived in Washington
for a long time, Joanne. (both laugh) I wanna say more than 20 years and maybe we leave it at that. – So, do you ever still
just kind of get impressed when you drive around
or walk around the city? It is an incredibly impressive city and when you live there, you appreciate just the, almost, grandeur of the place. – You know, it’s interesting you say that. I do feel that way;
when I left the Senate, and everybody who leaves the Senate, you get a badge, like
you have a badge here at Dartmouth-Hitchcock, and we had a badge that allowed us to walk freely and go into the Capitol itself
and go into the rotunda, and I was able to walk freely around wherever I wanted to go, and when I left I had to give up that badge. And it’s a little bit
emotional because to be able to walk in it at night,
there’s a lot of working. I did a lot of work in the
Capitol offices themselves, and at night when you left and turned back and looked and saw the grandeur of the Capitol building
itself, it is momentous and you see the history of
all that has occurred there. It’s a very old building; they
take very good care of it. But I think it’s important in Washington, given everything that goes
on, that you have to stop every now and then and say
that a lot of important things have happened here, and a
lot of more important things will happen here, and
you’re just a sort of a step along the chain. – So I’m just going to
break to remind our audience that I’m here with Karen Fisher, who’s chief public policy
officer at the double-AMC and if you have any
questions, just go on our feed and submit the questions, and
we have people monitoring that and they’ll hand them to us. You know, I have to say
of the number of times I went in the White House,
I think the first time I went in, I was impressed
by a couple of things. Number one, the incredible
efficiency of the security. Of course, we hope they’re efficient. But it was actually very seamless. 48 hours ahead of time you go through a complete FBI check, I’m sure. But the second thing was
when we had a meeting in the West Wing, it was kind of cool. I have to say, it looked like I could turn my head around the corner
and see Martin Sheen walking down (laughs)
walking down the hall with his group of aides. But what is that feeling? I know you’ve been in the White House a number of times when you do that. – I think it is a great feeling, and it’s even beyond
the White House itself. There’s two very large buildings that are connected to the White House, the old Executive Office Building and the new Executive Office Building that have staff that do a
lot of work in those places. And I would say just being on the Hill, I was so impressed with the amount of work that people did, and
regardless of what party you belong to or who was
in the administration, the people who worked
there were very dedicated and what they had in mind
was improving the country. In our space, improving
healthcare for people, the ways of which they
wanted to improve healthcare may have differed in that fronts, but there was a real commitment
to making a difference and as you mentioned,
for many of these people particularly as they get
older, it is a sacrifice, because you don’t make a
lot of money in that space and to see how many
hours a week people work, for that limited amount of money, the commitment they have because they feel that what they’re doing is helping to make the country better. And I felt that way about
representatives and senators. I always feel badly that we
talk when Congress recesses it sounds like your
school, you’re recessing, but they really go back to their districts and to their states, and
their schedules are very full back at home, meeting with
constituents, doing town halls, going to visit places
like Dartmouth-Hitchcock, and your senators and
representatives do that here. And they really are quite
hard-working as well, and I feel sometimes like they
aren’t given enough credit for the hard work that they
put in, generally 24/7. They go home in an airport,
and there’s generally a constituent who’s coming
up and asking them something or questions in that arena, and I do think it would be nice to step back
and we should acknowledge all that work that comes
in, recognizing that we still have differences sometimes about how the country should move forward. – You’re right; I remember
taking some flights to Portland, Maine, and
seeing Olympia Snowe working on her kind of homework as she was flying home for the weekend. We do have a question from the audience. “How important is it for
today’s medical students “to understand the current
health policy environment?” – I think it’s really
important to understand. Thank you for that question. There’s so much to learn
when you’re a medical student and you’re so focused on
just getting it right, and you, Joanne, being a
physician yourself know that feeling of when you
were in medical school and just wanting to do the
job right, of doing diagnoses and doing the right treatments and care. But healthcare has gotten so complicated and how it moves forward, I think having the physician’s voice as we move forward and see how should the healthcare change. And physicians and nurses and
other healthcare providers often are on the ground floor and can see what’s working and what’s not, and what can make a difference. And I think we’re seeing
that in some cases, and Dartmouth has been the lead in this in looking at different
models of how we provide care, more team-based care
and understanding that. And I found when I was in Washington whenever physicians came
and healthcare leaders and CEOs came, those were
extremely valuable discussions, not only for me but for
the senators I worked for to say, this is what we
need out in the hinterlands. You know how to do the
policy, but this is what we’re seeing on the
front lines; this is what our patients need in that front. And so I think it’s critical
that the medical profession stay involved to a certain point, and I think staying involved
in your professional societies as you move
throughout your career is a good way to be able to stay involved and understand healthcare policy. – It’s interesting; I remember
when we were kind of debating the ACGME 80-hour workweek assessment, and there was a comment that
it didn’t land very well always for the legislative staffers
because they often worked far more than 80 hours a week
when they’re staffing somebody during really difficult times, and I think when you
were on Senate Finance if they were actually debating something, the entire office was there, wasn’t it? – It was there, and you
know, the 80-hour workweek is an interesting example
of sometimes how Washington can work with the community. In a sense, there were so many issues, and you know them better than I do, of how long residents were on duty, over 100 hours, in some cases. And there was a lot of
discussion, a lot of science at that time that said that was too much, and there were problems with handoffs. And legislators started to get involved and policy makers and
said, um, we’re not sure this is a good way to
educate, we’re not sure this is a good way to do patient care, and basically came to the
stakeholder communities like the double-AMC and others, and said, if you folks don’t do
something on your own, we’re going to legislate something. And I think that brought
the community together and got principles, and it was difficult because all of the specialties
have different views on that and they have
different requirements. But it did bring the
community together to say, who is better to determine
how to make this work and how to limit the hours? Us, or policy makers in Washington? And while I just lauded
the skills and the talents of policy makers and staffs in Washington, there’s a limit of what
their knowledge base is. And so to the extent in that example the community did come together and the ACGME changed its requirements so that there wasn’t a need
for congressional action, and oftentimes that’s as
important as doing legislation is to when not to do legislation. And that was a good example you raised. – Yeah, so if we’re gonna
talk to the average employee about why they need to kind of
keep their ear to the ground on what’s going on in Washington, we serve a rural community. We are an academic medical
center, have a lot of research, have a lot of education,
what are the things that people need to just be aware of, ’cause they could affect our ability to actually deliver
those services up here? – Yeah, I think, for one
point, the last two years I think lots of the
country got educated more in healthcare policy and healthcare by virtue of the debate over
the Affordable Care Act, Repeal-and-replace legislation, whether it was the number of uninsured, whether it was the role of Medicaid, whether it was the role of
healthcare and insurance with people with preexisting conditions, so, in a sense, it’s
building on that momentum. But, what is it? 10,000 people are turning 65 every year and going onto the Medicare program, which is a very successful
program for beneficiaries, and so as that program has
changes that could occur to it, people need to be aware of them, either for themselves or for their parents or their grandparents going forward. And I think we’re making more
progress in the rural space with regards to telehealth
and opportunities to have more arrangements so
that an academic medical center lik Dartmouth can reach further
out into the rural areas. I know that your organization
has been very involved in a project that the
double-AMC has help shepherd; it’s the Coordinating
Optimal Referrals Experience to leverage electronic health records and allow specialists to do consults out in the more rural
areas with telehealth. And I see that type of activity
only increasing over time. The research that’s going to be occurring in the next 10 years, we’ve
already seen so much research. And all of it really starts
at academic medical centers, and then there’s a role for
the pharmaceutical companies down the line, but so much
of that research starts and what we have been seeing
over the last five to 10 years, and it’s only going to increase
exponentially in the future is the advances that
we’re seeing in research. And so I think there’s a lot
of excitement in healthcare. It is costly, and that’s
a concern as the country moves forward on fiscal
issues, but I think we all have a responsibility to pay attention to it because it affects each one of us. This is an issue that affects each one of us personally and individually. – So we do have another
question from the audience. “As we all get older, and more
people join AARP crowd …” Every single Sunday newspaper
that comes to my house now has an AARP card application. “… that means more people on Medicare. “Can the federal government handle it, “and what does this mean
for the future of medicine?” – I sort of led into that
question before it came. I think it’s an issue
as we have more people, particularly for those
Baby Boomer population, it will recede for those people who were born after 1960, 1961. But I think it’s a real issue
about the Medicare program and the rising cost of
healthcare generally. And what do we do about that? The Medicare program is
financed through payroll taxes and there is an issue about
how long that can continue. And I think that’s why places,
both at Dartmouth-Hitchcock and across the country
are looking at other ways to deliver care that promote efficiency while retaining high-quality care. And I think over the last five years, we’ve seen more institutions
and even insurance companies, etc., looking for those opportunities and I think that’s what
we’re going to have to do because the alternative
is, do you start looking at the benefit packages and
saying, well, we can’t afford to provide this level of benefits? And I think people in your position, your colleagues across the country, feel very strongly that we should be able to provide those benefits;
let’s do it in a way that’s cost effective while
maintaining high quality so we don’t get into a
position where we’re limiting, making decisions, financial decisions that impact patients directly. – Yeah, yeah. So we’re getting close to our 30 minutes. Have you ever thought about
running for public office? – No. – That was a really quick answer. (both laugh) – I wonder if you’ve ever
thought about doing that. No, I really like what I
do; I like doing policy. To be honest, I’m a little bit nerdy. I don’t like to tell
people at cocktail parties but I like getting into
the weeds a little bit about, how do you actually do it? When you look at the Medicare
program, for example, it is a federal program,
but yet it impacts every individual in this country, yet our country is so diverse. So whether it’s the rural
areas of New Hampshire or the very urban areas of Boston, to the South, to geographic areas, to the complexity of patients, and yet you wanna figure
out a payment system that will ensure we’re
providing high-quality care in all of those areas for
all of those patients, and it gets a little
tricky to do in that front. And I find that very
interesting and challenging, and so I sort of enjoy what I do. – Yeah, yeah. It actually is an incredibly
fascinating program that has pretty low administrative costs. People don’t appreciate it’s like 1.8%. – It’s very low administrative costs. – Which is amazing that
they can administer a program to so many
people at such a low cost. One more question.
– Okay. – “Vermont’s approach to health policy “is very different than New Hampshire.” That’s actually true,
since we actually straddle both states, it’s kind
of A Tale of Two Cities. “We are the tale of two states
because we are so close. “Can you talk about the
states’ roles in healthcare “and what national trends you’re seeing?” And just, Vermont has OneCare Vermont. – Right, right. So I’ll be brief ’cause I know
we’re running close on time. I tend to spend most of my
time on the federal level. The states tend to have a
much more prominent role in Medicaid and have been doing a lot of exciting things in
the Medicaid programs in terms of ensuring
good care on that front. There are opportunities
at the federal government for states to get waivers to
be able to experiment more. And the federal government
is allowing states to experiment more on their healthcare. There was an Innovation
Center that was legislated as part of the Affordable
Care Act that allowed for more innovation so I do
think there is this issue of allowing states to
work with the local areas and work with their local communities to what healthcare is best for them while recognizing that states
also have fiscal burdens as they try to deal with their
own budgets in that front. So I think having a balance of ensuring that across this country we’re ensuring that everyone’s getting
high-quality, good care, while recognizing that individual states may have different ways about wanting to do it is a good balance. – Do you think we have
identified one state that might be on the
road to doing it right? – It doesn’t mean that they aren’t. I just think there’s
still a lot of variation and I think people are still
trying to figure this out, and for good or bad,
the Affordable Care Act added in a new dimension to this, and added in a new role as to what role the states play and the
federal government play, what role insurers play and providers. And I think we’re still
trying to figure that out. And the pace of innovation
also is happening so quickly. I think in fairness to
payers and to states and even the federal
government, trying to figure out to make sure that we continue
to support that innovation while at the same time
having some stability for the system is still
always a balance for everyone. – Right, good. Well, great, thank you, Karen. And thank you everybody for
listening to our Facebook Live and have a wonderful week.

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