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April 1, 2021

The Case for Medicare to Cover Home Safety Renovations

with the USC Bedrosian Center

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Richard K. Green
Richard K. Green | Director, USC Lusk Center for Real Estate
Patricia F. Harris
Patricia F. Harris, MD | Geriatric Medicine Specialist, UCLA Health
Anthony W. Orlando
Anthony W. Orlando | Assistant Professor in the Finance, Real Estate, & Law Department, California State Polytechnic University

Originally recorded for “The Bigger Picture” podcast by the USC Bedrosian Center with host Oliva Olson.

Falling is the number one cause of injury and the seventh leading cause of death in adults ages 65 and older. In the newly published “Breaking Down Silos to Improve the Health of Older Adults,” Richard Green, Patricia Harris, and Anthony Orlando make the case for Medicare coverage of home safety renovations to minimize injurious falls. Olivia Olson speaks with the authors about their recent paper and the changes they hope to see in Medicare coverage.

Listen via podcast

 

Listen

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[Music]

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hello this is olivia olson and you are

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listening to the bigger picture

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a podcast where we interview scholars

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about their research about how their

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research can make our communities better

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and more democratic

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today we're going to look into the case

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for medicare coverage of home safety

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renovations for seniors to minimize

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injurious falls

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with me today are richard green

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anthony orlando and patricia harris

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welcome and thank you so much for

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joining us

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could i have you introduce yourselves

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starting with you richard hi i'm richard

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greene

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and i am director of the usc lusk center

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for real estate and a professor

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in the price school of public policy

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marshall school of business and

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department of economics at usc

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thank you for being here with us today

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patricia hi i'm patricia harris

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i am a geriatrician at ucla

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i run a medical home visit program

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and i that's what i do

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well it's wonderful to meet you and

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finally anthony i'm an assistant

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professor of

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finance uh real estate and law at cal

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poly pomona

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but more important for the bedrosian

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center i got my phd

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in public policy and management from the

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price school at usc

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wonderful well i'm so glad that you are

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all able to join us today

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and i would love if you could tell our

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listeners right off the bat just a

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little bit about your research

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richard you want to start it off it kind

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of started with a conversation between

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the two of us so i think

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you know the inspiration the best so the

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inspiration was this was actually a

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paper that was written by

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a couple of guys named gary engelhardt

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and mike erickson

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uh five or six years ago that looked at

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the impact of

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uh falls on the frail elderly and in

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particular

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the impact of grab bars on the

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prevention of balls

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and by grab bars i mean much

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specifically in bathrooms so

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grab bars to allow people to get out of

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showers and get off the toilet

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with some support and what they found is

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you had substantial falls reduction

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when you installed these grabbers and

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they had a very clever strategy

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for determining that it was the grab

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bars not that people

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were more cautious people would put in

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grab bars which is

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if one spouse fell and as a result of

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that had grab bars

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installed if you observe the falling

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pattern of the other spouse

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you would see that they would fall much

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less often than

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those in a control group whose spouses

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did not fall and who didn't so didn't

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have

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the grab bars and what they found long

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story short

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is the cost of installing grab bars pays

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over itself in less than a year

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because of false prevention and at the

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same time

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because falls are expensive to the

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health care system

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when people break something obviously

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that's going to cost a lot of money

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because you're getting into orthopods

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when you

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when you do that um and so what there

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was a possibility of a policy

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that both saved taxpayers money and led

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to happier and more dignified

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aging that seems like a no-brainer

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okay about the time i was reading this

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paper i was

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also in the uh obama administration as a

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senior advisor to the department of

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housing urban development and i said

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at hud we should just install this stuff

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and they said yeah but

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that doesn't score well from a budget

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standpoint because we would spend all

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the money and hhs would get all the

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benefit

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and so i went to hhs and i said to them

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well

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this should be a medicare benefit but it

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proved

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difficult from both an administrative

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and legislative standpoint to actually

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implement this and so that's sort of

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my point of departure and then i'll talk

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to anthony about

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how he picked it up from there yeah i've

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been doing some research for a couple

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of years with our mutual friend and

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colleague raphael bostic

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on social determinants of health

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and how so much of our health care

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expenditures can be linked back not just

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to the medical system but to

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things out in the world everything from

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the neighborhood you grow up in with the

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type of environment that you

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live in and the air that you breathe to

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the type of the housing quality that you

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have which includes

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whether it's been renovated to have

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these home safety kind of features

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one of the challenges that raphael and i

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faced uh we did a report for the

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national academies of science was

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it's challenging to pay for these things

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for exactly the reason that richard is

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talking about which is

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you're crossing over boundaries between

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silos

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so much of social determinants of health

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requires

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fixing something that doesn't seem like

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a health care problem

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but will result in a health care

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benefit to society and so

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when richard and i started talking about

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it it seemed like a natural thing that

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we should

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propose that medicare should be more

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interested in addressing these kinds of

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social determinants of health

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and then i'll pass it over to dr harris

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because

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we realize that neither of us has any

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expertise in gerontology or

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expertise in older americans health care

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and so we really needed somebody to make

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sure that we weren't crazy

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so i was very happy to provide the

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uh boots on the ground expertise

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including risk factors for falls

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interventions that have been shown to

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reduce falls

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and and just give a general background

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as to

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how one could implement a policy like

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this and and make it

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workable so i i kind of was the the

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background person and the

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um out of ivory tower person

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as well and i think it's a great idea

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and you're absolutely right this is a

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social determinant of health

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it is also a problem that people don't

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recognize as a problem unless it's

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brought up to them

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and a policy that would put a grab bar

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in place before

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a person actually fell could only be a

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benefit

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and i think the dark paper shows that

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wonderful so one of the things that was

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both mentioned in the article and that

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you all touched on to some extent was

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the issue of

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generating political will and actually

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implementing this policy

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how do you see overcoming the barrier of

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generating political will and

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what do you hope to have happen as an

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outcome well i i'd be curious for

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richard to say a little bit more about

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his experience in the obama

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administration and what he sees

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as the as he knows some of the people

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who are in the biden administration now

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but

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i will say that i think we're more

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optimistic that these types of ideas

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will be taken seriously

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over the next four years than they might

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have been over the previous four years

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and i do think that at least in the

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spheres that we work in in public policy

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there is a growing

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understanding of the fact that so many

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issues are interdisciplinary and that

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they require interdisciplinary solutions

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and

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places like usc and ucla are starting to

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invest more and more in that so

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hopefully there's a growing awareness

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that pushes for it but i can't speak to

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the inside politics as

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as well as richard came so well to some

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extent

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patricia helped me with the inside

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politics because she was a health policy

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fellow

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at the department of health and human

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services some years ago

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and while she was there one of her

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colleagues

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as a fellow uh became a senior official

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at cme who are the people

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who determine how medicare and medicaid

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spending is

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done is it both medicare i guess just

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medicare not medicare medicaid

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anyway it could be both okay that's

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where yeah dr harris knows a whole lot

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more than i do but anyway i brought this

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idea

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to this official and she was very

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enthusiastic about it

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and on the grounds that for starters i

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was the rare person who was bringing an

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idea about something that should be

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covered

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where i had no financial interest in it

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being

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covered is usually for if somebody wants

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equipment

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covered under medicare the person

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wanting that equipment to be covered is

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the manufacturer or inventor of that

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equipment they have a financial stake in

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it and so she said that

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the nice thing about me bringing this to

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their attention was

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that i was pristine

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in general i'm not a pristine person at

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all but in this particular matter i was

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pristine

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i had no financial interest in uh

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making sure this happened and so she was

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very enthusiastic about it she saw the

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idea

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right away but as she explained it to me

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there had been legislation

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several many years ago that defined grab

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bars and

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what are called convenience devices

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instead of medical equipment devices

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and as a result of that you needed to go

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through a process for a patient to be

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able to get access to this and have it

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be covered so

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it can be covered but it is it's almost

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like this is the problem it's an

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after the fact kind of thing right you

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have to show

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demonstrated need uh

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which often means people have fallen

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already well

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the whole point is you want to install

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it before it's fallen

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and in order for this to

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um so for in order for there to be a

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change there would have to be

280
00:09:33,839 --> 00:09:38,480
legislation

281
00:09:35,440 --> 00:09:40,399
that would allow for cme to

282
00:09:38,480 --> 00:09:42,480
designate this a medical device which

283
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could mean that they use it

284
00:09:42,480 --> 00:09:47,160
as a preventative as opposed to a

285
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curative

286
00:09:47,160 --> 00:09:50,880
[Music]

287
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intervention well when i was in the

288
00:09:50,880 --> 00:09:56,000
obama administration as you may remember

289
00:09:52,800 --> 00:09:57,839
republicans held both seats of congress

290
00:09:56,000 --> 00:10:01,040
both sides of congress

291
00:09:57,839 --> 00:10:03,680
and you know i will be bipartisan here

292
00:10:01,040 --> 00:10:04,160
although i really hate to be bipartisan

293
00:10:03,680 --> 00:10:05,680
uh

294
00:10:04,160 --> 00:10:07,760
i mean nobody was interested in making

295
00:10:05,680 --> 00:10:10,800
anybody look good in washington

296
00:10:07,760 --> 00:10:11,519
at that time and and so trying so so i

297
00:10:10,800 --> 00:10:13,760
talked

298
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with some of the usual lobbying groups

299
00:10:13,760 --> 00:10:17,839
they

300
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showed some interest in it

301
00:10:17,839 --> 00:10:20,399
i think people can figure out who i'm

302
00:10:19,120 --> 00:10:22,160
talking about but i don't want to throw

303
00:10:20,399 --> 00:10:24,640
them under the bus as being an effective

304
00:10:22,160 --> 00:10:26,240
because i think they tried but just

305
00:10:24,640 --> 00:10:27,440
getting anything through congress and

306
00:10:26,240 --> 00:10:30,640
onto the president's desk

307
00:10:27,440 --> 00:10:32,160
during that period was very difficult uh

308
00:10:30,640 --> 00:10:34,399
and now i think the key thing

309
00:10:32,160 --> 00:10:37,440
politically is now that we have

310
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uh a president and congress from the

311
00:10:37,440 --> 00:10:41,360
same

312
00:10:37,920 --> 00:10:43,279
party uh perhaps

313
00:10:41,360 --> 00:10:45,200
if this has adequately raised people's

314
00:10:43,279 --> 00:10:46,079
attention there might be an opportunity

315
00:10:45,200 --> 00:10:48,640
in the next two years

316
00:10:46,079 --> 00:10:49,920
to do something with this wow that is

317
00:10:48,640 --> 00:10:52,160
wonderful news

318
00:10:49,920 --> 00:10:54,800
well no no no i said perhaps i mean i

319
00:10:52,160 --> 00:10:56,320
just do a bunch of caveats out there and

320
00:10:54,800 --> 00:10:58,000
still i'm still taking that as a

321
00:10:56,320 --> 00:11:00,480
positive and here we are

322
00:10:58,000 --> 00:11:02,800
doing an interview and raising some more

323
00:11:00,480 --> 00:11:06,079
attention and interest in this topic

324
00:11:02,800 --> 00:11:09,120
so i can only help right

325
00:11:06,079 --> 00:11:11,040
well you mentioned your own pristine

326
00:11:09,120 --> 00:11:13,200
financial interest background

327
00:11:11,040 --> 00:11:15,120
but on the subject of this one

328
00:11:13,200 --> 00:11:16,480
particular and this one okay yes

329
00:11:15,120 --> 00:11:18,720
in this one particular we'll get into

330
00:11:16,480 --> 00:11:20,240
that a different time

331
00:11:18,720 --> 00:11:22,000
but could you talk a little bit about

332
00:11:20,240 --> 00:11:23,760
the financial feasibility

333
00:11:22,000 --> 00:11:25,839
of this getting off the ground and being

334
00:11:23,760 --> 00:11:27,680
financed by medicare i can give a couple

335
00:11:25,839 --> 00:11:28,240
numbers to get the conversation started

336
00:11:27,680 --> 00:11:30,880
so

337
00:11:28,240 --> 00:11:31,519
we uh richard mentioned that in the

338
00:11:30,880 --> 00:11:33,920
paper by

339
00:11:31,519 --> 00:11:35,200
mike erickson and gary englehart that

340
00:11:33,920 --> 00:11:37,120
you know they had done an initial

341
00:11:35,200 --> 00:11:38,480
benefit cost analysis and they

342
00:11:37,120 --> 00:11:41,279
essentially showed that

343
00:11:38,480 --> 00:11:42,079
in only a year or two afterwards the

344
00:11:41,279 --> 00:11:45,200
benefits were

345
00:11:42,079 --> 00:11:46,959
over ninety percent of the cost uh and

346
00:11:45,200 --> 00:11:47,440
inching towards a hundred percent and

347
00:11:46,959 --> 00:11:49,040
then

348
00:11:47,440 --> 00:11:51,440
what we did was try to update those

349
00:11:49,040 --> 00:11:53,519
numbers because the health care

350
00:11:51,440 --> 00:11:55,600
costs since they had done their study

351
00:11:53,519 --> 00:11:57,360
had grown a lot faster than inflation so

352
00:11:55,600 --> 00:12:00,320
the medical savings

353
00:11:57,360 --> 00:12:00,959
that you could get was actually now much

354
00:12:00,320 --> 00:12:03,279
higher

355
00:12:00,959 --> 00:12:05,360
than the costs we said we found that it

356
00:12:03,279 --> 00:12:08,320
was uh somewhere closer to over

357
00:12:05,360 --> 00:12:10,639
you know 20 percent so a dollar 20 cents

358
00:12:08,320 --> 00:12:12,480
is saved in the long run

359
00:12:10,639 --> 00:12:13,920
relative to the costs it extremely

360
00:12:12,480 --> 00:12:15,680
happened it wasn't really long run i

361
00:12:13,920 --> 00:12:16,560
mean a year is not oh sorry you're right

362
00:12:15,680 --> 00:12:18,160
over two years

363
00:12:16,560 --> 00:12:19,680
not the long run at all so that's

364
00:12:18,160 --> 00:12:20,320
another point that we made in the paper

365
00:12:19,680 --> 00:12:22,800
is that

366
00:12:20,320 --> 00:12:24,480
actually mike and his co-authors did a

367
00:12:22,800 --> 00:12:26,560
very conservative estimate because

368
00:12:24,480 --> 00:12:29,120
they're only looking over two years

369
00:12:26,560 --> 00:12:30,000
uh they're not looking at fatal falls

370
00:12:29,120 --> 00:12:33,040
which can be

371
00:12:30,000 --> 00:12:35,279
a lot more expensive uh and

372
00:12:33,040 --> 00:12:36,079
they're not looking at non-medical

373
00:12:35,279 --> 00:12:37,600
savings

374
00:12:36,079 --> 00:12:39,839
so richard mentioned you know the the

375
00:12:37,600 --> 00:12:41,600
stresses that come with a fall

376
00:12:39,839 --> 00:12:42,959
the stress is not only on the person

377
00:12:41,600 --> 00:12:43,839
who's affected but also on the

378
00:12:42,959 --> 00:12:46,000
caregivers

379
00:12:43,839 --> 00:12:47,839
which i think dr harris can speak more

380
00:12:46,000 --> 00:12:50,000
specifically about what that's like

381
00:12:47,839 --> 00:12:52,399
from the from the perspective of seeing

382
00:12:50,000 --> 00:12:54,399
the families go through all this so the

383
00:12:52,399 --> 00:12:56,160
benefit cost was one thing that we tried

384
00:12:54,399 --> 00:12:57,760
to emphasize

385
00:12:56,160 --> 00:12:59,360
and speaking is what we can do

386
00:12:57,760 --> 00:13:00,880
politically to your other question i

387
00:12:59,360 --> 00:13:02,639
think it's relevant to say

388
00:13:00,880 --> 00:13:04,240
as scholars there's only so much we can

389
00:13:02,639 --> 00:13:06,240
do but at least we can

390
00:13:04,240 --> 00:13:07,760
try to give the evidence that people can

391
00:13:06,240 --> 00:13:09,839
use to make the argument

392
00:13:07,760 --> 00:13:11,360
and so the other uh the other

393
00:13:09,839 --> 00:13:12,399
calculations that we did that we thought

394
00:13:11,360 --> 00:13:14,240
would be helpful

395
00:13:12,399 --> 00:13:15,920
is to show how much cost are we really

396
00:13:14,240 --> 00:13:18,480
talking about to medicare

397
00:13:15,920 --> 00:13:19,279
you can imagine a politician saying well

398
00:13:18,480 --> 00:13:21,200
maybe it'll

399
00:13:19,279 --> 00:13:23,120
pan out in the long run but right now i

400
00:13:21,200 --> 00:13:24,720
don't want to spend that much money

401
00:13:23,120 --> 00:13:26,959
and we said okay let's look at three

402
00:13:24,720 --> 00:13:28,880
different scenarios a very small

403
00:13:26,959 --> 00:13:31,440
scenario where you do a pilot program

404
00:13:28,880 --> 00:13:34,639
with a hundred thousand beneficiaries

405
00:13:31,440 --> 00:13:35,519
a middle scenario where you do any new

406
00:13:34,639 --> 00:13:38,240
enrollees

407
00:13:35,519 --> 00:13:40,079
each year which is about 1.7 million

408
00:13:38,240 --> 00:13:41,680
enrollees every year

409
00:13:40,079 --> 00:13:43,199
or a scenario where you try to cover

410
00:13:41,680 --> 00:13:45,040
everybody no matter how long they've

411
00:13:43,199 --> 00:13:47,360
been on medicare

412
00:13:45,040 --> 00:13:48,480
and in the smallest scenario which is

413
00:13:47,360 --> 00:13:50,480
not small 100

414
00:13:48,480 --> 00:13:52,880
000 people would be a great benefit for

415
00:13:50,480 --> 00:13:55,279
society you're talking about

416
00:13:52,880 --> 00:13:56,720
less than one-tenth of one percent of

417
00:13:55,279 --> 00:13:58,240
the medicare budget

418
00:13:56,720 --> 00:13:59,920
you know it's a very small amount these

419
00:13:58,240 --> 00:14:01,440
are very cost-effective things to do

420
00:13:59,920 --> 00:14:02,720
it's not expensive to make these

421
00:14:01,440 --> 00:14:05,199
renovations

422
00:14:02,720 --> 00:14:06,560
especially relative to the size of how

423
00:14:05,199 --> 00:14:09,519
much medicare spends

424
00:14:06,560 --> 00:14:11,279
and even in the situation where everyone

425
00:14:09,519 --> 00:14:13,199
could possibly get it and we were making

426
00:14:11,279 --> 00:14:13,760
very conservative assumptions about all

427
00:14:13,199 --> 00:14:14,959
of this

428
00:14:13,760 --> 00:14:17,199
you're talking about less than two

429
00:14:14,959 --> 00:14:18,480
percent of the medicare budget

430
00:14:17,199 --> 00:14:20,000
so those are kind of the ballpark

431
00:14:18,480 --> 00:14:21,680
numbers that we came up with and we

432
00:14:20,000 --> 00:14:23,760
hoped would be helpful to

433
00:14:21,680 --> 00:14:25,600
policymakers trying to make this pitch

434
00:14:23,760 --> 00:14:29,440
patricia do you have anything to add

435
00:14:25,600 --> 00:14:31,839
no i think he made his case very

436
00:14:29,440 --> 00:14:33,040
succinctly the the only thing i could

437
00:14:31,839 --> 00:14:36,000
add is sometimes

438
00:14:33,040 --> 00:14:37,519
in population health we look at the

439
00:14:36,000 --> 00:14:41,839
number needed to treat

440
00:14:37,519 --> 00:14:44,160
so how many people would require

441
00:14:41,839 --> 00:14:45,600
how many grab bars would be required

442
00:14:44,160 --> 00:14:49,120
before you actually

443
00:14:45,600 --> 00:14:51,440
prevented one injurious fall and our

444
00:14:49,120 --> 00:14:53,519
we don't have the exact numbers but just

445
00:14:51,440 --> 00:14:55,760
knowing not in this paper but in other

446
00:14:53,519 --> 00:14:58,240
papers a intervention like this the

447
00:14:55,760 --> 00:15:01,519
number needed to treat is quite low like

448
00:14:58,240 --> 00:15:03,519
five people would need to be treated so

449
00:15:01,519 --> 00:15:06,160
to speak with a grab bar before you

450
00:15:03,519 --> 00:15:08,959
prevented one fall

451
00:15:06,160 --> 00:15:10,480
you know in cancer number needed to

452
00:15:08,959 --> 00:15:13,600
treat is sometimes

453
00:15:10,480 --> 00:15:15,680
up to a hundred to get one benefit so

454
00:15:13,600 --> 00:15:19,360
you're looking at a very

455
00:15:15,680 --> 00:15:21,760
cost effective way of

456
00:15:19,360 --> 00:15:24,000
keeping people healthier and anthony to

457
00:15:21,760 --> 00:15:25,760
to go back to your earlier point about a

458
00:15:24,000 --> 00:15:27,199
limited role as scholars and

459
00:15:25,760 --> 00:15:28,800
implementing change

460
00:15:27,199 --> 00:15:30,720
what do you think that people such as

461
00:15:28,800 --> 00:15:33,360
our listeners can do to

462
00:15:30,720 --> 00:15:34,800
help promote this as change that needs

463
00:15:33,360 --> 00:15:36,000
to happen well that's a question i

464
00:15:34,800 --> 00:15:38,000
wrestle with a lot

465
00:15:36,000 --> 00:15:40,079
i think we all feel like we wish we had

466
00:15:38,000 --> 00:15:43,120
more influence for those of us

467
00:15:40,079 --> 00:15:45,759
who are um you know invested in caring

468
00:15:43,120 --> 00:15:49,360
about these issues and about our society

469
00:15:45,759 --> 00:15:50,959
um i mean part of it is is just

470
00:15:49,360 --> 00:15:52,800
making sure that you vote and making

471
00:15:50,959 --> 00:15:55,680
sure that you vote for leaders who you

472
00:15:52,800 --> 00:15:58,800
think take these issues seriously

473
00:15:55,680 --> 00:15:59,680
who both have the intellectual capacity

474
00:15:58,800 --> 00:16:02,160
that they really

475
00:15:59,680 --> 00:16:03,920
think about these issues and that they

476
00:16:02,160 --> 00:16:06,000
actually care about

477
00:16:03,920 --> 00:16:07,040
these issues i think it's i'm not going

478
00:16:06,000 --> 00:16:08,399
to again

479
00:16:07,040 --> 00:16:10,480
following richard's lead i'll keep it

480
00:16:08,399 --> 00:16:12,000
bipartisan i'm not going to recommend

481
00:16:10,480 --> 00:16:13,839
any particular

482
00:16:12,000 --> 00:16:15,279
politicians but i think it's clear that

483
00:16:13,839 --> 00:16:17,519
some uh

484
00:16:15,279 --> 00:16:18,880
experts think more about these things

485
00:16:17,519 --> 00:16:20,399
and care more about these things than

486
00:16:18,880 --> 00:16:23,600
others

487
00:16:20,399 --> 00:16:26,160
and i mean i i'd be curious to hear what

488
00:16:23,600 --> 00:16:29,279
richard and patty have to say because

489
00:16:26,160 --> 00:16:32,639
you know we in our personal roles

490
00:16:29,279 --> 00:16:34,399
as professors as a doctor

491
00:16:32,639 --> 00:16:36,079
you know we interact with people on a

492
00:16:34,399 --> 00:16:37,600
daily basis where we can educate

493
00:16:36,079 --> 00:16:40,160
them a little bit more about these types

494
00:16:37,600 --> 00:16:41,680
of issues and i think we all hope

495
00:16:40,160 --> 00:16:44,000
that people will then take what they've

496
00:16:41,680 --> 00:16:46,079
learned and then talk about it with

497
00:16:44,000 --> 00:16:47,920
with other people in their community i

498
00:16:46,079 --> 00:16:49,600
mean one challenge we have in

499
00:16:47,920 --> 00:16:51,519
with the social determinants of health

500
00:16:49,600 --> 00:16:53,680
is that some communities are just much

501
00:16:51,519 --> 00:16:54,800
better educated about these issues than

502
00:16:53,680 --> 00:16:57,199
others

503
00:16:54,800 --> 00:16:58,959
and even spreading the word about how

504
00:16:57,199 --> 00:17:00,800
important this issue is

505
00:16:58,959 --> 00:17:02,560
might inspire some families to make the

506
00:17:00,800 --> 00:17:04,079
renovations on their own if they can

507
00:17:02,560 --> 00:17:06,240
afford to do it

508
00:17:04,079 --> 00:17:08,559
and that would be a plus too if it's

509
00:17:06,240 --> 00:17:11,439
within their financial means

510
00:17:08,559 --> 00:17:13,439
yeah i would agree with that completely

511
00:17:11,439 --> 00:17:16,559
the big picture obviously

512
00:17:13,439 --> 00:17:19,679
is making it a medicare benefit but

513
00:17:16,559 --> 00:17:24,240
from a smaller

514
00:17:19,679 --> 00:17:27,439
scale we could consider education on the

515
00:17:24,240 --> 00:17:28,319
more local level including senior

516
00:17:27,439 --> 00:17:33,360
centers

517
00:17:28,319 --> 00:17:37,280
once they're up and running again

518
00:17:33,360 --> 00:17:40,880
or even uh considering

519
00:17:37,280 --> 00:17:43,520
a alternative payment

520
00:17:40,880 --> 00:17:46,480
system in medicare for example medicare

521
00:17:43,520 --> 00:17:50,080
advantage which is an hmo

522
00:17:46,480 --> 00:17:52,799
uh scheme for payment they have

523
00:17:50,080 --> 00:17:53,200
much less stringent requirements on

524
00:17:52,799 --> 00:17:56,720
their

525
00:17:53,200 --> 00:17:59,919
capitated fees and so they may actually

526
00:17:56,720 --> 00:18:01,200
consider putting in grab bars for their

527
00:17:59,919 --> 00:18:03,120
insurers without

528
00:18:01,200 --> 00:18:05,280
going through medicare was they're

529
00:18:03,120 --> 00:18:08,000
allowed to do that kind of thing

530
00:18:05,280 --> 00:18:10,000
so if we are thinking more broadly we

531
00:18:08,000 --> 00:18:12,880
should start thinking more locally

532
00:18:10,000 --> 00:18:13,760
can you explain cavitation briefly oh

533
00:18:12,880 --> 00:18:17,120
excuse me

534
00:18:13,760 --> 00:18:20,799
capitation is a system where an

535
00:18:17,120 --> 00:18:22,720
insurer will pay or

536
00:18:20,799 --> 00:18:24,640
in this case medicare will pay the

537
00:18:22,720 --> 00:18:27,039
insurer a top rate

538
00:18:24,640 --> 00:18:29,440
cover a patient for all of their medical

539
00:18:27,039 --> 00:18:32,960
needs regardless of how much that

540
00:18:29,440 --> 00:18:35,120
person actually costs so

541
00:18:32,960 --> 00:18:37,360
the idea is to pull resources among

542
00:18:35,120 --> 00:18:40,559
everybody in that

543
00:18:37,360 --> 00:18:43,440
hmo every patient and

544
00:18:40,559 --> 00:18:46,400
spend them according to to need rather

545
00:18:43,440 --> 00:18:50,480
than simple costs

546
00:18:46,400 --> 00:18:50,480
therefore they have many more

547
00:18:50,799 --> 00:18:54,960
what's the word they have much more

548
00:18:52,799 --> 00:18:55,360
leeway to do what they want with the

549
00:18:54,960 --> 00:18:57,679
money

550
00:18:55,360 --> 00:18:59,919
including population health and public

551
00:18:57,679 --> 00:19:03,200
health kind of measures

552
00:18:59,919 --> 00:19:04,480
like grab bars um whereas medicare would

553
00:19:03,200 --> 00:19:07,200
be much more stringent

554
00:19:04,480 --> 00:19:08,480
yeah so it's you just gave me an idea i

555
00:19:07,200 --> 00:19:10,559
didn't have before as we should be

556
00:19:08,480 --> 00:19:13,360
pitching this to hmos

557
00:19:10,559 --> 00:19:14,640
yeah we should be absolutely so patricia

558
00:19:13,360 --> 00:19:15,679
what you just mentioned that really

559
00:19:14,640 --> 00:19:17,240
resonated with me

560
00:19:15,679 --> 00:19:20,080
was not just thinking

561
00:19:17,240 --> 00:19:22,640
interdisciplinarily but also thinking

562
00:19:20,080 --> 00:19:24,320
so in the title of your study is

563
00:19:22,640 --> 00:19:25,919
breaking down silos to improve the

564
00:19:24,320 --> 00:19:27,600
health of older adults

565
00:19:25,919 --> 00:19:29,679
can you tell us a little bit about what

566
00:19:27,600 --> 00:19:31,679
it means to break down silos and why it

567
00:19:29,679 --> 00:19:34,320
is important to do so

568
00:19:31,679 --> 00:19:35,360
sure well the silo we were considering

569
00:19:34,320 --> 00:19:38,559
is the

570
00:19:35,360 --> 00:19:42,720
cost savings for medicare

571
00:19:38,559 --> 00:19:45,440
um would actually be

572
00:19:42,720 --> 00:19:45,760
so it caught it would cost uh somebody

573
00:19:45,440 --> 00:19:48,080
say

574
00:19:45,760 --> 00:19:48,960
in housing like in hud to put in grab

575
00:19:48,080 --> 00:19:51,520
bars if they're

576
00:19:48,960 --> 00:19:52,320
say building subsidized housing so the

577
00:19:51,520 --> 00:19:54,480
grab bar

578
00:19:52,320 --> 00:19:56,480
the cost would go to a hug but the

579
00:19:54,480 --> 00:19:58,880
benefit would go to medicare

580
00:19:56,480 --> 00:20:01,679
and so that's actually a financial silo

581
00:19:58,880 --> 00:20:04,159
that you can't overcome in government

582
00:20:01,679 --> 00:20:06,799
is hud doesn't really care if medicare

583
00:20:04,159 --> 00:20:10,000
saves money

584
00:20:06,799 --> 00:20:10,640
and and medicare is really not

585
00:20:10,000 --> 00:20:12,799
interested

586
00:20:10,640 --> 00:20:13,919
in getting into the home building

587
00:20:12,799 --> 00:20:16,400
business

588
00:20:13,919 --> 00:20:17,600
and so that silo there they would there

589
00:20:16,400 --> 00:20:21,120
would actually have to

590
00:20:17,600 --> 00:20:24,799
be some work among legislators to

591
00:20:21,120 --> 00:20:28,000
overcome that kind of financial silos so

592
00:20:24,799 --> 00:20:31,280
that we could actually implement change

593
00:20:28,000 --> 00:20:34,000
at the federal level

594
00:20:31,280 --> 00:20:36,640
there are other silos like the fact that

595
00:20:34,000 --> 00:20:39,520
working with um

596
00:20:36,640 --> 00:20:40,080
richard and tony meant that i had to

597
00:20:39,520 --> 00:20:43,120
look at

598
00:20:40,080 --> 00:20:45,440
statistics which i know how to do except

599
00:20:43,120 --> 00:20:48,080
our terminology is completely different

600
00:20:45,440 --> 00:20:49,520
so we could be running exactly the same

601
00:20:48,080 --> 00:20:51,600
calculations

602
00:20:49,520 --> 00:20:53,440
but my terminology was so different from

603
00:20:51,600 --> 00:20:54,720
theirs i had absolutely no idea what

604
00:20:53,440 --> 00:20:57,679
they were telling me

605
00:20:54,720 --> 00:20:59,200
and vice versa and and we've actually

606
00:20:57,679 --> 00:21:01,200
had to

607
00:20:59,200 --> 00:21:02,480
overcome some of that among the three of

608
00:21:01,200 --> 00:21:04,240
us

609
00:21:02,480 --> 00:21:06,000
well the other thing is from a standard

610
00:21:04,240 --> 00:21:08,559
of care standpoint

611
00:21:06,000 --> 00:21:10,320
is physicians tend to think too much in

612
00:21:08,559 --> 00:21:13,840
terms of silos sometimes

613
00:21:10,320 --> 00:21:15,840
is you know they are uh

614
00:21:13,840 --> 00:21:17,520
heart people and they don't think about

615
00:21:15,840 --> 00:21:20,000
the remainder of the body

616
00:21:17,520 --> 00:21:22,000
and and again this is not a criticism

617
00:21:20,000 --> 00:21:23,440
it's really really hard to be an expert

618
00:21:22,000 --> 00:21:27,360
on the heart

619
00:21:23,440 --> 00:21:29,200
it takes all of your intellectual power

620
00:21:27,360 --> 00:21:30,400
in order to be an expert on the heart

621
00:21:29,200 --> 00:21:32,480
but nevertheless you

622
00:21:30,400 --> 00:21:33,919
become so focused on the heart that then

623
00:21:32,480 --> 00:21:36,320
you forget about

624
00:21:33,919 --> 00:21:37,840
maybe other parts of the body and

625
00:21:36,320 --> 00:21:40,960
similarly

626
00:21:37,840 --> 00:21:43,280
physicians can look at patients as

627
00:21:40,960 --> 00:21:44,640
just people who show up on their in

628
00:21:43,280 --> 00:21:48,799
their offices

629
00:21:44,640 --> 00:21:51,679
or at the hospital whereas medicine

630
00:21:48,799 --> 00:21:53,440
say i'm queuing you up patty on this

631
00:21:51,679 --> 00:21:54,880
understanding the context in which

632
00:21:53,440 --> 00:21:56,640
people live is important to practice

633
00:21:54,880 --> 00:21:59,679
some good medicine right

634
00:21:56,640 --> 00:22:02,720
yes yes that's the yes

635
00:21:59,679 --> 00:22:06,000
the average cardiologist or

636
00:22:02,720 --> 00:22:08,000
cardiothoracic surgeon is

637
00:22:06,000 --> 00:22:09,600
sometimes unaware of the social

638
00:22:08,000 --> 00:22:11,039
determinants of health that we have been

639
00:22:09,600 --> 00:22:13,760
talking about today

640
00:22:11,039 --> 00:22:15,200
uh that that cardiologist may say wow if

641
00:22:13,760 --> 00:22:16,320
you fall again you're gonna have another

642
00:22:15,200 --> 00:22:18,880
heart attack but

643
00:22:16,320 --> 00:22:20,400
and has absolutely no idea how to

644
00:22:18,880 --> 00:22:23,600
implement change that would

645
00:22:20,400 --> 00:22:26,159
reduce the risk of falls

646
00:22:23,600 --> 00:22:27,200
so there are silos within medication in

647
00:22:26,159 --> 00:22:28,480
medicine as well

648
00:22:27,200 --> 00:22:30,640
yeah i always loved the story michael

649
00:22:28,480 --> 00:22:32,400
marmot who's who was one of the pioneers

650
00:22:30,640 --> 00:22:34,640
in social determinants of health who's a

651
00:22:32,400 --> 00:22:36,000
british epidemiologist talked about

652
00:22:34,640 --> 00:22:38,400
years ago

653
00:22:36,000 --> 00:22:40,080
before anybody was talking about this

654
00:22:38,400 --> 00:22:40,799
you know he's in the hospital they're

655
00:22:40,080 --> 00:22:43,760
treating

656
00:22:40,799 --> 00:22:44,799
a patient who had a heart attack and

657
00:22:43,760 --> 00:22:47,760
they they treated

658
00:22:44,799 --> 00:22:49,600
the man and then they sent him home and

659
00:22:47,760 --> 00:22:51,600
he realized i'm sending this person

660
00:22:49,600 --> 00:22:52,880
right back to the exact circumstances

661
00:22:51,600 --> 00:22:54,720
that caused the heart attack

662
00:22:52,880 --> 00:22:57,200
he's not going to change anything about

663
00:22:54,720 --> 00:22:59,280
his behaviors he's not going to change

664
00:22:57,200 --> 00:23:01,440
anything about his environment

665
00:22:59,280 --> 00:23:02,799
and so what good am i really doing i

666
00:23:01,440 --> 00:23:04,240
saved him today but

667
00:23:02,799 --> 00:23:06,000
shouldn't i be also thinking about

668
00:23:04,240 --> 00:23:07,760
saving him tomorrow and the next day and

669
00:23:06,000 --> 00:23:09,600
preventing down the line

670
00:23:07,760 --> 00:23:11,200
and so you know part of the silo is just

671
00:23:09,600 --> 00:23:12,880
what's happening inside your office

672
00:23:11,200 --> 00:23:14,400
which happens to all of us

673
00:23:12,880 --> 00:23:16,080
and trying to understand how the role

674
00:23:14,400 --> 00:23:17,360
that we're playing connects to the role

675
00:23:16,080 --> 00:23:18,720
that other people are playing

676
00:23:17,360 --> 00:23:20,640
i mean one of the things that was fun

677
00:23:18,720 --> 00:23:22,159
for me about this project was working

678
00:23:20,640 --> 00:23:24,320
with dr harris i

679
00:23:22,159 --> 00:23:25,280
you know that that's not a silo that we

680
00:23:24,320 --> 00:23:26,559
usually break down

681
00:23:25,280 --> 00:23:28,720
i learned a lot just from that

682
00:23:26,559 --> 00:23:29,120
collaboration see it from her point of

683
00:23:28,720 --> 00:23:31,520
view

684
00:23:29,120 --> 00:23:33,120
very interesting do you have anything

685
00:23:31,520 --> 00:23:34,960
else that you would like to make sure

686
00:23:33,120 --> 00:23:35,600
that we touch on before we wrap up for

687
00:23:34,960 --> 00:23:37,760
today

688
00:23:35,600 --> 00:23:39,200
i guess i'd like to ask patty one more

689
00:23:37,760 --> 00:23:41,120
question that occurred to me as we were

690
00:23:39,200 --> 00:23:43,039
having this conversation

691
00:23:41,120 --> 00:23:46,480
and if this is awkward i'm sure you have

692
00:23:43,039 --> 00:23:46,480
people jonathan editor

693
00:23:46,880 --> 00:23:50,480
you know on the political stuff since

694
00:23:48,640 --> 00:23:53,919
you're involved with

695
00:23:50,480 --> 00:23:55,600
um organizations that advocate for

696
00:23:53,919 --> 00:23:57,440
health care and particularly general

697
00:23:55,600 --> 00:23:58,480
internal medicine and geriatrics and so

698
00:23:57,440 --> 00:24:00,240
on

699
00:23:58,480 --> 00:24:01,760
do you think this would be a priority

700
00:24:00,240 --> 00:24:02,720
for any of the groups that you're

701
00:24:01,760 --> 00:24:05,760
involved with

702
00:24:02,720 --> 00:24:07,760
or are they so caught up in other issues

703
00:24:05,760 --> 00:24:09,120
that they would not make this a

704
00:24:07,760 --> 00:24:12,559
legislative priority

705
00:24:09,120 --> 00:24:15,120
that is a very good question

706
00:24:12,559 --> 00:24:17,679
i think that we have all been beaten

707
00:24:15,120 --> 00:24:21,039
down by the last year and are just

708
00:24:17,679 --> 00:24:23,200
now kind of coming back

709
00:24:21,039 --> 00:24:24,320
up and trying to figure out what our

710
00:24:23,200 --> 00:24:27,360
priorities

711
00:24:24,320 --> 00:24:29,760
are i my guess is

712
00:24:27,360 --> 00:24:32,480
not this year there's enough to do this

713
00:24:29,760 --> 00:24:34,720
here but perhaps in a year or two

714
00:24:32,480 --> 00:24:35,919
it might be an issue that they would

715
00:24:34,720 --> 00:24:37,600
address

716
00:24:35,919 --> 00:24:40,000
the other thing is sometimes all you

717
00:24:37,600 --> 00:24:43,360
need is a legislative advocate

718
00:24:40,000 --> 00:24:45,279
so for example if we could find a

719
00:24:43,360 --> 00:24:47,840
member of the appropriate committee

720
00:24:45,279 --> 00:24:50,240
whose parents both fell and broke a hip

721
00:24:47,840 --> 00:24:52,320
recently

722
00:24:50,240 --> 00:24:53,760
they'd get all on top of the grab bar

723
00:24:52,320 --> 00:24:56,320
and rush it through

724
00:24:53,760 --> 00:24:57,679
so um maybe we should read the gossip

725
00:24:56,320 --> 00:24:59,360
columns more often

726
00:24:57,679 --> 00:25:00,960
does she does it need to be both parents

727
00:24:59,360 --> 00:25:01,919
or would one parent be good enough do

728
00:25:00,960 --> 00:25:04,880
you think

729
00:25:01,919 --> 00:25:04,880
that's a good question

730
00:25:08,080 --> 00:25:12,159
but seriously you know advocacy is is

731
00:25:11,200 --> 00:25:14,880
all personal

732
00:25:12,159 --> 00:25:17,600
right you find the personal angle and

733
00:25:14,880 --> 00:25:19,760
perhaps we could take this further

734
00:25:17,600 --> 00:25:21,600
but without that personal angle it's

735
00:25:19,760 --> 00:25:23,760
going to be slower on the

736
00:25:21,600 --> 00:25:25,039
priority list right now yeah i think you

737
00:25:23,760 --> 00:25:26,559
know you mentioned the

738
00:25:25,039 --> 00:25:28,480
the difficulties of the past year

739
00:25:26,559 --> 00:25:30,320
weighing on this in some ways

740
00:25:28,480 --> 00:25:31,760
i think that could be an inspiration

741
00:25:30,320 --> 00:25:34,159
because if

742
00:25:31,760 --> 00:25:35,760
one thing that has become pretty clear

743
00:25:34,159 --> 00:25:37,760
to all of us in the last year

744
00:25:35,760 --> 00:25:39,120
is the importance of feeling safe in

745
00:25:37,760 --> 00:25:41,120
your own home

746
00:25:39,120 --> 00:25:43,279
and the importance of especially for

747
00:25:41,120 --> 00:25:46,159
older adults feeling like they have a

748
00:25:43,279 --> 00:25:48,320
safe place to age in place

749
00:25:46,159 --> 00:25:49,840
so that they won't be institutionalized

750
00:25:48,320 --> 00:25:51,520
prematurely and they

751
00:25:49,840 --> 00:25:53,480
they you know during a time like a

752
00:25:51,520 --> 00:25:56,240
pandemic it's becoming

753
00:25:53,480 --> 00:25:58,400
increasingly obvious um

754
00:25:56,240 --> 00:26:00,240
how important that is to our society to

755
00:25:58,400 --> 00:26:00,960
allow people to have that option if they

756
00:26:00,240 --> 00:26:03,840
can

757
00:26:00,960 --> 00:26:06,320
and that might just add an extra reason

758
00:26:03,840 --> 00:26:09,360
for people to care about this

759
00:26:06,320 --> 00:26:12,559
true absolutely well thank you so much

760
00:26:09,360 --> 00:26:15,279
for your time and for writing this

761
00:26:12,559 --> 00:26:16,240
really brilliant paper i encourage all

762
00:26:15,279 --> 00:26:18,480
of our listeners

763
00:26:16,240 --> 00:26:20,080
to read the whole the whole paper which

764
00:26:18,480 --> 00:26:22,240
will be linked with the summary on the

765
00:26:20,080 --> 00:26:24,640
bedrosian center website

766
00:26:22,240 --> 00:26:25,600
it's not very long either so it is not

767
00:26:24,640 --> 00:26:27,840
very long

768
00:26:25,600 --> 00:26:29,679
i think it is the most accessible

769
00:26:27,840 --> 00:26:32,400
academic paper i've ever read

770
00:26:29,679 --> 00:26:34,159
it is succinct it is clear and it is a

771
00:26:32,400 --> 00:26:37,360
really important issue

772
00:26:34,159 --> 00:26:39,440
so thank you all and i

773
00:26:37,360 --> 00:26:41,120
am honored to have had the opportunity

774
00:26:39,440 --> 00:26:42,480
to talk to you today

775
00:26:41,120 --> 00:26:44,400
thank you for listening to the bigger

776
00:26:42,480 --> 00:26:45,679
picture for links of some of the things

777
00:26:44,400 --> 00:26:49,919
we talked about today

778
00:26:45,679 --> 00:26:52,159
visit our show page bedrosian.usc.edu

779
00:26:49,919 --> 00:26:54,000
big picture and if you have more

780
00:26:52,159 --> 00:26:55,279
questions for our speakers or topic

781
00:26:54,000 --> 00:26:57,679
topics you'd like to cover

782
00:26:55,279 --> 00:26:59,440
let us know check out our website social

783
00:26:57,679 --> 00:27:01,360
media or even email us

784
00:26:59,440 --> 00:27:02,880
subscribe on your favorite podcast app

785
00:27:01,360 --> 00:27:03,919
and leave a review so other people can

786
00:27:02,880 --> 00:27:05,679
find us

787
00:27:03,919 --> 00:27:06,799
until we catch up again we hope that you

788
00:27:05,679 --> 00:27:08,559
will take care of yourself and your

789
00:27:06,799 --> 00:27:09,919
neighbors from all of us at the usc

790
00:27:08,559 --> 00:27:17,279
bedrosian center

791
00:27:09,919 --> 00:27:17,279
thank you

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