vision led to expanded drug treatment programs improved immunization compliance a wide range of extremely effective lead poisoning prevention initiatives juvenile violence prevention and the creation of a statewide initiative for universal health coverage in maryland called health care for all he's also the founder of the evergreen project an initiative that was inspired by a provision of the two thousand and ten patient affordable and protection affordable care act also known as obamacare and seeks to create health care co-ops to cut costs to both patients and providers while making sure that excellent health care is available to communities dr bill and was chosen as a visionary in two thousand and eleven joining a distinguished list of individuals who as described by editors of the publication are world visionaries who don't just concoct great ideas but also act out to be able to receive his undergraduate degree from harvard university his medical degree from emory university's school of medicine and holds a master's in public health and john hopkins johns hopkins university bloomberg school of public health insurance and so on and have you here it's an honor to be

here thanks for joining us. there's so many different places to start i can't can we start with the evergreen project and then work backwards to what is the evergreen project it's basically a health cooperative that's enabled each to each state is i'm able to have one health care cooperative a nonprofit health insurance cooperative which is a mouthful we'll talk about what it actually is but under the affordable care act as you may remember when the compromising was going on back in two thousand and ten in late two thousand and nine there was a public option which is sort of mini single payer that was in the original bill and fell out in sort of as a sop to liberals if you will senator kent conrad introduced a small section of the bill that allows for these nonprofit co-ops in each state so that's what we're trying to do in the state of maryland so you can have so each state could have basically want correct that's interesting and you can go right across the state. we were talking a little earlier before we came on the other you had run for congress once and and you. you see actually political solutions in some cases and some of these public

health issues yeah i do and i ran for congress against the iraq war and actually this was in two thousand and six actually for health care reform at the time obviously president bush was the president and when we now have health care reform i very much believe in the well stone approach to the world senator paul wellstone as you obviously know was a real progressive fellow and he actually proposed this in health but it could be used in education policy in all sorts of other arenas and that is to have the federal government be the kickstarter give subsidies to states to be the incubators of change rather than imposing a top down approach as the obama plan is which it's better than nothing without question but i think a single top down approach doesn't really work and this is not states' rights this is that each state is quite different and so the federal government provides funding to let's say ten or twelve states to try to reach universal coverage and the health care world and you can do it different ways of mississippi wants to do health savings accounts i don't think that's going to work but if they meet the

guidelines of ninety nine percent coverage and are well evaluated then the states become the incubators of change and so what ends up happening is you don't have these ridiculous bumper sticker mentality death panel type complaints or charges why because you've had a five year history of several states trying different things maybe a single payer in vermont maybe a romney care in massachusetts maybe a plan like our co-op in maryland and mississippi health savings account and so you have five years of evaluation experience on how it affects providers patients and outcomes and so these death panel things don't stick because you actually have experience to be able to say five years down the road no republicans in this case don't throw this death panel stuff at us in fact seniors and are doing much better under this x. type of proposal and maybe now it can be taken regionally internationally and that's the whole well stone approach that i believe in that's fasting you know senator bernie sanders on my radio show is a guest every friday and has been for. seven years now and i was startled

a few years back when the medicare part d. for everybody you know the national single payer health care system. actually started being discussed and i had bernie on the air and he said he said that would be my first choice and i was really going to why not he said i think i think it will work better at the state level you know this is what saskatchewan did and it then went across each one of the provinces in canada in fact there's still provincial systems it's not a national it's not a federal system and i believe switzerland does the same thing and it's cantons and there's other countries in the o.e.c.d. countries i mean to put an even more personal broader perspective worldwide the thirty most developed countries for lack of a better term but i think with turkey and mexico and being the only ones that don't have universal coverage and how states do how countries do it are different but you're absolutely right about canada and that's basically the idea here again the federal government has a role in subsidizing with the true subsidies so it kickstarts states to be able to

do these things and it could be education reform and it set up for example no child left behind done at the national level and it granted states have to do specific things have states try different education reforms again helpful help by subsidies from the feds with an evaluation based and so that five years later you can may find out that x. works better than anything else and maybe that gets taken immediately internationally instead of the other way around or the states just continue to administer it on it with a little help there you know if it's a problem of west virginia just doesn't have the money right and massachusetts does for example. that's that's fascinating what is fee for services in health care and what's wrong with fee for service is this perverse incentive to do more and test more and do more procedures because you get paid a fee for every service this is how things work right this is how things work in the united states of america and there are very very few programs and insurances insurance companies insurance policies that do things on a. salary basis and i grew up in california. kaiser of california is one of the few

places that does that work docs and and nurse practitioners were salaried and the idea is that they are less like they're more likely to do what's actually medically necessary and less likely to do excess tests sooner or later epidemic too isn't yes there are several very good places that are well known that do that but the vast majority of american medicine isn't fee for service world how could it be that. that americans can look at the mayo clinic and which has been around for years and years doing this not be for services or look at kaiser permanente we got is as has this incredible success record rate and lower cost than what we've got can look at this and not go wow look at this we should be doing this i mean republican democrat set aside the politics are there what are the forces that are keeping things broke the forces that are keeping things broken are the fact that we don't have public financing of campaigns you may be saying you wouldn't say this but people may be saying what in the world is that to do with what you're talking about and the answer is very simple let me take one step basher i ran for congress in two

thousand and six ran in a very competitive eight person race lost to the eventual winner a guy came in second he was a u.s. senator son a very good fellow. and came pretty close i spent fifteen months five hours a day five days a week calling to raise money and we didn't get any pac money special interest money what the average congressman or senator does to raise millions and millions of dollars is get money from pacs and special interests and the answer to your question is the pharmaceutical industry's care about fee for service why because each prescriptions and medications in the hospitals get billed on an individual basis hospitals so see asians big business big special interest vendors the a.m.a. to some extent you name it the big industries are. chipping in a lot of money to the decision makers and that's hate to sound cynical in my relatively young age although i'm not that young anymore but that's it is this very simple answer is the same reason the tea party people are going against their best interest economic. interesting because the big money interests who are funding them

are pushing their agenda so so we have the drug companies we have the for profit profit hospitals we've got the ways i guess that some doctors offices and practices are set up simply because that's the only option that's available to them and much of this is being driven or at least being perpetuated by the structure of the system which is defined politically and that's being defined because politicians are having to dance to the tune of big pharma and you know i mean jernigan sure i mean it hasn't and you know clearly the fact that we didn't even come close to a single payer or even the many public option in the bill is very much related to the health insurance companies in america. by the way we see the. massachusetts i guess has a preexisting waiver because they have romney care for model is trying to get a waiver montana i believe it is trying to get a waiver now so why you had one so they can do single payer and i'm not familiar

with the why and system but. does it look like that's going to happen is that maybe a first step or will this this evergreen project that you're working on we're obviate the need for that we're hoping that there i mean not to sound selfish. or organizationally aggrandizing but we certainly hope that the way but we're told when i think we'll talk about the way we're planning on doing the co-op is exactly the way it is exactly that don't approach try something at the regional state level and get babbitt well evaluated we work with hopkins and university of maryland researchers all the time and we'll be doing so for this and hopefully show after five years that this is a better mousetrap if you will or better rattrap right create some met some metrics for right and go with it you you said this is an attempt to make a cultural change to actually go from where doctors insurance companies and patients are operating the system with separate interests to put in them all on the same side that's a way of saying i guess flipping fee for service is upside down that. and and also

by providing wellness services and i think we'll get to talking about what's in it and primary care and primary care and by prioritizing primary care and wellness services and having the insurance company benefit from those services down the road by giving by giving retention bonuses if you will to our members then the insurance company makes money by having cheaper patients if you will healthier patients and the patients do better with a problem now is the average american stays two and one half years two and a half years in a given policy so if you look at it from the insurance company's perspective it makes no sense at all to provide health and wellness services or cigarettes or smoking cessation classes because the money saved and less smoking lung cancer or heart disease is fifteen years down the road on someone else's dime so it makes sense my mom used to do insurance work for an insurance company to set up as many barriers as possible because they're trying not to pay out anything because they're

not saving money down the road. and and you know fundamentally we need to fix this . the you talked about the as these three pillars. of well actually let's we have just maybe two minutes before the break we can start getting into and then after the break we'll get into the depth of the evergreen project what how did first of all how did this come about this project just came about in looking at the legislation and how we hoped it would have come out as we. were writing of sort of brain trust people myself and a few other folks that i worked with a healthy howard particularly. which is our sort of prototype for this and we so that's where the pillars came from and they are primary care medical home model which sounds. technical and everybody talks about now basically where almost all of your care is at the primary care level with your doctor or nurse practitioners who are really really knows you it's kind of old time medicine family with electronic

company connections second is getting rid of fee for service completely salaried providers which we can talk about and third is using evidence based practices help medicine is both a science and an art but there's plenty of science behind it and we're doing too many things that are not cost effective or don't work at all again because of fee for service there's a book i interviewed the author recently called all over diagnosed and he was he was pointing out. a whole variety of things that the of various types of diseases that i thought were the most startling once it was prostate cancer and in fact since that book can't come out now practices are changing work while you're looking at diagnoses and then you look at deaths and it's like you know no change and so. evidence based medicine is it's those are some of the protocols that we'll be using and and where do you get that information. you aggregated yes what we won't be creating it ourselves will be using them where there is meant analysis multiple

analyses of of a given condition and what kind of care should be given for that condition there. for example preventive services the u.s. preventive and u.s. preventive services task force is a well respected group that puts out these kinds of guidelines on when you do. testing so that is that is that a government agency that is a government agency that's interesting so so that would be one of the few agencies or one of the for group few groups that actually has an incentive to to have best practices yes opposed to all the disincentives that exist in the system yes and so it is one of them and that's and it's actually done a pretty good job and you know when the government brought in medicare and things like that so there's a little bit you have to single payer is that work pretty darn well in this country medicare and the v.a. yeah you're absolutely right perhaps it will be back with more conversations with great minds with dr peter b. and just of all. drives the world the fear mongering used by politicians who makes decisions it's

going to break through it's already been made who can you trust no one who is human view with a global missionary see where we had a state controlled capitalism is called sasha when nobody dares to ask we do our t. question more. welcome back to conversations with great minds tonight and speaking with dr peter

peel ansen the health officer in howard county maryland health excuse me howard county maryland and the founder of the evergreen project dr. the evergreen project what is this going to look let's say that i'm a client what does it look like to me you know where i was based on three pillars primary care medical home which will be located in predominately working class neighborhoods very neighborhood based what we call in them team let's there are smaller than the typical practice. and they'll for every ten of these in the region for example inside the baltimore beltway or be our first region for every ten of those will be regional specialty center work specialists will be located tele medically commit connected so that most of the specialist referrals will actually be done by telemedicine by skype for lack of a better term right to the customer home to the paid no to the primary care site to the primary care center. it will be everybody salaried so the specialists aren't interested in doing extra procedures the primary care doc isn't interested in doing

things that are not medically necessary or using evidence based practice is where they exist but the easiest way to do this is to explain from the patient's perspective so in the current health care system what we have in united states without exception and i should mention i was on a radio show in baltimore maybe a couple months ago and i said before i started talking about this because i use a cardiology example i don't want to just my cardiology friends and i'll tell you what the hop in the head of poppins cardiology said at the end of this so i'm fifty one years old some chest pain it goes away with exertion and exercise so it's probably not hard it's probably reflux and i come to see dr tom my primary care doc who has three thousand patients a typical patient panel you know me a little bit you do an e.k.g. right. you are you talk to me you think it's reflux which could be covered by over the counter privacy for example but you can get a cardiology console which is not outrageous considering i'm fifty one and my grandpa died in fifty six of heart attack so you can give me three names of

a cardiologist say it's not urgent but you should be seen in the few weeks so i go off on my own and let's say i am compliant which money patients aren't but i am and i find cardiologist dr hartman. dr hartman sees me does an e.k.g. duplicative not hugely expensive but you multiply that by millions of times a year fee for service and it adds up he's going to and he's going to unquestionably do a stress test much more now than in the past twenty years because now they do stress tests at doctors' offices in the cardiologist's office fee for service and they have a cardiology office visit so the cardiologist is paid for reading the k.g. being the stress test and the cardiologist office visit. she dr hartmann let's say decide this is probably reflux and so then decides to do what. everybody in my audience everybody that i ever talked with has sent him to a g.i. doc but let's say this let's just say doctors are all right it's over in docility or stomach acid right but let's say dr hartman sensible and sends me back to

primary care doc dr tom three weeks later i'm back with dr tom and you maybe have gotten a note from dr hartman maybe not that says thank you for saying peter beyond saying he doesn't have heart problems working out so you put me on over the counter prosecco what is what is that happened what has happened six weeks have gone by without me being treated for my symptoms it's inconvenient for me i've had to make appointments go visit wait three weeks and then wait three weeks again you have not had a primary care home model because you don't really know what's going on with me and and especially for all that you did. note and by the way it's pretty darn expensive yeah right and duplicate it so how would the co-op work and this is prototyping and starting in about three more months i come to see dr tom my primary care doc you have fifteen hundred patients why because what's been proven in group health the puget sound for example one of these good guy medical systems in washington state that the docs like it better patients like it better and you have better outcomes so we're not rewarding our docs and our providers for numbers of patients seen

because that's not going to them healthier but for they will be paid team bonuses everybody from the front office to office staff to the front to the doc for gabbing keep keeping their hypertensive their high blood pressure patients in their diabetics under control so you you actually do know me healthy keeping people healthy that's something unique so you see me you know me a bit as a hypochondriacal doctor because you've seen me a few times and have a small patient panel but my grandpa did die at fifty six of a heart attack and i have the same complaint so you do an e.k.g. . you then go on line because we're completely electronically tied and remember our specialists are salaried and work for us and the docs the primary care docs only work for us and only see co-op patients and caught patients only see our docs so it's a closed system. you go online for dr hartman dr hartman in downtown regional specialty center has time in half an hour has a fifteen minute block of time for a teleconference so you then send in the health coach who is our wellness coach who

has nutrition training and physical activity training to talk to me while you go see another patient what does she talk to me about she talks to me about preventing reflux getting reflux in the first place by going the gas is going to get it going office by eating what kind of food you should be looking at how you shouldn't sleep lying down posture etc etc twenty five minutes go by you come back in after having seen a patient we go online and it's sort of a super skype you know computer screen you present the case you've already electronically sent my e.k.g. so that does not need to be done again dr hartmann in the other especially center is looking at all this and asked me a few more probing questions and let's say dr hartmann talks to technically and to scientifically but you're there to instead of me just nodding like when i'm listening and i have no idea what the cardiologist to saying you're talking you're here you're talking with me. so ten percent of the time dr hartman the cardiologist is going to say it's sound squirrely i think maybe you should come in and get a stress test but ninety percent of the time she's going to say this is reflux dr

tom we're come up nice seeing you good job and so what does that mean a completely primary care medical home with continuity of care you know real time what's going on with your patient and what happened with the specialist. or the family doc was basically in the room with this is in and the beige actually right all together it obviously is much much less expensive because you boy did any unnecessary testing including the duplicated e.k.g. it's very convenient for the patient and by the way my symptoms were treated right at that time and even more importantly we've done prevention with a health coach talking about well how to prevent this from happening the future and that's the goal of our actuary we raised three hundred fifty thousand dollars for studies for the first year and a half that we've been planning this the actuaries show that will hopefully save about thirty percent compared to the major employer major policy major insurance companies offerings in maryland and we're waiting now for a federal decision on very low interest loans as part of the affordable care act that we'll hear about in about

a month as to where they'll be going forward with it you said that one of your college cardiologist friends had a kind of thinking is so i got back to after i gave this similar talk on the local n.p.r. i got back to my office and there was an e-mail from the head of cardiology at hopkins and so i went away on reading this and three hours later i got my courage up and opened it and he said you were under estimating how bad the system is this is why i got out of fee for service medicine it's outrageous this is what you're talking about is exactly the way to go and so you feel good that's great so. you're actually putting this thing together this is this evergreen project and the . and it will work in the context basically of a for profit system because it's being funded by the health insurance companies. or not you know you're not billing the health insurance companies and it wasn't so you're just cutting them out of the equation because we are our own insurance company so it has as your customer do i pay you a monthly fee gas you are

a member is a co-op you go ok let's talk about let's talk about co-ops that most states are or perhaps it's a minority of states but many states don't even provide for co-ops as a form of incorporation eric and there's a new one under the i.r.s. that's actually so new it's a five a one c. twenty nine for those who work in the nonprofit world a no five the ones in threes we can't even applied to be a new co-op nonprofit until the i.r.s. promulgated its final regulations shortly that will allow for this new status but yes that will exist ok and it does exist right now in maryland or maryland recognizes that quote maryland recognizes us as a applying for nonprofit status because it will be and we can start sees me starting we can't start until january one of two thousand and fourteen officially but by the affordable care act's so we have a year and a pretty your two years thing together so. so it's a member own to cooperate it's not a it's not a co-op that's owned by the doctors it's owned by the member so it's work around.

with the board so that up a member so it's more like a like a health food co-op where the customers own the co-op as opposed to like the union cab company in correct in madison wisconsin where only the drivers are the members of the customers are not that's correct that's us fascinated and. as a co-op how housing government is governed by a majority co-op member board and we certainly are encouraging and has read all the patients hardliner up here we have written our byelaws such that the nominating committee will hopefully pick people who are who are members who are thoughtful and and have some knowledge of the of the health care field but it's yes it's a co-op it's a majority co-op member. majority co-op member board along. my wife and i visited in spain for a chapter for one of my books co-ops and i've seen the world's largest and that's really quite remarkable i mean it's the in and in the the c.e.o.

makes three times what the janitors are you envisioning that sort of leveling of i can tell you without any of the our proprietary that our top seller our c.e.o. salary would be probably four times a janitor salary no actually maybe a third maybe three times three or four times more for them and and and. your guess senior year you know that there are people who will jump out of fee for services into this because while they're voting for the i don't see during the secret i don't wanna get too technical but the way the affordable care act is written for those who are individually insured or uninsured and can't buy anything but individual insurance which is too expensive currently or in small businesses and our who are not insured will be able to join in exchange the travelocity of health care i call it where you basically get market leverage by being brought on to this exchange of multiple individuals and multiple small businesses and you get a federal tax subsidy

a federal subsidy for the premium if you make between let's say twenty eight thousand for a family of four sounds like a decent amount however for that family of four making three hundred percent of poverty sixty six thousand a year well up the scale they'll still have to pay at least sixty five hundred dollars never seeing a doctor with the subsidies and with the exchange added an already added in that is simply going to be on affordable paying twelve fourteen percent of your take home pay so our our mission is to serve currently currently middle working class families who can't afford health care now and probably won't be able to afford it under the health care reform bill but would be put over this will be held up with this stick of an individual mandate that if they don't buy insurance they're going to have to pay a penalty on their taxes and they're not i so we are the cheaper option that we think frankly is not only cheaper but much better health care provide better services this is. this is absolutely horrible and you said that each state can have one so in the minute that we have left here yes how what's your advice to people

who might be watching this in other states about how they could set something up like what you do think big don't just do a purchasing co-op which a lot of the co-ops around the country are doing they're doing the typical midwestern farmer purchasing co-op where they purchase insurance for their cooperate members but they don't have a system that is generating healthier. more productive citizens like ours we think will do right here is. sensually reinventing the mayo clinic but nothing whatever you're doing it in by itself is unique putting the whole thing together is you need that's workable dr bills and thanks so much for being with us you for having a great it's a pleasure and an honor having you here with us to learn dr peter builds on that to learn more about the evergreen project you can log on to evergreen dot org and to watch this conversation again as well as other conversations of great minds check out our website conversations with great minds dot com. as the big picture for tonight for more information on the stories we covered visit our web sites at thom

hartmann dot com free speech dot org and. also check out our two you tube channels there are going over the top part of. this entire show is also available as a free video podcast on i tunes and we have a free tom hartman i phone or i pad app in the app store he sent us feedback at twitter of tom underscore our facebook underscore our blogs message boards and telephone comment line at thom hartmann dot com and don't forget the mock receive begins when you start participating when you get active when you see things like this interview and say wow you know we could stuff we could start something like that in our state let's put together a co-op let's let's make something happen so get out there and get active show up participate tag your it occupy so we'll see you next week.

it is the elite. elite. it's. awful.