 Today, I am simply delighted that Dr. Gerard Clancy has been able to come up from Tulsa, Oklahoma, to join us for the Disparity Seminar. I don't know where to begin, whether to begin with Dr. Clancy and his interesting background, or to begin with his current role. I think I'm going to begin with his current role, which is President and Dean of the Oklahoma University College of Medicine in Tulsa. It actually has a new name since 2008. It's called Oklahoma University School of Community Medicine, and that school has now enrolled its third class of students, thus far 40 students to a class. It's quite an unusual school, probably the first of its kind in the nation, which has an explicit purpose. Its mission is to improve the health status of underserved Oklahoma communities, both rural and urban. There is no medical school in the country, so far as I know, that has that as its primary mission and focus. To do that, it hopes to build a community that will improve the health of individuals and of their communities through learning and research and collaboration, and to educate a whole generation of new practitioners with these kinds of community-based and individual skills. Listen to some of the things that this new school does. For example, it recruits students nationally, I should say, not just Oklahomans, but it's a national recruitment. It charges no cost for any courses related to public health care, which is interesting in itself. But for those courses that it does charge for, which is to say for medical education, it provides educational grants and forgiveness for service such that students can leave medical school and essentially discharge their indebtedness. I learned only last evening what the cost of medical education is today, that is these days, at the University of Chicago. Four years of medical education in Chicago, this is tuition plus living expenses. Does anybody want to hazard a guess? How much? 300,000. 300,000. And the average indebtedness of our students coming out, I'm told, is between 170 and $180,000. So to think of a class of students coming out who can discharge their debts, it all comes from an extraordinary endowment from George Kaiser and his foundation, who's a local philanthropist in Tulsa that is provided to the students at the University. Mr. Kaiser has, as his commitments, early childhood education, health care, developing a safety net for Oklahomans, and community betterment, and this is part of his health care investment. So it's an extraordinary school, it has, as it's seen, an extraordinary man in Dr. Clancy whose training was largely at the University of Iowa in psychiatry, whose research interests have included the delivery of psychiatric services at the community level to the seriously mentally ill and disease management in behavioral and mental health at the community level. In Iowa City, he was known as, his program was known as psych on a bike. He and his students and residents would ride around on bicycles to find the homeless people of Iowa City, Iowa City has homeless people, and to provide mental health services and medication on site, which is to say in the homeless areas where people lived. He's working these days on changing the medical curriculum, changing clinical teaching experiences, such that both students and residents will develop the additional skills needed to provide health to communities, in addition to providing, as I say, health to individuals. Dr. Clancy has won many awards for his work, including seven distinguished teaching awards. Just yesterday in his new role, quite a new role, as the new chair-elect of the Chamber of Commerce of the City of Tulsa, Dr. Clancy had the opportunity to spend three hours with the recently elected governor of the state of Oklahoma. Her name is Mary Fallon. I expect that most of us here don't know very much about Governor Fallon, except to say that she is among the most conservative people elected in this last election cycle. And Oklahoma was one of the few states that had a state question on the ballot, and the state question was, should Oklahoma opt out of Obamacare and receive 70 percent positives to that question? So the three-hour meeting yesterday with the governor in the light of her own conservative views, as well as this recent state question that was posed, was a challenging meeting to develop resources from the state to support the kind of missions that I've talked to you about, missions of alleviating disparities at the individual and community level. Well, Dr. Clancy has his work cut out for him. Today he will talk to us about health disparities in Oklahoma, it's time for community medicine, and we'll also tell us about his work at the new medical school. Remember, this is not an amplifying microphone, but a recording microphone, so as in the question and answer session, please try to have this in hand as you pose your questions. It's a great pleasure to welcome Dr. Clancy to Chicago. Thanks, Jerry. Thank you for having me. I've had the pleasure of working with the University of Chicago now for the past year. I've gotten to know Eric and Sarah Ann and Dorianne, it's been a great pleasure. We were hosted here about last year at this time, and then we've had two conferences together, one in Tulsa, now one in Miami, and what I'm happy to say is we're all like-minded. It's as if the schools that we're working on, these types of initiatives, we've been working together for many years. Well, the name of this talk is democratization of health advantages in America, taking it to the streets, and this is the Doobie Brothers taking it to the streets album, the first album that I bought in 1977. When I bought that album, I was a dishwasher at Howard Johnson's, the music came on, and listen to this, I rode my bike downtown, cashed my check, and bought an album. None of those things we do anymore. It's just a sign. The students have no idea what we're talking about. So I'm going to give you a somewhat of a tour of Oklahoma as well as a tour of medical education and health care services delivery over the time period, but I need to introduce you a little bit to Oklahoma. So, welcome to Oklahoma, we're ranked 49th in health, and this is at the state fair where they had the donut burger, two Krispy Kreme donuts with a bacon and hamburger and cheese in between, and it was a seller. This is an actual donut burger right there. This person and this person got mad that I took a picture with my iPhone doing that. They knew I was up to something. Well, beyond the donut burger, we also have deep fried butter, which just makes no sense whatsoever. I mean, butter. So we're also ranked 49th in health system performance as well. Clearly diet is an issue for us. So the goals of today's talk, I'm really going to step back a little bit and go through a little bit of the history of health system and medical education design over the past century. The great benefits of that design, but also some of the shortcomings of how we're organized now. An opportunity within health reform legislation for democratization of those health advances. And then we'll do some case based learning with Tulsa, Oklahoma is an example where we've redesigned our medical education system. And we really think there's great opportunities within federal health legislation as well. So over the past 100 years, American medical education has had a great, great century. In the early 1900s, medical education in America was a disaster. It was not well organized at all. And Sir Osler came together and started formalizing how medical education pathways would follow. And the Flexner report came out 100 years ago, and it really married medical education to research and quality improvement. There was a formula for excellence in research and specialization. And over the next 100 years, you saw a tremendous growth of academic health centers. I myself was born in an academic center, health center at the University of Iowa, a wonderful, beautiful place. I was educated there and did most of my early career at the University of Iowa. At the same time, Alpha Omega Alpha, the honorary student society was established really to create a bar for students to shoot for as far as academic and professional excellence as well. So we've really had 100 years of tremendous, tremendous aspirations for excellence in medical education and services. This has contributed, not solely responsible, but contributed to a 30-year advancement in life expectancy in America. That's tremendous. Medical education has become very hospital focused during that time period. And revenues are highest in specialties, manual interventions, and hospitals. That's how you make money in healthcare. You don't make money in primary care. Students are selected that can thrive in this environment and that can afford this environment as Dr. Siegler talked about. And students emulated what they saw. We've seen tremendous growth and fellowship program development really in more and more super subspecialty areas. So here's some trends in federal funding over the past 30 years or so. You see that research dollars have had a nice steady growth in America up to about 16 billion per year now. Graduate medical education funding, the dollars that go to the hospitals that then go to pay for resident education, including our stipends, has had in general a nice steady growth as well. But Title VII programs, programs that are really public, medical care infrastructure, have not done very well over the past 30 years or so. They peaked in the 1970s and really has been a relatively steady decline over the past several decades. And we're starting to see the effects of that. As good as the past century has been, we really do have room for improvement. And as I go out and talk to governors and such, I talk about what I call the four C's of health reform. Whenever we start talking about health reform, there are some things that get pushed to the side as far as reasons for health reform that you have to bring back into the spotlight. It is very important. First of all, cost of health care in America is very high compared to other countries. We definitely have coverage issues as far as who is insured and who is not insured. We do not have enough clinicians to carry the load as we go forward and care quality and efficiency is not good enough. And we'll go over each one of these quickly. So let's go over cost first. Health care in America has steadily increased over the past 25 years at a rate much greater than other developed countries. These are the developed countries. This is gross domestic product over the past 25 years. This is spending per capita over the past 25 years. You see the U.S. in turquoise pulling away from the rest of developed world as far as health care spending. So our health care costs are escalating compared to others. Coverage-wise, we certainly have insurance design issues where individuals can reach their lifetime limits. I'm a psychiatrist. People reach their lifetime limits commonly. You can be kicked out for preexisting conditions and you can be cancelled for coverage if your health care costs become too great. We most definitely have coverage issues as well. We have 47 million Americans who are not covered in Oklahoma. That's 650,000 people out of 3 million. In the Tulsa area, we have 150,000 uninsured out of a population of 750,000. So one in five are uninsured. When Eric and I went through medical school, we didn't know about this research. But you worried about it when you were in residency. But now we know it by funding from the Kaiser Family Foundation. Individuals without health care coverage are twice as likely to be diagnosed late with cancer as compared to individuals with health care coverage. And if you look at these cancers, prostate, breast, melanoma, and colorectal, they all have a screening tool. If you look at these cancers, each one when caught early can be treated through surgery or chemotherapy. If you look at each one of them, if caught late, very, very difficult to treat. So it really is a moral crisis that we have ways to identify these cancers, we have ways to treat these cancers, and still people are dying of these cancers. Let's talk a little bit about clinicians. The U.S. is going to be somewhere between 125,000 and 150,000 physicians short in the next 10 years. We have an increasing population. We have an increase in life expectancy. The baby boomers have an increase in demand. In general, over the past several decades, medical school class sizes have gone down until recently. We have a new group of physicians that I call living off the grid who have decided they're going to do cash-only business. In Tulsa, we have several doctors who used to carry 2,000 patients. I've trimmed that down to just 500, and I've told those other 1,500 to go find a doctor somewhere else. And the business that they, the 500 that they care for, pay a subscription fee annually that they're in their special club. Oklahoma is also 49th in the country in primary care physicians. Care quality and efficiency. We have some high-cost populations who are getting very questionable care. I was just telling Eric, I just got back from the Center for Medicare and Medicaid Services, had some great talks with them. The area that they're most concerned with right now is a population that they call duals. These individuals are eligible for Medicare and Medicaid. They are poor and disabled or poor and old. Nine million people cost Medicare and Medicaid $350 billion. They average $40,000 per patient per year in this population, but the average in the United States is about $6,000 per year. This group is not well managed, and it's clear that they're not getting very good care either. This is going to be a target, one of the first things that will roll out as far as health reform, as far as practice on the streets. There's also great evidence that really we have a group of diseases that get readmitted over and over. Congestive heart failure, COPD, diabetes, and in my field, psychiatry, schizophrenia and bipolar disorder. When we talked to our residents, we polled our residents. They're very frustrated that these populations come in and out of the hospital, in and out of the hospital, and they don't have a good outpatient system to go to for them. Here are some examples of heart disease rates. This is heart disease mortality over a four-year period. The more intense red, the higher the heart disease mortality. You can't even see the borders of Oklahoma. We're obliterated, and you can't even see Mississippi. We're 49th in health status. Mississippi is 50th. So with what you've seen so far is just my introduction with the donut burger and the fried cheese. Where do you think Oklahoma ranks when quality of care is plotted against cost of care? Do you think we're a low-cost, high-quality state? Do you think we're a high-cost, low-quality state, or somewhere in between? Northeast, Northwest, Southeast, or Southwest? Where do you think we are? Well, this is Commonwealth Fund and United Health Foundation. Southeast. You are correct. We rank last in health system performance with some measures of quality and health status baked in there. Here's Illinois, by the way, right there. There's Oklahoma. And we're a relatively high-cost state as far as Medicare beneficiaries. The more intense green, the higher cost of Medicare enrolling. And when you plot it, there we end up, we end up down in the southeast corner. That's where we are. And here's Illinois, by the way. I didn't want to do a red because that would confuse you with OU. So I just put the Illinois red, but I'm certainly not a University of Illinois fan here. Okay. So let's move to health reform legislation. We just had the November elections, and there's a lot of things up in the air. What most people don't realize is actually we have three active health reform bills in play right now. The first is the Affordable Care Act that was passed in March. But the stimulus bill itself, passed a year previous to that, is loaded with health reform. Then we have the 1944 Public Health Services Act, which has been modified over and over and over again. So there's a lot of legislation in the air. And even if this is gone after, these are well down the road. So health reform is going to roll out. Those came together, passed into law, and now the agencies at Health and Human Services, including CMS, AHRQ, CDC and HRSA, are working through all the mandates that came from legislation and putting them into policies and procedures. This is a very busy time at those agencies. They have a huge amount of work to do, and they have a huge amount of control on how this will all roll out. The health reform basics that was talked about the most were health care coverage and insurance reform. Health care coverage, the mandate that 32 million will be now covered, 50% through Medicaid. That's where everybody's getting angry, at least in Oklahoma. Don't tell me what to do. The insurance reform limits, not too much arguing about that in the general population. I was doing grand rounds at the University of Iowa right after the health reform bill was passed, and someone handed me the health reform legislation in five-point font about that thick. And they said, here, read this on the way. And I said, yeah, yeah, yeah. But I took it with me. I was stranded in the Minneapolis airport on the way there for seven hours, and stranded in the Minneapolis airport six hours on the way home. I had 13 hours, there was nothing to do. I read the health reform bill. What I was amazed with was how much was not being talked about that was in the bill, and really how well it actually came together. So in the bill is a lot of efforts around workforce, expanding public health, nursing, physician assistance, nursing, primary care, and federally qualified health centers. A huge amount on expanding access to care, primarily through the FQHCs. A lot of efforts on changing reimbursement around quality of care, changing reimbursement around efficiency of care, changing reimbursement to bundle care together, where primary care and specialty care and pharmacy and nursing and occupational therapy and extended care afterwards all comes together. One of the best examples of that is for hip replacement now. There are pilots out there that 30 days of health care is paid for in one chunk. You have the hospitalization, which you have the prehospitalization workup, and the posthospitalization care all bundled together. We're doing one of those pilots in in Tulsa, and everybody's happy with it. There's much greater detection of fraud, waste, and abuse. There are faster transitions from research to care. And the most exciting part is the Center for Medicare and Medicaid Innovation, which allows communities to come together as far as creativity and health care design and payment. That's a really, really wonderful opportunity for communities to control their own destiny. This is a curve that I'm using frequently with our faculty to explain to them how things are going to change dramatically in the next five to six years. Right now, health care revenue is based off of volume, procedures, specialty care, hospital care, and what you negotiate with the insurance companies. What the health reform legislation does is makes payment based off quality, efficiency, performance, bundling, or working together, and actually reducing expenses. We call this transition from here to over here life in the gap, because it's going to be a very confusing time for hospitals, for physician groups, for the students that are going into residency, you're going to be living this. For the residents that are going into practice, you're going to be living in the gap very, very soon. It's already starting, and there will be a lot of ups and downs and a lot of confusion as to exactly how will this roll out. For us life in the gap, what we see is we're going to go from talk about health reform to actually implementing health reform. We're going to go from a lot of uninsured in Oklahoma to many newly insured, 100,000 individuals with health care coverage coming into the system. We're going to go from individual practitioners to team-based care. We're going to go from paper to the electronic medical record to now health information exchange. We're going to go from volume-based care to care based off of performance, quality, and efficiency. We're going to go from fee-for-service to bundle payments. We'll go from distance relationships with the payers to actually the payers being partners with us. Eric, when I was at CMS, surprisingly Medicare said, we want to partner with you. I never thought I would ever hear that. Medicare was something you just didn't deal with. You didn't talk to. They were a big building over in Rockville and you didn't work with them. They want to work with us now. Let's talk a little bit about Tulsa. How will this roll out in Tulsa? Tulsa's history is very important. In 1921, we had the darkest worst day ever possible in Tulsa. We had a terrible race ride where Caucasian Tulsa went across the tracks and burned down what was called Black Wall Street, which is a very affluent, successful part of town, and really wiped out any momentum that the African American population had in Tulsa. Estimated that 300 people were killed in this. This community of Tulsa is not over it yet. There is divide in our community. This is just underneath the service, and we have not healed on this as of yet. Understanding that is vital for us to actually start working on some of our terrible health disparities that we have in Tulsa. Our College of Public Health started giving us zip code data on where are the differences in health status in Tulsa, Oklahoma. The first thing that they came up with is that between North Tulsa and South Tulsa, we have a 14-year difference in life expectancy, which is dramatic. I live right here in 74114. This is a five-mile difference to 74106, 14-year difference in life expectancy, dramatic. At the same time, Northeast and West Tulsa have about 40% of the population, but they only have 4% of the clinicians. Our number one reason for patients not showing up to our clinic appointments transportation issues, and the clinics are all down here is where they are, but the patients in need are up here, so we've got a terrible maldistribution. So why do we have a 14-year difference? On the surface, you'd say, cancer, heart disease, stroke are three times higher than the national average. It's a lifestyle choice in its poverty. But as you start understanding the community, you actually learn that we have some terrible policies in the state. We have a very pro-tobacco state. We have a rule called preemption that no community can have a tobacco restriction more conservative, more serious than the state laws. So if a community wants to come together and say, we want to ban smoking in the entire community, you can't do it in Oklahoma. We talked a little bit about the strong desire, 73% of the population voted to opt out of health reform. We can say diet, but it's really access to good food and cost of good food. We can talk about exercise, but it's really a safety issue. We can talk about access, but it's really a transportation issue. And we can talk about infrastructure, but it's really failed infrastructure in Oklahoma, where we haven't taken advantage of the opportunity to build FQHCs, economic development, and do a better job with our schools. Our students run a evening walk-in clinic. They've been running it since 2003. It runs about 10 hours a week. And I was shocked when someone came in with this, and we had our derm clinic going, and I said, Dr. Adelson, what is that? He says, that's squamous cell carcinoma. That started as an actinic keratosis. That started as a little scabby thing that liquid nitrogen would have frozen off that even me as a psychiatrist could have done that procedure effectively. And instead, she waited two and a half years. So this is what when we learned in med school, squamous cell carcinoma is really not that dangerous unless you sit on it. This woman sat on it because she had no health care covers. It's now infected. She now has osteomyelitis, and she'll receive a partial amputation from something very, very simple. We did an analysis of where we short on visits. And in our area, we were 130,000 patient visits short a year, primarily in specialty care. We were 90,000 short on special visits compared to what we should have been doing as far as reaching the undersert. So that was the start of our pushing into renaming the medical school, the school of community medicine. Phase one was really all about access. And we put together more primary care outreach clinics. And then we put together an initiative to put specialty care in those zip codes that had no access to specialty care in the outpatient setting. Then we started working on workforce. We added a physician assistant program. And now we've added a four year track within the bigger College of Medicine with the explicit commitment to improve the health of the entire community. Now we're working on model patient care and teaching environment within health reform legislation. Our belief is that we're going to have to modify how we deliver health care to have a model teaching environment for our medical students. We don't want to have a teaching environment that is archaic to compared to where health care is going to be soon. So we're rapidly trying to change how we deliver health care. This is not totally out of line. Case Western put together in partnership with Cleveland Clinic, the Cleveland Clinic Learner College of Medicine. This is a special themed medical school. Really, we're looking at biomedical research. We thought to ourselves, let's do something similar. Let's do a special themed medical school around service to the underserved. So some of the things we've done is we've developed an outreach network of clinics. We have 19 clinics in elementary schools across the region that serve another total of 32 schools. Those clinics we see a lower ER utilization among those those families going to those clinics, lower absentee rates in school, lower family mobility, and increased test scores for the kids that have the clinics in them because the kids stay in school. We developed our traditional hospital based services in our traditional clinics, but we also have a huge amount of outreach clinics and special programs for special populations. So we have 346 docs doing 98 specialized programs at 52 sites across the region. We call it the Starbucks model of healthcare. We have something on every corner. The most complicated one we're working on right now is our HealthPlex, which is putting an advanced outpatient clinic in the heart of the underserved area where we can do chemotherapy, urgent care, cardiac care, but not hospital care. Off hospital location, we think we can do about 70% of what an ER can do. We'll bring surgery oncology and cardiology to that population that's struggling. It's under construction now. It's called the Wayman-Tisdale, especially health clinic. If any of you are NBA basketball fans, Wayman-Tisdale from North Tulsa died last year from bone cancer. It was a great jazz musician as well, but we named the clinic after him. So things are going along great. We're thinking we're in great condition. We start putting formalization to the medical student experience of a four-year track within the bigger college. We recruit for altruism and surveys show that in the environment we're teaching the students, altruism is holding up. We're comparing ourselves to the other track within the medical school. Altruism is diving. We have scholarships for services for all specialties. We have an MPH program integrated in. Students start medical school with what a six-day course called the Summer Institute where we teach them the anatomy of the community before they learn the anatomy of the body. So they understand who they will be serving. We have two student-run clinics. One is an acute care clinic in the evenings and the other is longitudinal team-based care where the third and fourth year students will have the same panel of patients over those two years and they do it with the nursing, pharmacy, and social work students as a team. Then the day-to-day environment out and about in the community and then they have research capstones on community health as well. We're all feeling good. Things are going great. And then things changed dramatically for us last year, earlier this year. In one week's time we got a very negative newspaper article on OU's Tisdale Clinic from the North Holston newspaper citing failure of OU's leadership. It was the same week we were doing the groundbreaking on the Tisdale Clinic. We were scheduled with the Tisdale family coming in from across the country. The mayor was there, president of the bigger university. It was also the same week that I was scheduled to be the grand marshal of the Martin Luther King Parade. So I'm stressed out big time. And the faculty said, what are we going to do? And I said, folks, this is what community medicine is. Community medicine is being out and about in the community and listening and weathering. Well, here's a little excerpt from that newspaper article. The title was, is Tulsa North being pimped by OU? To Tulsa North Rescue, Oklahoma University has come. Unquestionably, medical care is needed in Tulsa North. Why then pose such a negative question when OU appears to be doing the right thing? Our answer, pimps use the bodies of women to make money. For whatever reason, the women are vulnerable. The residents of Tulsa North are very vulnerable because of their poor health outcomes. Hundreds of millions of dollars will be spent ostensibly for better healthcare for North Tulsa. Who gets the money for such an endeavor, OU will. Who receives $20 million for building the facility, Manhattan Construction. If a healthy community is the goal of OU, does it not recognize that a healthy community involves more than improving traditional healthcare facilities and services? A healthy community must have a good economy, a chance for good jobs for its residents. Tulsa North's personal sense of well-being and its ability to thrive socially and economically are tied together. It's impossible to have a healthy community without a strong educational and economic engine in its midst. Why do we pose the question is Tulsa North being pimped by OU? Do not pimps use bodies to get income. OU will receive income from treating sick bodies. When will OU learn that the elimination of healthcare disparities among population groups is not a zero-sum game? How do you think the faculty and leadership responded? We got mad, mad, you know? We got mad. I couldn't help it. But also mixed in the mad was embarrassed and definitely a boy, we weren't listening to something. Boy, this is a big lesson for us to learn. When we met with the legislators and the leaders of North Tulsa and the writers of the article, the key line was you don't get it. We want you to bring the full resources of University of Oklahoma to help us, not just clinics. Bring business, bring architecture, bring education. Make it so North Tulsa companies build the clinic. And this has really been a turning point for our medical school and for our campus. The leadership of OU, including President Bourne, is really engaged now. It was a call to arm. It was a wake-up call. We've worked a lot with Penn in Philadelphia, broader University, and they had similar experiences where there was a crisis of conscience and culture at one point. And the question was, are you going to work through it, are you going to back off? They worked through it, we worked through it, and we're much better for it. So we really changed our architecture of our campus and our medical school. Of course, we are working on access to care. Of course, we are working on workforce. Of course, we are working on safety, quality, and efficiency. But we started working on linking our efforts to the broader determinants of health. Education, urban design, economic development, safety, literacy, and early childhood. And we're a much better school for it. We now integrate within our medical school initiatives, our early childhood programs, our urban design programs, pharmacy works on health literacy, our social work works on family, stabilization. And it has been much better for us as we've gone forward. So Ground Baking Day did happen in that week, and it was all a happy event. It was really almost a healing day where more leaders in Tulsa were in North Tulsa than had been there in probably 90 years. It was really a great day. This is Regina Tisdell, the wife of Wayman Tisdell. This is Wayman's brother, Weldon Tisdell, the lead pastor in North Tulsa, a wonderful, wonderful man. These are legislators. This is Tedra Williams, our clinical nurse manager for the Tisdell Clinic. Her granddad was a race riot survivor. It's the mayor. Just a great day. This is the Martin Luther King Day parade. Had a great day. And we started actually paying greater attention to all the different initiatives beyond the medical school that we were working with in improving economic vitality within our community. We changed how we build the building. Instead of just putting things out for a bid like the normal university policy is, we gave points for local participation. The highest amount of local participation for construction of clinics or any buildings in North Tulsa in the past had been six percent. We got it to 24 percent, which was very good. The city council called it a game chaser. New pharmacy next door to where the clinic will be. We started a new initiative called Taste of North Tulsa that highlighted all the restaurants as far as healthy food options. That was a great event. And our urban design studio is now working with community members on redesign of the community for a much healthier community. It's been a great experience as well. On health reform, there are some big opportunities as far as payment modifications that will line things up and hopefully get the incentives in the right place as well. We talked a little bit about this at the beginning. The Center for Medicare and Medicaid Innovation is going to be looking at special populations that are at risk. So when I was cycling a bike, the name of our program was called Impact. And we provided daily outreach care to a group of patients with very, very severe mental illness that were just on the edge of not being able to live independently in the community. We had an interdisciplinary team of doctors, nurses, social workers, substance abuse specialists, and actually client peers. We go out and do that care daily. And the nice thing was we pretty quickly reduced symptoms, improved independent living abilities, improved patient satisfaction, and we saved the system $15,000 per patient per year by delivering care differently than before. The Feds are now going to be looking for the same thing with this dual eligible program, dual eligible population. Opportunities for the University of Oklahoma, opportunities for the University of Chicago right now are significant within health reform legislation. And they really fall into three buckets. The first is the Federal Agency called HRSA is putting $11 billion into health workforce expansion, physician loan payback, and clinic expansion. The Center for Medicare and Medicaid Innovation is putting $10 billion into initiatives that decrease costs, increase efficiency, increase quality. And then CMS with local or with state Medicaid programs will ensure roughly 32 million Americans across the country. What we use that as our starting point to put together our strengths of our community to then hopefully build a much more rational healthcare delivery system in Tulsa. But the bottom line is our goal is to create a model healthcare delivery system for teaching the next generation of clinicians. So getting back to where we were with democratization. This is age adjusted death rate over the past 25 years. Death rate in the United States has dropped very nicely, a 30% improvement in death rate in the past 25 years. The age adjusted death rate in Oklahoma has only improved 11%. Something happened in 1992 or before that, that we started diverging from the rest of the country. I can't answer what that is, but it's probably multiple, multiple factors. But it's clear whatever is happening across the nation as far as improvement of health, we're not enjoying it in Oklahoma. So one of our missions is to catch up. Last week of the double AMC, Dr. Fitzhugh Mullin. Dr. Mullin really got national attention earlier this year because he put out an article in Anals of Internal Medicine that ranked medical schools by their ability to meet social mission. Well he was really a popular speaker this year at the double AMC, which shows that people have great interest in what he sang. But his closing comment was in the 20th century, science and medicine combined to create great benefit for humankind, leading to a 30 year expanded life expectancy. The imperative of the 21st century is the democratization of those benefits, so making sure everybody gets the benefit of those improvements. So my famous quote after that is, health reform legislation provides an opportunity to begin that democratization. With underserved communities like Tulsa, New Orleans, South Central LA, South Side Chicago, Detroit, Camden, probably standing to benefit the most if we can get organized. And I think that's a great topic for this series which starts with ethics. And this is ethics of populations. Well, I hope that was entertaining. If you don't mind, I would just like to hear more narrative about the article that you referenced. I mean, were you completely blindsided by it or had people reached out? I mean, it seemed like it was very strong on opinion. So was it reported or was it an op-ed? It was a front page story. I was tipped off to it the night before. And I think the intent, it was very intentional in when it was planned to really draw attention. And it was very successful in doing so. I mean, we really responded to it. Rather than trying to minimize it, trying to ignore it, we had no choice but to recognize it with those two big events coming. Martin Luther King Parade and the groundbreaking, it needed to be addressed. And I thought it was actually brilliant as far as how they timed it. Since Mark mentioned you had a three-hour conversation with your conservative governor, I'd love to hear more about what that involved, if you'd be willing, and how you expect the future to go forward given this scenario. That's a great question. It kind of starts with, I think of many of the, of all the medical specialties, one of the most misunderstood is psychiatry in the first place. So I'm used to being misunderstood in the first place. And when you sit down and explain to people what psychiatric illness really is, and when you sit down and explain to people what psychiatric treatment is like, they get an aha moment. I think that's where we are with explaining to the general population, the health status of America, how out of step we are with other countries, and what opportunities are there to improve things. So my conversations with our very conservative Oklahoma legislators, all of them are very conservative except for Dan Bourne, has really been educating them first and foremost. There's a lot of benefit in here. Rather than being so philosophically for or against, take some time and look at all the benefit that's in here. 80% of what the Republicans wanted in the health reform legislation ended up in the legislation. I mean, there was a huge amount of overlap. I mean, there really was. So my greatest frustration is, this is not about logic. This is not about what's best. This is still political maneuvering. And unfortunately, healthcare is being played as one of those pawns in political movements. And we need to make it a moral issue. We really do. If you think about this country, every 50 or 60 years, this country gets itself ready to take on a major civil rights initiative, from independence to women's rights to civil rights. Every generation or so, we take on something that is significant as far as civil rights movement and maybe the unfairness of health. Maybe we're ready for that as a country. I'm certain that you and Eric and Sarah Ann and Dorianne have spoken about ways in which your program and Tulsa and our program here on the south side might intersect. I wonder if you could say just a few words about that. This really was started by Eric. Eric invited me in September of 2009 to be part of the University of Chicago's set of symposiums on education and healthcare in Washington, D.C. last year. He invited me. He invited Joe Greer from Florida International, a physician who had won the Presidential Medal of Freedom. And when we three got together, it was as if we'd known each other for 20 years as far as what was important to us. You have Joe Greer coming? That's number one. Get ready. He's a lot more entertaining than I am. But from that we said we need to get together and what Florida International is trying to do, what you're trying to do, what we're trying to do is very similar. Eric knew people at New Orleans at Tulane. I knew people at New Orleans and Tulane, so we invited Tulane as well. Rand Corporation knew Eric and Eric knew Rand. Rand suggested Wayne State University in Detroit as well and Charles Drew University, UCLA, in South Central LA. So we have six communities that really have urban underserved populations with medical schools embedded in them that those medical schools really have an opportunity to play a leadership role in raising the health of that population through their clinical services, but also creating a new generation of physicians that are ready to take care of that population. And it's a really lofty goal. We've come together twice now as far as summits. They've gone very well. And as they've gone well, people are hearing about it and wanting to join in. Now Denver, University of Colorado wants to join, and Camden, the new medical school at Camden wants to join. So we think we're on to something as far as at least one arm of what medical school leadership should be taking on. Kind of like Case Western Cleveland Clinic, not every medical school needs to do everything incredibly well. You can have themes, you can take on submissions within the broader mission and do it very well. I just wanted to find out what lessons you've learned from being a part of the University Oklahoma system and taking this particular focus. And is there things that you could teach us? And secondly, you've been, I would say, blessed by having a benefactor who wrote a very large check and dialed faculty that allowed you to recruit people from all over the country. And to what extent do we have to look for those kind of angels as opposed to getting your state school and you likely wouldn't have gotten funding through state channels? You know, how do we replicate this? So that's a great question, Eric. How do you go forward with this? Starting point for us was data driven, understanding the data, the health status of the community by data. But that alone was not enough. We also needed to understand the emotion, the culture, and the history of the community as well. So the traditional knee-jerk response of most academic institutions is data driven, we're right, we're really smart people, we'll take care of things. But if you slow down and listen to the community and learn the history, learn the culture and get real feedback, now you've got good balance. You've got good data and you've got understanding. So I think that was lesson number one is those two have to have to integrate with each other. The second lesson, I think, is you've got to tell the story over and over and over again. So this is a brand new talk. I can give them this talk tomorrow for the Oklahoma Hospital Association. Now they're going to get glazed over on this real quick. So you have to be very repetitive in the talk. I think the third getting to funding is the ability to talk with multiple leaders at multiple levels. So we've talked to CMS, we've talked to the AMC, I'm in the Chamber of Commerce, I'm talking to the governor, and you've got to talk it to multiple, multiple power brokers. I think it's an important lesson. I think the next lesson is you've got to go where the money is. And right now the money is not at the states. The states have no money. Private philanthropy is coming up a little bit right now. They've had a pretty good year. So there's some money back with private philanthropy and clearly there's money at the federal level as far as opportunity for at least seeding funding to go forward. So I think those are some of our lessons. Good question. Yes, sir. It seems to me that part of the problem is in the funding stream that if you have the majority of funding through private for-profit organizations, you will always have disparities. Have you looked at, first, there are some states that are experimenting or at least there are some proposals for single payer systems? And what have you looked at other payment mechanisms other than bundling and efficiency that might decrease specifically disparities? I mean, if everybody was paid equally, physicians were paid equally all over the city, they would go where the business is. The business is here. Everybody's here is sick. Yeah. I think that's a great question as well. We're just starting to dip our toe into, it's kind of our, so I showed those different paths that we're working on, access, workforce, quality, safety, efficiency, linking to the broader determinants of health. That's our next chapter that we're just getting into is how do we work with payment to make it work right? Fortunately, we're a relatively small state. Oklahoma's got 3.1 million people. Oklahoma Medicaid really likes what we're doing, so we think we can really do some creative things with Oklahoma Medicaid. Oklahoma Blue Cross Shield really likes us as well. So we've got two major payers, but what exactly we'll do, I don't know yet. I mean, it's a great question of how do you align incentives to get the right behaviors out of the clinicians and the right behaviors out of the patient? I don't think anybody's cracked that note yet. I think that Obama mantra of keep hope alive is when you think about educators who've been trying to keep students and residents in working in underserved community, it's keeping altruism alive. And so how do you keep that going in medical school? What are the things you do to keep that going? Great question. Yeah, question is how do you keep that altruism alive? Several layers. The student that really has the calling in the first place, that's helpful. Student that altruism is not new to them, so that's helpful. The environment that the students learn in is key. You can't talk one way and walk another way. You have to walk and talk the same way on this. I think the very first days of medical school are very important. It's as if you go back in childhood and they are very formative years. I remember the first day of medical school like it was yesterday. I mean, I was so nervous and so amped up and I mean, I remember it very, very well. So the setting the tone in the very first days is very important. Dr. Siegler and I talked about this. There needs to be greater attention to the career paths that altruistic physicians want to follow. And it was the start of our loan payback program. Why penalize someone who wants to be altruistic and do good work? They're not asking for a whole bunch of money, but they're asking to be at least taking care of someone as far as debt. I also think we have to pay great attention to the patient care teaching environment that those faculty are in so that they can do it for the long run. I think it's one of the areas that the federally qualified health centers across the country and the National Health Service Corps have struggled with is that they have not paid attention to the environment you're going to be in. One of my good friends in medical school was sent to Northern North Dakota right on the Canadian North Dakota border and he's bitter still about it. It was a terrible, terrible experience for him. And whereas I did my Air Force time in Rapid City, South Dakota and had a great experience because the team that I was with, I was not isolated. I had a great, great experience with that. I do think pairing academics and service together is a nice combination. I'm in academics because I love the students. My wife knows when I've had a good day because I've been with the students. She goes, you've been with the students today, haven't you? Because I'm in a better mood. And that happens to almost every academician. The more time you have with the students, they are just uplifting. They're the next generation. They are wonderful. They are eager. They keep you on your toes. And I think pairing service with medical education is a wonderful combination that gets ignored. Within the health reform legislation is a new set of programs for the FQHCs to become teaching health centers. Waco has done it well. Boise has done it well. And Billings have done it well as far as family medicine residency programs. But it looks like they want to do more of those. And I think that's a real important piece to take care of. Good question though. I work a lot with our medical students on campus and some of their extracurricular activities. And I know that your campus is shaped a little different. I know a lot of the stuff that you guys probably do are very service-driven. I was wondering if there was any unique or just interesting extracurricular activity that your students are doing that isn't necessarily part of your direct medical education, but it's one of your strongest programs? No. Our students have a choice of going into the traditional program on our track. I think those that choose our track in the first place are a little bit more risk takers, maybe a little bit more mature. They're very committed in the first place to doing it. They really own our student-run clinics. And we staff those clinics with physician volunteers. The faculty come in as volunteers. And we put it on the students to do the recruitment of the faculty. And boy, do they get ticked off if they get mad at the faculty. So I think those are some of the pieces that are unique. But as far as extracurricular activities, we really let the students kind of take care of it. I don't meddle too much. Good question. This is a bit unrelated to what you want us to take home from this conversation. But earlier in the presentation, we talked about the cash-only practices and how doctors were some of them moving towards that. I'm wondering what happens to those patients when they need surgeries or something more that's not with their primary care doctor, or something like, how does that, how do they account for that in the system? Because surgeries and emerging care are very expensive. And I just, how do they, how do they figure that out? I guess it's my short question. Well, the patients don't come off the grid, as I call it. So they're still in shirt. So the patient plays a $1,500 a year subscription fee that he is in that physician's club, but they still have their commercial insurance. So those physicians are clearing between $500,000 and a million dollars before they see a patient just by having the patient in the club. Then insurance is billed on top of that. What we've seen is six or seven docs have done it in our local area that previously had about 2,000 patients in their panel. They went down to 500. Those 1,500 they got left out are desperate to find a doctor. It's really tough, really tough right now. Jerry. Hi, Grant. Can you talk a little bit about the viewpoint from either the Tulsa Department of Public Health or even the state of Oklahoma and your approaches to community medicine and their thoughts about health disparities and health outcomes? Great question, Dorianne. Our Department of Health locally, our county Department of Health has actually gone from really being a provider of primary care and actually downsize that dramatically. They really are in surveillance, vaccination roles right now. They've not really decided to get back into health care. So they've almost become a non-factor as far as delivery of health care. They are with us in the schools on the prevention side of things, but we struggle to really work well with them so far. We've not been able to accomplish that one yet. We're not there yet. The state health department, what we did was hire one of their associate directors as a part-time faculty member with us to create those relationships so things would start going. We'd be planning together. We just started in that. I had a question about the different tracks. How is there cross pollination between the sort of community tracks and the traditional med students because you worry that there's this dynamic group of people who are really on fire and really motivated and mature, who never interact with their peers to get them there or to expose them to it? Well, they're back and forth to Tulsa and Oklahoma City a fair amount. They do know each other well that way. They do a lot of coursework together in the first place, not as if they're entirely separated. What has happened is that as the community medicine track has done new things, the other track has said, well, we want to do it as well. So it's actually stimulated them to do things alongside that so there's not much of a difference. LCME right now, we're still accredited as a track within the medical school, so the LCME does not let us get too far away from what they're doing anyhow. Can I ask some questions? Yes. So Eric, you've just been to DC. What are your lessons from DC? So the double AMC meeting just in, is this still going on or is I left? So I don't know if it's still going on. So on Sunday I did a talk on a panel at the double AMC, the Association of American Medical Colleges. The panel was focused on health care reform and how research can inform patient experience, the health of populations. We talked about the work we're doing on the South Side and also some of the things we're doing jointly. To a room of maybe about 300 plus people, it was a really nice crowd. And I ended up getting approached by the University of Michigan and other major academic centers trying to understand more about what we're doing. And then the next day I went to meet with the folks at HRSA that oversee the Fairleigh Qualified Health Centers. And the way you're presenting, the way we're thinking about our South Side Health Care Collaborative where there are 33 community health centers working collaboratively with us and other hospitals on the South Side is where they're trying to move. So it was clear to me after spending, and I was supposed to be there an hour, I spent two and a half hours with them, that they think there's some fertile ground and they were asking about were we affiliated with our effort because I don't know if you all had just been there the day before or whatever. I also spent some time with the folks from the Congressional Black Caucus. They have a health brain trust and a group of Congress persons who bring together innovative folks in health care twice a year. And so I know we've gotten invited and hope to have Dorian Miller and some of her work just recently with the community on mental health and a play that Dorian wrote and community participants participated in and brought the best of the cutting-edge mental health services or I should say evidence-based mental health as well as the resources that are available in our community. So they were really jazzed about that and want us to have Dorian and some others come make a presentation in April of next year. So I didn't get a chance to go to the meeting with you to the Centers for Medicaid and Medicare Innovation but it's clear we're in the right spot for where health care reform is going. The other person I met when I was in D.C. was Don Weaver who's the head of the National Service Corps. Our REACH program which pays about $40,000 a year for each of four years for our graduates who practice in this network of clinics was something he was excited about because it dealt not only with primary care but also with subspecialty care. Holly Humphrey presented a paper at the W.A.M.C. meeting that also was well received about REACH. So I think that between Tulsa, our work, New Orleans, L.A., we're in the sweet spot of where health care reform is going. I think so too. That was one of the things that I really noticed is that at the W.A.M.C. this year there was a real energy about medical schools playing leadership roles in improving the health disparities. It was stronger than ever, stronger than ever that I've ever been in. I've been going to W.A.M.C. now for 14 years and clearly there's a swing as far as national intention of medical schools to play role. I think this has been a wonderful discussion, great questions, great presentation. Thank you again so much for coming up.