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Submitted: 13 May 2014
Five interview sessions: 5 February 2014; 13 February 2014; 11 March 2014; 9 April 2014; 13 May 2014
Total approximate duration, 4 hours.
Interviewer: Tacey A. Rosolowski, PhD
For supplementary materials:
Please contact, the Historical Resources Center, Research Medical Library:
Javier Garza, MSIS, firstname.lastname@example.org
About the Interview Subject:
Dr. Lewis Foxhall (b. November 17, 1950, Memphis, Texas) came to MD Anderson in 1993 to join the Department of Clinical Cancer Prevention in the Division of Cancer Prevention and Population Sciences. During his many years in private practice prior to this time, Dr. Foxhall had become known for developing networks with community physicians to improve communication and patient care. His work in this area continued to expand at MD Anderson, and in 1994 he was appointed Associate VP for Health Policy. Since 2005 Dr. Foxhall has served as Vice President for Health Policy.
Major Topics Covered:
Personal and educational background; a Texas upbringing and education
Interests in primary clinical care, health populations, cancer prevention, and tobacco
The Physician Relations Program
Health policy work at MD Anderson
Charity care programs
External networks and initiatives with health care providers
Texas state law, health care delivery, the Affordable Care Act, healthcare economics
Value based care
Regarding the Transcript and Audio Files
In accordance with oral history best practices, this transcript was intentionally created to preserve the conversational language of the interview sessions. (Language has not been edited to conform to written prose).
The interview subject was given the opportunity to review the transcript. Any requested editorial changes are indicated in brackets [ ], and the audio file has not correspondingly altered.
Redactions to the transcript and audio files may have been made in response to the interview subject’s request or to eliminate personal health information in compliance with HIPAA.
The views expressed in this interview are solely the perspective of the interview subject. They are not to be interpreted as the official view of any other individual or of The University of Texas MD Anderson Cancer Center.
Interview Session One: 5 February 2014
Growing Up in a Small Town; Medical Education
Chapter 01 / Educational Path
A Growing Interest in Cancer, Cancer Prevention, and First Connections with MD Anderson
Chapter 02 / Professional Path
An Opportunity to Leave Private Practice for MD Anderson
Chapter 03 / Joining MD Anderson/Coming to Texas
MD Anderson’s Outreach Programs—the Physician Relations Programs
Chapter 04 / Building the Institution
The Charity Care Program
Chapter 05 / An Institutional Unit
Interview Session Two: 13 February 2014
The Office of Health Policy: Focusing on Outreach
Chapter 06 / An Institutional Unit
The Office of Health Policy: Focusing on Survivorship
Chapter 07 / An Institutional Unit
Work that Takes Eternal Optimism
Chapter 08 / Character and Personal Philosophy
Associate Vice President of the Office of Health Policy
Chapter 09 / An Institutional Unit
The Texas Cancer Data Center
Chapter 10 / An Institutional Unit
Interview Session Three: 11 March 2014
Grant-Funded Projects in the Office of Health Policy: The Texas Cancer Data Center
Chapter 11 / An Institutional Unit
Grant-Funded Projects in the Office of Health Policy: Service for the Uninsured
Chapter 12 / An Institutional Unit
Grant-Funded Projects in the Office of Health Policy: Screening for Colorectal Cancer and Breast Cancer
Chapter 13 / An Institutional Unit
Grant-Funded Projects in the Office of Health Policy: Cancer Survivor Management
Chapter 14 / An Institutional Unit
Educational Projects with Physicians and Medical Students
Chapter 15 / An Institutional Unit
Projects in Cancer Prevention; the Lung Cancer Moonshot; CYCORE
Chapter 16 / An Institutional Unit
Interview Session Four: 9 April 2014
A Major Challenge: Serving the Uninsured as Health Care Changes
Chapter 17 / Institutional Change
Impact of Institutional Growth on the Office of Health Policy
Chapter 18 / Institutional Change
The MD Anderson Presidents; No Plans for Retirement
Chapter 19 / View on Career and Accomplishments
Interview Session Five: 13 May 2014
Texas and the Affordable Care Act
Chapter 20 / The Finances and Business of MD Anderson
MD Anderson’s Response to the Affordable Care Act; ACA Requirements; Value-Based Purchasing
Chapter 21 / The Finances and Business of MD Anderson
The Future Under the Affordable Care Act: the Value of Prevention Services
Chapter 22 / The Finances and Business of MD Anderson
Interview Session One: 5 February 2014 (listen/read)
Interview Identifier (listen/read)
Chapter 01 (Educational Path)
Growing Up in a Small Town; Medical Education (listen/read)
Dr. Foxhall gives a brief overview of his family life then notes his first interests in science. He touches on his experiences at the Baylor College of Medicine and explains that his interest in primary clinical care and in health populations began at this time, particularly when he spent time in his home town working with family physicians and saw a wide range of health problems. He also cites the influence of school integration –the seventies were a time when the nation was changing and there were opportunities to learn and grow.
Dr. Foxhall notes that his interest in cancer and cancer prevention grew during his residency and the first years of his private practice at Houston Northwest Medical Center where he was able to follow patients over many years and recognized the missed opportunities to intervene with patient and avert cancer risk.
Chapter 02 (Professional Path)
A Growing Interest in Cancer, Cancer Prevention, and First Connections with MD Anderson (listen/read)
Dr. Foxhall notes that his interest in cancer (and tobacco) began during his private practice; he mentions other professionals in Houston who were also focusing on tobacco. He lists the projects he implemented during this time and notes his involvement in the Texas Academy of Family Physicians and its subgroups focused on prevention.
Dr. Foxhall then explains that he met and worked with Dr. Joseph Painter of MD Anderson was also interested in community outreach at the time. He describes the projects the worked on to educate physicians (part of a national movement). Dr. Foxhall also explains that it was key to demonstrate to physicians the value of collaborating with a large cancer center. He explains the previous mindset physicians held about their relationship to cancer centers.
Chapter 03 (Joining MD Anderson/Coming to Texas)
An Opportunity to Leave Private Practice for MD Anderson (listen/read)
Dr. Foxhall first describes the ways in which he and Dr. Joseph Painter worked together in the late 80s. He then explains why he decided to leave private practice at that time: Dr. Foxhall first took a faculty position with UT Health Science in Family Medicine in 1991. In 1993 Dr. Foxhall was hired to help Dr. Painter with outreach and educating primary care physicians.
Chapter 04 (Building the Institution)
MD Anderson’s Outreach Programs—the Physician Relations Programs (listen/read)
Here, Dr. Foxhall describes what was involved in the Outreach Programs, which resulted in the Physicians Relations Programs. He notes the ill will created immediately after the Texas Legislature’s 1995 decision to allow patients to self-refer. He talks about the scope of the programs set up to preserve patients’ connection to the primary care physician during and after cancer treatment; he also outlines the significance of the primary care physician’s role in this process.
Chapter 05 (An Institutional Unit)
The Charity Care Program (listen/read)
Dr. Foxhall describes MD Anderson’s work with indigent patients and the Charity Care Program.
He notes that MD Anderson was founded as a charity care institution and sketches the later history of this obligation. He explains the financial stresses this caused the institution. He explains that he worked with the Charity Care Program to reduce costs while paying for care, helping to stablilize the financial situation. He notes the partnership with the Lyndon Baines Johnson Community Hospital to serve charity cases.
Dr. Foxhall observes that patients at MD Anderson in general represent the cancer levels in the general population, though MD Anderson sees insured patients and the rates of the uninsured in Houston are very high (1/3 of population). He explains why the level of uninsured is so high.
Interview Session Two: 13 February 2014 (listen/read)
Interview Identifier (listen/read)
Chapter 06 (An Institutional Unit)
The Office of Health Policy: Focusing on Outreach (listen/read)
Dr. Foxhall lays out the history of the Office of Health Policy.
He explains that it originated in the need to reach out to community physicians and develop their relationships with MD Anderson. He explains how a team was created to conduct surveys and also to work with programs internal to MD Anderson. Dr. Foxhall explains the issues that community physicians had in sending their patients to MD Anderson, largely in the area of need for more communication with the institution after their patients went into treatment at the institution.
Chapter 07 (An Institutional Unit)
The Office of Health Policy: Focusing on Survivorship (listen/read)
Dr. Foxhall goes into detail about the Office’s focus on survivorship, including connections with community physicians and mechanisms for survivorship information to community physicians so they can partner in a cancer patient’s after care.
He explains the origins of the Survivorship Initiative and discusses his role on the Survivorship Committee and other programs designed to create an integrated approach to care.
He lists health policy challenges that have an impact on survivors. He describes results of studies that have confirmed the benefits of survivorship programs for patients.
Dr. Foxhall sketches the history of thinking about survivorship. He lists key people at MD Anderson involved in the survivorship program. He also lists some of the places he has been globally (through the GAP program--Global Academic Programs—MD Anderson’s network of sister institutions) to speak about survivorship, stressing that the focus on survivorship is a world issue.
Chapter 08(Character and Personal Philosophy)
Work that Takes Eternal Optimism (listen/read)
Dr. Foxhall responds to a question about those particular gifts that suit him and others to policy work. He explains that a focus on outreach beyond the institution is key, as well as a comfort with collaboration. He also talks about the commitment to the institution and to its mission to cure cancer and a commitment to a sense of equity in reaching out to all patients. It’s a challenge financially to do that in an environment of limited funding and requires a high level of patience, persistence, and optimism to move issues forward.
Chapter 09 (An Institutional Unit)
Associate Vice President of the Office of Health Policy (listen/read)
Dr. Foxhall talks about his role as Associate VP for Health Policy.
He defines the scope of “health policy” and gives examples of policy issues addressed in collaboration with other health organizations. He stresses MD Anderson’s role as a resource and support for public officials who lobby for health policy in the legislature.
Dr. Foxhall next explains the relationship between the Office of Referral Relations the Office of Health Policy.
Dr. Foxhall next talks about the big projects he undertook as Associate Vice President: creating the network of physician referrals; a program to educate physicians about cancer screening; creating an internet based educational outreach program.
Chapter 10 (An Institutional Unit)
The Texas Cancer Data Center (listen/read)
Dr. Foxhall recounts the history of the Texas Cancer Data Center.
He explains the funding and mission to collect information from the state cancer registry and convert it to a searchable system that includes statistics on patients and other information. He explains how the system evolved, shifts in its management, and the programs it includes. He notes that a related education program has reached about 500 nurses and 1000 social workers with information about programs for patients. He notes that this was one of the first data centers of this type in the country.
Dr. Foxhall notes partnerships with the American Cancer Society and with other public health agencies to educate patients about cancer risk. He also notes the work with the Harris County Healthcare Alliance to support prevention programs in community clinics and improve access to healthcare for low income patients. (Additional information on the Texas Cancer Data Center is presented in Chapter 09.)
Interview Session Three: 11 March 2014 (listen/read)
Interview Identifier (listen/read)
Chapter 11 (An Institutional Unit)
Grant-Funded Projects in the Office of Health Policy: The Texas Cancer Data Center (listen/read)
Here Dr. Foxhall talks about a number of key projects run by the Office of Health Policy. He first follows up on a discussion of the Texas Cancer Data Center (discussed in Chapter 10), explaining difficulties in collecting information in the early days of the project and then sketching how services have evolved an been updated since the late eighties. He lists the kinds of information that the Center provides, its heavy use (around one million hits per year) and its impact. Dr. Foxhall notes that it is used as a platform for educational programs supported via CPRIT money. He also describes how the Center provides information for individuals with no insurance and education for nurses and social worker to help people get access to care. This need has been intensified since Texas made the decision not to participate in the Medicaid portion of the Affordable Care Act.
Chapter 12 (An Institutional Unit)
Grant-Funded Projects in the Office of Health Policy: Services for the Uninsured (listen/read)
Here, Dr. Foxhall describes initiatives supported by the institution and by federal money that are designed to reduce cancer risk among low-income individuals. He first talks about the tobacco program, mentioning the ASPIRE program designed to reach maximize tobacco avoidance/cessation in adolescents. Dr. Foxhall explained how the Office of Health Policy helped support this project. Next he talks about the project, Ask, Advise, Connect, a quit line service that services HIV patients. Dr. Foxhall notes that this is a good example of how the Office of Health Policy identifies a government program that can provide funding for initiatives relevant to the needs of at-risk individuals. He describes the individuals involved in organizing the funding mechanisms and notes where difficulties arise in the process. Dr. Foxhall explains that this is a slow and often frustrating process, but the benefits come when “you see that you help someone” and can track progress with use rates.
Chapter 13 (An Institutional Unit)
Grant-Funded Projects in the Office of Health Policy: Screening for Colorectal Cancer and Breast Cancer (listen/read)
In this chapter, Dr. Foxhall talks about projects that support screening for colorectal cancer and for breast cancer (via a mobile unit). The Office of Health Policy “provides the infrastructure,” identifying an opportunity and partners who can help accomplish goals that fit with MD Anderson’s mission. He provides additional information about both of these screening programs.
Chapter 14 (An Institutional Unit)
Grant-Funded Projects in the Office of Health Policy: Cancer Survivor Management (listen/read)
In this chapter, Dr. Foxhall talks about a grant that the Office is now preparing for Cancer Survivor Management –a training program that will be instituted in clinical around the state. Dr. Foxhall explains that his “love in life is education,” and that such projects are very significant for him. He explains the elements of the training program: identify survivors; create care plans to maximize the effectiveness of aftercare following MD Anderson guidelines; follow up with providers to help them adhere to best practices; monitor patients receiving services. He discusses a tele-mentoring system that will be used to provide support for health care personnel. He talks about collaborating on the Cancer Survivorship Manual that will be published this summer.
Chapter 15 (An Institutional Unit)
Educational Projects with Physicians and Medical Students (listen/read)
Dr. Foxhall talks about the importance of educational outreach to the mission of the institution.
He lists the impact that educational initiatives have in the community.
Next he describes the Preceptorship Program initiated in the eighties at the UT Medical School in Houston. The challenge, he explains, was (and is) that “we need more primary care physicians” and medical students need to know that family medicine can be a viable career path. Dr. Foxhall explains that the Preceptorship enables medical students to spend a month with a family physician. He talks about the importance of targeting students early. He notes that in a national ranking of states and the availability of primary care physicians, Texas ranks #42. The grant supporting the Preceptorship was renewed several times and the program has been successful at convincing medical students to enter family medicine. Recently funding was cut and then transferred to the Texas Council of Family Physicians.
Chapter 16 (An Institutional Unit)
Projects in Cancer Prevention; the Lung Cancer Moonshot; CYCORE (listen/read)
In this chapter, Dr. Foxhall talks a cancer prevention programs and the place of the lung cancer screening trial in the Lung Cancer Moon Shot. He then talks about CYCORE, a program that uses electronic devices to address patient needs and treatments. This project was funded by stimulus money and uses a tele-monitoring device created by Time Warner. He describes some of the benefits and also mentions the video conferencing systems that can support patients. Dr. Foxhall notes that the Office tries to keep up with the latest electronic advances that can help patients.
Interview Session Four: 9 April 2014 (listen/read)
Interview Identifier (listen/read)
Chapter 17 (Institutional Change)
A Major Challenge: Serving the Uninsured as Health Care Changes (listen/read)
In this chapter, Dr. Foxhall talks about the challenge of expanding access to care, his role as a governor-appointed member of the Texas State Health Services Advisory Council (2009 – present), and the challenge of transitioning from a fee for service system to a value-based care system.
He notes that Texas ranks number one in numbers of uninsured individuals, but there are early signals that the Affordable Care Act is reducing those numbers, though the issue is complicated by the decision Texas made not to participate in the Act.
Dr. Foxhall describes services provided by the Texas State Health Services Advisory Council and gives examples.
He defines value-based care, founded on careful documentation of care provided and outcomes. He explains the related concept of “the triple aim”: to improve quality of care, to reduce cost, to increase levels of patient satisfaction, noting that some policy makers include a fourth aim, insuring equal access to care. He explains why the status quo cannot continue.
Chapter 18 (Institutional Change)
Impact of Institutional Growth on the Office of Health Policy (listen/read)
In this chapter, Dr. Foxhall comments on how the MD Anderson’s growth since the nineties has had an impact on the activities of the Office of Health Policy.
He notes the huge expansion of external connections with network affiliates and also with international connections, with MD Anderson adopting the CDC’s Comprehensive Cancer Control Program to organize information provided to the external connections. He sketches the history of that program. He notes that the Lung Cancer Moon Shot is part of the Prevention and Control Platform.
Next, Dr. Foxhall talks about how the institution’s financial structure has changehealthcare delivery has changed and it is increasingly difficult to secure funding for research and also raise income from patient care. He notes that the institution’s ability to provide personalized and compassionate care for patients has not changed, because it is imbedded in the culture and tradition of MD Anderson.
He ends this chapter with comments on how MD Anderson is seen by the community.
Chapter 19 (View on Career and Accomplishments)
The MD Anderson Presidents; No Plans for Retirement (listen/read)
Dr. Foxhall begins this chapter with comments on MD Anderson presidents, Dr. Charles LeMaistre, Dr. John Mendelsohn, and Dr. Ronald DePinho. He then notes that he has no immediate plans for retirement (he is “having too much fun”), and explains that intends to further the tobacco agenda and to develop survivorship management, positioning the institution to work within more effective shared care models for survivorship.
Dr. Foxhall comments on the legacy he will leave: a network of collaborative connections designed for cancer control and management. He comments briefly on his love of travel, the enjoyable time he spends with his children, and his hobby, landscape photography.
Interview Session Five: 13 May 2014 (listen/read)
Interview Identifier (listen/read)
Chapter 20 (The Finances and Business of MD Anderson)
Texas and the Affordable Care Act (listen/read)
In this chapter, Dr. Foxhall discusses the Affordable Care Act (ACA) passed on 23 March 2010 and its impact on Texas Health and the activities of MD Anderson. He begins by noting that Texas has the highest rate of uninsured individuals in the nation and that only a limited number of categories of individuals are eligible for Medicaid, with the result that a percentage of individuals who are diagnosed with cancer are uninsured. He explains the hopes that the ACA would provide coverage to the uninsured, to cancer survivors unable to get affordable insurance, and to low income individuals in need of cancer prevention services. He then goes into more detail about the Texas limitations on Medicaid as well as some alternatives under discussion in the Texas Legislature to provide coverage to ineligible individuals.
Chapter 21 (The Finances and Business of MD Anderson)
MD Anderson’s Response to the Affordable Care Act; ACA Requirements; Value-Based Purchasing (listen/read)
In this chapter, Dr. Foxhall continues discussion of the Affordable Care Act.
He sketches MD Anderson’s programs to help with financial assistance.
He then talks about the requirement that institutions report on the quality of care. He gives examples to explain what is involved in this process, noting that historically, medical practices have not had enough transparency in care and outcomes. Reporting enables consumers to have a better idea of how well providers are doing. In addition, this information will be used as a basis for determining payment. Next Dr. Foxhall explains that the ACA requires that institutions participate in an Accountable Care Organization. He explains the reasoning for this, and notes that it is not clear how a specialized hospital will engage with them.
Next Dr. Foxhall talks about the ACA’s requirement for Value-Based Purchasing, giving examples of how examining processes has revealed unnecessary costs in deliver of care.
Chapter 22 (The Finances and Business of MD Anderson)
The Future Under the Affordable Care Act: the Value of Prevention Services (listen/read)
In this chapter, Dr. Foxhall sketches what the future looks like under the Affordable Care Act, noting that the a change in leadership in Texas might change any predictive scenario and the state will continue to have poor and undocumented individuals to cover.
Dr. Foxhall explains that the focus on preventive services is a very positive feature of the ACA. He explains the requirements and notes the benefits that can come from screening services and tobacco cessation programs. He cites statistics for the increase cancer risk that comes with smoking and obesity. He explains why institutions tend not to invest in prevention, noting that the ACA is unusual in adding this to its requirements.
In conclusion, Dr. Foxhall notes that the ACA is “still a political football” and that politics has an impact on each decision connected with it.
This interview with Dr. Lewis Foxhall (b. November 17, 1950, Memphis, Texas) takes place in over five sessions in spring of 2014 (approximate total duration, 4 hours).
Dr. Foxhall came to MD Anderson in 1993 to join the Department of Clinical Cancer Prevention in the Division of Cancer Prevention and Population Sciences. Since 2005 he has served as Vice President for Health Policy. This interview takes place Dr. Foxhall’s Office in the Office of Health Policy in Pickens Academic Tower on the Main Campus of MD Anderson. Tacey A. Rosolowski, Ph.D. is the interviewer.
Dr. Foxhall received his B.S. in 1973 from the University of Texas at Austin, Texas, and his M.D. in Family Medicine in 1976 from the Baylor College of Medicine in Houston, Texas. During his many years in private practice, Dr. Foxhall was increasingly active working with community physicians on a range of topics, collaborating at time with Dr. Joseph Painter, who recruited him to MD Anderson in 1993. In 1994 Dr. Foxhall was appointed Associate VP for Health Policy and in July 2005 he became VP for Health Policy.
In this interview, Dr. Foxhall traces the growth of his interest in primary clinical care, health populations, cancer prevention, and the risks of tobacco use. He traces his early work with Dr. Joseph Painter and describes his first task at MD Anderson: to set up the Physician Relations Program. Dr. Foxhall gives a portrait of the range of activities that health policy encompasses: education and information access; charity care programs, building external networks with health care providers; finding collaborative partners to fund and advance MD Anderson initiatives; working with stakeholders to work with challenges that Texas state law presents to health care delivery, building programs for survivorship care. He also discusses the Affordable Care Act and its impact on MD Anderson and patients in Texas. Throughout, Dr. Foxhall is able to provide insight into how MD Anderson addresses the needs of communities outside the institution’s walls, as well as responding to pressures from external economic and political factors that shape the growth of programs and how patients’ needs are addressed. He gives particular insight into the growing survivorship management initiatives, a relatively new and increasinglyimportant arena of activity at MD Anderson and around the world.