Overall, I thought that the symposium was tremendous.  Often speakers don’t want to disagree with either others ideas too much, or they disagree about minute details–at this event, there was no shortage of (very respectful) disagreement.  I walked away feeling like I understand the nature and magnitude of the complexities of health care reform much better than when I entered and armed with some new language and frameworks with which to approach the issues.  The longer I work in health delivery, the more I’m struck by the different sense of urgencies people feel: the speakers seemed intent of understanding the nature of the beast and saw it as a precursor to reforming health care.  All except Cutler felt that the pending legislation was trivial or harmful, but failed to offer other actionable recommendations.  I’m torn on this–I think history shows countless examples of how we’ve dug ourselves into a hole by not appreciating a problem fully.  On the other hand, when the decision not to act may result in suffering and/or death, there does seem to be a moral imperative to get out of the ivory tower and get busy (recent post by Bill Easterly on the pointlessness of airport security makes me a little wary to assert this too confidently or with too much moral indignation).

Recently I’ve been thinking a lot about the constitution–somehow, a bunch of white guys in a room (many of whom believed in slavery and were not keen on gender equity), centuries ago, managed to create a document that remains pretty relevant, with only a few alterations and additions,  in our court system today.  Is there an analogous product in health reform?  Even looking at the structure of Medicare, passed in the 1960s, it’s clear how far our understanding of health and disease, and our ability to prevent, diagnose and treat have come.  In many ways, its our advancements that have cursed us financially.  If we are to develop a durable health policy, it must build in room for changes in what health, health care, and medical services entail, as one would assume that they will continue to change, and in changes that we, where we stand now and even with all available information, cannot really conceive.

A few highlights and specific comments on the various speakers:

I thought Cutler outlined some of the existing system-level failures in health care very well.  Having been immersed in Michael Porter’s philosophy, I took issue with his liberal use of the phrase “value-based health care” when primarily outlining ways that the operational efficiency of health delivery could be improved, rather than strategically reconfiguring the systems more fundamentally.  I doubt that just moving along the curve that we’re on will be enough to resolve the issues.  For example, he mentions that (preventable) rehospitalizations are too common and the burden of acute care episodes is an indicator of “low productivity” in the health care sector.  Making hospitals “more efficient” will not necessarily result in the preventive care and changes in consumer behavior that could truly drive down that demand.  Some of the issues that he raised are pretty grim: most hospitals have more administrators than medical personnel.  He mentioned that additional spending not associated with better outcomes (even when controlling for “everything you could think of”); in Atul Gawande’s piece on McAllen, he goes so far as to quote study results from Dartmouth showing that the higher the average medicare spending, the WORSE the quality.  Yikes!

Cutler admitted that he thought that health care was supply driven–providers were much more sensitive to changes in policy than consumers, and to create large-scale change, we should focus on them.  Sounds good in theory, but upon thinking about this, I wondered if the insensitivity of consumer demand was a product of the system, rather than a precondition, and something that required change as much as any other part of the broken system.  Ultimately, if I’m the one whose most affected by my health (and though my roommate may argue otherwise when I’m complaining endlessly about a minor tweak in my knee, I think that’s true), empowering/encourage/forcing/choose your own verb ME to act in my own self interest seems like a necessary part of a functioning and rational health system.

Detsky appealed to the sociologist in me.  It’s a false comparison to just look at the health systems of different countries and say, which one’s the best?  All are embedded in a larger governmental, historical and cultural framework.  In the same way that those who went to see Toyota’s secret to high quality cars produced at low costs, took away the parts they liked and implemented them at home, only to find them completely ineffective, we can’t treat other health systems as a menu of items.  Nor could we import one as is.  Detsky explained this clearly and with an adorable amount of Canadian pride.  I hadn’t really considered, until he said it, that the major motivation of the American society right now around health care reform right now in the U.S. is motivated by fear of losing one’s insurance.  It’s not the uninsured that are up in arms.  Fear is usually posed as an irrational emotion–does this have implications for our ability to pass rational legislation that gets popular support?  How manipulable is it?

Which leads nicely into Goldhill, a very cool head despite joining the health care debate after watching his father died of a hospital-acquired infection, who lays out how patients are not regarded nor treated as customers by the system (and the incentives discourage it).  Goldhill described health insurance (differentiating it from coverage, care, services, and just straight up health) a form of financing that comes with “heavy administrative costs”; ideal for circumstances that rarely occur, but when they do, are very costly (true for car insurance and life insurance).  According to him, we never acknowledge the trade-offs: if we didn’t pay so much into the system, we’d have a whole lot more to spend–on education, wealth accumulation, etc.  Things that most likely could be good for our health (gym membership?  entering the NYC marathon at the STEEP price of $185!) and our happiness.  But we’ve been conditioned to think that the only way to have financial security for our health is the existing system.  And NOT consider the trade offs (security is priceless).  Or, even really evaluate the trade-offs–the body of literature looking at what the money could have done if we’d not poured it all into health care is scant if not nonexistent altogether.  Most of his points are laid of fairly clearly in his (rather long, but worthwhile) piece “How American Health Care Killed my Father” in the Atlantic, so I won’t summarize, but, his value to me (again, the sociological bias), was that as a health care outsider, he noticed the special language that has evolved (when was the last time you heard “price” of services mentioned in the dialog?  Cost and reimbursement rates are two more frequent terms) and he approaches health care with a business-oriented perspective that has been relatively absent.  Is he an expert?  No.  Should we put him in charge of reform?  No.  Should we be able to answer the questions he poses?  Definitely, and I think that was his main value as a speaker: raising questions that are currently unanswerable (including those about tradeoff), and fairly fundamental if our ultimate goal is improving health (and perhaps even more broadly, well being) at the population level (vs. salvaging a broken system).

I’m interested in his assertion that health care costs are growing faster than income across the globe—is it possible that the U.S. is just ahead of the curve in reaching the breaking point?  Maybe more on this another day; I’d like to explore a little deeper and see what statistics and explanations are out there.
Kessler summarized a lot of what had already been said and added a bit more of a legal, economic perspective, including a reference an article by Greg Mankiw (Harvard professor of economics and adviser to President George Bush) that explained the marginal tax rate disincentives embedded in the proposed health care legislation.  Another piece he commented on was Gawande’s recent article on agriculture along with Alan Enthoven’s  impassioned response on the Health Affairs’ blog.   While he was pro-experimentation, he cautioned, “We can’t treat experiments as a cure—by definition, we don’t know if they will work.”  He also compared current reforms (from the industry perspective) as the razor blade strategy–they can let the government drive down the cost of the razor all day, because they know that we still have to buy the blades (and they’ll retain control of that price and make up the difference there).  Without fundamental change, they keep winning because the game just changes superficially.

Several have argued that without broad support from physicians, any legislation will never pass.  As Leonard Schaeffer (University of Southern California) mentioned during his comments and build-up to a question to the speakers, the New England Journal of Medicine recently reported that the majority of physicians are not in favor of measures that use cost-effectiveness data to reduce utilization of services.  Will popular fear overcome faith in physicians?

I asked a few doctors-in-training for their thoughts on the event.  Their comments included:

[what I found most poignant were] “Mr. Goldhill’s comments that his dry-cleaner was ahead of his doctor on implementing IT because the incentives are so perversely aligned in healthcare that providers have no reason to improve”.  Alluding to that sense of urgency: The “alternative perspectives” presented in this symposium were not proposed adjustments to reform, innovative solutions or visionary proposals in any respect. The entire discussion revolved around critiquing the reform bill and postulating the direst outcomes, Some points were valid and significantly concerning, the legislation is far from perfect, but reform is inevitable and we have to face difficult realties. Why is so much of the time and engery of these brilliant experts spent nitpicking and naysaying instead of formulating solutions of their own? In this critical time, we need more than just perspectives.”  (From Ian Metzler, Harvard Medical School class of 2012; 2009 IHC Director)

Another felt that the central issues on his mind were not addressed in the debate. “Few have seriously addressed the question: what would happen if the bill passes, medical expenses skyrocket, but the projected savings don’t materialize? Some of the speakers offered an ominously plausible scenario in which Medicare and Medicaid go bankrupt, leaving a great number of Americans without insurance. By then the political climate would by necessity favor the idea of a nationalized single-payer system, but many lives would be lost along the way. Hopefully it won’t
take a national medical catastrophe for Washington to look beyond partisan interests and put in the sincere effort and resources needed to enact true reform.” (David Mou, Harvard Medical School class of 2013, 2010 IHC Director)

The speakers spent little time discussing how to engage physicians in the process of creating, advocating for, or implementing worthwhile reform, even when directly asked about physician opposition to current legislative activities.  Can we just view physicians as a part of the system–once we figure out how all the pieces fit together, we can just assume that they’ll tow the line?  Or, are they destined to be leaders, whether for better or for worse?

My only regret: that it happened at Harvard, and not in Washington.  Hopefully we don’t have to wait a generation to get to the action.

This post was written by Maria A. May.

Written by Maria May.

The survey results illustrate the public’s frustration with the health care debate in the last few months.  Despite the town hall meetings and constant media coverage, many individuals feel disconnected from the debates in Washington, with some complaining that Congress is more focused on the interests of lobbyists.  Yet, according to the poll, the public still remains evenly divided on whether interest groups are important to carrying out changes to the health care system. According to the survey results, respondents least trusted groups that represent insurance companies, drugmakers and large corporations. The most trusted groups were those representing nurses (with a 79% vote of confidence), followed by groups representing patients, doctors and seniors.

Robert Blendon, one of the authors of the polling report, and Professor of Health Policy and Political Analysis at the Harvard School of Public Health and Harvard’s John F. Kennedy School of Government, suggests that too much blame is placed on insurance and pharmaceutical companies and the federal government.  In an interview on NPR, Blendon suggests that there is not enough focus on the delivery system.  The public’s confidence in nurses, patients, doctors and seniors contributes to the disconnect and a as a result, misunderstandings occurs.  The public disagrees with lawmakers in Washington, but they also seem to disagree on who is causing the problem, according to Blendon.

In a recent blog post, Karen Davis, president and C.E.O. of the Commonwealth Fund, suggests the debate should focus on the areas of consensus among interest groups and politicians, rather than differences or individual preferred solutions.   She lays out the areas in which there is a common ground across all proposed bills. Davis encourages a “consensus-minded approach” in debate and when moving forward with legislation.

Considering the public’s trust in physicians and health care providers and the perceived detachment from current debate, how can physicians help bridge the gap between the public’s perceptions and political activities in Washington?  Do survey results highlighting society’s reliance on physicians to help them navigate the reform place a greater responsibility on providers to educate and represent public interests?

Karen Davis will be speaking at Harvard Medical School on October 9^th as the first guest in the annual Tosteson Lecture Series, which is organized by Improvehealthcare.

Written by Elizabeth Goodman-Bacon with assistance from Maria May.

Written by Elizabeth Goodman-Bacon with assistance from Maria May.

Sachin has recently published several articles on health policy that I thought some of you might be interested in reading.  One article in Modern Health Care chronicles his discussions with hospital executives on how to select effective leaders.  Another is more locally focused on improving the organ donation program in New Jersey, but has national relevance.  Sachin also published an article in Focus, a Harvard publication, emphasizing the need for a new alternative to “death-by-waiting” for patients with organ failure.

We look forward to more articles from Sachin and other IHC members.

I came across an article last week describing the Brazilian health system and what the U.S. could learn from it.  The historical perspective provided in the article is very interesting–the national program emerged as an effort to improve access to high quality care.  It has a decentralized management structure, but a central financing mechanism to prevent corruption at the local level.  Over 80% of the population has enrolled in the public insurance system.
Ever since Brazil decided to forgo U.S. money to fight AIDS because of restrictions around work with commercial sex workers in 2005, I’ve been interested in their health policy.  At one point, Brazil and South Africa had similar rates of HIV infection; now, South Africa’s epidemic has greatly outpaced Brazil‘s.  Brazil responded quickly with universal access to testing and once it became available, free antiretroviral therapy.  It continues to be held as one of the most successful national responses to HIV.
Brazil‘s health system is now being tested as Brazil undergoes the epidemiological shift that accompanies economic growth: the transition from infectious to chronic conditions.  As we see in the United States, conditions such as diabetes can tax health systems enormously; recent studies show that as many as 80% of large employers have contracted with chronic disease management groups to contain costs (more on that next week).  Brazil‘s health system seems well designed to handle the shift–since its inception, it has incorporated public health principles and strategies into its delivery model.  From vaccination campaigns to improved public sanitation, Brazil was able to greatly reduce the burden of some infectious diseases, such as rubella, and infant mortality rates.  Often, public health approaches to illness are more cost effective than biomedical solutions, and I would argue less invasive or costly (in terms of time, pain, anxiety, and money) for patients as well.
I wonder at the lack of public health principles that appear regularly in the dialog around health reform.  With obesity and tobacco topping the charts as causes of mortality and morbidity, they seem like obvious parts of a comprehensive response.  A third of adults are obese. Doctors are well versed in obesity’s myriad links to poor health outcomes, but its economic costs on the system are also significant.  Recent studies found that the average health care costs of an overweight American are $732 more than an American with average weight.  A study from 2003 found that a whopping 9% of medical costs were due directly to overweight and obesity, based on Medicaid and Medicare data.

There is a concept called “flat of the curve” spending, in which the marginal returns (amount for each additional dollar put in) approaches zero. Many have used this term in reference to pouring more money into a health care system, instead arguing that we should find new areas to invest that will provide a greater “bang for our buck”. I’m sure that there is a lot of relevant research that has fleshed out these issues in more depth, but I would be in favor of diverting the money flowing into the health care reforms to other health-related interventions: improving the food in public schools, making neighborhoods safer, reducing violence, even improving access to social services. A recent report from the Robert Woods Johnson Foundation lists more recommendations that focus on factors outside of the traditional purview of health care.

Bearing the costs of care has forced public health into dialog about health care in Massachusetts. Since the implementation of health reforms that expanded state-sponsored coverage and made insurance mandatory for most residents, Massachusetts has strengthened some of its public health efforts.  Coverage of the annual flu vaccine has increased significantly, and recent legislation in Boston prohibits pharmacies and convenience stores on college campuses from selling tobacco products.  It’s no secret that costs of the Masshealth program greatly exceeded predictions; finding more cost effective ways to approach health will be critical for the sustainability of the reforms.  As the new administration considers policies at the national level, it would be prudent to look at solutions outside of the hospital as well.

If doctors have hammers, do they only see nails?  As in, are physicians only good at prescribing a biomedical solution to a health issue?  Perhaps doctors are so trained to see conditions through a clinical lens that this is a contribution that they will not make to the dialog.  But who else will?  Doctors have a unique level of trust and legitimacy from the general public.  Must physicians always think about patients individually, rather than promote change at the population level?  I would welcome comments exploring these questions, and ways in which medical education treats (or should treat) public health.

For a totally different way of thinking about public health issues, check out a february post on the consequences of tobacco use and obesity on the Freakonomics blog.

Since then, I have also articles on what we can learn from the French health care system, Mexican health care system, and collective experience of countries that have moved to universal health coverage as well, if you’re interested in the global perspectives.

Maria May

http://www.nytimes.com/2009/03/03/business/03medschool.html?_r=1&ref=opinion.

The NYT article presents one side of this debate, highlighting concerns about industry compromising the integrity of teaching and research at Harvard.  However, this is only one side of the debate.  The opposing side is articulated in a rebuttal below, in which a defense of industry’s presence at academic institutions, including Harvard, is offered:

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Despite concerns over the influence of pharmaceutical companies on academic medical centers, pharmaceutical companies should continue to be allowed to have a presence at HMS.  Academic-industry relationships can bestow many tangible benefits on universities and researchers without compromising the integrity of research, medical education, or patient care.  HMS reaps the benefits of its relationship with the pharmaceutical industry; for innovation and scientific advancement are the fruits of industry support for: research conducted here, paper publication and conference attendance, employment of student researchers, and the development of ideas and research areas that would not otherwise receive funding (Campbell and Blumenthal 2008).

Academic-industry relationships can be “defined as arrangements in which academic scientists carry out research or provide intellectual property in return for financial compensation in the form of cash, equities, and other considerations” (Campbell and Blumenthal 2008:781).  These partnerships between universities and the pharmaceutical industry may take the form of research, consulting, licensing, equity, training, or gifts.  Industry support for university-based research through the provision of grants (typically small in size and short in duration) can serve as an important source of funding for faculty salaries and facility fees (particularly amid a poor economy and reduced federal funds).  In turn, this frees up money for the institution to invest in other ways while simultaneously providing a source of supplementary income (and thus incentive to attract the best and brightest) for faculty members who frequently have taken a pay cut to work at an academic institution instead of in private practice.  The usefulness of academics serving as consultants to industry is similar in terms of supplementing salaries, as well as providing another means to support professional activities such as conferences and paper publications.  Moreover, support for graduate training programs and medical education is another area where close relationships between universities and industry can be highly beneficial; for educational programs and continuing education can be costly, and industry support helps relieve the financial burden on cash-strapped institutions and allows additionally useful training sessions to be provided for scientists and health care workers.  Finally, the benefits of licensing and equity will be discussed below.  These are all benefits indirectly felt by the public in improved services/care and new products.

However, a historical perspective is necessary in order to fully understand the importance of allowing a pharmaceutical presence at HMS and other universities.  Although academic-industry relations are not a new phenomenon, scientific, political, and legal developments during the 1970s and 1980s occurred to strengthen ties between academic institutions and the pharmaceutical industry as a means of financially incentivizing scientific advancement.  Particularly as the field of biotechnology began to take off, policymakers realized the importance of scientific investment and technological development as potential drivers of economic growth.  Up to that point, however, academic scientists had only disciplinary recognition and acclaim to motivate their research (weaker motivators than financial incentives), but the passage of the Bayh-Dole Act (allowing universities and researchers to own products developed with federal research money) and the Diamond v Chakrabarty ruling (allowing patents for biologically manipulated life forms) provided great financial incentive for research efforts and added a new level of motivation for academic researchers to advance their field.   Such financial rewards were reaped with the help of industry, which was eager to aid academics in the exploitation of the commercial potential of breakthrough discoveries.   As such, the partnership between academia and industry became further entrenched as a means to advance research and science; this was a mutually beneficial relationship though as industry also developed a pipeline for new commercial products while funding more research at universities and providing even greater incentive for faculty research.  The breakneck pace of scientific development went hand-in-hand with the rise of incentives for researchers and closer relationships with industry.

Thus, the commercialization of academic research has yielded great public benefits in the form of scientific breakthroughs and the development of an array of products.  Economic incentives are powerful motivators of innovation, as psychology literature will attest; for people work harder when they have something to gain, or if they hold a stake in the pursuit (licensing and equity).  The large number of faculty who have also established start-ups to capitalize on their research is a means of aligning financial and academic research incentives.

It is important to recognize, however, that although pharmaceutical companies should be allowed to have access to HMS as an institution and to the students here, it is critical that certain safeguards are in place to protect the integrity of the research conducted here.  Financial conflicts of interests have the potential to influence research findings, so industry should in no way be given a carte blanche to operate as it pleases at HMS—particularly since the reputation of HMS and its faculty rests on their ability to generate objective scientific findings, which is essential for the maintenance of public confidence in scientific research.  HMS should take a proactive approach to preserving truth, objectivity, and proper protocol in research; to ensuring that scientific breakthroughs and developments occurring in university labs are not veiled in secrecy or delayed in publication; to protecting research participants through IRBs and full disclosure policies; and to ensuring a lack of conflicts of interest in oversight bodies.  This is especially important in the case of IRBs, where members are charged with the responsibility of protecting research subjects—making it critical that members are not strongly tied to industry so that they can objectively judge research protocols (i.e. HMS should avoid a situation as arose at Duke in 1999 over compromised IRBs).  Disclosure policies are a significant component of these efforts, and the monitoring of appropriate industry-university relations would benefit from a database that kept all of this information.  Moreover, industry provision of gifts should be banned in cases where they are not instrumental research (although in the survey cited in Campbell and Blumenthal 2008, 66% report that the gifts were in fact important to research).

If these standards are implemented and enforced at HMS, the benefits of academic-industry partnerships can be preserved, while protecting against possible excesses.  Under those circumstances, it is clear that the advantages of having a pharmaceutical presence at HMS far outweigh the drawbacks.

Video footage of the Tosteon lecture and the summary of IHC’s exclusive interview with Dr. Gawande will be posted on the website soon.

Checklist website referenced in NEJM article: http://www.safesurg.org/ You can also watch the recent appearance of the surgical checklist on ER on this site (very dramatic!).

While the shortage within itself is troubling, more troubling to me is that we continue to use and expend a delivery model that relies on a scarce resource. Is this sustainable? Will it produce the best outcomes, and at the best prices?

The concept of task shifting in health care has been well discussed in the developing world context (see WHO guidelines). In places where there is an absolute shortage of doctors, such as Zambia, where there is an HIV prevalence of about 16% and about 1 physician per 10,000 (nationally, though most doctors are concentrated in the cities), the only way to even begin to meet health care needs is to engage other medical professionals. Zambia chose to allow nurses to prescribe antiretrovirals. In three years, one NGO alone, the Centre for Infectious Disease Research in Zambia, has enrolled over 108,000 in HIV care and 70,000 on antiretroviral therapy. In Bangladesh, under the supervision of BRAC, a huge cadre of village women, most with just basic literacy, engage in active case finding for TB, assist with the collection of sputum smears, and oversee the treatment of all patients in their village (Achieving a treatment success rate of over 90%, I might add).

When there are no other options, it may seem only reasonable to find other professionals or lay people to deliver health services as much as possible. But should we rule it out when we have other options? How can doctors be utilized most effectively? They have huge amounts of training and have the skill to face complex health conditions. Can simple ones be diverted to lesser trained caregivers? Increasingly, we see this domestically as well. Retail clinics, such as Minute Clinic, are trying to cull common, easily diagnosed and treated illnesses out of the emergency room and into a new location–a local Walmart, CVS, or other retail store. These are staffed by nurse practitioners–no doctors on staff–and use a novel pricing structure. These new stores have incurred great wrath from physicians, but they are thriving financially–several large insurers in Massachusetts recently announced that it will reimburse care received at retail clinics. Other examples, such as one included in Bohmer’s recent article in Health Affairs, include Duke’s use of a NP and cardiologist team approach to congestive heart failure patients, limiting interactions between doctors and patients to only complicated cases. Boston’s Prevention and Access to Care and Treatment (PACT) organization provides wraparound services for HIV patients who are failing to adhere to their treatment regimen due to social and economic challenges. The work of lay adherence counselors underpin PACT’s model. They have demonstrated that their patients’ total health costs decrease and their health increases, but it’s unclear in the current system which player should pay for PACT’s services.

As future physicians, what are your thoughts on these new delivery models? What doctors overestimating their own skills relative to other medical professionals? How should we evaluate new delivery models? If you’ve had experience studying or working on a model that differs from the traditional US model (physician-based), it would be great if you could give us a sense of the quality of the services provided.

Maria May

Many medicines prescribed at la Clinica can be bought for $4 for a month’s supply at Wal-Mart or Kroger pharmacies. But sometimes, doctors want to prescribe the drug they really believe to be most effective, but instead must settle for a drug on the $4 list since that is better than prescribing a drug that the patient cannot afford to buy. (Question: Is the $4 cost of drugs available at Wal-mart and Kroger due to government subsidies for this medication or because they are generics or another reason?) A way to continue to make prescription drugs more affordable would would be to increase access to necessary medicines for patients. This should be a priority for the next administration. Additionally, though Obama’s healthcare plan does not contain a mandate for everyone to buy health insurance as in Massachusetts, a mandate seems to be necessary to get “invincibles” to buy into the system so that premiums go down for everyone. Even though Obama says if costs go down, people will buy health insurance, is that really going to happen? How else can the pool increase if there is no mandate to buy insurance? Moreover, the new administration could provide incentives for primary care doctors to practice in areas of critical need, for example, by offering to pay back some of doctors’ medical school loans. The administration must realize that rising healthcare costs and lack of access to healthcare are inextricably linked with the economy’s woes, and that to fix the economy, healthcare must be a top priority.