X-prize = Build the perfect health system

Readers of Health Policy Dialog...check this out. This is a really exciting offer from the X-prize this year to design a new health care system for an American community. Would be really exciting to develop a model system (though the scope is small only 10,000 people).

http://www.xprize.org/future-x-prizes/healthcare-x-prize


WASHINGTON (Reuters) Apr 15 - Organizers of the X Prize, who have set up
contests for space travel, DNA research and super-efficient cars, said on
Tuesday they are offering $10 million to the winner of a contest to
transform the health of people in a small U.S. community.

They invited written ideas for the Healthcare X Prize, and said they would
choose five for a three-year trial run in real communities or at employers.

The winner would be chosen based on a "community health index" of measures
such as an improved ability to climb stairs, reductions in visits to
emergency rooms and health costs.

"We need to show that the innovation works and then that the innovation is
scalable. It's going to be a public solution," Angela Braly, president and
chief executive officer of WellPoint Inc, a major U.S. health insurer that
is helping sponsor the prize, told a news conference.

"We are looking for teams to help individuals and communities proactively
improve their own health and (that) of their families," added Dr. Peter
Diamandis, chairman and chief executive of the non-profit X Prize
Foundation.

"Teams are actually going to have to design and implement a system across a
community of 10,000 people that improves health by 50 percent during a
three-year trial period."

The competition and all results will be audited by an independent panel of
judges and "trusted third parties," the group said in offering the prize
plan for a 45-day public comment period.

"The Smithsonian would never have funded the Wright Brothers to invent the
airplane," said Newt Gingrich, former speaker of the U.S. House of
Representatives who now helps head up the Center for Health Transformation.
"I think this will bring diversity."

The plan gives teams 18 months to conceive, model, and submit their plans.

Healthcare reform is near the top of the agenda for President Barack Obama,
the Congress and U.S. society as a whole. More than 80 percent of Americans
have said in several surveys they believe the U.S. healthcare system needs
substantial reform.

The United States ranks last among 19 industrialized nations on health
outcomes, quality and efficiency, according to a report by the non-profit
Commonwealth Fund.

In 2008, the United States fell from 15th to last on measures of
preventable death from chronic conditions such as asthma and heart attacks,
the report found.

Medical bills cause half of all U.S. personal bankruptcies, most among
middle-class workers with health insurance, according to a 2005 study by
researchers at Harvard University.

Global Health Career Advice

Kris Olson , in prep for our panel on GPH careers this Friday, shared this document with me:

Global Health Career

V. good set of questions to consider for people considering careers in global health. I think our group's list posted earlier today is more comprehensive in terms of where GPH jobs are. The broader questions are all worth considering... sort of the pro/con/considerations when weighing which of the options we listed before one should take...

Specter To Switch Parties - The Caucus Blog - NYTimes.com

Specter To Switch Parties - The Caucus Blog - NYTimes.com

This is unbelievably huge for health care reform given the recent nuclear option Obama was talking about earlier this week to avoid a filibuster when the HC bill comes up later this spring. Granted, it strikes me he did this partially to preserve his senate seat given he was losing to his opposition in the Republican primaries... but Specter has gotten much more moderate in recent years, and there really isn't space for moderate Republicans (see prev. post on Sebelius). His support on expanding NIH funding was critical. I'm thrilled for the short term debate on health care, but for the sake of the long term, I do hope the Republican party gets its act together and can put up a sensible opposition so we can have a healthy debate of a spectrum of ideas.

Just noted that kedar talked about this on his post also

Goosby for PEPFAR

This story comes buried on a day of some very serious political transformation with Arlen Specter switching party loyalty and clearing the way (possibly) to health care reform amongst other heavily democratic policy priorities:
Eric Goosby from UCSF was named yesterday to be Obama's pick for PEPFAR. Goosby's a Clinton-era veteran with good global health credentials (runs Pangaea). Will be interesting to see if he can keep up the funding line for PEPFAR which some have reported may be under threat.

Careers in global health

Am on a small informal panel discussion end of this week at MGH on careers in global health. Kedar, Nupe and Celine helped me put together this initial tree of careers in global health to help me prepare. If you have any thoughts, please let us know on how we can improve this. Thanks -

· Academia

o university based NIH research

o center based (e.g. HIGH) or divisions of Global Health at Hospitals (Penn, Pitt, BWH, MGH, UCSF, WashU, Columbia, etc) a la Salman Keshavjee, Jim Kim

o Maintain an academic faculty position as a hospitalist or consultant essentially at 75% time and spend the rest of time abroad with another institution further down the tree

· Industry

o pharma (e.g. novartis vaccines)

o consulting (e.g. mck, broadreach)

o occupational health (e.g. mining companies, agriculture, environmental health)

· NGO/ Non profit

o country specific (e.g. PHI - haiti/Rwanda, Aurum Institute for Health Research)

o theme based (e.g. MSF, IHI - pt safety / quality)

· Foundations (Gates, Rockefeller, Clinton, KFF, Elizabeth Glaser, Doris Duke, UN Foundations)

o portfolio manager (e.g. circ funding evaluator for gates)

· US Gov't

o Development based entities (e.g. USAID)

o foreign policy based entities (e.g. state dept)

· Multilaterals

o WHO, UNICEF, UNFPA

o WB - looking for docs to help them evaluate country loan proposals and make sure funding is in line with objectives

· Advocacy

o in-country: Treatment Action Campaign, AIDS Law Project, ARASA

o US-based: Treatment Action Group

· Bioethics

· Regulatory/Intellectual property

· Think tanks e.g Council on Foreign Relations

Allocation of US Global Public health funding

Kedar, thanks for linking to the KFF report.

What is interesting is that there is essentially a 50-50 split between the two engines of US GPH funding disbursement - the state department which is interested in GPH as a foreign policy tool, and the "development-oriented" entities like USAID. I wonder if this mix has changed over time (I imagine more has shifted into state dept over time) and what has driven this shift (rise of Anti - american terrorism and understanding that destabilized countries from famine, poverty, health inequity could be addressed through gph funding).

Also most money goes through bilateral channels. Wonder if this will change in Obama's new vision of multilateral global cooperation and what impact that will have on reprioritization of GPH issues.

Sebelius nomination and the RNC

I haven't been following the Sebelius nomination too closely, as I assumed that it would be with minimal issues. Michael Steele's comments (RNC Chairman who has been more scared of Rush Limbaugh than the American public) that Sebelius should be blocked unless she discloses more about her position on late-term abortions is ridiculous.
First off - the problems of the American health care system has nothing to do with the abortion debate
Secondly - isn't abortion now just a legal issue that will be decided in the Supreme Court? I'm sure there's probably some minor, arcane stuff that HHS could do, but in the end this is a legal issue.

So frustrating. Can't imagine that michael steele will be around much longer.

----
24 April 2009
The Boston Globe

The head of the GOP called on President Obama yesterday to withdraw Kathleen Sebelius's nomination as health secretary unless she answers more questions on abortion, after Republicans blocked immediate action on Sebelius's confirmation in the Senate, probably pushing a final vote to next week at the earliest.

Michael Steele, Republican National Committee chairman, said Sebelius, the Democratic governor of Kansas who would complete Obama's Cabinet if confirmed, has not been forthcoming about her ties to a Kansas abortion doctor, George Tiller.

"Significant questions remain about Governor Kathleen Sebelius's evolving relationship with a late-term abortion doctor as well as about her position on the practice of late-term abortions," Steele said in a statement. "If Governor Sebelius and the Obama administration are unwilling to answer these questions, President Obama should withdraw her nomination."

The White House declined to comment. A spokesman for the Senate majority leader, Harry Reid dismissed Steele's complaints.

"This is nothing more than a baseless attack from someone desperate to stake a claim as the leader of the leaderless Republicans and get right with the right-wing of his party," said Jim Manley, spokesman for Reid.

The Senate Finance Committee approved Sebelius this week with 2 of 10 GOP votes. Several Republicans - including the top committee Republican, Chuck Grassley of Iowa - raised concerns about her initial failure to tell senators how much campaign money she got from Tiller.

When the discrepancy became public, Sebelius acknowledged getting an additional $23,000 from Tiller and his abortion clinic beyond the $12,450 she initially reported. She apologized and said it was an inadvertent error.

Sebelius told the Finance Committee that she personally opposes abortion, but she also has a long record in Kansas politics of supporting abortion rights. She has drawn the ire of antiabortion groups for repeatedly vetoing legislation sought by antiabortion groups to impose more regulations on abortion clinics and rewrite the state's restrictions on late-term abortions, including yesterday blocking a bill to require doctors to provide more information to the state.

USG investments in Global Public Health

Ever wondered exactly how the USG invests its dollars in global health...Here's the breakdown from KaiserFF and Stimson Foundation. Very enlightening and interesting reading for anyone working in the field.

High Level Commission on Global Public Health

The newly formed "Commission on Smart Global Health Policy" will advise the Obama administration, among others, on how the US should spend its substantial resources on global health. This Commission will issue its report in December 2009 and will likely have a big impact on funding priorities for the largest overall financial contributor to global health budgets in the world. William Fallon and Helene Gayle to co-chair the Commission.
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=58139

The Economist
Health care in India: Lessons from a frugal innovator
http://www.economist.com/displayStory.cfm?story_id=13496367

NEJM -- Health Care and the New Administration

Just came across this link - very easy to navigate compilation of US Health Care Reform articles published in the Journal -

NEJM -- Topics -- Health Care and the New Administration

Changes in the Incidence and Duration of Periods without Insurance

Fascinating article which I'll need to dig deeper into. In short - David Cutler (Harvard health economist, advised Obama during campaign) has written an article in NEJM -- Changes in the Incidence and Duration of Periods without Insurance.

Key points in discussion are:
-Incidence of uninsured periods is rising over time

-When people become uninsured they are uninsured for shorter periods

-Uninsured periods are shorter because more people are obtaining public insurance

-From 2001-2004, persons in fair or poor health were substantially more likely to lose and to gain insurance as a result of the increase in public insurance

My thoughts:

-Time periods of comparison of 83-86 to 01-04. Uninsured periods were shorter likely due to expansion of economy which led to 1) greater employee health benefit access and 2) expansion of public health programs as tax base increases (and efforts to expand coverage for children)

-Incidence of uninsured periods rising maybe due to decreasing time with employer, leading to increasing periods of unemployment

- Rise of public insurance may crowd out private insurance

- The recession is going to have a profound impact on these trends. States can no longer continue to fund at the rates they have been - there will be likely reduction in public health benefits and programs. Unemployment is at some of the highest levels we have seen in recent history.

- This all makes me question the sustainability of current employer based health care:
*when patients are sick, they are more likely to lose their job
*the disabled account for I think approximately 10% of the uninsured but account for 50% of health care costs of the uninsured
*those who are employed are increasingly finding themselves "underinsured" - due to expansion of public health insurance and rising costs which limit the coverage that employees can provide

Thoughts that definitely need to be fleshed out and definitely need more of a fact base. Curious to hear your thoughts.

Linking Health Care to Economic Opportunity

Today I attended the 2009 Annual Hope Street Group Colloquium. The HSG is a bipartisan think tank focused on developing and implementing policies that promote economic opportunity - currently around the issues of education, health care reform, asset building, job creation and home ownership.

My role specifically is as a participant of the bipartisan working group on health care reform and adviser to the Economic Opportunity Index.

Economic Opportunity Index (EOI) | Hope Street Group

The EOI is a tool that policy makers, media and citizens can rely on to assess the potential impact of policies (such as health care reform) will have on economic opportunity for all Americans. The Index measures individual economic opportunity, as defined by "expected lifetime real income":
-Expected - luck, circumstance, and scoietal change always play a role in economic outcomes
-Lifetime - a single year might give a misleading snapshot of one's overall circumstances
Real - adjusted for inflation
-Income - economic, rather than non-economic opportunities such as freedom of expression

The EOI is an interesting tool that I think can really help policy makers quanitfy and measure economic opportunity change from policy reform. One of many challenges the Obama administration will have as the conversation heats up around health care reform is to explain to the public WHY health care reform is needed. I'm starting to come to the opinion that any health care reform in America will limit access (for those who already have access) in order to drive real meaningful cost control. If you limit access, you need to explain why they - and the entire system - will be better off. I have more thoughts on that, which I will post in the next few days.

Anyways, back to the EOI. The EOI looks at health care by determining what factors lead to better health - which implies more capacity for work and more productive working years. Some examples of factors are diabetes prevalence, worker absenteeism, violent crime rate, etc. So concretely, what if we increase access to health care from x% t o y%? How would that change what white women could earn?

As I listened to the conversations today, two things struck me. First, the need to sell health reform to the public - and I think the EOI can help push this. Secondly, if we decide to continue with employer based health care, then employers need more tools to understand how their employees' health can lead to more productivity. Large corporations - the Microsofts and GEs of the world - already get this, and are concerned about health care costs. However, the smaller companies need easier tools to allow them to quantify impact of improving health care on their worker productivity - because in addition to offering it as alternative compensation, employers provide health care to keep their employees productive.

Anyways, my role developing the health care portion of the EOI is just starting, but take a look, let me know what you think of the tool, and if there is anything you think is missing or can change. This is interesting for me since I have always looked at health care in isolation - how do you drive quality, contain costs and increase access - but this is the first time that I'm pushing myself to connect health care to larger macro and microeconomic phenomenon.

Over the course of the week I'll continue to post thoughts from the colloquium itself.

How far away are we from personalized medicine?

This week's NEJM has a number of articles on genomewide association studies and genetic risk prediction.

NEJM -- Genomewide Association Studies and Human Disease

Courtesy of a company called Proventys, I came across this curve below, which I found helpful in thinking about what personalized medicine could really mean, and what are the levers available for delivering it. Of disclosure, Jeff and I know the Chief Medical Officer - Surya Singh - who is also a hospitalist at the Brigham.


As you see from this chart, genetic studies can help determine both baseline and preclinical risk. However, I think we can continue to do more in developing out clinical risk models - that tiny little last bullet under dynamic testing. As we digitize more medical records, and migrate to increasingly standardized medical vocabulary, I can imagine a not so distant future where with powerful computing and robust clinical risk modeling, a physician can better understand and act upon a patient's "preclinical progression" or predisposition profile. This week's NEJM articles suggest unfortunately, that we may be further from understanding baseline risk than we originally thought, but that doesn't mean that personalized medicine is dead in the water as the New York Times suggests.

The NIH Stimulus Package

NEJM -- The NIH Stimulus -- The Recovery Act and Biomedical Research

The US health care system, despite its many issues, is the undisputed leader in health care research and innovation: more than two-thirds of all Nobel laureates in medicine over the past decade worked in the United States, and more than 80 percent of venture capital in the global health care sector flowed to the United States in 2007 (McK quarterly, Dec 2008).

The NIH is, in my opinion, is the primary driver of innovation in the health care system. The charts in the article are powerful - essentially a flat curve in the budget from 2003 to 2009, when you adjust for inflation.

I was in DC for the past two days, and had an interesting conversation with a Robert Wood Johnson Scholar, who said she's seen research where the average age of R01 awardees is rising, suggesting that people aren't getting their K awards funded as quickly as they used to (the entry level grants) and the old-timers keep accruing grants and aren't giving up to allow the younger folks to enter the research "market".

I know this bill has kept a few of my friends interested in pursuing research careers - they feel that the government is finally interested again in promoting meaningful biomedical scientific research. Hopefully we can sustain NIH's growth, and continue to keep bright, young talent within academia.

Docs who facilitate torture should lose their license

Pardon this entry if it is preaching to the converted. I hope most people have seen or read about the Red Cross report that outlines the role that American health care providers, including physicians, played in torturing detainees in Iraq and Cuba. (http://www.nytimes.com/2009/04/07/world/07detain.html?scp=1&sq=red%20cross&st=cse) Doctors, psychologists, and PAs monitored torture episodes, including waterboarding, prolonged standing (of amputees), and confinement of people in small boxes. Some of their actions, such as monitoring pulse oximetry during waterboarding, directly facilitated torture.

Some may argue that these doctors' activities protected torture victims. However, I believe this line of reasoning dumbs-down the essence of medicine and ignores the true role of a doctor: to serve as an advocate for patients. Patients are people at their most vulnerable moments: they are sick for reasons they often do not understand. They may not be able to think clearly. They are cared for in hospitals and clinics foriegn to them, and trapped in health care systems that, around the world, are at best confusing and at worst harmful. And they are scared, even if they are not being tortured.

The role of a doctor is to serve as a champion for patients, and to ensure they thrive amid the chaos of illness. Making sure they do not die during torture does not meet this bar. Health care providers need to stop torture before it happens. If they cannot do this, they need to speak up and publicize what is happening. Unfortunately for the medical professionals involved in torture, speaking up or taking other actions to help their patients may have cost them their jobs or landed them in legal trouble with the military. While this is certainly an unenviable situation, I do not think these costs outweigh their duty as physicians and other medical providers to care for their patients.

Implications of pushing the limits of when to start HAART for HIV infection

NA-ACCORD data is out - an observational cohort study that attempted to shed more light on the age-old question that has plagued the field - when do you start HAART. Below is the link to the NEJM commentary by Sax and Baden:

NEJM -- When to Start Antiretroviral Therapy -- Ready When You Are?

The commentary is thoughtfully written, but seems to sidestep the major question in my mind - assuming we shift recommendations to early HAART initiation - what is the implication for implementing these recommendations in the developing world, where a majority of new and existing infections reside? Already countries are cash strapped to expand public health expenditures, and I understand the GFATM is concerned about it's coffers given the global recession. This study has clearly pushed for the clinical effectiveness - now comes the tricky costing exercise to see what's "cost-effective."

I know that there are actual RCTs out there - HPTN 052 / ACTG 5175 I think was supposed to answer a similar question on when to start - curious to hear what folks think.

Drug trials in the developing world

Pfizer to pay �50m after deaths of Nigerian children in drug trial experiment - Africa, World - The Independent

I have to sadly admit I didn't realise the Constant Gardner was based on a true story.

I once took a look at global clinical trials, and a majority of big pharma clinical trials done in the developing world is for infectious diseases, cardiovascular disease or oncology (this is all public access information from clinicaltrials.gov). Many of them use contract research organisations to conduct their clinical trials. This industry is very sophisticated now (the outsourcing of clinical trials) so hopefully this sort of blatant disrespect of human life and the scientific process won't happen again, but unfortunately, I suspect it will without proper oversight (formal or informal).

Rehospitalization as a cost driver - is it important?

Article yesterday in NY Times highlights a NEJM paper that found that almost 20% of Medicare patients are rehospitalized within a month of discharge.

Many Medicare Patients Rehospitalized, Study Finds - NYTimes.com

The paper estimates that rehospitalization costs the system $17 billion and then there's a quote from Dr. Anne-Marie J. Audet of the Commonwealth Fund stating "“Given the current financial situation, this is no longer something we can ignore.”

I'm convinced there's an argument around QUALITY of care, but not convinced that it is a pressing issue for COST CONTAINMENT.

Let's have some fun with maths. Assuming a formal health economy of $2 trillion, readmissions only account for 0.85% of US health care spend. Now let's say I'm being unfair - let's limit to only US inpatient spend of $458 billion in 2006 - that's still only 3.7% of spend. Then one can argue this is a Medicare patient population - and that given their age, one is to expect that a portion of these patients are in their last years of life and will of course need multiple readmissions. So the real question is what is the cost to the system of unnecessary readmissions. Granted, maybe that's what this study did - I need to dig a bit deeper. Regardless the numbers don't work for me to be convinced that there is a pressing cost issue here.

Amy Boutwell, a colleauge of ours and a med school classmate, is quoted by the NY Times in this piece - she now works at the Institute for Healthcare Improvement - let's see if we can get her to comment on the importance of readmissions. Keep a note for comments and hopefully we can get her to post her thoughts!