Health Affairs

“The real challenge of human biology, beyond the task of finding out how genes orchestrate the construction and maintenance of the miraculous mechanism of our bodies, will lie ahead as we seek to explain how our minds have come to organize thoughts sufficiently well to investigate our own existence.”

The initial enthusiasm following the mapping of the human genome has given way to a more circumspect outlook. With the exception of a small number of promising interventions, advances in genomic science have yet to yield a critical mass of therapeutic breakthroughs – thus forestalling the birth of the era of precision medicine (PM).

While a comprehensive genomic understanding of disease and concomitant molecular-based patient taxonomy would doubtless hasten the arrival of PM, a significantly less costly alternative offers a promising interim approach. A methodology known as collaborative filtering (CF) which has already achieved widespread use in advertising and marketing, has the potential to offer powerful insights not only to advertisers and others desiring to influence purchasing behavior but also to physicians, allied health care professional, patients, and their families by offering personalized advice and recommendations regarding health and disease.

CF relies directly on aggregated subject/user behavior to reveal complex and unexpected patterns that would otherwise be difficult to capture using known data attributes. Recommendations generated from analyses of these patterns have demonstrated significantly greater reliability than those using more traditional demographic categories. The core idea behind applying CF to clinical decision-making is to make decisions about a patient based on historical data derived from multiple “similar” patients presenting multiple “similar” cases. As Victor Streecher explains, “collaborative filtering in the health area could match the coping strategies, medical decisions, and preferences of similar others with specific needs and interests of the user.”

Health Affairs plans a thematic issue on Alzheimer’s disease in April 2014. We plan to cover a range of topics with the aim of providing “one stop shopping” for our policy-oriented audience. Topics include overview papers on the state of the science of causes and treatment, costs, screening and diagnosis, drug development, medical and non-medical management, caregiver populations, federal and state roles, and more.

Request for abstracts

In addition to the papers we have already invited, we are seeking papers on several additional topics and therefore welcome proposals for papers, analyses, and commentaries on the following topics:
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• Exemplary models from around the globe (either individual countries or comparative pieces with lessons for other countries)
• Exemplary state or local approaches to care and treatment
• Opportunities for primary prevention

In order to be considered, abstracts must be submitted by August 1, 2013. We regret that we will not be able to consider any abstracts submitted after that date.

In the May Health Affairs Narrative Matters essay, two graduate students describe their fight with the bureaucracy to gain coverage for their son under the Children’s Health Insurance Program, and they express the hope that provisions of the Affordable Care Act will cut the red tape. The article, “To Cover Their Child, One Couple Navigates A Health Insurance Maze In Pennsylvania, is by Ari Friedman, a fifth-year medical-doctoral student in health economics at the University of Pennsylvania’s Perelman School of Medicine and Wharton School, and Tara Mendola is a sixth-year graduate student in comparative literature at New York University.

In today’s Q and A on Patient Engagenment, we feature Rachael Fleurence, a Senior Scientist at PCORI where she leads the research prioritization initiative to help identify important patient and stakeholder generated questions and establish a rigorous research prioritization process to rank these questions. (Also, check out her recent blog post and follow the link to her February Health Affairs article here.)

The Indian Supreme Court announced a decision this week that allows drug makers to continue developing cheaper generic versions of the leukemia drug Gleevec in that country. The case centered around whether certain patents held by the brand-name drug’s manufacturer were true inventions. The decision was shaped in part by the complexities of Indian patent law, which is considered far more stringent than U.S. patent policies.


The issue of secondary patenting or “patent evergreening,” to extend the life of a brand-name drug and whether secondary patents represent true innovation was the subject of an October 2012 Health Affairs article by Tahir Amin and Aaron Kesselheim.

A Health Affairs Web First article released today describes the new rapid-cycle approach to program evaluation at the recently established Center for Medicare and Medicaid Innovation. The Affordable Care Act created the Innovation Center within the Centers for Medicare and Medicaid Services (CMS) to test payments and service delivery models, reduce costs in Medicare and Medicaid, and improve quality.

As the Innovation Center moves ahead with innovative payment and service delivery models, the Rapid Cycle Evaluation Group at the center delivers frequent feedback to providers while evaluating the outcomes of each model tested. When a model is considered for testing, staff from the Rapid Cycle Evaluation Group and CMS’ Office of the Actuary are immediately assigned to help create the model. The Office of the Actuary provides timely and impartial actuarial, economic, and statistical estimates–and monitors Innovation Center initiatives once testing has begun. This group’s rigorous and speedy assessment and evaluation is driven by performance metrics and robust new methodologies.

Researchers from the evaluation group have also been organized into “affinity groups” and use CMS data to answer critical policy questions that may shape future payment and service delivery models. The Innovation Center also plans to identify and promote population health metrics–measures of the functional status, healthy behavior, and health outcomes of a population–to promote disease prevention and achieve a more accountable, equitable, and coordinated health care system. All these efforts will contribute to the Innovation Center’s success in carrying out its mission of improving the quality of care combined with the slowing spending growth.

For those of you who enjoyed the Q and A with Jessie Gruman last week, we’ll post the next in our series with patient advocates next week. This time our featured advocate will be Rachael Fleurence, a director at the Patient-Centered Outcomes Research Institute (PCORI). To learn more about her work and recent Health For those of you who enjoyed the Q and A with Jessie Gruman last week, we’ll post the next in our series with patient advocates next week. This time our featured advocate will be Rachael Fleurence, a director at the Patient-Centered Outcomes Research Institute (PCORI). To learn more about her work and recent Health Affairs article, visit this blog by Dr. Fleurance’s on PCORI’s website.

Now is your chance to ask questions of Dr. Fleurance.


Just go to Health Affair’s facebook page and post your question. We’ll post the answers on Health Affairs’s blog early next week.

Use rates for inpatient and certain hospital outpatient services are declining in many areas of the country, reflecting fundamental change brought by the new business model. Importantly, as evidenced by trends in Chicago and Minnesota, there also appears to be a correlation between the level and pace of a market’s shift toward value-based care and the level and pace of utilization decline.

We believe this trend is here to stay and that it has significant strategic and financial implications for health care providers. Specifically, providers that embrace the migration to value-based care will need to work aggressively to eliminate unnecessary and/or ineffective activities in order to thrive under risk contracts. This requires a fundamental change in mindset, culture, and attitude about volume and activity. It also requires providers to rethink the organization and structure of their delivery networks to avoid supporting unnecessary capacity, and to drive patients into the lowest-possible cost setting in which quality care can be delivered.

The goal will be to manage a population’s health across the care continuum, keeping patients healthy through preventive and primary care services, and out of acute care facilities whenever possible. The right place to provide the right care at the right time with the right quality, cost, and access increasingly will be a setting other than a hospital. By eliminating waste and redirecting patients to ambulatory centers, physician offices, clinics, and online and/or telephonic interactions, less work will be done in the hospital. To reduce well-documented overutilization, tests and services deemed inappropriate or unnecessary based on medical evidence will be eliminated in all settings. (See Note 1) Acute care will be one, and only one, component of the population-centric health management services continuum.

The “fiscal cliff” deal raised taxes on households earning more than $450,000 a year and sheltered everyone else from an automatic income tax increase. Tough decisions about spending were put off until March 1, the new deadline by which Congress must take deficit-cutting action if it is to avoid automatic across-the-board sequestration cuts.

As both sides return to the negotiating table, one of the biggest bones of contention is what to do about entitlement spending, particularly Medicare. Many Republicans want to raise the age of Medicare eligibility to 67. President Obama and congressional Democrats do not.

It will be difficult, if not impossible to meet a reasonable fiscal target without addressing federal health care spending. However, the current fight is misplaced. The health care “entitlement” we need to reform is the notion that America’s health care system is entitled to an ever-growing share of America’s wealth.

Proposal

The National Research Council’s Precision Medicine report found that it is imperative to create a new scientific base for biomedical research, clinical care, and public health that accurately reflects the genetic variations in diseases and in individual responses to therapies.

This proposal calls for using the nation’s rapidly expanding capabilities for computerized biomedical research to accomplish this goal as quickly as possible. Research databases and analyses for most diseases would be completed over the next three years (by the end of 2015).

Background

The US-led Human Genome Project was finished ten years ago (2003). In the past several years, key elements for moving forward on a Precision Medicine-type initiative have been coming together.

The mistake policymakers have long made in debating Medicare (and Medicaid, though that’s a topic for another day) is that they talk about Medicare the same way they talk about Social Security. It’s understandable at some level, since these two programs are the country’s largest entitlement programs and serve similar populations. However, the two programs could not be more different.

Social Security is a relatively simple program of transfer payments. The fundamental issue for Social Security is how to manage the inflow and outflow of funds.

Medicare is an entirely different animal.

Historically, legislative changes to the program have attempted to mimic the Social Security focus on budgetary inflows and outflows by adjustments to benefits and provider reimbursements. While expanding coverage has largely been an attempt to be more inclusive of vulnerable populations and allow access to needed services to improve overall health (while simultaneously lowering beneficiaries’ cost burden), it has always come at a price, literally. Similarly, while provider payment cuts — and in some cases increases — have often been critical to increasing access or controlling spending in the near-term, they have done nothing to address the structural reforms desperately needed to sustain the program over the long-term.

Unfortunately, while there remain budgetary questions to consider, the opportunities and demands inherent in future structural changes to Medicare are an order of magnitude more challenging.

Federal agencies such as the Agency for Healthcare Research and Quality (AHRQ) work with patients, consumers, caregivers, clinician, researchers, and policymakers to ensure that research is relevant and responsive to stakeholder needs. Involving stakeholders in the process helps to focus the research on meaningful outcomes and increase the likelihood that people will accept and act on the results. AHRQ’s Community Forum** team recently conducted an environmental scan to identify strategies to enhance stakeholder involvement in the Agency’s Effective Health Care Program and other health care research activities.

Our review included peer-reviewed articles (23), grey literature (15), and Web sites (43). (Grey literature is material produced on all levels of government, academics, business, and industry in print and electronic formats, but which is not controlled by commercial publishers, i.e. where publishing is not the primary activity of the producing body.) We also conducted 11 key informant interviews with individuals experienced in stakeholder engagement within and outside of healthcare.

In the review we found a range of methods and recommended practices for stakeholder involvement. We identify five stakeholder engagement methods that have been used relatively little in health care research and that appear to hold promise:

No other presidential election in American history has been freighted with such significance for health care as was last month’s vote. Uncertainty over the future of health policy dominated the discourse, and we all waited with bated breath for clarity from the voters.

Thirty-six days ago, we got just that. In one night, much of the uncertainty that had marked the past few years faded into history.

But now we all face a different and urgent kind of uncertainty — a pressing question: How, with this newfound certainty in the policy environment, can health care stakeholders best move forward on problems of high costs and suboptimal quality, of poor coordination and preventable medical error, soon enough to meet the social need?

Time is running out to find answers. Health care costs, much of them waste, continue to climb, and too many patients are not getting the high-quality care they need. If we do not act — and act quickly — to transform health care, we will face blunt cost cutting and declining access and quality, particularly for the poorest among us.

On November 21, Health Affairs released a series of Web First articles profiling the winners of Robert Wood Johnson Foundation (RWJF) Young Leaders Awards, which were announced this Fall on the occasion of the Foundation’s fortieth anniversary. The RWJF Young Leader Awards highlight the important contributions that people can make early in their careers to improving health and health care for all Americans.

The awardees, all age forty or younger, have made exceptional contributions in a broad spectrum of activities that display their commitment to their communities:

Editor’s note: Joe Selby’s post below responds to David Introcaso’s Health Affairs Blog post, also published today. For more on the concept of patient centeredness, comparative effectiveness research, and the Patient-Centered Outcomes Research Institute, see Health Affairs’ October issue, “Current Challenges In Comparative Effectiveness Research.“

The Health Affairs Blog post by David Introcaso, PhD, “PCORI’s Problem: Reasons Are Not Causes,” emphasizes the critical importance of the patient-provider relationship and communication in improving health outcomes. It also notes the challenges to changing practice through the creation and dissemination of new evidence, including the non-linear nature of the process of turning knowledge into action. But it argues that PCORI has missed the boat on these issues, specifically having failed to address them either in the $30 million in Pilot Project awards we issued earlier this year or in our current research priorities and funding announcements.

We genuinely appreciate the serious thought Dr. Introcaso has given to these matters and fully agree with him on their importance if we are to change practice and improve patient outcomes. And that’s why both our work to date and the work we continue to pursue focuses directly on these questions in a number of concrete ways – a point he seems somehow to have missed.

The significance we at PCORI place on communication between patients and those who care for them is evident throughout our work: in our foundational research roadmap; in our initial round of research support (the Pilot Projects Program); and in the scope and detail of our primary research funding announcements’ requirements.

Editor’s Note: This post originally appeared on GrantWatch Blog, Health Affairs Blog’s sister blog.

The Robert Wood Johnson Foundation (RWJF), based in Princeton, New Jersey, announced the ten winners of an award for young people with “strong potential for future leadership,” who are age forty or younger and are being recognized “for their exceptional contributions to improving the health of the nation,” according to an October 25 press release. Each winner will receive $40,000; these awards will be presented tomorrow.

This is a one-time awards program and ties in with the RWJF’s fortieth anniversary. As the foundation looked to the past to reflect on its accomplishments as it celebrates its anniversary, it “also wanted to look to the future,” to young leaders, born during the foundation’s existence, who have already achieved early successes and have the potential to improve health and health care in the United States, the RWJF’s president and CEO, Risa Lavizzo-Mourey, explained in the release.

Here are just a few fun facts about the award winners. These men and women hail from various regions of the United States; six of the ten hold medical degrees, three of the ten have Ph.D. degrees, and one out of the total group has a law degree. As for professional affiliations, one winner runs a nonprofit coalition of faith congregations, based in St. Paul, Minnesota; several are assistant professors. Go here to read the press release with the full list of winners and short descriptions of their work affiliations. You can also view pictures of the winners.

Editor’s note: In addition to Kenneth Kaufman and Charles Roehrig (photos and linked bios above), this post is coauthored by Paul Hughes-Cromwick, a health economist and Senior Analyst at Altarum Institute and Charles Kim, a Senior Vice President at Kaufman Hall.

Health care costs are a major focus of the nation and individual states. This summer, Massachusetts legislated to bend its health care cost curve. While Massachusetts residents benefit from near-universal coverage via 2006 legislation, the State’s health spending per capita has long been well above the national average. In an effort to rein-in costs and achieve a sustainable spending growth rate, the State passed Senate No. 2400—“an Act improving the quality of healthcare and reducing costs through increased transparency, efficiency, and innovation.”

The Act establishes limits on health care spending growth—defined as not to exceed overall growth in Gross State Product (GSP) in 2013-2017 and GSP growth minus 0.5 percent for 2018-2022. Linking health care spending growth to GSP growth aims to cap health care’s share of GSP. (More precisely, the Act ties spending to the growth of potential GSP, which subtracts the influence of business cycle fluctuations. Since this is roughly equivalent to the long-term average growth in GSP, for simplicity’s sake we use the terms GSP and GDP, or gross domestic product, in the remainder of this post.)

What if Massachusetts-like spending restraints were imposed nationally? National health care expenditures (NHE), which constitute about 18 percent of the nation’s GDP, have been growing about 2 percent faster than the growth of U.S. GDP for most of the past 22 years, though this excess declined in certain years. The blue line in Figure 1 (click to enlarge) shows the change in NHE growth since 1990; the red line represents GDP change during the same period. Economists and health policy experts have started to analyze the fiscal implications of applying Massachusetts’ GSP+0 growth limits to NHE. This post builds on such analysis, looking specifically at the effects on the federal deficit and the Medicare HI Trust fund.

Note: This blog summarizes key findings from a report by the National Academy of Social Insurance (NASI) Study Panel on Health Insurance Exchanges and the Center for Health Policy and Research at the University of Massachusetts Medical School. The report draws some key lessons from the experiences of the states most advanced in their implementation... Read the rest of this entry »

The newly released September 2012 issue of Health Affairs focuses on changing the way US health care is paid for to shift incentives away from fee-for-service medicine and produce better health and health care at lower cost. The issue, which was supported in part by grants from WellPoint Inc., the WellPoint Foundation, and the California... Read the rest of this entry »

When the Oregon Health Insurance Exchange began planning how to offer comparative information about health care insurance options, the organization turned to the Oregon Health Care Quality Corporation, a nonprofit regional health improvement alliance that compiles reports on the quality of care provided by Oregon hospitals and physicians. Why would a health insurance exchange, which... Read the rest of this entry »