By John Easton

Even in the court of ethics and medical professionalism, there’s nothing wrong with the occasional honor or award. On day two of the conference, the Maclean Center awarded its first Prize in Clinical Ethics and Health Outcomes - at $50,000, the largest such prize in the ethics field - to John Wennberg, the Peggy Y. Thomson Professor for Evaluative Clinical Sciences at Dartmouth Medical School and founding editor of The Dartmouth Atlas of Health Care.

In 2007, the journal Health Affairs named Wennberg as “the most influential health policy researcher of the past 25 years.” Fitzhugh Mullan, former director of the Bureau of Health Professions in the U.S. Department of Health and Human Services, described Wennberg as “both the Christopher Columbus and the Johnny Appleseed of clinical variation,” meaning he not only discovered the field but also brought it to the attention of the medical and health policy communities.

“While John Wennberg is regarded as a health services researcher,” said Mark Siegler, MD, director of the MacLean Center, “his fundamental work on patient preferences and shared decision making highlight his contributions to the field of clinical medical ethics.”

The Dartmouth Atlas examines the patterns of medical resource intensity and utilization in the United States, with special emphasis on end-of-life care, inequities in the Medicare reimbursement system and the under-use of preventive care.

From the start, it has brought surprises, according to Kenneth Polonsky, dean of the Division of the Biological Sciences and the Pritzker School of Medicine at the University of Chicago, who introduced Wennberg. The report comprehensively documented the “striking differences” in the amount of health care provided in different regions, adding the provocative observation that the amount or cost of care delivered did not correlate with good outcomes.

Joking that “when you get paid so much to give a lecture, you get a little nervous,” Wennberg spoke about the early days of the Atlas and how their studies of practice variation in the mid-1970s “challenged the notion that science was driving utilization.” Instead, decisions about surgical treatment for benign prostate hyperplasia revealed what the researchers called “surgical signatures,” patterns of practice based on the beliefs of individual surgeons.

When Wennberg’s team developed short, balanced videos to show to patients, explaining the risks and benefits of surgical treatment and showing taped interviews with two physicians who had made different decisions, patients were much less likely to choose surgery. “This was the first evidence,” he said, “that engagement of patients could lead to the right utilization rate.”

However, only about 25 percent of medical care turns out to be so “preference-sensitive,” forming what Wennberg calls “little islands of rationality.” Studies of end-of-life care found a far more limited role for shared decision making between patients and their caregivers. Instead, demand for resources appears to be driven by supply. Empty hospital beds and unused capacity strongly correlate with increased medical care late in life. For example, more than twice as many patients were admitted to an intensive care unit in the last six months of life at UCLA compared to Dartmouth.

Wennberg described the four goals of the Atlas’s end-of-life team for the next five years: to better inform patient choices, improve the science behind these decisions, promote organized care and constrain undisciplined capacity spending. At this point, he said, “we don’t need more research, we need more action.”

Another session at the conference focused on a very different book, not an atlas but a historical novel, based on true events and real people. Open Wound: The Tragic Obsession of Dr. William Beaumont, by former ethics fellow Jason Karlawish, a professor of medicine and medical ethics at the University of Pennsylvania, examines the professional and ethical issues raised by William Beaumont, a 19th-century surgeon who cared for - and experimented on - a patient with a shotgun-blast-induced hole in his stomach. Beaumont saved the patient’s life, but then used this wound, which never quite healed, as a window to decipher the mysteries of digestion.

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Every patient wants their doctor to be a professional. But the broader concept of “medical professionalism” is not a cut-and-dry matter, as it opens the door to debates over how physicians interact with politics and society, the regulation of doctors’ ethical and legal behavior, and the role of the physician in the new world of health care. Those are large enough questions to warrant a year of discussion in the MacLean Center for Clinical Medical Ethics Seminar Series, and a centerpiece slot at the 23rd annual Dorothy J. MacLean Fellows Conference, held last week.

“In recent decades, there has been a renewed focus in medical education on professionalism being seen as a way to improve patient care, strengthen the doctor-patient relationship, reduce conflict of interest, improve physician self-regulation and ultimately to strengthen the alliance between medicine, patients, and society,” said Mark Siegler, Director of the MacLean Center, in his opening remarks.

If professionalism is too abstract, the themes on the first day of the conference could be simplified as what a doctor should and should not do in today’s tumultuous health care waters. Driving that instability is the ever-growing chunk of the world economy eaten up by the health care industry, said the conference’s first speaker, Arthur Rubenstein of the University of Pennsylvania (and formerly of UCMC). The United States spent $2.3 trillion on health care in 2009, he said, roughly equivalent to the GDP of France. With economies slowing around the world, those costs are unsustainable, and physicians must come together as a profession to work with patients and policymakers to find solutions that benefit all parties.

“We need to do something about that as a medical profession. If we don’t, the future is going to be quite problematic,” Rubenstein said. “If in the financial crisis which we are now surely in, at both the state and national level, the medical profession puts their own interests before those of patients - particularly the poor and elderly patients - our now privileged position in society will be given up, and our contract with society will be changed for the worse, and we may not recover in the foreseeable future.”

Participation was also one take-home message of Christine Cassel’s talk, which emphasized how the classical definition of the medical professional would have to evolve in the new health care landscape envisioned by last year’s Affordable Care Act. Cassel, the president and CEO of the American Board of Internal Medicine (and another former UChicagoan), said that the three primary goals of health care reforms are affordability, access, and quality. Creating a system that addresses all three will require balancing the intrinsic motivations of physicians to help patients with the extrinsic motivations of financial and regulatory oversight. A new kind of medical professionalism that accepts a health care system based around technology and teamwork will help the field achieve that balance with a minimum of pain, Cassel said.

“To my mind it’s a new kind of professionalism that leaves behind these old ideas of what the nostalgic profession was, and becomes committed to collaboration, evidence, measurement, and transparency so that it’s not at odds with accountability, but in fact becomes accountability,” Cassel said. “This is a challenge for many of us, and it’s going to take change.”

A case study of how that change can happen was presented by Troy Brennan, Chief Medical Officer for the pharmacy chain CVS. Brennan recapped efforts over the last decade to eliminate gifts from pharmaceutical companies to physicians at academic medical centers. While this practice was once thought to be innocuous by many physicians, others argued that it created a conflict of interest. In an example of extrinsic regulation to alter physician behavior, the American Board of Internal Medicine proposed that academic medical centers regulate these interactions between Big Pharma and physicians - an initiative supported by medical students. As a result, physician-industry relationships dropped, though a CVS study is still collecting data on whether that has affected prescription behavior, driving more doctors toward prescribing generics instead of brand name drugs.

Preserving physicians’ integrity and reputation is important for the role of the medical professional proposed by Paul Starr of Princeton University. In a time of ideological polarization and lack of trust in public institutions, it’s important for professionals to bring trustworthy knowledge to the public debate, Starr said, citing the recent Republican debate where candidate Michele Bachmann claimed a link between the HPV vaccine and mental disability.

“When prominent political figures make uninformed statements on national television about the effects of a vaccine, or distort the findings of researchers on a cancer screening test, then politicians may have a real, substantial impact on public understanding,” Starr said. “It is just at those moments when the scientific community should hold its ground and insist on abiding by the evidence.”

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When the drug ezetimibe was approved in 2002, it was hailed by its makers as a new tool for lowering cholesterol and fighting heart disease in patients. In clinical trials, the drug (marketed by Merck as Zetia) lowered levels of low-density lipoprotein or LDL, the so-called “bad cholesterol” associated with atherosclerosis, the thickening of blood vessels that can lead to stroke and heart attacks. Though LDL was also the target of the highly successful statin drugs, Zetia passed the FDA because it offered an alternative mechanism for reducing cholesterol levels, and soon was making billions of dollars a year for the pharmaceutical company. But as more and more people took the drug and more research was conducted, the scientific data did not match the marketing hype, with large clinical trials failing to find a protective effect against cardiac events and even finding in some cases that it made blood vessels thicker.

Sadly, the story of Zetia is not that unusual. In recent years, other drugs such as Vioxx and Redux have been come under fire when dangerous side effects or underwhelming clinical results became apparent after approval. These high-profile failures (and the inevitable ensuing lawsuits) have threatened to slow drug development, as pharmaceutical companies are understandably nervous about investing big money in a potential dud. Expensive new drugs that offer little to no improvement over pre-existing treatments also cause damage, by needlessly raising health care costs. So what changes can we make to the U.S. health care system to promote the creation of innovative new drugs worth their price tag?

Three authors, including G. Caleb Alexander of the University of Chicago Medical Center, proposed five not-so-easy fixes in a recent issue of Annals of Internal Medicine. Their strategy includes reforms of the FDA’s drug approval process, drug labels, and the payment strategy of insurance companies on the other. For drug companies that may not like the extra squeeze, incentives can be built into the system to sweeten the deal for developing more effective treatments and drugs for currently untreatable diseases. “Despite these challenges, the United States has a long history of successfully improving the safety and value of prescription drugs, and substantial progress can still be made,” the authors write.

1. Raise the Bar

One way to prevent surprises when new drugs are transferred from clinical trials to the real world is to require that higher standards are met before approval. Instead of just demonstrating the drug’s superiority to a placebo treatment, researchers could be required to prove that the new drug is better than the current standard of care. Clinical trials should also be designed to measure effects on clinical outcomes, such as atherosclerosis, rather than physiological measures, such as LDL.

2. Semi-Approval

For an FDA approval process that some already criticize as to slow, these additional requirements could further gum up the works. To allow time for this more thorough review, the authors suggest a more nuanced FDA approval, adding a new “conditional” approval stage where the drug could be available with strings attached. For instance, direct-to-consumer advertising could be restricted while more data is collected on the drug’s effects in a larger, more diverse population.

3. The Patent Carrot for the Regulatory Stick

For the pharmaceutical companies, all of the above is a nightmare that would extend the cost and time it takes to bring a new drug to market. As an olive branch, the paper suggests extending the patent exclusivity for new drugs that meet these most stringent standards, giving the pharmaceutical company more time to collect profits before generics are allowed to reach the market. One suggestion is to start the patent clock when the drug is approved, so that the FDA process does not eat up valuable months and years of exclusivity for the drug’s developer. Such a measure would also ease up the pressure on the regulators, reducing “the tension between the ticking clock of patent protection and drug safety,” the authors write.

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By Dianna Douglas

The Affordable Care Act is nearly one and a half years old, but the complexity of its reforms and their gradual roll-out have made it difficult to grade. Different disciplines are still parsing the legislation, attempting to figure out how it will change the future of their field. Experts in the field of Family Planning and Contraceptive Research has been puzzling over an enormous and perhaps unanswerable question: How will health care reform affect the reproductive lives of women and girls?

That was the primary question at the section’s spring conference, “Reproductive Justice and Health Care Reform: the Impact of Reform on the Reproductive Health of Underserved Women and Youth.” The phrase “reproductive justice” connotes the activism to give women and girls of all races and incomes the access to the same choices and education for controlling their reproduction. Panelists argued that some aspects of the bill, particularly the expansion of insurance coverage, would benefit this cause. But there were also warnings about the political resistance, exemplified by Representative John Boehner’s statement that he doesn’t think reproductive health care services are the business of the federal government: “How can you spend hundreds of millions of dollars on contraceptives? How does that stimulate the economy?” he asked in 2009.

Speakers at the conference, which was co-sponsored by UChicago’s Center for the Study of Race, Politics and Culture, posed many unanswered questions about how the Affordable Care Act will affect women and girls in America. Some expressed hope that it could close the gap between black and white and rich and poor in all areas of maternal health, unintended pregnancy, intimate partner violence, and infant mortality.

But Harold Pollack, PhD, professor at the School of Social Service Administration, gave both sides of the story. He argued that the Affordable Care Act is not only health care policy, but it is the defining document of America’s public policy on reproductive health care.

“Near-universal health insurance coverage will reduce disparities in health,” Pollack said. One of the goals of the Affordable Care Act, passed by Congress and enacted by President Obama in 2010, was to stop people from skimping on health care when they couldn’t afford it. If enacted properly, the health care plan would extend reproductive health care to millions of women.

Under the law, Pollack said, insurers can no longer require a referral to see an obstetrician or gynecologist, and must offer women direct access to these specialists. They are required to pay for some preventative services, like screenings for breast and cervical cancers and sexually transmitted infections. Insurers are required to pay for certain vaccines for women. They have to pay for preventive care for children and adolescents, including screenings for pregnancy. And, insurers may be required to pay for contraception and other family planning services.

All of these requirements were designed to improve women’s health across income levels, but basic access to physicians is the key. “When you visit a doctor because your knee hurts, the truth is that she probably won’t do very much for your knee. But you’ll get your blood pressure taken. She’ll ask you about your diet. And she’ll recommend you for other screenings and lifestyle adjustments,” he said. Oregon recently found that poor people with health insurance were healthier than poor people without it.

Pollack’s keynote address was not uniformly cheerful, however. “The bill is vulnerable, and reform is a risk,” he said. The politics around health care reform have become poisonous, he said, and some of the best public policies in the bill are the most under attack.

Pollack lamented that the great benefits of health care reform won’t be enacted for a few years, during which time public opinion on health care reform could sour more dramatically. “Backloading was the sin of this bill,” Pollack said. It takes time for reforms to embed in society, he said and the legal challenges to the bill may stop the process before it can begin.

To keep the Affordable Care Act on track and make the reforms sustainable, Pollack suggested that the people who support the bill should put a human face on it. “Americans are deeply ambivalent about sexuality and reproductive health,” he said. “But even people who disagree with abortion are uncomfortable with making a poor woman carry a baby to term after a rape or if the pregnancy will seriously damage her health.”  The more human and less theoretical the reforms can become, the more likely they are to survive the next few years of budget cutting.

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It has been a couple months since the end of the spring quarter, and the with it the end of many of the Medical Center’s weekly lecture series. But a recent batch of videos posted to the website of the MacLean Center for Medical Ethics brought a whiff of the school year to the dog days of summer. The videos feature a selection of the lectures from the third and final segment of the 2010-2011 theme, “Health Disparities: Local, National, Global,” [pdf] and run the gamut of expert perspectives from libertarian law and the insurance industry to black history and medical education. If you are going through lecture withdrawal or want to get excited for next year’s MacLean Center series (“Medical Professionalism and the Future of American Medicine” [pdf]) beginning in late September, enjoy these videos.

The Case for Health Disparities - Richard Epstein, University of Chicago

Richard Epstein’s annual contribution to the seminar series is always a combustible reaction, where the classically conservative law professor’s market economics conflict with the more liberal lean of the regular audience. This year’s topic was especially flammable - after a couple dozen lectures on the struggle to reduce the health care gap in the United States and around the world, here was Epstein arguing for preserving those very same inequities. Beyond the deliberately provocative title, Epstein’s characteristically off-the-cuff speech recommended that health care reformers should choose a different target - instead of minimizing the health care differences between top and bottom, push policies that support growth and innovation for all patients, rich or poor, while encouraging charity instead of coercive giving.

Future Directions for Health Equity - Anne Beal, Aetna Foundation

The Aetna Corporation is in the business of providing health insurance to Americans. The Aetna Foundation is the charitable arm of that company, dispensing grants and funds to research ways of improving the health care system and reducing costs. Researcher and author Anne Beal is the current president of the Aetna Foundation, and focused her talk on reducing costs and inequalities via improving the quality of health care in America. “Giving people the right care at the right time and preventing disease is an amazing way for us to really rein back a lot of these health care costs,” Beal said. [Original Article]

“Without Health and Long Life All Else Fails”: African-Americans and the History of the Elimination of Racial Disparities in Health and Health Care - Vanessa Northington Gamble, George Washington University

Obviously, racial disparities in health care are not a new phenomenon. Efforts to improve the health of African-Americans also didn’t begin with the civil rights movement, though the strategies employed by the disparity-fighters of the segregation era were very different from today.

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There’s something quaint and charming about a family business, where multiple generations work shoulder to shoulder to keep an enterprise afloat. But when the business in question is academia and the salaries are paid by tax dollars, suddenly keeping it in the family carries the stink of nepotism. In the public universities of Italy, it’s no secret that nepotismo is the rule, not the exception. Despite repeated legislative efforts to reform university hiring, scandals such as the one at University of Bari’s economics department - where a father, two sons, and five grandchildren all work together - remain a perennial problem in Italy.

Stefano Allesina, an assistant professor of evolution & ecology at the University of Chicago, witnessed the damaging effects of these unfair hiring practices as a student in Italy. While pursuing his PhD, Allesina’s advisor told him not to waste his most productive years trying to get a job in Italy - advice he followed in emigrating abroad to the United States. Many of his Italian peers followed similar paths, while those who stayed behind languished in limbo waiting for scarce tenure track positions to open. Frustrated with the broken Italian system, Allesina decided to apply his talents for creating computational models in ecology to measuring the full scope of nepotism in the university system of his home country.

“In Italy, there is an enormous brain drain,” Allesina said. “Italy is losing so many graduate students to other countries, it’s unbelievable. It’s because the hiring is extremely slow, complicated, and not really based on quality…and I think these kind of hiring practices contribute a lot to this brain drain and the fact that Italian universities are not ranked very high internationally.”

In a study published yesterday in PLoS ONE, Allesina used a public directory containing the last names and fields of study for over 61,000 professors to look for systemic signs of nepotistic hiring. With a simple computer model, Allesina detected unusual clustering of last names within disciplines such as law and medicine, far from the random distribution expected with unbiased hiring.

“It’s not a few bad apples, it’s really bad,” Allesina said. “I found that in many disciplines there are much fewer names than you would expect to find at random, indicating a very, very high probability of nepotistic hires.”

The original model worked like a random lottery, repeated one million times. Over the entire dataset, more than 27,000 different last names were represented. For each discipline, Allesina tested whether certain names appeared more than expected at random. So for medicine, where there are 10,783 faculty members with 7,471 different last names, Allesina programmed his computer to test how likely it was to randomly draw only 7,471 names (or fewer) from the total name pool in 10,783 tries.

“It’s very basic, anybody with a laptop can do this analysis,” Allesina said. “I wanted to keep it as coarse-grained and simple as possible. Because then it’s more powerful - if this works, anything else will work. Even this very simplistic analysis can find that some disciplines are above and beyond what one could expect.”

Under this model, the worst offenders were law, medicine, and industrial engineering, all of which showed only a 1-in-1,000 chance of having so few last names by random. On the other end, psychology, demography, and linguistics  each contained a last name distribution close to random, suggesting that hiring was more fair in these fields. Another analysis, which mapped the likelihood of two faculty members in the same field sharing a name by geographic region, found that indicators of nepotism were stronger in the south - a result that would surprise few Italians, Allesina said.

“For an Italian, this is not that surprising,” Allesina said. “It is a narrative of two separate countries, where in the public sector we have more problems in the south.”

A much trickier task than measuring the breadth of nepotism in Italy is finding an effective solution for ending the unfair hiring practices.

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One of the sectors closely monitoring the debt debate in Washington is the medical world, where hospitals, physicians, and patients anxiously await the final agreement on cuts to Medicare and Medicaid. Of particular concern to academic medical centers [pdf] are proposed cuts to graduate medical education, funding used to pay the salary of residents and fellows who are both training as physicians and specialists and working on the front lines of patient care. In a time when a patient’s wait time to see a specialist grows longer and longer, squeezing the bottleneck of physicians-in-training even tighter could have long-term consequences.

This week, the Medical Center’s executive vice president for medical affairs and dean Kenneth Polonsky took to the newspapers to argue against these damaging cuts. In an op-ed letter published by the Chicago Tribune, he expressed concern that the proposed cuts would “would reduce access to doctors, multiply waiting times and do lasting harm to patients in Illinois and nationwide.”

No one questions the need to rein in spending on health care or the obligation of hospitals to do their part. But we need to maintain a high level of patient care, and to make certain that our country has enough physicians in the future. Policymakers in Washington must maintain their support for graduate medical education and find more equitable ways to distribute the budget-cut burden.

Elsewhere…

Speaking of Washington and health care policy, without the Patient Protection and Affordable Care Act, 63-year-old Glenn Bovard of Valparaiso would not have been able to receive life-saving gift this past Father’s Day: a new heart. The Post-Tribune profiled Bovard’s story and surgery, performed by the Medical Center’s Valluvan Jeevanadam and Jai Raman. “The surgery was a cakewalk compared to the heart attack,” Bovard told the paper.

As many as one-third of patients with epilepsy cannot control their seizures with medication. Local newsmagazine Chicago Tonight profiles efforts by Wim van Drongelen, technical and research director of our pediatric epilepsy center, to develop new ways of helping these patients by modeling how seizures begin and spread in the human brain.

At the end of a long, difficult week, many people like to unwind on a Friday evening with a drink? But does alcohol relieve stress, or prolong it? A new study by Emma Childs of the University of Chicago Behavioral Pharmacology Laboratory and written up by the Gannett News Service suggests a double-edged sword - stress reduces the positive effects of alcohol, while a drink may extend the tense feelings produced by a stressful event.

A cautionary tale about when newspapers twist the words of scientists for sensationalist ends - did paleozoologist Darren Naish really say that the Loch Ness Monster was “more fact than fiction?”

Evolution isn’t only a process that happened in the distant past. Carl Zimmer’s wonderful cover story in the Science Times this week follows New York evolutionary biologists as they hunt for signs of urban evolution in progress for mice, fish, ants, and other city-dwelling critters.

In a typical clinical trial, the results are reported in purely medical or biological terms. Did the patients in the treatment group live longer than those in the control group? Did the drug shrink the tumor or reduce symptoms? Were clinical measures such as blood pressure or cell counts affected? These are the details that the Food & Drug Association and the physician community look for when they decide to approve or prescribe new therapies. But looking at a new treatment’s effects in a medical vacuum might miss critical details about its actual usefulness out in the real world, where patients have different priorities and health care dollars are finite.

To create a more well-rounded and practical clinical trial, medical researchers need to reach outside of their discipline for expertise. Or, they can bring those experts into the hospital fold, as was recently done with the establishment of the University of Chicago Program in the Economics of Cancer. Led by Ya-Chen Tina Shih, an economist who specializes in the economic aspects of cancer care, the program has a unique premise: to study the economics of a disease that produces estimated yearly costs of $270 billion and rising in the United States. In a field where new treatments, devices, and procedures appear with startling frequency, Shih’s group aims to weigh the costs and benefits of these new technologies so that patients receive the best, most logical care rather than just the hot, new, often-pricey thing on the market.

“I see it as a place to bring researchers together to look at economic issues in cancer,” Shih said. “The issues to be addressed can be large policy issues or a cost-effectiveness analysis comparing two different treatments. What we would like to do is provide an environment where if there are oncologists who want to study those questions, they don’t have to try to learn everything themselves. They can team up with economists or people in operation research or health services research, and can work on issues together. Similarly, people with no medical training who are interested in exploring those questions can find their clinical collaborators here.”

Calculating the cost of cancer is harder than it might seem. A diligent researcher could, with much effort, simply total up all the money spent on drugs, procedures, doctor’s appointments, and devices, and calculate a price tag for cancer or cancer treatment. But one must also take into account the indirect cost of missing work, either temporarily due to illness, side effects, or surgery, or permanently due to death. Other factors are even harder to convert into dollars, such as quality of life under different treatments, while still others are politically fraught, such as cost-effective analysis to determine whether a new treatment is a significant enough improvement over the current standard of care to justify coverage by insurance companies.

Economists can estimate these figures retrospectively, after a given treatment has been out on the market for a few years or more, but at that point the horse is long out of the barn. If a new treatment is given to patients for three years, then found to be less cost-effective than the standard of care it replaced, it could unnecessarily cost society millions or billions of dollars. Shih hopes that the Program in the Economics of Cancer will help cancer researchers design clinical trials with such economic questions in mind, so that information about costs can be gathered before the widespread diffusion of a new technology that provides a very small benefit at substantial cost.

“You don’t at the conclusion of a trial say ‘let’s add a cost-effectiveness analysis to that.’ By then, it’s way too late,” Shih said. “The idea is to get more people interested in collecting this data at early timepoints, so by the time they really want to answer a question, they have the data to answer it.”

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In Akira Kurosawa’s 1950 film Rashomon, the story of a crime is told three times from the perspective of three different witnesses/participants. Due to the biases of each storyteller, the details of the three accounts fail to align, ultimately leaving the film’s narrator - and the viewer - unsure about what truly happened in the central incident. Historians have their own version of the Rashomon effect, filtering past events and organizing historical narratives according to their own beliefs, whether the influence is subtle or overt.

In an attempt to offset any such potential bias in his Regis J. Fallon Lecture at the University of Chicago, health law expert Timothy Jost of Washington and Lee University School of Law chose to present three parallel narratives in his discussion of the history and future of American health insurance. Despite a relatively brief run as a major player in our country’s health care system (”there are many people alive today in Chicago who were born before modern health insurance arrived,” Jost said), health insurance has quickly risen to a place of great importance, as demonstrated by the industry’s role in last year’s passing of the Affordable Care Act. The goal of that legislation to make sure that all American citizens have health coverage will likely be a key turning point in the story of American health insurance. But to understand which direction health insurance will travel after the ACA is fully implemented, you need to understand how it got there in the first place, for which Jost offered three tales.

1. A Failure of Socialized Medicine

In this tale, the public’s push for universal government health care was repeatedly rebuffed by special interests and conservative politicians throughout the 20th century. Though incremental victories were achieved, from the push by labor unions for employer-provided health benefits to the passage of Medicare and Medicaid during the Johnson Administration, the century ended with a whimper for socialized medicine advocates thanks to the doomed health care reform of the Clintons. Opposition from organized medicine, small-government Republicans, and an increasingly powerful private insurance industry thwarted the push to join other developed countries who had switched over to government-run health care after World War II - “for two decades, we saw no progress,” Jost said.

2. A Failure of Market-Driven Medicine

But according to the second narrative, this lack of progress was good news. From this perspective, Americans are “overinsured…because of misguided government policies that have encouraged private insurance for routine as well as catastrophic medical costs,” Jost said. By placing the cost burden on employers and government programs, the American health insurance system has severed consumers from the true price of their own health care - the main culprit, many economists believe, for the exponential rise in medical spending over the last century. Under this narrative, the steering wheel of health care should be handed back to the market with a strategy of tax credits, vouchers, and the roll-back of Medicare - key components of the current Republican budget plan.

3. A Messy Compromise That Kind of Works

Mixing the two narratives together creates a third storyline, one that Jost seemed to prefer despite describing it as “muddling through to moderate success.” In this history of health insurance, the industry grew haphazardly over the 20th century, incorporating elements of both government- and market-driven approaches according to the fickle political winds of different eras. From the birth of modern health insurance as “health services plans” (guaranteeing coverage of hospital costs) in Dallas in 1929, through the expansion of coverage to all types of care including routine visits, pharmaceuticals, and even dental, the unlikely bedfellows of consumer demand and labor union pressure combined to nurture the explosive growth of the industry. And for a while, this worked, Jost said - 82.4 percent of the population held private heath insurance in 1980, the peak of such coverage.

“The United States seemed to have solved, through private initiative supplemented by public programs…the problem of health security that other nations had addressed through social insurance or public provision,” Jost said.

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In the Norman Rockwell past, patients had one doctor who followed them from home to clinic to hospital, managing their health care over a significant portion of their lives. That sort of doctor-patient relationship in today’s medical world seems about as outdated as a family gathered around the fireplace listening to the radio. Now, patients are growing used to unfamiliar people in white coats, seeing multiple doctors at their clinic and a parade of physicians from their hospital bed.

Part of this shift has been the move toward medical specialization, with more medical students choosing careers in surgery, cardiology, neurology or other specialties. The coincident decrease in primary care or family medicine doctors has reduced the ability of those who remain to visit their patients when they are hospitalized and monitor their care. Into this void has rushed the hospitalist, a physician who spends more than a quarter of their time on inpatient service.

Since the mid-90s, hospitals have increasingly relied on this new class of doctor to handle the work of the wards, and David Meltzer, associate professor of medicine, economics, and public policy, has studied the impact of this cultural change. In his talk for the MacLean Center for Clinical Medical Ethics seminar series, Meltzer detailed the impact of an increased role for hospitalists, for both patient health and the hospital’s bottom line. But with the Affordable Care Act rewriting the rules about how Americans receive and pay for their health care, a new kind of hands-on hospitalist may be a key player in the medical landscape of the future.

Meltzer started his research by looking in his own backyard: at the Medical Center’s hospitalist program that he himself directs. From 1997 to 1999, one of the four general medicine services at the Medical Center was run by two hospitalists rather than the rotating house staff and general internists who normally take in new patients. Time revealed the benefits of the more consistent care provided by the hospitalists - by the second year, patient stays were a half-day shorter in the hospitalist service, survival 30 and 60 days after discharge was higher, and costs per patient were nearly $800 lower.

Why would hospitalists show such a profound advantage? The answer may come down to repetition and experience with commonly encountered conditions, Meltzer said. He compared the improvements on the hospitalist service to the growing efficiency of shipbuilders during World War II as they built more ships.

“The total effect was explained by disease-specific experience,” Meltzer said. “Hospitalists seemed to have shorter length of stay and lower costs not because they spend so much time in the hospital, per se, or have so much more experience overall, but because they actually saw these diseases again and again.”

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There are many different stakeholders in fixing the runaway costs of the U.S. health care system, including patients, doctors, hospitals, and the federal government. Another interested party, heavily involved in recent debates over health care reform, is the health insurance industry. As the Patient Protection and Affordable Care Act rolls out in the coming years, insurance companies will need to adapt to many new rules and regulations on matters such as pre-existing conditions and insurance exchanges. But they also have their own ideas about how to reduce health care costs, focusing on two key components of PPACA: health disparities and quality improvement.

Aetna is the third largest insurance provider in the United States, providing medical insurance for more than 17 million people. The Aetna Foundation, their charity and grant-dispensing arm, is focused on promoting wellness, health, and access to high-quality health care. Addressing those goals will also make progress in reducing health disparities, said Anne Beal, president of the Aetna Foundation, in her presentation to the MacLean Center for Clinical Medical Ethics. The strategy she outlined showed how parties who have sometimes been at odds in the health care reform debate can find common ground for the benefit of patients.

Beal, formerly a faculty researcher at Massachusetts General Hospital and the co-author of a best-selling parenting book, made a case for health equity to the seminar series, which this year is themed “Health Disparities: Local, National, Global.” Beal presented now-familiar statistics about higher rates of infant mortality, diabetes, and more in minority communities, but added a new voice to the mix - the words of Martin Luther King, spoken in Chicago in 1966: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

But aside from social justice, there’s also a bottom-line argument to be made for reducing health disparities, Beal said. If you think of disparities as a form of inefficiency in the health care system, billions of dollars could be saved by narrowing those gaps.

“When you talk about health disparities, it is an important opportunity for us to really try to bend the cost curve,” Beal said. “Giving people the right care at the right time and preventing disease is an amazing way for us to really rein back a lot of these health care costs.”

Ensuring that people receive appropriate care falls under the domain of quality improvement (QI), the idea that health outcomes can benefit from fewer mistakes and more efficient delivery of care. Beal admitted that quality improvement was just one of many possible causes of health disparities, but argued that QI was a way to improve care for all patients and reduce health disparities at the same time - a win-win situation, if done right. Simple interventions such as making sure patients receive the right hemodialysis dose or even basic vaccination programs can help overall population health while narrowing the gap between white populations and minorities.

“This is not to say we shouldn’t do special interventions and targeted population efforts and things like that, but we need to stick to the basics,” Beal said. “If you can’t look at a population of children and say that they’re 100 percent vaccinated against measles, then any other intervention you do is just trying to put a band-aid on a bad situation. I would argue that we really need to focus on high quality care as the first step for addressing population health in communities of color.”

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There’s no denying that preventive medical screens do save lives, whether through mammograms, colonoscopies, or prostate exams. But for all the benefits, screening is not a one-size-fits-all practice. In the case of prostate cancer, mortality rates have declined by more than 30 percent in the last 20 years as testing levels of prostate-specific antigen (PSA) became a common clinical screen in older men. But other studies of the benefits of PSA screening have been less decisive, including a large 2009 study that found no difference in cancer-specific mortality over the last 10 years. Why the discrepancy?

One answer is that the benefit of PSA screening changes with age - and the reduced life expectancy that comes with age. Though 1 in 6 men will be diagnosed with prostate cancer at some point in their lives, many older men diagnosed with prostate cancer die of something other than the disease. Screening elderly men who already have serious health problems can therefore do more harm than good, paving the way for invasive procedures, risky treatment, anxiety, and health care costs that may have been unnecessary. As a result, many clinical panels have recommended that PSA screening should only be conducted in men younger than 75 or men with at least 10 years of estimated life expectancy due to old age or health problems.

But recommendations do not always match up with practice. To measure the true screening patterns in the clinical setting, a team including Scott Eggener, assistant professor of surgery at the Medical Center, broke down the numbers from a huge national health survey. The data , published this week in the Journal of Clinical Oncology, showed a quite different shape than many would hope: rather than a bell curve with the highest screening rates appearing in men 55-69 who benefit the most, the curve is an uphill climb to a plateau, with men in their 70s receiving the most tests. Men aged 70 to 79 were screened for PSA at almost twice the rate of men aged 50 to 54.

“Our findings show a high rate of elderly and sometimes ill men being inappropriately screened for prostate cancer,” Eggener told John Easton. “We’re concerned these screenings may prompt cancer treatment among elderly men that ultimately has a very low likelihood of benefiting the patient and paradoxically can cause more harm than good.”

When measured according to life expectancy, the results were not much better. Roughly 750,000 men with an estimated life expectancy of 5 years - half of the recommended 10 years - received PSA screening in the previous year.

“The men most likely to benefit from PSA screening are paradoxically being screened at markedly lower rates than men highly unlikely to benefit,” the authors wrote.

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Like the rest of campus, the MacLean Center for Clinical Medical Ethics seminar series is on spring break, resuming in early April with a talk from provocative economist Richard Epstein. So now’s a good chance to get caught up on the previous quarter’s seminars, covering topics under the umbrella of health disparities from the biological factors of breast cancer to the relationship between crime and public health to some of the exciting projects from the Urban Health Initiative. Hopefully, the ScienceLife coverage has kept interested readers informed about the valuable contents of this unique seminar series, but if you prefer a more visual experience, the MacLean Center website has posted several of the lectures in video form. Here’s a recap of the Winter Quarter sessions that are currently available for viewing.

Eliminating Global Disparities in Breast Cancer - Olufunmilayo Olopade Jim Fackenthal, University of Chicago

Unfortunately, Dr. Olopade was unable to deliver her talk due to a last-minute conflict, but Jim Fackenthal, research associate assistant professor in her laboratory, was able to provide emergency relief. The disparity in the survival rates of white women and black women in the United States with breast cancer remains wide, and while some of this gap can be explained by socioeconomic factors, biology also plays a role. Fackenthal talks about the evidence for more aggressive and harder to treat forms of breast cancer in women of West African origin here and abroad. The group’s research projects span from laboratory experiments on genetics and epigenetics to blood testing and screening in Nigeria.

Births to Arab-American Women Before and After 9/11: Evidence of Stress Effects - Diane Lauderdale, University of Chicago

The terrorist attacks of September 11, 2001 were stressful for all Americans, but possibly most challenging for Arab-Americans who experienced discrimination in the wake of the events. Lauderdale, a professor of epidemiology, wanted to look at whether one could measure a negative health impact of this discrete period of stress, choosing premature or underweight births as a health outcome potentially sensitive to discrimination. It wasn’t an easy task, as Lauderdale and her collaborators first had to develop an algorithm to find names in California’s birth registry that are likely of Arab origin. But the results of the study were striking, as Lauderdale was able to measure a spike in babies born underweight to Arab-American mothers in the months after 9/11, without any significant changes among other ethnicities.

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Electronic health records are a hot topic in the world of medicine, as hospitals implement new computerized systems to meet federal incentives. Proponents of replacing paper records with electronic health records (EHR) in hospitals and other health care settings argue that the update will improve the efficiency of health care, cutting costs and making life easier for patients and doctors. But a less popularized - and probably more immediate - effect of the EHR wave will be felt by clinical researchers, who will suddenly have a flood of medical data where there once was a drought.

This new EHR-enabled world of clinical research was featured in a recent lecture at the Department of Medicine Grand Rounds by Ari Robicsek, visiting from the Medical Center’s partner institution in Evanston, NorthShore University Health System. Robicsek is an infectious disease specialist and a self-described “accidental informaticist,” a physician and researcher who found himself drawn to EHRs as a tool to address important clinical questions. As an early adopter of paperless medical records, NorthShore has had 8 years to build a “data warehouse” that can be used for research projects. While the Medical Center works toward the next phase of its own EHR launch, called Phoenix, Robicsek’s examples were an exciting peek at how the new resource can be used to prevent hospital-acquired infections and make the most significant change to the definition of fever in 140 years.

“These are, I hope, a series of interesting illustrations of the increasingly amazing things that researchers and hospital systems are capable of doing because of the growing informatics resources available to us,” Robicsek said.

A top priority and concern for any hospital is reducing the spread of bacterial such as MRSA, which can infect sick patients with suppressed immune systems during their inpatient stay. In the last decade, hospitals have launched intensive screening programs to find patients who are carrying these bacterial strains as soon as they are admitted to the hospital, so that extra precautions can be taken. However, it’s not cheap to test every single patient, and false positives in the tests create unnecessary expense. Being able to target tests to patients more likely to be colonized by MRSA could save millions of dollars - a shift that Congress has ordered, without offering any help on just how to find those “magical” high-risk patients, Robicsek said.

Sounds like a job for the electronic health record! Because NorthShore has been adding the results of its MRSA screening tests to patients’ electronic records, Robicsek and colleagues were able to quickly comb through the data of more than 23,000 patients to find characteristics that predicted a high chance of carrying the bacteria. Instead of pulling each paper record by hand as in the old days, computer models could be built to find predictors of risk. When tested in a second batch of data (built from more than 26,000 patients), the models published earlier this year could identify the 30 percent of “high-risk” patients who account for the majority of positive MRSA tests. If implemented (as NorthShore plans to do later this year), such models could direct testing to those patients most likely to be an infection risk, rather than testing willy-nilly and racking up giant expenses.

Besides alerting physicians to clinical threats, electronic health records can also help them do more with data they’ve been collecting the old-fashioned way for centuries. Fever might be the most basic biometric, simple enough for Moms to test informally at home with the back of their hand. But the meaning of fever has changed little since Carl Reinhold August Wunderlich established the normal body temperature of humans (roughly 37° Celsius or 98.6° Fahrenheit) in 1871, Robicsek said.

“[Wunderlich] is thought over the course of his career to have taken the temperature of some 25,000 individuals, and it was his monograph on clinical thermometry that caused temperature vigilance to be introduced into routine clinical care,” Robicsek said. “Remarkably, there has been very little subsequent work validating his data…almost nobody has looked at this in the setting of physiological perturbation,” - in other words, asking what is a “normal” fever after a surgery, and when is it a cause for worry.

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The fickle attention of political pundits has shifted of late from health care reform to budget cuts and labor union protests. But as the Patient Protection Affordable Care Act (known as “Puh-Paca” or the ACA in medical circles) nears its first birthday, much of the real drama is just beginning. Because its changes were designed to roll out slowly over 4 years, many people have not yet directly felt the effects of the ACA in their lives. But the primary players in American health care, including insurance companies, hospitals, and doctors, have been scrambling to guess where they will find their footing in the new medical landscape. That isn’t easy,  Jeff Goldsmith warned in his MacLean Center for Medical Ethics seminar, as the future landscape remains in unpredictable flux.

In the late 70’s and early 80’s, Goldsmith worked at the Medical Center as Director of Planning and Government Affairs and Special Assistant to the Dean of the Pritzker School of Medicine. Now he runs Health Futures, a health care consulting firm, and frequently writes and speaks on the changing world of health care. As you might expect, Goldsmith is pretty well-versed in the gritty details of the ACA, having read the entire 2900 pages of the legislation twice, he said.

“The depths of my masochism now stands revealed to you all here in public,” Goldsmith joked. “I’ve become a Talmudic scholar of this legislation.”

Now that he is well informed about the content of the act, Goldsmith’s critical assessment was a pretty firm thumb’s down - not as a partisan, but as a policy analyst. Goldsmith criticized the delayed activation of many of the act’s effects, arguing that spacing them out over two election cycles made it vulnerable to repeal if power shifted in Washington (as it started to in 2010). Though reducing medical costs was touted as a priority of the bill, the legislation does “nothing meaningful” along those lines, he said. And by expanding Medicaid and placing additional financial burden upon already struggling state budgets, the reforms may threaten the bottom line of hospitals who depend upon government reimbursement for treating patients on public insurance.

“We’ve taken an enormous fiscal risk, and it could turn out great, or it could turn out terrible,” Goldsmith said.

But many of these worst case scenarios are dependent upon how the legislation is implemented and whether new models of care and payment can be designed - quickly. The act gives the Centers for Medicare and Medicaid Services $1 billion a year (up from $30 million a year) to evaluate new ideas for delivering health care more efficiently and at lower cost. That’s one area where academic medical centers have the power to step up and steer the future of health care through programs like Healthcare Innovation Zones, Goldsmith said. The emphasis on cutting-edge research and the integration of clinics and hospitals at academic centers should also be an asset as the healthcare rules begin to shift.

“I think academic institutions have numerous strengths that give you a capability to respond that doesn’t exist in non-academic places,” Goldsmith said. “I think both the meritocracy and the reverence for science that pervades these places are a plus in environments where you have to begin making choices about what care people receive.”

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