I’ve said it before, but the AAAS Meeting is my favorite scientific conference, a cross-disciplinary feast of research that’s perfect for omnivores of science. As I wait for the meeting to return to Chicago (2014!), I spent the week attending from afar through the many online recaps. Depending on your preferences, you can get your AAAS download from The Economist (writing about alchemy, of all things), Science News, in podcast form from Scientific American, The Scientist, the inside-baseball view of the Knight Science Journalism Tracker, or AAAS itself. Or you can read more focused recaps of a study that suggests being bilingual can protect against Alzheimer’s disease, the debate over how to effectively communicate climate change to a skeptical public, or monkey video-game self-awareness.

The University of Chicago was represented at the meeting by two talks on very different subjects: the future of health care spending, and the history of human evolution. David Meltzer, associate professor of medicine, argued that cost-effectiveness studies must be performed to control surging health care costs in the United States and other countries. Runaway costs can be partially explained by the flood of new technologies and therapies that are dropped into the healthcare market each year, Meltzer argued. While the FDA makes sure that these new technologies are safe for patients, there is less oversight on whether they actually will offer enough clinical value for their often high price tags. Even old methods, such as pap smears to screen women for cervical cancer, have rarely been assessed from an economic perspective, Meltzer said. Yearly pap smear exams are three times as expensive as exams every three years, but increase life expectancy by only 32 hours compared to less regular screening.

“The value of scientific advance and the resources available for it are greatest when we use scientific advances wisely,” Meltzer said.

On the other end of the spectrum from the future of medicine, Anna Di Rienzo, professor of human genetics, spoke about the history of man. Expanding upon her PNAS study from 2010, Di Rienzo presented genetic data found by her method of using environmental differences to find regional variation. In this case, the search ended in sweat: a gene called keratin 77, expressed in the sweat glands of the body, that has a variant more prevalent in hotter regions of the world. That variant may have become popular in tropical populations due its role in cooling off the body, but in the modern world, such environmental adaptations may be counter-productive.

“We know for sure that a lot of these differences are due to environmental risk factors that differ,” Di Rienzo said, according to Science News. “But there’s also a growing consensus that genetic factors may also contribute to these differences in disease or trait prevalence.”

Elsewhere…

Last May, we told you about Zoltan Takacs, who spends half his year chasing venomous animals around the world and the other half studying their poisons in the University of Chicago laboratory of Steve Goldstein, professor of biophysics. The good people at PBS’ Nova series got wind of Zoltan’s exciting adventures, and featured him in an episode this week on the potential of deadly venoms to be re-cast as life-saving medications for diseases such as cancer and heart disease. That’s one of his snake photographs up top.

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The future of medicine, we are told time and time again, is genetic and personalized. Someday, physicians will call up the genetic code of a patient and determine their genetic risks and which treatments will work most effectively with the fewest side effects. That information can be organized into individual, unique medical plans for each patient, helping them avoid disease as much as possible and treat quickly and directly when illness does occur. Though completely personalized medicine remains years, if not decades, away, the first few glimpses of this future have arisen in recent years with gene tests that help inform decisions about blood thinners and cancer drugs.

But for all the talk of genetic medicine improving patient care, an important question lingers: what will it cost? The soaring costs of health care in the United States have been at least partially driven by the steep price tags attached to medical innovations. New drugs and tests tend to be expensive when they reach the market, and it remains to be seen whether the clinical advantages of personalized medicine will outweigh its potential costs.

To put this balance to the test, a team of University of Chicago researchers used one of the earliest successes of genetic medicine: monogenic neonatal diabetes. As profiled before on ScienceLife, some children who are born with a form of diabetes caused by a genetic mutation can be switched from daily injected insulin to a pill, with dramatic improvements to their quality of life and disease control. At last summer’s Celebrating the Miracles conference, the families of children who had successfully “transitioned” off of insulin spoke emotionally about how the switch had changed their lives for the better. But for all the heart-warming anecdotes, the financial benefits of testing for neonatal diabetes have not yet been assessed.

“Despite all the talk and the fact we have now sequenced the human genome, there are very few studies showing an actual benefit of all these tests,” said Siri Atma Greeley, instructor of pediatrics and first author of the study. “We have to prove to people that it can make a measurable and appreciable difference in dollars and cents.”

To test the cost-effectiveness of genetic testing in neonatal diabetes, Greeley and colleagues (many from the Kovler Diabetes Center) built a simulation of the costs and quality of life effects associated with the disease over 30 years. Beyond the daily costs of insulin and blood-sugar tests, children with diabetes are at risk of several complications, including blindness, stroke, and heart disease, that can further increase medical spending and decrease quality of life. But testing for the two most common genetic mutations in neonatal diabetes has costs too - roughly $2,800 at 2009 prices - and not every child tested will have a mutation that allows for switching from insulin to sulfonylurea pills. Children who develop diabetes before the age of 6 months have a high chance of testing positive for one of the mutations, but only 1-2% of children diagnosed between 6 months and 1 year old may have this form of monogenic diabetes.

Still, when the researchers ran the numbers, genetic testing clearly proved its worth. Alongside the health benefits one would expect to result from genetic testing of all children diagnosed with diabetes before the age of 6 months, the model also revealed dramatic financial savings over not performing the tests. By 10 years after testing, the average cost savings was over $12,000; by 30 years, the savings figure had climbed over $30,000. The results add a strong financial argument to the medical case for genetic testing of all infants with diabetes.

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Photo by "BankingBum" - Wikimedia Commons

The leading cause of death for American black men between the ages of 15 and 34 isn’t cancer, AIDS, heart disease, or even accidents. It’s homicide, which accounted for more than half of the deaths of black 15 to 24-year-olds and more than a third of those aged 25 to 34. In Chicago, African-American males aged 15-24 are 10 times more likely to be killed in a homicide than white males, and in 2004, more African-Americans died from homicide than diabetes, HIV, or stroke. Genetic predisposition, access to health care, diet and exercise - all pale in comparison to bullets and knives.

Those numbers clearly argue that any discussion of health disparities between white and black populations in the United States can’t be limited to disease, said Harold Pollack in his MacLean Center for Clinical Medical Ethics seminar in late January. Urban, minority populations bear the brunt of the consequences of crime, he demonstrated, including not only homicides but also non-fatal injuries, incarcerations, economic damage, and stress. So while a project like the University of Chicago Crime Lab, for which Pollack serves as co-director, is rooted in the social sciences, the success or failure of its mission will surely have an impact upon medicine and community health.

“If you actually count up the number of dead bodies and in particular the number of life-years lost, homicide is a significant public health threat and it requires a systematic, determined response,” Pollack said.

The most shocking graph Pollack showed during his talk had nothing to do with cancer rates or disease mortality, but instead with incarceration. While the proportion of Americans behind bars remained stable from 1920 to 1970 at roughly 1 in 1,000, from there the numbers took an upward spike to make the climate change “hockey stick” graph jealous, increasing fivefold to today’s rate. As the numbers of jailed Americans skyrocketed, the prison population also became significantly less white, Pollack said, with the white incarcerated population dropping from 60 percent to 30 percent of the whole.

The “incarceration epidemic” causes significant public health ripples, both direct (through violence, HIV transmission, and drug addiction) and indirect. Disparities of incarceration have strained relations between minority communities and police, Pollack argued, making crime prevention in dangerous neighborhoods more difficult. Hiring biases against applicants with criminal records make it hard for convicted felons to find jobs (not to mention health insurance) after their release, steering them back toward illegal activity. For those jailed as juveniles, the lost time in school only intensifies the struggle to find legit work.

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Racial health disparities in the United States have been repeatedly measured, demonstrated, and presented to the point where their existence is no longer in question. But still up for discussion is how to fix them, whether through sweeping legislation like this year’s federal health care reform, local efforts to improve health care access or social determinants of poor health, and/or by customizing care to better serve minority populations. But what about that time-honored American way of dealing with injustice and unfairness - why not tell disparities “I’ll see you in court!”?

The idea is not so far-fetched, said Anup Malani, a professor of law and medicine at the University of Chicago, in his lecture to the MacLean Center for Clinical Medical Ethics in early December. After all, the Civil Rights Act of 1964 was created to address segregation and inequality in schools, employment, and other important aspects of life, so why not medicine? History shows that Title VI of the Civil Rights Act, which forbids racial discrimination by any body that receives federal funds, was one of the most effective strategies ever in reducing racial health gaps. After its passage, hospitals and other medical providers (nearly all of whom receive federal funding in the form of Medicare/Medicaid), could no longer legally segregate patients into different wards or treat them with different personnel. The result was a rapid improvement of health care for black populations, and a brisk narrowing of the disparity in measures such as infant mortality, Malani said.

“It was a huge, huge success,” Malani said. “We spend a lot of time in law school thinking about the great civil rights successes in education, and we’re studying the wrong thing. In four months, you got 1,000 hospitals to integrate. This is unbelievable…One would like to achieve that sort of result again.”

But the rapid integration of American hospitals in the 1960’s only reduced the gap, it didn’t eliminate it. Some hospitals also exploited a loophole in Title VI and simply moved to more affluent, predominantly white communities, a strategy that turned out to be difficult to litigate in Title VI court cases. Because hospitals could plead at least one legitimate reason for the move - usually the argument that they would no longer be financially viable in the inner city - the charges of civil rights violation were denied. Other limitations of civil rights cases, including federal limits on damages, high cost, slow pace, and inadequate penalties, also make Title VI the wrong weapon to use in fighting today’s racial disparities, Malani argued.

Those loopholes may have even created a major driver of health gaps, Malani’s research has found, in that a disproportionate number of minority (and poor) patients receive their treatment from the country’s worst-performing hospitals. This dynamic creates what Malani called a “between” disparity, where minorities receive care from lower-quality providers than white patients, rather than receiving poorer care from similar-quality providers. Statistics have supported that observation, showing that hospitals and ambulatory care centers that treat more minorities have lower scores on measures such as mortality.

Therefore, though it hurt Malani to admit it (”it’s awkward for me as a lawyer to say I’m not the solution,” he joked), the most effective strategy may not be litigation but policy efforts to help the low-performing hospitals. Improve the statistics of these health care providers, and you hopefully reduce the racial gap by reducing “between” disparities.

“Let’s send funds to these hospitals,” Malani said. “If you just target the worst hospitals in America, you’re going to disproportionately help minorities.”

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In a time of worrying American health statistics, some states definitely have it worse than others. On many measures of health and health system performance, Oklahoma ranks near the bottom of the list - or in the case of fattest states, near the top. At his talk for the MacLean Center Seminar Series last month, Gerard Clancy illustrated his state’s health woes with a collection of photographs from the Oklahoma State Fair, including the “donut burger” and the elegantly direct deep fried butter.

As Dean of the College of Medicine at the University of Oklahoma-Tulsa, Clancy’s immense challenge is to find new ways of improving health in this decidedly unhealthy setting. To do so, Clancy has overseen a dramatic change in the medical school’s curriculum, mission, and even name, rechristening the program as the OU School of Community Medicine. Clancy and colleagues redirected the school to focus on health care access and training medical students in primary care and community health, all in the context of national health care reforms and their new emphasis on reimbursing quality over volume.

“Our belief is that we’re going to have to modify how we deliver health care to have a model teaching environment for our medical students,” Clancy said. “We don’t want to have a teaching model that is archaic compared to where health care is going to be soon. So we are rapidly changing how we deliver health care.”

That plan revolves around new community efforts, particularly in the poorer neighborhoods of North Tulsa, where life expectancy lags 14 years behind the more affluent south half of the city. Deploying the “Starbucks model,” Clancy said the school is trying to build health care access points on every corner, with more than 300 doctors working at over 50 sites. As a hub, the school broke ground on the Wayman Tisdale Specialty Health Center, named for the college basketball great who died of osteosarcoma in 2009.

But in the week before the groundbreaking ceremony, Clancy said the school learned a valuable lesson about not forgetting the “community” in community health. A newspaper ran a front-page editorial headlined “Is Tulsa North Being Pimped by OU?,” which challenged why the university was only providing health care without addressing social determinants that create poor health: lack of education, jobs, and other services.

“This was a big lesson for us to learn,” Clancy said. “When we met with the legislators, and the leaders of North Tulsa, and the writers of the article, the key line was ‘You don’t get it. We want you to bring the full resources of the University of Oklahoma to us, not just the clinics.’”

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Anyone who dares make predictions about the future of the U.S. health care system in 2010 is standing on shaky ground. With the passing of the Patent Protection and Affordable Care Act (PPACA)- the legislative product of the health care reform debate - everyone knows that the rules are about to change in this country, but nobody is quite sure how. The changes included in the act will not be fully phased in until 2014, and the complicated business of determining exactly how those changes are implemented is currently underway in the bureaucratic halls of Washington. Throw in the Republican gains in this month’s election - won at least in part on promises to repeal aspects of PPACA - and uncertainty is rampant about the most important overhaul to American health care since the creation of Medicare.

That foggy vision of the future dominated discussion on the opening day of the 22nd Dorothy J. MacLean Fellows Conference, this year’s edition of the MacLean Center for Clinical Medical Ethics annual event. Though the topic of Friday’s sessions was nominally health disparities on the local, national, and global stages, the discussion was magnetically drawn again and again to PPACA, which was designed in part to narrow notorious health care gaps in the United States.  The physicians, ethicists, and social scientists at the conference unsurprisingly agreed that it was imperative that those disparities be reduced, but less consensus was reached on whether PPACA would be the magic bullet to do so.

On its face, the legislation makes several sweeping moves that would appear to directly confront health disparities in America. No PPACA component is more significant for underserved populations than the expansion of medical coverage for the country’s 47 million people without insurance, the majority of whom are minorities, said A. Eugene Washington, the dean of the David Geffen School of Medicine at UCLA. The other major aims of the bill, improving quality and reducing cost, may produce more mixed results for disparity reduction, as new payment measures based on outcome, rather than volume, could push health care providers to avoid communities with poor health at baseline. Much relies upon how the broad goals of the bill are truly implemented by federal and state agencies, he said.

“The legislation is really a framework, and it’s going to get shaped,” Washington said.

The (mostly) pessimistic view of that shaping process was provided by Harold Pollack, professor of social service administration at the University of Chicago. Pollack said the legislation, as written, is the most important AIDS and drug addiction policy ever passed in the United States and that expanded coverage will help address some disparities. But he was also critical of the slow roll-out of policies because it makes them contingent upon “bipartisan goodwill,” a scarce resource lately in Washington.

“We’re in for a wild ride, and it’s going to be a wild ride in a time of fiscal crisis and political gridlock in the short run, when the most difficult implementation challenges in our health care system will have to be resolved,” Pollack said.

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Tuesday’s midterm election results appeared to deliver a strong message of discontent to the young Obama administration. With Republicans gaining control of the House of Representatives and closing the gap in the Senate, many analysts saw the election as a rebuke of the Democratic agenda of the last two years. Perhaps the highest-profile of those policies was the Patient Protection and Affordable Care Act, the product of the epic legislative battle over health care reform. Though many of the PPACA changes have yet to be activated, its opposition has loudly and repeatedly warned that the reforms will bring rationing of health care for the American public.

That’s a false bogeyman because rationing is already here, according to a commentary by the University of Chicago’s David Meltzer in last week’s Journal of the American Medical Association. Though the word “rationing” brings to mind making do with scarce resources during wartime, the term applies to any time a good or service is divorced from the economic forces of supply and demand. With the influence of government subsidies, private insurance companies, and managed care, the American health care system has long been subject to rationing.

“Attempts to resist change using the specter of rationing are not reasonable because rationing already exists and is inevitable,” Meltzer, an associate professor of medicine and economics, writes with Allan Detsky of the University of Toronto.

Because each individual’s personal demand for health care is unpredictable - a person could go the next year without needing to see a doctor, or get in a serious car accident tomorrow - insurance companies (and government programs such as Medicaid and Medicare) play the role of mediators, evening out the cost and lowering the risk. But that role gives insurers the power to make decisions about what care is appropriate and necessary, which may include the ability to ration health care through denial of coverage. Because a patient can pay for the procedure themselves, it’s not quite the same as the wartime rationing of goods, but when an unapproved procedure can run hundreds of thousands of dollars, the result may be no different.

The real debate then is over who should be making decisions about health care rationing: profit-driven private insurers, or politically-prone government officials, the authors write.

“I think it’s silly to talk about rationing without more subtlety,” Meltzer told ScienceLife in a separate interview. “We should absolutely have a debate about rationing, but it’s not a debate about whether, it’s a debate about how.”

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As discussed previously on ScienceLife, the microbiome is the ecosystem of billions of bacterial organisms living inside our bodies, influencing us in as-yet-undetermined ways. Most efforts to study the microbiome thus far have focused on how gut bacteria affect digestion and disease, but a paper this week in PNAS reveals a surprising new power for those microorganisms: the ability to shape sexual preference. Okay, so far it’s only been observed in fruit flies, but as Ed Yong at Discover Magazine’s Not Exactly Rocket Science explains, it’s still a remarkable example of how a change in diet can alter an organism’s behavior in unforeseen ways.

The relationship between science and films, Carl Zimmer writes in this week’s Nature, has largely been a one-way street. Science gives Hollywood the technology to make pictures move, talk, and appear to throw things at you (in the case of the recent 3D boom), but returns the favor by portraying scientists as mad, geeky, or both. Zimmer’s column was inspired by hosting the recent Imagine Science Film Festival, a New York event that showcases short films with scientific inspiration. And while Zimmer is skeptical about the use of Hollywood film to promote science - Citizen Kane “would not have been a masterpiece if Orson Welles had kept asking himself ‘Does this make journalism accessible to a broader audience?’,” Zimmer writes - he comes slightly around after seeing films portraying the sensory phenomenon of synaesthesia and the comedic adventures of a Norwegian cryonics laboratory.

Bad news: a new projection by former University of Chicago faculty member Nicholas Christakis predicts that 42 percent of Americans will be obese by the year 2050. Good news: the obesity rate will plateau at that ghastly figure; as the authors write, “While not great, this is a much more optimistic estimate than 100%.” As our own Elbert Huang calculated last year, that plateau will still mean billions more in health care costs to treat chronic diseases associated with obesity, such as diabetes and heart disease.

The health care reform measures passed last year, should they survive the new Republican-led House, put a greater emphasis on primary care and preventive medicine. But the question of who will provide that primary care remains unanswered, as Joanna Broder wrote in the Chicago Tribune this week. Broder leads her article with Pritzker School of Medicine graduate Nina Vergari Rogers, currently working at the Chicago Family Health Center as part of the University of Chicago Medical Center’s REACH program. Doctors enrolled in REACH can receive $40,000 a year toward their medical school loans - a serious incentive, given that the lower salaries paid to primary care physicians mean their expenses exceed their earnings for the first 3-5 years after residency.

Covering medical research for the University of Chicago, one hears a lot about racial health disparities and the efforts to narrow those gaps. But some statistics still pack a punch, and Otis Webb Brawley’s talk at the University of Chicago last Thursday contained several left hooks. The five-year risk of death after diagnosis with breast cancer is almost twice as high for black women as for white women - but 30 years ago, the risk was nearly equal. An uninsured patient with stage 1 colon cancer is more likely to die from their disease than an insured patient with the more-dangerous stage 2 colon cancer. Obesity in children has risen five-fold since 1970, and obesity is expected to pass cancer as the #1 cause of cancer by the year 2030…if it hasn’t already.

In Brawley’s role as chief medical and scientific officer for the American Cancer Society, it’s his job to use these statistics to make clear arguments to scientists, physicians, politicians, and laypeople about what must be done to reduce cancer disparities. But Brawley’s talk for the Bowman Society Lecture Series (named for retired professor, and former teacher of Brawley at the Pritzker School of Medicine, James Bowman), was distinctly not about just throwing money at the problem. His central philosophy was “equal treatment yields equal outcomes among equal patients” - but sometimes, deciding what that equal treatment should be is the hard part.

Brawley took care to set his talk in the context of spiraling health care costs in the United States, showing the now-familiar graph plotting our highest-in-the-world health care spending against the country’s mediocre life expectancy. Racial disparities could explain part of those poor returns on US health care spending, but Brawley put the focus on “faith-based medicine” - not health care based on religion, but care (and associated spending) based on assumptions about what works rather than hard evidence. As an example, Brawley cited the practice of chest X-ray screening, considered by physicians in the 1960’s to be a necessary routine procedure for the detection of cardiopulmonary disease. But clinical trials found that these screens caused more harm than good, through increased rates of lung cancer and over-diagnosis.

“We did all those things because we thought we were doing the right thing, but we didn’t do rigorous assessment before we started doing them,” Brawley said. “So I ask the question: are we willing to be scientific and accept scientific realities? There are things that we do that add to the incredible cost of health care, but make no difference in outcome.”

That tough talk should apply equally to the problem of reducing health disparities in minority populations, Brawley emphasized. While some pursue the genetic risk factors that may explain disparate rates of disease in minorities, Brawley argued that socioeconomic factors were a much bigger target for intervention. A 1998 study that compared the breast cancer mortality gap in the general population versus women in the U.S. military medical system (who receive free health insurance and easier access to hospital care) found that the gap was still there, but almost two-thirds smaller. The other third could be genetics, Brawley conceded, but the more significant - and, in his view, easier to fix - factors were social and economic.

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Last week, a multi-center study published in JAMA demonstrated the value of genetic testing for breast cancer risk, a simple test that allows women the choice of preventive surgery. The study and the accompanying editorial urged wider screening of women for the variants of the BRCA1 and BRCA2 genes that can create as much as ten times the risk of contracting breast cancer. But while a test for these risk variants has existed since the mid-1990s, only a fraction of women (and men) carrying the high-risk mutations have been identified. Some have blamed Myriad Genetics, the owners of the controversial patent on the BRCA 1 and 2 genes, for this shortfall. But what if a major contributing factor is something far less legally complicated: a physician’s finite time?

The average assessment of a patient’s genetic risk can take anywhere from 70 to 170 minutes, said Kevin Hughes, surgeon at Massachusetts General Hospital, who spoke to the University of Chicago Breast Cancer SPORE program Tuesday afternoon. Interviewing a patient about their symptoms and family history, running various risk assessment calculations and decisions, and producing the necessary paperwork eats up a great deal of time and effort even before the test is run. To find all of the approximately 1 million carriers of BRCA1/2 mutations in the United States, this exhaustive process would take an estimated 11,000 person years, Hughes calculated.

But a possible time-saving answer is to contract out some of those information-collection, decision-making, and paperwork-completing duties to a proven hard worker: the computer. Many of the electronic medical records systems rolling out in hospitals across the United States are ill-equipped to deal with the family histories and other information critical for genetic risk assessment, so Hughes and partners at Mass Gen developed their own free program, called Hughes RiskApps. A sort of electronic questionnaire that patients fill out on a tablet PC by checking boxes with a stylus, the program quickly gathers all the relevant information about the appearance of cancer in a patient’s relatives and their own medical history - but then, the real cool stuff happens.

Rather than dumping all the collected information on an overworked physician or genetic counselor, the program does its own thinking, a process known as Clinical Decision Support. By generating a family pedigree and running the various risk calculations itself, the computer program can make a recommendation in seconds on whether the patient - and other family members with a high risk - should be tested for BRCA mutations. What’s more, it can automatically generate all the paperwork necessary to obtain those tests, and even customized informational handouts to give the patient.

“The idea with this is to let the patient do the work putting the data in, let the computer do the work of doing the analysis, and then present it to the doctor in a way that makes it very easy for them to go on and take care of that patient and what to do next with them,” Hughes said. “It’s trying to take the workload away from the doctor and the center and putting it into the computer.”

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General internal medicine might seem like an awfully vague term. But assuming the health care reform bill signed by President Obama in March will be fully implemented, the general internists will finally have their day. Many of the bill’s provisions are focused on a reshuffling of the American medical landscape, which is currently dominated by sub-specialists focused on one organ system. In recent years, fewer medical students have chosen to pursue lower-paid and less glamorous careers in internal medicine, leaving a worrisome shortage in primary care doctors and hospitalists just as 32 million uninsured Americans are about to go on the books. The spotlight is about to focus on internal medicine.

“About time,” would probably be the response from most of the doctors assembled in Minneapolis last week for the 2010 Society for General Internal Medicine national meeting. Over three days, thousands of internists met in discussion groups and research panels to chart the course for a new age of American medicine. Though some fears were expressed about how an already overwhelmed system would be able to deal with the new influx of patients, the conference was more focused on seizing the opportunity to rehabilitate U.S. primary care and bring medical services to those who are traditionally underserved. The urgency of the moment was expressed right in the caps-lock and exclamation point of the meeting’s theme: “Value(s)-based generalism: THE TIME IS NOW!”

Of course, many of these efforts to expand the net of primary care didn’t start when Obama used 22 pens to sign the health care bill on March 23rd. Many of the presentations by University of Chicago faculty at the conference discussed pilot programs already being tested to improve the care of those who have traditionally fallen through the health care cracks, efforts to reduce disparity that may be instructive as the reform measures fall into place.

A workshop moderated by Marshall Chin, professor of medicine, presented four examples of programs funded by Finding Answers, Chin’s Robert Wood Johnson Foundation-supported group for studying racial and ethnic health disparities. Chin said the mission was to “evaluate interventions that reduce racial and ethnic disparities,” and the short presentations showed the breadth of that mission. Projects using cultural awareness training, electronic medical record software, and pay-for-performance programs were all discussed as potential solutions, with researchers from Harvard, Brigham and Women’s Hospital and Baylor outlining projects currently underway. One fascinating approach, described by Barbara Turner from Penn, employed African-American patients who had successfully controlled their high blood pressure as “peer coaches” to help fellow patients struggling to adhere to treatment - an elegant way of using community bonds to spread healthy messages.

Another successful example of community health intervention was presented in tandem by Deborah Burnet, section chief of internal medicine at the Medical Center, and Lorri McClinton-Powell, a teacher from Woodlawn Elementary School on the southeast side of Chicago. Last year, Burnet and colleagues conducted a pilot study of the POWER-UP program, an anti-obesity effort based around after-school activities for children and parents, with 40 children and their parents at Woodlawn. Fourteen weekly sessions - focused on themes such as “Muscle Mania” and “Stop & Shop” - taught the children about healthy eating, exercise, and behavior at restaurants and grocery stores. Though small, the study’s results held promise, with declines in overall body mass index among all but the heaviest kids at baseline. The group is currently working with Chicago Public Schools on the possibility of expanding the program for a larger study, Burnet said.

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Eric Goren and Eric Whitaker at Bloomberg Health & America Briefing (photo by John Zich)

If there’s anything clear about health care reform, it’s that it’s unclear. Over the last 15 months, what has mostly been heard has been the two loudest sides, as political supporters and enemies of the health care policy changes under debate in Washington state their views frequently, at maximum volume. But the landmark reform legislation signed by President Obama in late March is expected to cause ripples in many worlds, both in the health care industry and beyond. The rules for doctors, patients, hospitals and medical schools will certainly change, but so too will the effects be felt in the financial sector, the 2010 elections and the technology industry. As such, the health care reform bill is kind of an amorphous entity, one that takes on totally different shapes depending on one’s professional perspective, political beliefs, and educational background.

Getting a read on all the ramifications of reform is an ambitious project, and the Health & America Briefing, organized by the Bloomberg news organization and the University of Chicago Medical Center on Tuesday, was suitably epic in its scope. Drawing upon dozens of experts from all corners of the country and all sectors of the economy, the event at the downtown Gleacher Center employed interviews and panel discussions to try to circumscribe the enormous changes the health care reforms are expected to cause. Some voiced optimism, some voiced concern, and the entire chorus only agreed on one thing: no one can predict the ultimate impact of what some called the most significant legislation of the last 50 years.

The most optimistic view was presented, logically, by one of the health care reform bill’s lead architects. Ezekiel Emanuel, special advisor on health policy in the Obama administration, led off the conference in a one-on-one chat with Bloomberg News’ Washington editor, Al Hunt, and called the bill “the most complex piece of social legislation America has ever tried.” Emanuel, while slightly less strident than his younger brother, White House Chief of Staff Rahm Emanuel, was still demonstrative in his defense of the bill, which he said would still cause sweeping improvements despite the necessary compromises it required to pass through a divided Congress.

Reaching beyond the insurance extensions that have gotten most of the ink, Emanuel pointed to several measures he thinks will dramatically restructure American medicine: an independent federal cost-control commission, improvements in health care technology, and added incentives for doctors to practice primary care. The hope, Emanuel said, is that the health care system can learn from small successes in improving care and bring those lessons to a wider population.

“You see pockets almost everywhere in the country with fantastic practices, and the issue…is scaling them,” Emanuel said. “I think that over the next five years may be our biggest project, is can we scale the good things that the health care system does: the efficient things, the high quality things.”

One place where Emanuel allowed a modicum of defeat was in the arena of end-of-life care: the massive expenditures accrued by medical interventions in terminal patients. While more than a quarter of Medicare dollars (and 10 percent of health care costs overall) are spent on end-of-life care, “no one is satisfied by it,” Emanuel said. Efforts to change how that process is handled by doctors and patients were demonized during the legislative debate as “death panels.”

“We have to do better,” Emanuel lamented. “It was a sad loss for the entire country.”

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There’s a strange new addiction sweeping across the heartland. Unsuspecting addicts are lured in by word-of-mouth promises of unbeatable prices, made to feel exclusive with a membership card, and turned loose upon shelves and shelves of merchandise. But while the initial high of savings may be thrilling, the addiction always spirals out of control, until the poor victims find themselves with 25 pounds of peanut butter and 300 boxes of Cheez-Its overflowing their pantry.

Warehouse club stores such as Costco or Sam’s Club have changed the way people shop for daily items like groceries and cosmetics, teaching them the financial joys and storage dangers of buying in bulk. But the savings associated with buying large quantities - so long as those 25 pounds of peanut butter are used up before they went bad - are undeniable. So it was only a matter of time before the bulk-buying strategy crossed over to another market where cost-cutting is sorely needed: health care.

One place where people feel the most pain from health care costs is prescription drugs. Even though the cost of pills only makes up about 10% of total medical costs, there’s something dispiriting about having to throw down $20 bills - or even hundreds of dollars - on a monthly basis at the pharmacy to fill one’s regular medications. As such, many experts have recommended buying prescriptions in 3-month quantities rather than 1-month installments, a switch that retailers such as Walgreen’s, Target, and yes, Costco have thrown their support behind.

But while buying three months of pills at a time instead of one made intuitive sense, nobody had bothered to actually quantify just how much individuals and their insurance companies could save from such a strategy. Atonu Rabbani and G. Caleb Alexander of the University of Chicago Medical Center stepped into that breach with a paper published this month in the journal Applied Health Economics and Health Policy, calculating that 3-month prescriptions can give both individuals and the health care system a little more pocket change in tight times.

Per person per month, the savings of receiving 3-month prescription supplies rather than the 1-month variety saved people the modest sum of $5.91. But in some places, that’s still a matinee movie, and over the course of a year, it’s about $70 - a nice dinner-for-two out, for sure. Total costs per month also drop by 18 percent ($7.81), which means both you and your insurance company will be happier on a monthly basis.

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The question was a welcome one, given the heated, exhausting health care debate that has raged through the summer: On the day after health care reform (whatever form it takes), what are the potential stumbling blocks and opportunities?

That’s how moderator Michele Norris (of NPR’s All Things Considered) thoughtfully began the panel at the University of Chicago-curated “Chicago Contributes” health care forum, held Thursday in Washington, DC less than a day after President Barack Obama’s speech to Congress. Reform supporters might consider that question to be a jinx as Obama and the Democrats struggle to find a consensus plan, but it allowed the forum’s panelists to clear the political fog and put the focus back where it should be - on the challenging questions of access and cost reduction that face modern American medicine.

After a keynote address by Kathleen Sebelius, Obama’s Secretary of Health and Human Services, echoed many of the points the President made himself the night before, the stage was turned over to a national group of university experts that were grappling with these issues long before health care became the season’s political hot potato. The importance of access to health care, not just insurance, was summarized nicely (and immediately) by Gerard Clancy, Dean of the University of Oklahoma-Tulsa College of Medicine: “If we have 40-50 million people now with health care coverage, who’s going to take care of them?”

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Last night, President Barack Obama addressed Congress about the need for health care reform, and today the University of Chicago is presenting a timely forum in Washington, DC, on the subject of access to health care. With a keynote address from Secretary of Health and Human Services Kathleen Sebelius and a panel that includes several health care policy experts, the event promises to be a interesting discussion of how universities are participating in the current national health care conversation. In cooperation with the UofC News Office, we’ll be running a live-stream of the event from 12 noon Chicago time, along with live, updating commentary from blog editor Jeremy Manier and Medical Center communications director John Easton at the forum, and Rob Mitchum, who will be watching the stream with you. Below the video feed and live blog you can find the agenda and the participants in the health care forum, or you can read more about the Chicago Contributes event (which will also feature an education forum following the health care discussion) here:

Keynote: Kathleen Sebelius, U.S. Department of Health and Human Services Secretary
Panel: “Access After Health Care Reform”
Moderator: Michele Norris, Host of NPR’s All Things Considered

Panelists:

• Eric Whitaker
  • Executive VP, Strategic Affiliations, and Associate Dean of Community-based Research at the University of Chicago Medical Center
• Pedro Jose Greer
  • Assistant Dean of Academic Affairs and Chair of the Department of Humanities, Health and Society, Florida International University School of Medicine
• Gerard Clancy
  • President, University of Oklahoma-Tulsa, and Dean, University of Oklahoma-Tulsa College of Medicine
• Kavita Patel
  • Director of Policy of the White House Office of Public Engagement and Intergovernmental Affairs
• Patrick Soon-Shiong, M.D.
  • Executive Chairman & CEO, Abraxis Health, and Executive Director, UCLA Wireless Health Institute, University of California, Los Angeles