Search for tag: "cost"

Announcer: Examining the latest research and telling you the latest breakthroughs, the Science and Research Show is on The Scope.

Lynn: My name is Lynn Jorde. I'm the Chairman of the Department of Human Genetics at the University of Utah School of Medicine. I'm here today with Dr. Eric Green, who is the director of the National Human Genome Research Institute.

So, we've heard a lot about the ever decreasing cost of genome sequencing, about a million fold in the last decade. Does this mean that everyone should be sequenced? Or if not, who should be sequenced?

Dr. Green: So from a research perspective, I think there's great power in getting tremendous amounts of data from as many people as possible and using this in very robust ways to try to understand many aspects of health and disease. I think your question though, is aimed more at, "Should everybody get their genome sequenced as part of their medical care?" I'm not sure we're quite there yet. That might be where we are eventually, but just because we have the technical capabilities of doing that, I think we're far away from knowing what to do with that information in a clinical context to say that this should be sort of used for everybody. Rather, I think it's most useful now in very discreet areas where there's clear evidence that having genomic information will be helpful to that patient.

Lynn: Some critics have said that the Human Genome Project, of which you and many of us have been a part, hasn't really delivered on one of the original promises to revolutionize medicine. How would you respond to that?

Dr. Green: When the Genome Project ended 13 years ago, there was incredible celebration. In fact, many of use were euphoric about having achieved the goals that were set out for the Genome Project. I think in our exuberance lots of promises were made and lots of claims were made to have this was going to revolutionize this, that and the other and lead to great medical advances. I think much of that exuberance might have been over interpreted as meaning those advances were going to take place quickly.

There was no reason to believe it was going to happen that quickly. Actually, if you look back in the history of bio-medical research, there is usually periods measured in decades between very basic discoveries, such as the discovery of antibiotics, the discovery of the basic biochemistry of cholesterol metabolism and the actual changes in medical practice that led to advances in medicine. Decades. Here we are only 13 years in to having information about our genome available to us. So we've not seen the revolution, that I think will eventually come. I think for that we've been criticized.

I think we just have to take a step back, recognize that we're 13 years in. There's some vivid examples where genomics has had a profound effect on medicine, but they're the earliest examples. Even in aggregate those don't represent a revolution, but they're highly illustrative of what is coming.

So I think, when we look back at the history of genomics, say 10, 20, 30 years from now, I think that will be the fair time to assess whether or not our claims that were made when the Genome Project ended, were accurate or not. It's just too soon to do it now.

Lynn: So we're seeing investigations now, of all sorts of traits. The genetics of IQ, people claim to have found genes that influence things like aggressive behavior, anxiety. This gets pretty controversial. Are there areas that should be off limits, at least off limits to NIH funding?

Dr. Green: Absolutely. People get very uncomfortable with some of these ideas of doing genomic studies to better understand the basis for IQ, for aggression, various other attributes. It's also controversial scientifically, so before we even think about whether or not we want to limit this, I do want to put some reality on this. I think most scientists would agree that getting an accurate assessment of intelligence is not simple. Getting an accurate assessment of behavior is not simple. I think it is scientifically controversial whether we can even make major gains in this by doing these studies. So I think that really has to temper our enthusiasm for it. But then, of course, there's the ethical and societal implications of this. Are people going to be comfortable with it?

I think we need to be very cautious. When we are going to use these new tools of genomics, especially at this early stage, to prioritize things that are going to have great societal benefit. There's so many major medical challenges, disease areas, that will benefit from using these tools first and foremost, those are the areas that should be prioritized and I think that's where we should be putting our energies. At the same time, we should be very careful looking at what some of these other studies that might be envisioned, how they'll be perceived and how practical they are. I think they're going to end up being a low priority. In some cases, one might imagine doing some studies, along those lines. I just don't think they're going to be at a very high priority.

There's a lot of controversy of whether they'll be successful. It just doesn't seem to be the thing to be emphasizing right now. So, my enthusiasm level is low. I think in general people are making decisions about where money is going are going to deprioritize them. I'm not sure I want to say there should be a ban, but there should be careful scrutiny put on these. Research dollars are precious and we need to go to things that are more practical, and things that will have a higher impact on human health and disease.

Lynn: Over the past two years there's been quite a lot of controversy about patenting human genes. So, how does patenting, or not, affect scientists and consumers? Could it affect interests on the part of the private sector in investing and genetic and genomic research?

Dr. Green: There's not simple answers. The whole intellectual property construct and the ability to get patents and protecting people's advances are very important for the private sector and their ability to invest in things and feel comfortable that they will get a return on investment and so forth.

On the other hand, there's something a little special about the human genome. It is very basic, fundamental to humankind. It is our blueprint and the potential to have fundamental information about our blueprint be used. And a fast note, any day we be restricted makes many people uncomfortable. I think one of the things genomics has done, and its sort of cultural values associated with data sharing, is making as many things available to everybody, freely, widely. I think has served us very well. I think the fundamentals of understanding how the genome works in human genes and so forth, having no restrictions on their use, I think is very, very important.

There's a vision associated with using information about one's genome to tailor their medical care. I think many of us get very uncomfortable if in the process of doing so, if too many patents were laid down they would look like tollbooths across the double helix. Every single time we would go to one to analyze one part of someone's genome, we would have to pay a toll, and that would greatly hinder advances.

So, I think many of us have taken a position that it's so basic, that information, that just raw information, which is easy to get about the human genome and about genes, should sort of be off limits for patenting. Now, if you use that information you come up with a great intellectual advance and you design things around it and you come up with something that is more than just the basic fundamental information, yes, that should probably be fair game for patenting, for getting intellectual property and so forth. I think it's that raw information about genes that has made many people uncomfortable and have said that should be off limits for patenting.

Lynn: A big part of this then is the public understanding of traits, of what it means when we say a gene is associated with a trait. This gets us to the question of genomic literacy. What can we do to increase genomic literacy among the public so that they will better understand these kinds of issues?

Dr. Green: Genomics is a relatively young discipline. It's only been around a little over a quarter century. We are fortunate that it's been wildly successful. I think we're all very proud of that, but that's actually created a bit of a challenge for us. The challenge is that this field of science is finding it's way into medicine faster than any of us could have anticipated.

As a result of that, we have some complicated concepts, but also some basic language of genomics that it's finding its way into medical care. Yet, most people don't necessarily know the basics of this. They haven't been given the opportunity to learn it. Many of the healthcare professionals weren't taught this when they were in school. So this is happening so fast and furious that our ability to educate the public, educate healthcare professionals, is lagging behind.

As a result of that, this becomes very important when patients go to see their healthcare professionals and now will start hearing, in some context, about genomics. They don't really understand those words, they don't understand that language. If the patients don't understand it, they're going to go home and talk to their family. They may not understand it. They talk to their friends, they may not understand it.

So we have a societal responsibility to increase literacy about basic language of genomics, because that is a language that will increasingly be used by healthcare professionals, as part of patient care. It's not anybody's fault that we find ourselves in this situation. We're victims of our own success. We've been successful scientifically and now we need to sort of redouble our efforts to think about how to raise genomic literacy more broadly across society.

Lynn: Looking forward to the next decade, the next two decades, what excites you the most about genomic medicine?

Dr. Green: I think what excites me more than anything is the optimism that I have that what is going to transpire over the next decade is going to be significantly greater than what has transpired over the even last decade or the last two decades. I think we're so much more poised to accelerate progress than we ever have been in the last 25 years of genomics.

So, what I anticipate, what I'm excited about, is on multiple, multiple fronts, multiple areas, whether it's cancer, whether it's rare disease, whether it's infectious disease, whether it's in thinking about how to prescribe medications in a more precise and rational way, it just seems in so many areas, the progress I anticipate over the next ten years, I actually believe will be even more remarkable than what I've seen. Yet, I've been shocked by how much we have seen medical applications of genomics begin to be realized on a timeframe that I simply would not have predicted when I got involved in this field initially. I'm even more excited about the next generation of biodmedical researchers and healthcare professionals who I think are going to be the ones that are going to truly realize genomic medicine.

Announcer: Discover how the research of today will affect you tomorrow. The Science and Research Show is on The Scope.

The burning platform in health care is that the health care system really is not working. In fact, to even call it a system does an injustice to the word system. In the U.S. we spend perhaps 50% more per capita than anyone else in the world, and currently we have worse outcomes. So this is not a good situation when we're spending more than $3 trillion a year, 18% of our gross domestic product in an industry that is basically sick.

This is work I'm doing in collaboration with my colleague and friend, Michael Porter at Harvard Business School. Michael's a professor of strategy, and in fact, founded the field and he got interested in health care 10 to 15 years ago because he wondered, "How do you have a system like this sustain itself in such an inefficient way?" As he sort of threw it, he realized that the fundamentals for healthy competition, which ultimately is what drives value to consumers, does not exist in health care that we don't even agree on what goal of the system is.

So Michael has proposed, and I fully agree, that the basis for organizing the health care sector is around value, but we have a very specific definition of value is that for each medical condition, how do we improve the outcomes that are delivered and experienced by the patient and how do we lower the cost of delivering those outcomes, which doesn't seem revolutionary. But it is revolutionary because no one has defined the problem and the solution in that way. They've been all around this thing, how do we use checklists, how do we use lean and process improvement, how do we deliver better outcomes to patients and lower the cost of doing that?

So you think about a $3 trillion a year industry in the U.S. that doesn't know what its outcomes are and doesn't measure its cost, that explains a lot about the system that we have. And I got involved because I have developed a technology of how to measure cost and Michael's developed an approach on how to measure outcomes.

And then there's a third part, is when you have outcome measurements and you have cost measurements, you can reimburse providers in a very different way and right now, providers are reimbursed, in the U.S. mostly, by fee for service, and that rewards volume of stuff but not value, not good outcomes because the fees are independent of what outcomes get produced. And in fact, if you don't do a very good job and the patient has to come back for more work, you get more revenues. That's not a very good way of paying for health care.

So we're advocates of an approach that's beginning to come in called bundled payment reimbursement where you make a single payment to cover the treatment to entire medical condition. But we are actually doing it with [inaudible 00:03:04] flavor which is base it on, make the payment contingent on delivering good outcomes, which seems normal because if you buy a car and it doesn't work, you return it because it doesn't work. Every other industry that straight forward in health care, this is revolutionary. My role in this agenda primarily at this stage is the costing element and what I found does exist is that costs are not measured well in health care at the specific medical condition level.

Obviously, hospitals know how much they're spending. They can trace some of their spending to various clinical departments like orthopedics and cancer care, neurosurgery. They can't take the cost of that department level and drive it down to the patient level treating the patient for the clinical condition. I've helped to develop an approach called time-driven activity based costing which enables that assignment of expenses to be done well at the patient level. It just consists of really two types of two estimates and one of them is to understand the clinical pathway that is used to treat a patient with a medical condition.

What actually happens when the time they show up with a complaint until you diagnose it, treat it, through the surgery, the recovery and then the therapy and release them. What are all the clinical and administrative processes that are performed to get the patient through the entire cycle of care? And when we do that we try to find out at each process step, who is doing it. We can actually calculate how many minutes per year that a person or piece of equipment is available for patient work. That typically comes out to be 90 or 100,000 minutes a year. As you divide their annual expenses by their capacity, you get a cost per minute for every single individual.

And what's really fascinating about health care is the variation and cost rates. Until we have the MDs, whose cost rates could be somewhere between three and a half to six or eight dollars a minute. That would be typical rates, but you have a nurse, might be a dollar or a dollar and a half a minute and you have clinical assistants or scribes or receptionists for around $0.50 or $0.60 a minute. So you get this 10, 12 to 1 variation between the least highly and the most highly paid person which is really interesting because it says even if everybody is busy all the time and they're doing work, if you have a $5 a minute person doing something, that an 87 minute person could do equally well or slightly less efficiently, that's an inefficient use of the resources.

So there's an expression in medical care called have people work at the top of their license. But they don't really see the rationale or the economics behind it until you get to this caustic procedure. So combination of . . . they would take the process times for each person multiplied by their cost rate, cost per minute that tells you the cost of that person or the process step, and we just add it up across all the process steps over the whole cycle of care, and that tells you the total cost. This is not a quantum mechanics or genomic sequencing, it's really simple. What makes it difficult is just there's so many process steps.

So Michael and I are sitting there at the Harvard Business School four or five years ago and we realized, okay, this looks like this could work. But how do we get people other than the two of us to realize that this really could work in practice, there's a lot of good theories that don't work in practice. I said, well, the only way we're going to do this is to test it in practice and so we have to find pilot sites that are willing to try this out because we think we'll be able to create the change by demonstrating that it works. We want to work with leading providers. We're really excellent and they want to be better and they also want to prepare for the new environment where there will be fewer resources available to pay for health care.

And so the ones that are proactive and thinking ahead that they realize that this very forgiving fee for service environment will phase out over the next five years and they want to be ahead of the curve and see what can replace them. Currently, we're working with at least two dozen organizations and they're really distinguished organizations. They are leaders, the Boston-based hospitals and Yale Clinic and Cleveland Clinic, then about six or eight months ago, got contacted by Dr. Vivian Lee here at the University of Utah Health Center and Dr. Lee is a great visionary leader and those are the kinds of people I like working with.

So starting in January, I and my team came out here, we presented the ideas and we formed five teams to work on applying the time-driven ABC in three clinical areas and two support areas. We had the benefit of Dr. Lee, had already put into motion, with some terrific staff here, an emerging system called value-driven outcomes. We're getting outcome measurements very well at the clinical level as well as tracing starting to trace costs to the clinical level as well. And we had to just refine the costing module within that and to build upon this value driven outcomes approach that was being implemented.

It's been a great place to collaborate. We have the opportunity, the UHC has the opportunity maybe with some of our systems to really be one of the national leaders in implementing this value-based health care delivery approach. And so if we can use this as a shine, light, the example, this really can be done and it can deliver major improvements, and patients are better off and we're doing this at lower cost, people will see that this is really a successful way for transforming the way we deliver health care in the United States. There's a lot of skepticism in health care and they'll tell you 200 reasons why any innovation approach won't work and my role is to show it can work.

The gospel that I am trying to preach is to my colleagues in medicine, understand what's happening, learn the facts, lift up your heads enough to see what's going on around you. Understand the problem and then begin to ask yourselves "What can I do to help?"

When I started out in medicine in 1946 there was no such thing as a health care industry. The term health care industry had never been used. Nobody referred to it as an industry and nobody thought that being a physician was a business. Now we are dealing with the inevitable consequences of a health care system, which changed from a social service to a business. Just as you would predict it ignores more or less those who can't afford to pay. It exploits the opportunities to make money at the expense of the obligation to use resources conservatively in the most effective, medically appropriate way.

It invites all sorts of abuses including fraud and it's clear that it's not working and it can't work because there's a fundamental disconnect between medical care and almost all other economic activities in our society. A patient consulting a physician because they're sick, got injured, worried, or frightened that they may die or become seriously ill is not like an ordinary consumer in an ordinary market and physicians should not be like vendors in an ordinary market. Their objective should not be simply to sell whatever the consumer will buy.

Physicians are in the best position to decide how best to use the resources that we expend on health care. I've outlined what doctors might do if they wanted to. They could form multi-specialty group practices not-for-profit group practices that would be prepared to accept payment on a per capita rather than on a piece work basis, on a per capita basis for comprehensive care. There's no question that that system would work.

The only question is, how do we get it to occur politically in the current political climate? That's a big problem, we're going to have to change the attitude of the public and we're going to have to change the attitude of the legislators. It's issue of survival. We are simply not going to survive with the health care system we have now. It's going to implode. We must do something and doctors could help get it started. At least that's my hope and I think it's not unreasonable.

One of the hopeful aspects of all of this is that pretty soon half of all practicing physicians are going to be women. More and more multi-specialty groups are being formed and women are becoming a very significant part of that movement. I'm expecting that women may save the day.

As we really face this changing future, it's time for us to look deep inside and ask ourselves some fundamental questions about how we carry out our work. We have to hold close to our heart the core values and core purposes that are the essence of what we do in academic medicine, training the next generation of caregivers, carrying out the important biomedical and population research, caring for populations and individuals.

But how we do it can all change, and I think we have to start asking ourselves, how do we recognize and reward our researchers? Are we recognizing and rewarding the right things? We've had a tendency to focus on the RO1 or the independent scientist at the expense really of team science, or we acknowledge certain kinds of discovery as being more important than the science of integration or application.

In the education community, there are a number of questions. We use a four year time period to finish medical school. What are the skills that you need? Time should be a dependent variable, not the independent variable that determines how long medical school is.

We need to ask ourselves about cross training and residencies and across all the health professions. And then we have a lot of questions about how we deliver health care. We have traditions and structures. We tend to focus on inpatient care, but not as much on the continuum outpatient, skilled nursing, mental health, rehab. We really need to think more broadly about it.

So it's a time of reflection, of asking ourselves, why do we do things the way we do them, and if we did them differently could we do it better and as society is telling us, do it a lot cheaper? The challenge is, of course, that making change is difficult, it's painful. People often feel a sense of loss because they liked the way things are, but I think leaders have to step up and do it. Otherwise, somebody once said, "Lead, follow, or get out of the parade," and this is the time for leaders to step up and really be leaders.