10

IDEAS

for

Health Care
April 2012 | Featured Idea Open-Access Biomedicine

10 Ideas for Health Care

April 2012
National Director Taylor Jo Isenberg Field Director Winston Lofton Policy Director Reese Neader Program Director Alan Smith Chapter Services Coordinator Dante Barry Student Editors Matt Clark, Tatiana Eldore Alumni Editors Rob Nelb, Carissa Chu, Alex Hertel-Fernandez The Roosevelt Institute Campus Network A division of the Roosevelt Institute 570 Lexington Avenue, 5th Floor, New York, NY 10022
Copyright (c) 2011 by the Roosevelt Institute. All rights reserved. The views and opinions expressed herein are those of the authors. They do not express the views or opinions of the Roosevelt Institute, its officers or its directors.

10

IDEAS
FOR

Health Care

Congratulations to Rahul Rekhi, author of Open-Access Biomedicine: Unlocking the Floodgates for Healthcare Innovation Nominee for Policy of the Year

Inside the Issue

Banning Tobacco Sales at Health Care Provider Locations Rahoul Ahuja Improving Immigrants Access to Health Insurance Rachel Burns Improving Access to Primary Care in Athens County Smitha Ganeshan International Pharmaceutical Accessibility Reform Maggie Jacobi Curbing Health Care Costs Through Medical Innovation Adam Jutha Accountable Care Organizations: Reduce Health Care Costs and Improve Services Katelyn Lawrenz Improving Medical Education Will Improve Treatment For Obesity Rajiv Narayan A Public Option for Medicare Supplemental Insurance Will Cut Costs Wilson Parker Open-Access Biomedicine: Unlocking the Floodgates for Healthcare Innovation Rahul Rekhi Genetic Literacy Can Revolutionize Health Care Delivery Sima Sharara

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p Letter from New York City

here do groundbreaking ideas come from? How do they take shape? How do they fundamentally shift the way we see our world? It almost always takes the confluence of a seemingly intractable problem, people of intentional purpose, and a certain boldness to overcome. Its a potent mix that can be seen in the advancements in workers rights spurred by Frances Perkinss forward thinking labor policies to the environmental movement inspired by Rachel Carsons revealing work on the damaging effects of pesticides. Ideas have real impact when there is the realization that we need to do better combined with the people who are bold enough to ultimately do something. The Roosevelt Institute | Campus Network provides a way for young people to tap into this process, a platform for them to unlock the potential to drive progressive change. We received a record number of submissions to our premiere publication series this year from hundreds of students who invested the time and energy to research, write, and design actionable policy solutions for their communities. The 84 authors ultimately selected for the 2012 10 Ideas represent a generation of young people who recognize that it is because of, not in spite of, their age that they are uniquely capable of tackling some of our most entrenched challenges. With a thirst for action, many of these students will use these ideas to build coalitions, gather resources, and recruit supporters to create real, sustainable impact. Among this group of thinkers, visionaries, and doers, I encourage you to look for the future Frances Perkins and Rachel Carson, leaders who are already combating the injustices of our prison system, reimagining how we use energy, and solving the obesity crisis. We are proud to present the 2012 10 Ideas series, an inspiring exemplar of our generations unique propensity to engage with and accept the responsibility of todays complex and interconnected challenges. Each one of these pieces represents a powerful reminder that this generation is not only willing to build a better future, but has already begun. Taylor Jo Isenberg National Director, Roosevelt Institute | Campus Network

Strategists Note P
elcome and thank you for reading the fourth edition of the Roosevelt Institute | Campus Network 10 Ideas Series, our annual flagship publication. This series, encompassing six journals produced from our six student policy centers, represents the most innovative, game-changing ideas coming from our network. Our country needs a new narrative for how to address the problems we face: skyrocketing inequality, rising health care costs, unsustainable deficit spending, climate change, the list goes on. Defeating these challenges will require broad support from our citizens. And yet across the political spectrum the majority of the voting public has expressed strong dissatisfaction with their relationship with government. They feel that they dont have a voice in how decisions are made. The work of the Campus Network, and our 10 Ideas Series demonstrates that there is an alternative way forward-grassroots policymakingand that young people across the country are blazing a trail forward. Each idea in these journals represents the work of a student who independently took up the challenge of addressing our countrys problems. They worked at local nonprofits and visited community centers to identify the issues that mattered most to their constituents. They reached out to community leaders, professors, and government officials to identify resources that could address those issues. And along with writing the policy memos included in this journal theyve developed public campaigns to attract funding and popular support for their causes. With this new model of engagement our students are bringing government back to We the People. Were inviting you to join us. Reese Neader Policy Director, Roosevelt Institute | Campus Network

Banning Tobacco Sales at Health Care Provider Locations

Rahoul Ahuja, University of South Carolina To alleviate the burden that tobacco places on the U.S. health care system, the federal government should ban the sale of tobacco products in pharmacies and similar health care contexts.

The tobacco epidemic is one of the biggest public health threats the U.S. has ever faced. According to the CDC, cigarette smoking costs the U.S. nearly $200 billion in annual health care expenditures and kills 435,000 people per year.1,2 Yet while total cigarette sales have decreased recently, pharmacy cigarette sales have seen an unprecedented increase and are expected to triple their market share by 2020.3 The sale of tobacco products within a health care context is incongruous and poses a significant conflict of interest. To be specific, patients visit pharmacies to improve their health. Selling tobacco in a pharmacy implies that tobacco is not dangerous when in fact tobacco consumption is a major risk factor for non-communicable diseases, which are now the leading cause of death in the U.S.4 As a result, Boston and San Francisco have Key Facts banned the sale of tobacco in pharmacy settings While total U.S. cigarette sales decreased by 17 persuch as Walgreens that sell drug prescriptions (not cent from 2005-2009, just health products in general). However, they also pharmacy cigarette sales excluded settings like supermarkets that have inincreased by 22 percent 5 house pharmacies from the ban. 3 While some may object at this distinction, supermarkets draw the general population and are not health-promoting businesses. By contrast, if a pharmacy markets itself as an institution that improves health and sells tobacco products at the point of purchase to consumers who purchase smoking cessation products, then there is a clear conflict of interest. With a lack of coordinated national policy against cigarette sales in pharmacies and their detrimental economic impact, the U.S. is in need of cost-effective, sustainable prevention policies.
from 2005-2009. Pharmacy cigarette scales are expected to triple their market share by 2020 from 5 percent to 15 percent.3 Tobacco consumption is a major risk factor for chronic diseases.4

Analysis

The ban of tobacco products in pharmacies would yield much-needed economic benefits for the U.S. health care sector. Considering that the total economic cost of each cigarette pack is $10.47 and sales are rising fastest in the pharmacy industry, the ban of cigarettes in pharmacies nationwide would serve to alleviate the economic burden caused by the 315 billion cigarettes sold each year in the U.S.1 People are less likely to pick up smoking or buy cigarettes from pharmacies if health-related businesses are forbidden to sell them. If fewer individuals pick up smoking, total health care-related expen8

ditures in the U.S. on tobacco-related illnesses would be reduced. This is critical because the more successful a pharmacy is at selling tobacco products, the more money it makes selling medications used to treat tobacco-related diseases. Pharmacies will contend that cigarette sales constitute a significant portion of their sales. Yet when Canada banned tobacco sales in pharmacies, the number of pharmacies actually increased following the ban.6 In addition, 88 percent of independent pharmacies in California reported no loss of business when they eliminated tobacco sales.7 Finally, opponents will argue that pharmacies are still allowed to sell products with adverse-health effects such as alcohol. However, these products have a clear safe level of consumption; with tobacco, there is no safe level of consumption and thus it should not be sold in health-promoting institutions.

Efforts to reduce tobacco consumption will be offset by an increasing pharmacy cigarette market Bans on cigarette consumption cost governments next to nothing while yielding high returns on investment.

Talking Points

Next Steps

The FDA was recently given control over sales and ads of the tobacco industry; using this leverage, it could make it obligatory for any institution that sells tobacco to have a license.9 Pharmacies that advertise themselves as health-related businesses should be forbidden from receiving a license. Wholesale retailers with in-store pharmacies would have to sell tobacco products far away from their pharmacies. Finally, the U.S. should further explore the relationship between pharmacies and total cigarette sales so that it can make more viable health policy decisions for its citizens and create a healthier, tobacco-free environment.

Endnotes

1. Centers for Disease Control. Economic Facts About U.S. Tobacco Production and Use. http://www.cdc.gov/tobacco/ data_stati stics/fact_sheets/economics/econ_facts/ (Accessed November 29, 2011). 2. Mokdad, AH et al. Actual causes of death in the United States, 2000. Journal of the American Medical Association. 2004;291(10);1238-1245. <http://jama.ama-assn.org/content/291/10/1238. abstract?ijkey=65721c5431ed1cd4d1dd4 a2deae906a94560b570&keytype2=tf_ipsecsha>. 3. Seidenberg, Andrew B; Behm, Ilan; Rees, Vaughan W; and Connolly, Gregory N. Cigarette sales in pharmacies in the USA (2005 2009). British Medical Journal: Tobacco Control Journal (September 2011). http://tobaccocontrol.bmj. com/content/early/2011/10/06 /tobaccocontrol-2011-050108.short. (Accessed November 29, 2011) 4. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2011. Geneva, World Health Organization, 2011. (http://www.who.int/tobacco/global_re port/2011/en/). (Accessed November 29, 2011) 5. Katz, Mitchell H. Banning Tobacco Sales in Pharmacies, 2008. Journal of the American Medical Association. 2008;300(12):1451-1453. doi: 10.1001/jama.300.1 2.1451. <http://jama.ama-assn.org/content/300/12/1451.full>. 6. Taylor, Mark C. Banning Cigarette Sales in Pharmacies Does Not Result in Pharmacy Closures. http://www.smokefree.ca/pdf_1/pharmacy.PDF (Accessed November 29, 2011) 7. Prescription for Change. How Californians really feel about tobacco in pharmacies, October 2000. California Medical Association Foundation. <http://www.cal medfoundation.org/rxchange/pdfs/otherpdfs/califax.pdf>. (Accessed November 29, 2011). 8.Albers AB, Siegel M et al. Relation between local restaurant smoking regulations and attitudes towards the prevalence and social acceptability of smoking. Tob Control. 2004;13(4);347-355 9. CNN. House passes bill giving FDA power over tobacco ads, sales. http://articles.cnn.com/2009-0402/politics/tobacco.regulation_1_tobacco-products-tobacco-companies-tobacco-control-act?_s=PM:POLITICS. (Accessed November 29, 2011).

Improving Immigrants Access to Health Insurance

Rachel Burns, University of North Carolina at Chapel Hill Increase funding to community health centers and expand outreach efforts to help legal and illegal immigrants better access health insurance. In 2010, the United States immigrant population, both legal and illegal, peaked at a historic record of 40 million.1 Representing almost 13 percent of the nations total population, immigrants have become an essential part of American society, providing an indispensible labor force and a wealth of ethnic diversity.2 Despite their integral role, immigrants lack adequate and equitable access to health care. In 2007, 33.2 percent of all immigrants did not have health insurance, a number more than two times higher than native-born citizens.3 As a result of this discrepancy, immigrants have become identified as a Key Facts considerably vulnerable demographic. This status In 2010, the United States has been increasingly shaped by various factors, immigrant population, both including socioeconomic background, immigration legal and illegal, reached 40 status, limited English proficiency, access to pubmillion, representing almost licly funded health care, residential location, and 13 percent of the populamarginalization.4 Together these factors reinforce a tion. In 2007, 33.2 percent of all growing disparity that the United States has an obimmigrants did not have ligation to mitigate. Poor access to health care has health insurance, a number had and will continue to have serious implications more than two times higher on the health of immigrants and their children, and than native-born citizens. in turn the health of our nation.

Analysis

This policy calls for an increase in funding for community health centers and the expansion of outreach efforts to help legal and illegal immigrants to better access health insurance. With greater financial support, community health centers will be able to employ a larger and more culturally competent staff to help guide immigrants through the oftendifficult applications for health insurance. Additionally, the funds will allow for more community outreach efforts striving to educate and encourage immigrants to apply for health insurance. With greater financial support, community health centers can take a proactive rather than a reactive approach to improving the health of our nation. An increase in funds would be utilized in a myriad of ways, including the creation of comprehensive educational resources of the available health insurance programs for immigrants and the assistance for the actual application process. For many immigrants, acquiring insurance under publicly funded health care programs such as Medicaid and State Childrens Health Insurance Program (SCHIP) seems overly difficult and unattainable.5 The implementation of this policy will help immigrants to reconceptualize health insurance by reducing cultural barriers and thus providing more equitable access. This policy will have a profound impact on American society. Immigrants and their dependents will receive more equitable access to health care and in turn live healthier lives. On a state and local level, immigrants will rely less on clinics and hospitals that pro10

vide free or reduced-price services, relieving a significant financial burden. On a national level, a decrease in uninsured inhabitants will result in an enormous reduction of cost incurred by the lack of insurance.

Next Steps

The implementation of this policy will be divided into three phases. First, the funds will become available to community health centers. Second, the centers will expand their staff to include experienced and culturally competent workers. Third, each center will create an educational curriculum for immigrants and develop sustainable outreach programs.

Endnotes

1. A Record-Setting Decade of Immigration: 20002010 | Center for Immigration Studies. Center Talking Points for Immigration Studies | Low-immigration, Immigrants are less likely to use Pro-immigrant. Web. 01 Dec. 2011. <http://cis. org/2000-2010-record-setting-decade-ofpublicly funded health insurance immigration>. due to various cultural and struc2. Ku, Leighton. Why Immigrants Lack Adequate tural barriers. Access to Health Care and Health Insurance. Increasing access to health insurMigration Information Source. Web. 01 Dec. ance options through education 2011. <http://www.migrationinformation.org/ and procedural assistance will give usfocus/display.cfm?ID=417>. immigrants more equitable oppor3. IMMIGRANTS HEALTH CARE COVERAGE tunities to better health care. AND ACCES. Medicaid and the Uninsured. Kaiser Commission on Key Facts, Aug. 2003. Web. <http://www.kff.org/uninsured/upload/ Immigrants-Health-Care-Coverage-and-Accessfact-sheet.pdf>. 4. Facts on Immigration and Health Insurance | Center for Immigration Studies.Center for Immigration Studies | Low-immigration, Pro-immigrant. Web. 01 Dec. 2011. <http://www.cis.org/HealthCare-Immigration>. 5. Derose, Kathryn P., Jos J. Escarce, and Nicole Lurie. Immigrants And Health Care: Sources Of Vulnerability. Health Affairs. 2007. Web. 1 Dec. 2011. <http://content.healthaffairs.org/content/26/5/1258. full#R1>.

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Improving Access to Primary Care in Athens County

Smitha Ganeshan, University of Georgia Athens-Clarke County should apply for a health professional shortage area designation (HPSA) for its low-income population, which would make Athenss application for having a federally qualified health center (federally funded FQHC) more competitive and in the long term, improve access to primary care services for low-income patients.
In Athens, 19 percent of the population of 114,000 is uninsured and 38 percent of the population receives low-income Medicaid assistance.5 The uninsured and low-income population in Athens face severe barriers in access to primary care services.

The 27 FQHCs in Georgia are an effective model for primary care delivery and all have an HPSA designation. Both the need for better access to primary care and the funding for an FQHC exist in Athens. Assuming the Affordable Care Act (ACA) is implemented as planned, the ACA provides an additional $11 million to fund new FQHCs around the nation.1 In Athens, support for implementing this policy exists from various health providers and the Athens-Clarke Unified Government already.

Key Facts

Medicaid patients have three options; because they are not eligible to receive care at the two free clinics, they have to find a primary care provider in Athens, seek care from an understaffed and underfunded Athens Neighborhood Health Center, or must resort to using the emergency department. Less than 40 percent of providers say they accept Medicaid patients, and even those that do will not accept more than a few (3-5) each month.2 Athens Regionals Emergency Department sees 76,000 patients annually; about 80 percent of those visits are from uninsured and Medicaid patients, and about 80 percent of those are for non-emergent reasons, or reasons that could be better handled in a primary care setting. Delivering care through the emergency department for 58 percent of Athens population is costly, since the average emergency room visit costs $1,000, as compared to the average clinic visit of $29.3 Every year, Georgia spends $105 billion treating uninsured and low-income patients in its emergency departments.4

Analysis

Medicaid patients seen in an FQHC are 1.5 percent less likely to be hospitalized or seek ER care. Clusters in federally designated medically underserved areas (MUAs) that were served by an FQHC had on average 5.8 fewer public hospitalizations per 1,000 population over the three years than did the clusters in MUAs that were not served by an FQHC.6 If Athens-Clarke County could draft a competitive FQHC application to receive federal funding for an FQHC, which would be aided by a high priority designation score, emergency department (ED) usage rates would decrease. The interest for having an FQHC exists in Athens, but the community level data needed to make these applications competitive needs to be collected. The same information needed to draft this application is also the information needed to perform a thorough community needs assessment of the community, which has not been done since 2008
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when OneAthens, an initiative for a more prosperous Athens, was formed. By using volunteer student interns, the cost for data collection will be minimal. Any small sum of money needed to compensate hospitals and clinics for their participation could come from small grants for which the Athens Health Network is applying. The short-term minimal investment would save money long-term by reducing inappropriate ED use.

Next Steps

The Athens-Health Network should utilize volunteer interns from the College of Public Health to collect and analyze data from Athens-Clarke County to complete the HPSA designation application for the low-income population in Athens. Further, the Athens Neighborhood Health Center and Medical Partnership should submit a joint application for an FQHC in Athens.8

Endnotes

1. Doty, M., Collins, S., Robertson, R., & Garber, T. (2011). Realizing health reforms potential: when unemployed means uninsured: the toll of job loss on health coverage, and how the Affordable Care Act will help. Issue Brief (Commonwealth Fund), 181-18. 2. One Athens Health Team Final Report. Prosperous Athens. One Athens, 4 Jan. 2008. Web. 10 Oct. 2011. <http://www.prosperousathens. org/files/publicationpdfs/OneAthensHealthTeam-FinalReport1-07-08.pdf>. 3. Health Care Affordability in Georgia. Hospital Accountability Project. Georgia Watch, 2009. Web. 10 Oct. 2011. <http://www.georgiawatch. org/wp-content/uploads/2011/08/georgiawatch-healthcare-affordability-in-georgia.pdf>. 4. Health Care Affordability in Georgia. Hospital Accountability Project. Georgia Watch, 2009. Web. 10 Oct. 2011. <http://www.georgiawatch.org/wp-content/uploads/2011/08/georgia-watch-healthcareaffordability-in-georgia.pdf>. 5. Athens Demographic Profile. Rep. Athens: Center for Agribusiness and Economic Development; University of Georgia, 2011. Print. 6. Falik, M., Needleman, J., Wells, B. L., & Korb, J. (2001). Ambulatory Care Sensitive Hospitalizations and Emergency Visits: Experiences of Medicaid Patients Using Federally Qualified Health Centers. Medical Care, 39(6), 551-561. 7. Athens: HPSA. Find Shortage Areas: HPSA by State & County. Web. 04 Dec. 2011. <http://hpsafind. hrsa.gov/>. 8. Shortage Designation: Health Professional Shortage Areas & Medically Underserved Areas/Populations. Bureau of Health Professions (BHPR). Web. 07 Dec. 2011. <http://bhpr.hrsa.gov/shortage/>.

Low-income patients in Athens, which represent about 58 percent of the population, face structural barriers in access to primary health care services, which forces them into the emergency department where the cost of care is higher and the quality of longitudinal care is poor. To reduce inappropriate emergency department use, reduce health disparities, and improve overall community health, Athens needs a federally qualified, federally funded health center. To make Athenss application competitive when placed alongside the thousands of other applications, it needs a health professional shortage area designation that identifies Athens as an area in need of better access to primary care services.7

Talking Points

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International Pharmaceutical Accessibility Reform

Maggie Jacobi, Mount Holyoke College By creating a procedure for third world countries to access and produce patented medications under circumstances of extraordinary demand, curable and treatable diseases will become a significantly less threatening obstacle to universal millennium development. Key Facts

Since 1995, member countries of the World Trade Organization have been subject to the TRIPS (Trade-Related Aspects of Intellectual Property Rights) Agreement. TRIPS forces these countries, many of which are developing nations, to obey 20-year patent holding laws on pharmaceutical developments,1 monumentally impeding access to medications in immediate demand in countries without the resources to pay for expensive patented pharmaceuticals.

Only 0.001 percent of AIDS patients in Africa have access to modern pharmaceutical treatment. To treat all infected patients in the country, South Africa would have to spend 20 percent of its GDP.

In an attempt to balance the benefits of creative development fostered by pharmaceutical patents with the obvious need for better access to medical resources, TRIPS legalizes a process called compulsory licensing, which allows patent rights within a country to be extended to a generic company that can produce the medications needed at high volume without incurring massive costs.2 In emergency situations, this provision often represents the only possibility of medical relief. However, this process is poorly regulated and confusing, often backfiring on the country making use of the compulsory licensing provision. Member countries that have employed this emergency exception have faced trade pressure from first-world countries and costly lawsuits from the patent holding pharmaceutical companies themselves.3 Forcing countries to become individually responsible for fighting patents and organizing generic manufacture has become a significant barrier to the use of compulsory licensing. An oversight committee with the power to govern compulsory licensing procedures would allow for a buffer between countries and pharmaceutical companies, streamline the licensing process, and ensure that production of generic medications was only occurring in crisis situations. The Council for TRIPS already exists; it is a committee open to all World Trade Organization members that regulates the provisions included in TRIPS.4 In order to function fairly and effectively, the power to deliberate and decide on compulsory licensing requests should be delegated to this council. In South Africa, the percentage of the population infected with AIDS has reached epidemic proportions. 5.6 million of the 50 million current citizens of South Africa are infected. Under current patent law, treating all 5.6 million citizens in need of medication in South Africa would require impossible investment. Without access to less expensive generic drugs, only .001 percent of known AIDS patients in all of Africa have access to medication that dramatically improves both length and quality of life.5 In an attempt to
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take advantage of the access possibilities offered by compulsory licensing, South Africa passed the Medicines Act, which set up procedures for producing generic medications. Although compulsory licensing is specifically legalized in TRIPS, South Africa faced dangerous commerce pressure from the United States and trade threats from 39 powerful pharmaceutical companies.6 A committee system would have prevented this first-world bullying by making compulsory licensing a democratic choice and forcing all member countries to be equally responsible for the decision. Trade pressure would then no lon-

Forcing third world countries to fight patent laws alone results in threatening first world pressure. Creating a committee with the power to govern compulsory licensing procedures would allow for a buffer between pharmaceutical powerhouses and small countries in need, allowing the provisions included in TRIPS to be more effectively enforced.

Talking Points

ger be a concern, as member countries would have had an opportunity for dialogue and a democratic decision.

Analysis

The direct costs of delegating compulsory licensing decisions to the WTO Council on TRIPS would not, in itself, create a burden of additional cost. The structure of the committee is already secure, and this addition of responsibility is only measurably relevant under emergency conditions. Long term, it is possible that this policy will result in an increase in compulsory licensing. However, because first-world member countries are given an opportunity to influence policy decisions, this increase should be small and low-impact.

Next Steps

This policy should be acted on immediately by the WTO and enforced by the addition of an addendum to TRIPS delegating the power of making compulsory licensing decisions to the Council on TRIPS. Requests from countries to the committee for generic access would be decided on a case-by-case basis because emergencies that may require access to a compulsory license cannot be predicted under current circumstances. The current WTO selection process, which gives all member countries access to the Council on TRIPS, will remain in place to ensure and maintain the democratic nature of the decision process.

Endnotes

1. http://www1.american.edu/ted/aidstrips.htm. 2. http://www1.american.edu/ted/aidstrips.htm. 3. http://www.gpo.gov/fdsys/pkg/WCPD-2000-05-15/html/WCPD-2000-05-15-Pg1058-2.htm 4. http://www.wto.org/english/tratop_e/trips_e/intel6_e.htm 5. http://www.avert.org/aidssouthafrica.htm 6. http://www.avert.org/aidssouthafrica.htm

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Curbing Health Care Costs Through Medical Innovation

Adam Jutha, University of North Carolina at Chapel Hill Increased use of comparative effectiveness research in funding decisions for Medicare and Medicaid programs will ensure technologic advancements demonstrate cost containment strategies and improved quality of health care services when new Key Facts medical innovation is proposed for use The United States has the highest in the United States health care sysper capita spending on health care, tem, thereby reducing overall health upwards of $7,538 per capita in 2008 care expenditures.

Public and private health care expenditures in the United States have grown at unprecedented rates over the past four decades, rising faster than average income. The development and rapid spread of medical technology serve as the key drivers of health care spending, with new medical technology accounting for a large percentage of health care spending growth. Medical technology refers to the equipment and processes used to deliver medical care and health care services.1 This includes new medical and surgical procedures, pharmaceutical drugs, medical devices and support systems, and medical technology. Greater availability of new medical technology facilitates higher spending on services due to increased per capita usage.

with a projected increase to $12,320 by 2015.2 Health care and medical technological innovation is considered to be the key driver for rising health care costs in the United States. While the average OECD country spends 9.5 percent of GDP on health care spending, the United States spending has risen from 7.2 percent of GDP in 1970 to 17.6 percent of GDP in 2009.3

Analysis

Innovation has resulted in major advances in clinical abilities, the development of new procedures and treatments (including treatments for previously untreated terminal conditions), and improvements in the scope of medicine covered through the health care system.4 Through effective health technology assessments, it becomes possible to explore strategies to control rising costs without stifling technological innovation. Health technology assessment, the process by which health care systems conduct cost-benefit analysis for new technology, is particularly important in determining the spread of innovation. Assessments should be carried out in conjunction with comparative effectiveness research (CER), which is designed to inform health care decisions by providing evidence on the effectiveness, benefits and harms of different treatment options.5 The $1 billion in funding for CER through the American Recovery and Reinvestment Act, as well as the support for CER through the 2010 Affordable Care Act, present critical steps toward establishing the end goal of patient-centered outcomes research. While this research will determine the clinical effectiveness of medical treatments, new technology must also be assessed for cost-effectiveness and cost-benefits analysis when compared with existing technology.

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Without proper evaluation of new technology, there is a direct result of increased health care costs because of the United States primarily third-party payer system. New medical technologies are developed with the ability to spread based on a health care providers willingness to pay for such services. In this model, third-party payers determine what new technology is deemed effective and efficient based on individual standards.

Next Steps

The United States government should expand the mandate of the Technology Assessment Program through the Agency for Healthcare Research and Quality. This program is primarily responsible for assessing the cost-effectiveness and benefits of new technology as compared to existing technologies. In addition, it should introduce policy that requires manufacturers to demonstrate the effectiveness of technological innovation on quality of care as compared to existing technology rather than a placebo.

Although the United States spends the highest per capita on health care, the quality of life outcomes do not reflect the amount of expenditures in the system. Studies demonstrate consumers expectations for the development of new technology, but no nationally coordinated effort or government agency through HHS is in place to oversee new technological innovation. Moving the decision-making market power for the effectiveness of new technological innovation from public and private organizations and thirdparty payers to an Agency for Health Technology Assessment would focus on comparing new innovation to existing technology rather than a placebo.

Talking Points

Endnotes

1. KFF Snapshot: How Changes in Medical Technology Affect Health Care Costs March 2007, p.1. 2. Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. 3. Thomas Bodenheimer. High and Rising Health Care Costs: Part 1: Seeking an Explanation. Annals of Internal Medicine, May 2005, 142:10, p.932. 4. Snapshot. March 2007, p.1. 5. Snapshot. March 2007, p.1. 6. AHRQ. http://www.effectivehealthcare.ahrq.gov/index.cfm/what-is-comparative-effectiveness-research1/

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Accountable Care Organizations: Reduce Health Care Costs and Improve Services

Katelyn Lawrenz, University of Richmond The United States should expand incentives for Accountable Care Organizations throughout the health care system, as they represent a necessary shift from our countrys current fee-for-service policy.

Accountable Care Organizations (ACOs), as provided for in the Patient Protection and Affordable Care Act of 2010, coordinate and direct patient care across multiple disciplines while striving to contain costs and emphasize high-quality care.1 However, the ACO provision extends only to Medicare and Medicaid; without nation-wide implementation, health care costs will continue to rise. Accountable Care Organizations in the United States today exemplify the models cost-effectiveness. After three years as an ACO, the Medicare Physician Group Practice decreased expenditures by over 2 percent in half of the practices.2 Similarly, Community Care of North Carolina saved over $535 million in five years for its Medicaid and Childrens Health Insurance Program; and in Seattle, Group Health Cooperative also reduced costs, improved patient outcomes, and enhanced physician collaboration.3

Analysis

Health care systems typically utilize a fee-for-service payment system, in which physicians receive payment based on the number of services provided to a patient. This payment structure contributes significantly to the rising cost of health care. The most costly 20 percent of hospital referral regions in the United States produce 80 percent of all hospital expenditures, and the high volume of services similar patients receive in these referral regions explains the vast differences in spending.7 However, widespread implementation of Accountable Care Organizations could decrease health care expenditures, as ACOs emphasize the quality of care over quantity of treatments. For example, the Mayo Clinic typically spends $40,000 less per Medicare patient compared to fee-forservice hospitals. As Mayo Clinic President Dr. Denis A. Cortese explains, [Our physicians] have no financial incentive to do more than is necessary for the patient.8 Key Facts Physicians receive payments based on a Unnecessary treatments and prodefined clinical episode or a set period cedures lead to 30,000 American of management of a chronic condition.9 deaths annually.4 Unlike the fee-for-service system, this cap If costs continue to outpace our counitation payment encourages collaboration trys overall economic growth, health among physicians to prevent unnecessary care spending will rise to an unsusmedical expenditures, thereby promoting tainable 38 percent of GDP by 2075.5 patient care over profit. States with the highest Medicare

Next Steps

To create successful Accountable Care Organizations throughout the country, the structure of physician practices and hospitals needs to change. Currently, few ACOs exist because neither payers nor
18

spending (about $8,000 per patient) rank lowest in quality care; conversely, states that spend approximately $4,000 annually per patient rank the highest.6

physicians and hospitals have an incentive to implement payment reform before the other. Payers are reluctant to embrace capitation payment systems unless more successful ACOs exist. Unfortunately, hospitals and physicians have few incentives to become ACOs because the fee-for-service system does not encourage integration.10 Without future incentives for both the payer and the provider, ACOs will remain a rarity, instead of the norm, in the United States health care system. Policymakers must incentivize a national shift away from our fee-for-service system in the public and private sector alike. Medicare influences all other stakeholders in our countrys health care system; if it takes the lead in payment reform nationally, the private sector will follow in its path.11 Medicares change also can encourage the private sector to reform, because it will drive greater structural integration, which can increase the capacity for additional payment reform, and so on.12 As a result, widespread incentives to establish ACOs will help usher in a new era of health care policy in the United States -- an era marked by higher-quality care and more cost-effective practices.

ACOs prioritize quality over quantity, decreasing the number of unnecessary procedures that drive health care spending and reduce the quality of care. Existing ACOs have proved to reduce costs, increase efficiency, and enhance patient care. ACOs encourage physician collaboration and cooperation, which allows patients to receive more cohesive, effective treatment plans.

Talking Points

Endnotes

1. Fisher, Elliot, Diane Rittenhouse, Stephen Shortell. 2009. Primary Care and Accountable Care- Two Essential Elements of Delivery-System Reform. The New England Journal of Medcine 361, no. 24: 2301-2303. 2. Davis, Karen and Stephen Schoenbaum. 2010. Toward High-Performance Accountable Care: Promise and Pitfalls. The Commonwealth Fund. September 14. http://www.commonwealthfund.org/Content/ Blog/2010/Sep/Toward-High-Performance-Accountable-Care.aspx. (Accessed November 30, 2011). 3. Ibid. 3. 4. Brownlee, Shannon. Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer. New York: Bloomsbury USA. 6. 5. Gruber, Jonathan. 2010. The Cost Implications of Health Care Reform. The New England Journal of Medicine, 362 no. 2: 2050-2051. June 3. http://www.nejm.org/doi/pdf/10.1056/NEJMp1005117. (Accessed November 30, 2011). 6. Jencks, Stephen, Timothy Cuerdon, and Edwin Huff. 2003. Change in the Quality of Care Delivered to Medicare Beneficiaries: 1998-1999 to 2000-2001. Journal of the American Medical Association, 289 no. 3: 305-312. 7. Goodman, David, Kristen Bronner, Elliot Fisher, and Jonathan Skinner. 2009. Health Care Spending, Quality, and Outcomes. The Dartmouth Institute for Health Policy and Clinical Practice: A Dartmouth Atlas Project Topic Brief. February 27. http://www.dartmouthatlas.org/downloads/reports/Spending_Brief_022709.pdf. (Accessed November 30, 2011). 8. Pear, Robert. 2008. Researchers Find Huge Variations in End-of-Life Treatment. New York Times. April 7. http://www.nytimes.com/2008/04/07/health/policy/07care.html. (Accessed November 30, 2011). 9. Mayes, Rick and Jessica Walradt. 2011. Pay-for-Performance Reimbursement in Health Care: Chasing Cost Control and Increased Quality through New and Improved Payment Incentives. Health Law Review 19, no. 2: 39-43. 10. Crosson, Francis. 2009. 21st-Century Health Care: The Case for Integrated Delivery Systems. The New England Journal of Medicine, 361, no. 14: 1324-1325. 11. Mayes and Walradt 2011. 41. 12. Crosson 2009, 1325. 19

Improving Medical Education Will Improve Treatment For Obesity

Rajiv Narayan, University of California-Davis Efforts to treat the third of Americans who are obese are futile until we train key actors in medical academies to effectively handle obesity management. The catastrophic emergence of obesity as a public health challenge is as well-documented as it is perplexing. The incidence of obesity grew from a problematic 15 percent in 1980 to an epidemic 34 percent of the population in 2008.1 Not only is obesity a prominent risk factor for co-morbidities that run the gamut from diabetes to stroke to hypertension to cardiovascular disease, it also presents economic and national security challenges.2,3 Key Facts

Each year, obesity is the cause of $73 billion lost in economic productivity. ii Americans spend at least $150 billion every year on health care for obesity. iii 72 percent of health care providers have not been trained in treating weight issues.

Most obesity policies today come in the form of prevention, in response to obesity treatment policy of the past focusing on individual behavior change.4 Realizing that the effort to educate obesity out of existence is ultimately futile, most policy is now fashioned to prevent obesity by changing the built environment to incentivize healthy decision-making. However, the effort to prevent obesity eclipses, and ironically prevents, the passage of policies to treat currently existing obesity. As more than a third of Americans are presently obese, this represents a dangerously large blind spot in the policy environment.5 A recent ruling to include obesity treatment (in the form of screening and counseling) under Medicare is a step in the right direction.6 But even this step may be misplaced. While it will soon be incumbent upon a network of doctors, nurses, and other medical actors to engage obesity amongst their patients, few of these actors are prepared to do so. Indeed, 44 percent of doctors report not feeling qualified to treat obesity.7

Analysis

Medicare currently subsidizes the largest fraction of federal outlays to Graduate Medical Education (GME) at an annual $9.2 billion. These payments are designed to provide commensurate support for the supply side of the medical industry as Medicare works to make medical care more accessible, a move that increases demand for medical services. Given the increasing pool of insured Americans via the Patient Protection and Affordable Care Act (PPACA), it is projected that by the year 2015, nearly half the 28,500-person shortage in physicians will be of primary care doctors.8 Finally, the direct payments go toward teaching hospitals, which decide (with little recourse) how the funds will be used to train medical students. As a result, GME payments are partly responsible for the underproduction of primary care physicians in response to the highly lucrative payment schedules to specialists. Obesity is a disease first screened and then managed by primary care physicians. With obesity soon to come under expanded coverage via the recent rule change and the
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PPACA, the projected shortage of physicians is a projected catastrophe for health care management.

Next Steps

The Decision Memo released by the Centers for Medicare and Medicaid Services outlined the key actors, methods, and assessments necessary to the inclusion of Intensive Behavioral Therapy for Obesity under Part A and Part B of Medicare.9 Where the memo found screening, dietary assessment, and intensive behavioral counseling to be the therapies of choice, it also noted that this therapy would be administered in a primary care setting, be that delivered through physician, nurse practitioner, clinical nurse specialist, or physician assistant. With the use of team-based care eminent in the PPACA, it stands to reason that obesity treatment can be a shared enterprise both in the primary care setting and the funding model. Federal outlays to GME should promote team-based care with respect to obesity. This can be accomplished in an already-existing funding scheme; where GME payments through block grants to states are currently unburdened by few requirements, a proportion of funds can be formally allocated to training primary care teams, rather than specializing individuals, in the management of chronic diseases. Team-based care is likely to lift the burden of perceived ignorance among physicians, reduce the barrier to obesity treatment, and concurrently improve accountability in federally supported medicine.

A recent change includes obesity treatment under Medicare. Projections predict shortage of primary care physicians, who will be expected to treat obesity. Federal outlays to Graduate Medical Education should promote teambased care with respect to obesity to reduce the burden on primary care physicians.

Talking Points

Endnotes

1. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and Trends in Obesity among U.S. Adults, 19992008. Journal of the American Medical Association, 303(3): 235-41, 2010. 2. Levi J, Segal LM., St. Laurent R, et al. F as in Fat: How Obesity Threatens Americas Future. Rep. Washington, D.C.: Trust for Americas Health, 2011. 3. Ibid. 4. Nestle, Marion. Halting the Obesity Epidemic: A Public Health Policy Approach. Pubic Health Reports. January/February 115:12-24. 2000. 5. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and Trends in Obesity among U.S. Adults, 19992008. Journal of the American Medical Association, 303(3): 235-41, 2010. 6. Healy, Melissa. Medicare extends coverage for obesity. Los Angeles Times. November 30, 2011. 7. Jay, M., Kalet, A., Ark., T., McMacken, M., Messito, M.J., Richter, R. Physicians attitudes about obesity andtheir associations with competency and specialty: A cross-sectional study. BMC Health Services Research.2009;9(106). Available at: http://www.biomedcentral.com/1472-6963/9/106.19 8. Iglehart, JK.The Uncertain Future of Medicare and Graduate Medical Education. New England Journal of Medicine. 365:1340-1345. 2011 9. Jacques L, Jensen TS, Schafer J, McClain S, Chin J. Final Coverage Decision Memorandum For Intensive Behavioral Therapy for Obesity. Centers for Medicare and Medicaid Services. CAG-00423N. November 2011.

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A Public Option for Medicare Supplemental Insurance Will Cut Costs

Wilson Parker, The University of North Carolina at Chapel Hill Congress should create a comprehensive benefit option for Medicare to reduce administrative costs for beneficiaries and encourage insurers in the Medicare Advantage and Medicare Supplemental Insurance markets to become more efficient. While Medicare does an excellent job of delivering basic benefits to seniors, beneficiaries who want comprehensive rather than basic coverage are forced to choose between two bad options. Their first option is to receive benefits under traditional Medicare (Parts A and B) and enroll in a private Medicare Supplemental Insurance (or Medigap) plan, which fills the gap between Medicare and full coverage. This option frequently involves unnecessary expense and red tape as a result of managing more than one health care plan; as Commonwealth Fund President Dr. Karen Davis put it, the patching together of multiple plans creates confusion for beneficiaries; creates the potential for risk selection; and leads to higher administrative expenses.1

Medicare Advantage Insurers spend less than 85 percent of expenses on health care costs, in contrast to Medicare, which spends 98 percent.3, 4 Patching together multiple plans through Medicare Supplemental plans creates confusion and is inefficient. A comprehensive benefits option would drastically improve the quality of care and save $4 billion for consumers and taxpayers through reduced administrative expenses.6

Key Facts

Seniors other option is to receive all of their care through a Medicare Advantage plan that offers comprehensive benefits. Medicare Advantage Plans are offered through Medicare Part C and allow beneficiaries to receive the same level of coverage offered by traditional Medicare (Parts A and B) through a private insurer. Some insurers offer Medicare Advantage plans that only provide basic coverage, but others offer plans that provide comprehensive benefits by combining Medicare Part C and Medicare Supplemental Insurance in one private plan. For recipients of the latter type of plan, part of their premium is paid for by the government under Medicare Part C. They pay for the remainder through premiums. Unfortunately, these plans are often wasteful and inefficient in comparison to traditional Medicare. Representative Henry Waxman, citing a report issued by the Majority Staff of the House Committee on Energy and Commerce, said that Medicare Advantage insurers squander billions of dollars on overhead costs.2 The report revealed that less than 85 percent of Medicare Advantage providers revenue is used to pay for actual medical expenses in stark contrast to traditional Medicare, in which more than 98 percent of revenue is used to cover medical expenses.3,4

Analysis

To provide our seniors with a responsible and efficient alternative to these options, Congress should create a comprehensive public benefit option modeled after the Federal
22

Employee Health Benefits Plan. Doing so will provide beneficiaries with an option for quality, affordable, and efficient care. Such a public option would be a program that offers comprehensive benefits to beneficiaries for a price that completely covers the cost of the additional benefits. This program would be administered by the Centers for Medicare and Medicaid Services, using the same provider system for Medicare Parts A and B but offering more benefits. It would be completely funded by premiums paid by beneficiaries for the additional coverage and would be revenue neutral.

Seniors who want comprehensive health care are forced to choose between two bad options: 1. Purchasing multiple plans, which can be confusing and inefficient. 2. Purchasing plans from private insurers, which are substantially less efficient than Medicare. Creating a public comprehensive benefit option would offer seniors a third alternative, which would provide higher quality care at a lower cost and be more efficient.

Talking Points

According to the Medicare Payment Advisory Committee, a program offering such a public option would benefit from reduced insurance administrative expenses.5 An analysis of this proposal, based on data from the 2000 Current Medicare Beneficiary Survey and published in Health Affairs by the Commonwealth Fund, found that this option would reduce the average annual amount paid by beneficiaries by $357 and out-ofpocket costs by an average of $60. Such a reduction is no small sum; the overall market savings resulting from such a plan would be more than $5 billion for consumers. It would also substantially increase the quality and value of the care that they receive.6

Next Steps

Congress should enact legislation that creates a public comprehensive benefit option to ensure that Medicare beneficiaries have access to affordable and quality care. Doing so will make the Medicare market more efficient, improve the quality of care, and reduce costs to beneficiaries.

Endnotes

1. Davis, Karen et al. Medicare Extra: A Comprehensive Benefit Option of Medicare Beneficiaries Health Affairs 2005. http://content.healthaffairs.org/content/early/2005/11/15/hlthaff.w5.442.full.pdf+html 2. Committee on Energy and Commerce Majority Staff New Report Highlights Medicare Advantage Insurers Higher Administrative Spending Washington D.C December 9, 2009 http://democrats. energycommerce.house.gov/index.php?q=news/new-report-highlights-medicare-advantage-insurershigher-administrative-spending 3. Committee on Energy and Commerce Majority Staff Profits, Marketing and Corporate Expenses in the Medicare Advantage Market Washington D.C. December 2009 http://democrats.energycommerce. house.gov/Press_111/20091209/MedicareAdvantageReport120909.pdf 4. Centers for Medicare and Medicaid Services National Health Expenditures Washington D.C. 2004 5. Medicare Payment Advisory Commission, Report to the Congress: Assessing Medicare Benefits (Washington: MedPAC, June 2002). 6. Davis, Karen et al. Medicare Extra: A Comprehensive Benefit Option of Medicare Beneficiaries Health Affairs 2005. http://content.healthaffairs.org/content/early/2005/11/15/hlthaff.w5.442.full.pdf+html

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Open-Access Biomedicine:

Unlocking the Floodgates for Healthcare Innovation

Rahul Rekhi, Rice University The National Institutes of Health (NIH) and the Department of Health and Human Services (HHS) should make all federally funded biomedical and health research publicly available within six months of publication. In recent years, the rate at which we translate basic biomedical discoveries into novel therapies has stagnated. In fact, despite a doubling of the federal budget for biomedical research and development, the number of new drug approvals fell from 53 in 1996 to 19 in 2009, and though 800,000 medical research papers helping to identify novel therapeutic targets were published in 2008, a paltry 21 new drugs found their way to the market.1,2 A recent study in the New England Journal of Medicine found that the primary contributor to this so-called Valley of Death is the centralization of authority within large, inherently cautious bureaucracies in government, universities, foundations, and companies[which] disregar[d]the diversity of approaches that are necessary for innovation.3 This hyper-centralization exists in part because scientists, physicians, and biotech entrepreneurs lack access to cutting-edge research developments and data -currently monopolized by large research institutions in government, academia, and industry -- to materialize their ideas. Recognizing the severity of this barrier, the NIH instituted a new public access policy in 2006, Key Facts New drug approvals fell from mandating that its grantees freely upload their 53 in 1996 to 19 in 2009.1 research within 12 months of publication into a 4 800,000 medical research scientific journal. This year-long embargo, howpapers identifying novel theraever, has proven too restrictive. As such, later peutic targets were published that year, Senators John Cornyn (R-TX) and Joe in 2008, but only 21 new drugs Lieberman (D-CT) drafted bipartisan legislation hit the market.2 -- the Federal Research Public Access Act (FR Journal subscriptions cost as PAA) -- to reduce this delay to 6 months. The legmuch as $25,000 per year.9 5 islation was reintroduced in 2010. An analogous Free access to medical research could reap as much as $1 bill in the House of Representatives has been billion in benefits to the U.S.7 co-sponsored by several members of Congress and supported by 120 different leaders in higher education.6 Yet significant progress has not been made with either legislation, and both remain distant from any meaningful chance of passage. Indeed, in direct opposition, the Fair Copyright in Research Works Act, introduced in the fall of 2008, aims to reverse the existing NIH open access policy entirely, barring any open access mandate. This legislative stalemate has led both open access initiatives to flounder in Congress thus far.

Analysis

A study published by an economist at Victoria University established that reducing the year-long open-access embargo, and thus implementing the provisions of FRPAA, would reap over $1 billion in benefits over the next 30 years due to the catalysis of innovation in the creation of novel drugs and medical treatments.7 This amounts to an
24

eight-to-one rate of return. Furthermore, enacting a fuller open-access policy ensures that physicians -- most significantly those in rural areas -- would have access to the cutting-edge medical research they need to provide the highest quality of care. Patients, too, could research the pathologies that plague them and their families, Talking Points bolstering their ability to make informed Open access research permits pamedical decisions at the point of care. By tients, students, physicians, entrepreincorporating this data into the existing neurs, and educators to reap benefits PubMED database within six months of of cutting-edge medical research. publication while making efforts to edu Free access to data can catalyze drug cate the public about the openly accesdevelopment, providing the life-saving treatments of the future. sible nature of this database, the Obama An eight-to-one rate of return renders administration can ensure that the data open access policy not only cost-efcan be employed not only by patients fective, but enormously profitable. and researchers, but also students and the general public. Though the common critique of open access policy attests to the need to preserve publishers copyright protections, the six-month time lag ensures that the publishers can maintain profit margins while prohibiting the medium-term inaccessibility of the data to students, patients, and researchers.

Next Steps

Considering that students, patients, physicians, biotechnology/pharmaceutical companies, and educators can all benefit tremendously from this initiative, it is important to unify these stakeholders in support for open access policy for biomedical research. Strong opposition, however, will be faced from the publishers lobby, which has been largely responsible for FRPAAs stalling in Congress.8 The Obama administration and the Department of Health and Human Services should take on the mantle of halving the open access embargo, for which drafted legislation exists, while leveraging the best interests of community partners to stave off publisher opposition.

Endnotes

1. Research and Development in the Pharmaceutical Industry. edited by Congressional Budget Office, 46, 2006. 2. Hughes, B. 2009 Fda Drug Approvals. Nat Rev Drug Discov 9, no. 2 (Feb 2010): 89-92. 3. Moses, H., 3rd, and J. B. Martin. Biomedical Research and Health Advances. N Engl J Med 364, no. 6 (Feb 10 2011): 567-71. 4. Check, E. Nih Open-Access Plans Draw Fire from Both Sides. Nature 433, no. 7026 (Feb 10 2005): 561. 5. Federal Research Public Access Act 2006. Alliance for Taxpayer Access, http://www.taxpayeraccess. org/issues/frpaa2006/index.shtml. 6. Higher Ed Leaders Support Public Access, 2009-2010 (Sparc). Association of Research Libraries (ARL), http://www.arl.org/sparc/advocacy/frpaa/institutions.shtml. 7. Houghton, J.W., B. Rasmussen, and P.J. Sheehan. Economic and Social Returns on Investment in Open Archiving Publicly Funded Research Outputs. 34. Victoria, Australia: Victoria University 2010. 8. Key Points: How the Fair Copyright in Research Works Act Protects Copyright and Advances Science and Scientific Publishing. Association of American Publishers, http://www.pspcentral.org/PSPFairCopyrightKeyPoints.cfm. 9. Expensive Journals: Scholarly Communication. MIT Libraries, http://web.archive.org/ web/20050828210650/libraries.mit.edu/about/scholarly/expensive-titles.html.

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Genetic Literacy Can Revolutionize Health Care Delivery

Sima Sharara, University of North Carolina, Chapel Hill Integrating the detailed study of genetics in medical school curricula to enable responsible interpretation of individualized genomic tests will lead to more effective health care through targeted prevention, diagnosis, and treatment at a decreased cost. The complete sequencing of the human genome in 2003 and the introduction of genome-wide association studies (GWAS) revolutionized the role of genetics and genomics in the diagnosis and treatment of disease. In recent years, several companies have begun offering direct-to-consumer whole-genome tests, providing an individualized report of predicted health risks, traits, and disorders using a saliva sample. The problem remains, however, in translating these discoveries into benefits in health care.4 The private companies that provide genetic testing do not readily and comprehensibly explain the results to consumers, and genetic counseling remains rare and expensive. As a new phenomenon, information online about genome testing is limited and usually inaccurate.5 Thus, consumers often turn to their primary care physicians for guidance.

In a study of 1,000 individuals, 72 percent indicated they would turn to primary care providers with questions about genetics.1 11 percent of U.S. and Canadian medical schools reported practical training in the use of medical genetics as a part of their curricula.2 A study of 2,688 patients using blood thinners revealed that patients whose therapy included genetic testing were 31 percent less likely to be hospitalized for any cause when compared to patients using the blood thinner without genetic testing to determine sensitivity to the drug.3

Key Facts

Yet evidence indicates that these physicians are ill-equipped to deal with issues of genetics and genomics due to a lack of preparation in medical school. In a study requiring physicians to interpret the results of a single-gene test for colorectal cancer susceptibility, 33.3 percent of physicians incorrectly interpreted the results.6

Analysis

Less than half of medical schools surveyed reported offering a stand-alone course in genetics, while those that do frequently address irrelevant and rare genetic disorders that are of limited relevance to most primary health care providers.7 This lack of training risks incorrect and possibly dangerous misinterpretation of the tests by physicians that could cause patients to erroneously modify lifestyles or undertake unnecessary procedures or expenses. Correctly interpreting these tests benefits patients receiving individualized treatment, as physicians can more proactively prevent conditions and provide more effective care. This leads to positive externalities benefiting insurers, who will pay less by avoiding cost26

ly and ineffective procedures, as well as taxpayers, with significantly reduced costs of health care.

Next Steps

The solution to harnessing the potential benefits of whole-genome tests lies in equipping physicians with the necessary experience to responsibly interpret results, identify appropriate candidates for genome testing, and be informed of the available resources. This can be done by reforming medical school education, through an organization sponsored by the American Medical School Association (AMSA), to integrate considerably more relevant genetics in existing curricula.

The rise in individualized genome-tests reveals a high percentage of patients turning to primary health care providers who are incapable of accurately and responsibly analyzing genetic tests. Medical school curricula should be reformed through the AMSA to ensure physicians responsibly analyze genetic tests and effectively incorporate the results in their clinical practice. This curricula reform is essential to harness the advantages of this new and growing field and will lead to cheaper and more effective diagnosis, prevention and treatment of health conditions.

Talking Points

This should begin with replacing irrelevant and rare genetic diseases discussed in courses with prominent genetic conditions the physicians are more likely to see. Including problem-based learning is particularly suitable for medical genetics and will provide students with experience in advising patients about the information that can be extracted from genome tests and using this information to provide more personalized disease prevention, diagnosis, and treatment. This should also transition into more team-based learning approaches outside of courses, such as frequent patient conferences and workshops on ethics and genetic counseling, as well as lectures on the newest discoveries in the field, that are provided by the institution.8 This would keep both students and physicians up to date with the rapid developments in genetics and medicine. Medical school curricula should be constantly adapted to the dynamic new discoveries in science. Introducing genetic literacy will be one of the most important changes in harnessing the potential innovations to come in the field of genetics and genomics.

Endnotes

1. Mitka, M. Genetics research already touching your practice. American Medical News (April 6 1998): 2-3. 2. Thurston, VC, PS Wales, MA Bell, L Torbeck, JJ Brokaw. The current status of medical genetics instruction in US and Canadian medical schools. Acad Med 82: 441-445. 3. Morgan, S, J Hurley, F Miller, M Giacomini. Predictive genetic tests and health system costs. Canadian Medical Association Journal 8, no. 168 (2003): 989991. 4. Salari, K. The dawning era of personalized exposes gap in medical education. PloS. Med. 6, no. 8 (2009). 5. Lamb, NE, Myers, RM, Gunter, C. Education and personalized genomics: dechiphering the publics genetic health report. Future Medicine Ltd (2009): 681-690. 6. Harvey, EK, Fogel CE, Peyrot M, Christensen KD, Terry SF, et al. Providers knowledge of genetics: A survey of 5915 individuals and families with genetic conditions. Genet Med 9 (2007): 259-267. 7. Thurston,VC, PS Wales, MA Bell, L Torbeck, JJ Brokaw. The current status of medical genetics instruction in US and Canadian medical schools. Acad Med 82: 441-445. 8. McKee, E. Risk Analysis in Human Genetics - A Team-Based Learning Exercise. MedEdPORTAL (2011). 9. Farndon, PA, Bennett C. Genetics education for health professionals: Strategies and outcomes from a national initiative in the United Kingdom. Jo Genet Couns 17 (2008): 161169.

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