Studies in Patient-based Informatics for Comparative Effectiveness Research (SPICER)
The Marino Center, along with the University of Arizona, has been awarded a grant to study the comparative effectiveness of Integrative Medicine. The entire project award is just under 1 million dollars, with about half allocated to the Marino Center.
With the help of this grant money, we will examine the immense amount of clinical data, created daily at the Marino Center, to generate knowledge on the comparative effectiveness of treatment modalities. We will compare alternative and complementary therapies among themselves, and with conventional medicine. Traditionally medical research has relied on randomized controlled trials (RCTs) with specific focus. While RCTS's remain the gold standard for testing narrowly-focused questions, it has become increasingly clear that not all important questions about the delivery of health care can be answered by RCTs. Looking at real-world clinical encounters is a new way of conducting and thinking about research.
Ours is an observational study using event-stream analysis to provide patient-centered results. We will start by looking at four common conditions: back pain, fibromyalgia, irritable bowel syndrome, and peri-menopause. It is anticipated that further studies will also be done. While we intend to produce important disease-specific results from this project, we consider it a first step toward a much larger enterprise for changing how clinical research articulates with clinical practice. The long-range goal of this project is to create a sustainable model for collaboration of multiple clinical centers for conducting focused observational comparative effectiveness studies within and across multi-modality clinics, including more complex health care delivery systems and a very broad range of modalities.
Potential impact
1. Determine useful clinical treatments by providing patient-centered, evidence based medical information extracted from trajectories of care.
2. Improve research in IM by opening opportunities to mine clinical databases while maintaining scientific rigor.
3. Organize the collective experience and wisdom of medical practitioners in a way that spans medical systems, and bring the best treatment to each individual patient.
4. Create methodology that can develop neglected aspects of health and healing, such as patient choice and patient-practioner interactions.
Steering Committee:
Marino Center
Anne McCaffrey, MD, MPH
Robert DeNoble, MBA
Jennifer Cao, LicAc
Dan Himick
University of Arizona
Mikel Aickin, PhD
Ken Pelletier, MD
Tuesday, September 29, 2009
Wednesday, September 9, 2009
What’s Wrong/Right with the U.S. Health Care System
Recently, a young person applying to medical school asked me for assistance in getting information about our health care system so she could complete a section on the application that asked her to comment on what’s wrong with the health care system. Naturally, I was able to provide a lot of articles, papers, as well as my own analysis of the issues. After giving her the information necessary to do a decent job of responding to the question on her application, I began to think about how I would respond to such a question. I thought of two alternative responses; one that articulated the problems and deficiencies of the system and the other that concluded that there is really nothing fundamentally wrong with the system. Below is how I might have responded in each of these parallel universes, addressing the underpinnings of any health care system Access, Quality, and Cost.
The U.S. Health Care System is a Disaster and Needs Drastic Reform Now
Many recent books, articles, and presentations that I have read start with a variant of the statement "The U. S. Health Care System is a Disaster". Depending on the authors view point, the primary emphasis will be on one of the three underpinnings, Access, Quality, and Cost. Sometimes all three are woven together. The issues of access, or lack thereof, is usually made with the argument that 15% of the population at any one time is uninsured, and lack of insurance creates a barrier for people to seek and get health care services. For those lacking health insurance and become truly ill (as opposed to ailments that are relatively minor and self healing) the choice is often between suffering and/or dying or getting care and suffering the financial burden that in extreme cases can lead to bankruptcy and/or impoverishment . To place a significant portion of American citizens in this position is unconscionable.
Moving to quality, statistics that focus on medical errors leads the way. It is often said that errors occur from the overuse, underuse, and/or misuse of treatment interventions. Obviously, human error plays a part as well, even when there is no evidence of over-, under-, or mis- use of services. This is a topic for another day. It is tough to legislate quality, however incentives and/or penalties may be built into payment systems that reward or penalize a provider for behaving in a certain manner that is deemed to result in better outcomes or to reward or penalize on the basis of the outcomes themselves.
Cost is the really "boogey" man in the equation. The cost of providing health care to American Citizens puts a financial burden on employers, the government at all levels (federal, state, local), and on individuals and families. Cost may be controlled in two fundamental ways at the extremes, by (1) controlling supply and price at the payer level (i.e., restrict payments for services and reduce the price paid to providers for services) or (2) going to a totally consumer driven model where price is controlled by consumer choice and demand. Moving to either extreme would be a significant change and in many respects defines the two philosophical camps in the health care debate (government central control vs. a free market solution). However, unless costs are controlled, U.S. companies may be unable to compete in a global economy and governmental units will either have to curtail other services (education, defense, infrastructure) or raise taxes. Neither solution is very popular.
The U.S Health Care System is Fundamentally Sound and Does Not Need Significant Government Directed Reform
The health care industry is a significant driver of economic growth in the U.S. currently accounting for about 16% of the gross domestic product, and rising. The industry provides employment for numerous U.S. citizens from the highest level professionals to blue collar workers. Given the importance of health care to the U.S. economy any changes should consider the impact on the wider economic picture.
A key concern expressed about the current system is that it limits access to a portion of the population (the uninsured and underinsured). The percentage in this population segment is said to be about 15% or 45 million people. The reciprocal of these numbers are 85% and 255 million (the number of people who are insured). These numbers have remained relatively constant over the past several years. Obviously, the vast majority of Americans have good to very good access to health care services, at least from a financial standpoint. As for the minority who are un- or under insured, they have access to health care services, albeit limited, through government funded community health centers and hospital emergency rooms that are prohibited by law from turning people away. So maybe access is not such a big issue afterall.
The quality of care, as judged by the cutting edge innovation and treatment of serious diseases, in the U.S. is second to none. This innovation is fostered by the free enterprise system that provides big rewards for creative entrepreneurs. To take away the big reward incentives would severely reduce the advancement of medical care and hurt quality care going forward. So for the sake of continued advancement, do not inhibit the incentives to be creative.
So now we return to the "boogey" man, cost. The supporters or health care reform claim that if we do nothing, the rising health care costs will strangle government and make U.S. companies non-competitive in the global economy. Recent analyses of the Medicare spending have shown that there is a wide disparity in spending per capita for health care services in different parts of the country without much difference in mortality and morbidity outcomes. This begs for better standards of care that can lead to a more efficient system. The government, through the Medicare program, can take a leadership role, along with U.S. medical schools, to create "best practice" models. This will begin to push the cost curve for government expenditures downward over time. As for the private sector, the market will respond accordingly. Employers have already begun to shift the cost of health care to individuals employees through premium sharing, co-payments and deductibles. As this trend continues, we will move incrementally toward a consumer driven model. As more people with financial capability need to seek health care insurance on their own, the market will respond. Health insurers will develop products to meet the market need. It is likely the health insurance will move to a more catastrophic model, covering high cost interventions and procedures, while leaving individuals to pay for less expensive services out-of-pocket. When people need to pay directly for a service, they are more likely to become discriminating consumers. This will lead to people seeking better value for the dollars they spend, just like when purchasing automobiles or appliances.
What Direction Now??
Is the U.S. Health Care system so hopelessly broken that it needs significant government directed change or if we leave well enough alone, will the fundamentals of our free enterprise system take care of the problem?
In all likelihood, neither extreme position will prevail. We will see elements of both philosophical camps in a creative U.S. solution. Let’s hope that open minds and thoughtfulness on the part of our leaders prevails.
The U.S. Health Care System is a Disaster and Needs Drastic Reform Now
Many recent books, articles, and presentations that I have read start with a variant of the statement "The U. S. Health Care System is a Disaster". Depending on the authors view point, the primary emphasis will be on one of the three underpinnings, Access, Quality, and Cost. Sometimes all three are woven together. The issues of access, or lack thereof, is usually made with the argument that 15% of the population at any one time is uninsured, and lack of insurance creates a barrier for people to seek and get health care services. For those lacking health insurance and become truly ill (as opposed to ailments that are relatively minor and self healing) the choice is often between suffering and/or dying or getting care and suffering the financial burden that in extreme cases can lead to bankruptcy and/or impoverishment . To place a significant portion of American citizens in this position is unconscionable.
Moving to quality, statistics that focus on medical errors leads the way. It is often said that errors occur from the overuse, underuse, and/or misuse of treatment interventions. Obviously, human error plays a part as well, even when there is no evidence of over-, under-, or mis- use of services. This is a topic for another day. It is tough to legislate quality, however incentives and/or penalties may be built into payment systems that reward or penalize a provider for behaving in a certain manner that is deemed to result in better outcomes or to reward or penalize on the basis of the outcomes themselves.
Cost is the really "boogey" man in the equation. The cost of providing health care to American Citizens puts a financial burden on employers, the government at all levels (federal, state, local), and on individuals and families. Cost may be controlled in two fundamental ways at the extremes, by (1) controlling supply and price at the payer level (i.e., restrict payments for services and reduce the price paid to providers for services) or (2) going to a totally consumer driven model where price is controlled by consumer choice and demand. Moving to either extreme would be a significant change and in many respects defines the two philosophical camps in the health care debate (government central control vs. a free market solution). However, unless costs are controlled, U.S. companies may be unable to compete in a global economy and governmental units will either have to curtail other services (education, defense, infrastructure) or raise taxes. Neither solution is very popular.
The U.S Health Care System is Fundamentally Sound and Does Not Need Significant Government Directed Reform
The health care industry is a significant driver of economic growth in the U.S. currently accounting for about 16% of the gross domestic product, and rising. The industry provides employment for numerous U.S. citizens from the highest level professionals to blue collar workers. Given the importance of health care to the U.S. economy any changes should consider the impact on the wider economic picture.
A key concern expressed about the current system is that it limits access to a portion of the population (the uninsured and underinsured). The percentage in this population segment is said to be about 15% or 45 million people. The reciprocal of these numbers are 85% and 255 million (the number of people who are insured). These numbers have remained relatively constant over the past several years. Obviously, the vast majority of Americans have good to very good access to health care services, at least from a financial standpoint. As for the minority who are un- or under insured, they have access to health care services, albeit limited, through government funded community health centers and hospital emergency rooms that are prohibited by law from turning people away. So maybe access is not such a big issue afterall.
The quality of care, as judged by the cutting edge innovation and treatment of serious diseases, in the U.S. is second to none. This innovation is fostered by the free enterprise system that provides big rewards for creative entrepreneurs. To take away the big reward incentives would severely reduce the advancement of medical care and hurt quality care going forward. So for the sake of continued advancement, do not inhibit the incentives to be creative.
So now we return to the "boogey" man, cost. The supporters or health care reform claim that if we do nothing, the rising health care costs will strangle government and make U.S. companies non-competitive in the global economy. Recent analyses of the Medicare spending have shown that there is a wide disparity in spending per capita for health care services in different parts of the country without much difference in mortality and morbidity outcomes. This begs for better standards of care that can lead to a more efficient system. The government, through the Medicare program, can take a leadership role, along with U.S. medical schools, to create "best practice" models. This will begin to push the cost curve for government expenditures downward over time. As for the private sector, the market will respond accordingly. Employers have already begun to shift the cost of health care to individuals employees through premium sharing, co-payments and deductibles. As this trend continues, we will move incrementally toward a consumer driven model. As more people with financial capability need to seek health care insurance on their own, the market will respond. Health insurers will develop products to meet the market need. It is likely the health insurance will move to a more catastrophic model, covering high cost interventions and procedures, while leaving individuals to pay for less expensive services out-of-pocket. When people need to pay directly for a service, they are more likely to become discriminating consumers. This will lead to people seeking better value for the dollars they spend, just like when purchasing automobiles or appliances.
What Direction Now??
Is the U.S. Health Care system so hopelessly broken that it needs significant government directed change or if we leave well enough alone, will the fundamentals of our free enterprise system take care of the problem?
In all likelihood, neither extreme position will prevail. We will see elements of both philosophical camps in a creative U.S. solution. Let’s hope that open minds and thoughtfulness on the part of our leaders prevails.
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