Meeting & Mixing of the Minds at BU OTD’s Tech, Drugs, and Rock n’ Roll

It was an evening full of collisions of all kinds at the Boston University Office of Technology Development’s 6th Annual Tech, Drugs, and Rock n’ Roll (TDRR) held in the George Sherman Union on BU’s campus set along Boston’s Commonwealth Ave. Entrepreneurs, academic scientists, industry folks and funders from venture capital and government / non-profit entities alike mixed and mingled over the course of an eventful evening. Much of the action centered around “Funder Alley” – a row of booths and monitor displays that featured many of the area’s funders of upstart biotechnology...[continue reading]

A Nuanced View of the World of Drug Development & its Value to Society

It’s not every day that you have the opportunity to play audience to a preeminent biotech company’s chief executive (in Boston it’s more like every other day), so I couldn’t pass it up when I learned Genzyme CEO David Meeker, MD, would be sitting down with Boston Globe Life Sciences Reporter Robert Weisman for a “fireside chat” (hold the fire) hosted by the MIT Enterprise Forum at the Broad Institute of MIT & Harvard in Cambridge’s Kendall Square. Equally compelling was the thought provoking topic of conversation; “The Value of Drug Development: Can Society Afford Today’s New Wonder Drugs?” Given Dr. Meeker’s previous clinical and academic accomplishments as former Director of the Pulmonary Critical Care Fellowship at the Cleveland Clinic and Assistant Professor at Ohio State University, plus a variety of high-level managerial undertakings with Genzyme prior to becoming CEO, he seemed uniquely positioned to offer a nuanced take on the world of drug development and its value to society...[continue reading]

Leveraging Machine Learning Muscle at the Brigham & Women's Hospital iHub Idea Lab with Microsoft

The air was electric in the Shapiro Room at Brigham & Women’s Hospital (BWH), the setting for the BWH iHub Idea Lab with Microsoft on the evening of Monday, June 22nd. With innumerable ideas afloat on the topic of “Machine Learning in Healthcare,” it seemed it would be only a matter of time until lightning struck – in the form of a truly groundbreaking idea to improve population health and/or care management. Combining the clinical and technical acumens of members in attendance from the respective BWH and Microsoft communities, it appeared that the necessary parts were all in place, like a well-oiled Rube Goldberg machine, to harness the room’s bottled energy to propel forward real world solutions to some of healthcare’s most nagging problems...[continue reading]

Nine Teams Begin Commercialization Boot Camp, Canvas their Biomedical Business Concepts

On Day 1 of the CIMIT/B-BIC i-Corps Healthcare Commercialization Boot Camp, nine teams of innovators from a selection of the area’s most esteemed academic and medical institutions - including Boston Children's Hospital, Boston University, Brigham & Women's Hospital, Harvard Medical School, Mass General Hospital, MIT and Yale - convened at Boston University to start the process of developing a commercialization roadmap for their projects. They shared their ideas in confidence, received valuable insight and feedback from expert mentors and coaches, and learned more about the commercialization road ahead...[continue reading]

The Medical Perils of Error and Waste

"Variation equals opportunity" - words of Dr. Tom Lee, author of Eugene Braunwald and the Rise of Modern Medicine

He's got a point you know. We all have much thanks to give to variation - for if it weren't for variation, we as humans would undoubtedly not exist. Stealing a page from Darwin's On the Origin of Species, we see that evolution through natural selection depends and draws on this variation inherent to living things. The differences among individuals allow for competition, creating relative fitness; while within the individual, on a biochemical level, genes of sexually reproducing organisms are passed on to offspring, genomes are shuffled and variation is maintained within the population* (and this is important). For when, the circumstances change and the situation calls for a completely different set of traits for gaining a competitive advantage - dark features instead of light, speed as opposed to bulk - the "Greatest Show on Earth" takes center stage to showcase the utility of all of that wonderful variation - that that was on display and that that lay dormant - by mixing and matching until a more fit creature, possibly even species, emerges equipped for survival amid the new way of the land.

Of course, that's not the only possible end to this story. For the same reason that dinosaurs aren't walking alongside men today. Sometimes the genetic lottery comes out unfavorably and a species becomes extinct (and sometimes a giant asteroid collides with Earth).

Now think about this framework that I've laid out above, and instead of species let's think of health care systems. You may be privy to the tremendous amount of variation that exists in the United States' domestic system of health care today...We have patients who receive world class care and others who can't even access or afford care. We have primary care along with every kind of specialist and within each class we even have numerous different ways of practicing. We have a range of prices that we charge for essentially the same procedures. So a person going to hospital A might pay $4000 for X procedure, while a person who chooses to go to hospital B for X procedure pays only $3000...and I'm afraid that growing up dealing with its idiosyncrasies, we may have also grown deluded to believe that this is the way it has to be...

Luckily, we are beginning to see some ways out of this. First of all, with added transparency we can begin to map the variation that exists and persists in our health care system. Here, when I say we, I really mean Dr. John Wennberg and his colleagues at the Dartmouth Institute for Health Policy and Clinical Practice. For over two decades, the Dartmouth Institute has been collecting and analyzing stores of information on resource utilization via Medicare (our nation's single payer system), which insures America's 65-and-over population, and organizing their findings into freely available tools shared online at Dartmouth Atlas. Taking one quick look, it's not hard to see that things vary rather widely across the country, within regions and even within states and cities.

Mapping the variation in health care resource utilization across the fifty nifty United States. On their site you can zoom in and out to view different regions' variability on a range of topics in health care.

What this tells me, and Dr. Wennberg & Co. would agree, is that there is an incredible amount of waste in our health care system - waste defined as spending that doesn't result in better outcomes - by some measure almost 30% of all health care spending! Think about that. With health care spending running a total of $2.7 trillion a year, that means that over $800,000,000 is wasted per year! Think what we could do instead with all of that funding?? What a waste...

If that isn't enough, two weeks ago the Massachusetts Health Policy Commission released their Annual Cost Trends Report (full pdf), which showed that Massachusetts, the heralded gold standard of our domestic health care system, has exhibited 21-39% of spending as waste, measured at $14.7-26.9 billion in 2012. With much of our health care culture owing its roots to the values of the Hippocratic Oath, "first, do no harm", we're finding it harder to ignore the opposition to that rule apparent in these two distinct, but equally far reaching studies, and many else like them. In fact, it appears quite clearly, we do do harm, considerable harm at that (in the form of undertreatment, overtreatment and mistreatment or errors); to our patients and society at large.

Taking this all in stride, we're beginning to comprehend that, to some extent, we're all complicit.

But, there is hope. Going back to what I said earlier, in quoting Dr. Tom Lee, "variation equals opportunity"; we have our eureka moment. Our "Ah-ha I've got it!" If some are able to get by on less without adversely affecting health outcomes then how about we learn what enables them to do so and share best practices in order to bring all providers across our nation in line with a new standard of operation!? Some of you out there, with a few more years on me and your wits about you, may respond: "you mean what happened in the early 90's with HMO's (health management organizations)?" Expecting to get by on less, which equated to care rationing. For those unfamiliar to these times, care rationing is bad. And that's not what we hope to achieve with current and future reform efforts. No, instead we need to think bigger! We want to have our cake and eat it too!

I repeat. We can have high quality care and open access to it, covering everyone, improving the health of our population while cutting costs to increase affordability and reduce the financial burden of health care! Remember...Triple Aim'en! 

The question then is how do we get there?

Looking Ahead to 2014: The Dilemma of Transparency in Health Care

By now, I'd say it's fair to presume that the dust from last night's New Year's Eve bonanza has finally settled as many around the world gathered in city and town centers to celebrate the year that was while simultaneously turning over a new leaf, looking ahead to a new beginning in 2014. As the sun has set on Day 1 of the new year, marking the official start date of the Affordable Care Act (ACA), it's unlikely that anyone would be able to forecast with any certainty what we all have in store in the coming year. One thing I can state fairly is that the dust has far from settled in the individual health insurance marketplaces spread across the country - not even close in fact, as things have really just started to heat up! Over Christmas, the marketplaces played host to all sorts of activity as a few hundred thousand newly eligibles - those previously denied coverage due to pre-existing conditions in addition to those who previously held coverage now deemed insufficient - across the country were stirring (all through the house) to make their ways onto their respective insurance marketplaces to secure a health insurance plan for the new year (the best gift of all!).

The latest figures as of December 24th show nearly 2 million Americans having signed up for new coverage via the state and federally run health insurance marketplaces with the federal healthcare.gov website accounting for just over 1.1 million of that total - a drastic improvement from a few months back, but still a tad shy of the Health & Human Services' prediction of 3+ million by this date. Experiences in Massachusetts would suggest we have little to fret however, with still three months of open enrollment remaining (ending March 31, 2014).

This figure's title speaks for itself - health insurance enrollment data from Massachusetts, February - December 2007.

Despite these assurances, the media will most certainly be gearing up in all too characteristic fashion following the wake of yet another successful holiday season; with retail shops freshly picked clean, there will be only one logical story to turn our collective attention to - and that my friends is the tale of Obamacare, healthcare.gov and open enrollment. Over the coming month, fleets of straight shooting sensationalist reporters, who by definition never shy away from the heart of the issue, rather only becoming more bold as the issues become bigger, will inflict viewers with the usual onslaught of coverage on the new health care law, undoubtedly yielding stories of "promises" (broken, kept and empty), "trust", "accountability", "loved ones lost" and downright "fear" - a supreme repertoire fit for only the finest provocateur.

However, there is one word unmentioned thus far that may trump the lot when it comes to health care in 2014 and beyond. That is to speak of "transparency" in health care.

The word itself has shown increasing relevance in the legislation - jumping from being mentioned five times in Massachusetts' health care law of 2008 to a whopping twelve times in the corresponding legislation from this past year, just four years later. By no means a comparison of any statistical significance, it is however a hint, that we should take as signaling that maybe there's something to this word that the legislation has deemed worthy of repeatedly impressing upon, both in its legal and practical applications. Maybe it has something to do with the lack of transparency in health care to date??

For us to know exactly what the word entails for reform efforts, it's going to take a bit more than a simple show of hands from legislators. Rather, a more qualitative analysis must be employed - and for these purposes it will help if we remove our noses from the bully pulpit for a moment and take a step back to gain perspective on different ways that transparency could be applied in our ever increasing web of a health care system. For this exercise, it will be useful to recall the different players involved in our current state of health affairs; for a refresher, feel free to reference the list compiled in "Accountable for Change?".

As a means toward understanding what greater "transparency" may hold for different players in health care, we will be asking ourselves the following question:

What does transparency mean for _____________? Filling in the blank with one of the following:
"Patients", "Providers", "Payers", "Regulators", "Manufacturers", "Law", "Policymakers".

Who Should Be Accountable for Bringing About Change?

"Every system is perfectly designed to get the results it gets."

Reminiscent of Confucius or one of Yogi Berra's infamous isms, this quote offers us wisdom beyond just simple word play. In the case of system performance, especially when thinking about a particularly complex system such as U.S. health care, the above statement provides us with insight to explain why we're getting the results we're getting (which as we saw, in begging the question of "...How m'I Doing??", are not all that great) - and it isn't by happenstance. Rather the opposite, our health care system can be thought of as being finely tuned to get the results it's getting. The "tuning" in this case could come in the form of efforts to reform health care, but it need not be so deliberate, as our system of health is constantly having its dials turned by a countless number of shifts in processes that directly or indirectly link to our health. To help us get a handle on what matters in the world of health and what doesn't, health experts have created the term "determinants of health" to capture this comprehensive network of interactions associated with our health.

If you haven't already done so, before looking closely at the contents of the image below, try to come up with as many factors of health as you can on your own (write them all down if you'd like!) - after we'll gauge how closely our intuitive senses match the real thing.

The Institute for Healthcare Improvement provides us with this useful depiction of our health hemisphere. 
So how'd you fare? Did you account for all of the factors mentioned above? - leave me a comment with your thoughts!

As we see depicted in the above diagram, there's much more to our health than what we traditionally might have thought. "Health care", which receives an overwhelming majority of the funding for health matters in the U.S. (upwards of 90% of the $2.6 trillion dollars spent on health annually), comprises only one piece of the schematic's hemispherical puzzle. The rest of the amphitheater is occupied by our genetics, behavior, social environment and physical environment as well as interventions made on the part of society to promote or deter healthy living, much of which are the subjects of our attention in public health (which mind you, gets less than 5% of our financial attention in the form of funding). When we think about making changes to our system of health, we're going to need to think big picture about how any number of these factors could have an effect on our health outcomes.

Continuing on this matter, we find that significant improvements to our system of health tend not to arise spontaneously. A principle from the field of system performance sums up this notion succinctly in stating that "change can happen without improvement, but improvement cannot happen without change". A two-liner of which even JFK would be proud, and, I imagine, not just for its rhetoric, as we are able to unearth from it the concept that improvement never arrives unaccompanied by intervention (otherwise known on this blog as a "wedge"!). While observing properties of the natural world some centuries ago, Isaac Newton was coming around to a similar realization that culminated in his monumental laws of motion, which still stand true. Following a similar rhyme to the aforementioned adage of systems, his first law states that "an object at rest will stay at rest and an object in motion will stay in motion at a constant velocity, unless acted on by an external force." A concept cutting across historical and disciplinary divides has retained its relevance from the founding of classical physics all the way to the health care reform efforts of today.

Since we've seen that the U.S. healthcare system has significant room for improvement across the board (with a few exceptions like emergency care), we're now left with devising a means to change our ways as we've come to the realization that business as usual, i.e. no change, will not cut it. So what will we do? At present, much of our answer to this question can be found in the federal legislation as key decisions regarding domestic healthcare reform have already been drafted into law with the passing of the Affordable Care Act in 2010 - so at this time, the more appropriate question then, is not what are the changes that we are looking to make, but instead, HOW will we make them and WHO will be responsible or held accountable for carrying them out?

*Yearning for further coverage on how Congress came to the "what"? Refer to the perspectives offered in "Massachusetts: America's Next Top Model...".

"Who Accountable???", the healthcare reform spin-off of the classic "Who Done It??"

Are you ready to give it a whirl??