Culture of Health Blog

“Project ECHO is working to improve health care for underserved populations all over the world, and to do it fast,” Dr. Arora said during his TEDx presentation in Albuquerque last month. With more than 2,000 people in the room, Dr. Arora described how the ECHO model began in rural New Mexico and how it is quickly spreading around the globe to help clinicians on the front lines of care learn new skills and do more for more patients. Watch Dr. Arora’s TEDx presentation and hear his vision for the future.

Some good news came our way this week -- a story unfolding the way we hoped it would.

Freelancers Union, a Pioneer Portfolio grantee, will launch three Consumer Operated and Oriented Plans (CO-OPs)--nonprofit, consumer-governed insurance companies envisioned by the Affordable Care Act to expand health insurance choices for consumers and small businesses. This is made possible by $340 million in low-interest and no-interest federal loans announced Feb. 21 by the Centers for Medicare & Medicaid Services to start three of the first seven CO-OPs in New York, New Jersey and Oregon.

We’re delighted because Freelancers Union used a 2010 grant from Pioneer to shape its existing ground-breaking model for demand-side, consumer-driven health care into a proposal for the new world of CO-OPs.

It was a natural fit. Here’s the back story.

The existence of Freelancers Union is recognition that for the 30 percent of the workforce that earns its living as freelancers, contractors and temps – so-called independent or contingent workers – there are no employer-provided benefits, including health insurance. Many of these workers earn too much to qualify for public assistance and not enough to afford the health insurance available in the individual market, typically more costly than the group market plans offered by employers.

As a Foundation, we have been concerned for 30 years about Americans’ lack of access to affordable and stable health coverage, so a partnership took shape over the course of three grants.

We first partnered with Freelancers Union in 2007, when they were looking to start a health plan for the contingent work force, but with an important twist. They wanted the benefits to reflect input from the workers. Our first grant helped the organization conduct surveys and focus groups to shape the benefit design. It learned that its members wanted a product aligned to their holistic needs on top of catastrophic coverage.

With a second grant in 2008, we joined a consortium of funders that helped launch a for-profit subsidiary, Freelancers Insurance Co., with a line of products that combine catastrophic insurance coverage with special attention paid to mental health services as well as wellness, prevention and alternative therapies.

Then with a third grant in 2010 we sought to enable Freelancers Union to expand its group purchasing health-benefits program from New York into New Jersey and Georgia. We envisioned this work might produce a prototype for the CO-OPs, and it did. All CO-OPs won’t follow the Freelancers Union model, of course, but it certainly sets a standard.

The work of Freelancers Union reflects many of the core ideas that drive Pioneer Portfolio grant-making. It is transformative and disruptive. As large insurers back away from the individual market because of the tight profit margins, some fresh thinking is badly needed, like rolling individuals into groups even though they do not work together, and then listening to them carefully to design products that meet their needs.

That’s pioneering, and we’re proud to have played a part.

Follow @FreelancersU on Twitter.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

I have heard David Eddy present a half-dozen times, and each time come away with a richer appreciation of the door to the future he is opening for us. He was at the Foundation talking to staff today, and presentation stood out as being special because he started with an historical perspective of how we have defined quality of medical care over time, moving from qualitative judgment to quantitative measurement as the data and tools for modeling have improved.

And while he is somewhat modest, it is clear that David has figured prominently in that history, challenging the system to evolve as new data and methods have been developed. He gave us the concept of evidence-based medicine when we had none. He helped to create the HEDIS measures and gave us evidence-based guidelines of care for population-based health measures. Now he is giving us personalized guidelines which will be aggregated to develop new Global Outcome (GO) Scores for accountable care organizations to manage the health of their members.

It cements in my mind the importance of creating ARCHeS to give many more policymakers access to the power of the Archimedes model that David and his colleagues have developed.  I feel like I have had a glimpse of the future, and we really could have the best health care system in the world.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

“Whether Eddy will get a Nobel Prize, I’m not sure. But he’s certainly changing how we think about health care.” – Dr. Lynn Etheredge, Director of Health Insurance Reform Project at George Washington University and Pioneer grantee, on Dr. David Eddy

We encourage you to read “Modeling Human Drug Trials – Without the Human,” a profile of Pioneer grantee Dr. David Eddy and Archimedes, his mathematical model of human physiology, diseases, interventions and health care systems. Featured in the December issue of Wired and authored by Jennifer Kahn, the article explains that Archimedes is part of Eddy’s “vision for the future of medicine: faster, cheaper, broader, clinical trials — all happening inside a machine.” While clinical trials are still required to test the safety and effectiveness of new medications, Archimedes — which Eddy has spent more than a decade developing — recreates aspects of diseases not readily measurable by researchers and turns out results at a much faster rate, and for far less money.

Pioneer is currently supporting Dr. Eddy to develop and launch ARCHeS, a powerful Web-based interface that gets a brief mention in the article. As Kahn writes, ARCHeS “will allow doctors, policymakers and researchers to access Archimedes and design their own trials.” By doing so, Pioneer aims to ensure that health officials can attain a better understanding of the implications of their decisions before making recommendations for patient care, not only advancing disease treatments but also curbing unnecessary health care costs for patients. ARCHeS will not be a database of answers, but an evidence-based tool that can be used to find answers.

Dr. Eddy will be visiting with us at the Robert Wood Johnson Foundation in early December to share a beta version of ARCHeS and we’ll, in turn, share highlights from his presentation via the Pioneer Twitter account. We hope you’ll follow.

In the meantime, tell us what you think of the article. We’ll be monitoring blogs and tweets that write about the piece and sharing them here later in the week.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

Excitement about the power of genomics was palpable at TEDMED this year as some attendees lined up to spit in DNA vials and send it off to 23andME. Unfortunately, many may be disappointed to find out how little our genomes can tell us without research that a large population-based research program, such as we are helping to build at Kaiser Permanente, can provide. Ann Wojcicki, CEO and founder of 23andMe, stated from TEDMED stage that Kaiser Permanente plans to genotype the DNA of 100K members but does not plan to provide that information to the individuals who donated their DNA, implying that valuable information was being withheld.

We asked Cathy Schaefer, executive director of the Kaiser Permanente Research Program on Genes, Environment and Health (RPGEH), to respond.

The RPGEH is designed to conduct research on populations to improve health and medical care. The information collected, including the genotyping of 100,000 individuals for our NIH-funded grant, will enable researchers to conduct population-based research that may help them understand the genetic and environmental basis of disease, treatment response, and health.

We inform all participants about the purpose of collecting genetic and other information, and they volunteer to participate — at no cost to them — to facilitate this research, knowing their individual results will not be returned to them and that all data about them will be "de-identified." We also inform participants that if we discover something in their data or samples that may be important to their health, we will contact them to learn if they want to have the information. 

Why doesn't the RPGEH restructure so that it can return results to individuals? Because genetic information obtained through today's genome-wide studies has not been designed to be useful to individuals; it is designed for use in research. In most cases, it isn’t known whether the variants tested for are actually implicated in a disease process, or are markers for variants that play a role in disease, and results from these tests are rarely actionable.

Ann Wojcicki from 23andMe misspoke at last week’s TEDMED gathering when she said that Kaiser Permanente does not return genetic results. Kaiser Permanente Health Plan members have access to genetic testing as part of their Health Plan membership and through their physicians. Kaiser Permanente physicians order genetic testing and return genetic results to thousands of patients, for numerous conditions, when information that testing will provide could help to inform the patient’s health care, disease prevention, or future childbearing. For example, members with some cancers or HIV may have genetic testing to determine the most effective treatment. Couples considering pregnancy may also be tested to determine family histories for certain diseases that may be passed on to their children.  

Individuals who have questions about their genetic risks for various health conditions should talk to their physicians, who can provide useful information about risks and options for testing.

This commentary originally appeared on the RWJF Pioneering Ideas blog.

RWJF Senior Counsel Jim Ingram has co-authored this post with Nancy.

What if we could have a rational, consistent medical justice system that resolved claims expeditiously?  What if the bulk of the money spent on the system went to victims instead of to legal fees, court costs and other expenses?  Finally, what if this new system could actually promote patient safety by bringing the causes of medical injuries to light rather than pushing that information underground?

People on all sides of the medical liability debate see the system as broken and have strong opinions on various fixes, and yet for years we have been unable to break through the gridlock to make meaningful headway toward new solutions.

Pioneer, through a cluster of grants, is exploring a new approach — administrative health courts. Precedence for such a specialized administrative court already exists in the form of bankruptcy, tax and admiralty courts.

While health courts offer many advantages over the tort system, we find the potential for gains in patient safety, as well as in quality and transparency of care delivery, to be the most compelling.

• In a departure from today’s system, health courts would be overseen by judges dedicated full-time to addressing issues of medical injury.  They also would use court-appointed, neutral experts to testify on cases, and work from explicit compensation guidelines. Judges’ rulings would help set clear, consistent standards for future health care delivery, ultimately helping to improve care.
  
  
• Health courts would use “avoidability,” rather than “negligence,” as the criterion for determining whether a medical injury is compensable,  The concept of negligence brings with it professional shame and guilt – an unintended effect is that many physicians are reluctant to disclose information about medical errors or injuries to their patients and to reporting systems.  The use of “avoidability” reduces some of the stigma surrounding medical liability and could help promote a culture of safety and disclosure among physicians.
  
  
• The broader criterion of avoidability also means more victims of avoidable medical injury could receive compensation.  This alone is desirable and would also increase the availability of claims data for patient safety research.

For more than two years, with support from RWJF’s Pioneer Portfolio, the nonpartisan legal reform coalition Common Good has worked to design a separate specialized medical court system, calculate cost implications and determine compensation guidelines.  It also has led widespread outreach to educate stakeholders about administrative health courts, raising significant and broad bipartisan support for the concept. 

On a parallel track, researchers at the Harvard School of Public Health (HSPH) have developed a prototype for health courts and researched the viability and benefits of such a model (see resulting paper).

We are just beginning a second phase led by Common Good, in collaboration with HSPH and several other academic research partners. In this new phase, Common Good will (in addition to its national outreach and coalition-building activities), identify six states where there are favorable chances of successful reform, offer  technical assistance to interested parties within these states and support a state task force to develop a health court pilot proposal. Our goal is a successful health courts demonstration.

This is a high-risk proposition; there are entrenched interests determined to maintain the status quo.  What Common Good and its partners are working on, however, is worth pursuing…the health courts vision goes beyond incremental reform to promote a fundamental rethinking of the system.  With so much to gain in terms of transparency, efficiency, cost savings and patient safety, the time is right to test the viability of a state-based rational medical justice model.

We’re glad that Paul Barringer of Common Good and Michelle Mello and David Studdert of the Harvard-led research team have joined us in this initial exploration of the health courts model on Pioneering Ideas.  We look forward to their thoughts—and yours—on the prospects for a medical justice system that restores rationality and enhances health care quality and patient safety.

This commentary originally appeared on the RWJF Pioneering Ideas blog.