Christine Laine, MD, MPH, senior deputy editor of the Annals of Internal Medicine, says that the most important advice for health economists wanting to submit their research to clinical journals is to remember the journal’s audience. Specifically, she says:
As a top-tier journal, the Annals of Internal Medicine publishes only 6% of the manuscripts it receives, and most of the HE-related articles are cost-effectiveness analyses that affect healthcare policy decisions.
Dr. Laine says that HE research will interest clinicians if the work is placed in a context that is relevant to clinicians’ priorities.
The European Union is moving to strengthen rights of EU patients to seek care in countries other than their own, while the UK government has stated that the National Health Service definitely won’t fund medical tourism.
At the same time, India , Thailand , Korea and Thailand are all ramping up their efforts to attract medical tourists, and polls show that some 4% of Europeans sought treatment overseas in 2007. Some estimates put the global market for medical tourism at between 60,000 and 85,000 inpatient medical travels a year.
Leonard Karp (pictured right), president and CEO of Philadelphia International Medicine (PIM), heads an organisation that attracts medical tourists from outside the USA – more than 3,000 last year. He notes that inbound travel to the USA for medical care is valued at more than $1 billion a year by the United States Department of Commerce.
In an interview with HOC , Mr Karp said that in general he believes that international pooling of medical resources will save costs. But he warns that there’s a downside – visa and payment issues among them – plus possible language and cultural barriers. And then there’s the matter of legal recourse if anything should go amiss. That might be a problem outside the USA , he says; but patients coming into the country have the same legal rights as do US citizens. Before setting out for treatment at such well-known medical centres as the Mayo Clinic and at sites in New York, Boston, Miami, Los Angeles, Seattle and Philadelphia, patients should be able to show legitimate medical need, ability to pay – and should check with their clinic or hospital of choice, says Karp.
PIM, now in its tenth year of operation, not only brings overseas patients into Philadelphia , it is also, according to Karp, looking for new ways to enhance its mission. For example, it is increasingly active in Asia and recently signed its first payer contract with an Indian health insurance company; it also completed a feasibility study to develop an international hospital in South Korea . The company also plans to offer its services to additional hospitals that have an interest in medical travel but lack the infrastructure to manage an international patient population.
Back in Philadelphia , PIM not only attracts patients to the city for specific medical procedures, but also produces an adjunctive economic benefit. Says Karp: “Patients stay at local hotels, often for six weeks or more. Their families utilise the region’s restaurants, shop for gifts for family back home, and rely on local interpreters, medical equipment providers, and other services.”
Asked if he sees a time when US insurers will look to specific foreign countries for particular services or procedures, Karp notes that some Southeast Asian countries have established a focus on organ transplants. But so far, the major American health insurance companies have not bought into outbound medical tourism. As healthcare costs continue to soar beyond the present 16% of GDP, that might change. Having your heart transplant and getting to see the Taj Mahal in the same trip and for half the cost of the procedure at home could have piqued the insurance company accountants’ interest.
With healthcare in the US consuming about 16% of GNP, or around 2 trillion dollars a year, and still leaving an estimated 47 million people uninsured, is it time for Americans to adopt a universal, government-run health system?
Dr Walter Tsou (pictured right) certainly thinks so. A tireless advocate for such a system, the former president of the American Public Health Association and health commissioner for the City of Philadelphia, Dr Tsou is convinced that single-payer national health insurance would not only be more equitable, it would also be more efficient.
In an interview with HOC , Tsou pointed out that calls for the healthcare system he espouses are gathering momentum as the expense and waste of the existing system make it increasingly untenable. He cites the growing influence of Physicians for a National Health Program (PNHP), a non-profit research and education organisation of 15,000 physicians, medical students and health professionals who support a single payer.
Unlike the Canadian system, he says, which is both federally and provincially funded, he would favour a centralised US federal approach that would absorb the current Medicare and Medicaid programmes; but like the Canadian health system, which has been in place for almost 40 years, it would cover everyone.
PNHP, in which Walter Tsou is a board member, believes that because the existing US patchwork of private insurance bureaucracies and paperwork consume more than 30% of every healthcare dollar, streamlining payment through a single non-profit payer would save some $350 billion a year.
What would happen to existing private insurers if single payer came into force? Says Dr Tsou: “They could become fiscal intermediaries… process claims; or cover some services that might not come under the broad umbrella of a national health plan.”
And what about the physicians? Well, he says, primary care doctors would earn about the same as they do now; specialists would probably be paid less. However, he notes, practice overheads would be dramatically reduced, and the current cumbersome business of patient co-pays and deductibles would be eliminated.
Finally, Dr Tsou emphasises that under a national plan, prevention would be a priority, and smart cards with physician access would be universal. “It’s a win-win for society,” he says.
After selling his travel company – the third largest in the US – to American Express for $6 billion, Hal Rosenbluth could have spent his time fishing, golfing, or globetrotting; instead, he co-founded Take Care Health Systems.
The company, of which he is chairman and cofounder Peter Miller is CEO, is principally dedicated to placing health delivery into the workplace. They call it, as Take Care’s slogan puts it: “a better way to be well.” There are some 7,000 US companies with more than 1,000 employees, and Take Care is working with more than 100 of them.
Bringing healthcare services to the workplace is nothing new: bigger companies traditionally had a medical director, and perhaps some occupational health staff to speed injured workers back to fitness. But Take Care’s Employer Solutions Group, responding to employers’ concerns about rising healthcare costs and a growing shortage of primary care doctors, can bring comprehensive health services to the workplace. “In fact,” says Rosenbluth, “in many instances we bring a full range of care, including vision, dental, imaging, infusion, chronic care, and prevention.” In the town of Gillett , Wyoming , which has three mining companies but no physician, Take Care provides a complete health service.
The emphasis, says Rosenbluth, is on wellbeing – catching health problems before they escalate. For employers, this means reduced costs and a happier and more productive workplace. In fact, the happy workplace concept is central to Hal Rosenbluth’s approach to management. His bestselling book, “The Customer Comes Second,” focuses on how to create a great service organisation by first focusing on your employees.
The whole idea of a strong service ethos – market driven healthcare – is appealing to employers. And it’s what drives Rosenbluth who admits that he knew nothing about healthcare “but my whole life I’ve been in love with service.” Investment banking firms on Wall Street are especially enamoured of Take Care’s 24-hour care that allows brokers to remain “on the floor”. The company has a sales force of consultants who engage in a “corporate conversation” with prospects. Says Rosenbluth: “Corporations are made up of human beings; but all too often we make things more difficult than they need to be. Our concept is a simple one.”
Do physicians see all this as a threat? Well, the American Medical Association’s and the American Academy of Family Physicians’ executives are apparently supportive although some individual physicians may perceive that their turf is being invaded. Yet Take Care’s own doctors, relieved of onerous administrative duties and rising malpractice insurance premiums, seem happy enough. And anyway, how can you be against quality, affordable, comprehensive, and technologically up-to-date care? says Rosenbluth.
Asked about whether continuity of care might be a negative, he says that it’s not an issue “if you believe in electronic medical records and medical homes”. And asked further what he brought to healthcare from the travel industry, he says that it’s about improving the lifestyle of people – making things more convenient and easier by, for example, making airlines compete for business, making all facets of the operation electronic. Similarly, Take Care will negotiate payment and working arrangements with, say, ten cardiologists in a city.
In sum, Hal Rosenbluth wanted to find the biggest unsolved problem in the US and bring a private sector approach to solving it. Take Care seems to be a part of that solution.
While the Golden Age of the pharmaceutical industry is over, and its reputation similar to that of the tobacco and oil industries, there is hope at hand – according to former Merck CEO Roy Vagelos.
In a keynote address to the third annual meeting of the International Society for Medical Publication Professionals, Dr Vagelos suggested that a future golden age could be characterised by understanding genetics, producing as a result effective drugs for Alzheimer’s, cancer, etc, and thus re-establishing the pharmaceutical industry’s reputation.
For the present, though, he suggested three areas of concentration. The first has to do with pricing: how do you assess value? Productivity and lifespan factors have to be taken into account. “Most drugs are a terrific bargain,” he said, “but you have to weigh $25,000 a year to treat the once deadly HIV; or $50,000 for a cancer drug that extends life by four months.” The first represents value; the second does not, according to Vagelos.
The second area is in doing good works in the developing world. For example, Merck and other pharmaceutical companies are providing free drugs to combat river blindness and HIV in Africa… and a hepatitis B drug in China . Vagelos acknowledged that while these efforts are made for humane reasons “eventually these countries will be markets for us.”
The former Merck executive then turned to a third issue: the industry’s credibility. Some of this, he said, hinges on how well the company handles, for example, the Vioxx question. “Credibility will be restored as we respond appropriately,” he said. He went on to say that the FDA is undermanned, under resourced, and works with information technology that’s 25 years old, that drugs are coming off patent, and the fact that pharmaceuticals are no longer a growth industry means that clinical studies and manufacturing will both be outsourced.
Touching finally on the current debate over pharmaceutical reps’ access to physicians, Dr Vagelos acknowledged that some approaches might be inappropriate, giving the impression that physicians can be bought with free meals and trinkets. He chaired a meeting of 26 academics and for industry CEOs who came up with the idea of scheduled meetings in which pharmaceutical company scientists would explain drugs to academics and physicians. The committee also suggested training for physicians and for medical students about what drug development is all about.
On January 1st 2006, Dr Dennis Gross retired from Merck after 28 years; the following day, he took up his present position as Associate Dean, Masters Programs, in the College of Graduate Studies at Thomas Jefferson University.
At Merck, he had started out as a senior research pharmacologist working on the project team that discovered the angiotensin converting enzyme inhibitors Vasotec and Prinivil. Dr Gross went on to fill senior management positions in the company, directing research operations, and serving as director of programme resources and logistics. In that capacity, he was responsible for operations and financial oversight of Merck research labs in the UK, Japan, Canada, and Italy. He reckons that, all told, he flew a million and a half miles for Merck.
During that time, he fused a business career with an academic one… serving as an adjunct professor at Jefferson from 1977. No wonder Gross is a strong proponent of bringing ‘real world’ experience to the benefit of the 350 students in his masters programme in biomedical sciences. “It adds richness and diversity to the student experience,” he says, and helps to prepare those students for what he believes will be a very different future in pharmaceuticals.
Many of the professors in the department lecture on what they actually do for a living, he says, and he himself grafts onto his administrative duties a teaching schedule in pharmacology and toxicology. “I really enjoy interacting with the students,” he says, “and it really is a way of giving back some of what I learned in industry.” And those students themselves are pretty diverse – some just out of undergraduate studies; others with perhaps 10 years in the business world.
Off campus, Dennis Gross enjoys music and photography… and is a voracious reader who’s been collecting books – especially on the Middle East – for 40 years, prompted perhaps by the fact that his grandfather fought in Palestine in World War One and met the fabled Lawrence of Arabia.
Of HOC, he says: “The newsletter serves the useful purpose of exposing people in a succinct way to the issues of the day that affect them professionally.”
Entusiasmo. That’s a word that describes, in his native Italian, what Vittorio Maio brings to his work in health policy and outcomes research. “What makes me really happy,” he says, “is being able to see research theory translate into actual practice in the real world.”
Vittorio graduated from the University of Perugia and moved to the United States in 1999; there, he immediately joined Dr. David Nash’s Department of Health Policy at Thomas Jefferson Medical College, where he is a research assistant professor and director of the Fellowship programme in outcomes research.
But he has not lost touch with his professional and cultural roots. A few hours after our interview for this article, he was winging his way back to Italy – a trip he makes four or five times a year. In Bologna, he conducts population-based outcomes research with a unique healthcare database. The studies embrace differences in the use of health care services between men and women, the elderly, and children; they look at approaches to, say, cardiac care and how general practitioners might be persuaded to change their approaches to treatment and prescribing. They are even touching gently upon the idea of pay-for-performance among physicians.
Vittorio brings this international perspective to his professorial role at Jefferson. He finds that his students are particularly receptive to this… and he is not afraid of editorialising on the subject of American healthcare, which he describes as the most regressive system in the world. “We all pay the same,” he says. “People should pay according to their resources.”
In general, Vittorio’s particular research enthusiasm has to do with the elderly, with trying to change physician behaviour, and with pay-for-performance – linking quality to incentives. Beyond that, he says, non-adherence to drug regimens “is a huge interest.”
Asked about HOC, he is equally upbeat: “What you’re doing,” he says, “is an important way to connect health economists, researchers and decision-makers. It’s concrete, an easy read, and credible.”
Newly-installed ISPOR president Diana Brixner, RPh, PhD, has put together a challenging agenda for the society during her term of office.
The central point of that agenda, she tells HOC, is to bridge the gap separating academics and outcomes researchers from the people who actually make economic decisions. Achieving that, she says, involves giving decision-makers a more active role on ISPOR committees in order to influence our studies
Dr. Brixner, a medicinal chemist and chair of the Department of Pharmacotherapy at the University of Utah, plans to increase even further ISPOR’s international presence and to strengthen the Society’s voice in global health policy issues. “We need to reach outward,” she says… expanding our presence into Eastern Europe, Latin America, Singapore, South Africa, and Latin America.
ISPOR’s North America meeting next year will be held in Toronto, while the European version is scheduled for Dublin this year and Athens next year. In fact, Dr. Brixner is headed to Athens shortly to work with the Greeks in jumpstarting an ISPOR chapter in that country and to lay the foundation for the November 2008 European conference.
The new president points to the fact that ISPOR has grown from 35 founders in one country in 1995, to more than 3300 members in 80 countries today. “We are viewed as the predominant society focused on patient outcomes, including economic, clinical and patient reported outcomes,” she says, adding that the organisation’s Good Research Practice Reports are used as guidance for research throughout the world; moreover, the ISPOR Medical Device and Diagnostic Outcomes Research book is nearing publication.
It epitomises another strong agenda item for the organisation – the need to continue to broaden the scope of its membership by embracing all aspects of health technology, including devices, orphan drugs, biologics, genomics, and diagnostics.
By David Woods (firstname.lastname@example.org)
“An opportunity and a challenge”. That’s what Alan Bakst found when he became Director of Health Economics and Outcomes Research at TAP pharmaceuticals in Chicago in August 2004. Up until then, TAP didn’t have a stable and fully staffed group in health outcomes, so the opportunity came in building the group.
That, says Alan, meant hiring staff and educating TAP senior management and others about the precise role of health economics and its value in helping the product. The challenge came from integrating the group into the corporate culture which meant being a coach, a mentor, and a public relations presence for the often only vaguely-perceived science of health economics.
Before coming to TAP, Alan, trained as a clinical pharmacist, worked at Glaxo SmithKline for 10 years as an outcomes researcher and health economist. During that time he earned an MBA at Philadelphia’s Temple University, with a focus on marketing.
TAP has some 3500 employees and an ancestry that is both Japanese through Takeda and American through Abbott; its main products include Prevacid for gastroesophageal reflux disease, and Lupron, a drug for prostate cancer. The company has several products in late phase development, including a therapy for gout.
An additional aspect of Alan’s work is in setting up ISPOR’s first US regional chapter in Illinois – and serving as its inaugural president. The chapter’s primary goal, he says, is to bring local health outcomes researchers together to network and share their research. The organisation is in place and its first full meeting was held on 19 April at TAP.
Alan’s wife Karen is a hospital pharmacist and he has a daughter of 22 and a son of 20. When not promoting health economics and outcomes research, he enjoys golf and poker.
“I look forward to receiving HOC,” he says “ because it keeps me in the loop of current activities in the world of health outcomes and interesting techniques to keep in mind when communicating health economics information to others”.
Drs Lofland (pictured left) and Pizzi (below) are members of Jefferson Medical College’s Department of Health Policy where both are associate professors. They are co-authors of Economic evaluation in US healthcare: Principles and applications.
The health economics group at a major device manufacturer bought 100 copies of the book to disseminate within the company.
In fact, Jennifer and Laura agree that scientists don’t always understand health economics, in part because they want absolute, black-and-white answers. Health outcomes research is more of a social science, they contend, and is characterised by a lot of grey nuance. Hence, their book also serves to demystify the subject.
The pair believe that while health economics is still a relatively young discipline, broader issues in the current $1.8 trillion US healthcare system are providing the field with a higher profile and greater opportunities.
For instance, as federal and state governments increase spending on healthcare services, they’ll have to make hardnosed decisions about allocating resources; as employers face rapidly increasing healthcare costs, they want data on the costs and productivity impact of medical treatments.
In short, health economists will play a much larger role in decision-making at the highest levels… with presidential candidates of both parties wrestling with how best to streamline the US health system.
Even so, they acknowledge, in a market-based system of healthcare delivery there are political constraints engendered by competing and sometimes conflicting interests. In that sense, health economists may have to deal with politics. But there’s more consistency in how studies are designed, they believe. And we’re ripe for change, they say – a change that also expands the role of health economists into such research issues as the economic impact of such major public health issues as obesity and smoking.
One issue that bothers Jennifer and Laura is when academics are exploited for marketing and promotional purposes – for example, when companies in the pharmaceutical and biotech industries send nearly identical scientific abstracts to several conferences, or ask universities to issue press releases on findings that favour their product.
They contend that each contribution to the literature should be unique and published in a peer-reviewed scientific venue. They call on health economists working for the industry to exercise ‘etiquette’ when working with academics as this will ultimately foster credibility within the field.
As for HOC, the pair are big fans, particularly for the publication’s emphasis on the whole spectrum of communications; but they say they’d like to see more content listed in the subject line of emails… and catchier titles for articles (editor’s note: we’re working on both).
Madhus, as she prefers to be called, is a global outcomes fellow at a major pharmaceutical company. Responding to questions in the precise and mellifluous tone characteristic of those who grew up and were educated in India, she describes her work in outcomes research. It’s mainly in health service, she says, and disease related and product related.
What prompted her to get into this field? It was a conscious choice, she says. After completing her residency in internal medicine, she wanted to use her medical skills but to diversify into an area that, as a mother of one child and with another expected in February, she could combine professional with family life. She wanted what many young physicians are looking for – rewarding work plus a ‘lifestyle.’
What she enjoys most about her chosen field is the broad view she can take on health issues, the shift to different perspectives, and the opportunity to look at end results “not just the here and now.” She’s also intrigued by the intersection of policy and science and sociology. Is there a down side? Well, Madhus admits, “I’m not especially numerate; I have trouble with dense statistics and computer programs.”
Would she recommend her line of work to her children? Probably, she says, if that’s what they want to do. The important thing about any type of work, she believes, is to enjoy it. For her, exploring how to deliver optimum patient care is especially fulfilling.
Soon, she’ll be taking up a new challenge: moving to California with her husband, a researcher into Alzheimer’s disease.
Oh, and what about HOC? It’s concise and helpful, she says.
Most health economists, at some point in their careers, will be on one side or other of an interview. For interviewers, it helps to remember the sage words of Louis Pasteur: fortune favours the prepared mind.
In fact, the keys to a successful interview are preparation and relaxation: doing your homework ahead of time to prepare the questions, but being ready to let the interview offer the information in its own way.
Note: This article is based on the scientific writing and communications course offered at Thomas Jefferson University’s College of Graduate Studies (Philadelphia, PA, USA) taught by HOC editor David Woods, PhD, and from Jorgensen LB. Real-World Newsletters To Meet Your Unreal Demands. Alexandria, VA: EEI Press; 1999.