Last month, the National Heart, Lung, and Blood Institute (NHLBI) of the NIH awarded a “Grand Opportunity” 64 million dollar grant paid for by the Recovery Act (American Recovery and Reinvestment Act of 2009). This large investment is to “find genetic causes and contributors to phenotypes that typify heart attack, stroke, diabetes, obesity, hypertension, asthma, chronic pulmonary disease.” 

Stop right there.  Don’t we know a great deal about what causes heart attack, stroke, diabetes, obesity, hypertension, asthma, and COPD?  Have we maximized that knowledge through known, proven interventions? How, exactly, is genetic sequencing going to improve health? 

What if that $64 million of our taxpayer money went instead toward:

1. Decreasing smoking rates ($21.3 million)

2. Community-based exercise, nutrition, and health education groups ($21.3 million)

3. Improving medication adherence rates for patients who take generic statins and anti-hypertensives, including financial subsidization for patients unable to afford medicines ($21.3 million)

Improving the fidelity of known effective health interventions for heart and lung disease (and lowering known modifiable risk factors) results in predictable and significant decreases in morbidity and mortality. How will genomic sequencing that pinpoints risk factors for disease improve health?  Will new medications targeted to identified genomic groups cause dramatic improvement in health outcomes? Who will pay for the genomic sequencing of the general public?  Who will pay for the new patented gene-targeted medicines?

Who are the beneficiaries of this NIH recovery act money? Academic medical institutions and genomic sequencing tech companies benefit the most, an unfortunate and ironic use of the American Recovery and Reinvestment Act funds.

Along with a push for comparative effectiveness research, Americans should demand a health optimization analysis of all publicly-funded research to prevent our taxpayer money from continuing to fund research unlikely to improve population health.

Clearly, high-cost, fragmented healthcare does not make people healthier. What does? Having health insurance? Having access to brand-name pharmaceuticals?  The ability to choose or change doctors? Having access to a primary care doctor or a “medical home”? Amount of time spent with a doctor?

Wellness and health status may have little to do with healthcare.  Is health better reflected by other measures: a feeling of belonging, being valued and loved, contributing to a common good? Is health most directly correlated with fitness level, education, income? What public health interventions since 1990 have been shown to improve wellness?

Unlimited research paths to unite under one guiding theme: what is the best way to improve the slope on these 2 graphs?

Problem #1: a 14-year old’s comment on seeing these 2 graphs.  ”Well, it’s good for healthcare companies when people feel unhealthy.  They make money.”

Precisely.

Factor 1: Timeline

Academic or university-based research now has a project timeline of 3-6 years from inception of a project through the bureacracy of department approval, IRB review, then grant application and receipt, data analysis, production of manuscript, review of manuscript, then eventual publication and release of findings. This prolonged timeline ensures that findings will no longer be policy-relevant. The policy or political timeline is often on the order of days (!!), or at best one legislative cycle, which explains why academic research is typically trailing instead of informing policy. Informal guesses, back-of-napkin calculations, and stakeholder promotion push policy formation more than academic research.

Factor 2:  NIH Funding

Universities want their researchers to secure NIH funding, and as much of it as possible. NIH money dominates university ranking, funds infrastructure cost…and who can argue with a 51% indirect fee on every NIH dollar that the university is able to garner?  University-based researchers are encouraged (through promotion criteria) to pursue NIH/federal funding above other private sources, which typically allow for only a 10% indirect fee.  The problem is that NIH has no “health systems” or “health policy” institute (and in fact, no primary care institute), and AHRQ (and HRSA) have been woefully unable financially to provide sufficient funding to support health services research. So some health services researchers are stuck trying to mash their research to fit with an NIH institute (aging, kidney, cancer, etc.) or be marginalized within their institution.

Factor 3: Job Structure and Security

If health systems researchers are lucky enough to obtain federal (NIH or AHRQ) funding, their careers are put onto the hamster-wheel: complete enough of the grant objectives to satisfy requirements, then build a new grant application off of the findings to submit to the next funding rung up, and continue on. Job time structure is strictly controlled by funding: grants dictate a % of research time, and predictable clinical revenues demand a set schedule of clinic duties. Researchers tend to evolve into experts in one specific micro-silo of research, which becomes less and less understandable to the general public (and our legislators). The goal of the researcher may become furthering a research career and obtaining the next grant, rather than examining current policy issues, brainstorming new inquiry directions, and having the time to creatively collaborate with others.

Factor 4: Collaboration and Communication

Academic researchers are busy, often too busy to mentor or network. In the academic setting, channels of communication may be limited to other academicians. Collaboration with the business community, health industry, private citizens, and government is difficult. Communication of findings is focused on journal editors, and possibly a few reporters. There is little outreach to the general public, or solicitation of community input on priorities of health systems research. The new Clinical and Translational Science Awards attempt to engage the community but the structure is still based on university to community directionality.

Factor 5: Independence and Innovation

Academic medical centers have an agenda which is often dominated by maintaining and growing the funding status quo. Research that challenges current health system structures and funding streams is unlikely to be supported by the university. And unsanctioned communication of unconventional research findings–often a necessary step to spur innovation of ideas–is discouraged.

A New Path:

The Center for Researching Health Outcomes aims to produce policy-relevant research in the most timely manner possible, to solicit project funding from all sources (from individuals to the federal government), to generate projects through collaborative input from an extremely diverse group of contributors, to perform research in a transparent manner, to communicate results broadly (from social networking sites to traditional academic channels), and to emphasize the primacy of collaboration, innovation, research relevance, and non-traditional thinking.

“Never be afraid to try something new. Remember, amateurs built the ark; professionals built the Titanic.”

In collaboration with the Robert Graham Center in DC, and supported by generous funding by the AARP, this analysis of outpatient Medicare claims will examine the proportion of physicians (focusing on primary care physicians) with benchmark numbers of new Medicare patient visits from 1996-2006.  Subsequent analyses will report state-by-state patterns and identify physician-level predictors of greater numbers of new Medicare patient visits.