Ready, Fire, Aim!
By Marianne Glass Duffy and Mary Wendehack
Last month, a group of experts in academic medicine, biomedical research, health policy, medical ethics, and corporate health benefits met at NIH to discuss how the changing dynamics of the health care environment may affect scientific innovation and the continued integration of scientific advances into health care.
The conference, titled "Managed Care: Crisis and Opportunity for Biomedical Research," was the first in a series of conferences on "Extending the Horizons of Health Care through Research" to be sponsored by the National Institute of Nursing Research and the nursing department at the Clinical Center.
During the morning session, which addressed "Managed Care and Scientific Innovation," Dr. Neil R. Powe of Johns Hopkins University School of Medicine described the results of the first national survey to determine how decisions about medical coverage are made by managed care organizations. Powe and his colleagues found that, for three different laser therapies, decisions to provide coverage were based most frequently on five factors. Three involved clinical considerations -- the treatment was medically acceptable, reasonable and necessary; it increased efficacy; and it decreased complications. One involved regulatory issues such as FDA approval. The last involved the therapy's ability to increase cost effectiveness. Decisions to withhold coverage were based on evidence of increased complications and decreased efficacy, the experimental nature of the therapy, the availability of alternative treatment, and the lack of cost effectiveness.
The survey showed that, in making decisions, individuals in the private sector are looking for national, authoritative sources of information -- consensus statements and practice guidelines and comprehensive evidence from meta-analyses and randomized controlled trials.
Dr. Dorothy Brooten from Case Western Reserve University discussed the impact of managed care on clinical research and the value of nursing research. She referred to a model of transitional care that reduces the length of hospital stays and the substitution of outpatient with inpatient care. The model includes comprehensive discharge planning, post-discharge home visits and telephone contact by advance practice nurses, and daily telephone availability. Quality was assessed in terms of patient and family outcomes and initial and ongoing costs. This model has been examined in many patient populations in different age groups with different medical problems. Extensive cross-cutting analyses have been conducted on all of the patient groups to look at patterns of rehospitalizations and acute care visits, type and frequency of patient concerns, and the amount of resources consumed.
Dr. Colleen Conway-Welch from Vanderbilt University described the benefits and challenges of an innovative managed care demonstration project, called TennCare, introduced in Tennessee in 1994. This program was extended to more than 1 million Tennessee residents, including those previously covered by Medicaid and others who had been uninsurable or underinsured. Two years later, only 5 percent of Tennesseeans do not have some kind of health insurance. Positive outcomes achieved by this program include a 42 percent reduction in emergency room visits and a high (and still growing) level of satisfaction among recipients of TennCare services. Negative outcomes tend to be of an administrative nature that can be solved with time and better planning.
One of the highlights of the morning session was an NIH panel discussion by representatives of four NIH institutes who shared their thoughts about the intersection of clinical research and managed care and described a number of activities undertaken by their institutes in this area.
In the afternoon, the focus of the conference shifted to the implications of private sector support for clinical research. Dr. Jeffrey Harris, a staff physician from Massachusetts General Hospital and an economist, discussed private sector incentives to finance clinical research. When no single firm can appropriate the gains from research exclusively to itself, the "free rider problem" arises -- every company could benefit from research that one company finances. Acknowledging beforehand potentially significant difficulties, Harris suggested that the solution may lie in novel arrangements between managed care organizations, academic medical centers, and the federal government and the realignment of intellectual property rights and private incentives in the conduct of clinical research. Following his presentation, Harris moderated a panel of corporate health benefit managers -- Barbara Brickmeier of IBM, Thomas Cragg of GM, and Charles Newman of GE Power Systems -- who offered valuable insights into how corporations view the interrelationship between quality health care and biomedical innovation.
Two additional presentations concluded the conference. In the first, Dr. Madison Powers from the Kennedy Institute of Ethics at Georgetown University discussed broad societal ethical questions posed by managed care and the tradeoffs between equity and innovation. Dr. David Blumenthal of Massachusetts General Hospital closed the conference with a discussion of the problems academic medical centers are facing in today's health care environment and the importance of these centers not only to the research mission of NIH but also to social missions valued by the public.
Earlier in the day, one of the speakers characterized the implementation of a state-wide managed care program as "ready, fire, aim." The program had been introduced before it was planned. This comment applies as well to the arrival of managed care on the national scene, the panel suggested. We are only now beginning to understand the complexities of the paradigm shift in health care and the long-range implications for science.
Up to Top