Planned Segments

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First Seminar: Background session on health disparities - First Seminar - Stage Set (R J Bulger)

As a prelude to this first seminar on health disparities policy, I hope all participants and readers will envision our primary audience as those people who are already working in the field of disparities reduction, either through research or clinical work or community public health efforts. These are people who are not primarily policy wonks but rather find it important for them to gain some degree of policy sophistication so that they have a more realistic platform for appraisal of our situation and for advocacy for important changes or improvements. Thus our goal is to enlighten those who are reading our posts either through our insights or the questions we have raised. Participants can also be helpful if we can pass along through our posts, the best references or sources we have found most useful.

As an example at the outset here, I would offer my own impression that the journal Health Affairs is the monthly journal I would recommend to persons interested in following developments at the interface of health/health disparities policy, and health care. In the April 2010 issue, the focus was on Health IT, while the May 2010 issue concentrates on the reinvention of primary care with work force manipulations and innovative new team models for providing care for the expected expanding patient base. At the same time, professional medical and nursing journals (especially those with wide public exposure like the New England Journal of Medicine and the Journal of the American Medical Association) are providing fewer, but nonetheless excellent health policy articles which sometimes shape or reflect important movement.

I am old enough to remember quietly celebrating when Dr. Julius Richmond, President Carter’s choice for US Surgeon General, initiated the Healthy People Program, through which specific goals for improvement of our population’s health status were established and data was collected and made available for all to see concerning our progress toward our national health goals. Through the years, this data-driven instrument has become more and more useful, refined and precise. We, in 2010 are able to look back at the third decade of these public records and will have a fresh look at our nation’s progress towards the elimination of health disparities.

In the May 6, 2010 issue of the NEJM, the lead article is by MH Koh, Assistant Secretary for Health, US Department of Health and Human Services. Dr. Koh concisely presents the history of the Healthy People Program, summarizes the results of the last decade and prefigures the official plan or vision for the year 2020. Dr. Koh says, "As part of Healthy People 2010, ten leading health indicators were selected with input from the Institute of Medicine as high-priority areas for motivating societal action. These indicators provide both a concise summary of major, preventable health threats and a gateway into the broader framework; preliminary data show progress for about half of the indicator objectives.”

Dr. Koh gives, as an example of a significant gain in the fight against health disparities, the progress in immunization rates for infants 19 to 35 months of age, up from 72.8% in 1998 to 80.6% in 2006, with great progress in shrinking racial and ethnic differences. As examples from the down-side, we have lost ground in weight control and diabetes, both in the population as a whole and within virtually all racial groups.

The ten leading health indicators for Healthy People 2010, are: Physical activity; Tobacco use; Responsible sexual behavior; Injury and Violence; Immunization; Overweight and obesity; Substance abuse; Mental health; Environmental quality; Access to health care. (As an aside, it gave me great pleasure, having served as the chair of that IOM committee which recommended the list of Leading Indicators, to realize that the effort did not go in vain and that it is possible for people to come together to produce work that in turn influences public policy and seems to still be of some continuing value.)

The two overarching goals of the 2010 program were to increase the quality and years of life and to reduce disparities: the first was achieved; the second wasn’t. Of interest in Dr. Koh’s paper was his presenting some hints about the 2020 plan which will be presented in six months or so. Dr. Koh says, “It reaffirms the two overarching goals from the past decade but adds two more: promoting quality of life, healthy development, and healthy behaviors across life stages; and creating social and physical environments that promote good health.” This means that there will need to be a stretch beyond traditional health sectors to achieve these broader social goals for health, issues sure to spark important debate.

At this initial seminar, I am pleased to identify three very important books exploring the breadth and depth of health disparities, whose authors have been invited to comment early if they would in this seminar and of course as they are moved to in subsequent seminars. They are as follows: David Satcher MD, PhD and Rubens Pamies MD, Multicultural Medicine and Health Disparities, McGraw Hill, 2006; Brian Smedley, Adreinne Stith and Alan R. Nelson, Unequal Treatment – Confronting racial and ethnic disparities in healthcare, Institute of Medicine/National Academies Press, 2003; Richard Allen Williams, MD, Eliminating Healthcare Disparities –beyond the IOM Report, Humana Press, 2007.

For the next seven days, the seminar is open for anyone who has registered to add their comments, references and insights, all of which will be archived (saved) at the end of the week.

2)   Second Seminar: Health Care in the American Grain - Second Seminar – Stage Set (R J Bulger)

It does no one any good if we plunge straight into the details of the complexities of health care and health status in America without considering early on the special American values that we want to undergird the health promotion, disease prevention, and health care enterprises in our society. In this seminar, we ask our participants to give us their views of those value elements in “the American grain”, which they consider to be foundational to our culture; and, to consider how we can assess, on a continuing basis, how well or poorly we are living up to those values.

To illustrate the point of how differences in even closely allied value systems can affect people and stakeholders, let me describe the first Trilateral Conference on health and health care, health professions' education, and health sciences research. Groups of leaders in health affairs from each of the three countries (USA, UK, Canada) met in 1990, in California for most of a week, to discuss the goals, the strategies, the merits and demerits of each of the three nations' health care enterprises. We met each day in our individual national groups and together in plenary sessions, to share our ideas on various aspects of our health care efforts.
It is fair to say that each of the national delegations believed that their own system was the best of the three, even after having shared detailed criticisms of their strengths and weaknesses. It was hard not to conclude that national health care practices are very much conditioned by national values and characteristics often not supported by the available effectiveness data. At one point, one of our Canadien colleagues pointed out that whereas Americans in
general rallied behind the clarion call of "life, liberty, and the pursuit of happiness", Canadiens tended to follow the banner of "peace, security and good government". He was pointing out that these differing societal values led each nation in different directions as they organized their health care systems.Although most of the rest of us could agree with the main point he was making, I have never been satisfied that "life, liberty and the pursuit of happiness" did full justice to the goals and values of American health care.
It seems important that we attempt to gather some ideas and recommendations from our participating commentators re those values that can be said to comprise "the American Grain" when it comes to health care.

To add some specifics to the discussion of these issues and to get the ball rolling, let me offer some of my own opinions. For me, the foundational American values by which we should gauge the success of our health care enterprise are as follows: hope, mercy, justice and autonomy. Whether we wish to consider Medicare, Medicaid, the Veterans Administration Health System, a University System or Hospital, the Mayo Clinic, specialty or primary care group practice, or our own physicians' and dentists' practices, I believe each could and should be assessed ultimately against these four values.
That is my opinion - now let's hear from others as we try to identify more accurately the basic values of America's health care enterprise. Among the many books dealing with these specific values in health are the following: Compassion's Way, by Ralph Crawshaw,Medi-Ed Press,2002; The Anatomy of Hope,by Jerome Groopman, Random House, 2004; The Practice of Autonomy - Patients, Doctors, and Medical Decisions, by Carl Schneider, Oxford University Press, 1998; Physician Philosopher - the best essays by Edmund Pellegrino,edited by R.J.Bulger and John McGovern, Carden Jennings,2004;and a recent biography of "the Honorable Paul Rogers, A Portrait of Leadership and a
Fighter for Health" (and strong advocate for his view that "Without research, there is no Hope"),.by RJ Bulger, Carden-Jennings,2005

Commentators (invited) John Porter, Mary Woolley, Louis Sullivan, Ciro Sumaya, Mario Rojas,and Cornelius Hopper.

3)   Third Seminar: Specific Health Care Disparities- Stage Set

To go from the sublime and philosophical to some significant specifics, we now ask our experts to speak to some tangible big ticket items, both in terms of successes and regressions in Cancer, Maternal and Infant Care, Diabetes and Nutrition, and Hypertension and Heart Disease. We hope our expert posts will provide pertinent references as well as examples of successes and failures over the past decade that point to relevant policy interventions for the next decade.

Commentators (invited) are Dr. John Geyman (author of “The Cancer Generation”, Common Courage Press, 2009), Dr. Henry Foster, Dr. Con Hopper, Dr. Arthur Herbst, Dr. Ciro Sumaya, Dr Roz Scott,Dr. Rodgers NIDDK, Dr Richard Williams. 

4)   Fourth Seminar: Cultural Sensitivity and social/economic factors- Fourth Seminar –Stage Set

We have asked experts to comment on the evidence that supports the significance of this area of concern to the overall impact of health disparities on our population’s health status. Put another way, if we were to eliminate all of the health-reducing economic and culturally connected forces, how much would that alter measures of health status for the entire population, eg average life expectancy, incidence of diabetes, incidence of preventable diseases etc etc? Once again, we want to know our commentators’ views on what seems to be working, what interventions aren’t, and what future policy modifications might be useful in our collective efforts to reduce disparities.

Commentators (invited) Joseph Betancourt, Tom LaViest,  Ciro Sumaya, T K Li, Dennis Andrulis, Afaf Meleis, Con Hopper, Brian Smedley.  

Fifth Seminar: Health Care Reform-stage set (Roger bulger), commentaries by  health prof educators re workforce - Fifth Seminar – Stage Set (R J Bulger)

Many people believe that the current health reform legislation is unlikely to be the last stop on this wild societal ride. In four years, it is anticipated that 30 million currently uninsured Americans will have health insurance coverage, and  for the first time, an American President can claim that this legislation’s passage into law establishes that all Americans have a right to health insurance.
 

In this seminar, we ask our experts what else this law has provided with regard to health care disparities’ reduction and our foundational values. Many amendments are still making there way into our collective consciousness, eg the elevation of the National Center for Minority Health and Health Disparities to a full-fledged Institute of the NIH (NIMHD). We also want to discuss the impact of these expansions of coverage on the adequacy of the health workforce.
Four very important and/or useful recent articles recommended to everyone are as follows: S. Rosenbaum, A "Customary and Necessary" Program-Medicaid and Health Care Reform, NEJM 2010;362:1952-1955; B. C. Vladek, Fixing Medicare's Physician Payment System, NEJM 2010:362:1955-1957;Adashi,Geiger, and Fine, NEJM 2010;362: 2047-2049: J. Gruber, The Cost Implications of Health Care Reform, NEJM 2010;362:2050-2051.

Commentators (invited) are Ralph Neas, Walter Unger, Ronnie Lancaster, Fitzhugh Mullan, Don Fisher, Colleen Conway Welch, Jean Sinkford, Claudia Baquet, William Straub. 

6)   Sixth Seminar: Health Care Reform-IT, digitalization, and new technologies-Sixth Seminar – Stage Set

According to some American Historians, (see Daniel Boorstin, “The Republic of Technology”), our ideals/ideas are less important to our ways of living and our freedom from tyranny than are our new, transformative technologies, most of which were largely unforeseen and un-anticipated. We have already seen TV adverts showing a doctor seeing patients with a hand-held ultra-sound machine in her hand. In this seminar, we ask participants to forecast the heretofore un-forecast-able and give us a glimpse or hints about the technologic benefits to come and to think with us how to influence those changes such that they can be effective in reducing disparities, rather than exacerbating them.

Commentators (invited) Don Detmer, Ted Shortliffe, Don Lindberg, William Stead, Robert Galvin.

7)   Seventh Seminar: Health Care Reform-new diagnostic and therapeutic agents - Stage Set - (R J Bulger)

This seminar extends the focus of the Sixth Seminar to proteomics, pharmaco-genetics, tailor-made and individualized pharmaco therapeutics, advanced vaccines and immunity boosting agents, and nanotechnology; and it presents the same challenges as confronted the last seminar, including especially how to develop policies to encourage innovations that reduce disparities.
Along this line, it is useful to remember the wise counsel of Congressman George Brown, who before his death several years ago, persistently and prophetically reminded policy makers concerned with biomedical research, that research and development investments tended to be driven in our country by innovations that could be sold to people who could pay for them. That means he said that our vaunted progress into the future will be tilted towards the better off of society's segments. To the extent that health disparities are more frequently present in the lower socio-economic groups, we should expect that expanding the accessibility to these populations of health insurance should encourage greater research and development addressing their health disparities. We have seen examples of this in vaccine development over the past decade, in AIDS-related research, in certain preventive and public health areas, and in more effective and efficient devices for diagnosis, such as the portable ultrasound referred to in the Sixth Seminar above. This all implies that we should keep our health disparities policy eyes open to the level of R/D investment in efforts to reduce disparities and their overall burden on our poplulation's health.
Two important recent articles are: Feero, Guttmacher, and Collins, Genomic Medicine-An Updated Primer.NEJM 2010; 362:2001-2011, H. Varmus, Ten Years On-The Human Genome and Medicine, NEJM 2010;362:2028-2009.

Commentators (invited) are Francis Collins, Julie Gerberding,Lawrence Grouse, Arthur Ulene, Francis Cigeurroa, and T K Li.

8)   Eighth Seminar: Multiculturalism, Integrated and Complementary Care - Eighth Seminar – Stage Set (R J Bulger)


Instead of defining health care in terms of  scientifically validated  interventions from outside of the patient, modern neurosciences research has brought legitimacy to the individual pharmaceutical stores we all carry within our brains and elsewhere in our bodies. The value of the placebo effect and the healing contributions of the environment upon patients as well as the significance of earned trust among patients and caregivers, are among some of the game-changing advances affecting our health care. Multiculturalism clearly affects how therapists can/should implement complementary medical interventions with patients of various cultural backgrounds. Our challenges in this seminar to our discussants are to enlighten us concerning what is known about this important area and to suggest future policy implications for care and research with an eye towards reducing health disparities. (A book which may interest some bloggers is by Charles Taylor and Amy Gutman,"Multiculturalism and the Politics of Recognition", Princeton U. Press, 1992.)

Commentators (invited) are Brian Berman, Esther Sternberg, Herbert Benson, Joseph August, and T K Li.

9)   Ninth Seminar: Health Care is a Team Game  and New models for care – stage set (invited) John Ruffin and the NIMHD Centers of Excellence

Over the past few decades, Kaiser-Permanente and the HMO movement have illustrated the economic and preventive advances possible in coordinating primary and specialty care. The Mayo and Cleveland Clinics among others and several of the leading academics and university hospital centers have done good work in providing innovative teams of professionals to manage the most complex cases. The Veterans Administration turned what was an unfortunate safety record, into the safest of hospital systems, by management reforms and the introduction of high tech safety devices like the bar-coding of patients, nurses and therapeutic agents, to essentially eliminate a whole genre of serious hospital errors. Community health centers, established decades ago as a result of the legislative foresight of the Honorable Paul G. Rogers (D. Fla.), has evolved into a major association of primary care (rural and urban) centers offering care to under-served populations; but they still suffer from a dearth of effective and financially viable connections to specialty services. We could go on and on about team-building successes, public and private.

In this seminar, however, we seek insights and suggestions for the future about promising new models of care, which might offer promise in reducing disparities by enhancements of existing infrastructure, currently manifestly insufficient to meet the task of caring for fifty million or more people currently without coverage. We ask our commentators, as usual. for references and data as well as recommendations for future policy modifications.

Commentators (invited) are John Ruffin and selected NIMHD Centers of Excellence Directors; Tom Van Coverden (NACHC)

10  Tenth Seminar: The Interface between American and Global Health – stage set  (R J Bulger)

Much has been done globally by Americans over the past fifty years and in this seminar, we hope to tap the insights of some of those most prominent players on the global health scene. They will be able to tell us something of what they have done, what has been learned from those efforts that can be useful to  efforts to reduce disparities here at home. We are especially interested in whether they think it is a good idea for IAMMM’s Martin Luther King, jr. Center for Health Equity to initiate, in 2011, an annual national public meeting to assess the current trends and status of America’s struggle to reduce health disparities. For each of our discussants, whether involved in direct care-giving or in joint research efforts, partnerships have been at the core of their successes.

Commentators (invited) are Roy Wilson, John Howe, Jim Smith, Maria Sjogren, and Ruth Bulger