Welcome to the Think About This portion of the forum. In this section, HSC presents a series of articles and commentary on current issues and topics within the realm of Clinical Research and Health Policy.
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Within this page, you will find our current feature plus an introduction to each past column, followed by a link to read the full version. We hope that our efforts in the Think About This section will always help advance the quality of contemporary discourse and provide you with a reason to reach out and offer your valued feedback.
Diabetes, Accountable Care Organizations, and Preventive Health Care
This commentary has been sponsored by Dr. Russell M. Jaffe, Senior Fellow and Founder of HSC. Dr. Jaffe has spent the last 21 years working to further the concept of Preventive Healthcare. He has committed his life work to developing solutions, technology and products that directly impact the prevention of chronic disease and evoke healthy outcomes. Jaffe has continuously stressed the need for prevention as a tool for cost containment and has published and spoken widely in this regard. The following commentary looks at Diabetes and at the newly formed Accountable Care Organizations and how they can impact the escalation of chronic disease and in particular diabetes.
Fifty percent of Americans do not receive the age-appropriate preventive care and screening tests recommended and the U.S. health system does not produce results commensurate with the vast expenditures according to the 2011 Commonwealth Fund National Scorecard on U.S. Health System Performance. Click here to read this report.
Background of the Affordable Care Act
On March 23, 2010, President Obama signed the Affordable Care Act (ACA). The law puts in place comprehensive healthcare reforms that will roll out over four years and beyond, with most changes taking place by 2014. Under the ACA, and with the formation of Accountable Care Organizations, many insurers are required to cover certain preventive services. Beginning as early as August 2012, this list will expand.
As part of this process, the U.S. Department of Health and Human Services (HHS) on March 31, 2011 announced "proposed new rules to help doctors, hospitals, and other health care providers better coordinate care for Medicare patients through Accountable Care Organizations (ACOs). ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities. The Medicare Shared Savings Program will reward ACOs that lower health care costs while meeting performance standards on quality of care and putting patients first." Click here to read the full press release.
The ACA, in particular, has provided relief to many who suffer from chronic illnesses, and is specifically beneficial to those with diabetes. In the past, having no affordable access to care led many people to forgo the care they needed to prevent, delay or slow the progression of diabetes. With improved medical coverage and benefits, coverage for children and young adults, the ACA has and will continue to make positive impact in the lives of many Americans.
The long-awaited Interim Final ACA Rule (the "Final Rule") on the Medicare Shared Savings Program (MSSP) and ACOs was displayed by the Center for Medicare and Medicaid Services (CMS) on October 20, 2011, and published in the Federal Register on November 2, 2011 and became effective on January 3, 2012. This Final Rule ultimately allowed the designation of 32 pioneer ACOs adding to the extensive menu of options offered through the ACA to provide better health, better care and lower costs not only for Medicare beneficiaries, but for all Americans.
The Pioneer ACO Model is a Center for Medicare and Medicaid Services (CMS) Innovation Center initiative designed to test the impact of several innovative programs. The Pioneer ACO Model was developed specifically for organizations with experience offering coordinated, patient-centered care. These organizations were selected through an open and competitive process from a large applicant pool that included many qualified organizations. They were chosen for their significant experience offering this type of quality care to their patients. For more details on the Pioneer ACO Model participants, click here to read the HHS press release.
Experts Weigh in on ACOs
Can ACOs improve health care while reducing costs? On January 23, 2012, the Wall Street Journal published an article interviewing a group of health care policy experts. They discussed whether ACOs are an answer to problems of America's current health care system. The experts include: Donald M. Berwick, most recent former administrator of the Centers for Medicare and Medicaid Services, who oversaw the development of the CMS rules around ACOs; Tom Scully, former Center for Medicare and Medicaid Services administrator from 2001 to 2004; and Jeff Goldsmith, associate professor of public-health sciences at the University of Virginia, in Charlottesville.
The article allows the experts to discuss and debate the anticipated and potential effectiveness of ACOs in delivering better quality of care and better cost management. Berwick states the "[ACO] will work because it is set up to reward the right combination of goals for our time: transparency, coordination, consumer power and intolerance of waste." Goldsmith expresses his concerns about ACOs inability to successfully deliver savings on a wide scale. His opinion is that while the ACA represents a number of good ideas for saving money and improving quality, the ACO falls short. Scully, while generally supportive of the ACO concept, expresses concerns over organizational implementation and costs: "If the doctors had the capital to organize comprehensive ACOs to control their own fate and drive us to more efficient care, I would be bullish on ACOs." To read the complete article, click here.
What does this mean to Preventive Care Advocates
HSC strongly believes that the ACOs created by the Accountable Care Act have a notable opportunity to change the face of healthcare by searching out and adopting preventive healthcare solutions. The evidence based technologies and products available to ACOs can and will directly impact the cost of health care and the management of chronic disease. One such chronic disease, diabetes, is the focal point of this commentary.
Facts that bear repeating: According to the World Health Organization, over 364 million people worldwide suffer from the disease; The 2011 CDC National Diabetes Fact Sheet reports that nearly 26 million Americans have diabetes, and 1 in 3 could have diabetes by 2050. Diabetes costs $174 billion annually and affects 8.3 percent of Americans of all ages: Seven million Americans do not know they have the disease.
According to the American Diabetes Association, every 17 seconds, someone is diagnosed with diabetes. If left uncontrolled, it can lead to serious complications including heart attack, stroke, kidney disease, blindness, amputation and even death. Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced.
The three main types of diabetes are:
Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin.
(Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.)
Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes
combined with an absolute insulin deficiency. (Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM
for short, and adult-onset diabetes.)
Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level
during pregnancy. It may precede development of type 2 DM.
Diabetes Can be Contained: Can it be that Simple?
More than 90-percent of new diabetes cases diagnosed are of type 2. The CDC is working on the National Diabetes Prevention Program, as stated in the ACA. This program is based on the NIH-led Diabetes Prevention Program research study. By establishing local evidence-based lifestyle change programs, it is aimed at helping people reduce their risk for developing type 2 diabetes.
Well-known risk factors for type 2 diabetes include older age, obesity, family history of diabetes, prior history of gestational diabetes, impaired glucose tolerance, physical inactivity, and race/ethnicity. Prediabetes is a condition defined as having impaired fasting glucose, impaired glucose tolerance, or both. As the National Glycosylated Standardization Program committee reports, research is ongoing to ascertain the best use of laboratory blood tests to detect people who may have prediabetes and to improve the understanding of who has prediabetes.
As to the prevention of and/or delay of diabetes onset, research studies have found that moderate weight loss and exercise can prevent or delay type 2 diabetes among adults at high-risk of diabetes. More discussion of the role of diet and activity in prevention is presented by the CDC and can be viewed by visiting their Eat Right and Be Active pages.
On a daily basis, a number of writers, associations and research foundations address and publish on the topic of diabetes and HSC is pleased to share a selection written by Senior Fellow Dr. Russell M. Jaffe. Please click on the title to open the article.
Diabetes: Food and Nutrients in Primary Practice
Chapter excerpt from Ingrid Kohlstadt's book Food and Nutrients in Disease Management
Tolerance Loss in Diabetics: Association with Foreign Antigen Exposure
Letter published in the journal compilation of Diabetic Medicine
Underlying Issues in Diabetes
An integrative management approach to nutrition and diabetes.
In terms of innovative approaches to reduction or elimination of diabetes, at the Albert Einstein College of Medicine in New York, research by Meredith Hawkins, MD, and Preeti Kishore, MB, BS, is investigating the role vitamin D plays in diabetes. Past research has linked low levels of vitamin D to insulin resistance. Based on Hawkins and Kishore’s recent research presented in the December issue of Diabetes Forecast, the investigators have found that giving patients with insulin resistance high levels of vitamin D can be beneficial. Vitamin D may be a powerful tool in preventing type 2 diabetes before it starts.
At the research “FIND A CURE" level, HSC is pleased to share the news of a $5 Million award granted to Joslin Diabetes Center by the Massachusetts Life Services Center: This grant and matching funds raised by Joslin will be used to develop an innovative translational center for the cure of diabetes. This grant represents the largest ever provided for Diabetes Research in Massachusetts. According to Massachusetts Secretary of Housing and Economic Development Greg Bialecki, the new center will advance scientific knowledge regarding diabetes prevention and treatment. Click here to read the full announcement.
ACOs have a major challenge before them. Simple solutions based on evidence based practices exist but are often dwarfed by the efforts to fund the major research institutes searching for a cure. HSC believes that chronic disease management can be a containable cost if ACOs lead the way in establishing strong preventive care programs.
Focusing on Geographic Hot Spots
Despite advances in prevention, diagnosis, and treatment, diabetes and cardiometabolic disease have risen to epidemic proportions, particularly in the southeastern part of the United States. While challenging, it is a disease that can be prevented and effectively managed. A Comprehensive Diabetes Center known for groundbreaking research in immunity and autoimmunity, will investigate the biological mechanisms that cause diabetes, and offer new treatments.
For example, Alabama has one of the highest rates of diabetes in the nation. The National Institutes of Health (NIH) has designated the University of Alabama at Birmingham (UAB) one of only six Diabetes Research and Training Centers in the country, putting UAB at the forefront in the development of new methods to treat, prevent and, ultimately, cure diabetes and its complications. The NIH award gives UAB $6.3 million over five years to grow its diabetes initiatives. Working closely with the Multidisciplinary Comprehensive Diabetes Clinic is the Diabetes and Endocrine Clinical Research Unit (DECRU), the clinical research arm of the Comprehensive Diabetes Center. The goal of the DECRU is to match patients with specific clinical trials and develop a database to benefit epidemiological, outcome, and other patient-oriented studies.
There is a simple premise to Preventive Care that if you stop the disease before it begins, it will not become a treatable disease. The work of HSC is dedicated to finding evidence based solutions, technologies and products that work in concert to evoke human health. It is our sincere hope that ACOs will look to prevention as the cornerstone of their long term efforts to curb the cost of healthcare and, in so doing, effectively serve the lives of those in their care.
HSC recommends a selection of resources for those inclined to review additional material. The aforementioned National Diabetes Education Program (NDEP) which is a joint effort of the CDC with the National Institutes of Health (NIH), provides a variety of continuing education and multimedia material. Along with the NDEP Fact Sheet found here, one can visit the NDEP video library by clicking here. Established in 1940, the American Diabetes Association hosts a research foundation whose work can be found here. Another comprehensive resource, the Diabetes Research Wellness Foundation is an organization that awards research and educational grants to enhance the study and care of diabetes and its related health complications.
Of a number of timely reports, the 2011 National Diabetes Fact Sheet published by the CDC is recommended. The NIH-sponsored National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) has released the second edition of a tome entitled Diabetes in America which is designed to serve as a reliable scientific resource for assessing the scope and impact of diabetes and its complications, determining health policy and priorities in diabetes, and identifying areas of need in research. Access to individual chapters can be found here. The website for the National Center for Complementary and Alternative Medicine (NCCAM), also part of the NIH, features a fact sheet entitled Diabetes and CAM: A Focus on Dietary Supplements which can be found here. Under its Evidence-based Practice Program, the Agency for Healthcare Research and Quality (AHRQ) hosts relevant research including a paper Effects of Omega-3 Fatty Acids on Lipids: Glycemic Control in Type II Diabetes and the Metabolic Syndrome which can be found here. Finally, the report published in July 2011 entitled "F" as in Fat: How Obesity Threatens America's Future by the Trust for America’s Health with Robert Wood Johnson Foundation investigates the correllation between obesity, diabetes, and heart disease and the impact on American productivity. Click here to read this report.
In response to greater public interest and involvement in the science behind health headlines, the University of California, San Francisco created a series of educational seminars referred to as Mini Medical School for the public. In a seminar investigating obesity and diabetes, Dr. Robert Baron, UCSF Professor of Medicine and Director of the UCSF Weight Management Program, integrates his interests of primary care internal medicine, nutrition and obesity. Click here to watch Dr. Baron's video presentation entitled Obesity and Diabetes: Twin Epidemics of the 21st Century.
A small sample of international resources include World Health Organization who feature a robust media center found here. The International Diabetes Federation (IDF) is a non-governmental organization whose mission is to work to enhance the lives of people with diabetes throughout the world. The World Diabetes Foundation is another well recognized and regarded source and the Diabetes Research Institute is said to lead the world in cure-focused research and have made significant contributions presently being used in diabetes centers around the world.
The UK-based 3FOUR50 is an example of an organization that focuses on chronic disease prevention and control. Its name represents the key message: Three risk factors - tobacco use, poor diet and lack of physical activity - which contribute to four chronic diseases - heart disease, type 2 diabetes, lung disease and some cancers - which, in turn, contribute to more than 50-percent of preventable deaths in the world. 3FOUR50 proposes that a collaborative approach involving many different audiences is necessary in order to stem the global epidemic of chronic diseases. To that end, their goal is to help facilitate connections, conversations, and collaborations among experts, leaders, innovators - from a variety of sectors - and anyone genuinely concerned with chronic disease prevention and control.
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Focus on Autism and Autism Spectrum Disorders (ASD)
Health Studies Collegium looks at Autism in January and salutes those scientists who are working to find both cause and cure.
There are many ways to define the world of Autism. One thing that is evident is that it is a global problem and one that merits much attention. SCOPE, one of the largest non-profit organizations in Victoria, Australia defines it thusly:
Autism - A developmental disorder that is often diagnosed in early childhood and continues throughout adulthood. It affects
three main areas: communication, social interaction, and creative or imaginative play.
Autism Spectrum Disorders (ASD) - A broad term which includes autism, Asperger's syndrome and other closely related
developmental disorders. These are characterized by developmental difficulties in verbal and non verbal communication,
social interaction, and play activities.
The Center for Disease Control (CDC) weighs in by saying that ASDs are a group of developmental disabilities that can cause significant social, communication and behavioral challenges. According to the CDC, an average of 1 in 110 children have an autism spectrum disorder (ASD). This finding reflects data collected by CDC's Autism and Developmental Disabilities Monitoring (ADDM) Network in multiple communities throughout the U.S.
To read the complete article, please click here.
Reinventing Fire: Bold Business Solutions for the New Energy Era
HSC Senior Fellow Amory Lovins, Executive Director of the Rocky Mountain Institute, (RMI) has written a thought-provoking book and, yet again, has us thinking about sustainability.
According to Lovins' book, America's seemingly two-billion-dollar-a-day oil habit actually costs upwards of three times that much--six billion dollars a day, or one-sixth of GDP. This is primarily due to three kinds of hidden costs, each about a half-trillion dollars per year: the macro economic costs of oil dependence, the micro economic costs of oil-price volatility, and the military costs of forces whose primary mission is intervention in the Persian Gulf. Any costs to health, safety, environment, security of energy supply, world stability and peace, or national independence or reputation are extra.
To read the complete article, please click here.