Tuesday, August 4, 2009

Health Innovators Series: Sam Nussbaum, MD on Health Innovation


Sam Nussbaum is a very familiar name through the health care industry as a thoughtful physician executive and clinical leader for more than 25 years. In an informal interview with the X PRIZE team, he shared his thoughts on health care innovation.

Can you share some of your background with us and your current role?

I am currently serving as executive vice president and chief medical office of WellPoint responsible for our clinical health policy. In this capacity I oversee corporate medical policy, clinical pharmacy programs, health improvement and quality resources, including several programs in clinical excellence and health information technology designed to optimize care for our nearly 35 million members. I really have enjoyed the opportunty to serve as the companies chief spokesperson and policy advocate, particular during this intense time of serious health reform efforts.

I started my career as endocrinologist at Mass General after completing my residency there and my internship at Stanford. I ended up getting involved in some clinical and basic science research that ultimately led to some new therapies to treat skeletal disorders and to measure hormones in blood. Later on, I served as President of the Medical Group and well as executive vice president of Medical Affairs and System Integration for the BJC Health System. I have also enjoyed my association with several national committees, including NQF and AHIP. I have met some wonderful people along the way and hope that our collective efforts have and will continue to make a difference.


From your perspective, what elements of delivering care have the most potential for dramatic improvement (e.g., access, coverage, transparency)?


I have always been concerned that we define “health” too narrowly. As you know, actual health care is only 30% of the determinant of overall health. Things like education (schools), environment (air quality), and what resources are available in the community often have a far bigger impact. I also think we begin to think about health care way too late - when bad habits and worse behaviors have been culturally imprinted on our children. We need to get our children productive and engaged at a much earlier age when attempting to create a “culture of health.” This all leads to a general feeling that we are far too behind the health care - we need to get way out in front with prevention, wellness, early education, health promotion, and incenting individuals to optimize and maintain their health. Contrast that image with our current one of Medicaid wherein their is no incentive, no coordination, and most care is delivered in the hospital or emergency department setting.


We have know about wellness and prevention for a while - what are the drivers that prevent us from moving more toward this model?

Our current health finance and payment system rewards for doing things to sick people in acute settings. It is also highly physician-centric, and we as a society have not held our physicians accountable enough for the care they provide. The variations in costs, quality, and outcomes is totally unwarranted and should be completely unacceptable. Again, I think the way to most effectively tackle this is to begin to pay for the things and the type of system we want. There must be a large restructuring of the payment system in order to create the type of incentives that will lead to the change sought after in the X PRIZE.


How should the concept of a Healthcare X PRIZE be used as a catalyst in the reform conversations?

Well, I think anything that emerges out of the X PRIZE should accomplish three objectives - produce a healthier nation, lower the burden from chronic disease, and reduce the overall costs. In terms of the innovation that we hope to see out of the competition would be a platform to truly and effectively deliver personalized medicine. We continue to maintain a vision of the individual patient having personalized health information, individual health optimization plans, and trusted care teams providing high quality, evidence based, personalized care in a time, place, and manner that is desired by the patient. I believe the tools and technology to do this is just around the corner. Many of the preliminary or early concepts I have heard about deal with this notion of delivering care that is much more personalized.


Where do you see the major opportunities for reducing costs while improving outcomes?

We have certainly heard a lot about comparative effectiveness over the last several months. When you realize that 35% of all services that are offered have no evidence have any clinical effectiveness you can see that there is dramatic room for improvement. The challenge we have had traditionally had limited insight into knowing which of the services fall into that 35% bucket. We must develop a methodology to systematically assess the value of the various treatments and disseminate that information widely. Even preliminary information about effectiveness is better than no information at all.

You should also realize that someones inefficiency and waste is someone else’s revenue. We have this massive investment in the current infrastructure and the current players will not cut into their revenue streams as a way to contribute to the public good. We have to find ways to incent and reward them for doing this. We know from the work of Dartmouth and others that we have a huge over supply problem, and that when there is oversupply we have more services which can lead to worse outcomes. However, who is talking to physicians and hospitals about working together to reduce capacity? Who is working on the contracting mechanisms that would allow this to even happen? I don’t think it exists yet.

Even efforts to leverage new types of providers or deliver systems have been uneven in terms of cost reduction. Look at the big experiment and the work around's for disease management. The results indicate that the doctor can’t outsource the management of her patients health - somewhere along the line - they need to take responsibility for their patients, and perhaps more importantly, the health outcomes of their “population” of patients.


Speaking of outcomes, what will the X PRIZE use as a measurement framework to actually judge the competition?

Well there are so many outcomes measures that are available it is actually quite hard to narrow down to a manageable set for a competition. Since the competition is focused on health value, and we are still getting a handle on which outcomes over which costs will be our health value measure, I think we need to carefully think through our selection process as it will guide the innovation stream that emerges from the competition.

I don’t think the focus should be on death or mortality. Death is the ultimate “outcome” and represents a composite of health but it tracks very slowly. Several other measures, many which we have experimented with in our own Member Health Index (MHI), can be obtained directly from claims data as well as some of the health data (labs, diagnostics, etc) that we have access to. We also clearly capture relevant cost information. However, even this data does not capture everything that can and should be captured as part of our health value measurement. I would love to see us include measures of patient experience, health risk factors, and some measures of functional status as well. Therefore, I believe we will ultimately need to develop a new composite measure that includes all these factors in a way that is reasonable, replicable, and will pass muster. We are actually hopeful that our measurement framework will be one of the most important innovations in the competition.


Who else should we be speaking to as we gather health industry information for the X PRIZE?

Well, I am fortunate to run in many of the policy circles that include both public and private health care leaders. I think any of these conversations should certainly be aligned with the ongoing efforts of DMS, AHRQ, and the CDC. Former Health Secretaries, like Donna Shalala and Michael Leavitt, could certainly add perspective about the harshe realities of trying to implement change within the health care industry. I also would be talking to groups like the NQF’s Janet Corrigan which has done an excellent job with their consensus building process and the IOM whose publications have changed our perspectives multiple times. May other private institutes, like Hoover or Brookings, also have alot of talented folks working on big projects. I also like the mavericks in the industry, like Paul O’Neil or Regina Herzlinger or Atul Guwande or Don Berwick, who have been relentless in various areas that are slowly moving us to a next generation health system. These are just a few who can add broad perspective to your research.
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