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| Dr. Mark Smith |
CHCF is an independent philanthropy headquartered in Oakland, Calif. dedicated to improving the health of Californians with special concern for the underserved.
Q: In a blog post for JAMA Forum earlier this year, you argue that, regardless of the Supreme Court decision or the results of the upcoming presidential election, health reform is already happening, and will continue. Explain to our audience, briefly, what you mean by this?
A: While the outcome of the presidential and congressional elections matters a great deal in some areas of healthcare policy, there are number of big trends in the delivery system that are a result of forces that are independent of these elections. In particular, cost pressures on every sector of healthcare will only intensify, no matter what the outcome of the election. Consolidation (of hospitals with each other, hospitals with physicians, and physician groups with each other) will continue. Novel arrangements between payers and provider systems aimed at reducing spend will persist; and consumers, spurred, in part, by growing out-of-pocket responsibilities, will become more and more price sensitive and more demanding of convenient customer service attributes which they have come to expect from other aspects of their lives.
Q: The ACA gave rise to a lot of talk about cost containment. How big of a role do you suppose personalized medicine will play in driving down costs?
A: Too soon to tell. I can certainly imagine circumstances in which the ability to accurately predict an individual patient's response to an expensive medicine, say chemotherapy or biologic anti-inflammatory, may reduce expenditures on ineffective medicine, despite the expense of the initial test. But I can also see circumstances in which breathtakingly expensive personalized approaches provide only marginal increases of effectiveness with dramatic increases in costs. The good news (from the perspective of cost control) is that I think the approval and reimbursement environment of the future will be more on evidence and less on marketing.
Q: We stand at a time when policy often lags the pace of scientific advance. Genetic sequencing and biomarkers are examples. How do we keep the two in unison?
A: We can't. No matter how much we'd like to do so, the policy environment will never be as dynamic, nimble, or unpredictable as the breakthroughs in biomedical science. So, the question is not so much how we keep them in unison as how we can keep the policy environment from getting decades behind the science, as it is in many areas now. It will require new approaches to conditional approval, post-approval surveillance, collaborative funding of trials, etc. The most hopeful development is the progress of digitized medical records, computing power, and rapid learning systems which can compress the time needed for thoughtful collection, review and analysis of clinical data and, in some instances, replace traditional clinical trials.
Q: If you could change a single healthcare policy, at the state or federal level, what would it be and why?
A: Begin to develop a single national policy with regard to scope of practice, so that improvements and advances in the productivity and capacities of healthcare workers and patients themselves would not have to be battled out board by board, state by state.
Q: What are you most looking forward to in anticipation of CHI 2012?
A: The election will be over, some uncertainty will be reduced, and we can look forward to how to work together to strengthen the healthcare system while making it more affordable.
CHI-Advancing California biomedical research and innovation
