Health Care Reform and Translational Medicine

Abstract

In March 2010, the Congress of the United States passed the Health Care Reform Act and the accompanying Reconciliation Act and the President signed them into law. The most significant social and fiscal legislation since the passage of civil rights legislation and the creation of Medicare during the Johnson administration, the health care reform legislation will decrease the large burden of uninsured by approximately 35 million and abrogate the ability of private insurance companies to refuse insurance because of preexisting conditions or rescind an individual's insurance after the development of a new medical problem. It is likely that health care experts, political pundits, and the lay public will debate the merits of health care reform over the next decade: will individual states be able to efficiently manage health insurance exchanges; will reform increase or decrease the federal deficit; will patients who don't receive their health care insurance from their employers buy insurance or will they find it more cost effective to simply pay a fine; will safety net hospitals survive without the current levels of federal and state subsidies; will the current number of physicians and hospitals be overwhelmed by 35 million new insured patients; and will the middle class pay a disproportionate share of the total health care costs? Despite these points of disagreement one thing is clear—we will not be able to continue to deliver cost-effective and quality health care unless we are able to decrease overall health care costs. President Obama has reported and many experts agree that the most effective means of lowering health care costs over the next decade will be to eliminate “waste” in the health care system. The “science” that will inform health care reform fits well within the sphere of translational research as it spans the continuum of bench research, clinical research, and population health. As pointed out by Victor Fuchs, Professor of Economics and Health Research and Policy, Emeritus, at Stanford University, there are two possible definitions of waste (1) any intervention that has no possible benefit for the patient or in which the potential risk to the patient outweighs any potential benefit or “medical waste”; or (2) any intervention for which the value of the expected benefit is less than the expected costs or “economic waste.” Medical waste occurs when a physician or caregiver does the wrong thing either because they are uninformed or are delivering care in an unethical manner. Fortunately, the incidence of medical waste is small. By contrast, economic waste is far more common and has been blamed at least in part on a fee-for-service reimbursement model that incentivizes physicians to do more—often without justification—and a patient population that is highly demanding. For example, there are about three times as many magnetic resonance imaging scans performed each year in the US as there are in Canada; however, the increased number of scans does not translate into improved care. In many cases, economic waste does not occur because physicians are incentivized to overuse tests and devices but because there is little or no information that allows them to make sound judgments regarding the choice between differing treatment strategies. Without scientific documentation, it also becomes problematic for regulatory bodies to recommend or mandate one treatment option as opposed to a second and potentially more expensive option. This equipoise is important because newer treatments are often—but not always—more expensive than older therapies. Examples of these cost-related decisions abound; the use of bare-metal stents versus the more expensive drug eluting stents in patients with coronary artery disease; traditional open surgery versus robotic surgery for the treatment of prostate cancer; and the use of expensive new generation antibiotics versus older generic medications for the treatment of community-acquired infections. Similarly