Education, Prevention, Access, and Efficiency: Notes and Insights from a Conference of Health Care System Leaders from the Americas

Steven Ullmann, PhD, Chairman, Department of Health Sector Management and Policy; Director, Center for Health Sector Management Policy, School of Business Administration, University of Miami

Introduction

Communicable diseases are increasingly being brought under control globally.  Improved sanitation, water supplies, infrastructure, and mosquito control are all leading to improved health associated with these disease processes.  And while these issues are increasingly being controlled, the focus of health care management and policy globally is shifting to prevention and treatment of non-communicable diseases.

The University of Miami School of Business Administration’s Center for Health Sector Management and Policy recently hosted a working conference on heart disease, brain disease, and women’s cancers­­­­­ in Latin America.  The focus was on creating partnerships between not-for-profit firms, non-governmental organizations (NGOs), for-profits firms, and government agencies. The concept was to create symbiotic relationship to better manage disease processes.

Over 100 participants — individuals in leadership positions from each of the four sectors and representing many of the countries in Latin America — gathered for this one day intensive conference/workshop.  Presentations and discussions were centered around partnering in order to increase and improve processes and outcomes associated with disease prevention, education, access, and treatment. A key theme was development of interactive management processes involving cross-sectoral partnerships.

Partnerships are critical to address key challenges and achieve broad-based high quality care. This includes partnerships with the private health care delivery sector, partnerships with the private health care insurance marketplace, partnerships with the private medical device sector and partnerships with the pharmaceutical sector. Furthermore, there is a need to think beyond these generally recognized sectors.

Examples of Opportunities

Hypertension: Hypertension is one such challenge. High blood pressure is one of the leading factors affecting health worldwide.  Studies show that nearly 18% of myocardial infractions¹ are caused by hypertension and 35% of strokes are similarly caused by hypertension².  In 2010, high blood pressure was the cause of 9.4 million deaths and 7% of the disease burden globally³.  Smoking, physical activity and diet were other significant factors as indicated by the American Heart Association.

Ralph Sacco, a Chaired Professor of Neurology at the University of Miami’s Miller School of Medicine, Former President of the American Heart Association, and current Chair of the Board of Neurological Science, explained that one of the issues associated with prevention of hypertension was in the basic management of the technology.  Specifically, blood pressure measurement abilities are highly variable and particularly problematic in developing countries.  There is a lack of accessible, inexpensive, and accurate blood pressure measurement devices; those that do exist have not been validated for accuracy.  There is also a lack of human resources who have been trained to use the equipment accurately.  So, even if the interventions and actions associated with the perils of high blood pressure are undertaken, accurate measurement and provision of the needed information is not available to the population.  If this first step is problematic, then all the steps that follow relating to prevention, access, and treatment will be for naught.

Universal access to high quality care: Dr. Sacco moderated a panel of experts from ­throughout the Americas representing the government, for-profit, not-for-profit, and non-governmental organization entities from a variety of countries.  Discussion revolved around the concept forwarded by Enrique Rueles, former Vice Minister of Health of Mexico, that universal access to health care, a mantra forwarded by those in the health industry, should not be the goal if the health care one has access to is not good health care.   Dr. Lottenberg, former President of the Albert Einstein Israelite Hospital in Brazil and currently the CEO of United Health Care, Brazil, indicated that when one speaks to quality care, safety is part and parcel of this.

In Brazil by example, as well as in many other countries in Latin America, health care is considered a right.  But sometimes it is believed that a social right is equivalent to total government oversight, management, and responsibility, with the implication that there is little or no personal or private sector responsibility. But social responsibility does not mean that there is no role for the private sector.

 Funding of care is central to universal access. An interesting process enters in when discussing funding of care in a number of countries in Latin America.  A treatment for a given illness may be denied if not a part of a formulary of services under government provision of care.  But there is an option when the denial occurs.  An appeals process is available.  It is a costly process, but it is a process used relatively often, begging the question as to whether evidence of medical return on investment is being examined. Here, too, private sector firms can play a leading role.

Healthy cities: “Healthy cities,” a concept championed by former Mayor Bloomberg in New York City and a concept adopted by the World Health Organization (WHO) was brought up in discussion.  A healthy city concept involves partnerships with numerous partner categories and an integrated strategic approach. It involves an integration of educational institutions from the earliest child education and development stage through their years in school, and involves health care institutions and employee wellness programs.  The latter was suggested as an approach that indicates that employers value their employees, productivity is increased and, in turn, benefits accrue to both employee and employer. Ultimately, the benefits accrue to society as a whole.

Women’s cancers: The concept of partnership in health care between for-profit, not-for-profit, and government sectors, was also a subject of significant discussion with respect to women’s cancers. As discussed in a keynote address by Dr. Felicia Knaul, Professor and Director of the Institute for Advanced Study of the Americas at the University of Miami, Senior Economist at the Mexican Health Foundation, Founding President of Tómatelo a Pecho, and a honorary Research Professor of Medical Sciences at the National Institute of Public Health of Mexico, cancers appear to track economically.  Cervical cancer is more common in poorer areas and breast cancer is more common in higher income areas. Much of cancer death these days is avoidable, but as Dr. Knaul indicated, when we speak of prevention and cure, we should not speak “separate” but should think “diagonally.”  This requires thinking beyond just the clinical aspects, and looking at non-clinical areas including managerial, financial, and delivery aspects. Further when we speak “diagonally,” we should also speak to financing and delivery.

Thus, for example, in 2012 Mexico introduced universal health coverage for several prevalent cancers including cervical, breast and colorectal. Yet, even though treatment was and is now free for all, detection in poorer areas of the country continues to be a major issue and is the Achilles heel of the Mexican cancer system.

A theme of lack of training and accurate diagnostics was emerging, as this issue was brought up earlier in the discussion concerning hypertension. In Mexico, one of the first needed points of intervention turned out to be education of primary care physicians re: detection.  It reflected a similar discussion relating to hypertension in that primary providers are similarly not equipped to do basic and accurate testing for hypertension.

As Dr. Eduardo Cazap, Founder and President of the Latin American and Caribbean Society of Medical Oncology (SLACOM), past president of the International Union Against Cancer (UICC) and member of the Executive Committee of the National Cancer Institute of Argentina indicated, such issues are independent of the overall wealth or development of the country.  These issues are rather a function of distribution of income and variance in the level of education of individuals in the population of any given country.

There are 1.1 million cases of cancer and 600,000 cancer deaths annually in Latin America and the Caribbean⁴. Breast cancer has the highest incidence of all cancers among women in the world. In Latin America, approximately 114,900 cases are diagnosed annually with associated mortality of approximately 37,000⁵.  It is expected that the number of deaths from breast cancer will double by the year 2030⁵.  With respect to cervical cancer, nearly 75,000 women received diagnoses of cervical cancer and the number of deaths exceeded 31,300⁶.  In the absence of improvements in prevention, it is anticipated the number of deaths will reach over 43,500 by the year 2035⁶.  As indicated by the panelists, nearly all of these deaths are preventable.

Country comparisons are noteworthy.  With cervical cancer being one of the women’s cancers that is highly preventable, if one looks at the Americas in totality, 80 percent of cervical cancer deaths occur in Latin America⁷. In part, this is due to the fact that health expenditures are quite low in many countries in Latin America, coupled with the fact that a focus on health care expenditures continue to be focused on contagious infectious disease processes and there has been a lack of strategic shift to non-infectious diseases even though this has been the pattern of shift in disease processes⁸.

Here is where the use of big data analytics as a management tool can be instrumental in creating more focused, more effective, more efficient interventions.  Further, given that in industrialized countries, while there is generally a seventeen year lag from science and research to clinical practice, the time lag is longer yet in developing countries.  Managing the technology and focusing on translational medicine becomes critically important. Partnerships are critical in attaining this.  Health care systems and insurance providers can partner in the use of big data to assure mutually beneficial cost-effective and targeted care.  Effective translational medicine requires partnering between university medical centers and the medical research arms of government agencies and pharmaceutical companies with health care providers in the community to assure that new and effective prevention and treatment modalities get to the people.  Evidence based medicine was seen as a critical aspect but it was also noted that politics enter into what diseases are actually funded and covered by public insurance.

“Reverse” innovation: There is sometimes a perception that cutting edge health care and cutting edge health care management is a one-way street, with innovations coming from the United States, Europe, and Canada and flowing south to Central and South American.  It was noted that there are many medical advances that flow from Latin America up to the north.  For example, non-invasive heart valve replacement procedures have been done in a premier hospital in Brazil years before similar processes and procedures were provided in the United States.  As Alvaro Roto from Roche’s Latin America unit indicated, Cuba has become another country worth watching in terms of flow of medical innovation both north to south and south to north.  For example, a vaccine for lung cancer has shown effectiveness for a number of years in Cuba, and which for years was not evaluated or available in the U.S. due to the 55 year-old embargo with Cuba.  The Roswell Park Cancer Institute in the U.S. has now signed an agreement with Cuba’s Center for Molecular Immunology to further develop and test the vaccine in the U.S.  Similarly, the Feinstein Institute for Medical Research in the U.S. has been working with the Center for Molecular Immunology in Cuba for more than six years on another cancer vaccine.

Brainstorming

One of the most interesting aspects of the conference was the brainstorming sessions involving the health care leaders, panelists and attendees. Focus was on issues of education, access, and efficiency relating to women’s cancers and heart disease.

Education and communication: Education and communication critically important.  Educating students while they are still in school, where they are in an environment that is conducive to absorbing information about diseases and awareness regarding detection and prevention, can be highly effective. The role of modern communication is central here.  Smart phone technology is pervasive throughout the Americas.

Partnerships are highly relevant for education and communication. The activities cannot be reliant solely on the government. Early education is where things should begin.  The work environment is another significant point of contact in order to create an environment of wellness, and an opportunity to provide information on disease processes, prevention and detection.

Partnerships with cell phone carriers to disseminate information offer an efficient way of messaging and educating.  Further, it may create efficiency in processes and outcomes to communicate to younger individuals who are heavy users of the technology, so that they may learn about and observe older relatives and act accordingly in a time effective and therefore cost effective manner.  Many of the cultures in Latin America have very strong intergenerational family ties and this could potentially be a very powerful and effective tool.

Disease control: An example of the opportunities that exist for improvement in disease control, as we noted earlier, is hypertension.  According to the Pan American Health Organization (PAHO) somewhere between 20 and 35 percent of the population over the age of 18 had hypertension.  A journal of the American Medical Association (JAMA) of four countries in Latin America indicated that the rate of individual awareness of high blood pressure was only 57 percent⁹.  Only 18.8 percent of those individuals with high blood pressure had their blood pressure under control⁹.  And these were four countries in Latin America were ones that had a somewhat greater focus on health: Argentina, Brazil, Chile and Colombia⁹.

Many of these problems can be mitigated in the work environment. It becomes an important role for those overseeing human resources management.  What is common in many disease processes including women’s cancers and heart disease is that focus tends to be more on treatment after the fact rather than prevention before the fact.  Educational partnerships are critical to achieve these goals: government, policy makers, health workers, employers, medical device companies, health insurance providers, media, and others must all be in this together.

Going Forward

Going forward, it is critically important to achieve stronger partnerships across the health care sector, rather than rely solely on governments and front line health providers.  Clearly, health workers are a critical player in this process as well. Unfortunately, as indicated in the breakout discussion, physicians are focused on cures. They have few incentives to educate their population as to prevention or observing warning signs indicating early stages of a disease process.  Early detection brings about great efficiency.  And earlier and directed access also improves efficiency. This lack of focus is in part a result of how medical personnel themselves are educated.

In terms of efficiency, thought leaders also indicated that awareness, prevention and treatment needs to be more focused. Approaches need to be tailor made to the specifics of each community and the differential needs within that community.  Focus should be on high risk populations. Telehealth can be a highly effective tool to reach populations in a cost efficient manner. Returning to an earlier theme, efficiency also relates to the value proposition that value equals some combination of quality and cost.  Health care provision involves a cost. Efficiency is provided only if the quality of care is also fostered as one looks at the cost of the provision of care.

Perhaps what is the most important outcome from the annual LIFE conference is that the partnerships that are created between clinical providers, insurers, medical device companies, policy makers, and NGOS that were explored in the conference setting will now be operationalized at the local and national level within countries.  The concepts and relationships that were developed at the conference provide opportunities for partnering across countries. As the former Minister of Health of Mexico and current President of the University of Miami, Dr. Julio Frenk, indicated, health care is local but at the same time it is global. This conference pointed this out clearly.

References

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