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Health TLN Course

Multidisciplinary Studies in Healthcare Delivery (ID 399)

Sponsored by the Health Thought Leadership Network and coordinated by Danielle Hartigan and Chris Skipwith in the fall of 2018 and 2019, the course introduces and describes the health delivery system and the resources that comprise it. The theoretical basis for the system, as well as the principal means of system organization and evaluation are discussed.

Specifically, the course introduces and describes U.S. healthcare systems, addressing the components and complexities. The historical basis for the system’s organization will be discussed, as well as the various modes of healthcare delivery and the ways healthcare is organized, financed and delivered. In addition to presenting the foundations of healthcare organization, the course will include an overview of healthcare delivery, health insurance, policy, public health, healthcare finance and purchasing, and current challenges to innovation in the system. Each section of the course presents general principles, followed by an in-depth examination of a timely issue in healthcare. Students who complete the course will gain a basic understanding of the organization, functions, and delivery of healthcare.

Fall 2019 Modules 
Introduction to the Healthcare System

Module Leader: Prof. Danielle Hartigan, Natural & Applied Sciences

Guest Speaker: Prof. Alan Sager, Professor of Health Law, Policy & Management, Boston University School of Public Health

Healthcare Policy

Module Leader: Prof. Rob DeLeo, Global Studies

Guest Speakers: Nancy Turnbull, Senior Lecturer on Health Policy & Senior Associate Dean for Professional Education, Harvard T.H. Chan School of Public Health | Brian Rosman, Research Director, Healthcare for All

Health Insurance and Payer Perspective

Module Leader: Prof. Tony Kiszewski, Natural & Applied Sciences

Guest Speaker: Benjamin Day, Director of Healthcare NOW

Quality of Care and the Patient Experience

Module Leader: Prof. Danielle Hartigan, Natural & Applied Sciences

Guest Speaker: Matt Day, Senior Vice President, Network Payment Innovation & Contract Management, Blue Cross Blue Shield of Massachusetts

Health TLN class with Matt Day flyer

 

Artificial Intelligence in Healthcare

Module Leader: Prof. Marco Marabelli, Information & Process Management

Guest Speaker: Girish Venkatchaliah, Vice President of Data Strategy, Analytics and Machine Learning, athenahealth

Role of Technology, Gamefication and Social Media in Healthcare

Module Leader: Prof. Xinru Page, Computer Information Systems

Guest Speaker:  Josh Hollander, Manager, Enterprise Practice Consulting, CareFirst Blue Cross Blue Shield

Communicating Health

Module Leader: Prof. Danielle Hartigan, Natural & Applied Sciences

Guest Speaker: Prof. Jon Ericson, Information Design & Corporate Communication

Implementing Telemedicine into the Delivery System

Module Leader: Prof. Monica Garfield, Computer Information Systems

Guest Speakers: Ken Accardi, CEO,  Ankota | Shawn Farrell, Senior Vice President of Clinical Services, American Well

Opioids and the Healthcare System

Module Leader: Prof. Miriam Boeri, Sociology

Guest Speakers:  Linda S. Kahn, Professor, Associate Vice Chair for Research, University at Buffalo

Mental Health Delivery

Module Leaders: Dr. Peter Forkner, Director, Bentley Counseling Center | Jessica Greher Traue, Director, Bentley Wellness & Prevention Center

Guest Speaker: Prof. Gary David, Sociology

Workplace Wellness

Module Leader: Prof. Liz Brown, Law, Taxation & Financial Planning

Global Health Innovation

Module Leader: Prof. Christopher Skipwith, Natural & Applied Sciences

Guest Speaker: Sandra J. Butler, Senior Manager for Global Business Strategy, Consortium for Affordable Medical Technologies (CAMTech), Massachusetts General Hospital Global Health

Future of Healthcare Leadership

Module Leaders: Prof. Danielle Hartigan, Natural & Applied Sciences | Prof. Christopher Skipwith, Natural & Applied Sciences

Guest Speaker: TBD

Fall 2018 Modules 
Why Do Urban Hospital Closings Matter?

Alan Sager's Class

Professor Alan Sager, Professor of Health Law, Policy, and Management, Director, Health Policy and Law Certificate Program, and Director, Health Reform Program, at Boston University, presented his work on "The Meaning of Urban Hospital Closings", using a dataset spanning 1936 to 2010. His work provided an in-depth assessment of the constantly-evolving configuration of urban hospital care--studying the factors surrounding hospitals that are most likely to close, hospital efficiency, and the effects of closings on quality and healthcare costs. Prof. Sager proposed some methods to address these necessary centers of care from financial, legal, and political perspectives.

Key student takeaways from Professor Sager's talk:

  • Not one of the 6 key elements of free markets exists in healthcare.
  • Be empowered to make careers out of identifying important problems and improving healthcare.
  • Think of 10-20 years in the future. Identify the optimal scenarios for healthcare- and then figure out how to get there.
  • Be skeptical!
Patient Experience

Professor Danielle Hartigan gave an introduction to the multilevel factors that influence patient perspectives on their care. Students worked in small groups to understand the six key components of patient-centered care from the patient, provider, and healthcare system perspective. Then students incorporated their experience in the Bentley Virtual Reality lab to develop novel approaches to improving the quality of patient care.

Students visited Professor Jon Ericson's VR lab and experienced the following scenarios:

VR Lab

Doctor's Office

Students explored a simulated exam room that includes lighting, an examination table, anatomy charts, and other objects commonly found in clinical environments. We discussed how hospitals might leverage VR to prototype and obtain feedback on creative layout changes or technical enhancements for their existing rooms, how architectural firms are currently integrating VR into their workflow for designing clinical spaces, and the value of "participatory prototyping," a new approach to the development of products, spaces, and environments that involves end users in the design process.

CT Preparedness for Kids

Students experienced a virtual training scenario developed by Staples VR for Starship Children's Hospital in New Zealand. Researchers are currently examining this scenario as a possible adjunct or replacement for anxiety medications when preparing children for computerized tomography (CT) scan procedures. The experience includes an immersive video of the real playroom where patients would wait prior to their procedure, and a virtual reconstruction of the CT room. As patients explore the CT room, they play a game that gradually prepares them for the various sights and sounds they would experience during a real CT scan.

The Body VR

Students explored interactive simulations of the human body that enable them to stand on top of cell membranes, observe the actions of proteins and ions, watch cells fight viruses, and fly through arteries. The students also interactively manipulated 3D reconstructions of the human body, exploring the spatial and functional relationships among various body systems. Unlike screen-based interfaces, VR uses two images (one for each eye), enhancing our ability to see the 3D structure of the human body. As a result, simulations like this one are increasingly leveraged in medical education.

Read More about Professor Ericson's VR Lab

Managing Clinical Care Systems

Managing Clinical Care Systems

Professor Monica Garfield (CIS) described the factors needed to effectively incorporate IT-based healthcare interventions into clinical practice, using the case study of Telestroke, a remote stroke diagnosis and management platform administered by MGH. At the core, IT that makes a competitive difference was described as technologies that can be effectively deployed, innovated, and propagated. A key business strategist in the Telestroke case, Shawn Ferrell (currently VP of Business Development at American Well), provided an engaging overview of the evolution of digital health, describing the innovative technologies that allow hospitals to begin thinking about how to span the continuum from urgent care to acute care. Finally, Ken Accardi, CEO/CTO of Ankota introduced a framework for population health using IT infrastructures based on the principles of “value-based” reimbursement. He presented a unique case for the students, Flex the Falcon (FFH) Health, which outlined a proposed new delivery model for elderly care that optimized the delivery process across care settings and with automation. The case challenged students to think about key issues in developing technologies for population health:

  • Stratifying populations
  • Working with health statistical information
  • Use of the Triple Aim as a guiding principle
  • Disruptive business models
  • Improving healthcare by addressing non-medical aspects of care
  • Cognitive computing and its applications

Managing Clinical Care Systems

From this session, students came away with a thorough understanding of strategies of incorporating IT into healthcare settings, the types of IT that can achieve various clinical applications, and a framework for addressing healthcare issues using innovative IT-based approaches.

Shawn Ferrell:

“There have been few lawsuits from delivering telemedicine and having bad outcomes; there are many more lawsuits against community hospitals who don’t have the technology when they could have.

"Consumers are expecting every aspect of their lives to provide the same experience as Amazon—including their healthcare.”

Ken Accardi:

“New business models in healthcare require a swing from fee-for-service to value-based care.”

“The Triple aim has three aspects: happier patients, lower costs, and maximum population. The last one turns out to be the hardest.”

Health Care Innovation Challenges

Healthcare Innovation Challenges

For this class, students attended the 29th Raytheon Lecture in Business Ethics, presented by Sandra Fenwick, President & CEO of Boston Children’s Hospital. In a talk entitled, “Overcoming Contradictions in the Business of Compassion and Care,” Ms. Fenwick presented the various challenges that Boston Children’s Hospital faces as the #1 pediatric hospital in the U.S. She described the ethical and treatment challenges of dealing with a pediatric patient population and chronicled the hospital’s dilemmas when facing increasing demands to meet medical margins. Finally, she discussed how innovation at the hospital is promoted, financed, and regulated and how those functions have progressed in changing regulatory and economic environments. Students met with Ms. Fenwick in a special session following the lecture to ask questions and chat about her journey.

Watch Sandra Fenwick's lecture

Sandra Fenwick

Following the lecture, Professor Fred Ledley (NAS, MG) presented some of the principles of innovation theory and applied them to the challenges facing innovative gene therapy-based treatments employed by Boston Children’s Hospital and other pediatric centers dealing with patients that have genetic disorders. He discussed the inherent need for translational research to be promoted by researchers, physicians, and business operations professionals engaging in meaningful discussion. Students went through the application of management innovation principles in health care and the mechanisms of gene therapy approaches. Finally, students discussed the pricing dilemmas that occur with treatments (like gene therapy) that require a significant investment in research & development but may only be administered once (or very few times) to a limited patient population using the recently-approved LUXTURNA by Spark Therapeutics as a case study. Students attempted to devise novel pricing models and business models for these innovative treatments, taking into account the conflicting needs of patients, families, payers, providers, and biotechnology companies.

Impacts of Health Care Financing

Impacts of Healthcare Financing

In this class, Professor Tony Kiszweski (NAS) presented a comparative analysis of health systems using the U.S., Germany, France, the United Kingdom, and Canada as cases. The class explored the immense fragmentation of financing and delivery of health care in the U.S. and some ways that the system could be changed to improve efficiency and overall care. The class also investigated the causes of poor health indicators in the U.S., despite enormous health care expenditures. Finally, the class discussed the concept of adverse selection—a direct consequence of asymmetric information on health risk among health care consumers. Using a number of compelling cases, Prof. Kiszweski challenged students to devise ways to balance fragmentation and the effects of underinsurance to develop plausible innovative systems for U.S. health care.

Tony Remington

Following Prof. Kiszweski’s presentation, Tony Remington (CEO of Gravity Diagnostics, LLC) remarked about the challenges that a full-service diagnostics laboratory faces with variable, payer-dependent reimbursements and regulations regarding medical necessity for laboratory procedures. Building on the theme of financing fragmentation, he described how his company works with insurance providers to be paid for laboratory services. He also presented the conflicting interests of providing reimbursable services while being fully committed to a broader goal of providing testing to those who need it, regardless of their ability to pay. Students participated in a Q&A with Remington on topics of regulation, ensuring margins, negotiating payer contracts, differences in financing diagnostics services for laboratories, and medical devices.

Health Care and Future of Work

Healthcare and the Future of Work

Professor Liz Brown (LTFP) presented issues of privacy and data security stemming from recent requirements of fitness tracker programs in insurance plans. Prof. Brown stressed that there are, of course, privacy concerns whenever you give a third party access to your data, especially medical data. This is in addition to concern that in the long run, people who are disinclined to share fitness data may face difficulties like increased rates or even being cut off from insurance coverage completely. It was discussed that, in the long run, there may be real benefits for consumers willing to share their fitness data with insurers, particularly if the practice spreads to health insurance providers, as seems inevitable at this point. People who track their fitness may end up in better health and receive cheaper insurance relative to those who do not. Insurance companies may make more money off healthier clientele. Overall, it’s a win-win for everyone, except for the people who decide not to share their fitness data with their insurers.

Following this, students were introduced to the work of Dr. Ron Goetzel (Johns Hopkins University), whose work showed that workplace wellness programs are largely ineffective, partially due to their focus on individual-level health behaviors and suboptimal incentive structures. Dr. Goetzel presented 10 ways that workplace wellness programs could be effective:

  1. Creating a culture of health
  2. Leadership commitment
  3. Specific goals and expectations
  4. Strategic communication
  5. Employee engagement in program design/implementation
  6. Best practice interventions
  7. Effective screening and triage
  8. Smart incentives
  9. Effective implementation
  10. Measurement and evaluation

Through these principles, Dr. Goetzel indicated that workplace wellness programs are inherently flawed, yet they lack the essential elements to truly realize the intended outcomes.

Symposium

On Tuesday, students participated in a Student Symposium, where Bentley University President Alison Davis-Blake joined organizational experts Ryan Quinn (University of Louisville) and Shawn Quinn (University of Michigan) to help students learn how to make a positive impact on those around them, including fellow students and future colleagues. The symposium encouraged students to recognize the energy they can bring to the workplace by energizing themselves, promoting a sense of belonging among co-workers, and practicing gratitude in ways that can be as simple as saying “thank you.” “All of you hold more power than you may believe in the way you impact people’s lives around you,” Shawn Quinn told a packed hall of students in Bentley’s Wilder Auditorium.

On Thursday, students attended an academic symposium on the future of work, which brought together faculty from Bentley, Stanford University, Harvard Business School and MIT and provided a lively discussion for students, faculty and staff in Bentley’s Koumantzelis Auditorium. The symposium’s keynote speaker was Jeffrey Pfeffer, Thomas D. Dee II Professor of Organizational Behavior at the Stanford University Graduate School of Business and author of “Dying for a Paycheck: How Modern Management Harms Employee Health and Company Performance – and What We Can Do About It.”

Two panel discussions featuring faculty from Bentley, MIT and Harvard Business School followed Pfeffer’s talk:

Panel

In the first panel on “Human Sustainability and the Future of Work,” moderated by Associate Provost Patrick Scholten, panelist Rani Hoitash, John E. Rhodes Professor of Accountancy, discussed trust in the workplace. Sandeep Purao, Professor of Information and Process Management, presented on the topic of how workers fare in the gig economy, and Effie Stavrulaki, Associate Professor of Management, discussed the connection between organizational operations and employee well-being.

In the second panel on “Human Sustainability and the Future of Work,” moderated by Dean of Arts and Sciences Rick Oches, panelist Tamara Babaian, Associate Professor of Computer Information Systems, discussed human-computer collaboration. Jason Jackson, Assistant Professor of Political Economy and Urban Planning at MIT, presented on the topic of how technology changes the power relationships between managers and employees. Prithwiraj “Raj” Choudhury, Assistant Professor of Technology and Operations at Harvard Business School, discussed the need for parity between artificial intelligence and human capital.

Strategic Challenges in Health Care Delivery

Dr. Jill Brown, Harold S. Geneen Research Professor of Corporate Governance and associate professor of management, began by talking about hospitals as a really difficult industry. Hospital directors she consults with tell her that if they had to do it over again they might pick another career given the pressure on hospitals to provide indigent care with rising costs and lower reimbursement. But the health care market is growing and so there are also key opportunities. She introduced students to the fundamentals of strategy in the hospital sector, a set of actions that drive towards goals- either growth, stabilization or retrenchment. Growth can tap into the $94.2B of forecasted profits for a $1.1 trillion a year industry. Stabilization means consolidation, which occurs in about 100 hospitals/year. Retrenchment is in response to sweeping regulatory or pricing changes and frequently occurs in nonprofit hospitals in rural communities. Jill directly tied her talk of retrenchment strategies in rural hospitals back to Dr. Alan Sager’s talk in the first class. She went through a number of external and internal challenges that hospital strategists would examine in setting goals and developing strategies. To highlight the complexity of strategy development, she talked about the complex negotiations that go into directing supply chains and reimbursement structures, and highlighted key human capital issues, including physician shortages, physician burnout, and high churn rates (18 percent) in CEOs.

Guests

Next students heard from Kawinthi Fernando, ’14 MBA, network development project specialist at the MGH cancer center. Kawinthi is a Bentley MBA graduate and Jill’s former Graduate Assistant who was integral in the research papers described below that the students read for tonight’s class. 

Kawinthi’s role is to increase network affiliates and increase connectivity for the MGH Cancer Center. MGH is a tertiary care center affiliated with many community sites. Right now 60-70 perecent of oncology care is happening at the local, regional site—the cancer center is looking to connect to that market to provide the highest quality care at the local level through these partnerships and relationships. MGH has relationships with MGH-owned hospitals, non-MGH-owned hospitals which both operate under the Partners umbrella and privately owned hospitals and physician groups. Kawinthi directly oversees a number of these network relationships, for example the relationships with MGH-owned, struggling hospitals on Martha’s Vineyard and Nantucket. She discussed active business development in a number of state and regional hospitals. She walked students through the typical path of MGH’s strategic relationship building which involve: 1) Identifying points of interest or opportunity by considering the referral base, regional competition, and weighing gaps in quality or service, 2) Defining points of integration and willingness to collaborate with branding or referrals, 3) Signing the contract and the elements of the professional services agreement, and 4) Maintaining the relationship and plan for growth with quality standards and operational strategy. Kawinthi ended with the future of strategic relationships at MGH Cancer Center that brought the class back to Monica Garfield’s case study about MGH Telestroke programs to highlight the growth of telemedicine offerings in her affiliates.

Prof. Jill Brown then led a discussion of the two readings which centered on cases of human capital, networks and hospital strategy. The first case addressed how internal and external factors interacted to create a hybrid for-profit and not-for-profit organization structure in physician radiology group. The second article discussed the balance between competition and cooperation in hospital affiliations, a term known as co-opetition, which provides a framework to think about some of the complex business development activities Kawinthi discussed at MGH. The key is that hospital administrators need to work with physicians to find points of shared value.

Communicating Health

Emil Chiauzzi, PhD, Research Director at PatientsLikeMe, engaged students with a discussion of the patient-centered data perspective. We live in a data-oriented world- ratings are common when we shop on amazon; Uber drivers rate you and you rate your Uber driver. Health is no different. The idea behind PatientsLikeMe is that patient data is not just for health care providers. Data can be used for the patients themselves AND if patients share their data it can help others. Dr. Chiauzzi described how PatientsLikeMe is a research network; patients share their info which provides insights not just for the health care system but for patients themselves. Traditionally, patient data is locked up in academic file drawers or in electronic health records and never shown to patient. Here patients can see their data and use it for their benefit.

Dr. Emil Chiauzzi

Dr. Chiauzzi discussed the business model of a site like PatientsLikeMe that collects and aggregates and feeds back patient data. Pharmaceutical companies use the data to understand side effects and patient-reported outcomes associated with treatments. Clinical trials are based on a short term, highly controlled patient use of a treatment. But when the drug is approved and used in real world conditions over a longer period of time, there is a need for patient-reported outcomes (Phase IV trial) to understand what is going on in everyday life. The key to multiple stakeholders using this data is openness and transparency to honor patient trust. Emil discussed that it would be almost impossible to keep a site like this going as a nonprofit. Data is a gasoline that makes this platform run. Patient-reported data enables new findings and allows for a longitudinal perspective on the patient experience with chronic conditions. 

People who have multiple conditions have more than just medical treatments that help them cope with their symptoms. PatientsLikeMe captures the psychological and social aspects that go beyond what might be measured in a traditional study. Treatment for these patients is often anything that works. For example, one of the most effective treatments to improve function captured in the data is a parking permit! “Health hacks” are tips and tricks that can help with symptoms; for example what are the patients with fibromyalgia on the site saying about what might help them sleep.

With 40-50 million patient-reported data points that are not governed by HIPAA, Dr. Chiauzzi described that the platform does not promise privacy, but instead strives to be good stewards of patient data and provide feedback directly to patients. He touched on issues of privacy from Liz Brown’s discussion two weeks prior around the use of data monitoring devices by companies, such as life insurance providers, who may not have the patients’ best interest at the forefront. Patients using PatientsLikeMe own their data and are to withdraw their data at any time. The key to PatientsLikeMe is that patients should be the key beneficiary of their data. “If we don’t give something good back to the patients we don’t operate.”

Hints

In the second part of the session, Dr. Hartigan turned the discussion from patients’ health information sharing to patients’ health information seeking. She introduced students to the Health Information National Trends Survey (HINTS), nationally representative data of how US adults obtain, trust, and communicate about different sources of health information, including the Internet. The class discussed the challenges of health communication campaigns and the conflicting or inaccurate information that often comes from exposure to health information through mass media. Lastly, students used data from HINTS to appreciate how communication about health-related science can lead to frustration and confusion on the part of patients, with over 70 percent of the US adult population agreeing that “everything causes cancer” and mixed messages about cancer prevention make it difficult to know which recommendations to follow.

Communicating Health

emil ChiauzziEmil Chiauzzi, PhD, Research Director at PatientsLikeMe, engaged students with a discussion of the patient-centered data perspective. We live in a data-oriented world- ratings are common when we shop on amazon; Uber drivers rate you and you rate your Uber driver. Health is no different. The idea behind PatientsLikeMe is that patient data is not just for health care providers. Data can be used for the patients themselves AND if patients share their data it can help others. Dr. Chiauzzi described how PatientsLikeMe is a research network; patients share their info which provides insights not just for the health care system but for patients themselves. Traditionally, patient data is locked up in academic file drawers or in electronic health records and never shown to patient. Here patients can see their data and use it for their benefit.

Dr. Chiauzzi discussed the business model of a site like PatientsLikeMe that collects and aggregates and feeds back patient data. Pharmaceutical companies use the data to understand side effects and patient-reported outcomes associated with treatments. Clinical trials are based on a short term, highly controlled patient use of a treatment. But when the drug is approved and used in real world conditions over a longer period of time, there is a need for patient-reported outcomes (Phase IV trial) to understand what is going on in everyday life. The key to multiple stakeholders using this data is openness and transparency to honor patient trust. Emil discussed that it would be almost impossible to keep a site like this going as a nonprofit. Data is a gasoline that makes this platform run. Patient-reported data enables new findings and allows for a longitudinal perspective on the patient experience with chronic conditions. 

People who have multiple conditions have more than just medical treatments that help them cope with their symptoms. PatientsLikeMe captures the psychological and social aspects that go beyond what might be measured in a traditional study. Treatment for these patients is often anything that works. For example, one of the most effective treatments to improve function captured in the data is a parking permit! “Health hacks” are tips and tricks that can help with symptoms; for example what are the patients with fibromyalgia on the site saying about what might help them sleep.

With 40-50 million patient-reported data points that are not governed by HIPAA, Dr. Chiauzzi described that the platform does not promise privacy, but instead strives to be good stewards of patient data and provide feedback directly to patients. He touched on issues of privacy from Liz Brown’s discussion two weeks prior around the use of data monitoring devices by companies, such as life insurance providers, who may not have the patients’ best interest at the forefront. Patients using PatientsLikeMe own their data and are to withdraw their data at any time. The key to PatientsLikeMe is that patients should be the key beneficiary of their data. “If we don’t give something good back to the patients we don’t operate.”

hints logo

In the second part of the session, Dr. Hartigan turned the discussion from patients’ health information sharing to patients’ health information seeking. She introduced students to the Health Information National Trends Survey (HINTS), nationally representative data of how US adults obtain, trust, and communicate about different sources of health information, including the Internet. The class discussed the challenges of health communication campaigns and the conflicting or inaccurate information that often comes from exposure to health information through mass media. Lastly, students used data from HINTS to appreciate how communication about health-related science can lead to frustration and confusion on the part of patients, with over 70 percent of the US adult population agreeing that “everything causes cancer” and mixed messages about cancer prevention make it difficult to know which recommendations to follow.

Mental Health Delivery Innovation

Prof. Miriam Boeri (Sociology) introduced students to resources from the Substance Abuse and Mental Health Services Administration (SAMHSA), which provides critical statistics on drug use and abuse in the United States. There was particular focus on past year drug misuse, however the data may be underestimated because of the critical omission of many homeless, imprisoned, and mental health patients. This underrepresentation was pointed out as being particularly problematic because the social contexts of drug use and misuse are often left out when the data don’t include those individuals who are most often affected by social context. Many of the reasons why people were using certain drugs, rather than simply looking at population statistics, were presented, providing some context for the social influences on drug misuse. Prof. Boeri demonstrated the correlation between mental health issues and increasing trends of prescription and illicit drug misuse. Prof. Boeri then described the response to the opioid epidemic through harm reduction initiatives, which are interventions that incorporate a spectrum of strategies from safer use, to managed use to abstinence to meet drug users “where they are,” addressing conditions of use along with the use itself. Despite the increased acceptance of harm reduction programs in the U.S., Prof. Boeri pointed out two things that have been found to be effective in the literature that have not been allowed in America: safe injection sites and legalization of heroin. This overarching point here is that, even though Harm Reduction has been accepted in the U.S., the mere fact that many of the more effective methods have not been implemented indicate that there is a long way to go.

The first speaker of the night, Anastasia Wheeler, talked about her experience as a coordinator of a safe syringe exchange program. She pointed out the insufficiency of the initial stages of her program in Lawrence and Lowell without a budget and the resources that have emerged for grant programs to promote safe syringe exchange. She also described a new initiative, in which they are the second syringe exchange program to have a mobile component, which has expanded the capability of the program. The common stigmas surrounding needle exchange programs and the reticence of community members to accept these programs as anything other than “enabling” drug use was identified as a key barrier to implementation. However, the ability of community members to call in sighting of syringes has helped positive community interactions, because the program’s efforts for cleaning up used syringes and disposing of them responsibly has assisted them in their efforts to reach the community and justify their efforts. In explaining the physical and procedural steps for administering Narcan to overdose patients, Anastasia pointed out the relatively recent shift from heroin to fentanyl. Because of the relatively short effective time period of fentanyl, people were injecting more often—which could lead to overdoses, increased risky sharing behavior, and more Narcan needed to bring people back from overdoses. This presents a large public health problem for these types of programs because they may not have enough Narcan to counteract overdoses, but this is also leading to more HIV diagnoses because of the risky sharing behavior. In addition, there is a social phenomenon of people wanting to acquire the supply of people who overdose because of the perceived strength or potency of the drug. On top of all of this, there are serious issues of trust among the clients that result in them not utilizing municipal services as much as laws have intended, thus leading to limitations of programs effectiveness if ample trust is not established.

Anastasia Wheeler

Next, Prof. Boeri introduced the connections between marijuana use and improved retention of treatment for opioid abuse. She then introduced the second speaker of the night, Dr. Uma Dhanabalan, who discussed how her curiosity about how cannabis is used for various diseases emerged. She described the biochemical concepts of the endocannabinoid system and how understanding of the system led her to become a practicing medical marijuana physician. Beyond this, she described the research limitations on marijuana, by virtue of the schedule classification, in addition to federal restrictions on research of cannabis. She discussed the current paradigms for pain management and treatment, and highlighted the potential uses for cannabis. Connecting to the concept of harm reduction, she discussed the evidence of the benefits of cannabis. She described the etiology of Opioid Use Disorder (OUD) and ways that it can be addressed using cannabinoid therapy. As an example of this in her practice, Dr. Dhanabalan described a case study was presented of a 60 year-old woman who had been misusing opioids for 17 years. She described the process of titration and altering administration of cannabis for these types of patients, with the outcome being that the patient has decreased their opioid use to 10 percent of her peak usage. She also described the concept of cannabis as the “exit drug”, which describes how patients suffering from terminal diseases use cannabis. Finally, Dr. Dhanabalan discussed the payment model for her practice, which operates outside of the typical health care system and is not subject to a number of the reimbursement and delivery difficulties encountered by a number of other visitors in the course.

Digital Health Solutions

In the second part of the class, the focus shifted to the role of innovative technologies in improving health care delivery for patients living with mental health disorders. Victoria Smith, Senior Manager of Clinical Development presented about Companion, a mobile sensing platform to objectively and noninvasively collect, store, and analyze behavioral indicators and feed that information back to patients and clinicians. With the prevalence of mood and mental health disorders and the inability of the health care systems to meet the growing needs of individuals living with these conditions, technology can augment clinical care in mental health treatment. Recognizing mental health symptoms early and accurately is crucial for clinical care but in a traditional clinical setting patients and clinicians must rely on in person visits and a battery of self-reports. Companion uses passively collected smartphone meta data, and a technology platform that securely stores and analyzes that data for patients and their clinicians to track mental health symptoms.

Ms. Smith provided results from multiple research studies on the effectiveness of this platform to identify and improve mental health symptoms of PTSD, depression, and bipolar disorder.  Initial work funded by the Defense Advanced Research Projects Agency (DARPA) validated the meta data and vocal indicators as predictive of mood and anxiety disorder symptoms (publication available here).  Subsequent work has replicated those results using a large national cohort and tested their clinical effectiveness to improve depression symptoms using a randomized controlled trial, both funded by small business innovation research (SBIR) grants from the National Institute of Mental Health (NIMH) with clinical partners at Brigham and Women’s and Mass General Hospital. She presented work with the Veteran’s Administration (VA) demonstrating acceptability and feasibility of this technology given the high rates of mood disorders and suicide in veteran populations. She discussed how a digital health technology can and should be adapted to meet the unique needs of various populations. The presentation tied in well to previous sessions on integration of health information technology into clinical care and issues of privacy and security of health-related data.

Given the positive findings from the research studies, Ms. Smith shared the next steps for Companion, including pursuing additional research on the potential and limitations of this technology. In addition, Ms. Smith led a discussion of the complex business development options, challenges, and opportunities around scaling and integrating this technology platform and digital health solution into mental health care—growing a profitable business while improving clinical care.

Privacy and Ethics

Privacy and Ethics

In this session, entitled "Privacy and Ethics", Prof. Steve Campbell (Philosophy) talked about the definition of ethics, focusing on the central question of ethics (broadly construed): "How should we live and why should we live that way?" Ethics is a broad domain, and health care/medical ethics represents an area of applied ethics, which commonly overlaps with issues in business ethics. The concept of well-being was introduced from the standpoint of psychologists (quality of an individual's mental state) and philosophers (how well or poorly an individual is doing) to demonstrate that the frame of reference matters tremendously when discussing theories of well-being. The students underwent an activity to determine the intrinsic and instrumental things that are good for human beings to provide the framework for the three most widely-discussed theories of well-being: hedonism, desire-fulfillment theory, and objective list theory. Hedonism stipulates that an individual’s life is good to the extent that their experience is pleasant. Desire-fulfillment theory stipulates that an individual’s life is good to the extent that their desires are fulfilled. Object list theory stipulates that an individual’s life is good to the extent that it includes a range of “objective goods”. Detailing these theories led to a discussion of consequences and consequentialism (acting to bring about the best consequences), which brought about the overarching concept of utilitarianism, or acting to bring about the most well-being. The utilitarian approach to health and well-being has often been applied to the discussion of privacy as a right, or a claim that we have on others to act or not act in certain ways. Prof. Campbell left the class with the question, “Do people have the right to privacy?”

Prof. Xinru Page

Prof. Xinru Page (CIS) followed up the discussion with a dive into the concepts surrounding privacy in a networked world. The session started out with a lively discussion about concerns about privacy among the class, particularly in the context of events like GlaxoSmithKline buying a $300 million stake in Google-backed gene testing company 23andMe. Historical conceptualizations of privacy—or the right to regulate physical, informational, and social access—from Warren and Brandeis (1890), Westin (1967), and Altman (1975) were presented as foundational principles for privacy taxonomies. Descriptive vs. prescriptive views on privacy were discussed as an additional dimension that tends to be culturally dependent and evolving over time. Prof. Page introduced the “privacy paradox”, where people tend to say that they are concerned about privacy but tend to share personal information despite significant risk, sometimes for very little gain. Theories explaining the privacy paradox, including bounded rationality, privacy calculus, and central vs. peripheral route were presented, bringing up the key question, “Should our conception of privacy be revisited in a more socially connected world?” Many examples of privacy in the connected world, including pleaserobme.com (2010), the Facebook feed controversy (2006), and Cambridge Analytica (2004) to show the delicate interplay between ethics and legality. To end, Prof. Page challenged the students to think about the future legal concerns for addressing privacy in an evolving technological landscape.

Prof. Yunan Chen

The next speaker, Prof. Yunan Chen from the University of California, Irvine, spoke about health technologies, design, and privacy. Prof. Chen spoke about three major research projects that she has led, including evaluating health IT use in clinical settings, consumers’ health information management practices, and patient–provider interaction mediated by technology. The exhaustive list of Protected Health Information (PHI) was presented to students and the specific legal uses of PHI in the United States were outlined, demonstrating some stark inconsistencies between perceptions of health data privacy and the realistic privacy restrictions surrounding health data. The historical progression of the setup, design, and use of electronic health record systems in the United States was discussed in the context of increasing privacy concerns. Prof. Chen described the biggest challenge for health care technology as balancing ease of access to information and protection of patients’ privacy and confidentiality. Health Information Exchanges (HIEs) were proposed as the ultimate endpoint of the evolution of health information, with HIEs currently existing on regional bases but not widespread. Two major questions that the class discussed were:

  1. How do we protect people’s privacy in a networked environment?
  2. Should we allow expectations to access HIPAA protected information?

Using the cases of Mindstrong and the All of Us Research Program, Prof. Chen left the class with four questions to ponder as they thought about how health apps are changing the way we think about health data privacy:

  • How do we protect people’s privacy when increasingly personal data is being sensed and tracked?
  • How should personal health data be shared and used, by whom?
  • How do we raise individuals’ awareness about their privacy around personal health data?
  • How do we protect people’s privacy in bioinformatics and genomic research?
Health Policy and Global Health

Health Policy and Global Health

In this module, entitled "Health Policy and Global Health", Prof. Rob DeLeo (Global Studies) presented some key problems in US health care, including access (who has insurance coverage?), cost (how much is spent?), and quality (does the system result in positive outcomes?). Focusing on these areas, he presented some relevant indicators of uninsured rates, total health expenditures per capita, and healthy life expectancy at birth. Based on these metrics, it is clear that there are severe disparities, greater spending, and no significantly-improved outcomes in the US. Prof. DeLeo posed the question of how to address these issues, demonstrating four primary methods that have been utilized by countries:

  • National Health Service Model
  • Single-Payer Model
  • Mandatory National Health Insurance
  • Market Maximized

Prof. DeLeo pulled some examples from "The Heart of Power", a book that looks at the health policy agenda of many US presidents and identified three major policy eras in the health policy debate. 

The first era, the Social Security Era (1930-late 1950s), was championed by Franklin D. Roosevelt and imagined healthcare as a universal right secured by government--ideally through a national health insurance plan. Two efforts, the National Health Act (1939) and the Wagner-Murray-Dingell bill (1943), served to facilitate this goal. 

The second era, the American Way (1960s-70s), was championed by Lyndon B. Johnson and Richard Nixon, and stipulated a system where public policies would be delivered through private institutions. Some notable achievements during this era were Medicaid, Medicare, and the Comprehensive Health Insurance Plan (CHIP).

The third era, the Market Unleashed (1990-2000s), aimed to create a system where individuals are taking risks on an open market. A key failed policy in this era was the Health Security Act (1993), which enabled universal coverage, employer and individual mandates, government cost regulation, and competition between insurers. Notable achievements were the State Children's Health Insurance Plan (S-CHIP) and Medicare Parts C & D.

Prof. DeLeo noted that the takeaway of this tour through health policies is that many presidents have tried to address gaps in health care coverage and have failed--setting the stage for the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 by Barack Obama. The political struggle surrounding the individual and employer mandates stipulated by the ACA was described, as well as the model of Health Insurance Exchanges and various protections and expansions in the ACA.

Nancy Turnbull

The first guest of the evening, Nancy Turnbull (Harvard T.H. Chan School of Public Health) spoke about health reform in Massachusetts and some lessons for the US. She started the session by asking the class, "why is it so important to provide health insurance coverage?" The students enumerated reasons, including expansion of risk pools, preventative care, lowering of mortality rates, and basic human rights. She spoke about the Medicaid expansion provision of the ACA and highlighted the major characteristics of individuals who are most likely to be uninsured. Furthermore, she highlighted the critical links between the Massachusetts health care reform efforts and those under the ACA from the perspectives of outcomes (uninsured rates by race/ethnicity and state uninsured rates) and politics. States that expanded Medicaid through the ACA were shown to have the greatest change in uninsured rates, compared to states that elected to not expand Medicaid. 

The discussion shifted to subsidies, which are used to provide assistance for individuals who aren't eligible for Medicaid to purchase health insurance. Massachusetts subsidies were shown to be larger and better in coverage than federal subsidies, leading to better uninsured rates in Massachusetts. Furthermore, Massachusetts has experienced significant increases in many outcomes. 

The next topic of discussion focused on the recent administrative actions to weaken the ACA:

  • Weakening the individual mandate
  • Reducing subsidies 
  • Discouraging enrollment/re-enrollment 
  • Disinformation 
  • Encouraging states to weaken Medicaid

Despite administrative actions, Massachusetts still has a statewide individual mandate, leading to public outreach and marketing efforts to inform Massachusetts residents (the #StayCovered campaign). Turnbull presented some data showing details of the approximately 2 percent uninsured in Massachusetts, gathered from state tax filings. These data demonstrate that the majority (64 percent) of the approximately 180,000 individuals are actually eligible for programs based on their proximity to the federal poverty level (FPL). She also showed data indicating that the biggest gains in coverage have been among young adults, traditionally one of the largest (and least changing) demographics among the uninsured.

Brian Rosman

The second speaker of the evening, Brian Rosman (Health Care for All), presents his organization's work as an advocacy group working to improve the Massachusetts health care system. He presented the current state of affairs, including changes to Medicaid financial policies, court cases, the congressional stalemate, and action moving to the states--leading to a discussion about what states can do:

  1. Expanding Medicaid: Individual states are putting up ballot measures to expand Medicaid, and half a million Americans stand to receive care as a result of the recent elections.
  2. State-Level "Obamacare": Individual mandates are being implemented at the state level, and these efforts resist federal efforts to sabotage and allows states to regulate large employers' coverage.
  3. Better Obamacare: States can add money to Obamacare subsidies (some states are considering a hospital tax or other taxes).
  4. "Wonky" Insurance Things: States can merge individuals and small groups, enable reinsurance (state covering extremely sick patients as a "nod" to insurance companies), permit Medicaid buy-in options on exchange, and regulate minimum loss ratios (administrative costs that result in rising premiums).
  5. Better Medicaid: States can expand dental care in Medicaid to combat disorders that are intricately linked to dental health.
  6. No Worse Medicaid: States that have work requirements for Medicaid can result in worse Medicaid coverage.
  7. Lowering Drug Costs: States can facilitate transparency in drug pricing, regulate pharmacy benefit managers, import drugs, and set the maximum price for drugs.
  8. Pay Attention to Social Determinants of Health: States can spend a little more money on things that actually make people healthy (medical influence on health is estimated to be about 15 percent). Rosman then presented some efforts for Medicaid to cover health-related social needs, shifting away from traditional medical care. Insurers are also being taxed to fund public health programs to address community health factors leading to high medical costs.

In the final part of the session, Rosman gave some parting information about single payer/Medicare for All systems., highlighting the similarities and differences between them. He highlighted the failures of Vermont's attempt at implementing a single payer system because of the principles of behavioral economics--people fought against the potential losses of higher taxes more than the potential gains of health insurance coverage. He ended by challenging the students to engage in a  discussion on the future and feasibility of single payer (and other universal health care) systems in the US.

Changing the Landscape of Health Care

Changing the Landscape of Healthcare

In this class, entitled “Changing the Landscape of Health Care,” the class discussed efforts to build, improve and sustain health care delivery and healthier communities. The guest speaker for the evening was Sandra Butler, Senior Manager for Global Business Strategy, at the Consortium for Affordable Medical Technologies (CAMTech), Massachusetts General Hospital Global Health. She discussed the critical need for innovation in low-resource settings and provided some practical and clinical insights from collaborators in Uganda and India, some “rapid implementation” strategies and economic incentives for value-based design. Using the model of co-creation, which recognizes the need for cross-disciplinary and intergeographic teams to work in concert throughout the product development pathway, Butler described CAMTech’s approach to empower innovators to identify and solve for unmet health care challenges. Their five-step methodology, which progresses from problem articulation to rapid ideation to expert review to solutions sprint to acceleration and scale, facilitates the development of innovative medical technologies by employing iterative contributions from individuals in engineering, health and business in intergeographic teams. She emphasized the importance of “failing fast” using the Build-Measure-Learn approach, which is a feedback loop to quickly build ideas to products, measure how customers respond to products and learn whether to pivot or persevere.

This core approach has been applied to CAMTech’s recent activity as a public health “first responder” by promoting innovation in addressing domestic issues such as the opioid epidemic and gun violence prevention. They have found that their approach to global health innovation—which encourages a diverse community to co-create innovative solutions—has translated well to development of innovative approaches for these issues.

"Yes there’s social value but there’s also business value which means these [health innovations] will have legs."

- Sandra Butler, MGH CAMTech

Finally, Butler presented some case studies of innovations coming out of CAMTech, including a neonatal bag-valve mask device that was recently taken on by Philips, Sani Drop, a Ugandan hand sanitizer that addresses the unique needs of health care workers in Uganda and PillPack, a medication assistance platform that was recently acquired by Amazon for $1 billion. She noted the impact of these various types of technologies and the increasing need to revisit their non-profit business strategy in light of successful technologies. Students participated in a “show-and-tell” with demonstrations of all of these technologies, noting their usability, design and practicality.

Demonstration

To wrap up the session, Prof. Chris Skipwith (NAS) discussed how science and technology can be harnessed to improve the health of some of the poorest people in the world by highlighting the needs for drugs, diagnostics, vaccines and delivery devices to address high-burden diseases that affect the poor in low and middle-income countries. In particular, Prof. Skipwith focused on key constraints to investments in such products and financial and business model mechanisms to overcome these constraints and encourage the development and uptake of enhanced diagnostics, drugs, vaccines and delivery devices. Using the model diseases of tuberculosis, onchocerciasis (river blindness) and malaria, he demonstrated what ideal forms of drugs, diagnostics, vaccines and delivery devices would be to more effectively, more efficiently and more affordably address high burden, communicable and parasitic diseases. An emerging threat of drug resistance was demonstrated, showing a need to urgently develop new innovations in treating these types of diseases.

The conversation then shifted to identifying the constraints to meeting the ideals for products that enable better health of relatively poor people in low and middle income countries. Students identified, through many examples, a perception of a limited market in low and middle income countries, spurred by varying market forces, high costs of research and development and the high opportunity cost of development. From this conversation, the class discussed measures that countries or the global community together could take to address some of these constraints and change the perceptions of the market—generally categorized into push and pull mechanisms of development. Push mechanisms have to do with lowering the costs to potential developers of products by providing direct financing, financing clinical trials at the expense of the public or national research institutions, or offering tax credits for research and development. Pull mechanisms incentivize developers in the later stages of development. For example, encouraging countries to uptake more to help create the impression that there is a larger market can spur development. Offering prizes, patent extensions, market assurances and tax credits for sales are other examples of pull mechanisms.

Prof. Skipwith provided a number of examples of these efforts, such as Grand Challenges in Global Health sponsored by the Bill and Melinda Gates Foundation, the U.S. government and the Canadian government. He also described the creation and operation of Public Private Partnerships for Health (or Product Development Partnerships) to address market imperfections by brokering arrangements between the public sector, research institutions, the private sector and other important actors to set a foundation for the more rapid development of drugs, diagnostics, vaccines and delivery devices. Using the example of CAMTech’s co-creation platform presented earlier, Prof. Skipwith detailed the impact of these Product Development Partnerships. Finally, the class reviewed some innovative financing mechanisms, to help overcome global health market constraints, most notably the Advance Market Commitment (AMC) for vaccines, which aims to encourage investment, development and manufacturing of vaccines that can be sold at affordable prices in low income countries. At its onset, the AMC was a fund to make financing available to vaccine manufacturers that could create the number of vaccines needed by an agreed time to be sold at an agreed price. The overall effect of this innovative financing mechanism is to demonstrate market and capital viability in the face of market uncertainty.