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TAT’s flagship newsletter has been getting readers ahead of the day’s health news for two years — and to celebrate, we convened a group of experts in the Boston area to talk about the most pressing issues in health and medicine.

Our panel: Dr. Sandro Galea, dean of the Boston University School of Public Health; Kate Walsh, president and CEO of Boston Medical Center; Mary Tolikas, engineer and operations director of the Wyss Institute at Harvard; and Dr. Harris Berman, dean of Tufts University School of Medicine.

The following excerpts have been lightly edited and grouped together thematically.

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On the vast health gap between rich and poor

“There’s a lot about our health in this country that we find acceptable that should be unacceptable. For example, for those born in 1930, the life expectancy gap [between the richest 20 percent and the poorest 20 percent] was six years. For those born in 1960, it’s now 12 years. And because everybody knows this, we sort of think it’s how it is. But it actually shouldn’t be. Actually we, as a society, should be outraged by this. We have conditioned ourselves to say this is OK, and it’s not OK.” — Galea

“[We should think of health equity] a social justice construct … [so we’re] thinking about criminal justice reform as it relates to opioids, or housing it relates to health, or access to clinical trials. At Boston Medical Center, we treat a population that’s underserved and understudied. What does that mean to their clinical endpoints on the medical side?” — Walsh

“We, as a society, should be outraged by [health disparities between rich and poor]. We have conditioned ourselves to say this is OK, and it’s not OK.”

Dr. Sandro Galea, dean of Boston University School of Public Health

“Right now, Medicaid is so underfunded, and pays so poorly, that doctors really would much prefer to take care of people with commercial insurance or even Medicare than Medicaid. I think we make the disparities worse by skimping on Medicaid.” — Berman

“Our pediatricians will tell you stories of kids who are at our clinic, failure to thrive, they’re scratching their heads, they’re giving all kinds of nutritional supplements, kid isn’t growing, kid isn’t growing. Got into stable housing, kid’s thriving. We have story after story for that. And ‘got into housing’ was really the prescription for that kid.” — Walsh

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Mary Tolikas, center, operations director of the Wyss Institute for Biologically Inspired Engineering, speaks about health, medicine, and biomedical research with STAT reporters. Alissa Ambrose/STAT

On the half-million-dollar drug

“When I read these stories of $475,000 drugs [such as the newly approved Novartis CAR-T drug], I’m just perplexed. How are we going to pay for this? If this has to be factored into the premiums, which it does, the cost of health insurance is going to become absolutely unaffordable. And yet if we don’t give Novartis and biotech companies the opportunity to make money with their new discoveries, there’s the threat that we won’t have new discoveries. I don’t have an answer.” — Berman

“When I read these stories of $475,000 drugs, I’m just perplexed. How are we going to pay for this? … I don’t have an answer.”

Dr. Harris Berman, dean of Tufts Medical School

“Our concern primarily has to do with lowering the cost of the actual technology — using different materials, different approaches, toward trying to at least lower that cost. Once it gets translated and gets moved out into the commercial arena, other forces come into play. But it is encouraging [that] on the research side of things, I see a lot more risk-taking and a lot more lower-cost solutions coming.” —Tolikas

On how hospitals and doctors get paid 

“This seemingly boring, inside baseball topic of payment systems is probably the most important thing that we can collectively focus on to actually improve our outcomes from our medical systems right now. I am convinced no one understands that. I think it’s our shortcoming as a collective public health [community] that it’s not out there.” — Galea

“Hospital executives hate the Medicaid program because the payment is terrible. But I would submit it’s the most important program in our country. It insures about 83 million Americans — half the births, more than half the kids, and 70 percent of the long-term care spent. Think about that. And everybody hates it and doesn’t want to expand it?” — Walsh

“Hospital executives hate the Medicaid program because the payment is terrible. But I would submit it’s the most important program in our country.”

Kate Walsh, CEO of Boston Medical Center

“I think as a general test of basic literacy, we could ask people in the general population, ‘Do you think your physician is paid in some way to make sure that you stay healthy? Or do you think we pay your physician more the number of times that you show up to her office sick?’ My guess is the vast majority of people would say that, ‘Surely my physician is paid to keep me healthy.'” — Galea

On helping the public understand science

“I actually think that one of the biggest challenges that this country has in terms of understanding health is understanding that health is much more than medicine. We tend to think of health literacy as understanding my doctor’s prescriptions, understanding what I may read about side effects. I think that’s an extraordinarily narrow conception of health literacy. … Health is a product of medicine, but also a product of so many other traditionally non-medical factors.” — Galea

“We’re not educating the public enough. … And we can’t wait for another decade. … We have to start now.”

Mary Tolikas, operations director of the Wyss Institute at Harvard

“It’s very difficult to grasp it all. … Some of these topics they touch ethics, they touch pure science, they touch us as human beings and how we react to others. It’s very difficult to present them to the public.” — Tolikas

Particularly in medicine, we’re sort of used to things changing. We tell our students that what we’re teaching them today, 50 percent of it will turn out to be wrong 10 years from now and they just have to keep learning so that they stay up. But the public doesn’t quite understand that.” — Berman

“If you take someone average in the public and ask them what the microbiome is, they don’t know. Or synthetic biology. … There are things that are happening that we’re not educating the public enough about. And we can’t wait for another decade … for people to react. We have to start now.” — Tolikas

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  • Guess you can tell I’m pretty passionate about this…”And another thing”….In terms of educating the public about health, instead of talking about human biomes and such – let’s spend time, money and focus educating about nutrition and the effects of foods and chemicals on inflammation, heart disease, diabetes, etc. Heck – we have entire generations of kids growing up on nothing but chicken nuggets – which are barely chicken! And then we wonder why some kids don’t thrive? Let’s educate these teenage and inner city moms to cook with fresh ingredients and get them access to fresh foods. I’ll volunteer! Health really starts with what you put in your mouth! That’s where health education needs to begin – instead of prescribing meds to cover up the effects of poor nutrition. Final post. Pinky swear!

  • In regard to the cost of new/novel therapies like Kymriah – where the R&D costs are billions to bring it to market, why can’t the FDA and EMEA figure out a way to allow drug companies to obtain approvals along parallel pathways instead of paying for 2 separate paths using data from 1 overall trial? That seems to be a huge part of the expense. As for Medicaid & healthcare in this country, the lack of focus on mental health is a detrimental & underlying catalyst of so many other socioeconomic ills. How many of those kids who don’t thrive have a parent with untreated mental illness? So much to solve – and the government can’t be expected to pay for it all – but neither should the middle class.

    • And I suppose another thought about the cost of treatments is directed at payers – who are the ones that really control whether a patient gets the treatment. And thinking out loud in the case of Kymriah – apparently it will only be approved for these kids as a last resort option. I wonder how much cost of total treatment would be eliminated if administration of Kymriah was moved up in the treatment protocol timeline where the cost would then be offset by eliminating chemo/radiation etc. steps? (I don’t even know if that’s possible, but I do know that payer requirements sometimes drive these treatment requirements.) And yes – this is about 600 kids a year. But Kite is coming up with the same type of treatment that would potentially be thousands. But another thing that’s happening that people should be aware of is creative reimbursement! For instance, I read where Novartis is saying they don’t expect payment if the patient doesn’t respond to the treatment in a month. Outcomes based reimbursement is complicated but at least the community is trying to figure out reasonable options! So let’s not paint the dismal picture that greedy pharma isn’t trying to work on rational solutions! My family has been decimated by cancer – I don’t want R&D on these miracles to stop!

  • Whining about CAR-T price that can treat most, what maybe 600 kids a year? It’s a remarkable breakthrougg that cost over a billion in private research dollars, not including all the basic science research. And they’re clearly looking for other indications.

    So let’s not be so damn dense to suggest that medical development will come for free. The tradeoff of curing Hep C, of CAR-T, etc, is that health care is more expensive and people will live longer thus expending more. Is that a goal or not?

    And, frankly, how much of Medicare spending is drugs? How much hospitals? How much long term care? How much doctors?

    Instead of whining from a position of major cost basis, why aren’t we talking about outcome based pricing, static pricing, PBMs, etc?

    Could pharma lower prices some? Sure. But is the squeeze really going to be the pancea? Nope. It’s just a popular shint object

  • “For those born in 1930, the life expectancy gap [between the richest 20 percent and the poorest 20 percent] was six years. For those born in 1960, it’s now 12 years…we, as a society, should be outraged by this. We have conditioned ourselves to say this is OK, and it’s not OK.” — Galea

    it’s easy to express outrage about life’s inequities, but infinitely more challenging to identify and implement solutions. not to mention, each solution inherently comes with its own drawbacks.

    as long as healthcare draws upon scarce resources (hospital infrastructure, physicians’ time, etc) that come with real costs, the wealthy will always have better access to care and longer life expectancies.

    • “as long as healthcare draws upon scarce resources (hospital infrastructure, physicians’ time, etc) that come with real costs, the wealthy will always have better access to care and longer life expectancies.”
      This is only true in countries like the USA that do not view access to health care coverage as a right of everyone. These disparities exist for a variety of socioeconomic reasons, but a significant barrier is lack of access to robust health care coverage. Good health and access to care should not be reserved for the wealthy, and most other industrialized countries have made a commitment to promote health for all citizens. These countries have made a much larger dent in eliminating these disparities.

      And Vic- personal responsibility? Please research the root causes of poverty and institutional racism in the US. You cannot possibly be promoting the idea that these significant disparities exist because specific groups of people do not want to take responsibility for their own health.

  • Health literacy could easily be addressed. We here at http://www.quizzify.com have offered our product basically free — about $1 a member a year — to Mass. insurers and can’t get our calls returned. Play the sample questions on the site. Even readers of STATNews will learn a thing or two.

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