Ascending Colon Cancer

thomas miller: good morning, everyone. welcometo the american enterprise institute. i’m tom miller. welcome to our discussion thismorning on “closing the gaps in health outcomes.” this is a little different approach to healthcare and health policy in washington. you actually have to think about what works, asopposed to what you’ve been doing before. it’s been attempted on occasion, not thatoften. let me give you a little bit of a very highlevel, oversimplified, exaggerated overview. our purpose today is to think about healthoutcomes, not just intentions, not just we tried to look at what we, you know, threwup against the wall, but what actually began to, perhaps, could make some differences inwhat should matter in our health policy and

health care system, where the people actuallyend up being healthier. we do a lot of other things set to move in that direction.and we wanted to take a look at this from a longer time horizon than the standard washingtoncycle of two years till the next election. we’re already campaigning, so if it doesn’tpay off right now, i guess it really doesn’t matter. there’s a longer life that mostof us lead, as opposed to the political lives that our office holders have, and we mightwant to think about what actually matters over that long-range perspective.and also to think about, we know that health care, health insurance, coverage, all thewonderful things our system can do in treating people who are already ill is important andit’s necessary. and we’ve made some steps

to improve that. there are mixed opinionson that, but it may not be sufficient in order to actually get the type of progress we’reseeking. and we’ve got a long trail of evidence on that front.so it’s not just a matter of more or and – let’s put some more things on top ofthe pile. don’t take anything off. but perhaps a look at some better tradeoffs, at leaston the margins, because although we like to imagine that resources are unlimited for agood cause, they turn out to be a little constrained. we need to think about what we’re gettingfor what we’re investing and what we’re doing.what we’re going to talk about today are some promising areas of some other directionsor better directions to pursue more aggressively.

it’s not an exclusive list. there’s alot of other good ideas and things to do, but these are a few that we want to highlighttoday that perhaps haven’t gotten the emphasis that they deserve.so in that regard, we’re going to take primarily a look – and this is oversimplification– at about three alternative paths forward. the first, for want of a better term, is theimpact of early childhood development on not only your current health, but long-term adulthealth. and there’s a lot that goes into that. it’s more than just standard childhooddevelopment, a lot of science behind it. but that’s the broader framing perspective onit. now, that’s a lot of the focus on the frontend, which is what we can do in the future

and how we’re building a base of healthypeople. we’ve got a lot of people, though, who are currently in the system of differentages, different conditions, and you can’t just say, well, sorry, you came too late,we’ll just start all over again. so what do we do about improving the actualperformance of the system, so it begins to communicate and talk to and serve the peopleit’s supposed to be serving, which is the focus of another presentation on, for wantof a better simplified term, patient navigation. not how do we get – find someone to sellyou a health care – health insurance policy, but actually connect you up with the resourcesin a very complex and expensive system, so that you’re not just bobbing around in alot of disconnected parts of the system where

they don’t talk to each other and the peoplearen’t at all focused upon “how is it best focusing upon what the patient need andwhat can you best serve them?” and the third area, again, there’s moreinvolvement in this, but we’ll use the broader term of behavioral economics, what goes intohealth behaviors, shaping them, the various, if you will, psychosocial skills that go inshaping that. and there’s a broader perspective on that. but that’s kind of the overall.and all of this, we’re doing this from the framework of it’d be great that this worksfor everyone and across the board and we’re all coming out ahead, but particularly payingattention to, in our health care system, how the broad term “disadvantaged population,”which covers a lot of territory, who’s most

vulnerable and who gets hurt the most underthe current – (inaudible) – how can we help them more.so let’s put a little context on what we’re talking about. promising more of the sameis not surprisingly most likely to deliver more of the same. we’ve done that before.we’re doing that currently. we’ll do that again. but were trying to stretch beyond that.we’re also going to take a little bit look at it – in the time allowed – a bit moreof a multidisciplinary science of human development. a lot of factors go into not just whetheryou’ve got well-baby care, but how that child ends up developing and growing and allthe different things we’re learning in a much more sophisticated way about how thebrain develops, how that affects the rest

of the body, your health, the whole environmentin which someone grows into their adulthood and what goes on.and a bit look at – although we have a lot of phrases about – well, here’s the basicpolicy point. if we can think about early prevention, not in the standard way of “ibagged and tagged you and you got the required test,” but prevention which actually meansthat conditions that might otherwise occur don’t occur before they have to be treated.you actually reduce the demand into an expensive and complex health care system. that’s adifferent approach that we’ve done traditionally in the united states, which is a later remediationand treatment, fix it again and fix it again some more, which we can do sometimes verywell, but wouldn’t it be better if we didn’t

have to only resort to that at the back-endstage of what we try to throw money things in order to correct what wasn’t done earlier?also to take a look at both the whole (child ?) in all of its dimensions and the wholepatient. we tend to look at fragments of these things. if there’s not a billing code forit, sometimes perhaps it doesn’t look into the larger integrated matter. and then tolook at improving risky environments and helping fractured families; to take the american populationas it is, rather than as we imagine, but there’re some people who need a lot more help and howcan you reconnect those broken pieces at an earlier stage? and then, within the realmof what’s reasonable and possible, sometimes you can overpromise in this, more of an integratedcare approach for more complex clients.

now, this all sounds wonderful and then youunderstand we’ll have to face actual evaluation. so what are some critical questions behindall of this? you know, you can sketch out a theory, but you have to face some harderquestions. there’s real evidence for what might work and how effective it would be.what are some metrics of success? what impact are we looking at? what’s the timeframe,the net payoff? some things can deliver something right away, very visible, others have notonly longer term latent effects, but perhaps cumulative, where what you did at an earlierstage begins to pay off on a longer timeframe than what you first see right over the horizon.are a lot of these ideas and concepts and programs – are they scalable? can you gobeyond what works in one place to somewhere

else and replicate it and produce it on alarger scale? the tradeoff, though is you start saying, well, this really is great.we’re going to do it for everybody. there’s a degree in this field of – need for somecustomization, some localized approaches to things. so you can’t just say it’s, youknow, here’s my evidence. boom, we’re off with a kind of a national program. andthat’s the tradeoff between things that are sensitive to the community based resourcesand values in which they’re operating, as opposed to got a problem, got a national plan,got a program, we’re off to the races. so as things are going to be universalized,there’s always the temptation to say since it’s so wonderful, we’ll do it for everyoneand everyone will be happy about it or is

there a need to be a little bit more targeted?or is there an intermediate step, perhaps making things available to everyone, but recognizingthat other people need special assistance in getting access to them. that’s more ofthe sliding scale subsidy approach, although we can stretch that to where it looks likeit’s the same thing as a universal program. ok, so some dangers and pitfalls in goingdown this road. let’s talk about our political system fora minute. it’s hard to get success in washington for a good idea unless someone can gain politicalcredit for it. so you have to dial in the office holder and say, oh, you thought ofthis. thank you very much. and you can kind of put your stamp on it. that’s the tendencyto say if you can’t put it in legislation

or have a subdivision of a departmental programwith a funding stream, it doesn’t really exist, even though these things are much moreattenuated and indirect, perhaps, in the standard cookie-cutter washington approach.there was a paper, i recall, looking at the health policy in the 1990s by some esteemedresearchers, and one of their subtitles was – this is the clinton days – “feedingthe middle class.” i would add feeding the middle class first, feeding the middle classmost, feeding the middle class most visibly. that’s, unfortunately, our political formula,even though it tends to overlook the individuals who need the most help. and it’s not thesame thing as if you do something for everyone, you may not be doing very much for anyoneat all, wide and thin approaches. but that’s

another set of tradeoffs in the politicalmarketplace. overgeneralizing and overprescribing – we’veseen that before. things that can work well and be promising in one context may not necessarilybe the same everywhere, so you have to then respect some of the limits. and diminishingreturns: what may be very good in one application, if you keep doing it, may have diminishedreturns or it may apply to particular populations at particular times, but not necessarily havingthe same equation at different points in the lifecycle.another problem is what do you do about the installed bases i referred to before? i usuallyget this in computer terms, but, you know, there’re just a lot of people who are movingup the age scale who already have their chronic

conditions. they already have their medicalconditions. so it’s not just a matter of saying you’ll never get sick because wedid these things. you have to think about other ways in which the health care systemcan adapt to them. or the fractured families that need to be reconnected as opposed tostarting from the beginning. we have a little bit of a condition that’sbeen diagnosed more rapidly, political attention deficit hyperactivity disorder, where we getreally excited about something for a brief period of time and wave our arms, and thenmove along and forget about it. we need a little more patience and a longer-term lookat this. reimbursement food fights will, of course,be prevalent here. if you move some of the

dollars from where they currently are to somewhereelse, there may be a few cries for saying, “oh, we do that, too.” we have a billingcode for that that provides the same type of services. i’ve seen discussions of pediatricmedical homes. i’m waiting for a prenatal medical home coming next, probably have acosfor particular disadvantaged public – i mean, there’s a tendency to redefine thingsto say “we actually do that. we can get the money as well,” as opposed to what mightbe a fresher look at sensitivity to cultural norms and parental prerogatives.as wonderful and excited as we can be about how a particular intervention may work, weneed to remember that just imposing it from the top down, knocking people aside, sayingwe know what’s good for you, we have a better

idea as to how to parent your child than youdo. there’re some boundary lines here you want to be careful about how you cross themand how you do that in a much more sensitive manner. you can break things while you thinkyou’re fixing them. but in all of this, the more important thingis you can be paralyzed by all of the what-if and you having shown this and it could happenlike this, let’s get started and adapt along the way to actually do something by doingmore of it and learning, as opposed to it being a settled equation. soi’ve learned in a presentation a long time ago from someone else about how you actuallymake something work in washington, do it as a standard diversion. first, you have to havesome enemies. you have to have some allies.

you have to have some anecdotes. but one ofthe most important things in a program is you have to have a slogan. you actually – youcan simplify it on a bumper sticker. you’ve got to put it right up there.so i’m going to give you a couple of slogans that might work for this, some better, someworse, some visual, some not. we want to talk a little bit about tactical myopia. that wemight only be able to see what’s right in front of it and might need a little correctivelenses in order to see the wider field on a longer-range basis.some other slogans, this is the fram oil filter tv commercial, a long time ago, you can payme now or pay me later, with the mechanic coming out from underneath the care, suggestingthat perhaps what seemed like economizing

measures initially end up being more costlylater. sometimes it’s good to invest in something for whatever turns later. actually,in i think one of gabby’s papers, not quite as a ringing phrase, from redistribution topre-distribution, although it actually deals with the content as to how we change the wayin which we help out people who are going to fall behind the list. you give them someassistance. from the field of baseball and yogi berra, it gets late early, which wasoriginally referring to the shadows of yankee stadium in the fall, but it also means thata lot of the things that we miss out on in terms of what could be waged to improve people’shealth, if you don’t do them early, you’re going to pay for it later on.patient-centered is one of those overused

wonderful phrases that perhaps has lost meaningby being used too much. and “we’re here to help” is already one that has some problemswith governmental sources. but there are some people who are here to help that we need tothink about how they could help more effectively. so more visually, we want to break down andreconnect the silos so that they’re not all of the different bunkers and programsof our health care system which don’t talk to each other and integrate in the way inwhich they’re dealing with the entire patient or the person in front of them. is there alight at the end of the tunnel? this actually is not william westmoreland in the vietnamera, but it was robert lowell because he asked, is it just an oncoming train. so we thinkthere is some light, but you can dodge some

obstacles along the way.and finally, a couple of other things, going way back in time to a long-running tv gameshow, “truth or consequences.” that was actually bob barker’s big – and he’sstill alive today, by the way. i think he’s 91. but this was the idea where they wouldstart out by saying – they’d ask people a question. if they got it wrong, they’dhave to do some zany stunt. that’s pretty much what we do in our political system.however, the other idea is if we don’t begin to deal with some of these truths, we’regoing to continue to suffer the consequences. and in the larger scheme of things, althoughwe’ve had some progress in our health care system, health care spending, blah,blah, blah, it’s not as bad as it was, we

still got a lot coming into the system. we’regoing to need a bigger boat in order to have some other tools.so with that rather light introduction, let me introduce a couple of our speakers forour opening set of presentations. this is focusing upon early childhood development,because i scramble around. we have dr. frances campbell, who’s a senior scientist at thefrank porter graham child development institute at the university of north carolina in chapelhill. i mentioned barak richman, another speaker from north carolina – from duke. this isthe only nonpartisan, peacemaking effort we’re – (inaudible) – both unc and duke on thesame panel without any major conflagration occurring; if only they could learn aboutthis in the gaza strip, we’d have a safer

world all about this.frances is internationally recognized for her work on the abecedarian project, whichis one of the longest running longitudinal studies in the world. and she was there fromthe very beginning, working with a group of infants in 1972 and hiring the other folksin that project. it followed those children as they’ve aged into adulthood with someremarkable findings about what the effects are on their broader lives, but also theiradult health, in a more recent article in science magazine with gabriella conti andseveral other co-authors. i think those findings are quite remarkable and tell us a lot aboutwhat we can learn from that. frances also conducted research on how childrenin head start programs make the transition

to public school. she served as a member ofthe white house conference on early literacy and a member of – was member of the pritzkerconsortium on early childhood development. and she received the 2007 alumni distinguishedservice award from the university of north carolina, greensboro.now, i mentioned in passing, dr. gabriella conti was co-author on the article in science,but also a wide range of literature in this field. she’s an assistant professor in thedepartment of applied health research at the university college london, faculty researchfellow at the national bureau of economic research; research affiliate of the populationresearch center, university of chicago, and a host of other affiliations. i’ll compressthem right now. but what’s remarkable out

of her work it’s how it derives upon sucha wide range of fields: biology, genetics, epidemiology, neuroscience, medical economics,and the economics of human development. and she’s developing an integrated developmentalapproach to health from before conception and is modeling the economic, social, andbiological mechanisms that produce health inequalities over the life course and acrossgenerations. we have two other speakers, as well. but we’llstart at this point. we’ll open with dr. campbell, and then gabriella will completethe presentation, kind of a joint production. dr. frances campbell first.frances campbell: thank you. well, let’s see. the abecedarian project began, as hesaid, in 1972. it really was a multidisciplinary

study, so when i say it didn’t have a medicalfocus, that’s wrong. it had – two primary investigators were adevelopmental psychologist and an educational psychologist. and that was the psychologicalpart. the other three investigators were all doctors. and so from the get go, the childrenin the treated group got their primary care at the center and were closely followed medically.they were primarily looking at infectious disease kinds of things.that part’s not a randomized study. our part, the psychological part, was. i’llgo very quickly over this war on – you know, the problem of poverty and poor kids who arein trouble. we all kind of know that. the war on poverty had just happened and headstart had just happened and everybody was

so excited. and then, everybody was, oh, no,head start, what’s that. what happened? maybe we did too little too late and thiswas – can you hear me – this worked to the advantage of craig ramey, who was reallyinterested in contingently responsive environments for young kids. and he really wanted to seewhat kind of difference you could make if you really started with very young children.and as gabby will tell you, there’s a lot of literature that talks about the importanceof it very early in the lifespan. so craig wanted to see what he could do withvery young children. and broadly defined, the frank porter graham institute at thatpoint was an mrdd study. and so the prevention of mild mental retardation, which is moreprevalent in kids from low backgrounds who

don’t look sick, i mean they don’t havesome obvious syndrome. so that’s the kind of child that we were targeting to find.the focal question – and let me get to my focal question – could we prevent this progressive declinethat seemed to – cross-sectional research indicated that kids from poor backgroundslooked pretty good as babies. and then, if you get standardized measures on them, eventhough they don’t see anything wrong, they just go down, down, down. could you preventthat if you started early? so that’s what we did.the target population, it’s not – this is not a huge study. we started out – wehad about 122 families that agreed, either

at the social service and the medical school, yeah,we might be interested in talking. a hundred and twenty of them actually came in and iinterviewed the mothers and gave them a test. of those – those people got random assignments.at that point, who turned us down for the most part were people who got the treatmentbecause they did not want their infant in full-time care. so i won’t go into morethan that, but we ended up with 111 babies born to 109 mothers. ninety-eight percentof these children are african-american. that’s just what happens if you’re poor in chapelhill, north carolina. so this is our study design. we had a poolof subjects and they’re randomly assigned. they’d be either in the treatment groupor the control group. and this summarizes

the early experience of those children. youcan see on the right side what the treated children got. they were in full-time, all-daychildcare. we quickly found out that if we didn’t go get them, most of them couldn’tget where we were, which was not walking distance from where most of them live. so we broughtthem there and they were there for the first five years of their lives. and i think that’sprobably critical because they knew where they were going to go andthey knew who was going to be there when they got there. the staff was very stable.in order to have people not say, well, you made the kids look better just because youfed them better, for the first 15 months of life, the children in the control group weregiven iron fortified formula as much as they

could drink. we stopped it at 15 months, becausethen they’re sort of concerned about their teeth. the kids at the center got the samestuff. they got a good two and a half meals, two meals and a snack every day.i said they were in a stable environment, knew who was going to be there. the kids inthe control group, various and sundry, they weren’t all home with mom, but they probablyhad a lot more variety in their daily lives. primary pediatric care on site. i said therewere three doctors involved. so children in the treated group had their primary care thereand they were monitored daily. and i think our best carrot for the control group is theygot free disposable diapers. ok, the major outcome, because we were lookingat intellectual development was performance

on standardized tests. and here’s the bottomline for the first five years. you can see, the red line is the control group and lookat the very first thing, that’s three months. and the kids are right on top of each other.they really were not different at the beginning. by the time they’re three, they’re maximallydifferent. and i’m going to hurry here. this is what happened after that. this isthe – when they entered public school, we created two more randomized groups. the topgroup got three more years of early intervention in the public school. and the second one downjust had the five years and no follow on. in the control group, half of them got thatthree years in public school. and then, we have the untreated untreated. and that programlasted three years, till they were eight.

i’m not going to talk much about that. wefollowed them up when they were 12, when they were 15, when they’re 21, when they’re30. and every time we did that, we were looking at the random effect, you know, the randomizedgroups. and we’re primarily looking at cognitive development and, as they got older, what kindof academic performance they had and what kind of jobs they had, what kind of educationthey attained. that’s the iq trajectory up to age 21. andthe point of this is it’s very large in the early years, when they’re being treated.it goes down considerably from that when they get into school. but the point is they neverconverge. you could have knocked me over with a feather, when i thought they’d be on topof each other at 21. i really did. well, they

aren’t.ok. i’m going to tell you a little bit about what they were like when they’re 30. i think30 is the right time to tell you because if they were going to college, they were outof college, so we can look at graduation rates. and this is the educational attainment. it’sstatistically significant when they’re 30 years old. it’s not huge. it’s about oneand a half years more on average for the treated group. but this is my favorite slide. thisis college graduation. they were three – let me see,is it three – four times more likely to have graduated from college if they were inthe treated group. now, those are not huge numbers because at the time they’re 30 – isaid we started with 111 kids. at the time

– but the time they went to school, we weredown to 105. at 21, we saw 104 of that 105. at 30, we got 101 of them. and so our attritionhas been really, really good up to that point. but how many of them graduated from college?fifteen; 12 of them were treated, only three in the control group made it. and the otherpoint i want to make is that if you look at the treated kids who graduated from college,the males were just as likely to get out of college as the females. however, we had threepeople who had gone on to do some graduate work, and all of them are girls. let’s seeit for the girls. this is the income to needs ratio and thisfrustrates me considerably because it’s in the right direction for treatment, butthe income just by itself didn’t make statistical

significance because the distribution wastoo broad. we had some pretty good people in the control group and some pretty – anyway.full-time employment, that is significant. we went back for two years and to be countedfull time, you had to be working 30 hours a week. they were significantly more likelyto have been working full time if they had had preschool treatment. remember they’re30 years old now. need for public welfare, that’s a whoppingdifference. not that many of them were on welfare, but the probability that you wouldneed it is much, much greater if you had preschool treatment – didn’t have preschool treatment,as you said. ok, now the other biggie for early childhoodeducation, if you’d listen to the preschool

stuff, is the reduction in crime. how didwe do? we didn’t. we simply don’t see that in the abecedarian study. this is self-reportsand it’s in the right direction, but it’s just minuscule. and we have actually searchedcriminal records, too, and it’s the same story.ok, the point of this slide, and i’ll say it really fast, is that the home environmentstill mattered. it wasn’t that the quality of your home environment was irrelevant ifyou had treatment. we’d totally make up for that. but what you see is that if yourhome environment’s really poor – and what we’re modeling here is education at 30,how far you got. if your early home environment was really poor and you’re in a controlgroup, you really didn’t get very far when

you’re 30. but if you’d had early treatment,you’re almost as well off. but you can also see, if you look how it plays out, when youget to the really good home environments, the really good home environment adds on.so it’s not like we totally replaced what the family brings to the table. i want tomake that point. let’s see. now, we come to our latest claimto fame, which was a challenge grant. here was a chance to take a randomized look atthe health of these people. the early doctors did tons of research into lots publicationswith sort of correlational, what went with what, because we don’t have thekind of medical information about what the control kids, how sick they were, why theysaw doctors, and all that kind of stuff.

so we got a challenge grant to send everybodyto the same doctor for physical and to look at the results of those physical exams asa function of whether or not they had the early childhood program. so we got the money.we collected the data. we had our worst attrition problem ever. we had 12 people in both groupswho were eligible and we found them, and they said they didn’t want to do it. and a lotof them were afraid to go to the doctor and they just didn’t. some were very busy professionalsworking away and didn’t have time to – anyway, we had more attrition. the bottom line isof our 111 kids that we started with, we only got 78.that said, we found a significant difference in their health as a function of early childhoodintervention. when they were zero to five,

we know that they were in full time childcare,educational childcare. we know it made the kind of difference in cognition that i havesaid. it also made a difference in their health. and i’ll let gabby tell you what.oh, wait, let me flip, flip, flip, flip. here’s my acknowledgments. those are the name ofour famous start people. you’ll notice down there is the evaluator. and these are thepeople who work on the challenge grant. and these were our funders. thank you.mr. miller: thank you, dr. campbell. you know, there was a conference just last week i thinkon health care spending, where alice rivlin of brookings, who’s co- chair i think oftheir rwj commission on healthier america, said if she heard one more mention of theperry preschool project, she’d scream. and

i was listening in the distance. i don’tthink our ears are tuned to the abc project, but this is important findings and kind ofadds to the compilation of research in that field.and our next speaker, who’ll flesh that out further, is dr. gabriella conti, who iwould recommend you to look at some of her published worked because it’s quite impressivein this field and it extends over a wide range, which is going to build upon this and thedevelopmental approach to help policy. gabriella conti: i thank you very much, tom,for the introduction. i’m very pleased to be here. so i’m going to do, i’m firstgoing to talk about a general developmental approach to health, which is focused on prevention,rather than treatment. so it gives you a different

view of approaching health, as compared towhat is currently done in medicine and in the current health policy. and then, as francesmentioned, i’m going to go into details of the health facts of the abecedarian intervention.so what is the motivation for doing this kind of work? so we know by now there is lot ofevidence that early life conditions matter for health and that many countries, both developedand developing, pay the most of their health care costs in the non- communicable diseasesystem. but now, we also know that while current interventions focus on trying to remediatethese conditions in adults, these conditions are at least in part preventable. and lotsof evidence, and i’m going to go through a part of this evidencefrom the biology and the medical sciences,

tell us, so that we can actually do somethingbefore disease occurs, at least to delay its onsite.so this is why a developmental approach to help policy and to the reduction of healthdisparities is very promising, but at the same time, it’s very challenging becausethere is still so much that we don’t know, but we do have some very promising evidence.so in this talk, i’m mainly going to address three questions. so one, when health inequalitiesemerge and how do they widen throughout the lifecycle? two, what are the mechanisms throughwhich they are transmitted, both social and biological. and three, what are effectiveinterventions to promote health and prevent disease. and of course, these questions arevery important both for policy and for science.

so let me start with a simple graph. and youknow, you probably have seen many variants of this graph, which is just showing the differencesin many measures of health behaviors and health between more or less educated individuals.so the size of that bar just represents the difference, for example, in smoking behaviorbetween the more and less educated individuals for both males and females. and this is justshowing something which we all know that more educated individuals are likely to be in betterhealth, that they engage in healthier behaviors. they also do well on a variety of other aspectsof their life. and now the key question is, ok, what do wemake of this? does this tell us that education policy can be a good health policy or arethese actually differences? do they come from

somewhere else? do they come from order inlife? do they come from other factors early in the life of the child?well, in work we have done with james heckman from the university of chicago, we have actuallydecomposed these gaps. and if you look at exactly the same bars, you see that the whitepart to those bars represents the portion of health disparities, which can be attributedto early life factors. so what i’m going to go through now is basically what are theseearly life factors, how we can boost them, and actually giving some evidence that interveningthen reduces health disparities later in life. so when health disparities emerge? we actuallyknow that there are differences emerging since very early, since birth. well, now we knowthat they actually emerge before birth. so

if you look at these pictures, this comesfrom the work that i’m doing with a pediatrician in southampton and this shows differencesin anthropometrics of the fetus in the womb at three points during gestation. and thesize of the bar represents the differences in the head, the femur, and abdominal circumferenceof the fetus between mothers who smoke and who do not smoke during pregnancy. so whatwe see here? we see the significant differences by background, characteristics are presentsince the first trimester of gestation and they do widen already while in the womb.so it’s not surprising that then we see them at the birth. we see gradients in lowbirth-weight by social class. we see them widening up throughout childhood andadolescence. this is from a very famous paper

on the widening of the income health gradient.and then, if we don’t do anything, we just see them reflected in adulthood. so this isdifferences in the c-reactive protein, which is a measure of inflammation by parental socialclass at birth. and we see exactly the same gradient that we’ve seen throughout.so why those differences widen up throughout the lifecycle? what is the way in which wecan think about these? and what is the way in which we can think about – (inaudible)– interventions? so of course, if you’re thinking about lifecycle,you do need something like lifecycle framework. and so what this framework here does, it basicallyshows these capabilities of the child, which are on the right part, these – (inaudible)– which we can think variously of them of

traits like cognition, personality of thechild, these behavioral traits, health. and the point here is to show that these traitsare actually not fixed in stone and they’re not fixed at the birth, they do develop throughoutthe lifecycle. and then – i’m not sure i can really point here, but you see thatthere are these arrows, so they actually do boost each other. they are self-productive.and they can be affected by investment. you see these eyes in the second column. and then,by parental traits and environment. so there is actually something we can do about them.now, why do we care about these traits? because these were behind those differences in healthdisparities that i showed you in the previous slides. and we don’t have lot of evidencethat these traits of the child which developed

throughout the lifecycle matter for healthoutcomes. so here, i’m just summarizing a bit of theliterature and especially in economics. so we’ve just shown that capabilities of thechild like cognition, behavioral traits, personality, health, both physical and mental health, arestrongly predictive and cause later behavior and late health. and let me give you a littlebit of more specific evidence from my own work.so what i’m showing here, i’m showing the effects that improving traits of the child– you see that along the x axis, there is the percentile of the distribution of thetraits of the child. so when you move from the left of the right, you’re actually improvingthe child, moving him up along the distribution

of cognition, self-regulation, and early lifehealth, what is the effect that this has on late life health behaviors? so in this case,we look at the effect of improvement of these traits of the child on the probability ofbeing a smoker at the age of 30. and so if you look at the red line, you willsee that if you move a child from the bottom to the top of the distribution of self-regulation,so you increase his capacity to regulate his life and his behavior, then this child asan adult will be much less likely to be a daily smoker. so intervening, boosting thesetraits of the child have actually consequences in terms of late-life health behaviors.and let’s think of another outcome. let’s look at the probability of being obese, again,at the age of 30. so in this case, that blue

line is the physical fitness of the child.so what does it mean? that if we have an intervention which actually improves the physical healthof the child, moving him from a very unfit child to a fit child, this is actually goingto lead to a reduction in probability of being obese at the age 30. and keep this, too, inmind because these are actually two traits which can actually be boosted by intervention.and i’m going to talk next about two interventions which boosted these traits and caused a comparableimprovement in these very same late life outcomes. so how can we improve these traits? as i said,part of them may be genetically inherited, but part of them can be improved by investmentand environments. and again, there is being in the recent years a lot of literature showingthat inputs in the production of the traits

and the development of the child has actuallyboth short and long term effects on health. you might have heard a lot of time, you know,talking about stress, adversity. so that’s, i think, a very general definition. whileit’s more instructive to think of them as specific inputs that poor, disadvantaged childrenmight be lacking because their environments are not very rich. but then, if we can enrichthose environments by providing these inputs, then you can have an effect on health.and again, i’m going to give you evidence of interventions which actually provide thatat least some of those inputs and they had health effects. and here, a very simple anda very instructive characterization could be thinking in terms of attachment, providingthe children stimulation, good nutrition,

and of course, health care, as we heard fromtom, it’s necessary but not sufficient. so just let me give you another example onone of those inputs from other work that i’ve done, and this time not on humans, on monkeys.and you will see immediately why this is done on monkeys.so this is a work which is aimed at understanding what is the importance of early life attachment,and in particular, what is the importance of having a mother in the sense of havingsome form of warmth from a human being who cares about you and is there for you whenyou need it. so what this experiment does, in this experimentmonkeys are randomly taken away from their mother since birth. so there is a group, whichis the one where you see the picture on the

left, which is called mr, mother reared. thoseare monkeys reared with their mothers since birth. so think of children being reared,you know, with a mother or with a nice attentive caregiver.then, the ones in the middle, the pr, are the peer reared. so these are monkeys takenaway from the mothers since birth and reared with a group of peers of the same age. sothink of this as children raised in the orphanages, so children without a good caregiver, whobasically have to care of themselves. and last one, on the right, are the spr, arethe surrogate peer reared. so these monkeys are basically left – this would be a hotwater bottle hanging from the cage. so you can think of these as basically the worstform of treatment and neglect that children

can have.so what actually you can do with this data? we’ve looked at the health consequencesof being reared without a form of secure attachment. and what we found, perhaps not surprisingly,is that especially for males, so there are both physical and mental health consequences.so if you look at the bars there, you see that the monkeys reared without any form ofmaternal or social form of warm attachment, they develop physical health conditions. icould show you the gradient in mental health that’s even more striking. and these conditionsare not – they do not disappear once the monkeys are put all together and they aretaken away from these different rearing conditions. and so one question is, of course, how theseconditions affect the biology of the body

and then affect the health. so in these casesand many other cases, it actually works through the stress response system. so the conditionsoutside the body determine changes in the stress response pathways, so that the childrenwho are raised in these adverse environments, whatever the form of adversity could be, developa higher sensitivity to stress. and so what i’m showing here, i’m showing you twopictures, which – where the size of the bar is the percentage of abnormal cortisollevel. one picture is about monkeys. the other one is about humans.and if i ask you which one is which, well, you will be surprised to see how similar arethese biological reactions across the two different species. so you see that the twobars on the left are differences in stress

reactivity with children born in orphanagesand ones born with natural parents. and the one on the right is the counterpart of biologyof the differences in health that i showed you about the monkeys.and so how these early environments and experiences get under the skin? well, what we’ve learnedfrom the biology is actually children seem to be naturally wired to absorb all the experienceswhich come from the external system. so in a sense, it’s our duty to protect them fromthese. and how does it happen? there are signaling pathways and receptors in our cells such thatboth adverse experiences coming to the body and then they basically change the way thegenes express themselves. and then, they produce proteins, which basically they can changethe way in which the biology of our body works

and these can get reflected back in the externalenvironment. the good news is that bad conditions can getunder the skin, all good conditions can. so we can learn from the biology to design betterinterventions. and again, here i have another little bit of evidence, especially in therecent year, which shows that the social environment gets under the skin. in the previous years,there was lot of thought from the environmental neuroscience about the effects on the brainof poverty and adversity. in the more recent years, there is lot oftalking about social – about the epigenetic and gene expression effects of the socialand behavioral environment. and there are – are there the logical pathways throughwhich more evidence is building up to show

how the environments affect the body and thenhow can we – given this knowledge, how can we design better interventions to protector to remediate these. so we don’t know as much as we would like, but the evidenceis building up. and so it’s good to act upon it.and before i move to the early childhood interventions, i’m just going to give one more slide aboutthe biological effects of these environments, all of it’s from the monkey work. so youremember that the monkeys reared by their mothers, they had these adverse physical mentalhealth effects, which were a trigger through stress response pathways. what we found isthat these very same monkeys also show differences at the moral biological level, differencesin gene expression, which means there was

a change in the way genes were supposed towork, such that monkeys not reared with their mothers had bigger expression of genes involvinginflammation. so they had higher inflammatory response and a lower response to immune system,to viral attacks. and so this shows what happens, you know,within the biology of the body, so that the external environment can actually manifestitself into long lasting effects on health. we don’t know how persistent these effectsare, but it’s something that we are currently investigating.ok, given all of these, what can we do? well, what i’m going to do, i’m going to giveyou some evidence on interventions, and first, about early interventions like the abecedarian.so why early intervention, given all this

knowledge can be a promising avenue? well,because we can do something when it’s early enough, that the body is very plastic andyou have all, you know, the lifetime to reap the consequences.there are, of course, a few issues. tom mentioned some of them. i’m sure that in the discussionafter, they will come up. so i’m not going to talk about them right now. but i’m goingto talk about early childhood interventions. so the first is the perry preschool program.and the main point that i wanted to say about the perry preschool program is basically thecontent of this program. and that’s very important because knowing what they did tothe kids is going to tell you something about what were the inputs in terms of those investmentsand environments which affected some particular

traits, which then are closely related tosome later outcomes. so in the perry preschool program, the childrenare staying in daycare center two and half hours of the day. and what they did therewas basically some form of cognitive and behavioral stimulation. they stayed there and they wentthrough a so-called plan-do- review routine. so they had to plan the task at the beginningof the day, do the task, and then review it at the end. there was much – (inaudible)– you could do in two and a half hours. and so it doesn’t take much to think thatif you have to do that, you have to stick to do something and then you have to reviewit in front of your peers, that’s very likely that you develop some form of self-regulation,that you’d become very good at planning

things and then doing them at the end. andthis is exactly what happened. so when we went and looked at the health effectsof the perry, in the latest wave which we have available, which is age 40, what we found,we found that the bigger health effects of the perry preschool interventions were interms of health behaviors, in particular smoking and also having a more nutritious diet. andso if you look there at the means of the treatment and the control group, basically, the treatedgroup of the perry was both less likely to smoke at the age of 27 and 40 and if theywere a smoker, they were likely to smoke much less.and when we conducted some additional analyses looking at the mechanism through which thisintervention changed the smoking behaviors,

if you look at the red part of those bars,most of the effects of the treatment is explained by changes in these self-regulatory capacityof the child. and if you remember, that’s exactly the same trait that i showed you earlieron, which is related to changes in smoking behavior. so changes in these behavioral traits,interventions which can affect them seem to be effective in changing healthy behaviors.what about abecedarian, which is the intervention that frances was involved with? well, thefirst thing that we should notice, that the abecedarian was actually much more intensive,long, and complex intervention. it not only had a stimulation component, but it also hada nutrition and a health care component. and i think this is really important to understandthe effects that we found.

so when we look at this health data that theycollected in the mid 30s, we found something absolutely striking. so if you look at thedifferences in health outcomes between the treated and the control, you see the treatedis the blue bar and the control is the red, there are startling differences in the markersfor cardiovascular and metabolic diseases. so that one in four individuals in the controlgroup develop what is known as metabolic syndrome, while no one in the treatment did that. andcontrol individuals are also most likely to have low level of the good hdl cholesterol,to have high blood pressure, and to have high abdominal obesity.and just to give you more details, you see that the effects were both in terms of thediastolic and systolic blood pressure. there

were startling differences in the prevalenceof hypertension, vitamin d deficiencies. but i think what is very important is that therewere not only differences in single outcomes. so it was not that the treated were betterin each – only one of them. but what is really important is that the cluster of healthconditions which constitutes the bulk of health care costs which are spent now was significantlylower prevalence in the treatment group. the treated were less likely to be obese and lesslikely to have high blood pressure and less likely to have low hdl cholesterol.and so if you look at those means there, you see that there was basically nobody in thetreated group who had metabolic syndrome or this cluster of health conditions. andsurprisingly enough, because these individuals

who are in their mid 30s, we also found thatthey had lower prevalence of developing cardiovascular disease by looking at the framingham riskindex, which is an index predictive of these cvd risks.and some other question is, of course, where does this come from. if we think in termsof our model, how these health effects were affected by this interventions, through whichchanges in traits? was it iq? well, when we looked at it, it was actually not. so whatcould have been? so we had to look at the bmi of the child. so we started thinking ofwhat could be determinants of metabolic conditions later in life.now, if we look at the bmi at birth, of course, the two densities are perfectly overlappingbecause there wasn’t a difference at the

start. but already, after three months sincethe start of the intervention, we started seeing some differences. so if you look atthe solid line, that’s the line for the treated group. and the dashed line is thecontrol. now, let’s look at what happens as we move through the abecedarian intervention.so this is six months. this is nine months. this is 12 months, 24 months. you see thatthe treated group of the abecedarian intervention, the density of bmi is becoming less spreadout and shifted to the left. so these kids have actually good bmi. the control, instead,the density is much more spread out and there’s this long right tail. they are getting overweight.and this continues until 36 months, 60 months, which is the last time when we have data forthe end of the intervention. you see that

the control group is actually this huge numberof children who have above normal bmi. and we can look at this in another way. what isthis about, this is the bmi score where it’s plotting across childhood for both the treatedgroup, which is, again, the solid line, and the control group, which is the dashed lineabove. and you see that the treated group has a bmiwhich is on average at the median of the reference population. the control group has this hugejump, soon after the start of the intervention, and they keep being above average bmi throughouttheir childhood, until eight years of age, which is the last time for which we have thisdata available. and then, if we look at this in another perspective,if we look at the early life differences in

the bmi between those who were and who werenot obese in the mid 30s, what we see? the solid line shows the early bmi are those whowere not obese in adulthood. the dashed one are those who were obese. well, those peoplewho were obese in their mid 30s were already above normal bmi when they were children.and this is again throughout their childhood. so this really tells you a lot about the originsof those late life differences and the power of this intervention.and so the last question is like, of course, so why do we see these health effects? theintervention did actually quite a lot. so which of those components, you know, mighthave triggered those changes in adulthood? was it the nutritional component, the healthcare component? was it the fact that the parents

were informed about the parallelnutrition? well, we can’t really disentangle over them. the thing that we can really sayis that if we look at what explained the effects of the treatment in terms of most of the outcomesat the age of 35, that was the reduction in the bmi of the child among the treated group.that explained the huge proportion, more than 50 percent of the effects of the treatment.now, if i have time, i’ve got like three more slides on what we can do at a later pointof the childhood, if you like, on in adolescence, in terms of late intervention, just becausethere’s been a lot of talking about the effect of education on health. so if you look,again, at these into the lifecycle developmental perspective, then what you can do later on,once you have done something later on? well,

you can try to remediate something which wentwrong. and the easiest way to think about this is that can you provide a similar formof enrichment by targeting biological systems which are still malleable? and if we thinkin terms of education, what we know in terms of malleability of the traits, we do knowthat some traits like behavioral traits are still malleable in adolescence, which is whythere is some evidence that adolescence intervention works in improving the personality of thechild. and so getting back to the picture that ishowed you at the beginning, if we look at the effects of education on health, what wesee is that disparities, some of them are explained by early life factors entirely,like, for example, if you look at the bar

which is in the middle, which is totally white,that the differences in obesity are explained by early life factors. and that’s consistentwith the evidence that we have from the abecedarian intervention. if we consider differences insmoking behavior, we have seen that smoking is affected by these changes in behavioraltraits, the self-regulation. to the extent these traits can still be changed during adolescencebecause the part of the body which are affecting those traits are still malleable, there issomething which can still be done in adolescence for education and intervention.and the last thing is that, of course, the two things do not have to be seen in isolationbecause the human capital is a cumulative process. and so there is always going to bean interaction between early and late investment

because the two build on each other and theycomplement each other. and so if you look here at the effects of education, as a functionof these traits, which are announced by early intervention, what we see, this is the effectof education on the reduction of being a smoker. you see that the effect, if you look at theblack line, the effect is bigger for the children who were more cognitively able. and the effect,you know, on the other hand, is bigger for the children who had lower level of self-regulation.so if you look at the bottom left part with the blue line and the bottom right part withthe black line. so why is that? because if you think of what education is providing,education is providing information on the danger of being a smoker. if you are a morecognitive capacity, then you’re better able

to process that information.on the other hand, if you had lower self-regulation, to start with, that trait is still malleable.so education can improve the trait and you would see higher returns for the childrenwho had lower value of those traits. and finally, the last thing is that todaythere’s been also lot of talking about two generations interventions. intervening onthe parents and the children at the time where biology is most amenable to change for eachof them. so what have we learned after all this? we have learned that actually thesedisparities, which emerge only late in life, are not only a function of late life circumstancesbehaviors. at least, an essential part of them, and for some of them, the totality ofthem can be explained by early life factors.

we’ve also seen that what happened earlyin life can have longer term consequences because experiences can affect the biologyof the body. now, of course, on the one hand, this is no news. but on other hand, we canleverage on the malleability of these biological systems and we can intervene when they aremost malleable. so when we provide the enrichment interventions are critical periods which affects– which provide inputs affecting those traits which can be changed, then we can see longterm consequences. and so i guess the lesson we can learn fromthese, by knowing when to intervene, we can actually use early life investment as a usefuland effective mean to prevent disease and promote health.thank you.

mr. miller: thank you very much, gabriella.all of you out there, you’re not totally doomed, although it’s getting a little dimif you didn’t get an early start. but there’s still hope for your children or your grandchildren,remember that. think about the kids. and that’s one way of looking at this promising area,but what about everybody else? what about the folks who are bobbing around in the middleof a health system which promises to do good, but, sometimes, the front end doesn’t connectwith the backend and all the pieces involved in it.now we turn to our next speaker, dr. harold freeman. we thought we might actually havea physician here on occasion. he’s founder and president and ceo of the harold p. freemanpatient navigation institute in new york city,

professor emeritus of surgery at colombiauniversity college of physicians and surgeons. and he is a true pioneer in the concept ofpatient navigation in its purest sense that focuses on patients, a program to providelow-income patients with personal guides through the health care system.among his past and current roles, he’s a diplomat of the american board of surgery,so of the american college of surgeons. he served as president and ceo of north generalhospital in new york city. he was director of surgery at harlem hospital center for 25years, elected to the institute of medicine of the national academy of sciences, and servedas national president of the american cancer society. he receivedan honor as the mary lasker award for enlightening

scientist in the public concerning interrelationshipsbetween poverty, race, and cancer. and he’s here to enlighten us further about the potential,the progress and the application of patient navigation in its broader sense. harold freeman.harold freeman: thank you very much. i’m very happy to be here. and in reading thenew york times yesterday, i saw an article by arthur brooks, the head of this organization,who said that when you’re happy, the left side of your cerebral cortex is more active.so i assume that mine is active this morning. i’m going to highlight an experience ofabout 40 years. i was trained as a surgeon, came to harlem in 1967 as a cancer surgeonand faced a population of women in particular who were coming in with very late breast cancer.some of the women were coming in with ulcerated

masses on the first visit. it bothered mea great deal, frustrating because i trained to a high level, ready now to cut cancer outof harlem, in a way of speaking, but frustrated because the problem was deeply embedded inthe human experience with people in harlem who were poor and black.so it made to do certain things. the first thing i did was to find a way to screen womenfree of charge if they could not pay for breast cancer, including mammography. and that didhelp. but it did not solve the problem. after all, mammograms do not cure breast cancer,maybe need a mammogram, but if you only have a mammogram and you’re lost after that,you still have a serious problem. and so i had another experience. i got promotedto president of the american cancer society

in 1989. and i had a chance to look at thewhole country sensitized by the experience that i had in harlem with poor black people.but hearing the testimony of poor people of all races – white, black, asian, hispanic,native-american people – testify, the people who testified were poor and also had cancer,a combination of poverty and a lethal disease at the same time. and, out of those hearings,i got some guidance. the poor people who testified said, we meetbarriers when we attempt to get into – and through this very, very complex american healthcare system, we meet barriers. so that was a signal to me. they said other things. theysaid, we make sacrifices; we lose our jobs; we lose our insurance; we lose our dignity.they said the educational system in america,

no matter where it’s coming from, governmentor cancer society is often insensitive and even irrelevant to us. they said we’ve becomefatalistic and we’ve given up hope. so with that background of a local experienceand a universal experience looking at the whole country, i came to a conclusion thatwe had to do something special in harlem and that was the origin of the concept of patientnavigation. so, in 1990, a year after those hearings,i started this program in harlem with the idea of helping the people in that communitynot with the idea of generalizing to the whole country. what i did was to bring people intoa harlem hospital that i called patient navigators, put the navigators in the roomwith the doctors on initial examination in

the breast clinic. and after the doctor madea recommendation – and our doctors always make a recommendation – the navigator wouldtake the patient to a separate and talk to them one on one and ask questions such as,did you understand what the doctor just said to you?often, the patient did not understand – a communication barrier. is any barrier to yourgetting the biopsy which the doctor has recommended? i have no health insurance, ok, typically.so we’d have to find a way to get a person covered, the navigator had to do that. sometimesthe patient would say, i’m simply afraid and i don’t trust these doctors of thishospital. so the navigator would end up being in that as well. sometimes the patient wouldindicate the health care system is so complex

and i can’t really find my way; it’s toofragmented, so to speak, the navigator would help.so we put navigators as personal guides to solve the barrier to timely movements throughthe health care system. and, ultimately, we proved that it worked. the evidence of theproof is that before screening and navigation, in harlem and harlem hospital, looking at606 consecutive patients who came into harlem hospital with breast cancer, the five-yearsurvival rate was 39 percent before intervention. after screening and navigation, the five-yearsurvival was 70 percent, so something we had done had worked. and this was still a localsituation at this point but it seemed to me an idea that had some meaning.so the question is: can you through personal

guidance of people help them through the healthcare system? and the measure of success then is timeliness of movement through the systemand also a quality of care. so i began to know that there’s a differencebetween what i call patient navigation, which is the movement to the whole continuum, froma beginning point to an end point, and, in harlem, we started at the point of abnormalfinding to the point of resolution. resolution could be a finding diagnosis was benign, sonavigation is over at that point, or navigation, if the patient has cancer, now we have tonavigate them to the end of the treatment. so we’re focused on that window of opportunitybetween finding and resolution. we showed by actual research and publicationthat we changed the outcome from patient population

presenting with only 6 percent early diseaseto 41 percent early disease and changed the five-year survival from 39 percent to 70 percent.i had the opportunity to present this with a lot of other help to the political systemin america, to the congress. and, ultimately, the president of the united states georgebush in 2005 signed what was called the patient navigation act in 2005, which gave funds tosupport demonstration of patient navigation. so that’s the story.let me go to a few slides that i have here. my sense is that there are three elementsthat drive disparities, whether people have resources, a circle of poverty, or not; howpeople behave, the circle of culture; and whether people have been treated fairly ornot, the circle of social injustice. and these

overlap and drive disparities from prevention,detection, diagnosis, treatment, and provide the health care continuum, and that’s atheory that i’m living by. another way to look at this: poverty causesnegative events; that’s for sure. and looking at these boxes that are before you, povertycauses people to have inadequate social support, less knowledge, tendency toward a risk-promotinglifestyle, and the fourth box, diminished access to care, particularly to preventivecare. the health care system itself, as we have devised it in the world and in america,does not deal with all of these boxes. it deals with the fourth box so we talk aboutaccess to care. but access to care among poor people occurs in a broader context – thesame people with low access to care have low

knowledge and less social support. and sosomething has to be done, i think, to address not just access to care but the broader contextof low knowledge and even early things that you’ve talked about here before. so theconcept has come out of this issue. so where does culture fit into this? in my view, culturebecomes a prism through which poverty operates. let me explain.so to the extent that people are in a certain culture, such as the – (inaudible) – donot smoke cigarettes, eat vegetables and don’t drink alcohol, a culture like that, even whenthey’re poor, they won’t develop lung cancer very much or other diseases. the culturein harlem that i was facing for 40 years, a culture that smoked heavily, ate the wrongfoods, drank alcohol, and had a very negative

culture. the same occurred in appalachia.i compared harlem, new york, with harlem, kentucky, for example. and so the issue wasnot race in itself. the issue was behavior, and that’s an important distinction to make.and so i think this kind of outlines, if this is true, then you could think of so, whatthen should be the solutions to this kind of problem?the findings i’ve gone over from the american cancer society there. i won’t go throughthem again. the harlem experience, i’ll just outline briefly for you, stage of diseasein harlem. before intervention, only 6 percent of womenof 600 women had early breast cancer, and half of them had late breast cancer, and thefive-year survival rate, 39 percent. this

is at a time when the five-year survival ratein america was 75 percent. in harlem, we’re seeing 39 percent, something wrong, somethingvery wrong. after we did two things – screening thepopulation for breast cancer free of charge if they could not pay and assured that peoplewith findings were rapidly navigated to diagnosis and through treatment, which is navigation– the results changed to 70 percent. the five-year survival in this was published andpresented to the political system. and here is the patient navigation model that we approachedthis – started from point of finding, the yellow line on you left, and to resolution,the yellow line on your right. and here is the president of the united states in theoval office signing the patient navigation

act from the work that came out of harlemin 2005. we then thought of a broader model. so ifwe were concentrating on from finding to resolution, as i showed before, we felt that the healthcare continuum, which is at the bottom, prevention all the way to the end of life, people couldbe navigated across the whole system, therefore, you create outreach navigation, bringing peoplefrom where they live to a health care site for particular examinations, and then we couldcreate navigators that work with diagnosis from finding to diagnosis, diagnostic navigation,we developed treatment navigation, treating people who have a diagnosis all the way throughtreatment, and then, the idea of survival navigation, and so this is the current theorythat we have now, applying navigation across

the entire health care continuum.and so the question then, who should navigate, comes as a question. let me say that as analogythat i would give you as a mile relay. i’ll take a moment to say what this analogy is.so the mile relay, there are forerunners – there’s a starting point in this and an end point.and the race is not over until you pass the end point. and surgery, i learned that early,when we operate on people, we have to open, we also have to close. so that’s the kindof philosophy that i’ve kind of lived by. and so the navigation concept, you open itup, but you also have to close. there’s an end point to be considered.but there are also four runners carrying a baton. i want you to imagine that the patientis the baton so the first runner who has certain

skills and tasks carriers the baton and passesit to a second runner, who may be a different skilled person, and finally, the fourth runnercarries the baton across the finish line. you cannot drop the baton in a real race oryou will lose the race and nor can you drop the patient so we need to have a connectionof the whole race. so navigators then carry out phases of therace. navigation is the whole race. in order for this to be successful, there has to bea coach. you won’t win an olympic mile relay unless you have a coach coordinating the wholemovement. that’s an analogy that describes my plan.principles of navigation – what are they? briefly, navigation is patient centered soit’s an individual approach. i think individual

people through the system, we tend to specializein whatever. the more educated you are, the more specialized you become. and that couldlead to what, tom, you mentioned, are silos, and that does occur. and that’s somethingto think about. i became a highly trained surgeon, for example, and i could have keptdoing highly trained surgical work on late disease, i would have had no improvement ofresults so to be specialized, but you have to step out of a specialization, look at thewhole picture, and that’s an important point. navigation fundamentally is designed to eliminatebarriers to timely care, financial barriers, communication barriers, system barriers, barriersrelated to fear and distrust, barriers related to transportation, barriers related to childrenat home alone, whatever the barriers navigators

should solve there.and navigation, another way to look at this, can virtually integrate a fragmented the healthcare system. for example, if a patient with a complex disease such as cancer,which is an area where i’ve worked, has to go to four or five different sites whichare disconnected – and this is often the case – to get treated – you have to goto the doctor’s office, you have to go to radiology, chemotherapy, surgery, whatever.to the patient, this is very, very difficult. but a navigator can plot the course and connectthe dots for the patient and plan the movement of the patient through a fragmented system.so virtual integration is something the navigators can do.patient navigation, if you set it up anywhere,

you need to define what it is. if you don’tdo it, there will be confusion. and you need to say when navigation begins and when itends. who should navigate should be decided by the level of navigation that you’re undertaking.in the programs that i have developed, we have used laypeople, who cost much less money,by the way. and because the problems we’re solving in harlem have to do with do peoplehave health insurance, did they understand what the doctors said, could you guide themthrough a complex system, was there fear and distrust, so those problems can be solvedby people who are non-professional. and that was the weight of what we did was done bylay navigators. at a certain point, you can create navigatorsthat need to have medical knowledge. for example,

in prostate screening, which we have donemuch of, there’s something – there’s a blood test and there’s something – thepsa is elevated, we can’t have a lay person explaining what it means to have an elevatedpsa. you go to a doctor, you get a needle biopsy, it comes back gleason seven – youcan’t have a lay person explaining. it has to be somebody with medical knowledge, generallya nurse. the options for treatment may be complex, whilst for waiting radical surgery;forms of radiation cannot be explained by a lay person. you have to bring the medicalsystem in. so the team for navigation should include– select people according to the job that you’re trying to do – lay people on teamswith professional people, moving people through

the system, concentrating on the movementof the patient, which is different from concentrating on creating a good system of care. both needto be done. and so, to move on, navigation can also, ifind, help people to go across systems of care. most care in america and anywhere elseis given in a primary care system and the primary care system can carry the patientthrough a certain point. but when it’s a tertiary problem, the patient has to go fromprimary care to tertiary care. that is often a challenge. but we find that if you put navigatorsin the primary care system and navigators in the hospital system and connect the navigatorswho can in fact connect primary care to tertiary care. and, finally, as i said before, navigatorsneed to be coordinated so leadership to guide

the navigation program.let me go to some research findings to add some meat to this. so the most important studyso far that has been done on patient navigation was not the study that i did in harlem thatled to this, but it was a study done by the national cancer institute between 2005 and2010, a five-year period. the national cancer institute created something called the patientnavigation research program. i’m going to tell you what that program was.the program was testing whether it is a benefit to the patient to navigate from the pointof abnormal finding to the point of diagnosis of cancer. and it was set up at seven differentsites around the country to show whether or not navigation can improve the timelinessof movement from finding to diagnosis and

into treatment. six out of seven of the studiesshowed a positive effect and some of the effects were very positive and some were moderatelypositive. so we conclude that from that study – thegovernment spent $25 million to do this and it’s now concluded and published – thenavigation can diminish the time in a poor population from point of finding to beginningof a treatment, and that’s a very important thing to accomplish. previous research hadalready shown that navigation can increase the number of poor people who are screenedat all. so when you put together two sets of findings, the review in literature in 2011of all previous publications which were 44 publications by 2011 and that were reviewed,that met the criteria for research, that research

concluded that navigation can dramaticallyincrease the number of people who are screened at all in the poor publics. and the studiesfrom the nci showed that navigation can diminish the time from finding to diagnosis.so this – if you can do this with poor populations, you can increase the number of people whoget treated early, and the effect of this i think in the long run would be to save moneybecause if you treat poor people late – which is what i faced in harlem when i went there– you have to pay for that. you cannot not pay for the treatment of late disease. youwill pay for it. the society will pay. if you spend some money, what you said, upfrontrather than in the back – tom, i think you mentioned that concept of back versus front– spending some money upfront to get people

into the system early and treated early willultimately save money. so the major findings. a 2011 review of allthe literature has showed increase in the number of people who are poor who get screenedat all. the national cancer institute patient navigation program i’m going to summarizebriefly here, with studies that came out of denver, boston, chicago, ohio and san antonio,basically showed the weight of evidence that patient navigation diminishes the time fromfinding to diagnosis and treatment in breast cancer, colon cancer, cervix cancer and prostatecancer. the boston study – there was a study in washington, d.c., by the way, which wasin breast cancer and showed a very huge effect in reducing the time when women in washington,d.c., who had findings of breast abnormalities

to the point of treatment. i won’t go deeplyinto these studies. and so let me conclude with some generalizations.in 1967, some nearly 45 years ago, i was faced with a problem of late diagnosis of breastcancer and high death rate in women with breast cancer in harlem. by applying patient navigation,which was a system in which we assured that people with findings were rapidly diagnosedand treated, we reduced the death rate significantly. we had opportunity to argue this case in apolitical system. and now, the status is this: the americancollege of surgeons last year determined that patient navigation is a standard of care whichmust be applied to all cancer centers to meet the inspection of the college. this is about1,500 cancer centers in america next year

will have to meet the standard. the affordablecare act requires that patient navigators be used to assist uninsured people into theexchanges, into insurance. and that is going on right now. so these are some of the thingsthat have happened. let me generalize and end my talk. i thinkthat my own experience is summarized in three ways. i came to harlem as a surgeon operatingon individual people, and i think that’s important. i faced a population of peoplewho were poor and black. it made me look deeply into the meaning of what does it mean to bepoor, and what does it mean to be black, and what does it mean to be black and poor inamerica. and that led to national hearings that i described to you.so i went from a surgeon to a person who tried

to understand a population system and nowback to individual concern. so i’ve had a peculiar transition operating on individualpeople, trying to understand the population and, finally, believing that finally, youhave to help individual people. you can’t cure a population. you have to cure individualpeople. and i’ve learned that. and so, where do we get this energy? so inevery community in america and elsewhere, there’s a lot of energy to be harnessedand we have to find ways to harness human energy. and this will be at lower cost becausethe energy is there if you know how to harness it. so i believe that patient navigation isa method of harnessing human energy – a lot of people are born to help, some bornto volunteer, others need to be paid – so

patient navigation is a way of harnessinghuman energy, directing it specifically to help people who are disadvantaged to get througha complex health care system. and so i’m going to end my remarks there.this thing is still emerging. it appears that the concept of personalized guidance of peoplethrough the system is gaining a lot of weight in the country as a whole. i think, in theend, it not only will be a human benefit but it will be a cost saving benefit. thank youvery much. mr. miller: thank you very much, dr. freeman.our final speaker is barak richman. he’s the edgar p. and elizabeth c. bartlett professorof law and professor of business administration at duke law school. he researches the economicsof contracting, new institutional economics,

anti-trust and health care policy. more notably,i first met barak in connection with a symposium where he coedited with clark havighurst thevolume on “who pays? who benefits? distributional issues in health care.” you’ve got onerelated article on behavioral economics and health policy understanding medicaid’s failure.you could do that in only 66 pages? i thought you could write 700 on that one.barak richman: it’s into three articles. mr. miller: that’s right. barak has a bookcoming out. i’ll give you the plug, “stateless commerce,” to be published by harvard universitypress next year. is that covered under article one, section eight, would be interstate ifit’s stateless and subject to congressional regulation or outside the bands?mr. richman: it depends on if we’re talking

about this court or a future court.mr. miller: ok. well, it could be a five-four decision in any case. his recent work haseven included challenging illegal practices by rabbinical associations. there was a newyork times article on that. he’s on the health sector management faculty at duke’sschool of business and he’s a senior fellow at the kenan institute for ethics. he wonan award at duke for teacher of the year in 2010. apparently, it’s a more competitivecategory than when i was at the law school. things have improved on that front.in any case, i don’t know what barak is going to talk about today exactly but we knowthat what he’s going to say will be refreshing, thoughtful, and important. barak richman.mr. richman: thanks, tom. let’s hope i can

live up to that. i first genuinely want tobegin by expressing my admiration for the other people at the table up here.i have enormous admiration for tom for organizing this and for his opening remarks, which reallyis not just how he talks but it’s also what he really tries to do, pushing beyond conventionalpartisan thinking, pushing beyond partisan divides. and when we think about somethingas complicated as our national health system or specifically the health of our nationalpopulation, it is very, very refreshing to try to push beyond conventional wisdom andto, at least aspirationally, push towards some kind of bipartisan thinking really forcingthe policy world to think hard and to synthesize the science. and i am enormously gratefulto be part of that. so i admire tom an enormous

amount for that.i also additionally admire the three scholars up here. dr. campbell’s work in the oppositearea and project is – to say it’s seminal is an understatement. it’s extremely important.i became familiar with gabrielle’s work through her co-author, james heckman. i’man economist and it was through that backdoor that i realized exactly how value this workthat she does is. and i’ve been, not just myself by many of students have been an enormousadmirer of dr. freeman, the kind of work that he’s been doing in harlem and the kind ofthinking and leadership he’s shown on national health care policy. so it’s an honor tobe up here. and my role is really limited and i won’ttake a lot of time doing it. my job up here

is really to try to close the envelope. tomset this up by saying we have all of these policy questions. they very rarely get a lotof thoughtful scrutiny but it’s time to really – it’s time – it’s been timefor a long time – but we really – there’s a lot of opportunity to synthesize what thesepeople up here have been doing and synthesize them into lessonsfor health care policy. so these scientists up here have done the heavy lifting. i willdo at least a little bit to try to relate their findings to certain policy implications.the objective really is to try to make – try to illustrate, because, yeah, it’s obviouslyrelevant – try to illustrate the specific applications to this policy community. there’sa reason that this conversation is happening

here in washington. and my small role willbe to try to highlight some specific policy issues that are significantly and deeply informedby the kind of research that the scientists up here have developed.so, you know, just reiterating – i won’t spend a lot of time on this but reiteratingwhat tom said, we are really trying to encourage this entire community here, the policy communityto think about this, to think about it in a non-partisan way, to focus our priorities– it’s not on funding programs but on improving population health. and understandingthat although the right answer is illusive, there are some answers and a lot more – aremore right than others. and it’s hard. it’s very hard. so the more that this communitycan scrutinize and think about these issues,

the more there are some very significant opportunitiesto improve national health care policy. so i think i have three categories of observations.again, these are all ways of trying to synthesize what our speakers have identified into specificpolicy applications. and i’m going to go – you know, there’s an easy way to dothings and a hard way to do things. i’ll go in order of – with ascending complexityand ascending difficulty so i’ll start with the easy ones first.so there’s an overwhelming theme in the importance of early intervention and comprehensiveintervention. we know that it’s important to try to develop cognitive – develop itearly as opposed to later. it’s important to think about this as it relates to healthinputs, that early intervention is both more

effective and less costly than later intervention.so one obvious application, are there a certain number of programs that might enhance cognitivedevelopment? if we think about this from a – we’ll say a budget neutral perspective,we will certainly make the observation that we spend a lot of money on medicare and notnearly as much money on early intervention. so if we think about the value of a particulardollar input, there is a lot of evidence to suggest that we’re investing at the wronglife stage and dollars could be better used. similarly, related to this early interventiontheme and comprehensive intervention theme, specifically as it relates to cancer, certainlyearly intervention is less costly and has better outcomes. but, to a large degree, westill have a fee-for-service reimbursement

system, which means that providers, if theyare profit maximizing – and i’m not saying they are, but if they were profit maximizing,they would be much more enthusiastic about later interventions with costly surgical proceduresrather than early interventions with biopsies. there is a lot of money spent on complicatedchemotherapies that could be a lot less costly with early intervention.so how do we encourage early intervention? well, one way certainly is what dr. freemanhas done. we try to nationalize a navigator system. we simply decide that investing innavigators is a more cost effective intervention than later intervention for patients withcancer. we could also try to think about this through the lens of incentives, bundled payments,for example. you don’t want to be overly

general about the efficacy of bundled payments,but in the system – within the framework of treating cancer patients, it makes a lotof sense, where early intervention truly is less costly.if there’s a way to incentivize providers, to seek out patients early and to give themsome kind of flat fee, that would encourage early intervention. so there might be waysto incorporate these lessons into the reimbursement system and there might be some market-orientedapproaches to trying to figure out how to incentivize or induce early intervention.so that’s the easy stuff. we think about reinvesting dollars or reallocating dollarsearlier is better than later; detection and early treatment is better than later treatment.there are ways to do that through public dollars.

there might be ways to reorient programs andreorient regulations to encourage private parties to do those things.the second category of observations has to do with this theme of silos. we understandhere that health consequences – that, again, that is the outcome of interest, health isnot merely a function of health inputs or of medical inputs, very much to the contrary.there are inputs that are non-medical. there are social inputs. education is an enormousinput in producing good health. so it makes a lot of sense to break out ofthese silos, to think about health policy not as being administered primarily throughcms and not being – and health care you might say or health services not being deliveredprimarily through health care providers, licensed

providers but thinking a little more comprehensivelyabout how we can use policy dollars to embrace this more comprehensive and holistic approachto understanding how we can improve individual health.one specific example is the medicaid waivers. the medicaid program itself has a lot of inherentbuilt-in flexibility, but a lot of that flexibility has yet to be really capitalized upon. wedon’t need to – we’re not constrained to use medicaid dollars through conventionalhealth care providers. navigators i think would be an appropriate use of medicaid dollars.in fact, actually, you could even think of a navigation-based system being a centralpart of a state’s medicaid system. similarly, and i think profoundly, we thinkof only our national health care system being

delivered through our department of hhs, whereas,really, it’s possible the department of education influences our national health more.there is a very unnatural division between education policy and health policy, much like– i think there’s an unnatural division between how we allocate or deliver our healthcare system. schools really are not an instrument in that at all. we should, as we think – youknow, it would be nice to reorient the education department to not just care about test scoresbut to care about health outcomes also. and there’snothing wrong with encouraging that mandate and having our educational policies, stateand federal to think about health as a desirable outcome as well.and, similarly, if we want to think about

how cms through the medicaid program can improvehealth outcomes, it should embrace educational approaches also through educational providers.so what – so the second lesson – if the first lesson is the value of early interventionand allocating at early stages, the second lesson is we need to think about these thingsmore comprehensively. and our policy instruments are not comprehensive. they are the opposite.they are siloed. and there is – the current law allows for a lot of flexibility that wearen’t capitalizing on. and the research by these scholars have suggested that thinkingcomprehensively outside the silos, thinking flexibly and creatively would be a very, veryvaluable thing. the third observation is the most i guessthe most profound in the sense that it is

the most difficult. but in the spirit of bipartisanship,i will quote a tar heel. bill roper, who i believe is still chancellor of the unc healthcare system, put it really beautifully. he says, our health care system gives the wrongcare – i’m sorry. i want to get this right – gives the wrong care in the wrong placesby the wrong people. we are – either we, we deliver health care is really not naturalto what our patients need through health care. now, we have talked about how we need an individualizedapproach, how we need a patient centered approach. a lot of that involves trying to reduce complexity.a lot of that is directly handled through navigation. but i think that that really isjust – should be the beginning of our thinking very critically about how we structure ournational health care system and how we think

about health.i think there’s a lot of evidence up here to suggest that health is a much more organicexperience than a technical one. it is benefited through a bottom-up approach rather than atop-down approach. it is not like delivering water, where it’s purely a matter of puretechnicality and is the same everywhere. it is something that needs to be sensitive toenvironment, to social organizations and to other source of organic formations that reallycould do better than our top-down approach. and when you think of it – when i say top-down,i mean top-down in two ways. number one, it is a very – as opposed to a patient-centeredapproach, this is a very provider-centered approach. you need to get – you need togo to where the provider is, and all too often,

you need to go to where the multiple providesare. it is about reimbursement for services. it’s not about looking at what the particularpatient needs are. but also, not just is it a provider centered approach but also is anapproach that is predominantly reliant on providing health insurance.the way washington and states, the way we think about mitigating health disparitiesor improving a particular health outcome is saying, well, let’s cover it. let’scover particular services that can address that condition. and that approach is veryinsensitive to both the complexities of translating health care services into health but alsovery insensitive to the complexities of seeking health care to begin with.a bottom-up approach would be sensitive to

those a lot more. what would that look like?well, certainly, the professional – we might want to rethink the professional organizationof our health care system instead of only reimbursing for services provided by medicalprofessionals. we want to think outside that. we want to think about navigators. we wantto think about social workers. we want to think about, you know, all the people thatmake us healthier. at the risk of sounding implausible, we want to think about the healthcoaches. we want to think about people that really are trained to change behavior anddecisions. surgeons generally don’t do that but a lotof other people do, and they should be a central component to our national health care strategy.similarly, we should think about how we deliver

health care not just to complicated academichealth care centers or other sorts of hospitals, but through different social organizations.one problem – one real challenge with our formation of acos, accountable care organizations,is that many of them are hospital based. that is doing a little more than reinforcing ourcurrent delivery system. and think about other kinds of acos. certainly insurance-based acos,where there’s more focus on individuals, but think about other sorts of acos. whatif social workers formed acos and really tried to intervene at the decision-making leveland helped patients shop intelligently and navigate intelligently, there probably areenormous savings. and if social workers could really intervene at that level, i think therewould be significant beneficiaries of the

shared savings program.we can think about churches. we can think about schools. these are natural social organizationsthat are very in tune with the health care decisions and i think very attune to notethe health status of their members. they also could really – could fruitfully intervenein how individuals consume care, how they sought for care, and what kind of care theyneed. and, lastly, we want to think about our economicorganizations so professional organizations, social organizations, economic organizations.there should be lots of profit opportunities. if we’re spending 18 percent of our gdpon health care and we still, to use oecd comparisons, are no healthier than nations that spend halfthat much, that’s a lot of money on the

table. and if there are ways that entrepreneurscan tap into these valuable features, whether it’s through navigation, whether it’sthrough early intervention, other ways of trying to – other ways of trying to improveoutcomes through non-traditional ways and saving money, there should be enormous economicopportunities for that. that will require rethinking a lot of licensure law state bystate. it might require rethinking the shared savings rules. but there is enormous potentialout there, not just for policymakers, not just for providers, but also for entrepreneurs.so the bottom line is these lessons are enormously valuable. they have some specific applicationsbut they also challenge a lot of our foundational assumptions about the health care system.and we in washington, policymakers, should

be thinking about this. so i’m delightedto be a part of it. mr. miller: thank you very much, barak. iwas drawing upon my cognitive reserves. i understand that it will keep me from havingan early onset of alzheimer’s if i built up enough in my head. so that’s anotherbackend reward for all the frontend things that you load into your base. they’ve beentalking i think even about pediatricians issuing prescriptions of saying, read your child thebook and call me back in a couple of weeks as other ways to extend the bounds of this.a different trifecta, focusing a bit more perhaps on the health disparities than thebroad-based health outcomes ends might be to say the reason why we need to do this is,first of all, because it’s right. it’s

just. but, secondly, it works. and, third,oh, yes, it also saves money. that’s pretty good to get that in the package if you thinkabout not being wedded to the same means in order to achieve the ends we say we’re allabout. we’ve got about 15 to 30 minutes dependingupon the level of interest in questions from the audience. we’d welcome your commentsin the form of verbal op-eds but preferably questions to our speakers. we’ve got a questionright there. and if you can identify yourself before your question.q: i’m dr. caroline poplin. i’m a primary care physician. i’m delighted to hear thispanel. it seems to me that the logical conclusion from the earlier presentations about earlychildhood intervention, a very early childhood

intervention is a kind of european systemwhere they have paid family leave, the provision of childcare – extensive childcare that’savailable to everyone. i think that’s what they have in france. and i think that muchmore robust social services in general in europe is one reason they get better outcomesfor less money. mr. miller: stand on its own terms. any otherfurther questions or comments, back there. q: a question, not a comment. lauren semeniukfrom novo nordisk, pharmaceutical specializing in diabetes. when i hear your successful interventions,be it both health care and education, what smacks me in the head is, how did you or howwould you get by the congressional budget office that doesn’t recognize generallythe scoring, you know, of prevention? like,

dr. freeman, how did your bill get throughcbo? i mean, we have – in diabetes, there are lots of successful evidence-proven examplesof averting the onset of diabetes, but that’s always our barrier, cbo.mr. freeman: so the question is how did the bill get through the congress? a surpriseto me actually. it took a lot of people coming together, the american cancer society, forexample, and others helped to present this to the congress. there was a particular – congressmanmenendez, who’s now a senator, and a republican woman,whose name i forget, from ohio who came together, bipartisan. and they both were very sensitiveto these issues of poor people dying. and i got to meet with them and i think itwas menendez and the republican from ohio

whose name i don’t remember that got thisinto some kind of dialogue in the congress. and as people began to see the point thatthrough something that was not costing much money, the use of people in communities tohelp people in their own communities to get through the health care system in a definedway, particularly from the point of abnormal finding to resolution, began to catch on amongmany of the congress people, on both sides. in fact, i got as much support from eitherside, democratic – it wasn’t an issue of partisanship, an issue of understandingthat poor people are dying at a high rate and there may be some solution that involvesharnessing the energy in the community. so it got on to the plate – it got – thefirst time it got discussed, it didn’t pass.

about three years later, it did. so it wasa gradual gathering of support. and i think that it was the logic of it that made sensethat – the point if you’re either thinking only of a financial issue, you have to payfor people who are dying of cancer. in the end, you pay more money for an advanced diseaseand then people also die. so that shifting the energy toward the frontend, where youget people in for early diagnosis and treatment seemed to catch on among the senators andthe congressmen, and, ultimately, got all the way to the white house.mr. miller: we have the perennial problem of – so how are we going to pay for thisand what’s it going to come from and what it’s going to look like? one idea is tostart in more discrete bites – that’s

why you don’t universalize, what seems likea good idea, and say it’s a gigantic program and we’ll just find some more room on thecredit card to do it. to some extent, you may have to substitute on that.but there are also targets of opportunity. you look at things that are not as much nationalbut are more community based, within perhaps, the medicaid or the social services context.you could do all kinds of things locally with redefining how child welfare services areimplemented and administered at a state and local level.we can think of two generational programs which begin to work with the younger parentswho have already had their problems but you intervene with them to teach them the skillsto first have a job and maintain a job but

also begin to parent their children better.these are soft, touchy-feely things that, if you do them sensitively at the communitylevel, can have a large impact where they’re operating without someone going on a pressconference in washington and say i’ve passed the following bill and here’s the amountof money that’s being disbursed. and since we always need an acronym in orderto get anything done in washington, i will suggest abgs, accountable block grants, whereyou give the money out but you actually have to have some metrics in order to produce it,you’ll get less money or have to give some of it back and distribute it in that manner.so that might bypass some of the standard paradigm of, well,cbo on a mega-level says, this doesn’t look

like it’s a wash, which is the way you alwaysscored these things because there’s not the evidence until you’ve done it. so youhave to build the evidence in smaller bites. do we have another question or comment? goahead, barak. mr. richman: just very briefly to add to that.i mean, in many respects, actually, those two questions are two sides of the same coin.there are lots of ways to – there’s a lot of ways to spend money in wiser ways.one might be from the top down. yeah, i’m certainly a fan of a lot of what europeaninvestments do. that is one approach. and that would require quite significantly goingthrough the congressional budgetary process. but the other way, a middle way, is theseaccountable block grants which i think is

a great idea also. it’s interesting – look,you know, we’re giving you so much money for health and education, here’s the money,go ahead, do it creatively, but make sure that you show some kind of improvement fromthe way that you otherwise would have spent it.but the third – and this is i think the way the health care system is going at leastconceptually if not actually – is through things like the shared savings program andthrough things like bundled payments. and that really does not require, has not required– would not require any – will not necessarily require additional congressional approval.and the basic idea there is, look, if you – again, this is idea, not actually howit’s playing out – if you assume responsibility

for a certain population, and if you showways of improving health outcomes while saving dollars, the money is yours, or at least partof it. conceptually, i think that makes a lot of sense, especially because health careis such a social construct, it’s so sensitive to individual and social influences, it makesa lot of sense to have smaller populations, smaller organizations assuming responsibilityfor small populations and trying to think intelligently about what their health careneeds are. so we kind of have the conceptual framework.to some degree, we have a little bit of policy out there that’s trying to do that. andi think that that’s a direction we can go into further. and i think that where yourquestion originated from, thinking about the

population with chronic diseases, certainlythink about diabetes as a very, very useful application of these ideas.mr. miller: i think we’ve exhausted our time limits. i want to thank you for thinkingabout these issues. we know a lot about what doesn’t work or doesn’t work well enough.we ought to start thinking about what could work differently and work better and buildon that. please thank our speakers today. (applause.)(end)