Subcommittee on Oversight and Investigations
May 23, 2002
10:00 AM
2322 Rayburn House Office Building

Thank you, Mr. Chairman.

I represent the Center for the Advancement of Health, an independent, non-partisan nonprofit organization funded by the John D. and Catherine T. MacArthur Foundation. The Center promotes greater recognition of how non-biological factors affect health -- that is, how what we do, where we live, what we eat, and the resources available to us influence health and illness. The fundamental aim of the Center is to ensure that everything we are learning about health through scientific inquiry -- not just physiology and genetics -- is translated into policy and practice to improve the health of individuals and the public.

It is this mission that brings me here today. As Dr. Fleming has pointed out in his testimony, no single group of Americans more than the elderly has as much to gain from putting into practice what medical evidence strongly suggests -- that behavior matters.

From avoiding risky behavior, to taking your pills on time, to getting appropriate medical screenings, a solid core of evidence exists on how to stay healthy and productive for as long as we can. In the past five years, Congress has doubled the funding for the National Institutes of Health, and the payoff should be seen in dramatically improved health outcomes in the years ahead. Or maybe not.

The investment we have made in basic science will be diluted if we do not translate these advances into use -- and use implies systematic changes in the behavior of doctors, health systems and individuals.

Let me give you an example of what I am talking about. Biomedical researchers say that we are on the verge of seeing a new genetic test that will tell people whether or not they will get colon cancer. This development is a triumph of science; for many, it vindicates the nation's investment in discovery research at NIH by promising a tectonic shift in the burden of colon cancer, the cause of 56,000 deaths a year in the United States. But this incredible advance coming from basic science necessitates a more powerful understanding of human behavior if we are to make the best use of it.

Even time-tested, effective technologies -- mammograms and immunizations -- are not finding their way often enough to the people who need them. Physicians forget to recommend them, patients don't ask for them, are confused about how often they need them and fail to comply with their doctors' advice to get them. The technology is brilliant but it requires human behavior to make it work.

One recent action by CMS is an important, and unfortunately too rare, instance of attending to the behavior that connects the technology to its target. CMS reviewed the evidence on interventions directed at doctors, health care facilities and individuals to increase vaccine use, and, based on this review, implemented with CDC an effective pilot program in nursing home, creating standing orders to increase the possibility that the right immunizations get to the right seniors at the right time. CMS is proposing to take the next step to facilitate the delivery of immunizations and the use of standing orders in health care facilities.

But behavior doesn't just matter in realizing the health benefits of the clinical preventive services covered by Medicare. There is overwhelming scientific evidence demonstrating the great gains to be had by reducing behavioral risks. Quitting smoking, increasing physical activity and preventing falls, are extraordinarily important but until quite recently have not been viewed by CMS as part of the Medicare prevention mandate.

The new CMS-sponsored stop-smoking demonstration project is the agency's first effort to systematically address a major behavioral risk for disease and disability. And evidence has been gathered on the feasibility of pilot programs to assess risk, prevent falls and better manage chronic conditions. Each of these might have an important role to play in a Medicare program that aims to help Americans live as well as they can for as long as they can.

Mr. Chairman, it would a terrible waste of the nation's health and resources if the knowledge generated by the health research sponsored by Congress sits in file cabinets in Bethesda and is not used to benefit the American public.

The pharmaceutical and technology industries are responsible for bringing some of that knowledge to the marketplace, but they are not responsible for ensuring that what we know about quitting smoking or getting people to participate in screening tests becomes part of routine health care and community services.

There are several ways Congress can act to make certain that we realize the full benefit of our investment in health research. Congress can:

1. Raise the priority within CMS for addressing behavioral risks in the Medicare program, for example, by supporting demonstration projects to help seniors increase physical activity, reduce the impact of falls, manage chronic conditions, reduce alcohol and substance abuse and improve nutrition. These risks are critically important for seniors, and their health stands to gain from widespread availability of services to support behavior change to reduce them. We applaud the efforts of CMS to address expansion of prevention efforts to include smoking and other risk behaviors based on careful scientific review. Increased commitment on the part of CMS would expedite program and benefit design and feasibility assessment that would ultimately result in more effective prevention efforts.

But medical care, even with Medicare reimbursement, is neither organized nor equipped to shoulder the entire burden for reducing risk behaviors among seniors.

2. Foster better cooperation among federal agencies -- CMS, CDC, AHRQ, AoA and NIA -- to ensure that evidence drives the implementation of effective programs to improve health and prevent disease. Each agency brings different knowledge and resources to solving the problem of the health of seniors. Each agency is connected to seniors in different ways -- through state and local health departments, local senior services or specialized research programs. More frequent communication and stronger collaboration among these agencies would benefit those individuals and families that each of these agencies claim to serve.

But the federal government is by no means the only advocate for the health of seniors, and federal agencies play only a partial role in ensuring that the prevention programs for seniors are widely available.

3. Encourage public-private partnerships among federal agencies with responsibility for seniors and the organizations that can act on evidence-based strategies to improve the health of individual seniors in the communities in which they live. The most effective programs will be ones that integrate the authority of health care with delivery capacity of local services that support seniors in living full lives.

4. Increase the extent to which CMS makes use of evidence on how to overcome behavioral barriers in implementing preventive services. In implementing standing orders for immunizations, CMS showed that it understood just covering a service as a benefit is not enough; consistent policies and practices are necessary to get the right preventive procedure to be used right. More attention must be paid to ensuring that health care systems, group practices, physicians and other health professionals are encouraged to act on the evidence of the most effective means of ensuring that clinical preventive services reach the right individuals in a timely manner.

5. Finally, by promoting better balance of basic and applied research in the federal health research portfolio. Just as we plan retirement security in our investment portfolio by creating a mix of stocks and bonds and cash, the nation's science portfolio must also be balanced -- with an emphasis on application, translation and behavior.

Although it is not the direct responsibility of this subcommittee, I would make the point that while funding for the NIH is going up by 16 percent this year, funding for the lead agency for translating research -- AHRQ -- is being reduced by 16 percent. I am told that at CDC, less than 1 percent of its budget is spent figuring out how to apply what it spends the other 99 percent learning.

The challenge before us is to figure out how to make sure that when medical breakthroughs are made, they get translated at the right time, to the right people, in ways that will make a difference. Because when it comes to health, biology matters, pharmaceuticals matter, genes matter, but behavior really matters.

Thank you, Mr. Chairman.

SUMMARY of TESTIMONY

Evidence shows that seniors can stay healthy and productive by reducing behavioral risks such as smoking and obesity and making use of Medicare-covered clinical preventive services. But evidence-based interventions for behavioral risks are not covered by Medicare, and preventive services are often ignored by physicians, patients and policy makers, thus undermining potential health gains of seniors.
·Congress has doubled the funding for the National Institutes of Health in recent years but has not given the same priority to research that will ensure that what is learned is quickly put to good use to benefit the health of all Americans: the 2002 budget for the Agency for Healthcare Research and Quality, the federal agency mandated to translate new science into health policy and practice, was $307 million, just over 1% of the $23 billion allocated to the NIH.
A recent example of how applied research can help ensure that the best technology reaches the right targets to improve health: CMS conducted an evidence review of interventions to facilitate the use of immunizations; this review led to implementation of standing orders for immunizations at health care facilities and is expected to ensure that more seniors get the right immunizations at the right time, thereby preventing disease.
Congress can act in several ways to make certain we realize the full benefit of the nation's investment in health research:

* Raise the priority within CMS for addressing behavioral risks.

* Increase the extent to which CMS makes use of evidence on how to overcome behavioral barriers in developing preventive services policy.

* Foster cooperation among federal agencies with responsibility for applications research and program implementation for seniors.

* Balance the federal research portfolio better between basic and applied research.

Jessie C. Gruman

President and Executive Director

Center for the Advancement of Health

Washington, DC

Jessie Gruman's career has focused on application of scientific knowledge to effective health solutions.

Gruman is the founding Executive Director of the Center for the Advancement of Health, an independent, non-partisan Washington-based policy institute originally funded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation to promote a view of health that recognizes the role of behavioral, psychosocial, economics and environmental factors in health and illness.

Since its founding in 1992, Gruman has built the Center into a well-funded nonprofit that works to improve health by ensuring that all health research is translated into effective policy and practice, not just research on biological and genetic determinants of disease. The Center is governed by a board of nationally recognized experts from the health, research, health care and media sectors. In addition to continued support from the MacArthur and Cummings Foundations, the Center currently receives funding from the Robert Wood Johnson Foundation, W.K. Kellogg Foundation, Soros Foundation, the Burroughs Wellcome Fund, the American Cancer Society and other major national health philanthropies.

The Center:

Serves as a credible resource for information and news about health behavior research for the media, Congress and key health decision-makers.
Works with employers, managed care plans, and health professional and research societies, as well as the National Institutes of Health, the Center for Medicare and Medicaid Services and the Centers for Disease Control and Prevention to apply health behavior research in the development of effective policies and health care practice.
Works to improve the quality and priority of health behavior research, to make better use of available resources in conducting it, and to increase the abilities of researchers to conduct research with implications for health policy and practice.

Formerly at the National Cancer Institute, Gruman directed the initial phase of the American Stop Smoking Intervention Study for Cancer Prevention (ASSIST). Prior to government service, she served as the National Director for Public Education at the American Cancer Society and the Manager of Health Promotion at the AT&T corporate headquarters.

Gruman graduated from Vassar College and received her Ph.D. in social psychology from Columbia University in 1984.

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Assessing America's Health Risks: How Well Are Medicare's Clinical Preventive Benefits Serving America's Seniors? How Will the Next Generation of Preventive Medical Treatments be Incorporated and Promoted in the Health Care System?"

Jessie C. Gruman