MARCH 2008 HOT TOPICS

Improving Pandemic Preparedness in Southeast Asia and the Middle East

Congress has invested millions of dollars to shore up public health preparedness in the U.S. With the world bracing for the next influenza pandemic, many experts believe that it will originate in Southeast Asia. To help improve the region's preparedness for such an event, a RAND team led by Melinda Moore and David Dausey is working with a consortium of partners in the region. The consortium, known as the Mekong Basin Disease Surveillance (MBDS) project, is an ongoing collaboration among six nations—Cambodia, Laos, Myanmar, Thailand, Vietnam, and China (Yunnan Province). The MBDS is intended to strengthen regional cooperation in disease surveillance. Similar concerns about pandemic preparedness among nations in the Middle East led RAND to conduct a similar project at the invitation of a consortium of partners in that region, the Middle East Consortium on Infectious Disease Surveillance, a collaboration of Israel, Jordan, and Palestine. On March 10th, Moore was on Capitol Hill briefing experiences and findings from the work conducted in Southeast Asia and the Middle East.

The work has four principal aims: (1) help public health and other relevant personnel practice their joint responses to a hypothetical pandemic situation; (2) identify areas for improvement; (3) strengthen relationships among personnel from public health and other response agencies; and (4) train staff. To address these goals, RAND designed and conducted tabletop exercises, modeled on similar exercises that it has conducted extensively in the United States with federal, state, and local governments and a large private-sector organization. For the MBDS consortium, the researchers first developed and conducted tabletop exercises in individual countries. They then collaborated with MBDS countries to design and conduct a regional exercise, the first of its kind. It involved 60 participants from a broad range of sectors in the six countries, plus 25 observers from technical and donor organizations. The exercise addressed three preparedness areas that had also been addressed in the country exercises: surveillance and information sharing, communication, and disease prevention and control. The MBDS exercises are now complete. In the Middle East, the RAND team has conducted similar exercises in Jordan and Palestine (Israel has already completed its own). A regional planning exercise involving these three participants is scheduled for April 2008.

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A New Way of Pricing Prescription Drugs

Congress has long worked to make prescription drugs more affordable to Americans. High out-of-pocket costs for prescription drugs pose a quandary for health policy. Studies have shown that high costs can cause patients to stop taking needed medicine. Noncompliance with prescriptions can lead to worse health outcomes, especially among patients with chronic disease. However, attempts by government to mandate lower prices raise concerns about reducing incentives for future pharmaceutical research and development. A team of RAND researchers led by Senior Health Economist Dana Goldman has proposed a new pricing system for consumers who buy prescription drugs. The system is intended to increase prescription compliance without altering patients' out-of-pocket spending or affecting drug company revenues. Consumers would pay an annual fee up front that would entitle them to a year's worth of medicine for each prescription, with a small or no co-payment for each monthly supply. Such a system could be used to pay for medicines that treat chronic conditions without increasing the cost to consumers and may reduce the periods that patients go without such medicines because of the cost. The pricing scheme outlined by researchers is currently used to pay for products and services in many areas outside the medical world, such as Internet service, cable television, and software. Consumers pay a set fee to cover a period of unlimited access to the product or service and use it as much or as little as they need. Pharmaceuticals resemble these items because their production costs are low and few substitutes exist.

For example, a drug-licensing system might be used to pay for statins, prescription medication used to treat high cholesterol. In a hypothetical example, consumers would pay a $195 fee for an annual license for the statin drugs—equal to what most consumers now pay out of pocket each year if they have insurance plans that require $25 per-prescription co-payments. Insurance companies would pay an additional $374 to drug companies for each statin license. Because there would be no monthly co-payments for consumers, researchers predict that patients would be more likely to take their prescriptions. Analyzing past research about the impact of rising co-payments on patient compliance, the researchers suggest that average annual use among patients taking statins would climb from 7.8 months to 9.8 months under the new pricing plan. Increased use of medication among chronically ill patients should result in fewer long-term health problems and lower overall costs to insurance providers.

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Inside the “Black Box” of Health Care Quality Improvement

Quality of care and how to improve it have received considerable attention in recent years. As a result, researchers are now better able to measure levels of health care quality and the impact of quality improvement (QI) initiatives. However, relatively little is known about the organizational factors that contribute to poor quality in the first place, and even less is known about how improvement within health care organizations actually unfolds. Consequently, the process of implementing, managing, and sustaining QI—that is, the institution of organizational changes to improve quality in health care—has remained a “black box,” impenetrable to the outside observer. A recently published study conducted jointly by RAND's Peter Mendel and colleagues from University College London addresses this critical gap in understanding. The study consisted of in-depth case studies of hospitals and medical centers in the United States and Europe that have earned reputations for sustained achievement in QI and performance. The goal was to understand the process of improving quality, both in the ways that organizational and human factors influence each other and in how different levels of an organization can make this process effective. The authors concluded that there are many different paths to successful, sustained QI; however, the unifying features across all of them are an ability to address multiple challenges simultaneously and to adapt solutions and strategies to the organization's context. The findings emphasize the need for those concerned with driving change within health care organizations to attend to the organizational and human dimensions of change and to look at how these dimensions interact over time to sustain improvement.

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