The U.S. spends more than any other nation on biomedical research, counting on those outlays to make health care more efficient. Leading the way is the National Institutes of Health, which funds more than $30 billion on projects each year, chiefly in basic research.
Unfortunately, the NIH in its current form is too sprawling and disjointed to allow advances in medical research to move easily into medical practice. Structural changes are needed to help the agency live up to its full potential in improving medicine and health outcomes. The conglomeration of institutions should be streamlined from 27 to three.
The NIH took shape in the 1930s as a single institute but gradually multiplied into agencies that separately address areas of medicine such as aging, alcohol abuse, child health, cancer - - and almost two dozen more. Each institute is entrenched in the linear, disease-based model of science, which assumes that more fundamental research will automatically lead to better treatments. Little effort is made to consider the ways that patients’ behavioral, social and cultural aspects can add to lab-based insights based on molecular and physical findings.
To help the NIH transfer findings from its laboratories into clinical settings, Francis S. Collins, the NIH director, last year proposed to add a 28th subdivision -- a National Center for Advancing Translational Sciences. But there’s little reason to assume that adding still another institute to an already disjointed structure could help. A better approach is to redesign the entire NIH.
Too Many Institutes
Harold Varmus, a former NIH director, was among the first to raise an alarm over the continually proliferating institutes -- a process he described, in a 2001 article in the journal Science, as one of “fusion and fission.” While the NIH is seen as “the jewel in the crown of the federal government,” Varmus wrote, adding too many facets creates “a superficial sparkle that may be pleasing to the few but threatening to the functional integrity of the overall design.”
Streamlining has been proposed before. A 2003 report by a committee of the National Research Council voiced longstanding concerns that the agency had become fragmented and unwieldy. The committee considered a consolidation plan but deemed it too difficult.
On the contrary, a reconfiguration of the health institutes is both feasible and timely. We could do away with the present 27 and create just three: A “biomedical systems” research institute would maximize the impact of lab-based findings by integrating research from behavioral, sociological and environmental perspectives. An institute for health outcomes would combine research and clinical insights to help determine which treatments work best. And an institute for health transformation would develop new strategies to make health care more efficient and less expensive in the long run.
With this model, the NIH could move from its disease focus to a more holistic approach to health and disease, one that takes into account the interactions among medicine’s many components. A tripartite reorganization would take advantage of the fact that emerging medical technologies can often be used across a number of fields.
The reconfiguration we propose assumes that progress in medical care actually comes from the complicated interaction of expanding knowledge (in many disciplines), technological innovation and clinical practice, as a number of economists have argued.
Per-capita spending on health care in the U.S. is almost 2 1/2 times the average for the 34 nations that belong to the Organization for Economic Cooperation and Development. Yet clinical outcomes here do not match the huge expenditure. On average, citizens of more than two dozen nations may expect to outlive us. Hospital-admission rates for U.S. patients with chronic conditions best managed through primary care, such as asthma and diabetes, exceed those of all other OECD nations.
And in a comparison with six other advanced nations, including Canada and the U.K., American health care ranked last or next to last in quality, access, equity and what the report by the Commonwealth Fund called measures of “long, healthy and productive lives.”
These results are unacceptable. While basic science must stay focused on answering fundamental scientific questions, the knowledge and technologies that emerge from basic science need to be driven toward improving health care and lowering its cost.
A simple way to characterize the fundamental difference between the present system and the one we have in mind is the push-pull metaphor. In the NIH’s current model, fundamental science tries to push its discoveries on the health-care system. What would work better would be a pull model, in which the health-care system would identify what it needs and then choose the appropriate discoveries from basic science.
We must not slacken the pace of medical research nor decrease the amount of money we spend on it, but our investment should be focused on critical health-care outcomes and affordability in the long term.
(Michael Crow is the president of Arizona State University. Denis Cortese, a former president and CEO of the Mayo Clinic, is the director of the ASU Health Care Delivery and Policy Program. Leland Hartwell, the recipient of the 2001 Nobel Prize in physiology/medicine and a former president of the Fred Hutchinson Cancer Research Center in Seattle, is the chairman of the Center for Sustainable Health at the ASU Biodesign Institute. The opinions expressed are their own.)
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