Chapter 10: Research on Health Effects of Policy Decisions and a Study of Childhood ALL
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Description
In this chapter Dr. Elting talks about her current research focus on the health effects of policy decisions made by state and local governments.
She begins by noting that there is no federal health policy in the United States, so policy decisions made at a “semi-macro level” have an effect locally on subpopulations. Dr. Elting gives an example from Texas health care.
Dr. Elting explains that to study these effects, she began to study outcomes by volume of cancer procedures. She then gives an example of a study she conducted on the availability of mammogram machines across Texas, showing that in areas with no machine, patients suffered more late-stage breast cancer. She notes she is currently working with a pediatric surgeon looking at pediatric cancer in Texas.
Dr. Elting notes that few families can afford care for childhood cancer. She explains the funding of the study and its impact. She gives an example of partnering with the University of Texas Medical Branch to produce video talks and other educational materials for communities and primary caregivers. She mentions some other efforts to disseminate information beyond academia.
Dr. Elting talks about why Texas is an interesting state to study and why it allows conclusions about how barriers to care operate and affect outcomes. She talks about interventions her office has helped to create.
Identifier
EltingL_02_20150305_C10
Publication Date
3-5-2015
City
Houston, Texas
Interview Session
Linda S. Elting, DrPh, Oral History Interview, March 05, 2015
Topics Covered
The Interview Subject's Story - The Researcher; The Researcher; Discovery and Success; Discovery, Creativity and Innovation; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Patients; Patients, Treatments, Survivors; Fiscal Realities in Healthcare; The Healthcare Industry; Politics and Cancer/Science/Care; Women and Diverse Populations; On Texas and Texans; Beyond the Institution; MD Anderson and Government
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey A. Rosolowski, PhD:
So what was the next direction that you took?
Linda S. Elting, DrPh:
I guess the next direction I tookand I consider myself still in that phase. I started likeyou know, thethere's one thing that's really interesting about our country that I'm not sure everyday people recognize. And that is that, in spite of the number of organizations and people who tell us what our health policy should be or our public-health policy, there really is no health policy in the United States. It's managed by so many different factors, both public and private. The decision-makers are everywhere. And there is no one, other than occasionally Congress or Medicare, who specifies, "This shall be done for everyone." There arethere are very few of those specifications. And so, it became really clearthat's very different, for example, from the United Kingdom or from Canada or other places with a national health service, where there are national health policies and you can say, "Okay, this works better than this,"and it can actually have an impact on a whole country, or big numbers of people. The United Statesthat's not the case. And so, even MedicareMedicare doesn't decide what's covered. Lots of people don't know that.
Tacey A. Rosolowski, PhD:
Mm-hmm, no, I didn't.
Linda S. Elting, DrPh:
There are peoplethere are for-profit companies called fiscal intermediaries that dole out Medicare money, and they're all over the country. There's one for Texas. There's a separate one for other states. And they decide what they're gonna cover with very few exceptions. And so, you may be able to get one thing covered inby Medicare in Texas, but not in California, and vice versa. So, I got very interested in how those kinds of decisions made it sort of "semi-macro levels,"like state levels, local levels, and that have an impact on care in a community, in a popsubpopulation. But itbut it's completely different if you go across the state border. So, Medicaid is administered at the state level. A state decides what it's gonna pay for, and whom it's going to insure. And thosethat varies around the whole United States. Medicare fiscal intermediaries vary, although not as much as Medicaid, in what they'll approve. Whatthe public-health budgets for states vary a lot in how much money they set aside. In Texas, we havewe have property taxes, and in large municipalities those property taxes go into county health departments and city health departments. In places that don't have property taxes, they have city budgets or state budgets that are paying for large hospitals. And so, people who have chronic illnesses, like cancer, that cost a boatload of money, are the people who either benefit or suffer the most from these differences from one municipality to another. And that got me really interested in how, at that policy level, we allocate resources for cancer care. So theI did some studies on volume and outcome, as I described before, on surgery, that were specific to the state of Texas. And we looked atnot only at outcomes, which everybody who had studied that had done in the pastto see if you do only a few per year, then do you have worse? But also, we looked at, well, what would happen if we told the people thatwho normally go to these little hospitals, "Go to this other hospital, which is a high-volume provider." How far will they have to travel to do that? And, at the same time, if they take these very profitable big procedures and move them out of the little hospitals, will we hwill we have any surgical capacity left in the small places if somebody has a car accident on Saturday night and needs a surgeon to operate on them to save their life, if the surgeons don't have a steady income from profitable procedures like cancer procedures, they go and move to Fort Worth or Houston or Dallas or San Antonio. What's gonna happen if you're in Luling, Texas, and you haveand you need a surgeon? Those sorts of pluses and minuses of approaching things from a policy level are really fascinating to me. And so, I started doing some projects like that, and then started looking additionally to the allocation of resources, for example, like I did a study on mammography in Texas. And we looked at, you know, there are 254 counties in Texas. With a very blunt tool, we just said how many of them have a mammogram machine? And it was only half. [laughs] And inand soand people have studied that before, but we would lookwe looked at the outcomes. So, in women who are diagnosed with breast cancer in those counties, are they likely to have early-stage disease or late? And the answer was late. I mean, there was a real outcome that you could associate, at least biologically plausibly, with the notion that there was inadequate screening facilities. So, we'recurrently, I'm working with a pediatric surgeon. We're doing the same thing looking at pediatric cancer facilities. It's a rare cancer. Most children are treated in the hospital. So it's a risky kind of treatment, but in most childrenparticularly those inchildren with leukemia, most of them are curable if you treat them well, you don't kill them with the treatment, and you do a good job of follow-up. And so, we're now looking, in Texas, at where the children are who get cancer, and we're looking at how far they travel to be treated; how far to the honearest high-volume children's cancer provider is; and howwhether or not there are racial and ethnic disparities in who gets to the high-volume providers. So
Tacey A. Rosolowski, PhD:
So what is the cancer that you're looking at?
Linda S. Elting, DrPh:
Well, currently we're looking at acute leukemia in childrenALL [acute lympocytic leukemia]lymphocytic leukemia. That's the most common cancer in children. And we're looking at it because eighty percent are cured, or can be cured. So it makes a whole lot of sense, if you had a pot of money, to invest it in children who will have a long, healthy life because they'll be cured, in getting them to a high-volume provider.
Tacey A. Rosolowski, PhD:
Who is your colleague on this project?
Linda S. Elting, DrPh:
I'm working with a fellow of our CERCIT [Comparative Effectiveness Research on Cancer in Texas]a junior faculty member who's a pediatric surgeon named Mary Austin. And she came to ourCERCIT is ait's a grant that we hold with UTMB [University of Texas Medical Branch] and Rice [University]. And in the renewal, we hope to add in UT [University of Texas] Southwestern. And w haas a part of that, it's funded by CPRIT, the Cancer Prevention and Research Institute of Texas. And weas part of that, wethey gave us the money to link the Texas Cancer Registry data over a ten-year period to Texas Medicare and Texas Medicaid. So we have all the cases, and then we have them linked to their Medicare and Medicaid claims, and to some other datasets as well, but primarily to the claims. And so, part of that grant is a training program for junior faculty members at the participating institutions. And Mary Austin a junior faculty member in pediatric surgery here. So, she has an interest inshe's working at the School of Public Health on her certificate in disparities, and has a background in public health. And so, she has a real interest in the ability of children to travel to get the care they need. And we can say a lot, because aboutbetween seventy-five and eighty percent of children with cancer are Medicaid beneficiaries. Nobody can afford the care for those kids. And so, virtually everybody, you know, gets Medicaid for theiras their primary, and they have backup insurance as well. So, we have a good population to draw from.
Tacey A. Rosolowski, PhD:
And how many years has that study been in progress?
Linda S. Elting, DrPh:
We got the grant in 2010. We, just this month, started our fifth year, so we're busily planning our renewal application, which will go in after this year, probabwe expect it to be probably going in next fall. We think that's when the call will be for the RFA [request for application].
Tacey A. Rosolowski, PhD:
And what do you think the impact will be of this studythe information that you're gathering?
Linda S. Elting, DrPh:
Well, to tell you the truth, we've had a lot of impact that I never anticipated. We teamed up with a group at UTMB that has a network of primary care providers throughout the state. And we do video talks and educational sessions that are distributed to all of those places in order to talk aboutone of our projects is about screening. And so, all of that screening information is then done by video out to all thethese primary care practices . We have one group that's paid in our grant to disseminate information to the public. And it's all done via editorials in newspapers. And so, we have a group that's writing editorials full-time. UN, the most recent one that I was working onsome of it is just taking our papers that we publish, translating it into normal human talk, and putting it out in a press release. But the editorial usually have a theme and a purpose, like allevery year in May, Mary Austin and I write one on screening for melanoma in children because it's Sunscreen Awareness Month in May. And when it's Colonoscopy Awareness Month, we put out all of these editorials that go out to newspapers across Texas with the information from Texas, and information about screening: who should get it, who shouldn't, how often. you know, where can Iwhere can you go, and that sort of thing? So, we've done that. We've done a lwe've done some major reports. So, we did a major report on cancer in Hispanics in Texas, that was circulated widely to providers, but also to all members of the legislature, because they make decisions about money that goes to the Hispanfor treatment of the Hispanic community. Went throughout the UT system. So, we worked hard to use mechanisunusualless usual mechanisms to get information out to people other than other academic researchers. So, it has provided probably the first good picture of cancer in Texas. And it's ait's an interesting state to study. There is such a database for the US [United States] as a whole. Texas is not represented in it. We have a lot of Hispanics. Unlike many places in the US, we have a lot of rural Hispanics in Texas. And we have a lot of African Americans, but they live almost exclusively in cities. And that's very different from the rest of the South, where you have Hispanics in cities and African Americans in the rural areas. And because distance from providers can be really important in those groups, and particularly because they have high rates of insurance, it allows us to compare the effect of those problems in Texas to other state. And where you can tease out, then, how much of this is because you're far away from a center, and how much of it is because you don't have insurance, and how much of it is for other reasons? So, it's ait's an interesting dataset to be able to study.
Tacey A. Rosolowski, PhD:
What's your hope for thisthe long-term hope? And you'll gethopefully get this renewed for another five years. What's the long-term vision, really?
Linda S. Elting, DrPh:
Our initial vision was to provide a picture of cancer care in Texas. I think our next renewalour renewal will be to provide a roadmap for progress. We've done a lot, in the first five years; to identify gaps; to find problems, to find situations where there is no problem. [laughs] All of these areas are placesand when you put it together in a picture that's the whole state, it allows you to have a pretty persuasive discussion with the legislature about where to put money and where to save money. So, I think that'swe're still sort of noodling about what our renewal needs to look like. But I'mI think that's where we're gonna go, in some form or another. And I think what we'rewe will probably do is add newa new focus inprobably much more focus in children, because we did mostly adults in the first five years. I expect that we will have at least some component that involves contacting patients across the state and asking them how they're doing, and about their satisfaction with care, and getting real patient outcomes from them. And I think we will probably begin to look far more carefully at expenditure of funds, where it's been effective, and where it hasn't beenwhere we need to do better.
Recommended Citation
Elting, Linda E. DPh and Rosolowski, Tacey A. PhD, "Chapter 10: Research on Health Effects of Policy Decisions and a Study of Childhood ALL" (2015). Interview Chapters. 714.
https://openworks.mdanderson.org/mchv_interviewchapters/714
Conditions Governing Access
Open
