HHS launches a program to boost preventative care

A new initiative from Health and Human Services seeks to prevent preventable health problems in under-served communities. The HEROES Program will run through the Advanced Research Projects Agency for Health (ARPA-H). HEROES stands for Health Care Rewards to Achieve Improved Outcomes. To see how it works, the Federal Drive with Tom Temin spoke with program manager Dr. Darshak Sanghavi.

Interview Transcript: 

Tom Temin And I want to read a sentence from the description of this program, Heroes aims to trial and validate a radically different approach to creating preventive health care incentives in the health market. What does that mean?

Dr. Darshak Sanghavi I’ve been a physician for almost 20 years now, and I’m really proud of the work I do and many of my colleagues. But think about how we give health care in this country. You know, we wait until people have symptoms or some kind of problem. You go see the doctor. The doctor does something, you know, perhaps, don’t, you know, give you medications or diagnosed you at that point. The bottom line is it’s a very reactive system. And the reason it’s that way is because it’s the way we pay for care. You only get paid when you actually go out there. You seek out that care, and it’s often given in clinics or even in much more acute settings. Now, if there’s one thing we’ve learned in health care, it’s that we get what we pay for. As a physician, I know I spare an enormous amount about my patients, but it’s inevitable that the incentives that are set up also change the ways in which we give care. So, broadly speaking, if you think about care in our country, we should be really proud of the care we give. The challenge is that that it’s really weighted towards acute, sort of high intensity care when people are already having problems. You think about the fact that we don’t have great prenatal care. And yet when women sort of get critically ill, that’s when the system springs into action. We don’t do a great job with sort of thinking about, well, how are we going to prevent heart disease and stroke? But the minute you have that, you get access to some of the greatest care around. What our program wants to do is to sort of flip those incentives on their heads. And so, we want to create a system where innovating around prevention, it’s not only the right thing to do, but it also becomes the smart thing to do.

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Tom Temin And you mentioned in the program that it is the underserved communities because there’s lots of great preventive care. If you’re in Upper Manhattan, if you’re in the canyons of Rodeo Drive, the affluent areas of the country. There are health plans that pay for preventive medicine. You get covered for a couple of annual visits to checkup and so forth. Not the case for those that don’t have access to that type of plan.

Dr. Darshak Sanghavi There’s certainly an incredibly important sort of trend we’ve seen is that when you look at where you live, your zip code and your income often determine how long you’re going to live and how healthy you are. There’s no reason that should be the case, but it has to do with the ways in which we set up the system. So, you’re absolutely right. That part of our program and what we’re trying to do is to create an incentive and a way in which we care for Americans, that doesn’t depend as much on those things about where you live and how much money you happen to make, and to create that sort of accountability so that we truly create better health outcomes for everybody.

Tom Temin All right. And how will the program, the Heroes program, actually go about doing this?

Dr. Darshak Sanghavi So the key innovation is that maybe sort of using sort of the terms of business and economics, we are going to create an incentive to actually buy outcomes at geographic scale. Now what does that really mean? Well, think about it this way. Let’s take one of the potential outcomes we’ll look at, which is the rate of opioid overdoses. You know, we know that opioids are a major crisis, one of the leading causes of death for young people in the United States. And think about what we do now. You know, we wait till sort of people have overdoses. You kind of go out there, you treat them. But we don’t do a great job. Only 25% of individuals, even after they have an overdose and go to an emergency room. I mean, think about that. You’ve actually overdosed. They brought you to the E.R. Only 25% have actually get evidence-based care to actually develop a long-term path to recovery. And why is that? Well, that’s because nobody is accountable for that entire community. So, the Heroes program, for example, we’re going to do this for four outcomes and get comment on that initially. But what we’re going to do is an organization can say, look, we’re going to take this area literally. They’re going to draw a line around the population. So, they’ll say these half million people or, you know, or more, I’m going to be responsible for their rates of opioid overdoses. Doesn’t matter who you are, where you live, who your insurer is, but you’ll be responsible for them. We at ARPA-H then this is the magic. We will then actually create a payment program to say, well, if you can lower the rate of overdoses. And we’re going to measure it, you know, almost in real time. You get paid for that. For the entire population. So, in other words, for the first time, for a whole population, we create a business case and incentive to buy that outcome. Now, what that will do is then it’ll create an incentive for kind of innovation. Well, how are we going to get to that whole population? Are we going to get to the community? Are we’re going to move outside the clinic? All the kinds of things that our innovator can do to then truly address the need of that whole population.

Tom Temin We are speaking with Dr. Darshak Sanghavi. He is a program manager at ARPA-H. And what types of organizations will be eligible to do this? Because frankly, it sounds ambitious.

Dr. Darshak Sanghavi Well, we need all the help and creativity we can get. So, what we’re looking for is we want to move outside to just the traditional types of health care deliver doctors, clinics, nurses, physical therapists. So, these can be larger provider systems. It can be early-stage technology or startup companies. They can be nonprofits. And in the best-case scenario, we would get consortia where they would sort of voluntarily come together and apply as a team because this really is a team sport. We also want to unlock sort of the private sector’s ability to truly innovate here. So, our only recommendation is that the primary applicant, what we call health accelerators, can’t be a federal or state agency as the primary.

Tom Temin What types of incentives are available to these organizations or consortia to get hundreds of thousands, millions, billions? I mean, how much money is behind all this?

Dr. Darshak Sanghavi Yeah. So, what we’re doing is we have used our, you know, modeling and we’ve kind of looked at our data. And what we’ve done is we’ve set targets that we believe will generate realistically about $60 million of societal value in each of these areas. So, for example, you know, we’ve set a target if you choose, say, severe obstetrical complications. You know, we all talk about maternal mortality. We believe that we can reduce that by about 20% in an area, and that’ll generate $60 million of value. And that’s a lot of value for people. And it’s not just money, but behind that of real lives. So, we will pre-purchase in each region $15 million. And because we want to make this sustainable, we are going to preference areas where others also step up to supplement us, like for example, health care payers, philanthropy, employers, everybody who benefits at about a 2 to 1 match. That’s what we’re shooting for. And so, to be about a $45 million pot of money that can be earned. So that’s sort of the incentive for organizations to hit those metrics.

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Tom Temin And what is the baseline time period? Because if you’re going to say reduce fentanyl deaths or reduce obstetric complications, you know, how do you measure that and over what period of time?

Dr. Darshak Sanghavi Yeah, this will be the year where we’re going to sort of have people apply. And then the performance period will be starting in the first quarter of next year, and it’s going to be a three-year program. We actually believe that these are all urgent issues. And most importantly, we already know what to do around, say, opioid overdoses or obstetrical complications. It is not a mystery. So, what we’d like to do is to truly create that incentive for rapid improvements. As I said, 25% of people are getting evidence-based care. We don’t need to wait three years to get people into better care. An enormous number of women, when they’re hospitalized for childbirth, they’re exposed to a system that’s not doing the things that need to be done to prevent complications again. We know what to do. We don’t need to wait as long. So, our hope is that by creating this incentive will accelerate the adoption of that innovation in a way that’s truly accountable.

Tom Temin And you mentioned there are four areas. Where are they.

Dr. Darshak Sanghavi So the four areas are. And we chose these because we want this to be an American program. We want there to be something in here for almost every age group, in every geography. So, we intentionally chose outcomes that sort of span that. So those are, as I mentioned, severe obstetrical complications. Obviously, a big issue mentioned opioid overdoses. You know, affects generally younger people a certain geographic distribution and then risk of heart attack and stroke. You know, slightly older population and finally alcohol related health harms. So those are the four outcomes. What we’re doing right now and this very moment, people can go online and let us know which of those outcomes they’re most interested in pursuing. We put all four out there. We’re going to collect sort of feedback, and the initial program is going to sort of really zero in on two of those outcomes. And then we will potentially add other outcomes in the future. But we want people’s feedback about where they think the energy really is.

Tom Temin And how will you choose the geographical areas?

Dr. Darshak Sanghavi So we want a program as I said, that looks like America. And you pointed out, you know, we want to get to areas where historically we have needed to invest more. So, I’ll say two things. The first is that a requirement for the program is that an organization will have to choose a geographic area, and it has to be contiguous geographic area where the outcome is worse than the national average. We want people to sort of take on areas that where at least there’s some challenge. It’s not already doing great. The second thing is that we will also really think about that distribution. We want to have like rural areas represented. We want to have areas that have really kind of diverse populations as well. We will not be happy if there’s a program that’s just sort of concentrated, say, on the coast or only in the Midwest, but rather something which truly looks like it’s a national program.

Tom Temin That means that it’s open to anyone, anywhere at this point who will make these decisions within ARPA-H?

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Dr. Darshak Sanghavi We are hoping, first of all, that right now we have a letter of interest, period. So, as you said, anybody can sort of let us know they’re interested. What we’re going to do is we’re also going to have an in-person and hybrid event. We call it Proposers Days. People are invited to join us in Washington, DC on February 13th, and 14th to meet the team, to meet each other, how it’s supposed to work, you know, and you can attend hybrid as well. If it’s difficult to get in person and you get that information. We’re going to take that feedback and then release a formal and full solicitation. That’s our fancy term for like the application process in early April. I would emphasize one of the great things about ARPA-H is we don’t do stuff the way government usually works. In other words, the application process is going to be short, maybe 8 or 10 pages through an abstract. Tell us, what do you want to do? That is not how government usually works, because that’s signals that we want to be open to organizations that, you know, don’t have tons of lobbyists and hire grant writers and all that. That’s what we’re looking for. So, when they come in and answer your question, we will look at that. That’s where we’ll have a team of government folks that will sort of score each of those along all those criteria, and then we’ll come back and then solicit full applications for the program from those organizations.

Tom Temin And finally, are you working with HRSA because that organization, your sister organization, and HHS has hundreds of care facilities in those very places it might be concerned with?

Dr. Darshak Sanghavi Yeah, HRSA for those who are not familiar federally qualified health centers. And there’s even more than that. There’s Indian health services, there’s Medicaid programs, there’s opioid treatment facilities. So, what we’re doing is we’re trying to bring all the pieces of government together, not only, as you said, are there clinics that serve these locations, but we also need to make sure we’re bringing along the business case. We’ve been working very closely with colleagues at the centers for Medicare and Medicaid Services. Let’s make sure we do that in collaboration. The centers for Disease Control, you know, they thought a lot about public health over the past couple years. NIH has made investments in a number of technologies as well. So, we’re trying to pull them together and along. But keep in mind, we’re there really at the service of our private sector partners. So, we stand ready to help them. But what we’re doing is by creating this incentive, we want these communities to sort of rise up. They know their communities best. They’re going to sort of pick and choose. We’ll make sure all these things are available. They’re the ones that will be accountable. They’re the ones that you get the rewards from the program.

Tom Temin And a personal question for you. ARPA-H program managers come from outside. It’s a temporary type of position. Clearly, you’re passionate about delivering health care. And so, you don’t want to stay in the government likely. Or maybe you do for the rest of your career. Will you be around long enough to see the three-year outcomes of some of the grants? Yeah, essentially.

Dr. Darshak Sanghavi Yeah, I sure hope so. So, this is actually my third stint in government. Many, many years ago I was a pediatrician on the Navajo reservation before I trained as a pediatric cardiologist. I then spent a couple of years, actually, as a group director in the Obama administration at the Centers for Medicare, Medicaid Innovation, developing several nationwide programs. And then I spent time also in the private sector as an executive at large payer provider organization and even an international company. So, this is a three-year term were appointed to and we can be re-upped once. So, my goal is to be here to make sure that we execute this. The good news is that we’ve got an amazing team. So, you know, who knows where things go. But we believe that ARPA-H and our programs are here to stay, and we’re in it for the long haul as individuals, but importantly as an organization as well.

Tom Temin And do you hope to at some point before you hang it up, be able to place a stethoscope on a tiny chest? Again.

Dr. Darshak Sanghavi I do. The good news. And again, this is the other thing about ARPA-H. It’s an amazing place to be for somebody who wants to make real change because we’re flexible. I mentioned we’re flexible in terms of how we engage people, how people apply. It’s just different. I also, I may mention I’m a pediatric cardiologist. At ARPA-H, they’ve allowed me to still see patients, occasionally. So, I still take calls one weekend a month. So, the good news is, I still get to put that stethoscope on baby’s chest every now and then.

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