Sciences and MedImmune. This evolved out of NIH when conflict of interest policies were different, he said, but the government may have gone too far in the other direction. “What do we have to do to convince Congress and everybody else to come back to the middle so we can open up some pathways.” Dr. Barker said she had had to deal with such ethics issues at NCI, and went to a lot of Congressional hearings, “and we did have some problems. I think you’re absolutely right it’s swung too far back the other way. If you have investigators who can work on nothing that they’ve developed, especially the trials, then you’re not going to move anything forward.” Dr. Cosgrove said he would second that, and that the Cleveland Clinic had “tried to take a fairly aggressive policy, where all our physicians list all their financial relationships and make them public on the Internet. I think that’s the first and a very reasonable step to take.”

Robert Schmidt, of Cleveland Medical Devices, asked about some major medical trends, including the Internet and miniaturization. “Things that used to fill up a room and cost millions of dollars are now a few thousand dollars and then $49 at CVS.” With cutbacks in Medicare and Medicaid and higher insurance costs, he asked, will more medical devices be moving into the homes, and what other changes could be anticipated? Dr. Cosgrove agreed that technologies are changing, as are disease distributions. “We’re no longer seeing acute diseases in hospitals like we used to; now the majority are chronic diseases. And over the last 25 years, we have 200,000 fewer beds for 70 million more people. So healthcare is moving from inpatient to outpatient and eventually to homecare. In terms of the recent legislation and changes in government programs, hospitals are going to come together in systems. I think there will be fewer independent hospitals simply because of the complexity that is required in the back office to manage a hospital. I think there will probably be 500 to 1000 fewer hospitals across the U.S., as well as hospitals rolling up into systems.”

Towards a More Open, Holistic Research Model

Dr. Wessner asked what Federal or state investments the panel members would wish for. Dr. Barker said that “the short answer is everything,” but that she would begin by directing Federal money into regional public-private partnerships and clusters. “The emphasis could be IT or centralized biospecimens or networks for doing clinical trials, all are needed. I would start with measures that have promise in the personalized medicine space. Frankly, I don’t see this entire system developing quickly absent some Federal investment.” Dr. Douglas agreed on the priority of clusters. “You could insist on having a number of clusters, and those clusters would include IT, engineering, and biotech companies able to take innovations rapidly to commercialization. This would not require new money; the government could support a regional cluster with money already there.” Implicit in support for clusters, he added, is support for shifting toward a multidisciplinary, holistic approach. Dr. Cosgrove



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