I commend NFL Commissioner Roger Goodell for having the good sense to address this issue decisively, although, as I will point out, the BU research findings are potentially far more transformational for contact sports than the commentators about the findings have communicated.  What is most interesting, and, to some degree, saddening, is the fierce resistance of many players and commentators to an action that will benefit the players and the sport in the longer term.

The Boston University Research Findings

I have gotten to know two of the researchers in the BU Study, Dr. Robert Stern and Dr. Ann McKee.  I have particularly worked closely with Dr. Stern, who is the co-chair of the clinical studies and trials program in the Alzheimer’s Disease Center.  The research he and Dr. McKee have published makes a number of key findings:

• The dementia that many athletes experience, sometimes well before old age, is not Alzheimer’s Disease, but a condition brought on by chronic traumatic encephalopathy (or “CTE”), which creates the conditions for dementia, but has a different source of progression from Alzheimer’s Disease.
• Most important, CTE does not result from a single concussive event, but from the cumulative effect of many violent impacts on the brain, many of which would not be diagnosed as concussions. While the NFL and other sports are to be commended for their proactive approach to managing athletes who sustain concussions, the problem is more widespread.  Indeed, it is entirely possible for an athlete to be victimized by CTE without ever having been diagnosed with a concussion.
• While the end result of CTE could be dementia, the effect on certain sectors of the brain even earlier in time might be damage to those brain functions that inhibit individuals from drug or alcohol addiction or prevent depression and/or suicide.  Thus, many athletes who become alcohol or drug dependent, experience clinical depression, or even commit suicide long before old age may be victims of CTE.
• Because the root cause of CTE is cumulative and sub-concussive, it occurs in a wide range of contact sports, not just obvious contact sports like football and boxing.  Ice hockey players, soccer players who use their heads to direct the ball, and baseball players who are hit in the head frequently with pitched or batted balls might also be CTE victims.
• Because not every athlete who has participated in, or been a victim of cumulative sub-concussive impacts has experienced dementia or the loss of brain function, there is much more work to do before researchers can figure out the whole puzzle.

What We Need to Do in the Meantime

There are many good things happening in sports management already as a result of these findings:

• The NFL has funded further research at BU, which has created the Center for Traumatic Encephalopathy to conduct the research.
• A number of sports, including football and baseball, are starting to keep people with concussions from returning back to active sports participation too quickly.  I was pleased that the New York Mets and the Minnesota Twins kept Jason Bay and Justin Morneau out of action for the remainder of the 2010 season.  This was particularly painful for the Twins, who could have used Morneau’s incremental and sizable contribution in the playoffs.
• There is more active dialogue about how to keep the intensity and attractiveness of these sports while reducing safety risks for participants.

The best article I have seen recently on this last subject appeared in William Rhoden’s October 24, 2010, column in the sports section of the New York Times, a column entitled “Hall of Famer’s History of Compassionate Hitting.” Rhoden profiled the story of Willie Lanier, a Hall of Fame middle linebacker from the Kansas City Chiefs from the late 1960’s to the late 1970’s, The gist of the article is that Lanier was fortunate to have had a concussion early in his career and refrained from being as reckless and violent for the remainder of his career as he could have been.

The most important insight Lanier gained and shared with his fellow players was that keeping people of high skill and quality playing, rather than injuring them, benefited everybody.  If everyone successfully knocked the most skilled players out of competition for extended periods of time, there would be retaliation, and, over time, the quality of people competing would decline.  Lanier also recognized, as has Mike Golic, of the Mike & Mike in the Morning show on ESPN radio, that, to some degree, the violent hits result because players have not learned how to tackle properly.

That being said, this is a difficult issue.  Putting aside what I consider to be an overreaction of some players and commentators that the NFL risks turning tackle football into flag football, the legitimate issue is that football is a high-speed game played by abnormally large and strong men in which a traditional tackle may not always be possible in the context of a particular play.  Moreover, as noted above, the real issue is not the occasional violent hit that results in a concussion, but the broader problem of cumulative sub-concussive impacts.

On the cumulative force problem, the NFL needs to look at a whole range of issues, including the 3-point stance, which creates more force at the point of impact for both offensive and defensive linemen, as well as the people they hit, and the equipment used in the game.  The main equipment culprit is the current hard plastic helmet with the hard metal face protection system.  The hard plastic helmet protects against certain blows to the head, although its absorptive capability is not as good as it could be, but it is a lethal weapon when aimed at the chest or head of an opponent.

The other equipment issue is the problem of the face protectors, which create both an opportunity for an opponent to grab and twist a player’s head and another hard object to plow into an opponent’s chest or head.  One commentator mentioned that Joe Paterno of Penn State, the winningest college coach in the history of college football  proposed that the NCAA and the NFL go back to the helmet used before face masks were made larger and harder.

This is not an easy subject to address.  The economics of both college and professional football depend heavily on the excitement that the controlled violence football games present to viewers and participants.  Eliminating violence is neither practical nor desirable, but controlling it so that it generates excitement without an accompanying risk to the long-term health of athletes is a more realistic goal.  It is not a goal that will be reached quickly, but we are beginning a more productive journey because of the great work done by Boston University and other research institutions and the proactive response of the NFL.

We have made considerable progress over the last 20 years in covering preventive screenings in health plans, and in publicizing the importance of screenings such as mammograms for breast cancer, colonoscopies for colon cancer, and Pap smears for cervical cancer. We also are getting more people than ever to test for blood sugar to test for diabetes.

However, we still have too many medical conditions that go undiagnosed until it is either too late to treat them, or prohibitively expensive to do so. The investment in early diagnosis for many treatments is hugely positive for a health plan. For example, I learned that a diagnosis of breast cancer at Stage 1 results in a $1,500 per month treatment cost. A later-stage diagnosis results in a $9,500 per month treatment cost. The HealthCheckUSA blog provides more details about the specific benefits linked to health screenings of all kinds.

Furthermore, some experts believe preventive health screening should start with children, as pointed out in Boston’s WBUR Weblog.

But even before diagnosis is the process of determining when an individual is at higher risk. Genetic risk assessments have been around for a while, but the medical community generally did not share the results with the individuals studied. What I have learned through both Boston University and my own reading is the recent significant growth in the movement toward not only doing genetic risk assessments for individuals, but sharing the results with them. In November, The Wall Street Journal Health Blog highlighted different companies working to provide these genetic assessment tools to the general public. The blog questions whether or not this technology is ready for widespread use and asks readers to evaluate the cost.

With respect to Alzheimer’s, Boston University and other centers of excellence, as well as many other great research centers, continue to find ways to get better predictability on the risks of an individual getting Alzheimer’s later in life.

What does a person do with this kind of knowledge? At a minimum, there is an emerging consensus that engaging in general healthy behaviors and focusing on particular kinds of diets will reduce the risk of getting Alzheimer’s or, at least, delaying its onset.

Beyond engaging in healthy behaviors, a person at greater risk of Alzheimer’s is probably going to want to get a memory assessment done earlier than others might. Memory assessment clinics are operated by a number of different medical organizations, including Boston University Alzheimer’s Disease Center. The good news is that the research community tends to believe that earlier diagnosis and earlier treatment will eventually pay off in slowing the progression of this horrible disease, and potentially reversing it at some point in the future. A Duke University research study cited in Head Strong blog adds credibility to this theory.

The discouraging news on preventive screenings and on memory assessments is that, even when coverage exists, the penetration rate of these screenings, compared with the population that should be getting them, is very low. There are many reasons:

• In some communities and for some population sectors, awareness of the need for screenings is low.

• In other cases, there is limited availability or the availability is inconvenient or too costly.

• Health plan reimbursement levels, including Medicare and Medicaid, do not make doing these screenings particularly lucrative for primary care providers.

• In still other cases, there are cultural obstacles to getting screenings. For example, we know that messages to women of certain ethnic or religious groups on why they should get cervical cancer screenings have to be carefully crafted and delivered.

• There also exists concern about privacy and the loss of health and/or life insurance coverage if a genetic predisposition is identified. It is important for policy makers and elected officials to build and strengthen legal protections against discrimination for people identified as genetically at risk for a particular health condition.

I continue to be frustrated by the relative lack of attention in the presidential campaign to the value of preventive screenings. Most of the candidates are talking about them, but they are doing so as a subset of a broader message about insurance coverage. If we do not address the healthy behaviors, screenings, immunizations, and health care access issues, broader coverage, even if it is affordable, will redistribute the progressively larger health care burden and bring the whole health care system down.

Alzheimer’s, in particular, deserves a lot more of our attention. Behind cancer and heart disease, it is the highest-cost medical condition, and it will get worse, given the fact 330 Americans are turning 60 years old every hour, among our baby boomers, and, at least today, over 50% of those of us who reach age 85 will have Alzheimer’s disease.

There are a lot of very exciting developments in the Alzheimer’s arena. I am very proud to be associated with the exciting work Boston University Alzheimer’s Disease Center is doing in this space.

I should confess that I have a personal interest in Alzheimer’s.  I have had family members that either had Alzheimer’s or some other form of dementia.  I do not know whether my loved ones had Alzheimer’s because autopsies were not done, and, as I understand it, an autopsy is the only definitive way to determine whether a person has had Alzheimer’s.  Fairly definite diagnoses can be made through memory assessment, and the earlier memory assessment and diagnosis can be done, the more can be done for an Alzheimer’s patient.

I help advise the Boston University (BU) Alzheimer’s Disease Center, one of the slightly more than two dozen centers designated as a center of excellence by the National Institutes of Health in a highly-competitive process.  On June 20, I attended an advisory group meeting at BU Medical School.  I also visited a few university mail centers on this trip, and spent some time with one of our top sales professionals who has sold products to many colleges and universities. 

Several conclusions jumped out at me:

• While we want world-class research in trying to find breakthroughs for diseases like Alzheimer’s and we get it at institutions like BU, our government and other donors put ridiculous bureaucratic obstacles in the way of focusing on research and clinical care.  For example, as one college director of operations told me, universities and other research centers have to account for individual pieces of mail and other low-ticket items because of the government’s obsession with making sure that no dollar is “wasted.”  At the same time, no one in government thinks about the waste or opportunity cost of high-skilled researchers or physicians worrying about the cost of single letter or photocopy and charging it to the right account.
• Donors of all kinds congratulate themselves on restricted funding that is targeted only on research and not on “overhead” costs like administrative support, equipment, supplies, and facilities.  Yet, no institution can survive without some amount of overhead.  I have talked to many CEOs and Chairmen of non-profits who have seen the same thing I have.  Many worthy organizations hit a wall on their ability to accept restricted grants and perform on them because their funding for the necessary, but mundane, administrative tasks does not keep pace.
• Government funding for breakthrough medical research and clinical care is declining in relative and absolute terms, even when it would produce significant and measurable payback in future years.  Governments at all levels are so fixated on current-year budget-balancing activity that they routinely mortgage the future.  Medicare, in particular, ludicrously controls the payouts for individual clinical interventions for Alzheimer’s, and, I am sure, other conditions, to reduce today’s costs, but ignores opportunities for investments in health that will save on future costs.  By the way, this is one of the reasons I am strongly opposed to any “single-payer” health system in the United States.  Given our approach to democratic government, I have no confidence that politicians, who tightly control and micromanage Medicare and its clinical processes, would think beyond the current fiscal year in how they manage medicine.  If there were a single-payer, the whole medical system would make these dysfunctional trade-offs, instead of just the part controlled by Medicare.
• To a greater degree than many other centers of excellence, BU focuses on the less-glamorous activity related to bringing down the cost and devastating burdens of Alzheimer’s.  It focuses on genetic risk assessment, actions that might prevent Alzheimer’s, memory assessment programs to facilitate early diagnosis and treatment, and approaches that would slow down the progression of Alzheimer’s, as well as the needs of caregivers.  As a society, we are conditioned to have researchers look for “cures” for diseases.  I always think about the telethons for various diseases which use some variant of the phrase “there is no cure, but there is hope.”  I am glad that we care passionately about finding cures, but the more practical and better investment of resources has to be targeted at prevention and the infrastructure for early diagnosis and treatment. 
• The other concept presented to us was the notion that some of the capacity challenges for Alzheimer’s victims may not be memory-related, but may be perception-related.  For example, an Alzheimer’s victim may not have forgotten where he or she put the car keys.  That person may not be able to see the keys where they were placed.  That insight suggests that we can help Alzheimer’s victims to function by improving their perceptual capability with various kinds of tools.

I am confident that significant progress will be made in the next 10 years to slow down disease progression, and maybe even stabilize patient situations.  I would hope that we will see a time that the progression of this disease can actually be reversed.