The Greening of the American Health Care System

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  • 03/03/2008
Here is the second installment from our recent health care leadership forum on patient-centric medicine. These are the comments of Ralph Snyderman, M.D., recipient of the 2007 Leadership in Personalized Medicine Award from the Personalized Medicine Coalition.

Dr. Snyderman is Chancellor Emeritus at Duke University and former Chancellor for Health Affairs at Duke University, President and CEO of Duke University Health System and James B. Duke Professor of Medicine. He oversaw the development of the Duke University Health System, one of the few fully integrated academic health systems in the country. This integrated health system now provides an increasing continuum of care throughout North Carolina and beyond. Dr. Snyderman describes how the current health system is broken and how patient centric medicine could help repair it.

"We all recognize that the current healthcare system is broken. We’re spending $2.2 trillion a year, not on a healthcare system but a sick-care system that is highly inefficient.

Seventy-five cents of every healthcare dollar is spent for the acute treatment of generally late-stage chronic disease, which is often preventable.

The patient, of course, is in a quandary. I only know of two industries in which the consumer is given so little attention. One is the airline industry, which pretty much doesn’t care about the consumer. And, ironically, the healthcare system. The consumer is in there, but always as byproduct of all the technologies, the capabilities, that are being developed.

The likelihood of an individual developing a chronic disease is based on a number of things. Number one is their baseline inherited risk. That’s then modified by environmental or initiating events, exposure to things or various behaviors which may lead to preclinical progression, disease initiation. All of this develops over time, most often many years.

The irony is that as you wait, there tends to be an accumulation of disease burden. Once it becomes clinically manifest, and then there tends to be an inflection, a crescendo, in which things can get steadily worse in a series of acute events. Our current healthcare system is designed to focus on acute events. That’s where the cost is high and reversibility is low because there was a buildup of pathology.

Now the good news is that now we have powerful emerging technologies that are very producing powerful, and we’re developing important therapeutics, plus important diagnostics, including those that will enable personal clinical risk prediction,. Genomics, proteomics, metabolomics, new medical technologies, informatics and system biology, which is an approach to understanding the multiple networks of genes and metabolic systems, can all have a positive impact in empowering personalized health risk assessment..

We need to communicate that the power of these new technologies is allowing us to develop the capabilities of predicting risk in a much shorter time-frame and actually being able to predict risk across a person’s life. That’s a whole different approach to health care -- individualized risk prediction.

We’ll be able to measure what’s actually going on in a person’s circulation and tissues to determine if they are progressing along a disease pathway. It’s fairly clear that with risk prediction tools along with powerful digital imaging, metabolic imaging and other technologies, we can start to determine disease initiation and progression. We are going to get so much better with in being able to track development of problems very early on. Individuals are different. And where somebody might benefit from a thiazide diuretic, somebody else may be very badly harmed. We cannot assume that everybody will benefit from the same approaches or therapies.

We are beginning to understand that severe adverse outcomes can be predictable on a personalized basis, and the benefits of various therapies could be predicted at a personalized level.

A number of companies have sprung up to try to develop predictive tools for disease events, to personalize therapy. By studying a population of patients and outcomes, you can try to determine what individual factors helped predicted determine the outcome. Whether they be clinical data, genetic data, proteomic data, any other digital kind of information can be analyzed in clinical cohorts with the use of various types of biostatistical algorithms to come up with a predictive model. The power of these models is going to get better as we have more precise clinical data.

There is an emerging movement, what some people call P-4 Medicine or what I call prospective health care—personalized, predictive, preventative, and participatory. It would be personalized to the individual; predictive, so we could anticipate events before they occur, and then try to prevent them. The patient’s participation is a key feature. It’s hard to imagine a fix until we build this in, that people get invested in being more responsible for their own health.

For prospective healthcare to create an individual strategic health plan to for each patient, we need to develop these risk assessment and therapeutic evaluation tools. How is health care itself delivered to an individual over time? Our delivery system is designed for acute intervention that is not integrated and doesn’t provide continuity of care. The reimbursement system has a lot to do with that. Institutions can lose a lot of money trying to do the right thing in providing continuity of care.

At Duke, we have a prospective healthcare program where the participating population is university employees who get their care from Duke. They Duke is are essentially self-insured, so it’s one of those areas in which the reimbursement systems actually align. We have employees who stay with us very often for their entire professional lives. With the right tools, you can then, based on the chronic disease, divide the population into those that are low risk, high risk, early chronic disease, late chronic disease, and align the resources to the needs of the individual patient. So that in those individuals who may be high risk are given, we give them a lot of help in terms of risk modification, and allow helped them to develop their own strategic health plans. The general concept is to divide the population based on their specific risks and their health status and then give them access to the level of support they need.

The individual needs to play an active different role. We need to do something to raise the attention of the public of health as a value. One of the things that amuses me seems to be that over the last three to six months, virtually every major industry that contributes to environmental pollution has become green. Every oil company is green. General Motors is green. Everything is green to try to save the planet. Well, what about health? What about the individual? We talk about a sustainable planet, but what about a sustainable individual? We really need to get the appreciation of health as a value, similar to what we’re doing with the planet as a value."

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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