Bill Rowley, M.D.

1. Creating a Golden Age for Medicine: Opportunities and Challenges Navy LuncheonAMSUSNovember 15, 2004 Bill Rowley, M.D. Institute for Alternative Futures

2. Big drivers changing the delivery of healthcare

3. Health Care’s New Realities Shaping the Early 21st Century • Epidemics of chronic diseases & aging pop. • Post-genomic prevention strategies transforming medicine • Infotech expanding potential reach • Public becoming well-informed, eager participants in their own care • Evidence-based outcomes feasible • Payers demanding safety and value • The challenge of adequate reimbursement

4. Increasing demand for services

5. Shift to Aging Population Disabled over 65 30 26.2 100 20 19.7 % 65 & Older 10 80 85 & Older 0 1980 1990 2000 Millions 60 Life Expectancy 80 40 79.5 Female 77.4 20 74.1 72 Male 70.0 64 2010 2030 2050 1990 1980 1990 2000 Sources: U.S. Census Bureau 1996, Manton et al. 2001, Health United States, 2002

6. Shift to Aging Population Health Prevention & Effective Management of Chronic Diseases Disability Age

7. Shift to Chronic Disease • 125 million Americans have chronic diseases • Over half have multiple conditions • Those with 5 or more chronic conditions account for: • 1/2 of Medicaid spending • 2/3 of Medicare spending • 3/4 of private insurance spending • 2/3 of prescription drugs • 80% of healthcare visits Source: Gerard Anderson, MD, John Hopkins Bloomberg School of Public Health, Foresight Seminar, 12/16/03

8. Shift to Chronic Disease • Patient with 5 or more chronic conditions sees 13 different doctors a year • Challenges to overcome: • Patient must navigate complex system, coordinate care, and transmit information • Most records are paper; electronic records often incompatible • Not reimbursed for coordination • Disease Management focuses on one problem • Usually no team leader Source: Gerard Anderson, MD, John Hopkins Bloomberg School of Public Health, Foresight Seminar, 12/16/03

9. Insight #1 People will be older and live longer, healthier lives However, this will be accomplished by the expensive management of many chronic diseases

10. Delivery of healthcare is changing

11. Biotechnology Prospective Medicine • Analyze genome & proteome • Lifestyle & psychosocial profile • Analysis of exposures RESULTS INCREASED RISK: ConditionRelative Risk Lifetime Risk Alzheimer’s Dis. 3.4 40% Heart Disease 2.7 60%

12. Biotechnology Gaining an integrated understanding of health & disease at the cellular level leads to rational preventive strategies Prospective Medicine • Analyze genome • Lifestyle & psychosocial profile • Analysis of exposures • Tailored Prevention • Set health goals • Specific interventions • Ongoing monitoring & coaching • Prevent or delay

13. Insight #2 Treatment shifting from intervention to prospective medicine Deliberate and personalized preventive self-care

14. Biotechnology Biomonitoring

15. Patients Play Bigger Role Tele-conference

16. Information Technologies Please remember to take your medicine Smart Home

17. Insight #3 The center of care will be the home Empowered consumers take more responsibility for their health and therapy

18. Biotechnology Pharmacogenomics Diagnostics Prevention Underlying Basic Biologic Defect Proteins Stem Cell Therapy Gene Therapy Targeted Drug Therapy Disease Understanding at cellular level Genes

19. Biotechnology Therapy individualized to the unique characteristics of the patient’s disease DNA is not destiny 100 Trillion Cells Proteins Disease Understanding at cellular level Genes 25,000 300,000

20. Biotechnology Genome Screening Pharmacogenomics • Physician prescribes codeine based on symptoms • But, it doesn’t work! Individualize Therapy

21. Effective Treatment of Disease Therapy Evaluation & Staging Therapy for Recurrences Cancer Discover: Screening Symptoms Old Paradigm: Seek and Destroy Monitoring

22. Alterations for Malignant Growth • Multistep process taking years • Genetic alterations  autonomy  cancer • Each cancer unique • Cancer initiating ‘stem cells’ can be only 3-5% • Cancer cells can be made dormant Hanahan & Weinberg, “The Hallmarks of Cancer,” Cell, Vol 100, 57-70, 1/7/00 Begley, “ Stem Cells in Tumors May Help Explain Some Cancer Mysteries.” WSJ, 2/27/04

23. Effective Treatment of Disease Biosensor Monitor Response; Change Therapy as Needed Diagnosis: Genes & Proteins Modified Virus Targeted Drug Gene Therapy Monoclonal Antibody with Radioisotope Nanomolecular “smart drug” Unique cancer subtype Cancer • Eliminated • Chronic disease Combination of Targeted Therapies Photodynamic Therapy Encapsulated Drugs Cancer New Paradigm: Target and Control

24. Insight #4 Therapy will be individualized to the patient and disease Quality of life will be as important as elimination of disease

25. New ways of thinking New Approach Current Approach Episodic testing Extensive use of biomonitoring Engage when symptomatic Prospective prevention Rx targeted to unique disease Rx based on Sx & Dx Rx individualized to patient Rx: one size fits all Advances in biotechnology… Opportunities to shape the future: • Define processes and standards • Educate and encourage physicians • Educate payers, policy makers, public

26. Information Technologies Electronic Medical Record

27. Information Technologies Pervasive Computing

28. Insight #5 The electronic medical record will soon be mandatory It is time to embrace it for an improved work environment and better patient care

29. Evidence-Based Care Evidence-based medicine is the integration of • Clinical expertise • Patient values • Best evidence into the decision making process for the care of the individual patient.

30. Evidence-Based Care Prostate Cancer • Watchful waiting? • Radical prostectomy? • External radiation? • Internal radiotherapy? • Cryosurgery? • Hormonal therapy?

31. Evidence-Based Care If a doctor reads 5 articles per night on new treatments, after one year she would be 800 years behind! It takes about 17 years for new knowledge from a controlled clinical trial to be incorporated into the daily practice of clinical medicine Yearbook of Medical Informatics, 2000

32. Why aren’t outcomes better? Wide Variation in services Medicare Patients at Top 7 Teaching Hospitals Mayo Clinic 50 Mt. Sinai, NYC 30 10 Physician Visits Hospital Days Receiving Recommended Care: • 54.9% - preventive care • 53.6% - acute conditions • 56.1% - chronic diseases McGlynn, The Quality of Health Care Delivered to Adults in the United States, N Engl J Med. 2003;348:2635-45 Wennberg, Variations in the Longitudinal Efficiency of Academic Medical Centers, Health Affairs, 7 Oct 04

33. Evidence-Based Care Provider being CoachedExpert system prompting at the point of care Collaborative Teams Patient

34. The Safety Challenge 225,000 total deaths each year Medical Errors & Adverse Events 12,000 deaths from unnecessary surgery 7,000 deaths from med errors in hospitals 20,000 deaths from other errors in hospitals 80,000 deaths from hospital acquired infections 106,000 deaths from adverse effects to meds This doesn’t include outpatient and nursing home care! Source: Starfield, B. Is US health really the best in the world? JAMA 2000;284:483-485

35. Lessons from Aviation • Public doesn’t tolerate accidents • Commercial pilots don’t fly alone – team • Culture of reporting mistakes for improvement • Work within system to reduce variability - simple, redundant, computerized

36. Insight #6 Evidence-based medicine and safety will be demanded and rewarded

37. Shift to Patient Centered Care • Healthcare designed from the patient’s perspective • Patients empowered to manage their own care • Access to information & coaching • Involved in decision-making • Continuous healing relationships • Everyone accountable for health

38. Ensuring Access to Care • Supported self-care  telemedicine • Group visits • Internet access to information • E-mail with doctor • Well managed chat rooms The Patient Visit

39. Insight # 7 Consumers are more savvy, demanding and ready to take responsibility for their health They need our support

40. Type 2 Diabetes Epidemic 800,000 new cases/year Difficult to manage Serious complications 70% die of cardiovascular disease

41. Type 2 Diabetes New Drugs Noninvasive testing Diet Inhaled Insulin Exercise Implanted Insulin Pump Managing Obesity

42. Type 2 Diabetes Regulatory pathways controlling hunger and energy expenditure • Suppress Appetite • Block nutrient absorption •  thermogenesis • Modulate fat/protein metabolism/storage • Modulate central controller Counteract weight loss efforts Managing Obesity

43. Type 2 Diabetes Behavior modification: diet < 30% fat Moderate exercise 3-5 times/wk Cessation of smoking Drugs therapy: Glycosylated hemoglobin < 6.5% Blood pressure < 130/80 Cholesterol < 175 Triglyceride < 150 The Risk is Cardiovascular Disease! The Danish Intervention Trial Intensive Multifactorial Intervention by Team All received aspirin, dietary supplement, ACE inhibitor Peter Gæde, et. el., Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes. N Engl J Med 2003;348:383-93

44. Type 2 Diabetes Cardiovascular Intervention 50 Cardiovascular death Nonfatal heart attack Coronary artery bypass or angioplasty Nonfatal stroke Peripheral vascular surgery Amputation 40 30 Primary Composite End Point % 20 10 0 12 24 36 48 60 72 84 96 Months of Follow-up Intensive Therapy Conventional Therapy Peter Gæde, et. el., Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes. N Engl J Med 2003;348:383-93

45. New ways of thinking New Approach Current Approach Focus on current medical problem Focus on all risks Primary care physician Cooperative team of providers Care based on periodic visits Continuous healing relationships Short visits with little information Emphasis on education & coaching Decisions by clinical autonomy Evidence-based decisions Information restricted Electronic information flows freely One size fits all Care customized to needs & values Patient a passive participant Patient/family active participants Opportunities to shape the future: • Need to develop • New policies • New processes • New revenue options • New relationships • New skills • Need to train • Physicians and other professionals • Patients and families Electronic Medical Record Evidence Based Medicine Patient Centered Care Safety & Quality Effective management of chronic disease

46. The challenge of adequate reimbursement

47. Healthcare Becoming Unaffordable $3.58 Expenditures in Trillions of Dollars 2 $1.79 $1.66 1.5 $1.54 • Medicare is now projected to consume: • 24% of federal income taxes in 2019 • 51% of federal income taxes in 2042 • Just to pay for currently promised benefits $1.42 $1.30 Medicare Insolvent? 1 $0.99 $0.70 ~18.7% 0.5 9% 15.5% $0.25 0 2019 1980 1990 1995 2000 2002 2004* 2014* OECD Countries 7-11% Sources: CMS, 2004 - data & projections to 2013 (2014 extrapolated); Medicare Trustees Report, 3/23/04

48. Insight #8 Continuous struggle between our expectations and our ability to pay for them! • Change the focus from cutting and shifting cost to paying for outcomes • Government & business must make priorities and limit expenditures

49. Healthcare Becoming Unaffordable More money isn’t the solution! Opportunities to shape the future: • Reduce administrative burden to increase earnings for physicians and insurers • Change financial incentives • Reimburse coordination, coaching, etc. • Reward improved outcomes

50. Losing health coverage • Don’t offer insurance • Shift costs to employee $52,000 Gross Wage 4% Growth $35,000 10 years Gross Wage $26,000 $10,000 10% Growth Health Ins. Health Ins. 10 years Opportunitiesto shape the future: • The 45 million uninsured hurt the entire economy – not just doctors & hospitals • Health professionals must advocate for universal access to health coverage In 2002 1/3 of Americans had income <$35,000 Source: Uwe Reinhardt, May Day for the Uninsured: Will We Ever Achieve Health Care for All?, Center for American Progress Policy Forum, April 22, 2004