Dr. Steven Schimpff has written an important book. His website is here, the link to the book on Amazon is here, and consider his trenchant answers to our questions below:
1. We've been watching www.23andme.com, and you see Genomics (Chapter 1) as a megatrend. Do you imagine that a large number of consumers will pay to get their "personal DNA analysis" over the next three years?
ANSWER: Genomics is creating a real revolution in medical practice. One of the key advances will be the prediction of diseases that will occur or are likely to occur later in life. For example, one person might be found to have a high risk of coronary artery disease and hence could be given a “prescription “ for life style changes [exercise, diet, stress reduction] and drugs [cholesterol lowering]to slow the progression of the disease. Another person might learn that he is at high risk for colon cancer at a young age. His “prescription” would be one of life style changes also but different from the other individual – [high fiber diet, low fat diet], a drug to reduce the development of colonic polyps and a recommendation for colonoscopies beginning much earlier than for the average person. In short, medicine will change from the current “Diagnose and Treat” to “Predict and Prevent.”
But who will pay. Today, genomic tests are relatively expensive but the cost is rapidly dropping. Frankly, only a few are appropriate today but others will be developed in short order in the next few years. Just now I would not rush out to spend money on the tests that are currently available except in those situations where your doctor suggests it based on certain known high risks – such as a woman with multiple members of her family that had breast cancer. The tests to be developed and marketed in the coming years should become rather inexpensive. And in those same years there will be many more genes discovered that place us at risk for some of our most vexing diseases.
Of course, there are other uses of genomic tests such as ancestry exploration. This is perhaps more for personal enjoyment than looking for risk factors for disease.
2. You see medical records being digitized (Chapter 7), but so far consumer PHR trial has led to very limited adoption. What needs to change here?
ANSWER: Great question. You can go to an ATM machine anywhere in the world and take out money but you cannot access your medical data. Three things must change – and they will over time. We all need to recognize that your medical record is indeed your medical record, not the doctor’s and not the hospital’s. If it is yours, then you should own it and have it available on demand. Second, there is a need to create systems that are easy for the doctor to use to put in your history, examination and other notes that are now kept by pen and paper. Today, most of the systems available are just not “doctor-friendly” and actually impede productivity rather than enhance it. Once this is figured out, doctors will use it and that will be to your advantage. Finally, there are not currently standards for “interoperability.” The system used by one hospital does not interact with that of another, and so forth. Sooner or later, and hopefully it will be sooner, there will be standards for every vendor to follow. Once these three elements are in place, the electronic medical record will blossom rapidly.
3. We read this article with interest, and you address the High Cost of Medicine (Chapter 8) in your book-- do you see consumers assertively seeking health savings going forward, and how might they best do this?
ANSWER: Health care costs are high for many reasons. We are an increasingly older population and, like a car, older parts wear out more often than newer parts. We also do not take very good care of ourselves – on average we are over weight, we are over stressed, we eat a non nutritious diet and we do not exercise. These are leading to more and more illnesses and hence increased health care costs. Add to this that we still smoke, drink and drive, don’t wear seat belts and don’t get our vaccinations [e.g., influenza] or screening tests done [e.g., blood pressure, cholesterol.]
America is great at innovation and as a result we have many wonderful new approaches to treating and diagnosing disease. But these are expensive. It is imperative that we use the right diagnostic procedures and the proper treatments but not when unneeded or unnecessary. For example, a commonly advertised prescription drug for “acid reflux” is very expensive but most of us do not recognize that another essentially equivalent drug is available over the counter for about 15% of the advertised drug’s price [ $150 vs. $30 for a 14 day supply]. But even more important , most acid reflux can be dealt with by some life style changes such as waiting a few hours after a meal before going to bed, putting the head of the bed up on blocks [so the acid runs downhill, not uphill] and reducing alcohol. But we prefer to ask for the “pill” and our doctor is not paid to take the time to talk to us about prevention. A vicious circle that keeps medical costs up.
So each of us needs to address health care costs ourselves by appropriate life style changes, asking our doctor if a cheaper yet equally effective drug is available, if a test really needs to be done, etc.
4. Your Chapter 5 is "Devices-- Small and Powerful." Digital Home Health appears to be at the vaunted tipping point-- do you agree, and what is necessary for it to become mainstream?
ANSWER: There are many home health approaches that “distance medicine” can address. Perhaps most important are the simple things. Using email to query your doctor about an issue could save time and effort on your part, avoid an office visit and reduce costs. [Problem is that doctors are not compensated for answering email so they don’t like to spend that time.] Other approaches are more technical such as having a patient with heart failure use a digital scale each morning. His weight is automatically transmitted to the care management office where a nurse sees the data on her computer and if the weight is rising, calls the patient to see if there is a need to adjust the medications – avoiding an ER visit or even avoiding a hospitalization. The same would work for blood sugar measurements at home monitored by a care manager at a distance – if the trend is going the wrong way it would trigger a phone call from the nurse.
But to become mainstream as you ask will take a major change in the way healthcare is paid for. Today insurance pays for a visit, a procedure, an episode of care. It does not pay for this type of monitoring, for talking to the patient on the phone, for responding to the email. We need a new approach so that prevention and care management/ disease management can become mainstream. The opportunity for much improved patient care is there as well as significantly reduced costs. It all makes perfect sense but it just does not get compensated today.
5. Your Chapter 11 is titled "It's Your Body-- Keep it Healthy." It's obvious that preventive medicine can save many billions in healthcare costs, and extend life. Why has it proved so elusive to date in terms of implementation, and how might this change at long last?
ANSWER: The answer to this question is somewhat akin to the previous one. Our method of compensation for medial care is based on visits and procedures – for “disease and pestilence” treatment. But not for prevention! Primary care physicians are underpaid and cannot spend the needed time with their patients for prevention type care. Indeed America has about 30% generalists and 70% specialists whereas most other developed countries have just the reverse – 70% generalists. The reason is compensation – graduates of medical schools see that they will be paid much less as generalists and will not be able to practice in the manner that they would want, i.e., to spend the time needed to work on prevention and just listening to their patients. And they have major debts to pay off – usually over $100,000 – so they gravitate toward the higher paying specialties that focus on procedures.
So change will come only once we start to pay generalists more appropriately. [Today the average generalist earns about $150,000 after ten years in practice; about $90,000 starting out – hardly a meager salary but certainly not appropriate for someone with all those years of training who has such a major responsibility – your health!]This will mean a change in the way insurance companies compensate for generalist care. And it will mean that generalists will need to become not just “interventionalists” but “orchestraters” of care with a team of nurses, nutritionalists, pharmacists, social workers and others working with them.
And we need a system of incentive for each of us to do what is needed to prevent disease and maintain wellness. Incentives in our insurance system would help. For example, make a person pay more if he smokes or is significantly overweight – just as he would have to do for life insurance. But give the patient a break if he goes to a smoking cessation class or joins a weight reduction program – just as the car insurance industry does for driver’s education classes.
There are some other hopeful signs occurring. In New York City, trans fats are now “out” of fast food restaurants, in some locations the restaurants must post their calorie counts for each dish. All of these steps can add up to a healthier population. But in the end, the truth is “It is your body – keep it healthy” and that is our own personal responsibility.
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