Diseases That Will Drive Future Technology and Opportunity

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Diseases That Will Drive Future Technology and
Opportunity

• Michael D Parkinson MD, MPH, FACPM
• Past President

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In The News . .

• Drug companies merging biopharma
• Walgreens will not accept WA Medicaid
• US health care spending now 18 of GDP
• 1 increase in 1 year breaks record
• timulu bill health reform plan budget
• Docs opting out of Medicare
• Intel and GE in new health care agreement
• Readmitted patients cost billions
• Small medical companies feeling recession

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What Should Drive Future Technology and
Opportunity?

• Michael D Parkinson MD, MPH, FACPM
• Past President

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American College of Preventive Medicine

• National medical specialty society of public
  health and preventive medicine physicians (1954)
• 2,300 physicians primary commitment, training
  and interest in disease prevention, health
  promotion and systems-based care improvement
• Public health clinical perspective and training
• Major role in evidence-based prevention and
  application of prevention principles to clinical
  care, quality cost
• www.ACPM.org

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My Perspective . . .

• Primary care and preventive medicine
• Single payer health care system for 20 years
• Pioneer consumer-driven plan for 6 years
• Nations largest health insurer for 2 years
• Stirring the pot with the usual suspects
• Employers, foundations, academics,
  consultants/brokers, unions, legislators,
  (dis)organized medicine, PBMs, pharma, hospital
  ceos/cfos and docs
• Presidential conventions . . And Hill . . And . .
  
• And . . . Forgotten and least (most!) important?
• Consumers, taxpayers and patients

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High Performance Networks?How About High
Performance Patients?
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Six Unhealthy Truths Tell the Story of the Rise
of Chronic Disease and Its Impact on Health and
Health Care in the U.S.
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Truth 1 Chronic diseases are the 1 cause of
death and disability in the U.S.
133 million Americans, representing 45 of the
total population, have at least one chronic
disease
Chronic diseases kill more than 1.7 million
Americans per year, and are responsible for 7 of
10 deaths in the U.S.
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Truth 2 Patients with chronic diseases
account for 75 of the nations health care
spending
During 2005, the U.S. spent almost 2 trillion on
health care
In public programs, treatment of chronic diseases
constitute an even higher portion of spending
More than 96 cents in Medicare
and 83 cents in Medicaid
The United States cannot effectively address
escalating health care costs without addressing
the problem of chronic diseases. -- Centers for
Disease Control and Prevention
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Truth 3 Two-thirds of the increase in health
care spending is due to increased prevalence of
treated chronic disease
Level 0f health spending among the noninstitutiona
lized U.S. population, 19872000
627.9
(in billions of nominal dollars)
Increase attributable to rise in prevalence of
treated chronic disease
211 billion
313.5
Years
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Truth 4 The doubling of obesity between 1987
and today accounts for nearly 30 of the rise in
health care spending
Percent of U.S. Adults Who are Obese
1985
BMI 30, or 30 lbs overweight for 5 4 person
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Truth 4 The doubling of obesity between 1987
and today accounts for nearly 30 of the rise in
health care spending
Percent of U.S. Adults Who are Obese
If the prevalence of obesity was the same today
as 1987, health care spending in the US would be
10 percent lower per personabout 200 billion
less
2005
The percent of children and youth who are
overweight has tripled since 1980
BMI 30, or 30 lbs overweight for 5 4 person
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Truth 5 The vast majority of cases of chronic
disease could be better prevented or managed

• The Centers for Disease Control and Prevention
  (CDC) estimates
• 80 of heart disease and stroke
• 80 of type 2 diabetes
• 40 of cancer
• could be prevented if only Americans were to
  do three things
• Stop smoking
• Start eating healthy
• Get in shape
• Management of chronic disease could also be
  significantly improved Chronically ill patients
  receive only 56 of the clinically recommended
  preventive health care services

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Truth 6 Many Americans are unaware thatchronic
disease harms their health and wallets
National survey conducted in April 2007 on
Americans views of chronic disease and its
impact on health and spending

• Only a small fraction of Americans, less than one
  in six, comprehend the magnitude of the problem
• That chronic diseases represent more than 70 of
  the deaths in the U.S. and more than 70 of
  health care costs

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Per Capita Health Care Spending in Various
Countries in 2006, According to the Country's
Relative Wealth
Iglehart J. N Engl J Med 20093601381-1383
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Total Health and ProductivityCosts 3X Medical
Costs
Goetzel R, NIOSH background paper, Steps to a
Healthier US Workforce, 2004
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Current Trends in America for a Healthy and
Productive Workforce
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Opportunity for Smart Tech?
Medical Care Management Opportunity
Disease Management Opportunity
Health Promotion Opportunity
University of Michigan Health Management Research
Center
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Cincy Challenge Newly Diagnosed Diabetics WITH
Health Insurance

• PREVENT unnecessary chronic disease none of
  the diabetics had taken proactive, preventive
  actions to reduce diabetes (diet, weight loss,
  physical activity) or expressed concern about
  next generation risk despite family history and
  even deaths
• UNDERSTAND how to improve health behaviors
  food and diet were toughest challenge dont
  want to eat foods of another culture sense of
  stigma crave support and information doctors
  dont address diet, nutrition, exercise or
  depression
• ENGAGE patients in their care very
  inconsistent in taking meds, dont ask questions,
  not aware of checklists or guidelines, judge
  quality by personal demeanor only
• 20 type II diabetes patients, Cincinnati, OH
  2008

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The True Determinants ofHealth and
Disease
Social Environment
Physical Environment
Genetic Environment
Individual Response --Behavior --Biology
Health Function
Disease
Health Care
Well-Being
Prosperity
Evans, R. G., Barer, M. L., Marmor, T. R.
(1994) Why Are Some People Healthy and Others
Not?. New York Aldine De Gruyter
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Mediterranean Diet, Nonsmoker, Daily Activity
No or Moderate Alcohol Use
Knoops et al and Rimm, Stampfer, JAMA
20042921433-1439
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US LifeYears Saved If Preventive Service
Optimized
Currently QALYs Saved Service Receiving if
Use at 90 Tobacco Cessation Counseling 35 1.3
million Aspirin chemoprophylaxis 50 590,000 Color
ectal Cancer Screening 25 310,000 Influenza
immunization 36 and 65 110,000 Breast cancer
screening 68 91,000 Problem drinking
screening 50 71,000 Vision screening
(gt65) 50 31,000 Cervical cancer
screening 79 29,000 Chlamydia Screening 40 19,00
0 Pneumococcal immunization 56 16,000 Chol
esterol screening 87 12,000
American Journal of Preventive Medicine
2006, Volume 31, p 52-61
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Cost 1,700-2,000 PEPY

• Overuse
• Antibiotics
• Tranquilizers
• Lifestyle drugs
• Antiinflammatory drugs
• Hysterectomies
• Cardiac caths
• GI endoscopy

• Misuse
• Multiple uncoordinated visits
• Duplicate tests, procedures
• Medical and hospital error
• Underuse
• Vaccination
• Chronic care management e.g., diabetes, asthma,
  heart failure, cancer

Midwest Business Group on Health, Juran
Institute study, 2002
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Rates of Rehospitalization within 30 Days after
Hospital Discharge
Jencks SF et al. N Engl J Med 20093601418-1428
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Patients for Whom There Was No Bill for an
Outpatient Physician Visit between Discharge and
Rehospitalization
Jencks SF et al. N Engl J Med 20093601418-1428
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MD LamentHamster Health Care

• Symptoms
• Inadequate time with patients
• Administrative hassles
• Patients who know and demand more
• Greater accountability
• Decreasing reimbursements
• Rising overhead costs

• Signs
• Waiting times for appointments
• ER for non-urgent visits
• Managed care backlash
• Inadequate management of chronic illness
• MD burnout and retirement
• System collapse?

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Rockwell Had It Right Connectivity Trust
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McLipitor Syndrome

• "I call it the McLipitor Syndrome.  Patients feel
  they can eat whatever they want as long as they
  take a statin drug to lower cholesterol.  Because
  of time constraints, physicians may spend little
  time counseling lifestyle change, which can work
  as well as or better than the best drugs for
  heart disease, obesity, diabetes and high blood
  pressure."

Mark Goldstein, MD, NY Times Magazine Letter to
Editor Feb 11, 2007
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Top 10 Prescription Drug CategoriesHealth
Behavior Stress-related?

• Asthmatic drugs
• Anti-inflammatories
• Osteoporosis and related drugs
• Pain medications and narcotics
• Anti-seizure

• Cholesterol lowering
• Anti-ulcer
• Antidepressants
• High blood pressure
• Diabetic drugs

Caremark 2006 TrendsRx Report
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Top 20 Depression-, Stress- and Sleep-related
Prescription Drugs
Lumenos plan 2006 data
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Emerging MD Consensus?Conservative Prescribing

• Think beyond drugs
• Seek nondrug alternatives as first not last
  resort
• Treat underlying causes, not symptoms
• Look for prevention opportunities not just
  treatment
• More strategic prescribing
• Heightened adverse effects vigilance
• Caution and skepticism regarding new drugs
• Shared agenda with patients
• Weigh long-term, broader impacts

Schiff, Galanter, Promoting More Conservative
Prescribing, JAMA 2009 301865-7.
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Surgery SpendingA Hidden Epidemic?
Big Industry Tightly Managed
Bigger Industry - Unmanaged
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Surgery Realities

• Number of Unnecessary Surgeries Can Be Decreased
  and the Quality of Necessary Surgeries Can Be
  Improved
• Surgical utilization varies dramatically by
  region (Wennberg, Dartmouth Atlas)
• 25 of all surgeries are unnecessary (RAND)
• Need mechanisms to improve/guide surgical
  utilization
• Studies show that Decision Aids
• Decrease number of surgeries 23-75
• Quality of outcomes is maintained
• Overall effect 24 decrease in surgical
  utilization (OConnor et al. 2003)
• Whelan et al. 2004 Kennedy et al. 2002 Murray
  et al. 2001 Deyo et al. 2000 Morgan et al.
  2000 Bernstein et al. 1998 Barry et al. 1997
  Street et al. 1995

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State of Shared Decision-Making Implications
for Tech?

• Screening test, prescription drug or surgery
• 51 taking meds for HTN, cholesterol, depression
• Pros discussed more than 2X cons
• Physician initiated discussion 60-95 of time
• Physician offered opinion 80 of time
• Asked patients opinion about 45 of time
• Knowledge of those undergoing tests, drugs or
  surgery inadequate and not much different than
  those NOT undergoing intervention

Couper, Medical Decisions in America, FIMDM
National Conference, Feb 2009
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Role of Decision AidsImplications for Tech?

• Physicians perceived value of decision aids
• 60 increased comfort with decisions
• 53 provides more time to discuss goals/concerns
• 53 decrease unnecessary tests, procedures
• 40 increases extent patient preferences
  reflected in decisions
• What would increase physician interest?
• Being paid (90) for any of
• Providing decision aids, staff time or own time
  for counseling

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Who Wins . . Who Loses?Biotech ROI

• Development and introduction of genomic testing
  and targeted therapies vs usual care
• If alters current course of care (warfarin
  testing)
• Consumer - benefits within a year less therapy
• Providers need to be better informed but
  neutral
• Payors depends immediate or ROI 6 plus years
• Biotech/pharma likely negative due to fewer
  users
• Diagnostic companies ROI positive
• Much worse for other types of targeted therapies
  and innovations

The ROI for Targeted Therapies A Strategic
Perspective Assessing the Barriers and Incentives
for Adopting Personalized Medicine, Deloitte and
Touche, 2009
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timulu Bill . . And Beyond?Changing What Need
to Change?

• Total expenditures 150 Billion
• Medicaid (87B) and COBRE expansion (25B)
• NIH (10B)
• Health information technology (19B)
• Prevention and wellness (1B)
• HRSA (2.5B)
• More of the same . . But just more?
• No changes in underlying Medicare/caid payment
• HIT interoperability eventually fast enough?
• New requirements on PHRs slowing uptake?

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On the Biggest Payers Front

• Broken financially and getting broker
• Need totally new models for reimbursement but
  not forthcoming fast enough
• Can 535 CEOs save 20-30 on medical equipment
  not to date!
• Disease- and risk factor-specific thinking at NIH
  giving way to integrated thinking
• NHLBI ABCs PAD program in response to separate
  program functions for each risk factor
• Aspirin, BP, cholesterol, physical activity, diet

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ConclusionsImplications for Technology?

• Growing awareness that health behavior change can
  be used for treatment not just prevention and
  tech can support
• Self-care, linkages to communities, social
  networking, at-home technologies, virtual visits
  and connectivity in incremental stages
• Strategic investments to reduce costs, replace
  ineffective and costly care more important than
  ever no tech for tech sake

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ConclusionsImplications for Tech?

• Adding more to dysfunctional payment system in
  advance of fundamental payment reform risky
• Comparative effectiveness may be good place to
  start but can dampen innovation
• Think genomics, nanotech, biopharma AND interface
  with environment, behavior as new frontier
  (epigenetics)
• Guilds are losing their holds as consumers take
  charge and technology creates options