What are the critical innovations in healthcare? How are they changing the relationship between patients and caregivers ? What are the forthcoming developments in healthcare? These are some of the topics I talked about with Merv, an advisor for Bay City Capital in San Francisco and Merck’s former Chief Strategy Officer.
I/ Measuring outcomes
In clinical development studies, we are accustomed to the gold standard of the placebo-controlled, double blind trial as the best judge for the effectiveness of a drug. Increasingly, payers are interested not just in effectiveness, but cost-effectiveness of new approaches to treatment. How much does this cost compared to the existing standard of care? Is the improvement in outcomes – including quality of life – worth a premium? These are extraordinarily difficult questions, so fraught indeed, that when the Affordable Care Act was passed in the US in 2010, one of the most controversial elements was the establishment of a non-profit, tax exempt corporation, known as the “Patient-Centered Outcomes Research Institute” (PCORI) to provide comparative effectiveness information to assist patients, clinicians, purchasers, and policy makers in making informed health decisions. Controversial, because of concerns that might be placed on the freedom of choice of physicians and patients to prescribe as they see fit. Yet this is an unstoppable trend if the growth in an industry that is consuming 17% of GDP in the US is to be slowed. In the UK, NICE, the National Institute for Clinical Excellence, has taken a major role in determining whether patients treated within the National Health Service will have access to new medicines, and if so, at what cost to the NHS.
Interestingly, whether we call it outcomes research or comparative effectiveness research, there is a growing movement to subject more elements of the healthcare system to similar tests. The use of “placebo-controlled” approaches to assist in the evaluation of the best way to deliver health care remains extraordinarily unusual, but that may be about to change. A recent article in the New York Times illustrates the point – “collecting data can trump a powerful anecdote” as one of the investigators of a study of emergency room use put it. Contrary to Conventional Wisdom, the study showed that access to health insurance increased emergency room usage, rather than the reverse. How many other health care shibboleths would be demolished if subjected to randomized clinical trials?
It is an article of faith that the widespread use of electronic health records is making it easier to track patient outcomes. That may be the case, but it will not necessarily point to more effective alternatives without the proper use of randomization to remove institutional bias, even as new payment strategies from Medicare and private insurance companies are increasing pressure on health care delivery systems to lower costs. In health care, as in many fields, incentive-driven approaches to cost reduction are subject to the law of unintended consequences. With so many conflicts of interest among the different stakeholders, delivering objective information is both a challenge and an opportunity.
II/ Innovative patient monitoring technologies to improve prescription drug compliance
In 2012, it was estimated that the failure to comply with physician prescriptions cost $250 billion in doctor and emergency room visits, and increased hospitalization . An average of 130 000 Americans die each year because they don’t follow their prescription closely enough. Currently, most doctors simply ask patients if they are taking their medications as directed. The problems are many. Some patients get confused; others lie about what compliance. One doctor told us that patients don’t just forget to take their pills – they throw them out to cover up their forgetfulness. As a result, pharmacists can’t detect lapses based on presecription renewal rates. That is hard to imagine in the US. There, ever higher copays for prescription drugs lead may patients into “pill splitting” behaviour, or dose skipping. Many of these drugs may not be the very high priced “specialty drugs”, but generic versions of tried and true medications for the control of blood pressure, for example. A generic drug can deliver value for 100 years – think about aspirin – but it cannot deliver value at any price if patients do not take their medicine. Finding enhanced approaches to ensuring compliance is a Holy Grail, both for pharma companies, and for health care providers.
In The Age of Context, Robert Scoble and Shel Israel talk about Proteus. Proteus is a California-based startup, which is “developing sensor-based health technology.” Proteus make a silicon chip the size of a grain of sand that is embedded into a safely digested pill that is swallowed. When the chip mixes with somach acids, the processor is powered by the body’s electricity and transmits data to a patch worn on the skin. That patch, in turn transmits data via Bluethooth to a mobile app, which then transmits the data to a central database where a health technician can verify that a patient has taken her medications. The Proteus solution gives doctors real-time, irrefutable data on when pills are taken – or skipped.” Robert Scoble and Shel Israel, The Age of Context, chapter 7 “The Contextual Self”
Merv believes that in the next 6 years we will more companies such as like Proteus, leveraging our improved connectivity through the use of smart phones, etc., to nudge us towards better outcomes. The smartphone is going to become an increasingly common tool through which patients and physicians interact without the necessity for frequent office visits. In the US, most healthcare professionals have “portals” that help patients connect to physicians. However, uptake by patients has been slow. We have not yet found the ideal interface, which both satisfies the desite for ease of communication, with the need to protect patient information. But Merv believes that it will come, and come quite soon.. In the physicians office, electronic health records have yet to deliver material savings. Part of the issue is the lack of interoperability between different systems which prevents aggregation and the use of “big data” tools to make unexpected connections. This is an area of massive investment, which is likely to come to fruition within a decade..
III/ Merv’s thoughts on Ray Kurzweil’s Singularity
Then, Merv and I talked about Ray Kurzweil’s views. Ray Kurzweil is the founder of the Singularity movement which posits that technology follows a law of accelerating returns (LOAR) and exponential price-performance. One of the implications of the Singularity, in addition to the much-publicized moment in the future where artificial intelligence will exceed human intelligence, is the extension of life expectancy. Kurweil writes :
In 2019, “Many of the life processes encoded in the human genome, which was deciphered more than 10 years earlier, are now largely understood, along with the information-processing mechanisms underlying aging and degenerative conditions such as cancer and heart disease. The expected life span, which, as a (1780 through 1900) and the first forty, has now substantially increased again, to over a hundred. (…) Computerized health monitors built into watches, jewelry, and clothing which diagnose both acute and chronic health conditions are widely used. In addition to diagnosis, these monitors provide a range of remedial recommendations and interventions.” Ray Kurzweil, The Age Of Spiritual Machines, chapter 10 “2019”
In The Singularity Is Near, Ray Kurzweil goes one step further : “Achieving radical life extension is possible by applying today’s knowledge as a bridge to buy a technology which in turn will be a bridge to the era of nanotechnology. This offer is a way to live Indefinitely now, even though we don’t have all the knowledge necessary for radical life extension. In other words we don’t have to solve every problem today. We can anticipate the capability of technologies that are coming in five years or 10 years or 20 years and work these into our plans.” Ray Kurzweil, The Singularity Is Near, chapter 7 “Ich bin ein Singularitarian”
Merv loves Ray Kurzweil and his books on The Singulary. But, according to Merv, Ray’s timescale is off. Charles Darwin said that “the complexity of life exceeds all understanding”. That may not quite be true, but it certainly is a fact that biology has an enormous proclivity for revealing ever greater levels of complexity. “The more we learn, the more we see what we don’t understand. By 2020, we will not see anything that will create demonstrable benefit for increased longevity.
To sum up, key developments in healthcare include :
- increased pressure to measure outcomes
- innovative patient monitoring technologies
- skepticism on some of Ray’s life extension projections
In a follow-up conversation, Merv and I discussed more developments, including :
- the impact of behavioral change on healthcare
- the potential transformational nature of current Alzeihmer’s programs.