What would the American health care system look like if ordinary patients and their families could assume many of the most crucial tasks in primary care medicine?
What if, for example, people without any medical training could diagnose their own incipient cancers or heart disease? And what if they could do it reliably, cheaply and at such an early stage that no symptom was yet apparent?
What if recipients of such a diagnosis—or anyone with a medical concern—could simply pick up a telephone and immediately tap the personalized wisdom (or second opinion) of the world's most eminent medical specialists?
What if patients, their watchful families and their primary care providers could be absolutely certain—no need to rely on anyone's faulty memory or untrustworthy account—that every drug prescription had been filled and every dose swallowed on time and, as a kicker, allow caregivers to check that all the patient's vital signs were holding steady and that he or she was exercising dutifully or resting in bed as directed?
The Future Is Here
For one thing, notes health care venture capital adviser David Lawrence, M.D., the former CEO of Kaiser Foundation Health Plan and Hospitals, the nation's largest managed care organization, a lot fewer GPs, internists and front-line primary care physicians would be needed—which, we'll see, would be a very good and timely thing.
What's more, many of the basic functions of primary care that now occupy expensive physician bandwidth—routine checkups, wellness counseling, disease and disability prevention, management of common chronic conditions like asthma and diabetes, end-of-life ministrations—all could be handed off, as appropriate, to less costly but equally capable registered nurses, nurse practitioners and physician assistants.
The fact is, Lawrence points out, every one of the futuristic scenarios outlined above is rooted in the present.
Diagnose your own cancer? SomaLogic, of Boulder, Colo., is poised to commercialize that capability at convenient locations like your neighborhood pharmacy or shopping center.
Founded by renowned microbiologist Larry Gold, SomaLogic has developed a "wellness chip" that can analyze the small proteins circulating in the body and pinpoint those whose presence and combinations are the distinctive signatures of upward of 2,000 particular illnesses. SomaLogic's chips, the company explains, use "powerful proteomic reagents…that unlock biomarker discovery to detect even the rarest disease-associated proteins quickly, concurrently, effectively, and economically."
Diagnosis of lung cancer at an early, treatable stage is the first application scheduled for clinical introduction this year, says Lawrence. It will be followed shortly by tests for ovarian cancer and mesothelioma, with another 16 diseases, including Parkinson's, Alzheimer's and coronary artery disease, expected to be detectable through SomaLogic proteomics by the end of 2011. As many as 75 infectious, inherited, neurological and metabolic conditions are promising candidates for quick addition to the menu, he notes—diagnosed definitively by protein analysis, "not because you're genetically disposed, but because you've actually started the process."
SomaLogic's test results are so clear-cut, says Lawrence, that "not a lot of clinical judgment is necessary" to interpret them. "You get close to a binary yes-no." And the process is so simple "it can be done at Wal-Mart! It doesn't require a physician."
"This just puts another piece of the [health care] puzzle in the hands of the patient," he declares.
The same goes for reliable treatment advice, which is not a functional outcome of surfing Internet medical sites, and compliance with doctors' orders.
In real life, the latter is the bane of physicians' existence. How can they know—really know—that once they've left the office their patients are adhering to the regimen that will stave off asthma attacks, prevent progressive complications of diabetes or congestive heart failure, cure the infection but not contribute to the development of antibiotic-resistant strains of bacilli… and ultimately keep the patient out of the hospital?
The answer is, doctors can't. (In fact, studies show that a third of prescriptions go unfilled, another third are not refilled, and half of all pills are taken incorrectly.) They can't, that is, unless someone were to invent something—call it an "ingestible event marker"—that could reliably and conveniently record and report in real time exactly when every medication is taken—or, in case of noncompliance, not taken.
Well, that's exactly what Proteus Biomedical, of Redwood City, Calif., has done. Proteus has developed minuscule radio transmitters made of food-grade materials that can be inserted in every pill or drug capsule for only a few pennies each. Stomach fluids activate the sensor—the size of a grain of sand and digestible—to trigger an ultralow-power, encrypted, digital signal that travels through the patient's body to a microelectronic receiver, which is either a small bandage-style skin patch or a tiny device inserted under the skin (patients must consent, of course) .
The receiver date- and time-stamps the type of medication swallowed, the place of manufacture and the dose, along with concurrent physiologic measures like the patient's activity and heart and respiratory rates. This information then is sent to a nearby cell phone, which automatically relays it to the medical record and the physician. But the beauty of it is that anyone in the caregiver chain, from a home-health aide or visiting nurse to a friend or family member, can monitor the patient's condition and adherence to the prescription schedule.
What to Do?
As to the centrality to the medical care system of primary care doctors who are intimately familiar with their patients' medical histories, lifestyles and treatment preferences, and who can steer each patient to the right specialist at the best hospital for the "state-of-the-artiest" care for whatever arcane medical condition she or he might present…well, proposes Lawrence, once again, consider real life.
Harried PCPs on today's schedules see patients only briefly and sporadically, he points out, adding up to "maybe 45 minutes or an hour and a half" over the course of a year. "That doesn't provide a hell of a lot of insight," he shrugs. "The idea that you're going to know someone intimately enough to be able to help with a values decision is nonsense."
What's more, primary care physicians are generalists. It's unreasonable to assume that they can keep abreast of rapid advances across the broad range of medical science. (Indeed, the attraction of primary care medicine is "almost poetic," Lawrence muses; seven or eight years of costly medical education would be better spent, he implies, gaining one's chops for "the intellectual excitement and rigor of being in secondary or tertiary or even quaternary specialty care.")
But it's true that the average person confronting an illness needs "a navigator, an advocate, a sort of traffic director" to help in plying the complexities of modern medicine. And here's where another private enterprise steps into that traditional PCP role. MedExpert, also based in Redwood City, offers "individual medical-decision systems" staffed to take telephone inquiries and advise on a course of action grounded on a continually updated library of best practices in the prevention and treatment of any of 22,000 diseases or conditions.
MedExpert's 10-year-old IMDS service is an add-on to health care coverage for some 1.7 million employees of subscribing organizations. Advisers—who consult the latest evidence-based protocols, make personalized recommendations and even arrange appointments with the right specialists—field some 600,000 calls a year. One study found that MedExpert's services have saved participating employers 15 percent annually on health care expenses because not only have they helped participants to adhere better to prevention methods, but they also reduced unnecessary ER visits and hospitalizations.
SomaLogic, Proteus Biomedical and MedExpert are just a few of the most promising and successful of the "three to five companies a week I'm seeing coming over the transom with wild ideas about how to reach patients directly," says Lawrence.
His transom is a prime target for entrepreneurial pitchers because, among other postretirement posts, Lawrence sits on several influential corporate boards and advises two important health care venture capital funds, Physic Ventures and Health Evolution Partners. And from that outlook, he's convinced that the American health care system as constructed is in its death throes.
"Disruptive innovations" like those he's described—"wild ideas" that "disintermediate the primary care physician"—along with unprecedented competition to traditional providers by "nonhealth care, consumer-oriented companies that are positioning themselves to become health care delivery companies" (among them he lists Microsoft, Google, Wal-Mart, AT&T and Verizon) will combine to hasten the demise; and not a moment too soon, he suggests.
Riddled with waste, inefficiency and error, health care as we've known it deserves to die.
"Most of the people who're in the hospital are probably there for a good reason," he allows. "But if they didn't have to go in the first place, because they were treated differently… or if they didn't have to be there, because there hadn't been an untoward outcome or an unsafe practice… Yes, most of the people who are in the hospital are sick enough to need that kind of care—but not that many people need to be sick!"
Emptied of patients occupying a bed for the wrong reasons (like failure to take their medicine), hospitals can become centers of excellence in secondary and tertiary care, he proposes.
Empowered with real knowledge and new capability and responsibility, patients and nonphysician providers can take on the brunt of primary care. Freed of those mundane distractions, doctors can collaborate in multidisciplinary specialty teams (think Mayo, Virginia Mason or Kaiser as models), to "focus on critical work where ambiguity is greatest, and where diagnostic and therapeutic judgments require their unique preparation and skills. More predictable work can be shifted to nonphysicians who can be trained more rapidly and less expensively and who can be employed at less overall expense."
Health care reform, adds Lawrence, will accelerate the deconstruction. More and more Americans enjoy access to primary care benefits just as fewer and fewer primary care physicians are around to deliver it. "They're aging out and not being replaced," observes Lawrence. In California it's estimated that there will be a 10,000-physician shortage in primary care by 2015. And the Association of American Medical Colleges says the shortage will be 40,000 to 50,000 nationwide.
"Serendipitously," he continues, "we're beginning to demonstrate examples of how primary care can be provided alternatively. When I stand up before hospital directors and medical directors and boards of directors I say, 'I spent nearly 40 years of my career on your side of the fence. Now what I'm trying to do is to find every possible way I can to take 50 or 60 percent of your business away from you and give it directly to consumers.'"
That's not a comforting message for most of those audiences, Lawrence recognizes. Nor does he expect most of them to adjust smoothly to its implications.
"If you're a truly innovative health care system—and there are a few around—you will be able to find ways to bring [these] innovations into your suite of delivery services," he acknowledges. "But it's going to take a while. The system is so fragmented and dysfunctional it's very hard to unfreeze. That's why we argue that probably the disruptive model of change will occur first. Certainly that's been the case in almost every other industry we know. For the most part, successful companies, especially ones encumbered by all the hierarchical, social and economic constraints there are in health care, have a hell of a time changing."
But prepare for it. Forget, "What if?" Ask, "What now?"
David Ollier Weber is a regular contributor to H&HN Daily and the author of Catch/Release (Kila Springs Press, 2011).