OP-ED

Personalized Medicine vs. ObamaCare

Personalized medicine is the future. It is where the science is going. It is where the technology is going. It is where doctors and patients will want to go.  Yet unfortunately for many of us, this is not where the Obama administration wants to go.

First, the good news. Biosensors that can be worn on clothing or jewelry, or held against the skin by a Band-Aid-like patch, or inserted beneath the skin are capable of monitoring a whole host of chronic diseases. Among the technologies that have been, or soon will be, developed are devices that can continuously monitor the blood glucose levels in diabetics; the rate of breathing, blood oxygen saturation, etc., of asthmatics; and the heart rate and other parameters of patients with heart disease. There are even heart attack and stroke attack detectors. In some cases, personalized devices can activate therapies. A wearable, automatic insulin pump can be coupled with a blood glucose measuring device to create a virtual artificial pancreas. (See this fascinating summary.)

The science of genetics is also about to explode. There are as many as 1,300 genetic tests currently available that relate to about 2,500 medical conditions. Gene tests can predict your probability of getting particular types of cancer, whether you will respond to routine chemotherapy or whether there is a special therapy that only works on people with your particular physiology. The days when experts argued over whether men should get a prostate cancer test could be long gone.  A simple test can tell if you have a high probability of contracting the disease, or a low one.

We’re not that far away from the day when:

Sequencing the personal genome will take an hour and cost perhaps $300, or less than an MRI. It is not too much of a reach to postulate cell-phone-sized analytical devices able to test for 500 biomarkers that cross the body’s more than 50 organs in a single drop of blood.

All this is great news. Unless you happen to be in traditional Medicare. Or in Medicaid. Or unless you acquire subsidized insurance in a health insurance exchange. Or in some cases, even if you get health insurance from an employer.

So what exactly is personalized medicine?

[It] means gathering specific physiological information pertaining to individuals, compiling that information into a digestible and actionable form, and presenting that compiled information to the individuals themselves (and to their doctors or other designated agents), in order that they may decide what action to take on behalf of their own well-being.

Today, individualized medicine…is feasible for the first time in history. It is feasible because of the fortuitous convergence of several technologies, including the Internet, ubiquitous wireless communication, massive data processing power, new physiologic sensors, the power of genomics, social networking, and smartphones (i.e., personal information and communication systems)…[T]his remarkable technological convergence has made it possible to devise systems with which people can control their own healthcare in ways that were unimaginable a decade or two ago.

In thearea of gene therapy, progress has been slow, but in some cases remarkable. For example, there is now a genetic test that can determine with uncanny accuracy whether a patient’s eye cancer is curable or fatal. In another path breaking example, consider the case of Dr. Lucas Wartman, a young physician who developed adult acute lymphoblastic leukemia, a disease that is usually rapidly fatal, and for which there is no effective treatment. After his colleagues at Washington University worked round-the-clock for many days using the university’s 26 sequencing machines and a supercomputer:

[T]hey discovered a single gene mutation in his cancer cells that was producing a protein that appeared to be stimulating the cancer’s growth. It turned out that a new drug existed that was targeted specifically at shutting down the offending protein, a drug that to that point had been used only for kidney cancer. When they administered the drug to Dr. Wartman, his cancer went into complete remission. [more]

Now for some bad news. In an interview with CNN the other day former White House health adviser Ezekiel Emanuel called “personalized medicine a myth.” According to his own center’s summary of the interview:

[He] characterized excited public discussion of the potential of population-wide individual gene-based medicine as “hyperbolic.” He said tailoring medical treatments to individual characteristics of each patient is both overly optimistic and cost-prohibitive and likened the process to buying a custom-made suit versus one off the rack.

But if custom-made suits fit better and look better, what’s wrong with that? Ditto for health care. And if individualized care is better and more promising care, how does Emanuel know it would be cost-prohibitive? Even more puzzling, given the spectacular results with eye cancer, why would anyone — especially an oncologist — react so hostilely?

The answer is: ObamaCare’s entire approach to cost control is premised on the idea that we are all alike. And if we aren’t alike, everything they are doing doesn’t make sense. More about this in my next editorial.

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

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16 replies »

  1. Just like Nancy P and Harry R didn’t let facts get in the way of passing this garbage shill bill to begin with. Pure partisan legislation never benefits American citizens as a whole irregardless if Democrat or Republican generated. Wow, what a choice in less than 6 weeks, an out of touch rich guy from Massachusetts, or a thug from Chicago. At least they both believe government can force health care choice on all Americans.

    Failure does not discriminate between parties, eh?

  2. 4 letters to refute this above opinion: IPAB.

    Gimme a break, the only personalized part of PPACA is how the politicians are exempt from the legislation. Hey, the choir of this legislative assault on America should be singing “don’t stop believin’, we’re so good at deceivin’ “.

    Gotta love people keep telling you, young adults stay on their parent’s insurance and people with preexisting conditions are the cornerstones to this legislation. Yeah, as over 50% of this young adults can’t get a job nor one that will offer health insurance coverage, and really, you think insurers won’t find a creative way to still profit even if they have to cover everyone who had an illness?

    I’m sure Democrats will sing you more Journey songs to your liking!

  3. I think emanuel said what he said because he is a physician. We know that we are not even close to what John suggests. Even, or if, we get there, we will still rely upon the fact that most patients respond to most meds or therapies in a predictable manner. John forgets that guidelines have been pushed by physicians well before there was any governmental involvement. They have been instrumental in improving care and lowering malpractice rates. A good doc is not afraid of guidelines. He uses them, but knows when to depart from them and can explain why.

    Steve

  4. This is an interesting article and highlights some of the potential for personalized medicine. I believe that potential, however, will not be met until we change the structure for how we care for people in our healthcare system. A basic understanding of complex adaptive systems science (which describes our biologic world- cells, people/patients, hospitals, etc.) will allow us to design systems of care around patients and their problems. We can get all the information we want- genetic, sensors, etc. but if we don’t know what to do with it, we are as likely to help someone as to hurt them in many situations when we attempt to treat them based on the information (see the current research on screening tests). Take gene sequencing- our genome is constantly adapting and changing- except for a small minority of typically very rare diseases, the genome alone does not determine a person’s disease- it is much more complex than that.
    We do have a very hopeful future in healthcare- when we design systems of care with patients and diverse teams that are structured to learn and continuously improve care. Big data analytics will be an important component of this, but I believe the patients and care communities that are structured to learn and improve motivated by a love for caring for each other will be the soul of a better healthcare system.

  5. And why is Dr. Emanuel’s opinion on feasibility of these wishful thinking innovations in any way indicative of what private and public insurers will pay for, with or without Obamacare?

    Precisely. From what I gather there is a virtual stampede of doctors away from traditional practice models toward salaried positions in hospitals or other big outfits, or concierge alternatives. The comments thread at Dr. Lamberts’ “Dropping Out” post illustrates the point.

    All this Obamacare bashing is what was said above — both mean and stupid. The full measure of the new legislation has yet to be seen or tested. Healthcare at the moment looks like an anthill struck by a lawnmower, with lost ants crawling all over the place looking for a place to go. Anybody who thinks they know how it’s gonna end should buy time on cable TV along with those peddling everything from jewelry and sex toys to whatever kind of salvation fits your situation. Jack Nicholson’t line in “As Good as it Gets” fits nicely: Sell crazy someplace else, we’re all stocked up here.

    I just read an excellent on-point post about the surge in upcoding that plagues Medicare.

    http://reforminghealth.org/2012/09/26/hospitals-under-scrutiny-for-billing-practices-that-cost-medicare-11-billion/

    When tax dollars are up for grabs creative imaginations know no limits. It’s probably true that “personalized medicine” (like cosmetic surgery and medical tourism to Asia) is incompatible with public funds. So criticisms of how best to steward public money are way off the mark.

    All this is great news. Unless you happen to be in traditional Medicare. Or in Medicaid. Or unless you acquire subsidized insurance in a health insurance exchange. Or in some cases, even if you get health insurance from an employer.

    Exactly. Actuaries and other bean counters call it “risk management.” It’s a form of rationing one scarce resource, tax money. There, I said it. I used the “R” word. But unless and until a better way is found to manage what the petroleum people call a “disappearing asset” ACA may be the sharpest knife in the drawer. The jury is still out on Medicare Advantage and hosts of HSAs and other private sector adjuncts. Nobody’s stopping the private sector from working it’s magic. And you can be sure that as soon as those private sector miracles become feasible, mainstream and affordable, then and only then will they have earned a place at the table where tax money is picking up the tab.

  6. “All this is great news. Unless you happen to be in traditional Medicare. Or in Medicaid. Or unless you acquire subsidized insurance in a health insurance exchange. Or in some cases, even if you get health insurance from an employer.”

    Does this imply that voucher Medicare, unsubsidized insurance, insurance bought on the free-market, “across state lines” presumably, insurance from select (?) employers and uninsurance (instead of Medicaid) will pay for this sci-fi medicine?

    And why is Dr. Emanuel’s opinion on feasibility of these wishful thinking innovations in any way indicative of what private and public insurers will pay for, with or without Obamacare?

  7. This is, for a change, just stupid, not mean AND stupid. Yes, there is plenty of genetic testing – but there are very, very few treatments, let alone cures. I hope for many more to come, but we are simply not there yet. And regarding biosensors, you could probably get gigabytes of data from someone’s rectum alone, but the question remains: is the data meaningful and can be used for diagnostic ot therapeutic purposes?

  8. “The answer is: ObamaCare’s entire approach to cost control is premised on the idea that we are all alike. And if we aren’t alike, everything they are doing doesn’t make sense. More about this in my next editorial.”

    Well said. bureaucrats and politicians either just shudder in confusion or just start shouting idiocy when people bring up individuality in consideration of passing legislation affecting the public. Which is probably a main reason why Nancy and Harry were so dismissive of any debate to PPACA.

    And their lackies will echo here too.

  9. The ACA/Obamacare actually helps promote personalized medicine in a couple of important ways.

    First, by helping to ensure that folks will not lose their coverage because of per-existing conditions, we improve the reduce the risk of data sharing. In order to achieve any real benefit from genomic data, large number of genetic data will have to be viewed as a single data set and followed longitudinally to explore correlations between genetic variations and outcomes. I wrote about this back in 2009 when the bill was passed: http://healthinnovation.posterous.com/why-i-hope-reform-passes-today-the-building-o

    Compiling a genetics-based “Framingham for everything” possibly something similar to to Kanter Family Foundation’s vision, we’ll unlock a wealth of information to help personalize treatments: http://kanterhealth.org/?doing_wp_cron=1348698743.1372709274291992187500

    Secondly, by setting up Medicare shared savings programs, ACOS and encouraging PCMHs it opens the door to align organization to find out what works for individual patients. Aligning financial incentives between physicians and patients opens the door to innovations like personalized medicine to reduce costs. Sure, the savings are based on populations of patients, but that doesn’t mean that a personalized approach to each patient in the population won’t do a better job of reducing population health costs. It’s not mutually exclusive.

    A system that learns is dependent on incentives and feedback. Changing incentives is a necessary prerequisite to changing anything in health care. Otherwise, as Margalit points out, all you get are systems that are really great at billing more.

  10. I don’t know why people even bother with developing genetic tests or personalized medicine. There is no money to pay for this and it is a waste of time.

  11. With a few exceptions, “personalized medicine” is far from a practical reality – and its promise has also been exploited by direct-to-consumer advertising of DNA screening services that clearly aren’t ready for prime time. The GAO found that four different DNA testing services produced four different results from the same DNA samples.

    Personalized medicine is highly dependent on a solid foundation of electronic medical records because its data requirements are tremendous. Most of American medicine is still not prepared to support this fundamental infrastructure requirement.

    In short, genomic screening is currently unregulated and without standards to assure consistent methods for data analysis and interpretation. Get a good family history instead of worrying about “personalized medicine” that, with a few exceptions, is still many years off. Studies have found that for heart attack risk, your parental history trumps your genes in any event.

    This article simply plays on the public’s fears to stonewall standardization that is sorely overdue in medical care to avoid the incoherent practices that now dominate – and threaten to bankrupt – American medical care.

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