At the first full day of sessions at ISPOR 2019, held May 18-22 in New Orleans, Louisiana, Daniel Kraft, MD, implored his audience of healthcare stakeholders to consider the different ways that technology disruption can improve care away from what he called “sick care.”
Kraft described, as many physicians have before, how despite new, fancier offices with high-tech equipment, the mainstay of every medical building is a fax machine.
“We still have silos,” he said. And, he added, healthcare is still organized around “body parts.” Sickcare results from intermittent and episodic data, said Kraft, a medical futurist who is part of Singularity University, which describes itself as a “global learning and innovation community” and founder of Exponential Medicine.
Kraft was speaking at the first plenary session, “The Dawn of Disruption in the Health Sector: Will Innovative Technologies Require Innovative Ways of Thinking?”
Medicine and technology are both moving toward becoming exponentially faster and coming together to be more continuous and reactive. But a gap must be closed to connect the immense amounts of data that are generated to actionable steps clinicians can use, and patients will use, to move from disease treatment to wellness and prevention, he said.
Another important piece in all of this is understanding incentives, which are currently misaligned, Kraft said. “You get what you incentivize,” he said.
The convergence of technologies is providing the power to address challenges, such as variations in clinical practice as they stem from cost, demographics, and access, as well as helping to shift from fragmented care to a model of integrated care, he said.
He cited the example of Uber, which upended the taxi business, and changed the future of work for many, and is heading into healthcare; Kraft cited a unit called UberHealth, which promises services such as sending a nurse to your house to deliver a vaccination.
“You press a button and a nurse or doctor comes to you,” he said.
The lesson for his audience, he said, is that in healthcare, “you want to be the disrupter, not the disruptee.”
When it comes to individual health, Kraft said there are 2 things more important than what happens inside of a doctor’s office. Referring to social determinants of health, he said, “Our zip code is more important that our genomic code.”
But behaviors are even more important than genomics, and that is where sensors and virtual reality could prod people into improved health behaviors. In turn, data could help improve diagnostics if tied together with the right software, and diagnosis for certain rare conditions could be sped up through crowdsourcing, he said.
“Let’s not just think of ourselves as blood donors or organ donors, but data donors going forward,” he said.
Kraft then joined a panel, moderated by Clifford Goodman, PhD, of The Lewin Group, to discuss the potential and pitfalls of disruption. They were joined by Timothy Caulfield, LLM, University of Alberta; Ron Philip, chief commercial officer of Spark Therapeutics, which developed and launched, Luxturna, the first gene therapy that treats an inherited form of vision loss; Fleur Chandler, a health economist and parent of a child with Duchenne muscular dystrophy (DMD), a fatal, genetic childhood disease; and Alexander Billioux, MD, MPhil, the assistant secretary of health for the Office of Public Health for Louisiana.
Goodman asked what, exactly, gene therapy is disrupting. On the patient side, Philip noted that patients can be cured, potentially for a lifetime. There are price disruptions too, which also affects the business side. They are not traditional therapeutic models, such as for chronic disease that requires ongoing care; as such, it means that some payment models are outdated.
Goodman asked about reimbursement and payers. “That’s been a little bit more interesting,” said Philip. Commercial payers understand the value of a 1-time infusion, but there’s still work to be done on the government payer side in terms of price reporting and outcomes, he said.
Turning to Chandler, Goodman noted her dual roles as someone in the industry as well as a patient advocate. “You’ve put more cards on the table,” he said.
While the regulatory process has, in Chandler’s view, adapted well to newer therapies for rare disease, there are other aspects in which developments are not far as along as she would like or is needed, such as developing necessary levels of evidence. Part of the reason for that is the inexperience of some pharmaceutical companies, small patient pools, and conflicting results, she said.
“The innovation piece here is around collaboration,” she said. In addition, some companies don’t know they need to develop economic models, she said.
Referring to Kraft’s keynote, Goodman turned to Caulfield, whom he called a "well-known skeptic," and asked how we become more discerning around innovation.
“I think it’s tough,” said Caulfield. “We’ve got to watch the hype.” Otherwise, there is risk of unapproved therapies making it to market, such as stem cell therapies, he added.
As one example, when it comes to wearables that track physical activity, he said there is “very little evidence that giving personalized health information changes behavior at all.” Moreover, information blasted at consumers could lead to overdiagnosis and anxiety, Caulfield added.
“Are you at odds with what dear Dr Daniel Kraft presented, or do you have any advice back to him?” Goodman asked.
“I’m torn,” Caulfield replied. “We want to make sure that this stuff is going to be beneficial in a real way, not just in a commercial way, but in a real way.”
His other concern, he said, is that the bells and whistles of new technology and “disruption” could distract society from more basic things, like stopping smoking, eating well, and improving the built environment. Those are the things that have the biggest impact on population health, he said.
Kraft said the potential of these devices are still in the early stages. Prescribing a device like Fitbit doesn’t mean you lose weight, Kraft said, as the ways to individualize how to use these devices are just beginning.
Goodman asked Billioux to give an update on the state of health for Louisiana. Billiioux was filling in for his boss, Rebekah E. Gee, MD, MPH, who was defending her state budget request Monday, Billioux said.
Louisiana bounced between the numbers 47 and 50 when it comes to ranking US states based on health indicators, Billioux said, acknowledging the challenges. On the bright side, he said, it is one of the few in the region that expanded Medicaid, which allowed them to expand vaccinations, cancer screenings, and access to primary care physicians.
However, the issues of disruption, innovation, and technology have little immediate effect in their challenges, he noted. “We still have rampant smoking. We still have challenges with poverty. We still have challenges with obesity,” he said.
Goodman asked how the state copes with expensive therapies, like hepatitis C drugs, referring to Louisiana’s efforts over the past year to create a “subscription payment
“Our goal is to eliminate the disease,” said Billioux, and with the new model, it is something the state can “leverage over and over again...to make Louisiana one of the healthiest states in the nation.”
But to truly eliminate disease they have to think about other issues, such as transportation and housing and other barriers to treatment, and getting there will take new forms of working together, he said.
Goodman also asked the panelists a question from the audience about how disruption and innovation can tackle issues like medical errors as a cause of death. As a physician, Billioux said it would be helpful to address issues like implicit bias. As one example, he cited maternal mortality
for black women, who are 4 time more likely to die than white women. Part of the reason is because of the way some physicians may respond to the same clinical signal differently, depending on who is before them, he said.
While technology may be helpful, having a blood pressure reading of over 170/90 mmHg is always a concern in a pregnant patient no matter who it is, he said.