DUMC endorses prospective med

In a paper published today in the Journal of Academic Medicine, Chancellor of Health Affairs Dr. Ralph Snyderman and Dean of the School of Medicine Dr. Sandy Williams argue that prospective medicine--an individualized approach to medicine--is the future of healthcare in America.

Currently, healthcare in the nation is based on reactive medicine, which treats diseases and conditions only after the onset of symptoms, Snyderman and Williams state in the paper. Although there are also many instances of preventive medicine--such as vaccinations, annual mammograms and colonoscopies and admonitions to eat well and exercise--none of them target individuals.

Prospective medicine, on the other hand, employs a combination of behavioral- and genomic-based approaches to healthcare, tailoring advice after each person's health risks have been evaluated.

"The care given today is episodic and sporadic treatment of problems as they arise," Snyderman said. "We need to reorient the healthcare system to personalized health."

Dr. Larry Shapiro, dean of the School of Medicine at Washington University in St. Louis, agreed that prospective medicine needs to become more prominent.

"The idea is... to try to understand risk factors that predispose people to getting sick, to try to institute changes in lifestyle and to prevent disease before it occurs," he said. "Understanding the underpinnings of what motivates people is challenging and difficult."

Cutting-edge fields such as genomics and proteomics--which explore the functions of the body's specific genes and proteins, respectively--and diagnostic imaging lend themselves to early risk assessment, diagnosis and prevention of chronic diseases that pose two-thirds of the nation's overall healthcare costs, Snyderman and Williams assert in the paper.

"There is no question that genomics and proteomics and other diagnostics are going to allow us to personalize medicine," said Dr. Philip Pizzo, dean of the School of Medicine at Stanford University. He noted, however, that Stanford does not have immediate plans to incorporate this approach as a dominant theme in its instruction.

Using the genomic revolution to identify people who might be predisposed to certain medical problems and stratifying patients according to their risk would allow for focused intervention strategies for only those who need them, Shapiro said. He added that prospective medicine would also ultimately help researchers understand the mechanisms by which diseases work, resulting in altogether new treatments.

With continually increasing national healthcare costs--now upwards of $1.5 trillion annually--the nation cannot sustain the financial burden of its current healthcare practices, Snyderman said, adding that prospective medicine would create a more cost-effective system. He noted, however, that it is difficult to determine if prospective medicine would decrease overall healthcare spending.

"What needs to be proven is what kinds of prospective interventions will be cheaper in the long run," Shapiro said. Although Snyderman said he was uncertain about the financial effects of prospective medicine, Shapiro thought it would be less expensive than the current system, especially when the opportunity cost of being sick is considered.

For prospective medicine to be integrated into the national healthcare framework, Snyderman said, its proponents need to prove that it is better than the current model.

Snyderman is at the forefront of a coalition including high-ranking industry and government officials as well as organizations with a vested interest in the healthcare industry. The coalition is working to help enact policy changes necessary for the implementation of a feasible prospective medicine model.

Snyderman called for changing the incentives in the healthcare system to reflect the greater emphasis on medical care before rather than after the onset of disease and also pointed to the need for external regulation of insurance to make prospective medicine viable. Currently, most insurance agencies do not cover preventive or prospective services.

"We really need to reorient our healthcare reimbursement system to focus more on prospective medicine," Shapiro said.

A larger overhaul would be necessary, however, to ensure the viability of the insurance market. Today, uncertainty governs the demand for insurance, as insurance agencies are unaware of their member pools' real risks. The future of genomics-based medicine could potentially alert insurance companies to people's adverse selection of insurance, in which only the sick population wants insurance, Snyderman said. He acknowledged that insurance would not be able to survive if only these members subscribed to it.

Snyderman noted, however, that behavioral approaches would still play a large enough role in prospective medicine that the insurance problem caused by knowledge of genetic predispositions would be offset.

"Prospective health care will utilize but will not depend on genomics," he said.

Still, Snyderman suggested some solutions to the potential insurance problem, including the widening of the risk pool to include people of all risk levels and legislation to protect genetic information, which is currently being debated in Congress.

Before policy changes are enacted, the healthcare industry will have to decide how important prospective medicine is in its mission toward patients. At Stanford, Pizzo said, the emphasis is still on emerging fields of patient care.

"We're not moving in a similar direction to Duke in this regard, but I think that is okay," he said. "It's an important point to have different areas of attention, [because] none of us knows the right ways." Pizzo added that he did not think prospective medicine would be the overarching driving force of patient care.

Snyderman, on the other hand, believes prospective medicine will be available "very soon" and will be the dominant form of medicine in a matter of years. "I suspect, most optimistically, there is substantial promise within five years," he said. "I would be shocked if it's not by 10 years."

Although Duke is the definitive leader in prospective care, other medical centers have also committed significant resources to investigating the method's merits and pitfalls, including University of Pennsylvania Medical Center, Montefiore Medical Center in New York City, New York University Medical Center, Emory University Medical Center, University of California-Los Angeles Medical Center and Lehigh Valley Medical Center in Pennsylvania.