1 Prognosis for Healthcare: The Future of Medicine Bruce M. Cohen, M.D., Ph.D. Director, Frazier Research Institute, McLean Hospital President and Psychiatrist in Chief Emeritus, McLean Hospital Robertson-Steele Professor of Psychiatry, Harvard Medical School
2 Mechanix Illustrated Nov, 1968 Vehicular travel between the domed, evenly climatized cities of 2008 is controlled by the national traffic computer, which guarantees perfect safety even at speeds of 250mph.
3 Lessons From The Past
4 1500 BC 1940s Stardate You Are Here?
5 Looking Forward What Changes Can We Expect in Medicine?
6 Drivers of Change in Medicine Disease and the Spread of Disease Science and Technology Clinician Training and Roles Institutions and Care Settings All interacting and all influenced by wealth and its distribution
7 What Changes in Illness Can We Expect?
8 Disease Changes in Our Future New infectious diseases crop up now and then throughout history New toxic diseases can arise due to new manufacturing or environmental changes Climate change and increased travel can lead to the spread of existing diseases to new populations
9 Also The population is aging, and with that will come: Increased prevalence of some illnesses- Diabetes, Cardiovascular Diseases, Dementias, Cancers, Arthritis With increased costs
10 Can we take advantage of new advances in science and technology to discover better treatments for medical illnesses?
11 Some Technologies for the Early 21st Century that Could Change the Future of Healthcare Advanced Genetics/Genomics Molecular, Cell and Systems Biology Truly New Drugs New Vaccines Tissue Repair/Stem Cells Improved Prosthetics Better Tissue Imaging Computing/Information Technology Mechanical/Nano Technology
12 Two Examples: Genetics and Stem Cells
13 The Potential Contribution of Genetics The risk of illness, the course of illness, and response to treatment are all substantially determined by inherited factors.
14 With the sequencing of the human genome and the increasing power of genetic analysis, the pace of discovery of risk genes for human illness has accelerated.
15 Once genes related to risk of illness are determined, they can be used To help identify and study individuals at risk To classify those who are ill according to different subtypes of illness To study the function of genes related to illness in Biochemical preparations, Cell culture, Animal models, and Human subjects To define the mechanisms by which the gene predisposes to illness and, thereby, find targets for treatment Including medication or changing the genes, themselves
16 Beyond Treatment: Can We Achieve Prevention, Replacement and Repair?
17 Some Developing Technologies For Gene, Cell, Tissue and Organ Repair Gene Alteration Nanomedicine Organelle Replacement / Repair Cell Replacement / Repair Organ Replacement or Remodeling
18 Cell Replacement
19 Replacing Lost Cells The body has limited capacity to repair itself by growing new cells: The skin, the liver, bone and blood cells and blood vessels grow Brain, muscles, lungs, kidneys, etc. do not
20 We Can Provide New Cells to the Brain and Other Organs These cells may directly replace lost cells or They may provide factors to limit or reverse cell loss
21 Stem Cells Stem cells can grow to become all or most of the specialized cells of the body There are several sources of stem cells for use in tissue repair This includes stem cells obtained from each individual s own body
22 Stem Cells, Given Intranasally, Can Enter the Brain 7 days post treatment 14 days post treatment Cataldo and Cohen, 2008
23 Some Current Hot Topics in Developing Medical Technology Personalized medicine, based on individual genetics Tissue Repair by stem cells or nano-devices Better aging Prevention of illness All are possible with enough time, effort and funding
24 Areas for Likely Near-term Medical Success in Applying New Technologies Treatments targeted at genetic differences of individual cancers Stem cells to treat Type I (early onset, insulin dependent) diabetes mellitus -survey of one physician scientist
25 Issues in Developing and Applying New Medical Technologies Testing Efficacy and Safety of New Devices and Treatments- What degree of certainty and speed to require for approval (FDA) Access to New Technology-How to assure availability without overuse Electronic Medical Records-How to assure accuracy and privacy Affordability-Who pays for development and use
26 Is This the Key to the Future?
27 Costs of Healthcare
28 Annual US healthcare costs: $2.2 T, $7421/person, 16.2% GDP (22% higher on average than other developed countries) Over half is spent for care in the last six months of life 27% is spent on 1% of the population, much of it for emergency room care 75% of yearly increases is for new medications and technologies 30% is for unnecessary tests and procedures, in part related to malpractice concerns -American College of Physicians, 2009 White Paper
29 Paying for Healthcare
30 Healthcare Payments USA: 2009 Currently, a mixture of private, public and personal payments: Private Health Insurance: 42% Public Payment* Federal: 34% State: 13% Out of Pocket: 12% *(Includes Medicare: 19% And Medicaid: 15%) Uninsured: 20% under age 65 -Department of Health and Human Services, USA
31 USA vs. Other Developed Countries Hospital costs are 4X higher Physician and Nurse salaries are % higher Drug costs are 3X higher (Brand names cost more, generics less than elsewhere) Administrative and regulatory costs are 6X higher (Private plan administrative costs are 2X those of Medicaid and 4X those of Medicare) -American College of Physicians, 2009 White Paper
32 Health Insurance Issues US health insurance is built of ad hoc pieces: Private, largely through groups at work, and Public, through Medicare for older or disabled adults or Medicaid for the poor There are many other models for coverage, but in the current debate, they are receiving little temperate discussion.
33 More Payment Issues Should we have health coverage for all (beyond the ER)? Who should decide what is covered and for how much? Should payment be by service, person, group, illness episode, outcome? What deductibles or co-payments are reasonable? What maximums or catastrophic coverage are reasonable? (And yes, you will pay for it, but you are already)
34 The Future for Caregivers
35 Caregivers: Roles and Issues Are current numbers, roles and responsibilities of doctors, nurses and technicians the right ones? Shouldn t everyone have a primary generalist? (Specialists make % more than generalists) Is there a way for doctors to spend adequate time with patients? How broadly should doctors be trained? Should they know nutrition, exercise, holistic or alternative medicine?
36 Settings of Care
37 Partners HealthCare: a system of care including two academic medical centers, community hospitals and health centers, a physician network, specialty hospitals, and other health services. Brigham and Women s/ Faulkner Hospital Massachusetts General Hospital North Shore Medical Center: Salem and Union Hospital Newton-Wellesley Hospital Spaulding Rehabilitation Hospital; Partners Home Care; McLean Hospital
38 Settings of Care: Issues and Opportunities Providing the right care in the right place at the right time What mix and location of hospitals, clinics and doctors offices is best? (Convenience and special services must both be addressed. Currently, ERs are overused and routine and preventive care are overlooked.) What roles for , websites and telemedicine? Can we arrange better chronic care (home and clinic) and better end of life care (home and hospice)? Who will decide the location and types of care?
39 Quality of care
40 Quality of Care: Issues and Opportunities Over 100,000 in USA die each year from medical errors-iom The USA ranks #1 in effectiveness of care, but low on patient safety, patient centeredness and access to care-acp Most research on the effectiveness of treatment is funded by those with a product to sell: A drug, device, service or model of care Consumer assessments and input are minimal Consumer knowledge of options is poor
41 What Can You Do?
42 What You Can Do: Globally Most of the debate and decision making will be driven by private/vested interests-get involved Inform yourself-write and support politicians whose positions make sense to you Support research on illness, treatment and quality of care
43 What You Can Do: Locally Support education on health, illness, and healthcare in the schools and community Support healthy environments in the schools and workplaces
44 Illness is Personal: Risk can be Changed 45% of adults have one or more chronic medical illness; one third will develop type II diabetes 64% of the US population is overweight, 2-3 X the rate of other countries Smoking leads to 462,000 unnecessary deaths and $180 B in additional health costs per year
45 What You Can Do: Personally The risk of death or disability from many medical illnesses, including: cardiovascular diseases, diabetes, lung diseases, cancer and infectious disorders can be reduced by: Good diet, Regular sleep and exercise, Occasional medical check-ups, And following through with treatment
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