What if we paid doctors to keep people healthy Matthias Mllenbeck
It’s 4am in the morning.
I’m waking up in a Boston hotel room
and can only think of one thing:
tooth pain.
One of my ceramic inlays
fell off the evening before.
Five hours later,
I’m sitting in a dentist’s chair.
But instead of having a repair of my inlay
so that I can get rid of my pain,
the dentist pitches me on the advantages
of a titanium implant surgery.
Ever heard of that?
(Laughter)
It essentially means to replace
a damaged tooth
by an artificial one,
that is screwed into your jaw.
Estimated costs for the implant surgery
may add up to 10,000 US dollars.
Replacing the ceramic inlay I had before
would come in at 100 US dollars.
Was it my health or the money
that could be earned with me
that was the biggest concern
for my dentist?
As it turned out, my experience
wasn’t an isolated case.
A study by a US national newspaper
estimated that in the United States,
up to 30 percent of all
surgical procedures –
including stent
and pacemaker implantations,
hip replacements and uterus removals –
were conducted
although other nonsurgical treatment
options had not been fully exploited
by the physician in charge.
Isn’t that figure shocking?
Numbers may be slightly different
in other countries,
but what it means is that
if you go to a doctor in the US,
you have a not-insignificant chance
to be subjected to a surgical intervention
without there being
an immediate need for it.
Why is this?
Why are some practitioners incentivized
to run such unnecessary procedures?
Well, perhaps it is because
health care systems themselves
incentivize in a nonideal way
towards applying or not applying
certain procedures or treatments.
As most health care systems
reimburse practitioners
in a fee-for-service-based fashion
on the number and kind
of treatments performed,
it may be this economic incentive
that tempts some practitioners
to rather perform high-profit
surgical treatments
instead of exploring
other treatment options.
Although certain countries
started to implement
performance-based reimbursement,
anchored on a quality and efficacy matrix,
overall, there’s very little in today’s
health care systems' architecture
to incentivize practitioners broadly
to actively prevent the appearance
of a disease in the first place
and to limit the procedures
applied to a patient
to the most effective options.
So how do we fix this?
What it may take is a fundamental redesign
of our health care
system’s architecture –
a complete rethinking
of the incentive structure.
What we may need is a health care system
that reimburses practitioners
for keeping their customers healthy
instead of almost only paying for services
once people are already sick.
What we may need is a transformation
from today’s system
that largely cares for the sick,
to a system that cares for the healthy.
To change our current “sick care” approach
into a true “health care” approach.
It is a paradigm shift from treating
people once they have become sick
to preserving the health of the healthy
before they get sick.
This shift may move the focus
of all those involved –
from doctors, to hospitals,
to pharmaceutical and medical companies –
on the product that this industry
ultimately sells:
health.
Imagine the following.
What if we redesign our health care system
into one that does not
reimburse practitioners
for the actual procedures
performed on a patient
but rather reimburses doctors, hospitals,
pharmaceutical and medical companies
for every day a single
individual is kept healthy
and doesn’t develop a disease?
In practical terms, we could, for example,
use public money to pay a health fee
to an insurance company
for every day a single individual
is kept healthy
and doesn’t develop a disease
or doesn’t require any other form
of acute medical intervention.
If the individual becomes sick,
the insurance company will not receive
any further monetary compensation
for the medical interventions required
to treat the disease of that individual,
but they would be obliged to pay
for every evidence-based treatment option
to return the customer back to health.
Once the customer’s healthy again,
the health fee for that individual
will be paid again.
In effect, all players in the system
are now responsible for keeping
their customers healthy,
and they’re incentivized to avoid
any unnecessary medical interventions
by simply reducing the number of people
that eventually become sick.
The more healthy people there are,
the less the cost
to treat the sick will be,
and the higher the economic benefit
for all parties being involved
in keeping these individuals healthy is.
This change of the incentive
structure shifts, now,
the attention of the complete
health care system
away from providing isolated
and singular treatment options,
towards a holistic view of what is useful
for an individual
to stay healthy and live long.
Now, to effectively preserve health,
people will need to be willing
to share their health data
on a constant basis,
so that the health care system
understands early enough
if any assistance with regard
to their health is needed.
Physical examination,
monitoring of lifetime health data
as well as genetic sequencing,
cardiometabolic profiling
and imaging-based technologies
will allow customers to make,
together with health coaches
and general practitioners,
optimal and science-guided decisions –
for their diet, their medication
and their physical activity –
to diminish their unique probability
to fall sick of an identified,
individual high-risk disease.
Artificial intelligence-based
data analysis
and the miniaturization
of sensor technologies
are already starting to make monitoring
of the individual health status possible.
Measuring cardiometabolic parameters
by devices like this
or the detection of circulating
tumor DNA in your bloodstream
early on after cancer disease onset
are only two examples
for such monitoring technologies.
Take cancer.
One of the biggest problems
in certain oncological diseases
is that a large number of patients
is diagnosed too late
to allow them to be cured,
although the drugs and treatments
that could potentially have cured them
are already existing today,
if the disease had only
been detected earlier.
New technologies allow now,
based on a few milliliters of blood,
to detect the presence
of circulating tumor DNA
and thus, the presence of cancer,
early on in a really convenient manner.
The impact that this early-stage
detection can have
may be dramatic.
The five-year survival rate
for non-small cell lung cancer
when diagnosed at stage one,
which is early, is 49 percent.
The same, when diagnosed
at stage four, which is late,
is below one percent.
Being potentially able
to prevent a large number of deaths
by something as simple as a blood test
for circulating tumor DNA
could make certain cancer types
a manageable disease,
as disease onset can be detected earlier
and positive treatment outcomes
can likely be increased.
In 2012,
50 percent of all Americans
had a single chronic disease,
resulting in 86 percent
of the $3 trillion US health care budget
being spent for treating
such chronic diseases.
Eighty-six percent.
If new technologies allow now
to reduce this 86 percent,
why have health care systems
not reacted and changed already?
Well, a redesign of what today
is a sick care system
into a true health care system
that focuses on prevention
and behavioral changes
requires every actor
in the system to change.
It requires the political willingness
to shift budgets and policies
towards prevention and health education
to design a new set of financial
and non-financial incentives.
It requires creating
a regulatory framework
for the gathering, using and sharing
of personal health data
that’s at the same time
stringent and sensible.
It needs doctors, hospitals, insurers,
pharmaceutical and medical companies
to reframe their approach
and, most important,
it can’t happen without
the willingness and motivation
of individuals to change their lifestyle
in a sustained way,
to prioritize staying healthy,
in addition to opening up for sharing
the health data on a constant basis.
This change may not come overnight.
But by refocusing the incentives
within the health care industry today
to actively keep people healthy,
we may not only be able to prevent
more diseases in the first place
but we may also be able to detect
the onset of certain preventable diseases
earlier than we do today,
which will lead to longer
and healthier lives for more people.
Most of the technologies
that we need to initiate that change
are already existing today.
But this is not a technology question.
It is primarily a question of vision
and will.
Thanks a lot.
(Applause)