Eli Meir Kaplan
When consumers choose health care, they have precious little information on the outcomes that are meaningful for them. How long will I be out of work? How well is my pain controlled? How likely am I to get an infection if I have this procedure done by this doctor? If consumers had as much information about health care as they do about consumer products, we would see dramatic improvements in quality — and reduced costs. If consumers and employers and insurers had access to this data, perhaps then we would begin to reduce the disparities and the variation in quality of care among health care organizations. When you buy an airline ticket, do you ever think of checking to see how safe the airline is? No, safety is guaranteed. The airline industry has institutionalized safe practices so all the airlines are safe. You choose your ticket on price, or on service. That's where we need to go with health care. Part of that is being transparent about where we are doing well and where we are falling short."
Understand sex differences
If you look at American medicine, a better term for it would be American male standard medicine. When you go into the emergency room complaining of chest discomfort and they draw blood to evaluate whether you are having a heart attack, the blood enzyme test that is used is a male standard, and it misses 20 percent of heart attacks in women. This is despite the fact that we've known about female and male thresholds for these enzymes for 40 years. Ambien is another good example. The FDA had the data 20 years ago, when they approved the drug, that the dose should have been lower for women. [The FDA cut the recommended dose for women in half in 2013.] We have just put our toe in the water for the big common diseases to start to understand about sex differences. Some of this, like the blood enzyme for heart attack, we already know. We just have to enact a different threshold."
Encourage better health behaviors
In the 20th century, we saw tremendous advances in health because of public health improvements, such as safe drinking water, nutritious food, vaccinations and the development of antibiotics for infectious diseases. I think we'll have the greatest advances in health in the 21st century if we can improve the health behavior of our citizens, by which I mean encourage people to exercise regularly, have annual checkups, get their children vaccinated and reduce tobacco use. Today we see epidemics of measles cropping up around the country because parents have false information linking autism to vaccines. Citizens need to be better informed about how exercise prevents or controls diabetes, obesity, high blood pressure and other health problems."
Reward primary care
I would have a much more primary-centered — as opposed to specialist care-centered — system. And I would reward doctors who do primary care and who demonstrate that they are doing well in maintaining patients' health, rather than doctors who do last-resort issues at the late stages of chronic disease. Right now in the U.S., it's the opposite. We reward doctors who use the most high-tech elements rather than the most basic. So when a person has a heart attack, for example, they say: "Lucky you got to the hospital, we got you right on time. We have a cardiologist and an interventional radiologist to put a stent in you." The patient says: "They saved my life." This costs $120,000. But this patient may have a primary care doctor who, with the right incentive, could have prevented that heart attack. We are lagging behind other countries in Europe and Canada in many of these parameters. We are behind, despite that we spend double what they spend."
Look to Silicon Valley
What I think is most vital is continuing to support and promote the U.S. as a cauldron of innovation. We need to look to places like Silicon Valley and try to imitate what they've done for information technology that has allowed us to clearly outpace the world. We need to continue to draw in extremely talented people from all over the world who want to work here, so that our talent pool can be the world, and not just the U.S. If we are going to drastically lower the cost and the morbidity of surgical procedures and improve outcomes — which I think we can do in my lifetime — that's going to take innovation. I want to create a new field of intestinal surgery working inside the intestine that is centered on this concept. Instead of cutting out pieces of intestine for Crohn's disease, we're going to be able to put in a bioabsorbable stent that has medicinal therapies. That's only going to come about if a whole group of like-minded people, including surgeons, pharmacologists, imaging specialists and bioengineers, work together. The key is having interested parties and people to champion new ideas."
Implement a team approach to care
What we really need is more integration and team care, particularly for serious and chronic diseases. We have a health care system that is focused on episodic care, rather than how to deal with chronic care. As the baby boomers are aging, that's going to be a huge problem. Two years ago I was diagnosed with AML [acute myeloid leukemia], so now I've been a doctor and a patient. I'm really happy I'm still here, but now I have all kinds of issues I have to deal with — chemo brain, neuropathy, immunosuppression — and the cancer doctors are really not as interested in the collateral damage as the fact that they cured me. As a doctor, I was as guilty as anyone of ignoring the collateral damage until I had cancer and realized how much it impacts your life. Patients need more insight into how they can maximize the quality of their lives. At Dr. Susan Love Research Foundation, we have been asking women with breast cancer to tell us about their collateral damage from treatment and have been overwhelmed by the response. An integrated, multidisciplinary team approach to the whole person before, during and after receiving treatment — including surgeons, oncologists, radiation therapists, psychologists, physical therapists, pain specialists and those with expertise in palliative care — would facilitate the delivery of care to the whole patient and not just the disease."
We talk about patient-centered care, but we really have doctor-centered care. What I want are tools that patients can use to empower themselves. Right now I'm the doctor. I have all the knowledge. I'm in control. I want to flip that dynamic. In the same way I am required by law to ask about allergies and medications, and talk about a past medical history, I want doctors to take the time to sit down, slow down and ask a patient: What's a good day for them? What's important for them? What are their values? What are their religious beliefs, their ritual beliefs? I want to know what their hopes and fears are for medical care, and where they want to spend the end of their life. I want to be required to have to ask that of all patients, at least to give them the opportunity. And sure, there may be some patients who are not ready to have that conversation, but I want them to know that I am open to having that conversation. It's the ultimate wellness pitch, I tell people: We are all going to die someday, and part of living well means addressing this life's final chapter. That's not about end of life. It's about a good life, for as long as you can, as best as you can."
Create a unified system of care
My grand vision would be to have a system where all levels of care are linked. Transitions within health care are very problematic. That's where mistakes happen and errors creep in, because things aren't transmitted accurately. It's the most vulnerable point — especially for older people. So if someone were moving from an outpatient setting to the emergency room or from the hospital to assisted living, there would be a seamless ability to do that across financial boundaries. If we had one system where all those costs and expenses were seen as part of the whole, and any part of the system that saved money would save money for everybody, that would remove those barriers. Then complement that with a shared electronic record, so that when we have to move patients from one place to another, their information follows them seamlessly. The people admitting that patient back to the nursing home or back to the doctor have the information right there that says: This is what we know, and this is what needs to be done."
Put health data to work
The real change that needs to happen is one that puts patients in control of their data. Hospitals are monetizing your data all the time. Hospitals hold data and allow people to look or copy, but it is not always easy to bring together all the information. You should have control over your data and have the ability to share it securely with anyone you want. This will shift the balance of power toward the patient, allowing people to do comparative shopping for their health care, and reducing costs, because today it’s easier to repeat tests than get the data from another doctor or hospital. Sometimes bad things happen because critical information isn’t available; sometimes it’s because people are getting care at different places and the information never comes together in one place. There are personal health records out there, but they require the patient to do a lot of work. We need to get to a system where patients have access to their own data that they can use seamlessly. Ideally, it would be like your bank account. You can easily access all of your financial information online. Why not your health records?
Since World War II, the U.S. has been the leader in health care innovation. That has not happened by accident. The U.S. has provided an environment that was able to attract the best and brightest young minds to medicine by providing financial and cultural support to innovate and invest in basic and clinical research. This investment in U.S. medicine has been able to profoundly improve treatment outcomes. If you are a bright young medical student, resident or fellow who wants to learn the newest surgical techniques, test a brain scanner that distinguishes cancer from a harmless mass without surgery, or develop a new drug to treat blinding macular degneration, you have done this in the U.S., but this does not guarantee that it will be true in the future. Forces are at work today to create a future health care system that will foster standardized treatment protocols to reduce cost and improve outcomes for the most common diseases. While this is important, an equal focus must be maintained on the recruitment of the best and brightest young minds to be the next generation of physicians, surgeons and medical scientists who will bring their vision of the future to medicine. We need to support the innovators, both financially and by giving them the opportunity to be inquisitive and fearless in their efforts to change established treatment protocols for the better, back individualized care plans where appropriate and see the benefits of innovations translate into healthier patients who will enjoy a better quality of life.