The Genomic Revolution

In this video which was part of TEDMED 2010 Gregory Lucier, Chief Executive Officer of Life Technologies anticipates the coming of the genomic revolution within the next two years and the possible constraint on its arrival.



He envisions a day coming soon when cancer patients will receive prescriptions for custom combination of drugs based on what physicians learn by use of the genomes of the patient and of the tumor. In his opinion, the technology will be "there" and the likely constraint on the arrival of the revolution will be FDA approval requirements which he says need to be modified.

I am thinking now of the prospect of applying comparative effectiveness research to the use of genomics in medicine. Assuming the "revolution" happens within two to five years, there will be huge implications for clinical pathways. I don't pretend to know how this will work out. Will genomics possibly drive population-based preventive care? Will there be cures for cancer? Will many kinds of cancer become manageable chronic conditions and no longer life-threatening? How might organizations that derive large revenues from traditional cancer treatments adopt to dramatic changes in the treatment of people with cancer? What are the implications of genomic medicine on the costs of care for individuals and for populations? We all wish for cures for cancer and other serious diseases and conditions. The powers that be will assess the potentials of genomics and will shape the revolution and its results from interests defined by existing paradigms.

Getting the right mix of patients

Paul Levy recently included his BBC video clip on his blog, "Not Running a Hospital."






In the United States, of course, it would be the hospital administrators who would be more concerned about an empty hospital rather than a government official. The challenge going forward in the U.S. is for each hospital to have the right mix of patients for whom revenue comes from services provided and patients for whom revenue is from capitation. The costly facilities will have to be there for those patients for whom the hospital is at financial risk (the capitation groups). But there must also be enough patients for whom the hospital has a financial incentive to actually use the costly facilities and equipment. In such a situation, some patients are more likely to be admitted to the hospital than others based upon whether they are insured through capitation or through a fee-for-service group contract. At first glance, it would seem that it is the patients in capitation plans that are at the risk of being shorted. But if the revenue needs of the hospital lead to unnecessary utilization of inpatient services for others, they may experience unnecessary medical risks.

It would be nice if there was an easy alignment of population-based care, patient-centered care, and the effective financial support of hospitals. But neither the market nor a centralized command system (as represented in the BBC video clip) will produce or sustain such an alignment. Whatever comparative effectiveness research indicates is the best clinical pathway for a particular patient, the decisions made about his or her course of treatment will be shaped in part by how providers are compensated for that patient's care.

Comparative Effectiveness Research

Having recently been accepted into the MPH Informatics program at Georgia Health Sciences University I visited the campus recently to speak with a program administrator and a faculty member. We tentatively decided that my capstone research would relate to comparative effectiveness research (CER) and possibly to the modeling and simulation of clinical pathways in the context of CER. So it is likely that my posts here will become the evidence of my learning about CER.

In the following video editorial George Lundbery, MD, Editor-at-Large of MedPage today, (http://www.medpagetoday.com/) suggests that physicians may resist change in how they treat patients with particular conditions for reason of multiple motivations including money, collegial medical relationships and an aversion to simple remedies.

For what it may be worth, my initial impression is that physicians and others are likely to see evidence-based clinical pathways as a threat to professional autonomy. In the presence of a prescribed clinical pathway physicians may have to justify deviations from the pathway, which can be time consuming and annoying, especially when the physician has sound reasons for not following the evidence-based pathway in the cases of particular patients. If there were a compete set of clinical pathways it would only be by way of "deviance" that continued learning could happen. We are not at risk that through universal compliance with evidence-based pathwyas we will lose the opportunity to learn through variety of physicians' decisions.

As I anticipate my capstone research I hope to discover ways to model and simulate the financial and other implications of alternative clinical pathways in some identified clinical domain. I anticipate finding that no single pathway is optimal in light of every relevant value. I think too often references to the combination of population-based health care and patient-centered medical care are glossed to make it appear that both can be optimized at the same time. I think Dr. Lundbery's editorial suggests that it not as simple as understanding such trade-offs. There is the burden of precedent and comfort with existing practices and cultures that benefit multiple stakeholders. I am not sure his word, "courage" is quite the right word in this context, but perhaps it is.