What's Happening to Medicine: Autopsy Report (3)

2024 Author: Seth Attwood | [email protected]. Last modified: 2023-12-16 15:55

In a series of posts, I try to summarize what has been happening in medicine over the past few decades, and make assumptions about where it will develop next.

The third part of the "autopsy report" will focus on the following question:

What are the real prospects for the "most promising" directions in "medicine of the 21st century"?

It is impossible to predict the development of medicine both from the position of a simple user and from the position of a simple doctor. To see cause-and-effect relationships, you need to know from the inside the "kitchen" of medical ideology - where they come from and how new directions and approaches are being introduced. It is required to imagine how they relate to the needs and unsolved problems of medicine (and to know these problems), how to assess the prospects of a particular method (i.e., to know the principles of evidence). Much can be understood from the history of medicine and the relationship between "mainstream" and "unofficial" methods. It so happened that education and work experience allow me to navigate quite well in all of the above issues.

You can read about the author in the first note.

I am building my story from the answers to a number of key questions:

1. What are the needs and unresolved problems of medicine?

2. What are the advances in medicine over the past 50-100 years?

3. What are the real prospects for the "most promising" directions in "medicine of the 21st century"?

4. What are the obstacles to the development of medicine?

5. Where to develop medicine in the 21st century, taking into account the social, economic, scientific and technological context?

I try to adapt the text to the "skilled user" level - i.e. a person with common sense, but not burdened with many stereotypes of professionals.

I will make a reservation right away that there will be many controversial judgments and departures from the medical mainstream.

So, let's talk about the "most promising" areas of "medicine of the future."

Obviously, the term “promising” in this context means “capable of solving problems” - the unresolved problems of the main players in healthcare. Let's remind that consumers - patients and society as a whole - have three main problems: 1) it is expensive; 2) ineffective (does not solve the problem); 3) unsafe.

Representatives of different groups of “players” in the field of healthcare express their views on the future, but most often they are 1) experts representing the state or other “payers”; and 2) experts representing the business community (companies developing new drugs, instrumental diagnostics and treatment tools, new technologies).

Usually no one asks the opinions of patients, but it is in vain: consumers have their own opinion, and it manifests itself through the preference for those means and methods that sometimes puzzle the representatives of official medicine. It is good that these actual preferences of a large proportion of patients are reflected in the strategic documents of the World Health Organization (in English, in Russian). According to this document, 100 million people in Europe resort to alternative methods of treatment. Many more people are using alternative methods in other regions of the world. This does not mean that alternative medicine is definitely better: it is, at the very least, more affordable and safer.

In our discussion of "medicine of the future", let's start with an enthusiastic journalistic review of "The 7 Major Medicine Trends in the 21st Century." Judging by the sentiment, the author is not familiar with the gloomy analytics on efficiency, cost and safety cited in the first part of our notes. Nevertheless, the author insists on a personalized approach to each patient and the use of huge amounts of "objective data". The following 7 "main trends" have been proposed, each of which we will comment on:

And here's a prediction from the Institute for Global Futures on medical trends in the 21st century:

1. Most hospitals, clinics, trauma centers, doctors and patients will be linked into a single network that provides access to critical health information.

2. Information about the health of consumers, available through the many channels of this network, will become the most demanded in the whole world.

3. Medicine will face the ethical and social dilemma of patient disclosure.

4. Healthcare professionals, accessible through remote communications systems, will provide services to millions of people - those who previously did not have access to these services.

5. Medical robots will provide patients with medical care and help doctors around the world, saving money and spreading skills.

6. Thanks to advanced nano-biological and genetic technologies, many diseases will be defeated, they will accelerate recovery and prolong life.

7. Bioengineered food can help maintain health and prolong life.

8. A new generation of smart drugs, implants and medical devices will support our health and improve our physical and intellectual abilities.

9. Medicine education will take place mainly in the virtual reality simulation mode.

10. Digital personal medicine techniques will be widely used, which will track, diagnose, train and treat regardless of the location of the person and the time of day.

Predictions 1-4 are based on advances in information technology and are therefore quite realistic. But points 5-8 and 10 rely on the development of existing or the emergence of new medical technologies for influencing the physical body of a person. As has been said more than once, a person is not limited to a physical body, and health - to normal physiological indicators. So these predictions are nothing more than illusions, they do not rely on an understanding of existing technologies and do not take into account trends in medicine over the past 50 years. A.9, teaching medicine: this part of the prognosis is not directly related to solving pressing health problems, but one thing is certain: it is impossible to become a doctor without interacting with real patients.

After enthusiastic journalistic opus and futuristic illusions, let us return to the dark prose of life described in the A report from the Economist Intelligence Unit "The future of healthcare in Europe". Recall that this document indicates as the main problems: 1) the inconsistency of the health care system with modern realities (it does not cope with the treatment of a wave of chronic diseases); 2) the high cost of technological progress; 3) patients (and doctors as well) are accustomed not to prevent disease, but to look for “a quick fix” - a quick temporary solution.

The future of healthcare is shaped by seven separate but interrelated trends:

- Inevitable further increase in health care costs

As you can see, among the trends in comparison with the previous table, there is only an increase in the role of prevention. Nothing has been said about specific new medical technologies - most likely because none of them has yet met the expectations assigned to it.

Experts are considering five scenarios for the development of healthcare until 2030, depending on technological advances and the direction of systemic reforms. The authors acknowledge that the current debate is complicated by the fact that each of the players (such as insurance companies, doctors, government bureaucracy) pulls the blanket over themselves with little concern for the interests of patients.

These five scenarios are:

Since we are talking about the United States, the situation in this country deserves special consideration. The United States leads in terms of healthcare spending (17.2% of GDP), while objective indicators reflecting the effectiveness of healthcare (life expectancy, the number of chronic diseases, etc.) are far from the best in the world. So, in terms of life expectancy, the United States is in 50th place out of 221 countries of the world and in 27th place among 34 industrially developed countries. Of 17 high-income countries, the United States has one of the highest proportions of people with obesity, heart and lung disease, the number of people with disabilities, injuries, homicides and road traffic accidents, and a high infant mortality rate. Often, Americans bitterly compare their healthcare system with the Cuban one: having very close statistical indicators on health, Cuba achieves them at incomparably (20 times) more modest costs: $ 414 per year (Cuba) versus $ 8508 (USA).

Among the reasons for the high costs of medicine in the United States, analysts point out the following: 1) inflated prices for medicines and doctors' services; 2) low efficiency in the use of equipment and institutions; 3) high administrative expenses for insurance (6 times higher than in other economically developed countries); 4) frequent replacement of available technologies with more expensive ones with minimal gain in benefits; 5) a large number of obese people; 6) low labor productivity due to the fact that incomes are not tied to results (benefits from medical care), but to the volume of care provided.

What conclusions can be drawn from the analysis of the situation in the United States?

1) financial costs are not decisive for overcoming health problems; the correct organization of the system is much more important;

2) health problems are not solved by the introduction of high technologies; on the contrary, there may be a washout of simpler, less expensive and more cost effective technologies;

3) the US health care model has low economic efficiency (in the sense of improving people's health per unit of financial investment); the most likely reason is the maximum conflict between the interests of the players and the goals of medicine.

How do analysts envision the main trends in US health care? An interesting nuance: we are not even talking about health care, but about BUSINESS for health (health industry). Overall, the industry is projected to become more and more consumer-oriented.

Here are the main trends:

1) Technical solutions in the field of health on the principle of "do it yourself" (distribution of devices and programs for independent and remote diagnosis and monitoring of physiological parameters)

2) Increase in the number of portable medical devices

3) Finding solutions to the health information disclosure problem

4) Innovation in high-cost care to reduce costs

5) Increasing requirements for the proven effectiveness of new products (drugs and devices)

6) Facilitating access to the results of clinical trials, exchange of experience between doctors and patients, disclosure of information about the relationship between doctors and pharmaceutical companies

7) Studying the behavior of people who previously did not use health insurance (the consequences of health care reforms launched by Obama)

8) Enhancing the role of nurses and pharmacists in providing care

9) Taking into account the priorities and ideas of the new generation in the field of health

10) Search by businesses for new strategies of competition, partnerships between representatives of different niches.

So, the forecast for health care in the US is very different from analytics for the EU: it is more like optimizing business processes than analyzing problems and ways to solve them. In addition, the forecast for the United States does not take into account the socio-economic context: the debt crisis, the global crisis of confidence in the dollar as a reserve currency. But the dollar is the main export of the United States, and the very well-being of the inhabitants of this country is based on the ability to exchange goods and services for dollars created out of thin air.

Now let's look at how another key player - the business itself - sees its development trends: this is the subject of an overview of the new business model for innovative companies “Owning the disease: A new transformational business model for healthcare”. health care ).

The essence of the model is as follows: to integrate, within a single commercial proposal, the solution of all problems related to the diagnosis and treatment of a specific disease. In this case, the patient receives a full range of services to solve a health problem from one provider. Medical technology companies plan to borrow this business model from the IT business, companies such as Apple and IBM, which have evolved from OEMs to integrated solution providers.

This model takes into account to a much greater extent the threats of an economic crisis, a decrease in effective demand and a reduction in funding. Today, according to payers in the healthcare market, innovation should lead to lower costs and better results. Also, payers demand to implement a personalized approach and link payment to the result, and not to the number of procedures performed. All this is possible only through the integration of various elements of diagnosis, treatment and rehabilitation into a single process, through a systematic approach. Only with a systematic approach can one simultaneously increase efficiency and reduce costs, and act in conditions of a shortage of resources.

The transition to a new model provides for a change in priorities: 1) instead of selling specific characteristics - to offer a solution; 2) instead of a limited vision of details - a broad systematic approach; 3) instead of increasing profits due to a large volume - to increase the value of your offer. "Possession of the disease" involves the creation of tools to understand, track and influence the behavior of patients, to coordinate the actions of all participants in the process, including medical personnel and payers. In this model, the company should focus not on the episode of providing care, but on the entire complex of interaction with the patient: prevention, preservation of health and well-being; diagnostics; devices and devices; remedies for treatment; rehabilitation processes; accompaniment of a chronic disease; structures for patient interaction and even education.

To achieve possession of the disease, companies must build a model that can provide a comprehensive solution to the problem - similar to the iPhone (a combination of hardware, operating system, and commercial platform). Currently, no company has the full spectrum of solutions for any chronic disease. Moreover, more than 80% of health care costs (in the United States) are accounted for by chronic diseases that require lifelong support. Therefore, a company that can create a platform for “owning the disease” will have a strategic advantage over its competitors.

The described business model certainly has good prospects - primarily due to the use of the SYSTEM APPROACH, i.e. a holistic perception of a chronic illness as a physical, psychological and social phenomenon. However, specific examples of how this model is used by pharmaceutical companies are not enthusiastic. Thus, the Sanofi company decided to "privatize" diabetes mellitus, remaining within the framework of the old ideas about the mechanisms of development of this disease - and, accordingly, using unsuitable (in terms of the combination of effectiveness-safety-price) means of treatment.

The most suitable for the use of the model of "possession" are the following chronic diseases: metabolic disorders (obesity, diabetes), cardiovascular diseases (hypertension, coronary heart disease), neurological diseases (Alzheimer's disease, epilepsy), diseases of the respiratory system (asthma, chronic obstructive pulmonary disease). Interestingly, these diseases often develop jointly, complicate each other, and cause other complications: for example, obesity is often accompanied by chronic joint damage (arthrosis), most of these diseases are accompanied by depression, etc.

Within the framework of this model, the possession of information technologies becomes a very important asset: this factor determines the ability to create an information environment for patients and doctors, accumulate and effectively use experience, through training to influence the way of life - i.e. generally improve quality while reducing costs.

Thus, with the introduction of this model in countries with liberal economies, the healthcare business has good prospects to survive even during the economic crisis. However, will the implementation of the new business model benefit the end consumers - patients? This seems unlikely given the main PURPOSE of the business: making a profit. As the experience of recent decades has shown, the maximum profit can be obtained when there are a large number of people with chronic diseases. The very principle of organizing today's health care contains a conflict of interest between the goals of health care and the goals of its most important players.

Conclusion and conclusions:

1. Analysis of promising directions in medicine should take into account the existing urgent problems, the available tools for their solution, as well as the experience of the development of medicine in recent decades.

2. Representatives of the state and the business community argue about the prospects based on their interests. The opinion of consumers reflects their unsolved problems (ineffective-unsafe-expensive) and is ultimately expressed through the preference for certain available (including alternative) methods.

3. The forecasts related to the use of information technologies in medicine are quite realistic. However, these technologies are not able to provide a qualitative leap in solving the main problems of medicine, since the content of the information used is determined by inadequate ideas about health as normal physiological parameters of the body.

4. Most of the optimistic forecasts associated with the use of existing and the emergence of new revolutionary medical technologies (gene therapy, individualized and "smart" drugs, etc.) are wishful thinking and do not take into account the systemic nature of both human diseases and the problems of modern medicine. Given the context (economic crisis), the active development and widespread diffusion of expensive technologies seems unlikely.

5. Serious systemic forecasts for the EU are mostly pessimistic about new medical technologies and rely on the optimization of the health care system. A common theme is to empower prevention and self-management technologies.

6. The example of the USA is very indicative: the liberal model of healthcare has low economic efficiency and even dubious benefits for the consumer (remember the iatrogenic causes of death in the USA). Financial costs (without which technological progress is impossible) are not decisive for overcoming health problems; the correct organization of the system is much more important.

7. In a liberal healthcare system (when healthcare = health industry, business for health), business sees a promising model of “owning the disease”, which ensures the achievement of business goals - getting maximum profit. However, this business model does not eliminate conflicts of interest in healthcare and therefore is unlikely to be beneficial to end users.

Well, a review of promising directions in medicine in the 21st century revealed an extremely contradictory picture: for the main problems of consumers and the state (ineffective, unsafe, expensive), the future of medicine is not in the development of new medical technologies, but in increasing the role of prevention and in optimizing the health care system itself. The development of technologies within the framework of the modern biomedical paradigm (human = physical body, health = normal physiological parameters of the body) is promising and beneficial only for the developers of these technologies. The situation is aggravated by the economic crisis, in which the price factor takes the first place, which means that expensive new technologies, the benefits of which have not yet been proven, should fall under the cuts.

The reader, most likely, already begs a reasonable question: WHAT TO DO?

I propose to postpone the answer to it until the last note of the cycle, because we have not dealt with another key question: HOW WAS THE CURRENT SITUATION and what supports it? In the Russian fairytale tradition: where is the needle at the end of which is Kashchey's death?

I would venture to suggest that I managed to find this needle, and the following note will be devoted to its description: What are the obstacles to the development of medicine?

Ending here: