What if we paid doctors to keep people healthy? | Matthias Müllenbeck

68,629 views ・ 2018-04-18

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00:12
It's 4am in the morning.
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I'm waking up in a Boston hotel room
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and can only think of one thing:
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tooth pain.
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One of my ceramic inlays fell off the evening before.
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Five hours later, I'm sitting in a dentist's chair.
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But instead of having a repair of my inlay so that I can get rid of my pain,
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the dentist pitches me on the advantages of a titanium implant surgery.
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Ever heard of that?
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(Laughter)
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It essentially means to replace a damaged tooth
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by an artificial one,
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that is screwed into your jaw.
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Estimated costs for the implant surgery may add up to 10,000 US dollars.
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Replacing the ceramic inlay I had before
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would come in at 100 US dollars.
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Was it my health or the money that could be earned with me
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that was the biggest concern for my dentist?
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As it turned out, my experience wasn't an isolated case.
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A study by a US national newspaper estimated that in the United States,
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up to 30 percent of all surgical procedures --
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including stent and pacemaker implantations,
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hip replacements and uterus removals --
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were conducted
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although other nonsurgical treatment options had not been fully exploited
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by the physician in charge.
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Isn't that figure shocking?
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Numbers may be slightly different in other countries,
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but what it means is that if you go to a doctor in the US,
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you have a not-insignificant chance to be subjected to a surgical intervention
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without there being an immediate need for it.
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Why is this?
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Why are some practitioners incentivized to run such unnecessary procedures?
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Well, perhaps it is because health care systems themselves
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incentivize in a nonideal way
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towards applying or not applying certain procedures or treatments.
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As most health care systems reimburse practitioners
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in a fee-for-service-based fashion
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on the number and kind of treatments performed,
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it may be this economic incentive that tempts some practitioners
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to rather perform high-profit surgical treatments
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instead of exploring other treatment options.
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Although certain countries started to implement
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performance-based reimbursement,
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anchored on a quality and efficacy matrix,
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overall, there's very little in today's health care systems' architecture
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to incentivize practitioners broadly
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to actively prevent the appearance of a disease in the first place
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and to limit the procedures applied to a patient
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to the most effective options.
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So how do we fix this?
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What it may take is a fundamental redesign
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of our health care system's architecture --
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a complete rethinking of the incentive structure.
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What we may need is a health care system
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that reimburses practitioners for keeping their customers healthy
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instead of almost only paying for services once people are already sick.
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What we may need is a transformation
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from today's system that largely cares for the sick,
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to a system that cares for the healthy.
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To change our current "sick care" approach
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into a true "health care" approach.
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It is a paradigm shift from treating people once they have become sick
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to preserving the health of the healthy before they get sick.
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This shift may move the focus of all those involved --
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from doctors, to hospitals, to pharmaceutical and medical companies --
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on the product that this industry ultimately sells:
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health.
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Imagine the following.
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What if we redesign our health care system
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into one that does not reimburse practitioners
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for the actual procedures performed on a patient
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but rather reimburses doctors, hospitals,
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pharmaceutical and medical companies
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for every day a single individual is kept healthy
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and doesn't develop a disease?
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In practical terms, we could, for example,
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use public money to pay a health fee to an insurance company
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for every day a single individual is kept healthy
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and doesn't develop a disease
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or doesn't require any other form of acute medical intervention.
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If the individual becomes sick,
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the insurance company will not receive any further monetary compensation
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for the medical interventions required to treat the disease of that individual,
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but they would be obliged to pay for every evidence-based treatment option
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to return the customer back to health.
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Once the customer's healthy again,
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the health fee for that individual will be paid again.
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In effect, all players in the system
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are now responsible for keeping their customers healthy,
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and they're incentivized to avoid any unnecessary medical interventions
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by simply reducing the number of people that eventually become sick.
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The more healthy people there are,
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the less the cost to treat the sick will be,
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and the higher the economic benefit for all parties being involved
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in keeping these individuals healthy is.
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This change of the incentive structure shifts, now,
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the attention of the complete health care system
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away from providing isolated and singular treatment options,
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towards a holistic view of what is useful
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for an individual to stay healthy and live long.
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Now, to effectively preserve health,
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people will need to be willing to share their health data
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on a constant basis,
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so that the health care system understands early enough
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if any assistance with regard to their health is needed.
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Physical examination,
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monitoring of lifetime health data
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as well as genetic sequencing, cardiometabolic profiling
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and imaging-based technologies
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will allow customers to make,
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together with health coaches and general practitioners,
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optimal and science-guided decisions --
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for their diet, their medication and their physical activity --
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to diminish their unique probability
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to fall sick of an identified, individual high-risk disease.
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Artificial intelligence-based data analysis
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and the miniaturization of sensor technologies
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are already starting to make monitoring of the individual health status possible.
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Measuring cardiometabolic parameters by devices like this
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or the detection of circulating tumor DNA in your bloodstream
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early on after cancer disease onset
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are only two examples for such monitoring technologies.
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Take cancer.
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One of the biggest problems in certain oncological diseases
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is that a large number of patients is diagnosed too late
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to allow them to be cured,
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although the drugs and treatments that could potentially have cured them
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are already existing today,
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if the disease had only been detected earlier.
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New technologies allow now, based on a few milliliters of blood,
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to detect the presence of circulating tumor DNA
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and thus, the presence of cancer,
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early on in a really convenient manner.
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The impact that this early-stage detection can have
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may be dramatic.
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The five-year survival rate for non-small cell lung cancer
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when diagnosed at stage one, which is early, is 49 percent.
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The same, when diagnosed at stage four, which is late,
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is below one percent.
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Being potentially able to prevent a large number of deaths
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by something as simple as a blood test for circulating tumor DNA
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could make certain cancer types a manageable disease,
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as disease onset can be detected earlier
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and positive treatment outcomes can likely be increased.
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In 2012,
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50 percent of all Americans had a single chronic disease,
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resulting in 86 percent of the $3 trillion US health care budget
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being spent for treating such chronic diseases.
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Eighty-six percent.
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If new technologies allow now to reduce this 86 percent,
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why have health care systems not reacted and changed already?
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Well, a redesign of what today is a sick care system
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into a true health care system that focuses on prevention
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and behavioral changes
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requires every actor in the system to change.
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It requires the political willingness to shift budgets and policies
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towards prevention and health education
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to design a new set of financial and non-financial incentives.
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It requires creating a regulatory framework
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for the gathering, using and sharing of personal health data
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that's at the same time stringent and sensible.
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It needs doctors, hospitals, insurers, pharmaceutical and medical companies
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to reframe their approach and, most important,
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it can't happen without the willingness and motivation
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of individuals to change their lifestyle in a sustained way,
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to prioritize staying healthy,
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in addition to opening up for sharing the health data on a constant basis.
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This change may not come overnight.
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But by refocusing the incentives within the health care industry today
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to actively keep people healthy,
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we may not only be able to prevent more diseases in the first place
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but we may also be able to detect the onset of certain preventable diseases
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earlier than we do today,
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which will lead to longer and healthier lives for more people.
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Most of the technologies that we need to initiate that change
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are already existing today.
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But this is not a technology question.
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It is primarily a question of vision
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and will.
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Thanks a lot.
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(Applause)
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