by Sherri Kirk
America is in desperate need of a new healthcare model. With trillions of dollars spent on treating manageable diseases and comparatively little on preventive measures, our current system is backward. Leaders at Ohio State and a few other progressive medical centers are advancing a new approach that makes health care more predictive, preventive, personalized and participatory.
The Centers for Medicare and Medicaid Services reports that the total cost of health care in the United States topped $2.5 trillion in 2009, more than 17 percent of the American economy. Kaiser Family Foundation officials state that, although we spend more than 75 cents of every healthcare dollar on largely preventable and highly manageable chronic illnesses like type 2 diabetes and heart disease, we spend less than 5 cents of each dollar on prevention.
"Healthcare spending is out of control," says Michael Christman, MD, president and chief executive officer of the Coriell Institute for Medical Research, an independent nonprofit research center dedicated to the study of the human genome. "The U.S. spends $300 billion a year on prescription drugs. Half of that money is wasted because half the time the drug does not work." The New England Journal of Medicine reports that there are two million adverse reactions to drugs every year.
Even though healthcare experts generally agree that expanding access to care is a good idea, increased access adds another wrinkle to an already complex problem. Ralph Snyderman, MD, chancellor emeritus and James B. Duke Professor of Medicine at Duke University, says the Affordable Care Act, which was designed to improve access to care, now introduces the problem of increasing access in the face of high costs. "Accountable care is forcing the alignment of health care to a model that delivers care over time, rather than at a specific point of care for a disease event, and I feel good about that. However, the political focus is all over the map, which is not very conducive to focusing on the real issue: How do we improve the nation's health in the most cost-effective way?"
Today's medicine is reactive, focused primarily on the treatment of disease and the management of symptoms. Experts agree that to realize sustainable, cost-effective, higher quality care that delivers better outcomes, we must shift health care to a proactive, individualized model. Several organizations across the country are attempting to do just that, including The Ohio State University Medical Center (OSUMC).
"This is a transformational period. It's time for a major breakthrough in the focus of health care, and that's where P4 Medicine comes in," says Alan Brass, retired CEO of ProMedica Health System and current Ohio State University trustee, of Ohio State's efforts to make health care more predictive, preventive, personalized and participatory – the four Ps of P4 Medicine.
This new approach to medicine must also deliver what economists call "value innovation," that is, less expensive and higher quality health care.
What's In a Name?
The term "P4 Medicine" was coined in 2003 by Leroy Hood, MD, PhD, co-founder and president of Seattle's Institute for Systems Biology (ISB). By applying advancements in genomics and molecular diagnostics, P4 Medicine uses predictive information to help prevent disease, rather than waiting to treat it. If disease is unavoidable, P4 Medicine uses the genetic information of each individual to personalize treatments. This model for care is also more participatory, requiring individuals to take a leading role in the management of their health.
"By making health care more predictive, preventive, personalized and participatory, we minimize the impact of disease, shift our care model to one that promotes and protects health and wellness, and place the patient at the very center of the care team," says Steven G. Gabbe, MD, senior vice president for Health Sciences at The Ohio State University and chief executive officer of Ohio State's Medical Center.
"P4 Medicine transitions care away from the current one-size-fits-all approach and enables highly personalized care," says Fred Lee, MD, P4 Medicine Institute fellow and director of Clinical and Translational Informatics at Oracle Health Sciences.
Strength in Numbers
Redirecting the course of something as massive in size and scope as the U.S. healthcare system requires deliberative planning, hard science and hard work. In many circumstances, it benefits like-minded organizations to form partnerships, making the most of finite resources and complementary areas of expertise. It also can give purely scientific organizations much-needed access to a clinical environment.
In May 2010, Ohio State's Medical Center and the Institute for Systems Biology formed the P4 Medicine Institute (P4MI), a partnership that combines ISB's systems biology research and Ohio State's clinical resources to advance health services that prevent disease and promote the maintenance of health and wellness.
"At ISB, our focus is on technology and methods, and basic research in systems biology. We don't have access to patients, but we recognize how interdisciplinary biology and medicine have become," says David Galas, PhD, senior vice president of Strategic Partnerships at ISB. Now, with Ohio State's involvement, Galas says, "We have put together collaborative groups, which are absolutely critical to the future of medicine."
In addition to its work on the development and delivery side of P4 Medicine – systems biology, informatics, clinical research, care delivery and provider engagement – the P4MI also advocates for basic, translational and clinical research; healthcare policies that promote lower costs, higher quality and increased access; and dialogue around the societal and legal implications of P4 Medicine.
Ohio State's Medical Center is a member of the Personalized Medicine Coalition (PMC), a Washington, D.C.-based independent, nonprofit organization created in 2004 that educates policymakers and the public on the elements of personalized medicine and promotes new ways of thinking about health care. The PMC also works to advance the adoption of personalized medicine concepts and practices that benefit the health of patients and the healthcare system. Clay Marsh, MD, vice dean for Research at The Ohio State University College of Medicine and executive director of Ohio State's Center for Personalized Health Care, is a member of the PMC board of directors.
Ohio State was one of the first American universities to join the PMC, which now counts among its members the Mayo Clinic, MIT, Stanford, the University of Rochester, the University of Utah, Vanderbilt and scores of other universities and academic medical centers, healthcare organizations, providers and payers, patient-advocacy groups, nonprofit and commercial research institutions, and information technology companies.
Edward Abrahams, PhD, president of the Personalized Medicine Coalition, says that all elements of P4 Medicine need to be integrated and are all of equal importance. "We want to keep people healthy, and if they get sick, have targeted treatments available," says Abrahams. "Once we have a better understanding of the molecular tools, we will have a better understanding of the patient's part of the equation."
Perception is Reality
It is universally accepted that the current model for healthcare delivery in the United States is not financially sustainable. P4 Medicine, which is consumer-centered, clashes with the current culture of physician-driven care, creating obstacles that must be overcome.
"Participatory medicine runs entirely against the principles of our current healthcare system," says Lee. "Flipping the switch of the passive patient is the hardest piece."
"Engaging health consumers in a way that supports prevention and wellness is critical," says Stacy Feld, director of Physic Ventures, a venture capital firm with investments in consumer health and environmental sustainability. "For consumers, it's not just medical information but overall lifestyle choices that make an enduring difference in improving health and preventing chronic disease." Feld adds that convergence of all stakeholders will be necessary to bring new technology that will empower consumers to take a participatory role in their care.
Lee believes we have already made significant gains in that respect, and we are beginning to see the physician-patient relationship transition from doctors' offices to people's homes. "Care is certainly moving closer to the patient. You have remote patient monitoring and patient-centered medical home models making care more convenient and closer to the patients themselves."
According to Hood, another obstacle in the path to P4 Medicine is the time patients have with their doctors. This relationship will be crucial to patient education and the transfer of greater responsibility to the patient. "Physicians have busy schedules, which makes it difficult to educate patients about the importance of their role," explains Hood.
Christman says that educating clinicians about personalized medicine also presents a challenge and that the process needs to begin in the medical school curriculum, particularly around the new types of care that will result from personalized genetic testing. He goes on to say that these educational opportunities are increasingly valuable to driving the shift to patient-centered care. Medical schools are a great place to start because medical students are a highly motivated group of individuals on the front lines of health care who have little invested in the old care models.
The success of P4 Medicine hinges on being able to detect a person's likelihood of developing disease early enough that preventive measures can be taken to improve quality of life and reduce costs. In situations where disease is unavoidable, P4 Medicine must provide tailored treatments that lead to successful outcomes.
According to Marsh, these goals will be realized through advancements in genomics, diagnostic imaging, bioinformatics and systems biology.
"We are getting closer to the point where we can define wellness at a deep molecular level. Next, we want to use each person's genetic, behavioral and environmental information to create tools that empower them to take an active role in their health care."
Marsh says science can take us only so far, however. "For these predictive and preventive approaches to take root, both the ecosystem and healthcare culture that focuses on sick care need to change. Culture change just may be the most important component of this process."
The Future of P4 Medicine
What will P4 Medicine look like 10 or 15 years from now?
"Primary care will be wildly different than it looks today," says Hood. "We are pioneering systems and technologies that will gather billions of data points for each patient, and care will become very linear and commoditized."
Christman says, "Physicians will look up your genetic profile and your electronic medical record to see if your genetics predict that a drug will work for you or not, which will drive down costs. The more futuristic possibility is that we'll be able to predict disease onset and head it off before the disease manifests."
Hood predicts that patients will have an electronic device for health care that will digitally connect them to much of their private information and offer instantaneous feedback when they do things to optimize health. "We will be in a wonderful position to have deciphered most of the major types of diseases and be able to deal with them promptly and effectively," he adds.
Marsh says that not only will consumers have convenient, electronic access to their medical records and genetic profiles, but social networking tools and even games will also be able to analyze their medical data to produce precise strategies that promote wellness and encourage people to take ownership of their health.
Gerry McDougall, global partner in charge of personalized medicine and life sciences at PricewaterhouseCoopers, defines the future of P4 Medicine in simpler terms. "It's simply the evolution of medicine – the understanding that we must continue to invest as a nation and as a global community in deepening our understanding of the biology of disease. I really do think the glass is half full."
- Americans spend more than 75 cents of every healthcare dollar on preventable and manageable diseases, and less than 5 cents on prevention. As our population ages, this gap is economically unsustainable.
- Leaders at Ohio State and other progressive medical centers are advancing a new approach to health care that is predictive, preventive, personalized and participatory. It is called P4 Medicine.
- P4 Medicine uses predictive information to help prevent disease. When disease is unavoidable, P4 Medicine uses genetic information to personalize treatments and teach people to participate more in managing their health.
From Left: Edward Abrahams, PhD; Michael Christman, MD; Steven Gabbe, MD; Leroy Hood, MD, PhD; Clay Marsh, MD; Johanna DeStefano, PhD