# Presentation: 213578

## Prospective Health Care: 2003

- Ralph Snyderman, MD
- Chancellor for Health Affairs
- CEO/President of Duke University Health System
- Steps to a Healthier US: Putting Prevention First
- April 16, 2003

## c. 3,500 BCE

- 1628

- 1480

- 1800

- 1885

- 1895

- c. 500 BCE

- 1906

## The Practice of Medicine:  1900s

- Anecdotal
- Unscientific
- Unregulated

## Introducing Science:  1910

- SCIENCE

- MEDICINE

## Genomics and Health

- Therapeutic proteins
- Therapeutic targets
- Pharmacogenetics
- Gene therapy
- SUSCEPTIBILITY PROFILES

## Risk Profile Analysis

- Alzheimer’s
- Bipolar disorder
- Breast cancer
- Colon cancer
- Coronary artery disease
- Diabetes

- Epilepsy
- Hypertension
- Ovarian cancer
- Parkinson’s
- Prostate cancer
- Schizophrenia

## Genomic Medicine:  Newborn John/Jane Doe

- Genetic analysis disclosures:
-   Alzheimer’s disease (1X probability)
-   Breast cancer (50X probability)
-   Colon cancer (0.5X probability)
-   Coronary artery disease (40X probability)
-   Insulin-dependent mellitus (30X probability)
-   Prostate cancer (60X probability)

## DETECTION
Family history
Lipids
Stress test
Ultrasound
Imaging
Angiography

- DETECTION
- Family history
- Lipids
- Stress test
- Ultrasound
- Imaging
- Angiography

- PREVENTION
- Diet
- Exercise
- Aspirin
- Statins
- Beta blockers
- ACE inhibitors

- Risk Assessment for Heart Disease

## Proactive
Predict it; Prevent it; Fix it
Health care planning
Interactive
Integrated system for delivery

- Predict it; Prevent it; Fix it
- Health care planning
- Interactive
- Integrated system for delivery

- Practice of Medicine:  Future

## What’s Wrong With Health Care?

- How it is delivered!

- How it is paid for!

## Reactive
Find it; Fix it
Sporadic intervention
Physician-directed
Fractionated delivery system
Expensive

- Find it; Fix it
- Sporadic intervention
- Physician-directed
- Fractionated delivery system
- Expensive

- Practice of Medicine:  Today

## Health Care Choices

- Emergency
- Room

## Current Medical Evaluation:Medical Record

- Current Medical Evaluation:Medical Record

- Chief complaint
- History of illness
- Past medical history
- Family history
- Social History

- Physical exam
- Diagnostic tests
- Differential diagnosis
- Plan

**Notes:**
Sporadic treatment

## Health profile
Current health status
Health risk analysis
Genetic
Environmental
Lifestyle 
1 YEAR HEALTH PLAN
5 YEAR HEALTH PLAN

- Health profile
- Current health status
- Health risk analysis
- Genetic
- Environmental
- Lifestyle
- 1 YEAR HEALTH PLAN
- 5 YEAR HEALTH PLAN

- Future Medical Evaluation: Health Plan

## Risk assessment
Early detection
Means for prevention; early intervention

- Risk assessment
- Early detection
- Means for prevention; early intervention

- Requirements for Prospective Care

- Individual health plan
- Effective delivery systems
- Effective reimbursement

## 125 million Americans have 1 or more chronic conditions (e.g. congestive heart failure, diabetes)
Chronic diseases account for 75% of all health care expenditures
Current costs for chronic diseases is approaching $1 trillion
These expenditures are not delivering what is possible

- Chronic diseases account for 75% of all health care expenditures
- Current costs for chronic diseases is approaching $1 trillion
- These expenditures are not delivering what is possible

- Chronic Disease

**Notes:**
Chronic diseases account for 75% of all health care expenditures  (CMS, Jan. 2002)

## Disease Progression

- Symptoms

- Years

- Cost

## Slide 18

## Elements for Prospective Health

- Risk assessment tools
- Prospective medical record
- Practice standards
- Practice teams (structure of delivery)
- Education/motivation systems
- Information systems
- Quality assurance
- Analysis-outcomes-ongoing improvement
- Insurance
- Reimbursement

## Prospective Care Works

- Asthma
- Cardiovascular disease
- Cancer
- Diabetes

## What is Needed for Prospective Care?

- Collaboration between academic medicine and others
- Adapt medical education
- Research on prospective care
- Develop pilot projects
- Develop reimbursement mechanisms
- Implement working models

##     Prospective

- Risk assessment

- Preventative strategies

- Information technologies

- Developing health care models

- Diagnostic & therapeutic tools

- Rising costs

- Dissatisfaction of patients

- Inefficiency of current systems

- Dissatisfaction of providers

-     Prospective
- Health
- Care