The Separate Orbits of Medicare and Moore's Law

Every other sector of our day-to-day lives--financial, telecommunication, retail, travel, and entertainment--have been irrevocably changed. But to date essentially none of these technological triumphs have been leveraged to reduce the cost of health care, no less to achieve better outcomes for patients.
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Today is the 50th anniversary of the Medicare Bill--which transformed health care in the United States by providing insurance for people age 65 and older, irrespective of income or pre-existing medical conditions. Just a few months ago the 50th (gold) anniversary of Moore's Law was celebrated, which predicted the remarkable trajectory of the computer industry and led to the innovation hub in Silicon Valley. Yet even though these two major forces have grown up together, they barely if ever talk to one another. That's terribly unfortunate and unwise. But it's not too late.

Medicare will spend more than $600 billion this year and that number is rising quickly as the 75 million baby boomers reach the age of coverage. Many have projected that Medicare is ultimately headed towards insolvency, unable to meet it obligations, unless something is done. That something could be convergence with Moore's Law. Its cost curve over the past 5 decades is diametrically opposite to that of Medicare's.

The law that predicted a doubling of transistors that can be squeezed on a chip every 18 months is what numerically accounts for why we have over 2 billion transistors in our current smartphones. The explosive growth of computing power at exponentially lowered costs had also led to a digital infrastructure that now includes pervasive connectivity, mobile broadband, cloud and supercomputing. As a result, every other sector of our day-to-day lives--financial, telecommunication, retail, travel, and entertainment--have been irrevocably changed. But to date essentially none of these technological triumphs have been leveraged to reduce the cost of health care, no less to achieve better outcomes for patients.

The top 3 items for Medicare expenditures are hospitals, doctors, and medications.
American hospitals today carry a 25% risk of harm at an average charge of over $4,300 a night. But we have the technology to remotely and continuously monitor all of the vital signs of patients in the comfort, safety and low cost of their own bedroom. It's not just about replacing hospital rooms; there are paths to preventing their need in the first place. For example, wearable sensor chips in smart watches, necklaces, and Band-Aids have the potential to track and prevent congestive heart failure episodes, the leading cause of hospital admission and readmission.

As part of the Affordable Care Act, the government has already doled out over $30 billion to promote the use of electronic health records--which are uniformly disliked by physicians and patients. A major reason for their unpopularity is the diminished face-to-face contact and communication at the time of an office visit. But we live in a time when natural language processing could record and transcribe the entire visit. With edits of the notes by both the patient and doctor, along with machine learning, there could be avoidance of constant clicking at a keyboard and complete preservation of eye contact.

That's just one tech step towards liberation. Through the use of smartphones and computer algorithms, individuals can now get an immediate and inexpensive diagnosis of their own electrocardiogram for heart rhythm, scan of skin lesions and rashes, determine whether they have sleep apnea, and examine their children's eardrum for possible ear infection. Through mobile devices, telemedicine consults have been shown to lower costs compared with office or emergency room visits. Physical therapy could largely be replaced by virtual therapy. With the average individual covered by Medicare having more than 5 chronic diseases, it may even be prudent someday to provide smartphones, medical apps and data plans to certain individuals so they can more efficiently manage their conditions and avoid winding up in hospitals or emergency rooms.

The chips can do far more than sensor work. With a single drop of blood, tiny microfluidic chips can perform hundreds of routine lab tests at a fraction of costs of conventional central lab assays. We have handheld ultrasound devices that are the same size of a smartphone and should be considered as the modern stethoscope. If they were used during routine physicals, a large portion of the over 120 million ultrasound scans per year could be avoided. A negligible fee could replace the Medicare reimbursement of over $400 per scan.

Let's touch on medications, which exemplify the problem of imprecise medicine. Of the leading prescription medications by gross sales or reimbursement by Medicare, 80% of patients are unresponsive. Why waste Medicare dollars on a drug a patient can't respond to? We could determine many of these beforehand by using or developing simple and inexpensive genomic tests to know whether a medicine will match up to an individual--not just if the patient will respond but also to avoid a major side effect. It's a tragedy that our 4th leading cause of death is due to adverse medication events.

Ironically, Medicare has been appropriated $10 billion by Congress for its Innovation Center to "overall the nation's health system." But virtually none of these funds have been used for any of the digital medicine opportunities outlined here. Part of the justification could be that many technologies have not been fully validated or are not yet approved by the Food and Drug Administration, but Medicare certainly has the resources and impetus to catalyze the process.

An even bigger challenge is to deal with the incumbents: the hospitals, the payers, and doctors who are financially dependent upon Medicare, and who are most likely to oppose any changes that threaten reimbursement. Moreover, strong governmental lobbying by medical professional organizations and the pharmaceutical industry heighten the resistance. As Joseph Schumpeter wrote, "It's not the owner of a stage coach who build railways." We need pressure from outside the medical community to actualize these remarkable opportunities.

At these gold anniversaries, we can certainly look towards silicon and graphene to brighten the future of healthcare. It's high time to bring Moore's Law to medicine.

Eric J. Topol
Author, The Patient Will See You Now (Basic Books, 2015)
Professor of Genomics, The Scripps Research Institute
La Jolla, California

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