Bio+Tech was started as a monthly gathering to bring together the best and the brightest entrepreneurial minds in biomedicine and combine them with leaders in the SF tech start-up world.  The idea was that we have an amazing collection of biomedical entrepreneurial minds in SF and with the advent of bio-incubators and tech breakthroughs, the barriers to starting a bio start-up continue to drop.  There’s also a curiosity about biomedicine in the tech realm.  Who better to infuse biomedical and informatics start-ups with entrepreneurial energy and push biomedicine start-ups over the entrepreneurial hump than folks from this bastion of entrepreneurial energy? Plus, the biomedical start-up world doesn’t network nearly to the same degree as does the tech start-up world – that’s critical to the tech start-up world’s success in the SF Bay Area.  Thus Bio [plus] Tech – not just the same old biotech complete with high barriers, lack of networking and support.  Six months in to the Bio+Tech experiment I’d say that so far it’s been a success.

As a note: When I talk about biomedical entrepreneurship I mean that broadly – whether informatics, biotech, pharma, bio-energy, etc – it’s all welcomed and encouraged at Bio+Tech. And, I can’t emphasize enough that not only are we looking to bring together biomedical folks, we’re also looking to bring tech folks – developers, co-founders, start-up managers, etc – in to the mix.  You absolutely do not need a PhD in biophysics to join the group.  Just a healthy interest in bio or medicine – trust me, you’ll blend right in to the group!

Bio+Tech has grown from a group of 10 in January to an average of about 30 people at each monthly gathering.  To boot, that growth has been achieved solely through word of mouth.  I’ve been to a lot of meet-ups and gatherings where there’s lots of noise and very little signal – Bio+Tech has been purposefully kept small to keep the quality of the level of interaction high.  This set up was inspired, in part, by the SF meet-up Founder Dating, which requires an actual application and recommendations from other start-up folks.  Jess Alter and her crew do an amazing job!  Go check it out if you’re looking for a tech start-up or a techie person to help you build your start-up.  I also want to give a shout out to Vinnie Lauria and his Silicon Valley NewTech Meetup as the founding source of inspiration behind Bio+Tech.

Bio+Tech isn’t quite as complicated as Founder Dating and not as large as the SV NewTech Meetup, but to join the invite list you do need to demonstrate a basic interest in biomedical, tech or bio-energy entrepreneurship.  All too often a lot of biotech meet-ups are crowded with sales people and other vendors who are more interested in selling than sharing ideas, tips, contacts or starting businesses.  That’s not to say that we don’t accept sales people in to the group – you just need a genuine interest in creating a company or joining a start-up.

Michael Shuster speaks on the changing IP landscape and how that affects biomedical entrepreneurship.

Want to join us? Each month, the time and date of Bio+Tech will be posted on its webpage, with the location in SF to be announced. If you’re not already on the invite list, feel free to contact me at windmiller@gmail[dot]com and let me know why you’d like to attend.  Just a little paragraph with your interests and what type of company you’re looking to start or join, and a link to your LinkedIn profile – nothing too complicated.  In return, I promise to do my best to connect like-minded people at the meet-up.

We’ve had a couple bio start-ups find co-founders or developers – heck, there’s even been cross-pollination of neuroscience-principles back in to a tech start-up’s social media algorithms!  Yes, it’s a bit nerdy, but I can honestly say that out of the 6 gatherings so far, everyone who has attended has been someone I’ve really enjoyed talking with and sharing ideas.

Each Bio+Tech starts with a good bit of mixing and conversation.  It’s kept that way to maximize interaction and to warm things up.  We then get together to introduce each other to the group – with 30 people I’m always amazed at how efficiently we get through the group.  This is an opportunity to introduce yourself to the group and also spot others with like minded interests.  And, of course, we welcome solicitations for co-founders or technical help or any other start-up needs to the group.  This is a chance to network and find those you’d be interested in working with.

Starting in August we’re going to try to have monthly speakers as well.  It’s a highly informal 10-20 minute talk from people in the biomedical start-up or in the tech start-up world designed to bring ideas and prime the conversation.  We’ve had Michael Shuster, partner at Fenwick & West, speak on the changing landscape of Intellectual Property (IP) and how that’s affecting start-up strategy and execution.  A lot of biomedical start-ups are realizing that execution is just as important as securing IP to start-up success.  This isn’t news to tech start-ups, but this shift in perspective is somewhat groundbreaking in biomedicine start-ups.  We’ve got John Wilbanks, VP of science at Science Commons speaking at our August gathering on the open sourcing of biomedical data sets and tools and how that is altering and encouraging opportunities in the biomedical start-up scene.

And, Bio+Tech is purposefully kept free.  Whether you’re an undergrad or grad student, or on your 5^th start-up, everyone is welcome and encouraged to come.  I believe firmly that cost should not be a barrier to attendance.  And, please pass this along to people you think would be interested in Bio+Tech – that’s how we keep new, fresh ideas coming in to the group!

Looking forward to seeing you on August 18^th.

I haven’t posted on genomics in a while, so it’s about time. Two weekends ago I attended the Sage Bionetworks and Science Commons 1^st annual Sage Congress here in San Francisco. The main aim of the conference was to begin to gather science folks from across the country and begin thinking about making scientific research and data sets more open. While that may seem like an easy task in the era of open source, it’s tricky from many perspectives and the effort still has a lot of skeptics. But, more on that soon – personally, I think Science Commons and Sage Bionetworks are brilliant ideas.

At the conference Anne Wojcicki, co-founder and president of 23andme gave the keynote on the last day of the conference (video at right). To be fair, in the past I’ve been skeptical of 23andme – particularly from a clinical perspective. And, the MD side of me remains skeptical of genetic testing in general – at this point we know too little to apply genomic information to clinical care. There are a few exceptions, like breast cancer and a few other diagnostics, but otherwise in my humble medical opinion tests like 23andme should be used with a skeptical eye from a clinical and medical perspective. Again, there are a few case examples of where genetic testing has helped, but those remain too few and far between.

All that said, something about Anne’s keynote struck a chord with me – the amount of phenotypic data that the company is gathering in conjunction with their tests holds tremendous promise. Consumers purchase the test, and once their results are delivered, 23andme asks the consumer to participate in a series of surveys about their health and physical traits. To date, as was mentioned time and time again at the Sage Congress, research efforts to link patient, clinical and genomic data have proven to be arduous, time consuming and expensive. But, 23andme is capturing it right out of the box.

It’s hard to really convey how valuable this data truly is. A lot of the genomic data and research the scientific community has done to date has been on a couple cells in a petri dish or in mice, etc. Less has been done in humans, but that’s changing. With the collection of millions of genetic data points per consumer plus their trait/phenotypic data via 23andme, that will all begin to change much more rapidly. Being able to directly correlate genes to their traits will be a powerful tool for researchers to help push our genetic understanding and medical knowledge forward.

How we think about DNA and our genetic information as consumers is changing. Here, a DNA gel is aligned as art.

What makes 23andme special is that they’re utilizing social media and other consumer internet approaches to engage consumers and get them to provide their data essentially for free. While this might sound intuitive to most internet junkies, it hasn’t been for much of the scientific community. Indeed, from my perspective at the Sage Congress, 23andme’s approach seemed to me met with a bit of skepticism from the community – and this was an even more open and broad thinking group of people. But, it’s working. Consumers are readily contributing information, but it’s because of 23andme’s social media and internet approach. Not only will it change consumer genetics, but I bet that 23andme’s approach will alter how we collect research data, which will in turn, accelerate breakthroughs.

This shift in thinking will be critical as genetic research and genetic testing moves forward. Genes are far from being directly causal – i.e. very rarely does one gene lead to one distinct feature. And to uncover the patterns of the chaotic interaction of genes and their environment, gathering the type of rich data that 23andme does with their surveys will be absolutely critical as we move forward. Part of the next movement in genetic testing and genetic discovery will also require new tools to deal with massive data sets and help us find those needle-in-the-haystack discoveries that shed new light on human health and disease.

Again, more DNA as art - we're beginning to re-think our relationship to our genetic information.

And, to boot, one large win for society with companies like 23andme is that they are making consumers more and more comfortable with the concept of genomic testing. That in and of itself is a tremendous value to the market and for research. In the future I predict that we’ll look back on efforts like 23andme as landmark and critical to helping us reach the next plateau of genetic discovery and understanding. And, because of that and 23andme’s awareness of that fact, I think they’ll be successful in the long run.

I’ve got a job for you!  How does this sound – spend your college days studying away (sorry, only minimal time for parties) worrying about standardized tests, spend 7-8 years after college training for your job, go in the financial hole on average $160,000 and for the first 4 years of your career earn $45,000.  Sound good?  There’s more.

Spend the rest of your career jamming in as many clients as possible a day – maybe upwards of 20 or so – worry about malpractice insurance, be squeezed by Medicare. And, while earning a respectable salary, there’s really no hope of raises outside of adjustments for inflation.  In fact, there’s a high probability outsiders will likely attack your salary and maybe even reduce it.  Did I mention about mountains of paperwork and clients wanting your professional opinion for free?

Sounds a bit dramatic, but that’s the negative side – aka the con side –  that a person faces when deciding whether or not to be a General Practitioner.  I was sparked to write this post when a friend of mine – Ab Brody, PhD, NP – tweeted about a new Journal of the American Medical Association (JAMA) article laying out some of the challenges in recruiting MDs to General Practice.  The current healthcare reform debate has renewed the debate over the types of MDs we need to train.

Indeed, there are lots of benefits to being a GP – not the least of which is the satisfaction of getting to know families, helping people overcome day-to-day medical issues, etc.  It’s truly rewarding.  But compared to other professions and medical specialties I have no idea of why, from a financial perspective or even a career fulfillment perspective why anyone would choose General Practice.

Dermatologists – same professional satisfaction.  Sure, you have to look at the occasional butt pimple, but you can make a dramatic difference in someone’s life.  Career satisfaction?  Check!  Good hours? Check!  Oh, and on average they make $351,000 annually.  Or, 2.5 times what a GP makes.

I’ve done the math – a GP, making the average salary and with the average student loan debt load will never be able to purchase a house in San Francisco without significant additional income.  If that same physician buys a modest house in Atlanta, by the time they’re 65 they’ll have almost $500k in the bank.  However, that’s much less than what other careers bring in. It’s more than a lot of people, but given the struggles they went through to become physicians, it’s not all that much.

To be sure, I’m writing this post to be incendiary and provocative.  I truly believe that GPs will be the heart of healthcare reform here in this country and I hope we start treating them like so.  Why?  Because we need them – they coordinate care, they’re the first line and if trained the right way they can be beacons of savings – to the tune of several billions of dollars of savings each year.  But, we need to fix the factors that I spend time lampooning above.

How do we get more smart, young physicians to become GPs?

So how can we rectify this issue? I think that the first step is to come clean and admit that it’s, at least a little bit, about the money.  There’s absolutely nothing wrong with wanting to earn a great living.  If someone offered you a better lifestyle, more pay, better hours, wouldn’t you take it?  We need to change how we reward our GPs – base their income on outcomes.  Patient outcomes, that is.  Promote tort reform to help avoid frivolous law suits.  Provide scholarship opportunities to help them with the financial hole they face out of school.  And, to boot, pay them commensurate with other areas of medicine.  We’ll all benefit from that!

The demands we place on GPs are too great – the malpractice threats, the paperwork, diminishing incomes/reimbursements, etc.  It’s a tremendous burden even outside the financial disparities.  Add both of those to the pot and it’s a surprise anyone becomes a GP.

It’s also a reputation issue, too. Or at least that’s the way I’d argue it.  My medical school, for one, highly praised those who went to specialty residencies.  Let me be clear – I’m exceptionally proud of all my classmates and their choices.  However, the school did a super lousy job pointing students to general med.  I’d even say that it was actively passively dismissed though the school’s emphasis on specialties and choosing a competitive specialty as the highest success.  In fact, we really didn’t have a fantastic role model to emulate in the GP space – compared to access to the best heart surgeons, cancer docs, orthopods, etc in the world.  IMHO.  I’d say a lot of med schools actively dissuade the pursuit of becoming a GP through how the schools grade, praise specialties, elevate their leaders, etc.  Becoming a GP was passively aggressively looked down upon.

Lots has to happen between now and then – I’m really curious to hear your thoughts.  Should GPs be paid better salaries? What role should they play in our healthcare system?

Been busy working on some consulting engagements recently.  That’s a good thing for me, but bad thing for Medicine Think.  I’m working on a new entry for later this week, but for now I’d like to share one of my favorite graphics from Bud Caddell over at What Consumes Me created this awhile ago and I’ve been meaning to share.

Sometimes, as a one-man consulting business you feel a pressure crunch that most big firms don’t face.  It almost feels like what an artist or graphic artist must feel.  Most folks want things for free, they have some sort of expectation and only few ever plan on compensation.  The trouble is that I find most of the consulting problems that come my way to be really, really interesting.  I’m happy to report that I’m bringing Square6 closer to the middle!

And, for those of you who love infographics – head over to What Consumes Me! Fantastic work!

The Tesla Roadster Sport - really, there's nothing like it

Here’s a non-traditional Medicine Think entry, but I wanted to share my first drive of an all-electric car – the Tesla Roadster Sport.

I feel like last night I had one of those rare experiences where you feel like you’ve seen the future.  It might sound like a hyperbole, but that’s what it felt like to test drive the Tesla Roadster Sport.  And, no, I’m not in the market for one, but after driving it, I really wish I had about $110,000 in disposable cash laying around.

So, what is it about the Tesla that makes it feel so futuristic?  It’s an all-electric car – there’s no hybrid or gas component – it’s a 100% electric motor.  That means that from the moment you put your foot on the “gas” (is it more appropriate to call it an accelerator pedal? The “electric?” The “juice?”) it’s a different driving experience than you’ve ever had.  The only similarity is that there are four tires, the car looks like a Lotus Elise, and there’s a steering wheel – most other experiences are different.

There’s no engine noise.  Honestly, you don’t miss it.  An electric motor, by nature, has 100% of torque at 0 RPM – that means the thing accelerates so rapidly that it’s hard to believe.  0-60 in 3.6 seconds – that’s Lamborghini fast.  Instead of having to “rev” the car up, all the power is there and ready to go when you push down on the pedal.  It’s unlike any car I’ve ever been in.

There are no gears – nothing to shift, no transmission beyond forward and reverse.  After the car bolts to speed, the engine itself has a tremendous amount of braking power.  The moment you let up from the accelerator, the car begins to drag to a stop.  You literally don’t need a brake other than to come to a full stop at stop lights.  Put another way, to maintain speed, you have to keep the pedal down – even on downward slopes where gas power cars would shift to neutral or have a very low factor of engine braking.

Apparently, a lot of Tesla’s patents and intellectual property in how the car electronically mimics the way we drive today in gas cars.   By that, I mean it’s not in the nature of an electric car to cruise forward when you let up on the brake.  But the Tesla does – that’s a purposeful design and apparently very hard to do in an electric car.  From my understanding, this technical achievement will be difficult for others to mimic.  Apparently this technology bleeds over in to how the car accelerates smoothly and the car reaches cruising speed.  Whatever they’re doing it’s definitely working.

With the electric engine comes the need to store the electricity to power the car.  The battery “pack” alone weighs just shy of 1000 pounds.  That’s a lot of weight.  It’s positioned mid-car just like in a gas powered sports car, which helps balance the handling overall.  Regardless, the 1000 pounds is a lot of weight, especially when the car weighs a mere 2,700 pounds overall.

Otherwise, the car is definitely a stiff little roadster and to be honest I had a hard time seeing through the windshield.  I’d love for the car to have a few more inches, and I hope that comes at a later date.  Maybe by the time I can afford one.

It was truly an exhilarating ride, and I don’t think it really hit me until I stood up and I felt like I had just stepped out of a rollercoaster – the same shakes and legs feeling almost like rubber.  I don’t know if that was because I’m a pretty novice sports car driver, or the all-electric roadster really is that cool.  My gut sense is that the car really is that cool.  I was on a high for the entire rest of the night – I’m not kidding.

And, this sense had nothing to do with the environmentally friendly nature of the car.  That said, I’d be really curious of the overall carbon footprint of a mile in a Tesla versus an efficient gas car.  How many carbon emissions are released during the production of the electricity to power the car?  Is it really less than driving a mile in a gas car?  Either way, the electric car really is that cool.

Heading back tomorrow to get a behind the scenes look at the dealership and shop in Seattle.  More to come!

© 2003 Mark Stivers - www.markstivers.com

It’s all a matter of perspective, I suppose.  It’s been a few weeks since I’ve gotten back to writing on Medicine Think and I’ve got some more entries in store.  For now, this comic by Mark Stivers caught my attention.  Head over to his comic blog – very funny stuff.

The comic just reminded me that during a time of such intense national debate – healthcare, taxes, finance reform, housing reform, student loan reform (and on and on) – sometimes it’s best to step back and gain a new perspective and consider the other side.

Biology and technology have much to learn from each other - concepts from each discipline can inform and help create breakthroughs and new businesses. Image courtesy of Scientific American

I recently sat down with a friend who’s developed an ingenious way of using neuroscience concepts and neural networks as the basis for an information filtering algorithm. He’s taken that algorithm and created a personalized and customized news feed from Twitter.  In short, he’s helping to actually make sense of the Tweetstream.

So, what do I really mean by saying that he has employed neuroscience concepts as a foundation for his algorithm? First, think about the brain and how it processes incoming signals and stimuli – if it’s an important signal, say a pouncing mountain lion, it’ll get through all the other noise and register with you.  Much the same way, my friend’s technology uses a couple “filters” that determine whether the incoming tweet is relevant to your interests. If it’s relevant and important it’ll pop up in your news stream. In works much the way that neurons in the brain work – in order for a signal to pass along it’s gotta make the next neuron fire.  The same can be said about tweets this technology filters – if it’s relevant and important it makes it through the algorithm.

The second instance of neuroscience inspiration in this friend’s Twitter algorithm comes from the basic premise that how and what we forget is just as important as the things that we actually remember.  Think of it this way – if we remembered EVERYTHING that we see, hear, touch, smell and taste our brains would be overloaded and wouldn’t work efficiently.  We’d have trouble actually finding memories in our brains if we stored too much information.  The same goes for computer systems – learning how to forget, to get rid of irrelevant or increasingly irrelevant information is just as important as figuring out what to keep. However, the tricky part is figuring out what to forget and what’s worth remembering. That’s part of his trade secrets.

By merging his knowledge of computer science with a dabble of inspiration from neuroscience my friend has been able to pull together a really, really compelling product that might actually make Twitter useful for the 95% of the population that’s not on it. Where other techniques have failed to make sense of the Tweetstream, my friend’s inspiration from the fundamentals of neuroscience has greatly aided his product.

In the above example neurobiology has inspired and informed computer science design, but it’s also a clear case of how this interdisciplinary approach can help both fields make advances.  Another example would be 23&me. I clearly don’t think much of their business model or clinical relevance – but they did inspire some advances in bioinformatics through employing experienced techies to help build their data systems.

See, this is what you get when you mix biology with technology!

What I mean is that (as I’ve been told anecdotally) one of the things 23&me did absolutely right was hire a number of engineers from eBay who were fantastic at database engineering and management.  Instead of bringing in data folks with 10 years of background in bioinformatics and creating databases the way a biologist would, 23&me created an extremely efficient and scalable system for their genomic data.  This type of insight will enable science to make more advanced breakthroughs all that much quicker and effectively. It has also enabled 23&me to have a more feasible business model as well. Technology enabling and inspiring the advancement of biology.

All of this to say that in the world of entrepreneurship and design there’s a lot that the intermingling of bio and tech can bring to help inform and advance both fields.  I’m hoping that Bio+Tech can be one of those ways that technology and biology can intermingle to bring about not only a more vibrant start-up community here in San Francisco, but to help create breakthroughs and inspiration for the next generation of technologies. Drop me a line if you’d like to attend the meetup on February 17th!    windmiller[at]gmail

Biology and technology coming together isn't really a new concept - it's clearly been occurring for thousands of years. We just need to continue to encourage new interdisciplinary approaches as see what comes of it. A beer along the way doesn't hurt, either.

Most people want the best health coverage possible, but is it possible Cadillac Health Plans are the wrong way to think about it?

Cadillac Health Plans and insurance remain a hot topic of conversation since I pondered Cadillac Health Plans several months ago.  Generally a Cadillac Plan provides many bells and whistles for its subscribers, but also comes with a much higher premium.  Taking that car analogy in a different direction, what if we could rethink what it means to have good health insurance and model it after car insurance? This would give people more control over their health and health spending, much like the car insurance model.  Now, that would be more like a true Cadillac Plan . . . . I digress.

In an earlier post about health insurance costs I talked how we (my wife and I) will pay about $12,960 for health insurance in 2010. It’s a pretty good plan – a PPO – one that has more degrees of freedom than other plans. But it still dictates how we spend the dollars that we’ve paid in to the system and incentivizes wasteful spending.  Moreover, why does everyone have to be on the same paradigm? Put a lump sum in, get some care out – why not create insurance products that work differently while at the same time creating social pressures to reduce unnecessary costs?

The annoying thing about this insurance plan is that we only used about $2,000 worth of the benefits.  So, in essence, we pay almost $13,000 in to the system and the system tells us what we can and cannot do and only allows us to use $2,000.  And that was only for costs that were deemed “appropriate and necessary” by the insurance company.  We had to pay another $1,500 out of our own pockets for legit physical therapy and dermatology treatments.

OK, so clearly that extra $11,000 that we paid in is a risk premium to cover catastrophic costs – if something happened to either one of us, I’m sure we’d be glad we had the insurance.  That said, $11,000 sounds like an awful lot, particularly when you consider that you probably pay only $1,000 or so a year in car insurance.  Why can’t healthcare be structured more like that?  The person pays for maintenance and routine care, while insurance pays for catastrophic and serious illnesses/conditions.

For instance, let’s say such a plan existed.  My wife and I could contribute $2,000 (more or less, depending on how much we wanted to put away) in pre-tax dollars to a Health Savings Account (HSA – yes, it rears its head again).  That $2,000/year per person could be used to cover sick visits to the doc, derm care, physical therapy or other costs – any way we saw fit.  Another benefit is that if we needed more money, we could pay out of pocket and submit those receipts on our taxes much like we do today – all care dollars would be pretax.  Best of all, those HSA dollars would roll-over year to year just like cash.

For catastrophic illnesses, we could purchase insurance much like we do for our cars.  Let’s say it would cost us $2,500/year per person for that insurance – that’s almost 3-4 times more than our car insurance covers and our car insurance covers about $100,000 worth of damages and injuries. Seems decently reasonable.

And, according to this simplified model, we’d still only be contributing $9,000 for our healthcare – that would leave an extra $4,000 in our pockets over what we’re spending today.  We’re not used to thinking about that money as coming out of our paychecks because it’s part of our benefits. But, you can be sure it’s affecting our take-home dollars.  Additionally, I’m sure spending money out of our HSA would also cause us to pay more attention where our money is going and help curb frivolous spending.

When looked at from another angle, the current state of doing business in healthcare it pretty bad. Why not completely change some aspects to make it work better?

What I’m proposing is that we as consumers gain more control in how we spend our healthcare dollars.  This insurance model could be similar to how car insurance works today.  You pay for your own maintenance costs (i.e. the HSA dollars) and then pay-in to insurance for catastrophic costs.

For example – let’s say you went in to the ER with abdominal pain and the doc suspects you have appendicitis and a CT scan is performed.  Lo and behold you need to have an appendectomy – that’s a pretty serious illness, which would be covered by your catastrophic insurance.  Everything from the CT scan to the operation and anesthesia.  All told, about $20,000 worth of care – easily less than most car accidents, and therefore it seems that there should be a feasible business model like car insurance in there somewhere.

I’m sure that I’m over simplifying the catastrophic insurance proposal and it might cost more per person per year.  Even so – if we paid $3,000-$4,000 a person per year for catastrophic insurance that would still save us money over what we pay today.  To boot, we’d have more control and responsibility over our day-to-day healthcare spending.

This plan won’t work for everyone and we’d still have to make a determination of how to provide care for the uninsured and current Medicaid patients, but I’m sure we could use a system similar to what we have today.  Additionally, chronic illnesses would also need to be addressed, but it’s most likely do-able if some of the current healthcare reforms go through.  This high-level model that I’m proposing is at least a new way to start thinking about the change we’d like to see. Maybe it would be a sub-component of larger change?  It’s a start.

Cadillac care, indeed.  Or at least modeled after insurance for Cadillac autos.  What do you think?  Curious to your thoughts!

Composite image of some of the iconic images from Apple's "Think Different" campaign.

How we frame and think about subjects clearly has an impact on how we approach and attempt to solve problems.  The first image, right or wrong, that comes to my mind is Apple’s “Think Different” campaign back in the mid 1990s. But I’m talking about the importance of perspective in a much bigger sense – we’ve defined and approached some of our biggest problems using techniques and perspectives that were modern 50 years ago.  Specifically, I’m thinking about how we diagnose, treat and research cancer.

Today we diagnose a patient’s cancer based on the tissue of origin (i.e. breast cancer, colon cancer, leukemia, etc), what it looks like to the naked eye and under the microscope, and where it has spread in the body.  The American Cancer Society has a great description of how cancer is “staged.”  Once our doctors have diagnosed the cancer, the treatment is based off of that diagnosis – most often it’s either chemotherapy, radiation, surgery or some combination of the three.  The treatment was based on how we diagnosed the cancer, which was defined on the technology we had available to better understand cancer.  But, for anyone who’s had experience with a loved one with cancer knows that the current therapies and techniques are certainly lacking – we need to do better. As a side note, the history of cancer chemotherapy is pretty fascinating and also reason for moving beyond current therapies.

The molecular structure of the origin of modern cancer chemotherapy - developed by German scientists for war in 1917 - but identified by American scientists as a treatment for cancer. It's time to advance our cancer therapies past this brutal approach.

Today we finally have better tools that enable us to better understand the core of cancer and will help us get to the root of the disease.  Genomics and informatics – the sciences of decoding DNA and then comparing different DNA sequences – are helping to transform not only how we research cancer, but in how we diagnose and ultimately treat cancer.  In theory this will lead to better outcomes for cancer patients.  If you understand the root of a disease – in the case of cancer, the genetic mutations and internal cellular processes that have gone haywire – you’ll better understand and better treat the disease.

For example, instead of diagnosing breast cancer based on exams, images and pathology slides, we’ll begin to take a sample of the tumor itself, analyze its genome and compare that to cancer genome to your healthy genome (taken from a healthy cell).  This is where the recent advances in genomics and informatics come in to play.  As we gain the ability to sequence vast amounts of DNA, we’ll greatly increase our knowledge of the genetic make up of cancers.

Specifically, genes today can tell us why the cancer has grown out of control, whether it will metastasize, and we now know it may even help predict where it will metastasize to.  But, that technology isn’t ready for clinical medicine just yet – much more research needs to be done to help us better understand the disease process.  In the future, though, instead of defining cancer by the staging system or its pathological features, we’ll diagnose a cancer based on its genetic profile.  In turn this will help us better understand the best course of treatment, the prognosis and how to prevent the disease from spreading.  My guess is that it will even help us be predictive of whether the cancer will metastasize, how fast and to where in the body.

This is a microscopic image of breast cancer (click to enlarge) - it looks pretty standard for a pathology slide, but it's also indicative of new research - the dark brown spots are cell nuclei that contain a marker that has helped to redefine how we treat breast cancer. Taken from the National Institutes of Health. Courtesy of Ronald S. Weinstein, M.D., University of Arizona.

By better understanding the genetic mechanics behind the cancer, we’ll be able to more accurately target our therapies and medications to the specific cancer.  This will drastically cut down on unnecessary side effects and ineffective therapies, and potentially lead to better and faster outcomes.  We’ll discover new therapies and drugs based upon what we discover through this genomic research. In other words, instead of using cytotoxic agents, like today’s modern chemotherapies, we’ll have drugs that are targeted to the specific genetic make-up of a cancer.  This will lead to many fewer side effects, and better patient outcomes.

Taken to the next step, we may even be able to better predict what type of cancers a person may develop based on their genetic make-up.   This knowledge will be essential in our fight against cancer.  We may even begin to better understand how to harness the power of our own immune system to target cancers.  At the foundation of all this knowledge will be genomics and our understandings of the basis of the disease.  If we have a better understanding of the genetic mechanics, then we can better define, diagnose and treat the disease.  All this advance comes from a shift in how we define and therefore understand the disease in its most basic elements.  Maybe it’ll lead to a cure, or maybe improvements in cancer therapy. It’s an exciting time in cancer research.

My last post dove in to healthcare quality versus spending and introduced the Dartmouth Atlas as one of the key insight tools we have for healthcare spending and quality here in the US.  Essentially the Atlas takes a look at the entire country’s healthcare spending by using Medicare claim data as a proxy.  From this Medicare data the Dartmouth group can also glean quality of care data to pair with the spending figures.  And, for those of you wondering, yes, despite the fact that most Medicare patients are over 65, the data that can be gleaned from their data can highlight trends across the entire healthcare ecosystem.  Or, at least, it’s the best tool we’ve got.

I wanted to dive a bit deeper to look at regional differences in quality versus spending at a hospital by hospital basis. To take a look at the data provided by the Atlas and see if there were any high level trends that could inform the latest round of healthcare reforms.  I was wondering whether hospitals could provide high quality care in a cost effective manner.  In essence, the higher the quality of care, the better the patient outcome (and subsequently this saves the system money in the future from complications and further illness) – better outcomes for less money, aka a more efficient system.  Turns out it is possible to have high quality, yet more-affordable care.

Before I do that I want to recognize the limitations of the analysis of this work.  It hasn’t been blessed by a statistician or healthcare economist, etc.  It’s just looking at high level trends to show that, yes, there is pretty good evidence that quality healthcare doesn’t have to cost as much as it does today and that reform that properly aligns incentives can bring about not only savings but improved health outcomes.  In other fields, less spending often is equated with decreased quality.  In healthcare, this data indicates that it is possible to not only save money, but provide a higher standard of care at the same time.

Let’s break my analysis down by data type first.  I looked at overall spending per patient at hospitals during the last 2 years of that person’s life.  I’m not sure why the Atlas breaks the info down this way, but I was assured that this method does correlate to real world spending and is the easiest way to be consistent in collecting data.  That spending is reflective of the hospital’s overall spending habits.  The composite quality score measures how many patients out of 100 receive the right/highest quality of care.  So, if a hospital’s score is 85.4 that means that out of 100 patients that are seen in the hospital for a condition, 85 of them will receive the standard of care.

US Hospitals - total spending per patient in the last two years of life on the x-axis, and on the y-axis is an overall composite quality score. Upper left quadrant is the ideal - lower spending, yet high quality care.

For the country as a whole, you can see the plot of data for hospital spending (x-axis) vs quality (y-axis) – it’s quite a jumble, but all hospitals in the green quadrant are in the top half of being low cost (they spent less per patient), but are also in the top half of hospitals in terms of quality.  In otherwords, the hospitals in the green quadrant are low-spending, but high quality.  The opposite is true of the red quadrant – they are high spending, low quality hospitals.  It’s striking to see how many hospitals stray away from the top left part of the graph and it’s also striking how many high-cost, low quality hospitals exist across the country.  You can imagine that if all the hospitals in the red and white quadrants were able to change behaviors and become more effective and efficient just how much money the whole system could save.  And that’s not to mention massively improved outcomes.

To go a bit deeper with more meaningful numbers, I took the top 10% of US hospitals with low-spending/high-quality profiles and compared them to the remaining 90% of hospitals.  Overall, that top 10% spent $40,119 per patient, compared to $56,641 for high-spending hospitals for a savings of 28.9%.  The top 10% had a quality score average of 90.8, while the bottom 90% had a quality score of 85.7 – an improvement of 5.9%.  In summary, this means that the hospitals that perform at the top of the heap have a higher quality and they save, on average 28.9% of costs per patient.  Better outcomes, lower cost – it can happen, it does happen.

SF Bay Area Hospitals spending v quality graph. Click to expand.

However, it’s difficult to look at these stats on a nationwide basis because healhcare costs are more expensive (or less expensive) depending on where you live – just like every other living expense, healthcare is more expensive in expensive cities.  I took San Francisco (actually, the Bay Area) and Pittsburgh and subjected them to the same chart as I did the US.  The visual patterns are a little harder to discern, although in both cities you can still see that there are a handful of hospitals that have low-cost and high quality, while a majority are either high spending or low quality.  To me this means that there’s a lot of room for improvement across the board, even when looking at expensive and middle of the road metro areas.  While no clear pattern emerges, it is quite clear that most hospitals are not working as efficiently as they could be.  For you numbers oriented people, the top 10% in San Francisco saved 9.6% of costs and had 6.2% higher quality.  While in Pittsburgh, the top 10% saved 14.5% of costs and had 7.5% higher quality.

Pittsburgh Hospitals - spending v quality. Despite being a lower cost city than San Francisco, overall both cities have similar graphical plots.

There clearly are ways to save on healthcare expenditures, while still increasing quality.  Now, why is this in depth look appropriate for an entrepreneur blog that tends to focus on the biomedical sciences side of medicine rather than pure healthcare and policy?  Well, one reason is to help identify opportunities in healthcare for entrepreneurs.  Wherever there are inefficiencies in the system there is room for entrepreneurs.  However, the tricky thing is that it’s not so easy to just go start a hospital to introduce these changes de novo.  This change is going to require not only Congress, but the leads of hospitals to recognize the opportunities and to be entrepreneurial within their own hospitals.  Perhaps there’s even a market for efficiency tools from one hospital to the next – a sale of techniques that in the end save massive amounts of money and improve lives.  I wanted to point out these inefficiencies because I think they point to an opportunity for the right types of entrepreneurs to come in and make a difference.  I’m not sure how these ineffiiencies will be taken care of, but someone will figure it out.  I hope.  Put another way, if we leave reform only to politicians and insurance companies, more than likely we’ll have more of the same.

As a note, the higher the composite quality scores indicate not only better outcomes at that particular patient visit, but also tends to indicate a lower level of complications and ‘follow-on’ illnesses/diseases, thus saving the system a lot of money well in to the future in addition to the present.  Often these savings go unnoticed when thinking about healthcare reform.  The right care now not only amounts to savings in the present, but automatic savings well in to the future.