More information needed for medical genomic application

May 1, 2006

All projections of rising healthcare costs assume that advances inmedical science will add to the cost. This is a reasonableassumption, since it has been uniformly true in the past.Antibiotics are a great advance, but bacteria develop resistanceand newer and more expensive antibiotics must be developed. Peoplewho would have died at home in the pre-antibiotic era now survive,but after the greater cost of antibiotics and, possibly,hospitalization. The same is true for advances in cardiac stents,cancer treatment, imaging with CT scanners and MRIs, etc. Thetechnology can be life-saving but is typically expensive.

All projections of rising healthcare costs assume that advances in medical science will add to the cost. This is a reasonable assumption, since it has been uniformly true in the past. Antibiotics are a great advance, but bacteria develop resistance and newer and more expensive antibiotics must be developed. People who would have died at home in the pre-antibiotic era now survive, but after the greater cost of antibiotics and, possibly, hospitalization. The same is true for advances in cardiac stents, cancer treatment, imaging with CT scanners and MRIs, etc. The technology can be life-saving but is typically expensive.

The argument often is made that costs can be saved in the long run by using expensive technology up front. Hospital-based technology for trying to defeat death in the late stage of any disease only gets more expensive and harder to resist using. Dialysis for kidney failure is no longer considered a heroic measure by most physicians, although in the 1970s it was. Acute dialysis adds at least $10,000 to any hospitalization. Arterial lines in the ICU are routine; they cost several thousand dollars to place and maintain. Very few physicians have the courage to even mention withholding technology for a terminally ill patient on the basis of cost. Why invite a lawsuit from an angry, grieving family member who wants everything done, even if it costs $200,000?

Enter medical genomics, which studies the links between certain genes and certain diseases. Even a single step, if it's an early one, can result in dramatic improvements in clinical outcome. For example, using high dose angiotensin I-converting enzyme (ACE) inhibitors may be enough to reverse, or at least delay, atherosclerosis due to hypertension and diabetes, as well as emphysema. And inhibiting tissue ACE may be useful for treating and perhaps delaying most cancers. Angiotensin II receptor blockers (ARBs) are useful for autoimmune diseases and many viral diseases, perhaps including avian influenza. ACE may be the major aging gene and a "master" disease gene. Using ACE inhibitors or ARBs on patient populations should keep people healthier and out of the hospital, thereby lowering healthcare costs.

Although there's already a growing evidence-based medicine (EBM) industry distilling evidence-based guidelines from the medical literature, its knowledge base is inadequate, covering a few hundred journals at most. Worse still, in this time of daily genetic discoveries but little funding for clinical research, the EBM industry's grading system is too tough. It currently takes several hundred million dollars and at least two decades for a protocol to win approval from the EBM industry. As a result, EBM guidelines consist of medicine that made sense in the 1980s.

Unless the EBM industry adapts to the needs of consumers, rather than continuing to serve the needs of health plans, HSA-holders will have to get their information from the Internet, press releases, newspaper articles, blogs and word of mouth.

Dr. Moskowitz is founder, chief medical officer and CEO of GenoMed Inc., a public company pioneering preventive molecular medicine.