In NYC, if you an ominous orange “C” appears in the window of a restaurant, you’re likely to redirect your patronage to an establishment that has scored higher on the sanitary grade scale. Dr. Raz Winiarsky, cofounder and chief medical officer of Spreemo, thinks like restaurants, medical provider quality should also be more visible and influential. The focus of Spreemo is radiology in workers’ compensations claims. (This isn’t boring, keep on reading!) Why this specific niche? The answer is twofold: 1) radiology is a medical service that is treated like a commodity: people seek the cheapest or most convenient option. However, diagnostic imaging from disparate providers is not like varieties of apples;  there is an expansive range in the quality of radiology, and as such there is a significant degree of patient outcomes based on the radiologist. 2) Spreemo has found a niche where it is actually feasible to get providers to compete with each other based on quality instead of price: workers’ compensation. Workers’ compensation is insurance that provides injured-on-the-job-employees with wage replacement and medical benefits, provided the employee relinquishes his or her right to sue the employer (Wiki). As such, these insurance companies desire to get employees healthy and back to work as soon as possible. And as it turns out, if you get employees better treatment, they are likely to return to work quicker. Spreemo’s Yelp-like star rating system for radiology quality is based on several factors including education and training, the quality of equipment, and price. Patients are rewarded with better quality, while radiologists adhering to quality guidelines can expect higher reimbursements.

This idea that healthcare should be quality driven is not novel, but in this country, it is far from operational. The fee-for-service model, which predominates today, reimburses healthcare providers based on the volume of services they provide, not the quality of care. And while I do not wish to disparage healthcare providers– because I do believe physicians as a whole place the well-being of their patients first – why  invest in more expensive equipment, training, and services if there is no incentive to do so? As Dr. Winiarsky contends, our system chases the cheapest options for care, effectively driving healthcare quality lower and lower. A radiologist on Spreemo's site voices: why buy a new, $1.5 million dollar imaging magnetic resonance imaging (MRI) machine when an old $200,000 piece of equipment will suffice, and there is no forward incentive to cover the $1.3 million differential?

​But the problem is, that $1.5 million piece of equipment likely enables the radiologist to see the pathology better. Furthermore, an MRI on its own is not a conclusion: there is an extensive spread between MRI diagnoses. In New York City alone, the disparity of care was shocking. Dr. Winiarsky’s team took patients to a dozen different radiologists to get MRIs (don’t worry, no radiation here) and observed not just a range of diagnoses, but wrong diagnoses. And a radiologist’s diagnosis isn’t an isolated measurement: it affects patient treatment, prognosis, and time back to work.

Healthcare is driven by money, but in this little niche, Spreemo has indirectly found a way for quality to be the driving factor. But can this work in other areas of medicine?  In other industries, the consumer has a powerful voice, as the customer’s reviews, patronage, and freedom to choose between competitors drives businesses to satisfy the customer. However in healthcare, the consumer not only expects poor service at a doctor’s office, they still almost always return to the same office. Furthermore, even though consumers are allowed to select their own health insurance, the choices are often all just different tiers from the same provider. And what incentive does the insurance company have to deliver good service? The patient pays for services up front (because you select a plan and are locked in) so there is no incentive to foster patient-insurer relationship, loyalty, or quality of interchanges. 

But the patient as consumer is a revolution that is slowly approaching. Patients are interacting with the healthcare system much more frequently. Startups like ZocDoc allow patients to review doctors, while Medisafe is an app that allows users to track medication dosage adherence. In addition, social media outlets and wearable fitness devices mean patients are generating and viewing  much more data about their health. Moreover, the recent shift to high deductible health plans incentivizes consumers to shop around and make informed decisions for the best plans, For example, the WSJ reported that during this season’s healthcare enrollment season, many employers introduced computer tools to help recommend the best plan for each employee. 

There is another push for healthcare consumerism, and it comes from costs. Healthcare costs in the United States are high, and while there are proposals that could bring down the cost of healthcare (eliminating fee-for-service), costs will in all likelihood remain high. These costs could be kept in check by the government, but socialized medicine (socialism in general) is not something Americans easily stomach (Bill Maher and Bernie Sanders recently debated socialism on Real Time). Many Americans are uncomfortable with the idea that the government can give and take something away, especially something like healthcare. So if then healthcare is not treated like an entitlement, but rather a commodity, then the price of healthcare will be dictated by what the market can bear. In other words, the cost of a medication – say a medication that is the only approved drug for a disease – will be set at the highest point at which it will still be purchased. One can see the enormous hazards of such a handling of healthcare. However, if healthcare is still treated as more of a commodity, but it is possible for the patient-consumer to have a voice and a say, then perhaps medical care prices can be commensurate with the consumer’s regard for the medical care provider.  High costs could at least be justified with quality behind it. A consumer should be able to choose expensive, best-in-class services, or have the freedom to select a less expensive option when basic treatments will suffice. In this system, healthcare is still being treated like a commodity, but in a way that empowers the patient consumer. 

​Healthcare consumerism is dawning, but it has not yet arrived. Startups like Spreemo are pioneering change, making us realize old principles of healthcare are flawed and need to be recast. In order for healthcare consumerism to truly arrive, the consumer must be informed and truly understand both their options and what quality really is. The patient is the consumer, and they deserve to know what they are buying. The New Yorker claims that only 1 in 7 Americans understand the basics of healthcare plans. How can the patient demand the best quality when they don't understand the system? There are several steps that can help facilitate the change to a quality driven healthcare system. First, consumers must be convinced that there are quality problems in medical care, and that these problems can be improved (ie… I had no idea MRI diagnoses could vary so much, and in NYC alone.) Secondly, quality reporting must be standardized and universal, and the reporting must be relevant and easy for the consumer to understand, as well as widely disseminated. Lastly, insurance providers must reward quality improvements to healthcare providers.  

​It won't be an easy, but we must do our part to drive our healthcare system to one driven by quality. 

Sources
1. Spreemo 
2. The New Yorker: The Healthcare Industry's Relationship Problems 
3. Business Insurance: Higher doctor fees may get injured workers back to work faster
4. WSJ: Picking a health plan? An algorithm could help  
5. Pando: How to find a doctor that doesn't suck? Spreemo has a new answer. 
6. Commentary: Healthcare commodity, not entitlement 
7.Health Affairs: Consumers and quality-driven healthcare: a call to action 
8. Real Time: Bill Maher and Bernie Sanders debate socialism: US is 'already a socialist country'

Last month I attended a presentation by a biological therapeutics Pfizer VP. While several non-scientific nuances of this talk piqued me (in particular, how 30 years ago it was relatively easy to carve out a business role for yourself if you had medical knowledge), it was the focus on neurological science that really interested me. This executive said that many large pharmaceutical companies have exited neurological drug research and development. Why? The fruitlessness of the field. The exec contended that 90% of the mental health diseases today are treated with the same medication that they would have been treated with 30 years ago. While I cannot vouch for that statement, I agree the field hasn’t seen disruptive breakthroughs. Modern big pharma was arguably defined by neurologic medications – Valium in 1978 and Prozac in the 1990s –but stagnation in breakthrough neurological science has led to the exodus of many big drug companies from the field.  Although the aging population surely portends a surge in brain diseases and potential opportunities, big pharma giants such as GlaxoSmithKline, Bristol-Myers Squibb, and AstraZeneca have demurred.

While drug development has been stagnant, the research has not: I personally know scientists in Alzheimer’s whose research has shown very promising results, and moreover, there has been a spur of Alzheimer’s developments in the news lately. Nature recently published a fascinating publication from The National Hospital for Neurology and Neurosurgery in London suggesting Alzheimer’s disease could actually be transmissible. The tell-tale sign of Alzheimer’s - amyloid Beta pathology – was found in the brains of six out of eight people who had died of Creutzfeldt-Jakob disease. The shocking connection is that years before, the patients had been injected with contaminated growth hormone, suggesting that sticky amyloid-Beta seeds not only traveled along with the hormone, but actually prompted the development of disease plaques. It is believed that misfolding of amyloid-beta makes the peptide sticky, so that it forms clumps. Paired with this recent finding, the concern is that Alzheimer’s could be passed on by other routes such as blood transfusions or contaminated surgical instruments. While this research implies amyloid-plaque formation can be triggered by transmission of a seed, what of the other Alzheimer’s patients who have no history of such injections or surgeries?

A similar cadaver study implicated disparate findings, the results recently published in Scientific Reports. A lab led by Dr. Carrasco at the Autonomous University of Madrid examined the brain tissue of 25 cadavers. 14 of the subjects had Alzheimer’s when they were alive, while the other 11 were Alzheimer’s free. Surprisingly, the brains of all 14 of the Alzheimer’s patients had fungal cells in some of the neurons, while fungus was absent from the Alzheimer-free brains. While a sample size of 25 is quite small, the statistical significance of these results is nonetheless decisive. Does this mean fungi usher in the disease? Alzheimer’s progresses slowly and causes immune responses such as inflammation, and untreated fungal infections progress slowly and can trigger inflammation and blood vessel damage, which has also been observed in many Alzheimer’s patients. If fungi is responsible, this is welcome news: many medications have anti-fungal properties that could potentially be exploited to treat Alzheimer’s.  However, this study highlights a common conundrum is science: are the findings causative or associative? In other words, is it the Alzheimer’s disease that is allowing fungus to take a foothold? Perhaps there is not an ultimate cause for Alzheimer’s, but instead Alzheimer’s is a general response arising from a variety of neurological insults.  

PET(positron emission tomography) scan of three different brains. Left: Alzheimer's patient with amyloid plaques, which are colored in orange and yellow. Middle: a person with amyloid plaques but not showing cognitive signs of the disease. Right: a brain free of amyloid plaques. ​Lifelong brain-stimulating habits linked to lower Alzheimer’s protein levels

And herein lies one of the complexities of neuroscience: the intricacies of the brain and the diseases that affect it mean there is rarely just one cause of a disease.  For example, a single genetic mutation called 22q11 greatly increases the odds of an individual developing schizophrenia. However, even without that mutation, a series of small, disparate mutations can also lead to a high propensity of developing the disease. To even further complicate matters, the same small mutations that can lead to schizophrenia can lead to autism, attention deficit hyperactive disorder, or bipolar disorder in others.

Arguably, breakthroughs in neuroscience haven’t followed a deep understanding of causation. Instead,  many of the field’s most important treatments have been discovered by accident. Thorazine, the first antipsychotic, was found to stop hallucinations when it had originally been intended as a sedative. Imipramine was a failed antipsychotic but became an important antidepressant when its mood improving properties were discovered. More recent drugs such as Prozac, Celexa, Abilify, and Zoloft use the same basic mechanisms as older drugs: antidepressants boost neurotransmitters such as serotonin, and antipsychotics block the dopamine receptor D2.

However, recent scientific advancements in science could begin to convert to translational results in the mental health field. Advanced techniques such as genetic sequencing and DNA editing techniques could soon revolutionalize the field. And what that means is big drug companies are getting back in. Johnson & Johnson, Roche, and Novartis are reinvigorating their efforts into neurologics, and Forbes reports that last year, $3.3 billion was invested into companies that are developing treatments for the brain, a figure that dominates any in the past 10 years. And while treatments for Alzheimer’s and schizophrenia may be more elusive, developments in the treatment of depression, post-traumatic stress disorder, multiple sclerosis, and Parkinson’s Disease may be forthcoming. While I’d love to wax on, read here for more detail. While Pfizer may conjure up disillusionment in some, I do commend the effort to push developments in neurological treatments. 

Sources: (because if you cite a "scientific" development you should be able to show a credible scientific journal, people.... this bacon causes cancer nonsense is particularly irksome to me):
1. Forbes: The Coming Boom in Brain Medicines
2. Nature Letter: Evidence for human transmission of amyloid-beta pathology and cerebral amyloid angiopathy
Nature News: Autopsies reveal signs of Alzheimer's in growth hormone patients
3. Nature Scientific Reports: Different brain regions are affected with fungi in Alzheimer's Disease
4. The Economist: Fungi, the bogey man 
5. Bacon Causes Cancer? Sort of. Not really. Ish. 

So many programming languages to learn! This puts it in perspective for how popular each is. I'm learning Python (for webscraping, automating analysis, modeling), R (statistics and modeling), and Javascript (D3 - for data visualization). I have done some C++. Perl, and Matlab, and I think it's pretty great to break down problems and think like a computer. 

Here's another cool infographic showing the"modern" languages- PHP, Python, and Ruby- with the purpose, usability, ease of learning, and sites built with each.  

Sources:
http://i.imgur.com/7L5ECS9.jpg
https://blog.udemy.com/modern-language-wars/