Ten big ideas” for diagnoses, treatments, technology and even cost control, addressed in a talk by Dr. Ana Viamonte Ros will, in effect, sum up this month’s healthcare conference by peering into the future of medicine.
Her address will cap the sixth annual Ministry of Health conference, “Embracing Emerging Trends,” at The Ritz-Carlton, Grand Cayman, Oct. 29-31. Dr. Viamonte will, in a sense, summarize the efforts of nearly 20 speakers and three workshops, offering predictions of where the U.S. and global industry is headed.
Dr. Viamonte, director of medical staff development at Baptist Health International in Miami, was Florida’s first state surgeon general. Appointed in 2007 by Gov. Charlie Crist, she was the first woman and Cuban-American to run Florida’s Department of Health, overseeing more than 300 clinics in 67 counties, until 2011.
She says an aging population increasingly faces threats from a particularly stubborn – and increasingly prevalent – class of afflictions: chronic noncommunicable diseases, a theme explored in depth at last year’s forum.
The chief threats, she said, are heart and chronic lung disease, diabetes, cancer and mental illness.
“In 2014, three out of every five people died of noncommunicable diseases, a lot them before the age of 70,” she said.
Obvious factors include diet, smoking and exercise, but the medical community is particularly concerned with escalating costs of care and the rise of mental illness.
“Costs are part of the genesis of the problem,” she said. “We have a large aging population of people over 60, half of whom will develop these kinds of diseases by 2050, and it’s expensive.”
At least 86 percent of healthcare costs in the U.S. are dedicated to this group of patients, she said. The U.S. spends more than 1.5 times than any other country on them, consuming 12 percent of GDP.
According to the Centers for Medicare and Medicaid Services, part of the U.S. Department of Health and Human Services, healthcare spending in 2013 grew 3.9 percent from 2012, reaching $2.9 trillion or $9,255 per person, a 17.4 percent share of GDP.
Additionally, the centers forecast that health spending from 2014 to 2024 will grow 5.8 percent per year, 1.1 percent faster than annual GDP, forcing healthcare’s share to grow to 19.6 percent by 2024.
“Right now,” he doctor said, “we spend more money on waste than we spend on the entire grade-school education [system],” a problem perhaps magnified by the lack of government control of the medical system, notwithstanding nascent inroads made by President Obama’s Affordable Care Act.
Dr. Viamonte lists her “10 Big Ideas for the Next 10 Years in Healthcare,” leading with wellness and prevention, followed by setting and substitution, by which she means efforts – much of them technology based – to minimize in-person visits to healthcare providers.
Another “big idea” is empowering patients, boosted by increasing use of a healthcare advocate to consult with medical staff, administrators and insurers, ensuring medical decisions respect patients’ needs and preferences, and offering education and support to enable patients and families full participation their own care.
Another of Dr. Viamonte’s insights expands on two earlier ones: a growing role for wearable devices that will track a patient’s condition, providing an instant, running account of developments.
She describes her idea for mobile health as a sort of “telehealth” scheme, integrating hospital systems with data collection, previous advice, electronic medical records and more.
Data analytics bears on payment for services, but with a fresh approach to costs: “I will talk about results-based payments,” Dr. Viamonte told the Journal. “The U.S. is a prime example of out-of-control costs, and we are looking at how to incentivize an ability to pay a provider based on quality and value, on the results of care.
“Let’s say I’m a physician with a diabetes patient. She will pay based on how well we can control her borderline A1C [a blood-sugar test]. That is, if the information indicates you can control it effectively, we will pay you on that basis. It’s results-based.”
Technology is also at the heart of efforts to diagnose and prescribe based on an individual’s unique genetic composition, Dr. Viamonte said. Genomic treatment has its origins in the 2003 completion of an 11-year project to map the human genome, listing the 3.3 billion pairs of amino acids that form a person’s unique DNA.
With that decryption, she said, “we can do genomic preventive treatment, based on your genetics and what that indicates.”
Related to genomic analysis is Dr. Viamonte’s preventive analysis, using algorithms “to identify, for example, a patient who is likely to become diabetic. We can analyze technical information and predict how someone may be affected.”
While genomic indicators are far more precise than traditional markers, researchers have long identified pre-dispositions for cancer, diabetes, cardiovascular disease, alcoholism, asthma, congenital malformations, and mental problems such as depression, Alzheimer’s and schizophrenia.
Mental health issues
Increasingly, society has had to confront the realization that mental health – a relative newcomer to the list of chronic noncommunicable diseases and, in fact, to Cayman’s own list of healthcare priorities – is critical, pushing healthcare providers to seek health parity, or equal expenditures among physical and mental illnesses.
On Oct. 30 during the conference, Dr. Marc Lockhart of Cayman will speak for an hour on “Bridging the Gap, The State of Mental Health, Cayman Islands, 2015.”
“There have been efforts for years” to make mental health a meaningful public discussion,” he said, “but it’s gone under the radar or [reports] have been published and shelved, and it’s certainly never been consistently implemented or followed though.”
He points to the “Review of Mental Health Law” in 2001 by consultant psychiatrist John Bradley and “medico-legal consultant” Roy Palmer for the Ministry of Health. Their 13-page report “highlighted faults in the law and flaws with an antiquated treatment methods, like the police lockup. It affected some people,” Dr. Lockhart said, “but it was shelved.”
The report calls for a significant expansion of mental-health care. Little came of it, however. “I don’t know why,” Dr. Lockhart said. “Maybe it’s the stigma, maybe the civil service felt there were other priorities, but as we have continued to grow in these islands – and especially after hurricane Ivan – mental health issues have come to the fore.”
Analysts have long identified the 2004 category 5 storm as a source of inordinate stress and dislocation, both psychologically and physically. Dr. Lockhart pointed to increased homelessness, victims “acting out” fear and disorientation, and increasing public recourse to the police.
“You just cannot sweep these things under the carpet any longer,” he said.
Small steps have been taken, although none fast nor far enough. The Cayman Islands Hospital has an eight-bed in-patient unit, which, while too small, at least “is something.” In 2009, the first local mental health conference, supported by the Pan American Health Organization, convened.
Today, Dr. Lockhart said, Cayman has between 20 and 30 mental health professionals – counselors and psychologists in government, schools and private practice – who are, simply “not enough” for a population of 55,000.
“They are not allocated properly, and we have more in private practice than the public sector,” he said, “and all of them are in Grand Cayman, mostly George Town, and none in Cayman Brac or other districts.”
An “antiquated” law must be changed, if nothing else, to reflect fresh imperatives for people who may need treatment, but are not aware of it, he indicated. A 2013 law began to address some of the questions: “How do you detain these people? How do you get treatment to them? How do you take away their freedoms? What if they are a problem to themselves and to others? Second opinions, appeals, a patient advocate?” he said.
The 2013 law created a Mental Health Commission, which met for the first time in January 2014 to “develop policies and plans to move us forward proactively.”
Meetings with the Prisons Department, schools and medical personnel, supplementing between eight and 10 four-hour training sessions, constitute a start, Dr. Lockhart said, but “we still lack mobile interventions, for example, where someone can go out to, say, West Bay, and sit with someone till they are calm.”
He pointed to two areas for improvement: “Adult patients don’t have enough long-term hospital beds, and after a patient is stabilized, there is nowhere to put them. The hospital unit is an acute facility; it’s not designed for long-term or chronic care.”
Youth services are the second issue, presenting problems opposite to adults: “They do not need a long-term facility so much, but we do not have enough out-patient resources – and while there are enough private counselors for adults, there are not enough for young people,” whose distinct problems may require specialist services and even home visits.
Suicidal thoughts, drug and sexual abuse, lack of parental supervision, depression and alienation are some of the hurdles confronting troubled youth.
“After 20 years in this business – 15 of them here – I think we can come up with solutions, and maybe tie them into this new idea of medical tourism,” the Health City Cayman Islands-led effort to attract overseas – particularly U.S.-based patients seeking treatment for otherwise costly procedures.
Dr. Lockhart said if full services were available in Cayman, between 40 and 50 people – including 15 chronically ill – would be admitted to care within 72 hours. Another 10 to 15 patients would immediately return from Jamaican specialist shelters, which have housed Cayman patients for more than a decade.
In the past two years, more than 4,000 local patients sought care; a number that could triple in future.
“A significant percentage of the population could require some kind of counseling,” Dr. Lockhart said, pegging those numbers between 8,000 and 10,000.
The doctor is the only local mental health professional addressing the conference, although two other speakers will touch on related subjects.
Amanda Williams will discuss “How we all use psychology when we treat patients,” and James Clearly will speak on palliative care, in which easing stress and disorientation for patients and families is critical.
Innovations in physical medicine, however, will feature prominently, and perhaps none more so than Dr. Jamil Bashir’s work in regenerative medicine, described in his talk on “The Future is Now: 21st century healing with your own stem cells.”
Dr. Bashir performs advanced interventional orthopedics at the Centeno-Schultz Clinic near Denver, Colorado, and treats patients at here at Regenexx Cayman.
Regenexx specializes in a procedure in which a patient’s cells are extracted, multiplied up to 1,000 times in the laboratory, tested for quality assurance, then re-injected, boosting natural healing of the orthopedic injury or condition.
The company also offers “cryopreservation,” storing a patient’s healthy stem cells to create a “repair kit” for the future.
“We work with musculoskeletal tissue in regenerative healing throughout the body,” Dr. Bashir said.
Musculoskeletal disorders are degenerative diseases and inflammatory conditions in joints, ligaments, muscles, nerves and tendons, and in the structures that support limbs, neck and back.
A torn meniscus, for example, is a common athletic injury in the knee, while arthritis, particularly in the hand and thumb, is another familiar musculoskeletal affliction. Dr. Bashir’s work is largely with “day-to-day persons with wear-and tear: A guy that fell off a ladder and hurt his shoulder, a gardener whose knee hurts or someone who has picked up something and has a herniated disc,” he said.
“We use magnetic resource imaging and X-rays of the site to give us a three-dimensional view so we can diagnose the problem,” he said, “then use a combination of ultrasound and fluoroscopy to help ensure precise placement of the cells and optimal healing.”
Platelet-rich plasma therapy employs platelets from the patient’s own blood to rebuild damaged tendons or cartilage. PRP may relieve pain and jumpstart healing.
“It’s a way of spinning platelets from the blood and concentrating growth factors that, when injected, amplify the body’s natural healing process,” Dr. Bashir said, likening it to the swelling process that follows an ankle sprain.
“That is an inflammation of the vessels, leaking blood into the area, enabling platelets to tell the body to start healing,” he said, pointing out that icing an injured ankle to counter swelling may not always be a good idea.
“Or,” he said, “there may be stem-cell procedures, where we harvest from the bone of the pelvis. The cells can control and direct tissue repair, and can turn into any type of connective tissue – bone, ligament, tendons, muscle.”
Arthritis at the base of the thumb, for example, responds to PRP therapy, “depending on the severity and type of damage, and it’s easy and costs less” than surgical alternatives.
“In more severe cases, such as advanced arthritis or a badly torn rotator cuff tendon, where PRP is not as effective, we can go right to advanced stem cell procedures. We give options to [patients].”
While the therapy has been developed only in the last decade, it is advancing rapidly.
“We are just at the tip of the iceberg, just figuring out the ability of the body to heal itself,” he said. “The outcomes have been very good in the right patients, depending on the type and severity of their injury, as well as their overall health. We are hoping for a paradigm shift from simply masking symptoms or surgically excising injured parts to making tissue regenerate and healthy again.”
Finally, emerging trends in physical healing are perhaps nowhere better represented than in the minimally invasive, robotic cancer surgery pioneered by Dr. Adrian Legaspi.
Cancer has long loomed as a dark shadow in the Caribbean, creating a tight nucleus of fear, whispered only in close quarters. Dr. Legaspi, 62, the son of a surgeon father and nurse mother in Mexico, will confront it head-on, however, speaking plainly in his “Current trends in surgical oncology and management of gastrointestinal malignancies with minimally invasive robotic surgery.”
After completing a fellowship in clinical research and surgical oncology at New York Hospital at Cornell University Medical College and serving at Manhattan’s Memorial Sloan Kettering Cancer Center, Dr. Legaspi was named medical director of the Advanced Surgical Oncology Network for Tenet Healthcare’s 10 Florida hospitals. He works day-to-day at Palmetto General in Miami.
“My specialties,” he said “are the stomach, liver, pancreas, esophagus and small intestine.” He points to cancers of the stomach and liver as prevalent in the Caribbean, associated “with the socioeconomic situation, and not so much diets as a higher prevalence of infectious diseases,” he said.
Globally, he said, underdeveloped countries “account for as much as two-thirds of all cancers,” and points to the prevalence of the “helicobactor pylori” bacteria in the gastrointestinal tract.
While “H pylori” is relatively common globally, “infection is more prevalent in developing countries,” according to one text, and while the mechanisms spurring development of cancer remain elusive, researchers have proposed two related pathways, both involving increased cell mutations.
Dr. Legaspi’s innovations – and his Friday talk – are in regard to surgery, which he can do faster and better, with tighter procedures, addressing previously inoperable tumors and creating better outcomes.
For example, whereas initial surgical incisions might have opened the entire abdominal cavity, now, he says, using robotics, no more than a minimally invasive, half-inch cut is necessary.
A camera – part of the robotic console featuring a monitor and appropriate surgical instruments – magnifies the target area by three times, affording a three-dimensional view and enabling the doctor to manipulate surgical tools inside the cavity.
“We can cut and cauterize special tissues, grasp and staple, do a fine dissection, expand blood vessels and take a needle inside. We can operate with our fingers and hands, opening and closing clamps and scissors, but without the tremors of human digits.
“We can identify tissues with these instruments that we could not before with the naked eye, and using a green dye, we can see tumors that we couldn’t before.
“We can get a feeling of how tough tissue is, how it behaves and how it responds. We can get into parts, into small spaces, with the robot where we wouldn’t fit before,” and all with fewer complications, he said.
In the end, Dr. Legaspi said, it translates into an ability “to operate on tougher cases with a lot higher complexity, making one of the greatest innovations we’ve had.”
Outcomes are better as well.
“In terms of survival rates, on average we do as well as with any standard of care, but what has become ‘standard,’ well, we clearly show a trend toward fewer complications, and, especially with small incisions, faster recoveries, spending less time in hospital and the time for a patient to get back to work is quicker.”
Similar treatment is widespread and generally available, especially in medical academic centers like Miami, Houston and Philadelphia, he said, but noted, “Palmetto General is so far out in front, well, no one is doing what we are doing.”