Departing from a Disease Management Healthcare Model to Foster Public Health

Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don’t know which half is which.

-Dr. Charles Sidney Burwell, Dean of Harvard Medical School

Medical approaches of the past are somewhat shocking given what we know now–snake oil, lobotomies, blood-letting. The snake oils, lobotomies, and blood-letting practices of today, which we believe surely are not present, are very likely manifest in problems hidden in plain sight. While understanding of medicine has improved (Thimbleby 2013), much of what is incorrectly taught in medical school is still practiced today. What patients have today is a system overwhelmed by managing lifelong diseases and a system that profits more from keeping them sick than making them well. Given rapidly increasing healthcare costs and chronic disease prevalence, it may be time to pursue a transition away from disease management toward wellness, lest the U.S. face worsening economic and societal consequences.

The approaches to healthcare modeling tend to fall into either the traditional Allopathic Healthcare model or the model for Human Systems Theory and other progressive approaches. Allopathic medicine is a system in which physicians treat diseases using drugs, radiation, and surgery (NCI, n.d.). Traditional Allopathic Healthcare tends to take a reductionist approach to the body. Because the body is so complicated, it addresses this issue by looking at the body as consisting of many isolated parts. It employs specialists for each organ, like a pulmonologist for the lungs or a cardiologist for the heart. Traditional Allopathic care finds some success in the following model: reading symptoms, making a diagnosis, and prescribing the appropriate drug (Bayesian algorithm). This essay will cover the issues with the model that Human Systems Theory attempts to solve. Human Systems Theory approaches the body as built of hierarchical layers (molecular, cellular, and tissue/organ) that interact as a coordinated system (integrated care) (Goldman 2015). HST aims to shift focus from disease management to addressing root causes for disease resolution. 

Reviewing the literature on chronic disease prevalence reveals how the current system evolved into a collection of “siloed” specialties that address various disease systems. The term “silo” refers to isolation in the different departments or sectors of operation. Authors of the research point to unwitting, unintended, and unaddressed consequences of a healthcare system divided into specialties. Traditional Allopathic Healthcare, for better or worse, is rooted in decades of education and medical establishment, but some experts are looking for new solutions.

Looking to the Experts

Medical doctors such as Dr. Robert Lufkin are drawing the media’s attention to the hidden problems in healthcare and calling for a radical change in how we approach care. Dr. Lufkin's solution is to focus on the potential reversibility of many chronic diseases through lifestyle changes and prevention. He stresses the idea of a paradigm shift toward preventative action so that common chronic diseases do not occur in the first place. He posits a successful preventative healthcare system as one that could save healthcare millions and potentially billions.

Authors like Eric Topol point out doctors' tendencies to diagnose or make decisions without enough information or to rely on faulty or old information. He points to the potential benefits of a universal electronic healthcare record and highlights the benefits AI integration will bring to physician workflow. A technologically forward approach to healthcare will be required to address the demands of analyzing the body in greater depth with BrSM and using genomics/proteomics to make better diagnoses (elaborated on at a later time).

This essay will synthesize the ideas discussed by each expert to help us connect and see healthcare’s problems hidden in plain sight. Finally, the essay will look into how the Human Systems Theory offers an alternative solution in the form of Bioregulatory Systems Medicine (BrSM).

CHRONIC DISEASE’S PREVALENCE

Chronic diseases and multiple health conditions occurring at the same time, known as multimorbidity, are prevalent and expected to increase in the coming years. Chronic diseases in Western societies are becoming more commonplace due to the rapid aging of the population and longer lifespans of people with chronic conditions (WHO 2010). Likely, the rise in chronic diseases cannot be attributed solely to age increases in the population. Standardization for age does not entirely explain the observed trends, indicating that factors such as healthcare and societal developments also contribute significantly to the rise (van Oostrom 2016).

Preface on the Issue of Chronic Disease

In high-income countries, over 90% of deaths are attributable to noninfectious/proinflammatory causes (DOHaD 2022), with ischaemic heart disease being the most prevalent. In low-income countries, only about 20% of deaths are attributable to noninfectious causes, with lower respiratory infections being the most prevalent. Most notably, noninfectious etiologies (root causes) have become the top of all global causes of death, with ischaemic heart disease responsible for over 9 million deaths in 2016 (GHE 2016). Although life expectancy has increased due to modern medicine, chronic disease is now manifesting earlier and at higher rates, leading to economic strain on the nation (WHO 2010).

MANAGING DISEASE

Many patients in the U.S. seek care in a symptom-driven manner. They seek care when they feel symptoms (Taber 2015). The current healthcare system focuses on what is called disease management. Disease management is a system of care where the priority is eliminating disease symptoms. Unfortunately, eliminating symptoms of a disease does not mean that the disease itself is eliminated, like taking headache medication for the symptoms of chronic dehydration. The symptoms of the headache will go away, but one cannot consider the patient truly well until they are hydrated. Type 2 diabetes treatment uses a disease management approach to care. For example, a patient has Type 2 diabetes (disease), and they experience vomiting and fatigue (symptom) from a blood sugar spike. Giving the patient insulin and metformin to control the blood sugar spike may eliminate the symptoms of vomiting and fatigue but does not control the long-term effects of the disease, like amputation, renal failure, and blindness. Addressing long-term effects requires addressing the root cause (Lufkin 2023). In the case of Type 2 diabetes, a metabolic disease requires a metabolic intervention (Colberg 2010). The Allopathic treatment of Type 2 diabetes demonstrates how the disease management approach works to eliminate patient symptoms, but it may not be the best method for treating the disease long term.

Consequences of a Siloed Healthcare System: Witting and Unwitting

The healthcare industry's economics incentivize providers to specialize, leading to a fragmented system where integrated care is not a priority. Healthcare providers offer treatment through different avenues of care, but these avenues are not equally compensated. Physicians receive higher compensation for procedures done in the cath lab as compared to the initial diagnosis of the need for a cath lab. Our healthcare system does not prioritize the type of person-to-doctor care that addresses the root cause. Instead, there is a higher financial incentive for the more invasive procedure, often at the expense of long-term outcomes. The thinking is very much as follows: if, after surgical intervention, the problem reoccurs, just perform the surgical intervention again (with similar reimbursement) (Froemke 2012). The economics of this system incentivize less ownership over the outcome. 

Siloed operations and thinking can lead to a variety of inefficiencies and challenges. Often, information is not shared effectively across different departments, units within a healthcare organization, or between different healthcare organizations, leading to a lack of integrated care. Specialists often do not work collaboratively on patients but have separate offices with different biases in thinking. Patients may receive different treatments depending on the specialist they see due to varying orthodoxy of thought. Finding the gastroenterologist, rheumatologist, and pharmacist collaborating would be unlikely (Sperling 2020). The modern perspective treats the human organism as a collection of targets for individual intervention and symptom alleviation (the reductionist perspective) (Berry 2013).

The witting consequence of a system focused on disease management and symptom-driven care is that healthcare makes money regardless of the outcome. When healthcare systems focus solely on disease management and symptom-driven care, the result can be a lack of emphasis on preventive measures and long-term outcomes. Financial incentives can lead healthcare providers to treat symptoms rather than address the root causes of health issues. Consequently, healthcare providers may make significant profits even if their patients' health outcomes do not improve significantly. A disease management system's unwitting consequence is disease propagation, which leads to more business. The system supposed to cure diseases may sometimes unintentionally contribute to the propagation of the same disease. The business model of such a system may rely heavily on the treatment of patients, which in turn may require more patients to generate revenue. Therefore, it may be in the interest of such a system to keep the disease manageable but not completely eradicate it. While this may seem counterintuitive, it is a reality in some cases (Holman 2020).

The human body functions as an integrated network (Fiandaca 2017). Specialized care becomes increasingly siloed–focusing more and more on less and less–losing integration with the global perspective of the individual's health. Siloed and unintegrated care leads to increasing costs and unmitigated chronic disease.

SHALLOW MEDICINE

In his book Deep Medicine, author Eric Topol discusses the idea of shallow medicine, which states that doctors do not make decisions based on deep knowledge and understanding of their patients' genomics and health data. Between genomics and proteomics, healthcare providers could access a map of their patient’s genetic information and their cellular activities, respectively (Al-Amrani, 2021). Topol writes about how the practice of shallow medicine is affecting the cost of the U.S. healthcare system, which currently amounts to 3.5 trillion dollars per year (Topol 2019). He covers a study of the top ten drugs by gross sales. Of the drugs tested, even the best-performing drugs gave only 25% of patients the desired outcome (NTT) (these were Humira for arthritis, Remicade for Crohn’s disease, and Enebrel for Psoriasis). In one case, only 4% of patients received the desired effect (Nexium for heartburn) (Schork 2015). The data does not necessarily say that the drugs are faulty but rather highlights the fact that doctors may sometimes make inaccurate diagnoses of treatments. This is because physicians may not have sufficient knowledge about an individual's medical history or characteristics, which makes it difficult for them to predict how a patient will respond to a given treatment. Reduce medication use to reduce healthcare costs.

Using genomics, we can gain insights into how a drug will interact with a patient's body. This approach could also contribute to the Human Systems Theory by allowing us to understand the body at a molecular level and how this system interacts with the wider network of the body. In the future, AI analysis of sensitive health trackers and genomics mapping can provide doctors with powerful information. Future generations will possibly reap the rewards of detailed, AI-driven testing and have access to better family histories as a result.

CONCLUSION: ALTERNATIVE PATHWAYS FOR PUBLIC HEALTH

Bioregulatory Systems Medicine (BrSM) is an innovative medical approach that combines scientific insights into molecular networks, systems biology, and genomics with the body's natural regulatory capacity. This theory, also called Human Systems Theory, has emerged as a response to the limitations of the reductionist perspective central to the current healthcare model. The phrase "the whole is greater than the sum of its parts" succinctly captures the concept of this synergy.

BrSM recognizes the interconnectedness of human health at various levels, from the molecular to the whole organism. It aims to improve therapies for diseases and enhance healthcare strategies by integrating these complex relationships. The critical focus of BrSM is on the body's autoregulatory capacity, which enables it to maintain equilibrium despite challenges. BrSM seeks to address chronic diseases and multimorbidity more holistically by understanding and leveraging the body’s natural autoregulatory mechanisms. The rise of chronic conditions and the impact of environmental and lifestyle factors on health suggest that BrSM may be necessary to advance healthcare outcomes beyond what the current model offers (Goldman 2015).

Fostering public health in the modern era requires a holistic approach that transcends traditional boundaries and addresses the complex interplay of structure, function, and behavior. The persistent health challenges of our time, including chronic diseases, obesity, and mental health issues, demand a comprehensive strategy that targets all three domains simultaneously. Like putting make-up on a melanoma, the current system often addresses one of the three domains but misses on the other two. A multifaceted approach is crucial for creating sustainable health improvements and preventing the side effects and long-term propagation of diseases that often result from solutions focused on isolated aspects of health.

Works Cited