The Business Of Health

"The next 10 to 15 years should be pretty interesting," observes Matthew Holt, a health care consultant who also writes about health care and health care policy on his Web blog, "The Health Care Blog." "This is going to be a period of understanding how to use the genome and other forms of personalized testing, what kinds of drugs work best on different diseases in different people, and whether we can do it in a way that is economical."

Holt sees fewer new blockbuster products than have been developed in the previous 15 years. "That isn't necessarily good news for pharmaceutical manufacturers, because the evidence thus far shows that patients are better off taking generic drugs regularly than brand-name drugs irregularly," he says. Also, a large number of drugs, such as statins, will be coming off patent, and with employers and the government more likely to be paying providers on the basis of outcomes and process measures, "we will see more emphasis on the integration of pharmaceuticals into chronic care management programs," he says.

Holt foresees personalized medicine coming into the mainstream, although it's still unclear how that approach will work and how much it will cost. "There are four or five drugs in a certain therapeutic class in part because the same drug has a different effect on different people and there are some drugs that don't work at all for other people," he says.

"For example, everyone who has high cholesterol and high blood pressure basically takes the same medicine, but we don't really know how much variety of product type within that category is needed. If pharmaceutical companies now have to develop different versions of basically the same drug for genetically different patients, how much will it cost? A really big number would change the economics, so the industry has to either figure out a way to make it work financially or change the way it does clinical trials, where the bulk of its R&D costs lie. Either scenario presents significant challenges."

Chemoassay testing for cancer is an area Holt thinks warrants further investigation. "A patient comes in with cancer, and the oncologist can treat them with surgery, chemotherapy, or radiation. But even within just chemo, there's no scientific way to determine which regimens work best," he says. "There is a growing movement, however, to focus on pre-chemotherapy testing: attack a tumor in a test tube with various chemotherapy regimens to get a sense of what works best to treat that specific patient. It's more expensive up front than chemotherapy, but it promises better results and fewer failed regimens and maybe lower costs overall. It's still in the early stages, but it's an indicator of what's to come."

Another area for further investigation, which Holt describes as "still in the realm of science fiction," is the idea of using nanotechnology, through carbon nanotubes and buckyballs, to alter DNA at the cellular level in order to cure cancer or even halt aging. Some people believe that within 20 to 30 years this technology will be used to reverse and even stop aging. As an example, Holt cites Aubrey de Grey at the University of Cambridge. De Grey believes that aging can be "cured" and that the first people who will live to be 1,000 are already in their 50s today. "It's a concept that has enormous ramifications, but that's not likely to be something of pressing importance to decisions made in the next few years," Holt says.

Holt believes that the U.S. will eventually get a handle on the health insurance crisis, which will require significant reform. "In the next five or six years, we'll end up with a decayed employer-based health care system that will be for an elite group and not much for the rest," he says. "From a social insurance system point of view, it doesn't make sense not to have universal health care. My sense is that we will get there if things continue to get worse, but not for a few more years because there are many political issues that need to play out. I think because the situation is so bad at the moment, with employers dropping health care benefits, the issue of guaranteed access to insurance will be unstoppable."

When asked if he thinks more states will follow Massachusetts, which recently enacted legislation to mandate health insurance purchase by virtually every one of the state's citizens within the next three years, Holt says it will likely be more of a hybrid system. "Gov. Mitt Romney says this is universal health care without a tax increase. It may be that," but requiring individuals to acquire insurance is a form of taxation, Holt says.

Furthermore, "you can't expose the population to the whims of the unregulated insurance market, as individuals with chronic conditions cannot be profitably insured," he adds. "You need insurance regulation and some form of subsidy. My guess is that it will be a combination of the Massachusetts system and Japan's, where they tax the employer health plans to cover the cost of the people enrolled in the government-funded system," he explains.

"Health care is a service of which people can consume unlimited amounts," Holt adds. "At some point we are all sick, and we only stop costing money when we die. So we need to put some rational boundaries on it. We need to have a concept of the value we're getting, which we don't have at the moment."