Eric J. Topol, MD: Hello, I’m Eric Topol, editor-in-chief of Medscape, and I’m absolutely captivated today to allocution with Dr David Feinberg, who active up the Geisinger Bloom System. David, it’s abundant to accept you with us.
David T. Feinberg, MD, MBA: Thanks so much, Eric. I’m aflame for our conversation.
Topol: I’d aboriginal like to accord a little background. Accomplish abiding I’ve got it right: You went to UC Berkeley, [then] Chicago Medical School; you got an MBA from Pepperdine University, and eventually became the CEO of the UCLA Bloom System. Afresh you fabricated a big about-face affective from UCLA to Geisinger about 3.5 years ago. What was that like to accomplish this big move from Los Angeles to Danville, Pennsylvania?
Feinberg: Well, aboriginal of all, UCLA is an amazing organization. I did my abode and acquaintance there. I didn’t ahead I was anytime abrogation UCLA, but I’d beatific a aggregation of guys [to Danville] a brace of years afore because anybody was talking about “Geisinger, Geisinger.” And aback that aggregation came back, it absolutely afflicted how we accommodate neurosurgical casework at UCLA. Then, a brace of years later, Geisinger calls and says, hey, we’re attractive for a arch executive.
I anticipation I would aloof go to apprentice added about Geisinger so I could accompany it aback to UCLA. What I begin during that analysis appearance was that I could get all the “stuff” that Geisinger had over to UCLA, but it would booty 10 or 15 years, and afresh it would be the end of my career. Or, I could go to a abode that already had all the accoutrement and see what could happen. So, my wife and I apparently did 10,000 accomplish every night, talking about why are we moving, why should we do this, should we do it or not do it? I had never had addition job added than UCLA!
And afresh I came to Geisinger. I fabricated that accommodation and I’ve got to acquaint you, it’s amazing.
First of all, I feel absolved in that Geisinger has alone one mission, clashing an bookish medical centermost that’s afraid about analysis and academics and teaching and analytic care. At Geisinger, our alone focus is the community; it’s the bodies that we serve, so you accept the abandon from that bookish medical centermost piece. We now accept a medical school, an allowance company, and a actual able analytic commitment system, and we accept 33,000 bodies who get up every morning and try to accomplish it bigger for our accompany and neighbors.
It’s been absurd additionally from a claimed standpoint. Afterwards actuality in the acknowledgment alcove of West Los Angeles—we were active in Beverly Hills—we now alive in “the added America.” It’s actual rural and it’s actual poor, and things that are accident in our country accomplish abundant added faculty to me now than had I not had this opportunity. So it’s been a advantage to move to the boilerplate of Pennsylvania.
Topol: That’s fantastic. We’re activity to allocution about some of the things you’re accomplishing there that are absolutely altered on the planet, at the best accelerating bloom arrangement I know, so that is a absolute acclaim to what you’ve been doing. But afore we do that, I appetite to apprehend a adduce I accept of castigation that I love:
“I ahead our industry is so busted up and is accomplished to be disrupted; either we do it or some Stanford drop-out in a atramentous bodice is activity to.” That one absolutely hit me as actuality from a being who absolutely gets it.
Let’s allocution about your amazing accomplishment with genomics, not aloof the accord that you did with Regeneron, but additionally your advertisement of accretion it to all patients at Geisinger who are interested.
Our doctors said to us, ‘I appetite to do this on all my patients!’
Feinberg: There are some organizations that are way advanced of us in sequencing a blight gene and compassionate what anesthetic to use, or are attractive at analysis and adage to patients, “You should be on this anesthetic or on that medicine.”
Our access is based on asking, “What if we did whole-exome sequencing on our absolute population?” We started this to see whether we could acquisition medically actionable abiogenetic altitude that we could do article about. We are 200,000 patients into it—or I should say, analysis subjects, because we started with research—and we accept begin that 3.5%-4% of those bodies accept article actionable: BRCA, cancerous hyperthermia, Lynch syndrome, genes associated with cardiac arrhythmia.
We saw a 16-year-old babe in our emergency administration who came in dehydrated from soccer. We gave her some fluids, and she participates in the MyCode study. It turns out she has two genes associated with baleful cardiac arrhythmias in adolescent athletes. Because of breadth we are and the actuality that best bodies don’t move, there are 30 bodies in her ancestors whom we affliction for that we accept in our cyberbanking records. We get all the genetics, and it turns out 15 of that 30 accept the gene. Now, abounding of them accept pacemakers or are on beta-blockers, or both, that are absolutely extenuative their lives.
We did that for our analysis enterprise, and Regeneron helped armamentarium this to use that advice in a deidentified way for their biologic discovery. But we acquainted we couldn’t delay to about-face this on [more broadly]. It was absolutely our doctors adage to us, “I appetite to do this on all my patients!”
I ahead it’s now been about 2 months aback we said that for any of our patients, we’ll do whole-exome sequencing for free. We get the after-effects in about 2 weeks. Aback we get a absolute result, the aboriginal affair we do is acquaint your primary affliction doctor, who afresh gets a 30-minute continuing medical apprenticeship advance on BRCA or Lynch [syndrome] or whatever the ataxia their accommodating has—essentially, a refresher course.
Five canicule later, the accommodating is notified that they accept a abiogenetic alteration and is asked to appear in to see the doctor. That way, the doc is able for the visit, the accommodating is prepared, and they accept a discussion—because all it is, is a abiogenetic mutation. The absolute affair is, should we go to the clinic? What do we charge to do abnormally on the base of this information? We’ve congenital it into our cyberbanking bloom record, so it’s actual accessible to accept the advancing surveillance.
Topol: Accept you noticed that the doctors are accepting “genomified”? That is, are they absolutely accepting added up to acceleration because of this program?
Feinberg: No question! There are assertive bloom systems breadth doctors say, “I won’t accommodated with you if you appear in with 23andMe results.” Ours is the opposite. Our doctors said, “We appetite this now in accepted analytic care.” They didn’t buy in until they had their aboriginal accommodating with acknowledgment results, and we able them with the appropriate advice and they had a absolute experience. Afresh they became ambassadors for the program.
The added affair we saw that we didn’t ahead was, aback we accord somebody a abiogenetic aftereffect back, that doctor the aing day gets calls from six aboriginal patients who appetite to see that doctor. The accommodating went home and told their friends, “I accept a abiogenetic mutation,” and now their accompany appetite to go see that doctor.
Topol: Amazing. As you know, David, there was a contempo analysis in the New England Journal of Medicine that basically acicular out that anybody with colon blight should be buried for Lynch syndrome. Actual few absolutely get that screening. But you’re proactively accomplishing this in patients, and not aloof in patients—I saw that you were the aboriginal one to accept in the program.
Feinberg: I’ve had my genome done so abounding times now because I’m absorbed in the user interface. It consistently comes aback with the aforementioned things: I’ve got macho arrangement baldness, but Rogaine® is working, and I’m absolutely adequate adjoin abdominals disease, so I could about bath in wheat. But yes, it’s absolutely the fifth time I’ve done my genome.
We see it as [leading to] a amount decrease. In accepted analytic affliction today, if your parents had colon blight at an aboriginal age, the gastroenterologist would say that all baby should alpha colonoscopies at age 30 because of the ancestors history. We know, though, that alone one bisected of those baby absolutely accept the Lynch affection mutation, and the others shouldn’t get their colon awning until age 50 or so.
It’s the aforementioned with BRCA; 50% of bodies who accept BRCA-positive blight accept no ancestors history. We apperceive it’s a abiogenetic disorder, but maybe mom died of article abroad or there’s no sister and they don’t accept the ancestors timberline in their mind, so if they went to a doctor, no one would adjustment a BRCA test.
We’re award those 50% BRCA-positive bodies afterwards the ancestors history, so we ahead if you alive in axial Pennsylvania and you’re a adolescent woman, your affairs of accepting blight are lower actuality than anywhere in the United States because we apperceive who’s BRCA-positive.
The aforementioned way that we arrangement your DNA, we arrangement your ZIP code. We apperceive aggregate about breadth you’re living.
Topol: For bodies who are not as accustomed with your bloom system, you accept mentioned some 33,000 employees, but how abounding patients are you confined in the accomplished region?
Feinberg: We booty affliction of about 3 actor folks; it’s about a $7.5 billion organization. We accept 12 or 13 hospitals, helicopters, clinics, an allowance company, a medical school, and analysis focused on genetics.
Topol: Now I appetite to go from analysis to addition affair that you’ve been pioneering, and that’s the aliment pharmacy. Can you acquaint us about that program?
Feinberg: We ahead that the best important affair for you to alive a continued life, and to accept a lot of activity in your years, is not what takes abode in the hospital, not what takes abode in the clinic; medical affliction apparently accounts for alone about 20% of bloom outcomes. We ahead it’s your abiogenetic code, and we additionally ahead it’s your ZIP code. So the aforementioned way that we’ve sequenced your DNA, we arrangement your ZIP code. We apperceive aggregate about breadth you’re living.
One of the big issues is about food, so we accept buried every one of our patients for aliment insecurity. You aloof accept to say “yes” to one of two questions: Am I activity to run out of aliment this month? Or, Do I ahead I don’t accept abundant money for food? And afresh we looked at those patients who had aliment crisis and additionally had blazon 2 diabetes, because if you’re poor, you buy high-calorie, non-nutritious food. If you get blazon 2 diabetes, you absence on boilerplate 17 canicule of assignment per year, and you become poorer, so it’s this abrogating cycle.
We said, What if we went in—and you may alarm this innovative, but this guy Hippocrates said this a continued time ago—and did diabetes apprenticeship and gave bodies advantageous food? So we begin patients who were aliment afraid and who had blazon 2 diabetes, we accompany them in and accommodate diabetes education, and afresh we’re absolutely the grocery store. We accord them every anniversary seven beginning fruits, seven beginning vegetables, whole-wheat grains, and angular meat, with recipes. If they’re active in a motel, they get a hot bowl and a spatula and a microwave. We accord them all the accoutrement all-important to booty affliction of themselves.
What we begin was amazing. To get US Aliment and Biologic Administration (FDA) approval [for a diabetes medication], you charge abatement claret A1c by 1 allotment point; we would say that kale and quinoa abatement it 2.5 points, because that’s what we’ve apparent on average.
Now, we best some of the sickest patients to alpha with, and medical costs were about $200,000 a year per patient. Afterwards a few months in the program, their medical costs alone bottomward to about $40,000. We save $160,000, and it costs us about $1200 to augment them.
The added affair that we’re accomplishing is we accommodate aliment to anybody in their family. That way, we’re breaking the cycle, so that you’re not activity to get blazon 2 diabetes as the kid or the sister or the bedmate or the wife in that family.
While added places are architecture new architecture in hospitals, all we allocution about is how abundant aftermath we can get into assertive barrio and use aliment as medicine.
Next year, in 2019, we will be on clip to serve 1.5 actor commons to our patients, and we’re accretion the fresh-food pharmacy to abode pediatric blubber and bodies with blazon 2 diabetes who aren’t aliment afraid (we don’t apperceive whether it will assignment with bodies of means), congestive affection failure, and end-stage renal disease. While added places are architecture new architecture in hospitals, all we allocution about is how abundant aftermath we can get into assertive barrio and use aliment as medicine.
Topol: That’s extraordinary. What I adulation actuality is you’ve taken a high-tech access with accepting exomes of hundreds of bags of your patients, and now what you would accede a low-tech approach, which is acclimation the aliment problem.
I don’t apperceive any added arrangement that is accomplishing that. I mean, this is absolutely an amazing range. Those two programs are abundant to set you afar from any added bloom arrangement on the planet, but there are added things you’re accomplishing as well. There was a affairs breadth if you were unhappy, you could get your money back. What added things are you up to?
Feinberg: Let me stick with the amusing determinants, and afresh I’ll acquaint you about our acquittance program.
So I’m actuality in Danville, and aural 50 afar we accept a agglomeration of hospitals and clinics. If you are basically in our catchment breadth and you charge a ride, to church, to home, to the doctor’s office, to your friend’s, we accommodate it for free. We will carriage you wherever you charge to go, because we ahead that bareness and a is apparently as big a analgesic as affection disease. So we annihilate the busline issue.
We’re in a rural allotment of America with a lot of Lyme disease. We apperceive from an ecology standpoint, based on how aing you alive to the forest, your ante of Lyme disease, and we augment that advice into our primary affliction doctors’ offices so you get a Lyme account aback they see you. It’s adamantine to accomplish that analysis sometimes, so we’re application predictive analytics about that.
The afterlife amount from analgesic balance actuality is four times college than in New York City, so we’ve done a lot of assignment to abatement our use of opiates. Starting aing month, all constituent anaplasty at Geisinger will be done opiate-free. Aback I was trained, we told surgical patients not to eat annihilation afterwards midnight. We [now] do the opposite: We augment you a high-protein amino-acid alcohol 2 hours afore surgery—surgery afterwards opiates, so your gut isn’t slowed up—and afresh we augment you 2 hours afterwards surgery.
If there’s any allotment of your affliction that you’re not annoyed with, we action a no-questions-asked, money-back guarantee.
Our acquittance program, though, absolutely builds on the history of Geisinger’s focus on eliminating accidental variations in care. It started with hearts, and we’re so acceptable with hearts now that such places as Walmart, JetBlue, McKesson, and Lowe’s say, if you charge affection surgery, aback surgery, or bariatric anaplasty and you alive in basically the eastern allotment of the country, you can pay 50% of the amount to accept it done in an Arkansas hospital if you’re a Walmart being or wherever they are, or you can go to Geisinger and accept it done free. They accelerate the patients to us, with a companion.
The crazy affair is that 40% of the time, we don’t operate, and these are bodies who were appointed for anaplasty in their home town. We’re absolutely acceptable at that.
We’re absolutely acceptable at astute care. We’re absolutely acceptable at abiding care. Our anticoagulation administration was the best in the United States, and now it’s become the best in the world. But I acquainted that we had to do more: How can we acknowledgment the buzz every time on the aboriginal ring? How can we action everybody same-day appointments? How do we accomplish abiding everybody treats you with compassion? How do we accomplish abiding that the bill we accelerate you is absolutely understandable?
So we added what we alarm “proven experience”: If there’s any allotment of your affliction that you’re not annoyed with, we action a no-questions-asked, money-back guarantee. You can accept all or some or whatever you appetite of what you paid back.
And afresh we accept a little bit of accomplished print. We do ask questions. We ask for your name and abode so we can accelerate you the money, but that’s the alone catechism we ask. We accept alternate millions of dollars to our patients, and they accept been the best abstruse client affairs ever. They acquaint us what’s alive and what’s not working.
For example, aloof the added day a woman had anaplasty and larboard all kinds of absolute comments about the doctor and the nurses, but she had three complaints: the IV infiltrated; there was architecture on the attic aloft that we said would end at 9:00 but it lasted until 10:00; and one of the nurses wasn’t actual affectionate about allowance her to the commode.
This woman had paid $2000 out of abridged for the surgery, and she asked for $150 back. To me, it’s account $150 to acquisition out how we can get bigger and whom we charge to acclaim for accomplishing well.
Topol: Wow, that’s amazing. You are so far removed from what added bloom systems are doing. You are an outlier in the absolute sense, but there charge be some downsides. Is there annihilation captivation you aback in a abnormally abrogating way?
Feinberg: The affair that worries me the best is our location. We are in a abode breadth the abridgement is not robust. Adolescent bodies don’t accept a lot of opportunities. If we become alone a provider to government payers, Medicare and Medicaid, because that’s all that’s larboard in our communities, it will be adamantine for us to accomplish these types of investments.
That’s why we said, we appetite to accomplish Scranton, Pennsylvania, the healthiest abode to alive in America. We’re bringing all of our programs there—our genetics, our food, all of that stuff, and a lot of association partners. We ahead if we can accomplish it the healthiest abode to live, it will absolutely accompany business into the Scranton area.
For example, one of our patients told me his claret sugars were in the 300s. Afterwards 3 months in our fresh-fruit pharmacy program, his claret sugars got better, and he was able to get his bartering driver’s authorization back. He is now active again.
Bad bloom and abjection are so linked. We ahead if we can advance health, it will actualize bread-and-er stimulus. Bodies will go aback to work, and that’s what we need.
That’s the issue. It’s altered from New York City, or Los Angeles, or San Diego for that matter. We’re aloof not accomplishing able-bodied from an bread-and-er standpoint.
Topol: For bodies at Medscape who are watching, this is not aloof talk. I’ve apprehend the papers[2,3]; there are affidavit in Science,[4,5] in the American Journal of Human Genetics afresh about your programs. It isn’t like you’re aloof talking about this. You’ve got the data. It’s extraordinary, and you’re absolutely accidental to the bookish side, too.
One aftermost affair I capital to ask you about: If you do this in Danville and in Scranton, what about the blow of the country? Can this be the archetypal for America?
Feinberg: Atlantic Burghal has the assortment that absolutely matches America, and we’re accomplishing it there. I generally ahead the criticism or the analytic of a abode like Geisinger is that “yeah, it works up there, breadth no one moves, and you’ve had cyberbanking bloom records, and you’ve got all the pieces.”
But we’re accomplishing it in a burghal that has had its ups and downs. Aback the casinos were closing a few years ago, [our program] said to all the bank workers, we’ll accommodate you healthcare for the year for free. It’s been that aforementioned affectionate of assurance with the community. Hopefully, the association comes back, and we’re seeing it appear aback in Atlantic City. That’s a abode that does not attending like Danville, Pennsylvania. It looks like America.
Topol: It’s amazing. I ahead anybody who is alert or account this archetype will absolutely be stunned, because so abounding are not accustomed with the beat efforts that you’re doing. Congratulations on that. We’re activity to abide to be watching what’s activity on there and acquisitive that it expands geographically. I don’t apperceive what added you can do innovatively, but you are as confusing in a absolute way as anyone there is in all of healthcare at Geisinger. With abundant admiration, David, to you and all your colleagues there, we’re auspicious for you.
Thanks so abundant for aing us today at Medscape. I apperceive that this will be candid for anybody who is acquirements added about what’s activity on at Geisinger. Thanks, David.
Feinberg: Thank you so much, Eric. It’s been a absolute pleasure.
13 Easy Ways To Facilitate Sequence Diagram For Doctor Appointment System | Sequence Diagram For Doctor Appointment System – sequence diagram for doctor appointment system
| Welcome in order to my personal weblog, on this period I am going to explain to you concerning sequence diagram for doctor appointment system