A clever study by Bert Vogelstein & team of the impact of genetics on health outcomes was released last week. The study found that generally two people with the same genome (i.e. twins) were not significantly more likely than average to suffer from diseases with a genetic explanation. (n= 53,000 x 24 diseases.)
For some reason, the study's conclusion was trumpeted as revelatory, but I think this is overblown - we have long known that genetics does not dictate general health outcomes, but rather describes a general and remote tendency. We've also known that your "regular" genome does not equate to your "diseased" genome.
We've known for ~50 years that behavior and environment can have a tremendous impact on health outcomes (if you're a heavy smoker or work in a coal mine, your probability of lung cancer skyrockets regardless of your genome), and we're beginning to understand how other 'codes' such as the ribosome code and also epigenetics 'controls' DNA (though we're still far, far away from completing that understanding), so it shouldn't surprise that genetics is only a part of the health equation. If anything, the study above confirms once and for all that genetics - while part of the equation - isn't a majority explainer or even a plurality of the explanation. (Except for genetic disorders (like Tay-Sachs disease.) This isn't examined by the study.)
What I'm taking away from the Vogelstein study is that many of the public policy/privacy fears related to genomics are overblown - there are legitimate reasons to control access to your DNA - but in most cases, your insurance company learning that you have a gene that increases your likelihood of colon cancer by 10%, is less important than the insurance company knowing that you work at the Springfield nuclear plant.
Another good point here by Eric Topol: our current genetic understanding is based on a few dozen whole genome studies. It might be wise to wait until the 'n' = 1,000,000 or more profiles.
Showing posts with label policy. Show all posts
Showing posts with label policy. Show all posts
Wednesday, April 11, 2012
Friday, March 9, 2012
$1,000 genome a BAD idea?
So postulates Ezra Klein, policy wonk extraordinaire, in the Washington Post.
Klein worries that cheap sequencing could harm the health insurance industry:
"Those with a clean genomic result might go for a cheap catastrophic plan, while those with a high risk of developing pricey illnesses will opt for more comprehensive insurance…….The result would be, in insurance terms, an 'adverse-selection death spiral,' as the healthy opt out of expensive insurance, the sick opt into it, and premiums spin out of control."
Klein also argues that cheap sequencing guarantees an eventual individual mandate.
I call bull-feathers to all the above. Here's my reasoning:
-Our genome is not our pre-destination. (especially what epigenetics research keeps telling us).
-I suspect that even if it were, our health care costs have more to do with our behaviors than our pre-disposition. (Does someone's pre-disposition to Alzheimer's have a greater cost than their really bad diet and sedentary behavior resulting in diabetes?)
-You'd have to believe that treatment guided by sequence is a bad thing, because someone who lives longer ultimately costs more. If you've read any of the early impact stories from clinical sequencing, you see how detecting and treating childhood genetic diseases have the opposite and hugely positive impacts - both in terms of lives and $$$.
As for Klein's point about the necessity of individual mandates: Like a good wonk, Klein intends to see everything in healthcare in black or white - you're either fully covered, or you're not. I've argued for a long time that health insurance should be broken into 2 products "everyday, regular health insurance," and "catastrophic care insurance."
Everyday insurance is targeted towards things like broken bones, torn ACLs, delivering babies, or even diabetes treatment. Some would want to just pay "everyday" costs out of pocket, but if not, this insurance product would be VERY affordable, and the 'free rider' problem would be minimized.
The bulk of healthcare costs are driven by "catastrophic care." (I think the stat is that more than half of healthcare spending is for the last 6 months of life, or something equally eye-popping.)
If you're convinced that your predisposition to Alzheimer's means you don't have to worry about cancer, then you need not buy catastrophic insurance (likewise if you had neither predisposition), but I think most would buy some form of catastrophic insurance.
No matter, even with future health clarity driven by genomics, most would want at least one of the 2 insurances, greatly mitigating the adverse selection problem and obviating the need for an individual mandate.
Klein worries that cheap sequencing could harm the health insurance industry:
"Those with a clean genomic result might go for a cheap catastrophic plan, while those with a high risk of developing pricey illnesses will opt for more comprehensive insurance…….The result would be, in insurance terms, an 'adverse-selection death spiral,' as the healthy opt out of expensive insurance, the sick opt into it, and premiums spin out of control."
Klein also argues that cheap sequencing guarantees an eventual individual mandate.
I call bull-feathers to all the above. Here's my reasoning:
-Our genome is not our pre-destination. (especially what epigenetics research keeps telling us).
-I suspect that even if it were, our health care costs have more to do with our behaviors than our pre-disposition. (Does someone's pre-disposition to Alzheimer's have a greater cost than their really bad diet and sedentary behavior resulting in diabetes?)
-You'd have to believe that treatment guided by sequence is a bad thing, because someone who lives longer ultimately costs more. If you've read any of the early impact stories from clinical sequencing, you see how detecting and treating childhood genetic diseases have the opposite and hugely positive impacts - both in terms of lives and $$$.
As for Klein's point about the necessity of individual mandates: Like a good wonk, Klein intends to see everything in healthcare in black or white - you're either fully covered, or you're not. I've argued for a long time that health insurance should be broken into 2 products "everyday, regular health insurance," and "catastrophic care insurance."
Everyday insurance is targeted towards things like broken bones, torn ACLs, delivering babies, or even diabetes treatment. Some would want to just pay "everyday" costs out of pocket, but if not, this insurance product would be VERY affordable, and the 'free rider' problem would be minimized.
The bulk of healthcare costs are driven by "catastrophic care." (I think the stat is that more than half of healthcare spending is for the last 6 months of life, or something equally eye-popping.)
If you're convinced that your predisposition to Alzheimer's means you don't have to worry about cancer, then you need not buy catastrophic insurance (likewise if you had neither predisposition), but I think most would buy some form of catastrophic insurance.
No matter, even with future health clarity driven by genomics, most would want at least one of the 2 insurances, greatly mitigating the adverse selection problem and obviating the need for an individual mandate.
Tuesday, February 21, 2012
Werd!
Former FDA Commissioner and NCI director Andrew von Eschenbach has a good editorial in the WSJ about how the FDA needs to modernize to help patients and the medical industry.
I was particularly struck by his point that the FDA regulatory responsibility covers $.25 of every dollar in consumer spending - from tobacco products to vaccines. In essence, the FDA's mission applies as much to sprouts (which have been subject to e.coli breakouts) as stem cells.
von Eschenbach does't propose it, but what if the "D" part of the FDA was spun out into its' own agency? With an organization built specifically for regulating modern medicine, we might end up with regulations and processes optimized for 21st century medical innovation.
I was particularly struck by his point that the FDA regulatory responsibility covers $.25 of every dollar in consumer spending - from tobacco products to vaccines. In essence, the FDA's mission applies as much to sprouts (which have been subject to e.coli breakouts) as stem cells.
von Eschenbach does't propose it, but what if the "D" part of the FDA was spun out into its' own agency? With an organization built specifically for regulating modern medicine, we might end up with regulations and processes optimized for 21st century medical innovation.
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