Monday, August 3, 2009

Health Innovators Series: Dean Ornish on improving Health and Wellbeing

Dean Ornish is considered one of the most thoughtful spokespersons for comprehensive lifestyle change as a way to reverse chronic disease without drugs or surgery. His research, speaking, writing, and programs have influenced millions of people throughout the world.

As part of the development of the X PRIZE, we have had some great conversations with health innovators throughout the health industry. Dr. Dean Ornish, who has been a staple on morning talk shows as an authority on health and wellness, is the founder and president of the nonprofit Preventive Medicine Research Institute in Sausalito, Calif., where he holds the Safeway Chair. He is clinical professor of medicine at the University of California, San Francisco. Ornish received his medical training in internal medicine from the Baylor College of Medicine, Harvard Medical School, and the Massachusetts General Hospital. For over 30 years, Ornish has directed clinical research demonstrating, for the first time, that comprehensive lifestyle changes may begin to reverse even severe coronary heart disease, without drugs or surgery. Recently, Medicare agreed to provide coverage for this program, the first time that Medicare has covered a program of comprehensive lifestyle changes. He recently directed the first randomized controlled trial demonstrating that comprehensive lifestyle changes may stop or reverse the progression of prostate cancer. His current research shows that comprehensive lifestyle changes affect gene expression, "turning on" disease-preventing genes and "turning off" genes that promote cancer and heart disease.

The research that he and his colleagues conducted has been published in The Journal of the American Medical Association, The Lancet, Proceedings of the National Academy of Sciences, Circulation, TheNew England Journal of Medicine, the American Journal of Cardiology, and elsewhere. A one-hour documentary of their work was broadcast on NOVA, the PBS science series, and was featured on Bill Moyers' PBS series, Healing & The Mind. Their work has been featured in all major media, including cover stories in Newsweek, Time, and U.S. News & World Report. He is the author of six best-selling books, including Dr. Dean Ornish's Program for Reversing Heart Disease, Eat More, Weigh Less, Love & Survival, and his most recent book, The Spectrum. He writes a monthly column for Newsweek magazine.

We had the privilege to discuss the Healthcare X PRIZE with Dean early this year:

Tell us a little about how your career in health promotion evolved?

I began in 1977 with a series of studies how very simple choices—eating, stress levels, smoking, exercise, and social interactions could have powerful difference in health and well being. These types of studies are somewhat interesting, as it is somewhat challenging to get funding for such basic behavioral choices. However, starting with heart disease, we were able to show that basic diet and exercise can not only prevent but can actually reverse heart disease.

This was obviously impressive and caused quite a stir so we began to validate it with Mutual of Omaha. We were able to show a reduction in angioplasty rates within the first year that we formally substituted diet and exercise interventions instead of the angioplasty procedure itself. This amounted to a $30K/patient savings in our 3,000 patients. Because of the overwhelming evidence, ultimately medicare decided to cover the expense of our program as a benefit.
Moving from that success, we were able to show that we could also reduce or reverse the progression of prostate cancer. We also showed this for diabetes, hypertension, and cholesterolemia when incorporating very simple interventions. Inner Heart (which includes simple behavioral changes), COURAGE Study (angioplasty vs. medical therapy), and several other efforts showed us that if you can motivate people and leverage technology appropriately you can acheive impressive results with minimally invasive therapies.

Based on that success, how have your ideas spread?

Well, we have sought to train people to understand the cause of these issues and to address them at the most basic levels of health - understand how loneliness, depression, nutrition, etc all combine to affect what we term "health". As part of our work at the institute, we have been capturing and publishing this methodologies for more than a decade. More recently, we are working on creating online versions of this material to help people have a direct impact on their own health. I think the message of a proactive patient being good for the health care partnership is certainly getting out.

I often say that suffering can be powerful catalyst to transform our lives for the better. It seems that the “pain” we continue to experience from our health care system is ever increasing. I am not sure we have gotten to heart of the problem as of yet. My sense is that doctors are so busy mopping up the floor that no one has thought to turn off the sink. I would love to see us continue to work in ways that allows the bodies natural power of health to work for more and more patients.

What have been some of the barriers to getting this particular message out?

Its funny, when we were organizing some of our first trials, we had to get “permission” from NIH that it would be “safe” for the older study participants to walk, eat vegetables, meditate, and undergo the type of natural treatments we promoted. Later on, even when we were started to back some fairly impressive early study results, we found that our “evidence” was falling on deaf ears. It was not enough to have data, but we had to battle an entire culture and financial mindset that was trained and paid to use drugs and surgery as the only tools in the arsenal.

This was actually a bigger problem than we anticipated. Physicians were trained not to provide appropriate counsel or advice, as they had limited time to speak with people, and they weren’t even paid to provide this service anyway. We have subsequently tried several new channels to use high tech to make these issues known and our concept of health care more fun, sexy, and cool. So while we gather additional evidence about our message, we have also sought to improve the effectiveness of the messenger.

What do you see as some potential areas of innovation that might evolve from the Healthcare X PRIZE?

Something we have talked about alot is a new model of delivery that leverages technology to make everything much more personalized. Our computing power is such that we can personalize down to the individual level - we should be able to develop programs that help make it easier to define your health goals, outline the resources required to achieve these goals, and deliver it to you in whatever form you want. I think is very much along the lines of a “personalized health advisor” that provides both advice but also resources.

This model would have to be “mindlessly mindful” like using a Mac, or as Mark Zuckenberg says, enable “elegant organization” to emerge from the mass of chaotic health information on the web. We need to spend the time to make this as easy as possible for someone to be healthy. I also believe that we could create metrics that truly motivate people to make and maintain all the beneficial aspects of their behavior changes. Furthermore, I believe with the right combination of tools and technology this could not only be medically effective but also very cost effective.

You frequently mention changing behavior - what have you found to be effective ways to help people to make fundamental behavioral changes?

Look, risk factor reduction is boring, medication compliance is manipulative, and disease management is like outsourcing your mother in law to constantly nag you. What we need to do is find ways to interact with people and their health that are pleasurable, joyful and fun - this would make these efforts sustainable. Delivered in this way, these types of programs become motivational, shareable, and collaborative. Behavior change is tough, we should approach is from the positive as opposed to the negative side.

We are also certainly aware of the power of money to change peoples behaviors. We see this economically all the time and we should learn how to incorporate this medically as well. I have been actively involved with Safeway Health’s efforts at creating an incentive structure that actually rewards the type of fundamental behavrior changes you mention. In reviewing their health experience, they found that four chronic diseases accounted for 80% of their health care costs. More importantly, they realized that all four were addressable through lifestyle alternations. So they initiated a program whereby they reward their employees with reduced premiums for making smart health choices. Those who don’t make healthy choices pay more. Pretty simple stuff. They have been smart about only applying this differential premium program to very clear behavior choices. The results have been impressive - they have enjoyed flat premiums for nearly two years in a row with more and more of their employees utilizing this program all the time.

Physicians are not well trained nor compensated for counseling and followup work required to make fundamental behavioral change. How do you suggest they participate in this process?

Well you hit on a significant issue. In your seven minute hamsterwheel visit with a patient, there is no time to discuss this often complex issues. It is far easier to grab for the pen and write out a prescription for lipitor than it is to spend 30 minutes reviewing nutrition, exercise, and related behavioral modification plan. However, if the patient comes informed, and the provider is willing to work with ancillary health workers (dietician in this case), then a true care team can be formed and true behavioral change has a chance to happen. In this setting, change can happen quickly and be more long lasting - with often dramatic results. I believe you could achieve a 50% reduction in health cost related to heart disease by implementing our program.

However, to achieve this would require a complete upheaval of the current payment mechanisms to the current players. We currently practice "reimbursement-based" medicine versus the evidence-based medicine that is the ideal. Angioplasty and cardiac surgery are big time money makers for hospitals and physicians. Both of these entities are actually, quite perversely, incented to not want to dramatically reduce the number of these procedures as they are a significant source of their income right now. Even insurance companies, can be put in a position where they are incented to pay for surgery of a diabetic foot versus the foot care that would ultimately prevent the surgery. I am hopeful that some of the innovation that comes out of the X PRIZE might be addressed toward the entire incentive structure of health care.

How do you see the health industry evolving over the next couple of years?

We are already seeing a slow shift to consumerism. I believe that consumers will want more and more choices of alternative to traditional western medicine. I am also seeing a simplification, wherein patients are choosing to use low tech solutions to solve their health issues as opposed the latest and greatest MRI device. I also see that the internet will make us all health citizens where we are finding patients like us, reviewing treatments alternatives, and accelerating the shared human health experience. The web will continue to enlarge our health possibilites just as it has expanded the possibilities in every other industry.

On a side note, I was pleased to see the President Obama selected Tom Harkin, a good friend, to play a critical role in the health reform efforts coming out of the Whitehouse. The reason this is great is that Tom is steeped in the wellness and prevention tradition and will have a critical role at the health care

Who are the other innovators in this space that we should be speaking with?

I can think of several - Tom Harkin as I mentioned preivously, Larry Keeley from the Dobblin Group, and Steve Brown (physicist in Menlo Park who helped develop the health hero network). Each one of these individuals is doing wonderful work in the health promotion arena.
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