A Future We Make for Ourselves: Should We Expand Imperfect Treatments, or Create New Ones?

The Supreme Court's recent decision on health care exposes an age-old debate: focus resources on the treatments we have, or set our sights on pricey research for future cures?


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As the discussion triggered by the Supreme Court's recent health-care decision continues to swirl, we will need to ask ourselves whether medicine -- both clinical practice and scientific research -- should focus on the development of novel treatments or instead on ensuring that existing treatments are effectively used.

Health should be thought of as a function of two attributes: potential health -- a matter of identifying the best medical outcome available -- and attained health, or how close we come to achieving this goal.

When most of us think about medical breakthroughs, we think of advances that can increase our potential health -- a new drug for cancer or HIV, an improved transplant procedure, a novel vaccine. Like many of us, I take great comfort from the fact that so many resources are devoted to trying to cure the diseases that threaten to kill us.

But there's a second school of thought struggling to be heard, with growing success. When advocates of attained health survey the landscape, they see an appalling misallocation of resources. They see a lot of money being used -- in both research and practice -- to produce what are often only slight advances at best in potential health, and they believe that this money and time could be spent much more effectively by improving how Americans access the existing treatments now available.

From the attained-health perspective, some patients have little or no access to health care at all, and in other cases, patients and physicians make inefficient use of the health knowledge and therapeutic options that already exist; both these critiques ring true. If we could just make better use of what we have, argue proponents of attained health, we could make a profound impact on health.

To be clear: even attained-health proponents would dearly love to offer cancer patients a magic pill, just as potential health advocates earnestly would like to see all patients receive the best treatment. The difference is one of prioritization and emphasis.

There's also an obvious if imperfect political overlay here as well: most attained-health proponents tend to focus on the overall value to society, and imbue their arguments with the language of social justice. They worry that our fetishization of biomedical science and technology may have blinded us to the limitations of what we can accomplish and what we are likely to achieve. They worry about the excessive use of expensive technology to deliver what they see as proportionally little benefit -- hence their focus on "value."

Most attained-health proponents also feel that a lot of the dollars flowing into biomolecular research could be better spent improving care delivery and determining how best to use existing technology, giving rise to their emphasis on algorithms, best practices, and improving measurement (something I agree that medicine urgently needs).

Meanwhile, potential-health advocates emphasize the value of individual opportunity, and the downstream impact that that can have on society as a whole. Better to focus on the development of new treatments, as doctors did with the polio vaccine, rather than concentrate on improving access to inadequate solutions, such as the iron lung.

The focus on algorithims and best practices among attained-health supporters concerns many potential-health advocates, who worry that it will lead to a standardization of medicine that might dampen innovation; they also worry that asking doctors to simultaneously contemplate what's good for society as well as what's good for an individual might compromise the care of the patient, undermining the fundamental basis of the doctor-patient relationship. I share these concerns as well.

While it's a false choice to suggest we need to decide between potential and attained health, it's useful to appreciate the assumptions and ambitions of each approach -- not only from a policy perspective, but from an entrepreneurial perspective as well. Businesses founded around potential health (such as Genentech) usually aspire to deliver novel cures; companies focusing on attained health (such as Castlight) tend to emphasize the delivery of value.

The question, of course, is whether it's gloriously ambitious -- or foolishly impractical -- to expect anyone to deliver both.