MTT #108: Designer babies, chronic disease & AI-powered care

Speaker A: Foreign. Welcome to Medicine the Truth, one of the four weekly podcasts in our Fixing Healthcare podcast series. I'm, um, Jeremy Corr, host of the popular Books of medicine podcast and CEO of Executive Podcast Solutions. With me is Dr. Robert Pearl. For 18 years, Robert led the Permanente Group, the nation's largest physician group. He's a healthcare contributor at Forbes, best selling author and professor at both the Stanford University School of Medicine and Business. His Most recent book, ChatGPT How AI Empowered Patients and Doctors Can Take Back Control of American Medicine on the Impact Generative AI Will have in Healthcare, remains a bestseller. Information on a broad range of medical topics can be found on his website, robertperlamd.com Robbie for the past few episodes of Medicine the Truth, we focused on a variety of political topics ranging from limitations on vaccinations to the dysfunction in the cdc, FDA and nih. How about we start today with the actual medical issues and hopefully some positive scientific advances?

Speaker B: Jeremy I think that's a great idea. This function at the governmental level, that's disheartening. Fortunately, science hasn't waited for congressional action to advance. The first story is a breakthrough in gene editing that offers both tremendous opportunities to save lives and to to minimize tragedy, but it also contains multiple ethical considerations and risks that now need to be considered. The research was done at Columbia University in New York City, and listeners may remember that we talked in the past about a gene modifying technique that's called crispr C R I S P R. As part of our conversation, we highlighted the inventors who recently received the Nobel Prize for medicine and how CRISPR could eradicate certain inherited diseases. Today's lead story is about the researchers who used a different gene altering technique called base editing to achieve even better outcomes in embryos. And their success brings the possibility being able to reliably modify genes and correct errors in the DNA of unborn children. And it brings it one step closer. But it also raises the specter that some parents, they could request that this technique be used for genetic alterations in normal fetuses.

Speaker A: This work sounds both exciting and a bit terrifying. Let's start with the underlying science. Can you trace the history of it?

Speaker B: Jeremy As I mentioned, the first successful gene editing technique was called crispr. That's an abbreviation using the first letters of its scientific name clustered regularly interspersed short palindromic repeats. Why it's called that and uh, what it means, that's a topic for another time. But suffice it to say the technique, which was discovered in 2012, allows researchers to identify a specific Abnormal gene, cut it out and replace it with a normal one. Although this technique has a myriad of applications, when it comes to medicine, the most important one is to replace a disease producing gene with a normal gene. And for patients suffering from a disease with a specific genetic error, like sickle cell anemia, this approach offers the possibility of a normal life. Without correction, these children suffer greatly. They're likely to die prematurely. However, as promising as CRISPR seems, the science is far from perfect. And the application of it in human embryos, that's been limited. Often in embryos, a technique fails to identify the right target. And sometimes it cuts out the wrong piece of genetic information. And although it's been given FDA approval in children to treat severe cases of sickle cell disease, it's produced mixed results in the few patients in whom it has been used. Of course, some people have tried to use the technique in a broader way. Nonetheless, you may remember eight years ago, when a Chinese scientist used CRISPR to alter the DNA of three human embryos. He claimed to have produced three healthy babies with added HIV AIDS resistance. But none of the three patients have ever been seen or evaluated. The doctor was sentenced by Chinese authorities to three years in prison for his reckless work.

Speaker A: Remi this new gene editing technology that followed CRISPR sounds like a major advance. Uh, can you dive a bit deeper into the details, Jeremy?

Speaker B: The laboratory at Columbia with most recent advance was achieved. That lab has been focusing on genetic research and embryos for quite a while. We can trace their work back to 2020, when the geneticist Dr. Dieter Egley and his team decided to apply CRISPR technology to correcting an inherited form of blindness that affects children. To test the possibility of this application and to test its use of CRISPR in the laboratory, to do so, they took sperm from men with the form of hereditary blindness, and they used it to fertilize healthy eggs. This way, the embryos would have one gene that was normal from the egg and one that was affected by this genetic era from the sperm. They then used CRISPR as the tool to cut out the abnormal gene and replace it with a normal one. Unfortunately, as I mentioned earlier, the results were mixed. In some places, the genetic correction was perfect, Two normal copies of the gene being the result. But in around half of the attempts, it failed to work. And in some cases, it cut out long pieces of DNA and entire chromosomes. And were this to happen clinically, and an embryo in the womb of a pregnant mother, this would be a disaster. With CRISPR being the only gene editing technique available, the researchers saw the possibility of genetic modifications in human embryos, Ones capable of preventing horrific medical problems. They saw it as being at a dead end. Then Dr. Egny decided to make a pivot using a research technique from fellow researchers at Harvard. To understand how this works, I need to explain the makeup of the genetic material that's found in human DNA. Genes consist of a series of nucleotides. These are chemicals with a nitrogen base that form a ladder like structure along each chromosome. To understand the process, you don't need to be an expert on the exact chemical structure. But in general terms, there's an estimated 12 billion nucleotides that make up about 23 double strands of DNA. However, rather than a huge number of nucleotides, human DNA contains only four types. There's adenine, thymine, cysticine and guanine. They're usually referred to by their first letters, atcg. They work in the same way that letters are sequenced to make up words, Although in the English language, we require 26 letters from a to Z to represent our full vocabulary. In 2016, this is four years after CRISPR had been introduced. Dr. David Liu, a geneticist, and his colleagues in Boston modified the CRISPR technique. So the process, rather than cutting out the entire DNA segment, It would just nick the DNA. And then they were able to show how this approach would then allow single nucleotides to be replaced. Imagine if adenine was the right letter and by error, the DNA contained thymine. The tool would remove the A and replace it with a T without damaging the nucleotides on either side. This approach, called base editing, had already been used successfully on a nine and a half month baby to correct a genetic error that causes severe mental retardation. Having concluded that CRISPR wouldn't work clinically in embryos, Dr. Egley decided to try this alternative approach in the laboratory. Although this new research has been posted online and submitted for journal publication, at this point it hasn't been published in a peer reviewed journal, which, as you know, is the gold standard. However, Kern is under review and and assuming that it is accepted for publication, the article demonstrates that scientists can now alter DNA in embryos. Using this approach, they can replace the individual nucleotides with remarkable success and without damaging the surrounding DNA. And it opens the possibility of being able to safely prevent numerous life threatening diseases and in unborn children. What Dr. Egli and his associates did was take fertilized eggs that came from couples who weren't going to implant them and who donated them for scientific research. He and his colleagues were able to alter either the gene responsible for hemoglobin production in fetuses or a second related gene that affects blood lipids, or sometimes both. And although the technique wasn't perfect in every case, it was a massive leap forward in terms of reliability and safety from where the science was a decade before. Between 2020 and now, we've gone from the equivalent of having to rewrite entire texts to being able to rewrite pages, and now to be able to erase single letters in individual words and replace them with the correct ones.

Speaker A: Robbie, that sounds amazing. What's the problem here?

Speaker B: I agree, Jeremy. This level of accuracy, it's remarkable. And for families and children with one of the 7,000 or so very rare genetic diseases that come from these types of DNA errors, the advances are very exciting. Furthermore, for couples who have a, uh, major genetic problem in their ancestry, couples who are fearful that they could pass the incorrect genes to their children, this research offers previously unimaginable possibilities. They could go forward using IVF, knowing if the embryo had the faulty gene, the problem could be corrected. The child could have a normal life. The problem in this research isn't for these kids. The problem arises from the reality that if researchers can now modify genes with little risk of creating additional harm, this technology could be applied to normal embryos. And that realization opens the door to so called designer babies. Genetic manipulations not to correct an abnormality, to theoretically change a child's eye color, provide a few extra inches of height. Of course, this research is just the first step, with many more needed to demonstrate the safety and long term risks and the consequences of the technique. But even the possibility has ethicists terrified. And the risks are magnified when it comes to genetic alterations of embryos, since the government prohibits federal funding of any research that includes the use of human embryos. And as a result, all of this research is privately funded, which greatly increases the possibility that this revenue generating route could be taken by companies. The company funding this new research, that's Nucleus Genomics. It was founded in 2021 and currently screens embryos for genetic abnormalities. And as part of the typical IVF process, it can identify thousands of genetic diseases, as well as finding genetic patterns in the DNA that indicate a higher likelihood of adult diseases. We're talking diabetes, heart problems. But this company also can identify the genes that are associated with normal factors such as height. To be clear, most human traits say intelligence. It doesn't have a single gene, but dozens and maybe hundreds of genes contributing. And given that the more genes a person wants to alter the higher the risks of a problem developing. Many desirable traits won't be eligible for alteration. But even a small intervention for a non medical condition, that would raise massive ethical concerns and and red flags.

Speaker A: Can you expand a bit on the uh, ethical considerations?

Speaker B: As controversial as politics are, ethics are even more emotional, diverse and divisive. Powerful technology like this one, it can be used for a variety of goals and depending upon one's values and beliefs, the opportunities and outcomes can be viewed as positive or negative. The concerns that this technology will be used isn't just theoretical. Last year Nucleus, that's the company I just mentioned funding the research, posted ads in New York subways that encourage people to in quotes, have the best Baby ethicists will point to the word best and ask how is that being defined? They'll highlight eugenics across history with tens of millions of people slaughtered to achieve ethnic cleansing. They'll also point out how even the idea of one set of people being above another conflicts with many moral principles of humanity. Even the idea of using human embryos for this research is viewed as unethical by people who see an embryo as a person. To them the research is wrong because the unborn child hasn't been given permission to have its genetics altered with the inevitable risks explained. But on the other hand, there are people who are just as adamant to allow a child to be born with a terrible and devastating inherited problem when a potential solution exists that is unconstitutional, unethical and immoral. And there are dozens of mundane questions. I know you're very interested in sports. How should we classify individuals in athletic endeavors who've had their genes altered in ways to give them unique speed or strength when they break world records of competitive events? Is this just the equivalent of a performance enhancing steroid or is it just part of acceptable prenatal care as difficult as the underlying sciences? How best to solve the long list societal and economic questions at this technological breakthrough raises those will be equally great.

Speaker A: Ravi I'm enjoying talking about science and not politics for a change. What's another story?

Speaker B: Jeremy? Cardiovascular disease remains the number one killer of Americans. And for that reason preventing it is one of the greatest opportunities that we have to extend life. A study from Northwestern University and it included 9 million patients from both the United States and South Korea. It founded four risk factors in contribute in 99% of cases of heart attacks or strokes. The four conditions are high blood pressure, diabetes, elevated cholesterol and tobacco smoking. And this was true for both men and women, although the association dropped to around 95% in women under age 60. That's the subgroup of individuals with the lowest risk of a cardiovascular event and high blood pressure. This is a problem that can be controlled in 90% of patients. It was the leading contributor to these life threatening problems amongst the four factors identified. That means that a combination of diet, exercise and effective medication would have a massive impact on the health of the nation. As with so much medical research, the data doesn't prove that these chronic diseases and unhealthy habits are, are always the cause of these life threatening problems. The relationship could just be correlations rather than causations. But the data does demonstrate that programs and approaches that prevent detection control these underlying problems, be almost definitely of value to implement and most likely would have a positive impact on on longevity and overall health. And this research explains why I'm so bullish on generative AI. It can serve as a tool to reduce these risk factors, to preserve people's health and to save lives. It's also why I'm so concerned about the poor job we do today. With 50% of patients with hypertension not under control and an even lower percentage of successful control for blood sugar, 1 in 6Americans also continue to smoke. We have a long way to go, but tremendous opportunities to improve the health of our nation.

Speaker A: What else is new?

Speaker B: This one is a topic we don't discuss as often as we might and that topic is skin cancer. And among skin cancer is the most concerning cancer is melanoma. It's a malignancy that's often lethal. Research has shown the biggest risk factor for melanoma comes from sun exposure. They look at Australia, this is a huge country. In fact, it's a continent unto itself. A large percentage of the population living in Australia descends from uh, northern Europe and many are light skinned, which puts them at increased risk of melanoma. As a result, Australia is often called the melanoma capital of the world. But despite similar populations, individuals living on the north shore and the north shore has greater sun intensity due to closer proximity to the equator. Remember, it's in the southern hemisphere. The people living in the North Shore have twice the rate of melanoma per thousand individuals as people living on the less sun exposed south shore. The best way to reduce risk for melanoma is to regularly use sunscreen on, uh, all parts of the body unprotected by UV resistant clothes. But the sunscreen sold in the United States provide insufficient protection for the sun's harmful rays, particularly when measured against sunscreens sold in other countries. The good news is that the FDA has now approved for the first time in 20 years. A more effective ingredient, the chemical called momotrizonal or bemt, has been used in Europe for decades and appears to be very safe. Most sunscreens currently sold in the United States, they're effective against ultraviolet B, it's referred to as uvb. These rays are the ones that lead to sunburns. But experts say that it's the ultraviolet A or uva that is depenetrating and most responsible for cancer. The reason for the delay in approval was that the sunscreens are regulated in the United States by the FDA as medications, not cosmetics. As a result, the process of approval, it's long, it's complex. But of course, one of the things that we also have to remember is that protection depends on using a sunscreen on a regular and resistant basis. And many Americans fail to do that. For people concerned about melanoma, they should pay particular attention to the pigmented lesions on the body. The worrisome signs that may indicate a melanoma Are what surgeons refer to as the ABCDE criteria. The pigmented lesions are asymmetric. There's border irregularity inside the lesion, there's color variation. The diameter is greater than 6 millimeters, and the lesion is changing and evolving. In other words, when moles become melanomas, they tend to be larger, irregular, multicolored, and changing in appearance. When it comes to melanoma, the earlier the cancer is found, the better the prognosis, and often the more conservative the surgery can be. My take is that there are many areas of medicine in which FDA approval is too quick and based on insufficient scientific evidence. An example to me is the approval of drugs for many rare diseases when the treatments themselves have not been fully proven. And often, we learned years later, the treatments were of little or no value, and the complications were greater than expected. When it comes to sunscreens, particularly ones that have been used for two decades safely in other countries, the process for FDA approval is too slow and overly laborious.

Speaker A: Rami, what else is new?

Speaker B: Jeremy, We've talked about the growing unaffordability of medical care. Um, on multiple medicine, the truth and diving deep episodes. We now have data on projected employer and employee health care prices for 2027, and the information is distressing. Two thirds of companies are planning on raising premiums for workers, and half expect to increase deductibles and co payments that the employee will need to pay out of pocket as well. Already we've seen total premiums rise from 15,000 for a family of four two years ago to 18,500 this year. The question is at what point will smaller companies, these are the ones that aren't required to offer medical coverage. When will they decide to simply drop it for their employees? Doing that would have massive financial impact on millions of American families. Part of how fast prices are rising is the cost of, of GLP1 drugs. And as we might expect, many businesses are dropping coverage when the indication for these medications is obesity rather than diabetes. A quarter of companies in this MRSA survey said they already had made it harder for employers to obtain company paid coverage for the GLP1s, with 11% saying they had already eliminated coverage and and another 5% of companies say they're considering doing so next year. With one in eight Americans already on these weight loss medications, even some employers, we're talking Cigna, a health insurance company, have already dropped coverage. And others like Chevron, are, uh, requiring employees to undergo multiple weigh ins a month and consistently use meal tracking apps to keep the benefit. Now, all this is happening at a time when the indications for GLP1 drugs are expanding. Although originally approved for diabetes and then weight loss, these medications have now received FDA approval to prevent cardiac problems, to treat fatty livers, and to protect kidney function. And there are a variety of other problems that could in the future be added to the list, including treating both drug and alcohol addiction. As I pointed out, both, uh, in a recent Diving Deep episode at a social media video post, if GLP1 drugs were priced appropriately, let's say under $200 a month, coverage and utilization would expand dramatically with massive health benefits across the nation. And this price would allow pharmaceutical companies to remain very profitable since the cost to manufacture these medications is under $20 a month. And that's based on research from Yale University. But as we are currently seeing, the drug industry prefers massive profits over reasonable ones, despite the growing negative impact it has on Americans.

Speaker A: Rabi, let's stay with the non political themes. What's next?

Speaker B: Jeremy? The next story is medical, but there's a political component residing on its edge. As such, the narrative is one of both success and failure. The topic is the current infant mortality rate. As listeners know, the US has not only been the worst amongst a dozen peer nations in terms of infant mortality, but the number of deaths per thousand live births in the United States has become higher than the next two countries combined. But at least according to preliminary government data, last year our nation achieved an all time low at 4.5.4 deaths per thousand live births. But before listeners get too excited, that pace of improvement is teeny baby steps down from 5.6 in 2023, 5.5 in 2024, and now 5.4 in 2025. These numbers are still much higher than peer nations and absolute numbers. They too, are slowly declining as well, from 20,160 in 2023 to 20,050 in 2024 to 19,350 in 2025. But the reality is that anything around 20,000 infants dying before the age of one, that's unacceptable. The reason the U.S. mortality rate is so high or why it has declined is purely speculative. Many experts point to social determinants of health. There's more, uh, poverty in the US Than pure nations. There's far greater difficulty obtaining prenatal care for Americans than in most countries. Most of the places have universal health coverage. But a factor that some experts are pointing to in both the rise and the recent fall has to do with viral infectious diseases. We saw during COVID a steep rise in mortality felt to be driven by higher numbers of cases of RSV and flu, two infectious diseases that have the highest mortality among not only the elderly, as we see with most respiratory infections, but also in children under the age of one. These public health experts point out that the United States began to recommend vaccinations against the flu in infants and vaccination of mothers against RSV between 32 and 36 weeks of pregnancy. And these have proven to provide tremendous protection, uh, for their unborn children. However, it has been true in the past, the infant mortality rate among black mothers was still double that of white, Asian or Hispanic women. And that statistic clearly has components that reflect social determinants of health. The mortality rate also varied by State, with 9.65 infant deaths per thousand live births in Mississippi, but only 3 per thousand live births in New Hampshire. Poverty, race, and access to prenatal care were felt to m be the greatest factors accounting for this variation. Overall, this story reflects many of the challenges of the American health care system and the powerful impact that social determinants of health have. If I had to pick one example to represent the political problems that are impacting medicine today and to, uh, explain our nation's failed approach to health and medical care, it would be this one. The United States should be the world's leader in protecting the smallest and least able to defend itself part of the population, but it simply chooses not to do so.

Speaker A: Well, I guess the time has come to cover the political issues this month. Um, can you provide what you believe to be the Three biggest governmental stories.

Speaker B: Unfortunately, there are no positive breakthroughs to report when it comes to the government's role in advancing medical practice in the United States. The first big story is relative to Medicaid. The Trump administration released an interim final rule that allows states to implement Medicaid work requirements more quickly than originally authorized. This change could affect millions of people and families across the nation, and not in a positive way. Medicaid covers more than 70 million Americans, and it costs over $900 billion a year, 2/3 of which are paid by the federal government and one third by states. The program was begun in 1960s to provide medical care for the indigent, and it was tied to the nation's defined poverty level. It was expanded on the Affordable Care act in recognition of the fact that the continued rise in medical costs meant that Americans earning somewhat more than poverty level, they still couldn't pay their medical bills. When Congress passed tax reform one year ago and reduced tax rates for many Americans, the projected gap between the projected federal government revenue and the expected costs of the federal government increased significantly. And to close that gap, Congress voted to decrease funding for Medicaid by a trillion dollars over the next decade. And a, um, major part of the plan was more rigid work requirements. The regulations demand greater proof that people are either working or looking for a job or unable to work. They'll have to document the financial status twice a year rather than today only once.

Speaker A: Robbie what are the arguments on the pros and cons of this plan?

Speaker B: Jeremy Supporters of the original bill believed that there's major fraud with people continuing to enroll in the program who aren't eligible. Opponents point to data that show that this rarely happens and that nearly all people who will lose their health care coverage. We're talking families, families with small children, they're going to lose it because they made a clerical error in the forms, and they actually do qualify under the current rules. The experience from states like Arkansas, ones that implemented similar very restrictive work requirements in the past, showed that beneficiaries who lost coverage, most of them in fact nearly all, were eligible. Critics point out that from a national perspective, this whole plan makes no sense. When patients lose coverage, they still need medical care. So what do they do? They go to an emergency room. They know that the hospital has to provide medical care under HIPAA regulations. As a result, what will happen is that the total cost of medical care will rise since ERs are very expensive. And when that happens, states will have no choice but to take on a greater proportion of the total costs, eliminating the Medicare coverage doesn't decrease U.S. medical expenses. All it does really is shift the burden from Washington D.C. to each state. And since states need, they're required by the law to have a balanced budget, unlike, uh, the federal government, added health care costs will compromise other vital budgetary areas. We're talking police, fire, infrastructure, schools and rural communities, such as many of the areas of Iowa where you live. The impact is going to be disproportionately great for a couple of reasons. First, more people in rural areas are covered by Medicaid on a percentage of basis than in most urban centers. And they're likely to have more problems providing the paperwork due to the seasonal nature of much of their work.

Speaker A: Ravi what's the second story?

Speaker B: Jeremy Listeners may remember that in the past patients often found that their insurance, which covered a hospital, didn't include the doctors who worked in the ER or the anesthesiologists in the or. As a result, they received massive out of network bills for the services provided under these circumstances where they had no other choice but to be treated by the physicians who worked in the ER or in the OR. That's why the legislation passed in December of 2021 and took effect in January of 2022 was called the no Surprises Act. Prior to that time, hospitals and doctors, they often billed the patient for differences between what the insurance company paid and the bill submitted. Sometimes the insurer paid the full fee when this happened. Sometimes when this happened, the insurer paid, uh, the full bill to protect the patient. But most often they refused to do so. And then patients were caught in the middle. Some individuals and families could make up the difference, but most they couldn't afford to do so. When that happened, they frequently were sued by the doctors of the hospitals and the individuals and families had to declare bankruptcy.

Speaker A: How did these new regulations address the problem?

Speaker B: The original legislation prohibited this balance billing and it took the patient completely out of the middle. Unfortunately, that doesn't change with these new regulations. Patients will still only be responsible for the deductible or co payment required in their insurance contract, but no more. Now the battle is between insurers and providers. When there's a disagreement, the insurer submits what the company believes to be a fair payment. The doctor or hospital submits what it thinks is appropriate. An independent dispute resolution, often called an idr. An independent dispute resolution or IDR arbitrator then must concur with one side or the other. There's no splitting the difference. This is the same approach baseball arbitrators use when a player or a team can't reach an agreement and the expectation was that doing this would limit the number of disputes. However, that hasn't been the case. As part of the RDR process, the arbitrator making the decision is expected to include a calculation of how much is paid by insurers in the community, the so called community standard. And that is a point of major disagreement and previous legal suits with doctors and hospitals feeling that the community payment amount is unfair fair and that it reflects the ability of insurers to strong arm UM providers. In contrast, insurers point to hospitals consolidating markets and billing excessive amounts when they have monopoly control. Rarely did the two sides see the appropriate pricing the same. Before the legislation, many doctors didn't want to sue patients, so most just accepted the out of network fee that the insurer paid and wrote off the difference. But with legislation in place, the number of appeals filed have been far greater than anticipated. That's based on historical volume and as a result the backlogs are growing. The new regulations are designed to speed up the process. They include the ability of providers to batch up to 50 submissions that reflect the same dispute. And they add tighter guidelines on how quickly each side must submit the needed information so final decision can be reached. Both these changes should reduce backlogs, but at the same time the new regulations reduce the cost to file from $115 to only 15. So it's possible that uh, more people will avail themselves of the dispute resolution process. And what we're going to see is that delays will increase the, the reality is that ah, the cost of medical care is rising twice as fast as people's ability to pay. And until that's addressed, these type of disputes aren't going to end no matter how fair the resolution process becomes.

Speaker A: What about a third political change?

Speaker B: The final one is the efforts by cms, that's the Centers for Medicare and Medicaid Services, to reform the prior authorization process that's been imposed by insurers, particularly for expensive medications, imaging studies, procedures and surgical, uh, interventions. Doctors can't proceed without submitting the planned treatment for insurance review and approval. These requirements are uh, detested by both the providers and the recipients of medical care. These restrictions exist because insurance companies have almost no control over the provision of medical care, only the dollars that are paid for it. So they use the few tools they have to limit cost, regardless of the impact their actions may have on people and their health. It's less of a criticism than a statement of reality. Doctors and hospitals who have little incentive to rein in costs also do what they see to be in their interest, even when there are uh, massive financial implications for the patients that they treat. The current approach is being considered would require faster decisions on prior authorization requests, expand electronic authorization for medication approvals, and greater transparency about the final decisions which are reached, particularly when the requests are being denied. These tweaks like the previous ones, are unlikely to make more than a small dent in a big problem, particularly if, uh, private insurers resist implementing the same approaches as Medicare. Until there's major healthcare transformation, the improvements clinicians and patients see will be small.

Speaker A: Rabi what do you believe will make a real change?

Speaker B: Jeremy to answer that would take an entire medicine the truth episode or um, that combined with a diving deep one. But for listeners, we want to imagine when an efficient and effective medical system will would need to accomplish. I'll offer the following. First, keeping people healthy and that will mean effectively controlling chronic disease. Doing so would save as much as a trillion dollars annually. We have the medications and we have the protocols. We just need to follow them. Second, shift a significant percentage of medical care from medical offices and hospitals into people's home. And that will require acknowledgment of today's medical failures and require broad application of generative AI to empower and support patients 24 by 7 and finally, aligning incentives by moving from pay for volume, that's fee for service, to pay for value. We're talking capitation at the doctor and hospital level. Once incentives align, providers will be rewarded when they prevent disease, when they avoid medical errors, when they they control chronic conditions, when they improve healthcare delivery. And that will benefit both the providers and the recipients of medical care.

Speaker A: Robby Any final thoughts?

Speaker B: Jeremy Last week I saw two articles on the application of generative AI to medical practice. The first came from Boston Children's Hospital, where an AI tool is able to diagnose kids with unexplained illnesses that befuddled doctors, often for years and in some cases, decades. The Researchers noted that 1 in 10Americans have a rare disease and often results from a genetic error. The study was published in the New England Journal of Medicine. The second story came from the journal Nature. Medicine described a new AI tool that can find patterns in EKGs that doctors miss. The case presented involved a patient who came to the ER with symptoms that doctors thought were a result of asthma and pulmonary abnormalities in origin. But based on the ekg, the AI application highlighted the likelihood that the problem was instead cardiac in origin. Pursuing this lead, the patient's physicians diagnosed an inherited heart problem that subsequently required a heart transplant. I highlight these cases not to imply that these AI tools are always better than clinicians. They have not reached that level of expertise in most cases. But I do set a note how often commentators talk about the limitations of generative AI and the risk the technology poses when it doesn't have human oversight. They rarely mention the limitations of clinicians. I believe that the questions we should be asking aren't which is better people or technology? And instead I believe we need to ask how can we apply the combination of dedicated clinicians, empowered patients and generative AI to achieve safer and exponentially better outcomes for patients? As long as clinicians insist these tools be subservient, I predict that progress will be slow today. Today, the opportunities to use generative AI are visible in the most difficult cases. But in the future, I'm confident we will discover the power of generative AI in an ever greater number of mundane and everyday conditions and problems. And together, dedicated clinicians, empowered patients and generative AI will achieve clinical outcomes exponentially better than any of the three alone.

Speaker A: As a reminder to listeners, this episode is available on our website fixinghealthcarepodcast.com and on all podcast apps including Apple Podcasts and Spotify. If you like the show, Please rate it 5 stars and share it with your friends and family. To submit a question or comment to the host, please visit the contact page on our website or send us a message uh, on LinkedIn, Twitter or Facebook. Thank you for listening and have a great day.