The Udacity students at San Jose had an 83-percent finishing rate—including students who had been on the verge of dropping out of college—as opposed to the 5-percent rate in an ordinary MOOC. In each class, unfortunately, no more than 44 percent of students managed to pass the final exam. But considering the pool from which Udacity intentionally drew, this figure suggests possibility: in some courses almost half of the students who were “on their way out” actually passed the class.
Of course, the media didn’t see it that way. I talked with Thrun just days after those results were released and critical stories from all the usual suspects were circulating around the internet. According to the Chronicle of Higher Education, the numbers had been “leaked … to Inside Higher Ed and The Chronicle” by “the California Faculty Association, a union that has been vocal in its criticism of the Udacity partnership.”20
Thrun, however, was upbeat. He had expected they would learn a lot by taking up Bill Gates’s challenge, and they had. In short, they realized that “to be good in math requires more time than is normally given at college.” Students who were already behind needed more flexibility and more time to catch up—which online education was uniquely able to offer—but it was time they didn’t have in this case. They also found that students loved the online model, supplemented by people “on the ground,” and preferred it to traditional classes. That system “was able to really get these kids’ attention and really drive them through the program all the way to the end,” Thrun said.
That same year, Udacity announced a program aimed at a very different group—a partnership with Georgia Tech to offer a master’s degree in computer science for $7,000, beginning to end. That’s a graduate degree from one of the top-ranked computer science programs in the country, and it includes online course content supplemented by a lot of real people who have student contact and help them work through problems.
That kind of competition from Udacity and other online-learning options should put pressure on the higher education establishment, which charges students in the neighborhood of $200,000 for a four-year degree. If Udacity offered enough courses at $150 apiece to constitute a degree, it would cost well under $10,000. An education at that price would be a game-changing opportunity for millions of people who today can’t afford college or who struggle to cope with the debt. It would also have enormous implications for affordable, convenient learning for adults.
In 2013, President Obama announced a government-run, centralized system for rating institutions of higher education that will tie federal funds to a bureaucratic measurement of a university’s “value.” This is a step in the wrong direction. We should encourage more competition from upstarts like Udacity rather than locking the education system into a government formula.
Asked if he was prepared for the resistance of his Stanford colleagues and the other gatekeepers of higher education, Thrun replied, “Someone’s got to do it. I have nothing to lose. We can help get kids access to good education, important education for the nation. People understand America is the country of innovation. We’ve always innovated our way out of crisis. We have to innovate. We can’t be driven by people who are skeptics.”
Thrun is optimistic that projects like Udacity can overcome the opposition of the prison guards in education and offer American students—and for that matter, students all over the world—a real chance to break out. “Online education will way exceed the best education today. And cheaper,” he told the Journal. “If this works, we can rapidly accelerate the progress of society and the world. If you think Facebook is neat, wait five to ten years. So many open problems will be solved.”
CHAPTER THREE
BREAKOUT IN HEALTH
How much would you pay to have a heart attack? How does $45,000 sound—$7,000 out of your pocket and about $38,000 out of your insurer’s? Or diabetes? The average case will run you $9,975 every year. You can have asthma for just $3,300 annually. Other common health emergencies are really expensive: the lifetime cost of surviving a stroke is upward of a hundred thousand dollars. The average case of breast cancer is $128,500.1
If you don’t face these health problems, there’s a good chance you have friends or family members who do. Not one of them was looking to spend his hard-earned money, not to mention years of his life, dealing with an expensive medical problem.
You may be amazed to learn that these prices are not inevitable or immutable. They are a product of a badly functioning system that has gotten away with dramatic overpricing in the absence of competitive markets. The very regulatory system health professionals complain about has in fact been hiding the enormous inefficiencies that make American healthcare unnecessarily expensive.
Dr. Devi Prasad Shetty, a leading heart surgeon in India, charges $1,583 for coronary bypass surgery. The distortions in the American medical system produce a price of $106,000 for the same procedure at the Cleveland Clinic.2 Assume for a moment that the Cleveland Clinic is better. Is it sixty times better?
Dr. Shetty’s achievement is not isolated or accidental. His procedure cost twice as much twenty years ago. Then he set about methodically to eliminate waste and to lower costs so that more Indians could afford it. He now has twenty-one hospitals delivering this kind of care, and he hopes to bring the price down to eight hundred dollars in the next decade.3 There is every reason to expect that the Cleveland Clinic’s price will be even higher by then.
Despite America’s failure over the last four decades to control healthcare costs, however, there is a chance that our medical system will offer better quality and lower costs in the years to come.
In the past few years, the medical world has been rocked by two starkly different approaches to improving patients’ health. You’ve almost certainly heard of the first one, Obamacare, which Americans were promised would help them pay those pricey tabs. This approach comes with lots of bureaucrats in Washington, more regulations, IRS agents to wade through your medical bills, and boards of experts to tell you which treatments you may and may not have. Under Obamacare, the Department of Health and Human Services, the Food and Drug Administration, Medicare, Medicaid, and the rest of the healthcare bureaucracy will take over your doctor’s office. You might get a subsidy to help pay for that forty-five-thousand-dollar heart attack (then again, you might not), but you and your doctor will certainly make fewer choices about your care, while bureaucrats will make more. And by necessity, a large bureaucracy must make sweeping decisions for whole populations at a time.
While you have heard plenty about Obamacare, you might not have heard as much about a second approach to reforming our dysfunctional healthcare system. That’s because it sneaked up on us. While we were debating about insurance coverage and Medicare bills, many of the transformational breakthroughs in medical science that we had long been promised—personalized medicine, treatments based on genomics, and regenerative therapies—approached the stage of development at which they could be offered to average people. These technologies have the potential to give us much longer, healthier lives in a very different world—a world in which diabetes, heart attacks, and even cancer are either completely avoidable or merely short-term inconveniences.
Obamacare’s hyper-bureaucratized and depersonalized approach to healthcare and the new technologies of personalized medicine are headed for a painful collision in the near future. As medicine moves toward treatments that are exactly right for your problems with your body, our system for regulating and paying for healthcare is moving in the opposite direction—taking decisions away from you and your doctor and giving them to “experts” you have never met.
Many of the breakthroughs you will read about in this chapter must clear some technological hurdles before they are ready to transform medicine. When they finally come to fruition, they may look different from what we’re expecting. Other revolutionary technologies are here now, waiting for us to adopt them. What’s clear is that within the next ten years, we could achieve a breakout in health that would have been
almost unimaginable even one generation ago. In this new world, the prison guards keeping us trapped in a bureaucratic big-government healthcare system may be the greatest public health threat of all.
Personalized Medicine
If there’s a Moses of medicine, it might be Dr. Eric Topol. During a long tenure as head of the cardiology department at the Cleveland Clinic, Topol led clinical trials for a number of the major drugs on the market today. He was the first person to identify genes related to heart disease, and he is one of the ten most-cited researchers in medicine, according to the Institute for Scientific Information. Topol might be best known, however, for being the first to question the risks associated with the blockbuster drug Vioxx, which was eventually pulled from the market.
Today, Topol is the director of the Scripps Translational Science Institute and a leading thinker about personalized medicine and the future of his field. At the beginning of his book The Creative Destruction of Medicine, he describes what stands between us and a medical promised land: “Beyond the reluctance and resistance of physicians to change, the life science industry (companies that develop and commercialize drugs, devices, or diagnostic tests) and government regulatory agencies are in a near paralyzed state, unable to break out of a broken model of how their products are developed or commercially approved. We need a jailbreak.”4
We can achieve that breakout, Topol writes, by using the last decade’s giant strides in computer and information technology to rethink fundamentally how we do medicine. So far, he argues, “we’ve done virtually nothing to embrace or leverage the phenomenal progress of the digital era.” But the technology will soon enable something revolutionary: “For the first time in history,” he writes, “we can digitize humans.”5
If that language conjures some frightening images of a brave new world, don’t worry. Topol isn’t talking about downloading your brain into the Matrix. But some of his ideas sound almost as fantastic. Within a matter of years, he says, every patient in America could browse his own complete genome on an iPad. For more real-time data, tiny sensors on the skin—or even nanosensors in the bloodstream—could “remotely and continuously monitor each heart beat, moment-to-moment blood pressure readings, the rate and depth of breathing, body temperature, oxygen concentration in the blood, glucose, brain waves, activity, mood—all the things that make us tick.” These data will be available not just for patients in the hospital, hooked up to cumbersome monitoring contraptions, but for everyone at all times, accessible constantly with apps on our smart-phones.6
These breakthroughs aren’t decades away; many of the technologies are here now. An NBC News report in January 2013 showed Topol as he popped a special case onto the back of an iPhone—a case much like the ones many of us use to protect our devices—and handed it to a patient. Within seconds, the man’s fingers touched a pair of metal contacts, and a complete, bouncing cardiogram appeared onscreen. An indicator in the corner counted sixty-six beats per minute. The device, according to the report, cost only $199—the price of just two traditional echocardiograms with a technician.
“I’m used to having an ECG machine hooked up to me, and shaving my chest and putting stickem on there and putting on the electrodes or whatever,” his patient commented. “This is incredible.”
A moment later, Topol used a handheld ultrasound device to examine the man’s heart, a procedure he said would normally take place separately and cost eight hundred dollars. Later, Topol ate a handful of tortilla chips and watched on his phone as his blood glucose level responded, with data transmitted from a postage stamp-sized sensor taped to his abdomen. Any of these data and more, he said, could be monitored by doctors remotely: “You can do blood tests, saliva tests, urine tests, sweat tests—all kinds of things—through your phone.”7
Doctors will have access to all of this information, Topol predicts, plus our whole medical history in one file detailing who we are, biologically. They’ll use it to personalize treatment, monitoring patients who are genetically or constitutionally predisposed to certain problems and delivering custom drug cocktails or targeted treatments as needed. Nanosensors in the blood, for instance, might alert doctors to an impending heart attack. They could respond with precise doses of blood-thinning medication. Other sensors might monitor for early signs of breast cancer in the bloodstreams of patients who are especially at risk, while low-risk women could avoid the frequent screening procedures.
An even more revolutionary change, Topol says, could be that medicine won’t begin and end with a doctor anymore. We could have our own data. And we could harness it in entirely new ways, such as feeding it into apps that will diagnose us automatically—analyzing our ECG for early warning of a heart attack, for example, or applying pattern recognition to an image of our throats, confirming that we indeed have tonsillitis. In harder cases, we might try to crowdsource a diagnosis (perhaps by uploading segments of our personal health data to an internet forum) before we go to a doctor.
The digital era is making the old gatekeepers of information obsolete in almost every field of knowledge, and health information cannot remain an exception forever. It’s not hard to imagine that one day a “Wikipedia for medicine,” using sensor data and genetic profiles uploaded by tens of millions of people, could power a free, computerized version of Dr. House—far exceeding the capacities of even the best diagnosticians today. Such a system could keep much more granular data on treatments and results than is now reflected in clinical trials, allowing your smartphone to give you a more precise prescription than any doctor currently could.
Such intense personalization is the opposite of how doctors practice medicine today, which Topol describes as “maximally imprecise.” In what he calls “imprecise medicine,” doctors take their cues from guidelines issued by insurance companies and government agencies, guidelines that by definition are “indexed to a population rather than an individual.”8 Genomics and the new sensors (what Topol calls “wireless medicine”) are pushing medicine in a completely different direction.
Topol points to Lipitor, one of the most commonly prescribed drugs in the world, as a case study of imprecise medicine’s shortcomings. Advertisements for the drug proclaimed a 36-percent reduction in the risk of heart attack—an apparent triumph over a leading cause of death in the United States. The fine print, however, tells a different story: ‘“[I]n a large clinical study, 3 percent of patients taking a sugar pill or placebo had a heart attack compared to 2 percent of patients taking Lipitor,’” he writes. In other words, for “every one hundred patients taking Lipitor to prevent a heart attack, one patient was helped, and ninety-nine were not.”9
In the days before genomics, wireless medicine, and “big data”—the days when population medicine was the best we could do—it might have made sense to prescribe a drug to a hundred “at-risk” persons on the chance that one of them would be helped. If your doctor warned you that you were at risk for a heart attack, you would want the latest and greatest drug available. And you wouldn’t be satisfied if your doctor tried to reassure you, “But chances are you’ll be fine.” When you’re told you could have a heart attack, you want a prescription.
The medical industry today relies on this type of treatment, prescribing drugs to millions of persons who meet some broad criterion, knowing that a subset of the group will benefit. For the most part, pharmaceutical companies produce drugs that can be dispensed to these large populations. The FDA’s outdated clinical trial standards all but require it. And most doctors consider randomized controlled studies on large populations to be the paragon of evidence-based medicine. After all, they produce genuine statistical proof that at least some patients will be helped, maybe even saved, by a drug—and that is nothing to sneeze at.
But by now we should be doing much better. A decade’s worth of giant strides in science and technology should have made population medicine obsolete. Physicians should be able to identify (using sensors in the bloodstream, for instance) which three of a hundred “at-risk” pa
tients are in fact approaching a heart attack. The other ninety-seven, whom we consider “at risk” but who will never actually suffer a heart attack, should be unhappy about taking a costly prescription that may also have nasty side effects. For those patients, the drug is no good at all. “What constitutes evidence-based medicine today,” Topol concludes, “is what is good for a large population, not for any particular individual.”10
A modern medical system would place a high premium on producing a complete genetic profile for every patient and on integrating as rapidly as possible the personalization, wireless medicine, and cost-saving devices that Topol demonstrated on television more than a year ago. Every patient who is currently taking thousands of dollars’ worth of pharmaceuticals each year would become a walking, breathing, data-gathering medical machine (data that patients, of course, would own). Each person would get the most targeted, customized treatments available. Healthcare, like education, should be moving quickly toward mass personalization.
But since the passage of the Affordable Care Act—Obamacare—our medical system has been heading in the opposite direction. Just as individualized medicine has emerged as a practical possibility, the prison guards in Congress and in the vast federal bureaucracy have seized control of more of our healthcare. The so-called “reform” of healthcare has frozen an already problematic system in the past—and made it worse.
Breakout: Pioneers of the Future, Prison Guards of the Past, and the Epic Battle That Will Decide America's Fate Page 6