COMMENTARY

The New, Old World of Functional Medicine With Dr Hyman: Part 3

Hansa Bhargava, MD

Disclosures

October 12, 2016

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Editor's Note:
This is the final part of a three-part interview with Mark Hyman, MD, director of the Center for Functional Medicine at Cleveland Clinic. (Click to access part 1 and part 2.) It has been edited for clarity.

Integrative Therapies

Hansa Bhargava, MD: I am Dr Hansa Bhargava, a medical editor for Medscape and WebMD. I am joined again today by Dr Mark Hyman to continue our conversation on functional medicine.

How do you feel about all these integrative therapies? Do you have any thoughts on acupuncture, yoga, and meditation?

Dr Hyman: Yes, of course. I was a yoga teacher, trained before I was a doctor. I studied Chinese in medical school and learned about Chinese traditional healing systems. I've had much acupuncture in my life. In fact, it cured me of chronic pain that I had from back surgery. I do use other alternative modalities all the time as an adjunct to support my health.

But, when you use other modalities, how do you use them? When do you use the modalities? What is the diagnostic map? If you have migraines and you go to a group of integrative medicine doctors, one might say that you have a dosha imbalance, that maybe your vata/pitta is out of balance. An acupuncturist might say that your kidney chi is not right. The psychologist is going to say that maybe you're stressed and you should get therapy. The biofeedback person will say you need biofeedback. The herbalist is going to tell you to take feverfew.

In functional medicine, we don't do that. We ask, "Why are you having a migraine? What's the cause of your migraine?" If the cause of your migraine is that you're eating gluten, all these modalities are not going to help. We have a simple rule: If you're standing on a tack, it takes a lot of aspirin to feel better. You need to take out the tack. If you're standing on two tacks, taking one out isn't going to make you 50% better. You need to get rid of all the causes.

It's very important for us to understand that we have the capacity to think through this new model in a powerful way to really improve many chronic diseases. That's what we're focused on here at Cleveland Clinic.

Dr Bhargava: Now I'm going to take the lens of the skeptics. You have probably seen their websites.

Dr Hyman: I've seen them all. Have you looked at their credentials? They're usually shills for pharma. I'm saying things that are not popular.

Dr Bhargava:But when people have been trained in the traditional medical pathway, they may have questions. A lot of what you're saying makes sense and hopefully will help them to understand. If you have to say one thing about why functional medicine is important, what would you say?

Dr Hyman: We have been seeing increasing failure of our conventional approaches to dealing with the burden of chronic disease. One in 2 Americans has chronic disease.[1] We are seeing increasing costs. I think we're at $3.3 billion for our national healthcare bill. The annual cost per capita has now exceeded $10,000 in America. We are not winning this battle. There are increasing numbers of people with autoimmune disease, allergic disorders, diabetes, and cancer. Even with heart disease, although the death rate is going down because of better treatments, the incidence is going up. We saw a 400% increase in diabetes in the past 30 years across the globe.

These conditions are not getting better, and what we're doing is not working. We're good at ameliorating symptoms and managing disease, but our system is really broken. That's why Toby Cosgrove, MD, president and chief executive officer at the Cleveland Clinic, invited the Institute for Functional Medicine to partner with the Clinic to start the Center for Functional Medicine.

Dr Cosgrove and the Cleveland Clinic are investing a lot in this effort. He sees that the future is around root cause analysis and systems biology. There are initiatives around precision medicine, personalized medicine. This is exactly what functional medicine is. It's understanding that we're talking about an n of 1. We need to be able to think differently about disease.

Precision Medicine

Dr Bhargava: Precision medicine is another area that I wanted to ask you about. President Obama created the Precision Medicine Initiative, and WebMD has released a report on precision medicine called Path to a Breakthrough. How is functional medicine different from precision medicine? How is Cleveland Clinic integrating all of this into their system? Will they be doing research in this area?

Dr Hyman: The first question is, what is precision medicine and how does this apply clinically? Functional medicine is the original precision medicine. It's personalized medicine that focuses on the individual and understands that your genes and the influence of the environment on those genes play a huge role in your health. But it's not actually autosomal dominant genetics; it's about gene expression.

We have millions of single-nucleotide polymorphisms (SNPs). I had my whole genome sequenced with Craig Venter. I have 20,000 genes but 5.7 million SNPs, which is a lot of SNPs. There is a huge variation in the population. SNPs affect all the different functions in the body. One third of our entire DNA codes for enzymes, which are basically catalysts. Those catalysts require coenzymes, which are vitamins and minerals. So, we have this huge variation in our needs as individuals for different nutrients and different diets.

I think the concept of precision medicine is fantastic. It is in alignment with functional medicine. In fact, functional medicine is the first application of precision medicine.

I get concerned about this getting coopted by pharma as being about pharmacogenomics. Precision medicine is how we match the drugs to the person. We know that if you have a 2C19 polymorphism, then maybe you should be adjusting your warfarin differently. Fertility doctors will check methylated SNPs, MTHFR. If you have a methylated SNP, you might need methylated folate or a higher dose. These are more personalized drug therapies as opposed to a holistic systems approach.

I think we have to be careful with it. It's really looking at more of a Leroy Hood model in systems biology, what he calls P4 medicine: personalized, preventive, predictive, and participatory. That's essentially what we do in functional medicine.

Dr Bhargava: Will Cleveland Clinic be putting research dollars into looking at functional medicine? One of the questions that doctors will have is whether there is research and evidence.

Dr Hyman: Absolutely.

What Does Functional Medicine Cost?

Dr Bhargava: I want to make sure that we have enough time to talk about cost.

Dr Hyman: Part of the reason I decided to come to Cleveland Clinic was because of Toby Cosgrove. I asked, "Toby, what would you say if I could empty out half of your hospitals, if I could cut your bypasses and angioplasties in half?" I thought he was going to say that I was nuts. But he said that that's exactly what we need to be doing. And then, he wouldn't stop calling me after that.

I said to him that we need to do research to show that this model works. So now, Cleveland Clinic is spending millions of dollars of its own money to fund the research. We're not even going to the National Institutes of Health (NIH) or others, because it's very difficult to get money for these types of systems approaches. What we're looking at is reversing diabetes and getting people off insulin. We're looking at patients with treatment-resistant asthma. We're looking at inflammatory bowel disease. We're looking at doing research around autoimmune disease, and even reversing early dementia. We're being aggressive in our approach to doing randomized trials.

We're also doing something else, something that I think everybody should do, which is to look at outcomes and cost. In the healthcare system, we're not very good at doing this. It's one of the things that we implemented here when we started the Center for Functional Medicine. Every patient fills out an NIH-validated patient outcome test, which is called the Patient-Reported Outcomes Measurement Information System (PROMIS®). It's a free online tool. Any healthcare organization can use it, and there are many different versions of it. We test everybody at every visit. We've seen a 28% improvement in outcomes [Editor's note: unpublished data] over every other area in healthcare, on the basis of our own work at the Center for Functional Medicine.

We're also looking at the total cost of care. We want to know visits, prescriptions, and hospitalizations. We've seen dramatic changes in our costs in our employee health plan. We're measuring cost, and we're measuring outcomes. We're looking at value, because at the end of the day, it's about value-based care. We can do all the randomized controlled trials we want, but at the end of the day, there will be skeptics. The payers will start to realize that if they pay for this, we'll see dramatic improvements.

Dr Bhargava: In terms of the cost to the person, do you think that payers will be covering this at some point? Because innovative medicine costs hundreds of dollars.

Dr Hyman: Here's the challenge: We're in a no-man's land between the medicine we have and what we're going to have, and between the reimbursement model that we have and the reimbursement model we're going to have. Right now, we're in fee-for-service. We are going to be moving to accountable care organizations and more capitated per member per month payments, which is changing the landscape.

Here at Cleveland Clinic, we're moving toward population health, which means being accountable for the health of populations. It's not just waiting until they get into the hospital and getting a check for that. We're actually going to be reimbursed on the basis of how much value we create in the healthcare system. We are very focused on that. We started programs with population health to do decentralized care, working with people in groups. We're working with our employee health group.

Things are going to shift. The answer is that we're in a tough situation right now. We are now covered by insurance. People can come see us here, and they're covered by their insurance for their labs. But, it's still cost-intensive.

One patient whom I referred to in part 1 of our discussion saved $30,000-$50,000 per year on medication when she was able to discontinue Stelara ® (ustekinumab)‎. Who gets the value from that? The insurance company. The people who created the value don't get the value. So, we need to create a shared-savings model. We need to redistribute the economics. I think there are a lot of challenges, but this is all happening within healthcare right now.

The Secret to Good Health

Dr Bhargava: That's wonderful to hear. I just have one more quick question. We know that you were very involved with President Clinton's care. What is the secret to his good health?

Dr Hyman: Eating real food. No more McDonald's. He was the McDonald's President. You know, I used to watch those Saturday Night Live skits. Just eating real food.

Dr Bhargava: All Americans need to eat more real food.

Board Certification Coming Soon?

Dr Bhargava: Do you see board certification happening in this specialty at some point?

Dr Hyman: Yes. We are now building training at Cleveland Clinic. We've implemented a nutrition curriculum in the medical school. We have an 18-month certification program at the Institute for Functional Medicine. We're going to be putting that online so that physicians can get trained. Finally, we're looking towards building a fellowship program here at Cleveland Clinic, as well as residencies down the road.

Dr Bhargava: Thank you very much, Dr Hyman. It sounds like it's a great new specialty. We look forward to seeing certification in it. We also look forward to seeing payers help patients to actually afford it. Thank you so much for being here.

Dr Hyman: One additional comment. Functional medicine is not a specialty. It's a way of thinking, and it applies to every area of medicine. For example, I was talking to the chair of orthopedics here yesterday, who is interested in how we can improve the health of patients going into surgery and after surgery. We have people going into surgery who have osteoarthritis. Can we deal with them through other modalities that will help to reduce the cost of care? It really applies to every area of medicine. It's an overarching model of thinking about disease that applies to every disease.

Dr Bhargava: If it can help the chronic diseases in this nation, we'll all be very happy. Thank you, Dr Hyman.

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