By definition, precision medicine treats the individual while public health focuses on population-level interventions. While public health and precision medicine efforts overlap, some experts argue that precision medicine advancements fall short of public health goals due to their underemphasis on scalability and accessibility. Digital health can help reconcile this conflict by promoting precision medicine’s goal of delivering the right treatment to the right patient at the right time while improving health equity through scalable, accessible solutions.
“In many ways, PM investments may come at the expense of existing public health measures that could have a greater impact on population health” (source)
Many emerging precision medicine technologies, especially genomics-based ones, remain expensive and specialized, impacting only a small share of the population. Liquid biopsies, for example, have immense potential to revolutionize cancer care by enabling noninvasive early detection. Improved technology will likely lead to higher adherence to screening recommendations and higher survival rates as cancer is systematically detected at an earlier stage. However, the majority of approved liquid biopsy tests are indicated as companion diagnostics for treatment selection and largely apply to late-stage cancers only.Though screening is certainly a near-term priority for liquid biopsy companies, routine blood-based cancer screening at the population level is not likely in the near-term for a number of reasons. Firstly, the complexity of the molecular foundation underlying liquid biopsy necessitates lengthy and costly R&D for new products. Once a test is developed and proved efficacious, robust infrastructure is needed to ramp up such testing, requiring labs, technicians, and expertise. Patients further away from academic and specialty medical centers where novel techs are initially deployed will have delayed access to techs like liquid biopsy, let alone those outside of the healthcare system entirely (including ~27.5M people in the U.S. in 2018 without health insurance). Reimbursement recommendations dictate affordability for patients and health systems as well as financial feasibility for diagnostic manufacturers. If a patient’s insurer covers a test, the burden falls on patients and providers to ensure that those who should receive testing can access it, which a recent study found is not always the case. Additionally, experts expect that the overall cost per patient could actually increase down the line as cancer is treated like a chronic disease versus an acute illness, placing an additional burden on the health system.Due to the multiple levels of barriers to access, genomics advancements such as liquid biopsy may end up widening existing healthcare disparities in the near-term, with higher-income patients who receive care from advanced medical centers benefiting most. Unlike patients of high socioeconomic status and in the demographic majority, patients already disadvantaged by current structural healthcare disparities are unlikely to access technologies like liquid biopsy in routine clinical care any time soon. With that said, there are other areas of precision medicine that have more potential to reduce health disparities in the near-term.
Accessibility and scalability of liquid biopsies and other genomic-based interventions are limited by technological infrastructure needed, expertise, patient education, and regulatory barriers. Though regulatory barriers and affordability are challenges for digital health as well, digital tools leverage existing infrastructure and democratize healthcare to better impact population health.
Digital health shortens the runway between medical innovation and population health improvements by leveraging existing consumer technologies such as mobile phones and wearables. Digital care programs like Omada Health’s can easily enroll patients online, mail them a few devices to measure vitals, and offer direct counseling through their mobile app. As mobile phone usage increases globally, companies like these are able to reach more patients with minimal infrastructure costs. According to a Pew Research Study published in June 2019, 81% of all Americans and 71% of Americans with <$30,000 annual income own a smartphone, demonstrating the potential for mobile-based health solutions to reach traditionally disadvantaged populations. Additionally, digital booms in low and middle-income countries reveal the potential of mobile health to reduce health disparities by reaching historically hard to reach populations. Compared to genomics advancements which require implementation of complex and costly infrastructure, digital health can cost-effectively leverage existing technologies at-scale.Additionally, digital health helps lower intangible barriers to healthcare access by democratizing healthcare and delivering care in a format compatible with the consumer experience and existing infrastructure. Mobile-based digital therapeutics and diagnostics (e.g., Neurotrack) as well as personalized virtual care tools bring traditionally complex health information to the hands of patients. Wildflower Health’s mobile app, for example, delivers personal fertility and pregnancy information and helps women access benefits and care from their health plans / providers. Additionally, it democratizes utilization of healthcare – instead of having to take off work and go in person to a clinic, for example, patients can seek virtual care using digital tools. For many women, prenatal care is their first prolonged engagement with the health system. Virtual care solutions like Wildflower’s mobile app leverage platforms consumers already use on a daily basis to help patients navigate complex healthcare structures. Additionally, digital health can help prevent, treat, and educate patients on diseases that often come with stigma. Online therapeutics supplier Hims, for example, provides medications and physician consultations for men’s health issues like STIs and erectile disfunction. As the telehealth and digital therapeutics industry grows, companies like Big Health and Ginger are providing online counseling and treatment for common mental health disorders. Digital health comes with the inherent benefit of compatibility with the existing consumer landscape which is already saturated by digital tools. Unlike complex genomic technologies, digital health tools are more easily digestible by patients, lowering barriers to education and access.That said, digital health will still face a lot of the same challenges as genomics in the near-term. With relatively low barriers to entry for many digital health tools, there seems to be a new startup entering the space every day. The real challenge is demonstrating clinical validity and actionability and translating that into regulatory approval and reimbursement. If a tech is not reimbursed, or if it’s not offered by a patient’s healthcare provider, it probably will still only benefit those with the resources to spend out of pocket. If a patient can’t afford therapy for a mental health issue, they are unlikely to turn to an online counseling tool regardless of its convenience. Many digital health companies will likely continue to target high-income patients, focusing on improving the quality of care (e.g., One Medical’s primary care clinics) versus access to care on a population level. However, in the upcoming years we are likely to see more (and a more diverse group of) people accessing care using digital tools like virtual care clinics, hopefully leading to improved outcomes. As more digital health tools secure approval and reimbursement, there’s a lot of potential to leverage their scalability and ability to lower social barriers to access to rapidly address population health issues.Critics are probably correct to say that precision medicine could do more to impact population health and to reduce health disparities. However, they likely overlook non-traditional medical pathways such as digital diagnostics, digital therapeutics, and virtual care tools, which have significant potential to overcome both structural and social barriers to care, while still catering to the needs of individuals. Digital health and genomics will likely go hand-in-hand as precision medicine technologies shift from treating the individual to treating populations.
Tina is a Senior Analyst at DeciBio with a background in public health, health technology, and life science research tools. At DeciBio, Tina’s project work includes market intelligence, voice-of-customer research, and go-to-market strategy development. Connect with her on LinkedIn or email her at firstname.lastname@example.org.Disclaimer: Companies listed above may be DeciBio clients and/or customers