The Dr. Hyman Show - Integrating Functional Medicine into Cleveland Clinic’s Inflammatory Bowel Program with Dr. Reguiero

Episode Date: January 16, 2019

Inflammatory bowel disease, or IBD, is estimated to impact more than 2 million Americans. This term encompasses different disorders relating to inflammation in the digestive tract, such as ulcerative colitis and Crohn’s disease. And up until now, traditional gastroenterology took a linear view of treatment options, ignoring the impacts of diet and lifestyle, while many patients continued to struggle. Today’s guest on The Doctor’s Farmacy, Dr. Miguel Regueiro, is part of the positive shift happening in the conventional approach to IBD. Dr. Regueiro is the chair of Cleveland Clinic’s Department of Gastroenterology and Hepatology; his main clinical and research interest is IBD, with a focus on the natural course of these diseases and postoperative prevention of Crohn’s disease. Recently, he has been involved in developing new models of healthcare, including the first-of-its kind specialty medical home for IBD. This innovative healthcare delivery system has defined the concept of specialty medical home and will lead to further clinical programs and investigation of alternative models of care. 

Welcome to the doctor's pharmacy that's F-A-R-M-A-C-Y a place for Conversations that Matter. I'm Dr. Mark Hyman and I'm here for a great conversation with Dr. Miguel Ruggiero who's the chair of gastroenterology at Cleveland Clinic and we got to meet recently when he reached out to us as he came to Cleveland Clinic

even before I think he started his official job he reached out to us at Cleveland Clinic in functional medicine because he saw there was some connection between what he's doing, what we're doing, and a different way of thinking about inflammatory bowel disease. So he's come from another major academic medical center to do something really radical here. And I'm really excited to have this conversation. Your focus is on inflammatory bowel disease, which affects so many people, Crohn's, colitis. It's really a horrible disease.

It really creates so much suffering. And we have good tools, but not great tools. And Cleveland Clinic is arguably one of the best in the world in caring for these patients. We do a lot of care. We do a lot of surgeries. But there's another way of thinking about it that you sort of brought about,

not only what we're doing, but also how we're delivering care, your home delivery model. So he's really an extraordinary scientist, doctor, and a humanitarian, and he's such a kind guy. And I was sort of shocked when somebody who's leading one of the major departments at Cleveland Clinic reached out to us and said, Hey, I'm coming to town. Let's figure out a way to work together. And we've been concocting various strategies around that, which is pretty awesome. So as a gastroenterologist trained in traditional

medicine, how was it that you came to realize that there may be some other ways of thinking about how to treat this disease? So, well, first of all, thanks for having me on. And I think one of the aspects that I saw over the years treating Crohn's and ulcerative colitis patients are they would come to me and there would be a gap in what we could ultimately do. So as you mentioned, there were fortunately the majority of the patients were able to improve with standard medications or surgery, but there was a large gap in these patients who are looking for something more. And many of the patients I used to see prior to coming to Cleveland would talk about diet and functional medicine specifically

and some of the experiences that they had. So it's really the patients teaching me as the physician and over the years really understanding this. So I looked into some of your work and when I came here I wanted to collaborate and I think the unmet need is really that area beyond the science and what we know biologically and this gets into the microbiome the diet health nutrition and inflammation so that's really how it came about that's amazing so you basically were one of the few doctors who actually listened when their patients said hey i tried this thing it's a little wacky but it worked yes and you're like well maybe there's something there and when you hear this enough times when

enough people say i changed my diet i did this i worked on my microbiome and my symptoms got better my colitis got better you know then it starts to be something that you want to think about that's right and i think that you hit it on the head so so many of these patients they change their diet they find that they're improved stress plays a big role as well the environment and again i i yes i'm grounded in traditional medicine but the other aspect is i listened to them and some of these patients i find we were able to de-escalate off of medicines or change really their treatment paradigm yeah i remember uh when i first got this job uh actually very before i got the job i went to dinner with the ceo of cleveland clinic uh at the world economic forum and he had sitting next to me a very prominent uh guy from a technology

company and was telling him about what i was doing and he's like wow you know i have a niece who has ulcerative colitis and they told her she had to have her colon removed and i said well why don't you send her to me no harm no foul if it doesn't work she can always get her colon out but worth the try you know you're gonna have your colon for life and she's 30 years old so uh she said she came and and she was very skeptical and she lived in louisiana which is not the best diet state in the world and i said just do everything i say for six weeks and if you're not better fine she called me back in six weeks. She was completely symptom-free. She had a clean colonoscopy after that,

and it's five years later, and she still has a normal colonoscopy. Now, that's kind of a remarkable story, and I've had that story so many times because it's really about approaching this disease by looking at what are the root causes. You know, we're really good by, you know, using certain heavy-handed tools to suppress symptoms,

whether it's steroids, whether it's immune suppressants. They work, but they're not free of side effects, right? Right. So when you can start to think about the microbiome and diet, nutrition, and stress, and other modalities, it becomes a very powerful, different paradigm. Yeah, and I think so for me, again, so many of these patients, you're right,

from my aspect, do get better with medicines, but a lot don't. And the other aspect of this is I think that there is a complementary approach with functional medicine as an add-on or replacement in certain patients. And as you said, I really like the way you approach that patient.

So you said, look, you're probably going to need a colectomy, right? So you said, I really liked the way you approached that patient. So you said, look, you're probably gonna need a colectomy, right? So you said, and if this doesn't work, you're still gonna need a colectomy. So I think it's the acceptance of that there may need to be surgery, there may need to be some other treatment, but giving this a try and for the majority of patients that I send to you and that we work together

on these functional medicine patients, I tell them, I said, this is worth an approach. Some of the symptoms we're not controlling may get better with functional medicine, but let's use this as one of the tools that we have to treat IBD. It's not either or. I think of like building a house. You start with the foundation, which is a healthy lifestyle, a personalized diet, dealing with whatever the issues are and then you you know you use medications that are less you know dramatic and then you sort of escalate up as you need to and surgery is sort of last resort so that's sort of how i think about it it's not an either or it's a collaborative approach that integrates all the things we know and i think the other thing that we're learning about ibd and obviously you know this we've spoken about this and you're one

of the ones going around talking about this is the immune system is very reactive to the environment yeah so when we look at Crohn's and ulcerative colitis yes there is a genetic component in some but the escalation of these diseases worldwide in the last 10 to 20 years is not genetically founded that takes thousands of years to change so something about the environment probably diet playing a primary role and i tell my patients i do tell them and counsel them that diet is probably as important as anything we give them we're trying to figure this out obviously you've done a lot of the research and seen success but i think using that foundational approach is important it's so true i mean you know i remember i worked at canyon ranch years ago and i was playing basketball with one of the guests we were you

know have lunch and play basketball and he was a gastroenterologist and so i started talking to him this was got to be like 20 years ago or more and i'm like listen what do you guys think about like how food plays a role in digestive disease he's like i don't know like i haven't really thought about it and i'm like what do you mean you're putting pounds of food in your digestive tract in this tube every single day how could it not impact what's going on in there you know we have had stan hazen on the show we was talking about the microbiome being completely responsive to the foods you're eating and different foods to grow different bugs which have different effects whether they're inflammation or whether they're healing it's very fascinating yeah and i think the thing that i tell my patients i was thinking about my clinic

yesterday when i saw a variety of Crohn's and ulcerative colitis both and i hear what they're eating and unfortunately the processed foods high sugar foods lots of carbohydrate lots of fat and i tell them as important as what we may offer you in terms of a medical treatment, or some of them may need surgery. We really need to look at the diet component. The problem that I don't think I have the answer to is what is the only specific diet for each person. And it probably varies from person. So it's individualized to that person.

And that's where the precision comes in. It's totally true. You know, we have a rule in functional medicine. If you're standing on a tack, it takes a lot of aspirin to make it feel better right so let's say you're eating gluten and it's causing damage to your gut even if it's not celiac it takes a lot of immune suppressants to cover that over right so how about we work on both ends of the spectrum and figure it out know. I think that collaborative approach is important. And I think from a physician and traditional medicine side to poo-poo or ignore diet functional medicine is incorrect.

And I think conversely, I think you agree, because I know you and I work together, that we often complement each other quite a bit around our patient care. Yeah, it's very exciting. We're collaborating. But we're also talking about creating combined groups where we actually do this with people in a collaborative way and study it and do more

rigorous science around it because that's what's really lacking and some of the more rigorous science you hear the anecdotes you hear the patient stories but we really need to show okay can this be reproducible right you see the markers change can you see the scope and the endoscopies change you see the biopsies change and and if that's true then what are the implications of how we start to really think differently about this and and that's as a physician researcher what i like about your approach is that you are looking for the science behind the randomized controlled studies i mean we've talked about this i think we have a meeting later about this as well and looking at can we do true randomized controlled studies in a very controlled fashion and look at hard

outcomes objectively? And I think that there are certain diseases, not to give away everything that we may be doing in the future, but there are certain disease states within Crohn's and colitis that I think are really ripe for studying in functional medicine. And yeah, I'm looking forward to that. I think we're going to learn a lot. Very exciting. So what are you learning from the traditional gastroenterology point of view around diet

or around the microbiome and the role of that place? Because I think there's emerging science, even with the traditional medicine, that may not be quite translating the clinic yet, but it's in the ether. People are talking about it. There's research going on about it. Well, so I think the most important aspect, if you look at inflammatory bowel disease over the last 20 years, so in terms of research, probably 20 years ago to 10 years ago, the focus was on genetics. And initially the hope was genetics was going to answer everything. Unfortunately,

it's probably about 20% genetic and 80% is not. So then the focus became on the immune system and what the immune system was doing. So the focus became on the immune system and what the immune system was doing. So the downstream effect of the immune system, and this is where the explosion of medications has come. And now I think more recently in touching on what you said, the microbiome is really where the research is focused. So actually doing genetic maps of the entire microbiome, our own microbiome to understand the differences. And the biggest influence of the microbiome is the environment. And the biggest part of the environment is the diet. So how does this all play a role, not only for inflammatory bowel disease, but probably other

systemic immune mediated diseases that are diet related. So when we see our patients, and even I tell them, if you do something as simple as eliminating most of the carbohydrates, just starting with that. So whether it's a Mediterranean diet or something, even to that degree is a big step toward health, inching toward health. And then maybe actually when we see the buy in working and having functional medicine or some more approach to diet than they've been doing in the past yeah and you know from the microbiome perspective what's emerging from the science is it certain bugs is it the pattern is it something we can intervene people are talking about using fecal transplants for ulcerative colitis or probiotic pills or poop pills. I don't know if you want to swallow those,

but people are doing it. So you're on to something, right. So the fecal transplants, which actually used to sound like a completely grotesque approach to treatment, is now actually probably... Bloodletting. It's actually now being used. So I think what we've learned is...

For those people who are not sure what that means, it means you take the poop from a healthy person and you put it in a sick person and you cross your fingers and hope they get better. In fact, the only really effective treatment for C. diff in people who resist treatment is a fecal transplant. And it works 98% of the time, whereas drugs may not work at all. Right. So to carry on that point, so the real role for fecal transplant today at least has been in these C. difficile or clostridium difficile infected patients who are not responding to antibiotics. And it does work very well.

And that's FDA approved? Yes, and that's FDA approved. The next step is will it work in inflammatory bowel disease? I still think we have a lot to learn because some of the studies were positive. Others did not show as much of a benefit. There's a pediatric ulcerative colitis study going on right now, but it really lends to the fact that the microbiome is pivotal in treating inflammation. The other model that we've seen in inflammatory

bowel disease that we know works in a patient who has Crohn's disease, who has inflammation, and they get what's called a diverting ileostomy meaning their fecal stream with all the bacteria is diverted into an ostomy bag so the part below that that's inflamed doesn't have any stool washing over it that part will get better the inflammation will get better and if you reconnect them and the stool goes back over that inflamed area the inflammation comes back so we have countless studies that point to really microbiome, that poop is really the culprit. And then the question is, to your point,

what is it about the poop, probably microbiome, maybe some other things, and what are the bacteria? That's really what we're figuring out. Yeah, I was just reading about this, and that inflammatory bowel disease, that you may have different uh results on the implant studies for ulcerative colitis because it may depend on the type of bacteria so it's not like it's not like it's just random with cd if you give almost anybody's healthy poop and they get better on one treatment this may take multiple treatments it may

be important to characterize the microbiome that actually fixes it, whereas you might get a fecal transplant from one guy that's not going to help, or from another guy that's going to help. It's very complicated. Yeah, and when you look at the billions of bacteria inside, and you look at the studies, so trillions, right? If you actually look at the living microbiome, it's incredible. But to distinguish person to person, the anaerobic bacteria,

the different bacterial strains clearly there have been enough studies that points in a microbiome direction and have there been studies for them that characterize like you know 100 healthy people and 100 people with Crohn's or 100 people also with colitis are there patterns that emerge yeah so they're definitely patterns some of the what we call anaerobic bacteria fuso, some of the bacterial strains we think are linked. There have been even interesting studies looking at traditional African diets where we saw very low rates of colon cancer and inflammation and actually switching diets from the United States and Africa and seeing within two to four weeks changes in the microbiome that are pro-inflammatory.

So clearly there are specific bacterial strains that are linked to inflammation. Incredible. Incredible. So what about the diet research? Is there stuff emerging from the diet research about it's linked to inflammatory bowel disease? There's certainly been quite a bit on diet. Obviously, there are patients who find themselves when they come in that they've already experimented with diet.

So the diets that have been looked at in inflammatory bowel disease have included are patients who find themselves when they come in that they've already experimented with diets. So the diets that have been looked at in inflammatory bowel disease have included gluten-free diets, specific carbohydrate diet, meaning eliminate all carbohydrates, and certain carbohydrates, and then a Mediterranean diet, which is kind of a carbohydrate light diet, but not maybe as specific to the specific carbohydrate it's not the pasta and pizza diet it's not the pasta and pizza diet which is what people usually think so it's more the the fish the the oils the vegetable yeah exactly so it's not the pastas and people i look i've seen it in my clinics myself that they work with a dietician obviously you have much more

expertise but these patients will get better do all of them get better no i i don't think i can say that 100 but they get better and it's certainly an important part of their treatment and it can even help improve the response to other treatments right because even traditional drugs don't work 100 of the time but what if you combined it in a synergistic way with diet and other lifestyle factors yeah so i had a young woman recently i saw who was on a biologic therapy for her ulcer of colitis and she was doing okay but wasn't great and she changed her diet and actually with the diet change she actually had such an improvement that we're actually flirting with the idea of taking her off the biologic and trying to use diet alone with maybe a lesser

anti-inflammatory now that's one case and like you said up front i don't have a large randomized trial to control to say that that that's going to work but we've seen that time and time again that's true i mean there was a clinical trial where so i'm looking at a diet that's called autoimmune paleo which is essentially no grains or beans, nuts, seeds, eggs, or nightshades. And it's protein, vegetables, you know, some fruit. And there was a pretty good response rate in these patients with Crohn's and inflammatory bowel disease and ulcerative colitis. Yeah. So, so again, I mean, these, the variations, and again, I could ask you about the diet and you could probably tell me more, but when you look at the different diets and their impact on inflammation and probably on the immune mediated responses these are the diets that that we've heard and we know they work i mean

think about it we're here at cleveland clinic recording this interview in one of the leading health care institutions in the world and i've heard so many people patients tell me my doctor told me that diet has nothing to do with my inflammatory bowel disease and here you are saying yeah diet's important your microbiome is important. You're really thinking far ahead of what medicine is doing. And it's pretty exciting. Well, it's also an acknowledgement of what we don't know. So when I hear myself talk to my patients and somebody I saw this morning who asked me the question, does diet matter? And now, obviously, with your team and even diitians that i've hired within our

medical home we're having them integrated we know diet matters i tell them i just don't know exactly the exact diet for you and there may need to be some experimental phase about diet but we need to take these steps in terms of your treatment so it's such a refreshing perspective because it's it's it sort of breaks through some of the barriers between what people are trying on their own and they feel like they can't tell the doctor about it and you're creating a safe space for them to start to explore and think about these things. And it's really powerful. The diet part is huge. I've seen diet make a huge difference and you can't ignore it because again, you're talking about your GI tract where you've got pounds of this stuff and you're literally changing your microbiome with every bite of food it's not something that happens

over a long period of time it can happen in weeks or days or minutes even yeah no like i mentioned the one study uh research i used to work with literally flipped the diet from people who lived in africa people lived in the united states af, African diet very low in all fats, all carbohydrates, very high in plant-based foods, and then switched it with the kind of fast food diet of America and switched the diets. And in two weeks, the microbiomes actually changed in the African and in the United States population.

It's incredible. One for good, one for bad unfortunately but you probably remember dennis burkett and the study that he did in africa as a scientist from the uk who decided to go look at why were there different rates of chronic disease in colon cancer and other things in africa versus the west and and he basically looked at the stool weight of african stool it was like two pounds and the average weight of the western diet was four ounces right and that's because of all the fiber and the plant-rich foods and and they literally changed their diets dramatically when they were moving from a rural more indigenous culture and traditional food diet to the cities

even in africa they would get the same disease patterns as we would in the west absolutely so the kind of industrialized countries with the diets we have today are unfortunately not the right diet so the plant based high fiber so going back to the basics so a lot a lot of people talk about other therapies for inflammatory bowel disease which affects how many people so inflammatory bowel disease depending on the estimates you see are about two million americans have inflammatory bowel disease and the estimate may actually be higher but it's about two million americans a lot of people yeah uh and a lot of toilet paper a lot a lot of bathrooms and everything that goes with it yeah see i actually saw a funny thing about people traveling with autoimmune disease and there was this app that's like a bathroom finder.

If you're traveling, where do you find the bathroom? Hopefully we can get people so they won't need that. But there are other therapies that people are exploring that are out there like probiotics and various supplements and curcumin. And we had a speaker come, Josh Korsnick from Harvard who came to talk about some of the work he's doing looking at sulfide production in the gut that you get these sulfide producing bacteria. You can change them by giving butyrate,

which is a nutrient or vitamin B12 and using probiotics. And tell us more about where the research is around that. Yeah. So, so again, I think it's emerging and as long as this has been out there, I think we're still learning from this. So things, two things i wanted to pick up on the probiotics and extra curcumin as well based on the ibd studies so curcumin which is uh as you know turmeric or it's been an indian spice curry exactly the yellow in in a lot of the indian foods not the hot spices i tell my patients but there was a study where actually adding curcumin to misalamine, which is an anti-inflammatory for ulcerative colitis, versus misalamine alone actually showed that the curcumin group did better in terms of inflammation. The other is probiotics, and probiotics, especially in people who've had surgery already, and there's a lot of bacteria pooling in this pouch that they have after surgery. Probiotics have been a primary treatment for a lot of those patients and a specific one called VSL number three. Yeah, for hepatitis, right?

Yeah, so there's clearly probiotics. And then we use it in probably even more commonly in patients who may have a lot of gas and bloating. We think there's bacterial changes. And, you know, quite honestly, we're learning. There are a lot of probiotics that don't work. So I think we need to understand more. But there is definitely something there.

And it's of big interest. We're really at the infancy of our understanding of probiotics and the microbiome. There's so many probiotics out there. And they all promise different things. Very few of them have been studied rigorously. They might be small trials or some scientific studies. And the question is, what happens when it gets to the shelf? How long is it stable? Does it it work is it what's in there

uh it's challenging and and i think you know we're getting much more specific and thinking different strains and what they do it's pretty extraordinary we we actually are probably going to be involved in a study uh second the european um researchers who we may collaborate with and people who have had Crohn's and had surgery, and they get an intestinal resection then connected back together. So it's not an ostomy. And we know the recurrence rate is high in people who have Crohn's who have surgery and get connected. And this research group is looking at the microbiome specifically as the recurrence when people have Crohn's that comes back. And we're looking at it's not really going to be a probiotic, but it's going to be a different agent that alters the microbiome. And it's interesting.

These are probably the approaches that we're going to see in the next decade that are going to completely change what we do. It's really true because, you know, in medical school, we never learned, well, how do you create a healthy gut? We know how to treat symptoms. We know how to treat diseases. And sometimes the drugs we use, for example, to treat GI symptoms like the acid blockers cause secondary problems like diarrhea or bloating or bacterial overgrowth or other

things. And you end up with like, you might not have reflux, but you got irritable bowel now. And so we never learn about the science of actually creating a healthy inner garden or creating a healthy gut or what we should eat. And yet that seems to be where the future where the research is going and how do we combine that with traditional therapies to actually help people really recover well again so it's kind of going back to the future right so when we think about 40 50 years ago lower incidence of inflammatory diseases more of these whole based diets diets, whole food diets, less of the artificial processed foods,

lower sugar, lower fat. People weren't getting these diseases. So obviously there's something there. Fascinating. Yeah. And functional medicine, we talk about, we call the 5R program, which is a strategy, a method for helping to restore the gut function. And it works for so many diseases. We've been doing this for 35 years and it you know it's regardless what's going on you don't even know if you know know that much about what's actually happening you just try this it works and it's not just for for inflammatory bowel disease other digestive issues autoimmune issues and it's basically removing the things that may be irritants whether it's foods like you said processed foods it could be gluten and dairy

whether there's bugs growing in there that shouldn't be growing in there like bacterial overgrowth or maybe there's parasites replacing things that might be needed in dairy, whether there's bugs growing in there that shouldn't be growing in there, like bacterial overgrowth, or maybe there's parasites. Replacing things that might be needed in the gut, if there's pancreatic insufficiency, or if there's need for prebiotics, and replacing, re-inoculating with probiotics when we can. And then using things to help repair the gut line, like you said, curcumin, or fish oil, or zinc, or other things that the gut, glut glutamine that the gut needs to heal i mean and then we use restore which is to help deal with the stress response so it's sort of a very specific methodology that can be applied to help the gut function and it's sort of the foundation of our practice in functional medicine and it really helps now it doesn't get everybody better all the time sure but it's a it's a really interesting model and it's sort of a almost it would be

amazing to actually think about how do we start to integrate studying that as a foundation? And then, you know, you have treatment failures, you add on other things. Like you said, the diet plus the medication works better, like your patient or their curcumin plus the medication works better. So how do we begin to sort of integrate these?

Well, and I think it begins with a partnership. And I think that the thing I like about this relationship is that it's not either or. And I think for so long on the traditional side, it's been it only is the traditional way. We don't have any outside the box thinking or partnership. So the thing I like, too, is that you're saying and constantly to the patients we send to functional medicine, work together collaboratively with your IBD team and functional medicine and I think that's where we're going to see success so it's a complementation if you will if that's a word of working together well I mean there's a certain humility that comes with practicing for a while on either side like if you're alternative you don't know don't ever take

medication and you go wait a minute I'm like these people aren't getting better and you might need to you know do some of that. And then the other side is, well, yeah, maybe everything we're doing isn't working 100%. So what else can we learn? And I think that's just a wonderful collaboration attitude that you have here. And Cleveland Clinic is really one of the few places

where I've really seen that dynamic, where there's real openness and curiosity and willing to collaborate and asking questions. And it's really pretty exciting. Yeah, so one of the main reasons I came to Cleveland Clinic and willing to collaborate and asking questions. And it's really pretty exciting. Yeah, so one of the main reasons I came to Cleveland Clinic is obviously my interest in gastroenterology, but looking at population health and specialty health, but also in the field of IBD,

the interdisciplinary approach to treating these patients as a whole person and conducting not only studies, but clinical programs where we're not so uni-focused on one approach. It's looking at multiple disciplines. And it really has been something I've enjoyed about the Cleveland Clinic. It's great. And we've been talking together about creating, for example, shared medical appointments where people come in a group, they get nutrition coaching, they get life coaching, they get support from the doctor and various kinds of healthcare providers and a team that helps them change their behavior. Because it's easy to take a pill or get a shot every few months, but to actually start

to shift what you're eating and how you're taking care of yourself and dealing with stress, those are the big levers that we don't tend to use. Right. And so I think the secret sauce in any medical home, if you will, is really looking at the psychosocial stressors that patients often have and the diet that's impacted. And so when I look at the subsets of patients that I think benefit the most from this kind of this shared model, there are clearly a number of patients there and clearly we see results. Yeah. And you've also pioneered a really amazing thing,

which is this idea of a patient-centered medical home for specialty care around inflammatory bowel disease, which has dramatically reduced costs and improved outcomes. So almost sort of recommending the same thing as you would as a one-on-one visit, but it's done in a different delivery model. And that's really what's happening in medicine. We're realizing, wait a minute, the one-on-one doctor visit norman rockwell kind of style of medicine just ain't flying in today's world which is complex where chronic disease is prevalent where it's influenced

by our social determinants of health and all these other factors that are squishy and not part of your medical care but you're like no wait a minute we have to do this so tell us about that yeah so it really it came about for a couple different reasons and and again this was where i used to work for and we used to see patients come in all the time with unmet needs beyond what we were delivering so we knew we could get them better to a point but then the the secret sauce again was realizing that the psychosocial part the diet part but then looking at how we can integrate with payers, the insurance companies, how we can look at cost, how we can look at the whole person.

So these specialty medical homes, in my opinion, would be principal providers being a specialist. Doesn't mean not working with primary care. Actually, at the Cleveland Clinic, we're working on a medical neighborhood, which will really deploy our primary care physicians in these care models but really where the principal provider for Crohn's and ulcerative colitis often that's their only disease they're young and otherwise healthy so the medical home is principal provision by a gastroenterologist with a team and I think what you said a minute ago is important team is a key element to this it's not just one person. So they come in and they see somebody about the diet. I mean, it's what you do in functional medicine,

the diet, the psychosocial part. They may work on health maintenance issues in terms of how can we prevent diseases. And then yes, they might need to see the gastroenterologist and the surgeon and then other people as well. So it's a one-stop shop, whole person care, where we also try to keep the people back in their communities. So at school, at home, at work, really trying to avoid coming back and forth by also leveraging digital technology. It's incredible because what you're finding is that even though that sounds like an expensive enterprise, you've got all these extra providers and nutritionists and coaches and behavioral therapists and pharmacists and blah, blah, blah. And yet you found that not only was it cheaper, but that people did far better and the outcomes were better.

So it's quite a striking sort of thing to think about because we are so afraid in medicine to think differently about how to deliver care, but we have to. Well, I think and also a lot of, what we are talking to our patients about, when the past, when they get stuck, what do they do? They go to the emergency room. So by decreasing these unplanned care visits, ER visits, hospitalizations, going back and forth, getting testing after testing, and really saying, how can we flip this paradigm on its head?

So I agree, it is a bit outside the box. I wouldn't say it's the primary care physicians started these medical homes years ago, but now we're seeing different specialty areas that have chronic diseases really deploy these teams around whole person care. And it's really meeting a need, which is how do we rethink healthcare delivery? So we talked for the first part of our conversation about how do we rethink healthcare itself? How do we think differently about the medicine we're delivering and the care, but also how we deliver that care really matters. And so you've really focused on population health and want to develop research in healthcare economies and population health. How would

you see this extending? I see it extending. And so when we talk about populations and think about regions, in the past, traditional centers of excellence, we would be referred patients by other physicians. As a specialist, we would just focus on the disease and essentially send them back to the referring physician or the primary care physician. Where I see the population network or what I think people are starting to use the nomenclature of medical neighborhoods who are really a population. So for example, Northeast Ohio would be a population. We're linking to our primary care doctors, to the family practitioners. We're linking to different offices. And we're trying to figure out actually through some of the digital technology, how can we do this without having to bring people here? How can we do this remotely?

But then for those patients that may really need that specialized care, we also have almost a triage system electronically by which we can get patients in pretty quickly into these more complex care pathways. So it's really exciting. I think it's really bringing medicine not just focused on individuals and centers, but really across an entire population. Yeah, and functional medicine, we say, is really changing the medicine we do and the way we do medicine. And that's exactly what you're talking about.

Yes. Both the content of care and how we do the care. And it's really the future. It's so refreshing to hear that at Cleveland Clinic. So if you were in charge of health care and maybe the world and you were king uh for a day i don't know that anybody would want that i don't want the job actually i once took care of the king of jordan and i'm like you got to change your diet and do this he's like well i'm busy and then i'm like listen if people say

if i were if you were king you are king you can you can get them to give the food you need and make the food. It's really funny. So if you could do that, what would be the biggest things you would change if you could have sweeping change? Yeah, I think so. One of the things, and I think this is happening, but probably a few things. One is to try to break down the barriers between payer and providers. So we live in a world right now, which the insurance companies

and the physicians are almost in a way siloed. So I think the systems that are bringing the payers and the providers together through these models of care. The second is I do think we need new models of care. And you've touched on this a minute ago, where we're really getting back to what actually Cleveland Clinic was founded on this this team-based approach to care. So not individual and looking at the whole person. And then finally, I think we really are in the advanced modern era of medicine where we're using these platforms electronically. So how many times do you see people walking down the street?

You're looking on your phone, there's an app. So integrating these electronic digital platforms to remotely monitor and possibly deliver care, that's really where we're headed. And I think this disruptive technology, disruptive medicine era is here. Obviously, there are big companies that we hear about on news every day that are getting into this space. And I think that's where we're headed as far as technology. Well, that's amazing. And the first thing you mentioned about breaking down payer and provider connections and sharing information and data and resources, you've done something that I've seen rarely done in healthcare, which is you went to the insurance company and said, look,

I have this idea. I'm one of these patient-centered, especially medical homes. I think if I win, we all win. You lower your costs. Patients get better. It costs less money to the system. Everybody's happy. And it was a real risk because they could have said, no, no, we don't want to pay for it. It's going to cost more.

And you did that. And you got them to pay for it, which seems like a magic trick on how you did that. But that's the kind of thinking we need, which is breaking down these firewalls and saying, OK, let's share together. They're more willing to pay for a $50,000 surgery for Crohn's disease than they are for like a $500 medical home visit or whatever it is, right? Yeah, no, and I think actually, and as you said, breaking down the barriers, I'll give the payer was to their credit. Really, they took a risk as well. So having this-

That's what I mean really they took a risk as well so having this i mean they took a risk yeah so having this integration of care where we realize we're really all on the same team i know sometimes in medicine as a patient and on different sides we say different things but really integrating together that is novel and i think that more and more we're seeing that and i think the way that payers and even providers in the next five years are probably going to change completely. So, I mean, credit the insurance companies that are doing this already, the health plans that are doing this. I know at Cleveland Clinic, we have our own ACO and we're looking at actually some of these payment models. And I think the payers that are innovative as well and are willing to work with the provider side, this is where we're going to really see gains. Yeah. I mean, in terms of cost, autoimmune disease is one of the top cost drivers because

the medications are so expensive. It's like $50,000 to $80,000 a year forever. Well, and the unplanned care too, yeah. Yeah. And the unplanned care. And so we've got a situation where there's a real window to say, hey, how can we think differently about how to get these patients better and deliver care? Because if you could do that, that's a huge win. And the shared savings model, which I think is what you did, meaning if we save, if it costs, let's say, $50 million to take care of these patients and we save $30 million, we can split the difference. Right. And everybody wins.

Yeah. So not only alternative models, but alternative payment models. so how are we going to figure this out shared saving shared risk people hear these terms all the time and what you said a minute ago when you look at what's called the per member per month cost pm pm per member per member per month cost from the insurance side of some of these autoimmune diseases, they're astronomical. And there's a number of reasons for that. As you said, medicines, unplanned care. So by decreasing it, sharing that, and improving care,

really that's where I think we're headed, hopefully. It's the future. Well, it's exciting. If I were king. If you were king. Well, it's starting to happen. I mean, Cleveland Clinic in January of 2018 started a new institute called Cleveland Clinic Community Care, which is focused on rethinking healthcare delivery. The new CEO developed a whole new initiative about rethinking care delivery models. This is where things are

going. And I don't know how many people out there in healthcare are doing this, but Cleveland Clinic is really one of the most innovative groups out there. And people like you coming here and doing these kinds of things, it's just amazing. And I look forward to working with you and stay tuned everybody. Cause hopefully we'll be publishing studies in the next few years on how do we approach both changes in delivery and the content of care for IBD and, and even our regular digestive disorders, which is a huge issue. So thank you. And thank you, Dr. Guerra for being on the doctor's pharmacy.

You've been listening to this conversation, which I hope matters to you or someone you love. And if you've enjoyed this conversation, please feel free to share it with your friends and family on social media. Please leave a review. We'd love to hear from you and we'll see you next time on the doctor's pharmacy.