Integrating Functional Medicine into Cleveland Clinic’s Inflammatory Bowel Program with Dr. Reguiero

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 Regueiro, 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, 'cause he saw there was some kind 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 that 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 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, you know, 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?

Well, first of all, thanks for having me on. 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, 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 were looking for something and 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, yes, I'm grounded in traditional medicine, but the other aspect is I listen 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.

And I remember when I first got this job, actually, right before I got the job, I went to dinner with the CEO of of Cleveland Clinic at the World Economic Forum and he had sitting next to me a very prominent 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, it doesn't work, she can always get her colon out, but worth a try, you know, you're gonna have your colon for life and she's 30 years old. So, She said she came 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? We're really good by 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 to 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 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 use medications that are less 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 five-year 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. 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 yours 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, I remember I worked at Canyon Ranch years ago and I was playing basketball with one of the guests, we were, you know, over lunch we played basketball and he was a gastroenterologist. And so I started talking to him, this was gotta 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, well, 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, he was talking about the microbiome being completely responsive to the food you're eating and different foods to grow different 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? It probably varies from person. So, it's individualized to that person and that's where the precision comes in.

It's totally true. We have a rule in functional medicine. If you're standing on attack, 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?

Yeah, I 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 in 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? You see the markers change, can you see the scope and the endoscopies change.

Can you see the biopsies change? And if that's true, then what are the implications of how we start to really think differently about this. And that's as a physician researcher, what I like about your approach is that you are looking for the science behind it, 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 studying in functional medicine and yeah, I'm looking forward to that. I think we're gonna learn a lot.

Pretty exciting. So what are you learning from the traditional gastroenterology point of view around diet or around the microbiome and the role that plays? 'Cause 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 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 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 that degree is.

A big step up toward health.

Inch 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 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 want to swallow those, but people are doing it.

So you're onto 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 the 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 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 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 results on the implant studies for ulcerative colitis because it may depend on the type of bacteria. So it's not like it's just random. With C. Diff, 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, it's not gonna help or if another guy is gonna help. it's very complicated.

Yeah, and when you look at the billions of bacteria inside and you look at the study, 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.

Have there been studies for them to characterize like, you know, 100 healthy people and 100 people with Crohn's or 100.

People ulcerative colitis, are there patterns that emerge? Yeah, so there are definitely patterns. Some of the, what we call anaerobic bacteria, fusobacteria, 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 its 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 gluten fruit and free diet, specific carbohydrate diet, meaning eliminate all carbohydrates. Or certain carb- 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 fish, the oils, the vegetable. Yeah, exactly. So it's not the pastas. And people, 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 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 ulcerative 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's going to work but we've seen that time and time again.

Yeah, it'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, 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 again, 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 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 healthcare 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 dieticians 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.

It's such a refreshing perspective because it sort of breaks through some of the barriers between what people are trying on their own and they feel like they can't elect her to their 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 in your 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, and like I mentioned, the one study research I used to work with literally flipped the diet from people who lived in Africa, people who lived in the United States, African diet very low in all fats, all carbohydrates, very high in plant-based foods and then switched it with the 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.

Well, you probably remember Dennis Burkitt and the study that he did in Africa, he was 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 he basically looked at the stool weight of African stool was like two pounds, and the average weight of the Western diet was four ounces. And that's because of all the fiber and the plant-rich foods, and they literally changed their diets dramatically. And 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 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 2 million Americans have inflammatory bowel disease, and the estimate may actually be higher, but it's about 2 million Americans.

A lot of people. And a lot of toilet paper.

A lot of bathrooms and everything that goes with it.

Yeah, 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 Korzenik 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 and you can change them by giving butyrate, which is a nutrient or vitamin B12. and using probiotics. Tell us more about where the research is around that.

Yeah, so again, I think it's emerging and as long as this has been out there, I think we're still learning from this. Two things I wanted to pick up on, the probiotics and extra curcumin as well based on the IBD studies. So curcumin, which is, as you know, turmeric or it's been an Indian spice.

Curry.

Curry, exactly. The yellow in a lot of the in foods, not the hot spices, I tell my patients. But there was a study where actually adding curcumin to mesalamine, which is an anti-inflammatory for ulcerative colitis, versus mesalamine 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 pulling 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.

That's SIBO, 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. It's a big interest.

We're really at the infancy of of our understanding of probiotics in the microbiome. There's so many probiotics out there and they all promise different things. Very few of them have 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 work? Is it what's in there? It's challenging and I think we're getting.

Much more specific in thinking different strains and what they do. It's pretty extraordinary. We actually are probably going to be involved in a study, I was talking to the Europeans, 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 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 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, whole food diets, less of the artificial processed foods, lower sugar, lower fat. People aren't getting these diseases, so obviously there's something there.

Fascinating, yeah. In functional medicine, we talk about what 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 regardless of what's going on, you don't even 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 the gut. If there's pancreatic insufficiency, or if there's need for probiotic prebiotics, then replacing, reinoculating with probiotics when we can, and then using things to help repair the gut line. You said curcumin or fish oil or zinc. or other things that the gut glutamine that the gut needs to heal. I mean, and then we use restore, which is to help deal with the stress response. So instead of a very specific methodology that can be applied to help the gut function. And it's sort of a foundation of our practice in functional medicine, and it really helps now. It doesn't get everybody better all the time, 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 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, 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 complimentation, if you will, if that's a word, 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 ever take medication, and then you go, wait a minute. I'm like, these people aren't getting better. You might need to, you 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 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 you know 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 in 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 pressures 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 regular medical care. But you're like, no, wait a minute, we to do this.

So tell us about that.

Yeah, so it really, it came about for a couple of different reasons 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 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, we're the principal provider for Crohn's and ulcerative colitis often. That's their only disease, their young and otherwise healthy. So the medical Functional 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. just in 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 Robbie 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 times 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 physician 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 health care delivery? So we talked for the first part of our conversation about how do we rethink health care 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 health care economies and population health. How do you see this extending?

I see it extending in 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 where 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, 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 If you were in charge of healthcare and maybe the world, maybe you were king for a day. I don't know that anybody would want that.

I don't know if you 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 you were king, you are king, you can get them to give the food you need and make the food. It was 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 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. 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. I think that's where we're headed as far as technology.

Well, that's amazing. Trent, so 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, I have this idea. I want to 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. I don't know how you did that, but that's the kind of thinking we need, which is breaking down these firewalls and saying, okay, Let's share together. They're more willing to pay for a $50,000 surgery for Crohn's disease than they are for 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 pair was to their credit, really, they took a risk as well. So having this- But I mean they took a risk. Yeah, so having this integration of care where we realize we're early 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 is 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.

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. No, I mean, these shared-- everybody wins.

Yeah.

So not only alternative models, but alternative payment models. So how are we going to figure this out? Shared savings, 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, PMPM 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 on planned 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 kind of things, it's just amazing. And I look forward to working with you. And stay tuned, everybody, because 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 even regular digestive disorders, which is a huge issue. So thank you. And thank you, Dr. Guarneri, 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. Don't forget, there's a way to listen completely ad-free. With Hyman Plus on Apple Podcasts, you can enjoy every episode without any breaks. Just open Apple Podcasts and tap Try Free to start your seven-day free trial.