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November 26, 2014

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Q&A: Michael Modic

Chairman, Cleveland Clinic Neurological Institute

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Sam Morris

Linking care and research: Dr. Michael Modic, chairman of the Neurological Institute for Cleveland Clinic, is shown in his office Nov. 4.

Dr. Michael Modic is overseeing operations at the Cleveland Clinic Lou Ruvo Center for Brain Health after the two organizations joined forces this year.

He is a leading authority on neuroimaging, a science constantly in a state of evolution.

He also heads the clinic’s Neurological Institute in Cleveland, where he is based, and the emerging business division for the nonprofit organization.

He spoke with In Business Las Vegas about the role of the Ruvo Center, the potential of curing degenerative brain disorders and the Cleveland Clinic’s business model of paying doctors a salary.

IBLV: As chairman of the Neurological Institute for the Cleveland Clinic, what is your role in Las Vegas?

Modic: Actually, the responsibility I’ve had is to oversee the startup, the development of the clinical practice, to look at what can be done in terms of research and education, to integrate with the individuals out here in terms of developing a seamless transition from what has been, really, a startup into something that’s an active clinical practice. My major responsibility, then, has been to oversee the startup and the organization.

The Cleveland Clinic merged with the (Lou Ruvo Brain Institute) earlier this year, a surprise to many who consider Las Vegas less than ideal. What does Las Vegas contribute to the Cleveland Clinic’s mission?

Just a couple things: I think, actually, Las Vegas has a lower opinion of its health care than others might. This is something we hear a lot about. There are a lot of really fine doctors in Las Vegas. I think the hospitals are quite good. So, we hear that a lot, but I’m not sure how much of that is proven logic.

So, that’s one point. But on the other hand, what do they have to contribute? Well, there’s a couple of things. One, they have good community hospitals in the city that can take care of patients. There’s an opportunity to work with institutions that are already here. The Nevada Cancer (Institute), the medical school, some of the primary-care components, both of the allopathic and osteopathic schools. I think the major thing that Nevada and Las Vegas have to offer is a real interest in developing a, if you will, sort of a high-level neurocognitive center. The biggest advantage that we see right now is both the community and the medical profession seem to embrace this concept. That’s huge having cooperation.

I think (the Ruvo Center) has taught us a sensitivity to the caregiver, which is something that we didn’t possess before. One of the really interesting aspects of this operation is the dedication of the people that the staff here have —not just for the patient, but to the caregivers. That’s something that we have learned and have brought back to what we do elsewhere. Some things as simple as that, and it’s obvious when you think about it, sort of have to be drilled into you by someone else. So we took that home with us.

That’s something Larry Ruvo mentioned to me.

That’s a passion of Larry Ruvo and his family and was inherent in the creation and the construction of the processes that we have here.

What role will Las Vegas play as part of the neurology centers Cleveland Clinic operates?

The center here, the Cleveland Clinic Lou Ruvo Center for Brain Health, will be the hub, the central portion, the hub for our neurocognitive efforts across all the clinic’s facilities. So what we do here, and the clinical trials that will occur, the research, the education, and the standards of clinical care, really are the leaders in terms of this particular aspect of the neurological institute.

What we hope to do is model the program that we built here in Las Vegas, it will be duplicated in Cleveland, it will be duplicated in Florida on the East Coast. If we open up this type of effort in Toronto we would duplicate it there, and it would be duplicated in the Middle East (Abu Dhabi).

You have a strong background as a neuroimager. What advances in the field do you foresee that would allow for earlier diagnoses of brain disorders?

Everyone today is looking at biomarkers. That is the ability to identify something, whether it’s a test of blood, whether it’s an imaging test, something that will help us identify the disease at an earlier stage. There’s some really interesting research now that suggests that there are findings on imaging studies, either routine imaging in terms of brain volume or responses to functional imaging tests or even results from, if you will, physiological examinations, such as the Pittsburgh compound and the nuclear medicine examinations of the brain that will allow us to identify changes in the disease, and perhaps at a stage earlier than the clinical presentation. So, imaging is exciting because it may identify changes earlier, it may allow us to follow changes while the patient is on clinical trials and can give us a noninvasive way of assessing how the brain is doing with this condition.

What kind of work is being done in the research labs?

There is a whole spectrum of research happening right now on brain health in general. We talked about the biomarkers. That’s the first thing. We’re looking for both imaging as well as physiological, as well as chemical, as well as genetic markers for the diseases themselves. There’s a fair amount of research that’s going in that direction. There are drug trials that are taking place, both on animal models as well as humans, to see if there is a way to ameliorate the symptoms or to decrease the symptoms or to even prevent the symptoms in certain circumstances.

What we’re trying to do at the laboratory level is understand the basic changes that are occurring with this disease, and also to start looking at interventions, be they drugs, be they lifestyle changes, whatever, to modify the disease.

Do Cleveland Clinic researchers work with outside collaborators?

In most situations, basic science research takes place in a community of researchers so that there are national and international conferences and symposiums where people are constantly presenting what they do, so that no one works in isolation in today’s environment. So that’s the first thing.

The second is that much of what happens, particularly when it gets to the trial stage or to the intervention stage, takes place in a multisite environment. That is, a new intervention or a new drug will be tested not just at one place, but it will be tested at a series of places to be sure that the results are reproduced somewhere. In this world, there’s actually a significant amount of synergy among the researchers from different institutions, both nationally as well as internationally.

Are we close to a cure for any of these brain disorders?

Actually, it depends on what you mean by close ... Is it going to happen tomorrow? No. Is it going to happen in two or three years? Probably not. But I’d say we’re a lot closer, or think we’re a lot closer, than we thought even 10 or 15 years ago. I think people are now starting to see that we have a better understanding, although certainly incomplete, that we’re beginning to understand how certain drugs and lifestyle modifications can affect this disease — although certainly not conclusive. So we’re getting there. You know, it’s a long, hard road ahead to do this.

Which one of these brain disorders, in your opinion, will have a cure first?

Boy, that’s tough. I think that’s impossible to answer. You could look at vascular dementias as coming from abnormalities that we understand better. If you can prevent the vascular disease, you might be able to prevent the vascular dementia.

Alzheimer’s disease is probably a pretty hard one. Some of the genetic ones are going to be very difficult in terms of an actual cure.

Like Huntington’s?

Like Huntington’s, that’s right. Now if you look at some, say for instance Parkinson’s disease, there’s a disorder where certainly drugs have had a significant impact on the quality of life, and now more invasive treatments, such as deep brain stimulation, really, have had significant impact in a certain subsegment of the population, and there may be better drugs and there may be stem cell treatments. So if you were to ask which one has the best likelihood of the best progress in the short term, probably Parkinson’s disease. The ones that we are talking about here, which are Alzheimer’s, ALS, Huntington’s, Parkinson’s disease, vascular dementia, I’d say probably Parkinson’s has the best chance of seeing some breakthroughs that will improve patient life, not necessarily cure the disease.

In August you were named to lead Cleveland Clinic’s emerging business division, in addition to your position with the neurological institute. What is that division tasked with?

If we look at what’s happening in health care today, there’s a need for the institutions or the academic institutions, for lack of a better phrase, to start playing in adjacent spaces. To leverage their culture, their brand, their intellectual property so that they actually are able to produce products that are beneficial to the overall organization.

There are several reasons for this. The first is it’s useful for the organization to be able to commercialize some of its intellectual property. That’s important because you need to help support the core mission, which is the care of the sick. With today’s margins in health care, any advances that you can make in terms of supporting that are most welcome. That’s the major reason to commercialize intellectual property or to leverage the culture and systems and processes that are inherent in our organization so that they can be employed as a business.

The Cleveland Clinic pays its doctors a salary, unusual for Las Vegas, where doctors bill the patients and insurance companies individually. What are the benefits of following a salary model, and what are the pitfalls?

The benefits, far and away, are that we’re paid for what we do, not how much of what we do. For us, there’s no financial incentive to do more tests, to do more surgery. That’s the first, that it removes really the financial incentive to replace the number of things you do and be able to focus on what’s the most important thing to do. We like to think that in the main, we’re judged on the quality of our care and the access people have to us, not how much care we give in terms of numbers of tests, etc.

The second is that it really provides an environment where you’re attempting to standardize the care path, because, again, you’re not incented to do a specific thing. You’re really incented to do the right thing. It helps us in terms of how we develop the care of the patient and the pathways that we employ.

Now, the downside is that this is America. And in America, incentives are part of the system. It’s part of the economic fabric of the country. So it’s difficult sometimes for physicians who join the Cleveland practice to realize that, “Gosh, I’m not paid for how much I do, I’m paid for how well I do it.” The danger there is “Well, if I’m not paid for how much I do, I’ll just do a little bit.” But, in our environment, the peer pressure would prevent that from ever happening because everybody (who) comes here, comes here to work.

One of the other huge benefits in this huge salaried model is your colleagues. I think most of those who work here, work here because we get to work with individuals who are really high caliber and who are seeing things in the same way.

Earlier this year you told the Las Vegas Sun that the Ruvo Center provides a one-stop shop for patients needing care. What are the resources required to provide all of their treatment under one roof?

You have to have, first of all, a multidisciplinary approach. So the caregivers who (patients) would need to see live here. As we’re building up the staff, that’s one of the things we’re attempting to fulfill, so that there would be neurologists, geropsychiatrists, physiatrists and imagers as well as neurocognitive testers, such as neuropsychologists, who are all part of that environment. So, the one-stop shop applies to the neurocognitive disorder, not necessarily to all health care. It is restricted to that. The idea is, you have a multidisciplinary approach that is centered on the patient so that the specialists in a particular disorder are working together rather than at four or five different locations.

When patients come to Cleveland Clinic, can they just walk in with their insurance card and get care, or do they have to have a referral?

You can walk in, with or without your insurance card, and you should be able to see a physician. They do not have to be referred by physicians. In most cases, the scheduling is done with a triage, where a nurse is on call, or trained medical receptionists are able to extract from the patient the symptoms that they are having. Someone can refer themselves to the clinic, they needn’t have a doctor referral.

Clarification on that is that here, the focus and the interest is neurocognitive disorders. So, if someone came here with stomach ailment, we would try to be sure they were able to access some other health care provider. Really, our interest focuses on three things: disorders of memory, disorders of mood and disorders of movement.

So, if a wife, for instance, thinks that her husband is developing some form of dementia, she could bring him here?

Absolutely.

What is the most challenging aspect of your work?

In today’s health care environment, it is sometimes difficult to navigate because there’s a lot of confusion in the patients’ minds, there are a lot of ambiguity and vagaries in the reimbursement process, and sometimes the access to specialists is fragmented, so it becomes difficult. For us, I think the biggest difficulty that we have in health care is how our model of practice is different from others. We’re used to being a group practice, salaried physicians. We perform in a particular fashion. That doesn’t always translate into traditional community health care. So just being a little bit different can sometimes create some ambiguities.

What is the most rewarding aspect?

You know, I have to tell you that health care is fun. I mean it really is. Taking care of people is fun. If you have an opportunity to really have a positive impact in somebody’s life, that’s enormously rewarding. The second is the problems are really complex and they’re challenging and again I use the word fun, because the complexity of the brain and the central nervous system are second to none within the body. I think it’s an incredibly rewarding and incredibly stimulating profession.

When you were still a medical student, did you originally have the intent to study the brain?

I drifted into neurosciences. Initially, when I started in imaging, I had a general background (in medicine), and what happens, very quickly, even before I finished my training program, I knew that I was interested in neuroimaging. That’s basically what I have done since I finished my fellowship in 1979. So, for the last 30 years, that’s what I’ve done.

Another point that might be interesting: Neuroimagery, the field that I do, has undergone such revolutionary change in the time that I’ve been in it, but nothing I do today existed when I initially trained. Some of the most modern advances and applications of technology in health care are in the imaging field. That’s why it’s been the most attractive.

Cleveland Clinic is in Florida and expanding into Abu Dhabi and Las Vegas. Is the clinic trying to avoid the Cleveland winters?

You know, I think anybody with any sense will try and avoid the Cleveland winters. The sad part is many of us don’t get to leave during the winter, even though there are sites in other places (laughs). Did you see the quote that was done (in the Las Vegas Sun)?

No.

Oh, it was absolutely fabulous. A doctor here, who obviously is not pleased with the Cleveland Clinic coming, was saying that it’s terrible that the Cleveland Clinic is coming. It’s like a bad “Star Trek” episode: They’re on a dying planet and they can’t wait to get out (laughs).

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