Tomorrow's Medicine, Ep. 5: Health Economics - Prof. Lieven Annemans

With Prof. Lieven Annemans, Health Economics Professor. Hosted by Arseniy Arsentyev. Published June 13, 2025.

https://aarsentyev.com/podcast/ep5-lieven-annemans

Machine-transcribed and lightly edited: filler words and false starts are removed, and the wording is otherwise as spoken. Where the two differ, the recording is the record. Times are minutes into the recording. Not medical advice.

[0:00] Arseniy Arsentyev: Welcome, everyone. It's Arseniy and it is the fifth episode of Tomorrow's Medicine podcast. Today I'm talking to healthcare economist Professor Lieven Annemans. Professor Annemans has over 340 peer-reviewed publications and four books to his credit. He is recognized as one of the best healthcare economists in Europe, having served as an advisor of Belgian Minister of Health from 2001 to 2003. Please enjoy my fascinating discussion about healthcare economics. Professor Annemans, could you please tell us what is healthcare economics?

[0:41] Prof. Lieven Annemans: Yeah, healthcare economics or sometimes called health economics is of course a very broad discipline. The definition is we are applying economic theories and economic principles to the health sector and to the healthcare sector. So it's very broad. It can be cost of illness studies. It can be economic evaluations like cost-benefits analysis. It can be health systems reforms like how should hospitals be paid? How should hospitals be organized? How should clinicians be paid? What is the co-payment of patients in the healthcare system?

[1:19] The benefits of prevention, name it, and it's part of healthcare economics. So it's a very, very broad discipline.

[1:26] Arseniy Arsentyev: Alright. And what led you to a career in healthcare economics? And how has this field transformed over the years you're working in it?

[1:37] Prof. Lieven Annemans: Yeah, it was basically a coincidence in the sense that I did first a master in health sciences and then later on I was working in the health industry and did also studies in economics and then I did a PhD in economics. And only after a while having this combination of background in health and background in economics, I discovered that health economics is really something for me and that's where it started. Your second part of the question was how did it evolve over the time? Well it has become simply more and more complex because there are so many aspects to health and healthcare and there is no single country in the world that can say we have the perfect health system.

[2:21] So it means that there is a continuous search to improve our health systems and there are so many aspects to be covered that it's really becoming quite complex. And what we see is that more and more health economists have a kind of a sub-discipline within health economics. So some only specialize in co-payment for patients, others specialize in health technology assessment, still others specialize in the hospital sector. So we get some sub-specialization within health economics.

[2:54] Arseniy Arsentyev: Wow, that sounds great. And I'm curious as an additional questions, how do you believe, is it split in a similar way? So what percentage of knowledge you need to know in economics to become a healthcare economist and what is healthcare? So you mostly focus on economics. Is it correct?

[3:16] Prof. Lieven Annemans: It depends on your sub-discipline. What I see, for instance, in the field of health technology assessment, there are quite a lot of people who have a pharmacy background and then we're trained in cost-benefit analysis and health technology assessment and they're doing a great job. But if it's more about the pure economic principles, so what drives clinicians, so how should they be paid and what are the necessary financial incentives that work and do not work, then we see that a more economic background is more useful. So it depends a little bit on how you want to apply health economics.

[3:56] Arseniy Arsentyev: And when you Google healthcare economics, the most popular collocation that pops up is cost-effectiveness. So we're measuring the cost versus the effectiveness of some policy or some healthcare policy projects that we're doing. And can you break down this concept of cost-effectiveness and explain why money should have, as you say, quote-unquote, good marriage with healthcare?

[4:25] Prof. Lieven Annemans: Yeah, yeah. Very good point. I was mentioning, I think, the term health economic evaluation. And basically, that comes down to cost-effectiveness analysis. So what we do in a cost-effectiveness analysis, we look at the new health technology like a medicine, but it can also be a prevention program or anything else or a medtech solution. And the first thing that everybody sees is, of course, the cost of that new medicine. It will cost often more, or that new program, it will cost often more than what we currently are doing. But at the other side of the balance, that new treatment can also lead to cost-offsets elsewhere in the system. Thanks to that new treatment, there will be, for instance, less hospitalizations and less imaging needed, less consultations needed, and so on.

[5:13] So that's what we call the cost offset. But there is another benefit, namely the health benefit. Thanks to this new treatment, people will hopefully live longer in good health. And that's also very important. In fact, that's the ultimate goal of healthcare, to make sure, some people call it healthy longevity. So to try to get people to have a better quality of life and also a longer life. And in cost-effectiveness analysis, we make that balance. What is the net cost of the new treatment? So that is the cost of the treatment minus the cost offsets. And how much health do we gain? And then the key question is the ratio between the costs or the net costs of the treatment and the health gains, is that an acceptable ratio?

[6:00] You can imagine that if a new treatment costs a lot of money, it costs, let's say, hundreds of thousands of euros, and the health benefits is very small, then that's not a good investment. But if the new treatment costs more, but not that much more than current care, and leads to a lot of health gains, then it's a good investment in health, then it's called cost-effective.

[6:22] Arseniy Arsentyev: All right. I was extremely interested and extremely excited when I read that you worked for a Belgian Minister of Health. And I want to ask you, during that time when you were interacting in such close proximity to the people who actually make the decisions that influence our healthcare systems and probably the healthcare of our parents, children, and so on, what lessons did you learn during this experience?

[6:59] Prof. Lieven Annemans: Oh, my job at that time at the Ministry of Health was to improve the processes and criteria for making decisions about whether new medicines deserve a reimbursement by the healthcare system, yes or no. That was my task. So it was very much oriented towards that concept of cost-effectiveness analysis. And so I was preparing legal texts to allow transparent procedures and criteria to assess new medicines and the value for money of new medicines. At that time, I think there are two types of people, those who are more technocrats and those who are more political specialists. And so it was always very nice to work together with the technocrats, but sometimes those who were more politically inspired tried then to, how would I say, to change things into their own. benefits.

[8:05] And that was then a very good lesson. I was still young at that time and it was 20 years ago, almost 25 years ago. So that was a very good lesson to try to get a consensus between what is technically justified and politically acceptable. That was the challenge at that time.

[8:27] Arseniy Arsentyev: And here is the question that smoothly fits in this picture. Let me draw kind of my understanding. So I am a student and my other pupils. If we want to create a change inside the campus, we create some policy, some club, some initiative inside the university and try to move it higher, higher, higher in this university hierarchy. Until it is approved by the person that oversees this initiative. How does this work in the real world? And how healthcare system wise decisions are made on the country and regional level? What can you say about it?

[9:13] Prof. Lieven Annemans: Well, you have to know that for any decision in healthcare, there is this, let's say, let's call it an ecosystem where you have, of course, the stakeholders, the hospitals, the doctors, the pharmaceutical industry, the medical industry, the patients, other health professionals as well, not only doctors. Those are the stakeholders. Then there are also the processes, and there are also the criteria. Processes, I mean, how is a decision made, which steps are needed to make the decision; and the criteria: based on which criteria is finally a decision made. And then the final part in that ecosystem are what we call the enablers or disablers. For instance, the role of the media, if a given issue appears on page one of a paper that is influencing, of course, the atmosphere and the decision.

[10:06] So we call that enablers and disablers. And then of course, there are also the societal values. What do we want as a country? Do we want the best possible health for everybody? Or do we have other priorities? So that also plays a role. So you have to really work within that entire ecosystem. And my experience is that if you really want to change something, the first step to do is to show the sense of urgency. For instance, the example of the cost effectiveness of medicines 20 years ago, the procedure was totally not transparent. And so there were situations where a medicine that deserved to be reimbursed did not get reimbursement.

[10:44] And another medicine that did not deserve to be reimbursed got reimbursement, for instance, via lobbying, etc. And so there was a sense of urgency because it was really not acceptable that there was this lack of technical support in decisions about medicines. And then you have to talk to all the stakeholders and then to show your ideas. And then you get the feedback of those stakeholders. And then you come with the first proposal. And again, you get the feedback of the stakeholders. And step by step, you try to come to a proposal that is a win-win-win, a win for everybody, for the patients, for the stakeholders, for society, and so on.

[11:24] Arseniy Arsentyev: And this society's values, who assess them? Is there kind of a, because everyone of us understand that we want our parents to live longer, we want to live the happier, healthier lives ourselves. But who in the government decides what is socially valuable? Because as we know, in modern treatment, we also have some drawbacks and every positive policy has huge negative aspects. So who decides which social value product to put into the policy?

[12:07] Prof. Lieven Annemans: Well, in the end, it's also the public who decides because if policymakers say we don't care about, for instance, universal health coverage, and for me, that's very important. Universal health coverage means that every citizen has the right to receive good health care and affordable health care. If a policymaker says, I'm not interested in universal health coverage, then it's up to us, the citizens, to tell that policymaker you don't deserve to be a policymaker. So it depends on us as citizens. I'm assuming that the majority, hopefully, of citizens indeed believes in universal health coverage, that every citizen has the right to get good and affordable health care. Another example is the well-being of the population. We want our population to be happy or we try to make our population happy.

[13:02] If that is not a priority of policymakers, then we have to draw our conclusions and then we have to show as citizens that we don't believe in those policymakers. So in the end, it's hopefully still us, the public who can still influence what societal values are.

[13:21] Arseniy Arsentyev: Okay. It's one side of the equation, policymakers, health care economists. The other side is probably engineers and scientists. And I want to know, did you have an experience working with, like, biologists, professors? What insight can you give us of working with people who are heavily into science and technology?

[13:50] Prof. Lieven Annemans: Yeah. Well, of course, I worked all the time with people with biologic background, with the physiology background, clinical background, of course. And that's very good because they are most concerned in how can we improve health of the population, not regarding yet the money, just how can we improve the health of the population? How can we improve quality of life? How can we improve life expectancy? And that's crucial. That's the first step. That's the ultimate goal. We want to, we call it in economic terms, we want to produce health. So we want people to be more healthy.

[14:29] But then there is a reality check. Namely, we don't have all the money of the world to spend on health and on healthcare. So we have to make choices and the choices should be based on value for money. Because if we don't have all the money of the world and still we want to do so many things to improve health, we have to allocate the money to those interventions. And we come back to the same concept of cost effectiveness. We have to allocate the money to those interventions that per spent euro or dollar lead to the optimal production of health. So we need both. We need the clinical side to try to come up with new ideas and new methods and methodologies to improve health.

[15:12] But we also need the economic assessment in order to make better allocation of our healthcare money.

[15:21] Arseniy Arsentyev: Thank you very much for clarifying, because that was also my idea that the people who work in biology definitely want the best for the healthcare and sometimes they just can't understand that there are also such a huge policy landscape that we also need to keep in mind in order to provide the most benefit.

[15:43] Prof. Lieven Annemans: I would like to add something with that regard. There are some people who think purely clinical, so we don't care about the economics, but that's of course wrong because we have to take into account the reality that we don't have all the money of the world to spend on health and on healthcare. And then there are other people who think purely economic, so they try to cut prices, they try to only look at the impact on the budget of a new treatment, and they don't look at how much health you can gain with that new treatment. But that's of course stupid, because if your only concern is the money, then you can let people die, they will not cost any money anymore. But that would be so wrong.

[16:21] So only looking at economics is wrong, and only looking at the clinical part is also wrong. You really need that marriage between health gains and economic consequences.

[16:33] Arseniy Arsentyev: I hope such a vocal voices as yours will help everyone interested in the field to find this golden middle point between economics and healthcare. And next I want to ask you, how do you believe this system of decision making would change in the future, and would it?

[16:54] Prof. Lieven Annemans: Oh, that's a difficult one. I see positive, but I'm an optimist there. So I see a positive evolution in Europe, because in most decision making processes, we see now also that patient associations are represented. And before, let's say until 10 years ago, that was really rare that patients had a say in healthcare decision making processes. And yet it's so obvious, the patients claim, and they are right, there should be no decision about patients without the patients. So they need to be involved in decisions about approval of new medicines, about strategic choices of hospital networks, about reimbursement decisions of new medicines, and so on and so on. So that's the good part.

[17:46] Arseniy Arsentyev: And so my question was to you, whether you believe that patients should be at the center of decision making.

[18:01] Prof. Lieven Annemans: Well, I think patients are key stakeholders in the healthcare system and should then also be key stakeholders in healthcare decision making. But I believe more in a co-creation process. It's not like I am the key stakeholder and you have to listen to me. That will not work. It's co-creation of different stakeholders together with their respective interests, of course. But I do agree that the ultimate interest of the patients, namely to achieve as much as possible healthy longevity, that should still be the ultimate goal for everyone. And that's something that we see still today in many healthcare systems that several stakeholders do not succeed in looking further than their own perspective. So some say, oh, yeah, but I want to gain money with what I do and the rest I don't care.

[19:02] Yeah, that's not helping, of course. So the least we should expect from everybody is that you look broader than your own perspective and that you agree with the ultimate goal of value for money, healthy longevity at a reasonable cost. That should be the case for everyone.

[19:19] Arseniy Arsentyev: Do you think Belgian healthcare system goes into this direction?

[19:24] Prof. Lieven Annemans: Good point. I see some positive elements like more involvement of patients. And I see that more and more people understand that there is a sense of urgency to improve the system to make it what we call future proof. So let's say yes, there is some positive trend ongoing.

[19:45] Arseniy Arsentyev: And in the US, it's probably the reverse trend, as I can say to you firsthand.

[19:51] Prof. Lieven Annemans: Yeah, well, the US is a very, very complex healthcare system already since many years, of course. Since many years, there are issues in the sense that millions of people do not get the care that they should receive. Yet, the total expenditure is very high. And yet, the healthy life expectancy in the US, on average, is not very good. So there is a lot of inequalities also in that system. And that has been already for many years. And there have been attempts to improve it.

[20:26] And those attempts were then killed, and so on. So very, very, very challenging healthcare system. Yeah, it's another huge topic to discuss.

[20:37] Arseniy Arsentyev: Exactly. Let's go to the PDF file you sent me. Thank you very much. It was an interesting reading about the strategies to improve the Belgian healthcare system. And where are you going? What are you planning? What are you envisioning? And I want to ask you about some moments that I feel would be really necessary and important to my listeners. First of them is, what is QALY or Quality Adjusted Life Years? Could you explain it to someone who's not familiar with economics?

[21:14] Prof. Lieven Annemans: Yeah, sure. In fact, the famous QALY, so Quality Adjusted Life Years, we pronounce it as the QALY. That is a concept that, in fact, is a health parameter. Many people are confused. They think it's an economic parameter, but in fact, it's a health parameter. Because it's kind of a unit of health. Like a kilogram is a unit of weight. How many kilograms do you weigh? Then you express your weight in kilograms. And the same way we express health gains in quality adjusted life years. And if a person lives during one year in perfect health, that is one QALY. But if a person lives for 10 years, so still a life expectancy of 10 years, but the quality of life is only half, let's say one would be perfect health and zero is death.

[22:11] And that person has a level of 0.5. If you live during 10 years at only 0.5, then you have only five QALYs. So 10 years in perfect health would be 10 QALYs, but 10 years at only half the health is only five QALYs. And so the goal is to either improve that quality of life, then you will gain more QALYs, or prolong the life, then you also gain more QALYs. And the ideal is, of course, that we help patients by improving their quality of life and their life expectancy. And then, for instance, if you live 20 years at the quality of 0.8, then you have indeed 16 QALYs, which is a lot of QALYs. So that's what we try to achieve with that QALY. And then we were talking about cost effectiveness.

[23:04] Then the next question is, how much are we willing to pay as a society to gain one QALY in the population? And, for instance, in some countries, for instance, England, they are very explicit about that. They say the maximum amount of money that we want to pay to gain one QALY is 30,000 pounds. So, if there is a new treatment and the ratio between the cost and the QALY is lower than 30,000, then it's good. Because the cost to gain one QALY is, let's say, only 20,000. That's good. You stay below the line. It's a kind of what is societally acceptable. But if a new treatment costs £100,000 to gain one QALY, then they will say in England, sorry, you're too expensive.

[23:50] You cost much too much compared to the number of QALYs that you can gain. It's a little bit technical, but it's a crucial concept. It's on the one hand, the QALY, which is a health parameter. And then the next question is, how much money does it cost to gain one QALY? And is that acceptable, that amount of money that it will cost to gain one QALY with a given treatment? And the beauty of some countries like England is that they are very explicit about that. They clearly draw the line. This is how far we can go and not any further because otherwise we will see an explosion of our budgets and so on.

[24:30] Arseniy Arsentyev: QALY sounds like a reasonable marker. But are there other indicators of quality of life? And how do we measure them? Because for me, it is such an indefinite field. Like I cannot look at the person and accurately measure his quality of life. Could you give us an insight how does this measuring goes?

[24:55] Prof. Lieven Annemans: Yeah, very good point. The benefit of the QALY is that a QALY is a QALY. So you can calculate QALYs for any patients with any disease. You can measure that score between zero and one. You can measure or estimate the life expectancy. That's the beauty of the QALY. But to go a little bit more in depth, that score between zero and one, that score is created based on five dimensions of our life, namely mobility. So how mobile are you? Two, usual activities, then also social capacities, pain and also taking care of yourself. So can you wash and dress yourself, for instance?

[25:42] Then pain or discomfort and also anxiety or depression. So five dimensions. But if we look in reality at what really matters for people, then we see other things like fatigue, being worried about the future, being worried about the quality of my social relationships, etc. And those things are not sufficiently captured by the QALY. So the QALY has the benefit of being uniform and being applied in many circumstances, but it has a disadvantage of not sufficiently capturing what really matters for people. And so it's often underestimating the true benefits of a new treatment.

[26:26] Arseniy Arsentyev: Are there other kind of different indicators such as QALY or is it the only one measuring the quality of life?

[26:37] Prof. Lieven Annemans: Yes, there is research ongoing now, for instance, to look into more well-being adjusted life years. So that research says we have to look further than only the health-related quality of life. We also have to include whether new treatments can make people to have really a better life. And a better life meaning less fatigue, better sleep, better cognition, better social relationships, etc. And so this evolution towards well-being, so how are treatments affecting well-being of people, that's a new trend. It's not yet generally applied, but it's definitely already into research, let's say.

[27:27] Arseniy Arsentyev: I'm glad you also in your previous answer named things like anxiety, depression, social connection. And do you feel that these mental health parameters, these mental health coefficients are included in the calculating and what proportion do they take?

[27:48] Prof. Lieven Annemans: Yeah, in the traditional QALY calculations, they do play a role, but only in terms of anxiety or depression. So, not feeling well, not feeling happy is not included. You have already to have really anxiety or depression in order to make it count. And then it counts for more than one-fifth. So, the weight that the QALY gives to anxiety and depression is quite a strong weight. But as I said, it's not sufficient. It's not helping us to see the impact on well-being, on cognition, on sleep, on mood. Well, to some extent on mood, of course, on social relationships. All of that is not covered by the QALY.

[28:37] Arseniy Arsentyev: Other aspect from the paper was about value-based payments and traditional fee-for-service models. Many people mistake one for the other, and even more people do not understand what this concept means. So, can you give us an example of how the value-based payment model differs from the traditional fee-for-service model?

[29:03] Prof. Lieven Annemans: Yeah. I'll start with the traditional fee-for-service. The concept is quite simple. For every service that a healthcare provider delivers, that provider will be paid. So, a consultation, taking an image like an RX, a surgical intervention, all of that is paid by the service. So, each service is paid separately. That means that the more services a health professional delivers, the more money he will gain. Whether those services contribute to good value or not, it doesn't matter. They just get more payment if they do more performances, more services.

[29:53] There are two big disadvantages to that. First of all, it's kind of a perverse incentive because the sicker people become, the more the health professional will gain because the patients become sicker. They need more consultations. They need more imaging. They need more interventions. And so, the sicker they become, the more money is gained by the health professionals. That's a perverse situation. And the second disadvantage is that some will come into the temptation of doing more services than actually needed. So, they do overconsumption and oversupply of health services even where it is not needed. Those are the big disadvantages of fee-for-service. The alternative is to say, well, let's try to pay for value.

[30:41] And you can do that in an explicit way or in an implicit way. Explicit means that you really give a bonus at the end of the year. You give a bonus, financial bonus, to those who perform better. So, those hospitals who can show less in-hospital mortality, less infections in the hospital, less readmissions to the hospital because the patients were better taken care of and they don't need to come back, etc. Those who deliver better quality, they deserve a bonus because of delivering better quality.

[31:17] A second type of payment is an implicit quality-improving payment. It's what is called often bundled payment. So, the health professionals receive a fixed amount of money per period. So, for instance, a fixed amount of money per patient per month. And why is that stimulating value? Because the better you take care of your patients, the more you keep your patient healthy, the longer you will keep your patient and the longer you will keep on gaining money with that patient. So here the incentives is the opposite as with fee-for-service. Here, the more healthy you keep your patient, the longer you will be paid and the more you will be paid. So that's a second example of value-based payment.

[32:13] So you have either the pay-for-quality with a bonus or you have the bundled payment with a continuous payment as long as the patient is alive. And that is really value-based payment. What we now see in some systems, like in Canada, they work with blended payment systems. So a part is bundled, a part is still fee-for-service, a part is a quality bonus. So they try to come up with a mix of different payment systems.

[32:44] Arseniy Arsentyev: It's my personal opinion, but I believe the future lies exactly in these blended payment systems. Because fee-for-service, as you said, and probably, have also certain advantages. However, this fee-for-service makes, for example, getting back to the US healthcare, it's a huge bubble. Incentives are pointed to that way that prices are rising even faster than the inflation rate. And it is crazy to see new cancer drugs maintaining price levels that are completely unbearable and completely unpayable by the average person.

[33:29] Prof. Lieven Annemans: Yeah, that the latter thing that you say has less to do with fee-for-service, but has more to do with the way how new medicines have been evaluated in the United States. So there is not sufficient focus on that cost effectiveness concept. There should be a clear message to the innovative industry. We want your medicines because they are sometimes really fantastic. They can save lives. We want your medicines, but not at any cost. We have our societal limits. We have a given societal willingness to pay how much we are willing to pay for gaining quality adjusted life years, as we just discussed. And the US has always failed to make that explicit. And that's one of the reasons why these prices are so high. And we see then often that they are also not cost effective.

[34:25] Arseniy Arsentyev: And these radical changes in healthcare systems all around the globe are usually done by the politics shift or some external events. And the latest event we had was COVID-19. And what do you believe the impact of COVID-19 epidemic was on the state of the global healthcare system? What changed?

[34:49] Prof. Lieven Annemans: Oh, my perspective. Well, the conclusion of many is, oh, you see, with COVID-19, our hospital capacity is not enough. We should build more hospitals and increase capacity. And for me, that's the wrong conclusion of COVID-19. Because there is a trend of more telemedicine, there is a trend of better integrated care to avoid that people end up in the hospital. Hospitals also work more efficiently than before and patients can be discharged faster. So building more hospital capacity, that's the wrong conclusion. What we see with COVID-19, that is a large majority of those who had severe COVID, were people with obesity, with diabetes, and with anxiety. And so my conclusion is, we should invest much more in health.

[35:48] We talk about health promotion, keeping people healthy, and then their immune system will also be much stronger and we will be less vulnerable as a society against viruses like SARS-CoV-2, which then causes diseases like COVID.

[36:06] Arseniy Arsentyev: Absolutely. I'm talking to many people and everyone says this sentence. If we focus more on prevention, we'll have a lot better outcome than focusing purely on treatment. I know what the chronic diseases are like. It's a huge business market for the companies to create different treatment options, different drugs. And I myself have a psoriasis, which is a skin condition, which constantly needs certain ointments, and living in a certain way, a certain lifestyle. And it is such an economic waste of money, of health services, of professionals, that I believe, and many people to whom I talk, believe that we need to put our efforts in trying to prevent these diseases.

[36:58] Because at that point, we can certainly say that we can prevent or reduce the probability of diseases like diabetes and diseases that usually link to the bad lifestyles by educating the society, educating the people what they need to do. And kind of putting the seed into children's brain, that healthy lifestyle is important, and we need to live in a certain way.

[37:29] Prof. Lieven Annemans: Yeah, excellent point. In fact, there are two components. There is lifestyle, but there's also the quality of the environment, pollution, etc. That also influences our health and can trigger immune diseases and inflammatory diseases. So there is a need as humanity to change our attitude versus nature. Now we think we are the boss of nature and we can do whatever with our nature, but we should be more modest and understand that we are part of the nature and that we need nature to survive as mankind. That's one thing. And then lifestyle is both physical lifestyle and mental lifestyle. And you're absolutely right. The best place to start with that is childhood. And what is the place where all children go? That's school.

[38:25] So in schools, we have now an initiative in Belgium, which is called the Holistic Health Plan, where the children are informed about how they can take care of their health and what to eat and what not to eat, the importance of exercise, the importance of limiting social media time, the importance of having good relationships with each other and be helping each other and empathizing with each other. All of that is part of that holistic health plan. And we are now hoping, and tomorrow I have a presentation about that in the premises of the federal parliament. We are hoping that this holistic health plan will be adopted and it will take a generation, of course, but I hope it will help them to improve the health of the population.

[39:15] Because there was a health futurist from the Netherlands who said the best solution for our healthcare system is health. If we keep people healthy, then there will be no issue anymore with exploding budgets, etc., because we keep people healthy. But we have to start at childhood.

[39:33] Arseniy Arsentyev: And the best thing is that this approach actually works. I myself got a really great program during my school years, focusing on preventing smoking. And they showcased different causes, certain diseases that smoking causes. And it made such an implicit part in my brain that I didn't become a smoker. So many of my friends do smoke and even under this kind of social pressure during the teenage years, it helped me to really like stay on the more healthy side of the population I was growing in. And they actually work. I'm really proud that all around the globe right now there are more and more initiatives and thank you for the people like you who try to provide this viewpoint that we need to increase, not decrease such programs for children.

[40:35] Prof. Lieven Annemans: Exactly. Very good example that you are giving here.

[40:39] Arseniy Arsentyev: Yeah. So next we can talk about telemedicine. Did you hear the news that if I'm not mistaken in Saudi Arabia, they opened the first clinic without any specialists. So without doctors. Did you see this?

[40:57] Prof. Lieven Annemans: Yes. But it's not new. It was already announced years ago in a hospital in the Netherlands that they announced at that time, more than five years ago, that the hospital of the future will have almost no beds or clinicians. They will follow patients from distance and only intervene when it is necessary to intervene. Personally, I find it a little bit over the top. And I'll try to explain because there is more and more research that is arguing for hybrid systems. So where patients still do see physically health professionals, but that for a lot of part of their time, they are indeed telemonitored from distance and only called in when there is an issue.

[41:56] For instance, I remember a recent paper in Italy where the patients could choose how many times per year would you like to see your doctor once or twice or zero. And most patients preferred once or twice and then the rest of the time followed up with telemonitoring devices and wearables, etc. But purely without any human contact is not good because then it will also contribute to loneliness and other societal issues. So I think we need both. The human contact should never be forgotten. But of course, we should also build on the benefits of telemedicine, obviously.

[42:39] Arseniy Arsentyev: A couple episodes ago, I was talking with computational biologist, ex-MIT, Ben Lengerich, and I asked him a question. What do you want to see in the medicine, in the healthcare space in 10 years from now? And he gave such an extraordinary and non-conformist answer. He said, I want medicine to return to the state of the art. So I want the medicine again to become an art, not just some probabilistic game. And I was thinking about this concept and I asked myself, what do I value in the doctor I'm seeing? And the answer was that actually a huge part of my treatment is getting in touch with the real human being, seeing his expertise. And so sometimes, especially older people, as I see, use doctors as kind of psychiatrists, if we can say like this.

[43:50] And speaking about telemedicine, I'm not sure that in the close future we'll see alternatives that will provide the same experience for the patients.

[44:00] Prof. Lieven Annemans: Yeah, exactly. And that's why I was also arguing for that hybrid approach, because indeed, some are thinking about health and medicine in a too mechanical way, as if a human body or human person is just a composition of cells and tissue. Cells are forming in the tissue and organs with a given function and parameters that show us the functioning of that organs. And they think, oh, if there is something wrong with that machine called human being, then we have to just give a pill there or to this to reduce that parameter and then it's fine. But that is wrong. We should look at humans really as in a much more holistic way. And human beings need human interaction in order to improve or maintain their health. I'm really convinced of that.

[45:00] And just looking at a human being as a machine is, in my view, completely wrong.

[45:09] Arseniy Arsentyev: But talking about deterministic and indeterministic, I can give an analogy. For example, in physics, in classical mechanics, if we go to space and throw the ball, we know its velocity, its acceleration, and we can predict when the ball would be in two seconds. In healthcare, we cannot predict so many things, and it's extremely probabilistic. And how do you feel? Would the medicine of the future be deterministic, so it would be like a physical equation? Or, for example, you have certain disease, this is what you need to do. If you'll do this, you'll be healthy again. Or would it be more indeterministic? And there also be this probabilities, you can do that. With this drawbacks, you can do the other option. So it's going again with medicine as an art versus as a predictive system.

[46:08] Prof. Lieven Annemans: Yeah. I would like to say two things about that. First of all, we are all unique. We have all unique fingerprints. And in fact, we have unique genes and unique ways of responding to inputs and treatments, etc. So looking at it at a too deterministic way is wrong in the sense that then you are basing yourself on what we call the illusion of the average. If something on average would appear to work, then some think, oh, then we try it in all patients.

[46:47] And that's, in my view, not a good way of thinking. Second, when we look at the origin of what we call evidence-based medicine, so medicine based on evidence, some people think that evidence-based medicine is only based on scientific evidence. But that's not correct. In the original definition, they said evidence-based medicine is based on scientific evidence, the experience of the health professional, and the preferences of the patient. And you always have to take into account those three elements. And in that sense, it cannot be deterministic. It needs to take into account how people feel and what their preferences are and how they interact with their environment, etc., etc. And that's why I tend to agree with him that ideally it should stay an art and not become deterministic.

[47:41] Arseniy Arsentyev: So searching through the internet, I haven't found a descriptive answer from you on the topic of genetic technologies, playing God, genetic engineering, changing ourselves. Do you have anything to say on this field?

[48:01] Prof. Lieven Annemans: Well, maybe in a similar way, if you look into genetics again in a too deterministic way, well, I'll first complete my sentence. If you look at genetics in a too deterministic way, then you think indeed that you can play God. And that if you change, with those new techniques, a sequence, you can change everything. But what is realized more and more is the importance of epigenetics and the importance of how our emotions, how our social life can influence the way that genes are expressed from DNA into RNA and from RNA into proteins with different functions. And it is becoming more and more clear that negative emotions will stimulate bad genes and will block good genes. So our emotions can influence the way that our genes are expressed into functioning.

[49:09] And I find that part of the science much more promising and much more impactful in my view than the pure genetic manipulation. But having said this, it's fantastic that if patients have a genetic disease, they lack a gene that is coding for a given enzyme. And so they don't have that enzyme. And now there is a treatment that can restore that and the patient starts producing that enzyme again. Yeah, that's fantastic. Of course, you're saving the life of a patient who had the bad luck to have this very rare genetic disease. So that is as such, that is fantastic. But an overly belief in that we can change everything with that is not correct.

[50:06] Arseniy Arsentyev: Professor Annemans, correct me if I'm wrong, but I want to kind of outline for the broader audience what is the difference between genetics and epigenetics. Epigenetics is a specter of biology that explores how the genes are expressed. Is it correct?

[50:22] Prof. Lieven Annemans: Exactly, exactly. And looking at all the factors that make some genes being expressed or not being expressed. And so environment, behavior, etc. is playing an important role with that regard. Of course, I'm not a specialist. I'm not a genetic specialist. But we get in touch with that field on two types of situations. The first one is that indeed, I do quite a lot of economic evaluations of those genetic treatments. So cost benefit analysis of those genetic treatments. And the other one: I do a lot of research on what makes people happy, what makes people having a good life and being in a good situation of well-being. And there we also see a link with epigenetics.

[51:22] Namely that, like I just said, negative emotions can really make people sick, because the wrong genes are expressed and the right genes, the good genes, are blocked.

[51:36] Arseniy Arsentyev: You're working in such an interesting field, because you have some kind of understanding in many different areas, and a question sparked in my mind. If I would say to you, for example, Professor Annemans, I want to become a healthcare economist. What roadmap, what direction can you outline for me? For everyone listening, if a person wants to be top-notch, best in the world, healthcare economist in like 10, 20, 30 years, what should they do? Should they pursue special degrees? In which universities or probably outline the areas on which they need to focus?

[52:18] Prof. Lieven Annemans: Yeah. I think as a basic education, so your background can either be in health sciences or in economics. But in both cases, I recommend to learn intensively the other side. So if your first background is in health sciences, please do a second degree in economics so that you combine that knowledge. If your first background is in economics, please do an effort to follow courses on physiology, anatomy, pathophysiology to understand the human body. Because only then, in my view, you can be a health economist who understands health and understands economics.

[53:07] I will not talk about which university and so on. That's usually dependent on the person. I rather stay neutral there.

[53:17] Arseniy Arsentyev: Okay, I see. And so you told us the background and what are the differences between working as a healthcare economist in the government, in the policy section, or in the corporate sector? And are there corporate healthcare economists?

[53:37] Prof. Lieven Annemans: Oh, yeah, yeah, yeah. There are many. So within each pharmaceutical industry, there are health economists. Within each medtech company, there are health economists. In insurance companies, there are health economists. And everybody can choose, of course, what they want in life. But a health economist who is only interested in pure economics, like a health economist working for an insurance company and who is only interested in, let's try to make as much as possible profit with our insurance company. For me, that's not really a health economist. That's an economist who is working in the healthcare sector, but not a health economist. A true health economist puts health as a priority. We want the best possible health for the population. And then says as a second step, but there is this economic reality.

[54:29] We don't have all the money of the world to spend on health. So how can we spend that money in an optimal way in order to improve the health of the population? And if that is your attitude, then you need to understand both health and economics.

[54:43] Arseniy Arsentyev: And what is the social part of your job? So we talked about healthcare and the treatment. And on the other side, we can improve our health, not only by treatment or prevention, but also by fostering good accommodation. So people living, do you know what a sick building syndrome is? When there is extremely old buildings, just poisoning your health. And do you work with such societal decisions as better living standards, moving people to different districts? And what can you say on the subject?

[55:27] Prof. Lieven Annemans: Yeah, very good point. In the report that you mentioned and that will be presented tomorrow in the federal parliament, the title of the report is Towards a Future-Proof Health System. One of the strategies that we propose is to tackle much more aggressively what we call the social determinants of health. And we provide, with that regard, two important advices. First of all, we say we have to provide to clinicians the tools to do screening about the social situation of patients. So a very easy way to better understand what is the condition of that patient's life and to bring in social services, etc., to help those patients. That's one strategy. But the second strategy is looking at the root cause.

[56:16] And for instance, one of the advices that we give is that the minister who is responsible for housing invests much more in social housing, in quality housing, because one of the key causes of poor health is bad living conditions, bad housing. And so it's an explicit part also of our report. And so I'm glad that you mentioned that topic because health economics goes much broader than just the health sector. It involves also, of course, housing. It involves also how the community is organizing the activities like healthy cooking, etc. So there are so many things that can influence the health of the population where the responsibility is for people outside the health sector.

[57:16] Arseniy Arsentyev: But this system will definitely boost our prevention and increase the living standard of the people. However, the problem that I think would be present is again getting back to decision making. For example, there is a research in corporate firm organization, in startups. For example, in startups, you should have three people ruling, no more than three. And in the US, sometimes in a certain aspects, they require nine people to be on the board of the company. But research shows that three is enough. One founder, representative from the investors, and the CEO or some persons that helps actually run the company. And when you're talking about collaborating with the minister that provides housing and stuff, we're facing again the problem. So we have minister of health or something. We have the minister of housing.

[58:16] And the more people involved in this multi directional approach, it is tougher to create one policy and we'll need person above them to coordinate it. So that's just my thoughts about it.

[58:32] Prof. Lieven Annemans: Yeah, I see what you mean. But what we did in our report for every recommendation that we said, we pointed to the person who needs to take the lead. So who is here in the driver's seat. It is very important. And that person needs then to bring in a selected and, you're right, not too large number of people with whom they can indeed work out that strategy. Of course, at the really root cause of inequalities and bad living conditions that cause a lot of diseases is, of course, the socioeconomic inequality. We see that in those countries, like for instance, Scandinavian countries where there is less inequality, that there is also better average health.

[59:24] Because if you live in a country where there is a lot of people living in poverty or what we call material deprivation, then you should not be surprised that there are a lot of health issues in your country. In those countries where they can better correct for the large inequalities, they are performing better in many aspects. Less criminality, more happiness, more healthy life expectancy, etc. And I find it still amazing that some policymakers do not understand that.

[1:00:04] Arseniy Arsentyev: It takes time, but hopefully we as humanity go in this direction and the future is bright. Speaking about the future, right now we're living through the AI boom. Many people call it AI bubble. And I cannot stop myself from asking you, what do you feel the role of AI would play in the medicine that we have today?

[1:00:33] Prof. Lieven Annemans: Yeah. First of all, AI is too much referred to as a kind of a container term. Like imagine that everything that we use to have transport, like a bike or a car or a plane, that we would all of that call a vehicle. What do you think about vehicles? Well, it depends. And the same counts for what do you think about AI? There is really good AI and there is other AI that is really, I have to be careful with my words.

[1:01:13] Arseniy Arsentyev: That hallucinates a lot.

[1:01:15] Prof. Lieven Annemans: Yeah, definitely. And that's, yeah, some people call it bullshitting. And there is also AI that is even dangerous, that can lead to adverse consequences, etc. So the challenge for the future is to come with some kind of quality appraisal, labeling of AI. Like in many countries, they also do already with nutrition. So there is very good healthy nutrition and there is also very bad unhealthy nutrition. And in some countries, they work even with labels like quality level A, B, C, D, E, for instance, of different types of nutrition. And maybe we have to evolve to something similar for AI that people at least know if you work with a given application, what is the quality label of that application? How good is the transparency of the data based on which the system was trained?

[1:02:13] What is the likelihood that the system is mistaken? Have there already been events reported with that particular application that are not desirable, etc.? So we need really much more quality assessment of different AI applications. And we need to always keep the principle that AI is there to help us lead a better life, but we should not have our lives being led by AI. So we always should be as humans looking at it. It's a technology of which the goal should be to help us to lead better lives, but not vice versa.

[1:02:56] Arseniy Arsentyev: And to clarify my point, as you said, we have different stages and levels of artificial intelligence. For example, today's LLMs are great in certain tasks, but we definitely cannot say that they are as smart as the best professionals in the world. However, if we'll do a thought experiment and say that AGI or general intelligence, so intelligence comparable to the experts, the best experts in every field exists today. Can we speculate what changes may bring?

[1:03:32] Prof. Lieven Annemans: We can speculate as much as we want. Sometimes people say, yeah, let's speculate about how the future can look like. But I think the better attitude is, how do we want the future look like? How far do we allow AI to evolve?

[1:03:56] Arseniy Arsentyev: I'm sorry, Professor Annemans. Let's talk about the AI and the next question we'll talk about how do we want, what future do we want? So let's focus on the AI right now.

[1:04:06] Prof. Lieven Annemans: Well, but my answer is, what future do we want with AI? I think in the ideal situation, it will be up to a level where it can be really, and it has already in some cases, a peer of humans, where it has the capacity of thousands of brains, but where it still is considered as a peer provides advice, but where we as humans still have a say in what we do with that advice. And in some cases, which is already happening now, we say we trust the advice 100% and we are not going against AI, but in many cases, we will still have the pure human arguments, ethical, social, other aspects, emotional arguments that AI is not delivering that we can use to still change the advice of what the peer is telling us.

[1:05:09] So I believe very much in what we call collective intelligence, human intelligence and artificial intelligence working together. And indeed, the artificial intelligence is improving a lot. But it means that we also have to improve our human intelligence to bring more ethics, empathy, emotional aspects, which the AI is not so much able to do.

[1:05:37] Arseniy Arsentyev: Thank you very much for elaborating. And the last question is traditional for my show. What do you want the medicine to be like, let's say in 10 years? You can talk about a range of things, from the policy to just going to hospital: what do you want to see when you enter some hospital or some place to get some treatment? What do you want to see in the 10 years?

[1:06:05] Prof. Lieven Annemans: Well, in the 10 years from now, I think the ideal healthcare system is a system that is focusing in the first place on health. So keeping people healthy, and where the concept of health in all policies is generally accepted. And that concept means that health is not only the responsibility of the minister of health, but also the minister of education, the minister of work, the minister of housing, etc. That's a first thing that I see as really important. And the second is when people then still need healthcare, because that still will be the case, of course, even with perfect health promotion, there will still be people who need care, that the best quality care is available for everyone and affordable for everyone.

[1:07:03] And I'm 100% convinced that this is possible, maybe not within 10 years, but then hopefully within 20 years.

[1:07:12] Arseniy Arsentyev: Thank you very much for this great discussion. I learned a lot. I know that my audience will learn a lot. Thank you very much, Professor Lieven Annemans.

[1:07:20] Prof. Lieven Annemans: You're welcome. And it was really a pleasure to have this conversation.

[1:07:26] Arseniy Arsentyev: All right, everyone. Thank you for listening. Listen to Tomorrow's Medicine podcast, subscribe to my channel, share with your friends, and I'll absolutely appreciate your feedback and your support on my Patreon page. Bye bye, everyone.