The 16th Century English phrase, “A Jack of all trades is a master of none but often better than a master of one,” is often misquoted and used disparagingly, but this saying might be more relevant today than ever with regard to healthcare delivery in the U.S. While not undervaluing the need for highly specialized experts across the healthcare continuum, it does highlight a significant gap that our traditionally siloed, treatment-specific approach presents to providing optimal care for patients.
One of the greatest challenges of our times—the exponential increase in the utilization and cost of care—is arguably a result of fragmented, uncoordinated care. The “Quadruple Aim’s” focus on improving the efficiency, effectiveness, cost of, and satisfaction with healthcare seems to be as elusive today as it was nearly two decades ago when it became a popular rallying cry for healthcare improvement and reform initiatives. A major dilemma remains: How do we help patients address their unique health and wellness challenges before they become significant personal and financial problems?
The new healthcare ecosystem requires a collaborative, multidisciplinary approach to meet the healthcare challenges of an increasingly medically complex, socially diverse, and technologically sophisticated population. Like other healthcare stakeholders, pharmaceutical companies are invested in healthy patient outcomes. However, they are often excluded in medical and behavioral health industry initiatives, which are gaining momentum to address a patient’s overall health and well-being. Pharmaceutical companies should not be absent in the discourse around drivers of poor quality and outcomes, especially as related to health equity and social determinants of health (SDoH).
To become better partners, drug makers should invest more in collaborative, digital transformation strategies that help them leverage patient-centric data in a population health management framework. Healthcare claims and utilization data, predictive analytics, electronic medical and health records, as well as real-time community health information provide the foundation to identify, target, and address the significant drivers contributing to treatment and medication gaps, including problems such as nonadherence.
In-Person and Digital Health Interactions Enabling Better Actions
Accelerated by COVID-19, more patients are participating in digital health interactions and using healthcare engagement tools. Additionally, community of health and wellness ecosystems are increasingly being developed across the U.S. as a result of unmet demand and evolving consumer behaviors. Consequently, opportunities for altering delivery models for primary and chronic condition management services are arising for both in-person and digital care. These opportunities include optimizing delivery and fulfillment activities across all stakeholders such as providers, pharmacies, facilities, payers, suppliers, and manufacturers.
For example, some of the world’s largest retailers, such as Walmart, are becoming increasingly involved in both in-person and online healthcare. With reportedly nearly 4,000 Walmart Health Centers planned across the country by 2029, Walmart is focused on changing the way Americans view and use primary care providers. Additionally, Dollar General recently hired a Chief Medical Officer to lay the groundwork for its medical service offerings. Given the fact Dollar General has over 17,000 stores, its impact, along with Walmart, Amazon, and others, on the healthcare ecosystem will be dramatic but difficult to predict in the near term.
One can only imagine the opportunities available to constituents who can provide quality and affordable healthcare services and medications across all demographics, socio-economic statuses, and communities in greatest need of coordinated, patient-focused care. By using up-to-date, actionable information that accounts for all the factors that affect outcomes and care, a retail business approach might possibly provide a great solution for gaps in care for patients in both rural and urban communities.
As illustrated in Figure 1, over the last few years the healthcare ecosystem has been transformed to a great extent by the increased use of digital technological interventions. Moving from a reactive, “patient as a passenger” approach to a proactive, “patient as participant” approach, many of these transformational activities provide the foundation for stakeholders to integrate previously siloed functions into a more cohesive, collaborative framework which benefits all participants in the new health ecosystem.
Recently, partnerships and programs have emerged focusing on supporting this new health ecosystem. These partnerships are mainly driven through health plans or payers, bringing in resources such as pharmacy benefit managers (PBMs) to provide medication alignment as well as community resources to address and support SDoH impacting health equity issues. Companies such as CVS, Blue Cross of North Carolina, and OneCity Health have all created forward-thinking partnerships to address SDoH from transportation challenges to food insecurity.
For example, CVS Health’s “Project Health” community-based program, which provides free biometric screenings and no- or low-cost preventive care services, is designed to address health disparities associated with disadvantaged groups and at-risk communities. CVS reports that since 2006, this program has provided more than $134 million in free healthcare services to at-risk communities with high numbers of uninsured people. Moreover, this program is directly addressing the major SDoH challenge of medical transportation through creative partnerships with organizations like Lyft. This program has demonstrated a positive impact on ensuring appointments are kept as well as providing transportation to increase vaccination rates for COVID-19.
However, what is missing in many of these partnerships is participation by pharmaceutical companies, and opportunities are certainly available for the industry to engage in these partnerships to improve patients’ health and quality of life.
The Medication Nonadherence Problem
When patients fail to take their medications as prescribed, the negative impact on their health is significant, not to mention the impact on avoidable direct and indirect medical costs. Health and Human Services (HHS) estimates that as many as 50% of adults in the United States are nonadherent to medications. Depression, lack of motivation, misunderstanding, costs, and inconvenience are only a few of the causes cited for this problem.
A study published in the Annals of Pharmacotherapy1 shows that the annual avoidable costs for medication compliance issues resulted in over half a trillion dollars, which is nearly 16% of all healthcare expenditures in the U.S. To make matters worse, this problem appears to be prevalent across all demographics, socio-economic statuses, and health plan program types. For example, a review in the Annals of Internal Medicine2 estimates that poor medication adherence causes nearly 125,000 deaths a year.
Clearly, collaboration is needed to address this problem, and partnerships to identify and remove barriers associated with SDoH are warranted. This information could be used by pharmaceutical companies as part of these partnerships to improve patient engagement, mitigate SDoH, and establish integrated programs such as patient medication adherence assistance programs, community support hubs, and clinical trial support.
Evolving Healthcare Landscape—Examining the Payoff
The most important relationship in optimizing health outcomes and quality of life is the one between the patient and the provider. The challenge is how this relationship can be best supported to improve and sustain better outcomes. Often the actual drivers for poor outcomes are not necessarily specific medical diseases or conditions but, rather, the lack of understanding and appropriate actions related to medication adherence, SDoH, and health equity.
The Centers for Disease Control and Prevention (CDC) asserts that our life circumstances (for example, the social, financial, and emotional/spiritual conditions) have a “profound impact on health.” The National Institutes of Health (NIH) also recognizes that patients diagnosed with major medical conditions often suffer from behavioral health issues such as mood and anxiety symptoms exacerbated by their life circumstances. Consequently, aligning the best interventions to address SDoH can clearly decrease disparities and barriers to receiving appropriate care and developing healthy behaviors. This, in turn, will make effective and quality care fairer and more equitable for everyone.
Figure 2 represents the healthcare ecosystem with the patient (“self”) in the middle. Though already collaborative in nature across stakeholders, it does, nevertheless, require a higher level of participation and engagement by the individual patient than previously expected. In other words, stakeholders must drive innovation and change to support the “patient as participant.”
The methods to operationalize support of the whole person approach to health and wellness are varied. Advances in information integration and technology allow for an individual treatment regimen customized to meet the challenges of each patient or, in some circumstances, the cohort in which the individual belongs. As discussed previously, these challenges will most likely be comprised of medical, behavioral, and social issues that drive poor quality and outcomes. The health ecosystem is evolving to a future state where data are used to guide treatment choices and modify lifestyle behaviors, thereby optimizing care.
The payoff for stakeholders, especially pharmaceutical companies, include: (a) improved patient outcomes; (b) lower overall healthcare expenditures; (c) fewer emergency department visits and hospitalizations; (d) enhanced revenue recognition due to better medication adherence; (e) enhanced brand equity; and (f) a voice in improving health equity through interventions aligned with SDoH.
A holistic, dynamic approach to supporting the patient is critical to positive outcomes. Implicitly, one cannot fully and successfully treat a patient until their physiological (or medical), behavioral, and social challenges are addressed. For example, integration of health digital interventions such as patient-focused assistive technologies are shown to support readiness to change as well as improve compliance, adherence, and engagement of individuals, regardless of their unique circumstances or conditions.
Studies from the National Center for Biotechnology Information3 have shown that digital technology interventions help patients with medication and vaccination regimens, appointments and scheduling, and creating and maintaining health behaviors. Clinician and caregivers should incorporate these types of technologies to decrease disparities and improve outcomes.
We are in a unique technological and social position to update or fine-tune healthcare ecosystem partnerships to improve numerous components of care, thereby increasing the efficiency, improving the effectiveness, and, in many situations, lowering the overall cost of care.
This evolving health ecosystem presents many benefits and opportunities. But these changes will be difficult and disruptive for many organizations, shareholders, constituents, and participants. Is it worth it? Time will tell. Maybe there is a role for “jacks of all trades” to collaborate with the “masters of one.”
1. “Cost of Prescription Drug–Related Morbidity and Mortality,” Jonathan H. Watanabe, PharmD, MS, PhD, Terry McInnis, MD, MPH, Jan D. Hirsch, PhD. Annals of Pharmacotherapy. March 26, 2018. Volume: 52 Issue: 9, page(s): 829-837 DOI: 10.1177/1060028018765159. https://journals.sagepub.com/doi/abs/10.1177/1060028018765159.
2. “Interventions to Improve Adherence to Self-administered Medications for Chronic Diseases in the United States: A Systematic Review,” Meera Viswanathan, PhD, Carol E. Golin, MD, Christine D. Jones, MD, MS, Mahima Ashok, PhD, Susan J. Blalock, MPH, PhD, Roberta C.M. Wines, MPH, Emmanuel J.L. Coker-Schwimmer, MPH, David L. Rosen, MD, PhD, Priyanka Sista, BA, Kathleen N. Lohr, PhD. Annals of Internal Medicine. December 4, 2012. Volume 157, Issue 11, page(s): 785-795. DOI: 10.7326/0003-4819-157-11-201212040-00538. https://www.acpjournals.org/doi/10.7326/0003-4819-157-11-201212040-00538.
3. “Evaluating Digital Health Interventions: Key Questions and Approaches,” Elizabeth Murray, Eric B Hekler, Gerhard Andersson, Linda M. Collins, Aiden Doherty, Chris Hollis, Daniel E Rivera, Robert West, Jeremy C Wyatt. American Journal of Preventive Medicine. November 01, 2016. Volume 51, Issue 5, page(s): 843-851, DOI: 10.1016/j.amepre.2016.06.008. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5324832.