The healthcare market is a dynamic market in every aspect. From advances in biotechnology giving rise to genomic therapies to the continuous emergence and consolidation of the companies who operate in this market, healthcare is an evolving industry. It should be no surprise then that the legislative policy and regulatory framework governing the industry is also continuously evolving—all with the objective to improve the overall health system of the nation and its citizens. This evolution is an opportunity for pharma to proactively lead, not to defensively hide. How we as an industry participate in this legislative and policy change will go a long way in determining the nature of the market itself.
There have been many laudable initiatives to achieve improvements in the health system, and in the health of our fellow citizens. One such initiative is Triple Aim, a concise set of responsible and achievable objectives. Yet those objectives are overshadowed by the volume and intensity of the discourse on the means to achieve them. Turn on the news on any given day and you will see debate and demands for change to the Affordable Care Act (Obamacare). Yet many people overlook one key item about the ACA: It is a legislative framework that is designed to provide healthcare insurance to more Americans, not healthcare delivery, (e.g., Veteran’s Affairs, long-term care, home healthcare, etc.) This is an important distinction, because in many ways the politics around the ACA get confused with and cloud the policy objectives of Triple Aim.
Triple Aim is geared to improving three significant dimensions in the healthcare delivery system’s performance:
- Improving the patient care experience (including quality and satisfaction).
- Improving the health of populations.
- Reducing the per capita cost of healthcare.
The Affordable Care Act is simply a legislative framework put in place as one approach in meeting those policy objectives—and a limited approach at that.
Each of the Triple Aim’s objectives creates opportunity for all the players in the healthcare system today, and it doesn’t need to be a zero-sum game. What works for public payers (i.e., Medicare) doesn’t necessarily need to come at the expense of hospital systems and healthcare providers. Improvements offered by the pharmaceutical industry aren’t at the expense of insurance companies. We need to communicate that more loudly and with greater clarity.
In fact, the pharmaceutical industry needs to remember one key fact: Their very success has fundamentally transformed healthcare over the past half century. Advances in treatment have saved the lives of millions, prolonged the lives of millions more, and yet account for less than 10% of overall healthcare system costs. Better still, the pharmaceutical industry still has much more to offer in the years and decades to come as we develop, commercialize, and launch new brands.
Here are several ways that pharma is already contributing to Triple Aim, even if it wasn’t an explicit goal:
1. Improving the Patient Care Experience
How does one define a satisfactory experience? Is a satisfactory experience for one patient different from a satisfactory experience for another patient? Almost certainly. Each patient is unique, with different healthcare needs, goals, and experiences that led to where they are today. This is to be expected. We engage with each of our co-workers differently. We engage differently with each person we encounter every day—our spouse, the coffee vendor, the sales clerk, etc. Do we leave each engagement asking the question, “Was your experience during our interaction to your satisfaction?” Of course not. Yet this is a policy objective of Triple Aim. As such, we need to define metrics on how to measure patient experience in terms of quality and satisfaction. Often we rely on surrogate metrics that may be impractical or even impossible to collect.
One such surrogate metric is, “What did the patient do, and would they do it again?” Assuming that patients are like us, seeking reward again and again, it is fair to assume that patients prefer to repeat satisfactory experiences and discontinue unsatisfactory experiences, particularly when much of that experience is within their control. How patients behave is a fitting measure to determine if they are satisfied.
Patient behaviors are a variable that often escapes the treaters’ control. Once the patient leaves the physician’s office, the onus falls to the patient to recall and follow their physician’s instructions, as well as to embrace the responsibility for personal self-management. All too often, patients being the humans they are, don’t live up to physician expectations, preferring other behaviors that provide more satisfactory rewards. Pharma brands can help close the gap.
Rethinking chronic diseases is an important place to start. Diseases such as diabetes and chronic obstructive pulmonary disease (COPD) afflict millions, consume significant healthcare resources, and are cost drivers to the system, especially when not properly managed. These diseases are also not just about symptom management; they are about behavior management. Establishing more productive, engaging behaviors earlier in the disease can delay (or even prevent) progression, and is associated with reductions in nonadherence, drug switching, and hospitalizations. Better behavior management keeps patients in their current therapy class longer, with the desired quality-of-life improvements patients and prescribers seek.
Key to better behavior management is the development of brands that are intuitively designed for how patients will truly use their treatments in the real world. Brands that provide “reward” through feedback and confirm for patients that the treatment is being used correctly encourage and sustain positive behavior change. This feedback and confirmation is not unique to pharma. It is commonly used in the everyday world in which we increasingly want, seek, and need feedback (think of Uber’s real-time tracking system, or think of the “delivered” notification each time you text). These seemingly simple feedback and confirmation mechanisms have a profound impact on behavior change, and more importantly, on creating sustained behavior change. Every brand now or to come should be thinking about rewarding positive change through feedback mechanisms. We don’t need legislation to do that.
2. Improving the Health of Populations
Population health strategies conjure up thoughts of lofty goals that are dreamily desired by policymakers and payers. The reality is that there are more pragmatic and practical ways to deliver on population health improvement strategies. Many of these strategies typically focus on compliance and adherence, with the usual thinking around refill reminders, diaries, etc. However, one fundamental aspect of population health is frequently overlooked: Identifying and intervening in patient populations most at risk of a health crisis, precisely because they may want to avoid identification.
Some medical conditions come with stigma, whether real or perceived. Conditions such as HIV, major depressive disorder, schizophrenia, and postpartum depression are examples. These medical conditions are biological in nature, yet create significant psychological stress and strain on those who suffer. In the more severe cases, the strain can result in harm to the patient, caregivers, or those for whom the patient is the caregiver. These are populations in crisis.
Real strides have been made in reducing the stigma in some of these conditions, but more is still required. Several of these conditions may often go unrecognized and undiagnosed. Perceived stigma may compound the problem, worsening the situation by denying the patient of the will or inclination to seek help for fear of being judged. This delay in recognition, diagnosis, and treatment can often come too late.
Recognizing this crisis includes understanding that significant disease education and social awareness campaigns medicalize the condition, destigmatize the patient, and aid in identifying at-risk populations. This is true not just in the patient, but in those who care for them, including their partner, their family, and their friends (and of course their caregivers in healthcare settings). Recognizing the warnings signs of under-diagnosed diseases earlier affords the ability to intervene earlier and to better protect the health and lives of very vulnerable populations. Pharma needs to do more disease education and social awareness, not less.
3. Reducing the Per Capita Cost of Healthcare
Increasingly, pharma brands are investing in demonstrable improvements for care-delivery costs. This is a responsible advance. Health economics and outcomes research (HEOR) is an important and perhaps under-recognized hero in the industry. Too often the conversation about pharma brands is about cost. Recent new approvals of some brands, (e.g., in the hepatitis C market) or aggressive price hikes for existing brands (think Mylan’s EpiPen) get all the attention. But that conversation is off the mark. As an industry, we need to assert the value of our brands, not the cost. This is where HEOR comes in.
With foresight, new trials must include key endpoints that go beyond the required clinical endpoints of improvement over placebo. Additional endpoints that include reduced days in the ICU, fewer days on treatment, reduced hospitalizations (a very significant cost driver), reduced mortality, etc., translate into direct value to the healthcare system and all its constituent stakeholders. These endpoints illuminate the path to more efficient and effective use of limited resources to achieve better outcomes. These data points matter, as more stakeholders are increasingly held accountable to quality metrics. And the data serve as proof points that our brands have value, transcending the conversation about cost.
Pharma is working across all domains of Triple Aim to meet the objectives. Each day, our industry makes patients healthier, happier, and more satisfied. Populations are improving, and value is provided in tangible and intangible ways, regardless of the legislative framework developed in Washington. That is an accomplishment for which our industry should remain justifiably proud. We can do more with each new brand that comes to market to achieve the Triple Aim objectives. We don’t need legislation for that. Just commitment.