By Suresh Kumar
The year 2020 will determine who we are as a people — our values, what we stand for, and what we seek in our leaders and our policies. It will test our ability to move beyond binary choices caught in a time warp, to evaluating alternatives. 2020 must provide people with choices that can be embedded as healthcare options within 18 months. And those options must be evaluated within this decade to help develop a refined, programmatic policy that provides a high-quality and affordable plan to secure well-being.
As I write this article over the Thanksgiving holiday, I’m reminded of the Pilgrims who gave thanks back in 1621 to the native Americans who had taught them how to survive in this new unforgiving land. The Pilgrims gave thanks by sharing nature’s bounties with those who had restored their health and laid the foundation for future security. Sharing in a world of caring is an underpinning of so much of American history. Our land of immigrants with their different racial backgrounds and political and religious affiliations must set aside differences to celebrate our many achievements — including healthcare — and develop a shared view of how we will protect and care for citizens consistent with a one-for-all, all-for-one value.
I also recall the inaugural article, “Putting Patients First,” in this column in 2018. The goal then and now was/is to provide an opportunity to reflect if the current administration’s policies put patients first and consider if fresher approaches professed by politicians serve us better. Is America aligned on the principle of expanding access to affordable healthcare? Two-thirds of Americans — more than ever in the past — say we are, and a majority of us are willing to even pay more in taxes in pursuit of all Americans having access to healthcare. Is providing healthcare insurance to more or even all people an aspiration or a measurable goal to propel policy and programs? We have come a long way, but we still have a long way to go.
2020 HINDSIGHT: REFLECTIONS IN THE REARVIEW MIRROR
Thirty million Americans do not have access to healthcare, and 20 million are at risk of losing it. Even those with insurance cannot afford to comply with all doctor’s orders. Why? Adequate access and unaffordable price continue to be the Achilles heels of our healthcare system.
- We have made spectacular innovations in medicines and medical procedures in the U.S., yet outcomes of health interventions, while at times superior, do not cost as much elsewhere.
- Care protocol and price of procedures vary considerably across the U.S. A lower back scan in the South can cost $150 while in California it could be as much as $7,500. The price of a knee replacement ranges from $16,000 to $88,000 across different parts of the country.
- Access to care is inconsistent across the country. There is a surfeit of healthcare delivery points and insurance providers in urban centers and lack of choice and competition in smaller towns and rural areas. Hospital mergers have led to a concentration of services, and they exacerbate the economic burden on patients.
- A vast majority of patients do not know the cost of their medicines or procedures or why they cost as much as they do.
We know what needs to be done, but we just can’t agree on how to do it. We know there has been significant progress on EMR/EHR adoption and some progress on adoption of patient counselling, consumer-friendly technologies, and bundle pricing. But there has also been slow progress on pay for outcomes, negligible progress on mental and behavioral health policies, and glacial progress on transparent pricing of medicines, procedures, and diagnostics. Political partisanship and political brinkmanship have trumped practical solutions over the past decade.
2020 FORESIGHT: FOCUS ON THE WAY FORWARD
The U.S. population will grow by 30 million to 360 million in the course of this new decade. This means the healthcare budget will need to cover more people for more years than we do today. Healthcare spending will rise without:
- Refocusing efforts from managing to eliminating or retarding the trend of disease. Timely genetic screening and early-treatment interventions (e.g., premarital and prenatal screenings) can help retard and reverse disease. Scientific pathways are not just promising, they are real, and can be realized only by considering and constructing ethical and commercial pathways.
- Sustainable commercialization models for new medicines and procedures. Scientific innovation must demonstrate benefits and enhanced cost avoidance over current standards of care. Commercial models must simultaneously demonstrate how cost will be paid for, how profits are realized over time, and how risk will be shared between innovator, payer, provider, and patient. Outcome-based milestone payments will be necessary. Models used for business and technology acquisitions can provide insights for innovative pricing and guide commercialization of biotech and genomic treatments to go beyond rare diseases and become mainstream therapies. Pharmaceuticals, medical devices, diagnostics, clinical services, and providers have all struggled to deliver comprehensive solutions that encompass products and services, which has led to patient and payer angst. We have lacked the fortitude to give up antiquated, opaque models that are profitable to build appropriate alternatives compatible with newer realities. To use automotive analogies, industry must learn to drive with an eye on the rearview mirror while remaining focused on the way forward. Commercializing smart, electric cars requires a different approach than marketing autos powered by internal combustion engines. The healthcare industry needs similar transformation in its commercial practices.
- Covering mental and behavioral health programs. Lack of clear policies and resources is a travesty that has resulted in human tragedies and challenges to patients with anxiety disorders, depression, and addictions.
- Health education and preventive programs. Like the Pilgrims, nutrition and exercise are necessary regimens to keep populations healthy.
- Minimum healthcare coverage that is robust and at parity with the healthcare benefits provided to elected officials and government employees. The threshold cannot be watered down without putting citizen welfare at risk, and individuals must have the freedom to buy and pay for additional benefits. Minimum and basic coverages must be established by bipartisan groups of diverse stakeholders representing the healthcare industry segments, patient groups, and the government.
- Greater access to insurance and doctors and increased competition between hospitals in local markets. Mergers and consolidations of hospitals have restricted competition, increased prices, and diluted service quality in America’s heartland. A surfeit of hospitals continues to offer the opportunity to boost efficiency via consolidation in major urban centers. Consolidation and commercializing needs to be better balanced and managed locally.
- An egalitarian choice to opt in to Medicare or keep existing insurance plan. This will enable evidence-based determination of what works, what does not, and which approach provides better value for the money. This also will help identify areas that will benefit from consolidation and those where greater competition will deliver superior outcomes. The regulatory environment surrounding healthcare insurance is complex. Employer-sponsored healthcare (180 million covered lives) is privately run, competitive, and regulated by state insurance commissions. Access to ACA is a challenge in the absence of an individual mandate. Not surprisingly, individual markets (15 million covered lives) that are overseen county by county offer less competition. Medicare FFS (fee-for-service, 40 million lives) is regulated by the federal government, and Medicare Advantage (20 million lives) is also overseen by the federal government but delivered through private companies. One step to infuse more choice and competition will be to allow purchase and require private companies to sell health insurance across adjacent state lines.
PUT PATIENTS FIRST: BE IMPATIENT
Only twice during the last century has access to healthcare been extended to more Americans: in 1965 when Medicare and Medicaid were established and in 2010 when the Affordable Care Act became law of the land. These two events were separated by 45 years. We no longer have the luxury of such time. Health insurance coverage expanded in the last 10 years but declined during the last four. Acting purposefully to put patients first requires ensuring more Americans have access to care in the next five years and over this decade.
SURESH KUMAR serves on the board of Jubilant Pharmaceuticals and Medocity. Formerly, he was U.S. Assistant Secretary of Commerce and executive VP at Sanofi.