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Judith Kulich, principal, patient health and equity lead, ZS, and Nan Gu, associate principal, patient health and equity, ZS, discuss health equity in pharma, specifically racial biases, and how the industry can address access and inequities going forward.
Health equity is a challenge for the bio/pharmaceutical industry. It is no secret that there are racial—and gender—biases within the pharmaceutical and healthcare industries, as is apparent through the types of treatments that are researched and developed as well as through the people and communities who have historically had access to and been included in clinical trials.
Pharmaceutical Executive interviews Judith Kulich, principal, patient health and equity lead, and Nan Gu, associate principal, patient health and equity, both of ZS (a management consulting and technology firm) to further discuss health equity.
Kulich: Racial and ethnic bias in medicine has been, and remains, a significant problem. Looking first at insurance coverage, Latinos are significantly more likely than other groups to be uninsured: 18.3% versus 5.4% for non-Hispanic whites.1 Black and Latino Americans are also more likely than others to be covered by Medicaid and other public insurance.2 At the same time, Black and Latino healthcare providers are underrepresented within the medical profession, not only in the clinic but in leadership and governance as well.3 While a focus on increasing diversity should help reduce bias in the long run, studies still show the prevalence of unconscious bias among providers and that these biases influence diagnosis, treatment decisions, and (in some cases) levels of care.4 In one of many examples, unconscious bias has been shown to cause a significant and deleterious effect on how pediatricians manage care for Black adolescent patients suffering from asthma, attention-deficit/hyperactivity disorder, urinary tract infection, and pain.5
There are myriad social, behavioral, economic, and environmental variables that drive health outcomes for populations, with racial bias being just one. But these variables combine to create a significant gap in health outcomes, including life expectancy, with Black Americans living four fewer years on average than white Americans (77 years to 81).2 We see many organizations across the industry taking action to address these biases, but progress is slow.
Gu: While bias against the Black and Latino communities may be the most studied and discussed, biases against other communities are also common. Rates of private insurance coverage for American Indian/Alaska Native populations are among the lowest of any group,6 and they—along with Black Americans and Native Hawaiian, and other Pacific Islanders—have been about twice as likely as their white counterparts to die from COVID-19.7 Asians in the U.S., meanwhile, access fewer mental health services compared with other groups, even when controlling for perceived need.8 But outside of race and ethnicity, many populations (including those based on gender, age, and sexual orientation) also face bias that creates disparities and worsens health outcomes. Bisexual men and women, for instance, are significantly more likely than others to report poor health;9 transgendered individuals, meanwhile, report poor health at 1.7x the rate of cisgendered individuals.10
Kulich: From our work with many of the world’s largest pharma companies, and many emerging ones as well, we see the industry seeking to address health inequities in medicine in three broad areas:
While pharma clearly recognizes the issue of health inequity and is taking steps to address it (as seen in these examples), much work remains to be done around balancing clinical trial representation with evidence-based standards and partnering at scale with other healthcare sectors such as payers, pharmacies, providers, and community-based organizations. While pharma has invested heavily in patient support programs, further work is needed to improve reach. For example, a recent study found that only 8% of patients have ever used a patient support program.15 Long-standing trust barriers may blunt the impact of these types of programs today, but, while efforts to address this issue will take time, they are a critical piece of the puzzle.
Kulich: ZS works diligently not only to advance the public conversation about health equity but also to address its underlying causes directly through our client work as well as external partnerships. We have undertaken numerous projects with clients to help uncover the most glaring sources of health disparities, design innovative interventions, and then measure the impact of these efforts. We also have partnered with organizations such as the Healthcare Leadership Council to bring forward original research, insights, and specific recommendations to encourage cross-sector collaboration and best practice sharing around health equity.16 We also partner directly with the community and patient-facing organizations to address health equity issues directly, both within the U.S. and globally. ZS recently partnered with Shrimad Rajchandra Love and Care, a global nonprofit, to reduce the incidence of anemia, a prevalent disease in low-income counties.
Gu: Our research has shown conclusively that drivers of health differ depending on the disease being measured as well as the health outcome being measured. Studies have shown that socioeconomic status—a combination of income, education, and occupation—strongly correlates with a great many health outcomes.17 Besides socioeconomic status, access to healthy food, transportation, and affordable housing have all been shown to drive health outcomes across many disease areas. However, to properly understand these issues, and (most importantly) design appropriate interventions, disparities should be investigated at a disease or disease-class level and through the lens of where in the patient journey they manifest. For example, air quality is strongly correlated with asthma incidence; so, if one were to look at interventions here, one would need to potentially look at addressing zoning laws, public transportation initiatives, and other issues that affect air quality.
Kulich: This is highly speculative, but I see the possibility for numerous changes in the next five to 10 years that will greatly impact pharma’s ability to reduce health disparities. Even just focusing on the U.S., within five to 10 years the FDA’s guidance on clinical trial representation will have been firmly established, and pharma will (I hope) have built capabilities to reach underserved populations through decentralized clinical trials, expanded diversity among trial investigators, digital tools, and other means. The federal anti-kickback statute may have been revised, aimed at enabling pharma to more freely engage in partnerships and programs specifically targeted at improving health equity and patient outcomes. At the same time, we may have additional legislation designed to improve healthcare coverage for vulnerable Americans such that financial burden alone becomes less of a driver of inequity in care.
Some of these changes will have been brought about by advocacy from pharmaceutical companies and trade groups. Adapting in step with these changes, pharma will have built representation and inclusion into its operating model, impacting everything from research and development to marketing and frontline sales. Pharma also will have developed additional capabilities to partner more effectively with ecosystem players as well as competitors and will be able to seamlessly accommodate value-based and health equity-oriented payment models. Disparities won’t disappear in the decade ahead, but I’m optimistic that the sustained efforts by pharma will have made a measurable difference toward reducing disparities in health.