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Leela Barham is a freelance health economist and policy expert. She has published in peer-reviewed journals and presented at national and international conferences. She has provided advice to the Department of Health and Social Care on policy on pricing of branded medicines to inform the negotiation of a successor to the UK’s Pharmaceutical Price Regulation Scheme (PPRS), the Voluntary Scheme for Branded Medicines Pricing and Access (VPAS), as well as worked with patient groups, the NHS, pharmaceutical companies and many others internationally on the economics of healthcare and pharmaceuticals. Contact Leela on firstname.lastname@example.org
The Lancet's series of papers on moving from universal health care coverage to "right care" for health offers a truly global and comprehensive perspective, writes Leela Barham. But just what does "right care for health" mean for the industry?
The Lancet's series of papers on moving from universal health care coverage to "right care" for health offers a truly global and comprehensive perspective. But, asks Leela Barham, just what does "right care for health" mean for the industry?
Right care, as defined by Sabine Kleinert and Richard Horton, Senior Executive Editor and Editor, respectively, for TheLancet, is “care that weighs up benefits and harms, is patient-centred, informed by evidence, including cost-effectiveness.” Of course, despite the simplicity and attractiveness of the concept – catchy too, in this social media world – it hides significant complexity. The rest of the papers in the series delve into this.
Specifically for the pharmaceutical industry, “right” is a well-used term already. There’s the “five rights of medication” that’s been in use for years (right medication, right dose, right patient, right time and right route). There is an immediate and clear resonance to pharma, which is not new. But, arguably what is new, is the acknowledgement of the complexity that means that not always can a patient get the right care, whether that is less care than they need (underuse), or too much (overuse). The Lancet series focuses on underuse and overuse, but jointly these must surely be the ‘wrong care’.
Wrong care – both from under and over-use – should be of interest to the industry. Whilst the underuse might mean missed revenue from undiagnosed and/or undertreated patients, overuse should matter too if the pharmaceutical industry takes a longer-term perspective. Unless there’s a big boost to the world’s economy – and some of that goes into health care – there’s just not enough money to go around. Stopping overuse could provide the ‘headroom for innovation’ that used to be talked about.
Medicine is also, specifically use of antibiotics, cited as an example of where progress is being made in moving towards right care.
How much wrong care is there?
Shannon Brownlee and her colleagues draw on the published literature to explore just how much overuse of care there is. Their research looks at overuse of all types of care: from tests to interventions.
In their focused section on drugs overuse of antibiotics is cited. Overuse of bevacizumab for breast cancer is examined too. The authors point out that the National Institute for Health and Care Excellence (NICE) does not recommend it’s use, and the US Food and Drug Administration (FDA) has withdrawn the marketing authorization for breast cancer. Despite this, it is reimbursed in Colombia. They also cite epoetin alfa being used in Romania for ribavirin-induced anaemia in patients with Hepatitis C and organ transplants. That’s despite the absence of evidence to support use in this way.
Only a few examples are given for overuse. Brownlee and colleagues point out that it’s difficult to assess and that the evidence that is available is from estimates and extrapolations. Nevertheless, they present a compelling case, especially when consider the implications of overuse. For patients it can mean harm: whether physical or psychological. For healthcare systems, there’s the missed opportunity to use resources more wisely and likely generate more health.
Paul Glasziou and colleagues look at underuse. They cite a number of medicine related examples; underuse of anti-coagulation in countries Africa to France and slow and inconsistent uptake of beta blockers for heart attacks. The evidence on underuse is compelling too, once again with patients feeling much of the consequences in terms of disability and even death. The health care system may also need to pay for more expensive – and avoidable – care because of underuse.
Reasons for not getting the right care
The reasons for why patients don’t always get the right care are many and diverse. Vikas Saini and colleagues provide a canter through issues that range from the difficulty in deciding what is right care anyway, through to lack of adherence covering vested interests, money, media coverage, heuristics and a host of other factors along the way.
A particularly eye-catching subheading in the drivers of poor care paper is “flawed production and dissemination of knowledge: the price of innovation”, which discusses ignorance of the evidence. Not only that, but that some research isn’t useful in the first place. Regulatory capture is seen as part of the problem, along with the charge of ad hoc creation of patient groups who can be mobilized to influence regulatory and pricing negotiations.
Vikas Saini and his co-authors suggest that the deepest drivers of poor care come from “fundamental inequalities of information, wealth and power”. A tough nut to crack, then.
Changes to enable more of the right care, less of the wrong care
Just as the drivers of wrong care are many and varied, the changes being called for to move towards right care are too. Reducing greed features, although that needs unpicking further for actionable changes.
More clearly defined changes that would affect the pharmaceutical industry include the call for negotiation of affordable drug prices. The timing has worked well to call for this, the series comes out the month after the UK competition authority, the Competition and Markets Authority (CMA), has fined Pfizer and Flynn Pharma for inflated prices for phenytoin sodium capsules for patients with epilepsy. Whilst not the wrong care, it is a case of the wrong price.
Specific examples of what is already being done are made in the papers. The papers rightly point out that HTA can help in identifying right use. However, HTA tends to focus on new, expensive, high technology devices, services and pharmaceuticals. Low-tech treatment can escape HTA scrutiny, so expanding the scope of HTA is on the wish list.
This series also cites the ‘do not do’ list from NICE. Missing though is why such efforts – a database that clearly identifies, based on the evidence and consultation, what really should not be done by the NHS in England - aren’t more widespread, after all HTA is now a global phenomenom yet not all agencies identify what shouldn’t be done. Even where such efforts are in place, there’s little on whether they are effective, and if not, why not.
Adam Elshaug and colleagues call for policies hat move beyond the incremental. Part of the solution to getting more right care and less of the wrong care is to increase public awareness, mobilise and empower. The ambition is to move to deliver the right care, received by the right patients, in the right setting, at the right time, at the right cost. Getting there will mean much more research (which is never a surprise; as a result of these types of efforts, researchers tend to identify more research that needs to be done) and more than a little art and science to deliver the incentives needed to make changes, especially when there will be inevitable winners and losers. Those winners and losers are likely to be within the pharmaceutical industry too.