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Dr Joseph Saba, CEO and founder of Axios International (France), is an expert on clinical research and health access programmes in developing countries. A medical doctor specialising in infectious disease, health management and statistics, Dr Saba has previously worked with the World Health Organisation's global programme on AIDS and UNAIDS. He and the Axios team advise pharma industry clients on strategies, programme design, operations and strategic communication related to creative drug access strategies for developing and emerging countries.
As patients pay more healthcare expenses directly from their own pockets, the industry must look at patients' ability to pay alongside willingness to pay to understand the various factors of patient decisions to accept or decline treatment.
At the time I was starting out as a doctor, patients rarely ever questioned their physician’s prescription. This was partly because they lacked the knowledge that would allow them to challenge their physician’s opinion and partly because the medication cost was manageable. For countries where the cost wasn’t manageable for both the government and the patient, the medication wasn’t available in the first place. The availability and accessibility of treatments were very much linked.
Fortunately, vast changes have taken place in the healthcare sector since then. Medical treatments have progressed tremendously, and as a result medication became more sophisticated and thus more expensive. Patients now have access to a wealth of healthcare information through digital platforms where they can find out about all the latest treatments. At the same time, governments are facing unprecedented pressure on their budgets, leading to constraints to reimbursing more specialized medicines.
These changes have led to a tricky situation unfolding-patients are now required to pay for costly treatments and are forming their perception based on online information which can often be overwhelming, misleading, or simply incorrect. Physicians need to acquire enough knowledge on all the available medicines for a disease to be able to prescribe the proper one whilst trying to evaluate whether the patient’s economic status allows them to afford the preferred medication. But it doesn’t stop there: Even if the patient can afford the prescribed medication, they may not be willing to pay for it because they are not convinced of its value. As a result of these changes, a new factor in medical treatment is becoming crucial to consider: willingness to pay.
As more patients are paying for a large portion of their healthcare expenses directly out of their own pockets, they are significantly more involved in decisions involving their treatment. This is one reason why for an access strategy to be helpful, effective, and sustainable, we need to understand the many factors contributing to a patient’s decision to accept or decline treatment. In addition to the much-discussed ability to pay, we must pay more attention to the willingness to pay. The two are inseparable.
Our recent global “willingness to pay” (WTP) study identified several factors that contribute to patients’ and doctors’ willingness to pay and prescribe. We looked at two chronic conditions-chronic heart failure (CHF) and psoriasis-in 10 developing countries including Indonesia, Venezuela, and Egypt. Although the country-specific results differed for the two diseases, education, country, monthly income, and psycho-cultural factors all played a role.
We found, for example, a clear association between higher education levels and a higher WTP for both conditions, especially for the non-life threatening, but highly stigmatizing psoriasis. More highly educated people with psoriasis are willing to pay for drugs that will improve their aesthetic appeal, increase their quality of life, and help them with perceived career advancement. Physicians, more concerned about treating life-threatening illnesses, don’t always appreciate the very real psychosocial impacts of psoriasis, making them less likely to prescribe medication to treat it. People at all education levels, though, can understand-with doctor encouragement-that treating CHF in its early stages will save them money in the long-run, when more costly emergency treatments may be the only option.
The patient’s knowledge of the prescribed treatment’s benefits plays an important role in how they perceive its value. With all the information readily available at patients’ fingertips, however, a patient’s ability to identify credible healthcare information online is an influencing factor that can’t be ignored. Similarly, a physician’s knowledge about the impact of certain diseases will affect how effectively they address their patients’ needs.
Once we understand the factors that affect the WTP for a particular drug, we can develop a strategy that targets the sweet spot, where willingness and ability to pay intersect. While it’s important for patients to be willing to pay for the right treatment, it’s equally important that they don’t end up giving up basic needs, such as their homes, because they are too willing and for a limited benefit. Either end of the scale doesn’t serve anyone, and that’s why striking the balance between willingness and ability to pay is significant. By instituting solutions that help patients overcome both financial and willingness barriers, we can optimize access to treatment.
In Thailand, for instance, we learned that pharmaceutical sales growth was averaging 15% in the early 2000s due to an aging population and a sharp increase in government healthcare expenditures. But, by 2009, the Thai economy was struggling, and the government cut healthcare spending. That’s when we charted a path with pharma companies to rely less on government reimbursement programs and explored alternative market access solutions.
For example, one solution helped save a 49-year old Thai business owner’s life. Diagnosed with metastatic colorectal cancer in 2016, the family breadwinner decided that the amount he would have to pay for continuing his treatment was not worth the toll it would take on his family, including dipping into his children’s education fund. “I decided to put my family’s needs before my own,” he told us. “I could not be selfish and focus on myself.” That’s a huge barrier to break through, but his unwillingness to pay dissipated after a doctor enrolled him in an Axios-managed access and adherence program that allowed him to not only receive his medication at a price more aligned with his ability to pay, and better understand the value of the treatment he was paying for, but to also hit his own personal sweet spot: balancing the value of his treatment while providing for his family.
This program combined patient education with a unique financial assessment tool that lets drug manufacturers reduce the cost to patients without cutting their price, allowing patients to pay only what they can afford with pharma manufacturers covering the balance. Creating solutions around how patients make treatment decisions and segmenting by ability and willingness to pay are the only way we are going to get medicines to the greatest number of people, including the poorest, in the most sustainable way. This will also provide better ROI for pharma companies that join the movement. It’s a win-win solution.
Opportunities abound to help those in need while maintaining the bottom line. As more pharma companies realize this, great change will come. It behooves them to create financially sustainable programs. When treatment is available and accessible, patients have more incentive to seek disease education and diagnosis, kick starting a chain of demand that motivates physicians, payers, and policymakers to create lasting change.
But access without willingness to pay and prescribe is useless; they are intertwined. And more relevant now than ever.
Dr. Joseph Saba is co-founder and CEO of Axios International