Remdesivir powers activate! Wouldn’t it be great if remdesivir magically cured COVID-19? Too bad it doesn’t. So what should we be willing to pay for a drug that shortens hospital stays and might reduce mortality? In this episode of HealthBiz, physician and healthcare executive Surya Singh shares his take on drug pricing, ICER and the future of the pandemic.
The Affordable Care Act (aka Obamacare) is a comprehensive law that affects every corner of the healthcare system. It’s unreasonable to expect voters to grasp every nuance of the law, but it is useful to go a step beyond the current public discussion that says, essentially, individual mandate: bad, coverage for pre-existing conditions: good.
Bottom line: opponents can’t simply get rid of Obamacare, declare pre-existing conditions covered and call it a day.
Consider the example of a family friend whose son was diagnosed with an auto-immune disorder in his early teens. It’s kept under control with a biologic drug that costs over $100,000 per year. There are other costs for diagnostic tests, specialist appointments, and the potential need for hospitalization and surgery. The parents are self-employed; they pay Blue Cross about $30,000 per year for insurance.
In a free market, the family would be uninsurable –or the “pre-existing condition” wouldn’t be covered and the family would face financial ruin. My guess is Blue Cross pays out $100,000 to $200,000 per year for this family –guaranteeing a big loss on the $30,000 premium!
It actually makes sense from the insurance company’s perspective to reject people with pre-existing conditions. After all, you can’t buy life insurance if you’re at high risk of death, you can’t buy homeowners insurance if your house is on fire, and you can’t buy auto insurance to cover a crash you just had.
Under Obamacare we decided as a country that pre-existing conditions would be covered. That wasn’t the consensus before.
But there’s more to Obamacare than just requiring insurance companies to pay for the treatment of pre-existing conditions. Consider some related protections that would evaporate if Obamacare were repealed or ruled unconstitutional.
Obamacare prohibited insurers from doing a lot of other things they used to do. Under the law:
You can’t be charged a higher premium because of pre-existing conditions
Your premium can’t go up and your policy can’t be canceled because you got sick
Insurers cannot impose an annual or lifetime cap on medical expenses
In order for such a system to work, everyone needs to have insurance. That’s where the mandates for employers and individuals to buy insurance come in. The mandates are not about taking away the freedom to decide whether to buy insurance, they are about making sure there are enough healthy people in the system to cover the costs of those who get sick.
The likely alternative to Obamacare isn’t a “free” market. People won’t stand for it. Rather it’s some version of Medicare for All.
Shahir Kassam-Adams is one of the most knowledgeable and outspoken people in healthcare. In this episode, Shahir shares his initially unsettling but ultimately reassuring view that “data will eat public health.” He opines on interoperability and explains how his company, Datavant has promoted data sharing on COVID-19, leading to a plethora of interesting and potentially useful projects, including one that models the tradeoffs for specific American cities to reopen.
In April, with the pandemic raging, lockdowns underway in the Northeast and West, and widespread panic about what the immediate future would bring, I tried to look over the horizon to see where we were heading. My 4 predictions for the next phase of the COVID-19 pandemic and Prediction 5: The end of immigration, distilled what I was seeing in Boston plus what I was hearing from healthcare and life sciences clients and physician and scientist friends in US hotspots and around the world. I didn’t put a timeframe on when this “next phase” would be, but with the summer behind us and a new school year getting going, now seems like a good time to take stock.
Judge for yourself, but overall I think I did well. Let’s review:
#1: Treatment, not testing will be key to reopening the economy Grade: B
I was right that testing wouldn’t be our savior, but also overestimated how quickly treatment would improve.
In April, everyone was talking about the need for millions of rapid turnaround tests to get things moving again. Other countries, like Germany and Singapore had deployed testing on a massive scale. But when I looked at what was going on in the US I was unimpressed. There were lots of announcements about capacity but little follow through.
Sadly, we’re still doing poorly. Recent estimates suggest the need for 193 million tests per day; we’re only doing 21 million. In Massachusetts (one of the leaders in testing) it’s still hard to get a test if you’re not symptomatic. Test results elsewhere can take a week or even longer, if you can get tested at all. Bill Gates recently criticized the current state of US testing: too few, too slow to return results, wrong swabs.
The absence of rapid turnaround testing at scale and weak contact tracking has hampered the ability of scientists to inform policy makers and the public about what works and what doesn’t. This failure contributed to the rapid spread of disease in early hot spots. It also fed public confusion and undermined support for guidelines, which seemed vague, random and contradictory.
Remdesivir was already showing promise in April, and non-drug adjustments such as optimization of mechanical ventilation and turning patients on their sides were being tried. Intriguing stories of cardiovascular impacts and cytokine storms were emerging. I expected we’d have a bunch of drugs and other innovations that would make COVID-19 a manageable disease by now. The death rate is down, but treatment improvements have been incremental and some early hopes fizzled. Dexamethasone, an old steroid is the only drug beyond remdesivir with widespread evidence of effectiveness.
There are new possibilities ahead. Olumiant (baricitinib) appears to help patients on remdesivir recover faster and may gain emergency approval by the time you read this. And researchers are looking at new mechanisms, such as bradykinin storms to understand how COVID-19 does its damage and how to stop it. There are several other treatments under evaluation, too.
Bottom line: fatigue, denial and surrender were bigger factors in reopening decisions than I expected. The economy still isn’t fully reopened and we may need to wait for a vaccine to move back toward normalcy.
#2: Hybridization (virtual/in-person mix) will be the new reality Grade: A+
I’m proud of this prediction. At the time I made it, the consensus was that everyone would return to the office by summer and get back to school in September. That hasn’t happened. Instead, as spaces reopen, hybrid models are emerging everywhere to reduce density and decrease risk. You see it with schools, businesses, physician offices and clinical trials. Remote work and school are still happening, but work from home is no panacea.
I expect hybridization to outlive the pandemic as individuals and organizations learn that a mix of in-person and remote is best for most activities. But patients may have to assert themselves to receive the full benefits of hybrid care, because healthcare organizations have a tendency to revert to what works for them rather than what’s most convenient and affordable for patients. Telehealth was used for almost 70 percent of total visits in April before dropping to around 20 percent in the summer. Some patient-centric leaders, such as Boston Children’s Hospital have maintained rates at close to 50 percent.
#3: Public health post-COVID-19 will be like security post-9/11 Grade: B
When I started traveling again soon after 9/11, the sudden jump in security at airports, office buildings and public spaces was staggering. In the following months and years, security became a huge industry and an obsession.
In April, I wrote:
“Now that COVID-19 has struck, we can expect public health to be similarly elevated. It will become a pervasive part of our economy and society. Expect temperature –and maybe face mask and hand washing– checks at the office, school, and any public venue. Contact tracers may call or visit our homes or scrutinize our cellphone records. Event managers and employers will need to hire a health team and devise a health/safety plan to prevent outbreaks and provide confidence.”
I’ve certainly seen this in the private sector. For example, many private schools require daily health attestations, temperature checks, masks, outdoor eating, etc. Stores announce, “no mask, no service” policies in their windows. Some states and counties have good contact tracing programs, but unlike 9/11 there is no nationwide approach, and no Homeland Security equivalent.
As more venues reopen I expect that this trend will continue. What’s not yet clear is whether public health will receive additional funding and just how central it will be to our future. Much depends on how quickly and completely the current pandemic is brought under control, whether new health threats emerge soon, and who occupies the White House in 2021.
#4: Federal government will grow even more powerful relative to everything else Grade: A-
This prediction was paradoxical. Those I reviewed it with at the time found it novel and counter-intuitive. After all, the feds failed to prepare for the pandemic and threw everything onto the states. The CDC embarrassed itself with its testing approach and then was sidelined.
But the federal government has essentially unlimited spending power, which it used to prop up the economy with the $2+ Trillion CARES Act, and the stock market (via the Federal Reserve). Meanwhile, states had to come begging –quite literally—to the president for help, and our world-leading universities and colleges found themselves in desperate straits and unable to reopen.
In short, the federal government’s failures have weakened the rest of US society much more than the federal government itself has been weakened.
The reason I give myself an A- instead of an A is that I didn’t address what would happen relative to the rest of the world. The US federal government has lost international standing during the pandemic with its poor response. The country was rated as the most prepared for a pandemic –but botched things anyway. The withdrawal from the WHO weakened our hand, and our slow economic recovery means we’re losing ground on China and others.
#5: The end of immigration Grade: A
Crises present major opportunities for governments to enact policies they wouldn’t be able to get away with in normal times. The current Administration has made no secret of its disdain for immigration. It had taken some dramatic steps before the pandemic, such as curtailing the H1-B program for highly skilled workers and attempting to build a wall along the Mexican border.
In April, the president tweeted his intention to suspend all immigration. That’s about as dramatic as it gets and would have drawn much more fire even a month or two earlier. But with lockdowns and travel bans throughout the world, and a virus floating in the air, it was harder to argue against. Consider some of the additional actions taken against immigration during the pandemic, including bans on asylum seekers and refugee resettlement, a ban on international students coming to the US if their classes were not in person (rescinded after pushback), and more restrictions on H-1B lottery winners.
The pandemic has also made the US a less attractive destination for would-be immigrants, even without all of the explicit actions. That won’t be reversed quickly.
There are big questions for the next few months and years, including:
When will vaccination make a decisive difference? This includes when vaccines are approved, how quickly and rationally they are distributed, how well they work and for how long, and what the uptake is.
What will the economy of the early 2020s look like? Will travel and leisure return? Education at all levels? Office work? What new industries will emerge?
What will be the US’s role in the world? Much of this hinges on the results of the 2020 election and its aftermath.
I’ll offer my commentary on these topics as the situation continues to unfold. Check the Health Business Blog and HealthBiz podcast for updates.
In recent months, my strategy consulting firm, Health Business Group has helped our healthcare and life sciences clients factor the implications of the pandemic into their growth and M&A strategies. Would you like to discuss your own organization’s plans and how Health Business Group can help? If so, please email me: email@example.com.
Does anyone else find it ironic that the “America First” president has issued an Executive Order that says foreign countries will set drug prices for the US? President Trump has ordered Medicare to literally cede drug price decisions to France, Germany, Japan or New Zealand –where prices are dramatically lower than here. Yes, the idea is to take the lowest price that any of the other rich countries negotiate and use that as Medicare’s price.
What’s next? Will the EPA adopt France’s emission standards? Will the SEC let Italy set the rules for Wall Street? Will Medicare chip in to fund the cost of comparative effectiveness research and negotiations currently borne by foreign governments? Of course not.
So how do we understand this apparent transfer of power overseas? Two ways:
First, the president is trying to find any path he can to get an achievement on drug prices before the election. This one is simplistic, understandable and dramatic.
Second, it’s not really about following the lead of other countries. Rather it’s about forcing drug companies to raise prices in other countries in order to avoid losing out on the big US market. It is distinctly Trumpian in that it punishes our allies and blames them for “freeloading.”
It does make sense for US payers, including Medicare, to employ value based pricing mechanisms like those developed by the Institute for Clinical and Economic Review (ICER) and to negotiate prices. But we should reward true innovation and be willing to pay up for breakthroughs -yes, even paying hundreds of thousands or millions per patient for great products. I don’t want the US to leave those decisions to anyone else.