We usually think of Canada as a divided nation, with the province of Quebec perennially at odds with the rest of the county and threatening to secede. I was in Montreal over the weekend and it’s fair to say there wasn’t much evidence of enthusiasm for the upcoming Canada Day (the rough equivalent of our 4th of July).
When it comes to stoking national pride, Canadians and Quebecers are united in their appreciation for universal health care and the Canadian passport. They also see eye-to-eye on the importance of the monarchy, Air Canada and Tim Hortons as national symbols, in that they don’t find them particularly important.
A national survey asked the question, “How important are each of the following as a source of personal or collective pride in Canada?”
Universal healthcare scored highest. Seventy three percent of Canadians and 70 percent of those from Quebec ranked it as very important. Anglophones and Francophones responded the same way.
We usually think of the United States of America, but when it comes to healthcare that is certainly not the case. If anything, Americans might be united against the idea of a Canadian-style system.
Kind of odd, then that the people living under that regime are so proud of it.
The article itself is more balanced. Of course it quotes the parents of a couple of kids who take expensive meds, objecting to anyone putting a price tag on their lives. But it also quotes health economics experts pointing out that the price can’t be infinity.
The Institute for Clinical and Economic Review (ICER) follows a data-based approach to assessing the value of drugs, utilizing Quality Adjusted Life Years (QALY) and other well developed metrics. It provides guidance on what a drug could be worth, both on an absolute basis and relative to other treatment options. It doesn’t set prices or prevent a drug from being made available by a public or private health plan. At most, it helps contain the prices of drugs that enter the market and points out cases of outright rip-offs.
Elsewhere in the world (pretty much everywhere) there are real forces limiting drug prices and impacting access. In the UK for example, the National Institute for Health and Clinical Excellence (NICE) decides which drugs and treatments will be provided to patients in the National Health Service. Sometimes drugs are rejected or their use is heavily restricted. On the flip side, patients don’t pay for the drugs that are approved.
In the US the drug pricing forces are heavily weighted in favor of higher prices. We shouldn’t fret about an entity like ICER.
Many drug companies have decided to play ball with ICER by providing data to help justify the value of their products. Some, like Vertex and Serepta have pulled back, saying ICER is biased against drugs for rare diseases. I don’t read ICER’s analyses that way.
The quality of ICER’s research is high, but of course the reports are limited by the data and analytical techniques that are available to the organization. The correct response is to build up the availability of real world evidence (RWE), especially from clinical registries that demonstrate how a drug actually improves (or doesn’t improve) the lives of patients. Patient-generated data and information from claims and electronic medical records can be helpful as well.
With better data we can have answers we are more confident in, and we can accumulate evidence on how drugs perform after they are launched, which can offer a refined understanding of their value.
Thanks to the 21st Century Cures Act, enacted in 2016, there is an increased demand for the generation of RWE. The industry is ramping up its spending on RWE for drug approval, safety monitoring, and reimbursement. New analytical techniques and enhanced data availability from wearable devices and other electronic sources are ushering in a heyday for RWE.
Looks like Rhode Island would rather create a health system monopoly than allow in a competitor from Big Bad Massachusetts. Partners HealthCare has been trying to acquire the second largest hospital system in RI, but now the governor has pulled together the three biggest systems to see if they can come together instead.
Thankfully, I am not privy to the details of how things operate in Rhode Island and I don’t know how hard these three systems’ heads are being banged together to get them to team up. But my guess is there’s a good chance the parties will fail to coalesce and that Partners will be back.
Here’s what I told the Globe:
“It was clear that some of the powers that be in Rhode Island want to maintain a Rhode Island-dominated health care system,” said David E. Williams, president of Health Business Group, a Boston consulting firm.
“I don’t think it’s actually going to solve any of their economic problems,” Williams said, “and I think it’s reasonably likely that Partners will be back at the table in three to six months after Rhode Island determines that going it alone is not viable.”
For seven years, Missouri has been the only state in the country without a prescription drug monitoring program (PDMP). PDMPs are designed to help identify abuse of controlled substances like opioids and to spot potential drug interactions.
Missouri doesn’t have a PDMP because one State Senator blocked the bill year after year by claiming the government might use the data to prevent people from buying guns. The Senator hit his term limit and there was expectation this year that the bill would finally pass, ending Missouri’s ignominious distinction as the lone holdout. Alas, a new group of six Republican Senators took up the mantle of their departed colleague and filibustered the bill again citing privacy and gun rights fears.
The lack of a PDMP is a problem for Missouri but also for surrounding states, which face blindspots in their systems as a result of not being able to share data with Missouri. A variety of local jurisdictions in Missouri have moved forward and are cooperating with other states, but the gaps are serious and have potentially lethal consequences.
The state ranks as the third biggest problem area in the country (only Washington, DC and Michigan are worse) for drug use so it’s not as though everything is working out just great.
Missouri is known as the “Show-Me” State, an expression that conveys the “stalwart, conservative, noncredulous character of Missourians,” according to the Missouri Secretary of State.
Most people credit the birth of “Show-Me” to a speech by a US Congressman in 1899. “I am from Missouri. You have got to show me.”
But there’s another, less flattering origin story, referring to scabs from Missouri who replaced striking Colorado miners around the same time. “That man is from Missouri. You’ll have to show him.”
The second story seems about right for the current situation as the state continues to display willful ignorance about the opioid epidemic. I could include something similar about the attitude toward guns, but on that issue Missouri is sadly more representative of the country as a whole.
Steve Wiggins has seen a thing or two in his more than three decades as a healthcare entrepreneur. His Oxford Health Plans introduced “pods,” a precursor of the Accountable Care Organization and he led HealthMarket, an early player in the consumer directed health plan space. He’s carried the same themes into his current role as founder and Chairman of Remedy Partners, the leader in Medicare’s Bundled Payments for Care Initiative (BPCI).
As you’ll hear in this podcast, Steve’s a big believer in bundles, offering them as a proven solution for a large portion of the healthcare dollar, within almost any healthcare financing framework from traditional commercial coverage to Medicare for All.
Here’s what we discussed:
(0:18) What is a bundled payment? How does it relate to other new approaches like ACOs?
(3:05) Did bundled payments start in Medicare rather than the private sector? If so, why?
(6:52) How well has BPCI worked? What does the future look like?
(11:01) How do episodes and bundles tie in more broadly? I often hear that chronic care or end of life care are the big cost drivers, not episodic care. Can those statements be reconciled?
(15:10) How should we think about bundled payments and related topics playing into the campaign, or should we just give up on that?
(19:14) You’ve founded quite a few healthcare companies over your career. How does this Remedy compare?
(21:41) How do you expect the company to evolve in the next few years?