“The problems that exist in the health care system today are the catalyst to drive the innovations for tomorrow,” said Eric Palmer, president and chief executive officer of Evernorth, as he opened a panel discussion he moderated at the Evernorth 2023 Outcomes client event in Orlando, Florida.
But, according to Sharon Jhawar, who is chief pharmacy officer of SCAN Health Plan, as an industry we need to get better at defining the actual problems in health care that need to be solved. She cited an example of the rising state of homelessness among the senior population. “A lot of folks say it is more of a housing issue, but it is also a health care issue,” Jhawar said. “A lot of times these seniors’ health issues become a key contributor to them becoming homeless – and as they are homeless, their health issues get exacerbated, and can prevent them from getting back on their feet.”
Sharon Jhawar discusses ways to tackle the health care issues behind senior homelessness.
To help tackle the health care issue behind senior homelessness, SCAN Health Plan created a “street medical team” that provides direct care to homeless seniors. In addition to improving health outcomes, the program considers successful housing as a key performance indicator.
“We need to be crisp on how we identify the health care problems, because that definition dramatically influences how you solve for it,” Jhawar said.
Health care affordability
Paula Jakub, CEO & EVP of the American Foreign Service Protective Association (AFSPA) defines the issue of rising health care costs by exploring the key drivers behind it, which she referred to as “the C’s.” These include the consolidation of provider systems that hold the power to set pricing, the complexity of health care treatments, and the coordination of care, or lack thereof. Another “C” Jakub felt would require particular focus are chronic condition patients, particularly those with complex chronic conditions that require specialty medication.
Paula Jakub discusses solutions that can help people with chronic conditions maintain their health.
“Only 8% of the population AFSPA serves are complex cases, but they drive 60% of our healthcare spend,” she said. “What is that going to look like in five years?”
Jakub mentioned that solutions that can help people with chronic conditions maintain their health before those conditions become complex, as well as programs that address the other “C’s,” would make a big difference in changing the trajectory of health care cost trends.
Taking a holistic approach
Jean Moore, the North America health and benefits specialty practice leader at Mercer, emphasized the importance of addressing the health care needs of future patients, with the ultimate goal of developing care systems that are easy, intuitive, and fast. “Those three words are not what we typically think about when we think health care,” she admitted, “but that's the direction we need to go.” Moore believes that integrated systems and data-driven technology will drive many of the solutions patients need in the future.
Jean Moore discusses how integrated systems can drive quality care for future patients.
Moore experienced the value of integrated care systems firsthand, when she sought care for a bilateral invasive breast cancer diagnosis over nine years ago. “I had just moved to Scottsdale, Arizona, and I needed to find not one doctor but four,” she began, adding that the waitlist for one specialist could delay treatment for the others. “I wasn't able to get an appointment with my breast surgeon until I had one with a plastic surgeon, which was six months out,” she said, “I was really stressed out and scared.”
Fortunately, Moore “stumbled upon” an integrated cancer care team in Scottsdale and was able to schedule a consult. “I walked into a conference room and there were the four doctors that I needed to go through my cancer journey with me,” she said. “They were my care team, and it was amazing. I finally felt some comfort in having people that were going to help me with this, and they were with me every step of the way.”
Moore reiterated that integrated care systems are going to drive care quality that will lead to better outcomes and lower costs. While she was fortunate to have an integrated team of cancer specialists located in Scottsdale, Moore stated that digital technology can allow for the same close coordination between physicians, hospitals, and pharmacies virtually.
Jakub added that effective coordination of care involves a holistic view of the data. She illustrated her point with an evaluation of WeGovy, an expensive obesity medication that many patients would have to use for the rest of their lives. “We’ve got to look beyond that initial cost factor,” she began, “and look at what that drug is doing for the patient on the clinical side [in terms of reducing other symptoms and emergency room visits.]” An initial data analysis conducted by the AFSPA suggests that members who used WeGovy greatly improved blood sugar and cholesterol levels in a very short time. These improvements can help prevent diabetes and other medical issues, as well as the care costs associated with them.
Service and efficacy helps drive pharmacy affordability
The pharmacy space is producing the latest revolutionary treatments for disease, as well as the highest costs of health care. The panel discussed ways to leverage the pharmacy benefit to enhance the care experience and drive affordability.
“Pharmacy is the number-one benefit,” says Jakub, noting that pharmacy can act as a leading indicator of other health issues. “A pharmacist sees patients and can identify other areas of concern, whether it be a comorbidity or a mental health issue, in real time.” Jakub stated that programs can be developed to harness clinical data to inform pharmacists on the appropriate next steps for care when these other conditions are identified, so these care professionals can provide more value to patients than simply filling prescriptions.
Jhawar agreed, stating that community pharmacists, who are usually at the last stage of the health care delivery system, should be brought to the front line, where they can play a leading role to driving more cost-effective medication treatment. Jhawar believes that changing the reimbursement model from the volume of scripts filled to the quality of services provided by pharmacists can help effect this change. “Imagine a world where we pay zero for the drugs themselves and we pay for the service [performed by the pharmacist], and we pay the same amount for the service whether the drugs [dispensed] are brands or generics,” she began, iterating that this approach can encourage the pharmacists to determine the most appropriate and cost-effective drug the patient needs, as well as perform follow up checks for adherence and side effects. Jhawar added that such a change in our reimbursement model can drive these actions without the need for legislation changes.
Moore highlighted the importance of quality and ensuring clinical efficacy, as well as the weaknesses of the value-based arrangement models currently in place, which reimburses payment for medications that are not effective for the patients. “The challenge of that model from an employer perspective is that you’re not going to know for two or three years whether that drug actually worked or not, and that employee may no longer be working for you in two or three years,” she said. “So how would you get the value of that value-based contract and make sure that you're paying for meds that actually work?” Moore suggested that an industry-wide longitudinal data set can more effectively track the efficacy of medications for patients in the long term than the data collected by a single health plan, employer or pharmacy benefit manager.
Advancing health equity takes a narrow view
The panelists agreed that addressing the broad issue of health care disparities requires a focused approach. Jakub underscored the importance of maintaining the individual perspective and meeting people where they are. “The definition of health can be different things to different people,” she said, noting that care programs need to be able to support the individual motivations and address the unique challenges on each person’s health care journey.
Moore learned that you need to “go hyper-local” to identify health disparities within individual communities, during a study she conducted for a Northern California children’s hospital. Given the location and the substantial number of health care workers living in the surrounding area, she didn’t expect to find any major issues. However, the results revealed significant access and pharmacy inequities with dramatic variations between different neighborhoods and even different city blocks. “The study really highlighted the impact of health equity and how hard it is to get around,” Moore said. “The solutions are more challenging because they will need to be delivered neighborhood by neighborhood or even block by block.”
Jhawar added that using a “phased approach” to address different health inequities one at a time is much more effective than “trying to boil the ocean” to address every disparity at once.
Moving toward better care tomorrow
The panel discussion emphasized the key theme of the entire Outcomes event: to unlock “The Power of Possible” in health care to drive real solutions that ultimately enhance the health and vitality of the people we serve. Closing remarks advised attendees of the importance of action, collaboration, and individual focus in advancing health care.
“Take a risk,” said Moore. “I know in the world of health care we hesitate because we don't want to do anything wrong. But we sometimes need to take a risk to make a difference.”
“It’s important to work together and use the tools and resources available to you,” Jakub said. “Whether it’s a pharmacy team or clinical team, bringing the strengths of all of your people together makes a huge difference.”
“If we're putting a program or a benefit together,” began Jhawar, “we ask ourselves one simple question: Is this the way we want it for our mother, for our father, for our son, and for our daughter? If the answer is yes, then we are continuing to go ever north. And if the answer is no, and we got to continue harping at it and figure out the right solution.”