Ira Klein, MD, MBA, FACP: As James pointed out, if there are 10 to 30 middlemen between my company and the patient who gets the drug, isn’t that a crazy supply chain? So, if we want to do what Mike said, which is, get to the point where we’re all in agreement that we need to have some shared responsibility to fix this issue, I would prefer that our federal overseers and masters help us.
Some of the rules tie us up—even some of the anti-kickback rules that may need safe-harbor relief. There are a lot of innovative things that can be done that get grit out of the machine, and allow us to get much more efficiency in the same way that automakers have gained efficiency. We need to actually get better data flow instead of fragmentation.
On the consumer side, Experian and LexisNexis know exactly how much you, Alan, can spend on a refrigerator. But, they don’t know how much Mike and Bruce’s patients can spend. So I would just put a plea in for some of those other things that we’re very good at doing in this country, and that people, in the rest of the western world, envy us for—be innovative in reducing some of the costs that are not about just the price of a pill.
Alan Balch, PhD: This value conversation does open the door to rethinking about what it is we’re trying to achieve with healthcare. That’s exciting for patients, in particular, because it gives us a chance, hopefully, to be at the table to say, “All right, well, hey, as long as we’re paying a lot now and we’re the ones that are supposed to derive the benefit from the care, let’s talk about what we value.”
And to your point, Mike, we don’t have that information in a real world way that really allows us to be as adaptive and as nimble with that patient. So that’s the problem that we need to fix—how do we actually deliver data in a post-market world?
The challenge is that these products are so expensive out of the gate. It’s expensive to throw it out there in the marketplace and see what happens to it. So my gentle criticism of all the stakeholders is, while we’re talking about value, we’re not really trying to figure out how to create a new system that really understands and delivers value to the patient and determine the gaps that we need to fill to be able to do that. Instead, we’re creating tools based on the old way of doing things and the old notion of providers and payers.
Everybody could get together and decide what value is for the patient, and have the patient there at the table to talk about it. Then, the aggregate of those decisions should reflect net social value. From an insurance perspective, as a patient, I’m not having money taken out of my paycheck, and I’m not putting any money out of coinsurance and copayment in order to give it to the insurance company to try to generate some sort of net social value. Nor am I giving it to the drug companies to do that either. It’s my plan. It’s my coverage. I’m doing it because it’s supposed to provide coverage for me to be able to get treatment for what I need in order to get better and to protect me financially. In the head of a patient, that’s a different value proposition for insurance, and I’m not thinking of insurance as a way to increase net social value. I’m thinking of it as a way to make sure that it’s my plan—I’m going to have coverage. What we’re finding now is that most people don’t have coverage. They’re underinsured.
So, we need to rethink that. If we’re really going to put patients in the position of not being able to afford their care at that basis, then we’ve got to give them more information about how to make smart choices, and tell them the true risks, benefits, and costs to the choices that they’re going to have to make.