With so many novel therapies being developed, there has never been a more exciting time to be practicing medicine, says Dr Andre Goy, Chairman and Director, Chief of Lymphoma, John Theurer Cancer Center, Hackensack University Medical Center. However, rising costs combined with an ageing population and an increase in non-communicable diseases means that global healthcare needs to be “fundamentally reinvented”, he argues in this interview.
Why do we need a Global Future Council on health and healthcare?
Because, at present, our healthcare systems are not sustainable. The costs, direct and indirect, are huge. In the United States, where I work, healthcare costs are approaching 18% of GDP – and we still don’t get the best results, by a long way. Meanwhile, populations are ageing and non-communicable diseases are on the rise all around the world. Healthcare needs to be fundamentally reinvented.
What current trends are most significant?
So many novel therapies are being developed, this is the most exciting time in history to be practicing medicine – but the problem is that these new therapies are not yet necessarily translating into better outcomes, because we don’t have the real-world data that would allow us to stratify patients, help them understand their options and give them a roadmap for their treatment.
In my own field, oncology, some studies suggest that about a third of everything we spend is either completely useless or does nothing more than extend a poor quality of life by a few months. We’re seeing new drugs approved that may be extremely effective for a subset of patients, but that are known not to work at all in some 30 to 70% of cases. Obviously, that means there’s huge potential to waste resources and patients’ time if we don’t get the diagnostics right.
What needs to be done?
The greatest need is for more real-world data – structured, longitudinal data on outcomes for patients who present with different forms of a disease at different stages. Data from clinical trials in specialized facilities don’t necessarily help physicians to consider all angles when they see a patient: for example, will extra costs in one aspect of treatment reduce costs in another?
To illustrate with an example, the standard treatment for advanced lung cancer is chemotherapy. That gives patients an average of 10 more months. But if the cancer has a particular mutation, a targeted oral compound will give them 48 more months, on average. And 48 months of that oral therapy actually works out cheaper for the provider because they’re not dealing with, for example, costly hospitalizations resulting from the toxic effects of chemotherapy.
However, testing for that mutation incurs an initial cost, and right now only 40 to 60% of patients presenting with advanced lung cancer are offered that test. That suggests how much scope there is to improve outcomes by improving data and diagnostics.
Who are the key players in reform?
The challenge with healthcare reform has always been that incentives are misaligned: policymakers, providers, payers and patients all want different things. So our first task is to define goals that all can agree on, and pathways to get there. We need to get better systems for sharing data, because that’s what will help us to improve outcomes, which everybody wants to see.
With better data, it also becomes easier to move to a system of “bundled” payments – that’s in contrast to traditional ways of organizing healthcare, whereby payers reimburse providers either per service they provide, or per patient they see. Bundled payments work if you can define the expected cost per “episode of care” for particular types of patient. That can reduce costs for payers, improve outcomes for patients, and let physicians focus on medicine rather than money.
To what extent are the problems with healthcare common across different systems?
There are different issues between developed and emerging economies, and countries with different cultural approaches to healthcare – but the problem of sustainability is common to all. I’m originally from France, where the so-called “socialized” healthcare system has effectively been bankrupt for decades. There are some examples of countries doing relatively well, such as Singapore and Israel – but policymakers almost everywhere are worried, and rightly so.
How might health and healthcare look in 2030?
We’ll have more novel therapies by 2030. My hope is that we will also have diagnostic tools that enable physicians to stratify patients from the get-go, putting them onto treatments which are shown by solid, real-world data to lead to the best outcomes for their particular condition. I also hope that we’ll have much better tools for prevention: individuals will routinely have extensive checks of health markers that will not only give them personalized lifestyle advice, but enable them to see the benefits of following that advice as they can track their markers improving.
However, societies around the world will also have older populations and higher rates of non-communicable diseases. Even more than today, we will have to confront hard questions about the cost of treatment that extends life by short periods where the quality of life is low.