PART TWO: Setting the scene
Dr Graham Leask and Stewart Adkins return to address the shift from treatment to prevention and take a look at pharma’s future.
Shift from treatment to prevention
The change from treatment to prevention would represent a previously unimaginable societal shift over the next five to 10 years. Traditionally pharma makes money from selling treatments. To change the mindset of the industry, and its payers, from one of selling treatments to preserving wellness, will not be easy. To monetise the preservation of wellness means using the actuarial knowledge from population healthcare data to carve out populations and assume responsibility for their care in exchange for a per capita fee.
Customers within this population would then have to be regularly screened and encouraged, or even forced, to take significant responsibility for their own health. In exchange for not smoking, exercising regularly, eating healthily and staying within weight, a customer would expect to be treated for any acute or chronic condition that still arose. Individual companies may struggle to accept patients with co-morbidities since they may not be able to price the risk.
Nevertheless, there may be conditions, such as asthma, where companies could price the risk and prevent downstream co-morbidities by active monitoring and treatment. This was attempted 20 to 30 years ago by so-called disease management programmes, but perhaps availability of data and modern analytics makes this feasible today.
Rise of ‘social prescribing’
In the long-term, if the pharmaceutical industry finds a way of monetising the preservation of wellness, social prescribing must be a necessary part of that model.
Early intervention with lifestyle changes, for example, physical fitness, weight loss, healthy eating and smoking cessation, which are sustainable, will have huge downstream benefits for society as a whole, translating into a massively reduced prevalence of chronic diseases like type 2 diabetes, heart disease, strokes and COPD/asthma. These behavioural changes, although superficially obvious to all, may be very difficult to implement, however, and could easily take a generation or more.
Herein lies the barrier to change, since upfront investment in clinician time (cognitive therapy takes a lot longer than the prescribing of an SSRI and is considerably more expensive), gym memberships, diet clubs and e-cigarettes will be huge, whereas the clinical benefits and accrued cost savings will follow many years afterwards. This is certainly not a threat to the pharmaceutical industry unless it incorrectly prices the risks in a disease management programme.
It is far more likely that big pharma will need to partner with government and health authorities to implement change, while allowing life assurance and pension funds to design long-term funding schemes with a pay off at the back end.
If this is to work in a social healthcare model, such as we have in the UK, we will need a wholesale shift in the healthcare narrative, backed up by a ‘carrot and stick’ approach that rewards those that take responsibility for their own healthcare, while subtly penalising those that do not or will not. Whether society as a whole will consider this unfair remains to be seen; but perhaps expecting society to pay for its citizens to eat, drink and smoke itself to death is not fair either.
One cannot expect pharma to navigate such difficult waters without huge support from politicians and civic society. At the moment there are straws in the wind, but few signs of a definite direction of travel. In the meantime, social prescribing will be limited by short-term budgetary constraints and likely to be restricted to isolated pockets of far-sighted health authorities in a few pilot studies.
Death of a salesman?
The mantra, that the traditional role of the pharma salesperson will soon become obsolete, was first suggested in the 1990s when PBMs were introduced in the US and, similarly , during ‘Thatcher’s NHS Reforms’, and neither was correct. In reality doctors are individuals – some only respond to ‘face-to-face’ discussion, others may prefer digital, but few doctors see no representatives at all. To influence a committee requires active networking. Even when a strong guideline is in place, patients and doctors require choices. For example, UK practices using inhaled steroids for asthma stock, on average, seven products. In theory at least, these are interchangeable.
The healthcare landscape of the future
Most markets as they mature become more concentrated as power passes to the distributor and products become commoditised. To some extent this has occurred with the UK primary care market, yet companies still make considerable money from branded generics and ‘me-too’ products. If we assume that a guideline is in place restricting the range and a ‘use the cheapest first’ policy pertains, then such concentration will continue, and the ‘pan-continental wholesalers’ will drive supply.
It is likely that companies will embrace a more blended approach to promotion that perhaps mirrors how healthcare intervention is being guided by the internet and use of sophisticated computerisation.