The All of Us Research Program,43 launched in 2018 by the NIH, aims to enroll at least one million participants from diverse communities across the United States to gather data that can help improve health care for all—the program is over 50% of the way there.44 By including individuals from diverse communities, the program aims to generate evidence that is more relevant and applicable to all patients. Such partnerships in biomedical innovation can drive an upstream health equity approach by addressing major treatment inequities and social, environmental, and economic drivers of those inequities.
Patient-centricity and community collaboration can increase trust in the scientific process, may lead to more relevant and impactful outcomes, and it is a global movement.45 The European Patients’ Academy on Therapeutic Innovation (EUPATI)46 and The Helix Centre47 advocate for patient perspectives to be considered throughout the process and for patients to become more involved in the development of new medicines.48
Lay the groundwork to make cocreation routine. To truly understand patient and community expectations through new innovations, both groups should be part of the dialogue from the start as partners. The federal government players should also be mindful that there is no one-size-fits-all approach, even within a specific patient population. This involves more than seeking cursory patient input about whether they’ll use a product or technology, for example. Rather, patients and their families can codesign research questions, and communities can articulate priorities, aiming to make the innovation pipeline both equitable and well suited to real problems on the ground.
One need look no farther for insights and ideas than the robust community of health nonprofits, leading the way with a focus and dedication to meeting their patient populations’ needs. These groups tend to handle issues across the full innovation continuum, including uptake and use by the community after approval and access via reimbursement.
Those interviewed all cited more need to include patients in discussions and process mapping, as well as needing to pass the baton across agencies to hasten decision-making and problem-solving when it comes to access. As one interviewee said, “Government has the power to bring agencies together, but it also has to have teeth and coordination. It can be the innovation engine for therapies.”49 This harkens back to what we witnessed during the pandemic, a unifocus on solving the problem. “For a patient, time is not neutral,” cited one interviewee.50 An exciting place to start fresh is including the patient and community voice in ARPA-H, at scale. A Patient Advisory Council would be a novel way to incorporate real-time input into the processes being developed and would provide scale for the organization.
3. Implement last-mile infrastructure to support high-risk research endeavors
Government is uniquely suited to tackle big problems because of the volume of funding and diversity of programs it supports to advance discoveries into human trials that have the highest possible chance of success in terms of both safety and efficacy. An interviewee explained, “We saw a challenge that government innovation can aim to solve: NCATS studies over 10,000 diseases, but 95% of diseases don’t have a therapy. Can we develop tools that apply to all 10,000+ diseases?”51
The literal last mile of translational research, the delivery of therapeutics and devices to the bedside for those diseases, is one of the hardest steps for any innovative idea. It typically requires a truly jaw-dropping number of partnerships, expertise, and capital: in short, entire ecosystems. This area is more important than ever as funding in the private sector declines for commercialization.
And yet this space does not lend itself to a top-down process from federal government. A unique partnership of baton-passing is necessary for discoveries to be translated and commercialized to solve problems for patients, the ultimate customers. For example, pharmaceutical innovation is a critical factor in the development and commercialization of new therapies, and it is an important component of the ecosystem that the government needs to engage with to facilitate last-mile delivery. Yet, this industry has recorded the lowest projected average return on investment (ROI) of 1.2% in 2022 from 6.8% in 2021.52 There is also a gap in late-stage pipeline assets that would replace those that were commercialized in the previous years.53 In such a situation, accelerated speed of partnerships between the government and the industry is crucial.
Historically, the government has funded basic biomedical research and provided incentives for innovation hubs and similar initiatives. But the pandemic has demanded new approaches to innovation. Government can contribute to the last mile of the research and development pipeline through three main mechanisms:
- Quicken the pace of innovation with tools that apply across multiple diseases
- Fund place-based innovation ecosystems
- De-risk the commercialization process through incentives and subsidies
Quicken the pace of innovation. On the input side, government can begin to offer researchers the space to take bigger risks with programs such as ARPA-H as a counterpoint to the pace and intention of traditional NIH-funded research. ARPA-H becomes a mechanism to focus on breakthrough disruption areas to help them incubate, scale, and grow. The ethos of faster innovation also implies failing faster first, hopefully resulting in more novel ideas entering the last-mile commercialization pipeline. Eliminating the ideas likely to fail earlier in the process can also significantly reduce the overall cost of developing new products.
ARPA-H aims to create a culture of experimentation, embracing measured risk taking.54 As the first dedicated funding infrastructure in the health sphere for researchers to take bigger risks, it offers immense promise to generate impact beyond what is possible in the current ecosystem, complementing the work of partners in biopharma, philanthropy, and academia. The agency is intended to elevate visionary research ideas from across the innovation continuum, spanning disciplines and industries. Rather than develop specific drugs for specific diseases, ARPA-H seeks to generate new capabilities and platform technologies. The newly created agency is heavily leveraging lessons from DARPA and Advanced Research Projects Agency–Energy (ARPA-E), while considering the complexities of the health sector.55 While DARPA responds to defense needs, biomedical innovation requires coordinated action by public and private actors with differing incentives, and all research has implications for human health. The strategic focus areas outlined within ARPA-H are Health Science Futures, Scalable Solutions, Proactive Health, and Resilient Systems.56
Already the leadership of ARPA-H is discussing adding new questions to The Heilmeier Catechism, a set of questions developed by DARPA to help agency leaders evaluate research proposals.57 Additional question ideas include how an innovation will be impacted by cost and accessibility, what customer experience looks like, and whether the project could be misunderstood. It is important that ARPA-H program managers figure out “connector pieces” to the agencies that can help play key roles in approval and dissemination of any discovery.
As one interviewee shared, “the DARPA model works because the bureaucracy doesn’t slow the research.”58 Another interviewee spoke of “the huge gaping holes for incentives to engage on reimbursement” and cited later-stage cost impacts to Medicare if patients don’t receive adequate care in their lifespan.59 These points again highlight the importance of a holistic approach to discovery.