By 2040, a symphony of health could surround consumers and ensure their wellbeing

My Take

By 2040, a symphony of health could surround consumers and ensure their wellbeing

By Doug Beaudoin, vice chairman, US Life Sciences & Health Care leader, Deloitte LLP

The US health care system is a collection of disconnected independent components. From the consumer’s perspective, hospitals, physicians, health plans, pharmaceutical companies, and medical-device manufacturers might seem like a group of musicians who have never played together. Instead of a healthy harmony, the patient experiences a disjointed cacophony of complexity. As health data becomes more interoperable—and more aligned to the needs of consumers—the players in this orchestra will listen to each other, and the notes they generate will blend into a balanced symphony of health.

In this analogy, the patient is the audience, and interoperable data is the conductor that enables the players to play in sync. Some incumbent players might not be able to keep up with the new arrangements, or they might be replaced by new players who possess different abilities that improve the experience for audiences.

By 2040, we expect that health will be defined holistically as an overall state of wellbeing encompassing mental, social, emotional, physical, and spiritual health. While we don’t expect to eliminate disease, we do expect far more attention will be devoted to prevention and wellbeing, while sick care is limited to people who have complex conditions. If this vision for the future of health is realized, we will likely see healthier populations and dramatic decreases in health care spending.

The transition from sick care to wellbeing

The US has one of the best sick-care systems in the world, but it is a system designed to react to illness rather than prevent it in the first place. Most hospitals have patients who are there because they fell through the cracks of this system.

Imagine Larry, a recently widowed elderly man who relied on his wife to help him manage his type 2 diabetes and diet. In this scenario, Larry quickly becomes overwhelmed by everything needed to manage his illness, and he lacks the motivation to take it on himself. Without support structures, he misses doctor appointments, forgets medications, eats poorly, falls into a state of depression, and ultimately winds up being hospitalized. This is exactly how our episodic-based reactive health system was designed to work.

The ubiquitous, proactive, and integrated health system we envision by 2040 (perhaps even sooner) will reduce or even eliminate these types of situations. Immediately after Larry’s wife passes, a care advocate is automatically notified. The advocate might regularly visit Larry in person or virtually to check in and provide him with tools that will help him manage his health. A virtual assistant, for example, might remind Larry to take his medications or to take a walk outside. It might ask simple questions that allow his mood to be assessed through an artificial intelligence (AI)-enabled voice analysis. A smart toilet might analyze his urine and alert the care team to changes in glucose levels. Based on glucose levels—combined with data from his smart refrigerator and pantry—the care advocate might help Larry schedule a drone to deliver groceries, medications, and vitamins. A virtual care coach might lead Larry through daily exercises. When in-person appointments are needed, the care team might schedule a driverless car to transport Larry.

This might seem like an overly rosy picture, and we certainly expect people will be dealing with complex health challenges 20 years from now. But we think consumers will have a much different relationship with their health in the future. We anticipate early detection and prevention will help consumers sidestep chronic diseases and live healthier lives. People who have chronic conditions will likely be surrounded by virtual and human support systems that can keep them from falling through the cracks.

The four A’s that can drive the future of health for consumers

We all approach our health (and the health system) differently. While some of us eat right, exercise regularly, and schedule wellness visits with our doctor, others feel they don’t have time to focus on their health…or they are worried about hearing bad news from a doctor. Some of us just feel helpless when it comes to improving our wellbeing.

The future health system will likely be omni-present and will wrap around all consumers. We anticipate that by 2040, 60 percent of the health system will be focused on prevention and wellbeing, while 40 percent is devoted to actual care.¹ This is the opposite of where we are now.

To realize this future, consumers should willingly engage in their health. Rather than being passengers in a system, they should be drivers acting in their own best interest. We expect four key factors will influence how consumers experience health in the future:

1. Attitude: Connected and informed consumers will likely be more willing to make healthy choices as they gain a better understanding of the connection between their choices and their health. Improved health literacy will likely translate to an improved attitude about health.
2. Agency: Transparency can empower consumers to make informed decisions and reduce mistrust and frustration. Rather than just helping consumers be more compliant, transparency can help ensure consumers have complete information about their health that can help them make the most appropriate decisions.
3. Availability: Consumers can engage with access points in the health system that are convenient and personalized. Entry points are patient-specific and omni-present. Care availability will likely be woven into the fabric of each person’s life so access to information and solutions are always available.
4. Access: Care likely won’t be confined to brick-and-mortar facilities. We expect the center of gravity in health will be the individual rather than the system. Access will likely be about getting solutions to the consumer rather than getting the consumer to a solution. We see a blurred definition of access that will encompass digital, virtual, and physical access points. During a recent DBriefs webinar, 37 percent of attendees said access to personal health data would drive most consumer engagement and behavior change.

Like an orchestra, the future of health will likely require an ensemble of players that perform different parts but share a common purpose (there won’t be room for soloists). Some existing stakeholders will be reluctant to change their business models to ensure their spot in this ensemble. Others will drive change and help define the future of health. Health care stakeholders that don’t lead the change should adapt or they might not be around for the curtain call once the future of health arrives.

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¹ Deloitte Research

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In the News

Federal court rules against 340B payment cuts

On May 6, a federal judge ruled that the 340B drug-payment—set by the US Department of Health and Human Services (HHS) in its 2019 Outpatient Prospective Payment System (OPPS) final rule—is unlawful. Three hospital associations, the American Hospital Association, Association of American Medical Colleges, and America's Essential Hospitals, released a joint statement supporting the judge’s ruling. The groups also urged HHS to comply with the judge’s request to send a report on its progress revising the methodology by August 5.

The 2018 OPPS final rule reduced payments for covered outpatient drugs under the 340B program from the standard rate of average sales price (ASP) plus 6 percent to ASP minus 22.5 percent for most hospital-affiliated providers. The 2019 final rule extended the payment methodology to off-campus hospital clinics. In November 2018, HHS issued a regulation to implement the new 340B ceiling price (and penalties) on January 1, 2019 (see the December 4, 2018 Health Care Current). However, the same federal judge halted the final rule’s cuts with a December injunction (see the January 8, 2019 Health Care Current).

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Senate Finance Committee discusses improvements to MACRA during hearing

On May 8, the Senate Committee on Finance held a hearing to discuss the Medicare Access and CHIP Reauthorization Act (MACRA). According to committee Chair Charles Grassley (R-Iowa), the law’s passage, which followed 10 years of changes to the Sustainable Growth Rate (SGR) system, demonstrates that lawmakers can work in a bipartisan manner to address other significant issues, such as drug costs. During the hearing, leaders from physician groups and think tanks discussed options for improving the clinician experience under MACRA’s Quality Payment Program (QPP), which has two participation tracks: Merit Based Incentive Program (MIPS) and Alternative Payment Models (APMs).

During the hearing, a witness representing the American Medical Association (AMA) outlined several priorities for further improvement to MACRA, including:

• Continuing to support small and rural practice participation in MIPS
• Extending the bonus period for physicians who participate in APMs
• Replacing the freeze on physician payment rates, scheduled to occur from 2020-2025

The president of one physician group expressed concern that MIPS participation can be overly complex for physicians and other clinicians, which could detract from patient care. A research fellow from the Brookings Institution urged Congress to eliminate MIPS, noting that clinicians paid an estimated $482 million this year to comply with reporting requirements. Additionally, a surgeon called for MIPS to incorporate quality measures that align with care delivery and specialty workflows. Several witnesses also called for greater incentive payments to reward joining alternative payment models. While the goal of MACRA is to move as many clinicians as possible to APMs, witnesses suggested that the 5 percent bonus payment for Advanced APM participation is not high enough to encourage clinicians to adopt risk-based models.

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Insurance exchanges have become more stable, profitable for carriers

For health plans that sell individual coverage through public insurance exchanges, 2018 was the most profitable year they’ve seen since the exchanges opened their virtual doors in late 2013, according to a report from the Kaiser Family Foundation (KFF). Last year, individual plans returned to—or exceeded—profitability levels seen before the enactment of the Affordable Care Act (ACA). One reason could be that health plan operators boosted premiums for benchmark plans by an average of 34 percent going into 2018 in response to concerns related to the elimination of the individual-mandate penalty and uncertainty about the fate of the ACA, given Congressional action and the major lawsuit. Overall, benchmark premiums fell slightly for the 2019 plan year as it became clear that some health plans increased 2018 premiums too much, according to the report. Although enrollment for the 2019 plan year declined slightly from the prior year, “financial results suggest the market is still stable and sustainable,” according to KFF. The study also notes that more than 300 million enrollees will share $800 million in rebates from health plans that priced their products too high. This is because the medical-loss-ratio provision of the ACA requires that health plans in the individual market spend at least 80 percent of premium dollars on health care claims or quality improvement activities.

(Source: Kaiser Family Foundation, Individual Insurance Market Performance in 2018, May 7, 2019)

Related: While new enrollment declined for the 2019 plan year, many existing customers are keeping their coverage, according to a May 7 analysis from state-run exchanges in California, Massachusetts, and Washington state. In California, 89 percent of people who were enrolled in a plan last December renewed their coverage for 2019—up from 86.5 percent a year earlier. In Massachusetts, the renewal rate increased from 87 percent in 2018 to 91 percent this year, and in Washington state, the renewal rate increased from 79 percent to 88 percent.

(Source: Covered California, May 7, 2019)

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HHS finalizes rule requiring prescription drug list prices on TV ads

On May 8, HHS finalized a rule requiring prescription drug companies to include their drugs’ list prices in television advertisements. Once the rule goes into effect, pharmaceutical companies will have to include the Wholesale Acquisition Cost (WAC) in direct-to-consumer (DTC) ads for prescription drugs and biologics available in the Medicare and Medicaid programs. The WAC must be included in an ad if a one-month supply of the drug costs more than $35. Through the rule, HHS aims to inform Medicare and Medicaid beneficiaries about their potential expenses and out-of-pocket (OOP) costs for the advertised drug.

Pharmaceutical companies strongly opposed the proposed rule, saying the list price is misleading for consumers. Consumers could potentially pay much less at the pharmacy than what they see on television, pharmaceutical companies say, because their benefits might cover most of the price of the drug. The Pharmaceutical Research and Manufacturers of America (PhRMA) further suggested that drug companies could instead make pricing information available online. According to HHS Secretary Alex Azar, the rule is one piece of a larger effort to increase transparency and lower drug prices (see the January 8, 2019 My Take).

(Source: CMS, Medicare and Medicaid Programs; Regulation to Require Drug Pricing Transparency, May 2019)

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Breaking Boundaries

Innovations are needed to curb the urgent threat of antibiotic resistance

Antibiotic resistance could kill 10 million people by the year 2050, according to a United Nations (UN) report released last month. Antimicrobial (including antibiotic, antiviral, antifungal, and antiprotozoal) agents are critical tools for fighting diseases in humans, animals, and plants, but they are becoming ineffective, the report warns. Common diseases that were once considered treatable or manageable, such as respiratory infections and urinary tract infections, are increasingly difficult to treat using available medications. At least 700,000 people die each year due to drug-resistant diseases, according to the UN.

Misuse and overuse of antibiotics in humans and animals—as well as inadequate access to clean water and poor sanitation in the developing world—are the major causes of antibiotic resistance, according to the report. The UN’s Interagency Task Force, which wrote the report, lays out several recommendations that it says all countries should consider. They include:

• Prioritizing national action plans to scale-up financing and capacity-building efforts
• Implementing stronger regulatory systems and support awareness programs for responsible and prudent use of antimicrobials by professionals in human, animal, and plant health
• Investing in ambitious research and development for new technologies to combat antimicrobial resistance
• Rapidly phasing out the use of critically important antimicrobials as growth promoters in agriculture

What are innovative researchers doing to address antibiotic resistance?

One preclinical study is looking into ways to neutralize the toxins in the bacteria that harm the immune system by manipulating the proteins that bind to the toxins. This approach could be a step forward in developing a new class of biologics.

Phage therapy is another promising approach that is gaining traction. A US and United Kingdom research team used genetically engineered viruses to help treat a patient’s antibiotic-resistant infection, according to a study published early this month. The researchers relied on bacteria-destroying viruses known as bacteriophages that occur naturally—and are the most-common organisms on the planet. The researchers used genetic engineering to tweak some of the phages to specifically target the patient’s infection.

Phage therapy has been around since the early 1900s but fell out of practice when antibiotics were introduced. As antibiotics become increasingly less effective, researchers are returning to phage therapy. Academic institutions and biotech companies in the US are showing a renewed focus on bacteriophages, and a small number of patients have been successfully treated with the experimental therapy.

The journal article mentioned above highlights the first time genetically-engineered phages were used to treat a patient who had cystic fibrosis. The genetic disease makes it difficult for the lungs to fight off common bacteria. The patient had been on antibiotics for eight years to combat two persistent bacteria strains. After a lung transplant, the infection spread, and the patient stopped responding to antibiotics.

The team searched a phage database and homed in on phages that matched the type of bacteria they were fighting. They found three phages that matched, but only one of the matching phages would actually eliminate the infection. In this case, they needed all the three phages to perform distinct functions. Some phages reproduce with their bacterial hosts and can burst them open and destroy them, while others can replicate with the bacteria without harming them. The researchers used genetic engineering to remove a gene that prevents the phages from killing the bacteria. The team then administered the cocktail to the patient both intravenously and directly onto her skin, combined with a few antibiotics. The process worked, and the patient was healed over six months. Because this therapy was successful in combatting mycobacteria, researchers say it has potential to treat drug-resistant tuberculosis.

Looking forward: Several clinical trials are in the planning stages, but because phages are so specific when choosing their targets, it is unclear whether they can be effective on a larger scale. One downside is that phages cause bacteria to rapidly develop resistance, which means they could potentially run into similar problems as antibiotics. However, many researchers say that genetically engineering the viruses used in phage therapy, or using them in combination with antibiotics, could address that challenge.

(Sources: No time to wait: Securing the future from drug-resistant infections, Report to the Secretary-General of the United Nations, April 2019; Brianna Abbott, Genetically-engineered viruses treat antibiotic infection, Wall Street Journal, May 8, 2019)

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