Among our numerous health care grantees and their associates working to improve health care affordability, it feels impossible to highlight just a few to keep our eyes on this year.
We did our best.
State Reformer Gloria Sachdev
Gloria Sachdev is president and CEO of the Employers’ Forum of Indiana, an employer-led health care coalition of employers, physicians, hospitals, health plans, and other stakeholders. Sachdev represents many large employers who, year after year, were paying more for health care and wanted to understand what was driving these high costs. The Employers’ Forum piloted the first in a series of RAND studies that crunched the numbers in order to understand what hospitals were charging Indiana residents for care versus other states. The findings: some of the highest price tags in the country.
This research spurred a multi-year effort to understand why Indiana hospitals were charging such high prices. Under Sachdev’s guidance, the Sage Transparency tool launched in 2022. The tool reveals hospital prices, costs, and quality for most hospitals across the country and makes one point especially clear: High and variable prices aren’t a reflection of hospital costs or quality, but are often a product of hospitals’ market power to charge high prices. Sachdev is on an unrelenting crusade to shine a bright light on excessively high provider prices with tools like Sage. Her next steps are worth watching in 2023.
A New Coalition of Bipartisan Senators
People who jointly qualify for Medicare and Medicaid navigate two systems never designed to work together, all while managing chronic health conditions. Last year, U.S. Sen. Bill Cassidy (R‑LA), M.D., argued in a Modern Healthcare op-ed that the lack of aligned incentives across Medicare and Medicaid both hurts patient care and results in inefficient spending. He followed up on the op-ed by leading a bipartisan group of senators to launch an effort geared toward improving the care and coverage experience for the more than 12 million people dually eligible for Medicare and Medicaid. Other senators in the coalition include Tim Scott (R‑SC); John Cornyn (R‑TX), Mark Warner (D‑VA), Tom Carper (D‑DE) and Bob Menendez (D- NJ). We at AV were excited to answer the senators’ call for information on how to integrate the fragmented system, and look forward to supporting this bipartisan group of lawmakers as they work towards a solution.
Drug Patent Reform Champions Tahir Amin and Priti Krishtel
Prescription drug spending continues to strain the budgets of employers and families alike. Brand-name drugs account for just 8% of all prescriptions, yet these pricey medications make up 79% of overall U.S. drug expenditures. To extend these blockbuster monopolies, drug companies game the patent system by playing a host of anticompetitive games to prevent, block, and delay competing products.
“It’s the way the pharmaceutical companies now use that system — it’s all about taking up as much space as possible, making it difficult for anybody to enter,” Tahir Amin, co-founder of drug patents watchdog group Initiative for Medicines, Access & Knowledge (I‑MAK), recently told Reuters.
Amin and IMAK Co-Founder Priti Krishtel, recently named a MacArthur ‘genius’ for her work in this reform space, have been relentless in their efforts to shed light on the opaque patent system, educate and engage the public on the issue, and pound the drum on the need for reform.
Such success galvanized the New York Times Editorial Board to issue a special feature highlighting I‑MAK’s rigorous research to urge Congress and the administration to save the patent system. Overpatenting and blocking the dissemination of knowledge is a primary driver of persistently rising drug prices — and could present an opportunity for bipartisan reform in the 118th Congress. We anticipate Amin and Krishtel will be at the forefront of the next wave of drug pricing reforms in 2023 and beyond.
FDA Reform Advocate Dr. Reshma Ramachandran
Dr. Reshma Ramachandran is a family physician, Yale University professor, champion for patient-centered clinical research integrity and transparency, and the U.S. Food and Drug Administration (FDA) Task Force chair with AV grantee Doctors for America — an organization of more than 20,000 medical professionals and trainees dedicated to putting patients over profit. Throughout 2022, Ramachandran advocated for reforms to the FDA’s drug accelerated approval process that strikes an appropriate balance between ensuring timely access to promising treatments and certainty that these treatments truly work in patients prescribed them. She also argued that the PASTEUR Act is not the cure for antimicrobial resistance that industry-funded advocacy groups claim, but a blank check to the drug industry for more of the same.
The hard work and continued advocacy on behalf of stronger evidence standards and attention to patient safety struck a chord. The FDA uses a process called “accelerated approval” to make promising drugs for serious conditions available faster based on promising, yet incomplete evidence of safety and effectiveness. Companies agree to later conduct clinical research to confirm the drugs work — but often miss the deadlines by years or never complete their study at all. Congress included in omnibus language provisions that spelled out for those manufacturers missing their required deadlines that FDA now has explicit regulatory authority to withdraw the product from the market. Moreover, the PASTEUR Act was sent back to the drawing board. With growing momentum, we’re excited to see what Ramachandran will do next to hold FDA accountable and improve the quality of medicines.
State Medicaid officials in Colorado, Connecticut, Massachusetts, Montana, and New Mexico
Changing the way our health care system pays doctors, hospitals, and other providers can promote high quality, less costly, and more equitable care that improves population health. Currently most of the health care system relies on “fee-for-service” payments. Paying service by service may make sense for buying most goods, but it doesn’t always work well for medical care. The fee-for-service system incentivizes physicians to deliver more and higher-priced care even when services have no benefit to patients or could harm them. Up to $345 billion in wasteful spending arises from overtreatment or care coordination failures, and our nation is plagued by pervasive health inequities. But things are starting to change.
Medicaid officials in Colorado, Connecticut, Massachusetts, Montana, and New Mexico are moving to adopt population-based payments for primary care, which is at the center of a high-functioning health care system. Unlike fee-for-service, population-based payments hold providers financially accountable for the health of a group of patients, including the cost and quality of their care. Competing priorities and limited resources often leave state Medicaid officials without the capacity and time to design and implement innovative payment changes. That’s why efforts underway in these states are a critical step toward improving health care and advancing health equity goals. The officials have launched a learning collaborative to support the adoption of population-based payments for primary care with a focus on improving health equity. Officials in these leading-edge states are paving the way for other states looking to improve health care and patient outcomes.