Prescribing health: the vital role of the pharmaceutical sector in improving health equity
Addressing health inequalities is a pressing priority for healthcare systems and governments more broadly. Health inequalities refer to unfair health outcomes among populations; while health equity aims to provide everyone with an equal chance to reach their optimal health, regardless of socioeconomic status (SES), ethnicity, age or other factors. Unfortunately, health disparities persist, often tied to social determinants of health (the conditions in which people are born, grow, work, live, and age). These disparities exacerbate societal divisions and present substantial obstacles to public health endeavors.
The life sciences sector has a unique opportunity to drive tractable action to reduce health inequalities. In this Guest Column, Dr Jonathan Pearson-Stuttard (LCP Health Analytics), Dr Chris Lübker (Novo Nordisk) and Thomas Holbaek (Novo Nordisk) highlight the increasing relevance of health equity to payers and health technology assessment (HTA) bodies, underscoring their critical role in shaping access to healthcare innovations. As discussions around health equity gains momentum, stakeholders in the pharmaceutical sector have an opportunity to take practical steps to enable equity considerations across market access including collecting relevant real-world data (RWD) to identify variation in unmet need throughout the care pathway alongside demonstrating the equity benefits that their innovations can bring. Through collaborative efforts between payers, HTA bodies and manufacturers and a commitment to health equity, the industry can drive meaningful change and pave the way for a more equitable healthcare system.
Health equity: more relevant to payers and HTA bodies than ever before
The COVID-19 pandemic highlighted existing healthcare inequalities, contributing to higher infection and mortality rates among specific demographics. Despite healthcare progress, inequalities in life expectancy have grown, both within and across countries. In England, even pre-pandemic, significant gaps in life expectancy persisted, with women facing over 20 years and men over 27 years difference across small areas. Worldwide, life expectancy spans from 86 years in Monaco to 54 years in the Central African Republic.
In response, HTA bodies are increasingly considering how best to include health equity considerations. Entities such as the Institute for Clinical and Economic Review (ICER), Canada’s Drug and Health Technology Agency (CADTH) and the National Institute for Health and Care Excellence (NICE) are incorporating equity considerations into their assessment frameworks, with NICE having the reduction of health inequalities one of its core principles. The Innovation and Value Initiative (IVI) in the US has published principles supporting efforts to reduce health disparities and improve health equity, emphasizing that, “HTA advances health equity when it reduces health disparities by aligning access and affordability of healthcare technologies and services with the differing needs and values of diverse patient populations, especially those who are most marginalized.” IVI has also launched a health equity initiative and co-created a paper to advance racial and health equity in health technology. These organizations are championing fair and equitable access to healthcare resources by evaluating the cost-effectiveness and societal impact of healthcare interventions through an equity lens.
However, current implementations often leverage qualitative approaches which have several imitations. This includes a lack of quantitative measures which makes comparative effectiveness of interventions according to equity infeasible. Given the availability of methods in scientific literature, this highlights the urgent need for further work to understand how best to implement these methods into routine assessment. By quantitatively integrating considerations of fairness into the evaluation of medications, industry can have their value better recognized to patients and society.
One size does not fit all
In addressing health inequalities, specific domains of equity must be considered, such as ethnicity, deprivation/income, and age relevant to the disease area and country. For example, sickle cell disease (SCD) is substantially more common in patients of black African ethnicity and a 2018 review in the US found inequalities in health care access for these patients. An inquiry in England corroborated these findings, revealing substandard care and racism within healthcare settings for SCD patients.
By contrast, common conditions such as cardiovascular disease (CVD) and obesity exhibit a clear social deprivation gradient. Individuals with lower SES, living in greater levels of deprivation, face a greater burden of risk for CVD compared with those in more affluent groups. Meanwhile women in the most deprived quintile in England are nearly twice as likely to live with obesity compared to the most affluent 20%, and these inequalities persist throughout obesity-related conditions too. Several health conditions have variation in unmet need according to age, gender and several other factors too, highlighting the need for specific consideration of domain of equity according to nuanced factors such as therapy area, population and geography.
Feasibility of incorporating equity in market access decisions
Incorporating equity considerations into market access processes is now feasible, given the increasing availability of RWD and the development of methodologies to assess these factors. Understanding and quantifying variation in unmet need and measuring inequalities in access and uptake can further the equity agenda. ICER has been actively working on incorporating health equity considerations into its HTA methods. Their recent white paper recommends establishing formal processes for incorporating evidence on systematically worse outcomes, assessing clinical trial diversity, analyzing results by subpopulations and measuring opportunities to reduce health disparities. While this stopped short of adopting quantitative methods, established methodologies do exist. For instance, Distributional Cost-Effectiveness Analysis (DCEA) offers a robust framework to quantify the health equity impacts of an intervention alongside assessing potential tradeoffs between health equity impacts and aggregate cost-effectiveness. Recent work has shown how incorporating equity through a distributional approach can redefine value of treatment and hopefully improve access for disadvantaged patient groups; a gene therapy for SCD was found to be not cost-effective by traditional cost-effective analysis, but when assessed through DCEA was found to be cost-effective when accounting for the distribution of costs and effects across sociodemographic variables.
As discussion around health inequalities and incorporating health equity in market access considerations increases, targeted efforts are required to accelerate the journey of systematic implementation. To channel efforts into tractable action, an ‘Equity Framework’ building on frameworks like NICE have produced for real-world evidence is needed. Such a framework would provide guidance to manufacturers given the many facets to be considered including variation in domain of equity, disease, populations, alongside the most appropriate data sources and methods to guide manufacturers in a systematic and standardized way. This would be a practical approach to enhance equity considerations and make meaningful strides into reducing inequalities in access and uptake of medicines and improve health equity.
Authors
Dr Jonathan Pearson-Stuttard is Head of Health Analytics at Lane Clark & Peacock (LCP). Jonny completed his medical training at the University of Oxford followed by MSc Epidemiology and PhD Diabetes Epidemiology at Imperial College London. As a Public Health Physician and Epidemiologist he is Chair of the Health Inequalities Programme Board at Northumbria Healthcare NHS Foundation Trust and Chair of the Royal Society for Public Health. He leads a multi-disciplinary analytics team at LCP who work across the life-sciences sector to provide actionable insights and shift healthcare systems from importers of illness to exporters of health.
Dr Christopher Lübker is a health economist at Novo Nordisk A/S and honorary visiting research fellow at the University of York, where he completed his BA Philosophy, Politics, and Economics (first class honors), MSc Health Economics (distinction), and PhD Health Sciences at the Centre for Health Economics. As part of his Wellcome Trust funded research in the Equity in Health Policy (EQUIPOL) team with Professors Tim Doran and Richard Cookson, Dr Lübker evaluated the cost-effectiveness and equity impacts of the bodyweight effects from the Universal Infant Free School Meal Programme in England. He was also a seconded fellow and consultant at the Organisation for Economic Co-Operation and Development (OECD), where he researched educational inequalities in life expectancy across member countries, followed by a country report on cancer inequalities in Denmark commissioned by the European Union. Dr Lübker is currently responsible for the health economic modelling on the SELECT cardiovascular outcomes trial in obesity and supports efforts to ensure the reimbursement and equitable access to semaglutide 2.4 mg at Novo Nordisk A/S.
Thomas Holbæk, MBA from Rotterdam School of Management, Erasmus University, is the Vice President for Obesity Market Access at Novo Nordisk A/S, where he is responsible for market access strategies to in-market and pipeline anti-obesity medicines. Mr Holbæk has been in Novo Nordisk for over 20 years across operational and strategic roles in diabetes and obesity.
Interested in the topic and want to find out more?
Dr Jonathan Pearson-Stuttard will be speaking about the pharmaceutical sector’s role in improving health equity at the World Evidence, Pricing and Access (EPA) Congress 2024 in Amsterdam on March 12, 2024 at 15.35 in the main theatre. Further details can be found on the agenda here.
Alternatively, please reach out to Dr Jonathan Pearson-Stuttard, Head of LCP Health Analytics and Chair of the Royal Society for Public Health, directly: [email protected]
Acknowledgements
Writing assistance, provided by Katie McCool of The Evidence Base, was used in an earlier version of this column.
