by Sarah Hughes-McLure and Jen DeBerardinis
Healthcare sustainability goals for 2030 and existing initiatives
Broadly, healthcare sustainability goals are intended to promote more widespread access to healthcare while controlling exploding costs. Achievement of these goals will involve a combination of major public health interventions (e.g., controlling the spread of infectious diseases, reducing the prevalence of lifestyle conditions) and improvement in the efficiency of healthcare delivery and resource utilization (e.g., transparent pricing practices, electronic health record adoption).
Ensure access to basic life-saving medications and medical interventions across the world: As was underscored by the Ebola outbreak in 2014, which disproportionately impacted countries in West Africa suffering from a profound lack of healthcare resources, global disparities in access to medical care contribute to major differences in life expectancy, disease burden, and susceptibility to epidemics across the world[1]. While many Americans with private insurance enjoy access to innovative oncology therapies, hospitals in rural communities in South Africa frequently run out of intravenous antibiotics and tuberculosis therapies that could easily save patients from dying[2].
Given much of the disparity stems from the inability of poorer countries to afford drugs, a number of public and private initiatives have attempted to promote access to basic mediations and supplies. The Access to Medicine Foundation, which works with pharmaceutical companies to promote access to medications in low- and middle-income countries, has established an Access to Medicine Index that ranks manufacturers based on the degree to which they make medications more accessible[3]. Companies like GlaxoSmithKline have responded by capping the prices of certain medicines in the “least developed countries” at 25% of prices in the EU-5 and offering lowest price vaccines to organizations like GAVI, which supports widespread vaccine distribution in low-income countries[4].
The mere provision of products, however, is insufficient to address healthcare access in most countries. Moving forward, initiatives will be required to resolve the supply chain issues that also plague healthcare systems in less developed markets.
Resolve the global physician crisis: Limited availability of healthcare workers and increasing disease burdens in many parts of the world are creating a global healthcare provider crisis. Both a severe scarcity of healthcare providers as well as their inequitable distribution mean 57 countries face such severe healthcare provider shortage issues they are unable to meet minimum healthcare needs, according to the WHO[5]. Indeed, low income countries have ten times fewer physicians than high income countries[6]. In some areas of South Africa, for example, state-run hospitals lack a single doctor[7].
Lack of healthcare providers in the countries where they are most needed offers substantial opportunity for companies that are developing creative solutions to better match physician supply and demand, such as telemedicine providers.
Eliminate counterfeit medications: Counterfeit medications contain no active ingredient or below required quantities of a drug’s intended active ingredient, resulting in poor efficacy and potentially severe side effects. The Centers for Disease Control estimates 10-30% of drugs sold in developing countries are counterfeit: significantly higher than the 1% reported in developed countries[8].
The US Congress has passed a bill requiring the pharmaceutical industry to assign serial numbers to all “saleable units” of a drug beginning at the end of 2017. These can then be tracked by pharmacies before being passed to patients[9]. However, significantly reducing counterfeit drug sales in the developing world will require the design and implementation of innovative distribution models as well as providing pharmacies and other point of sale facilities with the tools to assess medication integrity before dispensing.
Combat antibiotic-resistant pathogens: Present in every country in the world, antibiotic resistance is caused by the overuse and misuse of antibiotics which leads to the proliferation of strains of pathogens that cannot be treated and is associated with a variety of infectious diseases. Alarmingly, the Centers for Disease Control (CDC) indicates the rate of antibiotic-resistant infections is growing rapidly, with 2 million people infected every year and 23,000 dying because drugs are no longer able to treat their infections[10]. The World Health Organization (WHO) reports that in many countries, resistance has rendered treatment of urinary tract infections caused by E. coli untreatable in over half of patients[11]. Ten countries have reported failures of the treatment of last resort for gonorrhea, leaving these patients without any options.
Sustainable healthcare over the long-term will require drastic efforts to lower antibiotic resistance globally. The WHO is helping countries manage resistance through surveillance programs and action plans as well as working with the UN to disseminate best practices for antibiotic use. Many individual hospitals are setting up antibiotic stewardship and surveillance teams who oversee antibiotic prescribing, track patients after they fill prescriptions, and reduce hospital-acquired infection rates.
Promote widespread access to electronic health records: Electronic health records, the storage and transmission of patient health information in a digital format, has the potential to dramatically improve quality and efficiency of healthcare delivery. These records allow for immediate safety checks on interventions, better coordination of specialists, and tracking of patients’ responses to various drugs and procedures as well as reduce hospital paper consumption and waste.
As a result of incentive programs developed by public payers, the portion of US hospitals that have adopted electronic health record technology has increased from 10% 10 years ago to a large majority today[12]. As North America constitutes half of the global electronic healthcare market, however, sustainable health practice will demand adoption of electronic health records more globally, including in developing markets.
Reduce obesity and prevalence of chronic lifestyle diseases: With over half of the global adult population expected to be overweight or obese by 2030, McKinsey has ranked obesity as one of the top three social burdens facing humans (behind smoking and armed violence, war, and terrorism)[13]. Obesity is associated with some of the leading causes of preventable death: heart disease, stroke, type 2 diabetes, and cancer[14].
The WHO has engaged in a series of obesity public awareness campaigns since the 1990s[15]. Moving forward, however, both healthcare providers and payers will have an increasingly important role to play in reducing obesity. In the US for example, the historical lack of reimbursement for weight counseling has meant many providers have referred patients to community weight loss programs, which are often unreliable and ineffective[16]. Both public and private insurers will need to devote sufficient resources to compensate providers for weight loss services as well as look to better incentivize their members to engage in preventative care.
Improve transparent pricing practices for drugs and medical devices: According to the OECD, public expenditure on health and long-term care in OECD countries will increase from 6% of GDP to 9% in 2030 and 14% in 2060 if costs continue to rise at current rates. Increases in costs are due to both healthcare delivery (e.g., provider fees, diagnostics and other services) as well as expenditure on pharmaceuticals and medical devices. IMS Health found average list prices for drugs increased more than 12% in 2015.[17].
Though widely touted as a potential solution, indiscriminate cost cuts in wealthier countries are unlikely to solve the long-term sustainability challenge given many healthcare companies rely on these markets to fuel both R&D and compassionate use programs (providing drugs at little or no cost) in other markets. Some drug companies have voluntarily taken modest price cuts and entered into licensing agreements to allow their products to be sold more cheaply in certain markets. Gilead, for example, has entered into licensing agreements with multiple drug manufacturers in India to produce less expensive versions of its branded antiretroviral drugs indicated for HIV[18]. GlaxoSmithKline reports it launched its six most recent drugs at parity or a discount to alternatives in their therapeutic categories[19]. Solutions to addressing rising drug and device costs will hinge on striking a balance between widespread access and maintenance of manufacturer profitability.
Promote sustainable environmentally friendly products by healthcare providers: Because hospitals consume more energy and produce more waste than other commercial buildings of a similar size, initiatives to promote environmental efficiency in medical care facilities are especially critical. Many hospitals are undertaking voluntary initiatives to recycle energy, water, and other materials as well as utilize alternative power sources[20].
Leadership in Energy and Environmental Design (LEED) certification, one of the most widely used green building certification programs globally with a set of rating systems for the design and operations of eco-friendly buildings, has recently created LEED for Healthcare: specific guidance for hospitals and medical centers. Payers could contribute to adoption of eco-friendly practices by taking into account environmentally sustainable practices in their negotiated reimbursement levels for procedures.
Business model innovation to achieve sustainability goals: supply chain and inventory management coupled with telemedicine for healthcare providers
Many key healthcare sustainability goals address the need to provide more widespread access to basic care in a way that is efficient, affordable, and viable for all stakeholders in the value chain. Two major factors contributing to this access challenge are: limited supply and inequitable distribution of medical personnel, and poor supply chain and inventory management in hospitals and clinics that leads to inefficient utilization of existing resources.
A low-cost solution for hospitals and clinics to more effectively manage their inventory as well as improve patient access to qualified healthcare providers could help to ease both drug and human resource challenges. To address these dual needs, we propose a web or app-based platform solution providers can use to track and order drugs and other medical supplies as well as access medical professionals remotely. This innovation effectively combines inventory management with telemedicine via a monetizable subscription-based solution.
Hospital or clinic staff could use the platform as a comprehensive inventory management system. The application would allow them to oversee medical inventory, easily place orders (from distributors or other hospitals with excess inventory), and forecast future demand for more intelligent ordering. With the same platform, nurses and other staff could connect with more specialized healthcare providers via video or telephone conference, if available in-person services were insufficient to meet patient needs.
Telemedicine, the remote diagnosis and treatment of patients by means of telecommunications technology, has seen widespread use in developed markets, particularly the US, where many insurers reimburse telemedicine visits. Many attempts to apply telemedicine to the provision of care in the developing world have involved non-profit initiatives, limiting their financial sustainability over time. For example, the Center for Connected Health, a Boston-based non-profit, is running a project that provides Cambodian villages with connections and basic medical equipment (x-rays, ultrasounds, etc.) and links them with physicians at Massachusetts General Hospital, who provide services free of charge[21].
Many non-profit and international initiatives are used to dealing with supply chain challenges in developing healthcare markets. The WHO has supported many markets in mapping and making improvements in supply chains for the provision of public healthcare[22]. Boston-based biotechnology company Biogen is currently working with the World Federation of Hemophilia to develop supply chains that allow donated clotting factors to actually reach clinics in Africa, Asia, and Central America[23]. While helpful, these efforts have not addressed fundamental issues related to hospital planning, stocking, and forecasting in a scalable or financially sustainable way (i.e., one that does not require charity).
A solution combining supply chain and inventory management with access to physicians via telemedicine offers several significant benefits to providers. Most obviously, it provides access to drugs/supplies and medical personnel they would not have had otherwise. Additionally, it eliminates potential wastage of drugs and medical personnel time that may be unnecessary to treat a small population in an area. Moreover, by allowing communities to set up clinics with more limited resources (lower requirement for physicians and administrative personnel), the solution promotes community empowerment and autonomy. For larger hospitals that would otherwise provide personnel to staff clinics on an ad-hoc basis, it eliminates risks of excess capacity, allows for better utilization of limited resources, and eliminates wasted travel time and logistics costs. This platform would expand on offerings like Medic Mobile, which have patient monitoring and tracking tools, as well as basic inventory management[24], but do not combine sophisticated telemedicine with full-scale clinic inventory management and supply ordering capabilities.
Operational innovations
Reducing information risk: Clinics and hospitals face substantial uncertainty in terms of their future drug requirements and current utilization (if not properly tracked). By tracking drug use over time, the system could predict the most appropriate ordering times given forecasted needs. This would reduce the wastage and scarcities associated with existing ad-hoc ordering practices.
Pooling information risk: By connecting the supplies of different clinics / hospitals (such that drugs can effectively be exchanged among them as needed), healthcare providers would be able to reduce risk and cost of drugs underage and overage.
Pooling resources: Beyond pooling and reducing information risk, an inventory management system allows for substantial cost savings through bulk ordering for multiple clinics from distributors or retail pharmacies. The application could automatically track and pool needs at nearby clinics to facilitate bulk purchasing discounts.
Splitting and resequencing decisions: Virtually connecting medical personnel in more remote clinics with specialists in larger hospitals allows physicians to utilize unexpected slack and clinics to ensure physician demand dictates and matches physician supply. Telemedicine effectively allows clinics to split and re-order the decisions to use a physician’s time for a particular patient and the decision to staff physicians longer-term.
Focus: Telemedicine allows clinics to focus on the common services they need to provide via in-person care (i.e., nursing staff to administer basic treatment), rather than investing in a more qualified doctor or specialist who might only be necessary for a small proportion of conditions.
Overall, this innovation is a self-sustaining solution rather than a non-profit intervention, as the model would be financed via modest subscription fees from hospitals and clinics. In addition, there is a positive feedback loop between financial growth and sustainability impact because growth allows for additional scaling of the platform, which allows for even more effective inventory management (i.e., sustainability impact). At full scale, all clinics and hospitals in an area can be fully integrated in terms of inventory management, meaning drugs unused at one provider could be shared with another provider who needs them.
Challenges and risks for implementation
Critically, the inventory management solution does not address major infrastructure challenges that currently limit the transport of goods between different clinics and hospitals. Several challenges also limit the potential for telemedicine in the developing world. Telemedicine requires sufficient internet for video, limiting usefulness in remote areas without the necessary bandwidth[25]. In addition, to be sustainable (rather than simply a donation of time), physicians in the same country will need to have time and be able to connect via the solution to provide care to avoid challenges associated with reimbursement across countries. This may present challenges in markets where even major hospitals lack sufficient personnel.
[1] http://www.nejm.org/doi/full/10.1056/NEJMp1409494
[2] https://www.voanews.com/a/inside-south-africas-rural-healthcare-crisis-149690295/370015.html
[3] http://accesstomedicineindex.org/
[4] http://www.gsk.com/en-gb/responsibility/health-for-all/access-to-healthcare/
[5] http://www.nejm.org/doi/full/10.1056/NEJMra1111610
[6] http://www.who.int/sdhconference/background/news/facts/en/
[7] https://www.voanews.com/a/inside-south-africas-rural-healthcare-crisis-149690295/370015.html
[8] https://www.cdc.gov/features/counterfeitdrugs/index.html
[9] https://www.pharmaceuticalonline.com/doc/making-last-minute-serialization-preparations-for-the-nov-dscsa-deadline-0001
[10] http://edition.cnn.com/2013/09/16/health/antibiotic-resistant-infections-cdc/index.html
[11] http://www.who.int/mediacentre/factsheets/fs194/en/
[12] http://www.practicefusion.com/blog/ehr-adoption-rates/
[13] http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/how-the-world-could-better-fight-obesity
[14] https://www.cdc.gov/healthyweight/effects/index.html
[15] http://www.who.int/nutrition/topics/obesity/en/
[16] http://khn.org/news/obesity-and-doctors/
[17] https://www.nytimes.com/2016/04/27/business/drug-prices-keep-rising-despite-intense-criticism.html?_r=0
[18] http://www.gilead.com/news/press-releases/2011/7/gilead-expands-access-program-for-medications-in-developing-world
[19] http://www.gsk.com/en-gb/responsibility/health-for-all/access-to-healthcare/
[20] http://www.hhmglobal.com/knowledge-bank/articles/designing-green-hospitals-of-the-future
[21] http://www.hcs.harvard.edu/hghr/print/spring-2011/telemedicine-developing/
[22] http://www.who.int/medicines/areas/coordination/tanzania_mapping_supply.pdf
[23] https://www.statnews.com/2016/04/06/hemophilia-donation-biogen/
[24] http://medicmobile.org/
[25] http://archiveglobal.org/limits-telemedicine-developing-world/