HBA Fellowship Program Cracking the Code on Healthcare: ´╗┐Key Takeaways

  As a Fellow with the 2020 Healthcare Business Academy (HBA) Fellowship Program, CCSI’s Pam Ayers had the honor of participating in the June 11th, 2020 Cracking the Code on Healthcare event, which focused on the topic off "Innovative Patient Care." The webinar-based event featured two nationally renowned keynote speakers, whose work has been decidedly influential across healthcare.

Both presenters highlighted the vital innovations taking place in the physical health realm that are not so unfamiliar to those of us working in behavioral health: Human Centered Design approaches, Person-Centered Care, and Data-Informed interventions. The trend toward a collaborative approach, to include the client/patient, which focuses on the whole person and their communities is promising and leaves much space for partnerships between traditional medical practices and behavioral health services.

Janet Woodcock, MD, is the Director of the Center for Drug Evaluation and Research (CDER), at the Food and Drug Administration (FDA). She has also held the roles of Acting Director of CDER’s newly formed Office of Pharmaceutical Quality, (OPQ), and the FDA’s Commissioner, among other titles.

Dr. Woodcock’s presentation, Pharma Impact on Care Delivery, explored drug development, costs, and innovations. Dr. Woodcock described that, historically, the process of determining what drugs to develop has been driven by several factors, none of which is patient-focused. These factors include: (i) the urgency of a health issue among an influential population; (ii) the impact of a disease among a large segment of society; and (iii) the availability of illness-specific research funding. Once the drugs are developed and ready for testing, the traditional design of a clinical trial has been to study one drug, with one population, against a placebo – a burdensome process for both patients and professionals, particularly when there are multiple treatments to be tested.  Between the relatively arbitrary, illness-led decision process and the complex clinical trial method, drug development has been a disease-guided process that does not attend to urgency, nor the patient perspective. Dr. Woodcock challenged the industry to consider ways in which innovation can create a more inclusive, efficient process. What she outlined is strikingly similar to changes that have been taking shape for some time in behavioral health.

Patient-Focused Drug Development
  • Improved focus on the patient and community: By understanding a disease in the context of the person it impacts, the patient experience drives the focus of the intervention, ensuring the impact is addressing what the patient population values most. In essence, drug development should be modeled on Human Centered Design thinking.
  • Better collaboration among developers: At present and historically, the research around new drugs has been uncoordinated and not always well-documented. The self-interest of the companies and universities involved in research and development of new drugs has inhibited a faster-paced, more comprehensive process. Often operating in vacuums, the interested parties slow down the process and waste resources by duplicating efforts. Better research would be coordinated, purposefully designed, and more transparent. By working together, researchers can learn with, rather than competing against, each other, a benefit to the entire healthcare system.
Drug Development and the Pandemic
All the above being true, and like much of the normalcy of the world, drug development has largely gone on hold in the interest of discovering a vaccine for the COVID-19 virus. While therapeutic development – interventions to treat COVID-19 symptoms – has taken place quickly, the vaccine process is slower. Usual drug development takes 7 to 10 years to complete, and often even longer in the case of vaccines. For COVID, there are now over 60 vaccine candidates around the world. These candidates will require very large clinical trials and, even with massive trials, outcomes can often look good in the lab and then not work in the real world. In an effort to accelerate the development of an effective, usable vaccine, the US Federal Government has initiated Operation Warp Speed, investing development dollars into assisting companies to scale up production “at risk,” meaning the companies will produce large amounts of their vaccine before actually knowing if it works. This way, if it is successful, production has already taken place and distribution can be immediate. The faster the world can find the vaccine to COVID-19, obviously the sooner scientists can return to researching other critical diseases – interestingly, however, perhaps with a new tool as a result of lessons learned during COVID: utilizing virtual options for clinical trials and other components of drug development. This may be another area where physical and behavioral health innovations align, as telehealth grows across the healthcare industry.

Christine Goertz, DC, PhD, is Professor in Musculoskeletal Research at Duke Clinical Research Institute and Director of System Development and Coordination for Spine Health in the Department of Orthopaedic Surgery at Duke University. She is also the CEO of the Spine Institute for Quality.

In Dr. Goertz’s focus on Pharma Alternative Care Models, she discussed the medical community’s reticence to embracing non-pharmacological interventions for back pain, specifically, as one of the most common ailments that lead to opioid prescriptions. The limited uptake in the medical community of non-pharmacological treatments – which include interventions like physical therapy, massage, acupuncture, chiropractic, and psychological approaches – is concerning, given the other options are medication or surgery. Doctors do not always consider or have reservations about the quality/ consistency of alternative treatments. While this is slowly changing, perhaps the biggest barrier to the adoption of non-drug interventions is that, within the existing healthcare system, access to and coverage of the types of clinicians who provide these services is still limited. Today, insurance companies are most likely to cover physical therapy, occupational therapy, and chiropractic. But options like acupuncture and psychological interventions are typically not covered or coverage is very limited. With a median out-of-pocket expense of $40-60 per visit and a normal course of treatment of 6-12 visits, the total cost of care can be upwards of $700, a price point out of reach for many, especially compared to the $10 per month out-of-pocket cost of generic opioids.

Additionally, while polls show patients prefer trying alternative methods of various treatments over medication, they also indicated that patients prefer to see medical doctors for their pain over alternative providers. So, while patients would rather try alternative methods for their pain treatment, they still look to their doctors as their most trusted resource, making it ever more critical that the medical provider community adopt the idea of alternatives to medication, including both physical and behavioral interventions. Certainly, more research needs to be done on the effectiveness of non-pharmacological interventions, but the medical provider community also needs to be armed with knowledge and tools to promote preventive care and coordinated, patient-centered approaches. Dr. Goertz described the ideal tactic as one that is driven by a systemic, population health philosophy. Care should be provided in a stepped, coordinated manner with evidence-based clinical care pathways, along with clear, evidence-based referral pathways. With stakeholders increasingly interested in value-based delivery models, a less-expensive, prevention-focused treatment approach is the rational place to begin. This includes lifestyle components such as activity, nutrition, mindfulness and education. And even upon entry into the formal health care system, approaches should first attend to self-care, then alternative practitioners, and only after those do not work should medication and surgery come into play. This approach, just like prevention in behavioral health, is expected to demonstrate better outcomes at a lower cost.

Panel Discussion: Following the keynote speakers, a panel of local healthcare executives, along with the speakers, fielded questions relating to topics including the transition from traditional western medicine to a non-pharmacological approach, and the importance of patient-centered care. The group highlighted two key takeaways:
  1. The critical first step is for providers to establish their own role in the space by seeking out more education on alternative solutions, building referral networks that include non-traditional providers, and actively seeking to break down silos, thereby encouraging collaborative planning.
  1. Addressing Social Determinants of Health will also help with every aspect of healthcare, and with relatively low cost. This could have an even larger impact on healthcare and patient trajectories for people with chronic pain, a complex condition with a significant biopsychosocial impact. This means also reaching out to diverse populations to understand their needs and interests and make connections to a range of solutions and strategies.
Throughout the morning, both speakers and the panel highlighted the critical connection between physical and behavioral health. Patient-centered care and outcomes were top of mind, and a running theme stood out: Ask the patient. Start with what the client wants and needs. As Dr. Woodcock said early in the day, it is critical to remember that the way the patient defines success is often very different from how the doctor defines it.

Pam Ayers
Senior Director, Strategic Initiatives
& Project Development
Coordinated Care Services, Inc.