Addressing inequality in patient access through closer partnerships between payer and provider
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A focus on:
Tens of billions are spent each year on market access strategies and reaching commercial agreements with payers that enable patients access to given therapeutics. However, while the eligible patient population and related care pathways are often well specified, the reality is that access is often not equitable across patient groups.
Our vision:
Equitable access to therapeutics benefiting those with greatest unmet need resulting in a reduction in health inequalities.
Looking to the future:
By understanding the impact of their therapeutics on patient inequalities and close to real-time post-marketing equity monitoring, medicine manufacturers can use that insight to work in partnership with payers and healthcare providers to improve access across those patient groups suffering from inequitable access.
Tom Porter
Partner and Strategy Director
Inequitable access to therapeutics across all points of the care pathway
There are several ways in which inequitable access manifests itself, with differing drivers and pathways. Here we outline four contributors to resulting inequalities in access to services with clear cross-over with access to medicines.
We consistently see variation in uptake of prevention programmes. For example, patients from more deprived areas are less likely to take part in bowel cancer screening programmes. Recent estimates have suggested that, in Scotland, 52% of people from the most deprived quintile take up the programme compared to 73% in the most affluent areas. This is further reflected in the presentation of conditions such as cancer, with higher rates of diagnosis via emergency routes such as accident and emergency departments in patients from more deprived areas compared to less deprived areas (Figure 1).
Figure 1: Time-trends in adjusted proportions of emergency presentations, by age group and by deprivation group
Source: J Epidemiol Community Health, Are inequalities in cancer diagnosis through emergency presentation narrowing, widening or remaining unchanged? Longitudinal analysis of English population-based data 2006–2013, 2019
Second, our work estimating the indirect impacts of the Covid-19 pandemic on the NHS elective waiting lists has consistently highlighted the presence of a ‘hidden need’ – patients who did not join the waiting list during the pandemic but would have been expected to had the pandemic not happened. This represents barriers to treatment access that is likely to represent a combination of variations in health-seeking behaviours alongside differential healthcare system pressures. The waiting list backlogs and hidden need estimates have consistently highlighted inequalities across geographies.
Third, variation in healthcare infrastructure is a likely contributor to variation in access to medicines and services. This is highlighted across differences in access between rural and urban areas to more advanced and timely diagnostics and treatment, which varies substantially. While the NHS Long Term Plan aims to address inequalities in care that patients receive, there are many issues yet to resolve. For example, patients living in rural areas have more than 50% worse access to health care infrastructures (Figure 2). This effect is exacerbated by factors including a lack of digital access and transport links.
Figure 2: Average travel time by public transport/walking to reach nearest key services, urban and rural areas, England, 2014
Source: Department for Transport, Journey Time Statistics: Access to services 2014
Fourth, there are also variations in the timeliness of adoption of advanced therapeutics. Areas associated with academic institutions and specialist tertiary hospitals, often located in affluent metropolitan areas, have tended to be faster adopters of innovative medicines and technologies resulting in unintended access inequalities. Examples of this include the regional variation in Rituximab use in 2003 (figure 3) and the use of the breast cancer drug, trastuzumab (Herceptin), where 61% of women in South West England had access to the drug compared to just 14% in the Midlands.
Figure 3: Rituximab use (mg/1000 population) July to December 2003
Source: Department for Health, Variations in usage of cancer drugs approved by NICE, 2004
The vision
Currently, information identifying and quantifying these inequalities and their potential health impacts are not routinely collated in a transparent and timely manner.
We envision an ecosystem whereby pharmaceutical, medical technology companies, and all providers of therapeutics have clear sight of whether medicine uptake is equitable and if not, which patient groups have most unmet need to redress.
This post-marketing surveillance of inequalities in access and subsequent impacts should be a core part of agreements between payers and providers of therapeutics as a shared responsibility and commitment to reducing inequalities across care pathways, including patient outreach, clinician communication and supporting care providers to increase equitable access.
Calls to action to address inequalities in unmet need
- Life science companies should actively monitor and publish inequalities in access to medicines and technologies as part of post-marketing surveillance.
- Life science companies should commit to monitoring trends in those receiving a new medication against the wider eligible population to provide a common understanding of inequalities of access between payer and provider. This is likely to identify under-utilisation of treatment and the potential for better outcomes for both patients and providers.
- Health inequalities should become a core part of commercial agreements between payers and those providing therapeutics.