As in COVID. Real world studies of COVID-19’s impact on health care utilization are arriving daily and their continued publication throughout the next year will be the defining characteristic of HEOR in 2021. One systematic review (in preprint) has already reported on 81 such studies. In these studies, which covered multiple countries and health care settings, there was a median reduction of 37% in services overall.
In November, about one in four people reported skipping needed medical care for something unrelated to the coronavirus. Yet a December assessment by the Kaiser Family Foundation reported a mere 2% annual drop in health service use. Reconciling these statistics will take careful analysis that, because of data lag, probably can’t begin until late next year.
Look for 2021 to bring more studies examining actual outcomes of deferred care, like increases in severe infections, later stage cancers, and hospitalizations for MI. Data for these studies should be widely available soon. For example, the CDC maintains a list of open access COVID-19 datasets on everything from epidemiology to SARS-COV2 genetic sequencing. State and local governments, universities, medical specialist societies, and private companies, among others, have started registries on every imaginable aspect of the epidemic. I’m particularly interested in the use of large data sets to examine whether the shameful health gap between Black and White Americans (almost 4 years of life on average) has been made even larger by the pandemic.
By the end of 2021, we should see real world studies examining the extent to which changes in medical practice (like the massive increase in telemedicine) have become permanent, as well as studies reporting actual health outcomes of the vaccinated vs. unvaccinated population.
Which leads to…
The number of coronavirus vaccines likely to be approved by mid- to late-2021, according to several industry trackers.
Sometime before the end of February, I guarantee a headline will blare “Vaccination linked to sudden death!” With 20 million or more doses given by then, it’s a statistical certainty that at least one otherwise healthy person will die after being vaccinated. Add events like these to the underlying breakdown of trust in civil society, stir in the early logistical problems we’ve already seen with vaccine distribution, and you’ll understand why I think hoping for “herd immunity” in late summer 2021 is wildly optimistic. Some interesting modeling by Rochelle Walensky supports this view, suggesting implementation (which the US healthcare system is not particularly good at) will matter more than the highly-touted 90%+ efficacy.
Taken together, this means we’ll be well into 2022 before vaccinations plus (unfortunately) more post-infection immunity get us closer to normality.
Some early cost-effectiveness models have already tried to put a number on the value of COVID-19 vaccination. Expect an increasing number of these models to come out (mostly via press release) in the first quarter. But traditional CE models rarely attempt to account for anything as massive as the multi-trillion-dollar hole COVID-19 opened in the US economy, so it remains to be seen how they will capture the true value of getting our “before” lives back. And what about the value of getting to visit your grandmother in a nursing home again? Modeling has long ignored many aspects of value like this, perhaps a small silver lining of the epidemic will be more attempts to do so.
Speaking of ICERs…
US health economists are less attached to this incremental cost effectiveness ratio (ICER) threshold than our European colleagues. But it won’t fade from US discussions of value in 2021, even though it should. This oft-cited article arguing for the demise of the 50,000 threshold was published 7 years ago, and I still hear people say that’s all they know about cost effectiveness.
For a multitude of reasons, the use of any single ICER thresholds is a terrible idea (it’s arbitrary, it hinges on a properly chosen comparator, etc., etc.). All the complaints are valid but miss an even larger point: we can’t even begin to define a unidimensional value scale until we agree on our actual values.
For example, I believe most racial differences in outcomes of medical care reflect social inequities and that reversing these inequities should be high on our list of national goals for health care, but others counter that now that racial discrimination is illegal, all government programs and policies should be “race-blind.” I believe a disabled person has just as much value as an “able-bodied” one, but the commonly used metric “QALY” clearly devalues the disabled. I believe deafness is a disease to be cured, but is it really a culture to be preserved? I believe you should have to wear a mask in public if there’s a pandemic underway, but is this really an unfair infringement on your liberty? How you think about these issues may determine whether a particular intervention seems “valuable” to you or not.
If we want to measure value, let’s start from our shared values. There are ways to articulate what values we do share—convening citizen panels, engaging experts, airing our differences, etc. With the polarization in society today, it’s hard to imagine finishing a productive conversation on value in 2021, but we can start.
And on the topic of polarization…
This is the total number of US House and Senate members. With Democrats holding a slim majority in both chambers, the chance that 2021 sees dramatic increases in who is covered by the ACA, or significant new limits on pharma payments to doctors, or CMS being granted the ability to negotiate prices, or the broad introduction of international reference pricing, is about the same as 2021 being the year scientists find that long-sought species Sus Passeriformes (pictured below).
One thing that won’t depend on government action is how the public will view the pharmaceutical industry in 2021…
This is the “net-positive” view Americans have of the pharmaceutical industry, according to the latest Gallup poll on the topic. There was a negative “net-positive” (calculated as % of respondents with a positive view minus % with a negative view) for only 4 of the 25 industries Gallup asked about, and pharma had the absolute worst score.
It wasn’t only pharma that got spanked in those ratings. The whole health care industry had a negative “net-positive.” Only the federal government was lower than health care (but higher than pharma).
Even though I’m not sure most Americans have the same values I do, who among us doesn’t see the value of being able to take antibiotics when sick, get less toxic chemotherapy, or watch once deadly diseases become manageable? Despite this, when I talk to my former academic colleagues, their view of the industry is nearly uniformly suspicious. This isn’t just an “optics” problem, pharma companies clearly need to do some things differently in 2021 to gain people’s trust. But if the dedication and commitment of industry professionals to turn the tide of this terrible epidemic doesn’t improve the public view of us, I don’t know what will.
Contact Michael at mbroder@pharllc.com or visit pharllc.com.
About the author
Dr. Michael Broder, a board-certified obstetrician and gynecologist, has 30 years’ experience in health economic and outcomes research. He received his research training in the Robert Wood Johnson Clinical Scholars Program at UCLA and RAND, attended medical school at Case Western Reserve University, and received his undergraduate degree from Harvard University.
In 2004, Dr. Broder founded PHAR, a clinically-focused health economics and outcomes research consultancy. PHAR is a team of dedicated, highly trained researchers —individuals who are singularly focused on delivering high-quality health economics and outcomes research insights to the life science industry. PHAR has successfully conducted hundreds of studies resulting in more than 800 publications on a wide variety of therapeutic areas, and maintains an expansive network of collaborators, including 8 of the top 10 academic institutions in the US, as measured by NIH funding. Download our bibliography here.
Unencumbered by corporate bureaucracy, PHAR can efficiently execute contracts and complete projects on time and on budget. PHAR prides itself on being reliable and responsive to clients’ changing needs, and welcoming the challenge of tackling problems others can’t.
