Health Equity in Pharma: Q&A with ZS

Health equity is a challenge for the bio/pharmaceutical industry. It is no secret that there are racial—and gender—biases within the pharmaceutical and healthcare industries, as is apparent through the types of treatments that are researched and developed as well as through the people and communities who have historically had access to and been included in clinical trials.

Pharmaceutical Executive interviews Judith Kulich, principal, patient health and equity lead, and Nan Gu, associate principal, patient health and equity, both of ZS (a management consulting and technology firm) to further discuss health equity.

Rivers: How would you describe the state of the industry as it relates to racial bias in medicine today?

Judith Kulich, principal, patient health and equity lead, ZS

Kulich: Racial and ethnic bias in medicine has been, and remains, a significant problem. Looking first at insurance coverage, Latinos are significantly more likely than other groups to be uninsured: 18.3% versus 5.4% for non-Hispanic whites.¹ Black and Latino Americans are also more likely than others to be covered by Medicaid and other public insurance.² At the same time, Black and Latino healthcare providers are underrepresented within the medical profession, not only in the clinic but in leadership and governance as well.³ While a focus on increasing diversity should help reduce bias in the long run, studies still show the prevalence of unconscious bias among providers and that these biases influence diagnosis, treatment decisions, and (in some cases) levels of care.⁴ In one of many examples, unconscious bias has been shown to cause a significant and deleterious effect on how pediatricians manage care for Black adolescent patients suffering from asthma, attention-deficit/hyperactivity disorder, urinary tract infection, and pain.⁵

There are myriad social, behavioral, economic, and environmental variables that drive health outcomes for populations, with racial bias being just one. But these variables combine to create a significant gap in health outcomes, including life expectancy, with Black Americans living four fewer years on average than white Americans (77 years to 81).² We see many organizations across the industry taking action to address these biases, but progress is slow.

Rivers: Which communities are most impacted by racial bias in medicine and why?

Nan Gu, associate principal, patient health and equity, ZS

Gu: While bias against the Black and Latino communities may be the most studied and discussed, biases against other communities are also common. Rates of private insurance coverage for American Indian/Alaska Native populations are among the lowest of any group,⁶ and they—along with Black Americans and Native Hawaiian, and other Pacific Islanders—have been about twice as likely as their white counterparts to die from COVID-19.⁷ Asians in the U.S., meanwhile, access fewer mental health services compared with other groups, even when controlling for perceived need.⁸ But outside of race and ethnicity, many populations (including those based on gender, age, and sexual orientation) also face bias that creates disparities and worsens health outcomes. Bisexual men and women, for instance, are significantly more likely than others to report poor health;⁹ transgendered individuals, meanwhile, report poor health at 1.7x the rate of cisgendered individuals.¹⁰

Rivers: How is the pharma industry currently addressing racial bias in medicine? Where is there still room for improvement?

Kulich: From our work with many of the world’s largest pharma companies, and many emerging ones as well, we see the industry seeking to address health inequities in medicine in three broad areas:

1. Clinical development. To ensure more equitable development of medicine, pharma is working to boost representation among trial investigators and participants through enhanced outreach and trial site selection, designing protocols that ensure trials reflect real-world demographics and comorbidities, and investing in drug candidates that reflect medical needs across diseases and populations. The Beacon of Hope initiative, begun by Novartis and subsequently joined by Merck and Sanofi, is a nice example; they’re partnering with 26 historically Black colleges and universities to create clinical trial centers of excellence, increase the number of Black and Latino healthcare providers, and spearhead other initiatives to improve health equity.
2. Access and quality of care. Pharma companies have built partnerships with other healthcare stakeholders (providers, payers, and community-based organizations) to expand disease awareness, screening, testing, and diagnosis to ensure the largest number of patients benefit from early, quality care. To give one example, in 2017 Gilead created COMPASS, a 10-year, $100 million initiative to build a coalition of academic institutions and community-based organizations to address the HIV/AIDS epidemic across the southern United States.
3. Adherence and other patient support. Research has shown wide disparities¹¹ in medication adherence among members of different demographic groups,¹² a key factor explaining disparities in health outcomes. Once a prescription decision has been made by a healthcare professional, drug manufacturers have some (but not limitless) latitude to provide patients with wraparound support in the form of logistical and financial assistance. In one example, AbbVie’s immunology patient support program demonstrated a 29% increase in adherence.¹³ In another, Boehringer Ingelheim created a game-like rewards program for COPD patients, which boosted medication adherence by 44% for participants over non-participants.¹⁴

While pharma clearly recognizes the issue of health inequity and is taking steps to address it (as seen in these examples), much work remains to be done around balancing clinical trial representation with evidence-based standards and partnering at scale with other healthcare sectors such as payers, pharmacies, providers, and community-based organizations. While pharma has invested heavily in patient support programs, further work is needed to improve reach. For example, a recent study found that only 8% of patients have ever used a patient support program.¹⁵ Long-standing trust barriers may blunt the impact of these types of programs today, but, while efforts to address this issue will take time, they are a critical piece of the puzzle.

Rivers: In what ways has your company been working to address racial bias in medicine?

Kulich: ZS works diligently not only to advance the public conversation about health equity but also to address its underlying causes directly through our client work as well as external partnerships. We have undertaken numerous projects with clients to help uncover the most glaring sources of health disparities, design innovative interventions, and then measure the impact of these efforts. We also have partnered with organizations such as the Healthcare Leadership Council to bring forward original research, insights, and specific recommendations to encourage cross-sector collaboration and best practice sharing around health equity.¹⁶ We also partner directly with the community and patient-facing organizations to address health equity issues directly, both within the U.S. and globally. ZS recently partnered with Shrimad Rajchandra Love and Care, a global nonprofit, to reduce the incidence of anemia, a prevalent disease in low-income counties.

Rivers: Are there other social determinants that can/should be addressed that impact health equity?

Gu: Our research has shown conclusively that drivers of health differ depending on the disease being measured as well as the health outcome being measured. Studies have shown that socioeconomic status—a combination of income, education, and occupation—strongly correlates with a great many health outcomes.¹⁷ Besides socioeconomic status, access to healthy food, transportation, and affordable housing have all been shown to drive health outcomes across many disease areas. However, to properly understand these issues, and (most importantly) design appropriate interventions, disparities should be investigated at a disease or disease-class level and through the lens of where in the patient journey they manifest. For example, air quality is strongly correlated with asthma incidence; so, if one were to look at interventions here, one would need to potentially look at addressing zoning laws, public transportation initiatives, and other issues that affect air quality.

Rivers: Where do you hope to see the pharma industry in 5-10 years as it relates to health equity? How do you think we can get there?

Kulich: This is highly speculative, but I see the possibility for numerous changes in the next five to 10 years that will greatly impact pharma’s ability to reduce health disparities. Even just focusing on the U.S., within five to 10 years the FDA’s guidance on clinical trial representation will have been firmly established, and pharma will (I hope) have built capabilities to reach underserved populations through decentralized clinical trials, expanded diversity among trial investigators, digital tools, and other means. The federal anti-kickback statute may have been revised, aimed at enabling pharma to more freely engage in partnerships and programs specifically targeted at improving health equity and patient outcomes. At the same time, we may have additional legislation designed to improve healthcare coverage for vulnerable Americans such that financial burden alone becomes less of a driver of inequity in care.

Some of these changes will have been brought about by advocacy from pharmaceutical companies and trade groups. Adapting in step with these changes, pharma will have built representation and inclusion into its operating model, impacting everything from research and development to marketing and frontline sales. Pharma also will have developed additional capabilities to partner more effectively with ecosystem players as well as competitors and will be able to seamlessly accommodate value-based and health equity-oriented payment models. Disparities won’t disappear in the decade ahead, but I’m optimistic that the sustained efforts by pharma will have made a measurable difference toward reducing disparities in health.

References

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2. U.S. Department of Health and Human Services Office of Minority Health (OMH). Profile: Black/African Americans. https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=61 (accessed January 2023).
3. IFDHE. Diverse Representation in Leadership and Governance. https://equity.aha.org/levers/diverse-representation-leadership-and-governance (accessed January 2023).
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5. Sabin J. A.; Greenwald, A. G. The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain, Urinary Tract Infection, Attention Deficit Hyperactivity Disorder, and Asthma. American Journal of Public Health. 2012. 102, 988–995. DOI: 10.2105/AJPH.2011.300621.
6. U.S. Department of Health and Human Services Office of Minority Health (OMH). Profile: American Indian/Alaska Native. https://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=62 (accessed January 2023).
7. Artiga, S.; Hill, L. COVID-19 Cases and Deaths by Race/Ethnicity: Current Data and Changes Over Time. Kaiser Family Foundation (KFF). 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-cases-and-deaths-by-race-ethnicity-current-data-and-changes-over-time/.
8. Yang, K. G.; Rodgers, C. R. R.; Lee, E.; et al. Disparities in Mental Health Care Utilization and Perceived Need Among Asian Americans: 2012–2016. Psychiatric Services. 2019. DOI: 10.1176/appi.ps.201900126.
9. Gorman, B. K.; Denney, J. T.; Dowdy, H.; et al. A New Piece of the Puzzle: Sexual Orientation, Gender, and Physical Health Status. Demography. 2015, 52 (4), 1357–1382. DOI: 10.1007/s13524-015-0406-1.
10. Meyer, I. H.; Brown, T. N. T.; Herman, J. L.; et al. Demographic Characteristics and Health Status of Transgender Adults in Select US Regions: Behavioral Risk Factor Surveillance System, 2014. Am J Public Health. 2017, 107 (4), 582–589. DOI: 10.2105/AJPH.2016.303648.
11. Xie, Z.; St. Clair, P.; Goldman, D. P., et al. Racial and Ethnic Disparities in Medication Adherence Among Privately Insured Patients in the United States. PLoS One. 2019. DOI: 10.1371/journal.pone.0212117.
12. Jhawar, S.; Batra, R.; Dinh, M.; et al. How One Health Plan Reduced Disparities in Medication Adherence. Harvard Business Review. 2022. https://hbr.org/2022/07/how-one-health-plan-reduced-disparities-in-medication-adherence.
13. Brixner, D.; Rubin, D. T.,; Mease, P.; et al. Patient Support Program Increased Medication Adherence with Lower Total Health Care Costs Despite Increased Drug Spending. J Manag Care Spec Pharm. 2019, 25 (7), 770–779. DOI: 10.18553/jmcp.2019.18443.
14. Accesswire, “Boehringer Ingelheim and HealthPrize Announce Study Results Showing Significant Increases in COPD Medication Adherence with Digital Support Platform,” 2022. https://www.accesswire.com/711289/Boehringer-Ingelheim-and-HealthPrize-Announce-Study-Results-Showing-Significant-Increases-in-COPD-Medication-Adherence-with-Digital-Support-Platform.
15. Snyder Bulik, B. Pharmas' Return on $5B Spent Yearly on Patient Support Programs? Only 3% Are Using Them: Survey. Fierce Pharma. 2021. https://www.fiercepharma.com/marketing/pharmas-return-5-billion-spent-yearly-patient-support-programs-only-3-use-survey.
16. Gu, N.; Kulich, J.; Deutsch, H.; et al. Advancing Health Equity: Practical Solutions to Address Variations in Care. ZS. 2022. https://www.zs.com/insights/advancing-health-equity-solutions-to-address-variations-in-care.
17. Fiscella, K.; Williams, D. R. Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care. Acad Med. 2004, 79 (12), 1139–1147. DOI: 10.1097/00001888-200412000-00004.