The COVID-19 pandemic heightened attention to the inequities that plague the healthcare system, with populations of color being disproportionately impacted. The underlying causes, including systemic racism, are not new. And all sectors of the industry are challenged to make healthcare more accessible and equitable. For pharmaceutical companies, there are multiple challenges, ranging from increasing diversity in clinical trials to capturing better data and creating population-based strategies. Oliver Wyman’s Fritz Heese and Elizabeth Southerlan talked with Merck’s Mary-Ann Etiebet, and Conrod Kelly, to examine ways the company is addressing health equity and how those lessons can be applied more broadly. The following is an edited transcript.
Southerlan: I'd like to dive into three areas — race in treatment decisions, clinical trial diversity, and then diagnosing the latency of diagnosis for Black and Hispanic populations. Can we start with clinical trial diversity?
Kelly: We've made progress around promoting and ensuring access to clinical trials, (like) partnerships with organizations like the Lazarex Cancer Foundation to be able to ensure that we're addressing some of those social determinants that lead to lower participation rates. Those could be things such as transportation, childcare, or missed wages from participating. This is really starting to look at the systemic issues and not just relying on it being a perceived risk to participating.
There's a need to find the appropriate stakeholders to be able to carry this message into their communities. We see a lot of partnerships with local organizations that are doing a better job of explaining the benefit of clinical trials.
Then you have the issue of navigating the system and being able to address some of the other issues such as not even having any clinical trials prevalent in an area that's disproportionately impacted by certain conditions where if you were to participate, you literally have to travel to another state or travel to another county to be able to have that treatment.
Etiebet: Our experience in clinical trial diversity and inclusion has been instructive for all the other efforts around health equity. If you don't ask the question and you don't look at the data, you are blind to how your decisions can have unintended and unintentional consequences. So even decisions about which medical centers do we do our trials in, which principal investigator do we work with, these have huge downstream implications around who is more likely to enroll in trials.
Heese: Can you talk a bit about the initiatives that you have to help populations navigate the process and understand where to go to get access to certain therapies and who's going to pay for it?
Etiebet: At Merck we have an organization called the Patient Innovation Team. Their core mission is to support patient journeys. There’s an example from a country in Europe where the team, with some external partners, including policy stakeholders, mapped out the patient journey, and it basically looked like spaghetti (with) all of these different lines overlapping each other. They (understood) how the information that was getting to the patient at each of these points was just so complicated.
So we asked the question, ‘how do we simplify that information and make it information that's actionable, as opposed to just raising awareness and imbuing concepts of health literacy?’ We’ve identified this as an area for improvement. We must simplify that information, and make sure that it is available and intentionally shared in a way that is understood by patients, family, and caregivers. This work is just one example of the way Merck has supported patient navigation, including supporting community-based organizations and other types of groups to support those types of tools and resources.
Heese: To what extent does equitable access to drugs play a role in discussions that you have with CMS, or is it starting to play a role?
Etiebet: I'd like to bring a maternal health example because I think it speaks to looking at the differences in insurance status. We see those disparities in maternal health outcomes occur, irrespective of let's say insurance status. Black women nationally are 2 to 3 times more likely to die (from pregnancy-related causes than white women). In some cities, like Philadelphia, it's four times, in New York City, it's 8 to 12 times. When you now dig deeper, yes, insurance access is a critical driver, but something else is happening.
The studies where a white woman and a Black woman, I'm just sharing this to illustrate what the data is telling us, walking into the same hospital with the same kind of characteristics — education, age, comorbidities, income — and having different outcomes in that same hospital. What else is going on? The impact of systemic racism, especially as it relates to the healthcare system or the healthcare team not listening to Black and Brown women when they are expressing their needs, when they're expressing their symptoms, including pain, and then not responding to them.
I do think that dynamic occurs in multiple facets of therapeutic areas. And I want to bring it back to the conversation we had about the calculator that incorrectly include race in diagnosis / treatment decisions. With Merck For Mothers and our support of many of the advocates and activists in this space, we are moving the conversation to race being its own factor. When you change that paradigm and when you have more people able to speak about it, that's what leads to the surfacing of how this is embedded in calculators. This has been going on for decades, but only now because people are raising the issue and there's an increased awareness, there's a change. For example, race was removed from the VBAC, vaginal delivery after C-section calculator. Change can occur, that is my broader point.
Southerlan: Let's segue over to sustainably getting drugs to the market. Conrod you previously shared a good example around targeting drug development toward the Hispanic population in need, on the West Coast, I believe.
Kelly: The example was around the diabetes market. What was interesting in the data is that as you looked at the prevalence of diabetes and the growth rates, the Hispanic population was a significant driver of that. When they got diagnosed, they were younger, but also further progressed in their disease. Just by being able to dig deeper, we found that over a third of the diagnosed diabetics in the US were of Hispanic descent. We realized that when we said Hispanic, that 60% of them were of Mexican heritage and that you could reach roughly 50% of that population by just focusing on California and Texas.
We were able to then build out the data ecosystem to understand their journey, to understand where they shop, where they got their prescriptions, where they lived, where they received care. We could be very targeted in our strategies in terms of how we engaged, who we partnered with, how we delivered communication to be culturally relevant and to be timely in that period when they were open, but also to engage in the conversation around prevention because there were also some cultural beliefs there that we had not previously picked up on. By really engaging in this community, talking about pre-diabetes and prevention and not just treatment, we saw an increase in the number of people that were actually going in to get tested. By doing so, we were able to reach them in the earlier stages of their condition.
That’s just an example of where you were able to use data to break up the stigma that might be there around certain populations, and then to be able to use ways and partners in those cultural insights to be very targeted in your engagement.
Etiebet: It really illustrates two important points. One, when you think about market growth and you think about inclusive market growth, you are not just expanding your portion of the pie, you're building a bigger pie and to that point, it has benefits not just for you as a company, but for society as a whole. Conrod just mentioned how that strategy could result in overall reduced healthcare spending and thus is a positive for policymakers and can be something that industry and policymakers can find common ground and shared goals. That's important to remember because it doesn't have to be a zero-sum game. We can really shift how we think about growing markets and growing inclusive markets.
The other point it hit home for me is how this doesn't have to be a short-term strategy but really a long-term strategy because when you support bringing new people into the healthcare system, or I would say the traditional formal healthcare delivery system, and you do so in a way that meets their needs and meets their needs respectfully and values them as human beings, most likely, you've developed some trusted relationship and some meaningful engagements with that person, with that customer that is not just going to be relevant for diabetes, but may be relevant for other health conditions he or she has, may be relevant for other health conditions family members have including children or parents. And so, thinking longitudinally, you're bringing more people into the system that may have other needs that, you can meet as a company.
From a market growth perspective, you use the term sustainably. We must be thinking not just what we do for success today, we need to be thinking about what we do for success in the future, both as a company and for meeting the needs of the population. This health equity framework sets us up for long-term sustainable success, both as a company and as a contributor to broader public health, population health goals.
Southerlan: What are the biggest barriers you are seeing in terms of applying your health equity framework in the market?
Kelly: The first one is just agreeing on a definition of what is value. Because you've got the value framework from the lens of the consumer, from the insurer/payer, from pharma, from the healthcare provider. As you start thinking about equity and what it means across those groups, you find that we're all saying “equity,” but it all means something different to each of those groups. That's the challenge right now, finding a definition where people can see equity as the win-win-win.
Etiebet: The other challenge is the data visibility and capabilities, because building on Conrod's point, not only do we need to have shared definitions, but shared understanding of what good looks like and what success is. We also need to be able to measure it and be able to understand how our actions help move the needle. If we don't have that, if we're not able to connect the dots around what the result of any particular action has been on any actor, it's hard to get sustained commitment to those efforts. And by commitments, I mean resources and dollars to continue to drive on those efforts.
Kelly: While there are things that can be done through education, there has to be a systemic kind of approach towards attacking the policies that are leading to inequity creating additional costs in the healthcare system. And in order for us to be able to pay for innovation, we have to help governments see this and to figure out, similar to the example earlier, how creating more equity and focusing on prevention could actually create budget headroom for innovation, and they need to know that's something that we're involved in.