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At what cost?

Soumya Roy interviews Brian Klepper

Brian Klepper PhD
Principal of Health Value Direct and Managing Principal
Healthcare Performance Inc.

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Brian is a healthcare analyst, commentator and entrepreneur who has specialised in healthcare market dynamics and the drivers of the cost crisis.

Soumya Roy PhD
(Former) CEO New York
Hall & Partners Health

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Soumya specialises in linking behavioural and attitudinal data to provide integrated insights for targeting and messaging strategies.

Without metrics, can patient-centricity ever be more than a promise?

Pharmaceutical manufacturers and marketers remain fascinated by patient-centricity as a potential guiding principle for delivering care. But claiming patient-centricity might just demand that pharma puts its own priorities – and performance – to the test.

Brian Klepper, healthcare analyst and activist (in my estimation), is author of the blog Care and Cost which delivers an unflinching take on care delivery systems and philosophies. As a commentator, he sent shockwaves through cancer care with his 2016 JAMA Internal Medicine publication, ‘Less is More: The Gold Standard for Current Cancer Treatment’, in which he detailed his own wife’s agonising experience with terminal peritoneal cancer.

It was while reading Care and Cost, indulging my own interest in patient-centricity and its ramifications for pharma, that I discovered a set of principles from the National Cancer Institute defining patient-centred communication between a physician and patient:

» Eliciting, understanding and validating the patient’s perspective (e.g. concerns, feelings, expectations)

» Understanding the patient within his or her own psychological and social context

» Reaching a shared understanding of the patient’s problem and its treatment

» Helping a patient share power by offering him or her meaningful involvement in choices relating to his or her health

I reached out to Brian for his perspective on how well the healthcare industry as a whole – and pharma in particular – is performing against these metrics. Given his professional acuity and his personal history with cancer care, I expected insights I wouldn’t find anywhere else.

Soumya: How well do you think the American healthcare industry delivers patient-centric care?

Brian: Well, I want to be clear on this. What I do is reflect on how the system actually works. The idea of shared decision-making, which is noble and aspirational and something that we absolutely should strive for, is given tremendous lip service. But it is absolutely not in the business interest of most physicians or hospitals to want to know what patients’ views are about the care that they’re going to get. Their job is to deliver services. So, there’s a conflict between what we should do in the best interest of the patient and what our business interests tell us to do.

Soumya: Let’s talk about that four-point definition of patient-centricity from the National Cancer Institute. In the context of these principles, what do you think makes physicians advocate the wrong choices?

Brian: Part of it is simply a cultural imperative. In the face of desperate circumstances, we must just do something, and hope against hope that it’ll work. And when it works one time in 100, that fuels doing it for the next 100.

Soumya: Pharma probably recognises that too, as cancer is perhaps the most controversial and difficult area. Thankfully, there are areas in which the FDA and the healthcare system have better measures, and patient-centricity is more readily achievable. Based on the successes you see, can you recommend solutions?

Brian: The best solutions have to do with the way we pay for care. And the way we need to pay for care is by paying for value. What I do today is go out and find organisations that get wildly better health outcomes at much lower costs, within specific niches, than the conventional approach. Unfortunately, the health plans aren’t particularly interested in those kinds of solutions because they want healthcare to cost more.

Soumya: Why is that? You’d think they’d want lower costs.

Brian: No, because they make a percentage of total spend. So, I take these solutions directly to large companies and unions, and they deploy them directly. If we started moving to a value-based system, then the system itself wouldn’t have barriers to innovation, and that would positively impact patients. There’s this complex interaction between the healthcare system’s interest and its spin on patient-centredness, particularly on shared decision-making.

Soumya: Yes, let’s talk about that. Shared decision-making requires understanding of the patients’ psychosocial context. And for that to manifest, patients need to be highly informed about what they’re getting into. Pharma has a real role to play here – would you say they could do better?

Brian: Of course they could do better. And they would do better if they had different incentives. My wife and I talked a lot about this. When doctors are in a discussion about why they’re prescribing – even when they know that the odds of a drug benefitting the patient are low – they’ll say patients are desperate for any help they can get. My response to that is, “Yes, but they don’t really understand. They’re not working with full information.”

For every doctor who says, “The patient really wants it” or “We wanted to give him/her a shot at making the wedding”, I respond, “Has that doctor really explained, in depth, what the side effects are going to be?” We simply haven’t done a good job of asking patients. I think it’s a big topic, and an important one.


Putting patients at the centre of pharma’s business model is likely a smart strategy, as the drive for value gains strength


My conversation with Brian left me initially disoriented, but ultimately re-oriented. Realistically, industry incentives for patient-centricity won’t be devised until it’s a validated, assessable service – not just a soaring promise. One critical next step for pharma, therefore, must be to develop standardised key performance indicators (KPIs) for its own patient-centricity.

With this in mind, I believe there’s an important principle missing from the American Cancer Institute’s definition: agreeing on treatment experience outcomes that can be measured and managed. If my talk with Brian taught me anything, it’s that patients can’t choose a journey that they don’t truly understand.

Motivated innovators like Brian will continue to challenge healthcare, calling out barriers and rhetoric that don’t match reality. Pharma’s best answer may be to lead – to define patient-centricity in sharp detail, and devise sets of measurements for critical doctor-patient interactions and results. Putting patients at the centre of pharma’s business model is likely a smart strategy, as the drive for value gains strength. It’s also, as Brian reminds us, the right thing to do.

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