Election years are always a great time to take our country's pulse with regard to an issue, and this year healthcare has emerged as the major topic on the nation's collective mind. We have enjoyed excellent healthcare in the United States for quite some time, yet today the system seems unstable. Record numbers of uninsured patients populate our delivery system during an era in which few would argue that access to insurance coverage is equivalent to access to good healthcare. Within the delivery system in most disease states, disparities exist with regard to access to excellent care and excellent outcomes. Providers endure the lower ratcheting of revenues and rising overhead costs (especially in the areas of liability insurance and labor costs). Yet in this environment of low margins, expectations are higher than ever, with patients, payors, and employers demanding evidence of quality care, safer care, more customer-focused care, and more efficient care.
Payors are struggling to maintain costs to manage their risks and to limit expenses that are paid by employers or purchasers. Employers again are facing high costs reminiscent of the early 1970s, when cost pressures drove the mainstreaming of managed care delivery systems. Employers also are demanding more from their health and drug benefit programs and designs. They expect excellent care when their employees are ill, but they also want a workforce that feels that the benefit is competitive, and one that is treated fairly and compassionately during a time of illness. Some sophisticated employers will also demand not only treatment of illness, but also prevention of illness and improvements in the overall health and wellbeing of their employees to stimulate a positive workplace culture and to engender a more healthy, efficient, and productive workforce.
Patients demand respect from this faceless system. In times of illness, they want a system they can navigate and that will lead them to the best possible outcomes. They want a system where prevention of illness and perpetuation of wellness are equally important as the treatment of disease. Out-of-pocket expenses are continuing to rise, and year after year, patients must accept a greater personal risk in managing these healthcare costs.
Our government is facing its own healthcare battles. As a growing number of baby boomers reach the age of eligibility, will the Centers for Medicare & Medicaid Services (CMS) and Social Security be able to generate the funding necessary to maintain the level of benefits? Will a Food and Drug Administration criticized a decade ago for being too slow in allowing new agents to come to market—and now criticized for safety flaws allowing unsafe drugs to reach the market—be able to achieve a level of review and safety that does not limit discovery of new agents? As CMS has become a if not the major purchaser of pharmaceuticals in the United States, can we measure a return on investment? Has the cost of providing pharmacy benefits generated reductions in other costs in the program? And will pharma, biotech, and device manufacturers receive clear and unambiguous messaging from all stakeholders to give them the guidance and incentive to produce innovative products that are relevant to pressing disease states and that exceed the expectations of government, payors, providers, and patients—by delivering true value? When they do develop important new medications, will formulary and benefit designs accommodate or inhibit their utilization, and will these utilization parameters be evidence-based decisions or cost-minimization policies at work?
Can we balance Quality, Access, and Cost, so that in the end we will have a system that meets our country's needs? Can we generate a benefit design that will allow payors, purchasers, patients, and providers to share a WIN? These are some of the questions with which we will wrestle within the pages of American Health & Drug BenefitsTM. We want you to participate in these discussions and to help shape the present and the future of healthcare. Although I guarantee there will be white water ahead, I also guarantee that it will not get better until the stakeholders engage one another in intelligent discussion and problem solving and begin to chart the course. I look forward to engaging with you—through the pages of our journal—in this vital process.