Backbone

We need to care for our backbone if we are to optimally support the words free and market in healthcare. 

Economists debate, summarize, describe and theorize what a free market means and how it is applied in healthcare. Decades of analytics has not provided the public with assurance of their individual health, nor has it given them an individual literacy around healthcare transactions. 

If we aim to nurture the healthcare field by tending to private enterprise, as Robert I Fields (1) describes as a current reality, the public must partner with backbone. Backbone understands power dynamics as they are and works to prevent power plays that distort healthy, nurtured growth. Backbone prevents regulated entities from wagging the dog, because backbone identifies and addresses when regulated entities gain enough power to control the oversight (1).   

Backbone, the tail extension of our collective spine, should be a direct reflection of the public. It should not be manipulated in order to shape our healthcare character, and it should only direct our character if it supplies courage. 

Backbone is entrusted to the public. And while we should expect and encourage it from public representation, backbone cannot be assured from (nor delegated to) legislators. Influenced by misguided definitions of power and/or lobbyists, legislators must be held in check. 

The backbone to cultivate and nurture a better healthcare economics exchange can be strengthened with several exercises. Flexes include: 

• Readability requirements. Health economics should be readable for the layperson; when it isn’t, it insults us all. This is especially true when economists use the words ‘free market’. The majority of my consumer life is dependent on experts in trades that I will never be an expert on, and all of these have met me at my level. Health economics can and should be required to do the same. The public is the main consumer of healthcare. Writing around current situations, problems and potential solutions to healthcare finances or economic influences should be readable. This could require scholars to have readable summaries, and it could also require thinktanks and industry partners to disclose at a specific readability for the public. If industry advocacy can gloss over issues and make points understandable to the general public when they want public support against regulation, industry can certainly be held to readability around all issues. The same is true for scholars, think tanks and legislative reports. Perhaps health economics analysts and industry relations experts can learn from utilities, automotive dealerships or real estate industries.  

• Publicly accessible tracking of loophole legislation. Legislation intended to close the gaps between regulated healthcare and ways that entities can take advantage of the public should be tracked in real time. Simple tables in publications offer legislation proposals, whether they were passed and comment on lobbyist influence (1). However, there is no one database that describes what these current proposals aim to achieve, what population is currently being taken advantage of, how much money and lobbyist time has been devoted to the bill. Nor is there a grade or measure to describe the public’s ability to influence the outcome. If an orphan drug status has been reapplied to a new formulary, stalling patent changes, simply for a company’s profit, what population is paying the high drug prices that result from the loophole? If the Risk Evaluation and Mitigation Strategies (REMS) used for a drug cannot be applied to the drug once it becomes generic (1), due to loopholes and brand manufacturer influence, what populations cannot access the drug? And, what is the specific savings to the public if we had a functioning enforcement system to uphold current regulation around the subject? These details could accompany the loophole legislation tracking, and the tracking could identify which incentives are the priority (3). 

• Publicly accessible tracking of the recommendations and proposed solutions to free market improvements. Countless think tank and expert reviews have proposed improvements for health economics between industry and the public. There is no repository or accounting for these, with real-time updates, tailored to any one country’s health system. In the United States, for example, health economics to healthcare free markets often prioritizes drug pricing. Nonprofits and government reports may supplement individual solutions with proposed improvements. If drug pricing improvements highlight clinical innovation, for example, the FDA or academic clinical trials innovation collaborations may have reports on how to realize innovation and clinical trial improvements. Yet there is no comprehensive repository for health economics recommendations, nor is there ongoing updates and tracking to these. When experts highlight solutions for health economics in pharmaceutical industry, such as better biosimilar and generic entry, creating an improved field for better consumer behavior through pharmacy benefit redesign and other avenues, and market incentives for old drugs, the specific actions should be catalogued. Often, this is not new advocacy; the actionable items are mentioned in other reports. Actions to achieve the solutions, such as anti-trust enforcement, regulatory enforcement, regulatory partnership for improvement and vigilance to supply and demand surveillance should be overarching solutions themselves - with tracked goals, progress and comparison across bordes. 

• Checks in place for the public messaging and political spin around ‘free market’. The politics of healthcare should be acknowledged and addressed by remaining factual in health reports. Divisiveness over healthcare and the government’s role should be addressed by requiring a sharp editorial and publication eye. The US government’s role in healthcare is significant, given Medicaid, Medicare and other tax-funded delivery. If over 1/3 of healthcare is government financed, and if the major contracts between pharmacy benefits are structured to government finance, and if “intellectual fuel” (1) in biological research is initiated by the government run National Institutes of Health (NIH), descriptors and terminology in communication to the public should be clear. Terminology that uses socialism (4) should either match definition or be replaced for accuracy. While the nature of politics is to spin, the reality of governed care in our medicine must be clearer. 

• Acceptance of healthy international peer pressure. The United States embraces an individualistic culture in healthcare delivery design, and the United States is known for being an outlier to universal health care or basic healthcare rights norms across the world. World health advocates often use collegiality to encourage shift toward healthcare as a right, and international authors are often more bold in messaging (5). Industry players, particularly pharmaceutical and biotech manufacturers, are concentrated in geography however. And global coordination remains a prospective reach (6). With a large presence and representation from the US, and with universal healthcare outcomes uplifted in other geographical areas, healthy international peer pressure can refine legislation across all borders. We have to be open to it, though. And being open to foreign conversation, open to global dialogue, open to assistance with nurturing private industry across borders, open to and honesty around self-improvement all takes backbone. 

We need to care for our backbone if we are to optimally support the words free and market in healthcare. In a world of endless opinions, floods of raw data and daily pressure to care for one another, cultivating a field of healthy free market can be overwhelming and abstract. This vulnerability also puts the public at risk of having their tail wagged for them. 

Instead, we can use these five flexes as conditioning. Let’s strengthen our own backbone. 

References

1 Field, Robert I. (2014). Mother of Invention: How the Government Create “Free-Market” Health Care. Oxford University Press. 

2 http://som.yale.edu/sites/default/files/wp30_scottmorton_competitioninpharma1.pdf

3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5394555/

4 https://www.emerald.com/insight/content/doi/10.1108/CR-08-2013-0072/full/html

5 https://www.scielo.br/j/csp/a/mNkwrDWkfC4NRXxB8YJSZgM/?lang=en&format=pdf

6 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.1003