Never has healthcare been in the spotlight as much as in the last year and a half. The mainstream audience is hearing stories about herd immunity, the R factor, mRNA and hospital triage. These topics are being discussed on social media and at pubs on Friday evening. Public health experts like Anthony Faucci are becoming superstars, presidents and prime ministers are having press conferences about very niche healthcare topics and pictures of lab scientists are appearing on the covers of Time Magazine.
That’s why I am happy to be sitting here with two real experts to talk about the present and future of healthcare. They have literally seen it all: they are both experienced healthcare professionals, they have been active in business, manufacturing, public health, academics and the government side. Shirley Okere and Anthony Ajose. Shirley has spent her career in the pharmaceutical business and is currently a Global Quality Lead that everybody knows: at Pfizer. Anthony Ajose used to work for the WHO, for the UK NHS and the Department of Health. He has also served in an advisory capacity across multiple businesses and health systems
Last week, we covered the current topic in healthcare: Covid, Covid, Covid. Today, we’ll be looking more at the future. Who will rule the healthcare of the future? – Incumbent players, like Pfizer, Siemens and the NHS or new entrants like omnipotent Amazon and Google, who are now spending more money on healthcare R&D than Big Pharma. We will also talk about how to make our healthcare sustainable: from the financial perspective, how to drive innovation and how to make every stakeholder happy.
Great having you guys here. I am looking forward to our conversation today.
Shirley: Hello again.
Anthony: Hi Jan.
Last week, we concluded with microbial resistance and asking who shall pay billions of dollars researching new antibiotics. We also slightly touched on whether healthcare systems are stable enough to afford it. So, Anthony, what do you think of our healthcare, both in the developed world and in emerging countries?
Anthony: Healthcare systems in the West have been very good to us in many ways. We have been very successful in terms of addressing population health issues. Look at the past tremendous success of the NHS in the UK as one of many examples. However, with an aging population, it has become more and more challenging to have stable financing of healthcare. It's also a lot more challenging to provide high-quality services to every patient. That's why I think the model of financing should change. There’s a lot of friction among various layers of the system. So what do we do about that? How do we make those systems more efficient? I think this is where technology comes into play in terms of automation, behavioral science, big data and telemedicine and so on... to keep people healthier longer, before actually needing care.
Anthony Ajose, MPH, MBA
Originally from Nigeria, Anthony studied in UCL, Cambridge and INSEAD. He has over a decade of experience in healthcare financing, economics and as a policy advisor. He has served in advisory roles to healthcare companies, government agencies, legislators and policymakers. In addition to roles at WHO and Gates Foundation, he has also worked in the NHS and UK Department of Health as well as advising companies investing in emerging market health systems in areas such as infrastructure, digital health and pharmaceuticals.
What about the emerging world?
Anthony: If we move over from the developed world to Africa now and to many other emerging regions, the systems we have in Europe would never work there because it's just very resource heavy, investment heavy and it would be very complicated to scale. But there a lot of cheap and easy solutions to help people in terms of primary care, health prevention and remote care.
Doctors are definitely not scarce in Africa as we have many African healthcare professionals globally. So, the question is how to leverage the skills, ideally, remotely? Everyone's been working remotely for the last year, including healthcare professionals. So we know it's possible.
Lastly, the health financing angle is very important. The health insurance system that is prevalent in the US and Europe would just not work in Africa because Western systems have too many layers. New technologies would have to be used to remove some of the layers to for example, automate payments, create micro-insurance, apply decentralized finance systems and erase administrative burdens. Make it all digital, mobile friendly to be more precise, and to leapfrog over brick and mortar into the digital healthcare era directly. Providing faster care in Africa may even be more of an opportunity than in New York.
Front end and backend digitalization, gamification and big data have been zeitgeist in healthcare for quite some time now. Blended offers are becoming more popular. More and more payers are also becoming providers, pharmaceutical companies have started selling products on a subscription basis and e-commerce platforms have started offering telemedicine check-ups and so on. How is Pfizer utilizing these new opportunities?
Shirley: That's quite interesting. So when you think about the value chain of healthcare, right, you have to start with research and development, manufacturing, supply, sales and marketing. But there's an opportunity here for pharmaceuticals to move more towards the patient’s experience, including prevention, predictive diagnostics, wearables and diagnostics. Let’s not forget remote monitoring and measuring, including clinical trials, and then to leverage all this information.
This requires blending a bit outside the traditional ecosystem. And I am fine with that. From the treatment perspective, there are connected devices, real time data connection for safety and efficiency and treatment management solutions, which are definitely transforming the out-patient care market. Doctors, pharmaceuticals and technology here are becoming a bit blended as well. So, from what I see, the future of healthcare is essentially an ecosystem, connected to the patient’s experience and to technology. Then, the physical out-patient presence may be a bit redundant. In-patient care is obviously a different story.
Most healthcare experts believe that healthcare is going to change enormously. And this change will either be driven by incumbents and companies like Pfizer or Siemens. Others believe that change will be brought on by new players, including big tech, like Amazon, Google and Alibaba, who are now investing more money into health R&D than pharmaceutical companies. This change may also be brought on by health unicorns, whose numbers are multiplying quickly and who are now shifting from being simple aggregators into the complex healthcare sector.
Anthony: I think these changes are actually a great thing. Everyone has realized that healthcare is one of the biggest industries in the world but it’s also quite an old fashioned industry from the structural perspective. If I may advocate for incumbent players here, I think many of them understand well that change is needed. They are now trying to get rid of a lot of friction and inefficiencies, which have been in healthcare systems for ages. I don’t think you can replace these incumbent organizations, like pharmaceuticals, biotech, medical devices or teaching hospitals, because we need the vaccines, we need the medicine, we need medical devices. So, incumbents are very important. But how do we connect all of them to ensure that the patient ultimately benefits? Here, I think it's all about the patient’s outcomes. Companies should shift more towards offering so-called patient outcome solutions and then get paid for patients being well, healthy and recovered. This possible transformation would be a great opportunity for everyone.
Shirley Okere, MPharm, MBA
Shirley is a trained pharmacist and expert in pharmaceutical law and ethics. She studied in Brighton and the University of Cambridge. Originally from Nigeria, she worked at NHS, at Mayne Pharma and she was also an EMEA quality leader at Hospira, a US based pharmaceutical giant and the world's largest producer of generic injectable pharmaceuticals. Shirley has been a Pfizer executive for the past five years, where is she currently the Director of Quality. In her free time, she promotes careers in science among children, parents and teachers.
Let’s now talk about the new players that are massively investing in healthcare and “own the customer” inside their CRM systems. Shirley, do you think that incumbent players, like insurance companies or big hospitals, will just become one line in their aggregator engines, something similar to the way hotels are at the mercy of Booking.com? And I'll be using my Amazon login or Google account when I need a healthcare solution and everything will be aggregated inside?
Shirley: What you're talking about is modular healthcare, kind of like a plug and play. And I think, yes, we are moving in that direction a bit. The way I see it happening is when you look at the ecosystems, Google or Amazon, they're bringing their supply, sales and marketing experience to the game. This is their playground. However, research and development would be a different story...that's quite a unique area, not easy to copycat: the patents, the science behind them... You will still need biotech for that. You will need the people that can actually deliver the drug molecules.
As for the future, we are obviously already seeing these tech companies in sales and supply. But their success won’t be complex because this is not just hotels, Airbnb or Uber. There are lives at stake here.
So, I think eventually the game will about the patents, the knowledge and the molecules. That's where IP ownership and innovation are. And then...the rest of the ecosystem might be licensed, including manufacturing. Mixed ownerships. Just think about 3D printing. We could find ourselves in a situation, where a 3D printing company manufactures personalized drugs that are based on your needs and based on the licensed patent from someone else. No more warehousing, no more stocking. Everything will be very lean. Even manufacturing is now moving into that space. On the other hand, as I have already said, research and development will be protected for much longer. But even if we go to this platform type, I do see traditional pharmaceuticals retaining their core and everything being penetrated by technology.
Pharmacists/Pharmaceutical Professionals and we are talking a lot about IT here. So, will doctors become IT gurus? If so, shouldn’t the medical curriculum also shift towards IT?
Anthony: Medical education has to change because healthcare is a very conservative industry. But I truly understand this conservatism because you don’t want a big picture Silicon Valley guy standing at the operating table, doing knee surgery on you. You don’t want to have your orthopedic surgeon focused on the big picture when reconstructing your knee, right?
But I think the new generation of healthcare workers, pharmacists, doctors, and so on... I think these guys are already growing up with the technology. It's naturally a part of them. Therefore, many changes will also happen naturally. For some time, the problem could be some people in senior-level positions, used to doing things a certain way. We see their restraints towards electronic healthcare records in hospitals and we see it with electronic prescriptions, and so on. However, this will also naturally change with the generational shift.
In the end, the key pillar of the healthcare system is “us”, patients, customers and clients. However, until recently, the relationship between patients and the healthcare system had been a bit asymmetric. Doctors used to be demigods. This is now changing and patients are moving into the driver’s seat - which is a good thing. However, drawbacks are also emerging and patients’ compliance is going south. Many patients actually believe Dr. Google more than their own doctors. Research has showed us that this creates a big problem because most of the healing is happening outside of the healthcare facilities, run by patients themselves, when and if they comply with their doctor’s advice. The data also indicates that our own behavior is the key aspect for our quality of life and health.
Therefore, do you guys think that this, let's call it behavioral science approach, should be used more by payers, by providers and even by regulators in the form of carrot and stick? In an era when the doctor–patient relationship is not so strong anymore?
Shirley: So that's quite interesting because there's a little bit of that already, right, with insurance companies, who provide premiums or bonuses as an incentive, when you adopt an active and healthy lifestyle. In their view, this will lead to patients filing fewer claims. Is it challenging to create insurance programs that work? Yes. Is it a good way to go? It is. But you need to determine who will enforce this behavioral aspect and who will prepare the criteria, right? So, it is a great idea, but the devil is in the details.
However, from the provider perspective, I think the way pricing works in the future should be interesting. Let’s use drugs as an example. Here, I believe that pricing should be based on outcomes; overall patient outcome, fewer side effects and actual treatment strategies, etc. So, patients will be influential in the sense that they will be driving the money because their personal health outcomes will matter. That's a positive element because it will bring more focus on patients. However, driving change through behavior is something else. To come up with holistic criteria that is unbiased to some populations or demographics, while taking culture, religion, and several other aspects into consideration.
Anthony: Let’s also look at the systems that work really well and see what we can learn from them. For example, Singapore is very, very good. It has health savings accounts, which essentially start when you're born. It is linked to government contributions, your salary and employer contribution, which make up the first block of your insurance. Then, it links to the catastrophic fund, to cover accidents. And then, you can co-insure yourself as a second block or level-off insurance. There are also some carrot and stick principles as well. So, Singapore is a good example in each country. However, we need to think about how it is going to work from a broader macro-economic perspective. At the individual level, once people have individual budgets that have been reserved for them, then you can think about behavioral programs on a regional or nationwide level. Then, think about meaningful pricing for that population, based on the demographics and the disease profile, etc.
But we always need to look at the individual patient level because in many cases, these policies and pricing are done at a very high level. What works in a tiny country like Singapore may not work elsewhere.
Many things can be done with automated finances: centralized on the one hand and individual accounts on the other. Through this, you can remove a lot of the friction that goes into health financing. I really, really hope we see this in the future.
It’s interesting to hear you say that the Singaporean health system might actually not be suitable for say the United Kingdom and vice versa. Unlike the economy, where basic principles are globally given and accepted, healthcare is connected and rooted in legacy. It's connected to a country’s history, culture, the size of the country, its population, demographics, economy...and we have an extremely diverse family of the healthcare system, with one extreme being the United States and the UK a bit of another extreme. Continental European systems that are based on insurance, with German chancellor Bismarck as its 19th century godfather, are somewhere in the middle.
So, is it possible to apply principles of customer incentives that work globally in mass-market retail and in e-commerce? Is it also possible to apply them to global healthcare? That for example, 5 % of your insurance money would be allocated for bonus and malus, for prevention, etc. And for example, if you abuse alcohol or are obese and not go jogging enough, this second level of insurance, the 5%, would either be given you as cashback or reversely, you’d be penalized more...
Anthony: Yeah, I think the key is bringing the patient as a client into the core of the equation. In many cases, the issue with a lot of the health systems is that by the time the patient turns up with the symptoms, it’s probably too late. This leads to huge costs incurred, reduced quality of life or maybe even life itself...
So, what can we do in terms of diagnosis? Make people go for medical check-ups and get routine screenings done. How should we educate and encourage them...
Here, we need better automation, via CRM, client segmentation and patient profiling, in order to send people the right messages, nudges and yes, also incentives. We need to motivate people towards healthy behavior.
The final piece of the puzzle is awareness. We don’t have enough of that. Healthcare managers should work more with creative marketing, simple videos, and social media in every aspect. What can we do? I know that for example, pharmaceutical companies are facing many barriers before actually reaching patients in Europe directly because the law forbids that. But how can we work with other companies and other organizations on delivering these messages to people? It’s not only about vaccines. People, as clients, have choices in all aspects of life, including healthcare delivery. How should we navigate them, educate them and motivate them to think about those choices - about vital check-ups, drugs that should be taken and to think about changing their lifestyle. I think that's extremely, extremely important.
Is Pfizer thinking about something like this?
Shirley: We are very involved in prevention. However, as Anthony alluded to, due to the rules, it's challenging to communicate directly with customers in the UK and Europe. Nevertheless, efforts towards prevention are being taken anyways, with help of devices, wearables and smart watches.
I just want to touch on what you mentioned before when you talked about a two-tiered insurance system. I think obesity may be one tale of caution. Sometimes, obesity is linked to a family’s social status. Then, it’s a bit more complicated to say, hey, were they able to afford healthy choices, so that they're not obese? If you're from a certain social class, you just might not be able to buy healthier food, your stress level will be higher and you may not be able to afford to do more sports, etc. So, the incentive strategies need to be thought out carefully, so as not to ostracize, but to help.
Wonderful answer. Unfortunately, our conversation is coming to an end. So, here’s a bonus question. What do you think healthcare will look like in ten years, in 2030?
Anthony: There’s a lot of opportunity in the future, but this also goes hand in hand with a lot of risk. I think companies are launching a lot of good technologies and a lot of disruptive innovations. I think the problem is that if we don't break the silos, we're going to end up with many different fragments of Google and Amazon doing the transformational stuff and Pfizer doing even more different stuff. So, there won’t be any centralized platform, no standard connecting these disruptions with current stakeholders: hospitals, doctors, payers, pharmaceutical companies and governments. As much as we're doing all this to empower patients, I think this is forgotten: that there should be one, so-called evidence-based medicine, with some standardized, predictable processes.
But let’s go to my prediction about 2030: I think we will have healthcare, where every patient will have sort of a health account, almost like your Google mail account or Facebook account, where you can go to your profile and manage your health and treatment needs. You will be able to choose flexibly and even anticipate things that are going to happen in some of the treatments.
You will also be able to manage your finances flexibly, see different money streams and choose how you want them to be allocated: money from the government allocated to you, money from social funds in the case of poorer citizens and money from your own funds and insurance. This is definitely possible from the tech perspective. Nowadays, no one ever talks about money in many healthcare systems and that’s not right because then, patients go to the hospital and it doesn’t matter whether it’s in the West or in emerging markets... and then, in many cases, patients leave with a huge bill; oftentimes a bill they can’t afford. This is going to change similarly to the way online banking or e-commerce have changed from being very traditional segments of finance and retail to empowering customers with integrated and user-friendly information.
Finally, in terms of the customer’s experience, I believe that a big part of healthcare will look like wellness in ten years. This is where a lot of the money will go, towards providing customers with a better experience on the individual level.
Shirley: The way I see our pharmaceutical industry, it’s going to change and build on what Anthony has said: Firstly, I think there will be more personalized treatments. What I mean by that is that there will be a shift from mass-market, uniform, chemical products to tailored products designed for you, based on your genetic information. So, you as a patient will have something specific. We can also use CRISPR technology to attach therapeutics to your genes in the form of a one-time cure. I definitely see more of that. Gene therapy is becoming more and more popular. On the other hand, there won’t be as much of popping the pills four times a day for longer periods of time.
Secondly, it'll be interesting to see how pricing will change because if there’s a single shot to cure diabetes for the rest of your life...how would you price that in comparison with taking one tablet twice a day? So, I think that would drive some change.
Thirdly, in a picture perfect world, I see out-patient care linked to the previously discussed online platforms instead of traditional healthcare. My genetic records will be stored in a cloud somewhere. Whenever a patient needs medication, it can be printed easily and locally using a 3D printer, with the patient’s name on the bottle, even if the Rx drug formula is in the US, the doctor is in India and the patient will currently be in Nigeria. This makes geographical location and distance much smaller. Technology makes the world smaller. Travel, communication and many other things are also good examples of how technology makes the world smaller. I see the world shrinking to a point, where remote medical consultations are standard. Drugs will be 3D printed and hospitalization will be reduced because it will be a one-stop shop kind of treatment, which will completely influence pricing. I obviously see a very, very, very empowered patient as the customer. So, that's the kind of world we are moving towards. Bottomless and frictionless healthcare.
What a great note to end on and what an interesting future we’re moving into! Thank you both for a wonderful conversation, for your insights about the past, present and especially about the future of healthcare. See you soon in Europe.
Anthony: Thank you very much.
Shirley: Thank you for having me. See you in London soon!