Take a look at our latest issue featuring eight healthcare executives and their careers.

Managed Healthcare Executive July Issue

Climbing the Career Ladder: Ninth* of 10 profiles of healthcare executives and their careers.

Gurpreet “Sunny” Singh’s career has been a series of stepping stones – always improving from one entrepreneurial start-up to the next, eventually leading to the successful founding of the now leading global health IT company, Edifecs. Throughout his business ventures and education at the Indian Institute of Technology in his native country of India, Singh approached every opportunity to learn as a new attempt at innovation. With a knack for learning and creativity, Singh took his entrepreneurial spirit to the United States with only $200 in his pocket to attend Montana State University on a full-ride scholarship for industrial engineering.

It was during his time as a student at Montana State where his work ethic and unrelenting drive to succeed took root. Singh accepted as many jobs as he could to send money back home – from tutoring student-athletes, to packing and moving hay bales, and even fishing in Alaska during the summer. When it was time to begin his career in technology and innovation, he joined Expeditors International and then Microsoft, where he started narrowing in on a goal: to make electronic data more accessible, shareable, and optimized, and as a result more powerful.

 in 1996 out of the garage of his home outside of Seattle. The company provides integrated solutions for data exchange, analysis, and insights. Today, it has more than 350 healthcare customers, serving more than 215 million people.

Not all 25 years of Edifecs’ role in healthcare have been smooth sailing The company lost a big deal, IRS notices began coming in, and it had to suspend salaries. The stress of this period was all-consuming, Singh says, but it also drove him turn things around and put Edifecs back on a path to success.

“I figured out how to hustle, to stretch a dollar, to find innovative solutions, to work hard and not accept no for an answer,” Singh sayss. “While these early trials were difficult, they ultimately strengthened the company and led us on a path of tremendous growth and resilience and a valuation of over $1.5 billion in 2020.”

Singh recently transitioned from being CEO to chairing the company’s board. He continues to serve the organization by ensuring Edifecs is on the path to produce leading health IT solutions.

When he’s not serving as chairman, Singh also leads innovative well-being initiatives for the state of Punjab by way of his next entrepreneurial venture, 

Singh said his previous experiences from early childhood in both India and Ghana, through school, and into the first years of his career shaped the leader that he is today. He noted there are a few principles that have been consistent throughout his career. First, would be the people.

“My early experiences gave me an appreciation for what it takes to make a company run successfully,” he says. “Edifecs would not be the outstanding company it is today without our world-class team of associates. They’ve helped build this company and continuously contribute to our growth and success.” 

Second, is the importance and value of workplace wellness: “In order for your team to perform well, you need to ensure they are healthy and happy.”

“Third, you can do “good” while doing “well.” “While I’ve had the opportunity to build Edifecs into a global health IT player, our team has also been focused on giving back to our community and being strong stewards of the planet,” Singh says. “We believe wellness extends beyond the healthcare industry to the planet we all share. Since founding the company, we’ve embraced a green approach to our operations and made conservation a pillar of our culture.”
For those who may sit on full commitment toward their passions or growing their entrepreneurial ventures, Singh recommends following the advice his father passed down to himself.

“My father always encouraged me to pursue my passions and to dream big,” he said. “He also raised me to be generous and compassionate – to honor the human spirit. This is something that I’ve carried with me for my entire life, and it’s shaped the work that I do.”

He said this philosophy stretches from his time at Montana State in the 1980s, directly to his work today in India to improve the lives of billions through innovative wellbeing initiatives with RoundGlass.

*Eight of these profiles were published in our print issue. Two more were published only online.

Articles

Gurpreet “Sunny” Singh, chairman of the board at Edifecs, said he follows a philosophy in life that stretches from his time at Montana State University in the 1980s, directly to his work today, at Edifecs, and in India to improve the lives of billions through innovative wellbeing initiatives with RoundGlass. “My father always encouraged me to pursue my passions and to dream big. He also raised me to be generous and compassionate – to honor the human spirit. This is something that I’ve carried with me for my entire life, and it’s shaped the work that I do.”

Gurpreet “Sunny” Singh, Edifecs: Difficult Roads Lead to Wonderful Destinations

Vice president of client strategy, Welltock

 showed that as a result — under an optimistic scenario — hospitals could face a $53 billion total revenue loss in 2021 because of the pandemic. While the world has begun to reopen, health systems must take action to close gaps in preventive care, annual screenings and elective surgeries. 

Encouraging patients to return to care sooner will not only ensure better outcomes but also ease the healthcare system back to normal. Given the magnitude of postponed care, this will hopefully quell a sudden wave of hospitalizations for newly diagnosed conditions that could overwhelm hospitals that may be facing another COVID-19 surge.

Here are three ways that health systems can optimize their outreach to improve patient outcomes and begin the journey of revenue recovery:

1. Count on the tried and true: Multichannel communications

Multi-channel communications reinforce critical messaging by maximizing reach and frequency. Analyst firm Gartner reported that “integrating four or more digital channels will outperform single- or dual-channel campaigns by 300%.” Simply put, the more an individual is contacted the more likely they are to engage. Using multiple channels increases the likelihood of motivating people to take action.

Engagement channels include text, automated voice, email and direct mail. Each of these has a different appeal for different patients, ranging from the tangibility of a direct mailer to the shelf life of a searchable email. Multi-channel outreach can be applied for a range of uses like an automated voice call to improve COVID-19 vaccine education, a postcard reminder to schedule an annual physical or text messages for preappointment guidelines. Hospitals can see significant results by employing each of these channels. The key, though,  is using data to know which channel resonates best for each patient.

2. Address crucial gaps for relevant populations

With millions of Americans postponing care, every specialty has experienced revenue loss. For health systems to kickstart their revenue recovery, it’s wise to focus on seasonal and age-based services, such as annual health screenings, vaccinations and well-baby visits because these kinds  of services are most likely to bring patients into the office. Focusing on familiar care services such as these first will help organizations maximize their engagement efforts and reach their target audiences without exhausting outreach funds. To further optimize their results, hospitals must identify the customer personas and tailor outreach efforts around their particular needs and motivations.

Additional data points derived from a combination of consumer data, predictive analytics, and social determinants of health insights can identify which patients may be more likely to seek out preventive care, are at-risk for a certain condition or are least likely to opt into elective services. While COVID-19 has reinvigorated the way the world views health and well-being, health systems should still ensure their outreach is personalized to the audiences they want to engage.

Data and insights can also predict what type of message and channel people will be most receptive to. By consistently engaging with patients over their preferred channel, the higher the likelihood that the patient will engage with the outreach and act.

Health risk assessments (HRAs) can be beneficial to gauge patients’ health needs and priorities. These questionnaires engage patients and aggregate data that are designed to be useful for personalized recommendations. Since the data collected come directly from a patient, health systems can see a significant increase in the success of targeting efforts for initiatives like annual appointment scheduling. HRAs can be promoted to a patient base with predicted data modeling that identifies those who are most likely to fill it out, thus bolstering the database’s ROI and information quality. Given that not everyone is comfortable returning to in-person visits in the clinical setting right now, these are a valuable intermediary to connect with patients and learn about their health concerns directly and in safe manner. 

The way that hospitals marketed themselves before the pandemic is not going to work now. Patient needs and expectations have changed. The hospitals and health systems that embrace more of a high-tech and high-touch world will be successful today and into the future, especially when it comes to closing critical care gaps. Patients want to hear from them, and traditional strategies aren’t going to cut it. 

By using data to identify patients most likely to close a care gap and then using multiple channels for more touchpoints, new leaders will emerge that drive patient engagement and improve health outcomes all while growing the bottom line — a win-win for everyone involved.

is vice president of client strategy for Welltok.

Hospitals can't go back to their old ways. They need high-tech, high-touch strategies to engage patients.

Closing Gaps in Care: Improving Patient Outcomes and Revenue Recovery

In what may usher in a new era of competition on price among insulin products, FDA has approved the first interchangeable biosimilar insulin product.

Semglee (insulin glargine-yfgn) is both biosimilar to, and interchangeable with, its reference product, Sanofi’s Lantus (insulin glargine), according to the FDA approval yesterday. Being interchangeble means that Semglee doesn’t need to be explicitly prescribed and can be substituted for Lantus by a pharmacist who is filling the prescription.\

The FDA has approved 29 biosimilars but Semglee is the first that wasapproved as being interchangeable with its brand-name reference product.

The FDA approved Semglee last year and it has been on the market since but interchangeable designation is likely to increase its use and is intended to stir up vigorous price competition between Semglee and Lantus.

Theinterchangeabilityapproval was announced yesterday in a press release by the FDA. Biocon Biologics developed Semglee and Biocon’s distribution partner is Viatris, a company that is the result of a merger between Mylan and Upjohn.

“This is a momentous day for people who rely daily on insulin for treatment of diabetes, as biosimilar and interchangeable biosimilar products have the potential to greatly reduce health care costs,” said Acting FDA Commissioner Janet Woodcock, M.D., in the 

The approval “furthers FDA’s longstanding commitment to support a competitive marketplace for biological products and ultimately empowers patients by helping to increase access to safe, effective and high-quality medications at potentially lower cost,” Woodcock added.

Biosimilars in the U.S. typically have launched with initial list prices that are 15% to 35% lower than the list prices of the reference products, FDA said.

“Access to affordable insulin is critical and long-acting insulin products, like insulin glargine, play an important role in the treatment of Types 1 and 2 diabetes mellitus,” said Peter Stein, M.S., director of the Office of New Drugs in the FDA’s Center for Drug Evaluation and Research. “The FDA’s high standards for approval mean health care professionals and patients can be confident in the safety and effectiveness of an interchangeable biosimilar product, just as they would for the reference product.”

An interchangeable biosimilar product may be substituted for the reference product without the intervention of the prescriber, FDA explained. The substitution may occur at the pharmacy — “pharmacy-level substitution”—much like generic small-molecule drugs are now substituted for brand-name drugs, although there is state-to-state variability because state-level pharmacy laws apply to interchangeability. In most states, patients will need to be told they are getting an interchangeable biosimilar and pharmacists will not be allowed to make the switch if the prescribing physician have expressly indicated they are prescribing the reference product (in this case, Lantus).

The approval of Semglee as an interchangeable biosimilar to Lantus is based on evidence that showed the products are highly similar and that there are no clinically meaningful differences between them.

Research has shown that Semgleecan be expected to produce the same clinical result as Lantus in any given patient and that the risks in terms of safety or diminished efficacy of switching between Semglee and Lantus (insulin glargine) is not greater than the risk of using Lantus without such switching, the FDA said.B

 for health care providers to enhance understanding about biosimilar and interchangeable biosimilar products, including a fact sheet about interchangeable biosimilar products.

FDA approval means that pharmacists can swap biosimilar Semglee, an insulin product, for brand-name Lantus, although state-level pharmacy rules may apply.

An FDA First: Semglee Is Approved As An Interchangeable Biosimilar

As we come to a stabilizing stage in the pandemic, there is a refocus back to the quest for value-based care. Who will be the next generation access decision makers (NADMs) that will successfully take the triple aim premise of value-based care, couple them with the lessons learned from the pandemic, scale these up, and sustain success over time to make a palpable difference in the US healthcare system?

As it turns out there are a lot of players taking aim and the target is a person’s first key point of contact with health services and the key point of entry to the entire health system - the primary care gateway. It also plays a significant role in shaping and determining a consumer’s overall access to various services and resources within the health ecosystem.

Emerging from the pandemic there are now many payers, health systems, and new entrants looking to become the NADMs to transform this gateway entry and shape the entire patient journey. NADMs are increasingly focusing on health and well-being while impacting access to downstream services and therapy utilization that is being driven by two Nextgen Models.

As consumers increasingly turn to virtual care for their healthcare needs due to the pandemic, companies such as Teladoc, MDLIVE, Amwell and many others, are addressing consumer’s short and long-term health issues including wellness and prevention care, chronic conditions such as diabetes, mental healthcare, dermatology, and other health conditions remotely. The use of virtual services has skyrocketed in the last year and has provided these Nextgen Virtual Care Delivery Models with incredible opportunities to gain a solid footing in delivering healthcare differently and quality care anywhere.

Nextgen Hybrid Care Access and Delivery Models

In addition to these primarily virtual care access models, other entities such as Amazon, CVS Health, Cigna’s Evernorth, Oak Street Health, Optum, Oscar Health, Walmart and many others are redefining the entry level of care leveraging virtual and in-person care delivery models – the hybrid model for patient optionality and convenience. While redefining the entry level of care and primary care, they are also creating new integrated healthcare ecosystems focusing on wellness and lifestyle changes, social influencers of health, chronic and population health, mental and behavioral health, streamlined pharmacy benefits as well as other services, where, when, and how the consumer wants it. 

These NADMs are seeking to redefine and optimize the patient experience, leveraging patient convenience and connectiveness while pursuing affordable and cost value care. As these organizations seek to leverage this hybrid model to change how consumers access care from the onset of a need or issue to addressing acute or chronic care conditions, to influencing the services and therapies patients utilize across their healthcare journey, they look to impact healthcare utilization and costs across the care continuum.

As the scaling of NADMs virtual care and hybrid models continue, they will increasingly become a first point of contact and gateway into the healthcare system for health services. The ecosystem, however, is extremely complex thus the strategies being put in place within these models, accelerated by new technologies, are helping to advance key focus areas NADMs are tackling to further establish themselves as next generation healthcare access providers and decision makers in the evolving healthcare landscape.

It is extremely critical, therefore, that traditional healthcare systems and practices pay attention to these gateway-to-health strategies, catalyzed in part by the pandemic and NADMs entrants to the game. They will need to transform their current organization and/or partner with these entities to leverage evolving health innovations and practices with their own experience to further accelerate the shift towards value-based care.

Drug manufactures and device companies with also need to work closely with these increasingly influential entities as they continue to raise the bar on value demonstration of resources including therapies, services, and digital devices against their costs.

So, as we head into the next generation of care and NADMs continue to grow and scale, gain influence and experience (especially the non-traditional healthcare entities), their impact on downstream access to specialty services, drug costs, and therapy utilization could be significant. Their aim is to deliver care differently and their goal is to go beyond the triple aim to the quadruple aim where patient and population outcomes will be optimized, the patient experience enhanced, the total cost of care reduced, while at the same time create an environment where the work life of clinicians and staff is supported so that they can deliver high quality affordable and patient-centered care to all.

Authors are Elizabeth Oyekan, PharmD, FCSHP, CPHQ, and Dominic Galante, MD, Chief Medical Officer, Precision for Value.

As we come to a stabilizing stage in the pandemic, there is a refocus back to the quest for value-based care. Who will be the next generation access decision makers that will successfully take the triple aim premise of value-based care, couple them with the lessons learned from the pandemic, scale these up, and sustain success over time to make a palpable difference in the U.S. healthcare system?









NextGen Access Decision Makers Influencing Impact on Services and Therapies Across the Healthcare Ecosystem

Source: Vizient Summer 2021 Pharmacy Market Outlook

Hospitals, health systems and other nonacute providers will spend 3.1% more on drugs next year, with oncology drugs accounting for roughly quarter of the expense, according to a 

Vizient, historically a group purchasing organization for hospitals that now bills itself as healthcare performance improvement company, based the result on analysis of its members’ purchasing pharmaceutical data. The company, which is headquartered in Irving, Texas, also surveyed members about 

The report, titled the Summer 2021 Pharmacy Market Outlook, discusses the effect of the COVID-19 pandemic on drug expenditures and usage. Between April 2020 and March 2021, the hospitals and healthcare providers in Vizient’s drug purchasing database spent more money purchasing remdesivir, the antiviral sold under the brand name drug Veklury, than any other drug besides Humira (adalimumab), the immunosuppressive drug used to treat a variety of autoimmune diseases, and Keytruda (pembrolizumab), the leading drug among the new generation of cancer drugs that work by harnessing the immune system.

Vizient analyst also had access to a clinical database that included 436 hospitals to track the usage of COVID-19 medications. As the report notes, use of 

, a low-cost corticosteroid with anti-inflammatory effects, shot up in July 2020 after the report in June that it was effective in reducing mortality from COVID-19. Vizient’s data shows that by November, about 70% of hospitalized COVID-19 patients were treated with dexamethasone. The Vizient data also show steep climb in the use of remdesivir starting in May, the month that the FDA issued an emergency use authorization for the drug.

The Vizient identifies specialty drug as a major factor hospital and other provider organization spending, with spending expected to increase by 4.68%. FDA approval of increasing number of drugs for rare diseases and Humira price hikes prior to 2023 when biosimilars to Humira are scheduled to come on the market are the main reasons for the upward trend, said the press release about the report.

The report sounded an optimistic note about insulin and biosimilar competition. Early last year, insulins were reclassified in such a way as to open them up to biosimilar competition, Vizient noted. The report also mentions the possibility that 

, a spin-off company from Pfizer, is seeking FDA approval for versions of insulin glargine and insulin aspart that would be 

How ‘White Bagging’ Affects Patients, Physicians and 340B Funding

The Vizient report covers a wide range of topics from overall spending patterns to white bagging to FDA’s accelerated approval pathway and the use of surrogate markers.

Cancer drugs are the big-ticket class (24.3% of the spend) followed by drugs to followed by infectious disease products (12.77%) and the disease-modifying antirheumatic drugs, or DMARDs (11.4%). Vizient says the therapeutic class with the highest estimated price change next year is DMARDs because of anticipated Humira and Enbrel (etanercept) price hikes.

Inpatient volumes at hospitals will rebound but not quite return to prepandemic levels, Vizient predicts. The company says inpatient volume is expected to decrease by 1% over the next decade, partly because of the push to changing the side of care to lower-cost outpatient facilities.

Vizient said “premixed drug formulations” of drugs that used to be combined (“compounded’) in-house is a “notable trend.” The report gave Myxredin, an insulin product, as an example of premixed drug that is far more expensive ($420.20 vs. $14) than the version that could be created in hospitals and other facilities. “While patient safety is paramount and ready-to-use/ready-to-administer formulations may offer a safety advantage (e.g. reduction in compounding errors), it is also paramount for the industry to strike a balance between charging a premium for safety and innovation and taxing providers with a price increase.”

The report applauds biosimilars and generics coming on the market. Vizient mentioned that four generic versions of intravenous acetaminophen have come on the market starting late last year, giving the brand-name version, 

, some competition. But the report also noted the Humira biosimilars won’t be on the market for another two years and that biosimilars to Humira will perhaps be most impactful given the price of the drug and how commonly it is prescribed.

The report includes criticism of white bagging — the provision of a medication directly from a pharmacy to a patient. Specialty pharmacies and payers say white bagging is safe and saves money because it eliminates the “buy and bill” markup providers charge when they take possession of the medication and administer it. But Vizient says white-bagging as disrupts patient care and winds up adding cost, not saving money. Today’s report includes results from a survey Vizient conducted from March 24, 2021, to April 16, 2021, that had 268 respondents. According to the report, 83% of the respondents said they had an experienced a white-bagged drug not arriving in time for administration and 68%, a white-bagged medication that was the wrong drug or the wrong dose.

Wide ranging report covers a lot of ground. It sounds an optimistic note about biosimilars but is critical of white bagging.

Vizient’s Outlook Report Is a Mixed Bag: Projected 2022 Drug Spend, White Bagging, Insulin Competition and COVID-19 Treatment. It’s All in There.

Podcasts

In this week’s episode of Tuning In to the C-Suite podcast, MHE had the pleasure of speaking with Sach Jain, CEO of Carrum Health. In the discussion Jain touched on how adopting value-based care is treating conditions and lowering cost burdens, but there remains to be concern in medical spend when it comes to planned surgeries. Jain also talked about how adopting bundled payments can be just as good of a solution as the newer price transparency rule when assisting in patient’s high medical costs. 

Value-Based Care, New Price Transparency Rule is Assisting Cost Burdens and More, But Focus Should be on Bundled Payments Too, Per Sach Jain of Carrum Health

How have you changed your practice to accommodate patients on targeted therapy in terms of patient care?

 We frequently see these patients in intervals when they receive treatment. So, if we see these patients every 3 weeks, frequently they require regular follow-up with echocardiograms to evaluate their cardiac function, as many HER2 [human epithelial growth factor receptor 2] targeted agents have an infrequent side effect of cardiac toxicity. Other toxicities need to be managed if they’re just on a nonchemotherapy-based regimen that has HER2 blockade and endocrine therapy. Frequently, they have to be seen even less by providers, once doctors or advanced practice providers that work with us can establish that they’re tolerating their treatment without significant side effects.

 What have been some of the challenges, and can you include both clinical and nonclinical factors?

 Some challenges in this patient population are some of the adverse events that we see. If you see that someone has cardiac morbidity related to infusion of HER2 targeted therapy, that needs to be managed appropriately. We’re very fortunate here to work with a cardiologist that really is an onco-cardiology expert. We’ve been very successful in referring patients, treating them on cardiac remodeling drugs like carvedilol, and then retreating them with HER2 blockade safely and effectively. So, while that’s an infrequent complication, because I have many patients with HER2-positive metastatic breast cancer I have seen some of it and have been very successful in patients continuing their remission despite these toxicities, because we can manage them well in collaboration with our cardiology partners and get patients back on effective therapy. So that’s been really encouraging. The other complication that’s challenging for providers and patients is that this patient population has a higher predilection for brain metastasis and managing brain metastases is complex. It used to be, 15 years ago, that frequently we would have these patients undergo whole brain radiation therapy whenever they had brain metastasis, because the long-term supply of whole brain radiation therapy wouldn’t manifest for many years. Generally, patients with breast cancer that had metastasized to the brain did not survive long enough to realize some of those long-term toxicities. That’s no longer the case in this patient population because we’ve had tremendous positive disruption because of innovation, and therapeutic interventions that cross the blood brain barrier. We’re very effective at controlling this patient population. I personally have many patients in my practice who had brain metastases more than a decade ago. They continue to live well, without any progression of their disease. They continue to work in their jobs. So, figuring out how frequently to look in the brain is always tricky in this patient population. The standard of care would suggest that we only look when patients have symptoms. But in my experience, patients can have some mild symptoms of mild lethargy, or could have focal neurologic deficits that leads you to image their brain. Imaging the brain is important because HER2 disease has such a predilection for the central nervous system that you need to work in collaboration with a multidisciplinary team to understand what exactly the best way is to manage this for the patient. Sometimes it might require surgery for the patient, which would involve a neurosurgeon. Frequently, it involves collaboration with a radiation oncologist that can give targeted therapy to the patient. Usually, it is combined with some sort of systemic treatment change to make sure that we’re giving a therapy that’s highly effective in controlling disease and the central nervous system. Many of these patients will go on later to develop other central nervous system metastasis. How we approach this each time is really a multidisciplinary treatment decision. So having a good multidisciplinary team can be really important in helping you navigate this complicated space.

 What have been the implications of these changes or challenges for your practice in terms of resource utilization?

 Frequently, when we have patients with cardiac complications or brain metastasis, we have weekly multidisciplinary tumor boards where we discuss these patients just for breast cancer. We frequently can benefit from multidisciplinary treatment planning. Well, we don’t bill for that service. Of course, it’s just sort of volunteer time on our part, but we think it’s a good part of patient care. So, it doesn’t directly impact health care resource utilization for the patient, the fact that we have to go through these additional steps, but patients undergoing additional steps of surgery and/or radiation and/or changes to new or novel therapies that may have better penetration of the central nervous system does impact health care resource utilization. Let’s say for example, I had a patient that was on an endocrine blockade and trastuzumab alone, and they had brain metastasis, and I chose to transition them either to ado-trastuzumab or tucatinib in combination with trastuzumab and capecitabine; that would be a higher cost choice, that would increase health care resource utilization, but it would be effective therapy for the patient.

 Can you share how you have had to educate staff or patients in light of changes in practice, due to the use of targeted therapies?

 We have to provide a lot of education. The pace of change in oncology is unprecedented. We have newer drugs all the time, and the advent of targeted therapies and immunotherapies has dramatically changed the field. So, we have to provide a lot of education. We have a lot of informational webinars for our nurses and for our physicians. I do an update here locally after our major conferences, and there are a lot of updates in general from various sources. There are many different ways in which people can sort of ingest the new oncology content. But I feel like once I finished school, I still have homework every night, because cancer care is continuously changing. Again, at a pace that’s unprecedented.

Videos

Debra Patt, MD, PhD, MBA, explains how clinical practice has adapted to the use of targeted therapies to treat HER2-positive metastatic breast cancer.

How HER2+ mBC Targeted Therapies Impact Clinical Practice

For this next segment, we’ll be looking at the regimen-specific costs and cost drivers. How do cost considerations factor into your treatment decision-making?

 I think for every therapy that we administer, we want to consider efficacy, toxicity, and cost or value. But specifically, about this population, I think the most important value-based initiative is that patients go on to live disease-free. You can’t discount that, because I think superior efforts and the best possible evidence for disease control is the most appropriate value-based choice. Really, it’s in the patient’s best interest to give the most effective therapy first. That’s the value-based care decision. Because, if you look at outcomes over cost, having a patient that goes years without disease progression, living their life on their standard where they continue to be in the workforce, continuing to interact in meaningful ways with their families; that’s really the most effective way to approach this patient population. We want to keep them on effective treatment. Aside from that, I will say that there are some HER2 [human epidermal growth factor receptor 2]-targeted therapies that are of higher toxicity and higher cost that do require special consideration. We may use them less frequently because of that consideration.

 Could you share what other kinds of costs need to be considered with these regimens?

 I think most of these regimens are relatively low toxicity. Putting patients on effective therapy keeps them in the workforce and their lives in a meaningful way that adds value to them. When you consider the burden of having poor disease control—disease progression, disability, leaving the workforce—those are really expensive choices that aren’t often factored in when we consider our choices about the value-of-care delivery. In addition, there are some therapies that have particular toxicities that can be quality-of-life limiting. For example, if you initiate a patient on treatment with nilotinib, it can cause a lot of diarrhea. That can be a challenge as you think about their costs, because if they are not well-managing that diarrhea, it can diminish the ability to work or participate in their life. In my opinion, there is a real opportunity here for oncologists to shine, because we have the ability to start them on a lower dose and gradually escalate them to accompany their therapy that could potentially be toxic with medications to try to mitigate those toxicities. I think there is an opportunity there for oncologists to act; to reduce some of those toxicities on the patient. That provides a high value care.

Thank you. Are you able to share what the primary drivers are of the cost associated with these regimens?

 I think a lot of innovator products do have a higher price point. We have a lot of new products in HER2+ [human epidermal growth factor receptor 2-positive] metastatic breast cancer over the last year. Many of them come with a higher price point. I think that’s true even when there is a higher price point when there is a biosimilar on the market. As you know, trastuzumab now has biosimilars. They are also at a high price point because these are therapies that are not chemically made but grown. They are monoclonal antibodies. Some of the innovator and biosimilar products in this space I think do have a higher price point. Again, they are effective therapy, so you need to give them. That’s the high value choice, but they drive costs in this space.

 Thank you. What is the impact of using HER2-targeted therapies, including dual HER2-targeted regimens, on costs to providers and patients?

 So, using dual HER2-targeted therapies does increase the total cost of care. But again, in frontline metastatic HER2 amplified breast cancer it is the most effective therapy that you can provide. Using chemotherapy in combination with dual-targeted HER2 blockade is the frontline regimen that most people use. It does increase the cost of care for patients. But again, I think that in the bigger picture, and certainly in conversations between doctors and patients, patients desire the therapy that is going to give them the best possible outcome. It’s going to keep them living their lives on their terms—whether that’s being teachers, or attorneys, or doctors in the workforce picking up their kids from soccer, at the dinner table with their families—I think that we can’t discount the benefit of having long-term disease control. So, while it does drive cost in this space, it’s really important because it provides tremendous value to patients.

 What else drives these cost differences?

 Chemotherapy that is no longer on patent, like docetaxel for example, is relatively inexpensive in comparison to HER2 blockade, whether it’s an innovator product or its biosimilar equivalent. Those are expensive therapies. But I don’t see that changing in the near term, and it adds so tremendously to the efficacy of the therapeutic intervention. I think it’s necessary to provide high value care.

 What would the cost implications be of using newer approaches in earlier lines?

 If you use newer approaches in earlier lines, you’re unlikely to have biosimilar equivalent to the innovator product. They’re likely to still have patent protection. So, it’s likely that their costs are going to be higher. We are seeing some of our newly approved agents being tested in earlier lines of therapy. We think that if they are approved in that setting, it likely will drive up costs to some degree. Again, I would say that while it is never a trivial issue, the cost of therapeutic intervention is always important to discuss; that the most effective way you can provide good-value, high-value care to patients is to control their cancer.

Debra Patt, MD, PhD, MBA, discusses the cost considerations of conventional and novel therapies for HER2-positive metastatic breast cancer.

Cost Considerations for HER2+ mBC Therapies

The United States does not have a uniform health system and has no universal healthcare coverage. The health disadvantage of the U.S. relative to other high-income countries is health disparities in health services. 

Although the U.S. is renowned for its leadership in biomedical research and cutting-edge medical technology, its medical system faces significant issues such as preventable medical errors, poor amenable mortality rates, and lack of transparency in treatment. Another problem that Americans are facing is difficulty in finding a good doctor. High costs of care and lack of insurance coverage for low and middle-class families have led to social and economic discrimination in healthcare services. 

Due to the shortage of nurses, physicians, and specialists in hospitals and health centers, among other rising challenges in public health care, Americans are unable to get the optimal quality of medical care they require.

The U.S. stands out from many countries in not offering universal health insurance coverage. Fifty million people, 16% of the U.S. population, lack insurance coverage. Medical expenditures such as pharmaceuticals and medical supplies have increasingly become unaffordable for marginalized communities. Therefore, paying medical bills and other medical costs have become high out-of-pocket expenses. Deprived communities continue to lack access to primary healthcare services and rely on emergency departments to treat chronic diseases and preventive care.

The Biggest Problems with the U.S. Health Care System


U.S. healthcare underperforms in most verticals. High cost is the primary reason that prevents Americans from accessing health care services. Americans with below-average incomes are much more affected, since visiting a physician when sick, getting a recommended test, or follow-up care has become unaffordable. These patients have acknowledged the difficulty in paying medical bills and other expenditures.

According to U.S. healthcare experts, the cost of new technologies and prescription drugs has risen. The availability of more expensive, state-of-the-art medical technologies and prescription drugs generate demand for more intense, costly services even if they are not necessarily cost-effective. The increased costs of medical services occur due to the rise of chronic diseases, including obesity. Nationally, chronic illnesses contribute huge proportions to healthcare costs, particularly during end-of-life care. For example, patients with chronic illness spend 32% of total Medicare spending, much of it going toward physician and hospital fees associated with repeated hospitalizations.

The National Academy of Sciences found that the U.S. has a higher rate of chronic illness and a lower overall life expectancy than other high-income nations. Therefore, medical experts focus more on preventative care to improve health and reduce the financial burdens associated with chronic disease.

High administrative costs are a contributing factor to the inflated costs of U.S. healthcare. The government outsources some of its administrative needs to private firms. The aim is to improve administrative efficiency and provide healthcare quality to the citizens.


The majority of U.S. citizens have health insurance; however, the premiums are rising, and the quality of the insurance policies is falling. In addition, average annual premiums for family coverage have increased, outpacing inflation and workers' earnings.

The lack of health insurance coverage has severe consequences for the U.S. economy. The Center for American Progress estimated that the lack of health insurance in the U.S. costs society between $124 billion and $248 billion per year. In addition, shortened lifespans and the loss of productivity are observed due to the reduced health of the uninsured.

Health insurance coverage is uneven; minorities and deprived families lack insurance coverage. As a result, they face more health hardships than insured Americans. Moreover, the uninsured may not seek medical care due to high costs and avoid regular health screenings. Hence, they are also likely to access preventive health services as well.

The United States Census Bureau annually reports that around 27.5 million lower-income workers did not have health insurance. Lack of health insurance is associated with increased mortality, ranging from 30-90 thousand deaths per year. The number of people without health insurance coverage in the United States is one of the primary concerns raised by advocates of health care reforms and policymakers.


Fraud and cover-ups are widespread in the U.S. healthcare system. For example, a significant problem is upcoding between providers and insurance providers. The providers “upcode” a procedure to get more money from insurance companies, but insurance charges higher premiums from employers. Hence, health consumers get stuck in the middle without any control over health outcomes and pricing.

Difficulty in finding physicians and specialists


With a lack of accessible doctor credentials and accomplishments, health consumers cannot easily find a good doctor. Instead, consumers rely on uninformed online reviews that can help with assessing traits like staff friendliness and wait times. But, these platforms do not evaluate a physician’s skill level in helping people with their health disorders.  A new AAMC study projects a shortfall of up to 139,000 physicians by 2033. According to the study, more physicians are reaching retirement age. More than 2 of 5 active physicians will be 65 or older within the next decade. Each doctor’s retirement plans affect the health system.

The growing concerns about specialists' burnout are also rising. The shortage of medical specialists has also affected America’s healthcare workforce, leading to a range of problems, from limited patient access to poorer outcomes. The increasing lack of physicians and medical experts over the last two decades has demonstrated that the medical system needs to increase the number of physicians to ensure safe and quality health care services for the people. Unfortunately, despite ongoing efforts by many healthcare leaders and academics to find long-term solutions, there doesn’t seem to be a solution in sight.


Broad changes are taking shape. For example, payers of health care are increasingly incorporating the concepts of social determinants of health into the way they think about compensating for healthcare services and providing incentives for health care service providers.

The Affordable Care Act (ACA) has made significant changes in the U.S. healthcare system. The provisions included in the ACA are intended to expand access to healthcare coverage, increase consumer protections, emphasize prevention and wellness, and promote evidence-based treatment and administrative efficiency in an attempt to curb rising healthcare costs.

A significant provision of the ACA was creating health insurance marketplace exchanges in which individuals provided with a program such as Medicaid or Medicare can shop for health insurance. In addition, individuals with incomes between 100 percent and 400 percent of the federal poverty line would be eligible for advanced able premium tax credits to subsidize insurance costs.

A national health service will be provided to low-income communities. The medical services are delivered via government-salaried physicians in hospitals and clinics that are publicly owned and operated—financed by the government through tax payments. In addition, private doctors have specific regulations on their medical practice; they collect their fees from the government.

A multi-payer health insurance system provides comprehensive health insurance via “sickness funds,” used to pay physicians and hospitals uniform rates. This health insurance coverage eliminates the issue of paying the medical bills and higher costs of the uninsured, especially for emergency services.

Developing consensus protocols that streamline medicine delivery and reduce variability can improve quality and lower costs in health care. However, more research on preventing medical errors from occurring is needed to address the problem.

Through technology and innovation, find a qualified doctor that treats the condition properly. Some websites attempt to help to seek out the best doctor but lack updates necessary to keep up with constant changes. New technology will enable the users to quickly identify health experts specific to location and health condition, all within one interface. Online techniques and various resources will help people to get connected with different physicians and experts around the globe.

The Affordable Care Act authorizes the state to negotiate the price of prescription drugs and bulk purchasing of prescription medications and durable medical equipment and supplies. This will help to lower the cost, and private insurers can continue to enter into private agreements between providers.

Thus, improving healthcare quality can be viewed on both a macro and a micro-level. It includes collecting data and analyzing patient outcomes, focusing on patient engagement, and collaborating with different organizations to provide access to health care.

, which is revolutionizing how industries offer healthcare benefits and increase healthcare access. 

The U.S. Healthcare System is Broken: A National Perspective

Climbing the Career Ladder: Eighth of 10 profiles of healthcare executives and their careers.

His passion was for music, specifically for the French horn, the curlicue brass instrument that is notoriously difficult to play. Being a pharmacist was strictly for paying the bills. While pursuing a master’s at Carnegie Mellon University in Pittsburgh, Michael Zeglinski squeezed in two days a week as a pharmacist. His master’s thesis was on the French horn parts in Gustav Mahler’s symphonies, and he studied with the principal horn player for the Pittsburgh Symphony Orchestra. There was an audition for the orchestra and gigs playing in the orchestra for the Pittsburgh Opera.

“But if you’re going to be a symphony-level musician and have that as your career, you need to have that je ne sais quoi, or that talent, that pushes you over the edge,” says Zeglinski. “I was kissing the pinnacle but never quite felt I was going to be able to stay there for 20 to 30 years.”

Zeglinski has reached a different sort of pinnacle — and stayed there — as a pharmacist and healthcare executive. The senior vice president and CEO of specialty and infusion pharmacy at OptumRx oversees a part of the business that accounts for roughly 10% of UnitedHealth Group’s revenues, and Zeglinski sits atop an organizational chart with roughly 6,000 employees.

His stab at a musical career has served him well, he says: “Being in an orchestra has its own dynamics — the conductor, being part of a team and doing your best to contribute to the whole. All of that applies to business.” Playing an instrument also instilled confidence, especially when it comes to public speaking. “There’s nothing scarier than being a soloist in an orchestra in front of 2,000 people. Everybody is listening to just you. Talking in front of people, that is a cake walk,” Zeglinski says with a laugh.

Zeglinski grew up outside of Pittsburgh in Beaver County, Pennsylvania, which is better known for producing football players (Joe Namath, Tony Dorsett) than musicians or healthcare executives. His father lost his job when the Pittsburgh steel mills closed, which may explain Zeglinski’s practical side and hedging a bet on a musical career. Armed with a pharmacy degree from Duquesne University in Pittsburgh that he earned before enrolling at Carnegie Mellon, Zeglinski says he tried nearly every aspect of pharmacy on before deciding on home infusion: “It was so complex. It wasn’t just pharmacy. It was business. It was nursing. It was dealing with payers and contracts.”

In one of his budding-career jobs at a small home infusion pharmacy business in western Pennsylvania, Zeglinski did all the hands-on work: compounding medications under a laminar flow hood, putting labels on IV bags, and medications into boxes. He says he was promoted into management partially because he was a serial volunteer: “If there was an opportunity to do something new, I’d volunteer. ‘Hey, we need somebody to work on this site project.’ Sure, I’ll do it. ‘Hey, we need somebody to travel over here and train these new pharmacies that we’re opening up.’ Sure, I’ll do it. Those types of things. I always just seized the opportunities as they came up.”

Zeglinski’s first full step into the executive career track was with Gentiva Health Services, a specialty pharmacy in Warrendale, Pennsylvania, outside of Pittsburgh. As with many people in healthcare, Zeglinski’s career path has been rerouted, then rerouted again, by acquisitions in a Russian nesting doll pattern. Gentiva’s pharmacy business was sold to Accredo, which was bought by Medco, which now part of Express Scripts, which was acquired by Cigna. He is at OptumRx because the company that hired him became Catamaran, which was acquired by Optum. In between, he had a stint of about 10 years with CVS Caremark, CVS Health’s PBM.

At Optum, Zeglinski’s career has gone back to his roots. “I worked in specialty pharmacy before it was even a word,” he says. “So as specialty developed, I moved out of infusion into specialty, and now I am back to where I am managing infusion, although there’s now an overlap. Before they were bifurcated.”

Zeglinksi wants to bring more self-service and digital tools to specialty and infusion pharmacy. “In specialty pharmacy we always said, ‘Oh we are high-touch specialty pharmacy, etc.,’ which means I know more than you, the patient. I’m here as the doctor, the pharmacist, and I’m going to tell you what you need to do,” he says. Self-service and digital services can help patients take care of themselves. “Why do they have to talk to me every month to get their prescription?” he asks. “If I were a patient, I would only want to get on the phone and talk to us when I wanted to, not the other way around. So how do we get there?” says Zeglinski.