Thursday, February 5, 2015

Uncertain Health in an Insecure World – 22

“80-20 Rules of 21st Century Global Health”

The Pareto Principle was described in 1906 by economist Vilfredo Pareto, when he reported that 80% of the land in Italy was owned by 20% of the population. Also an avid gardener, Pareto had previously observed that 20% of the pea pods in his garden contained 80% of the peas. The business version of his Law of the Vital Few, The 80-20 Rule, states that 20% of customers create 80% of total sales. Complex mathematics & probability theory (the Pareto Distribution) explain this seemingly simple rule.
Question: Does Pareto’s 20th century principle impact 21st century global health?

The World Innovation Summit for Health (WISH) is a global health care community dedicated to evidence-based ideas & practices. WISH and others estimate that the social determinants of health account for 80% of global health. The World Health Organization (WHO) reports that such “unavoidable inequities” (i.e., socioeconomic status, education, environment, employment, food access, etc.) vary greatly across the globe. WHO also recognizes that where people are born, grow up, live, work and age – the “social gradient” – exerts a complex but unquestioned cumulative impact on global health.

In 2013, a U.S. biopharmaceutical research group reported that 80% of rare diseases, some 7,000 diseases affecting <200,000 citizens each, are of genetic origin. Approximately half of rare diseases affect children. In 2014, the U.S. FDA called for policy change for rare disease therapeutics in children, because 80% of new drug approval (NDA) requests contained no pediatric information.
In 2013, the U.S. FDA approved 13 orphan drugs for rare diseases, while Pharma reported >450 medicines & vaccines in their pipelines. 

Complex new pharmaceuticals (biologicals, immunotherapies, etc.) make up a growing segment of the new drug development marketplace. Increasingly, these new drugs are delivered in a home care setting, often self-administered, and requiring a higher level of customer support services from Pharma’s so-called ‘health storefront’.

Per IMS Institute for Healthcare Informatics 2011 data, 80% of prescriptions dispensed by U.S. pharmacy chains are for less costly “generic” drugs. Switzerland’s Alliance-Boots GmbH and U.S. Walgreens Co. will complete their merger in early 2015, largely in response to the increasingly complex retail pharmacy & pharmaceutical global marketplace. Generics are the volume-based horse pulling in profits at Walgreen-Boots-Alliance (WBA).

WBA’s highly sophisticated 21st century business model anticipates many market trends, including what might be considered as invasive use of personal health information (PHI) & lifestyle information – either knowingly supplied by patients via on-line tools &/or mobile apps, or extracted from ‘big data’ activity monitors such as Google. WBA have analyzed market sector growth in the affluent world, finding a 10-13% annual growth in specialty medicine use (i.e., ‘specials’) consistent with an explosion of interest in personalized (a.k.a. precision) medicine (PM).

But non-generic medicine R&D is really expensive. 

Many “ethical” (i.e., non-generic) Pharma companies’ post-blockbuster era profit models imagine future ‘gap’ care in the home from drugs like Herceptin™ for HERS-2 positive breast cancer. While these PM drugs and biologicals are relatively expensive compared to generics, their home delivery could bend the ever-growing costs of health care compared to hospital or clinic drug administration.

The Kaiser Family Foundation Health Research & Education Trust (HRET) reports that between 2003 and 2013, U.S. employer contributions to family health care insurance premiums of non-elderly insured (covered) workers increased 80%.

Why is that?

Eighty percent (80%) of Americans still die in hospital. Of the 70% of total health care costs incurred by the elderly, 80% occur in the final month of life for a combination of acute plus end-of-life care. Obviously, this care model adds massively to health insurance premiums and to the public cost of health care. Non-physician health care aides (a.k.a. personal support workers) now provide 80% of health care to the Canadian elderly in senior’s homes and facilities (1/3rd of whom have dementia, or “brain failure”; See post #9).

These trends reflect growing 21st century developed world momentum towards more accessible, personalized, lower-cost home health care for a variety of medical conditions & patient cohorts.

Answer: None of these 80-20 associations speak directly to a Pareto Principle influence on 21st century health.
It is intriguing to imagine that some fundamental truth about health and health care could be connected, however indirectly, to a rule of thumb or a mathematical certainty.

However, this exercise convinces me that despite our medical bent towards empiricism, much of what goes on in health and health care is akin to Brownian motion – replete with data misses & manipulations, random non-causal associations, and irreproducible models.

Such nihilism aside, the complexity & rapid pace of change that define 21st century global health and health care are often plainly unfair, and certainly feel unprincipled.

We seek answers to explain this complexity!

And those of us in the Square doing the hard math continue our quest for the rules.    

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