Insight by: Debbie Lin
The US, historically, has been characterized by vast inequities in health outcomes across socio-economic groups. Poor outcomes across diseases from tuberculosis to cardiovascular disease were found to be associated with basic social infrastructure problems such as poor housing, malnutrition and poor education attainment.
The divide is only greater when it comes to certain populations accessing innovative healthcare technologies including new medications. Studies show that while CAR-T therapy, an innovation in cancer therapy has been approved 5 years ago, only 5% of African American patients were enrolled in clinical trials for this drug. This not only signals lack of equitable access to new modalities of medications in clinical trials, but further perpetuates lack of data and insights on clinical outcomes of patient response to new medicines. As such, our understanding of how diverse populations respond to medications has always been sub-par. This impacts how effectively patients can be treated.
The US is a high income nation at the forefront of medical innovation and technology but it has traditionally underinvested in resources to address social determinants of health. COVID-19 has only exacerbated these disparities. Policymakers have created safety net programs such as income tax credits to intervene, but it is clear that federal/state funding and policy solutions aren’t sufficient and broad enough to cover the widening social divide and healthcare needs in under-represented populations. In the last few years, there is greater focus within the venture and startup communities to fund and develop innovations focused on social determinants of health. I believe that more can be done across the innovation sector, the public sector and industry. Now is the time that creative partnerships between industry, health systems and technology companies have the potential to help accelerate solutions and expand coverage.
One example is to provide greater access to healthcare innovations simply through enhancing access to transportation. More than a decade ago, prior to the Uber era, while directing a US based social impact program from within a large pharmaceutical company, I met social entrepreneur and Ashoka Fellow, Katherine Freund, founder of non profit ITNAmerica (Independent Transportation Network). Founded in 2005, and a precursor to the modern Uber, Katherine’s mission was to provide sustainable transportation solution for seniors. ITNAmerica creates a transportation network for rural communities from Maine to California by incentivizing people within the communities to provide transportation to the seniors in their community. The business model is a marketplace connecting community members (the drivers) with seniors. Transportation credits can be purchased by relatives or the seniors themselves and used to finance rides. A database would match the drivers with seniors. In many ways, Katherine’s idea was the early Uber for rural communities.
Pharma companies have difficulty retaining clinical trial participants simply due to the logistics of getting to the trial sites.This leads to a large number of drop out in trials. Transportation is a main factor towards failure to achieve trial completeness (trial drop out rates in trials are upwards of 30%).
A simple opportunity was proposed. Perhaps Pharma could underwrite the transportation network to ensure that trial participants would not miss their appointments and thus, receive much needed treatments. Downstream, this would lead to enhanced diversity in trials along with enhanced clinical outcomes. A study was proposed to test the hypothesis; could we, in fact, increase retention rates and enhance the diversity of trial participants? To accomplish this, we would need to map trial sites with ITNAmerica coverage areas and determine whether there were adequate numbers of patients where ITN coverage existed at the time. Unfortunately, we discovered that the scale of the ITN network was not sufficient enough at the time to map to a large number of clinical trial sites. The business model hadn’t scaled sufficiently for the coverage needed. Had there been sufficient scale, the model could have significantly enhanced access to trial sites.
Subsequently, other organizations have also developed this concept in local and regional settings. In 2016, Mindi Knebel, founded Kaizen Health to work with healthcare systems to streamline the scheduling of medical transportation for hospital discharges; recurring appointments for dialysis, cancer treatment, physical therapy, and diagnostics/imaging; and clinical trials. Since its founding, Kaizen Health has built a transportation network in Chicago, including a national partnership with Lyft.
Healthcare meets Tech at scale
Fast forward to today, Uber is used by over 93 million customers globally with over 3 million drivers and as a byproduct increased access to healthcare. In 2018, Uber introduced Uber Health (Lyft has also made inroads in this area.) The mission of Uber Health is to enable healthcare organizations to arrange and pay for patient rides to reduced missed appointments all in a HIPAA compliant manner. The product currently partners with 2000 healthcare organizations to provide medical transportation and monitor patient progress to the sites. This year, UberHealth partnered with CVS in the Health Zones initiative to give people in underserved communities free rides to medical care, work or education. The rides, will be available to high-risk populations in such as Atlanta; Columbus, and Hartford ,leveraging ride-sharing technology to reduce barriers to care. A number of health systems such as ClinOne and contract research organizations are also partnering with Uber, as well as Lyft, to do the same.
I’m encouraged by these developments and the lives they are changing daily. While few health economics studies have been conducted, Michael J. Fox Foundation launched a survey in 2017, which demonstrated that providing clinical trial transportation suggested trial engagement increased in hard to reach populations, is cost effective and does not contribute to a heavy work burden for trial coordinators. Another small study has shown significantly increased rates of patient satisfaction and retention of patients to clinic sites with the use of Uber.
The example of UberHealth is compelling because it is where tech meets healthcare at scale. I am hopeful that more creative partnerships between the public sector, healthcare delivery systems, the pharmaceutical industry and tech organizations can be developed. These innovative partnerships have potential to make an incredible difference in bringing new medications to market. They can allow us to have a much finer understanding of how diversity contributes to drug response in new trials for medications, ultimately, substantially increasing treatment effectiveness and access to care.
