The launch of American Health & Drug BenefitsTM brings with it the sentinel question: How shall we frame the healthcare debate? The answer we propose involves a vision of how healthcare standards change; who is involved in the process of care; what are their systems, needs, agendas, and incentives; and what are the evidentiary methods proper for determining success or failure.
All the forces involved in healthcare delivery come to bear at the point of formulary and benefit design coverage, ie, the only real healthcare intervention is that which is covered. The managerial competency needed to make good coverage decisions entails a new type, and a blending, of clinical, financial, and regulatory best practices. This journal seeks to provide a forum for understanding the intersection of these forces and how they form the governing dynamics of health and drug benefits coverage. What's more, we will examine these forces from the different viewpoints of the key stakeholder groups—patients, providers, payors, purchasers, manufacturers, evaluators, distributors, regulators, academia, and investors—with the idea that they are seated at a round table where the idea of hierarchy is subordinate to the pursuit of consensus. The ideas and resources for healthcare progress have never been more sanguine. However, they require a new perspective to master them, a new spirit of cooperation, and a new willingness to try new systems and dispense with traditional prerogatives.
That this new and urgent pursuit of excellence was precipitated principally by cost rather than quality concerns does not detract from its value to the practice of medicine. What has become evident is that healthcare cannot tolerate inefficiency on any level: not clinical, not business systems, not regulations.
There is yet another new shift in the winds that attends this quest for consensus around best practices: reconciling the responsibilities of the disparate stakeholders toward one another. Could this mean inter-stakeholder cooperation and transparency? The only answer the healthcare system can tolerate—it is increasingly clear—is yes, though it will take years for the adversarial tone of the healthcare debate to be replaced by a sane, professional discourse. This will occur when they share one another's realities. In short, good communications will make not only good neighbors, but also a system that is not fighting against itself. The healthcare debate need not—indeed should not—take on the characteristics of a series of power plays, any more than the human body's own organs would compete with one another for "mastery" over the body.
The confluence of stakeholder interests and demands on healthcare delivery constitute a composite picture of the ever-changing healthcare debate. The vast scope of activity may make the prospect of aligning activities seem daunting, but there are few fundamental structural pillars to the process of care, and these form the scope of inquiry of American Health & Drug BenefitsTM.
The first is value, as reckoned by a balance of Cost, Quality, and Access. The second is the triad of Clinical, Business, and Regulatory forces that determine health and drug benefits. The third is the "college of stakeholders," each with its own incentives, data, and agendas. The fourth is Culture—healthcare coverage models are products of the culture in which medicine, and the ancillary business and regulatory pillars supporting it, is practiced. The fifth is Evidence—what do we know, what can we measure, about the Clinical, Business, and Regulatory actions we undertake in the name of healthcare?
There are 2 central questions asked by American Health & Drug BenefitsTM: (1) Will we conduct the healthcare debate among stakeholder groups as adversaries or as colleagues? (2) Is healthcare on the verge of profound success or imminent collapse? The editorial philosophy of American Health & Drug BenefitsTM is collegial, positive, and professionally optimistic, ie, the healthcare system paradigm is undergoing its transformation, not its demise. All parties to the process of care hold immense resources and answers for the quest for better healthcare; hence, American Health & Drug BenefitsTM gives all full respect and invites them to share their needs, data, systems, and ideas for change. The positive outlook of American Health & Drug BenefitsTM is predicated on the notion that challenges to healthcare are as fixable now as they were when scrubbing before surgery was a new idea. Right now, the looming question is financing for the many healthcare interventions that have been devised. This is not a cause for pessimism but for innovation: It means only that our ability to discover cures has lately outpaced our systems for paying for them. It would be infinitely more disturbing if the problem were the reverse.
Thus, American Health & Drug BenefitsTM offers a fresh look at the forces of change to healthcare benefits and their downstream effects on Cost, Quality, and Access. What will be the impact of value-based benefit designs? What, in fact, does this new term even mean in practical terms? How much regulation is for the good of healthcare innovation, and how can government contribute to an environment wholesome to R&D? How can payor models balance the needs of patients and investors alike? How can quality control standards provide doctors helpful guidelines without taking from them the professional latitude they require to avoid devolving into "healthcare vendors"?
The answer is that there are no simple answers, only lots of them, and they require a healthy, informed, 3-dimensional perspective on the part of all parties. Ultimately, the Great Healthcare Transformation is under way, and the system of care is going to require adept management of overall resource allocation, the Holy Grail of today's value-based healthcare system. In the following pages and issues of American Health & Drug BenefitsTM, you will encounter practical solutions and experiences advanced by different sectors. We are providing a repository of ideas for wresting healthcare improvement out of the countless forces and players driving benefits decisions. And we invite you here and now to contribute your articles and bring your vision and its outcomes to the table where all can assess them.
The editorial approach to achieving a managerial perspective in American Health & Drug BenefitsTM follows, therefore, a paradox that begins with the Roman Empire's "divide and conquer" tactic—identify the forces and players and their systems and the measurable effects of same—and then turns on its heel to align these forces and systems. The goal: a realistic unity among stakeholders based on taking the high road in every facet affecting the process of care. This amounts to "divide and reunite," always keeping the interventions under the magnifying glass to see how adequately they really serve Cost, Quality, and Access to care.
So let the debate continue, in the spirit of good will and common interest: the patient, the patient, the patient. American Health & Drug BenefitsTM will endeavor to help chronicle it. By balancing the Clinical, Business, and Regulatory forces in each benefits decision, by respecting and accommodating valid needs of every stakeholder group, we will continue groping forward in the search of the humane treatment of those who are ill or injured. And that is not a cause for alarm, but for unceasing, united action.