Dr. Hala Borno, Founder and CEO, Trial Library
Vanessa Broadhurst, Executive Vice President, Global Corporate Affairs, Johnson & Johnson Dr. Aditi Mallick, Chief Medical Officer, Medicaid and CHIP, Centers for Medicare & Medicaid Services
Moderator: Rachel Lobdell, FORTUNE

Brainstorm Health 2023 - Dollars and Sense of Health Equity 

Conferences

Dr. Hala Borno, Trial Library
Vanessa Broadhurst, Johnson & Johnson 
Dr. Aditi Mallick, Centers for Medicare & Medicaid Services
Rachel Lobdell, FORTUNE

Dr. Hala Borno, Trial Library
Vanessa Broadhurst, Johnson & Johnson 
Dr. Aditi Mallick, Centers for Medicare & Medicaid Services
Moderator: Rachel Lobdell, FORTUNE

I've been so personally impressed with the speakers we've had here over the last 24 hours and the leadership that they're bringing to health care, but really to the world, we obviously need more of that leaders who act with a sense of purpose. What Apollo Ono called Iki Guy and have a positive impact on all their stakeholders. Fortune is doing its part to help develop those leaders. It's, it's led to the creation of our membership driven community for next generation leaders called Fortune Connect. The goal is to create truly purpose driven leaders to help them understand what stakeholder capitalism is really about to help them understand what it means to lead truly equitable and inclusive workforces. The program is designed for mid career professionals who are rising fast on the executive track. I'm sure all of you have folks like that in your organizations. I would encourage you to check it out. Fortune Connect dot com or come to me directly if you'd like to get more information on it. So now let's continue our conversation here today where you're born, where you live, your age, your economic status, and of course your race all of those are just a few of the factors that figure into health equity. They're the so called social determinants of health. They can make the difference between a long relatively disease free life or conversely lead to excess morbidity and premature mortality. Inequities in health care have long been a chronic issue. We've talked about it on this stage before. It's a massive problem that will take a dynamic and multipronged approach to resolve. Uh Today. What we want to focus on is the economic impact of health inequity. There's data from Deloitte. New data that shows that the US US health system cost approximately $320 billion in equity costs. Approximately $320 billion could eclipse a trillion dollars in annual spending by 2040 if nothing is done to fix the problem and that's clearly not sustainable. Joining us now to talk about that, how equitable health can lead to better outcomes across the board are Hela Bono, Hela Bono, a former CEO of Trial Library, Vanessa Broadhurst, Executive Vice President of Global Corporate Affairs at Johnson and Johnson. Uh a male doctor, a male chief, medical Officer of Medicaid at the Centers for Medicare and Medicaid Services. All of them in conversation with Fortune's Jeff Colvin. Please welcome them to the stage. Ok, let's have a seat so much to talk about here. I want to start by asking you all for your views on the same question. Uh The pandemic changed everything is the United States as after the pandemic is the United States ahead of where it was on health care equity behind where it was pre pandemic or no change. I think all of us can recognize that the pandemic put a spotlight on health inequities in the United States. In the early days of the pandemic, we saw that racial, ethnic minorities were disproportionately impacted by the condition. It places an imperative on us to make sure that as we're developing vaccines, something that opened up society allows us to be in this room today, that we actually include the populations that are disproportionately impacted by the condition that imperative has led to a lot of innovation. I'm really excited about the innovation that we're seeing in improving and advancing access to clinical trials. It's also led to a lot of accountability. There's increasing regulatory pressure to make sure that study sponsors those supporting the implementation of clinical trials are actually fulfilling measures, mechanisms that are evidence guided to include diverse populations into studies or that will impact their ability to bring their drug to market. So that really shows this clear linkage that we've always recognized that doing the right thing, including everyone in clinical research is also good for business and that is a good outcome that has come out of the context of our pandemic. The innovation has also impacted the conduct of clinical research where we've seen a lot more decentralized models you know, using technology to access patients where they are engaging them, where they are to reduce the burdens that we're placing on them because we know that including everyone in clinical trials is actually good for all of us. Yeah, Vanessa, did we make progress on this during the pandemic? Listen, I think we did. I think what he said was true that it really exposes, you know, the underbelly of what was going on and COVID just amplified the problem and brought it front and center to everybody's attention which you know has good. Um I think that the the also the good thing that happened from a clinical trial approach, we had to do things very differently. We had to use A I to find out where the disease was going. We had to use predictive models. We had to think of different ways of recruiting patients that maybe were not as face to face intensive. So I do think that the industry is starting to change for good and just the critical nature of that need was exposed through the pandemic. What do you say? Totally agree. I think the bright spots I would highlight are to just foot stomp and echo what's been said, igniting a national conversation that centers health equity. Literally, I mean, you would be hard pressed now to find a health system and ensure any any entity that touches health care that doesn't have a diversity equity inclusion type of office if not entire sets of initiatives. The other thing that I highlight from a policy perspective is massive coverage gains. We are now in this country at historic levels of uninsurance. So a 30% increase in Medicaid enrollment or 21 million people that now have coverage through Medicaid and chip that didn't as of February 2020 right? And we know I will just add that that is disproportionately communities of color, right? So when you look at Medicaid expansion, both in the context of the AC and Medicaid expansion in the context of the Coronavirus Relief Act funding disproportionately that impacts people of color to have the peace of mind really that comes from having health insurance coverage. One of the other great things is just the massive amounts of partnership that it took to get through the pandemic. When you look at, you know, the governments, private corporations, health care providers, there was such a stress on the system that it really created a very unique environment where everybody was really forced to think about how we work together to solve big problems. Audie, I just can't help thinking. You, you mentioned all the people who got on to Medicaid among other things during the pandemic right now. Of course, that's coming to an end and a lot of them are going to be pushed out of Medicaid. What's going to be the result overall, I will say, I wish I had a crystal ball to know, I will say tremendous effort underway to ensure that every eligible person retains health care coverage. Whether that is in Medicaid through the exchanges for folks that are able to access employer sponsored insurance. The estimates are somewhere between 15 to 18 million people with of confidence intervals on either side are subject to coverage loss and about 50% of those people might be for administrative reasons, didn't have the right address, couldn't get a hold of them return mail, things like that, which suggests that they may, they may in fact be eligible and they may not know it. That's right. That's right. And so, you know, to everyone in this room, I think there are things that anyone everyone can do from your vantage point to make sure that people know where they can access coverage. It's check out this website, call, this phone number, go to this address. Um but we are um staring down the pike of what promises to be the single biggest coverage transition event since the launch of healthcare dot gov. Well, I can tell you what to say so. Well, I mean, I I'm concerned of course, that loss of coverage means that we're going to see unnecessary deaths. It's pretty well published that when patients cannot access preventative care, they present with more advanced disease. If they present with more advanced disease, they're less curable. And so that's a reality that we really need to think about and to and to put pressure to ensure that we don't have those unnecessary deaths in the United States. Yeah, there have been mentions of the clinical trials that were done in the uh development of the vaccines for the pandemic trials. Are your specialty? Uh What did we learn with regard to health equity about the clinical trials of these vaccine candidates during the pandemic? Well, the pandemic certainly showed us that clinical trials are a social good with vast benefits to society and an inclusive approach is worth it. But it takes effort. It takes community engagement and ear on the ground provider activation, activating the providers who are seldom offering these opportunities to their patients. So we've learned a lot about the ways that we can innovate to actually do the hard work to achieve inclusivity in clinical trials. And when you look at the demographics of patients that participate in the COVID-19 vaccine clinical trials, they were remarkably diverse and much better than what we have been doing for decades. We have known about a lack of representation in clinical trials for many decades. And there's been legislation around this since 1993. But now we're seeing this shift this real shift towards accountability and intention and actual investment in the innovation that's required to make the difference and continue this inclusivity. And I think importantly, getting out to the community centers, right. So when you look at, for example, cancer, uh if you take multiple myeloma it affects 20% of multiple myeloma patients in the US are African American. Now, they usually have a less severe form of disease, but they actually die earlier and that's because the diagnosis comes later and they aren't always afforded the opportunity because of, you know, inequities in the system to get the most infectious or recent medication. So when you look at how you change the clinical trial process and get um underrepresented minorities into the clinical trial process. You can't just go to the same institutions, talk to the same K O L s. You really need to expand the audience of who you're talking to in a culturally um with a health care, culturally appropriate dialogue uh to, to get them to seek care in that way. Uh We can't talk about any topic. Uh It seems these days without asking what's the effect of A I uh which has become so much more prominent in the past few months, Audie, I'll start with you. But uh what do you see happening? Uh One would suppose that a tremendous advance in technology must be good. Is it going to be two thoughts? One is, it's only as good as what goes in, right. So L's large language models are only as good as the data that they are trained on, right? We are all keenly aware of existing systemic biases. Certainly on the medical side, things like how we calculate kidney function, how we calculate heart function. Right. There are a variety of things that we think of as bread and butter. Certainly, I did as part of medical training that actually have race based adjustments to them. Um, garbage in, garbage out. Right. And so if that's what you are feeding an L L M to do, um, we, you know, it stands to reason that if we have trained it to be biased, the output will be biased. Um, And that's a, that's a solvable problem. So I don't mean to paint that as doomsday, I mean to paint that as let's all be keenly aware of what it means to make them equitable engines of innovation as opposed to perpetuators of inequities. I think the other thing I'll say is I think less so from uh well, I think this also has health activity implications around who exactly do, do A I tools sort of replace in the future of work, right? And I think generally speaking, um it tends to be the, I will say lower tendered or lower less skilled parts of the workforce. And so I think there is not just intentionality that needs to be put into how those LMS are trained, but also how they are deployed in such a way that is conscious of what that means for the future of work re skilling, upskilling. How do these models actually enhance productivity and not lead to uh employment and labor market implications that would disproportionately impact marginalized populations. I I think this is, this is critical because part of health equity and the bias there has to do with trust and has to do with historical trust within the health care system. So if we, we have to be really be careful um as we input data, garbage and garbage out to make sure that that trust is foundational because we could take a, you know, unit system and potentially um make it, you know, we need to use caution. Well, I totally agree that A I can perpetuate bias. If you're using biased data to train your models, you're gonna get biased recommendations. I think all of us understand that theoretically. But what does that mean in clinical application? I continue to see patients. I'm a medical oncologist at the University of California in San Francisco and I use risk risk scoring systems all the time, especially for patients with early stage disease. I'm trying to determine, are you at high risk for recurrence or are you at low risk? Should I give you more treatment now or should I put you on surveillance? So let's imagine, I have an African American woman with early stage disease where the model which was trained on non Hispanic white women with breast cancer tells me she's on, she has low risk and she recurs with metastatic disease. The next year I have failed her, I have failed her because I used biased data that gave me biased results that is a real harm. Let's think about the other scenario where we have a patient where we say she's high risk and I give her a lot of chemotherapy. She now has debilitating neuropathy and is on disability. She didn't need that chemotherapy again. I have failed her because I overt treated her based on biased data. So I am really concerned that if we are not, if we are more casual rather than cautious in our integration of A I in clinical practice, we can do harm. And that keeps me up at night. Uh I'm going to invite questions here in just a second, but just following up on this, uh if if we can get the bias out of the A I, I would think that it still could be a tremendous plus for equity in health care. Fair enough. I I think yes, of course, um technology can make a vast difference and we should be rapid adopters of technology. But we also need to look at the implementation of this technology which health systems in the United States are actually using these amazing technologies to deliver individualized treatment recommendations. Is it the same have and then we have the have nots. So really thinking also with an implementation lens to make sure that we have equitably distributed benefits of these technologies. But that's the same thought if we can get past the bias thing, which is gonna be a lot of work. But if we can do it then what's the issue? Well, I think that just like any other technology, there is also um non equitable, you know, resourcing of technology. So even if you think about, you know, a a medical center, a teaching center versus a community hospital, you can still get inequities of care if the same technology is not available everywhere. Um there are systemic issues that you know, the health care system in the United States is still trying to fix. For example, just having your records, you know, transfer and be visible throughout the medical system. So I think there is enormous hope here, but I think there's a lot of work to do before we get the great end state that we will be at someone who pays for it. Yeah. So like you can solve all the bias but like somebody's got to foot the bill comments, questions. They're so brilliant that there's really nothing we Yeah, I think so. Um Yes, uh a microphone will get its way to you very shortly. Yeah, there we go. Uh Please, if you could stand up, say who you are and hold the mic close to your mouth. I think, I think many folks who know me by now. I'm hi everyone. Um A general partner at X Capital. I'd love to hear a little bit more. We talked about A I but in the context of clinical trials, how you know, it's a crowded space there are a lot of companies doing, you know, trying to innovate and accelerate here. How can technology now actually change the game in a way that generations of companies have not been able to achieve earlier? Yeah, absolutely. Thanks for that question. So I am primarily focused on the oncology, therapeutic area that is the largest therapeutic area in research and development. And we know that in the United States, we see inefficiencies in recruitment, the vast majority of studies close early due to inadequate recruitment. We also see inequities, right? Um But what we also know is that only 13% of oncologists in the United States participate in research and there are a variety of pain points that are driving this and technology has a role to really activate providers to engage with them to make their lives easier so that they can see that research is an opportunity that they can implement into their actual care delivery. Yes. Yeah, I think that a lot has been tried, but the industry is really starting to see some successes and we saw that we see that in terms of a few things, one is the technology that we use, whether it be, you know, through partners or through our own organization to make sure that we are inclusive and and predictive of sites where they are, they're going to have diverse and qualified patients for clinical trials. So I think the application of using data sciences and A I to clinical trials is critically important in drug development and it's use that I have seen be most effective is expanding and to find the patient populations that we need to get into the trials. Personalization. Personalization. Yeah. Right. The ability when you've got billions and billions of records, you can be much more precise about this person. This treatment in a way that I don't think was possible before. Yeah, it's a great point. Uh, aggregating all of the data that's available has been this holy grail for a long time. We're actually apparently getting closer to it. Sound right. Yeah. Ok. That's great. Uh, our time has flown past but we're out of it now. So, uh, all I can say is to each of you. Thank you so much. Thank you. Thank you.