A tale of two healthcare systems
by Christina Lilliehöök
Christina is a Senior Science Writer at RA Capital Management where she edits and guides development of competitive landscapes of drugs and medical devices across a range of disease indications and capabilities.
Christina’s brother, Dr. Gustaf Lilliehöök, who lives in Sweden, offered additional perspective.
January 20, 2022
As a Swede who has lived in the United States for ~25 years, I’ve experienced two very different healthcare systems. As a child and young adult, I took free (or nearly free) healthcare for granted. However, when I left Sweden to pursue a graduate degree in the US, I was shocked to realize that the system here is very different. I learned new words like ‘deductible’ and ‘copay’ that were not previously part of my vocabulary.
The US Experience
How a nation’s healthcare system affects the patient experience became more tangible for me a few years ago, when a friend of mine here in the US was diagnosed with rheumatoid arthritis (RA), a condition in which the body’s joints are damaged by an overactive immune system. People with RA can suffer from swollen joints and severe joint pain, as well as other complications. If left untreated, RA leads to erosion of bone and cartilage tissue, and even with treatment, patients may have irreversible bone loss.
My friend did not visit a doctor immediately after experiencing the initial symptoms of RA, an unfortunate consequence of a healthcare system that is rife with copays and out-of-pocket expenses. They had lived with swollen fingers and toes as well as severe pain for many months before finally consulting a physician. When my friend finally saw a doctor, they were told that an effective therapy existed, but that decisions about their initial treatment for RA would be guided by insurance company requirements to try older (cheaper) drugs first before covering more recently developed (and more expensive) drugs.
For my friend, this meant that they were prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and methotrexate, inexpensive drugs that have been around for decades. My friend’s physician explained that the decision to start with these drugs for later-stage RA was not driven by their therapeutic benefits, but instead it was the only way to satisfy insurance company requirements before ultimately prescribing more effective ‘biologic’ therapy. After taking methotrexate for three months, my friend’s doctor could provide the required documentation and prescribe a biologic therapy called adalimumab. This drug is a monoclonal antibody therapy marketed as Humira, that provided them with a new lease on life. It eliminated the pain and swelling and allowed my friend to work without suffering through every day.
When drug prices are a Trojan Horse for other costs, we all lose
Want a closer look at the middlemen that drive up prices in the US healthcare system?
Unfortunately, this happy ending was upended by the COVID-19 pandemic, and this highlighted another characteristic of US healthcare: the coupling of healthcare coverage and employment. My friend lost their job during the pandemic, and as a result, their healthcare coverage and ultimately access to Humira, leading to a return of the pain and swelling. Fortunately, my friend found a patient assistance program run by the drug’s manufacturer that helps patients who lost access to these medicines due to the COVID-19 pandemic. After explaining the situation, my friend was provided with Humira free of charge.
The Swedish Experience
How might this ordeal have played out in my native Sweden I wondered? My friend’s experience prompted me to learn more, and I reached out to my brother, a general practitioner or ‘GP’ (commonly referred to as a ‘primary care physician’ or PCP here in the US) who has practiced medicine in Sweden for ~40 years. He described how GPs would note suspected RA through a combination of physical exam findings, lab tests, and x-rays of hands or affected joints. Those with suspected RA are ultimately referred to specialist academic institutions where a definitive diagnosis would be made.
But what really struck me about my brother’s description of patient care in Sweden is how patient-focused the process is. Since there are much lower financial obstacles to seeking treatment (Swedish residents pay a maximum of $123/yr for medical service and a maximum $246/yr for prescription drugs – partially because the Swedish government pays a fraction of what US payers do for drugs), patients are more likely to see a physician earlier in the disease course. Furthermore, Swedish law mandates that patients wait no longer than 1 month for an appointment with a specialist who can diagnose RA. In addition, there are no requirements by insurance companies to “step through” the cheapest drugs first – instead, the choice of therapy is made based on what best serves the patient.
Interestingly, my brother clarified that although patients in Sweden can receive more expensive biologic therapy earlier in their disease course, they don’t necessarily jump straight to those therapies. Oral methotrexate is still commonly used since it’s often effective with manageable side effects, and oral steroids can be used in the first month while waiting for the methotrexate to take effect. Those who don’t experience sufficient improvement on methotrexate will often try combinations of methotrexate and biologic drugs, and those who do not tolerate methotrexate are free to try alternative therapies.
At face value, the insured American and the average Swede have similar patient experiences. Both must be diagnosed by a specialist and are likely to receive cheaper generic drugs before being prescribed more expensive treatment options. But that’s where the similarities end. The Swede can trust that the use of cheaper therapies is a decision made by their doctor looking out for their health, not an insurance company with their eye on the bottom line.
Furthermore, the Swede can be confident that whatever their doctor prescribes will be covered by their national insurance program at reasonable cost to them. Meanwhile, the insured American patient bets on never getting sick in the first place, and hopes that any treatment they may need will be covered by their insurance. Receiving a severe diagnosis is then often a frightening wake-up call, compounded by worries about out-of-pocket costs and fear of losing their job, and therefore, their insurance.
What does the American get in return for all this headache? They might have access to the latest treatments before their Swedish counterparts, especially if they’re willing to pay for them. But there’s no good reason why Americans shouldn’t have both: the best drugs in the world and insurance that works. That's why organizations like No Patient Left Behind are working to propose practical solutions that keep costs low for patients while preserving the innovation ecosystem. We need a system that works for patients.
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