Preparing Young Professionals to Build a Better Future
By John Watkins, PharmD, MPH, BCPS,
Managed Care Perspectives, LLC, Bothell, WA, USA
Today’s healthcare environment is changing rapidly. Health economics and outcomes research (HEOR) educators and mentors must prepare their students and young professionals to manage change as they assume future leadership roles. Academic programs will revise curricula to incorporate new research methods and modes of learning. Mentors should be prepared to help graduates negotiate career patterns very different from the ones they have followed. Reducing health disparities will require a diverse HEOR workforce able to analyze patient heterogeneity across new dimensions of value. As the workforce diversifies, ISPOR is revising and updating its framework of basic competencies for HEOR professionals.
What will change?
Change in the science is occurring at several levels. Growth in the underlying knowledge of biology is followed by developments in pharmaceuticals and medical technology. Pharmaceutical companies address new targets with novel drugs. New technologies like gene and cell therapies appear. Improving health information systems will increase interoperability and real-time data exchange between health systems and payers. Digital health technologies and artificial intelligence (AI) promise to transform the way health professionals work. Robotics and bioengineering will support advances in remote surgery, prosthetics, and more.
Measuring outcomes and modeling cost-effectiveness of these new practices will require creative approaches that incorporate societal impact and new ways of measuring value to patients and caregivers. Technology will drive innovative clinical trial designs and outcome measures. Facilitated by cloud-based analytics, large database studies will proliferate, along with opportunities for interregional collaboration and comparison of methods and results. Since new health technologies usually increase cost, the global problem of affordability will have to be addressed.
“HTA institutions are slowly gaining traction and requiring clinical and economic evidence beyond regulatory evidence, increasingly incorporating real-world evidence into decision making.” — Federico Augustovski, MD, MSc, PhD
COVID accelerated adoption of remote work technologies. Social and economic change has created a “new normal” in workplace design and expectations. In the March/April issue of Value & Outcomes Spotlight, talent recruiting specialist Poppy King predicted a hybrid work environment with staff in office 60% to 80% of the time. Virtual work expansion lets employers hire talent from around the world, increasing workplace diversity. HEOR professionals that build models for settings where they have never lived will need a level of cultural competence not previously expected of them.
Young professionals will learn to work with machines in new ways, using AI assistance for routine tasks. Augmented reality will provide a richer experience when meeting with distant colleagues, more like being in the same room. Gen Z is bringing new expectations to the workplace. Because they have interacted with screens since infancy, they read, process information, and relate socially in different ways. They have a new emphasis on work-life balance. HEOR professionals will need to adapt and be comfortable in a variety of settings. Workforce diversity will increase as more students from minorities, low- and middle-income countries, and more women enter the field.
“Latin America tries to adapt to the current and upcoming challenges that high-income countries initially face,” notes Federico Augustovski, MD, MSc, PhD, Director, Department of Health Technology Assessment and Health Economics at the Instituto de Efectividad Clínica y Sanitaria (IECS), University of Buenos Aires, and the first ISPOR President from Latin America. “HTA institutions are slowly gaining traction and requiring clinical and economic evidence beyond regulatory evidence, increasingly incorporating real-world evidence into decision making.” Like their global counterparts, Latin American HEOR professionals have changing attitudes toward work. “Newer generations have a different value mindset, with weaker attachments to work and stronger ties to hedonism,” Augustovski observes. “Specific areas of knowledge growth include those related to precision or personalized medicine, data science, coupled very tightly to real-world evidence.”
“I envision three major changes graduates will face in the next 10 years,” Anirban Basu, PhD, MS, Director of the University of Washington’s CHOICE Institute, predicts. “Greater integration of AI-related technologies in HEOR work and evidence generation, the changing landscape of financing medical technologies, especially in the United States, and adapting to nontraditional work environments. Hybrid work means less commute, but it may cause more professional isolation.” Basu adds that, “Each cohort is different. We spend a lot of time during the first year getting to know them well. Overall, the past decade has certainly seen a shift in how new students learn and we try to adapt to new modes of instruction to keep up with such changes.”
Formal Academic Programs
Doctoral and master’s degree programs will continue to be the place to learn core HEOR skills. Hybrid fellowships are offered by pharmaceutical manufacturers in partnership with academic HEOR programs. Fellows usually spend a year at university earning a master’s degree, then a year with the sponsor’s HEOR staff. Postdoctoral research fellowships are offered in academic and other research settings.
HEOR doctoral programs focus on research methods and underlying concepts. For example, the required courses for a PhD in HEOR at the CHOICE Institute include applied biostatistics, survival data analysis, epidemiologic methods, large database research methods, causal inference from observational data, pharmacoepidemiology, economic and outcomes evaluation in health and medicine, health economics, and pharmaceutical policy analysis. The University of York offerings for a PhD in health economics include microeconomics, econometrics, mathematical research methods, and health economics for research.
Shorter programs for working professionals include remote learning certificate programs and short programs offered online or alongside major professional society meetings. ISPOR offers a number of short courses at its major meetings and online short courses (paid) and webinars (free to ISPOR members in the HEOR Learning Lab). These webinars allow those working in related fields to explore the HEOR profession with minimal time commitment and expense.
Academic programs will need to expand core offerings to address coming changes and influence health policy. Mike Drummond, MCom, DPhil, professor emeritus at the University of York’s Centre of Health Economics in the United Kingdom reflects on methodology. “The main challenges are likely to be driven by changes in payers’ evidence needs and the characteristics of products being assessed. Payers will ask for more information in the future, particularly on cost-effectiveness, but clinical evidence on new products seems to be getting less and less, owing to ‘fast-track’ approvals and smaller patient populations, such as gene therapies and personalized medicine. The greatest learning needs in the future are likely to be interpreting nonrandomized real-world data, validation of surrogate endpoints, understanding the types of uncertainty and how they can be addressed, and various types of outcomes-based managed entry schemes, which require actuarial skills.”
Scott Ramsey, MD, PhD, director of the Hutchinson Institute for Cancer Outcomes Research, predicts the need for targeted training for increasingly specialized research. “As real-world data expand and move closer to real-time data capture, HEOR professionals will have to be much more facile with databases. This includes merging databases, being better at extracting data to more closely represent real-world patient populations that match the US Food and Drug Administration’s labels. Real-world data will be used to actively monitor use and outcomes of costly new therapies. Gene therapy will be at the forefront of this trend. I think formal education will need to move away from broad-based master’s and PhD programs to specialized training in data science, modeling, and clinical epidemiology. Training will need to be shorter and more focused to attract students. Demand for multiyear degrees that cost students hundreds of thousands of dollars is already waning.”
“The past decade has certainly seen a shift in how new students learn and we try to adapt to new modes of instruction to keep up with such changes.” — Anirban Basu, PhD, MS
Drummond, in his role as Editor-in-Chief of Value in Health, cautions against relying too much on journals for guidance. “Most journals reflect the changing environment rather than guide it, since they consider whatever papers are submitted. To drive change, some journals (eg, Health Affairs) have established blogs, which enable them to publish highly relevant material very quickly. Value in Health has themed sections on topics that the journal feels are important or emerging. Some of these reflect the ISPOR’s ‘Top 10 HEOR Trends report.’
“Our students come out with great tools in the field. I want to strengthen their toolkit and policy evaluation,” says Sean Sullivan, PhD, BSc Pharm, professor and dean emeritus of pharmacy at the University of Washington. They need to be “creative and extend the basic methodology” to address the coming changes.
“I see 2 big things happening in the United States in the next 10 years,” Sullivan continues. “I see a lot of work on alternatives to the cost per QALY (quality-adjusted life year) framework, and we are going to learn how to apply those new methods and make them work. Then I see the Centers for Medicare & Medicaid Services (CMS) developing a value framework that all of us in the field will help develop, implement, and increment. The new final guidance from CMS opened the door for cost-effectiveness, so long as we don’t use the QALY. We can do cost per ‘life year gained.’ We can do cost per ‘health years in total,’ the metric that Basu, et al proposed1 or cost per ‘equal value life year.’ And there’s even the possibility of advances in the GRACE framework2 that will allow cost-effectiveness analysis that doesn’t have an inherent bias to individuals who are disabled. And you could potentially crank into that a factor that would counteract the bias that the QALY has. The 2 areas of key focus for a graduate student are going to be ability to be creative and extend methodology, and policy. They need to be prepared to interact effectively with government.”
HEOR Education in Emerging Markets
Drummond notes additional considerations for emerging markets. “The main differences are the paucity of data for adapting or populating models to meet local needs, the lower sophistication of decision makers, and the lack of definition of decision criteria. Many of the healthcare systems in low- and middle-income countries are ‘pluralistic,’ having several healthcare systems operating alongside one another.3 In very low-income countries, issues like equity and maintaining family income also have a greater emphasis, although equity is now becoming a big issue in high-income countries also.” Scholarships for these students will remain a priority. Ramsey agrees that “we should be much more active in bringing underrepresented populations into research. Waiting until someone gets to graduate school misses the opportunity to have a much larger pool from earlier years of training.”
Universities in Latin America are adapting curricula to the changing environment and needs. “On one side, both formal and practical training have to keep adapting to current platform demands,” says Augustovski. “One of the good things of the pandemia was the push for improving online education in its platforms, educational tools, and contents. For example, our master’s degree changed from mostly face to face teaching to an online-only program.4 Curricula have to be flexible and adaptative, incorporating increasingly needed tools and skills such as real-world evidence design and analysis, or managed entry schemes. ISPOR can take advantage of its existing portfolio of products. For example, social media and new platforms can attract new audiences, or leveraging different channels like ISPOR’s prestigious academic journals, namely Value in Health and Value in Health Regional Issues,” he suggests.
Experiential Training
Health professionals (MD, PharmD, etc) can enter the HEOR work force through manufacturer-sponsored fellowships. Shirley Quach, PharmD, completed the 2-year Managed Care Medical Communications/Managed Care Liaison fellowship at Genentech and is now a payer-facing Value Evidence Lead at Novartis. “The fellowship engaged me in challenging, varied, and fun projects that pushed me to my fullest potential where I learned invaluable skills such as leadership, time management, collaboration across cross-functional partners, interpersonal skills, and written and verbal communications. It helped me achieve my career goals. The professional network that I built during my time as a fellow has provided me with access to job opportunities, career advice, new ideas, and valuable information.” she says.
Quach found the relationship and networking opportunities particularly valuable. Her program allowed flexible learning: “A fellowship gives you the opportunity to train in an extensive program, but also provides the flexibility of exploring opportunities in other functions to grow in your professional development journey. Fellowship is a time of absorbing knowledge and learning what your interests are. Your preceptors and mentors are there to support you in those goals and ambitions. As a fellow, it was much easier for me to work on projects and partner with other functions if I had an interest in learning more than in a regular job position. New graduates bring new perspectives and ideas. This is an opportunity to encourage them to be innovative and take risks. There may be uncertainty involved, but these choices can bring unexpected growth and success for the team and company.”
Mentoring Future Leaders
Regardless of their formal education, young HEOR professionals need coaching and support now more than ever as they navigate today’s turbulent world. Young professionals may be frustrated by the unpredictability of career paths. Tania Luna and Jordan Cohen suggest that “we are suffering from the career myth—a delusional belief in the outdated idea of linear career progression.”5 They advise flexibility and a willingness to experiment and acquire transferrable skills. Mentors, particularly those that are older, should consider these changes when giving advice.
A mentor can be a veteran, mid-career, or young professional. Great mentors are passionate about their own work. “You have to love it or you won’t become expert and you won’t motivate people,” advises Sullivan. “Demonstrate passion yourself. Be really engaged in your mentees’ work. Strive for growth in your field. Continue to invest in your own knowledge acquisition, maintaining your level of proficiency and knowledge. Love what you’re doing to the point where you want to keep making yourself better.”
“Some of the things I value most in my mentors are their honest and candid advice, their experience and perspective, and their willingness to help me achieve my career goals,” says Quach. “The best mentors are those that remember what it was like to be a young professional themselves. Folks who have that characteristic are likely to be more generous with their time and a bit more patient with someone who is trying to learn,” adds Drummond. “Modesty is a good characteristic. Modest people realize that they don’t know everything. Working with a mentee could represent a learning opportunity for the mentor as well.” Chad Murphy, Chief Clinical Officer at Premera Blue Cross reminds us to, “Listen and hear from the young professional what their goal is so you can tailor learning. A mentor cares about the profession and is someone that really likes to see people grow and develop and shine.”
Great mentors use their networks to help mentees. “Continue to grow your own professional network,” advises Sullivan. “It’s always important to grow your sphere of people who like to talk and share ideas, and that takes time. It’s not just people connected to you on LinkedIn or social media, but it’s who you talk with—chat about what’s going on in the world, ask how their projects are coming along. It is a deep connection with these folks. Connect to people who can help you in your career—and that never stops.”
“The main challenges are likely to be driven by changes in payers’ evidence needs and the characteristics of products being assessed.” — Mike Drummond, MCom, DPhil
“A mentor is a coach to facilitate achieving the path the mentee has chosen but not to add barriers or redirect them. Provide encouragement. Help them overcome fear of the unknowns as they move forward. A mentor helps broaden the mentees’ view of the chosen field beyond the academic setting,” says Ed Wong, PharmD. “Mentors can be a calming presence in their mentees’ lives. Acknowledge the tension and help them learn to walk the tightrope. Help them find their own passions.” Mentors should model involvement in professional societies and demonstrate the importance of volunteering. Use your own success to promote your mentees. Society meetings are a great place to do this.
Ensuring Equity in HEOR Work and Education
Improving diversity is one of ISPOR’s core values. The Society’s mission, to improve decision making for health globally, includes addressing minorities that were previously overlooked, both globally and within local geographies. Two important factors in making this a reality are increased representation of minorities in the HEOR workforce and their inclusion in all phases of research and product development.
Since health economics is based in science and mathematics, improving workforce diversity must begin at lower levels of education, where there are established efforts to recruit minorities for science, technology, engineering, and mathematics (STEM) fields. We must interest these young people in our work, convince them that HEOR is relevant to their life experiences and can make a difference to their families and communities, and eliminate the barriers that hinder their education and entry into the STEM workforce. Strategies include visiting classrooms, working with teachers and trusted authority figures within the community, and disseminating information about STEM careers.6
When these young people enter college, health economists must recruit them. HEOR is a relatively abstract profession. Its tangible results are usually found downstream, in improved health outcomes through better decisions. Recruiters must answer the question, “Why should I study this complex field, and what difference will it make to the people that matter to me?” We must persuade undergraduates that a HEOR career offers rewards that are worth the extra time and investment. Geographic and financial barriers are even greater overseas. With established ISPOR affiliates (ie, consortia, networks, and chapters) on 6 continents, these members can play a major role in their countries’ universities.
Once minority students enroll in a HEOR graduate program, they should be offered opportunities to do research that impacts problems they care about. Faculty can engage in a mutual learning process to discover study opportunities. When research is completed, demonstrate its impact. Students from lower-income countries tend to establish a presence at certain universities, making it easier for others from their homelands to go there. HEOR programs can actively encourage this, and ISPOR’s New Professionals Network and the ISPOR Student Network are good resources.
“The professional network that I built during my time as a fellow has provided me with access to job opportunities, career advice, new ideas, and valuable information.” — Shirley Quach, PharmD
Improving equity in healthcare involves health system-level analysis. Recognizing this, the Joint Commission has created an optional healthcare equity certification, which provides “the structure to guide your organization’s journey to achieving healthcare equity.”7 This emphasizes the ongoing nature of the work. “Our health equity efforts have been a journey and there’s no destination,” says Mark Sparta, MPA, BS, president of Hackensack Meridian University Medical Center, the first hospital to receive certification. In addition to increasing diverse representation among hospital staff and leadership, Hackensack Meridian’s approach includes analysis of patient care data stratified by race and other sociodemographic factors. The results help the hospital tailor care to groups and individuals and support the institution’s community engagement efforts.8
Including minority representatives in all phases of research is a recent trend. Ashley Valentine, MRes, Co-Founder & President of Sick Cells, explains that “including diverse experts in clinical trial design, research, and healthcare decision making as a whole is an important step to achieving equity. When you increase diversity (racial, ethnic, gender, sexuality), you are increasing problem-solving ability. We all have different vantage points in how we experience healthcare. If a vantage point is excluded from the design process, it will be missed. That’s how blind spots and biases are baked into research.”
This includes chronic disease patient communities, many of which are represented at ISPOR Patient Roundtables, where patients can discuss their specific needs. For example, the May 2023 Roundtable featured a discussion of sickle cell disease, a devastating condition that disproportionately impacts Black and African American people. In addition to the usual social determinants of health issues, disease-specific bias results from history and culture. “It was reported that only 1 in 4 patients with sickle cell disease receive the standard of care within the United States.” Among other strategies, the group discussed an initiative to design and implement university curricula that lessen bias toward patients with sickle cell disease.
The Innovation and Value Initiative has called attention to the lack of diverse patient and caregiver representation in clinical research. The goal of its Health Equity Initiative is “to drive multistakeholder consensus in research and value.”10 Standard protocols for clinical research tend to minimize patient heterogeneity. Minority group patients may be more difficult to recruit and more likely to drop out of studies. Transportation and time off from work are common barriers to participation. More heterogeneity among subjects means a larger sample size for the required statistical power. As a result, findings are often less applicable to minorities. Use of digital health technologies can help overcome barriers to access for trial subjects and later for the communities they represent.
For example, a patient with sickle cell disease would probably be excluded from a trial of a new cardiovascular disease drug as a comorbidity that could confound results. Although most patients with sickle cell disease have cardiovascular disease, the drug’s impact on them will remain unknown. A physician considering prescribing the drug for a patient with sickle cell disease couldn’t predict whether the patient will benefit or suffer an adverse effect due to drug-disease interaction with the underlying sickle cell disease. By eliminating patients from a minority group, researchers may never learn how the drug will affect them physically, what impact it may have on their daily routines, or what their culture values are.
Inclusion of broader patient representation in all phases of research, including study design and planning, should become standard practice. Without the patient voice, we will never know their research priorities or what constitutes value for them.
The ISPOR Competency Framework
HEOR is a relatively young field that people enter from a variety of backgrounds, as can be seen from the attendees at any ISPOR conference. Recognizing this, the Society has assumed leadership in defining a set of core competencies that should be demonstrated by graduates of academic HEOR programs. The original version published in 2002 included 12 learning outcomes.11 According to Laura Pizzi, PharmD, MPH, ISPOR’s Chief Science Officer, “An update to the Framework is currently underway. A survey will be conducted in October to assess the importance of each of the updated competencies and relevance of each to the respondent’s job. The workgroup is also planning to look at whether these constructs differ by country and/or region. There will be forum on the update at the ISPOR Europe 2023 conference in Copenhagen.”12
As ISPOR has grown into a truly global organization, standardization is important. Employers should be confident that graduates of PhD programs in HEOR will be able to demonstrate these skills. Drummond, who was president of ISPOR during those years, notes that, “Acquiring a basic set of skills can only be a good thing since, as they develop, professions like HEOR need to determine a set of standards for their activities which, in principle, could be a way of auditing performance. I hope that the ISPOR framework will embrace much of the knowledge contained in the ISPOR Good Practices reports which, in my view, represent ISPOR’s best output.”
As the HEOR profession continues to grow in size and importance, we should be intentional about educating and mentoring a highly competent and diverse cohort of young professionals that are ready to take on the challenges healthcare will face in the coming decades. ISPOR will continue to provide creative ways for them to share knowledge and learn from others’ experiences.
References
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5. Luna T, Cohen J. How to mentor someone who doesn’t know what their career goals should be. Harvard Business Review. July 10, 2018. Accessed September 10, 2023. https://hbr.org/2018/07/how-to-mentor-someone-who-doesnt-know-what-their-career-goals-should-be
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7. Joint Commission. Health Care Equity Certification: Building a future of better health. Accessed September 12, 2023. https://www.jointcommission.org/what-we-offer/certification/certifications-by-setting/hospital-certifications/health-care-equity-certification
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10. Innovation and Value Initiative. Health Equity Initiative. Accessed September 10, 2023. https://www.thevalueinitiative.org/wp-content/uploads/2022/05/Health-Equity-Initiative-Overview.pdf
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12. Professional Competencies for Health Economics and Outcomes Research: 2023 update to the ISPOR Competencies Framework. https://www.ispor.org/conferences-education/conferences/upcoming-conferences/ispor-europe-2023/program/program/session/euro2023-3770/17180.
