Archive | March, 2008

Where Is “The Best Care”?

In a great post on the HealthBeat Blog, Maggie Mahar talks about research from The Commonwealth Fund called “Aiming Higher: Results from a State Scorecard on Health System Performance.” It provides a comparative state-by-state study of care in the U.S. (States in white are in the top quartile…ND, SD, NE, MN, IA, WI, ME, VT, RI, MA, HI.)

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As she points out, the researchers used 32 indicators which look at “Access”, “Quality”, “Potentially Avoidable Use of Hospitals and Cost of Care”, and “Healthy Lives”.

She also goes on to talk about the lack of connection between quality and cost of care. She talks about research from Dartmouth Medical School that supports the data from this study.

“If insurance rates nationwide reached that of the top states, the nation’s uninsured population would be halved,” the Commonwealth report observes. “If all states could approach the low levels of mortality from conditions amenable to care achieved by the top state, nearly 90,000 fewer deaths before the age of 75 would occur annually. Matching the performance of the best states on chronic care would enable close to four million more diabetics across the nation to receive basic recommended care and avoid preventable complications, such as renal failure or limb amputation. By matching levels achieved in the best-performing states, the nation could save billions of dollars a year by reducing potentially preventable hospitalizations or readmissions, and by improving care for frail nursing home residents. If annual per-person costs for Medicare in higher-cost states came down to median rates or those achieved in the lowest quartile of states, the nation would save $22 billion to $38 billion per year. While some savings would be offset by the costs of interventions and insurance coverage expansions, there would be a net gain in value from a higher-performing health care system.”

As the economy continues to be challenged and with the election coming, this will certainly be an issue that those planning the future of our healthcare system need to analyze. There are lots of opportunities for improvement to the system, but we have to realize the challenge of aligned incentives within the system and external to the system. I predict it would take three election cycles (12 years) for us to make fundamental change. How we get politicians aligned and committed to something that outlasts them may be as difficult as changing the system itself.

Cigna’s Digital Coupon

Cigna recently announced some changes to their website. The one that caught my eye was the ability for a patient to print a coupon for a reduced copayment on their first fill of a generic drug.

I think it is a great step. My hope and questions would be as follows:

  • Is it to promote therapeutic switching or simply for movement from a multi-source brand to its chemical equivalent?
  • Is the coupon for anyone who is using a generic? Or is it only for new starts on a generic? Or is it only for those switching from a higher cost brand to a generic?
  • How do you drive awareness of the coupon and adoption of the web?
  • If all they really need is a coupon code, can you send it to their phone (much more likely to have it with them at the pharmacy)? Or could you trigger a fax to the pharmacy?

Anyways, I think couponing and incentives have a role in driving behavior, and it is good to see a MCO jumping into the digital age with this.

Aging Impact on Communication Strategy

We all know that healthcare spending is concentrated and often very highly correlated with age. Yet, aging has several impacts on people that change their ability to receive information. I found the following statistics very enlightening as to why a multi-modal strategy (i.e., mail plus phone plus Internet) is important.

  • Impact on reading – slower reader, reduced contrast perception (source: www.preventblindness.org)
    • 17% of people over 40 have cataracts
    • 50% of people over 80 have cataracts
    • 2% of people over 50 have AMD (age-related macular degeneration)
    • 3% of people over 40 have a visual impairment (including blindness)
  • Impact on hearing – can’t hear certain sounds, need hearing aids
    • 30-35% of people between 65 and 75 have presbycusis
    • 40-50% of people over 75 have presbycusis
  • Impact on cognition – slower learning time (source: International Journal of Experimental, Clinical, and Behavioral Gerontology)
    • 1% of people age 60-64 have dementia
    • 30-50% of people over 85 have dementia
  • Impact on mobility – challenges operating a mouse or car
    • 37% of people over 55 have tremors

All this data was part of a Forrester teleconference on December 13, 2007 called The Customer Experience Review, Q4 2007.

I couldn’t find a link to the Journal listed above, but I did find a nice set of links to information on aging.

Two Solutions For Cholesterol: No Room For Vytorin / Zetia

In another study to debunk popular prescribing habits, the American College of Cardiology said that Vytorin and Zetia should only be used after other cholesterol lowering drugs have failed (e.g., Mevacor, Lipitor, Zocor). They actually went so far as to recommend patients on these two drugs go back to the other drugs.

The study was also released in the New England Journal of Medicine and is a disaster for these two drugs who had grown in marketshare through Direct to Consumer (DTC) advertising, aggressive physician detailing, and timing of their launches with the brand drugs in the class getting close to losing patent protection.

It makes me wonder what my reaction would be if I was one of the 18,000 participants in the Improve-It study which is looking at whether Zetia and Vytorin prevents heart attacks and deaths.

See follow-up in USA Today.

The Patient Experience Matters

It is a topic I am just hearing about although I heard my architecture friends talk about it 15+ years ago. Forrester even has a patient experience ranking now called the Customer Experience Index. They ask consumers 3 questions:

  1. Thinking about your recent interactions with these firms, how effective were they at meeting your needs?
  2. How easy was it to work with these firms?
  3. How enjoyable were the interactions?

Perhaps not surprisingly, but certainly unfortunately, healthcare ranks at the bottom. (Note: They ranked 112 companies.)

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So, it begs the question of how many of us think about things from an experience perspective.

One of the more interesting experiments I saw in architecture school was where some students set up a display where different areas of the building had color and sound that where activated by motion. The smiles and reactions from people were interesting. But, how often are we sitting down and mapping out the process and experience of the patient from open enrollment through different scenarios?

If we are, are we looking at all their different senses? Are we thinking about how different they are and how they will react to different information, events, colors, sounds?

One interesting think that a friend of mine introduced me to last year was the concept of sonic branding (i.e., branding a sound). I immediately think of Harley Davidson, but she talks about how Ford‘s door chime is viewed by them as a unique brand sound. I would guess Pringles has a unique sound when you open the can.

But, I can’t think of any healthcare organizations with a unique sonic brand (think AOL‘s “You’ve got mail”). Another missed opportunity…perhaps?

Real Life Biggest Loser

We all know that being in shape has lots of health benefits.  The issues of being overweight drive healthcare costs through the roof.  There is plenty of data out there about the obesity trends in the US.  The reality is that losing weight is hard.

The show The Biggest Loser does a great job of showing what exercise and diet can do.  The challenge of course is that most of us don’t live in a controlled environment with a personal trainer and 3 hours to workout per day.  So, a good friend of mine who has done it all on his own provides a great story.  He was just featured in our local paper here, but he has gone from 270 pounds to almost 200 pounds and from not exercising to running half-marathons.

In the end, it is basic…take in less calories than you burn per day.  Good luck.

From the World Health Organization (WHO):

Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. Some confusion of the consequences of obesity arise because researchers have used different BMI cut-offs, and because the presence of many medical conditions involved in the development of obesity may confuse the effects of obesity itself.

The non-fatal, but debilitating health problems associated with obesity include respiratory difficulties, chronic musculoskeletal problems, skin problems and infertility. The more life-threatening problems fall into four main areas: CVD problems; conditions associated with insulin resistance such as type 2 diabetes; certain types of cancers, especially the hormonally related and large-bowel cancers; and gallbladder disease.

The likelihood of developing Type 2 diabetes and hypertension rises steeply with increasing body fatness. Confined to older adults for most of the 20th century, this disease now affects obese children even before puberty. Approximately 85% of people with diabetes are type 2, and of these, 90% are obese or overweight. And this is increasingly becoming a developing world problem. In 1995, the Emerging Market Economies had the highest number of diabetics. If current trends continue, India and the Middle Eastern crescent will have taken over by 2025.Large increases would also be observed in China, Latin America and the Caribbean, and the rest of Asia.

Raised BMI also increases the risks of cancer of the breast, colon, prostate, endometroium, kidney and gallbladder. Chronic overweight and obesity contribute significantly to osteoarthritis, a major cause of disability in adults. Although obesity should be considered a disease in its own right, it is also one of the key risk factors for other chronic diseases together with smoking, high blood pressure and high blood cholesterol. In the analyses carried out for World Health Report 2002, approximately 58% of diabetes and 21% of ischaemic heart disease and 8-42% of certain cancers globally were attributable to a BMI above 21 kg/m2.

Fast Friday: First Edition

The good and bad of loving information is that you get a lot of it and hate to throw it away until you skim it and take some notes. But, I am getting backed up so I think I am going to start a Friday edition that will be less thorough and more a data dump of things that I have set aside. I welcome feedback on whether this is interesting, helpful, or just dumping.

  • ChangeNow4Health – I stumbled upon this website which interesting has a Humana copyright at the bottom. [Simplify, Prevent, Educate]

How do we go about fixing the nation’s health care system? Where do we start? ChangeNow4Health believes we begin with small first steps. We’re looking for changes we can confidently make in the short term, using existing resources in creative ways … changes that will result in genuine improvement.

    Facebook Application To Drive Blood Donations

    I must admit I am pretty conservative so it was with some reluctance that I finally joined Facebook.  After the Health 2.0 conference formed a group out there, I decided to join earlier this week.  First, my brother reached out to me.  Then, a roommate of mine from college who I hadn’t talked to in almost 20 years contacted me.

    Then, I became mildly interested.  So, I spent a few hours early this morning playing around.  But, I was most interested to find a post on Vijay’s Consumer Focused Healthcare blog about a non-profit using Facebook as a way to drive blood donations.  Will it work?  I don’t know, but it is a worthy cause and an interesting use of social technology.

    When a patient is in need of blood that isn’t available, it becomes a life and death situation. Historically the Red Cross will make efforts to alert the public during a shortage. But there may be a better way – leverage the social networks to get the word out. If shortages of a certain type of blood occur in a certain zip code, having a database of willing donors in that zip code to contact may be the most efficient way to solve the problem quickly.

    That’s where Takes All Types (TAT), a non-profit organization, comes in. Users install their just-released Facebook application, tell it their location and blood type, and say how often they are willing to be contacted to donate blood (maximum is every 57 days). If a shortage occurs, they’ll contact you via the methods that you authorize (Facebook, email, text message, etc.)

    Health Transformation 2.0: Follow-up

    The other day, I provided a few comments on this book (manifesto) that I picked up, and I reached out to the author. He got back to me last night and was kind enough to provide the PDF of the publication.

    In his words:

    “These are simply my thoughts and thoughts inspired by a community of friends. It’s written as a kind of manifesto with the hope to inspire more good minds to tackle a very major challenge facing our society.”

    I would encourage you to reach out to him if interested. (E-mail Scott Danielson – author)

    Here is the book for you to view. I hope you will enjoy the hard work his community put in both in terms of content and graphic design.

    Don’t forget to sign up for e-mail updates or put the blog in your reader. Thanks.

    Future of Marketing and Advertising

    Here is an interesting presentation on a view of marketing from outside healthcare.  I think it is a healthy way of thinking of the challenge.

    Drug Benefit News: Highlights / Comments

    I just flipped through the February 29, 2008 DBN edition.  A few things caught my eye:

    •  There is a whole article on PBMs and health plans focusing on physicians to manage Rx costs.  [Is this really new news?  The problem is not the focus, but on the incentives, the communications, and the age old question of who is in charge.]
      • As I pointed out in my recent webinar, most physicians agree that out of pocket spend is an issue for patients BUT most of them think it is the pharmacists role AND most of them are upset with the amount of calls they get from the pharmacists [who are trying to manage the spend].

    Brian Solow, MD, medical director at Prescription Solutions says
    “Physicians in the past have seen PBMs as maybe interfering with the practice [of medicine], but now they understand that [PBMs are] here and here to stay.  We’re trying to get the word out that the PBM is there to maximize the patient’s benefit, which hopefully in turn will make the physician’s life easier by helping the patient control the disease and get the proper medications.”

    A physician who they interviewed summed up the confusion well saying:

    “You just sort of pick [a drug], hope it flies, and if it doesn’t, somebody has to deal with it.” 

    Short of common formularies or working in a captive model (e.g., Kaiser) it will be hard to eliminate the confusion of different plans and different information.  Simplifying processes like Prior Authorizations could help.  Pushing information to the point of prescribing via electronic tools could help, but you are asking the MD to own the benefit management task which they don’t today.  (i.e., let me prescribe drug A…it has $x copay…would you prefer a cheaper alternative)

    It talks a lot about the CVS/Caremark settlement which is a lot like the Medco settlement from a few years ago.  The outcome [which is what I think they do today] is that they agree to:

    • Not move people to a more expensive drug (net cost or copay).
    • Not move from a MSB (multi-source brand) to a SSB (single-source brand).
    • Not move away from a drug whose patent is likely to expire in the next 6 months.
    • Inform patients and prescribers of the impact on copayment.  [very difficult]

    It also gives the latest on Medicare Part D lives:

    The total enrollment is 17.4M (as of January 2008).

    Poll Shows Real Issues

    survey_logo.gifThe AFL-CIO conducted a poll of almost 27,000 people about healthcare earlier this year. (The population was slightly biased with over 50% belonging to unions … which I don’t think is representative of the country.)

    The results I think are very telling about how the average person thinks about healthcare in the US:

    • One-third of respondents to the online survey, sponsored by the AFL-CIO and Working America, report skipping medical care because of cost, and a quarter had serious problems paying for the care they needed.
    • Ninety-five percent say they are somewhat or very concerned about being able to afford health insurance in the coming years.
    • Almost half overall (48 percent) and 60 percent of Latinos say they or a family member has stayed in a job to keep health care benefits when they would have preferred changing jobs.
    • Ninety-five percent of respondents say America’s health care system needs fundamental change or to be completely rebuilt.
    • Seventy-nine percent say health care is a very important voting issue, and 97 percent say they plan to vote in the November elections.

    I pulled a few of the patient quotes, but they are stunning in terms of the challenges and the hardship people are enduring due to healthcare costs.

    “What would you do if you had to choose between food or medicine? Because of rising health care costs, that is a question that is frequently asked in my home. I work full time and have health care through my employer, but only a percentage is paid by them….I recently needed medication for an ailment, but did not get the medicine—I couldn’t. What would I choose? I choose my children and what they need, whether it be food or medicine. I am the one who will go without before they suffer.”

    “My son joined the National Guard and went to Iraq so his wife could have health insurance. A very heavy price to pay though luckily he survived his first deployment and we fervently hope he will survive future deployments as well. ”

    You certainly should read the report and/or the website summary. I hope our presidential candidates and elected officials do.

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    EPS for EPS

    Express Scripts used to have a business line called Practice Patterns Sciences (PPS) which focused on using medical and pharmacy data to predict trends, improve costs, and improve outcomes.  This was back in the late 90s and probably ahead of its time.

    cog.gifI was talking with one of the people that was on that team yesterday and thought how similar that was to a lot of what I talk about.  So, I will call it Employee Pattern Sciences or Patient Pattern Sciences.  But, if I stick with the EPS, then it makes a clear point about focusing on Employee Patterns of behavior to drive Earnings Per Share.

    Any communication should have a clear ROI on it.  Building those and working to understand how to improve the business is where a lot of the fun is.  When you really understand data and metrics, you can start to see how one action can drive another action.

    For example, does better communications drive healthy outcomes?  If yes, does that decrease absenteeism?  If yes, there is a clear ROI.

    Healthcare Melting Pot

    Thanks to David’s post on the Health Business Blog, I came across the following study about the percentages of foreign workers that participate in healthcare roles in the state of Massachusetts.  Pretty amazing if you ask me.

    I think it clearly shows that we are making progress.  For those conservatives worried about immigration, it also shows how they are contributing to areas where we have a significant staffing issue today.

    According to the study, the percentage of foreign-born pharmacists doubled from 20 percent in 2000 to 40 percent in 2005. Physician assistants rose from 11 percent to 28 percent and paramedics increased from 4 percent to 14 percent.

    Other occupations with significant numbers of immigrants included foreign-born physicians and surgeons, who were 28 percent of their field in 2005, opticians (22 percent), licensed practical and vocational nurses (21 percent) and dentists (17 percent).

    Value Based – Impact on Pharma

    Kip has a good posting about the impact of value-based benefit design on the manufacturers.  He doesn’t allow comments so I will post some thoughts here.

    For many firms, this will require a significant, even scary change in thinking and tactics; payor-centric communications; comfort with a massive increase in transparency; and a greater willingness to partner. Therefore, while the financial risks of moving to a value-based world are daunting, ultimately the greatest challenges are intellectual.

    Value-based drug benefit designs will pose the greatest challenges to manufacturers with product lines (or pipelines) dominated “me too” drugs; rigid, risk-adverse organizational silos; and out-dated, prescriber-centric communications.

    While I certainly think the industry has been tip-toeing towards value based benefits for a while, it still will beg several key questions:  [Note: When I think about value based, I think about a grid showing outcomes mapped out versus costs similar to a quality over price analysis.]

    1. How do you value certain things – less pain, convenience, minor variations in outcomes, extension of life?
    2. How does genomics play in here when you realize that a drug may be better for one patient but worse for another?
    3. How do you communicate this to patients without making benefits more difficult to understand?
    4. Can patients “buy-up” to pay the difference to allow them to get an alternative that keeps the company neutral?
    5. Will we ever get standards and clean data?  We can’t even agree about whether anti-depressants work.

    I agree it’s a key trend and one to watch, but I think the implemented reality will be radically different than the solutions out there.

    Health Transformation 2.0

    I grabbed this little book off the table at Health 2.0.  I am finally getting around to flipping through it (rather than sleeping).

    I can’t figure out if it’s associated with a company.  If yes, they have done a great job of disguising it.  [For what purpose, I don't know.]  It is very well laid out with great graphics and is called:

    Health Transformation 2.0
    Can A Better Healthcare Operating System Make Us Healthier?

    The author’s name (Scott Danielson) and e-mail are in the cover so I have shot him a note to see if I could add it here as a flash or some other visual.  Here are a few of the comments from the book:

    •  Healthcare 2.0 uses emerging technologies to transform an archaic, disease-treating system into a progressive health-enhancing one.
    • In the past 4 years, healthcare costs have doubled.  Are we twice as healthy?
    • Today, we have the ability to create a set of tools, a healthcare operating system that will help people find and manage information, research and control costs, and get and/or stay healthy.
    • Connected.  Helpful.  Secure.  Organized.  Informed.
    • Personal + Health + Power = Personalized Health Empowerment

    Mistake or Deliberate?

    I must admit that I tend to be pretty compulsive about spelling and other mistakes.  I can’t read a book without circling errors or correcting grammar.

    So, I found it intriguing when visiting a company’s website that they talked first about the confidentiality of their clients, but all the links have the clients names in the URL.  It made me wonder if this was an innocent mistake or someone finding a deliberate workaround.  People clearly see that Healthways and Medco are their accounts without getting corporate approval to use their names.  [BTW - I whited out the company name since who it is isn't the point.]  

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    Does 1% Matter?

    The whole theory behind Microtrends is the 1% of the population matters and can form a force that can drive change.  Look at all the talk about marathoning in this country when only 0.17% of people have run one.

    From a healthcare perspective, I found it interesting that genetically “any two people are more than 99% the same at the genetic level” yet obviously genomics matters.  [We want to know what genes do.]

    If small gene differences can make the difference in how our body uses medicine, it could be a breakthrough, but (as the WSJ article suggests) will it bee too much for medicine to really master and take advantage of.  Great question.

    All of this made me think back to healthcare communications…does 1% matter?  Yes.  If you could develop communications that were specific to each segment, even if they varied by 1%, wouldn’t that improve results.  And, if you’re focusing on the measures that matter to drive your results, won’t that have an impact.

    Medication Adherence Devices

    I think we all can predict that the medical device industry should explode over the next few years.  USA Today had a recent article on a “smart pillbox” which caught my eye.

    According to Forrester Research, the market for home health monitoring technologies is expected to reach $5 billion by 2010 — and $34 billion by 2015.

    As the article stresses, this technology will be important with over 30M Americans taking more than 3 medications per day and over 100,000 dying from adverse drug reactions.

    Usually, I hear about things like glowing bottle caps to remind people to take their medications.  Although the Med E-Monitor is a little bulkier, I like the fact that it does more than simply remind you.  It also looks for adverse drug events and provides information.  Ideally, one of these devices will simply generate refills through a simple click.  [I have not read the studies but they claim to have raised adherence from 35-40% to 90% which would be significant.]

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    My big questions from looking at the website are:

    • It holds up to 5 medications.  What about those patients on 30 medications?  Can it be modularized?
    • Even if it can’t have modules, can it store the data and serve as the central reminder for medications not in there?
    • Who programs it with every medication change?  The MD.  The patient.  The company.
    • Can it generate a refill request to the pharmacy?  Can it generate a request for a renewal (i.e., a new prescription for my existing medication)?
    • Will people pay $60 a month?  Is the buyer, the children that live out of town and want their parent to be safe or the actual patient themselves?

    Some of the other sites out there talking about solutions include:

    Flooding

    I am fortunate to live in high ground in Missouri, but this is definitely the closest the flooding has come.  As close as 2 miles away, my friends neighborhoods are almost inaccessible.  They had to have a fire department park in their neighborhood for a few days since once the water crested, there neighborhood would be unaccessible if there was a fire.  Very scary.

    It reminds me of when I first moved to St. Louis in 1993 which was the worse flooding ever.  I have only begun to hear some concern for later in the spring when the record snowfalls up north begin to raise the water levels of the Mississippi.

    Here is a few pictures from our local news site KSDK.

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    3 Party Election

    Not that this has anything to do with healthcare other than the fact that the outcome of the election will be important in setting the direction for the US healthcare system.

    But, I can’t help but wonder why we wouldn’t finally see a legitimate 3rd party candidate this year.  If Obama and Clinton can’t have a clear winner, why wouldn’t someone like Ross Perot or even Romney step in and fund one of them so that they could finally get a legitimate opportunity to be vice-president.  [And, yes...I do realize that they are both republicans.]

    Great Book – Microtrends

    microtrends.jpgAt PBMI, one of the best speakers was Kinney Zalesne who with Mark Penn wrote the book Microtrends. I just finished reading the book – all 370+ pages. I found it to be one of the most engaging non-fiction books I have read in a long time…which says a lot. I have boxes and book shelves of books that I have bought, skimmed, and stopped reading. I get something out of them, but it is often not enough to continue reading the whole book.

    I found Microtrends to be interesting both personally and professionally. Let me throw out a few of the things that I highlighted and noted during my reading along with some of the potential implications within healthcare.

    Some of the topics they cover:

    • Love, Sex, and Relationships (Sex-Ratio Singles, Cougars, Office Romancers, Commuter Couples, Internet Marrieds)
    • Work Life (Working Retired, Extreme Commuters, Stay-at-Home Workers, Wordy Women, Ardent Amazons)
    • Race and Religion (Stained Glass Ceiling Breakers, Pro-Semites, Interracial Families, Protestant Hispanics, Moderate Muslims)
    • Health and Wellness (Sun-Haters, 30-winkers, Southpaws Unbound, DIY Doctors, Hard-of-Hearers)
    • Family Life (Old New Dads, Pet Parents, Pampering Parents, Late-Breaking Gays, Dutiful Sons)
    • Politics (Impressionable Elites, Swing Is Still King, Militant Illegals, Christian Zionists, Newly Released Ex-Cons)
    • Teens (The Mildly Disordered, Young Knitters, Black Teen Idols, High School Moguls, Aspiring Snipers)
    • Food, Drink, and Diet (Vegan Children, A Disporportionate Burden, Starving for Life, Caffeine Crazies)
    • Lifestyle (Long Attention Spanners, Neglected Dads, Native Language Speakers, Unisexuals)
    • Money and Class (Second-Home Buyers, Modern Mary Poppinses, Shy Millionaires, Burgeois and Bankrupt, Non-Profiteers)
    • Looks and Fashion (Uptown Tatooed, Snowed-Under Slobs, Surgery Lovers, Powerful Petites)
    • Technology (Social Geeks, New Luddites, Tech Fatales, Car-Buying Soccer Moms)
    • Leisure and Entertainment (Archery Moms?, XXX Men, Video Game Grown-ups, Neo-Classicals)
    • Education (Smart Child Left Behind, America’s Home Schooled, College Dropouts, Numbers Junkies)
    • International (Mini-Churched, International Home Buyers, LAT Couples, Mammonis, Eurostars, Vietnamese Entrepreneurs, French Teetotalers, Chinese Picassos, Russian Swings)

    Second, the countertrends are very interesting. More caffeine and more water. Shorter attention with a rise in knitting. More technology and more people abandoning technology. Obesity and intentional starvation. More sun tan parlors and more people afraid of the sun.

    “Microtrends is based on the idea that the most powerful forces in our society are the emerging, counterintuitive trends that are shaping tomorrow right before us.”

    Sample facts:

    • Less than 25% of the households in the US are married-with-kids. 26% are households of one person.
    • At birth, there are 90,000 more boys born per year than girls. By age 18, it has switched to a 51% female mix. Exclude out the gay men and lesbian women, you get a straight sex ratio of 53 women to 47 men.
    • 3M American adults in a long-term relationship or married met online which is the same number that met in church.
    • There are already 5M people 65 or older in the workforce and that number is expected to grow.
      • According to an economist at the Urban Institute, “if everyone worked just one year beyond expected retirement, we’d completely offset the anticipated shortfall between benefits and taxes in the old age insurance portion of Social Security.”
    • 3% of workers work from home. The average commute is 25 minutes. 3.4M people commute at least 90 minutes each way to work.
      • Researchers at Georgia Tech found that “every thirty minutes spent driving increases your risk of becoming obese by 3 percent.”
    • In a Gallup poll in 2006, when people were asked about how they feel about religious groups, Jews rated the highest with a net positive of 54%. There are more Christian evangelicals in the US that support Israel than Jews.
    • 5.4% of marriages are interracial which led to the US Census allowing people to select multiple races in 2000.
    • There are 10M Protestant Hispanics in the US which is more than the number of Muslims or Presbyterians.
    • 81% of American Muslims support gun control (compared to barely half of Americans).
    • There are 3x as many tanning parlors in the US as Starbucks.
    • 1 in 10 children aged 12-18 uses a sunlamp and only 1 in 3 uses sunscreen. And, at least 25% of skin damage occurs before a person is 18 years old.
    • 16% of American adults sleep less than 6 hours a night. But, this causes injuries, accidents, and health problems. Lack of sleep triggers hormones that boost hunger and appetite.
      • She calculated out what I have argued for years that this creates an extra 8.2 years of life for someone who lives to 82.
    • DIY (Do-It-Yourself) Doctors is a whole new group of people that self-diagnose, self-medicate, and challenge their physicians.
    • OTC sales are now $15B per year.
    • In 1997, Americans spend more out-of-pocket on Complementary and Alternative Medicine (CAM) that on hospitalizations.
    • 3 in 5 Americans worry about medication errors at the hospital.
    • Women make healthcare decisions in over 70% of households.
    • 81% of people would like to use e-mail with their doctors but only 8% say they do today. [If they were controlled and reimbursed for this without increasing risk, I think they would welcome it.]
    • 1 in 10 Americans have some hearing loss. Nine seconds into a rock concert, you experience hearing loss. [I have been to several concerts even in the front row so that seems like a problem.]
    • 1 in 18 births were to men over 50. [Changes your underwriting profile.]
    • 63% of American households have pets. And, the top 1% of pets live better than 99% of the world’s population.
      • Studies have show health benefits of pet ownership including lowering blood pressure, reducing stress, preventing heart disease, and warding off depression.
    • Only 15% of parents would take away their kids privileges if they found out their 15 year old was using illegal drugs. [And most of us think we are strict?]
    • Only 4% of people over age 65 live in nursing homes or assisted living arrangements.
    • 40% of the people providing unpaid care for infirm adults are men. [Counter this to the assumption that women make most healthcare decisions.]
    • 650,000 ex-cons enter society every year. [Have we increased their health literacy while in prison.]
    • Childhood autism has increased 9-fold since 1992.
    • The number of kids being treated with antipsychotic drugs shot up 138% between 1997 and 2000.
    • In 2005, the main medical manual on the mental health of infants added two new subsets of depression, five new subsets of anxiety disorders and six new subsets of feeding behavior disorders.
    • There are 20M knitters in the US and more than ½ of them are under 34 with almost 6M of them being under 18.
    • In 2000, over 8% of teens were making money on the Internet.
    • There are 1.5M kids (between 8-18) that are vegetarians. 3M more who pass up meat but each chicken or fish. And, 3M more that each just chicken. 11% of girls aged 13-15 don’t eat meat.
      • Vegetarian men have been shown to have a 37% lower risk of heart disease.
      • Vegetarians of both genders are ½ as likely to develop dementia.
    • There are 9M morbidly obese people in the US (100 pounds overweight). Women are 2x as likely as men to be morbidly obese, but 1 in 6 black women are morbidly obese.
    • There is a small group of people practicing Calorie Restriction diets (1,200 – 1,800 calories).
      • Scientists have found that this lowers blood pressure, LDL, clogging of arteries, and body temperature (which may slow aging).
    • 6 of 10 Americans drink coffee every day. And, Americans drink 23 gallons of bottled water per year and 52 gallons of carbonated soft drinks.
    • The average age of caffeine overdosers was 21 in a study done around the Chicago Poison Center.
      • Caffeine causes insomnia, anxiety, headaches, stomach problems, cardiac arrhythmias, and weight gain.

    “It is almost as though marketers see today’s society as an Amazon tribe, where women make all the decisions and men just go along for the ride.”

    • There are 12M “linguistically isolated” households in the US (i.e., no one speaks English well). And, in 2/3rds of these households, the head of household was born in the US. [Is multi-lingual soon to be a requirement?]
    • 1 in 3 Americans age 25-29 have a tattoo. 13% of Americans aged 18-24 have a tattoo and a body piercing.

    Sample Healthcare Questions:

    1. How do we respond to the change in the family – older dates, commuter couples?
    2. With people working longer, what does this mean for health benefits? Are your needs and expectations different at age 75?
    3. When people are doing things that influence their health – sun tanning, sleeping too little, drinking too much caffeine, will companies step in and try to control this? (I know one large company in the South that has decided they won’t serve any fried food in the cafeteria.)
    4. Why don’t we do things like encourage pet adoption to help people become healthier?
    5. What are the implications of vegan children and low calorie diets and should the industry embrace, reward, or monitor them?
    6. When people don’t want to indicate a gender, will healthcare forms have to offer a “neither” category?
    7. With so many people getting tatooes, how long until that is a covered benefit or where there is a negotiated discount like the gym.
    8. There are lots of messy people. How do you communicate with them knowing they will misplace many things?
    9. For the people that have tried the Internet and chosen not to use it again, do you risk offending them with your constant push to self-serve?
    10. If America wants numbers, should we communicate more details not less?
    11. Should we be tracking lots of other factors (diet, caffeine, commute) in our Personal Health Records?

    istock_000005278005medium.jpgI could go on, but I don’t want to give it all away. It is worth reading. It really makes you realize the value of targeting and personalization within a HealthComm framework.

    Retrenching? – Specialty Pharmacy

    PBMs getting into the specialty pharmacy business has been the focus for much of this decade. It was considered a logical extension of their core services – claims processing, customer service, trend management, fulfillment, supply chain, and rebate negotiation.

    But, in the course of 3 weeks, I have had 3 people (none of them at Express Scripts) ask me if Express Scripts is selling specialty. Given the disparity of these people, I have to believe it’s being considered. When I asked someone at the company, they were shocked at the thought of it.

    Express Scripts bought Curascript and subsequently Priority. I can’t see them putting all of those assets on the block, but I could be wrong. That would be an interesting change. George Paz [CEO] is known for his great focus on the bottom line and driving the share price so I wouldn’t doubt that if these were underperforming assets then they would be re-evaluated. But, given today’s market, I can’t see how they will get back what they paid for them.

    The company has driven the stock relentlessly over the past 10+ years. I know in one case he even went to a client where they were losing money and demanded a price increase. You don’t hear about those types of negotiations very often.

    So, I guess the true question is what would this mean. Would it mean that specialty doesn’t belong in a PBM? If they sold, is it their issue or an industry issue?

    More interesting perhaps, is what would they do with the money? As I talked about before, Express Scripts has lots of cash and has stated they are looking for an acquisition. If they were to sell some or all of their specialty business, they would have even more cash to pursue something else.

    Traveling Fun – No ID

    Of course, when I show up at the Boston airport yesterday for a quick day trip down south, I can’t find my license. I hate the fact that you have to take it out of your wallet at security and sometimes at the car rental place. It just increases the probability of losing it.

    And, I couldn’t lose it when I had just one flight. I had to fly down south, then fly back to Boston, and then fly to St. Louis. Three “extra” security checks, and no ability to rent a car.

    Fortunately, after two of the security checks, Avis called to say they found my license. (Now, I just have to get a plane to show up in Cincinnati to catch my connection.)

    But, I did learn several things in the process.

    1. You could actually use a lack of ID to cut through security lines as discussed at the Four Hour Workweek Blog. It would definitely work if they check ID at the beginning of a long security line.
    2. You can fly with some alternative forms of ID (other than driver’s license and passport). They told me that if I had a photo ID (e.g., Sam’s card) with a voter registration card or some other government issued ID then I could get through without the added security.

    Without ID, you get fully padded down and wanded. Then everything you have with you is tested for bomb materials and searched.

    Don’t You Know Me

    A Harris Interactive poll published in AdAge a few weeks ago, talked about the value people put on companies knowing who they are. We have all had that experience where you put in your phone into the IVR then get asked to verify it when the person picks up the phone and asked again for the number and your name when you get transferred. How annoying!

    I always joked with our VP of Call Centers that Dominos was more likely to know who I was based on my caller ID then we were. There are so many technologies out there that there isn’t a good reason for companies not to take advantage of them. There is technology that based on your voice can tell if you are depressed. There is technology that based on your voice can tell if you’re angry. There are plenty of screen pops and technology that can pull in the caller ID.

    Even the companies that do that don’t often have a consolidated view of the customer. They don’t know that you called yesterday; visited the website earlier; got a call last week; had a mailing sent to you last month; filed a complaint about the same issue you are calling about; etc.

    So, how do consumers feel…

    • 95% believe it is at least somewhat important that companies know “who I am, my buying history, past problems or complaints, preferences, and billing record”
      • 37% said personal history is important
      • 27% said it’s very important
    • 62% said they would not hesitate to cancel or switch services if they had a negative experience

    Of course, healthcare makes this hard. With employer sponsored healthcare, I can only switch annually or with certain events. With individual healthcare, I might not switch for fear of having some condition excluded. Plus, companies worry about trading privacy for personalization.

    But, the reality is that this is going to continue to be an issue. Technology is putting more and more information out there and raising the bar.

    On the flipside, doing something wrong quickly gets put on people’s Facebook pages, their blogs, or other tools where the experience ripples real-time and never disappears.

    Who Do People Think Are Honest?

    Not surprisingly (and fortunately) people believe their pharmacists and physicians are trustworthy and ethical. Here is a study from Gallup.

    trust-gallup.gif

    Savings From Wal-Mart Program

    I must admit that the $4 generics programs across the country cause me to have a mixed reaction.  On the one hand, it’s great.  It saves patients money.  In theory, it should encourage compliance.  On the other hand, if they get processed as cash transactions, I worry about them not showing up as claims which could limit the effectiveness of the POS (point-of-sale) DUR (drug utilization review) process.  [DUR includes things like drug-drug interactions.]

    But, I was very interested to see some of the Wal-Mart data being published.

    “While $1 billion in savings is an astonishing achievement, the real savings to America – and its health care system – are even larger. That’s because many of our competitors have also lowered their prices.  [Four dollar] prescriptions now represent approximately 40 percent of all filled prescriptions at Wal-Mart. Nearly 30 percent of $4 prescriptions are filled without insurance – significantly higher than the 10 percent industry trend.”  Dr. John Agwunobi, Wal-Mart‘s senior vice president and president of health and wellness

    You can go drill down on some of the data (e.g., state by state savings) here.  Some of the top states were:

    • Texas ($132,628,224)
    • Florida ($72,443,467)
    • North Carolina ($48,241,530)
    • Georgia ($42,279,383)
    • Missouri ($40,213,963)

    It is also great to see that 30% of all the $4 generics are being filled by people without insurance.   It was also good to see that they are focusing on bringing new generics into this group faster which was another historical criticism that I had.

    Trusted Source of Healthcare Information

    I often wonder who people trust for information.  So I was glad to come across this  article in Employee Benefit News.
    I must admit that I was surprised by several of the results.

    • Only 2% trust their employers?
    • More people trust their PCP versus their specialist?
    • More people trust general information portals versus content sponsored on their health plan website?

    ebn-trusted-source-info.jpg

    Non-PC: Is Recession Good For HealthCare?

    I am sure this is not a politically correct topic to discuss, but the thought crossed my mind.  Since 75% of the US thinks we are in a recession, I think we can assume that people will act as if we are in a recession.  Never mind the economist definition of whether it’s a recession.

    So, what are the implications for healthcare:

    • If I am cost conscious, I should be more willing to accept generics and mail. (pro)
    • If I am cost conscious, I may be more willing to go to a clinic versus a physician or urgent care.  (neutral)
    • If I am cost conscious, I may be more likely to skip doses or not refill my medications. (con)
    • If I am cost conscious, I may not join a gym but instead workout outside.  (neutral)
    • If I am cost conscious, I may not be preventative in my care.  (con)
    • If I am cost conscious, I may be more willing to accept free services offered through my employer or plan. (pro)
    • If I am cost conscious, I may take advantage of all the web tools and member portals which exists.  (pro)

    In the big picture, there is a chance that a recession could push individual health insurance faster.  Just like Medicare Part D was a catalyst, a recession could change the employer sponsored healthcare paradigm and drive people to find insurance for themselves.  Making that happen quickly will be an issue.

    Blinded By The Voice

    I heard an interesting arguement the other day.  Someone was saying that the only thing that matters in the automated voice space is the voice.  They suggested listening to a call and thinking about what the patient heard.

    This reminds me of advice from business school that the paper on which your resume was written makes all the difference.  Or that the font or color on your marketing materials is the key thing to get right.  It certainly matters.  But different people want different voices.  Ultimately, it’s about how you deliver that 1:1 personalized communication to the patient based on their preferences, their historical interaction pattern, and a blend of their claims and demographic data.

    The other thing that surprised me was the implication that voice was more important than reporting and technology.  If I have a great patient interaction, but I can’t mine the data and I can’t easily modify the program to be better than I am blind to the success.

    One of the things that I experienced when I ran campaigns is the need for in-flight modifications.  I may predict that I get a 20% response rate to a particular copay waiver program, but if I only get 5%, I rather stop it day one and tweak a few things rather than wait 30 days and miss a lot of opportunity.  On the other hand, if I get a 40% response rate, I may want to dial down the volume to manage my transfer rate to my call center and not mess up my ASA (Average Seconds to Answer) which probably has some SLAs tied to it.

    Think about your communications solution from every angle…the interaction, set-up, ease of change, flexibility, reporting.

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