Archive | July, 2010

Back To The Future: The Role Of The Pharmacist

Between the focus on differentiation and the focus on adherence, we have seen (and will continue to see) greater use of them as a strategic asset. CVS Caremark is leveraging them in their Pharmacy Advisor solution. Walgreens continues to leverage them at the POS. Medco is using them in their Therapeutic Resource Centers. And, the independent pharmacists have stressed this story for years.

In Medicare, the Medication Therapy Management (MTM) process begins to recognize the power of pharmacists and actually rewards them for their efforts. I was quoted in Drug Benefit News today about this topic. Here were a few quotes:

“The pharmacist is an under-utilized resource today,” George Van Antwerp, vice president of the Solutions Strategy Group at Silverlink Communications, tells DBN. “They go to school to work with patients and often end up simply filling bottles.”

While the benefits of pharmacist intervention are undeniable, Van Antwerp says, the challenge is finding the right balance of face-to-face interaction and automation. Issues also include getting a good return on investment for such services by condition and the fact that only an estimated 60% of the people picking up prescriptions are the patients themselves. In addition, “the staffing model right now would be stressed if pharmacists were spending significant time on cognitive services,” he maintains.


 

Aetna To Outsource PBM Functions To CVS Caremark

While the market seems more mixed on this than me, I see this as a good thing for CVS Caremark. If played right, this could be a huge factor for 90-day retail and/or Maintenance Choice since Aetna (as the payer) will have huge incentives to take advantage of this.

I was a little surprised since most of the rumor had been that Medco was going down this path with Aetna and that this was what they had pitched to Wellpoint prior to the Express Scripts acquisition of the pharmacy business.

And, for those of you that have been around this space for a while, you might remember that Aetna did outsource some of their PBM business up until about 6 years ago when they insourced in from Express Scripts. I’d be interested to understand what changed (which might simply be in the finer points of this new agreement which doesn’t appear to sell assets but to leverage CVS Caremark’s scale).

It clearly points out that there are scale efficiencies in the PBM business something that I think will come to end in the near future (as predicted in my white paper a few years ago). So, I think the question a lot of people are asking is whether this move will accelerate different models to get to scale:

  • A roll-up strategy of smaller PBMs by the large PBMs.
  • A consolidation of smaller PBMs into coalitions and buying groups.
  • Smaller PBMs contracting with larger PBMs for core services.

Let’s look at some of the PBM functions to think thru what makes sense to consolidate and leverage (IMHO):

  1. Sales – independent
  2. Marketing – independent although some physician or consumer marketing could be consolidated
  3. Implementation (Client Set-Up) – independent
  4. Research – drug trend, research studies, and analytics could be consolidated
  5. Plan Design – could be consolidated but not likely large efficiencies
  6. Drug Acquisition – consolidation would drive the majority of value
  7. Procurement – consolidation could add value
  8. Rebating – another big opportunity for consolidation but requires coordination on formulary (P&T) and other areas
  9. Mail Fulfillment – should offer consolidation benefits
  10. Call Center – should offer consolidation benefits
  11. Claims Processing – limited but possible consolidation benefits
  12. Clinical Reviews – easy to consolidate but minimal savings

I think given Express Scripts and NextRx and now CVS Caremark and Aetna (although different relationships) that this puts the spotlight back to Medco for the next move. I think the likely focus areas would be on Cigna and Prescription Solutions (part of United Health Group). After those two, there are other less likely targets – Prime Therapeutics, Walgreens (PBM), and MedImpact.

Drive: The Surprising Truth of What Motivates Us

I haven’t read the book yet, but this is a great video.  I love the fast paced whiteboarding to match the speaking.

DMAA Client Presentations

We (Silverlink Communications) are very excited to see three of our clients get selected to present at DMAA this year.  That is a tribute to all their hard work, creativity, inspiration, and willingness to leverage technology to improve outcomes.

Here are the presentation summaries from online:

Reducing Blood Pressure in Seniors with Hypertension Using Personalized Communications
CONTINUUM OF CARE SERIES
Wednesday, Oct. 13, 1-2 p.m.

  • Examine how an integrated communications program that utilizes remote monitoring and interactive voice response components combine for an easily scalable, cost-effective solution to reduce hypertension.
  • Review a program where 18 percent of participants transitioned their hypertension from out-of-control to well or adequate control.
  • Identify best practices for how personalized, automated, interactive communications can be leveraged to control hypertension in a scalable manner.
  • Evaluate how high blood pressure readings alerted patients with immediate feedback and education to help them better manage hypertension.

Improving Statin Adherence through Interactive Voice Technology and Barrier-Breaking Communications
Wednesday, Oct. 13, 2:15-3:15 p.m.

  • Examine how interactive voice response (IVR) and barrier-breaking communications can measurably improve statin adherence.
  • Review key barriers to statin adherence, including several barriers that are more significant than cost.
  • Identify best practices for using IVR technology to improve statin adherence by addressing specific barriers.
  • Evaluate how continuous quality improvement processes were used to drive higher response rates to IVR prescription refill reminder calls.

Addressing Colorectal Screening Disparities in Ethnic Populations
Thursday, Oct. 14, 12:30-1:30 p.m.

  • Examine how interactive voice response (IVR) technology and personalized messaging improves the rate of colorectal cancer screening for different populations.
  • Review the impact of ethnic-specific messaging on colorectal cancer screening rates and how this differs by ethnicity.
  • Examine how engagement is influenced by the gender of the voice in communications outreach.
  • Identify how to use predictive algorithms to project race and ethnicity to support tailored communications.

National Drive-Thru Day…and Pharmacy Impact

I know…I know. I’m reminding you late. It was July 24th. I’m sure it would have changed your plans for the day. (Who makes up these days?)

I do think the drive-thru is interesting for several reasons:

  1. What it says about us overall; and
  2. It’s impact on the pharmacy business.

In general, there aren’t many healthy uses of the drive-thru. It’s a productivity tool that (like technology) limits our interactions with other people.

A few facts for you:

  • We spend $110B at drive-thru fast food restaurants each year.
  • The first drive-thru fast food restaurant was at In-N-Out Burger in 1948.
  • Strangest use of a drive-thru (IMHO) was Gaitling’s Funeral Home in 1989.
  • In the mid-2000′s, drive-thru staffing was changed such that the order taker could be outsourced to allow the person taking your money to be more productive (i.e., you’re talking to a person at a different location).

So, what’s happened in pharmacy? I’ll have to find the date of the first drive-thru in pharmacy.

  • Walgreens certainly seems to be the dominant user of this strategy where they will typically have 1-2 lanes for drop off and pick-up of prescriptions. This is definitely a productivity play for the drive (suburban) culture. I’ve used it frequently when I have a first-fill and either kids in the car or it’s raining or cold.
  • 29% of people said they use this method in a WilsonRx 2008 study…but only 3% said they prefer this method.
  • 42% of people who used the drive-thru were highly satisfied (compared to 56% highly satisfied with either pick-up at the store or receiving by mail).

The big question a few years ago was whether this productivity enhancement damaged the pharmacist-patient relationship. I would argue “of course it did”. How could it not? You no longer talk to them face-to-face.

I would also question privacy here. On the one-hand, it’s harder for the patient’s behind you in line (i.e., in their car behind you) to eavesdrop. BUT, when there are two lines, it seems pretty easy for the car next to you to hear everything you talk about with the pharmacist. AND, if we’ve learned on thing from mobile phone headsets, it’s that people seem to talk louder into the phone (i.e., I think the pharmacist inside is talking to you louder).

Of course, one true question is whether you really had a relationship with the pharmacist to begin with. In most cases, you’re dealing with a pharmacy tech not the pharmacist. The majority of people (even at independent pharmacies) don’t know the first name of their pharmacists (BTW – mine are Marc and Renee).

Now, what I find most shocking in this chart from the 2008 Pharmacy Satisfaction Digest by WilsonRx is that only 1% more know the name of their pharmacist at a chain drugstore than at mail order.

Being Proactive and Reactive Improves Adherence

I don’t think any of us who spend a lot of time in the adherence area are surprised by this, but it’s always good to have a nice, published study to reinforce the point.

CVS Caremark published a study done last year using interactive outbound call technology to improve their adherence program. (Chang et al., Improving Persistency for Maintenance Medication Therapy Through an Interactive Voice Response Program, Journal of Managed Care Pharmacy, 2010. 16 (2): page 156.) It showed that being proactive (i.e., calling before the patient ran out of pills) was better than doing nothing (control group) and better than calling reactively (i.e., the patient has run out of pills). But, if you do both, you significantly improve the likelihood of them getting a refill and staying adherent.

Caremark iPhone App – Will Others Follow?

CVS Caremark announced today that they were releasing a Caremark iPhone application. First, I think it’s about time (for some PBM to do this). I would think the other PBMs will follow suit.

Second, I think this is a great opportunity for an expanded CVS Caremark iPhone application which expands the functionality of the app and is like Maintenance Choice in that it offers a benefit of the integrated company.

Today’s application is PBM centric and focused on ordering refills (I assume at mail only); checking prescription order history (I assume mail only); viewing prescription history; requesting a new prescription (retail-to-mail I believe); checking drug cost; and finding a nearby network pharmacy. Checking drug cost could be the coolest feature since it would give patients what they don’t have today – an ability to check the cost while they’re at the physician’s office. Finding a network pharmacy is an important tool if companies were to promote limited networks, but it’s only a nice to have if all the pharmacies are in the network.

So, of course the question that I would have is when will they add the retail components to request retail refills (at CVS stores or all locations); check status of prescriptions (e.g., prior auth required); request a renewal of an Rx; request a lower cost alternative; find a CVS with a MinuteClinic; or identify opportunities to save money (e.g., a generic alternative).

There are lots of other things to push out via the application, but I agree with the strategy of focusing on the core applications first. Caremark (or other PBMs) could push clinical suggestions; send adherence reminders; do satisfaction surveys; collect barrier data (why not adherent); and collect information (why not using generics). I also see it as a great way to push tools – e.g., 5 questions to ask your physician when you get a new Rx.

It would be interesting to see the statistics in a year – how many downloads of the app; how frequently is it used; patient satisfaction with the Caremark for those with the app (vs those without); adherence for those that use the application; what functions work best; savings versus other modes of communication; and effectiveness of their appliction versus other health applications.

ADHD Drugs – Long Term Effect

Given the frequency of use of medications in our society today, I think there is much to learn once we see what happens when people are on medications for chronic conditions for their entire life.

Although this study only looks at 10 years and was funded by drug manufacturers, I think it’s a promising study that shows that kids that take stimulants for ADHD may have an initial slowing in weight and height, but that over 10 years there was no difference.

How Much Do You Really Notice?

The Dateline NBC show “Did You See That” shows us just how little we see or how easily our minds are distracted. This is a real issue when we think about communicating information to patients who have hundreds of other things going on in their life.

Would you notice if the man who stopped to ask you directions on the street all of a sudden became a woman?

Would you notice a man walking thru a group of basketball players when you were focused on counting passes?

Would you notice when the talk show host’s shirt turned from blue to green?

Would you notice that the person helping you at the store was blond one minute and a brunette the next minute?

People in the videos on the show didn’t. It was amazing…scary…surprising.

It makes you think. It made me want to experience the tests. Would I notice?

Watch this video – http://www.msnbc.msn.com/id/21134540/vp/38287250#38287250.

Blog Sponsor – JRS Medical Supplies

I would like to thank the team at JRS Medical Supplies for sponsoring my blog. They offer over 20,000 discounted medical supplies from over 350 suppliers from their site.

Brand Drug Prices Continue To Go Up

As Medco highlighted several weeks ago, brand prices are going up a lot faster than generic prices. That’s nothing new. But, Barclays Capital recently highlighted that brand prices are going up faster in 2010 than any prior year (based on First Databank data).

Why?

  • Are they trying to make up for their concessions around Part D pricing and closing the donut hole?
  • Are raw material prices up?
  • Is it harder to develop a blockbuster drug and therefore R&D costs are going up?
  • Is it because the brand market is so much smaller with generic fill rates up?
  • Is it because their drug is losing patent?
  • Is it because they’re chasing more orphan drugs?

I’m not sure, but it certainly is a point of concern for many plans although in the big picture it’s not a huge driver of cost…

  • Prescriptions represent 10-15% of total healthcare costs.
  • Brand drugs represent 20-30% of prescription claims (but probably 70-80% of prescription costs).
  • Even a 10% increase in prices across the board would only be about 1% increase in total healthcare costs.

10 Numbers You Need To Know For Mobile Health

I found this great list of statistics yesterday from RxEOB. I won’t repost them all here so you click thru to the original content, but I thought it was very helpful.

23%. Percent of American households who use only a mobile telephone, no land line. Another 15% of homes with landlines report they receive all calls to their mobile device.

32%. Percent of Americans whom have accessed the internet from their mobile phone as of 2009. (19% reported they did it “yesterday”). In total 56% of Americans have accessed the internet via some form or wireless device (e.g., phones, MP3 players, laptop, game consoles).

81%. Percent of physicians will own a smart phone by 2012. Physicians are one of the highest using Smartphone demographics overall.

5,820. The number of health apps that were available for download from the major online Smartphone app stores (as of a report published Q2 2010).

66%. Percent of Americans who are interested in receiving health related emails from their health insurance company… 52% would be open to receiving emails that provide them feedback on their health process.

Is Slacktivism Good?

I guess it’s kind of like being an “arm-chair quarterback” or a “back seat driver”. Slacktivism (Slacker + Activism) refers to doing good without doing much. Donating thru a text message. Clicking on a link to generate donations. Wearing a rubber wristband to show your support of a cause.

Is this bad?

I don’t think so. Obviously, the world needs activist who actually roll up their sleeves and get involved in solving the world’s problems. But, are people that support them thru money (or clicks) or some other form of support not important?

In today’s social media world and connected world, donating and supporting causes should be easier. Everyone wants to announce their support for movements in Facebook from “my college is better than yours” (Go Blue!) to “I checked my H1c today” to “stop Communism”.

But, the article in Fast Company that got me on this topic talks about a few great case studies:

  • FreeRice.com – For every correct answer you get to the questions they ask, 10 grains of rice are donated to the UN World Food Program. Why not? 22 million bowls of rice have been generated by this program.
  • Haiti donations to the American Red Cross – The $10 text message pledges raised $38M.

So, how do we tap into this with healthcare? That seems to be the Holy Grail.

  • Lose weight without diet or exercise. (why so many weight loss pills sell)
  • Take my medication without having to remember every day. (e.g., patch)
  • Track my vitals without going to the physician’s office. (connected devices)

Social pressure certainly plays a role here. The question is whether our privacy concerns outweigh the benefits (often not understood) of participating in certain social activities. For the younger generation, this will not be an issue. They don’t view privacy the same way. For the older generation (who by the way are the sick and expensive patients today), privacy is a big deal and some of them are technophobic (although probably less than you think).

BTW – Did you click thru on the FreeRice.com link yet? Come on.

Cluster Marketing and Communications Challenges

This is a term that a friend of mine introduced me to a few years ago. How do you coordinate messaging across channels and the timing of the delivery of those messages to drive a behavior?

  • Do I send an e-mail and then call the individual if they don’t open it in 72 hours?
  • Do I send a postcard before I send a letter?
  • Do I call someone to tell them that I’m sending them an e-mail?
  • Should all the messages be the same? Or should they show a progression of urgency (for example)?
  • Do you have a single view of the consumer so you know what they have historically responded to?
  • Do you manage your communications as an integrated process so once they take an action you can immediately stop the next communication (e.g., the patient logged into the website last night so don’t send the e-mail scheduled to go out in the morning)?

These things aren’t easy especially in healthcare where the technology to manage direct marketing is several years (being nice) behind consumer markets like banking or consumer goods. But, this is one thing that Silverlink Communications does for clients. Understanding these challenges, providing industry experts to design solutions and test plans, and having a technology platform to execute, track, and report on these challenges is what we do.

Another common challenge is determining frequency. Should I call the person once a day, once a week, once a month, or once a quarter? How is that different based on the result of the prior interaction? How is that different based on their condition? How is that different based on the drug they’re taking?

For example, I might call a patient recently diagnosed with depression in the initial few weeks to remind them to stay adherent with their medications as it may take a few weeks for them to feel a difference. For patients on drugs with immediate side effects, I might need an earlier intervention.

A few points from Dan Ariely, author of Predictably Irrational (Spirit Magazine, pg 46, July 2010):

  • He observed that people doing work that involves decision making needed more positive feedback during the process. Do patients need more positive feedback for doing the right thing? Should you reach out and say good job for going to the physician?
  • He observed that people lose motivation if the work they do goes unnoticed. Should companies call patients and say thanks for moving to mail order and saving them money?
  • He observed that large rewards cause pressure which distracts from the task at hand. How do you break down your rewards into more near term reinforcement and don’t forget about non-monetary rewards?
  • He observed that people are more committed to change when it’s there idea. How do you get patients to think about things they should do? One of his suggestions was to ask more questions.

But, this is only part of the challenge. How do the attributes of your intervention affect their likelihood to act? Could the name of your call center agent matter?

A study by the Edinburgh International Science Festival found that people make assumptions about people based on their names:

  • People with royal names (James and Elizabeth) are assumed to be highly successful and intelligent.
  • People with soft sounding female names (Lucy and Sophie) are assumed to be the most attractive.
  • People with short male names (Jack and Ryan) are assumed to be more rugged.

If you’re using an automated call, does the voice talent you use matter? (see prior article)

Researchers at the University of Wisconsin-Madison found that a mother’s voice is as comforting as a hug which lowered levels of stress inducing cortisol and triggering the production of oxytocin (aka, the love hormone). [What's a male's reaction to their mother's voice?]

And, of course, all of this has to be thought of from the patient’s frame of reference. Calling a recently diagnosed diabetic about adherence is very different than someone who has stopped taking their medications after 5 years. How do you treat them differently?

What about their current location? Is reading an e-mail on the blackberry during a commuter train different than reading it at your PC while eating lunch…YES!

This is why communications is a blend of art and science. You have to use data to drive fact-based algorithms which are adaptable in scale (i.e., across millions of people) and are adaptable as people, situations, and messages change.

How Blunt Should You Be?

I’ve talked about this before from my personal perspective so I found this article about shocking men into going to the doctors right on point. But, I think this begs a great question…

“Should you communicate differently with men and women?”

My short answer is yes. In reality, it doesn’t always make a difference, but there are lots of times when it does. I’m not sure I’m ready to bet the farm on shocking messages to men all the time, but I would love to try that. Imagine an adherence message that told them they were improving their likelihood of death by 27% by not taking their medications. Or, a message about going to get a prostate exam which pointed out how many people die per year.

Most healthcare companies keep the gloves on when delivering messages. They are trying to motivate them, but they are hesitant to be too blunt (or direct). I’m sure that generally makes sense, but sometimes you just have to catch someone’s attention to get them to act.

Telling someone they are overweight and should start to workout and diet is very different than saying they are obese and are likely to die in their 50s if they don’t change their lifestyle immediately.

Related story – Top 5 Reasons That Men Don’t Go To The Doctor

Growing Horns, Turning To Stone, and Other Random Diseases

We can all be a hypochondriac at some point in our lifes. Now, there’s a handbook for you to make you think about all the completely random diseases which exist.

- Get addicted to carrots
- Unintentionally speak with a foreign accent
- Believing you’re dead (Cotard’s syndrome)
- Constantly shocking other people
- Alien hand syndrome
- Stone man syndrome
- Guinea worm disease
- Human botfly myiasis
- Alice in Wonderland syndrome

Performance Guarantees from PBMs

This article appeared a few months ago, but I’m finally digging out. (Drug Benefit News – 12/4/09) It’s an interesting article about how some PBMs are using performance guarantees in their sales efforts. I would expect this to be a growing trend as the PBMs focus on outcomes and have a need to commit to those.

The article mentions that CVS Caremark offers performance guarantees in five areas – adherence, generic-drug utilization, preferred pharmacy choice, specialty drugs, and utilization management. The results are aggregated into one guarantee. There is apparently no charge to the client, but there is a penalty paid if the goal isn’t met. Seems like a good deal if the guarantees are aggressive enough to account for any pricing differences.

A consultant says that Medco also offers performance guarantees (but doesn’t offer any details). The consultant also says payouts range from $800 to $1,300 per patient who have the targeted condition, receive interventions, and don’t achieve the compliance target. That seems like a great incentive for participation to the plan and for the PBM to develop an effective program.

Some of the keys for good performance guarantees are:

  • Good data (baseline and going forward)
  • Clear metrics
  • Comparisons to a control group and/or national metric (so you don’t just ride the curve of generic conversions for example)
  • Long-term contracts

Member ID Card Application on iPhone

Priority Health (which I find to be a well run and progressive managed care plan) announced their new iPhone application.  I suspect many will follow. It’s simple today, but imagine all the information you can put there – copays, drug history, lab values.

Retail Rxs Filled By State (Sorted by Volume)

I found this 2009 data at the Kaiser Family Foundation site and downloaded it to sort it by state and show the percentage of scripts that are filled within the state (versus the total US script count).  You should note that this is limited to retail claims (i.e., doesn’t include mail order Rxs). 

 United States               3,679,671,222  
 California                  312,440,433 8.5%
 New York                  255,792,543 7.0%
 Texas                  248,655,283 6.8%
 Florida                  225,312,255 6.1%
 Pennsylvania                  168,218,628 4.6%
 Illinois                  156,310,649 4.2%
 Ohio                  149,100,021 4.1%
 North Carolina                  127,081,439 3.5%
 Georgia                  119,238,095 3.2%
 Michigan                  119,163,703 3.2%
 Tennessee                  109,127,463 3.0%
 New Jersey                    99,570,267 2.7%
 Missouri                    92,754,941 2.5%
 Massachusetts                    92,658,258 2.5%
 Virginia                    90,704,636 2.5%
 Indiana                    82,549,426 2.2%
 Alabama                    80,669,107 2.2%
 South Carolina                    75,527,841 2.1%
 Kentucky                    73,756,811 2.0%
 Washington                    66,329,432 1.8%
 Wisconsin                    66,188,884 1.8%
 Louisiana                    66,142,285 1.8%
 Arizona                    61,297,786 1.7%
 Maryland                    58,080,852 1.6%
 Minnesota                    55,105,935 1.5%
 Oklahoma                    48,972,975 1.3%
 Arkansas                    48,242,080 1.3%
 Mississippi                    47,735,160 1.3%
 Iowa                    47,418,431 1.3%
 Connecticut                    46,489,823 1.3%
 Oregon                    40,342,008 1.1%
 Colorado                    38,093,247 1.0%
 Kansas                    36,214,744 1.0%
 West Virginia                    34,432,644 0.9%
 Nevada                    26,050,153 0.7%
 Nebraska                    25,239,082 0.7%
 Utah                    24,844,262 0.7%
 Maine                    19,087,484 0.5%
 New Hampshire                    18,033,822 0.5%
 Idaho                    15,939,958 0.4%
 New Mexico                    15,454,444 0.4%
 Rhode Island                    14,723,946 0.4%
 Hawaii                    14,249,708 0.4%
 Delaware                    11,388,995 0.3%
 Montana                    11,136,885 0.3%
 South Dakota                    10,051,942 0.3%
 Vermont                      9,682,741 0.3%
 North Dakota                      8,404,232 0.2%
 Wyoming                      5,991,536 0.2%
 District of Columbia                      5,185,455 0.1%
 Alaska                      4,488,495 0.1%

How Do You Pull, Push, and Pay?

I was reading something on Healthwise this morning.  We recently had Don Kemper (CEO) present at our client event in May.  He was talking about “Billion Dollar Decisions: Right Tools, Right People, Right Time”.  A few key things from the overview:

  • Today’s healthcare crisis can’t be solved with out helping everyone do more for themselves.
  • People need to ask for the care they need and avoid care that’s not right.  (a huge information and health literacy challenge)
  • Every year people make 300M major healthcare decisions, 50M surgeries, 100M medical tests, and 150M+ major medication changes.
  • Patient decision aids are key – http://ipdas.ohri.ca.

The summary was that to get people to uses decision aids you have to employ pull, push, and pay strategies.

Pull: Consumers pull the decision aids from the Web.

Push: Providers and payers push contextually relevant decision aids to consumers when they need them.  (What Silverlink does!)

Pay: Providers and payers create incentives to encourage the use of decision aids. 

Gender Bias – Postpartum Depression

We all know that females are different that males in terms of healthcare.  And, regardless of the data, we all have biases in terms of what we believe.  These biases can cause issues.  (As I often say…”When you assume, you make an ass out of u and me.”)

That being said, I found the study a few months ago interesting where it said that 14% of American men develop depression either during their partner’s pregnancies or in the first year after delivery (peaking when babies are 3-6 months old). 

This is important since depression is correlated with lots of health issues and has a family impact.  The article mentions that children of depressed fathers have more emotional and behavioral problems than other kids at age 3 and more psychiatric disorders by age 7. 

An interesting note was:

“Any healthy adult who goes without good sleep for a month is liable to become depressed.”

The big takeaway from the study is that physicians (and other healthcare entities) need to treat the family around birth.  This is probably also a great opportunity for social media to support fathers as much of today’s infrastructure is set up to support the mother.

5 Keys To Health Plan Survival

I thought I would re-post these from the Corporate Research Group.   

Bertolini outlined  five keys to surviving reform: 1. Payment reforms that shifts incentives from volume to outcomes; 2. Information technology that improves quality, lowers cost; 3. Wellness: engaging consumers with incentives and decision-support tools; 4. Transparency tools that provide information and improve accountability; 5. Revamped benefits and plan designs.

 These seem pretty logical and echo some of the things I brought up in my pharmacy white paper last year. 

1. The need to better engage the consumer in understanding their benefits and ultimately responsibility for their care;
2. The effort to automate and integrate data across a fragmented system and across siloed organizations; and
3. The shift from trend management to being responsible for outcomes.

Pay For Full Service

In several industries (e.g., travel), you pay when you access a customer service representative.  That forces you to use the self-service options of the Internet and/or the automated call line.  Could this work in healthcare?

I doubt that people would be so directive as to penalize people for talking to a representative or a clinical person especially on such a sensitive and personal a topic as healthcare.

BUT, on the other hand, a disproportionate amount of calls are for mundane issues or questions would could be solved using other channels.  The fact is that these channels have to be efficient and easy to navigate (which they aren’t always today).  But, technology continues to become more ubiquitous so it’s not unreasonable to expect people to self-service more often.

One idea that I tried to sell years ago at Express Scripts was more around incentives for self-service.  Why not offer large employers a discount if their use of the call center decreased?  They have some opportunities to influence this.  They could put a link to the website on their intranet.  They could leverage their e-mail network to push out messaging.  They could encourage people to use the PBM (or health plan) website.

On thing that several CFOs told me years ago was that they would frame the problem differently for their employees.  It wasn’t  about just saving money to reduce cost, but it was about re-directing funds to cover more things.  For example, one company had to cut $10M in expenses.  They were looking at plan designs to accomplish some of that.  But, they also thought they were going to have cut on-site daycare.  We looked at one strategy that might save them $15M so they could achieve their savings and actually grow both the daycare program and their 401K matching program. 

What great positioning to the employees!  Here are two things we are going to give you…all you have to do is help us shift costs from point A to point B by taking the following actions.

New Health Insurance Ideas

Just two ideas that I was playing with for health insurance.

1. Complete transformation from group to individual

Why not change the entire market to be an individual purchase…There are obviously some reasons such as adverse selection and group buying power, but I would think those were things where the government could add value.  If individuals selected the health insurance companies and products that they liked, it would create a very different dynamic. 

You could then change the employment paradigm not to a provider of health insurance, but make it more a part of your compensation.  Company A might fund up to $5,000 per year in health insurance while Company B provides up to $7,200 for family coverage.

One of the big benefits of this (beyond making individuals into consumers with power) is that health insurance companies could start to invest in outcomes.  Today, they are hesitant to make long-term investments (i.e., if I do this for 5 years, it will reduce the cost of this individual in 20 years) because their membership turns over.  This is a real issue in my mind.

2. Free insurance for healthy people

There is obviously an issue with funding and hyperbolic discounting, but what if we simply said that people who maintain some set of health standards (BMI btwn 20-25; HDL less than 180; able to run a mile in under 8 minutes) got free health insurance.  Would that make a difference?  I think so.  Companies would be better off – less absenteeism.  The US healthcare costs would drop.

Of course, it would take it’s toll on the providers while being a boom for gyms.  But, it’s hard to find that win-win-win. 

I know there’s a big issue of funding, but I was thinking about some radical ideas of what the money being raised by Gates and Buffet could be used to do and how it could motivate people.

Pelicans, Poverty, and Healthcare

I heard a talk the other day about the importance of localization and framing things in ways that people feel they can make a difference.  This person was framing the issue of poverty in the way that people respond to issues like the oil spill in the gulf and animals.  People care about animals.  They don’t want to see them covered in oil.  They can see themselves making a difference cleaning the animals.  Therefore, they respond.

This person was framing poverty in much the same way.  Thinking about global poverty and how to help the 1.2B people who make less than $1 per day is overwhelming much less trying to address the issues of the working poor.  But, he was framing poverty in ways that we could make a difference.  For example, you could buy a goat for $90 to feed a family.  Or, you could donate $2,600 which was matched by someone and could build a house.

This got me thinking about healthcare.  Not only because of the health and wealth connection, but the challenge of addressing a massive issue.  We need to continue to break healthcare problems down to finite issues that can be addressed by people like you and me.  This is not only for our own health – e.g., drink more water, but for the health of our communities – e.g., no more soda machines in our schools.

Bullets Do Come Down

Growing up in and around Detroit, I often think of glorious holidays like Devil’s Night or activities where people shoot off guns into the sky (not to stereotype the city too much).   People seem to forget that the bullets come back to earth to either injure people or put holes in roofs that become leaky. 

But, I have similar thoughts about 4th of July celebrations.  I heard a radio host say this morning that you can tell the smart people on the 4th because they print out the map to the local urgent care before they start drinking and lighting off fireworks. 

Nationally, 9,000 people were injured and 2 were killed last year from fireworks.  Additionally, the 4th of July has more fires than any other holiday with about 50% being started by fireworks (source).  How would you feel about lighting your neighbor’s house on fire and watching it burn to the ground?

Fireworks are great.  I enjoy watching them, but I always have some concerns about people putting on their own displays in the middle of a subdivision.  We had a house burn down in our old neighborhood, and I saw one catch on fire when I was a kid. 

Is Specialty Pharmacy Management Frozen?

Someone asked me an interesting (but I suspect somewhat rhetorical) question last week.  They asked if I had seen meaningful innovation in specialty pharmacy management in the past 5 years beyond simply increased automation.  It immediately made me think of this picture of Hans Solo frozen in time.

I had to say no.

Specialty has been focused on leveraging the PBM lessons from the past decade and implementing them.  How to manage spend?  How to get rebates?  How to push generics?  How to implement technology?  How to distribute drugs more efficiently?  What are the right plan designs?

Do you disagree?

I think the one area where you could easily argue is around pharmacogenomics.  This is an interesting one since it will have a big effect on specialty medication and you have two of the big 3 PBMs (Medco and CVS Caremark) who have embraced it while you have Express Scripts talking a little about it.  They seem to be taking a wait and see approach until it is clear how they make money in this space.

Death By Burger

If you really have no care for your health, here’s something for you – The Luther Burger which is a bacon cheeseburger where you replace the buns with Krispy Kreme glazed donuts.

Obesity Rates Vs. Population Growth

The research correlating weight with your social network is out.  So, it makes me wonder as I look at the states with the highest rates of obesity whether they will build on themselves.  Will they continue to get more and more obese?  The logical next question is whether that will at some point affect things like the healthcare costs in these states, employment growth in these states, and population growth.

Given two options, would you move to a healthier state or do you believe that you’re above this social pressure which will lead to less exercise and higher weight? 

The states with the highest rates of obesity were:

  1. Mississippi (33.8%)
  2. Alabama
  3. Tennessee (tied for 2nd)
  4. West Virginia
  5. Louisiana
  6. Oklahoma
  7. Kentucky
  8. Arkansas
  9. South Carolina
  10. Michigan
  11. North Carolina (tied for 10th at 29.4%)

The fastest growing states (2008-2009) were:

  1. Wyoming
  2. Utah
  3. Texas
  4. Colorado
  5. Alaska
  6. Arizona
  7. Washington
  8. North Carolina
  9. Georgia
  10. South Carolina

Innovation Has To Respect The Past

Cars provide us with some interesting examples of innovation which has had to adapt to fit our norms.

For example, we have keyless cars, but if you notice, several of them have places for you to put the key in.  It’s really just a holder for the key since it doesn’t activate anything, but otherwise, we don’t know what to do with the key once we get in the car.  [This may be more of an issue for me since I use this when I rent cars and don't have such a car everyday.]

Another example is the silence of hybrid cars.  US lawmakers are considering making manufacturers put sound back into the electric cars so that the visually impared who rely on sound to help them navigate can tell when a car is coming. 

I’m sure there are other examples.


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