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International Differences In Wellness Programs

I was looking for a statistic today on wellness programs when I came across this 2010 survey on global wellness from Buck Consultants.  I found the geographic differences really interesting, and I thought I’d share a few of the charts here.

Intl Drivers of Wellness strategy Buck

Top wellness programs by region buck

Wellness Program Objectives - Buck

If you want to see their 2012 report on what’s next for wellness, you can go here.

Internet Turns 25 – Looking Back And Forward

happy birthday

Wow!  The Internet turned 25.  Do you remember when you started using computers and technology?  I can.

I think my first computer was the Commodore 64 which we plugged into our home TV for a monitor and used a tape recorder to store files and access programs.

commodore 64

I can remember when we got 3 Macintosh computers to use at school.

first Mac

I can remember when we got our IBM PC Jr.

IBM PC Jr

After that, computers started being a little more common where we had them in high school for typing, but at the same time, people were using electric typewriters more than computers.  (I can’t believe that they still sell electric typewriters – see Wal-Mart ad.)

I can then remember being at the University of Michigan with massive computer labs of Apple computers.  At that time, I still remember using the Gopher technology that had been developed out of the University of Minnesota and pre-dated today’s Internet and HTML.

gopher

This eventually led to all the excitement about physical companies having websites and being able to do amazing things like order pizza online…the rise of e-commerce and eventually the dotcom bubble.

I still smile when I think that one of my first assignments in healthcare was to convince managed care companies to build a website.  I flew all around the country as a consultant with Ernst & Young LLP meeting with teams to convince them of what the Internet could do, why they should build a website, what functionality to put on it, and how to drive members to the website.

And, now, our kids grow up with this as normal.  Everything can be “googled”.  There is no card catalog to look things up or waiting to figure out why someone is late.  Things are instantly available.  (If you’ve never seen the list of what graduates will never remember, here’s a link to their 2017 graduate list.  Always interesting.)

So, I’ll wrap this up with a look at the future from a new report by PEW.  Here’s 15 predictions from their report:

1) Information sharing over the Internet will be so effortlessly interwoven into daily life that it will become invisible, flowing like electricity, often through machine intermediaries.

2) The spread of the Internet will enhance global connectivity that fosters more planetary relationships and less ignorance.

3) The Internet of Things, artificial intelligence, and big data will make people more aware of their world and their own behavior.

4) Augmented reality and wearable devices will be implemented to monitor and give quick feedback on daily life, especially tied to personal health.

5) Political awareness and action will be facilitated and more peaceful change and public uprisings like the Arab Spring will emerge.

6) The spread of the ‘Ubernet’ will diminish the meaning of borders, and new ‘nations’ of those with shared interests may emerge and exist beyond the capacity of current nation-states to control.

7) The Internet will become ‘the Internets’ as access, systems, and principles are renegotiated

8) An Internet-enabled revolution in education will spread more opportunities, with less money spent on real estate and teachers.

9) Dangerous divides between haves and have-nots may expand, resulting in resentment and possible violence.

10) Abuses and abusers will ‘evolve and scale.’ Human nature isn’t changing; there’s laziness, bullying, stalking, stupidity, pornography, dirty tricks, crime, and those who practice them have new capacity to make life miserable for others.

11) Pressured by these changes, governments and corporations will try to assert power — and at times succeed — as they invoke security and cultural norms.

12) People will continue — sometimes grudgingly — to make tradeoffs favoring convenience and perceived immediate gains over privacy; and privacy will be something only the upscale will enjoy.

13) Humans and their current organizations may not respond quickly enough to challenges presented by complex networks.

14) Most people are not yet noticing the profound changes today’s communications networks are already bringing about; these networks will be even more disruptive in the future.

15) Foresight and accurate predictions can make a difference; ‘The best way to predict the future is to invent it.’

 

Fail Fast To Succeed Sooner – The Big Company Challenge

I was reading an article this morning about asking the question “are you afraid to fail?”  It’s an article about innovation which reminded me of one of my favorite quotes from David Kelley at IDEO.

Fail Faster

It also reminded me of another article from 2006 in Business Week about How Failure Breeds Success which was when I left Express Scripts to pursue several entrepreneurial opportunities.

Stefan H. Thomke, a professor at Harvard Business School and author of Experimentation Matters, says that when he talks to business groups, “I try to be provocative and say: ‘Failure is not a bad thing.’ I always have lots of people staring at me, [thinking] ‘Have you lost your mind?’ That’s O.K. It gets their attention. [Failure] is so important to the experimental process.”

BW Failure Cover

It also got me thinking about success rates in companies.  We all hear so much about the success of entrepreneurs and these 20 year old billionaires.  Is that reality?  Here’s a few stats from an article in the WSJ and a study by the Census Bureau.

  • 80% of companies make it to year one
  • 60% of companies make it to year three
  • 50% of companies make it to year five
  • 35% of companies make it to year ten

Sounds pretty depressing.  What about the fact that according to the WSJ article, only 5% of them achieve the projected ROI and 30-40% of them liquidate all their assets returning nothing.

“People are embarrassed to talk about their failures, but the truth is that if you don’t have a lot of failures, then you’re just not doing it right, because that means that you’re not investing in risky ventures.  I believe failure is an option for entrepreneurs and if you don’t believe that, then you can bang your head against the wall trying to make it work.” (David Cowan – Bessemer Venture Partners in WSJ article)

Just watch the show Shark Tank sometime.  There are amazing entrepreneurs with interesting ideas who have sacrificed so much to try to make it work.  I always try to tell people that it’s not just about passion and hard work otherwise people would succeed all the time.  Some things you do learn from Shark Tank along with the book The Art of the Start is how to frame and present your ideas.

So, why is this so important?  We’re on the the verge of huge transformation in the healthcare industry.  I think Oliver Wyman did a good job of discussing this in a whitepaper last year.  You can read article after article about mHealth, telemedicine, and remote monitoring.  (I’ll point you to Rock Health or The Center For Connected Health as two starting points.)

Of course innovation has been the buzz for several years now.  I think Jim Collins does a good job of teeing up this issue in discussing churn in the Fortune 500 list.  With the technology and VC crowd, the more recent term for business model innovation is “pivot“.  I think you’ve seen a lot more Chief Innovation Officers and innovation labs in healthcare companies these days.

I came across an interesting blend of technology consulting, investing, and innovation last night in the BCG Digital Ventures group.  In watching part of a YouTube video by their CEO, I think he does a great job summarizing how consulting maps to the investment paradigm.

  • Innovation is like seed capital
  • Product development is like venture capital
  • Commercialization is like growth capital

Interestingly, I probably get 1-2 calls a week from people in big companies that really want to get out of the big company and come work in the exciting start-up space.  I always tell them that the grass always looks greener on the other side of the fence so be careful.  It can be great, but it can be really tough.  It’s just a different type of risk and not everyone can take the emotional and potentially financial risk.  On the flipside, I also get people that look at the different entrepreneurial things I’ve done and say “why?”  They want to know why I didn’t just stay in a F500 company.  Sometimes, I think of this 8 years as a boomerang where I’ll end up back in a F500 company, but I’ll be a much more valuable product development, strategy, and innovation executive.  [This idea of boomeranging was one that Gensler introduced me to years ago in architecture where they encouraged people to work at different companies and come back if relevant.]

Depending on the day, I also think about what I’ve learned since I’ve never had one of those huge exits that everyone talks about.  I’m not cashing in on all my options to make money.  I’ve summarized many of those learnings on the blog, but here’s a few that I’ll call out.

  1. Firepond was my first venture into this space.  It was a 20-year company that General Atlantic had invested in to turn around as a product configurator in the CRM space.
    • Learned about CRM (customer relationship management) technology.
    • Learned about how to develop, structure, and manage alliances.
    • Learned the importance and how to structure offshore deals.
    • Learned about global sales and embedding technology into different solutions.
    • Learned about evaluating and buying companies.
  2. CentralScript was my second venture I started it from an idea I tried to sell at Express Scripts (and later was suggested to them by Clayton Christensen).
    • Learned about writing a business plan and financial modeling and projections.
    • Learned about the legal structure of businesses.
    • Learned about raising money and how to work with and evaluate angels and VCs.
    • Learned about building a team and structuring contracts with them.
    • Learned about selling and evaluating partners.
  3. Talisen Technologies was my third venture which was another turnaround where I worked with a friend of mine who had raise some private equity to do a technology services consulting roll-up.
    • Learned about Business Process Management technology.
    • Learned about how to build support companies around a technology platform.  (The opposite of Firepond where I was the technology company.)
    • Learned about the difficulties of transforming an existing company and evaluating new companies.
    • Learned about how to use blogging and create exposure using social media.
  4. Silverlink was my fourth venture (and most successful experience) and first real start-up where it wasn’t trying to turnaround an existing asset but building off what the founders had built.
    • Learned about how to present to and work with the Board of Directors.
    • Learned about managing a sales force.
    • Learned about product development, training, documentation, and product lifecycle.
    • Learned about sales and marketing and being responsible for growth and a team.
    • Learned about account management.
    • Learned the value of using thought leadership, social media, and the press to drive awareness and pipeline.
    • Learned how to develop competitive analysis and differentiation.
    • Leraned about pricing and analytics.
  5. inVentiv Medical Management is my current venture which is part of a broader entity, but it’s still the same concept which is a 20-year old company that we’re transforming into a new platform and new business model.
    • Still in-progress so more to come…

So, I wrote all this to make the point that innovation is difficult.  You have to take some risks.  Like the article said upfront, you have to believe you can fail.  You have to have a plan for what to do if you do fail.  Big companies should provide a safety net to people to fail fast.  I think I’ve learned a ton that I wouldn’t have learned staying in the big company.  At the right time, that will be a huge asset as I look to help drive the transformation and pivoting of a larger entity!

Healthcare Gamification

If you believe all the hype about digital health, you might think gamification was a natural solution.  Of course, if you’ve never heard of gamification, let me provide a basic definition from Wikipedia.

Gamification is the use of game thinking and game mechanics in non-game contexts to engage users in solving problems.

Here’s several articles for more information:

  1. Four Factors Driving Gamification in Healthcare
  2. From FitBit to Fitocracy
  3. The Wellness Game
  4. Gamification: Drugmakers And Health Campaigners Turn To Games To Promote Health

I think this quote from the Perficient white paper on this topic is a good one.

Gabe Zichermann, the author of Game-Based Marketing, speaks of balancing the fun and frivolity of gamification with the task of making life easier for cancer patients. He says, “I don’t presume to think that we can make having cancer into a purely fun experience. But, we have data to show that when we give cancer patients gamified experiences to help them manage their drug
prescriptions and manage chemotherapy, they improve their emotional state and also their adherence to their protocol.”

You can also look at a post by Jane Sarasohn-Kahn (one of my favorite bloggers) on this topic where she highlights several trends from a recent paper on gamification in healthcare.

Now, why should you care?

  1. Gamification should improve engagement which is critical to changing behavior.
  2. Gamification creates opportunities to make healthcare fun which can be difficult.
  3. People are different and respond to different “incentives”.  Competition and leader boards are concepts that excite lots of people to take action.

The forecasts for the gamification market are huge.  They show a nice hockey stick which gets every investor excited.

1

Of course, the important question is who uses games.  Is it just teenage boys?  It’s not.  Here’s a good report which shows you breakdown by age, gender, and many other stats.

Gaming

Another quick article about gamification is from TEDMED.  The video is below, but it reminds me of some of my personal perspectives.  The sites also lists out several vendors and solutions in the obesity gamification space.

While one “easy” opportunity in my mind is to use gamification to address the rising number of kids with chronic diseases and to help address childhood obesity, there are many other opportunities like adherence.  A few examples of games out there include:

Companies like Ayogo, Mango Health, and Akili are ones that I’ve heard about, but I know there are a lot more out there.

One example I think of from watching my kids play games is from Webkinz which was a blend of real stuffed animals with online digital personas.  The animals could get sick if you didn’t nurture them and visit them.  It made me think of how an avatar could get fatter or slower based on their pedometer or eating habits.

A Few Corporate Wellness Tips

While Al Lewis has become the industry antagonist (in a good way), he makes a lot of great points that anyone working in the industry should understand and consider.

If you haven’t read some of Al’s articles, let me point you to a few:

His writing reminds me of some of the things my former boss pointed out several years ago about the disease management industry.

In one of his posts, he makes several points that I wanted to discuss here:

  1. You should use a source like the US Preventative Services Task Force (USPSTF) as the evidence-based reference for appropriate screenings – frequency, age, gender.  Of course, I agree with this.  We need some common source that we all can use that’s based on best practices and evidence.
  2. He argues that you should stop weighing people.  I’d argue that knowing your numbers is important.  As a country and a world, we’re seeing massive growth rates in obesity which is linked to numerous diseases.  We need people to be more conscious of this risk factor especially in our sedentary work environments – see sitting disease infographic.
  3. His third point is about targeting and nudging the right population versus over-sampling everyone.  I couldn’t agree more.  This should be what the Big Data push in healthcare gets us.  How to build predictive algorithms to identify people with multiple risk factors.  How to identify people with gaps-in-care.  How to figure out what someone needs to take an action.  I always say there are 3 factors to consider:
    • Is there value in the intervention?
    • What channel / method is going to get the consumer’s attention?
    • What information is going to get the consumer to take an action?

To follow-up on my points above, here’s some information on obesity and it’s link to other diseases.

The CDC says that obesity is linked to:

  • Coronary heart disease, stroke, and high blood pressure.
  • Type 2 diabetes.
  • Cancers, such as endometrial, breast, and colon cancer.
  • High total cholesterol or high levels of triglycerides.
  • Liver and gallbladder disease.
  • Sleep apnea and respiratory problems.
  • Degeneration of cartilage and underlying bone within a joint (osteoarthritis).
  • Reproductive health complications such as infertility.
  • Mental health conditions.

And, for a fun video by Mayo Clinic on Knowing Your Numbers watch this:

Who Is The NetFlix Of Healthcare HR?

I was sent this deck a few weeks ago.  It’s been out there for a few years.  It’s the HR / Human Capital strategy for Netflix.  Netflix has been known for things like no vacation policy (i.e., take what you need).  This gives much more insight.

It’s not really an industry that I’m focused on, but I’d love to find a healthcare company with this approach to human capital.  That would be a company worth following and working with.

Forbes “Most Promising” Companies – Healthcare

Whenever I see lists like the Forbes list of America’s Most Promising Companies, I like to look through the list and pull out the healthcare companies.  They say these are private companies that standout because of their growth and outstanding management.

#4 – Evolent

#24 – 24HR HomeCare

#28 – CareCloud

#39 – Intersect ENT

#41 – Therapearl

#95 – Boston Heart Diagnostics

If healthcare is 20% of the GDP and with all the mHealth and HIT spending, I was hoping to see a few more companies on this list.

The Boston Physician Dilemna

I often wonder why so many healthcare companies are in the Boston area.  These two set of statistics from the Merritt Hawkins study on physician appointment wait times paint an interesting picture.

First, you have the fact that Boston has the highest ratio of physicians per 100,000 people.  Almost double the US average.

Screen Shot 2014-02-01 at 6.51.20 AM

On the other hand, it takes you the longest time to get access to a physician.

Image

 

I’m a simple person.  This doesn’t seem to make sense.  I could say that lots of them are working in academia or in companies and not actually seeing patients.  I’m sure that explains some of it, but I can’t imagine all of it.

It’s also interesting that Boston also rises to the top of the list in terms of Medicare acceptance.

Medicare acceptance rates by city

8 Risks Drive 15 Conditions And 80% Of Healthcare Costs

This is one of my favorite images that I use all the time to talk about how our decisions drive our healthcare costs.  This is from the AON Hewitt 2012 Health Care Survey and based on the World Economic Forum’s data.

8 risks - 15 conditions - 80 costs - AON

New Harris Interactive Data Supports Focus On Hospitals And Retailers

As I’ve discussed before, trust is critical in engaging consumers.  The question always is “Who does the consumer trust in healthcare?”  We certainly know that individuals like physicians, nurses, and pharmacists are trusted, but they often aren’t the ones doing the big campaigns to engage consumers.  It’s the pharma manufacturers, the hospitals, the PBMs, the payers, the retail pharmacies, and other entities.  In my presentation at the CBI conference, I hypothesized that this is why retail pharmacy should (could) take a bigger role in the future.

The new survey from Harris Interactive reinforces that.  Of course, 42% of people don’t believe any companies, but with some healthcare companies being barely trusted more than tobacco companies, consumer engagement isn’t easy.

Harris Interactive - Trusted Industries 2013

The additional bad news from the survey is that people think more regulation is necessary in healthcare.

Harris Interactive - Regulated Industries 2013

 

Interview With IMS Health About AppScript – #mHealth13

“Today, there is growing recognition of mobile health’s potential to transform healthcare – to advance doctor/patient engagement and empower consumers to better monitor and manage their own health,” said Stefan Linn, senior vice president, Strategy & Global Pharma Solutions, IMS Health. “That potential can only be realized through a systematic evaluation of the clinical benefits of healthcare apps, clear professional guidelines around their use, and effective integration of apps with other aspects of patient care. With these game-changing solutions, IMS Health is establishing an intelligent, secure infrastructure for mobile health, backed by our market-leading real-world evidence capabilities and the most advanced technology platform in healthcare.”

Most of you that read the blog on a regular basis know that I was really intrigued by the idea of “prescribing information and technology” early on.  With 90,000 different health related applications, the question is which ones should you use and how should you find out about them.  Happtique started to get into this space earlier in the year, and I spoke with them at length about integrating this into a care management platform.

I was really surprised to learn that IMS Health which I think of as a healthcare data company was jumping into this space.

IMS Health is the world’s leading information, services and technology company dedicated to making healthcare perform better.

By applying cutting-edge analytics and proprietary application suites hosted on the IMS One intelligent cloud, the company connects more than 10 petabytes of complex healthcare data on diseases, treatments, costs and outcomes to enable our clients to run their operations more efficiently.

Drawing on information from 100,000 suppliers, and on insights from more than 40 billion healthcare transactions processed annually, IMS Health’s 9,000+ expert resources drive results for over 5,000 healthcare clients globally.

Customers include pharmaceutical, medical device and consumer health manufacturers and distributors, providers, payers, government agencies, policymakers, researchers and the financial community.

I talked with Matt Tindall who’s their Director of Consumer Solutions about this a few days ago (but was waiting for their press release to be out and their presentation at the mHealth Summit – which I am very disappointed to be missing for the second year in a row.)

I also read their press release about their new solutions.

IMS Health today announced the immediate availability of AppScriptTM, an mHealth app prescribing solution designed to help healthcare providers and health plans create proprietary formularies based on an objective assessment of healthcare app functionality and value. The company also announced the launch of AppNucleusTM, its customizable, cloud-based hosting platform that will enable developers to build secure, industry-compliant healthcare apps at very low cost. Both new products will leverage IMS Health’s comprehensive data on diseases, treatments, costs and outcomes.

The AppScript Software-as-a-Service solution classifies and evaluates more than 40,000 mobile healthcare apps currently available for download on iOS and Android platforms, categorized by stage of the patient journey. Each app is assessed using the company’s proprietary IMS Health AppScore, which ranks apps based on functionality, peer and patient reviews, certifications, and their potential to improve outcomes and lower the cost of care. As part of wellness, prevention and treatment regimens, physicians can organize these apps into formularies based on their specific patient population and practice preferences. In addition, AppScript enables them to securely prescribe, reconcile and track app use by patients from any mobile interface.

AppNucleus is the company’s innovative healthcare app development and hosting platform that makes it easier for app developers to offer HIPAA- and HITECH-compliant solutions. The platform, compatible with all mobile operating systems, uniquely integrates IMS Health information and analytics at every stage of app development to support design and performance evaluation decisions. AppNucleus features a suite of plug-and-play solutions, enabling patients and physicians to exchange health information on mobile devices via a secure, encrypted channel to protect patient information. It also offers app developers a highly economical way to build security into their apps and protect patient information.

Here’s my notes and key observations:

First off, I quickly learned that I missed a very interesting report that they put out in October.  This report titled “Patient Apps for Improved Healthcare: From Novelty to Mainstream” has lots of great information which I share below.  It also is essentially the business case for these new solutions.

In talking with Matt, he shared with me how IMS Health, a 60 year old company, is using their consumer solutions group to transform how people learn and manage their health.  He talked about how they want to make mobile safer, more effective, and easier.

I really wanted to understand how they determined where to look given all the apps out there.  A lot of it is in the report, but he shared how they looked at 40,000 apps and used over 25 different criteria (such as type of information, functionality, communication process used) and peer reviews to determine a shorter list to focus on.

We discussion how the short-term success of mobile is engagement, but the long-term success will have to be tied to clinical outcomes.

He walked me through the process for getting the app prescribed:

  • The physician would be using a white labeled platform (provided by their health plan, provider group, others).
  • They would select an app based on a curated formulary.
  • The patient would get a secure e-mail or a text message with a link to the app.
  • The patient would follow the link and enter a proprietary passcode.
  • This would take them into the app store.
  • They can then download the app.

This process will allow them to track “intent to download” and then whether they did download.  The key next step will be partnering with the apps and getting the patient consent to pull data back to know not only if it was downloaded but whether it was used and how often.  And, ultimately, this will have to be integrated with the provider platform.

We talked a little bit about why IMS and he talked about their knowledge of the prescriber and ability to recommend apps for their formulary based on their patterns of prescribing.

Ultimately, I think they may be in a good position to succeed here.  I think there are several key questions:

  • How are the apps evaluated?  Do clinicians evaluate the clinical algorithms?
  • How do you determine the financial viability of the apps?  Are they one-hit wonders or shiny objects or will they be around for years.
  • How do you modify the “formulary” based on user and prescriber feedback?
  • How do you integrate the tools into the physician’s workflow?
  • How comfortable will the physicians have to be with each app?  (Won’t the users have questions for them and will that be a barrier?)

From their report on healthcare apps:

  • Only about ½ of the 40,000 apps they looked at justified a deeper dive.

IMS Consumer App Functionality

  • They categorized the apps by:
    • Inform: Provide information in a variety of formats (text, photo, video)
    • Instruct: Provide instructions to the user
    • Record: Capture user entered data
    • Display: Graphically display user entered data/output user entered data
    • Guide: Provide guidance based on user entered information, and may further offer a diagnosis, or recommend a consultation with a physician/a course of treatment
    • Remind/Alert: Provide reminders to the user
    • Communicate: Provide communication with HCP/patients and/or provide links to social networks

They also looked at apps by therapy area and by which part of the patient journey they focus on.

IMS Apps By Patient Journey

“There’s a group [of patients] who each have several medical problems and often they have several specialists, all making recommendations. It’s often overwhelming for the patient and for the caregiver. They get overwhelmed by the number of pills and the number of recommendations that they have been given, so I feel that if everybody starts prescribing apps it could quickly lead to app overload”

Leslie Kernisan – Geriatrician and caregiver educator

IMS MD Hurdles To Apps IMS App Maturity Model

 

Are Sports Good For Kids?

This was an interesting question that I was thinking about this morning.

I could take this several directions:

  • I could look at the benefits of exercise from sports (assuming the kids actually got enough exercise in practice – see older blog post).
  • I could look at the benefits of working in a team which I see from team sports.
  • I could look at the recovery benefits of losing and coming back which is very important in business and life. (how do you handle adversity)
  • I could look at the dangers of sports.
  • I could look at concussions in football and the discussion of helmets for soccer.
  • I could look at the negative impacts of parents on their kids relative to sports.
    • Fighting at sport events.
    • Pushing their kids too far.  (below are some things I’ve heard and seen)
      • Just keep running even if you throw up.  You’ll be fine.
      • If you have to pee, just pee in your swim suit.  You can’t be distracted during the meet.
      • If you do that again, we’re going to get up at 5 in the morning and go to the gym and practice it 100x before school.
      • You need to work harder so you can be in the Olympics at 16.
      • This is our college plan.  They have to be the best at this sport.
      • I pulled them out of school so they could practice more.  (The kid was 7.)

But, I saw an article about the time that kids start school, and it got me thinking about sleep and sports and the impact on kids.

Let’s start with some established facts:

sleep guidelines

Now, let’s assume most grade schools start around 8:00.  (My kid’s school starts at 7:30.)  That means that they likely have to get up by 7:00 at the latest.  So, they should be in bed by 9:00 PM on average probably earlier for most kids and families where people are catching the bus or driving to school.

If their sports are starting practice or games after 6:00 PM, how likely is it that they’re home, calmed down, with their homework finished, and in bed by 9:00 PM?  Even if they are, how many parents are getting their kids to bed by 9:00?

“Sleep may be the most important, though overlooked, contributor to your children’s development and health. The reality is that children can survive without exercise and on little food (though I don’t recommend either), but all children need sleep. It’s often unnoticed because you don’t usually see your children sleeping and its benefits are not readily apparent (though its costs usually are).

The influence of sleep on children is profound. Quality sleep has been found to be associated with improved attention, reduced stress, greater emotional control, better mood, improved memory, greater ability to learn and return information, better grades, improved mental health, lower risk of obesity and other health problems, and longer life.” (From a good article on kid’s sleep in the Huffington Post)

So, just to be clear…I think kids should be in sports.  I just think we (as parents) need to be more concerned about making sure we don’t sacrifice our kid’s sleep on a regular basis for them to play sports and lead them into health issues and school issues.  The tradeoff isn’t worth it.  (IMHO)

Pharmacy Satisfaction – Retail Beats Mail

With the new JD Powers survey, the gap between retail pharmacy satisfaction and mail order has widened. The average mail order satisfaction score was 797 for mail versus 837 (out of 1,000) for retail.

I think one key comment from Scott Hawkins, director of the healthcare practice at JD powers was:

“One of the key things we’ve seen in the data is that if someone is feels compelled to use a mail-order [pharmacy] their satisfaction score is going to be lower than someone who chooses to use it on their own.” (From Nov 2013 Employee Benefits News article by Andrea Davis)

If I was still at a PBM, I’d push to see the results broken out both ways so I could compare apples to apples the then say the drag was from clients choosing mandatory mail.

The rankings for mail order were:

Kaiser – 868
Humana – 845
Walgreens Mail – 812
OptumRx – 798
Prime Therapeutics – 794
Express Scripts – 783
Aetna – 778
Cigna – 771
Caremark – 760

The two I find the most interesting are Prime Therapeutics and OptumRx as both of them have moved their mail order services in house in the past few years and seem to be doing well with it. Aetna has outsourced their solution to Caremark and Cigna just recently outsourced their mail order to Catamaran which wasn’t on the list (but may be in the survey).

If E-Prescribing Doesn’t Have All The Data…Is It Helpful?

This is an interesting dilemma.  At this point, I think everyone is pro e-prescribing even if it’s simply for the benefit of reducing errors.  But, I think the original intent of the solutions were to do a lot more than reduce errors.

The hope was to improve adherence (which I think may have been too lofty).  The idea was that e-prescribing would reduce the abandonment rate at the pharmacy.  I’m not sure picking up a prescription is the same as taking a prescription.  And, taking a prescription once isn’t the same as staying adherent over time.

Another hope was that the use of e-prescribing would drive formulary compliance and increase generic utilization.  The idea was that putting this information in the hands of the prescriber would allow them to make more real-time decisions that were aligned with the consumer’s interests (i.e., lower out-of-pocket spend).  The latest report doesn’t seem to support this at all.  It also echos my prior posts about whether e-prescribing was aligned with pharma at all.

Fewer than half (47.5%) of the 200 PCPs polled said they have access to formulary information when e-prescribing, and fewer than a third said they have access to prior authorization (31.0%) or co-pay (29.5%) information. Among physicians with formulary information access, that information was available 61.1% of the time and was said to be accurate 68.6% of the time.

Physicians with an EMR (54.1%) were more likely to have access to formulary information than physicians without an EMR (29.6%). And differences were seen depending on the EHR vendor: Allscripts physicians (32.2%) were less likely to have access to this information than “All Other” software suppliers (60.5%), Epic physicians (62.5%) and eClinicalWorks (68.8%). 

Another big effort that e-prescribing and integration with EMR was going to have was to push utilization management (UM) to the POP (point of prescribing) rather than having the pharmacy and the PBM dealing with it.  I never really thought this would work.  If the information isn’t there or they don’t trust the information, the prescriber isn’t going to want to deal with this.  It’s already work that they let their staff handle and isn’t something they want to deal with during the patient encounter.

While e-prescribing is definitely here to stay and becoming the norm, the question is whether it’s creating simply a typed “clean” Rx to transmit electronically or whether it’s actually an intelligent process which will enable better care.

Given multiple studies and surveys recently about transparency in healthcare billing and the general push with Health Reform to drive to outcomes, I’m not sure the “dumb” system process can be a sustainable value proposition.

Express Scripts Excludes 48 Drugs On 2014 Formulary

Is anyone really surprised here?  We saw CVS Caremark make some changes a few years ago that caught everyone’s attention.  (You can see a good list of 2013 and 2014 removals and options here for CVS Caremark.)  This year, it’s Express Scripts (ESRX) who’s caught the attention of the press.

Why do this?  I think Dr. Steve Miller did a great job of explaining it in a recent interview.  The most interesting thing to come out of this was the possible link to copay cards.

Pharmalot: Where to from here?

Miller: We obviously have a long-term strategy. This has sent a loud message to the marketplace that we have got to preserve the benefit for patients and plan sponsors and do things to rein in costs. As there are more products in the marketplace that are interchangeable, we’ll do more to seek the best value for our members. This is just the beginning of a multi-step process over the next several years.

Will there be more to come?  Of course.  The PBMs have to make a significant show of lowering the number of formulary drugs especially in the oral solid (traditional Rx) space to make the point to the pharmaceutical manufacturers that they control market access.  This is critical for them to create more opportunities in the specialty Rx space around rebates.  (Here’s the 2014 Express Scripts exclusion list)

Additionally, this is a low risk strategy for several reasons:

  • The disruption is minimal.  While 780,000 people sounds like a lot, it’s still just 2.6% of the population covered by these formularies.  The savings the employer will generate per disrupted member will pay for the extra customer service needed.  (Harsh reality to some people…I know)
  • As I’ve discussed before, the margins are in specialty pharmacy and mail order generics not in branded drugs which represent less than 20% of all drugs.  Therefore, this is a good place to make a stand.
    • From an old JP Morgan analysis from 2011, Lisa Gill estimated the PBM profits to be (all in 30-day equivalents):
      • $1.69 retail brand drug
      • $2.03 mail brand drug
      • $3.00 retail generic drug
      • $13.00 mail generic drug
  • This is based on a clinical review by an independent P&T committee.  Therefore, this is aligned with the health reform focus on outcomes and value.

New/Old Accusations About PBMs And Their Margins

PBMs (or Pharmacy Benefit Managers) are big business.  Just look at a few of the names and their place on the Fortune 500 list:

Not surprisingly, none of those are non-profits.  There is real money being made here.  It’s all part of the mark-up game in healthcare.  The question of course is does the money being made justify the profits.  For example, I’m happy to pay my banker lots of money as long as he’s earning me more than he’s making (and significantly more).

This is a complicated question.  (see past posts on What’s Next, Why People Don’t Save With Mail, and Growing Mail Order)  I’ve also presented on this topic several times in the past pointing out that the model needs to change, and re-iterating the fact that PBMs made a mistake by putting all their profits in the generic space.  I’ve always said that disintermediation would happen by focusing on generics at mail which is where all the money was at Express Script (8 years ago).  [People remind me that some of this has changed and is different across PBMs.]

The new Fortune article by Katherine Eban called “Painful Prescription” certains shows a dark story.  It focuses exactly on one of these scenarios which is the gap between acquisition cost and client cost.  The article talks about paying $26.91 for a drug but selling it to the client at $92.53.  I’m always reminded of the fact that at one time we used to buy fluoxetine (generic Prozac) for about $0.015 per pill.  On the flipside, we had brand drugs that we bought for more than we got reimbursed and lost money.  It was strange model.

So, here’s my questions:

  1. Do you want transparency?  If so, there are lots of “transparent PBMs” and many larger PBMs will do transparent deals.  You can also follow the Caterpillar model.  (Don’t forget that pharmacy represents less than 20% of your total healthcare spend so you can find yourself down the rabbit hole here trying to shave 2% of spend on 20% or 0.4% of your costs with a lot of effort.)
  2. Are you focused on anamolies like this one or average profits per Rx?
  3. Do you have the right plan design in place?
  4. Do you have a MAC (maximum allowable cost) list both at retail and mail order for generics?
  5. Are you getting the rebates and any admin fees from pharma for your claims passed through to you at the PBM?
  6. If you pay the PBM on a per Rx basis (i.e., no spread allowed), what are they doing to keep your drug costs down year over year (i.e., they have no more incentive to push down on suppliers)?
  7. Are you benchmarking your pricing?  Look at reports from places like PBMI.  For many smaller clients, I often wonder if the savings they find you is worth the costs.

I’m sure there’s more since I’ve been out of the industry for a few years, but while I don’t intend to be the defender of the industry, I do like to bring some balance to the conversation.

Can You Keep Your Prior Health Insurance – No

“That means that no matter how we reform health care, we will keep this promise to the American people: If you like your doctor, you will be able to keep your doctor, period. If you like your health plan, you’ll be able to keep your health plan, period. No one will take it away, no matter what.” President Obama, June 15, 2009, from a speech to the AMA

You know what…that was a great campaign soundbite. It might have even been what he wanted. But, it’s not reality. They made a mistake. Move on. Everyone in healthcare knows the industry needs reform. I think the administration would be better off to admit they were wrong and focus on the benefits of reform and stop trying to defend what they’ve said.

Instead, they continue to try to justify this statement – see whitehouse blog. Stop kidding yourself or get out of the ivory tower. It’s like trying to build a website without any experience. It makes no sense.

As I said the other day, just like healthcare.gov isn’t the same as Health Reform (PPACA).  The same goes for this statement.  Healthcare needs to change.  There are some good things here, but healthcare is complicated and the administration made some mistakes.

At the end of the day, I think we have all been surprised at the rate of change especially for big companies:

People are jumping on this opportunity to drop coverage and shift coverage to the exchanges. Someone should have been able to model out all these scenarios years ago. What if this drives lots of companies to lower hours so that people don’t get coverage and they don’t get penalized. That would be a disaster. We don’t want a society where everyone’s balancing 2-3 jobs just to get to full-time hours. (Of course, some people do it just to pay the bills.)

On the flipside, the idea of creating better healthcare coverage for individuals was a good one, but I’m not sure why anyone thought this would be price neutral. In establishing a baseline offering which everyone has to have (e.g., maternity benefits), this is going to drive up costs. By requiring pricing for 2015 before anyone has experience with 2014 is just going to require companies to underwrite a lot of risk and drive premiums up.

As a good summary read of issues, read 31 Things We Learned in HealthCare.gov’s First 31 Days.

Trajectory Modeling On Adherence By CVS

No one who works with consumers or who studies adherence should too surprised that people are different in how they fill their medications. I think companies are finally getting a better handle on longitudinal member records and ways of studying those patterns to determine how and when to intervene.

Our past behavior is always a great place to learn from about our future behavior but at the same time, people view different drugs and conditions differently. For example, I might be very likely to take my pain medication everyday since it’s a symptomatic condition versus my cholesterol medication since it’s an asymptotic condition. I also may take a different approach yo medications that have significant side effects.

At the same time, these data is well known so the quest for the “best” segmentation approach and behavior change model continues.

With that in mind, I finally got a chance to look at some research from September that researchers at CVS Caremark and Brigham and Women’s Hospital published in the journal Medical Care. They used trajectory modeling to follow statin users for 15 months and came up with six groups:

  • Brief gap in medication use or filled irregularly during the first nine months, but improved during the last six months (11.4 percent)
  • Slowly declining adherence throughout the 15 month period (11.3 percent)
  • Used statins only occasionally across the 15 month study period (15 percent)
  • Rapid decline in statin use after initiation (19.3 percent)
  • Virtually no fills after their initial fill (23.4 percent

They also identified some characteristics associated with adherence:

  • Higher adherence was seen with patients who were older, had higher incomes and held a high school diploma.
  • The highest adherence rates were associated with Medicare Part D clients and people who live in New England.
  • Those with the lowest adherence rates tended to be generally younger, male and less likely to have an initial prescription that provided them with more than a 30-day supply of medication.

Troyen A. Brennan, MD, MPH, Executive Vice President and Chief Medical Officer of CVS Caremark:


“The use of trajectory models could help us more accurately identify patients at risk for medication nonadherence so we can develop and implement targeted interventions to help them stay on their medications for chronic health conditions.”

Aetna’s Metabolic Syndrome Innovation Program

I’ve been closely following Aetna’s innovation for the past few years (see post on CarePass and Healthagen).  I had the chance last week to speak with Adam Scott who is the Managing Director of the Aetna Innovation Labs.

Here’s Adam’s bio:

Adam Scott is a Managing Director within Aetna’s Innovation Labs, a group developing novel clinical, platform, and engagement solutions for the next generation of healthcare.  Mr. Scott specializes in clinical innovation, with a focus on oncology, genetics, and metabolic syndrome, as well as “big data” analysis.  His work is aimed at conceptualizing and developing products and services that better predict illness, enable evidence-based care and lengthen healthy lives.  Prior to joining Aetna, Mr. Scott’s 15-year healthcare career has included management roles in consulting, hospital administration, and most recently health information technology.  Mr. Scott holds a bachelor’s degree from Washington University in St. Louis and a Masters in Business Administration from Northwestern University’s Kellogg School of Management.  Mr. Scott resides with his family in Needham, MA, where he actively serves as a director on community boards.

This is one of my favorite topics – Metabolic Syndrome (although yes…I still hate the term).

Definition of Metabolic Syndrome from the NIH:

Metabolic (met-ah-BOL-ik) syndrome is the name for a group of risk factors that raises your risk for heart disease and other health problems, such as diabetesand stroke.

The term “metabolic” refers to the biochemical processes involved in the body’s normal functioning. Risk factors are traits, conditions, or habits that increase your chance of developing a disease.

The Aetna Innovation Labs are focused on bringing concepts to scale and staying 2-3 years ahead of the market.  They are looking to rapidly pilot ideas with a focus on collecting evidence.  In general, Adam described their work as focused on clinical, platform, and engagement ideas.  They are trying to collaborate with cutting edge companies that they think they can help to scale quickly.  It’s pretty exciting!

As stated in their press release about this new effort:

“During the course of the last year, Aetna Innovation Labs has successfully piloted an analysis of Metabolic Syndrome and the creation of predictive models for Metabolic Syndrome. This prior work showed significantly increased risk of both diabetes and heart disease for those living with Metabolic Syndrome,” said Michael Palmer, vice president of Innovation at Aetna. “With this new pilot program with Newtopia, we are aiming to help members address Metabolic Syndrome through specific actions, before more serious chronic conditions arise, like diabetes and heart disease.”

Aetna selected Newtopia for this effort for their unique approach toward achieving a healthy weight with an integrative and personalized focus on nutrition, exercise, and behavioral well-being. Newtopia’s program begins with a “genetic reveal,” leveraging a saliva-based genetic test to stratify participants with respect to three genes associated with obesity, appetite, and behavior. Based on the results of this test and an online assessment, Newtopia matches each participant to a plan and coach trained to focus on the member’s specific genetic, personality and motivation profile. Through online coaching sessions, Newtopia will help members achieve results related to maintaining a healthy weight and Metabolic Syndrome risk-reduction, which will be measured by changes from a pre- and post-program biometric screening.

“Newtopia’s mission is to inspire individuals to make the lifestyle choices that can help them build healthy lives,” said Jeffrey Ruby, Founder and CEO of Newtopia.

If you’ve been following the story, this builds upon their project with GNS to develop a predictive algorithm to identify people at risk for Metabolic Syndrome.  As you may or may not know, there are 5 first factors for Metabolic Syndrome (text from NIH):

The five conditions described below are metabolic risk factors. You can have any one of these risk factors by itself, but they tend to occur together. You must have at least three metabolic risk factors to be diagnosed with metabolic syndrome.

  • A large waistline. This also is called abdominal obesity or “having an apple shape.” Excess fat in the stomach area is a greater risk factor for heart disease than excess fat in other parts of the body, such as on the hips.

  • A high triglyceride level (or you’re on medicine to treat high triglycerides). Triglycerides are a type of fat found in the blood.

  • A low HDL cholesterol level (or you’re on medicine to treat low HDL cholesterol). HDL sometimes is called “good” cholesterol. This is because it helps remove cholesterol from your arteries. A low HDL cholesterol level raises your risk for heart disease.

  • High blood pressure (or you’re on medicine to treat high blood pressure). Blood pressure is the force of blood pushing against the walls of your arteries as your heart pumps blood. If this pressure rises and stays high over time, it can damage your heart and lead to plaque buildup.

  • High fasting blood sugar (or you’re on medicine to treat high blood sugar). Mildly high blood sugar may be an early sign of diabetes.

So, what exactly are they doing now.  That was the focus of my discussion with Adam.

  1. They are running data through the GNS predictive model.
  2. They are inviting people to participate in the program.  (initially focusing on 500 Aetna employees for the pilot)
  3. The employees that choose to participate then get a 3 SNP (snip) test done focused on the genes that are associated with body fat, appetite, and eating behavior.  (Maybe they should get a few of us bloggers into the pilot – hint.)  This is done through Newtopia, and the program is GINA compliant since the genetic data is never received by Aetna or the employer.
  4. The genetic analysis puts the consumer into one of eight categories.
  5. Based on the category, the consumer is matched with a personal coach who is going to help them with a care plan, an exercise plan, and a nutrition plan.  The coaching also includes a lifestyle assessment to identify the best ways to engage them and is supported by mobile and web technology.
    newtopia
  6. The Newtopia coaches are then using the Pebble technology to track activity and upload that into a portal and into their system.

We then talked about several of the other activities that are important for this to be successful:

  • Use of Motivational Interviewing or other evidence-based approaches for engagement.  In this case, Newtopia is providing the coaching using a proprietary approach based on the genetic data.
  • Providing offline support.  In this case, Aetna has partnered with Duke to provide the Metabolic Health in Small Bytes program which he described as a virtual coaching program.

Metabolic Health in Small Bytes uses a virtual classroom technology, where participants can interact with each other and the instructor. All of the program instructors have completed a program outlined by lead program developer Ruth Wolever, PhD from Duke Diet and Fitness Center and Duke Integrative Medicine. Using mindfulness techniques from the program, participants learn practices they can use to combat the root causes of obesity. The program’s goal is to help participants better understand their emotional state, enhance their knowledge of how to improve exercise and nutrition, and access internal motivation to do so. (source)

We also talked about employer feedback and willingness to adopt solutions like this.  From my conversations, I think employers are hesitant to go down this path.  Metabolic Syndrome affects about 23.7% of the population.  That is a large group of consumers to engage, and pending final ROI analysis will likely scare some employers off.

Adam told me that they’ve talked with 30 of their large clients, consultants, and mid-market clients.  While we didn’t get into specifics, we talked about all the reasons they should do this:

  • People with Metabolic Syndrome are 1.6x more expensive
  • People with Metabolic Syndrome are 5x more likely to get diabetes
  • Absenteeism
  • Presenteeism

This ties well with my argument that wellness programs aren’t just about ROI.

Obviously, one of the next steps will be figuring out how this integrates into their other existing programs to address the overall consumer experience so that it’s not just another cool (but disconnected) program.  And, of course, to demonstrate the effectiveness of the program to get clients and consumers to participate.

Two quotes I’ll leave you with on why this is difficult (but yet exciting to try to solve):

“The harsh reality is that scientists know as much about curing obesity as they do about curing the common cold: not much. But at least they admit their limitations in treating the cold. Many doctors seem to think the cure for obesity exists, but obese patients just don’t comply. Doctors often have less respect for obese patients, believing if they would just diet and exercise they’d be slim and healthy.” (source)

Thirty percent of those in the “overweight” class believed they were actually normal size, while 70% of those classified as obese felt they were simply overweight. Among the heaviest group, the morbidly obese, almost 60% pegged themselves as obese, while another 39% considered themselves merely overweight. (source)

10 Healthcare Projects I’d Like To Solve

I always tend to see the glass half full so when I see a problem then I often want to rush in and try to fix it. With that said, here are 10 things that I’ve thought about that I’d like to fix or see as big opportunities:

1. The healthcare experience. While this is the third leg of the Triple Aim, it often seems like the one that is so hard for healthcare companies to get. The system is so fragmented that the patient often is forgotten.

2. Device integration. While devices are better and integration is possible, there is still a huge lift to integrate my data into the typical clinical workflow. This is only going to get much worse with ubiquitous use of sensors and will be the limiting factor in the growth of the Quantified Self movement. (See my post on FitBit)

3. Intelligent phones. This is something that people carry everywhere. They often live life through the phone sometimes missing out on reality. The phone has tons of data as I’ve described before. We have to figure out how to tap into this in a less disruptive way.

4. Consumer preferences. I’m a big believer in preference-based marketing. But the question is how do I disclose my preferences, to whom, and are my preferences really the best way to get me to engage. What would be ideal is if we could find a way to scale down fMRI technology and allow us to disclose this information to key companies so they could get us to take actions that were in our best interest. (see old post on Buyology)

5. Benefits selection. I’ve picked the wrong benefits a few times. This drives me crazy. As I mentioned the other day, the technology to help with this exists and all the data which sits in EMRs and PHRs should allow us to fix this problem.

6. The role of retail pharmacy. This is one of my favorite topics. With more retail pharmacies than McDonalds and a huge problem of access, pharmacies could be the key turning point in influencing change in this country.

7. Caregiver empowerment. Anyone who cares for an adult and/or child knows how hard it is to be a caregiver and take care of their own needs. This becomes even harder with the people being geographically apart. With all the sensors and remote technology out there, I see this being a hot space in the next decade.

8. The smart house. As an architect, I’ve always dreamed of helping create the intelligent house where it knows what food you have. It manages your heat and light. It tracks your movements and could call for help if you fall. I see this being an opportunity to empower seniors to live at home longer.

9. Helping the disenfranchised. For years, we’ve all seen data showing that income can affect health. The question is how will we fix this. Coverage for all is certainly a critical step but that won’t fix it. We have a huge health literacy issue also. Ultimately, public health needs a program like we had to get people to wear seat belts. We need yo own our fate and change it before we end up like the humans in the movie Wall-e.

10. A Hispanic healthcare company in the US. With 16% of the US that speak Spanish, I’m shocked that I haven’t seen someone come out with a health and wellness company that is Hispanic centric in terms of the approach to improving care, engaging consumers, and providing support.

So, what would you like to solve?

The Healthcare Mark-up Game – Driving Up Healthcare Costs

The idea of healthcare costs and the need for healthcare transparency has become a front page issue. With the shift to consumer driven healthcare and high deductible plans, the average consumer is increasingly aware of what things cost. And companies like Change Healthcare provide tools to help consumers navigate this maze.

But, what I don’t hear many people discuss is the issue of middlemen and how this adds cost to the system. I’ve worked for several middlemen so I think I understand the model well. Of course, these companies make good (and true) arguments which is that they lower costs due to scale based efficiencies. But, healthcare is big business so everyone has to get paid somehow. Some of the “non-profits” make the most money.

Let’s look at prescription drugs:
- This begins with the manufacturer who adds the marketing and sales costs to the actual ingredient and packaging and shipping costs.
- The drug is then shipped to a wholesaler who stocks the drugs and ships them to pharmacies.
- The drugs are then sold by the pharmacy to the consumer and the pharmacy bills the payer.
- Assuming the payer isn’t the actual employer, the payer will then bill the employer.

So who all gets paid in this process:
- The manufacturer of the drug
- The advertising companies (they name the drug, they create the packaging, they create the ads)
- The marketing companies (they set up the websites, they create the mobile apps)
- The law firms (trademarks, patents)
- The sales companies (they hire and manage the pharma reps)
- The data company (the manage the Rx data to help target the reps)
- The shipping companies (transportation)
- The wholesaler
- The pharmacy
- The marketing and communication companies (refill programs, on the bag messaging)
- The technology companies (switch company, adjudication company)
- The recruiters (hiring, staffing)
- The PBM (contracting, rebating, customer service)
- The payer (adjudication, customer service, risk management)
- The broker (commission)

Still wonder why healthcare is expensive?

I wish I had an easy answer. A lot of these services are needed and it would cost more if the employers all had to do this themselves. There would be no scale. There would be no efficiencies.

This is certainly one argument for the efficiencies of a single payer system but I don’t think that’s very efficient IMHO.

OMG – Prescription Coupons Could Cost Consumers More

Talk about an article that seems a few years late to the party…

Anyways, I was reading a link from the PCMA today about an article on philly.com about copay cards.  It stresses several points:

  • The cards are typically only for 90-days.
  • The cards get people started on brand drugs not generics.
  • People are less likely to switch to generics after they use the brand.
  • This costs people more money over time.

I’ve talked about copay cards many times and presented on this topic at the PCMA conference a few years ago.

Let me give some quick thoughts here.

  1. The cards may typically be for only 90-days, but most people that drop off therapy or titrate to other strengths do so in the first 90-days so perhaps this is saving some money.
  2. Of course, it’s for brand drugs not generics.  That’s the business model we’ve created in this country where generics are priced at pennies so there is no marketing to support those products.  It’s the PBMs and pharmacies that do the marketing for generics since they are the ones making money here.
  3. I think it’s a fair generalization that people are less likely to switch, but this is the problem.  If the drugs are the same (per the FDA), why is this an issue?  Is it an educational issue.  Or, is there really a difference?
  4. I’m not sure the consumer cost is the issue.  That’s marketing 101.  Don’t most consumers understand this issue that sales and coupons drive you to build loyalty often to higher priced products.  I think the debate here needs to stay on the payer who pays 70-80% of the drug costs.  They are the ones who really have an issue here since they don’t control the decision made in the market.

This one doesn’t seem to be going away, but I’m not seeing any net new information.

Diet Soda Versus Regular Soda – Ongoing Confusion

I view this as one more example of how the average consumer gets confused by all the information out there.

images

Should I focus on calories?

Should I focus on the ingredients?

Should I just drink water?  (of course)

Now, “new” research shows that the artificial sweeteners in the Diet drink can actually fool your body making it worse for you over time.  This isn’t completely new if you look at this blog from a few years ago.

But, we often wonder about why consumers don’t take responsibility for their actions and then get upset when more aggressive measures have to be taken.  (See the recent Penn State uproar.)

Consumers don’t know who or what to trust.

Should I drink alcohol?  Is it good for me in moderation?

How much exercise is needed?  New research shows that it can’t all be done at once.

Extreme Weather Isn’t Good For Our Health

After moving to Charlotte, it’s been raining and flooding here all summer.  It reminds me of 1993 when I moved to St. Louis, and they had their 100-year flood.

100yearflood-basic-1

All I ever hear from everyone is that this isn’t normal weather for Charlotte.  It begs the question of whether any weather is normal.  [I'll avoid going down the global warming path here.]

So, I found it interesting that there was a recent article says that this will essentially be part of a new normal which will be more weather extremes.  Drought.  Flooding.  Hurricanes.  Extreme Heat.

So, what does this have to do with health?  A lot.

When these extreme weather scenarios come up, people are less likely to leave the house.  Kids don’t go outside and play.  And, as you can see on the CDC website, they’re focused on analyzing these trends to understand the impact.  On the NC HHS site, here’s what it says about this weather change.

“Some of the health impacts of climate change may include illness, injuries or deaths due to heat, air pollution, extreme weather, and water-borne pathogens.”

Weather has an impact.  Just look at SAD (Seasonal Affective Disorder).

Or, just think about childhood obesity.  Our kids are supposed to get 60 minutes of activity a day.  While we assume that happens with sports, it doesn’t always as I blogged about before.  With many of them over-scheduled to begin with and schools dropping recess, weather may be the last straw.  As recent research shows, a structured recess program is important for academic success.

Some days, I think our kids work harder then us parents.  Let’s look at a kid playing a serious sport.

  • 7:50-2:55 school for 5 days a week
  • 1-2 hours of homework per day
  • 2 hours of sports practice 5 days a week
  • Homework on the weekend
  • Games / tournaments on the weekend

Now, add a second sport which many kids do.  Or a part-time job as they get older.  (I know I’m getting off on a tangent, but it’s been so long since I’ve had time to blog…I need to get back into a pattern.)

Walgreens Clinic Rebranding Is More Than A Name Change

As I talked about in my post about Walgreens and innovation, Walgreens has renamed their TakeCare Clinics to Healthcare Clinics at some locations.  This is more than just a meaningless name change.  This is the beginning of a business model change.  This is the shift from acute care to ongoing chronic disease management.  This is a big move that changes their place in the healthcare value chain.

It’s part of the overall strategy that has pulled them into the ACO space.

It will be interesting to see if CVS Caremark and their MinuteClinics follow them.  CVS Caremark already announced a different strategy in terms of providing advocates.  If I were them, I would jump fully into the remote monitoring / mHealth space and provide chronic disease management from a remote basis.  I think this would be different and innovative.

Walgreens Healthcare Clinics

Did You Know? Chronic Kidney Disease (#CKD) From The National Kidney Foundation

I was reading a document from the National Kidney Foundation (NKF) the other day.  Some of the facts jumped out at me.  I thought I’d share them.

  • 83,000 people are on the waiting list for a kidney transplant
  • 1 person dies every 2 hours while waiting for a kidney transplant
  • 26M Americans (1 in 9 adults) have chronic kidney disease (CKD) and most don’t know it
  • 367,000 people depend on dialysis for survival

It also reinforced some things that many people may know:

  • Once kidneys fail, patients need a transplant of dialysis to survive
  • People with diabetes, high blood pressure, or a family history of these conditions are at risk for CKD
  • African Americans, Hispanics, Asians, Native Americans, and the elderly are at increased risk

You can also find more information about CKD from the CDC.

There was an article this week in the NY Times about this silent killer.  Here’s a paragraph from there.

Only 1 percent of participants with no lifestyle-related risk factors developed protein in their urine, an early indicator of kidney damage, while 13 percent of those with three unhealthy factors developed the condition, known medically as proteinuria. Obesity alone doubled a person’s risk of developing kidney disease; an unhealthy diet raised the risk even when weight and other lifestyle factors were taken into account.

Obese Scouts (And Leaders) Told To Stay Away

Did you catch the story the other day that kids and adults that had a BMI of over 40 were told they couldn’t come to the annual Boy Scout Jamboree? And those that had a BMI of between 32 and 39.9 had to submit documentation that they could attend.

What do you think about that?

If you look at the adult US statistics, this would represent about 30%+ of the population. (United HealthGroup report: “United States of Diabetes“)

This is one story where I’m sure there’s a lot that we’d want to know. In Time, they talk about the fact that they published the restrictions two years ago. This would have allowed people time to improve their BMI. But, jumping from 40 to 31 might be too big of a jump in two years for some people to do in a healthy way.

If I were developing this type of program for a company, I’d expect to answer these questions:

  • What did you do to support the scouts and leaders in losing weight? Did you give them a coach? A registered dietician?
  • Did you create a culture of health? What types of foods are at boy scout meetings?
  • Is there a reasonable alternative for the obese scouts to get a similar experience if clinically appropriate?

Obviously, this isn’t a work environment so the rules are different. On the one hand, congrats to them for being brave enough to take this topic on and try to encourage scouts and leaders to have a healthy weight. On the other hand, they need to make sure they do this in a way that doesn’t shame these people and need to make sure they support their weight loss.

But, don’t be fooled. The world is going to continue to move this way. Obesity is too big of a driver of healthcare costs and other presenteeism and absenteeism impacts.

Just look at Japan…(source)

Under a national law that came into effect two months ago, companies and local governments must now measure the waistlines of Japanese people between the ages of 40 and 74 as part of their annual checkups. That represents more than 56 million waistlines, or about 44 percent of the entire population.

Those exceeding government limits — 33.5 inches for men and 35.4 inches for women, which are identical to thresholds established in 2005 for Japan by the International Diabetes Federation as an easy guideline for identifying health risks — and having a weight-related ailment will be given dieting guidance if after three months they do not lose weight. If necessary, those people will be steered toward further re-education after six more months.

To reach its goals of shrinking the overweight population by 10 percent over the next four years and 25 percent over the next seven years, the government will impose financial penalties on companies and local governments that fail to meet specific targets. The country’s Ministry of Health argues that the campaign will keep the spread of diseases like diabetes and strokes in check.

CarePass, Another Aetna Innovation – What’s Your Healthy?

Have you seen the new “What’s Your Healthy?” campaign?  Here’s a few shots.

BTW – My healthy is keeping up with my kids in sports and moving down a belt notch.

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As many of you know, I consider Walgreens and Aetna to be two of the most innovative healthcare companies today (out of the big, established players).  [And, full disclosure, I own stock in both.]  I’ve talked about Walgreens (see Walgreens post on innovation) several times along with Aetna (see Healthagen post).

That being said, the new campaign along with the press caught my attention.  I was glad that I was able to get some time with Martha Wofford who is the VP and head of CarePass.

“We want to make it easier for everyone to engage in their health and hopefully shift from thinking about health care to taking care of their health,” said Martha L. Wofford, vice president and head of CarePass from Aetna. “CarePass helps consumers connect different pieces of health data to create a fuller, more personalized picture of their health.”

I spent some time talking with Martha and team about their initiative.  Here’s some highlights that stuck out to me.

  • There use of goals was really easy and intuitive.  If you log-in to the CarePass site and get started, you have 3 options or you can create your own (see below).  We spent some time talking about the importance of making these relevant to the individual not focusing on “healthcare goals” like adherence or lowering you blood sugar.  Most of us don’t think that way.  As they described them, they picked “motivation centric goals”.
    Aetna Carepass goals
  • I was also really interested in how they picked which apps to recommend.  There are so many out there, and many of you know that I’ve been fascinated by the concept of curating apps or prescribing apps to people.  They had a nice, simple process:
    • Which apps are most popular?
    • Does the app have “breadth”?  (i.e., national applicability)
    • They also spent more time pre-screening apps which collect PHI to understand them before listing them on the site.
    • They’re using the consumers goals to recommend apps to them.
  • The other big question I had is why do this.  It certain helps build the Aetna brand over time, but there’s not direct path to revenue (that I see).  They described their efforts as “supporting the healthcare journey” through connected data.  Ultimately, it’s about making Aetna a preferred consumer brand which may be very relevant in the individual market and exchange world in the not too distant future.
  • I like the idea of companies being “app agnostic” as I call it.  Walgreens is doing this.  Aetna is doing this.  I plan on doing this in my day job.  This allows the consumer to pick the app that works for them and as long as the data is normalized (or can be normalized) and the app provides some type of open API (application programming interface) it’s much easier to integrate with.
  • We talked a little about what’s next.  Metabolic syndrome is something they brought up.  This is something that Aetna’s been talking about in several forums for a while now.  They launched a new offering earlier this year.  (I still hate the term metabolic syndrome from a consumer perspective, but it seems to be sticking in the healthcare community.)
  • We also talked about new goals to come around smoking cessation, medication, and stress.
  • Another discussion I have with lots of people is how this data gets used.  (see a good article about what’s next for QuantifiedSelf)  I personally really want to see my data pushed to the care management team to monitor and send me information.  (Eat this not that type of suggestions)  Martha talked about how the data belongs to the member and they have to choose to push it to the coach.  She also talked about how they’re integrating with their PHR (Personal Health Record) first and then looking at others.  (see old interview with ActiveHealth)

In summary, CarePass is a nice additional to your #QuantifiedSelf toolkit.  As you can see from the screenshots below, the GUI (graphic user interface) is simple.  It’s well designed.  Integration with your apps is easy.  It provides you with goals and motivation.  They help you navigate the app world.  And, it helps you bring together data from multiple sources.  Once it can pull in all my Rx, medical and lab data along with my HRA data and my device data, it will be really cool!  But, I know that I’m a minority in that effort.  I’m really intrigued by the lifestyle questions they ask and wonder how those will ultimately personalize my experience.

Carepass lifestyle questions Carepass dashboard

So, what apps do they share?  Here’s a screenshot, but you really should log-in and try the site and see the full list.  It’s simple and worth the effort.

Carepass apps

As an added bonus, I’m adding a presentation I gave with Aetna at the Care Continuum Alliance two years ago.  I was searching for my past interviews with Aetna people and found this online so I added it to SlideShare and put it here.

Prescribing An App vs. An Rx – Why Are People Surprised?

A staggering 90 percent of chronic patients in the US would accept a mobile app prescription from their physician, as opposed to only 66 percent willing to accept a prescription of medication, according to a recent survey from health communications firm Digitas Health.  (source)

Is this surprising to anyone?

I don’t think it should be…and here’s why:

  1. In general, most apps don’t cost anything while prescriptions generally do.
  2. I don’t know of any apps with side effects.
  3. It’s unlikely that your app will have a negative interaction with another app (like a drug-drug interaction).  It may give you conflicting information, but that’s about it.
  4. You don’t have to wait to get your app.  You can probably download it while you’re at the physician’s office.  A prescription can take time to get either waiting in line, waiting for it to get filled, or sending it in through the mail.
  5. You don’t have to refill your app.  You may have to update it every once in a while, but it tells you when and all you have to do is press a button.

Of course, most (all) apps won’t have the same likelihood as Rxs in improving your health.  Of course, Rxs only work if people take them…which they don’t.

Still surprised?

More CDHPs Are Coming – Is That A Good Thing?

I think we all see it coming.  It’s a tidal wave of responsibility being pushed from the employer to us the individual.  On paper, this seems like a great thing since 75%+ of healthcare costs are driven by personal behaviors.  On the other hand, this means we actually have to understand the healthcare system and how to make decisions.

Here’s the abstract from a recent Health Affairs article:

Consumer-directed health plans (CDHPs) are designed to make employees more cost- and health-conscious by exposing them more directly to the costs of their care, which should lower demand for care and, in turn, control premium growth. These features have made consumer-directed plans increasingly attractive to employers. We explored effects of consumer-directed health plans on health care and preventive care use, using data from two large employers—one that adopted a CDHP in 2007 and another with no CDHP. Our study had mixed results relative to expectations. After four years under the CDHP, there were 0.26 fewer physician office visits per enrollee per year and 0.85 fewer prescriptions filled, but there were 0.018 more emergency department visits. Also, the likelihood of receiving recommended cancer screenings was lower under the CDHP after one year and, even after recovering somewhat, still lower than baseline at the study’s conclusion. If CDHPs succeed in getting people to make more cost-sensitive decisions, plan sponsors will have to design plans to incentivize primary care and prevention and educate members about what the plan covers.

You can see some of the growth stats and concerns also in an American Medical News article.  But, as someone who’s live through it, there are a series of issues (all of which are addressable).

  1. Shifting first dollar payment to the individual also shifts a huge burden of time to the individual.  Which bills do I pay?  Which receipts do I send to the HSA?  Which to the HRA?  How much should I put in each account?  What’s the status of my payments?
  2. This only works if I understand my tradeoffs.  What should I be doing differently?  How could I have spent less money?
  3. It can create the wrong incentives.  My regular transactions like pharmacy seem to cost me a huge amount of money every month while my procedures seem very inexpensive.

My point here is that healthcare is like a balloon.  When you step on one area, it doesn’t eliminate the costs.  It simply shifts the costs.  Until we understand the macro-economic impacts of our short-term decisions, it’s unlikely that we’ll really change our path.  I see a huge shift happening and when the tidal wave pulls back it’s going to leave us with a huge Medicare bill in the future as people have put off preventative care only to have more issues in a decade.

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