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No Fat Customers Please – #BoycottAbercrombie

May 14, 2013 by George Van Antwerp 0 Comments

My kids have worn Abercrombie and Fitch clothes for the past few years even thought I find the advertising suggestive and the store environment not particularly inviting for the average adult (loud music, small aisles, very young staff). Even with that, I was shocked to see some of the recent news about their attitude towards their customers in response to why they don’t stock XL and XXL clothing sizes. With today’s focus on customer experience and competitive retail environment, this seems like not only a bad business model, but one that is shallow and unhealthy.

“In every school there are the cool and popular kids, and then there are the not-so-cool kids. Candidly, we go after the cool kids. We go after the attractive all-American kid with a great attitude and a lot of friends. A lot of people don’t belong [in our clothes], and they can’t belong. Are we exclusionary? Absolutely. Those companies that are in trouble are trying to target everybody: young, old, fat, skinny. But then you become totally vanilla. You don’t alienate anybody, but you don’t excite anybody, either.” (source article)

But, a bad business model and a shallow minded CEO isn’t a reason to boycott a company. And, after growing up in a family where we boycotted many companies due to business practices, I never saw myself as someone who would support this “hippie” approach. That being said, I think that Abercrombie’s attitude is a real issue for the health of our kids for 3 reasons.

  1. We have a major obesity issue in the US. (from CDC)
    1. Childhood obesity has more than doubled in children and tripled in adolescents in the past 30 years.
    2. The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2010. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to 18% over the same period.
    3. In 2010, more than one third of children and adolescents were overweight or obese.
    4. Overweight is defined as having excess body weight for a particular height from fat, muscle, bone, water, or a combination of these factors.3 Obesity is defined as having excess body fat.
    5. Overweight and obesity are the result of “caloric imbalance”—too few calories expended for the amount of calories consumed—and are affected by various genetic, behavioral, and environmental factors.
  2. We have a bullying issue in the US. (source)
    1. Over 3.2 million students are victims of bullying each year.
    2. 1 in 4 teachers see nothing wrong with bullying and will only intervene 4 percent of the time.
    3. Approximately 160,000 teens skip school every day because of bullying.
    4. 1 in 7 students in grades K-12 is either a bully or a victim of bullying.
    5. 56 percent of students have personally witnessed some type of bullying at school.
    6. Over two-thirds of students believe that schools respond poorly to bullying, with a high percentage of students believing that adult help is infrequent and ineffective.
    7. 71 percent of students report incidents of bullying as a problem at their school.
    8. 90 percent of 4th through 8th graders report being victims of bullying.
    9. 1 out 10 students drop out of school because of repeated bullying.
    10. Harassment and bullying have been linked to 75 percent of school-shooting incidents.
    11. Physical bullying increases in elementary school, peaks in middle school and declines in high school.  Verbal abuse, on the other hand, remains constant.
  3. We have a suicide issue in the US. (CDC fact sheet)
    1. Among young adults ages 15 to 24 years old, there are approximately 100-200 attempts for every completed suicide.
    2. In a 2011 nationally-representative sample of youth in grades 9-12:
      1. 15.8% of students reported that they had seriously considered attempting suicide during the 12 months preceding the survey;12.8% of students reported that they made a plan about how they would attempt suicide during the 12 months preceding the survey;
      2. 7.8% of students reported that they had attempted suicide one or more times during the 12 months preceding the survey; and
      3. 2.4% of students reported that they had made a suicide attempt that resulted in an injury, poisoning, or an overdose that required medical attention.

 

As adults, I believe we have a responsibility to break the cycle of bullying and set an example. This isn’t time to create a fraternity culture in adulthood. We have systemic issues to address in serious ways. I know we won’t be shopping at Abercrombie again, and I think my kids have lost their interest in wearing the clothes.

Books / Articles, Consumerism, General Thoughts

Why Do People Think Adherence Is So Easy?

May 6, 2013 by George Van Antwerp 2 Comments

I think we all know that medication adherence is a big deal. The most common number quoted is the $290B waste number from NEHI. There are numerous studies that confirm the value of non-adherence even one that just came out.

The amount of money spent on trying to improve adherence is huge! Pharma has worked on. Retail pharmacies have worked on it. Providers have worked on it. Insurance companies have worked on it. Employers have worked on it… And all of these have happened across the world.

At the same time, you see people get so excited about things don’t make any sense to me.

Let me take an easy example. A few months ago, a company called MediSafe put out a press release around moving medication adherence on statins up to 84.25%. Nothing against the company, but I read the press release and reached out to them to say “this is great, but it’s only 2 months of data…most people drop therapy after the first few months so who care…call me back when you get some good 12 month data.”

But, a lot of people got all excited and there was numerous press about this – see list of articles about them.

Now, tonight, I see another technology getting similar excitement. Fast Company talks about the AdhereTech technology which integrates a cellular phone with a pill bottle. And, it costs $60 a month. In my experience, companies wouldn’t even spend $2 a month to promote adherence so $60 is just impractical. The argument is that this is good for high cost specialty drugs that are oral solids not injectables. But, this isn’t a new idea. Glowcaps already built this model with a very slick interface and workflow.

And, I don’t know about you, but I think this would be obnoxious. And, I love data and am part of the QuantifiedSelf movement. I’m not sure I understand the consumer research here. I would have to believe all of the following to buy into this model.

  • Non-adherence people are primarily not adherent due to no reminders to take their medication on a daily basis.
  • People with chronic conditions that require high cost specialty drugs are going to change behavior because some bottle sends them a text message.
  • Manufacturers or some other healthcare company is willing to pay $60 a month for this service.
  • There won’t be message fatigue after a few months (weeks) of messaging.
  • Pharmacies would be have to be willing to change their workflow to use these bottles.

Yes. Will this work for some people…sure. But, if it helps 10% of people, then my cost is really $600 per success.

Should we be working on better solutions to address adherence…of course.

But, let’s stop trying to figure out some gimmick to fix adherence. Let’s look at root cause.

For example:

  • People don’t know why they’ve been given a medication.
  • People don’t understand their disease.
  • People can’t afford their medication.
  • People don’t know what to expect in terms of side effects.
  • People don’t see value in improving adherence.
  • People don’t know they have to refill their medications.
  • People aren’t health literate.

We have a lot of problems.

Books / Articles, Healthcare, Managed Care, Marketing / Communications, Methodology, mHealth, PBM / Pharmacy, Research, Value Propositions
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Presidential Physical Fitness Award – Reasonable? Role Models?

May 6, 2013 by George Van Antwerp 0 Comments

I must admit that I don’t remember taking the presidential fitness test as a kid. With that being said, I was surprised to learn from my daughter that in her class of club soccer, volleyball, and baseball players she was the only kid to meet the highest level (greater than the 85th percentile across several measures). She made it today by running her mile in 7:37.

So, what does this require? It made me curious. Here’s what you have to do:

benchmarks_presidential_large

Could you do that?  These seem pretty difficult to me.  I could probably do the mile in 6:06, but I doubt I could do 53 pull-ups.  And, I doubt I could sit and reach 7 inches beyond my toes.  (Looking at the 17 year old male standards.)

On the other hand, we certainly need our kids to be more fit.  We have a big childhood obesity issue.

Childhood Obesity

But, it also made me think about Michelle Obama’s efforts in this space.

Lets Move

I think these programs are good starts, but lets not forget that obesity is a social issue and kids learn from those around them.  Let me ask the uncomfortable questions about those who our kids look up to.

  • How many overweight coaches do you know?
  • How about overweight teachers?
  • How about policemen and firefighters?
  • How about clergy?

These are all key role models…not to mention us parents who are often overweight.

I guess my suggestion here to the President would be to think about how to use our massive government payrolls as a foundation for change. Let’s think about the Presidential Fitness Challenge and create a broader wellness solution to change the visual role models for our kids and figure out how to help companies invest in this.

For example, we know that sleeping is correlated to weight and health.  I was talking to my brother-in-law who is a police officer when he told me that they are expected to get 8 hours of sleep a night.  Imagine if companies set this expectation for their employees (sleep impact on work).  

“Sitting Disease” may make a great late night comedy story line, but it’s a reality of our information economy that has to be addressed.

sitting-disease-how-sitting-too-long-can-affect-your-health_5123e1818a55e

Books / Articles, Business Tools, exercise, General Thoughts, Healthcare, Infographic, Innovation, Leadership, Marketing / Communications, Methodology, Value Propositions

How Walgreens Became One Of The More Innovative Healthcare Companies

April 28, 2013 by George Van Antwerp 1 Comment

While we are generally a society focused on innovation from start-ups (and now all the incubators like Rock Health), there are a few big companies that are able to innovate while growing.  That’s not always easy and companies often need some catalyst to make this happen.  Right now, there are four established healthcare companies that I’m watching closely to track their innovation – Kaiser, United/Optum, Aetna, and Walgreens.  (Walgreens has made the Fast Company innovation list 3 of the past 4 years.)

I think Walgreens is really interesting, and they did have a great catalyst to force them to really dig deep to think about how do we survive in a big PBM world.  It seems like the answer has been to become a healthcare company not just a pharmacy (as they say “at the corner of Happy and Healthy”) while simultaneously continuing to grow in the specialty pharmacy and store area.

Let’s look at some of the changes they’ve made over the past 5 years.  Looking back, I would have described them as an organic growth company with a “not-invented-here” attitude.  Now, I think they have leapfrogged the marketplace to become a model for innovation.

  1. They sold their PBM.
  2. They re-designed their stores.
  3. They got the pharmacist out talking to people.
  4. They got more involved with medication therapy management.
  5. They increased their focus on immunizations increasing the pharmacists role.
  6. They formed an innovation team.
  7. They invested heavily in digital and drove out several mobile solutions including innovations like using the QR code and scanning technology to order refills.
  8. They’ve reached out to partner with companies like Johns Hopkins and the Joslin Diabetes Centers.
  9. They increased their focus on publications out of their research group to showcase what they could do.
  10. They started looking at the role the pharmacy could play and the medications played in readmissions.
  11. They partnered with Boots to become a much more global company.
  12. They offered daily testing for key numbers people should know like A1c and blood pressure even at stores without a clinic.
  13. They created an incentive program and opened it up to link to devices like FitBit.
  14. They partnered with The Biggest Loser.
  15. They increased their focus on the employer including getting into the on-site clinic space.
  16. They created 3 Accountable Care Organizations.
  17. They partnered with Novartis to get into the clinical trials space.
  18. They developed APIs to open their system up to developers and other health IT companies.
  19. They formed a big collaboration with AmerisourceBergen which if you read the quote from Greg Wasson isn’t just about supply chain.

    “Today’s announcement marks another step forward in establishing an unprecedented and efficient global pharmacy-led, health and wellbeing network, and achieving our vision of becoming the first choice in health and daily living for everyone in America and beyond,” said Gregory Wasson, President and Chief Executive Officer of Walgreens. “We are excited to be expanding our existing relationship with AmerisourceBergen to a 10-year strategic long-term contract, representing another transformational step in the pharmaceutical supply chain. We believe this relationship will create a wide range of opportunities and innovations in the rapidly changing U.S. and global health care environment that we expect will benefit all of our stakeholders.”

  20. They jumped into the retail clinic space and have continued to grow that footprint physically and around the services they offer with the latest jump being to really address the access issue and help with chronic conditions not just acute problems.

“With this service expansion, Take Care Clinics now provide the most comprehensive service offering within the retail clinic industry, and can play an even more valuable role in helping patients get, stay and live well,” said Dr. Jeffrey Kang, senior vice president of health and wellness services and solutions, Walgreens. “Through greater access to services and a broader focus on disease prevention and chronic condition management, our clinics can connect and work with physicians and other providers to better help support the increasing demands on our health care system today.” (from Press Release)

This is something for the whole pharmacy (PBM, pharma, retail, mail, specialty) industry to watch and model as I talked about in my PBMI presentation (which I’m giving again tomorrow in Chicago).  It reminds me of some of the discussions by pharma leaders about the need to go “beyond the pill”.

 

Books / Articles, Care Management, Consumerism, exercise, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, mHealth, PBM / Pharmacy, Press, Technology, Value Propositions
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Why CVS Caremark Asking For Your Weight Is Good For You

March 30, 2013 by George Van Antwerp 0 Comments

I continue to annoyed by all the fear-mongering in the industry around what CVS Caremark is “doing to their employees”.  What about focusing on how they are helping their employees to get better?  (If interested, you should read some of the information they have on their blog.)

Our “Plan for Health” combines an evolving, best-practice approach to health coverage with preventive care and wellness programs. Our colleagues will be more accountable for taking control of their health and associated costs. The first step is getting to know your numbers by getting a health screening and completing an online wellness review each year. If colleagues complete both by the May 1, 2013 deadline, they will avoid paying an additional $600 for the 2013-2014 plan year. (from the CVS Caremark blog)

I was hopeful to hear someone come out strongly and speak about it yesterday on CBS, but instead the CEO of Mercer just talked about “soft” programs that depend upon consumers being proactive around their health.  I would rather hear about the value of screenings and how it helps employees.  In talking with one friend of mine at a biometrics company, he told me that in one case almost 40% of the people that they identified with diabetes (or pre-diabetes) and hypertension (or pre-hypertension) didn’t know they had the disease (or were at high risk).  That to me is a valuable insight to the individual especially when coupled with a program to help them learn and manage their disease (or risk).

For example, companies for years have been using Health Risk Assessments (HRAs) to try to baseline employee health and use that to accomplish several things:

  1. Help the employee to understand their risks
  2. Identify people who should be in coaching programs to improve their health
  3. Learn about their population and how to improve their health benefits

Use of biometrics is the right evolution from the HRA.  People have tried HRAs for years with some success.  Companies pay as much as $600 for people to take this online survey that has no necessary link to reality.  Most HRAs aren’t linked to lab values.  Most HRAs aren’t linked to claims data.  Most HRAs don’t necessarily trigger enrollment in health programs.  They are supposed to activate the employee to be proactive which doesn’t work for many sick consumers especially those in the “pre-disease” phase.  (Here’s a good study that does show some increased activation.)

As I mentioned the other day, this use of biometrics and link between incentives and participation (and ultimately outcomes) is normal and will ultimately improve the link between the workplace and the employee around health.

Let’s take a broader look at insurance to help set some context:

  • For life insurance, you have to disclose certain data and depending on the policy level you have to do other things like get a physical and have blood work drawn.  That effects your costs and their underwriting.  
  • For car insurance, if you get in accidents, your costs go up.  In some case, you can have a monitoring device put on your car to lower your costs.  (like getting blood work done)
  • For home owners insurance, your costs go up if you live in a flood zone or a earthquake zone.  It also goes up if you have lots of claims.

Whether we want to admit it or not, we do determine a lot of our healthcare costs based on decisions we’ve made or had made for us since we were kids.  Some of these are conscious and some are subconscious.  And, obesity which is a large driver of many of these chronic conditions and has an impact on your likelihood of having cancer.  So, a company asking for your BMI and other data to help understand your risks for healthcare costs (of which they typically pick up 80%) doesn’t seem unusual.

Certainly, some are environmental such as those that live in “food deserts” like Detroit.  In other cases, workplace stress can affect our health.  We’re just starting to get smarter about “sitting disease” and it’s impact on our health.  Or, we may take medications that affect our blood pressure (for example).  It’s certainly important to understand these in context of your lab values and discuss a holistic strategy for improving your health with your physician and any care management resources which are provided to you (nurse, social worker, nutritionist, pharmacist).

This idea of learning more about employees in terms of biometrics, food, sleep, stress, social interaction, and many other data points is going to be more and more of a focus.  Companies want to learn how their employees do things.  They want to understand their health.  They want to improve their health.  They want to invest in their workforce to improve productivity, innovation, and ultimately job satisfaction.

While the glass half-empty people won’t see this and there are some companies that don’t always act this way, I generally believe that companies are trying to act in a way to increase their top line and most intelligent executives understand the correlation between health and wealth and the link between employee satisfaction and growth.

Ultimately, healthcare costs are estimated to put a $240,000 burden on us after we retire (even with Medicare) so if someone wants to help me become healthier and thereby save me money which improves my ability to retire and enjoy life I’m happy for them to do.

Books / Articles, Care Management, Healthcare, Leadership, Marketing / Communications, PBM / Pharmacy, Value Propositions
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How The CVS Program Will Change The Employer – Employee Contract

March 22, 2013 by George Van Antwerp 1 Comment

Have you heard that CVS Caremark is requiring employees to go get biometrics and going to take action on it? OMG!

I’m not sure I understand why people are all upset. Let’s look at the facts:

And, by the way, have we forgotten how much healthcare costs have gone up over time and who pays that bill. It’s either the employer or the government. Both of those things impact our pay as individuals either in terms of lower raises to cover healthcare costs, shifting healthcare costs to us, or taxes. It’s not sustainable so the person who pays the bill has to step in since we’re not. (Which is also why I support the NY ban on soda.)

Now, let’s look at our healthcare system where in the current fee-for-service model, there isn’t an incentive for physicians to address this.

For now, people should be happy. They’re only being required to do the biometrics. The penalty isn’t linked to whether they’re fat or have high blood pressure or smoke or have high cholesterol or have diabetes. A recent study by Towers Watson shows that while 16% of employers do this type of outcome based incentive program today (2013) that this is going to jump to 47% in 2014. So, this will be the norm.

And, guess what…sticks often work better than carrots in some cases.

And, healthcare costs are making us uncompetitive globally as a country.

  • The cost of healthcare is greater than the cost of steel in a car.
  • The cost of healthcare is greater than the cost of coffee in a Starbuck’s cup of coffee.

And, health reform is allowing (even enabling) this to happen. It says that you can treat people differently and create up to a 50% differential in costs associated with their health. (Not a legal definition so read the fine print.)

But, what I think all of us (consumers and employers) will need to realize is that moving to this (which I agree with) will change the employer and employee relationship in several ways.

  1. You can’t put these programs in place without something to help me manage my obesity, cholesterol, and/or other chronic condition. This will drive wellness and disease management programs to be more engaging and successful.
  2. This will put pressure on employers to create a culture of health since we spend so much time at work and work contributes to our health conditions.
    1. Need more time to be active. Less sitting. Treadmill desks. Standing meetings. Nap time. Walking breaks. Use of devices to track steps. Incentives. Gym discounts. Healthy food discounts.
    2. Need less stress.
    3. Need more sleep.
    4. Better food choices at work.
  3. This will drive a lot of the new tools and run counter to some trends about limiting dependent coverage since you can’t address obesity without engaging the entire family and the social network.
  4. This will also create a whole exception process by which people who gain weight due to certain drugs have to be excluded. People who can’t exercise may have to be excluded. People may have to see short-term goals (i.e., dropping BMI from 35 to 32). Physicians will have to be engaged.
  5. Coaching will have to expand to include dieticians, social workers, and others to help people beyond the historical nurse centric coaching model.

If none of this motivates you, then just think about the “gift” we’re giving our kids and maybe that will be a wake-up call why someone has to do something here. (As I shared the other day, I struggle with my weight so don’t think I’m some super skinny, high metabolism person who thinks this is easy.)

Books / Articles, Business Tools, Care Management, exercise, Healthcare, Leadership, Managed Care, Marketing / Communications, Research, Value Propositions
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What’s Your #Moment4Change?

March 20, 2013 by George Van Antwerp 0 Comments

I’ve being doing a lot of work lately on how to tackle the obesity problem in the US. This has been great personally as it has forced me to look at lots of research to understand all the tools out there.

  • Diet
  • Exercise
  • Coaching programs
  • Devices
  • Social networks
  • Physicians
  • Centers of Excellence

It’s also made me look at different drivers of obesity including sleep and stress. The new report out showing that sitting is a huge problem (even if you exercise) is very eye-opening also.

For years, I’ve talked about my challenges is managing my weight which lead to some fluctuations, but at the end of the day, I think a lot of this boils down to a “Golden Moment” or a “Moment4Change”. Even people who do this every day (e.g., doctors or sports coaches) are often overweight. We have to have something which prompts us to change our life. We aren’t generally motivated by dropping our HDL. We’re motivated by being able to play with our kids or living long enough to see our kids get married.

In my life, there have been several Moment4Change points so I thought I would put this out there to hear what’s motivated others:

  • In 2002, I went to the doctor for the first time in a decade. He saw some health risks in my blood work and sent me to another physician. He told me I was obese. (Something less than 50% of physicians actually tell their overweight patients.) I was shocked. I was 215 pounds and 5′-10″. After 2 days of agony, I decided that I couldn’t accept that diagnosis and proceeded to lose 40 pounds in the next 60 days (all through exercise and social motivation through a running group).
  • Last fall after letting much of that weight creep back on over the decade, I decided to do a 5K with one of my kids. I’d run 3 marathons and was running several days a week (although at an average pace of 9 minute miles). I got killed as my kid ran at a 7:30 pace in their first race ever. Not only did I feel old, but I felt like I wasn’t being much of a role model. That motivated me to change. Now, after using the FitBit (see several comments), I’ve had good success losing 25 pounds in 3 months and seeing my cholesterol drop 120 points in that same time frame.

So, I’m interested. What has motivated you to changed? And, how do you measure success? I suggested that while women may use the “skinny jeans” test that men might be more likely to use the “belt buckle” test.

 

 

I think this image below from the AON Hewitt 2012 Health Care Survey is a good one about the fact that 80% of our costs are driven by 8 behaviors.

I also thought that this presentation at the FMI by The Well which was a GSW project was right in line with this.

Books / Articles, Care Management, Consumerism, exercise, Healthcare, Leadership, Marketing / Communications
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Why It’s So Hard To Improve Consumer Engagement In Healthcare?

March 11, 2013 by George Van Antwerp 1 Comment

I spend a lot of my personal and professional time trying to figure out how to better engage consumers in healthcare.  If you can’t engage them, you can’t improve outcomes.

Never mind the fact that people experience about 5,000 messages a day so you have to cut through that clutter.

Even if we do cut through the clutter, people are busy living their lives.  They’re worried about their family.  They’re worried about the economy.  They’re trying to keep food on the table.  They are generally overwhelmed with too little sleep and too much stress.

But, let’s even assume that you can cut through the clutter and get them to listen, you still struggle with getting a person at a time when they are open to change.  These “golden moments” require them to see value in the change and feel like the short-term effort is worth the long-term gain.  This “value exchange” doesn’t often exist.  And, with 30% variance in the healthcare system, people often don’t trust the system.

Even with all that in mind, people still don’t engage.  They don’t get flu shots.  They don’t fill their medications.  They don’t understand the messages that are delivered to them.

Here’s a quick image I created for a presentation later this week.

Consumer

A few of the sources for this are:

Books / Articles, Care Management, Healthcare, Marketing / Communications, Research
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A Compelling Argument As To Why You Need More Germs

March 4, 2013 by George Van Antwerp 0 Comments

“In our modern effort to eradicate disease, we pop antibiotics like candy, apply hand sanitizers with abandon, and gargle mouthwash by the gallon. But this carpet-bombing of germs takes a huge toll on good microbes as well as bad. The March/April issue of The Saturday Evening Post, on newsstands now, reveals recent research pointing to medical problems including asthma, obesity, and chronic sinusitis that might be caused by the absence of certain microbiota in our bodies.”  (From a press release about the article Why We Need Germs.)

What if the bacteria in our body was a determining factor in chronic conditions?  Would you try to get more bacteria into your body?  Would you stop doing things to kill the bacteria?  Would this change our eating habits?

This is a fascinating article by The Saturday Evening Post, it shares some research that might explain why two people can have the same food habits and one be skinny and one be fat.  (A frustrating thing for many of us.)

You can even learn about a crowdsourcing project that will take your feces and tell you the bacteria in your gut.  

In the meantime, you might want to eat more asparagus and garlic.  Yummy!  And, be less stressed out.

For instance, Bacteroidetes—the microbes linked to slimness—proliferate in the presence of fructans, a form of fructose found in asparagus, artichokes, garlic, and onions, among other foods, notes microbiologist Andrew Gewirtz of Georgia State University. A diet high in fructans might support a good crop of slimming Bacteroidetes. On the other hand, he notes, stress decreases the abundance of Bacteroidetes, suggesting one more way stress causes obesity.

Books / Articles, Healthcare, Research

Healthcare Fails Again In Experience Survey

March 2, 2013 by George Van Antwerp 0 Comments

The fact that most people would rate their experience with their health insurer low isn’t a big surprise to most of us in healthcare.  But, with the Triple Aim and other quality metrics, the customer experience is becoming an increasingly important metric.  Several recent surveys have talked about this as one of the top priorities for hospital systems.  And, as use of CAHPS continues to grow, this will be more closely linked with incentives.

“Patient experience is on the radar of hospital executives, especially since Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores will soon affect reimbursement,” said Jason Wolf, executive director of the Beryl Institute. “However, the data shows that executives are still grappling with how to implement change within their organizations.” (source)

Like in years past, health insurers just barely nudge out TV service providers to prevent being the bottom of the industry in Bruce Temkin’s Benchmarking work.  While I’d love to see healthcare broken out into hospitals, physicians, pharmacies, insurance companies, PBMs, and care management companies, I think we can assume some similar concerns would fall out.

Healthcare companies need to find ways to address this.  I think there are several key first steps:

  1. Defining your customer;
  2. Mapping their experience;
  3. Creating personas or segments to think about (i.e., healthy, sick, insured);
  4. Identifying influences on their experience (some of which you might not control);
  5. Determining what matters versus doesn’t matter;
  6. Capturing baseline metrics; and
  7. Building a continuous improvement process.

Temkin Group 2013 Satisfaction Temkin Group Satisfaction

 

Books / Articles, Consumerism, Healthcare, Leadership, Research
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Body Peace Treaty As Mentioned On Biggest Loser

February 24, 2013 by George Van Antwerp 0 Comments

I was finally catching up on my Biggest Loser shows yesterday.  They talked about the Body Peace Treaty from Seventeen magazine. Not something I read, but there are some good points in the treaty.  Here are a few for you.

  • Do the little things that will keep my body healthy, like walking instead of hanging on the couch, or drinking water rather than something sugary.
  • Appreciate what makes my body different from anyone else’s. I love that I’m unique on the inside, I will try to feel that way about the outside too!
  • Support my friends, who just like me, have their own body issues. Hey, we’re all in this together!
  • Remember that the sun will still rise tomorrow even if I had one too many slices of pizza or an extra scoop of ice cream tonight.
  • Quit judging a person solely by how his or her body looks — even if it seems harmless — because I’d never want anyone to do that to me.
  • Remind myself that what you see isn’t always what you get on TV and in ads — it takes a lot of airbrushing, dieting, money, and work to look like that.
  • Respect my body by feeding it well, working up a sweat when it needs it, and knowing when to give it a break.
  • Realize that the mirror can reflect only what’s on the surface of me, not who I am inside.
  • Not let my size define me. It’s far better to focus on how awesome I look in my jeans than the number on the tag.
  • Surround myself with positive people. True friends are there to lift me up when I’m feeling low and won’t bring me down with criticism, body bashing, or gossip.

So, while some of the things on the list may be more biased towards young women, the fundamentals are the same for all of us.

Books / Articles, exercise, Healthcare
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2013 PBMI Presentation On Pharmacy Need To Shift To Value Focus

February 19, 2013 by George Van Antwerp 0 Comments

Today, I’m giving my presentation at the PBMI conference in Las Vegas.  This year, I choose to focus on the idea of shifting from fee-for-service to value-based contracting.  People talk about this relative to ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) from a provider perspective.  There have been several groups such as the Center For Health Value Innovation and others thinking about this for year, but in general, this is mostly a concept.  That being said, I think it’s time for the industry to grab the bull by the horns and force change.

If the PBM industry doesn’t disintermediate itself (to be extreme) then someone will come in and do it for them but per an older post, this ability to adapt is key for the industry.  While the industry may feel “too big to fail”, I’m not sure I agree.  If you listened the to the Walgreens / Boots investor call last week or saw some of things that captive PBMs and other data companies are trying to do, there are lots of bites at the apple.  That being said, I’m not selling my PBM stocks yet.

So, today I’m giving the attached presentation to facilitate this discussion.  I’ve also pre-scheduled some of my tweets to highlight key points (see summary below).

 

Planned PBMI Tweets

Books / Articles, Care Management, Healthcare, inVentiv Health, Marketing / Communications, mHealth, PBM / Pharmacy, Technology, Value Propositions
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59% Of MDs Want To Know About Employer Care Mgmt Efforts

February 12, 2013 by George Van Antwerp 0 Comments

I just came across this survey data from January of 2010 where the Midwest Business Group on Health (MBGH) did a survey of physicians. I found it really interesting. Let me pull out a few points with some comments…

  • 72% of physicians agree that employers should have a role in improving and maintaining the health of their employees with chronic disease. [Since they ultimately are the one paying the bill, this seems like a reasonable expectation in today's world.]
  • 59% believe that they should be informed about employer efforts to help their patients manage chronic conditions. [This is increasingly becoming important as we move from a Fee-For-Service (FFS) world to a value-based or outcomes-based healthcare environment.]
  • 46% agree that employers should have a role in helping employees adhere to their medication and treatment regimes. [Since MDs generally don't view this as their task, if it's not someone acting on behalf of the employer, I wonder who they think should be doing this.]
  • 32% agree that employers should play no role in the health of patients. [With healthcare impacting productivity and global competitiveness, I think this is an unreasonable expectation.]
  • 61% want the employer to provide physicians with information on what is available to patients so they can counsel them on the value of participation. [How would they want this information and what would they do with it?]
  • 49% would like to receive workplace clinical screening results to reduce redundancies in testing. [Do the other 51% want duplicative testing?]
  • 48% want to receive actionable reports (e.g., screening results, health coaching reports) to support them in treating patients. [I would hope so. If the employer (or really their proxy) is managing the patient in a chronic program, why wouldn't the physician want this data?]
The study went on to say that physician’s want employers to provide support around weight loss, smoking cessation, flu shots, and other broad programs. They also want the employer to focus on lifestyle change and health improvement not the chronic disease itself. This makes sense, but in general employees are more focused on trusted information coming from their physician not their employer so there’s a clear gap here. (See graph from Aon Hewitt’s 2011 Health Care Survey, New Paths. New Approaches.)
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The Prescribing Apps ERA – Will Clinicians Be Ready? #mHealth

February 7, 2013 by George Van Antwerp 1 Comment

Dr. Kraft (@daniel_kraft) recently spoke at FutureMed and talked about the prescribing apps era.  I’ve talked about this concept many times, and I agree that we are rapidly moving in that direction.  And, there’s lots of buzz about whether apps will change behavior and how soon we’ll see “clinical trials” or published data to prove this.

From this site, you can get a recap, but here are the key points that he made:

1) Mobile Phones (quantified self) are becoming constant monitoring devices that create feedback loops which help individuals lead a healthy lifestyle.  Examples include; monitoring glucose levels, blood pressure levels, stress levels, temperature, calories burned, heart rate, arrythmias. Gathering all this information can potentially help the patient make lifestyle changes to avoid a complication, decrease progression of a particular disease, and have quality information regarding his physical emotional state for their physician to tailor his treatment in a more efficient manner.

2) The App prescription ERA:  Just as we prescribe medications prescribing apps to patients will be the future. The reason why this is important is that apps created for particular cases can help the patients understand their disease better and empower them to take better control.

3) Gamification: using games in order to change lifestyle, habits, have been mentioned before. A very interesting concept was that created in the Hope Labs of Stanford. The labs created a game in which children would receive points after there therapeutic regiment, once points were optioned they could shoot and attack the tumor. Helping with the compliance rate of the treatments

4) Lab on a chip and point of care testing

5) Artificial Intelligence like Watson and its application in medicine.

6) Procedure Simulation: Several procedures done by medical professionals follow (not 100%) a see one, do one teach one scenario.  Probably very few people agree with this concept and that is why simulation has great potential. In this case residents, fellows in training can see one, simulate many and then when comfortable do one.

7) Social Networks and Augmented Reality

At the same time, a recent ePocrates study hammered home the point that while this is taking off physicians don’t have a mechanism for which ones to recommend and why.

According to the Epocrates survey, more than 40 percent of physicians are recommending apps to their patients. In terms of the apps being recommended, 72 percent are for patient education, 57 percent are lifestyle change tools, 37 percent are for drug information, 37 percent are for chronic disease management, 24 percent are for medical adherence and 11 percent are to connect the patient to an electronic health record portal.

Physicians also have several different sources for identifying which apps to recommend to their patients. According to the survey, 41 percent get advice from a friend or colleague, while 38 percent use an app store, another 38 percent use an Internet search engine, 23 percent learn of an app from another patient or patients, and 21 percent use the app themselves.

That said, the survey also notes that more than half of the physicians contacted said they don’t know which apps are “good to share.”

As I’ve discussed before, this is somewhat of the Wild West.  Patients are buying and downloading apps based on what they learn about.  They’d love for physicians, nurses, pharmacists, and other trusted sources to help them.  But, those clinicians are often not technology savvy (or at least many of the ones who are actively practicing).  There are exceptions to the norm and those are the ones in the news and speaking at conferences.

IMHO…consumers want to know the following:

  1. Which apps make sense for me based on my condition?
  2. Will that app be relevant as I move from newly diagnosed to maintenance?
  3. Should I pay for an app or stick with the free version?
  4. Is my data secure?
  5. Will this app allow me to share data with my caregiver or case manager?
  6. Will this app have an open API for integration with my other apps or devices?
  7. Is it intuitive to use?
  8. Will this company be around or will I be able to port my data to another app if the company goes away?
  9. Is the information clinically sound?
  10. Is the content consumer friendly?
  11. Is it easy to use?
  12. Is there an escalation path if I need help with clinical information?
  13. Will my employer or health plan pay for it for me?
  14. Is my data secure?

And, employers and payers also have lots of questions (on top of many of the ones above):

  1. Is this tool effective in changing behavior?
  2. Should I promote any apps to my members?
  3. Should I pay for the apps?
  4. How should I integrate them into my care system?
  5. Do my staff need to have them, use them, and be able to discuss them with the patient?  (Do they do that today with their member portal?)

mhealth_infographic_large

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Two Examples Of How Healthcare Is Going Local

February 6, 2013 by George Van Antwerp 3 Comments

I remember when I first started working in the healthcare industry in 1998, people kept reinforcing for me that “Healthcare is Local”.  As we move into a national effort to transform healthcare, the question is how will healthcare transform to gain scale efficiencies while still taking advantage of this simple reality.

With that in mind, I found a WSJ article today about hospitals trying house calls very interesting.  It talks about how insurers and health systems are using the old fashion model of house calls to engage patients to reduce re-admissions and improve outcomes…while lowering costs.  Since healthcare costs are massively concentrated with 1% of patients driving 22% of healthcare costs, this becomes possible.  Additionally, as you focus .  on people at high risk based on some model like the Johns Hopkins ACG model or people who have been recently discharged or people with multiple co-morbidities and other risk factors, you have a chance to make a difference.  It will be interesting to see how this takes off.

Another example of how healthcare is going local is the use of health apps.  I saw a number earlier today where someone was saying there’s now 50,000 health apps.  I usually talk about 16,000, but it’s obviously going up all the time.  Employee Benefit News recently had an article about how health apps were changing the engagement rates for wellness programs.  Obviously, the phone is the ultimate in local allowing the creation of an app that’s with us all the time and can be real-time in terms of interactivity.

Books / Articles, Healthcare, Research

Wellness In The Workplace – Optum Research

February 6, 2013 by George Van Antwerp 0 Comments

I found a summary of this Optum Study – Wellness In The Workplace in the January 2013 Employee Benefit News:

  • 56% of companies (surveyed) have a formal, written strategic plan for wellness
  • 28% of companies have an onsite clinic
  • 49% of eligible employees participate in company wellness programs (seems really high to me)
  • 90% of companies with 3,000+ employees say wellness solutions are an important part of their benefits (compared with 79% of employers with 2-99 employees)
  • 83% of companies use coaching to address weigh management
  • The top barriers to employee participation are:
    • Lack of time / energy
    • Lack of interest
    • Effective communications
  • 52% of companies offer wellness programs to employee’s family members
  • Onsite clinics are offering:
    • 77% flu shots
    • 56% wellness communications
    • 43% fitness challenges
    • 42% preventative care
    • 41% health risk assessments

wellness participation

Books / Articles, Healthcare, Marketing / Communications, Research

Healthcare Companies On The 100 Best Companies To Work For

February 5, 2013 by George Van Antwerp 0 Comments

Here’s a list of the Healthcare companies that were on the 2013 “100 Best Companies To Work For” list by Fortune.

  • #3 – CHG Healthcare Services
  • #17 – REI (although more of a retail company from the traditional view)
  • #20 – Millennium
  • #21 – W.L. Gore
  • #32 – JM Family Enterprises
  • #36 – Genentech
  • #39 – Meridian Health
  • #41 – Mayo Clinic
  • #43 – Scripps Health
  • #46 – Children’s Healthcare of Atlanta
  • #48 – Novo Nordisk
  • #49 – Atlantic Health System
  • #52 – St. Jude Children’s Research Hospital
  • #58 – The Everett Clinic
  • #61 – Stryker
  • #67 – The Methodist Hospital System
  • #69 – OhioHealth
  • #76 – Baptist Health South Florida
  • #89 – Roche Diagnostics

Given how much healthcare companies should know about the importance of workplace satisfaction and it’s correlation with overall health (less stress), healthcare costs, and overall presenteeism and absenteeism, I personally would expect more on the list.

Books / Articles, Healthcare

How Quickly Do Healthcare Companies Respond To Twitter Comments? (Test)

February 2, 2013 by George Van Antwerp 0 Comments

I was intrigued by this test done over in the UK to look at how quickly retailers responded to comments via Twitter (you can see an infographic about similar US data below).  Obviously, more and more consumers are using social media.  And, we know that comments can go viral quickly especially when they’re negative.

“A recent Spherion Staffing Services survey shows that when consumers have a good customer service experience, 47 percent are likely to tell a company representative; 17 percent will express their opinions via social media; and 15 percent will write a review. The same survey from 2010 showed that only 40 percent of consumers were likely to share a great experience with a company representative—proving that consumers are becoming more vocal with companies they interact with. If consumers have a poor experience, 36 percent are willing to write a complaint directly to the company, and one in four will express their opinions on social media. Nineteen percent, the same statistic as last year, will choose to write a review online.” (December 2011 Study)

Of course, some people actively monitor their social media feeds while others view them more as a PR channel.  It also depends on whether the feed management is outsourced or insource and whether it’s monitored by marketing, operations, customer service, sales, or some combined team.

Here’s a good post on measuring response and activity within Twitter accounts.

So, what I’ve decided to do is a Twitter test similar to the one above.  I’m going to post the following to different categories of healthcare companies and see how quickly they respond.

  1. To retail pharmacies:  Are you using social media to handle customer service?
  2. To PBMs:  Are you using social media to handle customer service?
  3. To Managed Care: Where’s the best place to find out about your Medicare products?
  4. To mHealth companies:  Can you share examples of how employers are promoting your products?
  5. To pharma:  Are you doing any value-based contracting with PBMs?
  6. To device companies:  Can you share examples of how employers are promoting your products?

Who do you think will be the fastest to respond?  Will the bigger companies simply have more resources to monitor and staff their teams or with more digital companies be more in tune with social media?

KeepingUpWithTwitter_2

Books / Articles, Business Tools, Healthcare, Infographic, Managed Care, Marketing / Communications, mHealth, PBM / Pharmacy, Research, Social Media
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Google Glass Plus The Checklist Manifesto

January 29, 2013 by George Van Antwerp 1 Comment

I continue to think about all the cool ways that Google Glass could be used to change healthcare.  Here’s my thought from today.

You could combine The Checklist Manifesto concept with Google Glass to allow surgeons to be reminded of the things they need to do with a patient while they were during the encounter or during the procedure.

In complex situations – such as those which arise in almost every profession and industry today – the solutions to problems are technical and demanding. There are often a variety of different ways to solve a problem. It’s all too easy to get so caught up dealing with all these complexities that the most obvious and common sense immediate solutions are not tried first. To overcome this problem, take a leaf from the commercial aviation industry and develop checklists people can use to make sure every base is covered quickly and concisely. Checklists are a forgotten or ignored business tool. It’s time for them to come in from the cold. 

“Here, then, is our situation at the start of the twenty-first century:We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And with it, they have accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our human inadequacies. And there is such a strategy – though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.”

(This is from this PDF on The Checklist Manifesto.)

Here’s an example of a checklist from the WHO.

 

Books / Articles, Business Tools, Healthcare, Innovation, Methodology, mHealth, Technology

PHM Is The New Black Post At CCA Blog With Diabetes Examples

January 25, 2013 by George Van Antwerp 0 Comments

This is a partial copy (teaser) of a guest blog I did on the Care Continuum Alliance blog earlier this week.

**********************

With all the talk about Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs), the adoption curve for the Care Continuum Alliance (CCA) model for Population Health Management (PHM) should move beyond the innovators in 2013 and begin to “Cross the Chasm.” I believe there are several preconditions that would set the stage for this to occur, for instance:

  1. Technology advances leading to the “Big Data” focus;
  2. The changing paradigm from fee-for-service to outcomes-based care;
  3. The realization of the role of the consumer led by the e-Patient movement, the idea of the Quantified Self, and the focus of large healthcare enterprises on being consumer centric; and
  4. The budget crisis that is driving employers and other payers to embrace PHM, wellness, and other initiatives that impact cost and productivity.

Of course, most companies are still in the infancy of designing systems to address this coordinated care model, which does not view the patient as a claim, but longitudinally aggregates demographical, psychosocial and claims data.  Additionally, training staff using Motivational Interviewing and integrating external staff into the virtual care team in partnership with the provider will continue to evolve as do our care delivery models.

To read more especially the diabetes examples that I shared, please click over to their blog.  Thanks.

 

Books / Articles, Care Management, Guest Post, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Methodology, mHealth, Research, Value Propositions, Weblogs
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Guest Post: Is It Too Late To Avoid The Flu?

January 24, 2013 by George Van Antwerp 0 Comments

By Paula Spencer Scott, Caring.com Senior Editor

The 2012-13 flu season is shaping up to be one of the worst in years. If you or your loved ones haven’t succumbed yet, these steps can help you stay healthy. And if someone does get sick, many of the same steps can prevent a wider spread of infection.

Get a flu shot. No, it’s not too late. This year’s shot only offers 62 percent effectiveness, according to Thomas Frieden, director of the Centers for Disease Control and Prevention. But it’s still considered the number-one prevention tool.

Give the flu shot time to kick in. It can take one to two weeks for a flu shot to offer protection (see: How Long Does It Take for a Flu Shot to Offer Protection? for more information on flu shot protection). So don’t expect instant immunity.

Keep vulnerable loved ones away from crowds. Given how widespread the flu already is, we’re all courting trouble by hanging out in crowded public places like shopping malls. But those who should especially keep away include the very young, the frail old, and those with health conditions that weaken the immune system or who are using treatments that can affect the immune system, such as.

Keep suspicious visitors away from vulnerable loved ones. If you live with someone with a chronic illness or who is a frail older adult, be a good gatekeeper. If a guest has a cough, a runny nose, or is complaining about being under the weather, don’t endure a visit. Invite him or her back at a better (healthier) time.

Stay home if you’re feeling under the weather. Best to avoid crowds, including the workplace, when your immune system is low. And in case your symptoms mean you’re coming down with something, you can avoid infecting others.

Wash hands often. Pretend you’re obsessive-compulsive and do it all day long. Be sure to wash hands (with soap and water or hand sanitizer) after touching doorknobs.

Become a clean freak. Stock up on cleaning supplies. You may use them more if you have them handy right in each bathroom and the kitchen. Wipe down surfaces often. Bring portable wipes to work so you can keep your keyboard and any shared spaces cleaner, too.

Try a face mask. It’s not clear they’re super-effective, but in a situation where some people are sick, they can provide an added barrier between a frail older adult and the flu.

Stay well hydrated. Keeping nasal passages moist helps them resist germs. Drinking lots of water and using nasal saline sprays helps — especially when flying, as aircraft cabin air is dry.

Get at-risk groups to the doctor at the earliest symptoms. Very young children and the very old should get swift treatment, says the CDC. Medicines such as Tamiflu work best within the first 48 hours.

About the Author

Paula Spencer Scott is senior editor at Caring.com, the leading online destination for caregivers seeking information and support as they care for aging parents, spouses, and other loved ones. Paula is a 2011 MetLife Foundation Journalists in Aging fellow and writes extensively about health and caregiving. You may also want to see Paula’s article 7 Ways to Have Fun While Fighting Cold and Flu.

Books / Articles, Care Management, Guest Post, Healthcare

CVS Caremark Adherence Study – Is Facebook The Solution To Adherence?

January 22, 2013 by George Van Antwerp 0 Comments

A new study funded by CVS Caremark as part of their ongoing research into medication adherence was recently published.

“Association Between Different Types of Social Support and Medication Adherence,” December 2012 issue of American Journal of Managed Care

In this, researchers reviewed 50 peer-reviewed articles about studies which directly measured the relationship between medication adherence and four categories of social support, including:

  • Structural support – marital status, living arrangements and size of the patient’s social network
  • Practical support – helping patients by paying for medications, picking up prescriptions, reading labels, filling pill boxes and providing transportation
  • Emotional support – providing encouragement and reassurance of worth, listening and providing spiritual support
  • Combination support – any combination of the three support structures detailed above

According to the study, greater practical support was more often linked to improved medication adherence, with 67 percent of the studies evaluating practical support finding a significant association between the support and medication adherence.

It drives some interesting questions as you dig into the actual research.  I sent several questions to Troyen A. Brennan, MD, MPH, who is the Executive Vice President and Chief Medical Officer of CVS Caremark, and heads the research initiative that conducted the study.  Here are his responses:

1. How will this research change CVS Caremark’s approach to medication adherence such as your Adherence to Care program? 

CVS Caremark’s Adherence to Care program is all about engaging patients more consistently and directly to ensure they are following their medication regimes. We understand that our patients’ social networks and communication preferences are diverse, and we know that multi-dimensional interventions help to change behaviors. Given these factors, this research can be an important reference point as we develop new approaches to our adherence programs, challenging us to look beyond traditional engagement strategies in an effort to most effectively support patients on their path to better health. We are planning to test some interventions along these lines in 2013.  As a pharmacy innovation company, we want to make sure we are anticipating patient needs and remaining relevant to them especially given the changing face of social communication and networks.  

2.  The data points required to assess these support factors aren’t readily available in the eligibility file or claims file.  Are you collecting that data at the POS or during the enrollment process and using it in any way to determine the correct intervention cadence or level of effort at an individual level?

While this may not be the standard today, it is clear from the research that a patient’s social network and resulting support can be important factors in helping them take their medications as directed. This research can help us and others in the industry think about how best to incorporate new approaches to identify and leverage social networks for greater medication adherence.  For now, we will rely on POS as a way to collect this type of information.

 

  • 3.  To me, it appeared the data was less conclusive than I would like.  There were lots of conflicting data points and qualitative data.  Do you plan to refine this testing within your population to look at differences across disease states and relative to other factors?

 

This study relied on a comprehensive analysis of current literature linking medication adherence to social support networks – so we recognize that there are limitations in being able to draw concrete conclusions on certain factors, such as disease-specific conditions. Regardless, we still believe these findings – which look at clinical, peer-reviewed studies – contribute to the knowledge base in our field. As with all of the research we conduct, we challenge our teams to consider how we might be able to use the information to find practical supports for patients, while at the same time contributing to awareness about the implications of adherence on the broader health care landscape. The best way to understand this research is as hypothesis generating, which we can use in the design of real interventions that we can then test definitively in subsequent studies.

4.        Some of these social factors might be correlated with depression.  Was there any screening done to look at how depression as a co-morbidity might have affected adherence rates?

The methodology of this study relied on literature review and analysis of fifty peer-reviewed research articles which directly measured the relationship between medication adherence and forms of social support. A full review of the medical conditions associated with these studies can be found in Appendix 1. While depression, alone, was not one of the conditions featured in these studies, several did look at mental health conditions and the linkage between adherence and social networks. We did not however stratify by existence of depression—it may be a factor we have to take into account in future studies.

5.   The one thing that I read between the lines was the need for a caregiver strategy.  This has been missing in the industry for years.  Does CVS Caremark have an approach to engaging the caregivers?

 

Our study found that practical support such as picking up prescriptions, reading labels and filling pill boxes – all within the realm of a given caregiver’s role – were the most significant in driving greater adherence. Considering this finding, and acknowledging the role caretakers have in the lives of our patients, there is certainly space for us to develop solutions that engage caretakers more effectively. Recent analyses of “buddy” programs do suggest such interventions do work- -we just need to consider how to scale it.

 

  • 6.        With all this talk about social networks, it naturally leads you to a discussion about Facebook (or Google+).  Neither of them have big focuses in the healthcare space.  In your opinion, will these tools offer an intervention approach for changing behavior around medication or will that be occur at the disease community level in tools like PatientsLikeMe or CureTogether where there’s no social bond but a connectivity around disease? 

 

 The role of social media has changed the way we communicate and connect with one another dramatically over the past decade. What we can say, based on this particular study, is that the more practical the support, the more significant the impact on medication adherence. Perhaps further studies looking into solutions that effectively combine online/social media platforms to complement practical support would help clarify their impact on medication adherence.

If interested, here are some of their other presentations on adherence:

Books / Articles, Healthcare, PBM / Pharmacy, Press, Research, Social Media
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Catching Up: Interesting Articles

January 19, 2013 by George Van Antwerp 0 Comments

As part of my efforts to start the new year, I’m cleaning out my inbox with all items I’ve tagged as possible blog topics.  Here’s the first list of things that caught my attention, but never made it into a story.

Books / Articles, Healthcare

Childhood Obesity Quiz On The Biggest Loser

January 15, 2013 by George Van Antwerp 2 Comments

This season, on The Biggest Loser, they’ve invited 3 kids to be ambassadors for childhood obesity. They aren’t living on the ranch, but they are coming out for some of the challenges. In last night’s show, they quizzed the contestants on several facts about childhood obesity. They were pretty scary. I thought I’d share them here with the research to support them (or at least as close to the questions as I can remember).

There are lots of efforts in this area. Here’s a few links to resources:

Childhood Obesity Epidemic Infographic
Brought to you by MAT@USC Masters in Teaching

Books / Articles, Healthcare, Infographic, Research
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Limiting Factor For Behavior Change is We Don’t Believe We Will Change

January 15, 2013 by George Van Antwerp 2 Comments

One of the biggest challenges in healthcare is getting people to change behavior or as Express Scripts would frame it – activating intent.  Since approximately 75% of healthcare costs are due to preventable conditions, it’s important that we can help people see the future value of change.  People often discount that future value of change based on the amount of effort required to get there.  They see the short-term pain not the long-term gain.

A new study puts an interesting perspective on this.  It shows that people can generally see the amount of change they’ve made in the past decade, but they fail to realize that change will continue for the next decade.  They appear to see themselves as stable at the current moment without significant change in the future.  I believe this is really important as we think about Motivational Interviewing techniques and communications for engaging consumers.

So, as you think about behavior change in healthcare for things like diabetes, you will likely continue to see more and more emphasis on behavior change and research in this area (see example from RWJF last year or Cigna whitepaper).

To learn more about this topic of behavior economics, you might look a few places:

And, here’s a good list of books to start with.

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Saturday Evening Post On The Placebo Effect

January 15, 2013 by George Van Antwerp 0 Comments

Do you know what the Placebo Effect is?  There’s lot of information out there.  For example, here’s what WebMD says about it.  Here’s my definition of it.

In general, it’s when someone is told they are given a medication (or procedure) that will work but instead are given a sugar pill or otherwise “deceived” into believing they’ve gotten the prescribed treatment.  It is often used in clinical trials for drugs to establish the baseline of side effects.  The amazing part is that it shows the power of the mind to influence our healing ability.  

Below is a video that I’ve used a few times before.  It’s also been a concept I’ve built on in a few other posts – New To Therapy, Price And Placebo Effect, Guest Post on the Topic.

The amazing thing that captured my attention a few months ago is that this can work not only for medication but also for surgery.  (Maybe this is the key to saving money in the US healthcare system.)  This was tested in the case of knee surgery in a trial that was published several years ago.  This article also points out another trial on patients with Parkinson’s.  The reality appears to be that this is happening in trials but also in real life according to an article in American Medical News (see quote below).

Nearly half of physicians use placebos in clinical care, and only 4% tell their patients the truth about it, according to a survey of Chicago academic physicians that was published this month in the Journal of General Internal Medicine.

This begs all types of questions about who will respond to placebos and when or if it’s ok to use them with patients.

The Saturday Evening Post just published an article on this topic.  They touch on a few of the same studies I’ve looked at, but they also point out several new things that I put below – conditioned response and ritual.  They also share a video on the placebo effect.

Conditioned responses are a third way the placebo response works. In one elegant experiment demonstrating this phenomenon, scientists showed 40 volunteers two male faces on a computer screen for 0.1 second. When the volunteers looked at one face, they got a mild burn on their forearm; when they looked at the other, they got a more painful burn. The volunteers became as conditioned as Pavlov’s dogs. In the next round when they saw the high-pain face and felt a burn, they rated it as more painful than when they saw the low-pain face and felt a burn—even though the applied heat was identical the second time around.

The perception of pain, says Ted Kaptchuk of Harvard Medical School, who helped lead the 2012 study, depends on “what the nonconscious mind anticipates despite any conscious thoughts.”

The placebo effect doesn’t even depend on deception. It can kick in even when people are told they are receiving an inactive drug. For instance, in a 2010 study led by Harvard’s Kaptchuk, scientists recruited 80 people with irritable bowel syndrome, or IBS, and gave half no treatment and half what they were told were “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body, self-healing processes.” It was full disclosure. Even without the deception, the placebo-takers’ IBS symptoms improved over the course of three weeks. That response suggests another avenue for the placebo response: ritual.

The author (Sharon Begley) asks the key question which is how does this placebo effect play out in the 21st century.  With all this technology that we have and the physician shortage, is there a greater opportunity here?  Can we tap into this in a positive way?  She also points out how doctors are using other techniques such as relaxation therapy to address the power of the mind.

Books / Articles, Healthcare, Marketing / Communications, Methodology, Research, Words Matter

Consume Cocoa Like The Kuna (aka Chocolate is Good For You)

January 14, 2013 by George Van Antwerp 0 Comments

For years, we’ve all heard pieces of information about cocoa being good for us.  Here’s a few articles about that:

And from Cleveland Clinic, here’s a key point about selecting your chocolate:

your best choices are likely dark chocolate over milk chocolate (especially milk chocolate that is loaded with other fats and sugars) and cocoa powder that has not undergone Dutch processing (cocoa that is treated with an alkali to neutralize its natural acidity).

It appears in a recent meta-analysis that the data generally supports this fact although some longer terms studies are needed.  One of the most interesting things mentioned in both of the hyperlinked studies above are the Kuna.

The Kuna, an indigenous group of approximately 50,000 people who live predominantly on small islands off the coast of Panama, are virtually free of hypertension and cardiovascular disease. Kuna who migrate to nearby Panama City, however, lose this advantage, a loss that cannot be attributed to changes in salt intake (1) or stress (2). The Kuna who live on the Caribbean archipelago, however, consume a striking amount of natural cocoa drinks, whereas those who migrate to the mainland do not (1).

I also got an e-mail from a PR firm about the meta-analysis saying the following:

Recent research published in The Journal of Agricultural and Food Chemistry found that a mug of hot cocoa had nearly twice the antioxidants as a glass of red wine and up to three times the antioxidants as a cup of green tea. Compared to black tea, cocoa had up to five times the concentration of antioxidants.
 
“The results of this Cornell University study corroborate earlier research showing the extensive health benefits of cocoa,” says Harvard nutritionist and epidemiologist Eric Ding, Ph.D. Dr. Ding was lead researcher of a landmark Journal of Nutrition meta-analysis on cocoa’s multiple benefits for cardiovascular and metabolic health. The study incorporated 24 papers with 1106 participants.
 
“Cocoa flavonoids are protective against heart disease,” says Dr. Ding. “We’ve found that they lower blood pressure, lower bad LDL, raise good HDL, improve insulin sensitivity, and improve blood flow and, in a long term study, lower the risk of heart disease.” Journal of Nutrition meta-analysis on cocoa’s multiple benefits for cardiovascular and metabolic health. The study incorporated 24 papers with 1106 participants.
 
“Cocoa flavonoids are protective against heart disease,” says Dr. Ding. “We’ve found that they lower blood pressure, lower bad LDL, raise good HDL, improve insulin sensitivity, and improve blood flow and, in a long term study, lower the risk of heart disease.”
So, don’t feel bad about enjoying chocolate.  Not only is it good for your mood, but it can be good for your health (if you pick the right kinds).  But, this shouldn’t be an excuse for binging on it since it’s also high in fat.
Books / Articles, Healthcare, Research

FitBit Review Summary – Device, Apps, And Suggestions

January 8, 2013 by George Van Antwerp 4 Comments

In the spirit of the Quantified Self movement and in order to better understand how mHealth tools like FitBit can drive behavior change, I’ve been using a FitBit One for about 6 weeks now. I’ve posted some notes along the way, but I thought I’d do a wrap up post here. Here’s the old posts.

Those were focused mostly on the device itself. Now I’ve had some time to play with the mobile app. Let me provide some comments there.  And, with the data showing a jump in buyers this year, I expect this will be a hot topic at the Consumer Electronics Show this week.

  • The user interface is simple to use. (see a few screenshots below)

  • I feel like it works in terms of helping me learn about my food habits. (Which I guess shouldn’t be surprising since research shows that having a food diary works and another recent study showed that a tool worked better than a paper diary.) For example, I learned several things:
    1. I drink way too little water.
    2. I eat almost 65% of my calories by the end of lunch.
    3. Some foods that I thought were okay have too many calories.
  • In general, the tracking for my steps makes me motivated to try to walk further on days that I’m not doing good.
  • The ease of use and simple device has helped me change behavior.  For example, when I went to go to dinner tonight, I quickly looked up my total calories and saw that I had 600 calories left.  Here’s what I ate for dinner.  (It works!)

Meal

But, on the flipside, I think there are some simple improvement options:

  1. I eat a fairly similar breakfast everyday which is either cereal with 2% milk and orange juice or chocolate milk (if after a workout). [In case you don't know, chocolate milk is great for your recovery.] Rather than have to enter each item, FitBit could analyze your behavior and recommend a “breakfast bundle”. (and yes, I know I could create it myself)
  2. Some days, I don’t enter everything I eat. When I get my end of week report, it shows me all the calories burned versus the calories taken in. That shows a huge deficit which isn’t true. I think they should do two things:
    1. Add some type of daily validation when you fall below some typical caloric intake. (Did you enter all your food yesterday, it seemed low?)
    2. Then create some average daily intake to allow you to have a semi-relevant weekly summary.
  3. The same can be true for days that you forget to carry your device or even allowing for notes on days (i.e., was sick in bed). This would provide a more accurate long-term record for analysis.
  4. The food search engine seems to offer some improvement opportunities. For example, one day I ate a Dunkin Donuts donut, but it had most types but not the one I ate. I don’t understand that since there’s only about 15 donuts. But, perhaps it’s a search engine or Natural Language Processing (NLP) issue. (I guess it could be user error, but in this case, I don’t think so.)
  5. Finally, as I think about mHealth in general, I think it would be really important to see how these devices and this data is integrated with a care management system.  I should be able to “opt-in” my case manager to get these reports and/or the data.

The other opportunity that I think exists is better promotion of some things you don’t learn without searching the FitBit site:

  • They’re connected with lots of other apps.  Which ones should I use?  Can’t it see which other ones I have on my phone and point this out?  How would they help me?
  • There’s a premium version with interesting analysis.  Why don’t they push these to me?

I also think that they would want an upsell path as they rollout new things like the new Flex wristband revealed at CES.

And, with the discussions around whether physicians will “prescribe” apps, it’s going to be important for them to be part of these discussions although this survey from Philips showed that patients continue to increasingly rely on these apps and Dr. Google.

Philips_Health_Infographic_12%2012_F3

Finally, before I close, all of this makes me think about an interesting dialogue recently on Twitter about Quantified Self.

Books / Articles, Care Management, Consumerism, Events, Healthcare, Infographic, Innovation, Marketing / Communications, Methodology, Social Media, Software, Technology, Value Propositions
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Court Decision Allows Pharma Reps To Discuss Off-Label Uses Of Prescriptions

January 8, 2013 by George Van Antwerp 0 Comments

I must admit that I’ve heard very little about this decision from the Federal Appeals Court for the Second Circuit of Manhattan that decided that discussing off-label uses for prescription drugs was an issue of free speech. This could change the way pharmaceutical manufacturers interact with physicians. It could change the job of the pharmaceutical rep. It could change how clinical trials are done. It could change how prescriptions are used. It could also lead to a whole new set of prior authorizations by companies that actually have to actively manage off-label usage as it becomes widespread.

On the other hand, I wonder if this door hadn’t already been opened. Have you looked at some of the peer-to-peer (P2P) healthcare websites out there or the disease based communities (e.g., PatientLikeMe or CureTogether)? Patients are already talking about what medications they are using to treat their diseases and their symptoms. Don’t you think those are leading to requests to the provider and discussions with them about off-label utilization?

And, I’m sure that Dr. Google has helped many patients identify other uses of medications. This process (to the best of my knowledge) is completely un-managed. It’s a popular enough topic that Consumer Reports talked about it earlier this year and even put together the following table on drugs commonly used off-label.

Specific drug, type of drug Examples of off-label use**
Aripiprazole (Abilify), antipsychotic Dementia, Alzheimer’s disease
Tiagabine (Gabitril), antiseizure Depression
Gabapentin (Neurontin), antiseizure Nerve pain caused by diabetes, migraines, hot flashes
Topiramate (Topamax), antiseizure, in combination with phenteramine for weight loss Bipolar disorder, depression, nerve pain, alcohol dependence, eating disorders
Risperidone (Risperdal), antipsychotic Alzheimer’s disease, dementia, eating disorders, post-traumatic stress disorder
Trazodone (Desyrel), antidepressant Insomnia, anxiety, bipolar disorder
Propranolol (Inderal), high blood pressure, heart disease Stage fright
Sildenafil (Viagra), erectile dysfunction To enhance sexual performance in people not diagnosed with erectile dysfunction, to improve sexual function in women taking certain antidepressants
Quetiapine (Seroquel), antipsychotic Dementia, Alzheimer’s disease, obsessive-compulsive disorder, anxiety, post-traumatic stress disorder
SSRI antidepressants such as paroxetine (Paxil) and sertraline (Zoloft) Premature ejaculation, hot flashes, tinnitus (ringing in the ears)
Prazosin (Minipress), high blood pressure Post-traumatic stress disorder
Amitriptyline (Elavil), antidepressant Fibromyalgia, migraines, eating disorders, pain after shingles infection
Bevacizumab (Avastin), certain types of cancer Wet age-related macular degeneration (eye disease)
Statins such as atorvastatin (Lipitor), simvastatin (Zocor), high cholesterol in adults, children with an inherited cholesterol condition Rheumatoid arthritis, to lower cholesterol in children who lack the inherited condition
Clonidine (Catapres), high blood pressure Smoking cessation, hot flashes, attention deficit/hyperactivity disorder (ADHD), Tourette’s syndrome, restless legs syndrome

* Not meant to be a comprehensive list. Many of the drugs listed here are also available as generics.

** Does not imply that use is clinically appropriate or inappropriate, or beneficial or not.

***To find out if a drug’s off-label use is supported by evidence, click on the medication name.

 

I would imagine that pharma is going to tip-toe through this open door not simply crash through it. They’re generally risk adverse so their discussions of off-label utilization will be fact-based (to limit exposure) even if (as we all know) statistics can lie. I would suspect (as I’ve seen on other blogs) that this will ultimately go to the Supreme Court before anyone really takes advantage of it.

I guess I’d also point to the issue that physicians have responsibility here. They prescribe off-label today. Here’s what the FDA says about this:

Good medical practice and the best interests of the patient require that physicians use legally available drugs, biologics and devices according to their best knowledge and judgement. If physicians use a product for an indication not in the approved labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain records of the product’s use and effects. Use of a marketed product in this manner when the intent is the “practice of medicine” does not require the submission of an Investigational New Drug Application (IND), Investigational Device Exemption (IDE) or review by an Institutional Review Board (IRB). However, the institution at which the product will be used may, under its own authority, require IRB review or other institutional oversight.

One way to begin to manage this would be to require the use of diagnosis codes (Dx) on all prescriptions. This would at least great a way of tracking how the medications are being used and allow for better technology oversight across the provider, payer, pharmacy, and PBM.

In the interim, Consumer Reports suggest consumers do the following:

  • When your doctor prescribes a drug, ask if it’s an approved use. If he or she doesn’t know, ask your pharmacist.
  • Check for yourself. Go to DailyMed (dailymed.nlm.nih.gov/) and search for the drug. Then click on the tab for “Indications & Usage” to see if your condition is listed.
  • If it’s an off-label use, ask your doctor if it’s supported by well-designed trials showing significant improvement for people with your condition.
  • Ask your doctor why he or she thinks the drug will work better than approved drugs for your illness.
  • Find out if your health insurer covers payment for the off-label use. Some may require evidence of effectiveness or failure with conventional treatments, especially if the drug is expensive.
Books / Articles, Care Management, Consumerism, Healthcare, Marketing / Communications, Methodology, PBM / Pharmacy, Words Matter
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Fortune Article Questions Generic Equivalency Of Drugs

January 7, 2013 by George Van Antwerp 3 Comments

A new Fortune article “Are Generics Really the Same as Branded Drugs?” (1/14/13) sets a dangerous tone for something that has become a standard across the pharmaceutical industry.  This is either:

(a) giving consumer credibility to a long-standing rumor with a case study or

(b) a dangerous perspective which will only further activate the conspiracy theory consumers and clinicians.

Let’s start with a few basics from the Generic Pharmaceutical Association:

  • There are over 4B prescriptions filled in the US per year.
  • Of those, over 80% are generic medications.
  • Generic medications saved over $190B last year.

For facts on generics, I would point you to the FDA website.  I posted some of their slides years ago on SlideShare which I put below along with their latest infographic.

The article in Fortune focuses on a case regarding an anti-depressant called Wellbutrin and its generic counterpart.  The article goes on to point out that the active ingredients in the generic (compared to the brand) can vary from 80% to 125%.  (I think a good more detailed explanation of this is available here).

But, the author goes on to point out the risks associated with the fillers (or inactive ingredients) and talks about the issue of NTI (Narrow Therapeutic Index) drugs that no one substitutes for anyways.

One big thing that I was always taught was to understand that the difference in active ingredients between brands and generics was similar to the differences in different lots of the same brand drug.  And, given the fact that traditionally, 50% of generic drugs were made by the brand manufacturers, it would seem difficult to believe that they were simply throwing caution to the wind by producing substandard product.

I would hope that Express Scripts, CVS Caremark, Walgreens, PCMA, and many other groups will come out strongly to address this article. This is the type of article that could be a significant setback to the generic industry which has proven itself under lots of scrutiny over the years to save money and have very few negative impacts with the FDA’s scrutiny.

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Books / Articles, Consumerism, Healthcare, Infographic, Marketing / Communications, Methodology, Research, Value Propositions
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