A new Walgreens study analyzing relative medication adherence of patients filling 90-day supplies of maintenance medications using retail and mail order channels over a one-year period concluded that patients who fill prescriptions via retail have as high or slightly higher adherence levels than those utilizing mail (77 percent vs. 76 percent). The study, “Medication Adherence for 90-Day Quantities of Medication Dispensed Through Retail and Mail Order Pharmacies,” was recently released in the November issue of The American Journal of Managed Care.

This reflects other studies from CVS Caremark, Express Scripts, Kaiser, and BCBSNC.  (Although sometimes it shows mail order as better and sometimes retail.)

Of course, the data is slightly different in either case, but the general consensus is the same.  So, the question is what’s next.  How should you compare the two channels?

• Generic fill rate
• Overall health literacy and health outcomes
• Patient experience / satisfaction
• Payer cost
• Cost to fill

This issue won’t go away so it’s going to be important to continue to find ways to compare the channels and find populations that are similar for comparison or remove the bias.

But, I’m not an ACO expert so let me focus on what I found interesting in the NYT article.  It points out a few things:

1. The focus on preventative care
2. The fact that some managed care organizations are changing (and others will too)
3. The fact that “ACOs” (in whatever form they take) will need a platform

This is what I find interesting.

I think the concept of an ACO (or Patient Centered Medical Home) where care becomes localized and there is greater focus on prevention and wellness not just sick-care is great.  We should all want that to happen in some form.

But, in all cases, this changes the data needs and role of the physician.  They need to be empowered with new information and tools.  How do they manage their panel of diabetics?  Will some database track them and monitor their screenings and blood sugar?

When the field of medicine is constantly changing with new drugs and new studies, how will physicians have the best practices pulled into their practice?  They won’t want to wait the 16 years it takes for things to work their way through the system.  They’ll actually want to embrace the best solutions and see more comparative effectiveness information.

I see a huge opportunity here for someone to create an ACO “platform” that embeds business rules, tele-monitoring, consumer engagement, and reporting into a way to create the “i-physician” (informed physician) of the future.

A quick summary of the big winners are:

• For Medicare Advantage (by percentage)
  • Humana +13.5%
  • Amerigroup +13.3%
  • Coventry +12.2%
• For Medicare Advantage (by membership)
  • Humana +262K
  • United +132K
  • Aetna +35K
• For PDP (by percentage)
  • Coventry +25.3%
  • Cigna +14.8%
  • Humana +12.3%
• For PDP (by membership)
  • Humana +312K
  • Coventry +291K
  • Cigna +80K

This is also interesting in light of Kermit Crawford (CEO of Walgreens) comment yesterday:

“Based on our preliminary analysis of the Centers for Medicare and Medicaid Services (CMS) data, Medicare Part D plans with Walgreens in their network gained market share in the aggregate, while those without Walgreens lost market share. Importantly, we were very pleased to see that those plans that included Walgreens grew nearly twice as fast as those Medicare Part D plans without Walgreens. In fact, several health plans that partnered with Walgreens grew significantly faster. For example, Coventry, who partnered with Walgreens and introduced a low cost Medicare Part D option, grew five times faster than the overall market.”

The one obvious account that he’s talking about is Wellpoint which lost 2,000 (0.3%) members in MA and 73,000 (11.6%) members in PDP.

1. Number of medications
2. Plan design (i.e., cost)
3. Gender
4. Health literacy and engagement (see PAM score research)

And, this is a hot topic (see post on FICO adherence score).  You can see my prior posts on some different studies, on the Merck Estimator, and some notes from the NEHI event on this topic.  It generated a good dialogue on Kevin MD’s blog when I talked about paying MD for adherence.

I had a chance to talk with Josh Benner the CEO of RxAnte the other day.  It sounds very interesting, and they have an impressive team assembled.  In general, they’re focused on:

• Predictive modeling
• Decision rules
• Monitoring and managing claims to track adherence
• Evaluating effectiveness of interventions
• And creating a learning system

There are definitely some correlations to the work we do at Silverlink Communications around adherence.  We’re helping clients determine a communication strategy that might include call center agents, direct mail, automated calls, e-mail, SMS, mobile, or web solutions.  We’re looking at segmentation and prioritization.  We’re looking at past behavior and messaging.  The goal is how to best spend resources to drive health outcomes from primary adherence to sustaining adherence.  This is a challenge, and we all need to build upon the work that each other is doing to improve in this area.  We have a huge problem globally with adherence.

This is a great list from what Beth Braverman calls “The Beaten Generation” looking at what’s happened since 2005:

• Their home equity has dropped 51%
• Their net worth is down 55%.
• Their student debt is up 19%.
• Unemployment for college grads is up 64%.
• Their income is down 4.5%
• 31% more are living with their parents.
• The birth rate is down 7.1%.
• 22% less think they’ll be able to retire by age 65.

And, we wonder why they’re pessimistic…

According to some data shared by Money Magazine, here are some examples of stress related ailments and their average annual costs:

• Obesity – $2,600-$4,900
• Back Pain – $1,300
• Insomnia – $200-$1,200
• Hypertension – $1,100
• Teeth Grinding – $200-$1,100

That’s real money!

Some of their suggestions (other than going on a long vacation):

1. Take advantage of the EAP (Employee Assistance Program) that your company might offer.
2. Use the wellness programs that your employer might offer (since 74% of them do offer something).
3. Go see a therapist and look into CBT (cognitive behavioral therapy).
4. Workout.
5. Take a break from e-mail (or your smartphone and constant Facebook updates).
6. Stop multi-tasking.
7. Meditate.

(Beat Stress For Less by Kate Ashford)

Since happiness is correlated with better health, I thought this article in Money Magazine was relevant in the hints it gave about becoming happier. (Jan/Feb 2012 article by Donna Rosato)

1. Spend a little a lot of the time. (multiple, small indulgences are better than less, large indulgences)
2. Free yourself from credit card debt. (less satisfied in your relationship when have debt)
3. Focus on having a rainy day fund. (best predictor of financial satisfaction)
4. Find a new job. (if you’re not happy)
5. Give more to charity.
6. Use your vacation days. (even anticipation of a vacation increases happiness)

Here are a few more articles on happiness and health:

• RealAge article
• Health Affairs article

• 53% of Americans aren’t sure their kids will better off then they are.
• 67% are worked their quality of life will suffer in retirement.
• 80% say they’re eating at home more.
• 75% say time with family is more important than ever.

“Big periods of economic upheaval can define a generation. Not so much because of the depth of this recession, but because of its prolonged nature, it will have lasting impact.” Paul Flatters, Managing Director of Trajectory Partnership. (How The Economy Changed You by Dan Kadlec)

• 85% spend more time looking for deals before they buy. (hence the couponing craze)
• 57% are building an emergency fund.
• 51% are pessimistic about the US economy in the next 12 months.
• 61% are pessimistic about government officials spurring growth.

I don’t know about you, but I see a ton of nuggets in here about positioning generic drugs, preventative health, adherence, mail order, and many other cost savings actions in healthcare.

“Someone who has your best interest in mind will welcome that conversation.” Is what Dr. Jeffrey Cain, president-elect of the American Academy of Family Physicians says about telling your physician that you’re getting a second opinion

So, according to an article in Money Magazine, here’s what you do:

1. Check your coverage. You may be covered if you get a second opinion. If not, you might be able to appeal that decision.
2. Find the right doctor. The article suggests getting multiple names and finding MDs that work at different hospitals (to avoid group think).
3. Get your documents together. Make sure the physician has all the documentation before you go or bring it with you.

(Get More From A Second Opinion by Anne Lee)

One interesting example he talked about was the expression of a person on a poster (for example). If the expression is too easy to decipher, we simply move on…BUT if it’s hard to decipher, it causes us to pause and think.

He also talks about always putting images on the left hand side of the screen and words on the right. (Seems applicable to direct mail and maybe my next slide presentation.)

Another example is that the brain loves curves not sharp edges.

Given the shifting pharmacy marketplace, I would think this is a study that the industry needs. The PBMs should better understand what the consumer thinks about when they hear the word mail order. Manufacturers should understand the reaction to brand names or copay cards. The retailers should think about how brand equity plays into choice. There are endless opportunities here. (A business opportunity perhaps!)

(They Have Hacked Your Brain by Adam Penenberg)