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Healthcare Companies Sitting On Lots Of Cash…What Will They Do With It?

In the September 8-15 edition of Time Magazine, they have a whole article about data and numbers.  One of the pages is on which companies have the most cash.  Apple is number one and the one you always hear about.  As we’ve all seen, there are lots of rumors about Apple, Google, and Amazon and what they’re doing that is health related. 

At the same time, I was intrigued to see all the health related companies on the list:

  • Medtronic – $13.7B
  • Abbott Labs – $8.1B
  • Merck – $27.3B
  • Pfizer – $48.8B
  • Johnson & Johnson – $29.2B
  • Abbvie – $9.9B
  • Eli Lilly – $12.7B
  • Amgen – $23.1B
  • Bristol-Myers Squibb – $8.3B

You have several other non-healthcare companies which are doing things in healthcare that are also on the list:

  • Walmart – $8.7B
  • GE – $14B
  • Procter & Gamble – $8.5B
  • Qualcomm – $31.6B

If you look at the Rock Health recent report, you can imagine how these companies could leverage all this money to really change healthcare.  They could fund companies.  They could buy companies.  They could invest in orphan drugs.  They could create new technology standards.  They could educate consumers.  They could push technologies like the Internet of Things. 

Dynamic Journey Mapping and P2P

I’ve talked several times about what P2P (peer-to-peer) healthcare is.  We have examples of PatientsLikeMe and CureTogether.  This is something that Pew has talked about several times over the years.  Additionally, here’s a blog post by Susannah Fox on this.  The point is that people turn to Dr. Google and social media often before they talk to a healthcare professional.  That’s critical to understand. 

Interestingly, as I was reading the IMS whitepaper on Journey Mapping, it really got me thinking about how all this social listening and patient content can influence and shape the Patient Journey (see example).  We’ve already heard about the influence this channel is having on clinical trials.  And, we know that Big Data trends are driving lots of new data sources for analysis and insights.  I think this JAMA list is a good starting point.  But, as Jane Sarasohn-Kahn points out, we can’t forget about the Open Notes initiative and the power that it will bring with it. 

The question of course is how this will all be reflected in the way we think about the consumer in all the “patient experience” and “consumer engagement” hype in healthcare.  For example, this image from a Deloitte whitepaper shows some of the ways a health plan can influence the consumer experience.

Consumer Experience Payer

We all know this is tricky, and it’s critical to establish trust between the consumer and the entity influencing the journey.  Health plans and pharmaceutical companies are usually not high on the trust scale. 

That being said, the IMS whitepaper does a good job of pointing out the need to expand beyond the traditional effort of focusing on key influencers.  It’s important to understand the payer view and the patient view in new ways.  It’s also important to understand what matters to each group.  While adherence may seem like the right metric, I would argue that it’s simply the easy metric.  It’s important to really understand the overall health of the patient.  They care about their experience.  They care about their quality of life.  These all need to be factored into the patient journey

Book: My Healthcare Is Killing Me

“A hospital bed is a parked taxi with the meter running.”  Groucho Marx

While I was flying last week, I had the chance to read My Healthcare Is Killing Me.  I could probably think of a few other titles for the book like:

  • Don’t let healthcare bankrupt you
  • Navigating the healthcare billing maze
  • Negotiating to better health
  • The $20 disenfranchisement fee

Those should give you a hint about the topic of the book.  It’s written by Chris Parks, Katrina Welty, and Robert Hendrick who are all part of the founding team at Change Healthcare.  If you’re not familiar with Change Healthcare, you should look at them and others in the transparency space.  (You can look at Jane Sarasohn-Kahn’s series on cost transparency for more information.)

Here’s a few of my notes from the book:

  • Hospitals and doctors view their patient’s bills as Days Sales Outstanding (which is why you can negotiate for prompt payment).
  • 22% of people have been contacted by a collection service for a medical bill
  • 60% of consumers that asked for discount on a medical bill were successful
  • The bill is NOT what the provider will (or expects) to get paid…It is the most that they will get paid
  • The chance of getting the right diagnosis and treatment on the first visit is 50% (scary)

The book has an interesting analogy from Patsy Kelly comparing healthcare to a restaurant:

“In healthcare, the patient does not order the service or have the primary responsibility for payment.  Additionally, the person who pays for the service does not order it or consume it, and the person who orders it does not pay for it or consume it.”

Another quote from Unity Stoakes was:

“We must arm ourselves with knowledge, wisdom and information.  Demand transparency in pricing by researching alternatives.  Negotiate!  Take control of your own healthcare now.  The more you know, the more power you have.”

The authors do a good job of simplifying down some of the complexities of the healthcare payment system.  Some things have changed with health reform, but the fundamentals are the same.  For someone taking on a large, complex condition which is likely to result in lots of costs, its worth reading.  For someone trying to change healthcare and understand the fundamentals, it’s also a great quick read which you can then follow-up on to see how this became the foundation for Change Healthcare. 

 

Gilead’s Sovaldi Is The $5.7B Canary In The Coal Mine For Specialty Medications

In case you haven’t been tracking specialty drug costs for the past decade, the recent news with Gilead’s Sovaldi ($GILD) is finally making this topic a front page issue for everyone to be aware of.  I think Dr. Brennan and Dr. Shrank’s viewpoint in JAMA this week did a good job of pointing that issue out.  They make several points:

  • Is this really an issue with Sovaldi or is this an issue with specialty drug prices?
  • Would this really be an issue if it weren’t for the large patient population?
  • Will this profit really continue or are they simply enjoying a small period of profitability before other products come to market?
  • Based on QALY (quality adjusted life years) is this really quick comparable cost to other therapies?

If you haven’t paid attention, here’s a few articles on Sovaldi which did $5.7B in sales in the first half of 2014 and which Gilead claims has CURED 9,000 Hep C patients.

But, don’t think of this as an isolated incident.  Vertex has Kalydeco which is a $300,000 drug for a subset of Cystic Fibrosis patients.  In general, I think this is where many people expected the large drug costs to be which is in orphan conditions or massively personalized drugs where there was a companion diagnostic or some other genetic marker to be used in prescribing the drug.

The rising costs of specialty medications has been a focus but has become the focus in the PBM and pharmacy world over the past few years.  This has led to groups like the Campaign for Sustainable Rx Pricing.  Here’s a few articles on the topic:

Of course, the one voice lost in all of this is that of the patient and the value of a cure to them.  Many people don’t know they have Hepatitis C (HCV), but it can progress and lead to a liver transplant or even ESRD (end state renal disease) which are expensive.  15,000 people die each year in the US due to Hep C (see top reasons for death in the US).  So, drugs like this can be literally and figuratively life savers.  These can change the course of their life by actually curing a lifetime condition.

This topic of specialty drug pricing isn’t going away.

At the end of the day, I’m still left with several questions:

  1. What is the average weighted cost of a patient with chronic Hep C?  Discounted to today’s dollars?  Hard dollars and soft dollars?  How does that compare to the cost of a cure?
  2. What’s the expected window of opportunity for Gilead?  If they have to pay for the full cost of this drug in one year, that explains a lot.  If they’re going to have a corner on the market for 10-years, that’s a different perspective.  (Hard to know prospectively)
  3. For any condition, what’s the value of a cure?  How is that value determined?  (This is generally a new question for the industry.)

And, a few questions that won’t get answered soon, but that this issue highlights are:

  1. What is a reasonable ROI for pharma to keep investing in R&D?
  2. What can be done using technology to lower the costs of bringing a drug to market?
  3. For a life-saving treatment, are we ready to put a value on life and how will we do that?
  4. What percentage of R&D costs (and therefore relative costs per pill) should the US pay versus other countries?

Mars versus Venus – HDHP variation

Ideally, we’d all get individualized or personalized healthcare, but we’re still years away from that happening.  But, there are several basics about segmenting individuals which are relevant.  One of them is that men and women are different in how they experience healthcare.  Another one is that different plan designs drive different behaviors.

With those in mind, I found an article in the June 2014 Money magazine interesting.  It pointed out that while both men and women reduce their use of the emergency room with high-deductible plans that it varies.  As you can see from the table below, this is especially relevant for high-severity issues where men dramatically reduce their use of the ER which can lead to significant issues.

HDHP

You can see a few studies on this topic here:

12 Innovation Lessons from 2014 (Fast Company)

Back in March 2014 (yes I’m behind), Fast Company put out a report on the World’s Most Innovative Companies.  I thought the list of 12 trends or lessons from their research was worth sharing.

  1. Exceptional is the Expected…Google is the case study here, but they make a point that for most companies, the best businesses focus on less not more.
  2. Innovation is Episodic…Innovation ebbs and flows so people don’t stay on the list every year.  This is also known as regression to the mean or the Sports Illustrated curse (of being on the cover).
  3. Making Money Matters…This is very true for mHealth.  I’ve seen so many really cool ideas, but if they’re not self-sustaining, that’s a problem.
  4. Sustainability Has Found A New Gear…”Green” is no longer a gimmick.  Companies are innovating and using alternative fuels and recycling as part of that.
  5. Unlocking Global Talent Unlocks Possibility…I can’t believe companies still don’t get this.  To innovate, you need diversity and a culture which allows those different opinions and perspectives to hash it solutions.  (Just look at the graphic at the bottom of this post for Silicon Valley which makes that point.)
  6. Passion is Underrated…While crowdsourcing sounds like old news to many industries.  I think there’s still a huge patient empowerment push that will happen in healthcare.  (Just look at this article in the WSJ.)
  7. Conflict Isn’t Required…This is the perfect Blue Ocean example.  You don’t always have to try to change the establishment but sometimes you have to figure out a whole new way.
  8. Happy Customers Make You Happy…Not much to say here.  Healthcare is about to learn this lesson with exchanges, but we have a long way to go.
  9. Software Beats Hardware…YES!  A great computer with a horrible data entry process which messes up the physician workflow and consumer experience is bad.  We need outside-in design to develop user-friendly software that takes into account workflow and regulation but improves the overall experience and outcomes.
  10. “Made In China” Is A Compliment…I’d expand this point to say that while we’ve outsourced for years for cost that’s building up knowledge and a middle class abroad.  As their expectations and experience rise, we’re going to see more innovation and quality from abroad.
  11. The Biggest Winner In The App Economy Remains Apple…And, now, Apple is taking it’s “moral obligation” and bringing it to healthcare.
  12. Dreaming Big Isn’t Folly; It’s Required…Eliminating cancer.  Changing payment paradigms in healthcare.  Getting patients to take action.  Changing food at schools.  We have to have some BHAGs in healthcare and make them happen.  (Perhaps some of the HealthPeople 2020 initiatives will get us thinking.)

Silicon Valley Workers

Above: Tech Immigrants: A Map of Silicon Valley’s Imported Talent (from VentureBeat article)

 

$83,000 In Savings On 3 Procedures – The Driver Of Transparency & Reference-Based Pricing

At the front of the HealthLeaders Magazine, they have a FactFile every month with data from Truven Health.  The one from March 2014 focused on price variation and transparency.  I thought I’d share a few of the charts.

This first chart shows their projections about the impact of a price transparency tool on cost savings over three years.  (BTW – If you’re looking for information on price transparency tools, I would go to Jane Sarasohn-Kahn‘s blog HealthPopuli and look at her posts on transparency – Part I, Part II, Part III, Part IV, and Part V).  Their projection was $6,786,000 in year 3 for an employer with 20,000 employees (or about 46,000 total covered lives if you assume a ratio of 2.3).

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The other topic in the FactFile is about price variation and potential savings.  They looked at three procedures and the variation in pricing for them.  They then estimated the savings from those three procedures for an Chicago based employers.

As you can see, the variation is dramatic.  What this will eventually lead to is called “reference-based pricing” where payers will agree to pay a fixed amount (or reference price) for a procedure and consumers will have to use transparency tools to figure out which providers will meet that price or pay out of pocket to go elsewhere.  The hope is that this will drive down prices, make consumers aware of differences, and finally help people understand that price and quality are NOT correlated in healthcare.

Here’s a few articles to read on price transparency:

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A Few Corporate Wellness Tips

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

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

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

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

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

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

The CDC says that obesity is linked to:

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

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

Dossia: Not Just a Personal Health Record Anymore

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I had a chance to see a product demo of Dossia the other day.  I was really impressed which I don’t easily say.  I was expecting to hear a pitch on Personal Health Records (PHRs) and why they were different.  Instead, I got to see a robust patient engagement portal which did some really interesting things. (see image above from the Health 2.0 demo they gave)

From their website, here’s the “about” description which lists some very influential players…

Dossia is an organization dedicated to improving health and healthcare in America by empowering individuals to make good health decisions and become more discerning healthcare consumers. Backed by some of the largest, most respected brands in the world – Applied Materials, AT&T, BP, Cardinal Health, Intel, Pitney Bowes, Vanguard Health Systems, NantWorks and Walmart – Dossia’s founding member companies have united under the common vision of changing healthcare.

Having these companies involved over the past 6 years has been really important for them to accomplish what they’ve done.  As someone that’s worked on a lot of the same population health challenges, they’ve accomplished things that not even Google Health could do.

So what were the features and functions that really impressed me:

  1. They’ve built integration to health plans, PBMs, pharmacies, lab companies, and even EMR companies.  This creates a data rich longitudinal view of the patient for the patient.  (I like the expression on their website where they say “Dossia is the connective tissue that powers healthy change.”)
  2. They’ve incorporated health content which by itself isn’t impressive, but the content is tailored to the individual based on their medical data.  Not hard, but not something that many people do well.
  3. They’ve built out a series of partnerships and integrations with over 50 apps where you can navigate that turn them on as widgets within the portal.  This is very similar to some of the cool things that CarePass is doing.
  4. They’ve built the system out using open APIs (application programming interfaces) which allows other companies to easily integrate with them.
  5. And, probably one of the cooler things from my consumer engagement lens was their ability to do WYSIWYG rules creation to trigger outbound communications based on clinical data.  The idea of a rules engine isn’t difficult, but the ease of their solution with the integrated data makes it very powerful.

And, they’ve expanded their reporting.  They’ve pulled in ways to manage those family members for which you’re a caregiver.  They’re doing lots of interesting things.  They are definitely worth talking to if you haven’t seen them in a few years.

CarePass Updates – Medication Adherence and Stress

A few weeks ago, I had a chance to follow-up with Martha Wofford, the VP of CarePass about their latest press release.  This was a quick follow-up interview to our original discussion.  As a reminder, CarePass is Aetna’s consumer facing solution (not just for individuals who they insure) which integrates mHealth tools and data to help consumers improve their engagement and ultimately health outcomes.

“Many Americans have a lower quality of life and experience preventable health issues, adding billions of dollars to the health care system, because people do not take their prescribed medications. There are a myriad of reasons why medication adherence is low and we believe removing barriers and making it easier for consumers to take their medications is important,” said Martha L. Wofford, vice president and head of CarePass from Aetna. “As we continue to add new areas to CarePass around medication adherence and stress, we seek to provide people tools to manage their whole health and hopefully help people shift from thinking about health care to taking care of their health.”   (from press release)

As part of this update, we talked about one of my favorite topics – medication adherence.  Obviously, this is a global problem with lots of people trying to move the needle.  In this case, they’ve included the Care4Today app from Janssen.  This tool does include some functionality for the caregiver which is important.  It also links in charitable contributions as a form of motivation.  We talked about the reality that adherence is really complex, and people are different.  This may work for some, but adherence can vary by individual, by condition, and by medication.  But, they hope that this is a tool that may work to nudge some people.

I was also glad to see them taking on the issue of stress by adding the meQ app.  This is a key struggle, and Martha pointed out to me that 1/4 of adults are either stressed or highly stressed.

“When people are under chronic stress, they tend to smoke, drink, use drugs and overeat to help cope.  These behaviors trigger a biological cascade that helps prevent depression, but they also contribute to a host of physical problems that eventually contribute to early death…” – Rick Nauert, PhD for National Institute of Mental Health, 5/2010

She mentioned that they’ve gotten a great reception to this program, but they have a lot more to learn.  They’re still in the early period of getting insights and interconnecting all of their efforts.  We also talked about some of the upcoming opportunities with the caregivers (or the sandwhich generation).  I personally think the opportunity to improve aging in place through a smart home strategy with remote monitoring is going to be huge of the next 10 years.

I did interview the Janssen people as a follow-up which I’ll post separately, but I also thought I’d include this video interview of Martha that I found.

Pharmacy Satisfaction – Retail Beats Mail

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

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

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

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

The rankings for mail order were:

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

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

Aetna’s Metabolic Syndrome Innovation Program

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

Here’s Adam’s bio:

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

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

Definition of Metabolic Syndrome from the NIH:

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

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

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

As stated in their press release about this new effort:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

10 Healthcare Projects I’d Like To Solve

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

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

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

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

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

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

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

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

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

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

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

So, what would you like to solve?

The Healthcare Mark-up Game – Driving Up Healthcare Costs

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

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

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

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

Still wonder why healthcare is expensive?

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

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

The 15 Year Old Technology Missing From Healthcare.gov

I talked about my experience trying to use the site day one. I honestly hoped it was an anomaly but it doesn’t seem to be.

But, as I think about Healthcare.gov and the general benefits selection process, I see two huge gaps.

Back in 1999, I was working with a company called Firepond. The had what was called a product configurator. At the time, I was at E&Y and Empire BCBS and several other Blues hired them to build a tool for brokers. The tool sat behind a really slick web interface which allowed the broker to ask a consumer less than 10 questions. They would move a sliding bar across the screen and it would dynamically rank their plan options to tell them what was the best option for them to buy. It seems like that wold be great for Medicare.gov and Healthcare.gov.

What we were missing then which Big Data might actually help us solve now is individual claims data. This is what drives me crazy when you have to pick your benefits at work. Why can’t I upload my benefits information and have a tool actually tell me what to buy? If I had my claims history plus a predictive model, I could make smarter decisions about how to select my benefits.

Retail Pharmacies As The Distribution Point For Information

It’s always exciting to be “right” in a prediction.  When I spoke at the CBI conference a few weeks ago, one of the key points I made was that today’s healthcare consumer is overwhelmed with information.  They get conflicting data.  They don’t have enough time with their physicians.  They are increasingly responsible for decisions and even with transparency, they don’t always know what to do.  With that in mind, one of my suggestions was that retail pharmacies had a great opportunity to step in and be this information management source for consumers.  (aka – The retailers can serve as the physical resource for the retailing of healthcare.)

With that in mind, I find the announcements by Walgreens and CVS very interesting.

From the CVS press release:

“Humana’s partnership with CVS/pharmacy reflects our proven and ongoing commitment to educate individuals and their families at the places they go when they have questions about their health,” said Roy A. Beveridge, MD, Humana’s Chief Medical Officer. “We’re working to ensure people develop a better understanding of how their health coverage can help them make better, and healthier, decisions.”

“Providing information about new health insurance coverage opportunities is in keeping with our purpose of helping people on their path to better health,” said Helena Foulkes, Executive Vice President and Chief Health Care Strategy and Marketing Officer for CVS Caremark. “We are pleased to combine our innovative suite of services and our new and existing relationships with organizations such as Humana to help patients understand and have access to information about insurance options in their community.

From the Walgreen’s press release:

Walgreens store personnel are directing individual customers who inquire to the GoHealth Marketplace, a resource where they can shop and compare health insurance plans, enroll and find other important tools and information. Consumers can access the GoHealth Marketplace online from www.walgreens.com/healthcarereform or via phone at 855-487-6969. Walgreens also is providing informational brochures and other materials in stores.

“As an accessible, community health care provider serving more than 6 million people each day, Walgreens can help connect those customers who may be considering new health insurance options with resources and information,” said Brad Fluegel, Walgreens senior vice president and chief strategy officer. “Our goal is to help ensure people fully understand the marketplace, and working with GoHealth, to provide personalized consultation from experts who can help them make informed decisions.”

In both cases, they may have addressed one of my questions about this strategy from my presentation which was how would they monetize this.  I think it’s the right role, but I wasn’t sure how it would lead to revenue other than general revenue related to store traffic.  I assume both of these have some “commission” or “referral fee” for traffic generated.

Diet Soda Versus Regular Soda – Ongoing Confusion

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

images

Should I focus on calories?

Should I focus on the ingredients?

Should I just drink water?  (of course)

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

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

Consumers don’t know who or what to trust.

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

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

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

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

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

Image

Image

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

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

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

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

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

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

Carepass lifestyle questions Carepass dashboard

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

Carepass apps

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

No Fat Customers Please – #BoycottAbercrombie

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.

How Walgreens Became One Of The More Innovative Healthcare Companies

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”.

 

How Aetna’s Pivoting With Healthagen – #whcc13

Do you know the term “pivot“? It’s all the rage now in terms of describing how companies continue to evolve their models with this rapidly changing business environment.

Of course, Aetna is one of the big healthcare players in the US. They’re not going to abandon a model that’s been working for well over 100 years. But, thanks to some great leadership from people like Mark Bertolini, CEO of Aetna, they’ve created a new business unit called Healthagen (building on the company they bought known mostly for iTriage). The screen shot says it all.

I got the privilege to sit down with Dr. Charles Saunders who runs Healthagen at the World Healthcare Congress in DC (#whcc13).

Charles E. Saunders, M.D., is responsible for leading the strategic diversification of Healthagen’s products, services and global opportunities. He focuses on identifying new growth opportunities and developing market strategies that can help Healthagen and Aetna profitably manage quality and cost for its customers.

Prior to joining Healthagen, Dr. Saunders served as executive in residence at Warburg Pincus, one of the world’s largest and oldest private equity firms. He has held a number of other significant leadership positions during his career, including CEO of Broadlane, Inc., President of EDS Healthcare Global Industry Solutions; Chief Medical Officer of Healtheon / WebMD; Principal of A.T. Kearney; and Executive Director of San Francisco General Hospital Managed Care Programs.

Dr. Saunders received a B.S. in biological sciences from the University of Southern California and an M.D. from Johns Hopkins University. He is board certified in Internal Medicine and Emergency Medicine and has served on the faculty of several universities, including the University of California, San Francisco; Vanderbilt University; and University of Colorado.

I also got to hear him speak right before I talked to him. (As a side note, he is a great presenter which is something that I really respect in a world of people who present too many slides, use notes, talk to the screen, and can lose you quickly.)

He hit on several key themes in his presentation that we then discussed further face-to-face:

  1. Social Caregiver Model
  2. Game Theory
  3. Digital / Mobile

One of my first questions was to really understand Healthagen and what it was set up to do. (As you can see from the screen shot below, they’re doing lots of things in this group.)

He boiled it down nicely to three things:

  1. Physician (provider) enablement
  2. Patient engagement
  3. Population Health Management IT

Our next discussion was really around why and how to create and innovate within a large company like Aetna. He reiterated what I believed that Mark Bertolini championed this new vision along with several of the other senior leaders. But, I think the key was that they recognized that issue of trying to do that internally and were willing to form a group to be different. To minimize bureaucracy for this group. And, to leverage their capital and assets to support this group. Not many big companies do this well. My impression is that Aetna is and will continue to be successful here. (Full disclosure – I own a minor number of Aetna shares and have believed this since I bought them about a year ago.)

Of course, in today’s market, there’s an explosion of innovation with questions on the short-term and long-term ROI of many initiatives and start-ups. With that in mind, Dr. Saunders pointed out that they don’t want to own everything. They want to create a plug and play platform of enablement. iTriage is a great example of this where they brought in a mobile technology with 2M downloads in 2011 and now have over 9.5M downloads of the tool (on top of massive increases in functionality and integration). You can download it here – https://itunes.apple.com/app/itriage-health-doctor-symptoms/id304696939?mt=8.

Certainly, one concern others have historically had in this space was how to own solutions and sell them to their peers (competitors). Dr. Saunders talked about their ability to do this with ActiveHealth and a perception that the industry is over that issue as long as Aetna can continue to demonstrate that they are good stewards of the data and are keeping the appropriate firewalls in place.

We wrapped up the conversation talking about the social caregiver and game theory. I think both are important in our mHealth / digital world. With the sandwhich generation, this is increasingly important. That is where Aetna is focusing…enablement of the caregiver for infants and seniors leveraging a social approach. This reminds me of their recent announcement of a pilot with PatientsLikeMe. We also talked about game theory and the role of that in healthcare which is a common theme from my discussion with Keas this morning and a theme from the overall conference.

It should be interesting to watch Dr. Saunders and his team and how Aetna continues to pivot.

What’s Your #Moment4Change?

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.

Short Sighted View Of Freedom With NY Soda Ban

pouring-on-the-pounds

There are lots of fundamental issues here:

  • Was the law legal?
  • Does soda make you fat?
  • Should the government be able to steer you to positive choices?
  • Did this impact our freedom?

At the end of the day, I look at it very differently.  I think the proposed ban was great.  I was very annoyed last night to find out it was overturned.

Why?

  1. I don’t see this as any different than moving unhealthy foods to a less obvious place in the food line at school.  It simply was meant to help steer people to make healthier decisions.  We should all be thankful for someone helping us since we generally don’t seem to be able to help ourselves.
  2. Government has to be run like a business.  (It usually isn’t.)  Obesity is a big driver of costs.  It requires more power for public transportation.  It requires bigger chairs.  It requires bigger hospital beds.  It requires bigger ambulances.  And, all of us taxpayers pay for this.
  3. 80% of healthcare costs are driven by personal decisions that we make mostly around diet and exercise.  Since most people will end up on Medicare at some point, we need to change the cost curve in healthcare sooner rather than later.  Otherwise, we either bankrupt our country or we bankrupt Medicare.

So, enjoy your big 64 oz soda now, but when you’re 69 and Medicare has been rolled back to 70 due to funding challenges, you can smile and remember that you got to enjoy all that sugar for years without anyone trying to help you. (I can picture a great political cartoon here of the patient getting a healthcare bill looking over their shoulder from their wheelchair to see a big pile of soda cups!)  Never mind the fact that you’re bankrupt due to your healthcare bills and not able to walk around to keep up with your grandkids.

The Business of Obesity
Source: top-nursing-programs.com

Healthcare Fails Again In Experience Survey

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

 

Only 50% Of Healthcare Companies Respond To Twitter Messages – Test Results

12 Of 23 Companies

As I mentioned a few weeks ago (2/2/13), I wanted to test and see if healthcare companies would respond to consumers via Twitter. To test this, I posted a fairly general question or message on Twitter to see the response (see below). Of the 23 companies that I sent a message to, only 12 of them ever responded even after 6 of them received a 2nd message. Those results are shared below. What I also wanted to look at was the average time to respond along with which group was more likely to respond.

  • PBMs – All of the 3 PBMs that I reached out to responded. (This could be biased by my involvement in this space since two of them e-mailed me directly once I posted a comment.)
  • Pharmacies – Only 2 of the 4 retail pharmacies that I reached out to responded.
  • Disease Management Companies – Only 1 of the 3 that I reached out to responded. (I was surprised since Alere often thanks me for RT (re-tweeting) them, but didn’t respond to my inquiry.)
  • Managed Care – 5 of the 7 companies that I reached out to responded. (For Kaiser, they responded once I changed from @KPNewscenter to @KPThrive.)
  • Health Apps or Devices – Only 1 of the 5 companies that I reached out to responded. (This continues to surprise me. I’ve mentioned @FitBit on my blog and in Twitter numerous times without any response or comment.)
  • Pharmaceutical Manufacturers – Only 1 of the 3 companies that I reached out to responded. (This doesn’t surprise me since they are very careful about social media. @SanofiUS seems to be part of the team that has been pushing the envelope, and they were the ones to respond. I thought about Tweeting the brands thinking that those might be monitored more closely, but I didn’t.)

I will admit to being surprised. I’m sure all of these companies monitor social media so I’m not sure what leads to the lack of response. [I guess I could give them the out that I clearly indicated it was a test and provided a link to my blog so they could have chosen not to respond.]

Regardless, I learned several things:

  1. Some companies have a different Twitter handle for managing customer service.
    1. @ExpressRxHelp
    2. @AetnaHelp
    3. @KPMemberService
  2. Some companies ask you to e-mail them and provide an e-mail.
  3. Some companies tell you to DM (direct message) them to start a dialogue.

From a time perspective, I have to give kudos to the Prime Therapeutics team that responded in a record 2 minutes. Otherwise, here’s a breakout of the times by company with clusters in the first day and approximately 2 days later.

Company

Response Time (Hrs:Min)

Prime Therapeutics

0:02

Aetna

1:12

LoseIt

1:19

Healthways

2:07

Walmart

3:01

Express Scripts

8:35

Kaiser

29:22

BCBSIL

47:32

OptumRx

47:39

BCBSLA

48:18

Sanofi

53:30

I guess one could ask the question of whether to engage consumers via Twitter or simply use the channel more as a push messaging strategy. The reality is that consumers want to engage where they are, and there are a lot of people using Twitter. While it might not be the best way to have a personal discussion around PHI (Protected Health Information) given HIPAA, it certainly seems like a channel that you want to monitor and respond to. It gives you a way to route people to a particular phone number, e-mail, or support process.

As Dave Chase said in his Forbes article “Patient engagement is the blockbuster drug of the century”, this is critical for healthcare companies to figure out.

The CVS Caremark team told me that they actively monitor these channels and engage with people directly. I also talked with one of the people on the Express Scripts social monitoring team who told me that they primarily use social media to disseminate thought leadership and research, but that they actively try to engage with any member who has an actionable complaint. They want to be where the audience is and to quickly take the discussion offline.

If you want to see the questions I asked along with the responses, I’ve posted them below…

The Prescribing Apps ERA – Will Clinicians Be Ready? #mHealth

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

Limiting Factor For Behavior Change is We Don’t Believe We Will Change

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.

FitBit Review Summary – Device, Apps, And Suggestions

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.

Court Decision Allows Pharma Reps To Discuss Off-Label Uses Of Prescriptions

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.

Fortune Article Questions Generic Equivalency Of Drugs

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.

ucm305899

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