My favorite point from talking to him was…

Cancer is a process not an event. Communication is critical.

In his presentation, he talked about several things:

• The $227B total cancer cost in the US (2007).
• The personalization of risk assessments and interventions.
• The services of MD Anderson.
  • Mortality reductions
  • Wellness education
  • Vaccinations and chemoprevention
• The US Preventative Services Task Force.
• The work that they’re doing direct with an employer (Shell).
• The CEO Cancer Gold Standard.
• The impact of aspirin on all-cause mortality.

So, after his formal presentation, we talked about several things.

1. One of the big focus areas for MD Anderson is prevention. As we know from research, many cancers are preventable. And, the promise of personalize medicine and genetic testing is beginning to help us understand these cancers and their treatments even more.
2. The three types of prevention:
   1. Primary – this would include lifestyle changes such as diet and smoking which help prevent the disease
   2. Secondary – this would include screening and detection to help slow the progression of the disease
   3. Tertiary – this would include the focus on the patient (not the tumor) for treatment and helping them with quality of life
3. He talked about how cancer is really 200 different diseases to be understood and managed.
4. He gave a great analogy about how CVD (cardio-vascular disease) evolved and talked about how all the individual risk factors became asymptomatic diseases which have led to all the “know your number” campaigns around lipids and blood pressure.
5. We talked about cancer as a process which led us into the discussion about palliative care and shared decision making. He made another good analogy here about driving a car. We need to understand the value of wearing our seat belt and having insurance, but we have to make the final decision about whether to do that or not.
6. We talked about personalized medicine including genomics and epigenetics. We talked about how this impacts dosing and understanding of the tumor. (Interesting in a conversation with another person in this field this week they were telling me about how tumors and viruses change over time and those implications on genetic test results.) We also talked about SNPs and the complications in getting validation in studies due to sample sizes. We wrapped up this topic with discussions on coordinated registries and work that companies like 23andMe are doing.
7. Our final topic of discussion was around clinical practice algorithms and how evidence-based medicine (EBM) gets implemented. We talked about the use of guidelines and how those allow for monitoring the use of EBM standards. We also talked about the need for integrated EMRs that would allow for benchmarking and linking outcomes to use of guidelines.

This is a fascinating area. Cancer affects most of us either directly or through some family member or friend.

The first thing we discussed was the concept of ACOs (Accountable Care Organizations) and how employers think about them (or similar concepts).  She talked about the fact that most employers don’t understand the ACO framework in specific.  They may have heard something about the idea of a medical home or mention of the ACO, but they are more broadly focused on the conversion to an outcomes-based future.  Initially, there are some leading edge employers and coalitions that you hear talking about these concepts at conferences, but in general, employers are going to look to their payors to lead this effort and think about how to embrace these new quality and payment frameworks.

We then talked about what are the issues that keep her up at night.  In general, we focused on three things:

1. Reform – What is the future of healthcare reform and how will that impact employers?
2. Cost – How can we control costs both direct and indirect?  And, what is the role of prevention in cost management?
3. Engagement – Even if we understand how to control costs, how do we engage consumers to take action?  Is it through incentives, gamification, social media, mobile, or other tools?

We then talked about incentives and paying consumers (employees) for healthcare actions.  She described three phases here:

• Phase I: Payment for completing and HRA (which many companies have done for several years).
• Phase II: Payment for completing specific screenings and participating in programs for which the patient is engaged (i.e., respond with the case manager calls you).  (This seems to be a rapidly emerging standard with many employers.)
• Phase III: Payment tied to achievement of different outcomes (weight loss, BMI, smoking cessation, blood sugar, blood pressure).  (This is a lot further off and much more complicated, but it’s something that people are beginning to look at.)

We wrapped up with two topics – new technologies and ROI.  In today’s environment, everyone is looking at mobile health and telemedicine.  The question of course is how to get these tools used, paid for, and demonstrating the ROI.  From a technology perspective, we talked mostly about the idea of the “digitally naive” (i.e., people under 16 today) for which technology is the norm.  They’ve never experienced life without mobile phones and computers and Google.  As this generation becomes patients, they won’t think twice about using technology as a way to see their physician and monitor their health.

From an ROI perspective, this has become a table stake to play.  Everyone requires some case study for use.  But, we had a great discussion about the flexibility of calculating ROI and how companies do look beyond just the simple avoided medical costs.  They look at presenteeism.  They look at satisfaction.  They look at overall impact.  This is a very important point as companies think about designing studies and monitoring their solutions.

• Incentives
• Biometrics
• Evidence-based medicine
• Steerage of consumers to lower cost “Centers of Excellence”
• Reference-based pricing to address unwarranted variation
• Cost / transparency tools
• Consumer engagement
• Integrated care

First, let’s define palliative care:

Palliative care (from Latin palliare, to cloak) is an area of healthcare that focuses on relieving and preventing the suffering of patients. Unlike hospice care, palliative medicine is appropriate for patients in all disease stages, including those undergoing treatment for curable illnesses and those living with chronic diseases, as well as patients who are nearing the end of life. Palliative medicine utilizes a multidisciplinary approach to patient care, relying on input from physicians, pharmacists, nurses, chaplains, social workers, psychologists, and other allied health professionals in formulating a plan of care to relieve suffering in all areas of a patient’s life. This multidisciplinary approach allows the palliative care team to address physical, emotional, spiritual, and social concerns that arise with advanced illness. (from Wikipedia)

The challenge of course is that most people don’t want to talk about dying, and physicians are taught to try everything to cure someone. After talking with a few people working in this area, the general scenario is where clinicians and other social workers are helping to enable to a patient to talk to their family and care team about their wishes. It’s not to make the decisions, but to give patients the tools to have an informed discussion.

Here were some of the interesting things from this chapter in the book:

• Less that ¼ of physicians were familiar with the term in a survey
• The American Society of Clinical Oncology has established a goal of integrating palliative care into its model of comprehensive cancer care by 2020.
• A 2009 study of cancer patients found that palliative care improved patient satisfaction and eased pain, fatigue, nausea, insomnia, anxiety, and depression. And, increased appetite.
• According to the Worldwide Palliative Care Alliance, more than 100M people worldwide would benefit annually from either palliative care or hospice…yet only 8% have access to it.
• The average physician’s estimate of how long a patient will live was 530% too high.
• Fewer than 40% of oncologists speak candidly with patients about end-of-life treatments.
• Physicians equate suggesting hospice as “giving up”.
• A 2008 published study showed that patient satisfaction was higher, more advance directives were completed, fewer ICU admissions were necessary, and medical costs were lower for patients in palliative care.
• Patients with lung cancer that received palliative care lived 3 months longer than those with standard care (which compares to only getting 2-3 months of life from chemotherapy). [BTW – 1 in 5 cancer patients are still receiving chemotherapy in the last two weeks of life.]
• A hospitalized palliative-care patient costs $279-$374 less per day.
• In a Medicare study, patients who received palliative care cost $6,900 less during a hospital stay.

This seems like great data. Imagine that you can improve a patient’s experience in the last months of life and lower costs. To me, that’s a lot of what our healthcare system needs these days.

Powered by a combination of clinical and financial algorithms and evidence-based decision-making rules, inVentiv Medical Management’s Accountable Care Solutions ensure that physician-ordered procedures are the best option from a treatment effectiveness and patient risk perspective. The new suite of solutions includes Comprehensive Oncology Care Management(TM), Comprehensive Cardiovascular Care Management(TM) and Comprehensive Kidney Care Management(TM). These Accountable Care Solutions offer customers – such as third-party administrators, employer groups and reinsurance carriers – best-in-class resources to effectively and efficiently enhance healthcare quality, while reducing overall costs of medical claims and improving patient outcomes.

I focused on three key points:

1. Copay cards are a direct threat to the PBM model. They can run against the idea of copay differentials and formulary tiers. Since they’re not allowed at mail order, they create a disconnect there. And, eventually, I believe they will be in conflict with rebates (i.e., why pay for both).
2. The cost numbers to the payer are huge ($32B according to Visante) although this is less than $1 per Rx over that 10 year time period. But, it’s concentrated on 3% of all scripts which makes it a big deal.
3. There should be a win-win IF they are concentrated on specialty medications with a link to improved adherence and health outcomes.

There doesn’t seem to be clear data (although another article says it is available) but the general data shows that availability and use of copay cards is growing rapidly.

Investing in copay cards seems to be based on four myths:

1. Cost is a large issue in non-adherence. It’s an issue but not the dominant issue.
2. Costs will influence physician choice. The reality is that they don’t know the costs and see this as a pharmacist issue.
3. Copay cards are a cost effective way to improve adherence. They get about a 10% improvement in MPR which sometimes produces a positive ROI. There are much lower cost ways to get a similar improvement.
4. Copay cards can delay conversion to generics. This is still in the air with the Pfizer Lipitor program, but if it works, it will be a lightning rod for PBMs and payers to focus on.

This topic’s not going away. For now, the easy PBM response is to close down the formulary, move more scripts to mail, and implement prior authorization programs. I would expect this will happen more often unless there is more transparency here around what’s happening and the benefits.

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

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

This is what I find interesting.

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

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

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

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

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

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

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

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

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

As anyone who follows the pharmacy industry knows (and now millions of consumers), Walgreens and Express Scripts have had an ongoing contract dispute since mid-2011.  Most of us expected this to get resolved by the end of the year to minimize patient disruption, but it didn’t.

Ultimately, payers/employers care about cost.  If a PBM creates savings for them thru a limited network, can you summarize what they lose by not including Walgreens and how that transfers to hard dollar savings?  Are Walgreens consumers more engaged with their health?  Are they more satisfied with their healthcare?

Our research demonstrates the importance of Walgreens presence in a payers’ network in addition to the cost factor. A Walgreens proprietary survey conducted in December of 823 executives and managers who are key decision makers for pharmacy benefit decisions or provide input found that 82 percent of employers said that they would not exclude Walgreens for less than 5 percent savings on their total pharmacy spend. Sixty percent of employers would not exclude Walgreens for less than 10 percent savings, and 21 percent would not exclude Walgreens from their network regardless of the amount of savings. These findings on employer attitudes are consistent with recent research published by several leading equity research analysts. Clearly, employers value having Walgreens as a pharmacy option for their employees, but Express Scripts wants to take that choice away.

Now, add to that the small variation in costs among pharmacies. We believe that the vast majority of pharmacies, including Walgreens, receive reimbursements per prescription that fall within a narrow band, typically within less than 5 percent of one another. Therefore, excluding any pharmacy with our 20 percent market share from a 5 percent pricing band can only result in savings on the order of 1 percent or less. And that doesn’t take into consideration the additional savings Walgreens can provide through our leading generic dispensing rate or the 7 percent savings that payers can see by adding a 90-day refill option at our retail pharmacies.

It’s also important to point out that during negotiations, Walgreens offered to hold rates for a new contract flat and did not seek an increase in rates. The response from Express Scripts was to insist on being able to unilaterally define contract terms, such as what does and does not constitute a brand and generic drug. Express Scripts also proposed to slash Walgreens reimbursement rates to levels below the industry average cost to provide each prescription.

Walgreens is focused on helping payers with their total health care spend, not just the 10-12 percent of their health care costs that are spent on prescription drugs. While a patient with asthma can lower drug spend by not getting refills on their medication, the resulting emergency room visit that could result will be much more expensive overall for the payer. So we are focused on expanding the pharmacist’s role among health care providers to lower overall medical costs rather than focusing on drug spend alone.

Adherence is a big issue these days especially in Medicare where it is one of the key Star measures for PDP. One of the key value points in the paper is about adherence. How has Walgreens improved patient adherence and are you collaborating with payers to do this?

While CVS has opted to own a PBM, Walgreens has sold their PBM.  Has this experience with Express Scripts changed the way you interact and contract with PBMs?  Do you think this will have broader implications on the industry?

I think it has helped us tremendously in terms of building closer relationships with other PBMs and payers. We’re moving forward with partners such as Catalyst Rx, Prime Therapeutics and SXC Health Solutions, and health plans such as Coventry and Humana. All of us see this as an opportunity to create a differentiated offering during the upcoming selling season.