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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. 

 

Is There A Future For Community Oncology?

Cancer costs are expected to reach $174B in the US by 2020.  Right now, it’s about 10-11% of total healthcare spend which makes it a big area of focus within the healthcare industry.

The question is how to manage this spend:

  • Is it about site-of-care and where the care is provided?  (community oncology; Centers of Excellence; outpatient clinics; inpatient)
  • Is it about specialty drugs and how they are managed and charged?  (Buy-and-bill; white-bagging; brown-bagging; on-site pharmacy; 340B)
  • Is it about evidence-based care and following NCCN guidelines or clinical pathways?
  • Is it about palliative care and managing spend in the last 3-6 months of life?
  • Is it about personalized medicine?

One of the challenges is the survival of the community oncology practice (see ASCO report) that is an issue that physicians have struggled with in other specialties.  Over the past few years, we’ve seen continued consolidation of practices with many of them being acquired by hospitals and hospital systems.

In some cases, oncologists have seen a reduction in their income tied to a reduction in buy-and-bill and are looking to be employed in order to continue to maintain their incomes.  They are one of the few medical professions that have seen a reduction in income recently.  At the same time, this trend is also driven by hospitals taking advantage of the 340B pricing which allows them to generate approximately $1M in profit for every oncologist they employ.  And, the complexity of oncology treatment also is prompting the need for a more comprehensive care model which requires a broad set of services which is sometimes difficult for a small practice to provide.

Of course, this shift in care from community oncology to hospitals is driving up costs without a demonstrated improvement in outcomes.  This is driving a lot of payer focus and driving discussions of payment reform whether that’s in the form of ACOs, PCMHs, or bundled payments.  United Healthcare recently released some data from one of their pilots.

This seems like another classic example of misalignment across the industry.  Hospitals clearly see an opportunity to buy up more oncology practices while payers and others are going to push for reform around 340B and payment differences.  Oncologists are struggling to continue providing care but replace the income they were making of buy-and-bill of specialty medications.

I’ve talked to a lot of people about this struggle.  It doesn’t seem clear whether community oncologists are destined for extinction or will payers will find a way to enable them to survive.  The other question is how things like teleoncology, tumor boards, big data, and the focus on prevention and survivorship will ultimately change the care delivery approach to oncology which may impact the role of the community oncologist in the future.

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?

Curing Camden: Book Review

Curing Camden is a quick read on how different groups collaborated to change the healthcare cost curve in Camden, NJ.  Here’s the official language from the Amazon site, but after reading it, I thought I’d highlight a few things that caught my attention.

As the federal health reform debate played out in the national media spotlight, author Christina Hernandez Sherwood was reporting on the American medical system from the street level. From 2010 to 2012, she wrote a half-dozen stories for thePhiladelphia Inquirer that focused on an innovative healthcare nonprofit: the Camden Coalition of Healthcare Providers. These stories centered on the nonprofit’s role in combating falls, violence, diabetes, and other issues in Camden, New Jersey, a city known nationally as one of the country’s poorest and most violent, but that is now making a name for itself as an innovation leader in the public health sector.

In Curing Camden, all of Sherwood’s articles have been collected into a single book, including the unpublished final installment profiling the nonprofit’s founder. This book takes readers from the living rooms of Camden residents to the halls of the New Jersey State House in Trenton and beyond. Sherwood highlights how Camden could be the first US city to bend the cost curve by lowering healthcare costs while improving care. The ideas revealed in this book could be translated into practice across the country, and Camden could become a national model of 21st century medicine and public health.

The book goes through several core chapters.  The first one is on creating a citywide health record by working with the 3 primary health systems in the city.  The core part of the success here is that they used the framework of opt-out not opt-in which would drive more participation at the consumer level.  This behavioral economics framework called “active choice” has been used by several companies that I’ve worked with in the healthcare space to shift behavior patterns.  This obviously has the opportunity to reduce duplicate testing and improve care coordination.

The second chapter is about create an ACO for Camden with a 3-year Medicare demonstration project.  It’s an interesting discussion about how Dr. Jeffrey Brenner began using data to learn things about the Camden population.  For example he found out that most of the population will vista a hospital at least once in a 2-year period (which is 2x the national rate).  He also found that most of the top reasons for going to the emergency room were all primary care issues.  He makes a great point in the book that while people think that complicated patients simply like going to emergency rooms the reality is that they don’t have better choices.

The third chapter was about protecting against the risk of falling.  From 2002-2009, Camden residents made more than 17,000 trips to the hospital (the number one cause of hospital visits in Camden).  This isn’t a localized issue either.  Falls affect 1 in 3 seniors every year and drive $19B in costs according to the CDC.  In the book, they make an interesting point about the “vicious cycle” of falling which leads to less activity which leads to weaker patients increasing the likelihood of another fall.

The fourth and fifth chapters are about diabetes.  In Camden, almost 13% of adults have diabetes.  These patients can be high utilizers which is something they talk about along with their focus on the 13% of patients that drive more than 80% of the costs in Camden with one patient having over $5M in charges over 5 years.  Of course, people in dangerous communities are at higher risk of obesity due to lack of access to food and safe places to exercise which contributes to the diabetes issues.

The sixth chapter is about violence and helping victims.  Camden’s 77,000 residents experience more than 13 aggravated assaults per 1,000 residents (which is 5x the national rate).  This lead to 9,361 trips to the hospital from 2002-2009.

It’s an interesting read.  They had a lot of grant money, but at the end of the day, it was about several things:

  • Coordination and collaboration across the different systems
  • Localized care – being in the apartment building with a clinic or going into people’s homes
  • Using data to target the areas where they could make a difference
  • Caring to make a change

$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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Should Providers Have Private Conversations With Your 12-Year Old?

There was an interesting story which came out of Michigan this past week from Christy Duffy about how her physician’s office was requiring all minors between the age of 12-17 to have a 5 minute private conversation with them (according to the law).  Of course, it appears that they made a mistake per her later post, but I think it serves to make several interesting points.

1. Don’t always assume that someone’s interpretation of the law is right if it doesn’t make sense.  Sometimes, you have to apply common sense and push back or ask questions.

2. There is a gray area between protecting the rights of our kids and protecting our rights.  While the intent of allowing our kids to have honest and open conversations is appropriate, there needs to be some involvement of the parents.

It’s an interesting topic for discussion.  Should our teenagers have access to providers on their own?  Yes.  If a teenager has a health issue, I think we’d all prefer that they talk to a professional rather than Dr. Google or their friends to find the answer.

Should a provider be able to force a private conversation with a minor?  Yes…if they have a legitimate concern about abuse, but I don’t see any other reason.

Should a teenager who’s covered by my insurance and lives in my house be able to block me from having access to their medical records?  Yes.  This is the law, but should providers be having private conversations to offer them this option?  I don’t think so.  I would like them to have those discussions with me and my child to say that here are their options.

Should a teenager have a private conversation with their provider about STDs, HIV, and birth control?  Yes, BUT I’d like to have the conversation at the right age with me in the room initially and then offer the private option.  I don’t think forcing that conversation on a 12-year old would make sense in a private setting.

Ultimately, this comes down to the issue of access to the medical records online.  What I heard was that this would also require the provider to get a cell phone and e-mail address for my kids.  Obviously, if they’re doing something confidentially with the doctor, that’s one thing, but as a matter of record, I disagree.  (I don’t even give out my kid’s Social Security numbers.)  I don’t want my kids to start getting e-mails, phone calls, and letters sent directly to them as early as 12-years old.  And, yes…I do try to shelter them a little.  We talk about all the issues, but in a way that my wife and I want them to learn, not according to some formula driven approach that’s mandated.  But, ultimately, I don’t think a 12-year old is mature enough to make all their own health decisions or to feel like they should.

Obviously, some part of this falls on the parent regardless to create an environment of open dialogue with their kids.  The kids have to feel comfortable talking with their parents which is important for health and many other challenges that our kids have to deal with.  And, unfortunately there’s always bad people in any profession so while sexual abuse by a physician or nurse is rare it’s not unheard of.  Ideally, I think you should have the choice of when to encourage a private conversation and never have it mandated (unless of course the provider suspects abuse).  Unfortunately, with a report of abuse being made every 10 seconds, we have a huge problem in our country.

Great #BigData JAMA Image Missing Some Data Sources

JAMA image data

When I saw this article and image in JAMA, I was really excited.  It’s a good collection of structured and unstructured data sources.  It reminded me of Dr. Harry Greenspun’s tweet from earlier today which points out why this new thinking is important.

 

But, it also made me think about this image and what was missing.  The chart shows all the obvious data sources:

  • Pharmacy
  • Medical
  • Lab
  • Demographic
  • EMR / PHR

It even points out some of the newer sources of data:

  • Facebook
  • Twitter
  • Online communities
  • Genetics

But, I think they missed several that I think are important and relevant:

  1. Structured assessments like the PHQ-9 for depression screening or the Patient Activation Measure.
  2. Communications data like:
    • How often do they call the call center?
    • What types of questions do they have?
    • Do they respond to calls, e-mails, SMS, letters, etc?
    • Have they identified any barriers to adherence or other actions (e.g., vaccines)?  Is that stored at the pharmacy, call center, MD notes?
  3. Browser / Internet data:
    • This could be mobile data from my phone.
    • What searches I’ve done to find health information.  What have I read?  Was it a reliable source?
  4. Device data (e.g., FitBit):
    • What’s my sleep pattern?
    • What am I eating?
    • How many steps do I walk a day?
  5. Income information or even credit score type data

These things seem more relevant to me than fitness club memberships (which doesn’t actually mean you go to the fitness club) or ancestry.com data which isn’t very personalized (to the best of my knowledge).

In some cases, just simply understanding how consumers are using the healthcare system might be revealing and provide a perspective on their health literacy.

  • Do they call the Nurseline?
  • Do they go to the ER?
  • Do they have a PCP?
  • Do they use the EAP?

We’d like to think this was all coordinated (and sometimes scared into believing that it is), but the reality is that these data silos exist with limited ability to track a patient longitudinally and be sure that the patient is the same across data sources without a common, unique identifier.

The Boston Physician Dilemna

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

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

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

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

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

Medicare acceptance rates by city

Listing of Medication Adherence Solutions

It’s been a few years since I’ve worked on medication adherence solutions.  It seems to have become a big focus again in the industry both with the Medicare Star Ratings program and with all the emphasis on waste.

As I started thinking about adherence, I thought it would be good to create a list of solutions and vendors.  I couldn’t find one anywhere on the web.  So, here’s my initial list of almost 100 companies.

I’ll make this a dynamic list so please comment or send me suggestions to add.

Here’s some old posts on adherence that I think are still relevant here:

I’ve divided the list of solutions and vendors into the following:

Devices

  • Adherence Solutions LLC – develop programs to create alliances between different players, sell Dose-Alert which is a smart pill bottle cap, and provide a mobile tool
  • AdhereTech – smart pill bottles
  • Automated Security Alert – medication dispensers to complement their medical alert system
  • Biodose – electronic tray for monitoring time and day of use
  • CleverCap – smart cap for pill bottle
  • Didit – manual tracking device that attaches to a pill bottle
  • DoseCue – smart pill bottle
  • eCap – electronic compliance monitor
  • ePill – medication reminder devices
  • eTect – biocompatible tag on the pill with connectivity and a mobile solution focused on clinical trial adherence
  • iRemember - smart pill bottle cap with voice reminder and smart phone synching
  • MedCenter – monthly organizer and reminder system
  • Med-E-Lert – automated pill dispenser
  • MedMinder – automated pill dispenser
  • MedVantx – medication sampling at the physician’s office
  • Proteus – smart pill technology
  • Quand Medical – uses Near Field Communications and mobile to do medication management and reminders
  • SMRxT – smart pill bottle
  • TalkingRx – audio device attached to pill bottle
  • uBox – smart pillbox
  • Vitality GlowCap – smart pill bottle with communication programs

Mobile / Digital

  • 2Comply – patient portal with web coaching
  • ActualMeds – online medication management for consumers, caregivers, and providers
  • AI Cure Technologies – digital health solution
  • AssistMed – web and mobile based adherence solutions
  • Ayogo – social games and apps to improve engagement and adherence
  • CareSpeak - mobile solution
  • Care4Today – two-way messaging platform, app, and website
  • CellepathicRx – mobile solution
  • CloudMetRx – cloud based solution to help caregivers with medication management
  • Dosecast – mobile medication management and pill reminder
  • GenieMD – mobile medication management and reminders as part of broader solution
  • iPharmacy – mobile pill identifier, medication guide, and reminder app
  • Mango Health – mobile medication management with gamification and incentives
  • Medacheck – mobile reminder system that incorporates caregivers
  • MedCoach – mobile medication management and pill reminder
  • MedHelper – medication compliance and tracking app
  • mHealthCoach – reminder based solution creating a digital support system
  • Mscripts – mobile solution
  • MyMeds – mobile and web medication management and pill reminder solution
  • MyMedSchedule – mobile Rx management tool with reminder service
  • Nightingale – mobile solutions for reminders, engaging your physician, and notifying your caregivers
  • PillBoxie – mobile medication management and reminder app
  • PillManager – mobile medication management and pill reminder
  • PillMonitor – mobile medication reminders and logs
  • PillPhone – mobile phone solution with biometric authentication
  • Prescribe Wellness – automated, digital interventions
  • RightScript – platform to manage prescriptions through mobile reminders that connect patients, caretakers, practitioners, and health plans
  • RxCase Minder – mobile medication management
  • RxNetwork – mobile medication management and reminders with rewards
  • Quintiles – building digitally, connected communities
  • Virtusa – multi-dimensional interventions across the patient’s journey

Platform

  • Adheris – adherence suite and advanced analytics (just acquired Catalina Health) [note: they are owned by inVentiv Health who I work for]
  • Avanter – an adherence program for pharmacies in Argentina
  • Capzule – pill reminders as part of PHR
  • Dr. First – embedded tools into EHR
  • HealthPrize – platform with gamification, incentives, education, and communications
  • LDM Group – suite of compliance products
  • McKesson – sampling, coaching, coupons, and messaging
  • MediSafe – mobile medication management app and adherence platform
  • MedPal Health Solutions – platform for medication adherence solutions
  • MedSimple – medication management, pill reminders, coupons, and PAP programs
  • mHealthCoach – care collaboration platform using machine learning to personalize communications
  • Tavie – virtual nurse for improving adherence focused on several conditions

Communications

  • Ateb – multi-channel communication programs for pharmacies
  • Atlantis Healthcare – custom adherence solutions
  • Eliza – multi-channel communication programs
  • Intelecare – multi-channel adherence communications
  • MemoText – messaging platform
  • Patient Empowerment Program – medication adherence program for pharmacies
  • Pleio – adherence solutions for the first 100-days (when most people stop taking medications)
  • Silverlink – multi-channel communication programs [note: this is the company that I used to work for and still use]
  • Varolii (now Nuance) – multi-channel communication programs
  • Voxiva – web and text messaging solution
  • West – multi-channel communication programs

Big Data

Tools / Enablers

  • 5th Finger – assessment and personalization tools
  • GNS Healthcare – using data and predictive models to identify targets and fuel intervention programs
  • HumanCare Systems – creating patient and caregiver support solutions
  • Insignia (PAM) – measure of patient activation for segmentation and scoring
  • MedMonk – help pharmacists obtain funding for patients who can’t afford their out-of-pocket pharmaceutical expenses
  • MedSked – low tech, high impact labeling solution
  • Merck Adherence Estimator – screening tool available as a widget or online at Merck Engage
  • NaviNet – communications network to enable adherence
  • NCPA – toolkit and ROI calculator for pharmacies
  • ScriptYourFuture – tools and text reminders
  • Walgreens API – an application programming interface for developers to use to connect their adherence solutions to Walgreens

Medicare focused

  • Dovetail – pharmacist led programs including MTM, in-home visits, and telephonic coaching (focused on Star Ratings)
  • Mirixa – incorporated into the MTM program
  • Outcomes – data and tools as part of their MTM solution
  • Pharm MD – Medicare STARS program

Condition specific

  • GeckoCap – adherence offering for kids with asthma
  • MyRefillRx – mobile adherence app focused on high blood pressure

Packaging

Pharma

  • 90Ten Healthcare – providing adherence programs in 23 countries
  • TrialCard – voucher and co-pay programs for consumers to stop Rx abandonment
  • Triplefin – customized programs for pharma brand managers
  • Adherence Engagement Platform – a Pfizer program of adherence materials and tools (I couldn’t find it online only in hard copy)
  • RS Associate – a company working with manufacturers in India
  • Rx.com – MTM, pre-edit messaging at the POS, and print-on-demand messaging at the pharmacy

International (recommendations send to me without English sites)

What other companies am I missing?  Send them to me directly or add them in the comments section here.  Thanks.

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.

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)

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.

I Thought I Got To Keep My Doctor In Health Reform

We all remember when President Obama pointed out that you wouldn’t have to change your doctor with health reform.  That’s probably true in the most expensive plans, but you can’t always eat your cake and keep it too.

We know healthcare prices vary from semi-rational to outrageous.  It would be hard to get any concessions if every physician had to be in the network.  So, like we’ve seen in pharmacy with some initial screaming but general acceptance, plans are going to reduce the size of their networks in return for some price concessions.

Should this be a surprise?  No…unless you actually believe politicians.

Will this lead to a different set of issues around monitoring out of network use?  Yes.  This is something plans historically don’t do very well.

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.

More CDHPs Are Coming – Is That A Good Thing?

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

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

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

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

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

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

Why Do People Think Adherence Is So Easy?

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

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

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

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

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

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

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

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

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

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

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

For example:

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

We have a lot of problems.

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.

Key Topics At #WHCC13 In DC

I’m at the World Healthcare Congress (WHCC13) in Washington DC this week.  This has always been one of the top 5 events for me to try to come to every year (admitting that there are a few like TED that I haven’t attended due to budget yet).

It’s interesting  how trends start to flow within a conference and how the trends change year to year.  This year, the key themes that I continue to hear are (in no order):

  • Engagement is critical.  Between MD and Patient.  Between social network / influencers and member.  Between employee and employer.
  • We have to get past the barriers to health enablement (i.e., legacy IT systems) and make change happen.
  • Game theory can help improve engagement.
  • Mobile tools are important.
  • Data integration has to happen and employers are doing it themselves.
  • Biometrics are critical path.
  • We can’t solve healthcare if we don’t solve health.  The community.  Our food choices.  Work / life balance.  (I would add sleep and stress.)
  • Rapid innovation.
  • Reform isn’t going to be easy on the employer or the employee.

But, since Twitter is my new note taker…here’s a few sets of tweets for you.

#whcc13 tweets whcc13 tweets3 whcc13 tweets2 whcc13 tweets1

How The CVS Program Will Change The Employer – Employee Contract

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

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

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

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

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

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

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

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

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

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

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

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

59% Of MDs Want To Know About Employer Care Mgmt Efforts

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

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

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

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

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

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

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

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

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

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

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

KeepingUpWithTwitter_2

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

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

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

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

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

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

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

 

Using Gilligan To Drive Colonoscopies

While I do applaud the creative concept here, I wasn’t overly impressed with the creative itself.  At the end of the day, the question for me is results.  Did it pay for itself?  Did it get more people to get colonoscopies (in the target audience) than otherwise would have?  I’m unsure of that.

Here’s what I did find in a HealthLeaders article…At the end of the day, I’d want to compare that to a program we did at my last company for UHG in this area.

The campaign also netted 44 colonoscopy appointments. Of those 44 appointments, 13 were current Good Samaritan patients and 31 were new to the hospital. Forty-three of the 44 scheduled an appointment through the call center and one booked online. Of those who called, 27 cited the radio spot as how they found out about the service. More than half of the patients were in the target group of 50–59 year olds, with 24 female and 20 male.

When Is It Good To Pay 300% Profit For A Medication?

Another interesting discussion at this Oncology event was about physician reimbursement for drugs.  In Oncology, one historical source of revenue (~50%) for physicians has been the medications they dispense and administer in their offices.  And, depending on who you believe, this has some degree of influence on what drugs they dispense.

The problem that was discussed is that today’s reimbursement model is ASP (Average Selling Price) plus 6% mark-up.  This assumes that everyone buys at some price near that average which by definition means that not everyone does.  One of the presenters suggested that physicians lose money on about 20-25% of the drugs they dispense and that it would need to be ASP + 12% for them to be positive on every drug.  (I don’t know the math here and am simply sharing the dialogue as I found it very intriguing.)

The examples that they kept talking about in several presentations were that for a generic drug that costs $40 then their margin is theoretically $2.40 (6%) versus for a brand drug that’s $4,000 where their margin is $240 (or 6%).  The suggestion was that if generics were reimbursed at 200-400% of ASP then it would take this economic factor out of the oncologists influence (when conscious or subconscious). 

It’s an interesting debate.  (Here’s some comments from another conference on this topic.)

On the flipside, some of this may go away with oral oncolytics being more common in the future (and therefore being more likely to be controlled by the PBM) although companies will look to enable in-office dispensing of these drugs also to help the physician from losing this income. 

The other strategy being pushed has been called “brown bagging” where the patient is directed to obtain their medications from a specific specialty pharmacy and then bring those to the oncology practice for them to use.  This eliminates the “buy-and-bill” approach but is not something that the physicians like (from what I know). 

At the end of the day, I don’t really care.  I think there are several key principles that if met would make me neutral to any solution:

  1. Are decisions made in the patient’s best interest or do financial implications impact clinical decisions?
  2. Is the safety of the patient impacted in any way?
  3. Is the patient experience impacted negatively in any way?
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