I was reading one of their brochures looking at data from 1/2/10 – 12/30/10. Here’s a few observations:

• The index score across all states varies by a narrow range of 9.3 points.
• The top 5 states (in 2010) were:
  • Hawaii
  • Wyoming
  • North Dakota
  • Alaska
  • Colorado
• The top 5 large cities were:
  • Washington-Arlington-Alexandria, DC-VA-MD-WV
  • Austin-Round Rock, TX
  • San Jose-Sunnyvale-Santa Clara, CA
  • Seattle-Tacoma-Bellevue, WA
  • San Francisco-Oakland-Freemont, CA

The overall composite score is based on six sub-indices:

• Life Evaluation
  • Partially based on the Cantril Self-Anchoring Striving Scale
• Emotional Health
  • A composite of how the consumer felt yesterday along nine dimensions
• Physical Health
  • Body Mass Index
  • Disease burden
  • Sick days
  • Physical pain
  • Daily energy
  • History of disease
  • Daily health experiences
• Healthy Behavior
  • Life style habits
• Work Environment
  • Feelings and perceptions about work
• Basic Access
  • 13 items measuring:
    • Access to food
    • Access to shelter
    • Access to healthcare
    • Having a safe and satisfying place to live

This gives an interesting macro view of healthcare at a localized level. The thing I’d like to learn is how this is shaping communities and health care entities to act different. Is this changing engagement strategies? Is this changing regional investments? Can the data be tied back to individuals and used to help improve outcomes?

Mason’s article is a frontal attack on the Visante paper on the topic that talks about copay cards increasing costs by $32B over the next 10 years (which by the way is less than $1 per Rx over that time period). But, I’m not sure it really clears up the debate for me. Let me discuss a few points.

• He talks about the APLD (Anonymous Patient Longitudinal Data) from Wolters Kluwer which can identify secondary payers. And, it can tell you if they were new to therapy, changed therapy, or simply were continuing therapy when they used the cards. This sounds great since everyone I’ve ever talked to said they can’t get to this data.
• He proposes that the Lipitor $4 program to extend the brand after a chemically equivalent generic is available is more an anomaly than a standard program. Perhaps. While I agree that the focus of many cards is in specialty (51% according to his estimate), if the Lipitor program works (still TBD), why wouldn’t others jump on board (which would likely increase costs to payers).
• He proposes that copay cards be used for Medicare Part D members (which most people tells me already happens). He also says that they’re the least adherent which is probably true based on total number of prescriptions which has been shown to correlate with lower adherence (not really their insurance).
• He states that most copay cards are used for Tier 2 (formulary) medications. It makes me wonder why the manufacturers pay rebates and use copay cards…which he alludes to in his article.
• He states that formulary access is attributed to marketshare which I think is true in a world of “me-too” products, but if products have new clinical value and better outcomes, they can get placed on a formulary without marketshare.
• He states that copay cards won’t drive up costs in Part D because over ½ of the utilization of brand drugs is by low-income patients where they won’t need a copay card for their $6.60 average copay. I personally disagree. I think that’s a red herring as this group is very price sensitive.
• Without giving away too much of my presentation for Wednesday (which I’ll post the slides and summary that day), he makes a key point but without the key data. “Combined medical and pharmacy costs in Medicare for oncology, rheumatology, and MS might actually be lower as a result of compliant patients.” The key word here is might. While I (like many) believe this to be true, I don’t think there are studies to support this. I agree that IF copay cards could demonstrate improved adherence AND that adherence could demonstrate lower medical costs and better outcomes THEN we would be having a different discussion.

It’s an interesting area. I’ll share a lot more thoughts on Wednesday, but I think Mason’s article is a good one for discussion on the topic.

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

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

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

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

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

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

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

This is what I find interesting.

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

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

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

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

A quick summary of the big winners are:

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

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

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

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

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

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

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

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

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

Source: Text Marketer Bulk SMS Services

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

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

And, we wonder why they’re pessimistic…