Archive | December, 2007

Wellpoint Investor Presentation

I was looking at a Wellpoint investor presentation and picked a few slides to pull out. It is definitely an interesting read to see all the things they are doing and how they approach the market. The first one talks about the prevalence of chronic diseases. The second about the obesity trend, and the third about some of their activities around consumerism.


Are You Growing Your Vegetables

I read this interesting analogy this morning about marketing and comparing it to gardening.  I think the author’s points are very relevant when you think about patient retention within healthcare.  A few of the points that come through in the blog entry are:

  1.  It takes effort.  (i.e., vegetables don’t just grow by themselves)
  2. You have to be consistent.  (i.e., you can’t overwater one day and not water for weeks)
  3. Not all vegetables are the same.  (e.g., some like more water or light than others)
  4. You do get better with practice. 
  5. There is lots of competition (e.g., bugs, animals), but it is healthy.  You can’t simply kill the competition with pesticide (i.e., price war).

Two points that the author didn’t make which I think are relevant are:

  1. You can’t grow all vegetables at once.  (i.e., you have to focus on what will respond given your soil, environment, etc.)
  2. You have to plan long-term.  (e.g., some professional farmers rotate fields to optimize yield over multiple years)

When Leaving a Message Isn’t Optimal

I heard two quick examples yesterday that seemed relevant to share.  Sometimes it is good to learn through others mistakes…

  1. An executive at a company decided that they didn’t want to fill a particular drug since they were losing money per prescription.  After the decision was made, he called the CEO of the manufacturer and left a voicemail saying “call me back in 24 hours with a lower price or we will stop filling your drug”.
    • What about their other drugs?
    • What about all the patients that you have in queue?
    • Do you think the CEO might be busy?
  2. In another case, a person in procurement called a vendor and said that every time the sales people called or made a suggestion that they were just going to send it on to their competitor and grow that relationship.  [Steve – This is you guys.]
    • Is that really what your business people want?  They don’t want new ideas?
    • Any worry that you might be breaking confidentiality by sharing this information?
    • Did you ever realize that this is a small world?  Don’t burn a bridge if you can avoid it.

Sometimes, you just should try talking to the person live and thinking through the conversation.

The Right Prescription

I stumbled across a site today called The Right Prescription which is supported by a coalition that includes all the large PBMs along with some large employers and others.  It is primarily focused on generic biopharmaceuticals.  Here is the text on the home page:

Skyrocketing prescription drug costs are crippling America’s health care system and pricing many consumers out of the medicines they need to live. One clear answer to this health care crisis is to ensure consumer access to safe, effective, affordable generic drugs.

Yet today, an entire class of drugs called biopharmaceuticals lacks a clear pathway for the development and approval of generic versions, brand name drug manufacturers are using legal loopholes to extend their patents and the Office of Generic Drugs (OGD) lacks sufficient funding to review and approve of generic drug applications. Congress must provide a definitive FDA approval process for biogenerics, pass legislation such as the Lower PRICED Drugs Act (S. 2300) to close the loopholes that keep generic drugs off the market and increase funding for OGD to reduce its backlog and increase competition in the pharmaceutical market.

It’s time to tell our lawmakers that generic drugs save lives.

A Few Slides on Specialty

I only have one more post queued up on content from the Outcomes conference. Here is some data on specialty drugs that shows the growth, their percentage of the market, the prevalence, and the cost per patient.

More From ESI Outcomes

Continuing to pull some facts from the prior Outcomes conferences

When we first began using what we called AEC (Automated Educational Calls), we did a couple of quick pilots with control groups to see how they worked and if they increased lift in our existing programs. For one of my programs (retail-to-mail), we saw a boost on top of our direct mail program not only from those people that received a generic message but especially from those people who listened to the call. Here was a quick snapshot since over the course of multiple attempts we had a 5% success rate with direct mail and in certain programs had gotten our success rate as high as 16% in direct mail while still seeing additional “lift” in the success rate by coupling calls and letters together.

Another question answered was whether DTC (direct-to-consumer) advertising worked. Here you see that the most heavily advertised space had significant trend. In other studies, we showed that although DTC may not grow the specific drug in a 1:1 correlation it did grow the total pie for that therapy class.

As I mentioned yesterday in the entry about big pharma, the discovery of new products has dropped dramatically as shown here.

If you are focused on what’s happening from a generic drug perspective, this chart is a good picture of what’s expected over the next few years.

This is a little old (2004), but based on order of magnitude, it is relevant. The question is what is a theoretical maximum generic fill rate for some of the high cost therapy classes and what is this worth to a plan sponsor in terms of savings.

Another set of data that I always found interesting was the variation in use of generics by state.

The ESI Outcomes Conference

It was always fun to prepare for our annual Outcomes conference at Express Scripts. What research did we have? Who would it surprise? How would it impact us or clients? Anyways, all of these presentations and even some audio are on the website (2004, 2005, 2006, 2007). I pulled a few slides / graphs with some key points below.

Is there compliance elasticity with prescription drugs? Of course. The research team replicated a published study and found results that were much less dramatic and echoed prior research supporting the following. (elasticity in this case meant that for each 100% increase in the cost of the drug what was the decrease in utilization of the drug)

The differential between your brand and generic copays makes a difference in your generic fill rate (GFR). The data supports the null hypothesis that would say that the greater the difference (i.e., the more the patient saves) the higher the use of generic drugs.

Why are people non-compliant (actually from the WSJ)?

A question I often hear is what percentage of people call into the call center. Obviously this varies by population, but as shown below, it also greatly matters by how aggressive the plan design is and how many changes they are making.

The next question should be whether disruption (measured by the proxy of inbound call volume) is worth it. So, the slides show the trend versus the call volume.

Sticking with the theme, the question is how long does the disruption last. Not too long.

It is never easy to get information out to patients in a timely and effective manner, but the question that also had to be asked is whether they wanted the information. From a 2002 Express Scripts survey:

  • 74% “feel more valued” when they understand the rationale behind their benefit design.
  • 85% “want information” about how to save money on their prescription drugs.
  • 80% feel “more in charge” when they understand choices

IBM HC 2015 – Win-Win or Lose-Lose

I skimmed another IBM publication today which I thought was a great piece – IBM Healthcare 2015: Win-win or lose-lose?. (A little long at ~70 pages, but good with concise charts.) It talks about what healthcare has to do to survive and create a win-win model. It looks at it from multiple perspectives – payor, provider, consumer, and supplier. They also do a good job of describing several unique models around the world and talking about several trends here in the US.

Here are a few quotes, facts, and charts from the publication which should tempt you to go read it…(note: I am not going to show all their sources, but you can get them from their publication.)

“The United States spends 22 percent more than second-ranked Luxembourg, 49 percent more than third-ranked Switzerland on healthcare per capita, and 2.4 times the average of the other OECD countries. Yet, the World Health Organization ranks it 37th in overall health system performance.

In Ontario, Canada’s most populous province, healthcare will account for 50 percent of governmental spending by 2011, two-thirds by 2017, and 100 percent by 2026.

In China, 39 percent of the rural population and 36 percent of urban population cannot afford professional medical treatment despite the success of the country’s economic and social reforms over the past 25 years.

Approximately 80 percent of coronary heart disease, up to 90 percent of type 2 diabetes, and more than half of cancers could be prevented through lifestyle changes, such as proper diet and exercise.

Preventable medical errors kill the equivalent of more than a jumbo jet full of people every day in the US and about 25 people per day in Australia.”

Table on IBM’s recommendations by stakeholder for what has to happen to transform to a value-based healthcare system (win-win).


IBM chart pointing out the obesity issue’s growth


They talk a lot about the current system’s focus on episodic care while the problem is chronic disease.


You will see lots of the buzzwords we hear today (transparency, empowerment, consumerism, infomediary, value-based) throughout the article, but they are delivered with facts and anecdotes to support their perspective.


I could go on, but I will leave it with a nice adaptation of Maslow’s Hierarchy of Needs which they present around healthcare.


You will find information in here around telemedicine, retail medicine, health tourism, and they tee up some of the hard discussions about when is it too much. How much should we spend (individually or as a society)? What expectations should we have? A lot of it requires a different mindset for all the constituents. This would be a good read for the presidential candidates.

Prioritization Framework

I was cleaning out some files over the weekend and came across an old prioritization matrix that we used at Ernst & Young when I was a consultant there. I found it to be relatively easy to use and understand so I thought I would share it. Ever person I know always struggles with how to select which project to do using a consistent framework that takes into account more than simply financial ROI.

We ranked each of the following on a scale of 1-5 and weighted each category to total 100%:

  • Potential Value
    • Strategic alignment (5 = enterprise sustaining and helps build learning organization vs. 1 = tactical)
    • Financial impact (5 = high ROI, lowers costs, and is growth oriented vs. 1 = lowers costs)
    • Customer satisfaction impact (5 = affects all constituents, builds loyalty, and creates differentiation vs. 1 = affects only one constituent)
    • Competitive status (5 = used by all traditional and evolving competitors vs. 1 = used by no competitors)
  • Ability to Execute
    • Organizational readiness (5 = requires minimal cultural, process, or technical change vs. 1 = requires new systems, business model, and staff)
    • Proven technology ( 5 = implemented at multiple sites with proven value proposition vs. 1 = concept only, no proven value proposition)
    • Time and resources required to implement ( 5 = resources easily accessible and can be broken into 3-6 month deliverables vs. 1 = scarce resources and no deliverables until after 12 months)

WSJ on the Future of Pharma

On 12/6/07, the WSJ had an article “Big Pharma Faces Grim Prognosis”. The manufacturers have been a good punching bag for a few years here as their creativity has slowed down (regardless of reality this is clearly the perception) and healthcare costs have become a front page issue. It is much easier to understand and compare drug prices than it is to look at provider costs. Now, with all the cost cutting at pharma, we will enter a new era.
In the article, the authors (Barbara Martinez and Jacob Goldstein) predict that “over the next few years, the pharmaceutical business will hit a wall”. Their statistics on the movement to generics is even bigger than I remember. They say that roughly half of the manufacturer’s US sales are scheduled to lose patent between 2007 and 2012 (or more than 36 drugs representing $67B in annual US sales). (See charts from the article)

“The rise of generics wouldn’t matter so much if research labs were creating a stream of new hits. But that isn’t happening. During the five years from 2002 through 2006, the industry brought to market 43% fewer new chemical-based drugs than in the last five years of the 1990s, despite more than doubling research-and-development spending.”

“It has never been easy to take a drug from the lab, through animal testing and into human trials. The industry estimates only one out of every 5,000 to 10,000 candidates makes it to human trials. And many drugs that work beautifully in animals fail miserably in people.”

The article goes on to talk about regulation and the FDA and whether the lack of new products is their issue or some other issue such as the R&D organizational model. It also talks about the fact that not much has changed since the 1800s in terms of the framework for developing drugs. Obviously, this has been the driver for biotech where the drugs are made of proteins and there is no generic competition.
Of course, targeting niche patient groups with biogenerics creates very expensive drugs such as the $200,000 a year that Genzyme charges for Cerezyme to treat Gaucher disease. [If you’re total market size is smaller but your costs to develop and bring a product to market stay the same, prices have to go up or no one will develop the products. It is a problem.]
Given the focus on generics in the market and by the payors along with the battle between brands and generics, I always find it interesting that some of the big companies own generic companies (e.g., Novartis owns Sandoz and Pfizer owns Greenstone). I guess if you can’t beat them…join them.
It will be interesting to see how the companies react. As I have talked about with friends for years, it is relatively easy to be a successful executive in a wildly growing company and industry. It is hard to be a successful executive and leader in a cost oriented industry that is contracting and where the competitive pressures are great. Can these guys make the transition?

Is Prior Auth Purely For Sentinel Effect?

In talking with a few PBMs, it is clear that they approve 90%+ of all prior authorization (PA) requests that come in. With that, I instinctively think of two questions:

  1. Why do it at all?
  2. If you’re going to do it, why have humans involved?

I haven’t seen the data on prior authorizations and how many people who hit a reject at the point-of-sale (POS) actually get a fill ever, but I imagine it is like step therapy (ST). With step therapy, only 50% of the people who hit the reject get a claim. (As I have mentioned before, 90% of those that don’t get a claim get samples, buy an OTC, pay cash, or find another solution.) But, the huge step therapy savings that plans and employers realize is not really about the movement to generics but about the lack of claims. Reduce your claims by 50% in a category and you save money.

So, I have to assume that PA has a similar role. The people that don’t really need it (or don’t understand the process) will either pay cash or find another solution, but they won’t have their doctor call the PBM for approval. (aka – The Sentinel Effect) Those that really need it (and understand the process) will call in and get approved.

So the next question is why are people doing this. I have heard from some pharmacists that it has to be humans so that physicians can’t figure out the approval algorithm and “game” the system. Somehow, I doubt that is what they are staying up at night trying to figure out. And, the agents taking the calls are following a very tight script anyways. I have argued for years that either a website or an inbound voice IVR that asks questions and based on answers determines the next question until the physician either fails the request or gets approval. Only exceptions would require a live person.

Medco Medicare Plan Options 2008

This came out a few months ago, but I am digging out while stuck in Philadelphia waiting for my 11pm flight which is delayed until 1am which means I should get to my hotel in Hartford almost 24 hours after I woke up this morning on the west coast.

On October 1st, Medco unveiled their new plan which has three different options for seniors for Medicare Part D:

  • Access plan – a $0 deductible plan with copays for chronic medications available for as little as $2 for a 30-day supply (when purchasing a 90-day supply of a generic medication via mail), and generics coverage in the coverage gap;
  • Choice plan – which features a $0 deductible, $2 for a 30-day supply (when purchasing a 90-day supply of a generic medication via mail), and access to more than 3,400 prescription drugs;
  • Value plan – a low premium plan with access to thousands of medications including generic, brand name and specialty drugs.

“We’ve asked seniors what they want from a drug plan and they responded with value, choice and access – so that is what we’re committed to providing.” David B. Snow Jr., Medco chairman and CEO

Medco also talks up their Therapeutic Resource Centers as a feature of the offering. These are pharmacies that are focused on one disease state such as diabetes, cancer, cardiovascular disease, and pulmonary conditions. The pharmacists receive special training in the chronic conditions and can help patients to really understand their disease and prescription options. They also offer Medicare Advisors which was a new offering that I hadn’t heard of. I am not sure if this is their MTM (medication therapy management) solution or another group, but the 24×7 access for consultation seems like a nice feature.

They do talk about one thing which I have been surprised not to hear more people talk about which is alerts to members when they approach the gap in coverage (aka the donut hole) where the seniors have to pay for the full costs of their medications. I am still waiting to see someone come up with a plan to minimize this cost (e.g., manufacturer’s covering the cost for the patient as long as they have been loyal to their brand drug prior to hitting the donut hole). More information about Medco’s plans is available at

Consumerism Impact on Productivity

Several years ago, I read an article in CFO magazine that talked about the drag on employee productivity that healthcare consumerism could have. I saw a factoid the other day that said that fantasy football could cost US organizations as much as $4,675,000,000 this season now that there are 13.6M fantasy footballers that devotes something like 2 hours per day to their teams. Now, of course 40% say that fantasy sports creates camaraderie, but I think there are cheaper options.

So, I am surprised that I haven’t seen more about what happens to consumers and workplace productivity as patient own more responsibility. If I have to research quality and price and make more decisions, I am likely to use more time to do this which will drag over into my work time directly or indirectly. I would love to find a study of this if anyone has seen it.

Incentives in Healthcare

Will incentives be a focus in healthcare? Certainly in lots of other industries, they are a minimum requirement to play at the table – hotels, airlines, banking, consumer products, and casinos. Consumers expect them in many cases. One of the big challenges that any presidential candidate hoping to change healthcare will have to solve is alignment of incentives.

There is lots of data out there validating this as a focus. In The Road Ahead: Emerging Trends in 2007
by Hewitt Associates, they say that 48% of employers offer or plan to offer incentives to employees who participate in wellness or health related initiatives. Health plans have started to tier payments based on patient activities around wellness. Companies are paying patients to take HRAs (Health Risk Assessments) and results have shown that the more they pay the better the participation in taking HRAs.

Wellpoint offers employers credits to offset deductibles when members engage in certain activities. Highmark has an outcomes program where members get points for taking classes and participating in other programs. And, IBM offers employees as much as $300 a year for exercising regularly and logging into the companies preventative-care website.

On the other hand, companies like Target have used gift cards as an incentive to get patients to fill their prescriptions at the Target pharmacy for several years. Many companies have used copay waivers or $0 copay programs to encourage patients to try generic drugs. Earlier this year, Democrats in MN recommended giving publicly insured patients $20 gift cards for following their physician’s orders.

Several traditional companies that have worked in other industries are focusing on healthcare. IncentOne is the one that appears to be the market leader with Hallmark Insights and Maritz quickly ramping up.

So, when could you use an incentive:

  • If you’re an MCO, you could use incentives for:
    • Health Risk Assessments
    • Disease Management Program Engagement
    • Health Education Class Enrollment
    • Brand to Generic Programs
    • HEDIS Reminders
    • Multi-step Milestone-Oriented Wellness Programs (many employer-group driven)
    • Member Portal Registration or Utilization
    • Personal Health Record Registration
    • Product Design Surveys
    • Satisfaction Surveys
    • Refer a Friend Programs
  • And, if you’re a PBM, you could use incentives for:
    • Retail to Mail (or Specialty)
    • Retail to Retail (Limited Retail Network)
    • Brand to Generic
    • Brand to Preferred Brand
    • Rx to OTC
    • Dose Consolidation Programs
    • Pill Splitting
    • Cross Sell opportunities with supplies companies—transportation services, DME, etc
    • Refer a Friend

Cariten Article on Silverlink

There was a nice article in today’s Knoxville News Sentinel about a program that one of our clients did. The client is Cariten Healthcare, the insurance arm of Covenant Health. They used Silverlink to get a flu shot reminder out to their patients. The article includes several comments from Linda Lyle, VP of Operations.

“The words may be recorded, but real thought went into the message.”

“An effective way to get the message out in a timely manner.”

She points out that it would have taken their live agents 100 days to get out the message which Silverlink did in six days. (contacting 44,000 people)

The article also talks about the tweaking that they went through in trying to find the right voice. They are now using automated calls to seniors for other purposes (e.g., reminders for mammograms, cholesterol screenings and colonoscopies; brief information about diabetes and osteoporosis; a customer-satisfaction survey; and reminding patients with dual coverage to let them know).

“There’s not currently a way to track how many members follow the messages’ advice, but numbers from another national company indicate Cariten is having a 73 percent “reach rate” among seniors, compared to a national average reach rate of around 40 percent.”

Would You Pay for Disease Management?

After landing (I often blog on the plane), I posted the last post about the Medicare pilot.  When I looked at my iGoogle page that tracks many of the blogs I watch, I saw a new posting on the WorldHealthCareBlog about Disease Management.  It is a good discussion on the value (if any) and talks about the different types of value (i.e., absenteeism versus lowering medical spend).

With such ambiguity, I think I would think differently.  If you had $X to spend per year and you were responsible for your total healthcare spend, would you (a consumer) spend money on DM?  At least intuitively, I would…assuming I had a chronic disease which was high cost and complicated.  Having someone push me information, coach me on how to get better and/or manage the disease, helping me find resources, navigating my benefits, etc., seems like something of value.

Obviously, there are lots of challenges here, and I think the current models often use too high cost of channels and don’t leverage technology.  At the same time, patients don’t have the same incentives today so they don’t necessarily always do what’s best for them.  (Think of all the people that still smoke given all the research that shows how bad it is for you.)

Medicare Pilot Results

I saw some amazing results the other day for a Medicare pilot program (not a Silverlink or automated call program). The company was showing us their analytical solution and how a health plan had used it to drive enrollment in a disease management program. They were targeting a Medicare population to get them enrolled to see if they could control spend around the disease.

This vendor broke the population into 7 “clusters” based on similar attributes and then tested different messaging patterns (e.g., disease name then benefits then process versus benefit then process then disease) across 8 different messaging components. They were able to get an 83% enrollment rate within the population. From what I understand separately, several of the companies that signed up for the pilot dropped out since they couldn’t get any meaningful enrollment.

In this case, they used lifestage, household type (e.g., single), household size, race, and income as the five variables that defined a cluster.

And, you still wonder about the benefits of data-driven communications that use segmentation? As you append external data to your claims information, you can create a robust data set that allows you to create personalized messaging to a targeted niche of patients that is designed based on a predictive model of getting them to take action. That should be the key for your communications and marketing programs.

Here is a good blog entry on e-CareManagement on the pilot program. My quick take is that the pilot won’t serve to prove the DM has an ROI, but that doesn’t discount the success that this company had using targeting to drive enrollment.

Do Seniors Use Automated Calls?

Without hesitation, that is the number one question I get from people in healthcare. Since seniors make up ~45% of the spend in healthcare, it would be difficult to promote a solution that didn’t work for that portion of the population. We have had some great success with the calls we have done around Medicare Part D and can provide a detailed set of data offline if you’re interested.

Here are a few of the key observations:

  • If you use the Medicare Part D experience, you can see from the data that the CMS website was very busy during the week and much less so on the weekends. [Implying that the target population doesn’t use the Internet at home or had their caregivers or some public access facility helping them.]
  • If you compare the 800# for Medicare Part D to the website volume, it is 4-5x as high. [Implying seniors use the phone primarily.]
  • Comparing authentication by age for a refill program and a COB (coordination of benefits) program, the senior population (>64) responded best.
    • Authentication means people that received an automated phone call and confirmed that they were the intended recipient (“are you bill jones?”).
  • Once seniors started receiving the calls, they continued to be receptive over time to additional calls.
  • The likelihood of saying “repeat” during a call rose very slowly from 60 to 90 years of age.
    • On an automated call, the patient has the opportunity to say “repeat” to hear the prior message again.
  • We followed up on one call program and surveyed 70,000 seniors…95% said the messages were easy to understand and 91% said the calls were quick and helpful.
  • Seniors answer calls all day, but more at night. [Gives you a good option for smoothing inbound call volume or transfers from outbound call programs.]

$200K Word Change

I was talking with a friend last week who has spent all his time at small, nimble companies. He was amazed at the challenge of getting something prioritized and completed in a big IT shop where process can often kill flexibility. There are lots of reasons for this – doing all the small projects would use all the time, the big projects have great ROI, the risk of something going wrong is much higher, etc. There are also dozens of reasons why you want to figure out how to be big and nimble.

When I was focused on this technology challenge (see old blog), I used to talk about SOA (service oriented architecture) and BPMS (Business Process Management Systems) where you could create a process abstraction layer that sits above your existing legacy environment. This abstraction layer allows companies to make rapid changes within a controlled environment.

The one example I always use is when we decided to move from the word “member” to “patient”. To do this systemically, you have to change call scripts, job titles, system fields, metadata, contracts, letters, etc. Of course, you also want to change the website. When I put this request into IT, I got back an estimate of $200,000 to make that change (or 2,000 hours at $100 internal cost transfer per hour). How do you justify the business case for this other than strategically and qualitatively? And, given a shortage of resources, why would you focus on this rather than some other web development project?

It was an interesting and frustrating process. We obviously wanted to show clients that we had fully transitioned to focusing on patients. We wanted to show consumers that we were thinking of them differently. But, we were stuck in the project prioritization process for scarce resources.

This ability to drive branding through every interaction and evolve your branding as you learn about your consumers will be an interesting challenge to an industry like healthcare where companies are slow to change and change takes time.

Stanford Study: Automated Calls

Stanford just published a report called “Computer calls can talk couch potatoes into walking” which is a great valuation of the automated call technology. The study compared calls by real people to automated calls encouraging sedentary adults to exercise.

It is interesting since it is conceptually similar to the technology which we provide at Silverlink Communications. They used Text to Speech (TTS) which can sound a little “computer-like” while we record our calls with voice talent. In their study, participants had to respond using the dial pad (e.g., press “1” if you have exercised today) while our calls respond to voice (e.g., say “one” if you have exercised today). We have studied the improvements in success rates on calls simply from using all recorded voice versus some TTS and seen a very positive lift. [It is obviously hard to record variable fields such as first and last name, but we have done some of that to improve results.] Additionally, given all the variables you can play with in a more sophisticated system – different voices, different speed of the message, dynamic paths, etc., it would be interesting to do that head to head comparison.

A couple of key takeaways from the article:

  • Many of the participants in the program were over 55. [Which are your primary users of healthcare services.]
  • Initially 80-85% of those in the program said that they preferred or needed a human after listening to the computer program. [What you hear from lots of people until they use it a few times.]
  • Participants who lacked confidence in their abilities to be successful and who were less comfortable interacting with people did better with the computer voice. [A client of ours in the specialty pharmacy space was emphasizing this for certain therapy classes recently.]
  • The computer voice was just as helpful for men and women.

“The goal was to get participants out walking at a brisk pace for 30 minutes most days of the week, or some other form of medium-intensity physical activity, for about 150 minutes a week, as recommended by the U.S. Surgeon General. They were divided into three groups: a control group that didn’t get calls, a group called by trained health educators and a group called by a computer delivering an interactive, individualized program similar to that being delivered by the health educators. Exercise levels were measured with the use of an accelerometer, which provides an estimate of physical activity amount as well as intensity.”

Worker’s Compensation: Focus Moving to Prescription Optimization

As a pharmacy (retail or mail and to a lesser degree specialty) or as a PBM or pharmacy administrator, one of the best ways for you to save clients money (lower average ingredient costs), save patients money (lower copays), and drive margins is typically to manage the distribution channel, drug utilization, and drug selection. There are traditional ways of doing this – formulary / preferred drug list, copays, and coverage rules (e.g., step therapy). But, more and more, companies are looking for softer solutions that focus on patient education.

How do you get patients to understand the value of generics and request that from their physician? How do you get patients to understand when mail order or specialty pharmacy is appropriate? How do you recruit them and work with their prescribing physicians? [hint: aligned incentives, proactive education and messaging, data management, patient segmentation models, online tools, and multi-modal coordination]

Worker’s compensation is typically its own animal. Patients pay no copays. Patients don’t really have eligibility cards. In some states, you can direct care (i.e., you have to go to these pharmacies). And, you have a whole industry of companies called third party billers (TPB) that buy the prescriptions from the retailers based on a factor for the receivables and then try to find the carrier or employer who covers that claimant and charge them more then the TPB paid. It solves the problem for the retail pharmacy of knowing who to bill for the claim (since there is no eligibility card…at least on the first fill).

Typically, this business is separate from the traditional MCOs and PBMs and done by companies like PMSI, Cypress Care, and MSC while some companies have a small group focused on it (e.g., Express Scripts). On the 3rd, there was an article titled “Workers comp PBMs can help employers control drug costs”. The article talks about the need to get an identification card to the patient (aka injured worker…aka claimant) as soon as possible so that their future claims process under the negotiated discount rate.

“If you have discounts, and your plan members aren’t going to network pharmacies, it doesn’t do any good.” (Vicki Wheeler, Express Scripts)

Several industry experts chime in to point out that it’s not about the billed rate per claim but about the utilization management. (Joe Paduda, a blogger on the topic, was also quoted in the article.)

“PBMs that intervene early in the prescription drug management process also can encourage the use of generics or less-expensive brand medications whenever they are available.” (Nick Page, PMSI)

Obviously, the holy grain is getting the patient better and back to work so understanding compliance and the link between appropriate drug utilization and overall medical spend for the patient is critical path. But, it appears from the story that the WC business will follow the route of the commercial PBMs and begin looking more aggressively at how to change behavior when you have no plan design (i.e., no copays). Couponing may be the option, but who pays?

(Another blog on WC that I just discovered is called Workers Comp Insider.)

Access, Price, Service…The Next Phase for MCOs

It seems a logical evolution of the marketplace. Have we moved to a point where MCOs can really differentiate themselves based on their service? (The indicator for me on this would be whether consumers are willing to pay more out-of-pocket to have one plan versus another simply because of service.) It will certainly happen. Web tools. Pro-active communications. Personalized messaging. Educational programs. Friendly call center reps. Consumers care about these things.

Coverage, the AHIP magazine, had a recent article called “Creating a Culture of Service” which is about this topic. It talks about a health plan where the average call is picked up in 12 seconds, the call abandonment rate is 2%, and 88% of questions are resolved on the first call. I am not sure this is a sustainable model of differentiation since there is a floor to improvement. It is similar to the Kano Model which is used in Six Sigma. This model points out that there are different curves of expectations. Initially, you can delight a customer with something new, but it quickly becomes a standard expectation in the marketplace.

The article does point out a key point which is that patients expectations of service are not based on healthcare companies. They look at Starbucks, Nordstrom’s, Amazon, Dell, Disney, and other companies for what they expect in terms of online presence, response time, and service culture. In many companies, the call center agent is the first (and potentially only) point of contact for a patient (or member). They are not highly paid and often take the brunt of complaints all day long. Finding a way to make them happy and patient centric is essential.

Another challenge which exists in any human centric function like customer service is consistency. As benefits get more complex and companies have huge turnover issues at their call center, getting the same answer every time is difficult. Which is massively frustrating as a consumer. We used to have to do “secret shopper” calls constantly to determine what parts needed more training. This is of course one area where automated voice solutions are being used both inbound (reactively) and outbound (proactively) to address consistency and timeliness. In many cases, you can predict events that will drive a call and see a patient’s history to understand their probability of calling (versus using the web). Why not launch a call to them before the call which is less expensive?

One hiring model we saw work very well in specialty pharmacy was hiring people who had a family member with a chronic condition. They were empathetic. They understood the patient’s frustrations. And, they could project their family member’s experience. They were great.

BTW – The article has a great sub-story about what Connecticare has done in their call center to address recruiting and turnover.

Other things I have seen work are empowering the end agent to resolve an issue up to a certain level. If a person is complaining about a $5 copay change, it may be worth waiving it one time and sending them some information rather than taking 3 calls from them at $5 per call. Or, it may be worth providing a one-time override rather than spending 8 hours trying to resolve it.

Incentives along with metrics are also another obvious tactic. Definitely don’t incent them to get off the phone quickly. That always creates issues. Look at ways of turning them into “sales agents” for the company and reward them for getting patients to change behavior or based on satisfaction scores.

And, one thing to avoid that drives patients crazy is having different information on the web than at the call center. And, even worse is not letting the call center agents have Internet access so they can’t see what the patient sees.

There are a few words on technology such as CRM (customer relationship management) and voice recognition software (e.g., routing to a different agent based on an angry voice). This surprises me a little since I think using data to segment and address different patients differently. Are they a frequent caller that we should route to a live agent without IVR (interactive voice response)? Do we know why they might be calling and have an answer?

As I have talked about before, I believe MCOs and other healthcare companies will be differentiated based on communications. How do they use their data and a permission based marketing approach to understand the patient, push information to them at the right time using the right medium, and support their needs? That is what I am focused on building with clients.

One Experience With Motivating Pharmacists

Yesterday, a client was asking me about using incentives to motivate pharmacists to take action on behalf of the patient. I had done a pilot with a government client that had a concentration of lives in a small geography and had the majority of their prescriptions filled at one regional pharmacy chain. It seemed like the right scenario to try a program.

I wrote up a mini-case study last night which I thought I might share.


The client decided to implement five new step therapy (i.e., the patient is required to use a lower cost generic drug prior to being able to get a higher cost brand drug) programs to go live simultaneously. We were asked to look at innovative solutions to manage the member “disruption”.

We approached the regional chain about a pilot program to reimburse pharmacists for helping patients resolve step therapy rejects at the point-of-sale. We designed a fax form for each of the five therapy classes which outlined the first-line alternatives. The objective was for each pharmacist to fax the prescribing physician using one of the five fax forms upon receiving a reject.

We agreed to pay the pharmacy/pharmacist $10 per fax sent. [Legally, we did not believe we could pay for results but simply for taking action.] We ran the pilot for 6 months and subsequently compared the amount of claims filled within the therapy class (aka GPI) after the rejects at the participating chain versus the amount of claims filled within the class at other chains for the client. We also looked at the number of prior authorizations and percentage of first line agents filled for patients that hit a step therapy reject.


At the conclusion of the pilot, we found no statistical difference between results from the participating chain versus other chains that did not participate in the pilot. In this time period, I believe we paid out approximately $20,000 for the program and concluded that this was not a solution for influencing physician behavior around plan design.

Lessons Learned:

Because of other priorities, we did not do a thorough analysis of the reasons for this not being successful (e.g., interviews with participating pharmacists), but we had numerous hypotheses about the pilot program.

  1. The incentive did not actually get to the retail pharmacist from corporate and therefore the incentive was null.
  2. $10 per fax was not enough, given the volume of rejects, to make a financial difference to a pharmacist making over $100K per year.
  3. Pharmacists were already doing everything possible to help the patients and the incentive was simply additional cost for a task already being done.
  4. Sending faxes to the physician needed to be followed up by the patient and/or pharmacist to make sure the physician acted on the request.
  5. There needed to be more education from the corporate office of the retailer.
  6. Patients were concerned about the follow-up. Our research had already shown that 50% of people who hit a step therapy reject don’t fill a claim, but that 90% of those that don’t fill a claim either get a sample, purchase an OTC, or pay cash for the rejected drug. (i.e., only 5% of those that hit the reject get nothing)

If I were to do it again, there were several things I would do differently. Trying to drive behavior at the pharmacy is a question of aligning incentives and pushing information to them through channels like the Point-of-Sale (POS) system and reject messaging. But, changing behavior has to involve physicians, consumers, and the pharmacist.

A New Pharmacy Model

I had a chance to ride on a plane today with a man who sits on the board of a pharma company. He has worked in pharma for 30 years, and we had a good discussion. One of the things we talked about was the “arms race” in pharma to build up their number of detail representatives. Obviously this changed over the past few years especially with some of the limitations which have been placed on how pharma reps can incent physicians. We went on to talk about the challenge of physicians keeping up with all the drugs on the market and even understanding all the basic pharmacology. With over 10,000 different drugs, this is a challenge for pharmacists much more so for physicians who have other information to manage.

In discussing the topic, it reminded me of a law which exists in a few states that allows physicians and pharmacists to have a legally binding agreement around therapeutic substitution (i.e., allowing the pharmacist to change drugs or chemical entities for the patient without getting a new prescription). I can’t remember what these are called, but I threw out a new model to him that would seem very logical.

Could physicians simply write a prescription for a lipid lowering drug (aka cholesterol medication) and put the relevant diagnosis code and lab values on the prescription? The pharmacist would then be responsible for determining the right drug for the patient based on their prescription history and their benefit plan. It seems like a simple model which focuses every constituent on their primary role – the physician owns the diagnosis and care plan while the pharmacist owns the prescription selection.

It would eliminate the need for pharma reps in many ways because the conversation would be with pharmacies who use online information and have a corporate infrastructure that could have models for selection of drugs based on DUR (Drug Utilization Review – e.g., drug-drug interactions), copayments, UM (Utilization Management – e.g., step therapy, prior authorization, quantity level limits), and perhaps profit.

Biometrics – Role in HC – What About a Voice Print?

I have always found biometrics a fascinating topic (i.e., fingerprint recognition, retinal scans). Usually, you only see them employed in James Bond type movies or movies like The Bourne Identity. But, my first job out of undergraduate school was at SH&G which is a large architecture firm in Detroit. We designed US embassies and access to that area of the building was only through a retinal scanner.

Healthcare, much like financial services, is massively paranoid about security. [For good reason.] Just like you don’t want fraud on your credit card, you don’t want all your private healthcare information being shared with the world. One of the challenges in healthcare communications is therefore authentication. When you send a letter, technically it can’t be opened by anyone other than the recipient (without breaking the law). With the phone, you typically ask a question or questions – is this “John Smith” and/or “what is your member id”. The more questions (aka layers of authentication) or the more unique the question (e.g., give me the prescription refill number off your bottle) then the more sure you are of who are speaking with. Of course, as you make the questions more specific the questions or add more questions, you increase the difficulty for the consumer.

So, would consumers use a voice print? It is easier than fingerprinting or retinal scans in that you don’t need hardware at the patient’s location. You simply have to match an audio file against a prior file. It seems like an easy solution. Perhaps, once all computers are touchscreen, we could use handwriting recognition to send secure e-mail.

Pricing Options

So, if you were responsible for your healthcare costs, would you rather have the Saturn model (i.e., lowest price is posted – no negotiation) or the jewelry model (i.e., retail price means nothing other than a point to negotiate from). This would be an interesting discussion as we get into more transparency about price / cost in healthcare services.

I on the one hand love the research and negotiation process and believe that coming informed to a discussion allows me to get a better price / value. Now, it requires work, but I think the tradeoff is worth it. On the other hand, I know lots of people that would rather simply go in and pay the list price (and do so today). There is a fine line somewhere. You don’t want people to get gauged for not doing their research, but the provider of the service needs to be able to make a decent living. Market economics should drive price efficiency (i.e., if the price is too high, there should be new providers that are willing to take a lower price to steal marketshare).

I think being forced to do the research is good. You end up learning a lot more and becoming a better consumer.When I buy a house, I look at public information on the builder to understand their margins. I ask people that have bought from them what was negotiable. I compare prices for additional features (e.g., is it cheaper to have them finish my basement or someone else). Then, I can evaluate the tradeoffs.

Why is this such a big deal:

  • Compare buying furniture at your local store with North Carolina. NC offers the same furniture at about 50% off.
  • Try going to a jewelry store and don’t ask “how much” but “what will you sell this for”. I wouldn’t settle for less than a 40-60% discount.
  • Go buy appliances or electronics. If you don’t get price matching or at least 15% off list (even the sales price), I would be surprised. I have bought things for as much as 40% off at the large stores.

Once these healthcare dollars are yours to control, this could make a big difference.

Physician Double Standard (What’s Ours)

There was an article out yesterday summarizing a survey of physicians.  The key point it made was that “up to 96 percent of those surveyed said they should report all instances of significant incompetence or medical errors to the hospital clinic or to authorities.”  [It was only 45% among cardiologists and surgeons??]  BUT, 46% of those surveyed knew of a serious medical error that had been made and did not report it.

Given all the focus on quality and error rates over the past few years, this seems concerning.  Although I am equally as concerned that the surgeons didn’t feel it was necessary to report issues. 

At the same time, I believe we can’t expect different standards from others that we wouldn’t be willing to be held to.  So, if you knew a collegue did something wrong, would you report them?  If they acted inappropriately at a client social event.  If they presented poorly and lost a sale.  If they made a mistake in their financial model.  If they had a spelling error in a marketing piece. 

Of course, not all of these are life and death, but I could certainly argue that rejecting a claim that pushed undue financial stress to a patient would be a serious issue.  Or, simply telling them a service wouldn’t be covered might discourage them from getting needed work performed. 

“There is a measurable disconnect between what physicians say they think is the right thing to do and what they actually do,” said Eric Campbell of Massachusetts General Hospital and Harvard Medical School in Boston, who led the survey.

Some of the other findings included:

  • Doctors are willing to order unnecessary — and often expensive — tests.  [How many of us don’t always take the least expensive path?]

  • Only 25% consciously tried to avoid gender or racial bias in how they treat people.  [How many of us consciously do this in our job?]

  • 93% of doctors said they should provide care regardless of a patient’s ability to pay but only 69% actually accepted uninsured patients who cannot pay.  [How many of us would be willing to provide our services for free to someone that needed them?]


Staying Current – Blog Options

Obviously none of us have time to stay current with everything. Remembering all the blogs you like, visiting them regularly, and reading all the e-mails, mail, and publications can be overwhelming. I can’t simplify it all, but I thought I would suggest two ways of staying informed if you find this or other blogs interesting.

First, you can subscribe to the e-mail list. What this means is that any day there is a new post you will get an e-mail sent to you. Here are a few screen shots so you see what that means. It is an easy to read format sent by Feedburner. It has links to forward the article and unsubscribe at anytime. (But, you should know that you will get a confirmation e-mail from Feedburner after you register. Make sure it doesn’t get caught in your spam filter. I have about 10 people that have signed up to receive updates, but they have never confirmed.)

I find this easy since I read a lot offline, and I visit when I need to not trying to time new posts.


The second option is to use a blog reader tool like iGoogle where you can have all your blogs. I use this as my start-up page in my browser so I can see what the world is talking about from traditional media to different bloggers.


IBM on HC 2015 – Part II

I think the entry got too long.  I got a system error that made me think I should split this up.  So, continuing on my review of the IBM publication on the future of healthcare, here are some additional notes I took:

  • They envision the growth of a “health infomediary” that helps people navigate their benefits and options within the healthcare marketplace:
    • A “health coach” – expert in lifestyle and behavioral change
    • A “value coach” – expert in benefits, pricing options, and cost-quality tradeoffs
    • A “wealth coach” – expert in financial planning for health related needs
  • They say that health plans as well as physicians could step into this role (along with new players).
    • 80% say hospitals are “doing a good job”
    • 60% say health plans are “doing a bad job” [which may challenge them in some of these future roles]

“Today, healthcare delivery is overly focused on the episodic treatment of acute care.  However, the emphasis of the healthcare system will contine to expand from episodic acute care services to include prevention, chronic condition management and better care coordination.”


  • There is good discussion about the needed change in the healthcare system to be more focused on wellness and greater alignment of incentives.  They say “today, there is more variability at the point of contact with the consumer (that is, the point of care) than in virtually any other industry.”
  • If you read the report, figure 8 summaries the current state versus future state that they envision along numerous dimensions – sponsorship, competition, innovation, revenues, networks, etc.  The things that captured my eye were:
    • Competition being based on information access [and in my opinion…easy of use of these tools across multiple channels]
    • Competition being drives by targeted products and services [one of my favorite topics…microsegmentation]
    • A wellness ROI
    • Value-based reimbursement [which I am sure is much more than P4P]
  • They talk about the blending of product and service (i.e., the offering as I would call it).  This has been a topic in other industries for years.  [Look at the book Blur from 1999.]
  • They layout four different roles for health plans:
    1. Health / Wealth Service Advisors – personal health concierges
    2. Health Services Optimizers – guide individuals to wellness and through healthcare maze
    3. Applied Research Advisors – aggregate knowledge to help patients
    4. Transaction Processors – clearinghouse
  • I didn’t know that the top 6 healthplans cover 60% of all insured Americans while their are another 500 plans.
  • They go on to propose some questions and sample indicators of readiness for the new healthcare environment.  Here are a few indicators:
    • single view of the member across products and business partners
    • proactive contact center
    • real-time analytics regarding wellness calls
    • member loyalty
    • value-based arrangement with providers
    • consistent answers across multiple channels

Hopefully, this is a helpful summary and enough for you to read the document.  Is a quick 18 pages with good facts and realistic proposals for the future.

IBM on HC 2015 – Part I

I had a chance to catch up on a bunch of reading on the plane including an IBM brochure I picked up the other day on “Healthcare 2015 and US Health Plans“. I found it to be a good piece with several good frameworks although it doesn’t take any radical views on the future (which I would have liked to see).

Here were a few of the facts / takeaways from the brochure:

  • US healthcare expenditures per capita are 2.3 times higher than other developed countries and projected to increase 83% over the next 10 years
  • Medical errors cause between 48,000 and 98,000 patient deaths per year
  • Medication errors cost the US over $3.5B per year
  • On top of the 47M uninsured, there are 15.6M underinsured
  • There are five issues that will make change difficult for healthcare:
    • Funding constraints
    • Societal expectations and norms
    • Lack of aligned incentives
    • Inability to balance ST and LT perspectives
    • Inability to access and share information

    “We believe that the U.S. healthcare system will not achieve a comprehensive “win-win” transformation by 2015 because of political gridlock and inability of key stakeholders to work collaboratively to reach solutions for the ‘greater good’.”

  • They do predict that some form of universal coverage will be enacted by 2015 and will be focused on the individual not the employer to address the “job lock” challenge.
  • They see a key role for health plans and call upon them to lead the transformation to a “more patient-centric, value-based, accountable, affordable and sustainable U.S. healthcare system”.
  • They predict that employer-sponsored health benefits for family coverage will increase from $8,167 in 2005 to $17,362 in 2015.
  • In 2006, PPOs (preferred provider organizations) accounted for 60% of private insurance enrollees (up from 41% in 2000).
  • Employers offering coverage has dropped from 69% in 2000 to 61% in 2006 and is predicted to go below 50% by 2015.
  • They talked about employers putting a lifetime cap on retiree benefits which was a new concept to me, but they said that 49% of employers polled in 2005 had a cap (of which 59% of those on the plan had already hit the cap).
  • They talk about lifestyle choices impacting premiums which would lead to increased wellness and preventative programs.
  • There is some scary data about money needed post retirement. They say that half of all bankruptcies are in part due to medical expense. They also say that “a couple retiring in 2016 at 65 years of age would need US$560,000 if they lived an average lifespan. They would need US$1.05 million if they lived to 95 years.” This is specific savings for healthcare costs in addition to Medicare. WOW!! And, they say that 40% of people over 55 have $50,000 or less saved.



“The health–wealth intersection is already taking shape. Players from each sector are experimenting with offerings that cross the boundary between the two, such as reverse mortgages to finance nursing-home costs and arrangements that let individuals tap into their life insurance policies to cover medical costs. But the new health–wealth business will evolve and change shape for at least the next couple of decades, as the retail health-care market coalesces and consumers take on more responsibility for their medical needs.”

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