Archive | February, 2008

When Is PHI Not Covered By HIPAA

February 12, 2008 by George Van Antwerp 0 Comments

I think most of us now assume that our Protected Health Information is covered by HIPAA anytime we disclose it. But, that’s not true. I have noticed several examples lately where they ask you for your prescriptions, but there is no HIPAA disclosure. And, you now struggle with making something public or risking a counter-indication (i.e., drug-drug interaction) if you don’t disclose it.

  • In one case, I was getting a massage, and they asked for a list of medications. Regardless of whether I had anything to disclose, I immediately wondered what could happen with that data and thought that their lack of security could be an issue.
  • In another case, I was talking with a worker’s compensation provider who said that they were not covered by HIPAA (which appears to be true).

Can you think of other examples where you disclose information that you might prefer to keep private about your health condition only to realize that they are not held to the high standards which exist in the healthcare industry?

Of course, the most glaring example I always see is physician’s offices who have a sign-up list of patients just laying on the counter.  Isn’t that a HIPAA violation?  What about all the patient’s files laying around or the names you see pop up on the screen while they are scheduling an appointment for you.  Isn’t that an issue?

Healthcare

10 Ways To Fix Healthcare (From LiveSmarter)

February 11, 2008 by George Van Antwerp 1 Comment

I am not sure whether this is a new blog or some content off a business site, but I think it is a good entry.  This lays out comments from a bunch of people in and outside the industry about how to fix the situation that we are in.

It includes comments like:

  • “encourage healthcare professionals to cooperate and develop a shared mission.” [Health 2.0]
  • “market forces bear no consequence on rising healthcare costs” [individualized health insurance]
  • “individuals rely on random health events like hospital stays and office visits for care.” [preventative care]
  • “Though preventive programs incorporating diet, exercise and stress management might cost more money upfront, overall costs will drop by 30 percent and may save the patient from going for tests and getting treatment with expensive machinery.” [low-hanging fruit exists]
Consumerism, Healthcare, Managed Care, Value Propositions, Weblogs

Data Access Issue

February 11, 2008 by George Van Antwerp 0 Comments

For those of you that ever wonder how easy it is for big technology companies to get to internal data, the WSJ blog highlights an issue that Vioxx litigants are having with Express Scripts.  They want to charge for the data access since it will take 420 hours (or one person for over 10 weeks fulltime) to pull the data at a cost of $150/hr for a total cost of $63,000.  [Not a bad job for someone…$300K per year to run a bunch of queries.]

Healthcare, PBM / Pharmacy, Value Propositions, Weblogs

Myers-Briggs in Healthcare: Part 2 of X

February 10, 2008 by George Van Antwerp 1 Comment

I was looking for a book the other day to read on some of my flights and came across Health Care Communication Using Personality Type by Judy Allen and Susan A. Brock. I have just started reading it, but I related very well to their key assumptions:

  1. People prefer to communicate in different ways.
  2. Most people have a preferred style of communication.
  3. It is easier to communicate with some people than it is with others.
  4. A system exists which provides a simple framework for understanding these differences.

As I have mentioned before, I think that Myers-Briggs is a good framework for understanding people. I often pull up my notes about my personality type and can see that I respond as predicted to certain situations.

Applying some of their initial thoughts with my perspective, it would seem like there are some basic hypotheses that you could make in talking with patients.

  • Extraversion: People that like to talk things out. Probably more likely to respond to verbal outreach.
  • Intraversion: People that like to think things through. Probably more likely to respond to print (e.g., letter or web).
  • Sensing: People that like the specifics and the details. Probably more responsive to a detailed message (e.g., you can save exactly $X by doing this). Probably want to see the path of exactly who needs to do what.
  • Intuition: People that see the big picture. Probably more responsive to a communication that helps them understand the impact of their decision on overall healthcare trend. Probably want to understand their options versus being guided down a path.
  • Thinking: People who are very logical. They should respond well to automation and would want an if/then type of message.
  • Feeling: People that are more emotional. They would likely respond best to live agents where they could empathize with them and potentially even respond to a “peer pressure” type of message (e.g., most people are now using generic prescription drugs).
  • Judging: People that are organized, punctual, and focused on getting things done. They would likely respond to messages about how to save time and money delivered in the quickest format possible.
  • Perceiving: People that are flexible, don’t plan ahead, and are often more disorganized. They would likely respond to a just-in-time message, a compliance reminder, and a communication process that did everything for them (e.g., you should go in for a colonoscopy…would you like us to schedule that for you).

Obviously, one framework doesn’t solve everything, but I expect that there is a lot more to gain from this book as I read through it. I was just so excited after the first section given my interests that I wanted to post this quick entry.

Books / Articles, Business Tools, Consumerism, Healthcare, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Research

COB Predictive Values

February 8, 2008 by George Van Antwerp 0 Comments

COB (or Coordination of Benefits) is a core managed care function that is often ignored (and varies by state to make things more complicated). It is a required process by which managed care companies need to identify if people have other coverage (i.e., should I send someone else the bill). Given the high dollars here, you would think companies would be focused on driving this as a cost management or profit initiative.

Good companies find 2.5% or more of their population have secondary insurance. I have seen analysis saying that if you include claims that should be billed to worker’s compensation, auto insurance companies, etc. that the number could be as high as 15%, but that seems really high.

An interesting fact that one of our experts shared with me was that claims data could explain over 65% of the variance in COB responses for a working age population while it could only explain just over 40% for seniors. They have found some incredible correlations to create ROIs for clients in the 2,000% range. [Not bad. If I could get my boss a 20:1 return, I think he would pay attention.]

Of course, as a patient, all I care about is that my claim gets paid, and I don’t get a bill from my provider.

Again…I may be preaching to the choir, but this is why data matters. This is why you need metrics. This is why you need to know your baseline and track how you improve this.

And, always make sure you understand the definition, the data sources, and the data quality. I remember doing data standardization processes for Sprint back in the mid 1990s. It took a while just to get agreement on what a customer was from a business and systemic perspective. Another example I previously had when looking at two vendors was defining success. They attempted to create a standard metric of abandonment for people that came to a website to take a survey (i.e., how many abandoned the process before completion). One seemed dramatically better than the other.

Upon research, we found that one broke the survey into sections and offered them an out on each page. As long as the consumer exited at a planned opt-out point, they were a “success” and had not abandon the survey (even though they hadn’t completed it). The other only counted those that finished the survey. Not surprising who had a better score.

Healthcare, Managed Care, Marketing / Communications, Technology, Value Propositions

Why Consumerism Matters For Pharmacy

February 7, 2008 by George Van Antwerp 0 Comments

I found this Hewitt data in a presentation by UHPS (United Healthcare Pharmaceutical Services) which is the subsidiary of United Healthcare that manages the Medco relationship (they still outsource their pieces including mail and claims adjudication) and the RxSolutions (former Pacificare PBM). It was from a slide deck given by their National Sales Director at an AeA Seminar on 9/20/07.

[On an interesting side note, UHPS recently won a 1M life competitive contract for PBM services which I believe is one of their biggest wins as a PBM selling outside their existing base.]

I think the key point from this image is that patients have the most influence over the drugs they utilize. With multiple drugs for any therapy and lots of information out there, patients can have an intelligent dialogue with their physician about their choices. This becomes much harder for certain medical situations.

If you get fascinated by the space, they talk about a few of their differences:

  1. A different formulary strategy – evidence based, real-time changes, place drugs on any tier (e.g., generic on 3rd tier if appropriate)
  2. They recommend a $35 differential between Tier 2 and Tier 3 (which probably means that their clients are price neutral if the patient chooses Tier 3…they may even be better off as the rebates to be at Tier 2 are probably much less than $35)
  3. They recommend a 2.5x to 3x multiplier for mail order (i.e., take your 30-day copay and multiply it by2.5 or 3 to determine your 90-day copay). This probably means very little mail adoption, but that patients that use mail will save the payor money on brands. They probably save on generics no matter what.

It is interesting to see the different models emerging in the PBM space. For a while the companies were highly clustered and faced with a price path. Now, you have a few key differences:

  • CVS / Caremark has the play of integrating retail and mail
  • Medco is going down the path of disease state differentiation
  • Express Scripts latest presentations have focused on consumers and engaging them
  • United is talking about their different approach along with the benefit of an integrated data set and captive PBM working with the managed care entity. If they figure out the evidence-based strategy and convince their clients of the value of this, they may be able to get a jump start on the market from a clinical perspective.

The one constant for all of them is communications and engaging the consumer. Interesting. A friend of mine who works with benefit consultants told me that that is the hot topic he hears everywhere today. They want to know how to engage them, what the value is, and how to prove it.

hewitt.png

Books / Articles, Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy, Research, Value Propositions

Glass Ceiling for Adoption of New Programs

February 6, 2008 by George Van Antwerp 1 Comment

A common discussion point that I have had with many people is why don’t companies adopt more cost control mechanisms.  Some typical programs from a pharmacy perspective would include:

  1. Limited formulary (cover less drugs)
  2. Percentage copay versus flat dollar copay
  3. Mandatory generics (you have to get the chemically equivalent generic if available or pay the difference)
  4. Mandatory mail order (you have to fill any maintenance drug at mail after the 2nd fill)
  5. Limited retail network (you can only use certain preferred retail pharmacies)
  6. Step therapy
  7. Prior authorization
  8. Quantity level limits
  9. Intervention programs (you are taking a brand name drug with a therapeutically equivalent generic.  if you switch to the lower cost drug, with your physician’s approval, we will waive your copayment for the next 6 months.)

Since the reality is that the most effective programs have traditionally been programs that contain a hard edit or reject at the pharmacy or ones that clearly transfer cost to patients if they don’t take the preferred route, these programs cause disruption.  Some people hate that word, but it is the reality.  People call into the call center.  They call HR.  They log onto the website.  They talk with their friends.  They have to call their physician to get a new script.  It is not business as usual.

So, in a theory proposed by Larry Zarin (Chief Marketing Officer at Express Scripts), you could visualize a glass ceiling which blocks adoption of new programs.  So the question is how to raise the glass ceiling such that those paying the bill would be willing to be more aggressive in managing their drug trend.  (The same theory applies to managed care also.)

I agree with the null hypothesis that says that education is the key.  The question is how to drive information at a broad scale when you don’t know who will be affected necessarily.  And, the reality is that those that aren’t immediately impacted will likely ignore the general educational message.  We want targeted, personalized messages that are timely and come exactly when I am about to be impacted.

You are likely to be going to refill your prescription for ABC in the next 3 days.  If you continue using this drug, your copayment will have increased from $25 to $50 as the drug has moved to the third tier of our formulary.  Please say help to talk to a live agent or log on to our website at www to see your alternatives. 

So, it is really a question of creating generalized information and then having a communication campaign that is triggered by events – a claim, a diagnosis, logging into the website, calling a call center agent, etc.  Something has to happen that tells you the person is a likely target and receptive to the message.  Then, you can target them with a personalized communication.

Healthcare, Marketing / Communications, PBM / Pharmacy

Information Latency: Why Don’t We Change?

February 4, 2008 by George Van Antwerp 2 Comments

I have had this note to self for a while so I am finally going to put a quick entry out here on the topic.

The issue is data latency or more appropriately information latency.  The data often exists right away, but the challenge is how to you get the data into a usable form, with context, and with enough data to make decisions.

In communications, this manifests itself in healthcare in two ways that immediately jump to mind:

  1. In a traditional letter program:
    • You send a letter to a patient (7-10 days from data targeting to mailbox)
    • Patient opens the letter and has to contact their physician (if they choose to do anything)
    • Patient trades messages with physician and/or has to schedule an appointment
    • Patient meets with physician who (for example) writes them a new prescription
    • Patient waits for medication to run out then refills with new drug (e.g., generic, on-formulary drug)
    • Claims get aggregated and reports run
    • Best case – 30+ days to see if program had any effect (most likely 6 months)
  2. In a traditional survey:
    • Company prints a survey and mails it to 10,000 people hoping for a 10% response rate to get a statistically valid sample size of 1,000
    • Patients fill out the survey over the next month and mail them to a data entry company
    • Data entry company manually enters them, aggregates the data, and creates a report
    • 45-60 days later the company has information from the survey

Of course, the issue with both of these is that you have lost a huge window of time especially if you need to make changes to your program or the survey tells you that you need to gather more information.

Why don’t more companies talk about on-the-fly program changes and how to use modern technology to get real-time feedback for programs where they can pause the program, make change (e.g., change the message, add a new question), and then continue the program?

Business Tools, Healthcare, Innovation, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Technology, Value Propositions

Another AIS Gem

February 4, 2008 by George Van Antwerp 0 Comments

AIS has a daily newsletter that comes out which starts with a quote.  I have found a lot of these good teasers.  Here is one from last week.

“Providing education and information [about Health Savings Accounts] is very important. Too many companies talk too much about the money. That’s not the key. The tax benefits are nice, but people want to know what happens if they get sick. They want to know how the HSA works and whether they’re going to be stuck with a medical bill.”

— Roger Abramson, director of legal, compliance, education and human resources at Fontis Healthcare Services, Inc., told AIS’s Inside Consumer-Directed Care.

It is a good point about how often we communicate one thing which seems relevant to us without thinking about the receiver of information’s framework and hierarchy of information needs.

Consumerism, Healthcare, Managed Care, Marketing / Communications, Value Propositions

Generic Changes: Patient’s Confused

February 3, 2008 by George Van Antwerp 0 Comments

Typically these things play out behind closed doors or in court and don’t always impact the patient, but I think the latest Protonix saga will have a brief impact on patients.  Primarily causing some confusion.

The basic scenario:

  • Teva decided to challenge Wyeth’s patent and launches generic Protonix early (this means that they are going at risk and if they lose the patent fight that they owe Wyeth 3x the revenue collected from the product)
  • Teva ships about $300-$400M worth of generic Protonix in December and January
  • Wyeth fights them in court and decides to bring its own generic version of Protonix to market
  • Now, Teva has decided to stop shipping generic Protonix (see WSJ blog on this)

If you’re a United patient, you likely just got a letter telling you that they have moved the generic to the third tier (i.e., highest copay) and moved the brand to the first tier which is typically for generics.  They obviously worked a deal directly with Wyeth.  But, the consumer has to deal with issues such as state mandatory generic laws that require the pharmacy to fill a brand drug that has a chemically equivalent generic available with the generic unless the physician has checked DAW (dispense as written) for the brand drug.

Good business logic saving everyone money, but this may burden the consumer and the pharmacy and the physician.  Hopefully, they have an effective communication strategy to drive patient behavior.

So, your prescription history might look something like this (while staying on the same drug):

  • November – brand Protonix (2nd tier)
  • December – generic Protonix from Teva (1st tier)
  • January – generic Protonix from Teva (1st tier)
  • February – brand Protonix (1st tier)
  • March – generic Protonix from Wyeth (1st tier)
Consumerism, Healthcare, Managed Care, Marketing / Communications, PBM / Pharmacy, Value Propositions, Weblogs

Healthcare Decisions

February 3, 2008 by George Van Antwerp 0 Comments

I will get this roughly right, but I was talking with a non-healthcare person a few days ago.  He has built several successful companies and was studying the healthcare industry.  He described healthcare decision making as “passively aggressive, supposedly consensus driven”. 

istock_decision-cube.jpgAs anyone in the industry knows, it is not always a logical process given all the different constituents, the embedded processes, the historical momentum, the confusing data, and many different frameworks (e.g., clinical versus financial).

It made me think of a quote by  who wrote several books on great companies.

“No major decision that we’ve studied was ever taken at a point of unanimous agreement.”

I agree.  Companies can’t focus on consensus.  They need to focus on open debate and then come to a decision which the company rallies around.

General Business, Healthcare

Making Good Decisions

February 3, 2008 by George Van Antwerp 0 Comments

This is a classic article that I have reused several times.  The article “Great Escapes” by Michael Useem and Jerry Useem appeared in Fortune (6/27/05) on pg. 97.  It is about thing to use to avoid typical decision making problems.

These are all relevant for anyone in business or healthcare, but with the massive amount of change required in healthcare, it seems like these will be relevant at the macro level.

  1. Problem: Analysis paralysis
    Solution: 70% solution
    “A less than ideal action, swiftly executed, stands a chance of success, whereas no action stands no chance.”
  2. Problem: Sunk-cost syndrome
    Solution: Burn the boat
    “There is no such thing as timeless perfection, only obsolescence.”
  3. Problem: Yes-man echoes
    Solution: Voice question not opinions
    This one is pretty obvious, but if you have a strong personality or executive in the room, once they state their opinion you will get a much different level of interaction.
  4. Problem: Anxiety overload
    Solution: Look at the clock
    “A panicked mind stops processing new information, reverts to tried-and-true responses, and is prone to snap decisions that make things worse.”
    It talks about fighter pilots looking at the calm clock while things are spinning on their gauges.  The idea of finding a calming point to focus on.
  5. Problem: Warring camps
    Solution: Let the battle rage
    “Political infighting can be destructive, but battles over substance, managed well, can be constructive.”
    This reminds me of a boss who taught me that it was critical to have a close team where people could share opinions openly to drive value.
  6. Problem: A wily adversary
    Solution: Clone your opponent
    “Assigning a person (or a group) to think like your competitor can expose flaws that, identified early, are less likely to be fatal.”
  7. Problem: To be?  Or not to be?
    Solution: Go with the omen
    I am not so sure about this, but the point is that sometimes your mind is made up and allowing an event to trigger a decision may make sense.
  8. Problem: Inexperience
    Solution: Educate your instincts
    “Blind instincts cannot be trusted, but they can be educated.”  (Think flight simulator as preparing you for different situations.)
  9. Problem: Self-interested thinking
    Solution: What would Sara Lee do?
    Harder to use advice, but they suggest imagining that the company is a person with rational desires – security, growth, good relationships, respect, and a sense of purpose.  Then thinking about how they would react.  (Or our test at Express Scripts was what would Barbara Martinez say.  She is a journalist on the topic for the WSJ.)

Henry Ford said, “My advice to young men is to be ready to revise any system, scrap any methods, abandon any theory if the success of the job demands it.”

Books / Articles, Business Tools, General Business, Healthcare, Leadership
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