Archive | May, 2008

Hall of Shame – Customer Service

On the positive side, there were no healthcare companies that “won” this “competition”.  Winning being that you were rated as having poor customer service the highest percentage of times.  (On the flipside, very few were included.)  [full rankings here]

“We’ve seen a fall in customer service as we’ve gone into a recession,” said Richard D. Hanks, the president of Mindshare Technologies, a customer-service consulting company. “As the cost cutting occurs . . . they start to cut the wrong things.” (Article)

Not surprisingly, the people surveyed said that being knowledgeable, available, and friendly were very important.  As we all know, the key attribute is knowledge and with the complexity of benefits, multiple systems that healthcare reps need to access, and turnover, this is a challenge. 

It’s no wonder that everyone is trying to move people to self-service.  In a related article, some of the benefits of self-service were clearly articulated:

“What better customer service is there than self-service?” ask the marketers. “It’s fast!” “It’s accurate!” “It’s convenient!” “It’s confidential!” (No more bystanders overhearing that triple-cheese, extra-mayo order.)

 

  • People buy more. Customers spend 39% more per order at fast-food kiosks and are twice as likely to upsize than if a person takes their orders. (Machines are programmed to ask every time, and no one can overhear.) Customers also buy more at deli kiosks in supermarkets.

 

  • More people buy. Good Web self-service allows for far more customers to be adequately served.

 

  • People remain loyal. “You mean I’m going to have to upload all my data into a new bank? And learn a new system? No way.”

 

  • People give the company high marks for customer service. Yes, funny but true. It’s hard to complain about a food order that you placed yourself, a transaction that you scripted or the way you pumped your own gas. When customer service is self-service, you have only yourself to blame.
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Guest Post: Health Researchers Obtain Grants for Video Game Study

12 US research groups were awarded grants this week in order to conduct studies on how interactive video games affect players’ health. There has been a lot of press lately for Nintendo Wii and its many health benefits. It seems that the Wii isn’t the only gaming system to influence a person’s lifestyle choices where health is concerned. Of course, not all games are having a positive influence.

Grants totaling up to $200,000 were given to each research team, all of which are connected with a major US university. The generous donations come from Robert Wood Johnson Foundation (RWJF), a private foundation that is dedicated to improving the health of all Americans.

In regards to the grants, RWJF program officer Chinwe Onyekere stated:

We have been actively working in this area since 2004. Over this time, we have heard repeatedly that there is a need for stronger evidence that games can improve health and healthcare and support the growing realization that games can make a real difference in public healthcare in the United States.

Our vision is that in the coming years we will have a thriving marketplace of well designed, compelling interactive games that draw on this evidence base to become highly engaging and effective tools for improving the health and healthcare of Americans.

The 12 teams are currently working on projects that focus on different age groups and behaviors. Maine Medical Center, for example, was awarded a grant for its study, “Family-Based Exergaming with Dance Dance Revolution (DDR)”. The aforementioned game, DDR, is extremely popular with children and young adults. It involves moving on a small, portable dance floor while a video with instructions plays on the screen.

Research grants were dispersed by RWJF in order to study things like “the potential of physical activity video games to serve as innovative, cost-effective ways to help people recover motor skills after experiencing a stroke” or “health impacts of online mobile mini-games for people with type 2 diabetes.” Another group of 12 research grants will be awarded next year.

By-line: Heather Johnson is a regular commentator on the subject of CNA Classes Online. She welcomes your feedback and potential job inquiries at heatherjohnson2323 at gmail dot com.

American Cancer Society on YouTube

I think it’s interesting to see how the American Cancer Society is using YouTube to create a call to action both around the election, the uninsured, and other issues.

Our First Think Different Event

Today was our first Think Different event in Boston. This is a road show we are doing around our new positioning and how health care companies need to get outside the box to improve the effectiveness of their communications. It has four external speakers plus our CEO.

[Spoiler Alert: If you are attending an upcoming session, I may reveal some of the content here.]

I missed ½ the session today due to a client call, but I will be at 3 of the other 5 events. In listening to the first two speakers, I jotted down a few thoughts.

From Kinney Zalesne:

  • She spoke about moving to the Starbucks economy and how we have much more choice today in what we do, who we love, religion, and our gender. Everyone immediately thinks of gender meaning sex change operations, but the point here is that there is a group of people who don’t want to be forced to select a gender identity. Before you discount it, you should know that 100 corporations, 75 colleges, and 8 states now ban discrimination based on gender identity. This was a bit of a surprise to me, but when I was talking with a large health plan about this, they informed me that their new EMR (electronic medical record) allowed for 5 possible gender options.
  • She talked about people basically starving themselves to focus on the theory that has been demonstrated in animals, but not yet in humans which says that by eating 30% less calories you can extend your life by 40%. (Not something I will be doing.)
  • She talked about the Do-It-Yourself (DIY) Doctors which are the people who use the Internet to self-diagnose and treat the MD as an ATM for drugs (i.e., I need a prescription for simvastatin can you please write it for me). I have heard a lot of talk recently about the changing perception of physicians. I haven’t seen the statistics, but one person said that they have lost the most respect over the past 20 years than any other profession. I think Kinney’s point is more about them moving from being a supervisor role (i.e., you should do this) to an advisor role (i.e., thanks for your opinion…I will take it into consideration).
  • Her statistics about 5M working retired (i.e., >65 years old) and 2M working teens (i.e., using the Internet to make money before they leave high school) says a lot about how benefit design will need to change. The implications on needs and flexibility (e.g., imagine two primary addresses for snowbirds) could be significant.
  • In her talk about micro-targeting, my mind drifted to a few thoughts:
    • How has gas prices changed our opinion of other costs? A $15 copay used to be equal to 7 gallons of gas. When it only equals 3 gallons of gas, do we view the $15 differently? [Have you caught yourself saying gas is only $3.75 at this one station near my house?]
    • Just like your segmentation can change in healthcare, it is important to consider the macro-economic and political environment when communicating. Have you listened to all the car advertisements lately…they all talk about gas mileage?
    • If you need a simple example of why personalization matters, think about buying a car. I am not a mechanical person so if I came in and someone talked to me about horsepower and cylinders then I would be turned off. I care about comfort and low maintenance.
    • Finally, getting back to health, I thought about how difficult it is to be successful. Let’s assume there were 10 primary reasons for non-adherence and 3 primary channels for delivering information (live, letter, automated call). In this case, you have 10% chance of hitting the right message and a 33% chance of using the right channel (i.e., a 3% chance to be successful).

From Liz Boehm:

  • She shared a lot of great facts about patient awareness of technology and how adherent they are.
  • She points out a scary fact that while our health care needs are going up with the boomers we simultaneously have an issue with health care workers retiring which will only make things worse in the short term.
  • She showed that 47% of people had visited their health plan’s website. [I will have to push her on this data since I believe they visited, but I think the percentage that log-in and use the site has to be very small. I would estimate 10-15%.]
  • She talked about use of social media and gave an example of a MySpace group on diabetes.
  • I found the discussion on wellness very interesting where she pointed out that things like chocolate, riding an elevator, or for some smoking gives you an immediate positive feeling while dropping your cholesterol by 10 points or even trying to lose 1 pound per week is pretty abstract.
  • I have talked about loss aversion several times, and she talks a lot about it. Using it to make a link to why incentives matter in health care.
  • Talking about motivation, I like her point that it isn’t a reasonable suggestion if you can’t achieve it. It may make good clinical sense to have a BMI of <25, but for someone with a BMI of 31, perhaps setting a goal of 28 is more reasonable and not as discouraging.
  • In her talk about trust, it made me wonder how many people that work for managed care companies and pharmacy benefit management companies reveal that fact at cocktail parties. I am not talking about professional networking events, but your neighborhood events. Do you say who you work for and address their comments about service and/or coverage issues?

I finished my client meeting in time to hear Stan Nowak, our CEO and co-founder, speak and tie together the different points of view with some potential actions that people could take. As he often does, he talked a lot about the power of data and the fact that what’s new to health care is often old in other industries. We are an industry with the most data about people, but the least ability to use it effectively.

It’s also interesting to hear him talk about some of the “data exhaust” that is created by the analysis that the team does. These are facts that get revealed which may be surprising and may be things you never even thought to look for. For example:

  • Patients with emphysema are 40% more likely to engage in a communications program related to additional coverage than patients with migraines.
  • Patients with uncommon names are 18% more likely to complete a healthcare survey than those with common names.
  • Males with depression are 83% less likely to do pill splitting than females with depression.

Skin Cancer Widget

I get a lot of solicitations to talk about products on the blog. I also get a lot of general e-mails. The ones I generally respond to are people giving me a heads up about an article, press release, technology, or something else that I just wouldn’t have known about. That doesn’t mean I will do anything about it, but if I have time and find it interesting, I will usually click through the link. And, if it still catches my attention then I will write about it.

This one is fairly self-explanatory, but I found it interesting. VisualDxHealth has built a widget for you to self-diagnose your skin cancer. Which, according to the statistics they sent me, is valuable since 1 in 6 Americans will develop skin cancer and the survival rate is high when found and treated early.

The Recognizing Skin Cancer widget interactively provides information about the different types of skin cancer and includes a visual identification quiz that tests the user’s knowledge about recognizing the signs of these conditions.

Unfortunately, I can’t add widgets and other code to my blog or I would have lots of these types of cool things on the site.

Wii Fit: Using Technology To Teach Wellness

I talked about the Wii a few months ago when we first got one. At the time, I didn’t know that Wii Fit was coming.

This past weekend we happily bought it, and I enjoyed it. It tells you your BMI. You can do yoga. You can do aerobic exercise (running, hula hoop, step aerobics). You can do agility exercises (downhill skiing, tight rope walking). I was a little skeptical, but I have been fascinated by the Wii so far.

And, I loved the fact that my 6 year old could get into it. She loved that once you put in your height, and it calculates your weight that it changes your Mii (avatar) to reflect your likely dimensions. She spent lots of time on the yoga moves that I probably never could have gotten her to do in a traditional forum.

This creative use of technology gives me a lot of hope for how we can teach our youth, drive rehab programs, and impact people.

Now what I am looking for is when will we see a competition to lose the most weight only using the Wii for training.

Groups And Microsegments

When I was listening to Kinney Zalesne (Microtrends author) present this morning at our Think Different event, there were several things that crossed my mind:

  1. Which micro-trends am I part of?
  2. How much micro-targeting is too much?
  3. Will consumers self-identify into groups?

Without going back to the whole book, I can think of several micro-trends with which I associate:

  • Marathoning
  • Stay-at-home worker and extreme commuter
  • 30-winker (don’t sleep a lot)
  • DIY Doctor (research my own care)
  • Pet Parent (pamper my dog)
  • Video Game Grown-ups (enjoy playing Wii w/ and w/o my kids)
  • Blogger

It has come up in the past two sessions where I have seen Kinney present. The question is how much is too much. Just because I know that you like cats, subscribe to Popular Mechanics and GQ, and have 3 siblings, should I use that information?

  • I certainly think that more targeting is better although I might not always want you to tell me how much you know about me.
  • You have to be flexible enough to allow for mistakes in interpretation and/or not too presumptuous. (For example, one of our co-founders is from Brazil but has been here for years. He recently started getting all of his communications from a few companies in Spanish. He didn’t opt-in, but they assumed his last name meant he spoke Spanish (which is not what they speak in Brazil BTW).)
  • You have some issues of parity which must be either addressed or are legally required (i.e., you may have to treat everyone in a similar way). I am sure we might all like to drive high satisfaction for healthy members to increase their retention, but this deliberate adverse selection would be an issue and abuse of information.

Finally, there is a lot of discussion about capturing preferences (i.e., I prefer calls over letters) and how to segment populations. I think there is an interesting trend in social media for people to self-identify into groups. For example, I pulled up my LinkedIn profile to look for a second at all the groups to which I belong. The same thing is happening in Facebook. Until recently, this was not a huge driver of activity, but over the past 6 months, I have noticed people forming and joining groups. We want to be associated with certain things. I think if I knew how the information was being used that I would spend a few minutes during enrollment filling out information about how and when to communicate and interact with me. I think I would even reveal my Myers-Briggs category (INTJ) if it helped someone better deliver information to me that would make me healthier.

The younger generation is rapidly becoming used to revealing lots of information about themselves. I don’t think that things are considered as private as they once were.

Express Scripts Settlement on Statin Switches

I don’t know the insider details, but I am certainly familiar with the original program in 2005/2006 which targeted users of 3rd tier branded cholesterol (statin) drugs to get them to move to a lower cost agent which could either be a brand or generic drug on formulary (obviously wanting it to be the generic).

Apparently Express Scripts settled with 28 states for $9.5M associated with their program.  I would guess there were several issues:

  • Switches within this class might require follow-up physician visits and/or lab work to be done.  That could increase copays for the patient and/or drive up plan costs.  How clearly that was explained could be an issue?
  • Depending on timing some of these switches might have occurred right when Lipitor was moved off formulary.  It would have then been more expensive for the plan sponsor, but I believe all the clients would have signed off on this knowing that they would save money over the initial 12-month period.
  • Depending on when this is from, they moved Lipitor back on formulary for 2008 which might mean some people were bounced around different formulary agents.  (But, I can’t imagine this was already identified and settled.)

It basically appears to be a communication issue.  Was the right information disclosed to the right person at the right time with the right amount of detail?  And, even if it was, is it worth fighting it?

From a patient perspective, I would hope that this doesn’t prevent my health plan / PBM from reaching out to me to tell me how to save money.  I spend a lot on health care each year and hate to believe that there aren’t ways to save money.

From a PBM / plan perspective, I wouldn’t be discouraged.  This just continues to clearly layout the rules about what needs to be done.  There are still plenty of opportunities, but they need to be designed the right way with the right information included in the communications.  There is nothing there that is not achievable or unreasonable.

Missing The First Step

When I saw Forrester’s data around Personal Health Records (PHRs), it reminded me of one of the facts we struggled with around increasing mail order utilization…most people didn’t know what it was or whether they had it as a benefit.  (From their Q2 – 2007 Social Technographics Online Healthcare Survey)

So, given all the buzz about PHRs and which one will work and what needs to be included, I wonder if we often miss the first step as people in the industry.

The first step in any “marketing” or communication approach has to be to build awareness.  Although it might sound great to say that I have 80% of chronic drug users that are aware of their mail order benefit using mail order, I am not maximizing the size of the pie.  (I.e., 50% have chronic medication x 50% aware of mail x 80% use mail = 20% penetration)

Are You Going To AHIP Institute 2008?

Are you going to the AHIP (America’s Health Insurance Plans) Institute 2008 event in San Francisco in June?  I will be there and would love to connect.  Just let me know.

Additional Blog Site

I got asked to contribute to the Drug Safety Hub Blog and just posted my first entry there on patient’s awareness of technology solutions around pharmacy.

Book Review: Health Care Reform Now!

Health Care Reform Now! A Prescription For Change is the latest book by George Halvorson (CEO of Kaiser Permanente). I have been talking about it and using quotes from it for a few months. I finished the book a few weeks ago and figured that I better carve out the time to capture my thoughts now.

First, if you are looking for a great book on why healthcare is a big issue in this election, you don’t have to look any further. As someone running one of the biggest healthcare entities in the US, George clearly knows what he is talking about and speaks from a position of authority. I know that he has talked with all of the candidates about their policies.

If you are in healthcare and trying to be a catalyst for change, you have to read the book. It is pointed, opinionated, and supported with lots of facts and examples. If it doesn’t make you want to change what we have, I would be shocked. Some of the examples of mis-alignment are scary.

Some of the facts he shares:

  • Family health insurance rates in CA already exceed the per capita income of 147 countries.
  • General Motors now spends more money on healthcare then on steel.
  • Nearly 50% of the time, patients in the US are receiving less than adequate, inconsistent, and too often, unsafe care.
  • Healthcare costs are unevenly distributed in America.
    • 1% of the population uses 35% of the healthcare dollars
    • 5% uses 60%
  • Care linkage deficiencies abound – and can impair or cripple care delivery.
  • Economic incentives significantly influence healthcare.
  • Systems thinking isn’t usually on the healthcare radar screen.
  • Most of our costs are for chronic diseases – primarily diabetes, congestive heart failure, coronary artery disease, asthma, and depression.
  • Prevention is a lot less expensive than addressing these chronic diseases at their late stages.
  • The US ranks 35th in the world in infant mortality.
  • We could cut the complications of diabetes by 90% with best care and involved patients.
    • We could cut second heart attacks by 40%.
    • We could cut school and work days lost because of asthma by 90%.
  • Incentives work…yet while we have 9,000 billing codes for procedures and services not one of them is for curing someone or improving someone’s health.
  • There is up to a 60% difference in the 5-year mortality rate for breast cancer patients, depending on which hospital’s surgery team did the surgery.
  • 1 in 10 doctors use electronic medical records (EMR) and only 5% of hospitals use computerized physician order entry (CPOE). This means our history exists mostly in paper files with no standards.
  • Almost 50 developing nations have higher immunization rates for preventable childhood diseases than the US.
  • The Institute of Medicine showed that it takes “seventeen years before a proven new technique becomes the standard of care in a given medical specialty.”
  • There were 2,000 published clinical trials in 1985 and 30,000 published in 2005. (Can your provider really keep up without an electronic system?)
  • Diabetes is the number one cause of new blindness (90% preventable) and foot and leg amputations (85% preventable). It is the number one co-morbidity associated with death from heart failure.
  • Asthma causes – 2M emergency room visits, 500,000 hospital stays, 5,000 deaths, and 14M lost school and work days per year.
  • The vast majority of asthma attacks can be prevented.
  • If Americans were 5-10% thinner and walked just 30 minutes per day, the incidence of Type 2 diabetes could be cut by more than half. (Culture and incentives matter)
  • We spend $250,000 every minute on heart disease.
  • More than 15M Americans have depression…and on average, people with depression have 3 other chronic diseases.
  • A 10% reduction in spending for the top 0.5% of patients would create enough savings to fund universal coverage for the uninsured.
  • The most expensive acute conditions are cancer, maternity, and trauma care. (Acute conditions account for 30% of the health care spend.)
  • The median life expectancy across the 117 cystic fibrosis centers is 33, but it is 47 at the highest performing center. (This seems embarrassing that there could be such a difference here.)
  • US employers pay an average of $6,600 Per Employee Per Year compared to $600 in Canada.
  • 4% of people believe they have insurance…but they don’t. (Who are these people?)
  • Government pays 44% of the healthcare bill today; employers 26%; and individuals 30%.

Key Point – I think everyone wishes that we could address the uninsured and underinsured issue here in the US. It is ridiculous. But, I think most people feel it would further complicate the economy and be a downward drag. George presents a good case that today’s model simply cost shifts so that we are paying for care but paying at the high cost of emergency care not preventative care for those people. In the book, they say that this cost represents $922 per employee today in what is paid. Someone has to pay the providers for these real costs that they incur and can’t recoup. We could cover the costs of the uninsured without any real increases in costs.

Some of my favorite quotes:

  • “We don’t really have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited Microsystems, each performing in ways that too often create suboptimal performance both for the overall health care infrastructure and for individual patients.” (introduction)
  • “Performance reporting that actually exists about either processes or outcomes is almost always regarded in the current culture of American health care as an onerous, externally imposed burden, extraneous and irrelevant to the actual business and profession of care delivery.” (pg. 23)
  • “I do not want ‘rules-based’ medicine. I do want accountable care.” (pg. 29)
  • “Process reengineering will not happen on any scale in health care until there is a financial reward for doing just that.” (pg. 33)
  • From the book Escape Fire: Designs for the Future of Health Care by Don Berwick – “A patient with anything but the simplest needs is traversing a very complicated system across many handoffs and locations and players. And as the machine gets more complicated, there are more ways it can break.” (pg 86)
  • “We need highly credible doctors, nurses, and health educators talking to patients in targeted and effective ways to help people make the lifestyle changes necessary to avoid diabetes.” (pg 117)
  • “Health care can be improved. The challenge is to do it consistently and systematically, not incidentally and haphazardly.” (pg 122)
  • “Improving care by 50 percent for diabetics is wonderful, but not as wonderful as reducing the number of diabetics by 50 percent by preventing the disease.” (pg 206)

Comments:

  • He talks about studying the international models and that none of them are the same. They have all been individually developed to fit the culture and needs of the country.
  • He talks about creating a “patient-centered American health care marketplace”.
  • He is careful about not just pushing the Kaiser model of vertical integration. He focuses on virtual integration which is more achievable.
  • More care is not better care.
  • He gives several examples of how following best practices for evidence based medicine improved outcomes but reduced revenues for the providers which is a hard model to sell.
  • He compares HEDIS scores (which measure how often health plans offer care that complies with best practices) with Six Sigma:
    • Average performance for screening for colorectal cancer is 49% (or 1.5 sigma).
    • Recommended treatment of acute depression is 61.6% (average) and 70.8% (90th percentile) which are 1.8 and 2.1 sigma performance.
    • Note: 2-sigma performance means 308,000 cases of non-compliance per million patients…6-sigma means only 3.4 cases per million.
  • He talks about the fact that 5% of patients experience an adverse drug event. I think the PBM industry has consolidated a lot of data to minimize this, but I am surprised more people don’t talk about samples here. Although they are supposed to track samples, I bet most physicians don’t record them in the chart and they certainly aren’t electronically managed to look for potential drug-drug interactions. (In my opinion, there is still opportunity for improvement, but it is at the pharmacy level not the provider level.)
  • He proactively addresses one major excuse about controlling patient behavior. Yes…we can’t control the patients, but we can make sure that the right events happen to align them for success.
  • I like his suggestion that a personal health record could be a more logical first-step than a full blown EMR solution due to costs and ability to execute.
    • “That personal health record data set for each patient should show all care received by that patient, all prescriptions paid for, all tests given, all diagnosis made, and all providers who delivered care to each person as a patient. The information should be in an easy-to-use format and available to each patient on demand, either electronically or on paper.”
  • He provides a good, quick comparison of PHR and EMR:
    • EMR has the exact Rx dosage and level. PHR may just have the name of the drug.
    • EMR will have the x-rays and scans. PHR will just say the date the test was done.
    • EMR will have notes from physician visit. PHR will just know the patient visited.
  • Preventing a CHF (congestive heart failure) crisis might only generate $200 in billable revenue while treating a crisis creates $10,000 – $20,000 in revenue. (And, we really wonder why people aren’t acting preventatively.)
  • Preventative care makes me think of two examples:
    • People have to want to be healthy and manage their risk. I know numerous people who are told to be on bed rest when they’re pregnant that don’t listen to their physicians.
    • People have to know there is not a risk of discrimination. I know a friend with MS who didn’t go see a doctor for several years until she had found a job with good health insurance.
  • He talks a little about it, but I think the issue of helping patients evaluate trade-offs is a big one. Enabling them with information is important, but how do we help them compare two treatments based on both outcomes and the experience (i.e., pain, functionality). Is it always better to simply live longer even if you have limited functionality and are always in pain?
  • He talks about plan design with some very good insight:
    • Deductibles only work if the unit of care being purchased is less than the deductible.
    • Deductibles tend to discourage chronic patients from getting preventative and maintenance care.
    • Percentage copays only work on big dollar differences. Otherwise, paying 10% more of a drug or office visit that costs $20 more is only $2.
  • In talking about plan design, he talks about something that in pharmacy is referred to as Therapeutic MAC. (MAC = maximum allowable cost) This allows patients access to any drug, but the plan only pays for the lowest cost drug which produces equal outcomes. Therefore, a patient might get the first $70 of any office visit covered, and they pay the difference. Then they care about where and when they go to the doctor.
  • For all the talk about price transparency and driving decisions, he makes a great point that this is thrown out the window at times. For example, when you are having a heart attack, you don’t have time to research your options and make tradeoffs.
  • Kaiser saw first-hand what happens after seniors pass a cap on prescription coverage (pg 137):
    • 18% started skipping doses of medication
    • 9% increase in ER visits
    • 13% increase in hospital admissions
    • 22% increase in mortality
  • He talks about 8 developments that have made health care reform possible:
    • Common provider number
    • Computerized databases
    • Electronic claims data portability
    • Government transparency about payment data
    • Universal awareness of the quality issues
    • Buyers are ready for change
    • Internet functionality used for care
    • Lawmakers are ready for reform
  • He talks about blending virtual care and live care with a technology infrastructure which I think makes a lot of sense. I wonder how we change physicians to be more comfortable with the “DIY” (Do It Yourself) patient that comes in with lots of information and suggestions from other caregivers or even getting “second-guessed” by the rules engine of the EMR.
  • He talks about health care needing a Target, Best Buy, or Wal-mart to manages the buy and sell side of health care.
  • (I am going to massively over-simplify this) He talks a lot about having the buyers issue an RFP requiring certain things and creating a new type of entity – the Infrastructure Vendor (IV). “The IV should facilitate and operate electronic connectivity support tools for the patients and caregivers and should demonstrate their effectiveness to the buyers.”
    • He doesn’t see the government playing this role which limits who could do this nationwide.
    • Conceptually, I agree that a technology backbone that connects everyone would be key.
    • It sounds a little too build it, and they will come to me. This is a radically and risky change that would need everyone on board.
    • Some mandated change at a government level has to be required.
    • Could you do this at a state level first?? For example, I know a coalition that got all the employers to agree to a RFP and moved all their business to Humana for one area after they won the RFP.
  • At many points in the book, I kept thinking about the need for SLAs (service level agreements) on outcomes. (I haven’t studied the capitation modes tried in the US years ago, but there seems to be something there about paying a provider a fixed amount per year. Their job is then to act preventatively.)
  • I am a fan of using incentives and penalties in the system with one caveat. I think you need to tie this to genomics. So, someone who has high cholesterol based on their family history and tries to treat it shouldn’t be treated the same way as someone who eats junk food all the time with no family history.
  • I think making people buy-up to different providers or drugs works great for events that can be planned, but not for emergency. It would be possible to tell which one was which with a fully integrated system. Of course, you have to manage people not gaming the system, but that is where there should be incentives for being preventative. Trading off metrics in your design to balance behavior will be key.
  • Another sad fact that he relays toward the end of the book is some of the data pointing to the racial and ethnic disparities in coverage and care in the US.
    • The death rate from asthma for African American children is 4x the death rate for white children.
    • Minority Americans make up ~ 1/3rd of our population but over ½ of the uninsured.
  • One thing I didn’t see or get was whether any of the international models that he studied had a focus on outcomes.
    • I thought one interesting point he made that in a government system where votes are at stake there is a strong focus on primary care which is used by the masses (i.e., more votes) versus specialists which are used by the minority of patients. Another example of how incentives skew solution design.
  • I am always shocked when I see the Federal Poverty Guidelines. How does someone survive on $9,800 or $20,000 for a family of 4? If you ever wonder how all the tasks get done around you and still feel like addressing the uninsured and underinsured is an issue, you should try to live on that income.

My summary after reading the book was:

  • Wow! We have a lot of work to do.
  • We can make a difference pretty easily.
  • There are three things that matter – infrastructure, incentives, and culture.
  • Employers have to be willing to push incentives or penalties to their employees. The strategy of lowering costs without “disrupting” people doesn’t work.

Go read the book. Help make a change.

Medco’s Trend Report

Medco‘s Trend Report recently came out for 2008 (which looks back at 2007). Here are some of the graphs and information from it.

“Generic drugs have been a tremendous asset in controlling runaway health care costs,” Medco Chairman and CEO David B. Snow Jr. said. “Generic cholesterol medications have helped contain our drug trend to a new all-time low of 2.0 percent. Patients and our clients are reaping the benefits of generics as we enable them to hold down costs and make prescription drugs one of the few areas where spending trails overall health care inflation.” (Source)

  • Drug trend was 2.0%.
  • They talk a lot about what drives trend by class.
  • It shares a lot of tables and charts. (I pulled out those below that most interested me.)
  • They talk about legislative and technology issues / opportunities such as e-prescribing.
  • They talk about consumer driven health plans (CDH):
    • Lot of plans offering them; low adoption (2.6M members)
    • Mail order use is only 1.2% higher and generic use is only 1.0% higher (so much for easy ways of saving money)
  • They talk about the rapid growth of people using social networking tools to learn about diseases and medications.
    • Which presents risks and opportunities

  • They introduce a new metric…the Generic Opportunity Score.
  • They introduce a new topic to me which is “adjunct therapies”. The key to this topic here is whether plans should consider coverage of over-the-counter (OTC) drugs that are prescribed for use with prescriptions to treat a condition.
  • They talk about Medicare driving a focus on quality.
  • They talk about coverage for the uninsured.
  • They talk about biosimilar drugs (aka – biogenerics).
  • The talk about genomics (i.e., personalized medicine).
  • They talk about BTC (behind-the-counter) and OTC (over-the-counter) trends.
  • They talk about nanotechnology.

I didn’t read it word for word, but it seems to cover the landscape well and give good easy to read metrics with lots of charts.

Walgreen’s Trend Numbers

I think the next thing I need to do is put all this data side-by-side, but in the interim, here is some recent data from Walgreens:

  • Highly managed plans had a -0.07% pharmacy trend last year. (I think we started this breakout of trend numbers back in 2005 at Express Scripts.)
  • Total drug trend was 5.66% (based on all clients)
  • They had a generic dispensing rate of 61.2% (or 69.6% incuding Medicare)
  • They state that a 1% improvement in generic utilization equals a 2% savings in plan cost

“The outstanding -0.07 percent trend for highly managed plans demonstrates the effectiveness of our cost-containment strategies and illustrates the enormous impact our plan management options can have,” said Richard Ashworth, executive vice president, Walgreens Health Initiatives.

They also say their Trend Report will be available in early summer. (link will be good then)

Morning “Excitement” and Vultures

I got up early this morning to catch the first flight out of Logan. (Even for a morning person, it is hard to set my alarm for 2:30am.)

As I was waiting in line at Starbucks, the person behind me fainted while he was on the phone. I must admit it was a little scary. He was awake but twitching and hardly responsive. After a minute or two, he sat up and seemed okay so we helped him stand. (Probably a mistake in retrospect.) He immediately collapsed again hitting his head for the second time. We were able to brace his fall somewhat, but he seemed to be having some type of seizure. His tongue swelled up and was stuck between his teeth (making me realize that I have no idea what the right protocol is here). He then started to vomit.

At this point, I am holding this guy’s head and hoping that some emergency help comes before I see somebody die in my hands. It seemed like it took forever, but someone came. No one really seemed interested in what I saw instead relying on the individual to answer questions (which was only possible since one of the Starbucks employees spoke Spanish and English). The man only spoke Spanish and was traveling alone to go back home. To the best that I could figure out, he was a 61 year old male on several medications which he kept all together in a pill bottle so they weren’t sure of his condition. They were keeping him overnight in a hospital here.

It made me think of a lot of questions which I am sure are going through his head:

  • How do I contact my family? (I think the Starbuck’s employee called them.)
  • How do I pay for this care? I don’t have health insurance in the US.
  • What happened to me? I can’t imagine that he knew.
  • How am I going to get home? Will I get a new ticket or have to pay for it?

A few lessons for all of us on having emergency contact information and lists of allergies, conditions, medications, etc. with us. (or a case for some type of personal health record accessible by medical professionals)

The most amazing part to me was people’s focus on getting their Starbucks. The area is roped off with a man on the floor, vomit on the floor, a policeman, airport personnel, and two EMR people. Regardless, people were trying to go around them to get to the register to order. When they started to wheel the man out on a stretcher, I saw one man go in and actually step over the EMR people who were sitting on the ground where the man had been 30 seconds earlier.

They definitely needed a big neon sign that said to go someplace else for your caffeine. (There is a Dunkin Donuts less than 100 yards away.)

Silverlink HealthComm Behavioral Index

Although this new index was released in a story a few weeks ago, the official press release should be out this morning. It has been interesting to watch this transform from a concept to an initial survey with some data.

What is it? The Healthcomm Behavior Index is a quarterly survey of 1,000+ commercially insured adults in the US that measures the effectiveness of healthcare communications. It focuses on three areas – personalization, satisfaction, and action.

What are some of the key findings?

  • Effective healthcare communications (i.e., targeted and personalized) have the potential to build member affinity, loyalty and trust, and significantly drive behavior change.
  • There is a direct relationship between healthcare behavior change (the willingness to take action) and how personalized and satisfied members are with their healthcare communications.
  • Respondents are generally lukewarm on healthcare communications and there is significant opportunity for health plans to improve the effectiveness of their communications programs.
  • Unlike other consumer industries, demographics are not as predictive
    of healthcare behaviors.
  • The single most consistent
    determinant of healthcare behaviors is health status.
  • Unhealthy members (those who arguably use health benefits more actively) are the least satisfied and the least likely to take action. These are the members who are the most costly to the health plans so if the plans improve the effectiveness of their communications, they will be able to drive behaviors within this segment and thus have the opportunity to significantly reduce healthcare costs.
  • Seniors are more satisfied and take more action relative to other age groups. This was a counter-intuitive finding as it was assumed that seniors as a whole would have a higher percentage of ‘unhealthy’ members. However, we found that people tend to rate their health status relative to their age.

What are the conclusions? Personalized healthcare communications leads to better satisfaction which leads to a higher likelihood that a healthcare consumer will take action relative to their healthcare behaviors. To most effectively drive member behavior, health plans should micro-segment their populations and deliver extremely targeted and personalized communications programs.

I found the most interesting fact to be that those who took action were the most satisfied with their healthcare communications and felt that they were personalized to them. Digging in a little on the research process, those terms were based on questions that addressed the following:

  • Took action = acted on information + adopted a healthier lifestyle + improved my health
  • Satisfaction = got the right amount of communications + easy to understand + timely + useful
  • Personalization = trust the communications + specific to my needs + treat me like an individual

It will be interesting to see how we can use these results with clients to create a benchmark, compare them to a national average, and then look at how self-reported data correlates to claims data. Ultimately, this could prove to be a defining moment in creating the business case for why healthcare communications are so important beyond the obvious – patient satisfaction, lowering inbound call volume, driving behavior, improved profits, etc.

Literacy and Consumer Empowerment

A few of the highlights from external speakers at the Spring client event for Medco included:

Helen Osborne talking about the “Prescription for Savings: Using Health Literacy Principles in Your Communications.”

  • Finding the right words for the best reasons
  • Not about dumbing down but about smartening up
  • Health literacy is a shared responsibility between patients and providers and each must communicate in ways the other can understand.
  • Age, disability, language, cultural barriers, emotion, and literacy all come into play
  • Eight ways to improve health communications:
    • Know your audience
    • Tailor communications
    • Create a welcoming and supportive environment
    • Communicate in whatever ways work
    • Confirm understanding
    • Offer ways to learn more
    • Weigh the ethics of simplicity
    • Collaborate for good communication
  • Keep things clear, simple, and written for the end-user

“You need to develop an allergy to miscommunication and then turn that allergy into advocacy.”

Steve Case talking about streamlining healthcare by empowering consumers:

“I believe there is a degree of skepticism about managing one’s health, but we need to spend less time on the public policy debate and more time on how to change consumers’ thinking about health.”

  • It may take time for consumers to get fully invested in the notion of taking charge of their health
  • It took nine years for AOL to get its first million users and then rapidly jumped to 25M

“We want to engage people on the Internet and move them from a static situation, where they only go online when they have a problem, to a situation where they go back more habitually.”

  • Many employers are frustrated with their attempts to get employees involved
  • Revolution Health is working more with employers, hospitals and providers
  • Revolution Health is now the top visited site (passing WebMD in January)

Most Medicated Generation

Well, we have finally broke the 50% mark of people using maintenance (or chronic) medications. It shouldn’t be a big surprise. Sit around the table with your friends and ask who takes a medication (without asking what for). Why do so many people take medications:

  • We are in worse health…think obesity.
  • There are better medications.
  • Doctors are more willing to prescribe.
  • Patients know more about using medications through DTC (direct-to-consumer) advertising.

This is all according to a Medco report that was just published looking at a sample of 2.5M customers of all ages from 2001 – 2007. A few of the facts:

  • 2/3 of women 20 and older take maintenance medications.
  • ¼ of children and teenagers take maintenance medications
  • 52% of adult men take maintenance medications
  • ¾ people 65 or older take maintenance medications
  • Among seniors, 28% of women and 22% of men take 5 or more maintenance medications

“Honestly, a lot of it is related to obesity. We’ve become a couch potato culture (and) it’s a lot easier to pop a pill” than to exercise regularly or diet. (Dr. Robert Epstein, Chief Medical Officer at Medco)

Dr. Epstein makes the point that in some cases we have turned diseases that were once a death sentence into chronic conditions – AIDS, some cancers, hemophilia and sickle-cell disease. I was just talking about this yesterday with a nurse about an adherence program where I said we needed to look at some specialty drugs because they are being used chronically.

The biggest jump was in the 20-44 year old age group where utilization grew 20% mainly for depression, diabetes, asthma, ADD, and seizures.

Medco estimates about 1.2 million American children now are taking pills for Type 2 diabetes, sleeping troubles and gastrointestinal problems such as heartburn. (This should be troubling to everyone in terms of the long-term implications to our health care system.)

The Brand Only PBM

A few years ago, I would have argued that PBMs could one day simply cover generic drugs and not cover brand drugs.  With most therapy classes (excluding specialty) having multiple generic options, this seemed possible.  Already, some companies have generic fill rates which are above 70% (meaning that 70% of all prescriptions filled are filled with a generic).

But, now I am wondering the opposite.  If retailers drop generic drugs to $4 and make them available in 90-day supplies for $10 (see Wal-Mart), do you need to PBM in the middle managing those claims?

There are of course several questions to be answered:

  • What percentage of the total generics filled in the market are available at these prices?
  • What happens with new generics that typically have a higher price for the first 6-months?
  • Do these claims still get processed so that they show up in the PBM claims database to be used for drug-drug interactions?

And, Wal-Mart upped the ante here including over-the-counter drugs which typically aren’t covered by insurance.  We aren’t there yet, but it poses an interesting question about the future breadth of coverage and what the implications could be.  Today, most PBMs don’t make money on the brand drugs other than perhaps an administrative fee paid by the pharmaceutical manufacturer for those drugs that are on formulary.  (Something in the range of $1-$5 per claim depending on the cost of the drug and the contract.)

It would turn the market upside down also since a lot of the intervention programs today are in place to drive use of generics as first-line therapy so if they weren’t part of the benefit then the programs wouldn’t have as much value.

Just a thought.  BTW – I have asked the Wal-Mart people to answer the last question above for me since I am interested in whether this is a real issue today or whether most of these claims get paid out using the U&C (usual and customary) field and logic in the POS (point-of-sale) system (i.e., they process as paid claims not cash claims).

Pharmacy Satisfaction Did You Knows

PharmacySatisfaction.com puts out a weekly factoid. They are very interesting and make some great points. I have talked about it before, but here is an updated list with the new factoids from 2008.

  • Independent drug stores continue to score highest in customer satisfaction, followed by food stores, clinics, and chain and mass merchandise pharmacies, in that order.
  • The number one concern across all pharmacy users is that their prescriptions are filled accurately.
  • Independent pharmacy customers are the most satisfied with the services their stores provide.
  • The most useful feature those Web sites offer to them, the survey found, is the ability to order refills online.
  • Nearly three in 10 order their refills online.
  • An average of 69.4% of customers own or use a computer.
  • Customers average three visits each month to their pharmacy.
  • Only about 1-in-5 pharmacy customers, overall, say that they use a loyalty card that provides points, discounts or other savings.
  • While the majority of loyalty card users are satisfied with the expected cost savings by using their card and with the ease of enrolling and understanding the benefits of their card, fewer than 1-in-4 card users are highly satisfied.
  • The drug store industry remains largely up for grabs, with nearly half of pharmacy customers saying they use more than one pharmacy to fill prescriptions.
  • Pharmacy use varies considerably by population. Chain pharmacies are most commonly used among residents of areas with more than 100,000 people. Independent pharmacies are most commonly used among rural respondents (areas with less than 100,000 people). Use of independent and mass merchant pharmacies decreases as population increases. Chain, food store, mail/online, and clinic pharmacy use tend to increase with population.
  • However, as pharmacy customers age, they are much less likely to use chains and considerably more likely to use mail/online and clinic pharmacies.
  • Seven-out-of-ten pharmacy customers indicate that they “definitely would” or “probably would” use their local pharmacy if they could receive the same amount of medication at the same price as their mail-order pharmacy.
  • The heaviest users of prescriptions are survey respondents in their 60s, averaging 5.4 new scripts and 29.2 refills per year.
  • The most preferred method for filling those prescriptions among respondents is to take them to the pharmacy and wait for them to be filled.
  • Indeed, physically handing a paper script to the pharmacist or tech in the store—or picking up a script phoned in by the doctor—remains the overwhelming choice among consumers. Most shun the use of drive-through windows.
  • How long patients have to wait for their scripts to be filled is a key component of customer satisfaction.
  • Fully 93 percent of those surveyed expressed satisfaction with the ability of pharmacies to dispense their new prescriptions in the time promised.
  • Pharmacy customers’ most commonly preferred method of refilling prescriptions (assuming prices and amounts of medication are the same) is calling an automated telephone system and picking up prescriptions at the store.
  • Independent customers are the most likely to receive prescription refills in less than 15 minutes, followed by food store, chain and mass merchant customers.
  • The average survey respondent is spending a considerable sum each month on drugs at their pharmacy—$82 on average (versus $57 a month on food and groceries at their pharmacy).
  • Customers who paid full retail price for their medications, paid an average of $81 for their most recent prescription.
  • Customers who paid the store discounted amount for their medications, paid an average of $75 for their most recent prescription.
  • Customers who paid a fixed-percent co-pay for their medications, paid an average of $56 for their most recent prescription.
  • Customers who paid a fixed-dollar co-pay for their medications, paid an average of $36 for their most recent prescription.
  • On average, respondents spend $82 a month at their pharmacy on prescription drugs, $57 on food/groceries, $18 on non-prescription (OTC) drugs and $14 on personal care/cosmetics.
  • An average of 85.9% of computer owners/users use the computer to improve their health by looking for information about diseases.
  • Much has been written about the value of closer pharmacist-patient relationships, but Americans seem to feel far more connected to their physicians, dentists and nurses than to their pharmacists. That’s clearly not all pharmacy’s fault; the same survey respondents agreed that they were usually given the opportunity to speak with their pharmacist when filling their last prescription. What’s more, pharmacists ranked a close second to doctors as sources of information about medications.
  • Only 16 percent of respondents describe their relationship with their pharmacist as “We are on a first-name basis and have known each other for a very long time.”
  • Walgreens’ “Dial-a-Pharmacist” initiative, launched in February 2006, allows non-English speaking patients to connect with pharmacists speaking 14 different languages.
  • Doctors (94%) are the most commonly referenced source of information on medications, followed by pharmacists (83%), nurses (57%), pharmacy brochures (50%) and the Internet (42%).
  • Doctors (77%) are the most trusted source of information on medications, followed by pharmacists (64%), nurses (43%) and pharmacy brochures (20%).
  • Independent pharmacy customers have the most trust in pharmacists, while mail/online customers have the least. Compared to last year, customers of all types of pharmacies place more trust in their pharmacist as a source of information.
  • More than one-third of pharmacy customers failed to fill all their prescriptions last year, and only 35 percent of all respondents said they were fully compliant on the medications they did take. Nevertheless, refill reminders from the pharmacy remain relatively rare, most patients profess.

2008 Factoids

  • In general, older patients tend to be more compliant than their younger counterparts.
  • The biggest reason for not taking all medications as directed was simply, “I forgot.”
  • Nearly 2-out-of-3 (65%) indicate that they missed a dose or took less medication than prescribed in the past year.
  • The most commonly cited reason for not filling all prescriptions is not needing (42%), followed by too costly (27%), changed by doctor (20%), side effects (17%) and insurance did not cover (16%).
  • Among the medical conditions displayed, those treated for HIV/AIDS and high blood pressure are the most likely to have filled all of their prescriptions in the past year. Those treated for RLS are the least likely to have filled all their prescriptions in the past year.
  • For competing pharmacy providers, satisfaction is a key measurement. Customers who say they are “highly satisfied” with their pharmacy are much more likely to return than those who are simply “satisfied.”
  • Pharmacy customers who are “highly satisfied” with their pharmacy overall are considerably more likely to have positive return intentions, compared to customers who are simply “satisfied” (97% definitely intending to return versus 65%). Survey results have also shown significant revenue differences between highly and poorly rated pharmacies, health plans, and PBMs.
  • Compared to last year, pharmacy customers place more importance on four of the six overall areas of pharmacy services—most notably professional services — followed by pricing and insurance, and overall convenience.
  • 31% of customers consider it “very important” that Pharmacists give advice on OTC/herbal products.
  • 38% of customers consider it “very important” that Pharmacists give advice on health conditions.
  • 57% of customers consider it “very important” that Pharmacists are friendly and courteous.
  • 65% of customers consider it “very important” that they are able to speak to a Pharmacists give clear instructions about Rxs.
  • 65% of customers consider it “very important” that they are able to speak to a Pharmacists about their concerns/questions.
  • 66% of customers consider it “very important” that their pharmacy protects the privacy of their health info.
  • The most common ailment that drives customers into your stores is high blood pressure, which afflicts nearly 50 percent of the respondents surveyed by WilsonRx. High cholesterol, allergies, ailments of the esophagus, arthritis and diabetes also are extremely common among patients.
  • When asked about their satisfaction levels, respondents who received birth control prescriptions were happiest with the medical treatment they’re getting, followed by those thyroid disorders, epilepsy/seizures and type I diabetes.
  • Among the pharmacy services customers say are most important to them is: Help untangling complicated insurance issues, and money-saving alternatives like generic drugs.
  • Consumers are generally satisfied with many of the services, medicines and health-oriented advice they find at their local pharmacy, but they’re also keenly aware of the high costs of pharmaceuticals and quick to shift outlets if they feel their needs aren’t being met.
  • Those who are covered by prescription plans—including nearly 39 million Medicare patients enrolled in some kind of coverage—often feel overwhelmed by the complexities and co-pay issues they encounter at the pharmacy counter.
  • Know your customer — whomever, wherever they are. Being able to identify different customer types is an important first step in anticipating customer needs and managing the expectations of each person.

Are You Doing Enough To Drive Generics?

From the Express Scripts Outcomes event a few weeks ago, here is an estimate of all the money left on the table by not increasing your generic fill rate in certain key categories.  Are you doing enough?

  • Utilization management programs – step therapy, prior authorization, quantity level limits?
  • Formulary coverage?
  • Plan design incentives?
  • Pharmacy incentives?
  • eRx messaging?
  • Web tools?
  • Patient communications?
  • Patient incentives?
  • Driving people to mail?

Here is a graph from CVS/Caremark‘s trend report from last year that shows correlation between certain programs and generic fill rate.

Incentives and Communications

Everybody looking at the healthcare system understands that incentives and alignment of goals is a critical component for successful change.

  • Providers need to be motivated to focus on wellness and prevention.
  • Individuals need to be motivated to care about the cost of care and to act in a healthy manner.
  • Pharmacists need to be motivated to take the extra action of moving patients to lower cost agents, resolving administrative edits, and counseling patients.
  • Hospitals need to be motivated to focus on Six Sigma type process initiatives.
  • Health Plans need to be motivated to invest in long-term care initiatives that prevent people from getting sick.
  • PBMs need to be motivated to drive optimal prescription use even if that includes more over-the-counter (OTC) drugs.
  • Employers need to be motivated to offer benefit plans to cover their employees which are simple to understand and align employees with healthy outcomes.
  • Pharmaceutical manufacturers need to be motivated to drive adherence across clinical conditions and to bring new drugs to market that represent significant improvements in therapy (better outcomes, less side effects, easier deliver methods).

With that in mind, I am glad that Silverlink Communications announced this morning that we are partnering with IncentOne to incorporate incentives into our communication programs.  Going forward, incentives will offer us another lever to improve outcomes in our programs that we conduct for clients.

“If applied appropriately in healthcare, incentives are an influential lever to motivate healthcare behaviors, arguably the most powerful force for changing the economics of healthcare,” said Stan Nowak, CEO and co-founder of Silverlink. “We’re excited to be partnering with IncentOne to design highly flexible, personalized and incentive-driven outreach that enables health plans to better connect with and engage their members to drive healthcare behaviors and reward them at the same time.”

“This is a truly integrated technology partnership that seamlessly connects healthcare consumer participation to incentives,” said Michael Dermer, CEO at IncentOne. “Silverlink and IncentOne together can deliver complementary solutions that drive participation and ultimately cost savings in healthcare. The combination of our expertise in finding the right incentives and Silverlink’s personalized communications to drive consumer behavior delivers the ability to implement more effective programs.”

Matthew Holt (author of The Healthcare Blog) did a podcast with both the CEOs yesterday that you can listen to to learn more.

You can also look at a study by Hewitt Associates of large employers which covers several related topics:

  • 2/3rds plan to offer incentives to motivate sustained health care behavior change.
  • 67% will utilize health care data and measurements to drive their organization’s health care strategy.
  • 74% of employees think their employer should help them understand how to use their health plan better.
  • 12% of employees think employers should help them become healthier.
  • Employee decisions on healthcare were influenced by cost:
    • Nearly one-third (30 percent) said they did not go to the doctor when they were sick because of cost.
    • 27 percent didn’t fill a prescription given by a doctor.
    • Almost one in five (19 percent) stopped taking medications before their prescription ran out, and of those, 18 percent did so due to finances.

Certainly, there are numerous examples of incentives being used to drive behavior.  Moving patients to evaluate mail order pharmacy has been a solution where coupons have been used over th years.  Driving therapeutic conversions have used incentives in the form of copay waivers.  Getting patients to complete health risk assessments (HRAs) and other tools have given incentives.

The interesting component will be the personalization of incentives.  While I may enjoy a $10 gift card to the dog store, my wife may enjoy a $10 gift card to the spa.  Flexibility of incentives and alignment of incentives with what drives behavior will be important.

Addressing Medicine Adherence

There are numerous studies on this, but they all point to the same issue…compliance.

The National Council on Patient Information and Education (NCPIE) released a report last year that I just came across titled “Enhancing Prescription Medicine Adherence: A National Action Plan“. With only 50% of patients using medication as prescribed, the systemic costs are enormous – $177B annually according to their estimates.

“Besides an estimated $47 billion each year for drug-related hospitalizations, not taking medicines as prescribed has been associated with as many as 40 percent of admissions to nursing homes and with an additional $2,000 a year per patient in medical costs for visits to physician’s offices.”

  • Between 40% and 75% of older people don’t take their medications at the right time or in the right amount.
  • As few as 30% of adolescents take their asthma treatments as prescribed.

Look at this in light of the recent study that showed about a quarter of people share drugs.  Another huge problem.

Their 10-step national action plan includes:

  • Elevate patient adherence as a critical health care issue
  • Agree on a common adherence terminology that will unify all stakeholders
  • Create a public / private partnership to mount a unified national education campaign to make patient adherence a national health priority
  • Establish a multidisciplinary approach to compliance education and management
  • Immediately implement professional training and increase the funding for professional education on patient medication adherence
  • Address the barriers to patient adherence for patients with low health literacy
  • Create the means to share information about best practices in adherence education and management
  • Develop a curriculum on medication adherence for use in medical schools and allied health care institutions
  • Seek regulatory changes to remove roadblocks for adherence assistance programs
  • Increase the federal budget and stimulate rigorous research on medication adherence

I am a little surprised that they didn’t talk about technology.  Integrated electronic medical records, personal health records, etc.  Since at least 1/4 of people don’t even fill their initial script, I don’t see how we can address adherence without beginning there and providing full lifecycle data to physicians about the status of scripts and refills.  I think there is also a huge role for collecting data about why people fill or don’t fill.

Poor Health Plan Satisfaction Due To Poor Communications

JD Power just finished their second annual National Health Insurance Plan Study which looks at member satisfaction.

“The study finds that the majority of health plan members rate their insurer lowest for the communications and information that are provided to help them understand their plan. Only 45 percent of members reported they fully understand how to use their health insurance coverage and member services. Enhancing member understanding with critical plan details—such as prescription coverage, co-pays, how to locate physicians and how to appeal coverage denials—can lead to higher satisfaction ratings for insurers.”

They evaluated 17 regions and publish reports like the following:

Information and communications is the third largest driver of health plan satisfaction at 17%. The only two things above it are coverage and benefits (#1) and choice of physicians, hospitals, and pharmacies (#2). So, it makes a great case for why communications is something to invest in and focus on. It drives satisfaction which drives retention. Additionally, it is something through which you can create sustainable differentiation. Benefit design and network size are pretty easy to copy.

Health: A Luxury

With rising food costs and constantly increasing costs for health insurance, could health become a luxury? It’s an interesting (and sad question).

Let’s take a pessimistic view of the situation for someone living in poverty:

  • Fast food is probably cheaper than many health foods.
  • The working poor likely have less time to exercise and no money to belong to a gym.
  • The working poor may have more than one job to make ends meet and/or may work in an environment which is hazardous to their health.
  • Financial stress could impact sleep which impacts obesity.
  • Access to quality health providers may be limited based on location and/or access to transportation.

I saw an article in the Philadelphia Inquirer about this, and it made me think. Talk about a long-term crisis. This is a great rallying call for why reform is necessary.

Does Social Media Help With Retention?

Lois Kelly posted an interesting entry on her Foghound blog about the Catholic Church beginning to use Social Media.  This is an obvious reaction to the statistics she quotes about retention of active membership.

As she asks, the true question is whether tools themselves can impact this or whether the message has to change also.

On the other hand, it also makes me wonder what we are waiting for in healthcare relative to social media.  If a conservative organization like the Catholic Church can embrace it, why aren’t we jumping into it more aggressively.

Five Ways To Recognize the Best Doctors

An average visit to the MD lasts less than 20 minutes and when you ask questions, you are interrupted in 18 seconds (see article).

Is this a fulfilling experience? I think they forgot to add the time you wait to get in the office and the lost opportunity cost for many of us (i.e., what else I could do with that time)?

“On the one hand, there are claims that doctors or drug companies are evil and dishonest. On the other hand, news reports describe triumphs of modern medicine in curing disease and improving quality and quantity of life,” says Dr. Brown in his new book, Navigating the Medical Maze: A Practical Guide. “How can so many seemingly intelligent, caring people reach such different conclusions? The solution is teaching people how to sort through conflicting advice so they can arrive at the best choices for themselves and for their families.”

I haven’t read the book yet, but I have a copy of it. I have a few things in front of it, but I did get this article from Dr. Brown that I thought I would post here.

Five Ways to Recognize the Best Doctors
By Steven Brown, M.D., PhD.

Doctors are just like any other group of people. Some are good, some are bad, and some are mediocre. How can you be sure you are getting one of the good ones? Rate your doctor in these five areas and see how he stacks up.

1. Thoroughness
The best doctors want to get your whole story. The first time she sees you, she (or her staff) should get your whole medical history, not just the details of the problem that brought you in that day. Since the parts of our bodies are all connected, problems in one part often relate to another part, even if the connection is not obvious to the layperson.

2. Communication
Does the doctor take time to listen to your story? Does he take time to explain the problem and answer your questions? Do you have to sit in front of the door to keep him from leaving? Doctors today are under considerable pressure. Costs of practice are rising, and payments from insurance companies are falling. Since doctors are paid based on how many patients they see, the only way to maintain their income is to see more patients in less time. If the doctor takes the time you need, that shows that he has decided to make less money in order to take better care of you. That is the kind of doctor you want.

3. Knowledge
Does your doctor know what she is talking about? When you ask why she is recommending one treatment over another, does her answer reflect knowledge of the medical literature? Is she threatened by questions, or does she welcome them? By the way, it is a good sign, not a bad one, if the doctor tells you she needs to look something up. That shows that she is humble enough and careful enough to check for the latest facts.

4. Self-sacrifice
If you need a doctor who does a lot at the hospital, such as a heart doctor, a lung doctor, or a surgeon, make friends with a nurse or secretary at the hospital. Ask them what doctors answer their pages quickly. Some doctors call back in less than a minute. Others take two hours to call back despite multiple pages. A doctor who cares about his patients will call back right away. He wants to know what is wrong, and he wants to do something about it. His patients are more important to him than his other activities. This exemplifies self-sacrifice. We all want a doctor who makes us a priority. If the doctor is in a specialty that does not go to the hospital, look for other evidence of self-sacrifice. Your friends may be able to tell you stories about a particular doctor who went the extra mile to help them.

5. Character
The single factor that ties these areas together is the doctor’s character. Anything you see that suggests poor character is a reason to go elsewhere. Has the doctor had any serious issues with your State’s Medical Board? You can find out by going to their web site. Does she treat her staff badly? Does he treat you and others with respect? If a doctor does not have good character, at some point it will affect his decisions. As vulnerable as we are to our doctors, we cannot afford that risk.

Anything that shows good character, for example doing well in the areas above, is a reason to overlook minor annoyances, such as an unpleasant receptionist. Having a doctor with good character is also more important than bedside manner. Some doctors may not seem particularly warm or friendly, but they exhibit the attributes we have discussed.

Fortunately, there are not a lot of truly bad doctors out there, but there are a lot who are mediocre. If your doctor does not show these traits, try to find one who does. If your doctor does show these traits, rest assured – he’s a keeper.

Dr. Brown is the author of Navigating the Medical Maze: A Practical Guide. He is a cardiologist in private practice, and is also a Clinical Associate Professor of Internal Medicine at Texas Tech University. He is a contributor to Chest, Circulation, and other health journals. For more information, please visit www.drstevenbrown.org.

College Grads On Work Hours

As you can tell, I have been slow on the posts lately…too much work. Today (for example), I have a breakfast meeting in Boston, an afternoon meeting in Minneapolis, and then fly to Phoenix for a morning meeting on Wednesday. Crazy day.

But, all this made the USA Today Snapshot in Section B catch my eye. It was an Accenture College Senior survey about how many hours they expect to work in their first job (post graduation). What would you guess? I would have said 50-60 hours especially when you’re in your initial job and proving yourself.

I at least find this surprising. What are the 5% doing that work less than 30 hours per week? And the 41% that think they are working between 31-40 hours per week. These are college graduates most of which I would think are taking salaried jobs.

Robot Animals

In the spirit of research, I found this an interesting article. It talks about using robotic squirrels to infiltrate the squirrel population and learn about their communication techniques, social queues, and survival instincts.

“Animals and humans are all affected by behaviors, body postures and signals from each other that we may not be aware of.” Sarah Partan, Asst. Professor in Animal Behavior at Hampshire College

Obviously, I don’t think we are going to build robots that mimic humans and get responses, but it is often hard to fully understand the situation response that you get especially since so much of an individual response if framed by past experiences. But, that being said, my one takeaway (other than general interest) was the need for thinking holistically about multiple channels (e.g., web and chat) or sonic branding (i.e., the voice delivering the message).

Shared Savings With The Patient

Shared savings is always an interesting idea. It is often something that companies look at in a business to business relationship. What about health plan or employer with the patient? Is this an avenue to drive smarter decisions?

The whole theory behind consumer directed health care is making the consumer more responsible and aware of cost. [Although I will continue to argue that the original premise years ago was about driving quality of care not simply cost effectiveness.] But, clarity around the total long-term cost of a healthcare decision is not always readily apparent. In a best case scenario, I may understand the cost of a provider compared to another provider, but do I understand their comparable outcomes and those implications on longer terms costs…NO.

Pay-for-performance is something being tried (not for the first time) in healthcare. But, I don’t hear anyone talking about incentivizing the patients. If they go to the clinic instead of the Emergency Room, why not give them 25% of the savings generated. If they use self-service (i.e., the Internet) versus calling a live agent, why not give them points towards a healthy reward? There are a few innovative models being tried, but it is certainly not the focus. The focus is on making them pay the first X thousand dollars out of pocket with limited information. Transparency and access to data in a real-time setting is critical. I should be able to text message Google and say compare price of Dr. Smith versus Dr. Adams or Hospital A versus Hospital B and provide me with their comparable outcomes for my disease.

Perhaps the bigger question is whether or not incentives can be a key element in any structural re-design of healthcare. We know that providers clearly aren’t aligned to provide preventative care in most cases. If they treat you and educate you to not get sick, you don’t come into the office and you don’t need surgery. It’s great for the health plan, but it reduces provider (i.e., MDs and hospitals) revenue and drug company revenue. I am sure I am not the only one who sees that that is a problem.