Archive | June, 2008

Why Can’t I Go To Any Physician?

In pharmacy, there is a rarely used benefit structure called Therapeutic MAC (Maximum Allowable Cost).  What this does is say that in any class of drugs (e.g., cholesterol lowering drugs) there is a maximum amount of money that will be paid by the plan.  But the individual can get any drug.

That can be controversial since a patient could end up being required to take a more expensive drug by their physician costing them a lot of money.  (Although most pharmacy plans allow for a clinical prior authorization in cases like this where they might pay less.)

My thought is why not do the same thing at least for physician visits.  If my health plan simply published statistics that said they will pay $100 for any visit to a physician’s office.  I could then go to any physician and that physician would know they were going to get $100 for my visit plus whatever they charge me.  It would eliminate a whole process of constantly managing the network and focus patients on the price that their physician charged.

I am sure there is something that I am oversimplifying, but it seems logical.

Would You Pay $100 To Be Told To Take Your Rx?

We know adherence is a serious issue that drives healthcare costs.  And, as I have talked about a little here and a lot with many of our pharmacy clients, it’s not a simple issue.  People aren’t adherent for a variety of reasons – cost, side effects, health literacy, or simply just forgetting (among others).

There are lots of tools out there to help you organize your medications and manage them.  Whose job is it to help you – yours, your physicians, your managed care company, your pharmacy, your pharmacy benefit manager?  Obviously, you (the patient) have the primary responsibility.  After that, your pharmacy is best positioned to help you with this.  But, the managed care company stands to benefit the most by preventing serious medical conditions associated with non-compliance.

So, I was a little surprised to see a new company come up that offers to send you calls, e-mails, or text messages to remind you to take your medications.  And, you can even talk to a pharmacist.

Let’s break this down:

  • Whatever pharmacy you use (mail, retail, specialty) will offer you consultation with a pharmacist for free.
  • I believe most pharmacy benefit management (PBM) companies offer automated e-mail reminders that you set up yourself off their website for free.

I don’t know why I as a consumer would pay for this.  And, it seems pretty high for a managed care charge.  If I went to a client of ours and told them I would send messages to patients for $100 PMPY (per member per year), I think they would choke on that price tag.

So, will it work??  Who knows?  I have been surprised by business models before.

Dental Experience

I am a big believer in the fact that the experience matters for healthcare.  From my architecture days, this means physical space, sequence of events, bedside manner of the staff, clarity of communications, and processing of the claim (at the simplest level).  Everything that the patient experiences as associated with an event drives their satisfaction.

So, I was pleasantly surprised taking my daughter to the dentist a few weeks ago.  We had gone to a “kid’s dentist” before which was an hour away that I thought did a good job (although the kids hated going).  But, this one was over the top.

When you walk in, the entire room is covered with art (e.g., there is a giant Spiderman climbing on the ceiling).  There are video game stations in the corner.  There is a large flatscreen TV playing a slide show of pictures of the kids coming to visit that day.

And, it doesn’t stop there.  Each room is decorated.  The staff talks to the kids (more than the parent).  Every tool and process is explained to the kids in simple terms.  They sometimes give out balloons.

Just something to think about when you try to look at things from an outside-in perspective.  How is the patient experiencing your service?

Genetic Art

I was reading about this company DNA 11 the other day, and I found it a pretty cool concept. They take your DNA and make it into art focusing on the 1% that is unique. According to the article in American Way magazine, prices ranged from $390 to $1,200 with 25 color options or the ability to request a custom color (to match your sofa perhaps).

They can do pets, fingerprints, and lip prints.

A Few New Blogs

I always enjoy coming across new blogs with interesting articles. Here are a few that I found yesterday and added to my blogroll:

The Health As Human Capital Blog (sponsored by a company described as “dedicated to providing better information for better decision-making in health care and business”)

The Doctor Comes To You Blog about the onsite healthcare industry

Medication Non-Adherence Blog by Alex Sicre who comments on my blog often

LinkedIn Question On HealthComm

I think it was earlier this year when LinkedIn rolled out a new feature called questions which allows you to pose questions to LinkedIn users and get answers. I continue to like this tool, and it has been interesting to watch it evolve from a “startup” (when I joined there were less than 2M members) to a tool that well over 10M people use and has gotten lots of press.

I finally decided to pose a question:

Do you have any good (or bad) examples of healthcare communications? I am looking for how your healthplan, disease management company, pharmacy, or PBM communicates with you. What worked or isn’t working? This could include letters, websites, phone calls, social media, etc. Examples might include communications around moving you to a 90-day prescription, moving you to a generic drug, improving your awareness of a disease, addressing compliance and adherence, reducing your out-of-pocket costs, etc.

I received four answers:

Answer One: I had some great success marketing to Medicare members by conducting health and fitness seminars as well as bring in experts to discuss retirement and other topics of interest. Initially, I’d obtain a 3% response through postcards and an additional 1.0% through phone calls. Conducting a series of seminars in one area can also bring in additional attendees (0.5%), through word-of-mouth buzz.

I found seminars to work well because the attendees were getting something of true value for their time (information and a social event with their peers) and I had a captive audience to market. A win, win situation.

Answer Two: My experiences with Blue Cross have been pretty good, there’s the health mag they send out with information articles, etc. I’ve never been able to access the website services though, something to do with the number that CS can never work out though I’ve tried on several occasions. I love my primary doctor and feel she and her partner give excellent care and plenty of information to their patients. They’re the only ones who’ve ever given me a reading list and web printouts! It was just a general question I had, not a condition I suffer from.

In addition to other tasks, I handle the health documents for the children enrolled with us and find that often the doctors have done a very poor job in informing the parents of what to watch for, what a result means, etc. Their offfice staff often do a shoddy job of filling out the forms correctly. Last month I recieved paperwork for a child, the physical form stated passed 20/20 for vision, it was accompanied by a referral from the doctor for a full eye exam as the child had failed the eye test miserably! I once received a normal hearing result for a child we knew was deaf as a door nail. When trying to get an insurance company to cover a needed service or therapy for such is incredibly difficult with that kind of paperwork.

Thanks for the opportunity to raise awareness!

Answer Three:

Aetna sent me a letter suggesting several plan options that may be cheaper than the one I currently have. That was a positive. I wish that I could compare the plans side by side on the website. It is difficult to remember the details of each one as you look at them individually.

Answer Four: As a health promotion practitioner, we are at a time when the national consciousness of health has never been higher. The most important thing we can do at a workplace is create individuals and systems that are health literate. We spend enormous amounts of money in our wrongly terms “health care” system. What we actually have is a “sick care” system, and what is truly missing are incentives and action by companies to recognize the billions of dollars we could save and then return to economy by protecting our workforce with sound health promotion. Our children are contracting early onset adult diabetes and we commonly refer to our bleak situation of the obesity epidemic. Our “health care” system, and thus the traditional “disease management” is from a biomedical chronic disease model.

It is time to work at reducing costs related to health care and absenteeism from a proactive rather than reactive approach. Many companies and organizations provide services that have yielded significant economic returns from building well companies.

According to the the NIH, most people are unhappy with our current system, and unable to continue to straddle the costs of ever increasing health care. We can avoid chronic disease by acknowledging new paradigms of business operations that include well companies. For information, contact

Tier Zero

Frank Koronkiewicz, the Director of Pharmacy, at Blue Cross of Northeastern Pennsylvania (BCNEPA) just launched a new plan where people can get 65 different generics focused on chronic diseases at no copay AND without any premium.  It’s called Tier Zero.

Frank has always been a progressive Director of Pharmacy.  We worked on several programs together at Express Scripts.   You can also find some of their collateral and videos on generics on their website – click here.

It would be interesting to look at the overlap between these drugs and the Wal-Mart list of drugs, but I think you would find that an individual could have a pretty comprehensive benefit of generic drugs between these two solutions with low out-of-pocket (OOP) costs and no increase to their medical premium.  A compelling story to many.

Three Sad Healthcare Stories

First, I think this is a very disappointing article about workplace violence in the healthcare industry.  I certainly could believe (unfortunately) in the verbal violence since people are very emotional about their healthcare and often stressed over the financial implications and unintuitive processes.  But, this story has some scary statistics which are an issue at a time when we need more healthcare service workers.  [Ask your friends in the industry.  I plan to.]

  • Health care workers are 16 times more like to face violence at their job that workers in any other service-oriented profession.
  • More than 50 percent of reports of aggression in the workplace come from the health care sector.
  • Over 9,000 nurses and other health care workers are verbally or physically assaulted on the job every day, according to the National Institute of Occupational Safety and Health.
  • A 5-year survey of 170 university hospitals showed that over half of all emergency room employees had been threatened by weapons.
  • Almost 90 percent of nurses in every specialty said they were verbally assaulted during the past year and almost 75 percent claimed they were physically attacked, according to a study published in The Journal of Emergency Nursing, which related reports of 100 percent verbal and 80 percent physical assault rates for emergency room nurses.
  • Almost half of all psychiatric physician residents reported an assault during their career and other medical residents in the hospital setting reported a 16 percent assault incidence.

The second article which I read which I think is also sad is about the rise in seniors filing bankruptcy. Sometimes, seniors don’t even have enough resources to install stairlifts in their homes. Not only is it disappointing to see people reach retirement only to have their dreams dashed away from them with crashing house prices, rising food prices, rising gas prices, and lower return on their investments, but they are facing huge healthcare costs that are pushing them over the brink.  22.3% of the bankruptcy filings in 2007 were from seniors.  We also know that even without filing this stress can get people to skip medications or not take care of themselves only worsening their health.

The third story which I saw on CNN this morning was about a group of high school girls making a pregnancy pact.  Talk about a need for sex education and health literacy.  It’s one thing to happen by accident and quite another to intentionally put yourself in that challenging situation of getting a high school diploma and raising a child.

Diabetes or Depression: Which Comes First

Since many of us understand the risk of co-morbidities (i.e., two diseases that commonly exist together), I think it makes a lot of sense to ask this question.  Dr. Gupta from CNN had an article earlier this week on his blog about a study that was recently out on the relationship between diabetes and depression.

  • Those that started with depression but no diabetes had a 42% higher risk of developing diabetes during a 3-year period.
  • Patients with type 2 diabetes but no symptoms of depression were 54% higher risk for depression during that same period.

St. Louis – Less Beer More Health

Here in St. Louis there has been a lot of upset people about the potential buyout of Anheuser-Busch by InBev.  Isn’t that business?  Don’t the shareholders want to maximize their return?  Of course, we have lost several big companies to international entities which obviously changes the dynamics, charity support, and other things but isn’t that part of globalization.

So, I was a little surprised (not totally) that the WSJ blog talked about St. Louis moving more toward high growth health care than slow growth manufacturing companies.  St. Louis has been trying to drive a bio-tech focus now for many years, and it has the headquarters (or large presence) of several healthcare companies:

And, there are numerous smaller companies and healthcare start-ups here.  According to the St. Louis RCGA’s information on the BioBelt area here, we have more that 15,000 employees and 400 companies in this life science space.

Brand Prices Up; Generics Down

For those of you who are interested in this type of stuff, I think the AARP Watchdog reports (Brand Report, Generic Report) which track prescription drug prices over time are pretty interesting.  (Note: This is for drugs most commonly used by Medicare recipients, but I think you’ll get the point.)

Why People Choose Mail Order Pharmacy?

I was looking for something else in the Express Scripts Drug Trend Report 2005 when I came across this study referenced on page 209. I should have remembered since I wrote this section (yes I was a contributor see page 332). This is a Morgan Stanley study which talks about why people choose mail order pharmacy. Of course, the primary reason here is savings. The more savings the higher the likelihood of a person moving to mail order. This is a factor of savings per Rx multiplied by the number of maintenance drugs that an individual has that can be filled at mail order (or home delivery). This study shows the frequency of the response. If you focus on the weighted scores, you would see a dramatic cliff after savings. (I.e., 61% of people may choose mail for convenience, but they are much less likely to do it than someone with significant savings) So, why don’t all PBMs communicate exact patient savings to each individual? It’s hard. Given minimums and maximums; deductibles; percentage copays; and other benefit plan designs, the systems are stressed to produce this.

Sprint Response

Just to continue on the Sprint story I posted the other day. The response time to get a live person was 5 days (but only 3 business days). I then received an e-mail and a voicemail message. Interestingly, when I call back the individual’s direct dial number (nice), her voicemail says “from the office of”. I am not sure if I will get the context to help relay my story to healthcare, but I look forward to the conversation.

Good afternoon Mr. Van Antwerp,

I am certainly happy to hear that you are enjoying the simply everything plan. I called and left you a message on your voice mail with my contact information. If you would like to call me that would be just fine. I am here Mon-Fri from 8 AM to 4 PM eastern time.

Thank you for your loyalty. We really do appreciate it. Have a great evening.


Her Name

Sell Your Captive PBM – Why?

I was a little surprised by the quote from Lisa Gill from JPMorgan Chase about why health plans should sell their in-house PBMs (Pharmacy Benefit Management):

“I think it makes a lot of sense for PBMs [pharmacy benefit managers] to be sold or spun off as a stand-alone business. The only time it will make sense for a managed care company to actually own a PBM is after they move to real-time [medical] claims processing. And that’s not going to happen near term.”

Maybe I am missing some context here, but I don’t understand.  Why would you have a “captive” PBM (i.e., owned by a managed care company)?

  • Able to align total healthcare interests (e.g., drive Rx usage up to manage ER visits)
  • No conflicts of interest (real or perceived)
  • Able to keep margins of the PBMs (look at the stocks of Medco, Express Scripts, and CVS Caremark)
  • Manage the customer service experience

What does any of this have to do with real-time claims access?

Why would you use a standalone PBM?  (Again an easy decision)

  • Economies of scale on rebates
  • Mail order pharmacy efficiencies
  • Manage capital outlays
  • Get a dedicated focus on pharmacy which as only 10% of the total healthcare spend will be a stepchild under a managed care plan no matter what
  • Best practices being leveraged across companies

And, we all know from bidding on RFPs that managed care companies use this service to win business talking about the integrated solution and underwriting pharmacy with medical.

If you understand the rationale here, help me out.

Express Scripts Jumps Into Worker’s Compensation

Express Scripts has been in the Worker’s Compensation space for years now.  As I suggested several months ago (see #2), buying a worker’s compensation PBM makes some sense.  The margins are good, but it does require a different service model.

That being said, they jumped in last week with the announcement to buy the worker’s compensation PBM business from MSC down in Florida.  It would have been intriguing to see them buy the other ancillary business that MSC has to get their footprint a little bigger.  Now, this can go from being someone of a stepchild for Express Scripts to a major business unit.  As Joe Paduda points out in his blog post, they have good teams at both organizations so they should be able to make some things happen in the market with a focused team, financial resources, and some efficiencies.

Given that fact that PMSI has been on the block, this may create a reason for a Coventry or a CypressCare to step in and buy them to gain more marketshare to take on Express Scripts.

A Few AIS Quotes Of The Day

I have a few more to post, but I often find their quotes interesting (

“Specialty medications require significant education for patients to feel confident self-injecting and achieve a successful outcome. For many patients, injecting a medication into the skin or muscle can be very intimidating. Because of the expense and the complexity of the medication, we cannot assume that the patient is just going to figure it out on their own.” Kari Amundson, director of specialty pharmacy services at Fairview Pharmacy Services, LLC.

“I think it makes a lot of sense for PBMs [pharmacy benefit managers] to be sold or spun off as a stand-alone business. The only time it will make sense for a managed care company to actually own a PBM is after they move to real-time [medical] claims processing. And that’s not going to happen near term.” Lisa Gill, a JPMorgan Chase analyst, speaking with AIS’s Health Plan Week about why health plans should jettison their in-house PBM units to shore up ailing profits.

“We went back and asked the 37,000 consumers we surveyed how long they had been with their last health plan, and found that the plans with the highest levels of involuntary turnover had the lowest levels of customer satisfaction.” Jim Dougherty, health care practice leader at J.D. Power Associates.

“The hepatitis C medications are pretty effective, but patients will feel much more sick from the treatment than from the disease, [so] companies that make those drugs are very willing to education patients” to improve their chances of remaining on the medication.” Mark Rubino, chief pharmacy officer at Aetna Inc.

George Paz (Express Scripts) on Adherence

Paul Levy who is the CEO of a hospital has a blog called Running A Hospital.  He posted a summary the other day of a presentation by George Paz who is the CEO of Express Scripts.  It has some good facts and there are several good comments on there about defining the terms in this area (see my old post) and whether these are reasonable rates of compliance.  There is also a patient commenting about getting nurse calls and reminder e-mails which sounds great but puts them in the 1% of the population for which this happens.

The numbers do seem understated to me – 85% compliance with cholesterol lowering drugs.  That might be the amount of people that get a paper prescription and then fill the drug or it might be the amount of people that get one refill, but I believe by month 6 or certainly by month 12 most compliance rates are closer to 50%.

There is clear value in adherence.  Everyone should (in key therapeutic categories and using evidence-based standards) want to increase adherence to reduce total medical costs.

What surprised me most recently around this was what Kaiser had observed when looking at how doctors shared information with patients (Archives of Internal Medicine, Sept 2006):

  • Only 74% of the time did the physician tell the patient the name of the prescription drug
  • Only 35% of the time did the physician discuss adverse events with the patient
  • Only 58% of the time did the physician explain the frequency and timing of dosing

A Few Blog Entries About The Think Different Event

We wrapped up the road show this week in Hartford and NY.  I missed both events to be at client meetings on the west coast (and now down south).  But, one of the presenters and someone who was in the audience posted entries on their blogs about the event:

The Automated Sprint Reply

As a reply to my e-mail (see my last posting), here is what I got.  Now let’s see how long it takes to get a real reply.

Thank you for taking the time to write.  To truly revolutionize wireless, we need your input. It’s people like you who are using our services everyday that can provide the best perspective. We’ll be looking through all the ideas and feedback we receive.

This will, of course, take some time. I appreciate your patience until we can get you a response. A representative from my office will be contacting you in about a week.

In the meantime, if you are interested in learning more about our new Simply Everything plan, you can find the details at

Once again, from all of us at Sprint, thank you.

Dan Hesse

President and CEO – Sprint

Giving Out Your CEO’s E-mail

From the perspective of soliciting feedback, how many companies post their CEO’s or anybody’s real e-mail these days? Sometimes you can’t even find a number to call on the website. You simply get some generic form to fill out and get feedback. You sent it into the black hole and wonder if you’ll ever hear.

So, given Sprint’s challenges over the years, I think it was (is) a bold move to post the new CEO’s (Dan Hesse) e-mail ( at the end of some of their television commercials. I have been using Sprint as a great example of a company building loyalty because they reached out to me recently to move me to a better plan which reduced their revenue in ½. So, to test this e-mail address, I just sent the following. I will let you know what happens.

Dan (or whoever answers these for you):

I have been a loyal customer for 15 years now with Sprint PCS. I am not sure if that puts me in a minority, but I bet it does.

I was recently impressed when you guys called me to make sure I knew about the all inclusive plan (not sure of the actual name) which was something like $99 per month. Especially, since I was spending about $200 per month before. I work for a healthcare technology company and have been using that as an example about how to build loyalty.

I would be very interested (if you can share) how you guys made the decision to “down-sell” people and whether it has had the desired effect (which I assume is less churn).

The NY Times had an article about this on 6/9/08. Apparently, the initial response is an automated reply from Sprint, but most people then hear from someone on his staff (or likely a group of dedicated customer service agents) to address their questions.

“Yeah, we were worried,” said Mike Goff, vice president of advertising and marketing communications for Sprint. The company had a reputation for poor customer service, and soliciting critiques for the new chief to read was a risk. But, Mr. Goff said, Sprint wanted to “show we were serious about our intent to improve our customer service. We knew this was happening at a time when the perception of our customer service in the market was poor, so this is a chance for Dan to hear back from the market.”

The question is whether bold tactics like this can work to help change their image. If so, maybe health plans and PBMs should start posting their Chief Medical Officer, SVP of Customer Service, and CEO’s e-mails and see what happens. I can only image the look on some of their faces of doing something like this. Even though I am sure the reality is that he has a confidential e-mail address that gets used for internal purposes and personal purposes. As the Times article says, I am sure shareholders don’t want to think that the CEO sits in front of his PC all day answering questions.

Exercise Supercenter – Lifetime Fitness

Have you ever heard of Lifetime Fitness?  I didn’t until they started building this huge facility near my house outside St. Louis.  My first reaction was that somebody had the wrong business model.  A million square foot gym in this economy.  No way.

After an initial run in with an overly aggressive salesperson, my neighbors slowly signed up after their strong marketing push.  Given that I primarily run, it seemed hard to justify, but everyone who I talked to that had been to one of their facilities raves about them.  People compare them to country clubs (other than everyone in casual clothes) where there is great service and quality design and materials.

When you review their website, you get a much different view of the company.  Not your typical gym.  The facilities include a restaurant with healthy foods, a spa, and all of what you’d expect – classes, equipment, pools.  But, they also provide corporate wellness programs.

It finally opened, and I had a chance to go there Sunday.  Very nice.  Lots of staff.  Lots of equipment.  Lots of people (but not too many).  [I have no idea what the breakeven model is for a facility but it has to be 3,000+ members.]  And, a great example of old world social networking was the fact that there were tons of people who we knew and who knew each other there.  It was a destination to be at where hanging out at the pool was a social event by itself.

Since we know that peer pressure can influence wellness, it would be interesting to study the health dynamics in neighborhoods with a Lifetime Fitness versus other gyms and versus no facility.  Could it be the catalyst or tipping point?  It’s only a couple of days in, and I am on the west coast so we will see.

More On Silverlink’s Think Different Event

I am now up in Minneapolis at our 4th Think Different event on how to engage the healthcare consumer.  I talked about the first few speakers the other day, and I finally had a chance to hear the other speakers present.  This week, I had the chance to listen to  James Taylor (of Smart (enough) Systems fame not music) and Fred Jubitz (American Express).  Here are a couple of my takeaways.

[Again, if you are coming to the upcoming events, this might be a little bit of a spoiler.]

A few notes from James’ presentation:

  • He gave a great example of a program they did at Fair Isaac where they compared the standard, baseline program with one that was highly personalized.  What was the improvement – 2,000%!!
  • He gave a good real-life example of the need for channel coordination talking about buying tickets for the Chunnel and how he got different prices on the web and phone which were also different from the prices his father in England got using the same channels.
  • The Chunnel example reminded me of something that someone told me the other day.  They were using the Dell self-service example and pointed out that Dell now uses real-time chat right before you buy.  They have found that this increases the average sale by 15%.
  • The Chunnel example also made me think about how web technology allows us to do a lot of customization by visit, but most companies don’t do this.  At the simplest level, I remember a competitor of Firepond (previous employer) where if I visited their website from work it looked one way and from home looked different.
  • James talked about ATM customization as an easy example.  How much money do you normally take out.  Only showing you services that you have access to.  Some of this is starting to happen, but not much.
  • He also talked about rules creation and how that varies.  I think it is always interesting to trace the evolution of rules and policies within a company.  Are they there because of regulatory issues?  Is it because someone coded the legacy systems that way?  Is it based on a personal interpretation?  Or are they dynamic and regularly reviewed?  One of the worse examples that I have ever seen was a large healthcare company that believed that HIPAA required them to re-code everything as it moved from development to production.  (A very costly error in interpretation.)
  • He also talked about the evolution of interactions:
    • Automate decisions
    • Apply rules
    • Segment customers
    • Predict risk and value
    • Optimize
  • James hammered home the point of never stopping to try to optimize since as the environment and your customer base change the optimal solution might change.

Fred who ran the gold and green cards at AMEX talked about:

  • American Express really wanted to be a lifestyle enabler not a payments company.
  • He talked about the Centurian Card (black AMEX card) which apparently is able to charge $5,000 initiation fee plus a $2,500 annual fee.  (Surprising that people still pay it, but I have heard examples of people buying a plane with their black card so I guess that level of service requires something.)
  • He gave examples of how companies think about cards and showed a lot of affinity cards which made me think about groups and how people like to affiliate with others (e.g., by diseases).
  • He talked about the importance of several things:
    • Know your audience
    • Key metrics
    • Segmentation
    • Personalize
    • Continuous improvement
  • He showed the standard framework for segmentation looking at size of wallet (i.e., how much you charge / spend per year) versus their share of wallet (i.e., how much of that is with AMEX).  Each box on the grid then had a strategy – invest, retain, focus, divest, etc.
  • He showed a lot about how the financial services companies can personalize the web experience, but he pointed out that this took months to develop as they built up your profile.
  • I think a key point he made relative to healthcare is that a lot of a new member’s behavior was determined in the initial months which led to how they used their card.  He gave an example of his blackberry.  The first couple features he learned are all he uses.
    • What are you doing in the initial months to “train” your members or be trained by your healthplan to use the website and leverage other ancillary services (e.g., gym membership) that they might offer?
  • He stressed evolving your segments but not starting over each year or you will lose some of the lessons you have developed.
  • Finally, as you always want to stress, he said to keep it simple.

Additionally, you can see some of Matthew Holt’s comments about the event at The Health Care Blog (here and here) and Les Masterson’s comments in The Health Plan Insider.

GINA – A Good First Step For Personalized Medicine

Whether you are a patient or a health care company, I think you should be happy about this. GINA is the Genetic Information Nondiscrimination Act of 2008 which was signed into law on May 21st. It is a good step in encouraging individuals to participate in genetic testing without worrying about that information being used against them by an employer or health plan/insurer. It also bans companies from requiring genetic testing.

Based on an e-mail I got from Fulbright (a law firm where a friend practices), they offered the following definitions:

A. Genetic Information = includes the individual’s genetic tests, the genetic tests of family members of the individual, and the individual’s family medical history. Any information related to the individual’s or any family member’s participation in clinical research offering genetic services is included as is the genetic information of any fetus and embryo of an individual or family member of an individual who is pregnant. The sex or age of the individual is not considered genetic information, however.

B. Genetic Test = any analysis of DNA, RNA, chromosomes, proteins, or metabolites that detects genotypes, mutations, or chromosomal changes.

The use of genetic information (i.e., genomics) is a key step in creating personalized medicine. We know people are different and their bodies react differently to different drugs and different treatments. Some (much) of that can be attributed to their genetic make-up and likely to environmental factors.

The future holds a lot of promise once we can delivered personalized therapy that is specific to an individual. But, no one is going to get these tests if they distrust or worry about how the information is used. I have talked about this issue before when looking at companies like 23andme.

Wisdom Of The Crowd – Socializing Wellness

You probably caught the articles last year about how obesity seemed to spread throughout social networks. Now, in an article in the Washington Post (5/27/08), they talk about another example of research showing that smoking is similarly affected by social networks. Theoretically, this research could have significant implications for using social media (i.e., Facebook, MySpace, SecondLife). I can easily imagine blogs out there following people’s efforts to lose weight or quit smoking. I can see a Facebook “badge” or “sticker” congratulating someone for not smoking.

In a study published last week in the New England Journal of Medicine, the team [Nicholas A. Christakis, a medical sociologist at the Harvard Medical School, and James H. Fowler, a political scientist at the University of California at San Diego] found that a person’s decision to kick the habit is strongly affected by whether other people in their social network quit — even people they do not know. And, surprisingly, entire networks of smokers appear to quit virtually simultaneously.

Some of the observations that they found which seem interesting included the way non-smoking spread throughout a interrelated but not always directly related group. I don’t find that too surprising. If everyone quits and it is no longer “cool” or accepted you are marginalized and likely to feel pressure to quit. This was a concern that they noted which might lead to other negative health outcomes for the group that doesn’t change.

In a small group of my friends, I have seen one person’s efforts to lose weight (which included drinking less) impact the broader group. Others lost weight. Less beer is consumed when we get together. And, there is more discussion about the gym and running and other activities. For those who aren’t interested in those topics, they miss out on part of that dynamic.

  • A person whose spouse quit was 67 percent more likely to kick the habit.
  • If a friend gave it up, a person was 36 percent more likely to do so.
  • If a sibling quit, the chances increased by 25 percent.
  • A co-worker had an influence — 34 percent — only if the smoker worked at a small firm.

“It could be your co-worker’s spouse’s friend or your brother’s spouse’s co-worker or a friend of a friend of a friend. The point is, your behavior depends on people you don’t even know,” Christakis said. “Your actions are partially affected by the actions of people who are beyond your social horizon” — but in the broader network.

“People quit in droves — whole groups of people quit together at roughly the same time,” Christakis said. “You can see it ripple through a network. It’s sort of like an ant colony or a flock of birds. A single bird doesn’t decide to turn to the right or the left; the whole flock has mind of its own.”

From a employer, health plan, or even individual perspective, the question is how do we capitalize on this? How can we create wellness programs that leverage this “viral marketing” approach to drive behavior across the “colony or flock” to quickly and efficiently drive change. Certainly, this is where I see an opportunity for some of the Health 2.0 type of companies to play a role in creating communities and enhancing dialogues on key topics to enable this process faster and make the reach broader.

NCPA Survey on Adherence

I have been talking a lot about adherence lately (or lack of). A friend sent me the results of a survey of 1,000 adults by NCPA (National Community Pharmacy Association) from October 2006. This is now the 3rd study I have read this week with different results. Of course, they all used different channels – web, mail, and phone. And, I am sure that the questions asked were slightly different.

  • While most consumers believe they are highly compliant when it comes to taking their prescription medications (64% said they follow their physician’s instructions “extremely closely”), the survey found they are not as compliant as they believe.
  • Nearly three-fourths (74%) of respondents admitted to non-adherent behaviors in the past.
  • Nearly half (49%) said they had forgotten to take a prescribed medication.
  • Nearly one-third (31%) had not filled a prescription they were given.
  • More than one in 10 (13%) had taken someone else’s prescription medicine.
  • Nearly one-quarter (24%) had taken less than the recommended dosage.
  • Nearly three out of 10 (29%) had stopped taking a medication before the supply ran out.
  • More than one in 10 (11%) substituted an over-the-counter medication instead of filling the prescription they were given.
  • Nearly four out of 10 (38%) had forgotten whether they had taken a medication.
  • Less than half of respondents (48%) said they had consulted their doctor or pharmacist before making these changes.
  • An overwhelming 90% of respondents saw non-adherence as a serious problem.
  • More than eight out of 10 (83%) respondents agree that pharmacists can play a role in improving adherence by helping to make sure patients are taking their prescription medications correctly.
  • More than two-thirds (68%) believe pharmacists are more knowledgeable than other health care professionals when it comes to information about prescription medications.
  • Two-thirds (66%) go to one pharmacy for their prescription medications, which presents an opportunity for pharmacists to advise patients how to take their medications properly.
  • Nearly nine out of 10 (86%) say they would be likely to talk to their pharmacist about their medications.

When Would I Pay More – Z-Lists and Green

The other day, someone was talking to me about the Z-List at Harvard. Basically, Harvard will allow a certain number of students to come in if their parents give $1M. Makes sense, and it allow them to provide lots of other students with aid.

At the grocery store, we pay a premium for organic foods.

We pay a premium for green buildings.

We pay a premium for energy derived from sustainable sources (e.g., wind).

Yet, in healthcare, we are always focused on how to lower premiums and/or ashamed of the constant increases.

  • Is there a place for a premium product with a different service model? E.g., no inbound IVR…you always talk to a live agent
  • Is there a place for more bundled services? E.g., vision, personal health concierge, OTCs
  • Is there a place for a wide open formulary? E.g., every drug is covered for a flat copay of $10
  • What about a preventative care plan that focused on getting you better?

The one that immediately jumped to my mind is pre-existing conditions. I am sure the underwriters could figure it out like Harvard, but why can’t I pay a one-time penalty or annually higher rates to be insured even with my pre-existing condition and maybe I can earn credits for being preventative.

It ultimately gets to the idea of personalized insurance that is specific to me where I weigh my need for simplicity, my financial assets, and my risk profile against the insurance companies underwriting model for risk management.

Variance In Children’s Healthcare

I think state-by-state variance in basic statistics is fascinating. It seems like we should have standardized around some fundamentals by now, but the variances continue to be significant.

In a recent report out by The Commonwealth Fund, it showed some wide variation:

  • Only 46% of kids visit the doctor and dentist at least once a year in Idaho, but 75% of Massachusetts children do.
  • Infant mortality rates are 2.5 times higher in the District of Columbia than in Maine.
  • Kids in South Carolina are 5.7 times as likely to wind up in the hospital for asthma as those in Vermont.
  • The percentage of children who received five recommended vaccinations from ages 19 months to 35 months ranges from 94% in Massachusetts to 67% in Nevada.
  • Utah has the lowest spending per person at $3,972. The District of Columbia has the highest at $8,295.

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PBM Satisfaction Survey

It should be out soon, and it will be interesting to see the data. The WilsonRx PBM Satisfaction Survey is the only (I think) independent survey done of the industry. [Although I never remember paying attention to it at Express Scripts.] From what I know, they seem to get a good sample of more than 25,000 responses rating 18 PBMs (Pharmacy Benefit Managers).

Some of the new factors they are including:

  • Overall Medicare costs and availability
  • Annual increases in premiums or costs
  • Overall delivery of pharmacy benefit services
  • Courteousness and helpfulness of PBM plan representatives
  • Ease and timeliness regarding conversations with a PBM representative
  • Ease and ability to access prescription records and order refills
  • Resolution of denied drug claims or appeals
  • Overall quality of care
  • Adequate coverage of treatment medication needs
  • Personalized care for Rx needs

They seem like logical factors, but some of them aren’t controlled by the PBM but by either the self-insured employer or the managed care company (1, 2, 9). Depending on the service model, several others may be done by the managed care company (4, 5, 6, 7). And, I have no idea of how they are going to gauge things like overall delivery (3); quality of care (8); or personalized care (10). I hope they at least look at how responses vary by high utilizers versus low utilizers (of drugs) along with the type of coverage (which I doubt the individual knows whether their pharmacy coverage is through Aetna’s PBM or Medco (for example)).

Walgreens Health Initiatives (WHI) won the award last year and is certainly building a very competitive offering:

  • A goal of 10,000 retail locations
  • Mail pharmacy
  • Specialty pharmacy
  • 90-day at retail
  • On-site (or worksite) pharmacy
  • PBM

“While we already knew from our own surveys that members are highly satisfied with the wide selection of innovative products and services we offer, it was gratifying to have it confirmed by an independent third-party,” according to Richard Ashworth, Pharm.D., MBA, executive vice president for WHI, a wholly owned subsidiary of drugstore giant Walgreen Co.

He believes member satisfaction ultimately boils down to choice and convenience, noting how a 90-day medication option at the retail level serves as an important mail-order alternative for those who prefer face-to-face consultations with a pharmacy team they know and trust. Of WHI’s national retail network of more than 62,000 pharmacies, more than 39,000 offer this option and the number continues to grow.

Walgreens also offers worksite pharmacies on many corporate campuses across the U.S., which encourages employees to be more proactive about their health and, in turn, helps reduce absenteeism and the overall health care spend. Serving just one employer allows pharmacists to focus solely on that particular patient population, maximizing plan design and wellness strategies as part of a tailor-made approach to comprehensive care.

Pharmacists can help engage, educate and empower employees, as well as provide informed feedback on clinical prior authorizations, therapy-specific programs or the impact of formulary changes on medication options. There’s also room for leveraging a company’s core cost-containment strategies by promoting generic utilization, formulary efficiency and other key clinical programs whether or not WHI is the plan’s PBM. (Text from article by Employee Benefit News)

The Doctor Will See You…IF You Promised Not To Critique Them

It takes a lot for me to get offended, but I find this offensive.  The WSJ Blog mentioned it this morning, and when I clicked through the links, it seems like a total disconnect with the technology world.

Medical Justice Inc. has put together a contract physicians can ask their patients to sign. In it, patients promise not to post anything about their experience, good or bad, without your prior approval. The organization calls it a “vaccine against libel.” (AMA article)

This seems ridiculous to me.  Don’t we all have reputations that we work and go to school to create and protect.  Doesn’t every business have a brand equity that they work to protect.  This is nothing new.  So trying to create a fascist environment where public comment about your services is not allowed is ridiculous.

What’s next?  Hotels that won’t let you stay there unless you don’t rate them.  eBay not allowing feedback on buyers and sellers.  Architects not letting you visit their buildings unless you promise to like them and not comment about them.

This is a new economy which is driven by consumers.  Healthcare is going to be part of that like it or not.  Patients should have choice and should have transparent access to how physicians and other providers perform.  I am not against establishing some standards in terms of how the experience is evaluated, but censoring speech seems like the WRONG way to accomplish this.

Why don’t they focus on helping the physician create a positive experience, be responsive to criticism, and get patients that like them to post their comments.  We all realize that one or two people can be negative about a person or company, but that can be outweighed by a hundred positive reviews.

Pavlovian Response To Sound

We recently got a new dog (a Tibetan Terrier), and we decided to start training the dog using the clicker method.  I kiddingly commented that it would be great to have something like this to train people.  Apparently there already is such a method, and it can be used as a teaching method for autistic children (for example) along with sports training.

Basically, clicker training is an audio reinforcement for positive behavior…think whistle with dolphins.  TAG Teach is a website where you can learn more.

What I found interesting is how to link this in with sonic branding and the Pavlovian response concept.  Could I create an audio sound that drove behavior?  For example, I have my dry cleaning dropped off and picked up at my house.  They use an automated call to remind me to set it out.  All I have to do is pick up the phone and hear the voice.  Once that happens, I know what to do and hang up on the call.

TAG stands for Teaching with Acoustical Guidance and uses a sound marker to indicate correct performance.

The TAG refers to the distinctive sound made to mark or “TAG” a moment in time. This sound becomes an acoustical binary message, a sort of “snapshot” that is quickly processed by the brain.

A TAG means “yes.” Absence of a TAG means “try again.”

The student no longer has to perform a time-consuming language analysis while attempting complicated movements. The immediacy and clarity of the feedback allows the student to form a mental picture of the movement or position.

TAG points are the individual pieces of a desired response action or position. Students receive a TAG (the click sound) when the points are correctly performed.

The set up for a golf swing may have TAG points for grip, body position, foot placement, and club placement. The swing component may have TAG points for hand, arm, and club position at the top and end of the swing, TAG points for leg position, arm position, and weight transfer during the swing. With a beginning golfer a limited set of key TAG points are defined and executed individually. With an experienced golfer a diagnosis is performed and TAG points are identified based on technique errors requiring correction.

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