Enabling Healthy Decisions

I was driving past a hospital this morning and saw several workers outside smoking.  They both looked like physicians, but I could be wrong.  Given all we know about smoking, I wondered if the prevalence of smoking is higher or lower within employees of the healthcare industry. From a quick Google search, it didn’t reveal much.

About a month ago, an analyst was asking me about the e-prescribing legislation and trends and how that would impact the financials of the PBMs. I told her that I remained a little bit of a skeptic for several reasons:

[Basically e-prescribing is the use of a handheld device or personal computer to automate the generation of prescriptions to eliminate hand writing errors and streamline the process which is a great concept.]

1. E-prescribing generally requires the use and adoption of new technology into a physician’s practice. The highest prescribers (due to their high patient load) are typically the older and more established physicians. They have the least likelihood of adopting the new technology.
2. While safety is very important to the physician, the benefit to the PBM is if they can use the technology to push plan design edits to the physician. I don’t know any physicians who want to get into a conversation about plan design with their patients during their very brief office visit. They don’t want to compare copay levels. They don’t typically want to look at step therapy, prior authorization, quantity level limits, and other edits. This would require them to educate the patient and debate their options real-time with no financial benefit to them.
3. The prescriptions could be sent electronically into the fulfillment systems for the retail and mail pharmacies, but that requires integration that doesn’t exist in many cases today and certainly doesn’t exist across the myriad of software vendors that provide this technology.
4. The technology companies have had high turnover requiring physicians to learn new systems and leaving lots of equipment sitting in closets somewhere.
5. There are funding issues of what (if any) hardware and software is needed and how that is financed. Why would a physician pay for this?

So, yes. E-prescribing is a great idea. It will come to fruition as the younger generation of doctors age. For them, technology is part of life not a new task. The first phase I see is physicians telling their staff what to enter into a web-based system or using a real basic handheld solution that cleans up the writing issues and has some basic clinical logic. I don’t see them doing much real-time integration with benefits information meaning that the 40% of new Rxs which have an edit still require work at the pharmacy.

I am playing in a golf tournament this weekend and was talking with a couple of golf pros about handicaps and rules. They were talking about people “sandbagging” their handicaps which to me implies directly trying to influence their handicaps by not recording good scores or intentionally scoring poorly. (Your handicap is basically how many strokes on average you score above par.) Since I only play 9-holes a week on average, my handicap hasn’t moved in the 3 years I have been tracking it although I have scored anywhere from an 86 to a 116 on the same course that I play. My average is 103.

I told the pro that my plan was to play two months worth of golf in the 10 days before the tournament with a hope of playing well below my handicap. He said that I would clearly get ridiculed for sandbagging if I came in 10 strokes below my handicap or something similar. It made me wonder. I don’t score well, but I play pretty well. For example, in my last round (adding two 9-hole days together), I shot +8 for 13 holes and +17 for the remaining 6 holes. (Which should play well to match play not stroke play.)

Let me compare my typical golf to my preparation this week for the tournament.

To me, this seems perfectly legitimate. I know what messes me up mentally and physically when playing golf, but between work, kids, and other activities, I usually can’t control those factors. So, is it really sandbagging if I optimize the scenario to play well.

It made me think about the whole concept of practice makes perfect (as if perfect is achievable). I have seen this several times before:

• When I went to Europe as an architecture student, I sketched all day long for 3-months. The initial drawing were horrible, but by the end, I had developed a much better eye and had improved my use of materials and colors. [Maybe I can find and post a few sketches.]

• Running is very much the same for me. If I don’t have my warm-up and get mentally in the zone, it is hard to do well. For races, I plan everything out…what I eat, what I wear, when I want to get there, drinking stops, etc.

My old boss and someone for whom I have great personal and professional respect is Steve Miller, MD who is the Chief Medical Officer at Express Scripts. I still remember the day I heard he was coming to the company and desperately trying to Google him to find out something about him. I couldn’t find anything. That has changed in the past few years. Now, you can find lots of information on him via Google as he is often interviewed and very active in Washington. (By the way (BTW), you should Google yourself and see what you find.)

As I sit her flying back to St. Louis from a meeting down South, I caught up and read an article where he was widely quoted as part of a panel. It has some good information for those of you interested in the pharmaceutical market.

• He talks about the electronic prescribing market with a few interesting facts:
  • 4% of the prescriptions in the US are prescribed electronically compared to 95% in the Netherlands.
  • If we increased the generic fill rate to the theoretical maximum, we would save $40B a year which is enough to pay for all the charity hospital care.
  • In his time at the hospital, they observed that in 25% of heart failure cases the diagnosis and treatment was different if they had the patient history at their fingertips…A great example being that the patient says they are on a drug but the physician seeing that they haven’t refilled it for 6 months.
• He talks about what happens after a drug gets approved by the FDA and how companies look at access, cost, and safety.
• He talks about drug pricing and the fear that people mistakenly have about generics being produced in other countries.
  • “By and large, generics, no matter if their source is in the United States or foreign, have proved to be extraordinarily safe.”
• He talks about reimportation of drugs from Canada.
• He talks about reference-based pricing that allows other countries to have lower costs for pharmaceuticals and about how manufacturers provide low cost access to patients through Patient Assistance Programs (PAPs).
• He also talks about the point at which cost can affect compliance with prescriptions – $150 for specialty drugs (which cost $1,500 a month on average) and $10 for oral solids. He also points out several of the other issues and points to the fact that price elasticity varies by class.
  • “It turns out people are most price sensitive to narcotics because narcotics are more of a discretionary drug, so if I am feeling economic pressure, I can forgo that pain pill.”

Often I talk about prescriptions as a driver of consumer awareness of healthcare costs. Since prescriptions really only represent 10% of total healthcare costs, this could be misleading. Certainly, it is important to focus on programs to reduce total medical costs. Ultimately, of course, we need to focus on prevention before either prescriptions or hospitalization is important, but for many reasons, that model isn’t one that aligns with our current healthcare system.

One of the reasons that prescriptions drive so much awareness is that we fill 4 billion prescriptions a year in the US and “only” visit the physician’s office, emergency room, or outpatient facility 1 billion times per year. Of course, all of these numbers clearly follow your 80/20 rule meaning that costs, prescriptions, visits, hospitalizations, etc. are really focused in a very narrow percentage of patients.

Another reason that my old boss recently talked about in an article is the fact that patients pay a greater percentage of costs (22%) for their prescriptions than they do for other healthcare costs.

While I wait for my meting, let me try one more blackberry post. I was shocked to see a story the other day about kids as young as 6 doing mixed martial arts fighting.

This is a brutal enough sport for adults but teaching your kids to fight like this and be ultra-aggressive seems a little extreme to me.

Maybe, I am too sensitive but the pictures looked like a good way for kids to get hurt and teach them to pummel and drive submission versus compete and defend.

Whenever I take the dog for a walk in my neighborhood, I am always amazed at the difference in lawns and upkeep.  Some people have immaculate lawns while others have lawns full of weeds.  This seems to be consistent regardless of neighborhoods.

So, it made me start to wonder if there is some correlation between the attention people pay to their lawns and the attention they pay to their health.  Are the people who spend the time caring for their lawn more or less likely to be healthy?

I don’t know the answer to it, but I have to believe there are some attributes that are consistent.