Archive | August, 2008

Communicating With Michelle Obama

First, congratulations to Barack Obama on getting the nomination.  He is a great orator and regardless of who I vote for I think he will be an exciting candidate.

From a healthcare communications perspective, I found an NBC Today Show interview with Michelle Obama very interesting yesterday.  She talked about three things that seem to be telling about her personality:

  • She said she was more of a fatalist than an optimist meaning that if Barack is meant to be president than he will be.
  • She said she was superstitious.
  • She talked about not believing that living in the White House will change their family dynamic.

So, I would suspect that trying to get her to change behavior would be very difficult as a fatalist.  If she believes that becoming sick is inevitable, why would you change your diet or habits.

If she is superstitious, I would suspect that there are actions, phrases, colors, or other queues that could encourage her to take action.  What those are…who knows?

And, if she doesn’t believe that the White House will change the family, it makes me think that she is very inwardly focused.  She admitted not watching TV or reading the paper.  But, as an ivy-league lawyer, I have to believe she does those things and reads aggressively.  So, I am confused as to why she wouldn’t believe history.  I haven’t read the history of presidential families, but I am pretty sure kids raised in the White House are very different.

My take would be that she would be a hard candidate to motivate to change and successfully communicate with.

Smoking Among Healthcare Workers

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.

Hospital Death Rates

USA Today now has an interactive chart to show you the hospital death rates for several diseases (heart attack, heart failure, and pneumonia).  It’s worth checking out.

When you run a scenario, here is an example of what you see:

Selling Hope

I will admit that I have been a closet democrat for years although that may finally be changing.  I have watched about 15 minutes of the Democratic National Convention (DNC) this year and can’t seem to get motivated.  I get so turned off by selling “hope”.  Are you kidding?

Working in the communication field, I find that a desperation play.  Imagine calling sick patients and telling them that they don’t like being sick so they should try doing something different that you “hope” will make them better.  Just because the economy is bad and people are unhappy doesn’t mean that any path will make things better.  People want a defined path with data to support it being better.

Otherwise, would this be like the Sports Illustrated cover effect where the athlete that is featured on the cover under-performs in subsequent months.  In business speak, we would call this regression to the mean meaning that over time people perform at the mean value and can’t always over-perform.  (I am sure someone will correct my use of statistical terms here.)

There are lots of things we can fix in this country, but simply a message about them being broken so trying something different isn’t enough…for me at least.

Healthcare Reform Won’t Be That Easy Mr. Obama

Election campaigns typically feature pontificating politicians flashing silver bullets to painlessly slay the nation’s problems.

Just move some money from here to there, cut some government waste no one apparently ever noticed, and then fund an unattainable promise with an outlandish price tag.

Barack Obama’s healthcare reforms fit this model nicely. He bundles three evergreen feel-good concepts — electronic medical records (EMR), disease prevention and chronic-disease management — and totes up dubious savings to fund his ultimate goal of making health insurance affordable to everyone. (Article in Fort Worth Star-Telegram)

It sounds like Barack’s advisors read George Halvorson’s book on the healthcare system.  Maybe they skipped the sections on the difficulty of aligning incentives and driving change.  If he thinks he can make major changes in 4 years, good luck to him.  Maybe that is a sign of his inexperience.  I think we all want change, but we definitely need a person who understands how to make change happen given the fixed constraints that we have.

He reminds me of the new consultant who comes in fresh out of business school and sees all the changes the company should make.  They are so obvious.  But, without all the history and the ability to manipulate the political landscape and knowledge of what it takes to get things done, it just becomes the flavor of the month that no one takes seriously while they wait for the consultant to move on to their next project.

Great ideas (not that this is one) don’t by themselves guarantee success.  A good idea implemented well is a lot better than a great idea implemented poorly.

Less Sketchy: More Scary

When you think about identity theft you think of your credit card information being compromised and someone ringing up $1,000s of dollars worth of charges that ruin your credit history.  If I say medical identity theft, you probably think about your information being stolen and used to ring up fraudulent bills by crooked providers.

But, in an article on the topic in the Chicago Tribune, they introduce a much scarier concept.  What happens if someone who can’t afford care, steals your identity to get free care provided to them.  During that process what happens if information is added to your permanent health record which subsequently impacts your future care (e.g., a note saying you are not allergic to something, a pre-existing condition which impacts coverage).

No Pharmacy Coverage – I Doubt It

In the AIS e-mail on Friday, it had the following quote:

“If the economy remains weak over the long term, we could certainly see employers and government agencies looking to investigate cutbacks on the type of pharmacy benefit they are offering, or eliminate pharmacy as a benefit altogether [in commercial plans]….The problem with [this] is that if an individual is unable to obtain their necessary drug therapy, you will typically see an increase in the overall health care costs associated with an individual.”

— Mesfin Tegenu, president of PerformRx, the pharmacy benefit manager division of the AmeriHealth Mercy Family of Companies, told AIS’s Drug Benefit News.

I must admit that I am more than a little skeptical of this.  The pharmacy benefit is the most used part of a benefit plan (average of 14 times per year).  Don’t you think there would be lots of other things cut back first?  Heck…I even see them cutting out 401K matching before they cut out prescription drug coverage.

Sure, it might get scaled back in terms of cost sharing or # of drugs covered, but that’s been happening for years.  But, elimination seems unlikely in a society that is very prescription drug focused.

E-Prescribing…Here to Stay?

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.

Practice Makes Better

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.



This Week



Two times

Arrive before my tee time to warm up



Holes per week

9 (weather permitting)


Time of day

1:00 (in St. Louis heat)

8:00 am


Usually eat while playing and play after doing my long run

Plan to run on other days and eat before warm up


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.

8 in 8: Michael Phelps Wins The Gold

What great motivation for a generation of people. First, you have Dara Torres winning 3 silver medals at the young age of 41. She shows us all how you can be a semi-normal person with a family and still compete at this level. (I say semi-normal since I don’t know if she has a nanny and other staff helping her or is independently wealthy and doesn’t need to work and can train all day…but I don’t think she is.)

Next, you have Michael Phelps winning 8 gold medals to increase his total and become the first one to win 8 golds in an single competition. (Not to mention the fact that he is a University of Michigan alumni like me.) I am sure a few people will be thrown off by the 12,000 calories he eats per day…don’t try this at home.

I think it’s also interesting that Michael has ADD/ADHD.  (Here’s a site that lists several famous people with ADD/ADHD.)  I think there is one good article which talks about his Hyper Focusing on swimming which is a common ability of people with this disease.  In this case, he has harnessed it very positively.

There are several motivations that people can take from the Olympics not least of which should be to get up and be active at any age.

Which Bathroom To Use?

I finally found a few minutes to post.  It has been a good, busy week.

On the radio this morning, they were having a debate about what a man should do when taking their young daughter to the bathroom.  I didn’t even realize it was an option.  Unisex bathrooms are an obvious solution, but what about when you only have a men’s room and a women’s room.  Don’t you just go to the men’s room?

Apparently, some people don’t.  Several women called in and said they would rather their husbands take their girls into the women’s room.  More sanitary.  No potential exposure issues (i.e., urinals).  And, several men said that they do it by simply knocking and announcing that a man is coming in with his daughter.

I couldn’t help but comment.  I have always taken my daughter to the men’s room with no incidents that I know of although a few times when it was dirty and we went somewhere else.

Express Scripts Chief Medical Officer

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.”

Prescriptions: Office Visits (4:1 ratio)

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.

Health Plan Week on Retention

I had an opportunity to get interviewed a few weeks ago by one of the contributors to Health Plan Week about retention within health plans.  With growth in the group market stagnant and ultra-competitive, the individual market offers lots of upside, but makes satisfaction and retention a much bigger issue.

You can read the article here where it discusses things like the “top box”, the importance of personalized communications, and champion / challenger processes to determine the best approach.

Skip The Patch…Send Them To Church

“Overall, 21% of Americans interviewed in our Gallup Daily tracking program this year say that they smoke.  (By the way, that’s down from an all-time high of 45% back in 1954).

But the percentage of smokers is only 12% among those who attend church once a week.  Smoking rises to 15% among those who attend almost every week.  Then 22% for those who attend once a month, 26% for those who seldom attend church, and finally 31% among those who never attend church.” (see 7/31 entry on USA Today Gallup blog)

I am always fascinated by correlations such as this.  Who thinks of the null hypothesis to look at this?  (Null hypothesis being that people who go to church smoke less which is what they collected the data to prove or disprove.)

With smoking being a huge health driver, what can you do with this information?  It’s hard to believe your employer or health plan could drive church attendance.  Perhaps this gets us back to social networking and your peer group.  Groups of friends or others coordinating and talking about quiting smoking may be more successful if someone active in a church was part of the team helping them.  (I am grasping at straws here.)

Smart People Doing Stupid Things

I was reading a post on the Foghound blog which made me think of an article I saw this morning on medical administrators using homeless people to defraud the government.  Lois points out eight things that smart people do that are stupid – impulsiveness, indulgence, and tempting fate (for example).

Why is it that seemingly intelligent people so easily and frequently seem to skirt the law to try to make money.  Do they think they are above the law?  Are they that greedy?  Do they believe (like the common criminal) that they won’t get caught?

It’s cases like this one with the homeless that cause distrust in the system.

Median US Age Now 37.9

The USA Today reports this morning on the shifting demographics of the US.  I found the map of the US showing the different variances from the median interesting.  (Note: Median means that half the people are below that age and half are above that age.)

It appears that some of the states like North Dakota, South Dakota, and Kansas are increasing their median age quicker than other states. (Source: Census Bureau, analysis by Paul Overberg, USA TODAY)

MMA for kids – wow

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.

Compliance is complicated

I am going to try a posting from my blackberry.

I just read this in the AIS newsletter and was surprised that this was news.

“Personally, I believe the reasons people take prescription medications are quite complex. There are a lot of motivations and issues in that, and copays may not, in and of themselves, be enough to change adherence and compliance.”
— Keith Bruhnsen, manager of the University of Michigan, Ann Arbor, prescription drug program, told AIS’s Drug Benefit News when discussing the need for research and data to support the idea that lower copays for essential services actually remove barriers to their use.

Other Contributors

I have had a few guest posts over the past year, but I have now invited my team at Silverlink to contribute to the blog so don’t be surprised if you see a few other contributors in the near future.  Each of them owns a market area within healthcare (Medicare, Medicaid, Loyalty, Payor, Population Health, Clinical, Individual) and has great experience and ideas.

Lawns and Health

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.

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