Archive | July, 2009

How Teeth Are Like Trees

I was at my dentist the other day, and he spent the whole time using analogies to explain things to me.  He began by asking me if I was really sick when I was about 4 years old.  I was a little confused, but he pointed out that I have a white spot on the back of one of my teeth.  He said that teeth are like trees and like the rings in trees you can learn things from your teeth and date them.  Apparently, that spot would indicate high antibiotic use or malnutrition right during the period of development.

He later went on to explain the surface of the teeth and how a round object that hits the ground is less likely to break than a square object.  He was talking about how the tops of teeth get ground down over time and the risk that it creates to the stability of the tooth.

Nick Jonas And His “Diabetes Buddies”

I was with my kids at the Jonas Brothers concert in St. Louis the other night. They put on a great show, but my healthcare takeaway for the night was that Nick Jonas has diabetes and is a great spokesperson on the topic.

As seems to be more and more common these days, he (as a public figure) is out talking about his health and management of his condition. I think this is a great way to help kids learn about diabetes from someone they adore. It also normalizes the condition so patients don’t feel they are alone.

I also like his concept of giving guitar picks to his “diabetes buddies” or people he meets. I could see a Facebook application where you can get a virtual guitar pick from Nick Jonas.

“To newly diagnosed kids with diabetes, Nick would say, ‘Don’t let it slow you down at all.  I made a promise to myself on the way to the hospital that I wouldn’t let this thing slow me down and I’d just keep moving forward, and that’s what I did. Just keep a positive attitude and keep moving forward with it. Don’t be discouraged.’ ” (article)

During the concert, they stop to let him do a piano solo to the following lyrics from their song “Don’t Know What You Got Till It’s Gone”. During the song, he pauses to talk about how he made a promise to not let it hold him back and all the things he has accomplished since being diagnosed.

Got the news today
Doctor said I had to stay
A little bit longer
And I’d be fine
When I thought it’d all be done
When I thought it’d all been said
A little bit longer
And I’ll be fine

But you don’t know what you got
Till it’s gone
And you don’t know what it’s like
To feel so low
And every time you smile or laugh you glow
You don’t even know
No, no
You don’t even know

All this time goes by
Still no reason why
A little bit longer
And I’ll be fine
Waitin’ on a cure
But none of them are sure
A little bit longer
And I’ll be fine

But you don’t know what you got
Til it’s gone
You don’t know what it’s like
To feel so low
And every time you smile or laugh you glow
You don’t even know
No, no
You don’t even know
No, no
You don’t even know
No, no


But you don’t know what you got
Til it’s gone.
Don’t know what it’s like
To feel so low, yeah
And every time you smile or laugh you glow
You don’t even know
Yeah oh
Yeah oh
Yeah yeah
You don’t even know
No, no

So I’ll wait ’til kingdom come
All the highs and lows are gone
A little bit longer
And I’ll be fine
I’ll be fine

Cosmetic Neurology

Not surprising…students using ADD/ADHD drugs to help them perform better.  Probably not a good thing.  This shows how badly overwhelmed or overstimulated our population is.  We can’t focus on one thing at a time to get it done w/o some drugs.  Could it really be 20% of college students using these drugs?  There is certainly some dependency risks.

From a blog posting on this:

I got most of my Adderall information from a great article in the New Yorker by Margot Talbot titled Brain Gain: The underground world of neuroenhancing drugs. In it, Sean Esteban McCabe, from the University of Michigan’s Substance Abuse Research Center says that at some universities, up to 20% of the population is using these drugs: “White male undergraduates at highly competitive schools—especially in the Northeast—are the most frequent collegiate users of neuro-enhancers.”

Anjan Chatterjee, a neurologist at the University of Pennsylvania , coined the term “cosmetic neurology” to describe the trend of taking drugs to enhance ordinary cognition. He says, “Many sectors of society have winner-take-all conditions in which small advantages produce disproportionate rewards.”

Good cartoon to sum this up.

The 5 Questions (Regence Group)

Regence Group recently put out an interesting website –  It takes an unorthodox (for a health plan) approach to delivering several important points.  It reminds me of what Wellpoint has done with Tonik or some of the things Humana is doing at HumanaGames.

One of the things I found interesting and very straightforward for patients to think about were their 5 questions:

  1. How much does that cost?
  2. Is that really necessary?
  3. Is there a cheaper option?
  4. Is there a generic for that?
  5. Has anyone out there had this before?

Imagine if every time we were asked to take a test or start a new therapy that we (patients) asked these five questions of our provider.

A Pet’s 10 Commandments

My aunt who has several rescue grayhounds sent this to me… (The original source is here – 


1. My life is likely to last 10-15 years. Any separation from you is likely to be painful.
2. Give me time to understand what you want of me .
3. Place your trust in me. It is crucial for my well-being.
4. Don’t be angry with me for long and don’t lock me up as punishment. You have your work, your friends, your entertainment, but I have only you.
5. Talk to me. Even if I don’t understand your words, I do understand your voice when speaking to me.
6. Be aware that however you treat me, I will never forget it.
7. Before you hit me, before you strike me, remember that I could hurt you, and yet, I choose not to bite you.
8. Before you scold me for being lazy or uncooperative, ask yourself if something might be bothering me. Perhaps I’m not getting the right food, I have been in the sun too long, or my heart might be getting old or weak.
9. Please take care of me when I grow old. You too, will grow old.
10. On the ultimate difficult journey, go with me please. Never say you can’t bear to watch. Don’t make me face this alone. Everything is easier for me if you are there, because I love you so.

Google Voice, Mail Order, Depression, & Linguistic Profiling

I have a whole pile of articles that I’ve meant to blog about. I’m going to try to clear out some of these with a bunch of quick mentions here.

USA Today Gallup Poll (7/14/09)

  • Majority say controlling costs should be legislation’s top goal regarding healthcare, but more than 9 in 10 oppose limits on getting whatever tests or treatments they and their doctors think are necessary.
  • 26% of those polled say that Congress passing a major health care reform bill this year is extremely important – 24% say it’s very important; 22% somewhat important; and 25% say not important.

Google Rolls Out Google Voice

  • You can use one new phone number to tie together your various numbers – cell phone, home phone, and business line.
  • People call one number which rings all the numbers. You can switch back and forth between lines. Voicemail flows to all of the phones and you get free transcription.

Linguistic Profiling (Washington University alumni magazine, Summer 2009)

  • Interesting article on the work by John Baugh, professor of psychology, linguistics, English, education, and anthropology.
  • He first documented the “discrimination based on the sound of someone’s voice”.

Article “A Battle Over Mail Order Drugs” (Boston Globe, 2/2/09)

  • Owners of mail-service pharmacies (i.e., PBMs) say Medicare could save billions if more people used mail. Right now it’s only 10% of all Medicare recipients who use mail according to the PCMA.
    • The PBMs estimate that the savings is $1B over 10 years for every 1% of patients that move to mail…or $40B over the next decade.
  • Community pharmacists see mail orders as “shady operations”.
  • David Snow, CEO of Medco, says about PBMs – “The real truth is, we’re an intensive clinical company with thousands of pharmacists who take care of patients each and every day in a very advanced way.”


Good article “The Importance Of Deciphering Your Insurance” (WSJ, 6/4/09)

  • The most surprising statement in the article – “researchers at Georgetown University found that several health plans required consumers to inform the insurers when they reached their out-of-pocket totals.” Is that really possible??


Article “Depression, Anxiety Pass From Parents To Kids” (USA Today, 6/3/09)

  • Group therapy was able to break the cycle.
  • Depressed children are more likely to have trouble in school and are at increased risk for suicide or substance abuse.


Article “Conflicts Of Interest Bedevil Drug Research” (USA Today, 6/3/09)

  • Good discussion with some specific examples about the people who evaluate criteria for when drugs should be used and their ties with the companies that manufacture the drugs.


Article “Layoffs Cost More Than You Think” (Fortune, 3/30/09)

  • Good reminder of some of the additional costs of laying people off.
    • Brand equity costs
    • Leadership costs
    • Morale costs
    • Wall street costs
    • Rehiring costs
  • One of my early consulting projects looked at this years ago and it was amazing how much it cost also looking at lost productivity as you ramped up a new hire.


Jan Berger Co-Author Upcoming Book

Leveraging Health is the first book from the Center for Health Value Innovation! Using real-world case studies from public and private organizations — even small companies — this book illustrates 15 “levers” that can be used to motivate value-based changes in healthcare design.  The book will make its debut Sept. 30 at 8 a.m. at the National Press Club in Washington, D.C., with a book signing to follow at 5:30 p.m. at the Consumer Health Care Congress in Alexandria, Va. Author Cyndy Nayer will be presenting at the conference, and authors Jack Mahoney and Jan Berger will be on hand to sign the first copies! If you can’t make it to the congress, look for Leveraging Health this fall on

Misaligned Incentives

A perfect example of one of the big issues with healthcare reform.

We all know that hospital readmissions is an issue.  We have been working with several clients to address this issue.

I called a few senior people in some hospital systems to talk about it.  I think one of their responses summarized it up nicely:

It’s not something we are focused on.  We still make positive contribution margin on these readmissions.

As many people have pointed out, misaligned incentives make it hard to improve the system.

Conceptual Consumption

I’ve just begun reading and thinking through the book Predictably Irrational.  So far, I’ve found it fascinating.  Additionally, for those of you without the time to read, I’d recommend following Dan Ariely’s blog.

One of his posts from last month is interesting and lays out three ways that conceptual consumption affects people’s physical consumption (and provides a link to the details on the research):

  1. Consuming expectations
  2. Consuming goals
  3. Consuming memories

I think this area of behavioral economics is critical to Enabling Healthy Decisions (SM).  Since in most cases, we already have a framework or anchor price for our healthcare it becomes increasingly challenging to reframe the issue and change behavior.  But, these insights around peer pressure and message framing that evoke different memories or emotions are significant insights for us in the communication space.

The Impact Of Cash Rxs…No One’s Talking About

I’m only somewhat surprised that no one is talking about this since it can be a touchy subject with little data easily accessible.

The question is what is the clinical impact of the “$4 Generics” type of programs that Wal-Mart has championed and others have followed.  The most obvious potential issue is DUR (Drug Utilization Review) which looks for things like drug-drug interactions.

Let’s look at a few of the issues / challenges here:

  1. Is the number of Rxs really going down like IMS and others report?  Who knows.  Wal-Mart (to the best of my knowledge) doesn’t provide IMS with data…so, if their market share is going up, this would skew the market data.
  2. Are people moving from using their pharmacy benefit to paying cash?  Again, who knows…the PBMs can’t tell since they don’t process cash transactions.  This makes it hard to know the impact of non-adherence.
  3. Are there more drug-drug interactions due to more Rxs being processed as cash?  Again, who knows…are the retailers that process cash transactions pulling in a full profile of all the members other drugs?  Does the member even know all their other drugs?  (Here’s some data on drug-drug interactions)

So, what I would be asking for in the market is an independent study that looked at all data (covered and cash) for a series of patients and see how many drug-drug interactions were missed and what the resulting hospitalizations were attributed to this new poly-pharmacy issue.

Are Sport Courts The New Suburban Swimming Pool?

I guess I’ll call this a “microtrend”, but I’ve now seen 2 neighbors (and a 3rd coming) put in sport courts in their backyards.  There are lots of companies that do this, but it’s essentially a flat surface with a basketball hoop and some lights.

This seems much more practical than a pool which is often a fad and kids stop using it after a few years.  (And requires ongoing maintenance and liability.)

If you expand the sport court concept from basketball to include any sport, you can have a putting green, a basketball court, a hockey surface (non-ice), volleyball, tennis, and several others. 

I guess the question is why do this?  I can think of several reasons:

  • Convenience (not having to go to a park)
  • Safety (having kids right outside)
  • Driveways aren’t flat anymore
  • Developments are moving farther and farther out meaning more land per yard (and more need for destination homes where kids gather)

Is this a fad like tennis courts were in some neighborhoods in the 60’s?  That’s still to be seen, but I have a friend who has had a company doing this for about 5 years.

I certainly have seen more parks going to alternative surfaces that are safer for kids that fall.

Using Analytics To Improve Health Outcomes

One area where healthcare has definitely lagged other industries like consumer products and financial services has been in the area of analytics. Silverlink Communications is the first company to bring analytics to the area of healthcare communications.

We have been doing this for years and focus on the different ways to use analytics to improve results. This is not simply custom reporting which is what lots of people mean when they talk about analytics. And, it’s a lot more than simply best practices like co-branded communications (i.e., employer plus health plan) work better than communications simply from a health plan to a member (patient / consumer).

Interested in learning more…We are hosting a webinar series this month that might interest you. The first one is tomorrow.

It includes Stephen Baker who wrote The Numerati; Kinney Zalesne who wrote Microtrends; and Tom Davenport who wrote Competing on Analytics. You can register here.

If you enjoy this topic, I would also encourage you to register and read our white paper on Adaptive HealthComm Science (which is what we call our approach to healthcare analytics for communications). We also have a video on engaging consumers in their healthcare. Both can be found at the bottom of our homepage at

Why Frameworks Matter

I hope you all had a good Fourth of July. One thing I always think about this time of year is my perception of fireworks. I’ve never been a big fan.

Of course, like most young boys, I had my fascination with fireworks, but after two incidents, I began to view them as more dangerous.

When I was about 10, I had a pack of firecrackers go off right near my ear just as I threw them. Then, in high school, I remember watching bottle rockets hit someone’s house and worrying about it catching fire (which it didn’t).

Why should you care (this is a health care blog – right)?

I think it’s important because our frameworks about going to the doctor, going to the dentist, eating healthy, exercising, preventative care, and so many other things are set in place as we grow up. As a parent, you need to think about the example you are creating. As a communicator to the patient later in life, you need to think about what their attitudes are towards health.

Two-Thirds Support A Public Plan?

According to the latest research from a Kaiser Health Tracking Poll of 634 respondents from June 1-8th:

Since, I strongly believe responses are biased by context, I wonder how many people respond that way when they realize that they will be pushed to this plan. [The Lewin Group estimates that as many as 118.5M people (2/3rds of those who have insurance today) would be shifted to public coverage.]

Poll On Cost Of Treatment For Life Extension

A hot topic is how much is an additional day / month of life is worth.  With some costs for a medication rising to $50,000 or more, this is something that we need to grapple with.  I’m interested in your thoughts on the following questions:

  • What would you pay for an additional day / month of life?
  • What would you expect your employer to pay for you to have an additional day / month of life?
  • What would you expect your insurance company to pay for you to have an additional day / month of life?
  • What would you pay if there was a 1 in 1,000 chance that the additional month turned into an additional year?
  • Does that change if there is significant pain involved in the extension of life (i.e., you aren’t comfortable during your additional days/months)?

Finally – New Blog Name

I mentioned a few weeks ago my need to get a new name since the people that had Trademarked “Patient Centric Healthcare” asked me to stop using it for the blog.  I looked at a bunch of names.  Finally, I’m going with “Enabling Healthy Decisions SM”.  I think that summarizes what I’m interested in – healthcare communications, healthcare analytics, healthcare marketing, healthcare technology.  I generally am most interested in those subjects when they relate to leading consumers to make better decisions about their health.

Deloitte 2009 Survey of Health Care Consumers

This is based on a Deloitte web-survey of 4,001 Americans in October 2008.

  • 73% are confused about how the US healthcare system works
  • Over 1/2 believe that 50% or more of healthcare dollars are wasted
  • 7 of 8 Americans believe themselves to be in good health
  • 1 in 3 are interested in working with a health “coach” to help them create and stick to a plan
  • 68% are interested in home monitoring devices that would check their condition and send results to their MD
  • 3 in 5 say financial penalties would improve their adherence
  • Only 1 in 3 Rx users say they compared treatment options
  • 22% say they looked or asked for information about a health insurance plan in the last 12 months
  • 9% have a PHR
  • Physicians who are more prescriptive (paternal) were preferred by a ratio of 2:1
  • 8 in 10 say they would consider switching from a physician recommended Rx if a pharmacist (RPh) indicated a cheaper alternative was available
  • Only 12% said they understood the term – biologics (should they?)
  • 35% are willing to accept a smaller provider network for a reduced premium and lower copayments
  • Only 25% favor increasing taxes to help cover the uninsured

Their major conclusions were:

  1. Health care is a consumer market
  2. The health care market is not homogeneous
  3. Cost concerns are changing behaviors
  4. Consumers want holistic care and resources to pursue wellness and healthy living
  5. Consumers embrace innovations that enhance self-care, convenience, personalization, and control of their personal health information

Impact on Life Expectancy

I’ll stay with the same theme here for a minute…

I found this one page graphic in the back of Newsweek (6/22/09) which caught my eye.  It was titled “Can You Cheat Death”.  It had some interesting facts from, Archives of Internal Medicine, PLOS Medicine, and the Journal of the American Board of Family Medicine.

  • Life expectancy for the average American man = 75.2 years (80.4 for a woman).
  • Positive impacts:
    • +10 years if you have a blood relative who has lived to be 95 or older
    • +5 years if you regularly play puzzles like Scrabble or Sudoku
    • +5 years if you’re a married man
    • +5 years if you take 81mg of aspirin a day
    • +3 years if you eat 5 daily servings of fruits / vegetables
    • +2 years if you floss daily
    • +1.7 years if you go to church regularly
  • Negative impacts:
    • -0.5 years if you drink more than 5 cups of coffee a day
    • -1 year if you get less than 6-8 hours of sleep a night
    • -1 year if you have a family history of diabetes
    • -2.5 years if you don’t wear sunscreen and are outside a lot
    • -5 years if you are slowly putting on weight
    • -5 years if you regularly feel stressed out
    • -5 years if you eat red meat more than 2x per week
    • -5 years if you have less than 12 years of education
    • -7 years if you engage in unprotected sex with multiple partners
    • -15 years if you smoke
    • -15 years if you use IV drugs

Obviously, these are only average so you’re not doomed, but I view them as reasonable indicators of how you might influence your length of life.

One Cigarette vs. 11 Minutes of Life

So, if smoking a cigarette knocks 11 minutes off of your life, you would think that would capture people’s attention.  Or would you?  Given the framework of hyperbolic discounting, what is the value we put on that 11 minutes of life.  If I’m young, I see that as a very distant value with a lot of things that could happen between now and then.  The “benefit” of smoking the one cigarette is very real and immediate.  (I’ve never been a smoker, but I assume there is an enjoyment.)

It’s not very different from eating.  The extra spoonful of sugar in my coffee can (over the course of a year) add a pound and over the course of a decade add 10 pounds…BUT can I really make that tradeoff.

This is one of the fundamental challenges in healthcare especially for asymptomatic diseases where there aren’t regularly experienced symptoms – e.g., high cholesterol.

Regarding House Bill 458 (MO) On PBMs

To Whom It May Concern:

You should be embarrassed to produce this bill. It’s obviously based on a one-sided view of the world regarding Pharmacy Benefit Managers which is generated by sensationalist journalists, jilted employees, independent pharmacists who have lost marketshare to chain drugstores, and pharma manufacturers who have seen their marketshare decline. This type of legislation will only serve to drive up healthcare costs and is exactly the reason why a government run plan won’t work in this country. They’ll focus on lobbyist interests and not the true interests of the consumer.

Let’s go point by point through your legislation and point out some flaws – (see bill here)

1 – Why would a PBM have to tell a consumer what they pay the pharmacy? That’s like Best Buy being required to tell the consumer what they pay for a TV. Most PBMs and/or pharmacies often print on the receipt what the consumer’s payor (employer, managed care company) paid for the drug (i.e., your insurance saved you $100).

2 – Why is the government telling businesses how to do their job? As an HR manager, if I can get a better discount for my employees on their prescription drugs by limiting the pharmacy network, why shouldn’t I have that option. We have preferred vendors in most companies. Why shouldn’t that be true in pharmacy? There are ~60,000 pharmacies in the US which is more than enough.

3 – Again, why is the government interfering in pharmacy law and telling me (the consumer) what I can or can’t do? Why can’t I move my prescription from one pharmacy to another based on discount, convenience, service, or other issues? All you are doing is creating a consumer burden and physician burden with no benefit to anyone.

4 – Now you want to take away my ability to manage drug coverage. There are plenty of circumstances where limiting or denying coverage makes sense due to inappropriate utilization, availability of lower cost options, abuse, and other issues.

5 – I’m completely confused here. You want to tell the insurance companies that they can’t increase the percentage of costs that the member pays (which is really a benefit design issue for the employer) unless the drug prices go up.

6 – This topic has been discussed a lot around switching medications. Of course, the communications should be clear. The patient should understand their choices. They physician should be in the loop (which they are since they have to write the new prescription). You hopefully realize that these are done to lower healthcare costs AND that physicians neither discuss costs with patients (generally) nor do they believe it’s their job to do this.

7 – Do you really believe that the dispensing physician who is focused on caring for their patients has the time to keep up with all the medical literature that a Pharmacy & Therapeutics (P&T) Committee reviews in determining protocols around step therapy? Look at the research…it shows that it takes 17 years for evidence-based standards to become standard practice. I personally don’t want to rely on my individual physician (who does a damn good job) to understand all the latest literature (w/o an EMR). And, I would hope no MD would willingly write an Rx that causes harm. All step therapy programs offer a prior authorization override to the MD and the PBM systems look for drug-drug and other types of interactions.

So, I guess the question is why are you (the legislation) trying to force me (the consumer) to have more administrative headaches, higher costs, and be treated with outdated protocols? And, at the same time, you’re going to force my employer to have higher costs and likely have to stop offering healthcare. And, you’re going to put more administrative burden on my physician who is already overworked and potentially underpaid.

Oh, wait, I get it…If you make the existing companies unable to run their business and unable to use evidence-based standards to lower costs then a government run experiment in socialized medicine will look much better. I hope that the Obama camp recognizes you for your hard work in advocating for them.

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