Archive | December, 2009

H1N1 – Trying To Match Supply And Demand

When there was a large demand several months ago, there wasn’t any supply.  Now there is adequate supply, but the demand has gone down.  Will there be another spike in demand in the Spring? 

With all the retail pharmacies and clinics having supply, we are now going to see the competition for the consumer.  (See WSJ story)

Some Foods And Drugs Don’t Mix

Without getting into all the clinical rules, I’ve always looked for a cut-to-the-chase consumer list of when to avoid what specific foods if you take certain medications.

Finally, in Real Simple magazine (pg. 74, Jan 2010), I found one.  Here it is:

  • Avoid grapefruit [including juice] if you’re taking a cholesterol lowering drug or a prescription sleep aid.
  • Avoid chocolate if your using an MAO-inhibiting antidepressant.
  • Avoid black licorice if you’re on heart medication.

I’m not sure of the science here, but I’m assuming that it’s real.  I’ve heard the grapefruit advice before, but never the others.  Do physicians and/or pharmacists tell you this?

The story also goes on to recommend a few foods:

  • Shiitake Mushrooms – help boost the immune system and prevent the growth of cancer cells
  • Brazil Nuts – may ward off colon, lung, and prostate cancer
  • Horseradish – increase the liver’s ability to fight carcinogens and suppress growth of cancerous tumors…and may help avoid urinary tract infections.
  • Walnuts – help reduce cholesterol and inflamation that may lead to high blood pressure and heart disease
  • Black rasperries – may retard the growth of precancerous cells

So…watch what you eat!

Why Didn’t I Know There Was A Generic Version

I got this question e-mailed to me today.  The patient has been using the same drug for years and it lost it’s patent about 6 months ago.  They just found out that they could have saved a lot of money and wondered who should have told them.  Here’s my thoughts.

  1. It’s the member’s responsibility ultimately to search for ways to save money and ask for generics.
  2. A lot of managed care companies and PBMs won’t reach out when patents expire because 90% of the time the drug is switched to the generic within 90-days by the pharmacy.
  3. The key players who would communicate are aligned – the pharmacy / PBM makes more money when generics are used and the managed care plan saves more money.
  4. BUT, sometimes managed care plans or individual employers (groups) will opt-out or never sign up for communication programs so their members don’t hear about ways to save money.
  5. BUT, sometimes consumers opt-out of communications from the PBM or managed care company and therefore miss out on opportunities.
  6. BUT, sometimes physicians won’t allow the prescription to be switched to the generic drug (even when chemically equivalent) and will write the prescription DAW (Dispense As Written) or say no substitution allowed.
  7. BUT, there have been a few instances when due to exclusivity on the generic that it actually costs more than the brand during the initial 6-months and people don’t move to the generic.

So, with lots of nuances, my reply was that no one had a legal obligation to tell her, but they all had good incentives to do it.  I suggest talking to the physician and/or the pharmacist.

Brand Drugs That Might Lose Patent In 2010

Here’s a short list of the big drugs that might lose patent protection (i.e., have a chemically equivalent generic become available) in 2010.  This is always subject to change and is based on data from PBMI which is summarized from presentations at the AMCP

2010 Aricept® donepezil Alzheimer’s disease
  Cozaar® losartan High blood pressure
  Effexor XR® venlafaxine Depression, panic disorder
  Flomax® tamsulosin Benign prostatic hypertropy
  Hyzaar® hydrochlorothiazide and losartan High blood pressure

FDA “Listed” Drugs – A New Hassle

As of 1/1/2010, Medicare beneficiares will face a new hassle at the pharmacy.  How big of a deal will this be?  I honestly don’t know.

But, from their site:

Starting January 1, 2010, if your pharmacy tries to sell you a version of a drug that isn’tlisted with the FDA, your Medicare drug plan might not pay for it. This means you mightgo to the pharmacy where you regularly get your Medicare-covered prescriptions filled, andif the pharmacy stocks only a version of the drug that isn’t listed (and, therefore, your planwon’t cover), the pharmacy may not be able to fill your prescription that day.

Since there are multiple manufacturers of a generic medication, multiple forms (capsule, tablet), and sometimes repackagers, this could complicate things for patients simply trying to fill their medications.  I’m not sure I understand what’s being addressed here.

You Know You’ve Had A Good Workout When

Every once in a while you have that great workout.  As we get ready for the 60% surge in gym memberships that occur with 1/1, I started thinking about what criteria I use to know this.

  1. An inability to walk up stairs without pain.  I even had one workout years ago (kickboxing plus spinning) where I had to crawl up my stairs at home for day.
  2. You have to take Advil before you workout again since you’re still sore.
  3. You have to use IcyHot before you workout again to try to relax your muscles.
  4. An inability to lift light objects (such as kids) since your arms are too sore.
  5. An ability to wring the sweat from your clothes as if you had just jumped in a pool.
  6. Throwing up from a workout.  (I have to trust this.  I’ve come close, but my body seems to stop before I get there.)
  7. Totally physical collapse.  (I also have to trust this.  You often see this with marathoners or people doing the IronMan, but my body seems to stop before I get to this point.)

Of course, you can’t do this everyday or you can’t recover (and you probably aren’t very comfortable).  But, I often find that the best way to get this is to try a new routine or new workout.  I’ve done this new core workout a few times at the Lifetime Fitness in Chesterfield, MO which seems pretty easy but is really hard.  I have trouble with certain movements the next day for sure.

Because People Are Different

I’ll borrow our tagline from Silverlink Communications Because People Are Different – to follow-up on my post on direct mail from yesterday.  The first commentor makes a good point.  Certainly e-mail doesn’t work for everyone.  Nor does the phone (although it is generally ubiquitous today). 

The reality is that different segments require different modes of communication.  The question is how to figure that out. 

  • Do you ask people for their preferences…realizing that many times people don’t know what they want or need?
  • Do you look at historical behavior to predict what will work best for people like them…realizing that healthcare is intensely personal and while predictive may not be indicative…and people’s healthcare behaviors change over time?
  • Do you pursue a cluster approach – i.e., send multiple modes simultaneously…realizing that this isn’t very cost effective?
  • Do you pursue a strategy of sequencing – i.e., call then e-mail then letter – and which pattern works best…and what spacing between modes works best?  (This will vary by message, objective, and audience.)

And, the question that I surprisingly don’t hear many people ask is why is there so much direct mail when we as a culture are generally more interested in being environmentally aware than ever (although we still have a long way to go).  Why kill a tree when other modes are more effective, less expensive, and offer better consumer insights?

Why Does Direct Mail Exist In Healthcare

Given all the progress we’ve made in the past 15 years around communications, I wonder why direct mail is still a primary component of communications. Obviously, there are some times when compliance requires a written notification, but considering you can’t tell if someone opened the mail and most companies don’t process return mail, you really have no visibility or ability to audit.

Written communications are also so static unlike a website or an automated call where a response can alter the next step in the communication.

Additionally, there is a time lag on written communications that you don’t have with e-mail or with an automated call.

I’ll break it out more in the table below, but in the end, direct mail costs the most yet gives you the least data, the worst customer experience, and is the least time sensitive. Seems like a problem to me.


Automated Call

Direct Mail



Low – Medium



Ability to Personalize




Dynamic Content




Know if received by consumer




Know how long consumer interacted




Time from event to consumer




Response Rate




 Now, don’t get me wrong, there is a place for direct mail.

  • People who don’t respond to automated calls or e-mail.
  • People who request more information.
  • Communications which require detailed information to make a decision.

But, why is it that so many companies begin their communications to consumers with direct mail. Is it that people are simply stuck in a rut of what they’re used to and can’t embrace decade old technology? Or is it that people don’t believe the facts in front of them?

How will PBMs be affected by current trends?

You can certainly see the piece of the PBM world that I’m wrapped up in right now, but these seem to be important trends.

What are the most likely developments/trends that could affect pharmacy benefit executives in the year ahead? Why?

While healthcare reform or market consolidation could impact the industry, we don’t see either as having a material impact in 2010.  We expect several trends.  There will continue to be a focus on mail order utilization, specialty pharmacy market share, and generic fill rate, and the sophistication of those programs will continue to evolve.  PBMs will look at how to predict responses by patients to offers such as retail-to-mail and subsequently segment the market using variables such as condition, age, and plan design.  PBMs will continue to develop strategies to address programs like $4 generics, 90-day retail, and pharmacy to employer direct contracting.  We have also seen a huge focus on adherence which will take several forms – automated refill programs, physician focused programs, and pharma-funded programs.  Additionally, there will continue to be efforts to create a single view of the member in a longitudinal view of their claims and intervention history.  PBMs will begin to think and act more like consumer companies employing techniques like motivational interviewing and behavioral economics.

How might pharmacy benefit executives most effectively prepare for these important trends?

Executives should be developing processes with an inside-out perspective that focuses on how the consumer experiences the PBM not how the PBM optimizes their process.  They should be looking at how they blend claims data, lab data, communications data, and event data (e.g., website visits) to have a holistic view of the patient.  Additionally, PBMs need to have a rapid testing strategy for how they evaluate consumer hypotheses and rapidly improve programs while capturing insights about their population.

What are the biggest challenges facing pharmacy benefit executives in 2010?

Another question from the recent Drug Benefit News where I was interviewed with several other experts on the industry.  My answer…

  • How to continue to grow (top line, bottom line, marketshare, functionality, internationally)?
  • How to avoid commoditization within specialty and how to scale specialty operations with a lower FTE to Rx ratio without impacting outcomes?
  • How to prevent “churn” from mail whether due to non-adherence or movement to $4 generic type programs?
  • How to simplify consumer messaging and drive health outcomes?
  • How to develop restrictive benefits that drive behavior with minimal disruption?
  • How to structure client and pharma financial relationships that reward them for better outcomes?

Other thoughts?

Will there be more PBM acquisitions in 2010?

My response to this question…

The Express Scripts acquisition of Wellpoint’s NextRx certainly put several captive PBMs in play, but that appears to have died down.  There may be small acquisitions, but the big 3 appear focused on expansion into more health services and internationally more than buying new lives. 

Other opinions?

Should Rx Data Be Used By Pharma?

This is a great question as posed by numerous people (see WSJ blog).  Now, the one reality that most people don’t realize is that the data is only directionally correct.  Not everyone sells their data to the aggregators so depending on pharmacy (or PBM) marketshare the data could be close to significantly off.

Perhaps, that’s not the issue.  The question is whether pharma should have a right to see prescription data by physician to understand their behavior.  It’s not patient specific data so that alleviates what I think should be the big issue.

Between patients visiting healthcare sites, registering for coupons, buying disease specific publications or supplies, the individual data is probably a lot easier to get and use…and probably more accurate (at least at the household level). 

Assuming no one says that pharma can’t communicate with physicians, I think the data is relevant.  Certainly, they have an agenda – drive marketshare of their drugs.  I think we have to assume that physicians aren’t just guppies that hear the pharma rep talk and do whatever they say.  Physicians are smart, well-trained professionals that should be able to hear messaging about drug pros and cons; look at the research; talk to their peers; talk to their patients; and appropriately prescribe. 

I think the prescription data probably creates a more efficient system.  Physicians that use a drug frequently are visited less often by the rep and don’t spend time away from patients.  Physicians that don’t prescribe a drug frequently (and prescribe a high volume of competitive drugs) probably get more visits…BUT they have the choice of saying don’t come. 

[I’m taking a little extreme of a view here since nothing is black and white, but I’m not sure I see the privacy issue here.]

Lance Armstrong And Diabetes

Lance has decided to focus some of his passion and conviction on diabetes.  I think this is great.  Certainly, this is a condition which affects a lot of Americans and continues to get worse with the obesity epidemic. 

Given the focus on the pharmacies (CVS, Walgreens) and the PBMs (Caremark, Medco, Express Scripts) on management of this condition, I wonder who (if anyone) will get Lance Armstrong to be their sponsor or public face.  For the PBMs that traditional don’t have a consumer brand, I would think this is a great opportunity.  I compare it to Medco having Amy Tendrich from DiabetesMine promoting Liberty Medical.  While Amy might not be a household name, she is certainly a name in the diabetes community.

Phones On The Planes – Please No

The fact that there is even a coalition called the Inflight Passenger Communications Coalition which is focused on getting passengers the “right” to use their mobile phones on planes in the US is crazy.  I don’t care what they do in other countries.  This would drive me insane.  As someone who spends a significant amount of time on planes, the last thing I want to hear is some person talking the whole flight.  This is great downtime and work time for me. 

I completely agree with having Internet access.  People can stay connect via SMS (text messaging), e-mail, web chats, or other written modes.  Having dozens of people talking out loud in a confined space would be unpleasant for everyone.

Hoarders – Scary Pictures; Big Health Consequences

Have you seen the show Hoarders?  Very scary.  It’s amazing that people can live like this.  Logically, it would appear that there is some type of additive or compulsive behavior issue here.  Go to the website and look at some of the pictures.

I can only imagine the social and health consequences of this on the entire family.

Can Un-Athletic Coaches Be Role Models?

As a parent, I always think about setting examples for my kids.  Since I do believe that playing sports is important to teach kids teamwork, coordination, social skills, and competitive skills, I think this is a key question.  Sports is an integral part of our society.  I see three potential role models for kids around sports:  [Also, over time, I think that kids peers can become role models or certainly older kids.]

  1. Parents
  2. Coaches
  3. Professional Athletes

While I think there are some great professional athletes who can serve as role models (e.g., Michael Jordan, Tiger Woods), there are a lot that aren’t due to drugs, violence, unsportsmanlike conduct, gambling, cheating, and financial mismanagement.  And, that’s a very hard thing to control.  We’re always (IMHO – in my humble opinion) going to pay to see the best even if they’ve used steriods or have control issues. 

As parents, we have the most control over ourselves.  We can make sure our children see us play sports and exercise.  We can stress the importance of this.  We can help them learn sports and make sure they take away lessons from their playing – e.g., winning isn’t everything.  [One interesting observation that I’ve had is that athletes make good sales people because they know how to keep trying and get focused even after a loss.]

But, the one I struggle with is coaches.  Sometimes you may have control over the coach, but they can be a very powerful influence on your kids.  They spend hours with them and provide guidance.  There are some things that you obviously don’t want in a coach – too demanding, not demanding enough, someone who encourages winning at any cost.  But, what do you do about the coach that is very smart and understands how to play, but isn’t in shape at all?  They can’t even run down the field with the kids.  What type of image does that give the kids?  It seems mixed to me, but maybe I’m wrong. 

[Note: I was originally going to call this “Fat Coaches”, but I think there are plently of overweight people who are athletic.  But, I’m not so sure about this guy above or some other coaches I’ve seen.]

RoadID for your athlete

Here’s a simple, yet valuable gift for your athletic spouse, friend, co-worker – RoadID

This is something you can wear or put on your shoes so that if you get into an accident while you’re working out (i.e., road running, biking, hiking) people can contact someone for you.  I think it’s great.  I was skeptical of the need for it for a while, but I realize that accidents do happen.

They’ve now come out with RoadID interactive.  I have mixed impressions.  It’s great in that you can log information into an online profile – addresses, contacts, physicians, medical information, insurance coverage, etc.  If you’re in a horrible accident, all of that would be good to have.  And, the reality is that you control how much is there.  But, I’m still a generally paranoid person so I would worry about someone stealing my shoes and all of a sudden having access to my information.

[Too bad you couldn’t make it so that it was only enabled if some of your vitals signs were off and transmitted via a sensor to the site to unlock the information.  That would be cool!]

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