Enabling Healthy Decisions

I know…I know. I’m reminding you late. It was July 24^th. I’m sure it would have changed your plans for the day. (Who makes up these days?)

I do think the drive-thru is interesting for several reasons:

1. What it says about us overall; and
2. It’s impact on the pharmacy business.

In general, there aren’t many healthy uses of the drive-thru. It’s a productivity tool that (like technology) limits our interactions with other people.

A few facts for you:

• We spend $110B at drive-thru fast food restaurants each year.
• The first drive-thru fast food restaurant was at In-N-Out Burger in 1948.
• Strangest use of a drive-thru (IMHO) was Gaitling’s Funeral Home in 1989.
• In the mid-2000’s, drive-thru staffing was changed such that the order taker could be outsourced to allow the person taking your money to be more productive (i.e., you’re talking to a person at a different location).

So, what’s happened in pharmacy? I’ll have to find the date of the first drive-thru in pharmacy.

• Walgreens certainly seems to be the dominant user of this strategy where they will typically have 1-2 lanes for drop off and pick-up of prescriptions. This is definitely a productivity play for the drive (suburban) culture. I’ve used it frequently when I have a first-fill and either kids in the car or it’s raining or cold.
• 29% of people said they use this method in a WilsonRx 2008 study…but only 3% said they prefer this method.
• 42% of people who used the drive-thru were highly satisfied (compared to 56% highly satisfied with either pick-up at the store or receiving by mail).

The big question a few years ago was whether this productivity enhancement damaged the pharmacist-patient relationship. I would argue “of course it did”. How could it not? You no longer talk to them face-to-face.

I would also question privacy here. On the one-hand, it’s harder for the patient’s behind you in line (i.e., in their car behind you) to eavesdrop. BUT, when there are two lines, it seems pretty easy for the car next to you to hear everything you talk about with the pharmacist. AND, if we’ve learned on thing from mobile phone headsets, it’s that people seem to talk louder into the phone (i.e., I think the pharmacist inside is talking to you louder).

Of course, one true question is whether you really had a relationship with the pharmacist to begin with. In most cases, you’re dealing with a pharmacy tech not the pharmacist. The majority of people (even at independent pharmacies) don’t know the first name of their pharmacists (BTW – mine are Marc and Renee).

Now, what I find most shocking in this chart from the 2008 Pharmacy Satisfaction Digest by WilsonRx is that only 1% more know the name of their pharmacist at a chain drugstore than at mail order.

I don’t think any of us who spend a lot of time in the adherence area are surprised by this, but it’s always good to have a nice, published study to reinforce the point.

CVS Caremark published a study done last year using interactive outbound call technology to improve their adherence program. (Chang et al., Improving Persistency for Maintenance Medication Therapy Through an Interactive Voice Response Program, Journal of Managed Care Pharmacy, 2010. 16 (2): page 156.) It showed that being proactive (i.e., calling before the patient ran out of pills) was better than doing nothing (control group) and better than calling reactively (i.e., the patient has run out of pills). But, if you do both, you significantly improve the likelihood of them getting a refill and staying adherent.

As Medco highlighted several weeks ago, brand prices are going up a lot faster than generic prices. That’s nothing new. But, Barclays Capital recently highlighted that brand prices are going up faster in 2010 than any prior year (based on First Databank data).

Why?

• Are they trying to make up for their concessions around Part D pricing and closing the donut hole?
• Are raw material prices up?
• Is it harder to develop a blockbuster drug and therefore R&D costs are going up?
• Is it because the brand market is so much smaller with generic fill rates up?
• Is it because their drug is losing patent?
• Is it because they’re chasing more orphan drugs?

I’m not sure, but it certainly is a point of concern for many plans although in the big picture it’s not a huge driver of cost…

• Prescriptions represent 10-15% of total healthcare costs.
• Brand drugs represent 20-30% of prescription claims (but probably 70-80% of prescription costs).
• Even a 10% increase in prices across the board would only be about 1% increase in total healthcare costs.

I guess it’s kind of like being an “arm-chair quarterback” or a “back seat driver”. Slacktivism (Slacker + Activism) refers to doing good without doing much. Donating thru a text message. Clicking on a link to generate donations. Wearing a rubber wristband to show your support of a cause.

Is this bad?

I don’t think so. Obviously, the world needs activist who actually roll up their sleeves and get involved in solving the world’s problems. But, are people that support them thru money (or clicks) or some other form of support not important?

In today’s social media world and connected world, donating and supporting causes should be easier. Everyone wants to announce their support for movements in Facebook from “my college is better than yours” (Go Blue!) to “I checked my H1c today” to “stop Communism”.

But, the article in Fast Company that got me on this topic talks about a few great case studies:

• FreeRice.com – For every correct answer you get to the questions they ask, 10 grains of rice are donated to the UN World Food Program. Why not? 22 million bowls of rice have been generated by this program.
• Haiti donations to the American Red Cross – The $10 text message pledges raised $38M.

So, how do we tap into this with healthcare? That seems to be the Holy Grail.

• Lose weight without diet or exercise. (why so many weight loss pills sell)
• Take my medication without having to remember every day. (e.g., patch)
• Track my vitals without going to the physician’s office. (connected devices)

Social pressure certainly plays a role here. The question is whether our privacy concerns outweigh the benefits (often not understood) of participating in certain social activities. For the younger generation, this will not be an issue. They don’t view privacy the same way. For the older generation (who by the way are the sick and expensive patients today), privacy is a big deal and some of them are technophobic (although probably less than you think).

BTW – Did you click thru on the FreeRice.com link yet? Come on.

This is a term that a friend of mine introduced me to a few years ago. How do you coordinate messaging across channels and the timing of the delivery of those messages to drive a behavior?

• Do I send an e-mail and then call the individual if they don’t open it in 72 hours?
• Do I send a postcard before I send a letter?
• Do I call someone to tell them that I’m sending them an e-mail?
• Should all the messages be the same? Or should they show a progression of urgency (for example)?
• Do you have a single view of the consumer so you know what they have historically responded to?
• Do you manage your communications as an integrated process so once they take an action you can immediately stop the next communication (e.g., the patient logged into the website last night so don’t send the e-mail scheduled to go out in the morning)?

These things aren’t easy especially in healthcare where the technology to manage direct marketing is several years (being nice) behind consumer markets like banking or consumer goods. But, this is one thing that Silverlink Communications does for clients. Understanding these challenges, providing industry experts to design solutions and test plans, and having a technology platform to execute, track, and report on these challenges is what we do.

Another common challenge is determining frequency. Should I call the person once a day, once a week, once a month, or once a quarter? How is that different based on the result of the prior interaction? How is that different based on their condition? How is that different based on the drug they’re taking?

For example, I might call a patient recently diagnosed with depression in the initial few weeks to remind them to stay adherent with their medications as it may take a few weeks for them to feel a difference. For patients on drugs with immediate side effects, I might need an earlier intervention.

A few points from Dan Ariely, author of Predictably Irrational (Spirit Magazine, pg 46, July 2010):

• He observed that people doing work that involves decision making needed more positive feedback during the process. Do patients need more positive feedback for doing the right thing? Should you reach out and say good job for going to the physician?
  
• He observed that people lose motivation if the work they do goes unnoticed. Should companies call patients and say thanks for moving to mail order and saving them money?
  
• He observed that large rewards cause pressure which distracts from the task at hand. How do you break down your rewards into more near term reinforcement and don’t forget about non-monetary rewards?
  
• He observed that people are more committed to change when it’s there idea. How do you get patients to think about things they should do? One of his suggestions was to ask more questions.
  

But, this is only part of the challenge. How do the attributes of your intervention affect their likelihood to act? Could the name of your call center agent matter?

A study by the Edinburgh International Science Festival found that people make assumptions about people based on their names:

• People with royal names (James and Elizabeth) are assumed to be highly successful and intelligent.
  
• People with soft sounding female names (Lucy and Sophie) are assumed to be the most attractive.
  
• People with short male names (Jack and Ryan) are assumed to be more rugged.
  

If you’re using an automated call, does the voice talent you use matter? (see prior article)

Researchers at the University of Wisconsin-Madison found that a mother’s voice is as comforting as a hug which lowered levels of stress inducing cortisol and triggering the production of oxytocin (aka, the love hormone). [What’s a male’s reaction to their mother’s voice?]

And, of course, all of this has to be thought of from the patient’s frame of reference. Calling a recently diagnosed diabetic about adherence is very different than someone who has stopped taking their medications after 5 years. How do you treat them differently?

What about their current location? Is reading an e-mail on the blackberry during a commuter train different than reading it at your PC while eating lunch…YES!

This is why communications is a blend of art and science. You have to use data to drive fact-based algorithms which are adaptable in scale (i.e., across millions of people) and are adaptable as people, situations, and messages change.

This article appeared a few months ago, but I’m finally digging out. (Drug Benefit News – 12/4/09) It’s an interesting article about how some PBMs are using performance guarantees in their sales efforts. I would expect this to be a growing trend as the PBMs focus on outcomes and have a need to commit to those.

The article mentions that CVS Caremark offers performance guarantees in five areas – adherence, generic-drug utilization, preferred pharmacy choice, specialty drugs, and utilization management. The results are aggregated into one guarantee. There is apparently no charge to the client, but there is a penalty paid if the goal isn’t met. Seems like a good deal if the guarantees are aggressive enough to account for any pricing differences.

A consultant says that Medco also offers performance guarantees (but doesn’t offer any details). The consultant also says payouts range from $800 to $1,300 per patient who have the targeted condition, receive interventions, and don’t achieve the compliance target. That seems like a great incentive for participation to the plan and for the PBM to develop an effective program.

Some of the keys for good performance guarantees are:

• Good data (baseline and going forward)
• Clear metrics
• Comparisons to a control group and/or national metric (so you don’t just ride the curve of generic conversions for example)
• Long-term contracts

If you really have no care for your health, here’s something for you – The Luther Burger which is a bacon cheeseburger where you replace the buns with Krispy Kreme glazed donuts.