Archive | January, 2011

Are You A Defeatist, Catastropist, or a Triumphalist?

In a post by Atul Gawande, he talks about “Seeing Spots“.  It’s an interesting piece on the generalized reactions to focusing care on those that really drive the costs in our system. 

It’s an important issue.  If 5% drive 60% of our costs, why wouldn’t you treat them differently.  If 1% drives 40% of the costs (or whatever the number is), shouldn’t you be driving out to their house and helping them. 

Of course it’s not a scalable model to the entire population, but 50% success with 5% of the population would save us 30% per year (not accounting for regression to the mean).  But, it would be meaningful. 

So…which are you?

Best Healthcare Companies To Work For

I was reading through the Fortune 100 Best Companies To Work For and pulled out the list of healthcare companies on there.  I was surprised there were not more pharma companies.  There were lots of hospital systems.  There weren’t any insurers or PBMs.

The top companies across all industries were:

  1. SAS
  2. Boston Consulting Group
  3. Wegmans Food Markets
  4. Google
  5. NetApp

In healthcare, the companies were:

#19 – The Methodist Hospital System

#27 – CHG Healthcare Services

#35 – Genetech

#36 – Southern Ohio Medical Center

#37 – Scripps Health

#42 – Baptist Health South Florida

#47 – Novo Nordisk

#54 – Atlantic Health

#56 – Millennium: The Takeda Oncology Company

#60 – Children’s Healthcare of Atlanata

#61 – Mayo Clinic

#62 – OhioHealth

#68 – Stryker

#75 – Arkansas Children’s Hospital

#80 – St. Jude Children’s Research Hospital

#88 – Meridian Health

#91 – The Everett Clinic

Some of the perks they call out in the list are:

  • Paid volunteer time
  • On-site conceirge
  • 100% coverage for healthcare
  • Unpaid sabbaticals
  • Paternity leave
  • 401K matching
  • Pensions
  • Training
  • On-site childcare
  • On-site gyms
  • Charitable matching
  • Diversity

The “New” Consumer

In the September 2010 issue of Inc. magazine, there was an article called “Decoding the New Consumer”.  It is an interview with John Gerzema, who is the Chief Insights Officer for Young & Rubicam.  Here’s a few comments from the article which are elaborated on in his new book – Spend Shift: How the Post-Crisis Values Revolution is Changing the Way We Buy, Sell, and Live:

  • Large numbers of people say money is no longer as important to them.
  • 76% say that the number of possessions they own doesn’t affect how happy they are
  • We are moving from mindless to mindful consumption
  • 71% of people say they make it a point to buy from companies who have values similar to their own
  • More and more consumers are moving from consumption to production (raising chickens, home canning, bartering)
  • 64% of people want to do more things and make more things themselves
  • Kindness and generosity are qualities customers increasingly demand from business
  • Many Americans no longer consider TVs, dishwashers, and air conditioners to be necessities
  • Irony isn’t dead…cynicism is dead.
  • Microsoft beats out Apple in reputation, leadership, and being the “best brand”…much of that has to do with the philantrophy of Bill Gates

I think this poses lots of interesting questions for healthcare companies.  What is your brand?  How is it perceived?  What are your values?  How do people experience those?  How do they add value to your company?  How does your call center display these qualities?  How do your communications?  How do you monitor the shifting of these values and expectations over time?

Patient Responsibility in Readmissions

There has been lots of discussion over the past year about readmissions. With healthcare reform, it is estimated that we can save billions over the next 10 years by addressing this problem.

The new regulations will cut federal reimbursements for ALL discharges if hospitals have a greater than expected 30-day readmission rate. In FY 2013, the cut is one percent, but it goes up from there. I think everyone agrees this is a problem. I’m sure some would debate if this is the right metric, but it certainly is a tangible one.

For those of you that don’t know…In 2009, the NEJM published the article that set this in motion but you can see some of the discussions before this in this nice piece by Academy Health.

“Almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. In the case of 50.2% of the patients who were rehospitalized within 30 days after a medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization. Among patients who were rehospitalized within 30 days after a surgical discharge, 70.5% were rehospitalized for a medical condition. We estimate that about 10% of rehospitalizations were likely to have been planned. The average stay of rehospitalized patients was 0.6 day longer than that of patients in the same diagnosis-related group whose most recent hospitalization had been at least 6 months previously. We estimate that the cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion.”

I think the interesting question here is what is the patient’s responsibility post-discharge.

You have several gaping issues:

  1. Health Literacy: 2/3rds of US adults over 60 have marginal or inadequate literacy skills and in one study, 81% of patients over 60 couldn’t even understand instructions on a prescription bottle. How are they supposed to navigate the system? (see this site for research on health literacy)
  2. Memory: Most patients forget what their physician or nurse tells them. I’d always heard that patients remember about 10% of what they’re told (see NYTimes article on this), but thanks to @trishatorrey, I found this study that showed that 40-80% of information is forgotten immediately. Now, some of this could be addressed by having companions at the encounter (see 2002 paper on this), but there have to be better ways to address this systemic issue.

I guess I would add these two together to equal understanding. How are patients who can’t read and don’t remember going to be successful at home.
This article suggests 12 ways to address readmissions. Additionally, our Chief Medical Officer at Silverlink Communications, Dr. Jan Berger, shared some of our research and also did a podcast on the topic last year.

We’ve always struggled with home monitoring. We can’t force the patient to take the pill. It’s also possible that they get prescribed a medication that they can’t afford and therefore don’t fill. They might have transportation issues and not be able to get to a pharmacy.

Another issue is access to a primary care physician for follow-up after discharge. One study estimated that one in five Americans had limited or no access to a primary care physician.

I don’t know about you, but these statistics scare me. You have people at high risk who are the primary cost drivers in our healthcare system, and they aren’t necessarily equipped or supported to be successful.

Now, we’re going to put the burden on the hospitals to fix this. I agree that it has to start there. The question I wonder is how do we link the patient to this somehow. Is there a way to make them responsible for avoiding readmissions by following the discharge instructions? Is there a way to incent them to be successful? What would we systemically have to do to enable them to be more accountable?

This will require a major effort to address physician and patient interactions, address the discharge process, create a follow-up process to education and monitor the consumer, and ultimately to create a system that provides the support they need to improve their health.

I think we all want the right thing, but I’m sitting here trying to figure out how it gets done.

FL Pharmacists to Fight Medicaid Mail Order

The Florida Pharmacy Association along with a local pharmacy in Florida have filed suit against the state for allowing Medicaid patients to use mail order.  This seems silly to me.  The mail order pharmacy ship has sailed a long time ago.  Approximately 13% of all prescriptions filled in the US are through mail order. 

While I would still disagree if it was mandatory mail, this isn’t.  The state is simply giving patients the option to get their drugs through mail order.  If the community pharmacies have an issue, they should match the mail order rates and dispense 90-day prescriptions and delivery them to the patient’s house at no cost. 

We’re in a budget crisis here as a country.  If we can save money in Medicaid and therefore in the state budgets, why wouldn’t we do it?

The lawsuit says that the change –  

 “at a minimum deprives the patients’ access to a provider having extensive knowledge of their medical conditions and unique clinical problems.”

Really?  I’d love to know how many of those Medicaid patients have a long standing relationship with their pharmacist, know them by name, and don’t use multiple pharmacies.  Maybe I’m wrong. 

It comes down to losing business BUT if the patients are so happy, won’t they stay with their local pharmacy.  This is a transient population so it’s always been hard for mail order.  It’s not easy to send them refill reminders.  There’s not always a consistent address to mail to.  Some of that is changing as text messaging becomes more normal as a communication medium, but that’s still a small percentage of companies. 


Medical Data From Thomas Goetz

Here is a video of Thomas Goetz (Wired magazine) from TEDMED…

He talks about redesigning medical data and how to present it for people to understand.

He talks about a key notion of helping people see their way to better health.

He talks about the feedback loop of Personalized Data – Relevance – Choices – Options.

He talks about how Captain Crunch can inspire information delivery for prescription drugs.

And, then he shared the Wired article on redesigning information.

Vaccines and Autism…the Long Path Back

The 1998 article that started this all has been retracted.  Well, guess what…it’s going to take a long time for that to permeate the thinking of people across the country (world). 

A recent poll by Harris Interactive showed several things:

  1. 69% of those polled had heard the theory about them being linked BUT only 47% knew the Lancet article had been retracted.
  2. 18% of people think that vaccines cause autism
  3. 30% are unsure if they do
  4. 52% don’t believe they do

That 18% represents a lot of children who aren’t getting vaccines. 

USA Today had an article about this the other day.  They talked about the fact that 40% of parents have delayed or declined shots for their kids.  They point to 5 myths:

  1. Vaccines cause autism
  2. Too many vaccines overwhelm children’s immune systems
  3. It’s safe to “space out” vaccines
  4. Vaccines contain toxic chemicals
  5. Vaccine preventable diseases arent’ that dangerous

They go on to point out that there is more aluminum in breast milk (10 mg) and milk based formula (30 mg) than all the recommended vaccines combined (4 mg) based on total consumption in the first 6 months of life.

Compliance For Donations?

Would you be more compliance with your medications if you knew that every time you took a pill or refilled that a donation was made in your honor to a certain charity?  It’s an interesting hypothesis being put forth in this article – Leveraging Altruism To Improve Compliance… BUT I personally am fairly skeptical. 

Let’s just look at the barriers identified in one recent barrier survey we did at Silverlink Communications for patients who had not refilled their statin medications. 

What do you see?

  1. Significant literacy issues.  People didn’t even know they were supposed to refill. 
  2. People don’t understand the medication and remember what the physician told them.
  3. Convenience…an easy to address opportunity.  These are key targets for a retail-to-mail or 90-day retail program.
  4. Side effects…this is harder to address but some of it can be managed by setting expectations up front.

Are those going to be addressed because a donation is being made?  I don’t think so.

Lipitor Going Generic

If you work in pharmacy, this has been on your radar since Zocor went generic years ago. Lipitor has been the biggest drug worldwide, and I believe the spend in the US is still almost $7B a year even with generic Zocor available. (See Consumer Reports on statins)

Now, it appears that generic Lipitor (atorvastatin) will be available 11/30/11 according to the Pfizer site. It looks like Ranbaxy who was first to file the ANDA will get the 180-day exclusivity (but I know several other generic manufacturers have challenged the patent).

So, what does this mean?

  1. Lipitor will likely move to the 3rd tier either immediately or at the next formulary update period once the generic is available on the market.
  2. Atorvastatin will become a part of statin step therapy programs.
  3. Pharmacies in states that have mandatory generic laws will begin auto-substitution of atorvastatin for Lipitor prescriptions unless there the script has a Dispense As Written (DAW) indication.
  4. Depending on the pricing of the generic, PBMs and pharmacies will be very aggressive about encouraging use of the generic version (as allowed with the AG settlements from years ago).

We’ve already seen Pfizer take some action which is to promote a $4 copay card (or 30-day sample) for patients. This is to protect market share, but it also makes me wonder if they won’t do something like Merck did by pricing the generic below the Ranbaxy price (see WSJ article).

Given that Pfizer owns a generic company (Greenstone), I have to imagine that they plan to sell atorvastatin thru that company. But, I think the big question that I would be focused on is whether there will be an “authorized generic” (look at the FTC interim report on this topic). This is a big topic in the industry. It allows the manufacturer who owns the patent to allow a generic manufacturer to make and produce a generic version outside of the ANDA process. Right now, it appears that Watson may get to bring an authorized generic of Lipitor to market.

Will you see the same energy around this as you did around Zocor? I remember having a whole “control room” that we developed at Express Scripts to encourage utilization of generic Zocor. It was built around several key things:

  1. What were all the channels that a patient communicated with the PBM and how did we educate them around the new generic? [And which could we do at what time so as not to limit the short term rebates that our clients were getting on brand Zocor which kept the prices down until the generic was available?]
    1. Member portal
    2. Mail order invoices / stuffers
    3. Inbound IVR messaging while on hold
    4. FAQs
    5. Training call center reps
    6. Formulary notification programs
  2. How did we inform physicians?
    1. Academic detailing – fax, letter, phone consultations, face-to-face visits
  3. What plan design changes did we encourage?
    1. Step therapy
  4. What could be done at the POS with the retail pharmacies?
  5. What could be done at mail?
  6. How would we track success?

Personally, as a PBM or pharmacy, I’d be trying to lock in a period of exclusivity with Watson or Pfizer to have the limited distribution of the generic Lipitor for a period of time. That would be a huge deal (if it could be pulled off).

Guest Post: The Strong Connection Between Education and Health Outcomes

Is there a correlation between education and health? Studies do in fact indicate that there is a positive relationship between advanced education levels and health outcomes. This association has been well-documented in many countries and for many different metrics of health.

Jobs that require a particular level of education typically provide better access to quality healthcare. Studies indicate that unemployment rates are highest for people without a high school diploma. Additionally, evidence indicates that the unemployed population experiences worse health and higher mortality rates than the employed population.

Other studies have shown that more education can reduce a woman’s risk of depression and obesity. Of course, there are health benefits for men as well: educated men tend to drink less and have less of a chance of dying young.

Multi-Generation Implications

Education has some positive multi-generational implications, as a mother’s level of education is correlated with the health of her children. The parents’ education level affects their kids’ health directly because of resources available to the kids and also indirectly because of the quality of schools their kids attend.

Emotional Health Benefits

Evidence shows that more education means a greater sense of personal control. Individuals who view themselves as having a high degree of personal control report a better health status. These folks are at lower risk for physical ailments and chronic diseases. Also, more education improves an individual’s self-perception of their social status, which also predicts a higher self-reported health status.

Health Literacy

Studies show that only three percent of college graduates have below average health literacy skills. On the other hand, fifteen percent of high school graduates and forty-nine percent of adults who don’t have a high school diploma have health literacy skills that are below average. Reports indicate, not surprisingly, that adults with less than average health literacy are more likely to be considered unhealthy.

Education and Health Report

The authors of the Education and Health Report, David M. Cutler of Harvard University and Adriana Lleras-Muney of Princeton University, find a clear connection between education and health. This connection cannot be completely explained by factors such as the labor market, income, or family background indicators. Health and education have a complicated relationship.

The report shows that for some health outcomes, including obesity and functional limitations, the impact of education appears to be even more positive after people have obtained education beyond a high school diploma. The relationship between health and education seems to be the same for men and women across most outcomes; however, there are a few exceptions.

Race, Education, and Health

Studies show there are few racial differences regarding the impact education has on health. For outcomes that do show differences between Caucasians and Blacks, such as being in fair or poor health, Caucasians tend to experience more positive health benefits from more education when compared to Blacks with the same level of education.

Literacy and Health

Low literacy is associated with adverse health outcomes and negative effects on the health of the population. Additionally, poor literacy skills often contribute to a poor understanding of spoken or written medical advice.

Ten studies showed a positive, significant relationship between literacy level and the participants’ knowledge of the following health issues:

  • Contraception
  • Smoking
  • Hypertension
  • Human immunodeficiency virus (HIV)
  • Asthma
  • Diabetes
  • Postoperative care

Clearly, there is a positive connection between education and health. A better educated society leads to better overall health and lower healthcare costs.

Useful Resources

Brian Jenkins writes about a variety of career and college topics for BrainTrack.

Wireless Healthcare Quote

This is from a Qualcomm marketing piece so take it in context, but I thought it was a good quote by Dr. Paul Jacobs (Chairman and CEO):

Consumers have already adopted a wireless lifestyle and the phone in their pocket is not just for voice communications anymore – it’s also becoming the most personal device for information access.  Since the mobile phone is always on and always with you, it is the most logical platform for monitoring and maintaining personal health.  And new types of mobile devices and services have tremendous potential to improve productivity for medical professionals and help consumers manage their own health.  Mobile technology has the potential to improve public health overall and ultimately to make health care more accessible and affordable for all of us. 

A Few Health Studies

(Trying to dig out of my work pile and grab a few blog ideas I’ve had on my desk.)

This article in Spirit Magazine (Jan 2011) mentioned 5 different studies that I thought were interesting:

  1. Too much ice-tea can wreak havoc on your kidneys according to researchers at Loyola University.  Add a splash of lemon to inhibit the growth of kidney stones due to the oxalates in iced tea.
  2. Resveratrol, the anti-aging compound found in red wine, grapes, blueberries, and peanuts, stops out-of-control blood vessel growth in your eyes according to a study by Washington University in St. Louis.
  3. Women who regularly wear high heels over a 2-year span showed 13% shorter muscle fiberts in their calves BUT a simple calf stretch at the end of the day will keep the muscles in balance according to Manchester Metropolitan University.
  4. Fast-paced video cames like Call of Duty help players make decisions in other areas of life faster according to researchers from the University of Rochester.
  5. Researchers at Virginia Tech found that people who drank two glasses of water before a meal lost (on average) 5 pounds more than the non-drinkers during a 12-week study.

Presto: E-mail Into Newsletters

I’ve seen several ideas over the years to try to figure out how to connect those of us that live and die by our electronic tether (e-mail, SMS, Facebook) to loved ones who don’t use a computer or in other countries where they don’t have computers (e.g., rural India several years ago).

Now there’s a new service called Presto (  You set up a “printer” in their home which connects to an analog phone line.  You can then send them e-mails which get re-formated into a newsletter with the attachments printed.  You can tag photos in facebook for them to get printed.  You can schedule reminders for them that get triggered and printed at a fixed time. 

Sounds pretty cool to me.  In general, the older population (65-80) are pretty responsive to phone based solutions (like we do at Silverlink), but you do see a drop off after 80.  If this solution ever were to take off and the caregivers could opt-in their parents to accept reminders (e.g., adherence, medical appointment) from health plans, PBMs, ACOs, and other organizations, this would be an interesting new channel for reach.

Grand Rounds (volume 7: number 17): Engagement Is Multi-Faceted

The concept of “engagement” in healthcare is a difficult one. Traditionally, we’ve had a build it and they will come approach that didn’t encourage preventative care. It also didn’t openly acknowledge the challenges that consumers have in dealing with medication adherence and even understanding the system or their physician’s instructions.

In this week’s edition of Grand Rounds, I looked at submissions and recent posts from several angles on this issue.

One of the most engaging was from the healthAGEnda blog where Amy tells her personal story about being diagnosed with Stage IV inflammatory breast cancer and trying to work though the system. Her focus on patient-centered care and support for the Campaign for Better Care make you want to jump out of your seat and shake the physician she talks about.

“It doesn’t matter if care is cutting-edge and technologically advanced; if it doesn’t take the patient’s goals into account, it may not be worth doing.”

Another submission from the ACP Hospitalist blog tells a great story about how to use the “explanatory model” to engage the patient when it’s not apparent what the problem is. I think this focus on understanding that physician’s don’t always have the answer is an important one, and one that Joe Paduda talks about when he addresses guidelines as both an art and science. Dr. Pullen also talks about this from a different perspective by describing some examples of “Wicked Bad” medicine on his blog.

One of the common focus areas today from patient engagement is around adherence. Ryan from the ACP Internist blog talks about the recent CVS Caremark study which looks at how total healthcare costs are lowered with adherence. He goes on to point out the fact that understanding the reasons for non-adherence is important so that you can – simplify, explain, and involve.

Interestingly, my old boss from Express Scripts recently started her own blog and also talked about this same study but from a different perspective.

And, Dan Ariely briefly touched on this topic also when he shared a letter he got from a reader on getting their child to take their medications.

While I think a lot of us believe HIT might save the day, the Freakonomics blog mentions a few points about HIT to consider. And, Amy Tenderich (of DiabetesMine) who I think of as a great e-patient gives a more practical example when she talks about what diabetics need to do to stay prepared in the winter. (What’s the basic “survival kit” and where can you go to get one.) I think this has a lot of general applicability to how we plan our days and weeks and try to stay healthy. One physician I know who travels a lot always talks about the need to be prepared with healthy food on the road and at the airports.

On the flipside, we hear a lot about genomics and social networking as ways to engage the consumer and to understand their personal health decisions. To that affect, I liked Elizabeth Landau’s post on how your friend’s genes might affect you.

Of course, there are lots of other considerations. Louise from the Colorado Health Insurance Insider talks about the fact that we are so focused on health insurance reform rather than health care reform. She goes on to point out the lack of connectivity between the consumer and the true cost.

And, Henry from the InsureBlog points out a change in the NHS to look more like the US system and cut out one of the steps for cancer patients. Will it help?

But, at the end of the day, I think we have to address the systemic barriers while simultaneously figuring out how to better engage consumers. Julie Rosen at the Schwartz Center for Compassionate Healthcare talks about Patient and Family Advisor Councils. This was a new concept to me, but it makes a lot of sense that engaging the family in the patient’s care will lead to better outcomes and a better experience. I also heard from Will Meek from the Vancouver Counselor blog who talks about how dreams can be used as part of therapy, and Dr. Johnson who presents a story of woe about her challenges as a physician.

And, since many of us “experience” healthcare thru pharmacy and pharmacy thru DTC, I thought I would also include John Mack’s Pharmacy Marketing Highlights from 2010.

Next week’s Grand Rounds will be hosted by 33 charts.

Average Number of Claims and Pharmacy Spend

I was reading a Barclay’s Capital report this morning put out by Larry Marsh and team. In it, it included some data on the PBM market. What I found interesting were two key data points:

  1. The average number of prescriptions PMPY (per member per year) by insurance type
    1. Medicare Part D uses approximately 30 Rxs PMPY
    2. Commercial uses approximately 15 Rxs PMPY
    3. Medicaid uses approximately 11 Rxs PMPY
    4. Uninsured uses approximately 5 Rxs PMPY
  2. As you might expect, the costs per member per year are also different
    1. Medicare Part D is approximately $1456 PMPY
    2. Commercial is approximately $844 PMPY
    3. Medicaid is approximately $522 PMPY
    4. Uninsured in approximately $257 PMPY

Interesting, if you look at the assumptions and data around the uninsured, they pay more per generic script than anyone else, and less (on average) per brand script. BUT, the brand script number is deceiving since they have no specialty scripts in there (since the uninsured could never afford those prices).

[Note – I use the term “approximately” since these were derived numbers based on CMS, CBO, and Barclay’s estimates.]

Get Wellness Article in Time – Silverlink, Aetna, Hypertension

The recent issue of Time magazine includes an article called “Get Wellness” about wellness.  It talks about having MDs “prescribe” wellness (think Information Therapy or Ix) and the fact that Medicare enrollees will be eligible for wellness visits begining 1/1/11. 

The new wellness benefit tasks doctors with creating “personalized prevention plans,” which ideally will be tailored to each patient’s daily routine, psyche and family life. And if that sounds more like a nanny-state mandate than medicine, consider that some 75% of the $2.47 trillion in annual U.S. health care costs stems from chronic diseases, many of which can be prevented or delayed by lifestyle choices.
The article goes on to talk about the challenge this may create for physicians.  Can they act as nutritionists?  Can they change behavior? 
Of course, MDs won’t be the only one’s focusing here (although some of that could change with ACOs and PCMHs).  Disease management companies and managed care companies have focused here for a long time.  The focus in many ways these days is how to reduce costs in these traditionally nurse-centric programs with technology but without impacting outcomes and participation.  There is one example in the article from some work we are doing at Silverlink around hypertension
Some firms, in trying to bring down health care costs, have hired health coaches to reach out to the sedentary or overweight to get them moving more. Others use interactive voice-response systems to keep tabs on participants’ progress. In a study, Aetna set out to see whether it could reduce hypertension — and the attendant risks of stroke, heart attack and kidney failure — among its Medicare Advantage members. More than 1,100 participants were given automated blood-pressure cuffs and told to call in with readings at least monthly. They also got quarterly reminders to dial in. When they did so, an automated system run by Silverlink Communications provided immediate feedback, explaining what the readings meant and where to call for further advice. Alerts were also sent to nurse managers when readings were dangerously high. The result: of the 217 people who started out with uncontrolled hypertension and stuck with the program for a year or so, nearly 57% got their blood pressure under control.

Ambulance For Obese People

When I heard this story, I reflected on two things:

  • This is a sad state of our reality that people are so heavy that the EMTs can’t get them from their house to the hospital; and
  • Why is this happening in Boston.

I think we all know the obesity statistics in the US.  This is a crisis / epidemic that all of us in healthcare will be dealing with the for the rest of our lives…so, from that perspective, retrofitting hospital beds, stretchers, ambulances, etc. is a reality.

On the flipside, Massachusetts is the second healthiest state in the country so why not start this service in some other state where the likelihood of having an obese patient is higher?

Walgreens To Focus on 90-Day Rxs

I’m not sure I see this as new news since Walgreens has traditionally had more 90-day claims between retail and mail than anyone other than Medco (per data from a few years ago), but I think it’s a good supportive message for the general trend.  Walgreens has had 90-day networks for most of the past decade.  I remember them offering mail order pricing to us at Express Scripts years ago. 

“We think this is going to be one of the fastest-growing parts of the Walgreen’s pharmacy business for several years to come.”  comment by Colin Watts, Walgreen’s Chief Innovation Officer in article yesterday

The more interesting things to me in the article were:

  1. It says that filling 90-day Rxs is more profitable.  You certainly save on supplies, but I don’t think that savings would outweigh the additional margin on foot traffic.  They didn’t talk about central fill which would certainly be one way of saving by filling 90-day offiste and delivering them to the store.  That leaves me with the assumption that they view the cost of the script using only the variable cost of the pharmacist’s time.  (A perspective I see from both sides – direct cost versus the pharmacist as a fixed asset until you reach a certain volume of drugs per store per day.)
  2. It says that filling 90-day Rxs improves adherence which has certainly been the biggest push by the PBMs regarding mail order for the past 12-18 months.  No longer is the biggest advantage on saving money…it’s all about adherence.

The one interesting question I would have is what do they see as the theoretical maximum on 90-day utilization.  If they were close to 40% penetration a few years ago, do they believe they can get that to 45%, 50% … more?  Knowing that would create an interesting industry discussion about benchmarking and upside in this space for both 90-day retail and mail order. 

There’s a section about Walgreens90 in their 2010 Drug Trend Report (pg. 12) which talks about a 10% improvement in adherence and the savings they saw with 90-day prescriptions for diabetics.  This new press release certainly increases that improvement in adherence and also seems to apply broader. 

I think it’s the one time you can see all the industry focused on 90-day prescriptions.  The interesting thing will be how Medco and Express Scripts try to partner (or if they try to partner) with retail to offer a choice option like Maintenance Choice by CVS Caremark

The new Walgreen’s tagline is “Go 90″…”Get three refills in one, and for three months you’re done.”  Going back to their original press release, here’s a quote from Kermit Crawford (President of Pharmacy Services):

“The role of the pharmacist in the health care system has steadily evolved for some time, and it’s clear if people have questions or concerns about their medications, they want to be able to rely on the pharmacist they know, trust and are confident talking to about their health. We also know that an approximately 15 percent increase in adherence to medications occurs for consumers receiving a 90-day prescription versus those receiving a 30-day supply. So our Go 90 program can improve health outcomes and reduce overall costs to the health care system through better adherence while providing patients the choice they want.”

The Art of Creating A “Campaign”

For a little more color on this program – click here.

What you saw here:

  • Engagement takes planning and creativity
  • Engagement is a process
  • Messaging before the event is critical
  • A retention strategy for sustained involvement is important
  • Think about your influencers and how to turn them into advocates
  • Clear goals and objectives
  • A defined metric of success

Compliance “Rapid Response” Team

In the future, will we have teams who rapidly engage patients who don’t take their medications as prescribed?  Will those be medical teams for patients who recently got a transplant and police teams for mentally ill patients with a history of violence?

Seem pretty farfetched?

Compliance with medication is such a hot topic today that you’re finally see the technology innovators jumping in.  You have solutions like the GlowCaps system that have been around for a few years and demonstrated their impact.  Now, you have technology going even further to attach itself to the pill and send data back. 

The LA Times had an article that talks about some of these technologies:

  • Camera pills
  • A device that you wear around your neck to monitor swallowing the pill using RFID
  • A device that detects when it encounters stomach acid

BUT, the kicker here is that the article estimates this will only improve adherence by 5-15%.  Remembering to take the pill isn’t the only reason people don’t take their pills!!!

Just look at this on the 11 Dimensions of Non-Adherence or this on the Predictors of Non-Adherence or some of the research coming out of CVS Caremark.

You have to address health literacy.  You have to address side effects.  You have to address beliefs.  And, many other issues.

These solutions are “cool” and will finally tell us if people take a pill, but I’m not sure that’s the silver bullet.  Plus, at what cost?  Get a 5-15% improvement in adherence isn’t that impressive.  We’ve done that multiple times at Silverlink with a quick remind to patients about taking their medications or asking patients about their barriers and addressing them. 

As with any solution, it’s about figuring out who it benefits most and getting it to them at the right time.

Hosting Grand Rounds Next Week

Well, I’m finally getting around to hosting a blog carnival. Next week (January 18th), I’ll be hosting Grand Rounds which a weekly round-up of the best medical and healthcare blog posts (see here for more information). While I’m open to any submission, I’d like to make the theme “engagement”. How to get patients more involved in their healthcare or the role of other healthcare constituents (MDs, RPhs, RNs) and healthcare entities (Payor, PBM, Employer) in getting consumers engaged.

You can see this week’s Grand Rounds at FDAzilla.

Please send me your submissions by Sunday night (1/16/11) at 10pm EDT, and I promise to use as many submissions as possible especially if their on this week’s topic. You can e-mail me at gvanantwerp at mac dot com with a subject heading of “Grand Rounds Submission”. Please include your name, Blog Name, and blog post URL.


Key Themes From PBM Whitepaper

For those of you that haven’t downloaded it yet, here are the key themes of the whitepaper. [BTW – I know many of you don’t like to comment publicly, but I welcome your feedback privately or publicly on the whitepaper.]


While there are certainly some opportunities for PBMs or pharmacies to differentiate by specializing in certain markets (e.g., Medicare, Worker’s Compensation), the best opportunities for sustained differentiation are found in two areas of innovation:

  1. Using an evidence-based approach to consumer engagement and
  2. Developing integrated solutions that are patient-centric.

These business strategies go beyond the traditional fundamentals – location, operational excellence, customer service, reporting, account management, managing trend, and leveraging efficiencies of scale (network pricing, rebates). While it’s possible to create some differentiation in those areas, they are often difficult to maintain over time especially as you approach a point of diminishing returns.

Ultimately, understanding and succeeding at engaging the consumers whose choices drive the costs in our healthcare system is the path to success. This is a change for the PBMs more than the retail pharmacies, but, to succeed at this transition, both PBMs and pharmacies have to be nimble organizations that innovate and learn quickly. They have to understand the consumer from the outside-in and make decisions from an experiential perspective.


Download the complete whitepaper to see:

  • Recent changes in the PBM and pharmacy industry.
  • Examples of innovation
  • Why consumer engagement matters?
  • Examples of Silverlink insights into consumer behavior

An example of a multi-channel adherence solution

Looking Back – 1999 MCO Web Survey

Back in 1999, I was working at Ernst & Young LLP helping MCOs (managed care organizations) figure out what they should do about the Internet as “eCommerce” was all the buzz.

I came across an old presentation this morning.  In it was a survey we did of how companies were using their websites at the time (n=64):

  • 84% had a provider directory online
  • 82% had job postings online
  • 72% had health links on their website
  • 63% allowed you to e-mail customer service
  • 48% allowed you to e-mail provider relations
  • 45% provided member services news
  • 35% provided provider relations news
  • 25% provided their formulary
  • 20% provided clinical guidelines
  • 18% allowed you to verify coverage
  • 18% allowed you to check claims status
  • 15% allowed you to verify benefits

(Note: Exact values are approximate as the chart only showed increments of 10%.)

I’m not sure, but I would hope that this was 100% on all of these by now.

Pharmacy Customer Experience

When most people start to this about segmentation in the pharmacy space, it becomes quickly overwhelming:

  • Age
  • Gender
  • Plan design
  • Geography
  • Income
  • Condition
  • Drug
  • New to therapy or ongoing therapy
  • Co-morbidities
  • Depression
  • Physician relationship
  • Support system
  • Education
  • Literacy
  • Etc.

I want to spend some time over a few posts beginning to break this down.  Today, let’s look at the five logical customer types:

  1. New Nancy:
    • Newly diagnosed
    • Not very familiar with her condition, the medication, the pharmacy process, or the PBM
    • Needs lots of hand-holding and education
    • Need to address gaps in the physician-patient encounter
    • Need to help her build a routine
  2. Caring Carin:
    • Caregiver for either dependents or parents
    • Picking up prescriptions for them and responsible for translating (sharing) information with them
    • Important to educate, but not the patient
    • Likely to be the “e-patient” but also stressed out (see sandwich generation)
  3. Sporatic Sam:
    • Someone who gets some acute medications occassionally (e.g., antibiotic)
    • Understands the healthcare system somewhat but not overly interested or engaged in the semantics
  4. Forgetful Frank:
    • Chronic medication user
    • Likely to have or develop multiple conditions
    • Not great with adherence to therapy
    • Understands their condition, but not worried about it (even if they should be)
  5. Steady Suzy:
    • Chronic medication user
    • One or more conditions
    • Understands the value of medication
    • Feels better when taking her medications
    • Actively managing her health
    • Generally adherent
    • Engaged with MD and pharmacist

I guess I could add Corrupt Cindy to talk about patients that abuse the system (a pharmacist friend of mine was telling me about a patient they caught this weekend with 6 different names across different pharmacies and a fake prescription pad). 

From a basic segmentation framework, are there others without getting into demographic attributes?

Benefits Package Blog Carnival


The new blog carnival (3rd edition) is up this morning with one of my submissions and lots of other great posts.  I would encourage you to visit or participate if you’re a blogger.  Thanks.

DBN: 2011 Pharmacy Predictions

Drug Benefit News (which is a must read publication) just came out with a summary of opinions from people about the new year (DBN, 1/7/11).  Here are a few highlights:

  • Focus on clinical programs to help MCOs hit their MLR targets
  • PBM consolidation and need for smaller PBMs to innovate (as my whitepaper discusses)
  • Potential for generic only formularies as generic fill rate is in the 70-80% range
  • Focus on specialty drug costs including the claims processed under the medical benefit (Express Scripts big push right now)
  • Outcomes based contracting (i.e., Merck and Cigna)
  • Direct contracting (i.e., Caterpillar, Delta)
  • Continued pharma shift to niche markets as brand oral solids make up <20% of claims
  • Health reform fallout
  • Continued streamlining and focus on MA and PDP
  • Continued innovation (i.e., Wal-Mart and Humana model)
  • Limited or restricted networks take off (finally)
  • Cost plus pricing
  • Modernizing Medicaid management and controlling costs

I was one of the people interviewed for the article.  My comments from the article are:

The things that I’m monitoring and think will affect the industry include mobile health, behavioral science application, preference-based marketing, risk based contracting, and integration with home monitoring devices. Rising costs will push several things such as increased management of the specialty benefit, more focus on adherence, and an increased understanding of how consumers impact health outcomes and how to best engage them. In 2011, innovations and changes in benefit design could include limited networks, more and more utilization management especially step therapy and 90-day retail or mail.

The biggest area of discussion in Medicare Part D right now is the Star Ratings. There are questions for PBMs about how they support the MA metrics and there are now specific PDP metrics. Understanding what those are, how to track them, how to influence them, and how to improve them will be a major focus in 2011.

New Pharmacy Whitepaper: Innovate Or Be Commoditized

In early 2009, I published an initial whitepaper on the PBM industry.  With all the changes going on in the industry, it seemed relevant to put out a new whitepaper although the total impact of reform and the definition of MLR is still TBD.  As I did before, I’m putting a summary here, and I welcome your comments.

You can download the whitepaper by registering on the adherence site at Silverlink Communications.  Thanks.  [If you’re a regular reader but not a logical client, you can request the whitepaper by contacting me.]

I think a quote from Larry Marsh (Managing Director, Equity Research) at Barclay’s Capital does a good job of summarizing it:

“Innovation will be increasingly important in the PBM world, as these companies seek to solve a greater set of pharmaceutical cost issues for their customers over the next 10 years.”

[BTW – If you want to get updates e-mailed to you as I post them, you can sign up here.]


Innovate Or Be Commoditized: The PBM and Pharmacy Challenge for 2011

Doing more with less; dealing with constant change; and having technology be a part of everything…  Those are things that the next generation will take for granted.  For the rest of us, those are dynamics that are changing our personal and professional lives.  We’re constantly bombarded with information and decisions to make.

While the pharmacy industry has generally avoided the collapse of the automotive industry and the radical change of the health insurance industry, we’ve seen unprecedented change in the past few years.

It’s almost impossible to go a few days now without seeing information about prescription drugs in the mainstream news.  You might hear a financial analyst talking about the lack of blockbuster drugs in the pipeline.  You might read about a drug recall in USA Today.  You might see a new report talking about the $290B cost of non-adherence[ii] to the country.  Or, it might simply be water cooler discussions around how more than 25% of kids[iii] now take a prescription medication or how non-adherence can lead to hospital readmissions[iv].

This has raised the average consumer’s awareness of the industry and continues to push the trend of consumerism with which the entire healthcare industry is dealing.  Most of us in the industry already knew that pharmacy was the most used benefit (12 Rxs PMPY for PPO members[v]) and believed that pharmacists were a critical part of the care continuum.

The challenge now is for the industry to demonstrate their value beyond simple trend management.  The growth in generics will slow down while specialty spending grows.  Pharmacy and pharmacists have to become critical path in the care continuum and demonstrate how they engage consumers to improve outcomes.  It will become increasingly important to link outcomes and reimbursement as CIGNA Pharmacy did in their diabetes deal with Merck[vi].

[i] “Still More Pharma Jobs Go By The Wayside”, Pharmalot blog, posted on Nov. 3, 2010,

[iii] Berkrot, Bill, “Prescription Drug Use By Children On The Rise”, Reuters, accessed on 1/4/11,

[iv] Leventhal MJ, Riegel B, Carlson B, De GS., Negotiating compliance in heart failure: remaining issues and questions, Eur J Cardiovasc Nurs., 2005;4:298–307 (abstract online at

[v] Managed Care Digest Series: Key Findings, last updated Nov. 2010,

[vi] “CIGNA and Merck Sign Performance-Based Agreement”, CIGNA Press Release from April 23, 2009,

CVS Caremark: Causal Link Between Adherence And Overall Costs

I’ve argued many times that prescription costs should (in many cases) go up not down.  But, the evidence to support that has often been anecdotal or from studies that people have struggled to replicate. 

CVS Caremark just released the results of their study “Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending” in the January issue of Health Affairs.

  • Looked at pharmacy and medical claims
  • 135,000 patients
  • Patients with with one of more of the following – congestive heart failure, diabetes, hypertension, and dyslipidemia

“There have been many studies through the years that suggest adherence can save on health care costs, but the issue has not been central to health care cost discussions because those studies did not establish a causal link. We took the research further and what we found is that although adherent patients spend more on medications – as much as $1,000 more annually – across the board they spend significantly less for their overall health care costs”  by Troyen A. Brennan, MD, MPH, EVP and Chief medical Officer of CVS Caremark (source)

The savings associated with being adherent were:

  • Congestive heart failure = $7,823
  • Diabetes = $3,756
  • Hypertension = $3,908
  • Dyslipidemia = $1,258

It will be interesting.  Will this replace the “Sokol study” that everyone has historically quoted?  Will this lead to a rush of adherence programs for key conditions such as those studied here?  Will others try to replicate this study? 

I for one hope this changes the conversation from “prove the ROI” to show me how to best improve adherence across categories and segments of the population.  (To learn more about how Silverlink works with clients on adherence, you can go to our microsite.)

Humana and Concentra

I’d forgotten about this deal until someone sent me a note about 2010 earnings for Humana and the fact that this was Humana’s 11th acquisition over the past 5 years.  (Can you name them all?)

Given the push for ACOs and PCMHs and clinics, I think the acquisition of Concentra which owns 300 clinics and almost 250 on-site facilities is an interesting one.  It will give Humana another tactic for managing care and creating stickiness with employers.  I also think that clinics have a lot of opportunity to coordinate with pharmacy and improve adherence, therapeutic conversion, and use of mail order.  (See some of Joe Paduda’s comments here.)

With the Concentra staff, I’d be interested in seeing a deal with American Well or another company where they could be leveraged further in a virtual consultation setting with the option of driving them to a physical facility for follow-up. 

The other potential here is to leverage the clinics to improve HEDIS scores and STAR ratings

I think there is more to come here and with similar deals.

CVS and Universal American – 2 Additional Facts

Well, two things I didn’t know yesterday came out as everyone returned from vacation and started analyzing the acquisition.

  1. Adam Fein pointed out the close relationship that NCPA has with UA’s PDP plan and the fact that that is different from their prior relationships with CVS Caremark.  Will that change anything?
  2. Carl Mercurio points out that this now makes CVS Caremark the second largest PDP plan after United.

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