Enabling Healthy Decisions

I appreciate the submissions that I got for this week’s Benefit’s Package Blog Carnival.

Adam Fein of Drug Channels submitted a post that was near to my heart since it is a study that everyone has been talking about (in the pharmacy space). He wrote up a summary of the research that CVS Caremark published about choice of retail versus mail and what they were seeing. Like adherence, past behavior is a good indicator of future behavior. In this case, people who had used mail before, were more likely to use it again.

In Dave Kerrigan’s submission, he talks about the need to Percolate the Perks. He brings up a great point around how to sustain engagement. The reality of differentiating your benefits, keeping people aware of them, and getting people to use them is a real challenge. Some of the ideas he brings up are relevant across the spectrum of engaging consumers.

Building on engagement, one of the things that scares a lot of people is being misdiagnosed or given the wrong treatment (or getting surgery on the wrong body part). Evan Falchuk talks about this in his blog post on Third Place Health Care. The opportunity to get a 3^rd party opinion is one that I think lots of people would like to access. And, interestingly, Jennifer Benz also talks about this in her submission about Boosting 401k Participation. Her post talks about what’s happened from a tax perspective and stressing that with the consumer.

While I’m not sure of the relevance from a health benefits perspective, I did get an interesting submission from the Action For Better Healthcare blog on what Geisinger is doing around making facilities more efficient. This plays into a lot of the green architecture efforts that are ongoing (see a blog and book from a classmate of mine from architecture school). But, I found another post on the blog more interesting –an interview they posted with Karl Rowe which is interesting given the Kaiser research that many people think healthcare reform is already repealed.

Next up, I thought the Free Range Communication blog does a great job of breaking out highlights from the recent SHRM report. A lot of topics of focus to the HR community are very health centric, and a lot of the trends around aging, increased use of caregivers, more people with chronic conditions, etc. are all very relevant. For those of you looking for similar data around pharmacy benefits, I just pulled out some data from another report from PBMI here.

Dr. Liu wrote on Why Consumer Driven Healthcare Will Fail and also had a piece on the recent Consumer Reports story about What Doctors Wish Their Patients Knew. He draws some parallels around CDHC and 401k plans which I think is very relevant.

Another post from this past week that I liked was Dr. Val’s write-up on Tabloid Medicine. Given the fiasco around vaccines and the false research, this should be a hot topic.

I also liked an AMA story about Secret Shoppers and Susannah Fox’s video and writing on Healthcare Out Loud. A few other things from this week were a brief summary of some of the work Sanofi-Aventis is doing in social media, a paper on The Connected Patient by Jane Sarasohn-Kahn, and some research on storytelling and hypertension.

It’s not a surprise to any of us that most people are much more distracted today then they were in the past. Remember the days when there were no mobile phone, no video games, no DVDs in the car…it seems so peaceful. On the flipside, it seems so unproductive. I can’t imagine not multi-tasking.

Ultimately, there are three questions that come to mind:

1. Do we learn more this way?
2. Does this affect our social relationships?
3. Does this change our productivity keeping in mind quality?

I don’t know the answers to these (although I have opinions). But, I started thinking about this when I was reading an article in Time (Wired For Distraction). The author talks about “continuous partial attention” which is a key complication in the world of health engagement.

On the one hand, I can’t tell you how many times I hear people say how critical multi-tasking is. BUT, there are times (IMHO) that you have to buckle down and focus. I remember a few years ago when I had to essentially just focus on one big project for a month. It was hard, but the project was successful. At the end of the day, there is a difference between being used to distractions and dealing with multi-tasking.

Is this a prevalent issue? Yes. You don’t have to look any farther than those advertisements on TV with the father walking around the soccer field on his BlackBerry or phone. Or look at all the efforts to get people to stop texting while they drive.

“Constant distraction affects not only how well kids learn but also how their brains absorb new information.” (Time, 2/22/11, pg. 56)

I think the study mentioned in the article from UCLA in 2006 makes the point:

• Multi-taskers and focused learners deploy different parts of their brain
• Multi-taskers use their striatum which is focused on building procedural memory
• Focused learners use the hippocampus which helps people apply knowledge

So, what do you want for your kids – them to be good at routine tasks or them to be good creative thinkers. Does that play into Michelle Obama’s decision not to let her kids use Facebook?

But, apply this to the healthcare challenges we face…

• Are people using the devices during their physician visit further limiting what they retain?
• When you send someone a direct mail piece, an e-mail, or a phone call about their healthcare, are they really hearing the information? Or are they listening to TV and reading e-mail? Or taking a phone call while watching a soccer game?

Given the health literacy issues we face, this lack of focus when we’re delivering critical information to an overwhelmed patient is a real cause for concern. Maybe there are simple answers:

• Appeal to the basic research on learning which shows that people learn the most when you leverage multiple ways of delivering information – verbal and written; or
• Simplify the message; or
• Leverage plain language; or
• Ask the person to pause to listen to the message; or
• Increase your attempts to change behavior (without annoying the consumer).

We know the message matters, the channel matters, the person or entity delivering the message matters, and now I’m suggesting that the environment in which the information is received matters.

Just another one of the many confusing messages in healthcare. Is red wine good or bad? Is this drug good for me? How do I weigh the side effects? How much should I work out? Should I stretch before I work out? Is BMI critical if I have muscle mass? Am I genetically doomed? Should I provide feedback on my physician or will I get sued? Do I have to take my drug every day or just most days?

Well, I’m sure in this case moderation is important, BUT Japanese investigators have found that polyphenols in cocoa attach to genes in the liver and intestines which activate the ones that produce good cholesterol (HDL) and help suppress bad cholesterol (LDL).

Great news for those of us that love sweets!

Dr. Atul Gawande wrote The Checklist Manifesto.  Here’s a video of him on the Colbert Report talking about using lists.

Do you use checklists?

I do. I’m a big believer in the fact that they help you organize your thoughts. I also believe that in today’s day and age with all the information coming at us and the pace of change that you need to use a list to optimize on the best practice. I recently gave my team a checklist of things to do each week. It’s basically what I think about on each Friday to make sure I can wrap up the week and that I’m prepared for the next week.

Last week, I had a chance to talk with Mark Merritt, President of PCMA, over the phone.  I reached out to Mark as a follow-up to my whitepaper on the future of the PBM to get his thoughts on where the market was going.  It was a great discussion as I appreciate Mark’s perspective.  He spends his days working on behalf of PBMs navigating the changing tides of Washington.  He also previously worked with the health plans so he has an appreciation for their perspective as well.

My first question to Mark was about how the PBM model will change in the next 5-10 years.

He reinforced for me that the PBM will continue to drive value.  While some had forecasted PBMs becoming commoditized 5-6 years ago, they have continued to grow and demonstrate value time after time.  But, he admitted that the exact model they hold in the future is unknown.  PBMs have focused on affordability and access and with that mantra, they have continuously changed and adjusted.  They’ve evolved from claims processes to trend managers.  They’ve moved from mail order companies to add specialty pharmacies.  They’ve moved from focusing on rebates to focusing on generics.  And, at the same time, they’ve launched new technologies such as electronic prescribing and been critical to the Medicare Part D solution. 

He went on to talk about how the relationship with payers has evolved and how PBM clients have become more educated about how to partner with the PBM and not simply look at them as a transactional service where the lowest price is all that matters.  [I felt like his comments reinforced a lot of my thoughts about how the PBM needs to be more focused on patient engagement and condition management.  Drug trend is not the only answer…outcomes matter.]

We then went on to talk about how PBMs are developing a consumer brand. 

Mark talked about consumer branding as a company by company decision since there are a variety of factors to consider.  [In my experience, some clients don’t want the PBM to be a “brand” in the consumer’s mind.]  We talked about how historically pharmacy has been an after-thought to medical, but that specialty drugs may change that paradigm.  We also talked about how an increased focus in preventative medicine would push pharmacy to the forefront where prescription drugs are often first-line therapy for most diagnoses. 

We also then talked a little about the difference between the claims processing business of the PBM and the mail or specialty pharmacy.  Where the PBM has a pharmacy – patient relationship, their “brand” and awareness to the consumer is [and needs to be] different.  They have to be able to engage the consumer to provide them with information and help them understand their drugs, their condition, and help them stay adherent.  We wrapped up this section talking about how patient engagement improves savings whether it is on generics, mail order, or overall medical costs.

Finally, we discussed Medicaid growth and some of the research that PCMA has been disseminating around the potential savings with more managed Medicaid and greater use of pharmacy management tools.

My Summary

The summary for me was a reinforcement of why the PBMs have survived.  They focus on the patient [while making money].  They evolve to the place where the market needs a solution.  They leverage technology.  They invest in understanding consumer behavior.  And, there are enough of them that clients can find a PBM that fits their needs whether it’s claims processing, mail order, trend management, transparency, limited networks, retail connectivity or some other point of differentiation. 

When I first worked on electronic prescribing (eRx) back in 2001, there were grandiose expectations for the technology. A decade later, we’re finally starting to see adoption happen with over 20% of new Rxs (NRxs) written electronically according to several people. (see article or go to Surescripts for more data)

The holy grail of this technology is not simply to get a clean prescription sent electronically, but to minimize the more that 40% of NRxs which fall into the exception process for drug-drug interactions, step therapy rejects, or other follow-ups. (see prior post) That doesn’t even take into account the amount of times that cost is an issue for the patient leading to further work effort by the pharmacy and/or patient to get a new prescription. Obviously, cost is one of the issues which is driving the increased abandonment rate at the pharmacy.

Whether or not physicians should or will take on this additional responsibility at the point-of-care (POC) has always been a question…of course CMS incentives help. BUT, I was disappointed to hear from PCMA that some manufacturers are trying to limit the eRx functionality. They don’t want physicians to be able to:

• See lower cost alternatives
• See drug-drug interactions based on the patient’s history
• See lower cost pharmacy alternatives

That seems a little bitter to me. The manufacturers were one of the biggest advocates of the technology early on to the point where they saw lots of opportunities for promoting their brands. Fortunately, the vendors didn’t sell out as a vendor the retail pharmacies use for messaging did years ago. That vendor allowed the manufacturers to buy out a therapeutic class and didn’t allow any plan specific messaging to be delivered to the consumer which was very frustrating.

Next week (2/21/11), I’ll be hosting the 6^th edition of the Benefits Package Blog Carnival. You can see last week’s edition at BeyondHealthcareReform.com.

If you’re interested in participating, please send your blog post to me at gvanantwerp at mac dot com. I’d appreciate submissions by Friday night (2/18), but I’ll try to include any I receive by Sunday night (2/20).  Please include the name of your blog, the link to the blog post, and your name. Think about submissions that are interesting to people in the benefits space especially thoughts about how they can engage their population to more effectively manage their health.

Thanks.

I’ve talked before about the great experience I’ve had on the Disney Cruise Line, and Disney is often held out as a model company. Well…I just got back from a Disney Cruise last week, and I was disappointed. BUT, I learned several things about the customer experience.

1. A failure at one part of the process can overshadow other successes
   
2. Expectation management is critical
   
3. Front line employees make the difference
   
4. Keep it simple
   

Situation:

Let’s set the stage correctly. Disney just added a new boat (the Dream) which is 40% larger than the old boats. This was the third sailing (for the general public) although people had been on the ship for about 3 months. We booked late which impacted our choices, but we upgraded to the concierge rooms at the port.

Food As A Failure:

When you think of cruising, you think of food. It’s a big part of the cruising experience. Although the boat was beautiful and we had a lot of fun, the food was a failure. They have two seatings – 6:00 and 8:30. We couldn’t get into the 6:00 seating which meant we were at 8:30 (which is my kid’s bedtime). So, we requested to get moved to the 6:00 seating (which the concierge should have been able to help us with). It never happened. (I personally can’t believe that there was never a table any night for us to eat dinner at the restaurants since some people go to the adult restaurants and several hundred people didn’t make the trip due to cancelled flights.)

At first, we didn’t care. We’ve cruised before, and there is always a buffet to go to for lunch and dinner. Not on this cruise. Ok, we decided we could survive on room service. We tried that the first night from a limited menu, and the food was disgusting. I’d rather eat at the airport food court. Ok…in concierge, you can order from the family restaurants for room service. We did that, but the food took almost 90 minutes to get to us. That defeated the purpose. Then, to top it off, we put out our card for breakfast in the morning on the last day, and no one ever picked up the card.

In the end, the kid’s club was great. Bingo was fun (we won 3 times). The new cabanas and private beach on the Disney island were very relaxing. BUT, each night as we went to wind down and have a meal, things fell apart. I spent more time chasing food and eating junk then I thought possible.

Lesson: The experience is a collective set of activities not just a few. (i.e., focus on the weakest link)

• Think about the doctor’s office. If the office staff doesn’t greet you, your visit satisfaction is impacted. If you’re bill is wrong, your satisfaction is impacted.
• Think about the pharmacy. If you have to wait too long for your medication, your satisfaction is impacted. If you don’t understand the instructions, your satisfaction is impacted. If you can’t figure out how to log into the website to order a refill, your satisfaction is impacted.

Managing Expectations:

This was our fourth cruise with Disney. The first three we stayed in the same room on the concierge level. By now, there were certain things we expected. All of them seemed to change.

• My kids love the Mickey bars (ice cream). They no longer carry them on the boat.
• One of my kids likes the Mickey mac n cheese. They no longer carry it and replaced it with some slimy version of bad mac n cheese. (Disney should just stick with the microwave Kraft version… it would be better.)
• The dining was always a little “fancy” in terms of the options, but it had some appreciation for the simple foods that kids like. That wasn’t true anymore. (Although we never made it to dinner, I looked at the menus.)
• One of my kids is super picky. He always defaulted to peanut butter and jelly if he didn’t like the food. They always carried Crustables (frozen PB&J). They no longer carry them, and when I asked for bread, peanut butter, and jelly, they couldn’t get it right.
• The concierge always was out to surprise you in the past – chocolate covered strawberries in your room one night or we always got a drawing to take home and frame on the last night. They no longer do that. They’ve moved to a lounge where we come to them. They no longer come to you.

Would I have been more satisfied if I knew this up front, I don’t know. But, I know that learning piecemeal all the changes and hearing “no” to all my requests was frustrating. (Most of these are things they could have anticipated by tracking my past cruising experiences and behavior.)

Lesson: It’s important to know market expectations or expectations from prior experiences and manage them appropriately.

• If you’ve been getting an Explanation of Benefits (EOB) for years, you’ve probably figured out some way to read it (since it’s not easy). If it’s going to change dramatically, you may want to help people understand.
• If you’ve been sending people a generic version of a drug that is colored red and you switch manufacturers to have a blue pill, you might want to let them know.

Frontline Employees Are Where The Rubber Hits The Road:

It’s always easy to sit in the ivory tower and plan out how things will happen, but at the end of the day, I think the Disney question about “did anyone make this a magical voyage for you” summarizes it. It’s the people who make a difference. In every previous cruise, I felt like there were people who went out of their way to know who we were or who my kids were and what they liked. They then would bring them their favorite bread (banana bread) or bond with them in the kid’s club. This didn’t happen. There was one guy at Bingo who made some connection with us, but that was it.

I also find it frustrating that they don’t have any “memory” of me from cruise to cruise. I have the same allergies as last time. Why don’t you use a CRM system to remember the basics about me and validate them?

Lesson: Remember to empower and encourage your employees to engage the customer not simply go through the routine of talking to them.

• When the patient comes into the pharmacy, does the pharmacist or pharmacy technician know their name? Do they at least remember them?
• When your call center agents talk to someone on the phone, do they reference the prior conversations? Do they know what the customer was doing on the website 10 minutes ago that prompted them to call?

Keep It Simple:

This issue has been around forever (aka – KISS). They gave me so many examples of over complicating the process. Let’s just stick with the room. My room (one-bedroom suite) had two TVs. First, one wouldn’t work, but after they fixed it, it made a constant buzzing sound. After 3 calls for service and waiting from 9-11 PM, I finally figured out where the wires were and pulled them out of the wall to stop the buzzing so we could sleep. (It turns out it was just the surround sound which needed to be turned off. Never mind the fact that surround sound isn’t necessary on a cruise, or the fact that there was nothing telling me there was a separate system.)

We also had a whirlpool tub which my son loves, BUT after he used it, it kept going. We couldn’t figure out how to turn it off. (It turns out it takes several minutes after you press the button to clean the tubes, BUT no one tells you that.)

Then we had several lamps in the room, but they didn’t have light bulbs for them. (We didn’t need the lamps, but why put lamps in the room if you can’t supply light bulbs.)

We had two bars of soap – one for the shower and one for the sink. Of course, I grab the sink one to use in the shower. Well, guess what…It didn’t have rounded edges so once it dried you could move it. It was “cemented” to the soap dish. Not to mention that the sink design was such that it wasn’t functional. (Who let the designer in here without any practical experience.)

Now, to top it off, the concierge level is in a gated area which I think is unnecessary, BUT the gates didn’t work. ½ the time the gates were propped open or I had to get down on the floor and put my hand thru the iron fence to reach the inside handle and open it.

Lesson: Focus on what matters and doing the simple things right. Don’t over complicate the process if it doesn’t add value.

• How user friendly is your website? I’m sure most people use the pharmacy website for refills and formulary look-up. Are those prominent and easy to navigate.
• When you get information about your benefits, can you navigate it and understand it? What about lab reports?

*******************

My overall impression is that someone messed up. They brought too many new cast members into a situation without enough experience. They tried to reengineer and change too many things. This should have been a great experience. Being the “chief experience officer” for Disney or the Disney Cruises has to be one of those jobs that people strive for, but my impression is that this person (a) doesn’t have kids; (b) probably never cruised with Disney before; and (c) didn’t spend enough time with the repeat cruisers to understand what they like.

I’ll be interested to see if they respond to my comment card from the cruise. I always hate customer satisfaction surveys that no one takes action on. I see from the message boards that I’m not the only one disappointed with the cruise.

If this was my first cruise with them, I would never cruise with them again. Now, I’m struggling with whether to go back to the old boats in the future or risk the new boats again. We originally booked for the inaugural cruise of the next Disney boat in 2012, but then they changed the inaugural cruise (what a jerk move). But, what this taught me is that experience has residual value. I had three good cruises so I’m likely to try them one more time. I hope they get it right.

And, I hope you see how this translates to healthcare. We overcomplicate healthcare. We make process changes all the time. We don’t manage expectations. There is so much to do to improve this. We have to improve the customer experience in order to get them to trust us and improve our ability to influence outcomes.