Archive | March, 2011

Trust As The Foundation For Healthcare Communications

Trust improves medical outcomes. It is the number one predictor of loyalty to a physician’s practice. Patients who trust their doctors are more likely to follow treatment protocols and are more likely to succeed in their efforts to change behavior. (Introduction of The Trust Prescription)

I just finished reading The Trust Prescription For Healthcare by David Shore. I would recommend it. It definitely framed things in a differently light. I also had a chance to talk with David on the phone and pick his brain a little. He sounds like a great speaker, and I’m looking forward to his new book coming out around building trust as an intermediary (i.e., managed care company or PBM).

A few of my highlights from the book are:

  • Trust can be a differentiator.
  • Trust is good business.
  • The physician to patient relationship is where the baseline of trust exists today. Although he brings up the question of whether that trust erode as you get more and more time pressure.  [I don’t remember the book specifically addressing the pharmacist – patient trust relationship although one would assume it is a similar foundational element.]
  • Trust is critical in healthcare because you’re asking a vulnerable patient to believe you can help them.
  • Profits may be negatively correlated with trust in healthcare (but not in other industries).
  • He pointed out the fact that it’s ironic that while pharmaceutical companies do so much good they get such a bad rap.
  • It was the first time I had seen someone introduce the issue of how healthcare entities are portrayed in TV shows and how while this is generally neutral that managed care organizations in the early 2000’s were portrayed negatively (and probably still are).
  • He talks about the concept of “response shift” which I think it an important phenomenon about how our expectations change over time and the effect of expectations on trust.
  • He talks about how two things happen when trust erodes – government intervention and consumer activism. [Hey…that’s where we are today!]
  • He uses two examples many times which are very relevant:
    • Volvo is known for safety not specifically for making cars. They make sure this is consistent in their branding (e.g., not funding NASCAR races). It gets to the core of defining who you are. [This concept also made me think about the new Dawn campaign about saving wildlife.]
    • You can build trust equity like Johnson & Johnson did which helps you when you have issues. [The question is how long they can draw on this given their current issues.]
  • He holds out a few healthcare power brands but says there are very few – Mayo Clinic, Cleveland Clinic, BCBS, Kaiser, Massachusetts General.
  • He talked about the concept of a Brand Architecture which made me think about some of the recent rebranding efforts at United Healthcare.
  • He talks about how consumer understanding and communications are key to building trust.

Communication in healthcare typically runs into a series of obstacles related to listening, clarity, and confidence.

Some of the interesting research data was [noting that this was a book from 2005]:

  • 56% of consumers say they will pursue something simply because it was made by a company they trust. (Macrae and Uncles 1997)
  • About half of people agree that “doctors are not as thorough as they should be” and “doctors always treat patients with respect”. (National Opinion Research Center 1998)
  • Race was a highly significant variable in trust correlation even when researchers controlled for other variables. (Corbie-Smith, Thomas, and St. George 2002)
  • Patients are more likely to take a drug that they have requested than a drug with which they are unfamiliar. (Handlin et al 2003)

It book made me think of some interesting questions:

  • Does transparency build trust with consumers?
  • Does concierge medicine build trust overall?
  • Does the use of technology by physicians enable or erode trust? [I believe he said that a lot of physicians didn’t think so.]
  • Do non-profit systems have more consumer trust?
  • What does all the news about drug problems, medical errors, and other issues do to the overall trust of the system?
  • What are the trust queues for consumers by type of healthcare entity? (For example, a dirty bathroom at a hospital might make you worried. What’s true for insurers, PBMs, pharmacies, etc.?)

One key point to pull out that he makes is that

Without branding, healthcare becomes a retail industry, and in retail, as in residential real estate, the three most important factors are location, location, and location.

Only 56% Want To Set MD Appointments Online – Why Not?

To me, this survey has three major themes:

  1. People are still hesitant to communicate with their MDs using social media [not that surprising].
  2. People are slow to use the web even for administrative functions [why].
  3. Hispanics are much more willing to use technology to engage their provider [why].

Some of the data:

  • 85% would not use social media or instant messaging channels for medical communication if their doctors offered it.
  • Only 11% of respondents said they would take advantage of social media such as Twitter or Facebook to communicate with their doctor.
  • Only 20% said they would use chat or instant message.
  • 52% said they would confer via e-mail.  (versus 89% of Hispanics)
  • Only 48% said they would pay their physician bills online. 
  • 72% would take advantage of a nurse line if it was offered by their doctor.

Social Media Is A Health Issue?

Social media as hazardous to your health!  Talk about a nice counterintuitive report.  I think we all worry about our kids spending too much time online and not getting enough exercise, but what about “Facebook depression”, cyberbulling, and sexting…not to mention age-inappropriate material?

In yesterday’s USA Today, there’s an article about how social media can enrich children’s lives but can also be hazardous to their mental and physical health.  It’s focused on a report by the American Academy of Pediatricians, but I think this also builds on the Kaiser report out earlier this year about the amount of time kids spend in front of electronic media – 7.5 hours PER DAY. 

because tweens and teens have a limited capacity for self-regulation and are susceptible to peer pressure, they are at some risk as they engage in and experiment with social media, according to the report. They can find themselves on sites and in situations that are not age-appropriate, and research suggests that the content of some social media sites can influence youth to engage in risky behaviors. In addition, social media provides venues for cyberbullying and sexting, among other dangers. Youth who are more at-risk offline tend to also be more at-risk online.

Interesting.  Do you agree?

You Need An Experience Architect

I’m often asked how my 6 years of architecture school plays into what I do right now.  I have a variety of things that I believe I learned in architecture that help me, but it wasn’t until the other day that it really clicked.  I was reading an interview about a CEO who had been trained as an architect.  She described architecture as building experiences.

All of sudden it hit me…that’s what I do.  I help companies look at an objective and architect the consumer experience to get to that objective.  And, it’s a lot of fun!

So, what are the parallels between healthcare communications and physical architecture?

  • There is no one answer.
  • You have to listen.
  • There is lots of data.
  • You have to use lots of materials. (print, e-mail, web, automated call versus concrete, glass, steel)
  • Each person’s experience is different.
  • Compliance matters. (building codes versus CMS)

Now, unfortunately, I can’t coin the term “experience architect”.  It’s been used by others.  For example, Tom Kelley from IDEO used it as one of his Ten Faces of Innovation.  He says an experience architect is one who:

Is that person relentlessly focused on creating remarkable individual experiences. This person facilitates positive encounters with your organization through products, services, digital interactions, spaces, or events. Whether an architect or a sushi chef, the Experience Architect maps out how to turn something ordinary into something distinctive—even delightful—every chance they get.

Fast Company talks about the Experience Architect in an article from 2005.  More commonly you’ll find articles or references to user experience architect. 

The point is that you need to think about things in this light, and I think the architectural paradigm is helpful in how you construct and embrace the creation of an experience for the consumer whether it’s around shopping, adherence, or managing diabetes.

The Changing Pharmacy Marketplace

I had the opportunity to listen to a few executives talk about how the marketplace is changing.  While I don’t think any of it was surprising, it did bring up some interesting discussion points.

The discussion focused on five themes:

  • The fact that the small molecule market is essentially going generic and will be a low cost market.
  • The fact that biologics is the focus and is where innovation and the spend will be.
  • The challenge of wiring healthcare to get that last mile to the physician.
  • The unknown implications of health reform and exchanges.
  • The continued focus on the consumer as central to healthcare.

I thought it was very interesting that several people talked about this evolution from brand to generic to biologics as the “circle of life” where there was a natural redistribution of cost.

I thought the discussion around personalized medicine was interesting especially as it dealt with the non-biologics and looking at where there were still opportunities to differentiate in the small molecule world.

One of the more interesting discussions was on whether bio-similars were really a “generic” type strategy or a new type of innovation.  Given the clinical work and other hurdles that are imagined for bringing bio-similars to the market, it isn’t expected that you’re going to see massive price drops.  And, if they aren’t therapeutically equivalent, then they become another option within the category.  As one person pointed out, the likely scenario is more of a step therapy strategy where if the bio-similars (or bio-betters as one person called them) are less expensive that the original biologic AND there is no difference in likelihood of success with an initial patient then you would simply require patients to start with the bio-similar.

There was some interesting discussion on the use of biologics from a prevention perspective which was only touched on.

One person talked about the blurring of the brand and generic manufacturer demarkations, but I think Teva’s already done that over the past few years. 

There was some discussion of current state tactics around copay cards and how they are used.  The question being whether this is to drive lower consumer costs, avoid switching, or avoid generic substitution.  This led to the classic debate of patient – physician versus payer. 

The biggest thing that scared me was some of the discussion around how DC and politics can play a role in determining care versus allowing for evidence-based standards of care to drive decisions.  As I was taught in consulting, you should make your decisions based on facts not on opinions.

CMS Treatment Of Generic Samples Offers False Hope

It’s interesting but irrelevant that CMS is now proposing that Part D plans can treat generic samples similar to OTC drugs.  Who cares?

Why do I say that?

  1. Generics represent more that 80% of the non-specialty drugs dispensed in many cases.
  2. The technique doesn’t work.

At Express Scripts, I ran a program for a year.  We hired pharmaceutical representatives to detail doctors.  We bought generic drugs and repackaged them.  And, we tracked GFR (generic fill rate) in the six categories for a year. 

Guess what?

In most cases, the GFR for the doctors with the samples barely exceeded the GFR for the doctors without the samples.  In one category, it was even lower.  The GFR was going up too fast in the general market.  If you add in the costs, it was a money loser. 

We even compared our GFR in certain geographies to the published statistics from another company doing generic sampling…our clients GFR without samples was going up faster than their GFR with samples. 

If you want to give away free drugs as a “gift” to make your academic detailing program more effective, have at it, but lets keep reality in mind here.  This is not going to make a difference.  All it’s going to do is drive up administrative costs for PDP plans.

Using the “Placebo Effect” in New to Therapy Situations

I was reading a book about trust which pointed out the concept of “remembered wellness“.  This concept is similar to the “placebo effect” in that it shows that patients who trust their physicians and their course of therapy are more likely to have better outcomes (e.g., HIV study).  WOW!!

I’ve talked before about the gap that exists when patients leave their physician’s office with a new diagnosis and we all know that health literacy is a big issue.

So…what are you doing to address this?  I’ve been talking a lot lately about “primary adherence” (i.e., getting people to start therapy) and about engaging patients when they first get a new prescription or a new diagnosis.  This concept of trust only makes this a more pressing issue.

Here’s your worse case scenario:

  • Patient is newly diagnosed with a chronic condition and given a new prescription.
  • They don’t have a great relationship with the physician and/or have limited understanding of the condition (due to literacy, fear, or other issues).
  • They fill the prescription once and stop taking the medication after a few days.

How can you step in here?

  • You can trigger an outreach based on diagnosis code.
  • You can assess their understanding of the condition and help them learn more by addressing their barriers.
  • You can engage them when they fill their first script.
  • You can follow-up with them after the first few days to make sure they stay on therapy.
  • You can enroll them in an adherence program.
  • You can enroll them in a condition management program.

But, the point here is that you need to be doing something that reinforces the decision to manage the therapy and help them to understand and believe in that course of treatment.  If they don’t believe and have trust, they are less likely to get to a successful outcome.

Likelihood Of Being Wealthy

I found this test in Money Magazine (Sept 2010) interesting especially when you dig into the research behind the questions and the scoring.

  1. Optimists do better financially than pessimists although extreme optimists don’t save as much money as moderate ones.
  2. A child born into the wealthiest 20% of families has a 55% chance of staying in that quartile.  A child born in the poorest fifth only has a 9% chance of reaching the top and one born in the middle a 13% chance.
  3. If you’re raised in a home your parents owned, your more likely to stay in school and buy your own place.
  4. If you have chronic conditions (diabetes, arthritis, Crohns), these are associated with less wealth.
  5. People with IQs over 130 (top 2%) early $6K-$18.5K more per year…but that doesn’t correlate with better savings.
  6. A college grad will earn $450K more in their lifetime than someone with only a high school education.  Getting a graduate degree adds another $120K.
  7. A 6-foot tall man earns $5,525 more per year than someone that’s 5′-5″.  “Hotties” (their word) are twice as likely to make an above average income as their homelier peers and slim people have a higher net worth than heavy ones.
  8. The more brothers and sisters you have the poorer you tend to be.
  9. Boomers who got and stayed married accumulated 93% more wealth than their unmarried counterparts.
  10. Kids drain wealth.
  11. Being too agreeable leads to lower earnings.
  12. Affluent people exercise more.
  13. Families that own businesses are more affluent.
  14. Although adreneline junkies earn more than their cautious counterparts they are also more likely to make poor investing decisions.
  15. 84% of millionaires shop for bargains.

So, this may be neither hear nor there, but I’m fascinated by tests like this as they are data that can be used to predict and segment people from a communication perspective.  Understanding their behavior within sub-segments is critical in understanding why they act or don’t act.

JD Power Customer Service Leaders – Pharmacy

Understanding how top performers achieve excellence is the first step to becoming a Customer Service Champion. The rest is up to you.

This is the statement by Gary Tucker, SVP, J.D. Power & Associates at the beginning of their publication Achieving Excellence in Customer Service from February 2011. 

If you’ve never read their reports, you should understand that they look at five areas – people, presentation, price, product, and process.  Interestingly, they use several examples from pharmacy to make their points about these five categories:

  • Proactive communications
  • Private space for consultation
  • Clear information about how to save money
  • Auto-refill

Another interesting thing they look at is whether the gap between high performing and low performing company has increased or decreased over time.  In the product industries, the gap has decreased due in many ways to quality improvements.  In the service industries, the gap has increased…WHY?

First, advances in technology have created new expectations among customers, resulting in new challenges for services. For instance, customers expect multi-channel service delivery and expect to choose whether to interact with their service provider in person, via the phone or e-mail, through online chat, or via Web-based self-service, among others. More challenging is that they expect the same level of service across communication channels. With ever-improving technology, it has been difficult for companies to keep all systems up to date and to remain equally effective in each.

They are preaching to the choir here.  This is exactly what I tell clients all the time. 

One of their examples that I’ve used for years is around the power of communications.  They show satisfaction with auto insurance based on whether your premium stayed the same or increased.  For those that it increased, they look at whether you were pro-actively informed and whether you had the option to discuss it.  What group do you think had the highest satisfaction?

  • Decreased premium
  • Increased premium, pro-active notification, and chance to discuss
  • No change
  • Increased premium, pro-active notification
  • Increased premium, no notification

Worried about satisfaction or churn?  Have lots of changes to plan design?  Here’s why you communicate.

In this report, they call out 40 companies as exceptional out of the 800 that were ranked.  7 of those 40 were pharmacies:

  • Good Neighbor
  • Health Mart
  • Kaiser Permanente
  • Publix
  • Veteran’s Administration Mail Order
  • Wegmans
  • Winn-Dixie

How To Select What Pharmacies Are In Your Network?

This seems to be the “meta-question” that everyone is talking around. 

  • Should every pharmacy be in the network?
  • Should mail be allowed?  Should I do mandatory mail?
  • How do I design a limited network?  Is it ok?
  • What about any willing provider?  [should that just be about cost]

Let’s start with the basics…You want a network that meets access standards, has high quality, improves outcomes, keeps members happy, and offers you the best price.

So, how do you build your network to decide who is in or out (ideally)?

  1. Select the minimum number of local pharmacies required to meet access standards for acute medications (this is your baseline)
  2. Look at your best price to add more pharmacies into the network – who will meet your price for generics, brands, 90-day, specialty
  3. Evaluate your tradeoffs – will you get a lower price if you exclude certain pharmacies?  will that impact access?  will that impact care?  will that impact satisfaction?  can you manage the disruption?
  4. Look at difference in satisfaction between pharmacies – should you take a lower priced pharmacy if the satisfaction is less?
  5. Look at difference in outcomes between pharmacies – should you take a pharmacy that has a lower generic fill rate (on an adjusted population) or a lower adherence rate (on an adjusted population) at the same price? 

Network design should look like formulary design.  You have to look at the value versus the cost.  You might include a higher priced pharmacy in the network if it gives you access, better outcomes, or lower net cost (i.e., better GFR).  You might exclude a lower priced pharmacy if it can’t prove any of this or if consumers who go there are dissatisfied. 

At some point, I would think we’ll see more metrics beyond price be used to measure pharmacies – discounts, GFR, safety (quality), medication possession ratio, satisfaction.  That would make this a lot easier with some standards. 

This would make it easier to have discussions about access in NY (for example) as PCMA is doing.  It would make it easier to have discussions about the Department of Defense (for example) as NACDS and NCPA are doing. 

The DoD is a good example here…Since the military (government) buys drugs better than anyone, I can’t imagine how much better some of these metrics would have to be to justify paying the additional costs at retail for fulfillment.  The base pharmacies and the mail order pharmacy all get their drugs from the government contracts.  At mail, the supply is managed separately so that they are replenished under those contracts.  I bet the cost is $10+ on average more for a drug at retail (non-replenishment) than it is elsewhere.  How do you justify that?  In my mind, retail should figure out how to replenish and segregate their inventory to stay in the network rather than fighting the shift away to mail.

Who’s Your HOL For Improving Engagement

Following up on my post earlier today, I went to an article in PharmaVOICE from January 2011  called Engaging the Empowered Patient by Carolyn Gretton.  It has lots of interesting statistics and quotes.  Here’s a few:

These consumers have done at least one of the following based on finding information online:

  • Challenged their doctor’s treatment or diagnosis
  • Asked their doctor to change their treatment
  • Discussed information found online at a doctor’s appointment
  • Used the Internet instead of going to the doctor
  • Made a healthcare decision because of online information

I’ll have to drill into the report because I’d love to know how many have done the first two things, what the physician response was, and (ideally) if it impacted their outcome in any way.

40% of online consumers engage with social media on health sites either by reading or posting content, though frequency of engagement varies widely.  (based on a survey from Epsilon and eRewards)

That last part is where the issue is (IMHO).  Consumers do use lots of these tools BUT sustaining their interest and engagement over time is difficult.

The Epsilon report – A Prescription For Customer Engagement: An Inside Look at Social Media and the Pharmaceutical Industry – pointed out that consumers use healthcare social media for:

  • Support
  • Sense of intimacy with others with a similar experience
  • Foundational information about their condition and symptoms
  • Information about drugs and supplements
  • Health news

Many of the individuals who are highly engaged in social media feel better equipped to manage their health.  (Mark Miller, SVP, Epsilon)

I was really surprised that the Epsilon study said that consumers viewed product sites to be as important as healthcare provider interactions.  I could argue both sides here.  Obviously, the product site is going to have some bias.  On the other hand, given the complexity of treatments and therapies these days, it has to be close to impossible for the provider to stay up on all the latest information. 

Not surprisingly, the author of the article talks about people having mixed feelings about the product managers participating in a social media site.  BUT, I think everyone would agree that with proper disclosure and the right person, this can work very well. 

The article introduces a new term (for me) here – HOLS or Health Opinion Leaders.  It talks about them becoming active parts of the pharma brand team.  That sounds like an interesting role. 

It was also interesting that they talked a lot about gaming as an engagement mechanism.  It’s not something I’ve spent as much time with, but it keeps coming up (even more than incentives).  They talk about several examples:

They also bring up an older game as a cautionary tale – Viva Cruiser – which riled critics for trivializing ED. 

At the end of the day, it’s the same old challenge – how to get the consumer to act and stay engaged?

Should Drug Makers Take Action Off Social Media Comments?

I think it’s a fascinating question that was raised around Actos. Here’s the text about a wool.labs report:

In this month’s report on social media’s influence in the world of diabetes, wool.labs presents an analysis of social media conversations beginning as far back as 2002 and continuing to the present, noting a significant shift in patient attitude toward the drug.

Early on, the presenting side effects such as weight gain and edema drew concerns and warnings from some patients. Some questioned whether the drug should be used in combination with insulin. But even while the debate raged on, wool.labs’ analysis showed the conversation could have been shifted had drugmaker Takeda meaningfully interceded before 2006 when comments about the drug began to turn sarcastic, and before long, angry and hostile.

There are enough tools and companies out there that IMHO companies (and brands) should be able to actively manage social media sites to understand what consumers think.  I don’t know this case specifically so I won’t comment on it, but certainly, companies need to have a robust Voice of the Customer process by which they understand what consumers think of them.  And, if it avoids future litigation, leads to add-on products, or even helps re-position a current product, this mechanism can be very valuable.

Hillary and Abe Talk Healthcare Communications

I’ve wanted to try this Xtranormal technology for a while.  It was pretty simple.  I’m interested in your feedback on whether this is an interesting delivery mechanism, annoying, or fun (see anonymous survey).  Here’s the video.  [BTW – If you get this in e-mail, you might have to come to the web to view this.]

Seven Million Remote Caregivers (and rising)

In September 2010, Money magazine had an article about the challenges of caring for a parent remotely.  For those that do it, the challenge is an obvious one and the toll can be significant.  For the rest of us, here’s a few things to understand what they’re going through.

  • Long distance caregivers spend an average of $8,700 a year providing support (nearly 2x what those closer spend…largely due to travel costs).
  • 49% cut back on leisure activities.
  • 47% spend less on vacations.
  • 38% have reduced or stopped saving for their future.
  • 48% have used sick or vacation hours to care for their loved one.
  • 37% have had to either cut back on work hours or quit their job.
  • 17% had to take on an additional job or work more hours.

This can be a lot to ask especially for those still caring for young kids at the same time.  The article gives a few suggestions:

  • Frequent phone check-ins.
  • Skype or some other online video chat.
  • Local contacts who can help you keep an eye on them.
  • Meet their physicians and get a HIPAA consent form signed.
  • Look into what help they need – food delivery, transportation, cleaning, paying bills.
  • They suggest for coordination.
  • They also suggest PointerWare and InTouchLink for simplifying computer interfaces for the elderly.
  • They also suggest contacting the local Agency on Aging.

Healthcare Mash-up Of Articles

Since I’m so far behind, I’m going to share a bunch of things here I think are interesting…

CalPERS and Medco

Those of you that follow the industry are certainly aware of this news story.  It was definitely a surprise this past week when CalPERS announced that they were dropping Medco as their PBM based on allegations of improper behavior.

For an industry where transparency has replaced years of opaqueness, this will be an issue.  Whether Medco is guilty or not-guilty, industry foes will use this to taint the perception of the PBMs.  I am sure some people cheered when this came out thinking “finally we may have found something” while the rest of us shook our heads in disbelief.

Happy Fat Holiday!

Not to be a party popper since I love the holidays, and I ate my Corned Beef & Cabbage meal a few days ago (and hope to have another).  But, I pulled up a quick recipe to see the calories (700), the calories from fat (470), fat grams, etc. in such a meal (assuming you only eat one serving), and it got me wondering.

If we look at all our holidays – New Years, Valentine’s Day, St. Patrick’s Day, Fat Tuesday, Fourth of July, Easter, Christmas, Thanksgiving, etc., is there any wonder we have food issues?  A lot of our favorite memories are tied to holidays which are tied to food.  You take those experiences (which typically include some snacks and deserts), and you can eat a few days calories in one day.

Not that it’s bad if you burn off more calories than you take in, but it certainly embeds this food problem right into our culture.

PBMs and Star Ratings

Finally, I’m hearing more talk about PBMs and their role in Star Ratings for Medicare. It seemed like this was a subtlety at the end of last year when I raised it as a 2011 priority.

Drug Benefit News had a story about it in their March 4, 2011 edition with examples from HealthTrans and PerformRx.

In general, there are opportunities to help impact Star Ratings by:

  • Blending pharmacy and medical data
  • Helping monitor patients on long-term medications
  • Increase cholesterol screening
  • Increase use of flu shots
  • Controlling blood pressure
  • Addressing physician communication gaps
  • Improving Customer service
  • Prior authorization process
  • Churn
  • Time on hold
  • Appeal process
  • Accuracy of information provided by customer service
  • Managing complaints
  • Helping with access issues
  • Timely information about the drug plan
  • Monitoring use of drugs with a high risk
  • Making sure diabetics us hypertension drugs

Since pharmacy is the most used benefit, it can have a very direct impact on the overall satisfaction. It can drive calls. It can be complicated. It can affect perception. And, it can lead to churn.

PBMs need to be working to proactively engage consumers. They need to use data to personalize the experience. They need to use clinical data to identify gaps in care. They need to drive adherence.

I personally hope that the Star “concept” becomes a more normal set of metrics outside of Medicare for measuring success and ultimately leads to a performance-based contracting framework.

Should The State Board Of Pharmacy Govern PBMs?

Mississippi has introduced legislation that would move the oversight of PBMs from the State Insurance Commissioner to the State Board of Pharmacy.  From a clinical care perspective, there seems to be some logic here, but from a business perspective, it doesn’t work.  Right now, the State Boards are generally made up of local pharmacists with an occassional PBM pharmacist on the board. 

Since that group negotiates with the PBMs for rates, it would seem to create a major conflict of interest.  PCMA has honed in on this and is actively fighting it. 

I guess that’s like saying that hospitals should govern managed care organizations.

Improving Your Call Center Without Just Adding People

In today’s economy, the last thing we want to do is scale up a company by simply adding people. Technology has to play a central role in allowing you to grow your company more efficiently.

At the same time, you want to grow without dropping your level of service. You want to improve the consumer experience.

And, to further complicate matters, you have to manage quality both to make sure that you comply with regulatory oversight and achieve goals around first call resolution. With our rapidly changing healthcare environment and legacy systems in many places, finding, training, and retaining good staff that can continue to keep up with the changes and understand the semantics between plan designs isn’t easy.

So, how do you do that? You’re in a balancing act between cost, quality, and experience.

This is one of the big areas where I’ve seen Silverlink Communications play a role. (Note: There are certainly other efforts which you can undertake in terms of single desktop and process reengineering, but I usually refer in some people I trust for those projects.)

Some people call our technology a “smart dialer”, but there is a difference. If you ever get a call at home from a call center using a dialer, you hear that silence after you say “hello”. The technology is looking for an agent to connect you with. On the flipside, if you’re an agent, you’re being connected with someone or even an answering machine that might not be the right person. That’s what a dialer does.

In our case, Silverlink is using mass personalization, voice detection technology, and speech recognition technology to screen the recipient for the call center. You hear the message right after you pick up the phone. It’s a message that has been carefully crafted using behavioral sciences and health literacy. It asks for you by name and identifies who’s calling for you. It then confirms your identity, and depending on what information is being used in the call, it may have to use multiple forms of authentication to verify who you are. Once we’ve assessed who you are (based on your responses), we’re able to deliver a personalized message to you about your healthcare. That personalized message is scripted in such a way to engage you in a conversation. During that conversation, we can then determine:

  • Are you interested in learning more?
  • Is this a good time for you to talk?
  • Would you like to talk to an agent or hear more now?
  • Would you like us to send you information in an e-mail, SMS, or snail mail?
  • Would you like a URL to go to for more information?

Occasionally, people ask about authentication. When you send a piece of direct mail, it’s a federal offense to open it if you’re not the intended recipient, but you have no proof that they did that unless your “nanny cam” picks it up. When you call someone, you have a record of when the call was made and what they person who picked up the phone said to authenticate themselves. This certainly seems better to me than any other channel.

Of course, this begs the question of recording all the calls. I’ve heard a few people tell me that they do this with other companies. I find that hard to believe since 12 states have consent laws which would require people to consent to being recorded when they were called. That would limit the effectiveness of the program, or if you didn’t do it, it would open you up to a big lawsuit.

So, how does Silverlink add value to a call center:

  1. Improving agent productivity. Automating standard questions. Connecting with the right person at the right time.
  2. Improving consumer engagement. Using behavioral sciences and health literacy to engage people and route them to the right agent based on skill set.
  3. Improving quality and consistency of experience. Personalizing the experience to engage the consumer but doing it in a way that addresses the clinical guidelines, regulatory requirements, and custom client requests in a consistent manner.
  4. Improving agent satisfaction. Your agents would rather talk to pre-qualified people or people who have an issue.
  5. Learning new information. In some cases, patients feel judged when people ask them questions (why aren’t you taking your medications). They may reveal more or other information in an automated environment.

Of course, automated calls aren’t the answer for everyone (although they work better than any other mode other than people…and sometimes beat them also). But, multi-channel coordination is a post for another day.

40% Meat And Wood – Yummy Food

There are numerous strategies for eating better. One simple thing you often hear is to eat simple, natural foods. I think one friend of mine described his diet as the “gorilla diet” (i.e., eat only foods that a gorilla could find naturally).

That being said, I was surprised to hear that something could be considered “beef” even if it only contains 40% beef. This came up in a recent lawsuit where Taco Bell was found to only have 36% “beef” in their products. Does that surprise you?

So, maybe I shouldn’t have been shocked to learn that we are eating wood. Yes. There is wood in some of the food we eat. Well, technically, it’s wood pulp called cellulose that’s used in cat litter, plastic, and food. It gives you fiber and helps canned goods last longer, BUT up to 3.5% of meat can be from cellulose.

These types of stories remind me of when I was in fifth grade eating my hotdog for lunch and found a ziplock bag cooked inside of the hotdog. Sometimes, you don’t want to know what happens in the kitchen / factory. I was glad years ago when I worked on a Y2K project for a big food company that I got the corporate project not the factory project at the meat processing plants.

This information combined with the text message I got from a diabetes program we’re running for a client (as part of the test deployment) which said that you gain 15 pounds a year if you drink a soda a day maybe enough to make me change my eating habits.

Rules Based Communications

After working with data warehouses, configuration engines, and workflow management systems, I’m a big believer in embedding rules into a process. Communications is no different.

Let’s look at a few rules:

  • Don’t communicate with someone more than X times per week.
  • Don’t call these people.
  • Use Spanish for people with that language preference.
  • Send a text message to people who have provided their mobile number and opted in to the program.
  • When applicable, use a preferred method of communication for reaching out to someone.
  • If a caregiver is identified and permission is on file, send the caregiver a copy of all communications to the patient.
  • Call the patient if the amount being billed for their prescription is greater than $75.
  • For patients between these ages, use the following messaging.
  • If the patient hasn’t opened the e-mail after 48 hours, then call them.
  • For clinical information, use this channel of communications.
  • For John Smith, only call them on Tuesdays between 5-6 pm ET.
  • For Medicare recipients, use this font in all letters.
  • For Hispanic consumers, use this particular voice in all call programs.
  • If the patient doesn’t respond after two attempts, send a fax to their physician.
  • For patients with an e-mail on file, send them an e-mail after you leave them a voicemail.
  • For patients who are supported by Nurse Smith, only call them when she is on duty and use her name in the caller ID.

I could go on. But, the point is that communications, like healthcare, is a personalized experience. We have to use data to become smarter (historical behavior, segmentation, preferences). We have to use customization to create the right experience. AND, probably the most difficult thing for lots of companies, we have to coordinate communications across modes (i.e., e-mail, direct mail, SMS, automated call, call center, web).

Ultimately, I believe consumers will get to a point where they can help set these rules themselves to create a personalized profile for what they want to know, how they want it delivered, and ultimately provide some perspective on how to frame information to best capture their attention.

To learn more, you should reach out to us at Silverlink Communications.

A Few Allergy Facts

Fortune magazine (7/26/10) had some great allergy data that I thought I would capture here:

  • 37M allergy sufferers in the US in 2010 (vs. 19M in 1995)
  • $5.4B in spending on allergy drugs in 2009
  • 6M workdays missed in 2010 due to allergies
  • 16M allergy visits to the physician in 2010
  • $17.5B in medical expenditures in 2010 (~$473 per allergy sufferer per year)

I also heard on the radio this morning in St. Louis that now that we passed a no smoking ban we’ve dropped from the worse allergy city to #6.

Peptides, Wnts, and Volume Rendering

It’s always interesting to see information on future developments that are underway (all from Spirit magazine):

  1. Using a peptide to help you lose weight.  Based on research at Indiana University with mice this might be possible. 
  2. Using “Wnts” to heal broken bones faster.  Based on work at Stanford University where the stem cells in the bone tissue are stimulated.
  3. Using volume rendering (ala 3-D movies) to provide images of people innards to help with surgery and diagnosis.
  4. Using probiotics in smoothies to administer vaccines.  Based on research being done at Northwestern University. 


The Rider, the Elephant, and the Path

If you haven’t read the books by Chip and Dan Health (Switch and Made to Stick), you should.  I was reading a story they had in the Experience Life magazine by Lifetime Fitness the other day.  I pulled out a few things here to share:

“For anything to change, someone has to start acting differently.”

Such a simple phrase, but it’s the key of most marketing programs.  I was talking to a friend the other day, and he asked why do people bother sending marketing pieces.  In today’s world, people know all their options so if they want to change they will.  For some people, that might be true (at least on a finite list of things that matter). 

In this article, the Health brothers talk about Jonathan Haidt’s book The Happiness Hypothesis where he argues that our emotional side is an elephant and the rational side is its rider.  We have to find the balance between the two. 

It’s interesting that they talk about the rider as wearing out easily pointing out that exerting self-control and focusing on the next thing to do can leave you worn out.  You need to create a path that makes it easier to be successful.  This is relevant around adherence.  This is relevant for addressing obesity. 

All of these articles and books on behavioral economics have fascinating studies in them.  In one story they talk about a group of maids which were split into two groups.  One group was told that all the work they did cleaning was great exercise.  The other group went upon their job as normal.  Four weeks later, the group that thought they were exercising had lost an average of 1.8 pounds compared to the other group.

Or they talk about the book Mindless Eating which shows that “people eat more when you give them a bigger container.  Period.”

They then introduce 3 surprises which can be helpful in framing messages:

  1. What looks like resistance is often lack of clarity.  Don’t say eat healthier.  Say eat more dark leafy greens.
  2. What looks like laziness is often exhaustion.  Change is hard…acknowledge it.
  3. What looks like a people problem is often a situational problem.  Make sure to think about their environment and support system. 

Why Aren’t There More Collaborative Practice Agreements?

Collaborative practice agreements (aka collaborative drug therapy management) are legal documents between a specific pharmacist and physician to allow the pharmacist to have more direction in the care of the patient relative to their medications. Given the challenge of the physician to keep up with all the mediations and their lack of access to plan design information and full drug history, I’m surprised that these documents haven’t become more popular.

My guess is that the logistics of a one-to-one legal document around standards of care is complex to scale (see how to set up). But, I always think about how easy this could be for addressing formulary management. The physician could agree to which drugs they considered therapeutically equivalent. They could then tell the pharmacist to choose the drug which was lowest cost for the patient.

Is Royal Pains Good Or Bad For Concierge Medicine?

I really enjoy the show Royal Pains which highlights a physician providing concierge medicine to the super wealthy in the Hamptons. The physician (Hank) and his staff doing an amazing job of diagnosing complex conditions based on a mix of science and deep dives with the patient to really understand their condition, their symptoms, and their environment.

On the one hand, it shows the power of building a relationship between the patient and the physician. It also shows how convenient it can be to have the physician coming to your house and monitoring you.

On the other hand, the type of attention and care shown here with all the technology being available within the home seems unreasonable. The cost to participate would be outrageous (I think).

So, it makes me wonder whether this is beneficial for the whole movement that companies like MDVIP or people such as Dr. Jay Parkinson are providing.

Physicians Want A Long-Term Patient Relationship

In a recent survey by Consumer Reports, 76% of physicians say that a longer-term relationship with their patients would be very helpful.

Is that feasible in today’s environment with consumers more likely to move cities and states?

Assuming it is, this would seem to make EMRs more important especially as they could act as a CRM system for the physician. The average physician probably supports about 2,000 active patients (“physician panel“). It would be difficult for them to remember and personalize their experiences without some mechanism for capturing notes about the patient. Certainly this can and has been done on paper for years, but technology would make this much more efficient.

“A primary-care doctor should be your partner in overall health, not just someone you go to for minor problems or a referral to specialty care,” said Kevin Grumbach, M.D., professor and chair of the department of family and community medicine at the University of California at San Francisco.

The article says that there is research that supports the fact that patients who stick with one physician over time have less healthcare issues and lower healthcare costs. I would assume that it therefore holds that patients who like their physician begin to trust their physician and therefore stay with their physician longer.

Physicians said that respect was the second thing that could help patients get better care. Does that mean that disrespect causes you to get worse care or simply that you’re less likely to engage the physician in a dialogue and understand their recommendation?

There were lots of surprises to me in the data:

  • 33% of patients track their changes and activity between visits. I’m guessing those are the chronically ill patients with complex diseases not the average patient.
  • 80% of MDs thought that patients would be better off with a family member or friend joining them for the visit…but only 28% of patients have someone with them.
  • Only 8% of MDs thought that online research was very helpful with the majority of them thinking it provided little to no value.
  • 9% of patients had e-mailed their physician in the past year.
  • ¼ of patients indicated some level of discomfort with their physician’s willingness to prescribe medications.

What’s Your Fitness Personality?

If you don’t read Experience Life magazine from Lifetime Fitness, I would recommend getting it or following them on Twitter. They put out some very interesting articles on expercise and food.

One that I found interesting was about Fitness Personalities. By using the Myers-Briggs test as a framework, Suzanne Brue developed 8 different categories (I’m a white). Given the difficulty of making exercise a lifetime habit for many of us, this could be a helpful framework for understanding what works, what doesn’t work, and with some rationale for why.

Here’s the quick summary:

  • Blues are safety-conscious, and good at creating their own space and concentrating in a gym.
  • Golds are traditional, conservative, and like to share their exercise experiences and results with others.
  • Greens are nature lovers who enjoy outdoor activities.
  • Reds like to live in the moment and compete in team sports.
  • Whites prefer to plan, hate to be rushed and are visionary types who enjoy calm spaces.
  • Saffrons like to express themselves as individuals and are attracted to spontaneous, engaging activities.
  • Purples are routine-oriented and enjoy repetition.
  • Silvers like exercise to be disguised as fun.

Online Company Looking For Pharmacy Partner For Customer Acquisition

A friend I met years ago when I looked at the Duane Reade pharmacy kiosk is now at Everyday Health. He recently asked if I new anyone in the pharmacy area (independent, chain, mail, specialty) that might be interested in partnering with them to drive new customer acquisition based on their online content.

I figure there are several people that might be interested. I asked him to write up a brief note and provide some contact information. Here it is for anyone who’s interested.

Everyday Health is online health network that connects more than 27MM monthly users to in-depth medical content for health condition prevention and management, as well as lifestyle content in pregnancy, diet, fitness, and much more. Our network of 25 sites consists of our flagship,, in addition to many well-known health brands such as What to Expect When You’re Expecting, South Beach Diet and Jillian Michaels.

Everyday Health is currently exploring the local health frontier and trying to determine how our organization can better leverage relationships with local doctors, dentists, pharmacies and hospitals. For pharmacies, we’re wondering if there is any value in driving Rx’s to a given storefront and whether there would be economic upside for doing so.

We’d like to connect with people with experience in marketing acquisition of patient Rx’s and/or anyone who can help clarify the above opportunity. Email Dan Wilmer in Everyday Health Business Development at dwilmer at

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