Archive | April, 2011

Interview With Dr. David Wennberg At #WHCC11

I had the opportunity to sit down with Dr. David Wennberg (Chief Science & Product Officer, Health Dialog) at the 8th Annual World Healthcare Congress (Twitter hashtag #WHCC11).  David is a fascinating and engaging speaker.  He has lots of publications, works with the Dartmouth Atlas, and leads the Health Dialog Analytic Solutions group. 

David and I began our time talking about “informed choice”.

In this environment, doctors need tools that identify patients lacking evidence-based care. They also need to ensure that patients undergoing surgery have been exposed to informed choice, not just informed consent, when there is more than one legitimate treatment path. With these resources in place, physician groups can ensure that they are in control of their own destiny when it comes to performance evaluations.  (source)

This is an important issue in healthcare.  Giving patients (1) complete information in (2) language that they can understand and helping them (3) frame their options relative to their preferences is at the core of this issue. 

Health Dialog calls this Shared Decision Making and focuses on how to engage targeted consumers and help them make their best decision.  Their customer support personnel go through a certification process and use decision aids to enable the process. 

This led us into a discussion about “trust” (see prior post) and then into a discussion about “embodied conversational agents“.  Obviously, if you’re going to help consumers make decisions, they need to trust you.  We talked about the need to have transparency, the need to for disclosure, and the importance of using clinicians in the engagement and discussion process.  In many cases, nurses and the empathy that they have are critical to this process.

But, I know from prior exposure to Health Dialog that they have figured out ways to blend technology and agents.  They do a lot with data and analytics to really understand the popluation.  They’ve worked hard to avoid the traps that “disease management” has fallen into over the years.  He shared with me some amazing engagement statistics. 

We talked about the value of peer-to-peer videos for people to understand their condition and talked about some recent studies around storytelling and distributing that information via DVD to patients (see more on study).  We went on to talk about how engaging the consumer in the decisions about their care increase success, but that many models have been a challenge to scale.  Health Dialog just published an article in the NEJM called A Randomized Trial of a Telephone Care-Management Strategy which demonstrated an ability to scale the solution and get results. 

At baseline, medical costs and resource utilization were similar in the two groups. After 12 months, 10.4% of the enhanced-support group and 3.7% of the usual-support group received the telephone intervention. The average monthly medical and pharmacy costs per person in the enhanced-support group were 3.6% ($7.96) lower than those in the usual-support group ($213.82 vs. $221.78, P=0.05); a 10.1% reduction in annual hospital admissions (P<0.001) accounted for the majority of savings. The cost of this intervention program was less than $2.00 per person per month.

Before I could even jump to my next question about ACOs, he made the natural transition to the fact that the new ACO regulations mention shared decision making 8 times.  I believe we both agreed that whatever actual form these new practice settings take that they will accelerate the importance of leveraging technology and things like shared decision making to engage the consumer.  The key is to leverage the PCP setting whether it’s the MD or someone on their staff as the foundation for engagement.

This led me to ask him about physician acceptance of technology as part of their practice (more on this later).  He felt that they had moved from resistance to understanding the technology and “guides” can enable them to practice better medicine.

Does virtual exercise count towards physical activity?

I remember when I first played Wii Boxing and was sweating like I just went for a lite run.  It made me believe that there was something about using games to get kids to exercise even if they weren’t playing outside (which is ideal). 

A new study published in the Archives of Pediatrics & Adolescent Medicine confirms this.  I guess the category is formally called “exergames”, but they looked at several games including (with their Metabolic Equivalent Task value):

  • Wii Boxing: 4.2 METs
  • Dance Dance Revolution: 5.4 METs
  • Cybex Trazer: 5.9 METs
  • LightSpace: 6.4 METs
  • Xavix: 7.0 METs
  • Sportwall: 7.1 METs

Here’s the summary:

[the researchers] found the games “compared favorably with walking on a treadmill at three miles per hour, with four out of the six activities resulting in higher energy expenditure”

Data: Should You Be Paranoid?

I think we all know or are quickly realizing that everything we do leaves a trail of breadcrumbs.  That trail is a series of data points which now can be aggregated to create a record of you.  What you do?  What you buy?  What ads you respond to?  Who your friends are?  The list goes on. 

The question of course is whether you should be paranoid and worried about it. This video below shows you the extreme scenario of how data could be abused.

In a more balanced view, Time Magazine had an article call Your Data, Yourself which just appeared on March 21, 2011.

Oddly, the more I learned about data mining, the less concerned I was. (Joel Stein, author of article)

The article talks about a variety of companies that collect and sell data:

  • Google Ad Preferences
  • Yahoo!
  • Alliance Data
  • EXelate
  • BlueKai
  • RapLeaf
  • Intellidyn

The author makes a key point…a lot of the things we get for free are free because people collect and sell our data.  Otherwise, these “free” business models wouldn’t exist.  Would you pay for all the content and other things you get today or do you just want to understand what happens to your data?

On the other hand, the author shows you how data put together adhoc can paint erroneous pictures of you.  Should you care?  Do you want to fix this?  Can you control it?

This is all important since there is some do-not-track legislation being discussed.  (See Joe Manna’s post on this for some additional perspective)  Several people bring up the good question…

While we say that we don’t like to know that our data is being used to target ads at us, do we really want to have to sort through all the irrelevant advertisements?

Of course, we all become a lot more sensitive around healthcare data.  But, somehow, I doubt many of us think about what happens when we use our work PC to research a condition (see article on 10 ways to monitor your employees).

The article also suggests some sites for protecting yourself:

Don’t expect this one to go away.  With issues like the data breach at Epsilon, people are concerned.  Additionally, as data gets co-mingled and your credit score is used to determine health programs (for example), there may be limits about what and how information is used.

The Changing Specialty Drug Pipeline

In 2010, only 30% of the specialty drugs were oral solids or eye drops. 65% required clinical administration. Only one was a self-injectable drug. (Summary data and chart below c/o BioPharmRx Consulting.)


This is important since it changes the PBM and pharmacy paradigm as we know it. If increasingly specialty drug spend is managed by the PBM, this creates a greater need for a relationship between the PBM and/or the pharmacy and the provider. Or, it requires infusion services as several specialty companies provide.

It’s expected that this trend will continue, and specialty will quickly become the focus in the payer world (from a pharmacy management perspective). You’ll have low cost generic drugs for most common conditions and high cost biologics for the more rare conditions.

I’ve heard several projections now that specialty will move from ~15% of spend today to about 40% of spend in the next 5 years (from a PBM perspective). You combine that with generics making up 80-90% of all non-specialty prescriptions in that timeframe, and you have a very different world.

On a related note…Will that change the manufacturer to PBM relationship? Maybe. I personally believe that the PBMs will get closer to the pharmaceutical manufacturers in the specialty space like they used to be with the manufacturers when branded drugs were the majority of prescription drug spend. Given the detailers (i.e., feet on the street) that the manufacturers have versus very small academic detailing teams or even the provider relations teams that payers have, there will be a need to figure out how to interact with the physician in new ways. And, with the cost of these drugs averaging $1,800 per month and running into the $100,000s, there is a lot more money to be spent on supporting the patient.

Drink Chocolate Milk After Workout

I found this very interesting. A swimming coach suggested to my daughter that she look at drinking chocolate milk instead of water or Gatorade after working out. He said that it led to better recovery.

Of course, I was intrigued. But, it looks like there are several studies and references out there to back it up.

If you swim, run, or do other endurance sports, you should check this out.

A Few Points On Generics

I’m sharing a few quotes from the recent Drug Benefits News on generics here:

“Despite the fact that generics use has long been mainstream, a recent survey we conducted found nearly one-third of Americans still do not know or believe that generics have the same active ingredients and effectiveness as brand name drugs,” Brian Solow, M.D., senior medical director for clinical services at Prescription Solutions, the PBM subsidiary of UnitedHealth Group

It would be interesting to look at that data based on age, gender, number of prescriptions used, physician, geography, and several other factors.  That 1/3rd is similar to what I’ve seen in terms of skeptical physicians which would then make a lot of sense as patients of those physicians would be skeptical of generics.

“We are advocating an increase in the differential between generic and brand name copays,” David Lassen, Chief Clinical Officer at Prime Therapeutics LLC says. “Right now the average differential between Tier 1 generics and Tier 2 preferred brands is about $15. We think this difference should be bigger.  We’ve seen research suggesting consumers need to save an average of $25 in order to select a generic over a brand name drug.”

An interesting point on copay differentials that a friend of mine recently made is what is the actual differential after grandfathering and formulary overrides which happen.

Cured After The First Fill!

I was at a presentation recently where a Chief Medical Officer from one of the PBMs was talking about a survey they did on statin users and why they didn’t refill.  Amazingly, he said that 21% of people said they thought they were cured after the first fill.  Talk about a problem.

This data reminds me of a barrier survey from a statin adherence program that we did where 37% said they didn’t know they were supposed to refill their medication. 

This topic then reminded me of a study that was published in the Archives of Internal Medicine in 2006 which looked at the frequency with which physicians did certain things when talking with patients.  So, how often did they explain the duration of therapy to the patients – 34%!

Sometimes, we spend so much time trying to solve the complexities of adherence when there are baseline activities which can make a huge difference.

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