Archive | April, 2012

Discussing Oncology Prevention With Dr. Hawk From MD Anderson #WHCC12

Last week, I had a chance to sit down with Dr. Hawk right after his presentation at the World Health Care Congress (WHCC). Dr. Hawk is the Vice-President and Division Head for Cancer Prevention and Population Sciences at the University of Texas M. D. Anderson Cancer Center. He’s been there since late 2007 when he came from the National Cancer Institute.

My favorite point from talking to him was…

Cancer is a process not an event. Communication is critical.

In his presentation, he talked about several things:

So, after his formal presentation, we talked about several things.

  1. One of the big focus areas for MD Anderson is prevention. As we know from research, many cancers are preventable. And, the promise of personalize medicine and genetic testing is beginning to help us understand these cancers and their treatments even more.
    1. Primary – this would include lifestyle changes such as diet and smoking which help prevent the disease
    2. Secondary – this would include screening and detection to help slow the progression of the disease
    3. Tertiary – this would include the focus on the patient (not the tumor) for treatment and helping them with quality of life
  2. He talked about how cancer is really 200 different diseases to be understood and managed.
  3. He gave a great analogy about how CVD (cardio-vascular disease) evolved and talked about how all the individual risk factors became asymptomatic diseases which have led to all the “know your number” campaigns around lipids and blood pressure.
  4. We talked about cancer as a process which led us into the discussion about palliative care and shared decision making. He made another good analogy here about driving a car. We need to understand the value of wearing our seat belt and having insurance, but we have to make the final decision about whether to do that or not.
  5. We talked about personalized medicine including genomics and epigenetics. We talked about how this impacts dosing and understanding of the tumor. (Interesting in a conversation with another person in this field this week they were telling me about how tumors and viruses change over time and those implications on genetic test results.) We also talked about SNPs and the complications in getting validation in studies due to sample sizes. We wrapped up this topic with discussions on coordinated registries and work that companies like 23andMe are doing.
  6. Our final topic of discussion was around clinical practice algorithms and how evidence-based medicine (EBM) gets implemented. We talked about the use of guidelines and how those allow for monitoring the use of EBM standards. We also talked about the need for integrated EMRs that would allow for benchmarking and linking outcomes to use of guidelines.

This is a fascinating area. Cancer affects most of us either directly or through some family member or friend.

What’s Next For The PBM Industry?

A lot has changed to the PBM industry in the past year:

And, there will certainly be more (e.g., the rumor about Cigna’s pharmacy business).  I also think that we’ve seen Walgreens become a lot closer to the independent pharmacies and would expect more changes from them.

So, while I still get people that call me and ask me whether they should start a PBM, I think it’s more interesting to think about this using the GE framework of  To do that, we have to think about where are the profit drivers for the PBM and how can those be impacted:

  • Mail order has certainly been a driver, but as I’ve discussed and Adam Fein has discussed, this is a challenge to grow these days due to pricing, generics, and 90-day retail.
  • There’s been lots of generics coming to market, but many others have written about the patent cliff and it’s potential impact.
  • There’s been plenty of discussion about generic spread and some of the transparency efforts have impacted this.
  • While many still think rebates are a profit driver, my perception is that most of that is already shared with clients.

So, if you wanted to destroy the PBM model, how would you replace it:

  • You would eliminate spread which has been tried by numerous companies under the “transparency” framework.
  • You would eliminate rebates and move to an outcomes-based contracting approach.
  • You would create a competitive market for mail order which is 90-day retail.
  • I might even look at how the Prime Therapeutics ownership model could be applied at a broader level to unions, employers, and small payers.

So, the new model in my mind would look very different:

  • A big focus on specialty with oral solids being basically just coordinated for DUR purposes around claims processing.
  • A shift over the next decade to be very genomics oriented.
  • A shift in customer service from general call center to a broader self-service option.
  • Much greater involvement in condition management possibly even with a shift to work with the providers.
  • A role in coordinating Rx, Dx, and lab data to drive outcomes.
  • Being known more for clinical care then cost management.

I personally also think you’ll see the pendulum swing back to a closer relationship between the PBMs and pharma which I think is important as you focus on more and more orphan drugs and specialty conditions with genomics and high costs.

I think the key question is whether one of the traditional PBMs evolve and own this space or whether a new challenger comes in and shakes up the industry.  Traditionally, the industry has been basically driven by consolidation with limited success by new entrants.

Number Of Chronic Conditions And Costs

I found this data from BCBS of MI in 2008 which shows how costs go up as patients have more chronic conditions (comorbidities):

Another chart shows the annual costs by chronic condition which is good data:

 And, from another area of the website, I found this data on US discharge costs interesting:

Costs Of Presenteeism and Absenteeism

At the World Health Care Congress (WHCC), one of the presenters was making a great case for why employers want to continue to be involved in healthcare.  Their point was that the costs of presenteeism and absenteeism are significant and make health a bigger issue than simply the obvious medical and pharmacy claims costs.  (In one study, presenteeism costs alone were more than medical costs.)

While absenteeism costs are obvious as in sick days paid out, presenteeism is harder to estimate but can have significant costs.  Presenteeism occurs when people come to work sick and are not productive.

I’m sure there are numerous methodologies out there, but I found this one that seemed simple and gave me some data by condition on both factors.

Infographic: Floss or Die

After going to the dentist this week, I thought this was a good infographic:

Floss or Die Infographic

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Interview With Laurel Pickering NEBGH At #WHCC12

Yesterday, I sat down with Laurel Pickering, MPH who is the President and CEO of the Northeast Business Group on Health.  This was a great follow-up to the session she moderated with PEBTF and CalPERs and allowed me to validate my list of focus areas for employers(Note: I did not use a tape recorder and have translated our dialogue into the discussion below so while it is based on my discussions with Laurel these should not be considered specific quotes.)

The first thing we discussed was the concept of ACOs (Accountable Care Organizations) and how employers think about them (or similar concepts).  She talked about the fact that most employers don’t understand the ACO framework in specific.  They may have heard something about the idea of a medical home or mention of the ACO, but they are more broadly focused on the conversion to an outcomes-based future.  Initially, there are some leading edge employers and coalitions that you hear talking about these concepts at conferences, but in general, employers are going to look to their payors to lead this effort and think about how to embrace these new quality and payment frameworks.

We then talked about what are the issues that keep her up at night.  In general, we focused on three things:

  1. Reform – What is the future of healthcare reform and how will that impact employers?
  2. Cost – How can we control costs both direct and indirect?  And, what is the role of prevention in cost management?
  3. Engagement – Even if we understand how to control costs, how do we engage consumers to take action?  Is it through incentives, gamification, social media, mobile, or other tools?

We then talked about incentives and paying consumers (employees) for healthcare actions.  She described three phases here:

  • Phase I: Payment for completing and HRA (which many companies have done for several years).
  • Phase II: Payment for completing specific screenings and participating in programs for which the patient is engaged (i.e., respond with the case manager calls you).  (This seems to be a rapidly emerging standard with many employers.)
  • Phase III: Payment tied to achievement of different outcomes (weight loss, BMI, smoking cessation, blood sugar, blood pressure).  (This is a lot further off and much more complicated, but it’s something that people are beginning to look at.)

We wrapped up with two topics – new technologies and ROI.  In today’s environment, everyone is looking at mobile health and telemedicine.  The question of course is how to get these tools used, paid for, and demonstrating the ROI.  From a technology perspective, we talked mostly about the idea of the “digitally naive” (i.e., people under 16 today) for which technology is the norm.  They’ve never experienced life without mobile phones and computers and Google.  As this generation becomes patients, they won’t think twice about using technology as a way to see their physician and monitor their health.

From an ROI perspective, this has become a table stake to play.  Everyone requires some case study for use.  But, we had a great discussion about the flexibility of calculating ROI and how companies do look beyond just the simple avoided medical costs.  They look at presenteeism.  They look at satisfaction.  They look at overall

8 Common Employer Healthcare Themes #WHCC12

I had the opportunity to listen to some heads of HR a few weeks ago and then sit in on an employer session yesterday at the World Healthcare Congress here in DC.  It was interesting the common themes that clearly were emerging from the presentations by PEBTF and CalPERs along with the event I was at before.

  • Incentives
  • Biometrics
  • Evidence-based medicine
  • Steerage of consumers to lower cost “Centers of Excellence”
  • Reference-based pricing to address unwarranted variation
  • Cost / transparency tools
  • Consumer engagement
  • Integrated care

Will Evidence-Based Medicine Become Reality?

Pills and surgery are potent symbols of healing power, but our faith in these symbols has often blinded us to truths. Somewhere along the line, theory trumped reality. Administering a medicine or performing a surgery became more important than its effect. (from NY Times story)

Did you ever think about the fact that your physician might not be using evidence-based medicine? This is an interesting discussion topic since we know it takes years for research and information to be disseminated throughout the medical community and become the standard of practice.

Scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. It now takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice, and even then application is highly uneven. (According to the Institute of Medicine)

Will that change? One would think so. With technology, you can see more and more tools being used by the physician. You can also see more and more companies doing things like claims editing and then using clinical edits to support the process essentially creating the safety net for the physician, the consumer, and the payer. By implementing clinical standards from places like NCCN or using clinical pathways, companies can help physicians to drive better outcomes at lower costs. This is key for us to manage our healthcare costs here in the US and eliminate unwarranted variation.

So, what is evidence-based medicine? (from Wikipedia)

Evidence-based medicine (EBM) or evidence-based practice (EBP) aims to apply the best available evidence gained from the scientific method to clinical decision making. It seeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic tests. This helps clinicians to learn whether or not any treatment will do more good than harm.

Evidence quality can be assessed based on the source type (from meta-analyses and systematic reviews of double-blind, placebo-controlled clinical trials at the top end, down to conventional wisdom at the bottom), as well as other factors including statistical validity, clinical relevance, currency, and peer-review acceptance.

EBM/EBP recognizes that many aspects of health care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBP, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.

Here’s a few more articles on the topic:

So, there is certainly some debate about this becoming “cookie-cutter” and not being personalized to the individual patient, but I think that’s a common misnomer. EBM is a tool to help guide care to the best decisions based on research and data, but it is balanced with the physician-patient relationship and specific needs.

[BTW – Another aspect of this is enabling consumers with information about how to select locations that are low-cost given the variety in pricing which exists. There was an article in the USA Today about this recently.]

Infographic: Decoding Your Medical Bills

Here’s a great infographic on costs.  This is another reason why you need a company monitoring your claims for cost savings opportunities and working with patients and physicians to implement evidence-based medicine and route patients to centers of excellence (better outcomes for lower costs).

Decoding Your Medical Bills
Created by:

Medco Guide To Moving To St. Louis

Now that the Express Scripts’ acquisition of Medco was approved (surprisingly without any caveats), I’m going to guess that a lot of employees are in one of four positions:

  1. I just made a ton of money based on my vested options, and I’m not going to work for the new organization (by my choice);
  2. My job is safe, and I work in the field with clients so no real impact;
  3. My job is likely being cut so I need to find a new job without triggering my non-compete; or
  4. My job is safe, and for some… I have to move to St. Louis.

The people in the grey area that are uncertain are the people that are probably the most anxious.  And, of course, some of this is happening to the Express Scripts’ people also where there are overlapping jobs.

Since I’ve been out looking to move for my new job, I have some idea of the basic types of questions that those employees looking to move have, and I haven’t found the information that easy to get.

So, here goes with two caveats – (1) this is my biased view after 19 years here and (2) St. Louis is not NY:

Pharmacies: Generally, the majority of pharmacies in town are Walgreens, but you won’t have access to them.  CVS is building a presence here, but you’ll likely go to the grocery store, big box, or independents.

Grocery Stores: The town is dominated by two local chains called Schnucks and Dierbergs.  There is a Whole Foods and a Trader Joes.  There are a few Shop and Saves.

Workout: There are lots of chain and small gyms around town.  If you haven’t been to one, you should look at the Lifetime Fitness in West County.

Restaurants: St. Louis Bread Company (Panera to you) is headquartered here and is everywhere with free wi-fi.  There are lots of Starbucks.  Some of my favorites (non-chains) include Yia-Yia or Charlie Gittos or Cardwells or Bristols.  You should try Crown Candy in the city and Ted Drewes for deserts.  (I also really like Silky’s in West County.)  [I’m obviously not a foodie.]

Places: You’ll hear people talk about “the Hill” which is an Italian area in the city.  You’ll hear about Clayton which is the one business area outside downtown.  You’ll hear about West County, South County, and North County which are just like the names (counties around St. Louis city).  You’ll hear about 40, 70, 44, 270, and 170 which are the highways.  You’ll hear about Forest Park (which is our version of Central Park).

Vacation: The two Missouri vacation places you’ll hear people talk about are Branson and Lake of the Ozarks.

Casinos: There are several casinos around town.

Smoking: Smoking in restaurants was banned a few years ago.

Other Big Companies: A lot of the big companies like Anheuser-Busch and Ralston have been bought, but they still have a big presence here.  Emerson Electric is here.  SSM Healthcare is here.  Ascension Health is headquartered here.  Centene is here.  Enterprise Rent-A-Car is headquartered here.  EdwardJones, AG Edwards, and Scottrade are all here.  Citibank has a large presence here as does Mastercard.  Build-A-Bear was started here.

Colleges: Washington University (WashU) and St. Louis University (SLU) are both here in town.

Areas to Live: I would say that many people from Express Scripts management live in West County (Chesterfield, Wildwood, Ellisville) which is where I’ve lived most of my time here.  There are lots of transplants out here.  Traditionally, most people from St. Louis will live east of 270 in Clayton, Ladue, Frontenac, Webster, Kirkwood, or in the city (see Delmar Loop area or Washington St. downtown).  Some other areas where people will live include St. Charles or some people in Illinois.  If you like a new house with lots of square footage, you can get that in West County or other areas farther.  There are even a few new subdivisions being built by Pulte homes.

Golf: If you like to golf, there are lots of places to go.  I really like Tapawingo and Peveley Farms.  There are also many good clubs which can be joined for a reasonable fee like St. Albans or Forest Hills.

Schools: The public schools are very good (at least from what I know out here in the Wildwood/Chesterfield area).  There are also a lot of private schools with a huge emphasis on Catholic schools.

Things for Kids to Do: There are lots of great places like Purina Farms, Six Flags, Dave & Busters, City Museum, The Magic House, Grants Farm, and of course…the Arch.  Additionally, there’s the zoo and the Science Center.

Sports: Of course, you have the Rams, Cardinals, and Blues.  There is no NBA.  (Tickets are probably a lot easier to get here than in NY.)

Places to Shop:

  • Chesterfield Mall
  • West County Mall
  • The Galleria
  • The Valley (Chesterfield)
  • Frontenac
  • Fleet Feet (for runners)


  • If you go south in Missouri, you’ll see armadillos.
  • The first question that many people will ask you is where you went to school.  (They mean high school not college which allows them to quickly stereotype you.)
  • There is wine made in Missouri (although I can’t vouch for quality).  You can do a bike tour stopping at multiple wineries which is fun (and maybe dangerous).
  • Here we fry our ravioli to make toasted ravioli.  You can also get lots of gooey butter cakes and cookies.
  • Another big food favorite here is pork steaks (which are actually quite good).

More information:

Eating Chocolate = Lower BMI!

Here’s a study that all of us with a sweet tooth should love…

In Time (4/9/12), they say:

Eating chocolate five or more times a week on a regular basis can translate to a one point drop in BMI on average, compared with those that don’t eat it.

It sounds too good to be true, but apparently chocolate can help the body absorb fewer calories from fat.

See the full study here.

(My question is why don’t I hear these messages from my health plan.)

And, for those of you that like salty snacks instead, the same page in Time talks about the fact that popcorn has more polyphenols by weight than fruits and vegetables. (Polyphenols can neutralize cancer causing free radicals.)

Changing Marketing Paradigms

Traditionally, consumer marketing has focused on the “young invincibles” as they are sometimes referred to in healthcare. Those are the 18-34 year olds that traditionally were the DINKs (dual income no kids) and younger population with more disposable income or focused on acquiring goods (as they bought homes and started careers).

Well, I think this quote by Sunil Gupta summarizes the issue:

If [young adults] have no money in their pockets, there is nothing to sell them.

With 46% of those age 18-24 unemployed and 20% of those 25-34 living at home, this group’s financial dynamics are very different. The focus on both those with money and those driving the healthcare costs have shifted to Baby Boomers. (Facts from Time article on page 16 in the 4/9/12 edition.)

At the same time, I read an article about marketing to women which continue to make majority of healthcare decisions both for themselves and their families. (and caregivers (often women) are less likely to be adherent to their own medications.)  Here were the recommended approaches:

  • Offer highly personalized formats
  • Provide complete anonymity
  • Eliminate the middle man
  • Understand self-perceptions
  • Consider the unique point of sale

And, some of these changes are driven by the economy. For example, according to NCH Marketing and Parks Associates, 81% of people are using coupons regularly and they redeemed them for 3.5B in 2011. (Of course, the jury is still out on the Groupon model…)

AHRQ Questions are the Answer campaign

I often talk about the issue of communications in healthcare. That could be patient to patient, healthplan to patient, pharmacist to patient, or physician to patient (or many more).

Understanding health literacy and personal motivation are critical as are so many other factors. With that in mind, I was glad to see this new campaign from AHRQ.

(Here’s the text they sent me about it.)

“When patients become more actively involved in their own health, there’s a much stronger likelihood their health outcomes will be better.

That’s why “Questions are the Answer,” a new public education initiative from the U.S. Agency for Healthcare Research and Quality (AHRQ), encourages patients to have more effective two-way communication with their doctors and other clinicians.

“Questions are the Answer” features a website — — where you will find these free educational tools to use with your patients:

· A 7-minute video featuring real-life patients and clinicians who give firsthand accounts on the importance of asking questions and sharing information – this tool is ideal for a patient waiting room area and can be set to run on a continuous loop.
· A brochure, titled “Be More Involved in Your Health Care: Tips for Patients,” that offers helpful suggestions to follow before, during and after a medical visit.
· Notepads to help patients prioritize the top three questions they wish to ask during their medical appointment.

Clinicians can request a free supply of these materials by calling AHRQ at 1-800-358-9295 or sending an email to”

All of this is good information, BUT:

  • Do physicians have time for this and are they prepared for these dialogues in plain language and with handouts and URLs they recommend?
  • Are patient’s prepared to slow their physicians down and make sure they explain everything?
  • Will this get measured at some point as a qualitative metric and correlated to outcomes?

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