Archive | July, 2012

Prescribing Information and Applications

I’ve talked about the “Information Therapy” concept before. I suspect as physicians take a greater role in outcomes, and with the emergence of ACOs and PCMHs, they will increasingly play a greater role in providing information and applications suggestions to patients.

I was at the mHealth conference in Boston today, and I mentioned the opportunity for nurses to do this as part of disease management and case management. As soon as I talked about that, I got taken over to the CEO of Happtique who happens to be working on a solution for this from a health application perspective.

In my mind as a patient, I’d like to know:

  1. What do you recommend for managing my condition?
  2. Does it provide clinically sound information?
  3. Is it secure?
  4. Is the application stable and likely to continue existing? (I don’t want to start putting data in something to have it disappear.)
  5. Will it integrate with the care management system?
  6. Is it easy to use and understand? (regardless of my level of sophistication)
  7. Does it work with any devices?

I haven’t ready their draft certification process (open for public comment), but here’s the link to it.

Here’s their boilerplate…

Happtique is a mobile health application store and app management solution that helps healthcare providers, physicians, and patients easily integrate mHealth into treatment. It offers medical enterprises—like hospitals, continuing care facilities, and physician practices—the ability to create individually branded, secure, multi-platform application stores for staff and patient use.

Condition Specific ACOs – Perhaps Kidney and Oncology

One of the more interesting discussions out there about ACOs is that around carving out specific conditions. While the general ACO concept is built around the idea of a Medical Home where the PCP is your “guide” (not gatekeeper) and helps you to make decisions, complex patients with certain chronic conditions may be better served to have a specialist managing and coordinating their overall care.

While DaVita with their push for Kidney specific ACOs built around their focus on dialysis has been one key player here, BCBS of FL has actually come out with what they referred to as an Oncology ACO. What CMS will do here is still TBD, but the idea of taking some of these high-cost and complex conditions and putting them into a fixed fee or bundled payment structure tied to outcomes sounds right.

I personally could even see more drug companies and medical device companies playing in this area since they could directly control certain costs and often have incredible amounts of research in certain conditions.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

P4P, PCMH, ACO…The Concept Is The Same

Healthcare is very good at creating TLAs (Three Letter Acroynms). The Accountable Care Organization (ACO) and the adjacent models are no different.

You have:

These are of course governed by:

And, they were significantly impacted by the SCOTUS (Supreme Court of the United States) decision regarding PPACA (Patient Protection and Affordability Care Act).

But, at the end of the day, the goal here is the same. We need a solution that addresses:

  • Cost, Quality, Care (the Triple Aim)
  • Our existing infrastructure
  • Our unique healthcare environment in the US
  • The challenges of changing patient behavior

We all know that the healthcare system is not sustainable without change. What will happen to health reform with the election is still TBD, but at the end of the day, change is needed. PPACA might not be perfect, but it was better than a lot of options (IMHO). As I said before, I would focus on phased change:

  • Improve access for all Americans
  • Build out connectivity and technology
  • Develop a new payment model
  • Integrate payment with outcomes

The Core Of The ACO – The Provider

While my other post talked about the IT priorities of the ACO, I believe that a large part of the ACO (Accountable Care Organization) effort driven by CMS is about creating a provider-centric approach to care management. While medicine certainly began as a provider to patient relationship, that has changed over the years to a managed care driven relationship. This peaked years ago with the HMO backlash that led to the revised system that most of us have grown accustomed to operating within.

Then, with the discussions around exchanges, Medicare, and the individual market, we’ve seen a shift to a more patient-centric approach to healthcare focused on the patient experience and understanding their behavior. Is anyone necessarily wrong – no. But, there needs to be a balance. I personally think that the ACO approach is trying to build some of that with a Kaiser type of framework. Physicians would be at the heart of the solution with technology, process, and financial support from managed care companies and medical management companies. And, they would have to partner with the patient to really affect behavior and ultimately health outcomes.

Will it work? Who knows. There have been a lot of smart people who have spent a lot of time and energy trying to figure out health outcomes and cost with limited effect in any scalable way.

There have been a few initial articles about ACO success:

There have also been a few people talking about ACO 3.0 and the future of how ACOs will evolve from what we know today.

Of course, most of this is focused on the CMS ACO model while others are using the “ACO” moniker as a framework for pay-for-performance (P4P) within the physician world.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Building Accountable Care Solutions

Right now, it’s a little bit of the Wild West in terms of building Accountable Care Solutions (ACS’s)…which is not necessarily bad.

You have physicians building ACOs. You have hospitals building ACOs. You have managed care companies buying physician groups to have ACOs. You have managed care companies providing technology to providers to have ACOs. You have consultants helping design ACOs. You have technology companies building components of ACOs. Eventually, my prediction is that you’ll end up with some type of franchise model on ACOs that providers can leverage. Perhaps it’ll be like the Medicine Shoppe model for pharmacies.

But, as I read through all the literature and try to have opinions on this space, there are a few core things I keep coming back to:

  • Leveraging Evidence-Based Medicine (EBM) guidelines
  • Consumer engagement and behavior change
  • Quality tracking and reporting
  • Technology enablement
    • Patient registries to collectively manage similar patients
    • Gaps-in-care identification
    • Risk modeling
  • Coordination of data and care across PCP, specialists, hospitals, pharmacy, clinics, and labs
  • “Care coordinator” role (probably a blend of human and automation)
  • Sharing value and risk

While traditional providers have been focused on actual diagnosis and care, they haven’t focused on most of this. This is a fundamentally different business (at least at the individual physician level). Even the one that most naturally fits with the practice of medicine – Evidence Based Medicine – is a challenge given the pace of change and information. Plenty of studies have documented this challenge.

So, while everyone is now using this term that our team started using last year, the reality is that ACS’s are complex solutions that take a holistic view of the patient and their care and manage using EBM with an integrated solution that blends technology and face-to-face care with a focus on specific health outcomes.

To borrow from Ernst & Young, here’s a framework they propose on their website about Accountable Care:

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Five Critical Components Of An ACO

The Advisory Board out of Washington DC has jumped headfirst into the pool around ACOs. They have some great information on their website and like any other consultants, provide some great frameworks to leverage.

One that I found helpful lays out the 5 critical IT components for developing an ACO (see image below):

  1. Network Interconnectivity (Practice Management System and Electronic Medical Record integrations in my words)
  2. Clinical Knowledge Management (Evidence-Based Medicine in my words)
  3. Patient Activation (or Engagement)
  4. Financial Operations
  5. Population Risk Management (or Medical Management or Population Health Management)

I think this is a good starting point for understanding what technology you need to provide an ACO (and theoretically make money doing it).

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

What Is An ACO?

Here’s my paraphrased summary from the HHS (Health and Human Services) website about ACOs and the CMS site

  • Established on October 20, 2011, by CMS under PPACA
  • ACOs create incentives for health care providers to work together to treat an individual patient across care settings – including doctor’s offices, hospitals, and long-term care facilities.
  • The Medicare Shared Savings Program (Shared Savings Program) will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first.
  • An ACO refers to a group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) that will work together to coordinate care for the Medicare Fee-For-Service patients they serve.
  • The ACO will be responsible for maintaining a patient-centered focus and developing processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost, and buy phen375,  and coordinate care.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

$WAG and $ESRX Reach New Pharmacy Deal!

Wow!  Finally! 

Those are my immediate reactions.  I just saw the news that Walgreens and Express Scripts have reached a new pharmacy deal effective 9/1/12.  I’m sure there are lots of consumers that will be happy about that and a few competitive PBMs that will be disappointed. 

A few things that this makes me think about:

  • The Walgreen’s shareholders will be happy.
  • Both parties can claim some victory by holding out so long.
  • I imagine that the limited network was working ok, but there wasn’t huge adoption.  It was probably also an issue in RFPs and with consultants.
  • Other PBMs were likely using this in selling against Express Scripts so they’ll be disappointed.
  • Obviously, the Medco contract with Walgreens was the big catalyst here.  Letting that transition to a point where they didn’t get any Medco or Express Scripts patients would be a disaster.
  • Will this change Walgreens collaboration with the NCPA against the PBMs and mail order or is that just the natural conflict here?

The biggest battle now will be around customer retention and winback.  Can Walgreens get their old Express Scripts patients to come back?  Can CVS and others hold on to the patients?  This will really test the theory about customer loyalty in the pharmacy space. 

The other interesting thing here is that this pushed Walgreens to really re-evaluate their strategy and market positioning.  Will they emerge as as stronger and different company because of this 9 month period.  I would think so, but that is still TBD.

The Express Scripts 2011 Drug Trend Report – Full of Infographics

Those of you that have been readers for a few years know that I love to read and summarize these reports. They provide a huge set of aggregated data and summarized information that is useful in creating business cases and identifying trends.

This year is no different although the graphics within the Express Scripts Drug Trend Report continue to get better … ala infographics (as they even posted one recently on their blog).

So, what caught my eye this year…

  • There was one ex-Medco person who signed off on the intro letter…and interestingly (compared to other DTRs), no George Paz signature.
  • They have a big picture of their Research & New Solutions Lab upfront (see below). It reminds me of the NOCs (Network Operations Centers) that I had at my past 3 employers. [Maybe one day before I move out of St. Louis they’ll take me on a tour.]

  • I was definitely interested to hear what they would say about Walgreens. They tackled it early on in the document.

Our 2011 retail-network negotiations marked another milestone in our heritage of independence from pharmacies and alignment with our plan sponsors. One retail pharmacy chain, Walgreens, was unwilling to offer rates and terms consistent with those of the market, and instead opted to leave our pharmacy network at the beginning of 2012. Although we remain open to Walgreens being part of our pharmacy network in the future, the positive reaction we received from plan sponsors and members during the process of transitioning patients to other pharmacies confirmed what our prior analyses had shown: the vast majority of the U.S. has an oversupply of pharmacies, suggesting that networks can be tightened significantly while maintaining sufficient patient access.

  • 17.6% of the total Rx spend was for specialty
  • 47% of specialty medications are processed under the medical benefit
    • 78% for oncology
  • They talk a little about evaluating genetic tests and when to recommend a test. It’s definitely an evolving space, and it will be interesting to see the Medco influence here in terms of what they recommend.
  • They talk about $408B in waste from adherence, generics and mail order. All consumer behaviors. (see last year’s report focused on waste)
  • They show the breakdown of waste by state where the South is the biggest problem. It looks a lot like the Diabetes Belt although it also includes the SouthWest.

  • Not surprisingly, diabetes, cholesterol, and hypertension represent 3 big opportunities.



  • FINALLY…For years, I’ve been comparing two older studies to make the point that people think their adherent when there’s no way that perceived adherence can match reality. The most exciting thing to me was that they actually looked at perceived and actual adherence on the same patients.

For example, patients in the least-adherent group in the survey of Express Scripts members had an average actual MPR of 24.3%. The average perceived MPR reported by patients in this group, however, was 90.6%. We therefore found a staggering 66% gap between perceived MPR and actual MPR.

  • They talk about how this data is being used to predict non-adherence with some crazy high reliability. (Meaning only that it sounds too good to be true.) Regardless, they’re right in using data to identify behavior gaps (current and future) and developing personalized interventions to address barriers.

  • The overall drug trend was 2.7%
    • 17.1% specialty trend
    • 0.1% traditional drug trend
  • Here’s the breakout by class of specialty spend

  • Actual member out-of-pocket and percentage of cost actually went down $0.14.  Surprised?

  • Perhaps most interesting (and new) is a huge section on Medicare and Medicaid trends. Obviously this shows their focus here in an area that CVS Caremark has also been focusing on.

I’d also point you to Adam Fein’s breakdown of this report (in a more timely manner).

inVentiv Medical Management and Vital Decisions

I’m excited about a new relationship at work with Vital Decisions.  Some of you have heard me talk about Palliative Care before.  The whole area of working with patients that have an advanced illness is a hot discussion topic especially within the CMS community (see yesterday’s WSJ).  But, while many consumers focus and worry about the idea of cost containment at this emotional time, Vital Decisions does a great job of using their behavioral counselors to work with patients to help them articulate their desires to their family and their physicians.  They’re not counseling them on medical decisions or trying to limit care.  They are simply trying to help patients to find a way to talk about this topic with their caregivers.

In some ways, it reminds me of the Engage With Grace movement to try to get families to talk about this with each other.  In this case, the conversation is coordinated with our care manager and part of an overall patient-centric approach to care.

Here’s some of the press release:

inVentiv Medical Management (iMM), an inVentiv Health company and provider of best-in-class medical management services to the healthcare industry, today announced that it has formed a partnership with Vital Decisions to better serve the needs of payers, providers, and seriously ill patients nationwide. The joint offering will support patients by empowering them to be more proactive decision makers when it comes to their health, and, thereby, reduce the use of costly care that is medically inappropriate or unwanted by individuals with advanced illnesses.

Together, iMM and Vital Decisions – an Edison, New Jersey-based company that provides patient-centered behavioral counseling programs for those with advanced illnesses – will offer a unique care management and counseling program to individuals battling metastatic cancer, end-stage heart or lung disease, and progressive neurologic conditions, such as Alzheimer’s or Lou Gehrig’s disease (Amyotrophic Lateral Sclerosis-ALS). The program is designed to encourage patients to work with their physicians and family members to make well-informed care decisions as their illnesses progress. inVentiv Medical Management case managers will provide patients with clinical advice, while Vital Decisions specialists will offer counseling support using the company’s proprietary “Living Well” program, which helps individuals with advanced illnesses communicate their quality-of-life preferences to those involved in their care.

Organ Donation Infographic From NHS (UK)

It’s organ donation week in the UK…so in the spirit, here’s one of their infographics on the topic.

Organ Donation Facts and Figures

Join the NHS Organ Donation Register

Highlights From The Prime Therapeutics Drug Trend Report

It’s been a busy year, and I’m getting a late start on reviewing the drug trend reports as I’ve done in the past. I’ll try to get to the CVS Caremark and Express Scripts reports next week.

As I mentioned last year, the Prime Therapeutics Drug Trend Report takes a more aggressive stand and how they compare to the competition. I’ll give a lot of that credit to Eric Elliot’s presence there as the CEO.

“Smart car buyers know that the actual cost of a car does not always align with the price on the window; the same is true for pharmacy benefits. Yet plan sponsors continually focus on “sticker price” measures such as brand-name discounts or manufacturer rebates — metrics that can be manipulated to make a deal look more attractive.”

The one thing which is noticeably different this year is that the document has more of a care management sound to some of the programs they talk about with an emphasis on total healthcare cost savings. Again, I attribute that to both being owned by the Blues and having several people in the management team that came from payers. Buried towards the back, they call themselves “total health focused” versus their competitors.

As always, here’s a few things that caught my attention:

  • A $4.73:$1 ROI for using the local pharmacist to address gaps-in-care.
  • 1.3% trend increase.
  • 74.7% generic fill rate.
  • 20.1% specialty trend increase.
  • 15.4% of client’s pharmacy spend is for specialty drugs which cost on average $2,654.
  • 0.4% of Rx claims processed are for specialty drugs.
  • Their Rxs PMPY have gone up to 12.4 which I think is closer to industry.
    • This is an interesting one. I pointed out a few years ago that they were below average which I wasn’t sure if this was due to plan design, member mix, or client mix.
    • They seem to be going up even though some industry data suggests a downturn in Rxs filled which again is something I can’t explain.
    • It could simply be more people >50 years old are staying in the insured mix…and they use more drugs.
  • Their average net costs per Rx were:
    • $165.33 brand
    • $17.95 generic
    • $57.53 combined
  • They breakdown specialty spend by category and also show how it’s growing and is projected to grow as a percentage of total drug spend.
  • Of course, another big piece of the specialty picture is how the spend breaks out between medical and pharmacy benefits. This is why blending data to understand the complete picture is important.
  • I thought the list of specialty drug management tools was a good starting point although I expected to see more here about how to integrate with the payers especially around categories like oncology and what BCBS of Florida is doing around an oncology ACO solution.


Some ACO Facts From Modern Healthcare and CMS

In a Modern Healthcare article about ACOs, there was the following graphic which is a quick snapshot.  The key here is that companies are rapidly moving forward with ACOs (commercial and Medicare).  The initial data is positive, and it seems like everyone is jumping on board.

McKinsey Quarterly On B2B Social Media

The recent McKinsey Quarterly had an article called Demystifying Social Media which I thought was a good read with a good framework to use (see below). 

In short, today’s chief executive can no longer treat social media as a side activity run solely by managers in marketing or public relations. It’s much more than simply another form of paid marketing, and it demands more too: a clear framework to help CEOs and other top executives evaluate investments in it, a plan for building support infrastructure, and performance-management systems to help leaders smartly scale their social presence. Companies that have these three elements in place can create critical new brand assets (such as content from customers or insights from their feedback), open up new channels for interactions (Twitter-based customer service, Facebook news feeds), and completely reposition a brand through the way its employees interact with customers or other parties.


Scary Infographic On the Effects Of Soda

The scariest stat in here is that kids ages 1 and 2 are drinking soda on a daily basis.

Now, the fact that we’re fat and drink too much soda isn’t the soda’s company’s fault.  We drink soda of our own free will, but this is a contributor to our obesity and this is why the NY soda law makes sense.  (And, IMHO, this is why the soda companies supported removing their drinks from schools and went into the business of selling non-soda beverages…they know there are issues regardless of what they say.)

Soda Infographic

Drug Trend Reports: Quick Summary Of Big Three PBMs

“Comparative” is a very loose word to use here since each PBM has a slightly different approach to their analysis.

But, while it’s truly impossible to compare apples to apples and I will continue to argue that trend may be an irrelevant metric, I know may consultants and others are focused on these metrics.

With that in mind, I pulled the trend numbers (overall and specialty) along with the generic fill rate from the Express Scripts, CVS Caremark, and Prime Therapeutics trend reports.


Overall Rx Trend

Specialty Trend


CVS Caremark




Express Scripts




Prime Therapeutics





  • I used the CVS Caremark health plan overall and specialty trend data which I thought would be most comparable to Prime’s data.
  • Express Scripts reports their overall trend (without specialty) being 0.1%.
  • CVS Caremark provides a break out of trend along with best practices by sector (see below).


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