Archive | August, 2012

My Visit To The Express Script’s Lab

The topic of innovation labs in healthcare is an interesting one (see other post). The other day, I had the chance to go and visit the Express Script’s Lab here in St. Louis.

This is a newer facility built back in November 2010 and has 26 scientists working there. It’s where some of the research team that I worked with years ago still is, but it now has a big focus as both a showcase facility and a hub for managing pilots.

There are a few key things in the facility:

  1. An open floor plan for collaboration with a giant whiteboard and chalkboard and several meeting rooms.
  2. The large screen you can see above which shows different metrics and can have any section expanded to drill down on current pilots or other activities.
  3. An interactive board in one area for a more intimate client discussion looking at their data.

There are now some people on the research team from Franklin Lakes (i.e., Medco). It will be interesting to see how they incorporate some of their research studies. Someone had recently told me about some cool work they had done using technology on the bottle (similar to my augmented reality idea).

A big focus of the team is on predictive modeling drawing from work in the financial services industry. They are looking at things like fraud and abuse, re-admissions, and adherence.

Like the team has always done, they use a champion / challenger approach to evaluating pilots. I thought the example they showed me on the big screen was interesting. It looked at both linguistics changes (i.e., words) and graphical changes on the web to evaluate consumer behavior. They carve out 10% of the population to randomly get these different scenarios and compare their success to the “champion” which is the existing strategy.

I had a chance to then see the interactive client board which focused a lot on network, generics, mail, and predicting adherence. They have some very cool mapping software to break all this data down to the block level and let you see how things compare. For example, they showed me claims based adherence on the map versus predicted adherence. This is important to think about where you focus resources especially when you understand that a majority of non-adherence (according to their studies) is due to procrastination. They are thinking about and treating adherence like you would a disease. How can you act preventively?

Right now, their ScreenRxSM solution is focused on 9 different conditions and uses their model to identify and trigger tailored interventions based on patient identified barriers or obstacles. As I’ve talked about before, while most people think it’s cost…it’s only about 16% (according to their research). Therefore, you can focus your more expensive interventions on the patients with cost and clinical barriers versus simply waiving copays for everyone (for example).

Where’s Your Healthcare Innovation Lab

This past week, Aetna announced their innovation lab (see press release). This adds to several other labs out there including the Express Scripts lab, the Humana Innovation lab, and the two Kaiser facilities (Garfield and the Center For Total Health). I’m sure there are more.

It made me think about this as a tool for driving innovation. Based on my limited experience visiting 3 of these 4, it seems like they fall into a few types:

  1. An operational prototype for showing how innovation can affect process and experience.
  2. A showcase for demonstrating technology and new ideas.
  3. A demonstration center for showcasing research and the pilot process.

This makes me think of visiting the Domino’s Pizza facility years ago where they had different pizzas being served and tried there to see how employees reacted. In other cases, you see companies like Walgreens rollout new locations and test the consumer response as a type of living lab.

How And Why I Use Twitter

I often get stopped by people I know who say things like:

  • I see a lot of your tweets in LinkedIn.
  • You use Twitter. Why? I don’t really want to tell people that I’m going to eat dinner or some other miscellaneous fact.
  • Can you really get anything out of 140 characters?

So…let me share my perspective on how my use of Twitter has evolved and what I get out of it.

It took me a few tries before I found out how to use Twitter effectively.

  1. First, I tried just using it to share thoughts or opinions across a variety of topics. I didn’t find that valuable and wondered why anyone would follow me to know that.
  2. Second, I tried using it to pose questions about healthcare topics that I was interested in. That worked ok because it synched with LinkedIn, but I didn’t have enough Twitter followers for that to make a difference.
  3. Finally, I decided to just use it as a “notebook” to capture facts while I read or to bookmark articles that I found interesting. (Of course, some of this became possible as every web article now offers a “share” feature.) This works especially great when you’re at a conference and is even a good way to follow a conference that you miss.

The next thing that I had to figure out was just understanding the technology.

  1. Reading things in Twitter is ok, but a lot of people post links. Often times, it’s not that effective to be constantly going out to the links to see what they say. In comes Flipboard to save the day. (see older post here)
  2. To make things more searchable, you have to use hashtags where you put a “#” in front of a key expression or search term.
  3. Most people don’t get a lot of followers although you hear about all the celebrities with millions of followers. (see HubSpot presentation below for general Twitter statistics)

I figure it must be working for me now. I have over 1,000 followers which according to this site is true for less than 1% of people on Twitter. But, I don’t think followers is the best indication (especially since almost ½ of followers might be bots and you can buy followers). I know that it’s working for now since I can post a question and sometimes get an answer. I can connect with companies and meet people. I’ve even heard from people at conferences that they follow my feed. Probably my best experience was when I read an article early in the morning, posted a quick summary, and then had a national reporter call me to ask me for the source so he could write an AP article…all before 8 am.

Just to check, I went out to the StatusPeople application which tells you how many of your followers are bots versus simply inactive. I was pleased with the results.

Comparing Obese States With Less Obese States

You can’t really call any state “non-obese” these days with every state having at least 20% of their population considered obese and 12 states having over 30% of their population obese.



But, in a separate study, I found it interesting to compare some metrics from the most obese to least obese states.  Not surprising.



One of the things that I do always find interesting is whether people consider themselves to be obese.  People generally don’t.  I’ve spoken about it before, but I sometimes think healthcare providers need to be more direct with people to let them know that they are obese and this in going to increase their chances of dying sooner (2x more likely to die prematurely) and having other health problems.

Infographic: Patient Education

I’ve talked about this before.  The gap between what patients should hear and remember and what they do hear and remember is huge.  It’s one of those root cause issues that are hard to address.

Mindset List For The Class Of 2016

Let me highlight a few of the things from this annual list by Beloit College. It’s put together to help highlight the mindset of incoming college freshman. Generally, in healthcare, these are the healthy people that don’t get much focus, but increasingly, it will be important to understand them for preventative services, caregiver engagement, and exchanges. (Note: numbering below reflects original numbers from the list)

Ultimately, this will change the way we support and provide healthcare information.

2. They have always lived in cyberspace, addicted to a new generation of “electronic narcotics.”

4. Michael Jackson’s family, not the Kennedys, constitutes “American Royalty.”

7. Robert De Niro is thought of as Greg Focker’s long-suffering father-in-law, not as Vito Corleone or Jimmy Conway.

8. Bill Clinton is a senior statesman of whose presidency they have little knowledge.

9. They have never seen an airplane “ticket.”

14. There has always been football in Jacksonville but never in Los Angeles.

15. While still fans of music on radio, they often listen to it on their laptops or replace it with music downloaded onto their MP3s and IPods.

21. A significant percentage of them will enter college already displaying some hearing loss.

23. Women have always piloted war planes and space shuttles.

27. Outdated icons with images of floppy discs for “save,” a telephone for “phone,” and a snail mail envelope for “mail” have oddly decorated their tablets and smart phone screens.

28. Star Wars has always been just a film, not a defense strategy.

32. Newt Gingrich has always been a key figure in politics, trying to change the way America thinks about everything.

34. Billy Graham is as familiar to them as Otto Graham was to their parents.

35. Probably the most tribal generation in history, they despise being separated from contact with their similar-aged friends.

47. Before they purchase an assigned textbook, they will investigate whether it is available for rent or purchase as an e-book.

49. There has always been a World Trade Organization.

67. Chronic Fatigue Syndrome has always been officially recognized with clinical guidelines.

68. They watch television everywhere but on a television.

74. Genomes of living things have always been sequenced.

Do Employees Really Engage During Open Enrollment?

Human Resources professionals, consultants, and healthcare companies spend a lot of time trying to figure out what benefits packages to offer, how to frame those out to employees, and then how to get them to choose the right package for them. The key question is whether this works and whether employees care?

A recent survey from the Aflac WorkForces Report would indicate that the answer is no.

  • 56% estimate that they waste up to $750 a year because they make mistakes with their health benefits.
  • Only 16% are confident about their decisions on healthcare benefits.
  • 52% say that their company doesn’t communicate with them at all about open-enrollment.
  • 89% say they simply elect the same options every year.
  • 47% say they rarely or never exceed their deductibles.
  • 16% contribute the right amounts to their flexible spending accounts.

All of this while benefits are getting more complicated and consumers are being expected to pay more of the bill.

More People Have Had A General Physical Than A Dental Exam In The Last Year?

I found this study on health exams interesting. It was done by KRC Research for Bausch & Lomb. According to their data, only 52% of adults surveyed have been to the dentist in the past 12 months. That by itself isn’t that surprising, but the fact that it was fourth on a list of five exams was very surprising to me.

(Note: This data was from a graphic that appeared in the USA Today this past week. I could not find the original source in a Google search.)

Infographic: ACO Survey

Here’s an infographic from some data on Accountable Care Organizations (ACOs) from Health Intelligence Network.

Digital Dimension Of Healthcare Paper – Global, mHealth, Halvorson

I was just skimming the Digital Dimension of Healthcare whitepaper which has as one of its authors – George Halvorson from Kaiser.  There’s not a lot of new information in here if you’re well read on the space, but I like their framing of a fourth space for health delivery along with their two dimension matrix of opportunities.

The other piece that I’ll pull out here is the Six Principles that they identify:

  1. Set the direction, and commit to it
  2. Balance patient confidentiality and information sharing
  3. Empower patients
  4. Adapt payment systems
  5. Reduce barriers to regulatory approval and licensing
  6. Accelerate the healthcare evidence base

Would You Pay $100 A Month For A Diabetes Application?

An article in MobiHealthNews caught my attention this morning when it talked about 2 payers agreeing to pay $100 a month for Welldoc’s diabetes application. This is fascinating to me since (a) I’m always interested in how people price and value services and (b) I’d love to bundle something like this into our diabetes offering. 

This of course begs the key question which is what is the value of the application.  We’re all familiar with the fact that diabetes drives significant costs within our healthcare system.  Here’s a quick summary from the ADA.

The national cost of diabetes in the U.S. in 2007 exceeds $174 billion. This estimate includes $116 billion in excess medical expenditures attributed to diabetes, as well as $58 billion in reduced national productivity. People with diagnosed diabetes, on average, have medical expenditures that are approximately 2.3 times higher than the expenditures would be in the absence of diabetes. Approximately $1 in $10 health care dollars is attributed to diabetes. Indirect costs include increased factors such as absenteeism, reduced productivity, and lost productive capacity due to early mortality.

Of course, diabetics also spend a lot of money on out-of-pocket costs themselves.  $6,000 from one study mentioned here.

But, I think the key question here is what assumptions make this a good investment.  Let’s me walk through my thought process.

  • At $100 per month, you pay $1,200 per year per member.
  • BUT, members won’t actively stay engaged with the application all year long so you have to assume some percentage of engaged members.  (A key question is whether you pay only for actively engaged members or all members enrolled in the program.)  And, how long does a patient have to use the application to achieve the results?
    • If 20% are engaged, the cost per engaged member would actually be $6,000 ($1,200 divided by 20%). 
    • If 60% are engaged, the cost per engaged member would be $2,000.
  • The next question is how you estimate the value of the application.  Based on their study, they saw a 1.9 point drop in A1c which is a good one-year drop and a good outcome metric to focus on (see article).  So the question becomes…what is the value of a 1.9 point drop in A1c?  This is a question I was looking for earlier.
    • This pharmacist based study talks about a 0.8% reduction in A1c leading to $1,200 in total savings.
    • This CVS study showed a $3,756 annual savings for an adherent diabetic versus non-adherent.  (But, adherence wasn’t shown in the Welldoc study.)
    • The President from Welldoc quotes a savings of $3,500-$4,000 per point drop in A1c, but I couldn’t find the study to support that.  (I e-mailed their PR people about this.)
    • And, a few weeks ago at a mHealth conference, I heard someone say the value was $7,000 per point reduction in A1c.

As you can see from this tweet, I was looking for this study yesterday and mentioned DiabetesMine to see if Amy might know, but she didn’t.


So, my conclusion is that this is worth it if:

  1. The value is closer to the $3,500 point.
  2. You pay based on actual engagement or utilization…or you only give it to people who actually use it versus the overall population. 
  3. The application improves adherence.

I hope to figure this out since this was the first FDA approved device and looks very promising.

Vaccine Excemptions By State

This is an interesting map from Every Child By Two which is a pro-immunization advocacy group.  And, per the article in USA Today, this discussion around vaccines is heating up with kids coming back to school and the biggest epidemic of whooping cough in 50 years.

I’ll also pull up this video that I posted last year which I thought to be a fun presentation of this topic.

Health Companies On The Inc. 500 List

I always find lists interesting.  The Inc 500 gives you a view into some of the quicker growing companies althougth there certainly is a mathematical bias towards having a small base to grow off.  But, it can help you see some trends and areas of market activity.  Here’s this year’s list from the September 2012 edition of Inc Magazine.

Do 40% Of Students Use “Good Grade Pills”? – Infographic

This is one of those debated topics that is hard to quantify, but I don’t think anyone doubts that it happens. The question is to what extent. But I think this infographic gives some data and points out some of the risks associated with this behavior.

The Good Grade Pill

36 Rules of Social Media

In the September 2012 Fast Company magazine, there was an illustration of 36 Rules of Social Media.  Let me pull out a few that caught my attention:

  • Everyone says they don’t want to be marketed to…Really, they just don’t want to be talked down to.
  • Always write back.
  • People would rather talk to “Comcast Melissa” than Comcast.
  • If fans distribute your content without your permission, offer to help.
  • If you don’t see financial results, you wasted your money.
  • People don’t want to shop where they socialize.
  • Don’t use ads to accelerate boring content.  Use ads to accelerate successful content.

But, I think the one that summarizes it the best is – If you’re bored by social media, it’s because you’re trying to get more value than you create.

Pew Slideshare On ePatients

I’m sticking with my theme this week of sharing presentations.  Here’s one from Pew on the Rise of the e-Patient.

Several Slideshare Decks From RockHealth

Have you looked at RockHealth at all.  They are a seed money accelerator for digital health startups.

I found a few of the their decks in Slideshare which I thought I would share.  They make some great slides.

Slideshare: Consumer Engagement And Evolving Technology

I thought I would share this presentation I found.

2 New Health Infographics

I found this list of data visualization winners and grabbed two to share here.  Although I like their first place winner on cancer, I found it to hard to read on the site.  These use bigger fonts and images with less detail which I personally think is important.

Chronic Kidney Disease (CKD) Action Plan Poster

I was at my physician’s office yesterday and noticed this great poster on the wall from the Renal Physicians Association (RPA).  I reached out to them and got a PDF of the poster – RPA Toolkit Action Poster FINAL.  (Note: It’s meant to be a poster on the wall not a graphic in a blog post so it’s here for you to go look at, but it’s not easy to read and digest here.  Use the link to get to the PDF.)

The key points are that it shows you stages of CKD based on GFR along with the action you should take.  It also highlights the risk factors for CKD and the possible complications.

Express Scripts Study: 89% Of Consumers Don’t Know How Adherent They Are

So much for self-reported data.  In the recent Drug Trend Report by Express Scripts, they mention a study they did looking at patient self-reported adherence and comparing it to actual adherence.  (I can’t believe no one had done this before.)  89% of the consumers incorrectly reported that they were taking the medication as prescribed.  For years, I’ve used two separate studies to point out that this gap had to exist, but it was not done on the same population. 

This is critical to any care manager or anyone else talking to the patient.  If you trust their perspective on adherence, you’re likely overestimating it.  In some cases, this might not be materials, but some of the gaps are significant.  Therefore, integrating pharmacy data to get to a true MPR (medication possession ratio) or PDC (percentage of days covered). Petition Regarding Pharmacists

Someone posted a link to this in LinkedIn.  For those of you in the pharmacy world, pharmacists, PBMs, and even medical professionals that work with them, this seems very relevant.  We all know the value that pharmacists bring to the over all care team.  With that in mind, I signed the petition and thought I would share it here.

(BTW – I’ll admit that I thought the Medicare legislation did recognize pharmacists.)


Recognize pharmacists as health care providers!!!


I just signed the following petition addressed to: Congress.

Recognize pharmacists as health care providers!!!

Despite overwhelming evidence of the positive impact pharmacists can have on patient health, pharmacists are not recognized as healthcare providers under the Social Security Act and, therefore, cannot be paid by Medicare for therapy management and patient consultation services. The Social Security Act does recognize other healthcare professionals such as dieticians, nurse practitioners, physician assistants, nurse midwives, and clinical social workers.

By changing the compensation structure allowed under Medicare, we can ensure that patients have access to the medication expertise of pharmacists. Studies have shown that when a pharmacist is directly involved in patient care, patients have fewer adverse drug reactions, experience improved outcomes, and healthcare costs are reduced.

The perils of adverse effects from taking multiple medications affect all age groups. According to a recent survey, just over half of all Americans take at least 2 medications each day and nearly one-third take 4 or more medications each day. For the Medicare population, medication use is even higher — nearly half of Americans aged 65 and older take at least 4 medications each day.

This is a critical safety issue!!


George Van Antwerp

FDA Approves Proteus “Digital Medicines”

The FDA recently approved the Proteus system for creating digital medicines.  What does this mean?  It means that in the future the pill you swallow could have a digital tracker that confirms that you really did take your medication.

This is a fascinating development especially as adherence continues to be a focus in quality metrics.  And, with the recent study by CVS Caremark, you now have two critical reasons that adherence should be a part of any health intervention program:

1. Adherence is proven in several conditions to directly lower overall medical costs; and

2. Adherence is shown to improve absenteeism.

BUT, does that justify a device in your pills.  Not alone, but if you look at the recent Express Scripts’ study (that was unfortunately buried in their drug trend report), you’ll see that there’s a material gap between how adherent patients think they are and their real adherence.  That might justify a device.

The big questions will be:

  1. What will the cost of the device be?
  2. How easy will it be to use?  (Right now, you’ll need patches and connectivity to a mobile device.)
  3. How easy will it be to manufacturer it into the pill?  (Right now, you take a second pill with the device.)
  4. Will integrated manufacturing change the pill or the production line requiring any capital investments by the manufacturer?
  5. How many drugs will this be cost justified by?
  6. Will we really want to be monitored that closely or will this seem too big brotherish?

This story (and others like it) will continue to come out.  It’s an interesting one.

When Is It Good To Pay 300% Profit For A Medication?

Another interesting discussion at this Oncology event was about physician reimbursement for drugs.  In Oncology, one historical source of revenue (~50%) for physicians has been the medications they dispense and administer in their offices.  And, depending on who you believe, this has some degree of influence on what drugs they dispense.

The problem that was discussed is that today’s reimbursement model is ASP (Average Selling Price) plus 6% mark-up.  This assumes that everyone buys at some price near that average which by definition means that not everyone does.  One of the presenters suggested that physicians lose money on about 20-25% of the drugs they dispense and that it would need to be ASP + 12% for them to be positive on every drug.  (I don’t know the math here and am simply sharing the dialogue as I found it very intriguing.)

The examples that they kept talking about in several presentations were that for a generic drug that costs $40 then their margin is theoretically $2.40 (6%) versus for a brand drug that’s $4,000 where their margin is $240 (or 6%).  The suggestion was that if generics were reimbursed at 200-400% of ASP then it would take this economic factor out of the oncologists influence (when conscious or subconscious). 

It’s an interesting debate.  (Here’s some comments from another conference on this topic.)

On the flipside, some of this may go away with oral oncolytics being more common in the future (and therefore being more likely to be controlled by the PBM) although companies will look to enable in-office dispensing of these drugs also to help the physician from losing this income. 

The other strategy being pushed has been called “brown bagging” where the patient is directed to obtain their medications from a specific specialty pharmacy and then bring those to the oncology practice for them to use.  This eliminates the “buy-and-bill” approach but is not something that the physicians like (from what I know). 

At the end of the day, I don’t really care.  I think there are several key principles that if met would make me neutral to any solution:

  1. Are decisions made in the patient’s best interest or do financial implications impact clinical decisions?
  2. Is the safety of the patient impacted in any way?
  3. Is the patient experience impacted negatively in any way?

What Would You Pay For A Week Of Life?

I was at an Oncology meeting earlier today, and there was a brief discussion about pharmaceutical costs which is certainly one factor in overall healthcare costs.  (See article on the 11 most expensive drugs ranging from $200-$410K / year)  Ultimately, this always brings you back (at some point) to the topic of Quality Adjusted Life Year (QALY) or (a new term to me) “futile care” meaning care done essentially with a very low probability of working. 

Of course, like the lottery, we all like to believe that we’ll be the 1% for which this effort pays off.  (see Prospect Theory or a broader article on use of incentives in healthcare).  This can often be a very cost effective way to get people excited.  This is especially true for poorer people who spend as much as 3% of their income on lotteries which have a very low return

But, the question at the center of this is what you would pay for a week of life?

  • $100
  • $1,000
  • $10,000
  • $50,000

And, would that answer change based on timing?  I believe so.  If asked today, when you were healthy, would you agree to spend $50,000 to gain one week of life?  Perhaps not.  When you’re on your death bed and realize that you still want to see a few more people, your answer may change.  And, your family’s answer might change.  If you had to make that decision for your parent, it might be tough to make at the hospital, but if you sat down with them when they were healthy and asked them whether they would like you to spend your kid’s college savings account on gaining them a week of life, the answer might change.

But, what about when the money’s not yours.  We all know the infamous diner’s dilemna where we’re likely to spend more money when your splitting the bill with everyone.  When you’re covered by insurance or by the government, it’s not always your money being spent.  So, what if it was positioned differently?  If you knew that spending $50,000 for that one week of life meant that there wouldn’t be money to fund a shelter for 3-months that provided 20 homeless families with a place to sleep.  Would that change your answer?

It’s a tough question.  No one like to put a financial value on life.  I don’t have an easy answer other than having the discussions earlier with the patient and framing them the right way. 

Never mind the question about quality of life…Would you rather die in 2 days at home or would you rather live 8 days in the hospital where your throwing up all the time?

I don’t know the economic tradeoff of these treatments or drugs so this isn’t specific to any scenario, but is a situation which come up and everyone runs away from.  I understand why.

Shifting Spend In Pharmaceutical Spending

Pharmaceutical manufacturers are dealing with massive shifts in their industry – less blockbuster drugs, more generics, emergence of different global markets, a greater payor emphasis on outcomes and adherence, less interaction with sales reps, more use of biologics, and the emerging biosimilar opportunity.

All of that is causing a massive shift in where they invest.  In some cases, you’re seeing manufacturers invest in devices (e.g., Sanofi diabetes device) or into education and content at a disease (not drug) level or even in mHealth (e.g., Boehringer and Healthrageous). 

With that in mind, I found this Booz & Company survey interesting in highlighting how their shift in spending is changing.

Infographic on Running

It’s been a few years now since my last marathon.  There’s just not enough time to put in the right training these days.  That being said, I’m finally getting back into running after taking some time off.  With that in mind, I thought this infographic was good.  It also reminded me to go back to my older post about running basics

Running Toward a Better You
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