Archive | January, 2013

Why We Need Whole Patient Adherence Programs

While prescription adherence continues to be a $290B+ problem, we still address the problem in a drug by drug approach due to silos within our healthcare value chain.

For example:

  • Generic drugs (about 80% of the prescriptions filled) are the lowest cost and most profitable drugs (to the suppliers).  For these medications, you’ll usually have several programs:
    • Refill reminder calls, text messages, letters
      • From the PBM
      • From the retail pharmacy
      • From the mail pharmacy
  • Auto-refill programs
  • Brand drugs are usually higher cost and profitable (to the manufacturers).  For these, you have pharma funded programs such as:
    • Messaging attached to your bill at the pharmacy
    • Letters sent to your house by the pharmacy
    • Specialty drugs which are the highest cost and typically profitable (across the supply chain).  For these, companies often take a higher touch approach:
      • Pharmacy techs calling you
      • Nurses calling you

Additionally, there is additional effort made to keep you adherent if:

  • You’re a Medicare Advantage member in one of the categories where adherence is measured for the STAR metrics program
  • You’re have a condition where adherence is a key metric for HEDIS or some other quality program

For those of us that have studied adherence, you know that this is a multi-factorial issue meaning that there are numerous things that impact your adherence.  Some people will respond to nudging.  Some people need to better understand their disease.  Some people need co-pay relief or patient assistance programs.  Some people need a different medication.

But, the two things we don’t need are:

  • Being treated like a disease not a patient
  • Getting 4, 5, 10 different communications from different parties on different schedules

So, what’s the answer.  There isn’t a silver bullet (which is what we’d all like).  I believe the best alternative is to drive adherence through the disease management and case management companies.  These nurses are treating the patient.  They are discussing their multiple co-morbidities with them.  They are talking about and understanding their barriers.  They should be able to help “prescribe” information and tools to help them with their adherence.

Of course, the issue here is engagement.  If we’re only getting 10% of the patients with chronic illnesses to participate in our programs (which is about the national average – I believe), what about the other 90%.  This is where a care coordination program that incorporated the provider and the pharmacy into a technology solution which pushed gaps-in-care and messaging through the EMR and pharmacy system to drive coordinated solutions is the answer.

I don’t know when this will happen, but I don’t believe we’re going to put a dent in adherence until we think differently about this problem.

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The Quest For The Stinkless Workout Shirt

Any workout can lead to a nice sweaty shirt that can stink, but when you’re traveling, that can be a real issue.  You can certainly bring multiple sets of workout clothes on your trip, but that’s not always efficient packing.  So, if you bring one outfit and workout multiple times, it can start to be problematic by the second, third, or fourth run in the same clothes.

Now, to make it even worse, you can travel to different cities where each day you run then pack up the sweaty clothes, lock them in your car all day, jump on a plane, and unroll them 12 hours later.  I’ve wondered for years why someone didn’t develop a bag with some basic chemical in there that you could put your clothes in where it would absorb the sweat and freshen the clothes.

Well…I may have found another answer.  I just bought one of the LuLuLemon Silverescent shirts which they said is anti-stink.  I was skeptical, but I’ve put it to the test.

  • No stink after running in it.
  • No stink after rolling it up (post-workout) and leaving it in a laundry basket for a week.
  • No stink after wearing it several times back-to-back.

Google Glass Plus The Checklist Manifesto

I continue to think about all the cool ways that Google Glass could be used to change healthcare.  Here’s my thought from today.

You could combine The Checklist Manifesto concept with Google Glass to allow surgeons to be reminded of the things they need to do with a patient while they were during the encounter or during the procedure.

In complex situations – such as those which arise in almost every profession and industry today – the solutions to problems are technical and demanding. There are often a variety of different ways to solve a problem. It’s all too easy to get so caught up dealing with all these complexities that the most obvious and common sense immediate solutions are not tried first. To overcome this problem, take a leaf from the commercial aviation industry and develop checklists people can use to make sure every base is covered quickly and concisely. Checklists are a forgotten or ignored business tool. It’s time for them to come in from the cold. 

“Here, then, is our situation at the start of the twenty-first century:We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And with it, they have accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That means we need a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our human inadequacies. And there is such a strategy – though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies. It is a checklist.”

(This is from this PDF on The Checklist Manifesto.)

Here’s an example of a checklist from the WHO.

 

PHM Is The New Black Post At CCA Blog With Diabetes Examples

This is a partial copy (teaser) of a guest blog I did on the Care Continuum Alliance blog earlier this week.

**********************

With all the talk about Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMHs), the adoption curve for the Care Continuum Alliance (CCA) model for Population Health Management (PHM) should move beyond the innovators in 2013 and begin to “Cross the Chasm.” I believe there are several preconditions that would set the stage for this to occur, for instance:

  1. Technology advances leading to the “Big Data” focus;
  2. The changing paradigm from fee-for-service to outcomes-based care;
  3. The realization of the role of the consumer led by the e-Patient movement, the idea of the Quantified Self, and the focus of large healthcare enterprises on being consumer centric; and
  4. The budget crisis that is driving employers and other payers to embrace PHM, wellness, and other initiatives that impact cost and productivity.

Of course, most companies are still in the infancy of designing systems to address this coordinated care model, which does not view the patient as a claim, but longitudinally aggregates demographical, psychosocial and claims data.  Additionally, training staff using Motivational Interviewing and integrating external staff into the virtual care team in partnership with the provider will continue to evolve as do our care delivery models.

To read more especially the diabetes examples that I shared, please click over to their blog.  Thanks.

 

Physician Information From The Patient’s Care Manager

Long gone are the days where a small practice can afford to have an onsite case manager.  Aggressive cost cutting, defensive medicine, and other pressures continue to pull at the budget for running a practice for most physicians.

At the same time, the value of a nurse or pharmacist to work with the patient to coordinate care, provide medication reconciliation, and answer clinical questions has been demonstrated in numerous settings.

Of course, most patients with chronic illnesses like diabetes or asthma or even cancer often have a disease manager or case manager provided to them by their employer through a population health management company or their health insurer.  So, if this work is being done, what should be done to coordinate this care with their PCP or their specialist?

I’ve never seen it done when which prompts several questions:

  1. What information a physician would want to receive?
  2. In what format?
  3. And, with what frequency?

Here are some of my ideas:

  1. A copy of the care plan that’s been created for the patient based on evidence-based guidelines.
  2. A list of any gaps-in-care that have been identified and discussed with the patient.
  3. Any assessment that has been made of the patient’s risk level along with information about how that assessment was made – i.e., claims based modeling versus nurse based assessment.
  4. Information about the patient’s Rx adherence and/or barriers to adherence.

But, what about things like:

  1. Benefit information.  Does the physician want to better understand any network limitations, Centers of Excellence, or other clinical pathways to be followed?
  2. mHealth.  Does the physician want to understand any apps that the patient is using and how that data is being incorporated into the care plan?

The more challenging question is how to deliver this information in a valuable format.

  1. Direct mail seems slow and difficult to manage.
  2. Faxing seems quick but an outdated modality.
  3. Secure e-mail could work, but I don’t think most physicians want to have multiple secure e-mail accounts to coordinate.
  4. A physician portal could be efficient, but probably only if there’s a concentration of patients at that office that use the same care management company.
  5. Integration into the EMR is probably ideal, but this is a challenge with all the different vendors out there.

The other question is frequency.  Should this data be provided after every interaction?  Should it be batched and provided weekly or monthly?

And, in the case of print materials, should the data be sent per patient or aggregated per physician?  It would seem overwhelming to get one letter with data on 20 patients, but on the other hand, having 20 letters would allow the information to be more easily filed per patient.

This type of coordination is critical as we move from a fee-for-service to an outcomes-based environment where care coordination is more important than ever.

Guest Post: Is It Too Late To Avoid The Flu?

By Paula Spencer Scott, Caring.com Senior Editor

The 2012-13 flu season is shaping up to be one of the worst in years. If you or your loved ones haven’t succumbed yet, these steps can help you stay healthy. And if someone does get sick, many of the same steps can prevent a wider spread of infection.

Get a flu shot. No, it’s not too late. This year’s shot only offers 62 percent effectiveness, according to Thomas Frieden, director of the Centers for Disease Control and Prevention. But it’s still considered the number-one prevention tool.

Give the flu shot time to kick in. It can take one to two weeks for a flu shot to offer protection (see: How Long Does It Take for a Flu Shot to Offer Protection? for more information on flu shot protection). So don’t expect instant immunity.

Keep vulnerable loved ones away from crowds. Given how widespread the flu already is, we’re all courting trouble by hanging out in crowded public places like shopping malls. But those who should especially keep away include the very young, the frail old, and those with health conditions that weaken the immune system or who are using treatments that can affect the immune system, such as.

Keep suspicious visitors away from vulnerable loved ones. If you live with someone with a chronic illness or who is a frail older adult, be a good gatekeeper. If a guest has a cough, a runny nose, or is complaining about being under the weather, don’t endure a visit. Invite him or her back at a better (healthier) time.

Stay home if you’re feeling under the weather. Best to avoid crowds, including the workplace, when your immune system is low. And in case your symptoms mean you’re coming down with something, you can avoid infecting others.

Wash hands often. Pretend you’re obsessive-compulsive and do it all day long. Be sure to wash hands (with soap and water or hand sanitizer) after touching doorknobs.

Become a clean freak. Stock up on cleaning supplies. You may use them more if you have them handy right in each bathroom and the kitchen. Wipe down surfaces often. Bring portable wipes to work so you can keep your keyboard and any shared spaces cleaner, too.

Try a face mask. It’s not clear they’re super-effective, but in a situation where some people are sick, they can provide an added barrier between a frail older adult and the flu.

Stay well hydrated. Keeping nasal passages moist helps them resist germs. Drinking lots of water and using nasal saline sprays helps — especially when flying, as aircraft cabin air is dry.

Get at-risk groups to the doctor at the earliest symptoms. Very young children and the very old should get swift treatment, says the CDC. Medicines such as Tamiflu work best within the first 48 hours.

About the Author

Paula Spencer Scott is senior editor at Caring.com, the leading online destination for caregivers seeking information and support as they care for aging parents, spouses, and other loved ones. Paula is a 2011 MetLife Foundation Journalists in Aging fellow and writes extensively about health and caregiving. You may also want to see Paula’s article 7 Ways to Have Fun While Fighting Cold and Flu.

CVS Caremark Adherence Study – Is Facebook The Solution To Adherence?

A new study funded by CVS Caremark as part of their ongoing research into medication adherence was recently published.

“Association Between Different Types of Social Support and Medication Adherence,” December 2012 issue of American Journal of Managed Care

In this, researchers reviewed 50 peer-reviewed articles about studies which directly measured the relationship between medication adherence and four categories of social support, including:

  • Structural support – marital status, living arrangements and size of the patient’s social network
  • Practical support – helping patients by paying for medications, picking up prescriptions, reading labels, filling pill boxes and providing transportation
  • Emotional support – providing encouragement and reassurance of worth, listening and providing spiritual support
  • Combination support – any combination of the three support structures detailed above

According to the study, greater practical support was more often linked to improved medication adherence, with 67 percent of the studies evaluating practical support finding a significant association between the support and medication adherence.

It drives some interesting questions as you dig into the actual research.  I sent several questions to Troyen A. Brennan, MD, MPH, who is the Executive Vice President and Chief Medical Officer of CVS Caremark, and heads the research initiative that conducted the study.  Here are his responses:

1. How will this research change CVS Caremark’s approach to medication adherence such as your Adherence to Care program? 

CVS Caremark’s Adherence to Care program is all about engaging patients more consistently and directly to ensure they are following their medication regimes. We understand that our patients’ social networks and communication preferences are diverse, and we know that multi-dimensional interventions help to change behaviors. Given these factors, this research can be an important reference point as we develop new approaches to our adherence programs, challenging us to look beyond traditional engagement strategies in an effort to most effectively support patients on their path to better health. We are planning to test some interventions along these lines in 2013.  As a pharmacy innovation company, we want to make sure we are anticipating patient needs and remaining relevant to them especially given the changing face of social communication and networks.  

2.  The data points required to assess these support factors aren’t readily available in the eligibility file or claims file.  Are you collecting that data at the POS or during the enrollment process and using it in any way to determine the correct intervention cadence or level of effort at an individual level?

While this may not be the standard today, it is clear from the research that a patient’s social network and resulting support can be important factors in helping them take their medications as directed. This research can help us and others in the industry think about how best to incorporate new approaches to identify and leverage social networks for greater medication adherence.  For now, we will rely on POS as a way to collect this type of information.

 

  • 3.  To me, it appeared the data was less conclusive than I would like.  There were lots of conflicting data points and qualitative data.  Do you plan to refine this testing within your population to look at differences across disease states and relative to other factors?

 

This study relied on a comprehensive analysis of current literature linking medication adherence to social support networks – so we recognize that there are limitations in being able to draw concrete conclusions on certain factors, such as disease-specific conditions. Regardless, we still believe these findings – which look at clinical, peer-reviewed studies – contribute to the knowledge base in our field. As with all of the research we conduct, we challenge our teams to consider how we might be able to use the information to find practical supports for patients, while at the same time contributing to awareness about the implications of adherence on the broader health care landscape. The best way to understand this research is as hypothesis generating, which we can use in the design of real interventions that we can then test definitively in subsequent studies.

4.        Some of these social factors might be correlated with depression.  Was there any screening done to look at how depression as a co-morbidity might have affected adherence rates?

The methodology of this study relied on literature review and analysis of fifty peer-reviewed research articles which directly measured the relationship between medication adherence and forms of social support. A full review of the medical conditions associated with these studies can be found in Appendix 1. While depression, alone, was not one of the conditions featured in these studies, several did look at mental health conditions and the linkage between adherence and social networks. We did not however stratify by existence of depression—it may be a factor we have to take into account in future studies.

5.   The one thing that I read between the lines was the need for a caregiver strategy.  This has been missing in the industry for years.  Does CVS Caremark have an approach to engaging the caregivers?

 

Our study found that practical support such as picking up prescriptions, reading labels and filling pill boxes – all within the realm of a given caregiver’s role – were the most significant in driving greater adherence. Considering this finding, and acknowledging the role caretakers have in the lives of our patients, there is certainly space for us to develop solutions that engage caretakers more effectively. Recent analyses of “buddy” programs do suggest such interventions do work- -we just need to consider how to scale it.

 

  • 6.        With all this talk about social networks, it naturally leads you to a discussion about Facebook (or Google+).  Neither of them have big focuses in the healthcare space.  In your opinion, will these tools offer an intervention approach for changing behavior around medication or will that be occur at the disease community level in tools like PatientsLikeMe or CureTogether where there’s no social bond but a connectivity around disease? 

 

 The role of social media has changed the way we communicate and connect with one another dramatically over the past decade. What we can say, based on this particular study, is that the more practical the support, the more significant the impact on medication adherence. Perhaps further studies looking into solutions that effectively combine online/social media platforms to complement practical support would help clarify their impact on medication adherence.

If interested, here are some of their other presentations on adherence:

New mHealth App – Interactive HRA – Recommendations – Zuum

In the Winter 2012 Innovate Magazine from Barnes-Jewish Hospital and Washington University Physicians, they talk about a new iPad app that they developed that calculates disease risk and offers a customized plan.

I just downloaded it and used it.  Here’s my quick summary:

  • Nice GUI (graphical user interface)
  • Easy to use HRA (health risk assessment)
  • Cool interactive tool (you can see how your risk for certain diseases changes with your changes in behavior)
  • Content seems to be well written with basic health literacy taken into account
  • Links out to more research and content
  • Messaging feature (which I guess will push me updates and other messages over time)

Overall, it seems like a nicer than normal HRA with the ability to interact with it.  My question would be how it integrates with my care team and how it gets used over time.  If this integrated into my other devices and monitored my data, it would seem more valuable than a standalone app, but I certainly think it’s great for a one-time use.

If you’re interested in downloading it, you can go to iTunes here.

Zuum 2 Zuum 1

3500 Calories To Lose A Pound – Myth?

Well, it’s not that straightforward (of course), but 3,500 calories does equal a pound of fat so it’s a good rule of thumb (in my non-clinical opinion).

So, to figure out when this does or doesn’t work, I looked at the this article in the Journal of Obesity which was very difficult to understand, but here’s a discussion on MyFitnessPal that discusses it in something closer to plain language.  You can also see this article in the NY Times about de-bunking this myth.

So, if it’s wrong, why use it as a rule of thumb?  IMHO  I believe it gives you some numbers to track just understand that it’s not a perfect correlation.  But, if you take in less calories than you burn and focus on creating a deficit, then you’ll be doing the right things – being active and watching what you eat.  Of course, you can go work with a Registered Dietician to help you actually understand and refine your plan to address the gap between this assumption and reality.

mythbusters

Catching Up: Interesting Articles

As part of my efforts to start the new year, I’m cleaning out my inbox with all items I’ve tagged as possible blog topics.  Here’s the first list of things that caught my attention, but never made it into a story.

17 Healthcare Blogs You Should Read

This is just a list of my favorites.  Feel free to add your own recommendations.  I broke them into 3 categories.

(BTW – I’m sure I missed a few of you so I’m sorry.)

1. Key Foundational Blogs To Follow

2. One’s I Read Frequently

3. Good Blogs That I Use For Certain Topics

I’ll also give a shout out to a new blog that has started that I have high hopes for based on their initial content – http://hoopayzblog.com/.

Favorite Health Infographics In Pinterest

While I’m sure I’ll still integrate some health infographics into my blog posts, I’ve decided to use a different tool for simply sharing the infographics that I like.  I built a Pinterest account and put 70+ infographics in there to get it started.  Most of those are ones that I’ve used before in the blog, but there are some new ones.  Enjoy.

http://pinterest.com/gvanantwerp/health-infographics/

Healthcare Infographics

 

Childhood Obesity Quiz On The Biggest Loser

This season, on The Biggest Loser, they’ve invited 3 kids to be ambassadors for childhood obesity. They aren’t living on the ranch, but they are coming out for some of the challenges. In last night’s show, they quizzed the contestants on several facts about childhood obesity. They were pretty scary. I thought I’d share them here with the research to support them (or at least as close to the questions as I can remember).

There are lots of efforts in this area. Here’s a few links to resources:

Childhood Obesity Epidemic Infographic
Brought to you by MAT@USC Masters in Teaching

Limiting Factor For Behavior Change is We Don’t Believe We Will Change

One of the biggest challenges in healthcare is getting people to change behavior or as Express Scripts would frame it – activating intent.  Since approximately 75% of healthcare costs are due to preventable conditions, it’s important that we can help people see the future value of change.  People often discount that future value of change based on the amount of effort required to get there.  They see the short-term pain not the long-term gain.

A new study puts an interesting perspective on this.  It shows that people can generally see the amount of change they’ve made in the past decade, but they fail to realize that change will continue for the next decade.  They appear to see themselves as stable at the current moment without significant change in the future.  I believe this is really important as we think about Motivational Interviewing techniques and communications for engaging consumers.

So, as you think about behavior change in healthcare for things like diabetes, you will likely continue to see more and more emphasis on behavior change and research in this area (see example from RWJF last year or Cigna whitepaper).

To learn more about this topic of behavior economics, you might look a few places:

And, here’s a good list of books to start with.

Saturday Evening Post On The Placebo Effect

Do you know what the Placebo Effect is?  There’s lot of information out there.  For example, here’s what WebMD says about it.  Here’s my definition of it.

In general, it’s when someone is told they are given a medication (or procedure) that will work but instead are given a sugar pill or otherwise “deceived” into believing they’ve gotten the prescribed treatment.  It is often used in clinical trials for drugs to establish the baseline of side effects.  The amazing part is that it shows the power of the mind to influence our healing ability.  

Below is a video that I’ve used a few times before.  It’s also been a concept I’ve built on in a few other posts – New To Therapy, Price And Placebo Effect, Guest Post on the Topic.

The amazing thing that captured my attention a few months ago is that this can work not only for medication but also for surgery.  (Maybe this is the key to saving money in the US healthcare system.)  This was tested in the case of knee surgery in a trial that was published several years ago.  This article also points out another trial on patients with Parkinson’s.  The reality appears to be that this is happening in trials but also in real life according to an article in American Medical News (see quote below).

Nearly half of physicians use placebos in clinical care, and only 4% tell their patients the truth about it, according to a survey of Chicago academic physicians that was published this month in the Journal of General Internal Medicine.

This begs all types of questions about who will respond to placebos and when or if it’s ok to use them with patients.

The Saturday Evening Post just published an article on this topic.  They touch on a few of the same studies I’ve looked at, but they also point out several new things that I put below – conditioned response and ritual.  They also share a video on the placebo effect.

Conditioned responses are a third way the placebo response works. In one elegant experiment demonstrating this phenomenon, scientists showed 40 volunteers two male faces on a computer screen for 0.1 second. When the volunteers looked at one face, they got a mild burn on their forearm; when they looked at the other, they got a more painful burn. The volunteers became as conditioned as Pavlov’s dogs. In the next round when they saw the high-pain face and felt a burn, they rated it as more painful than when they saw the low-pain face and felt a burn—even though the applied heat was identical the second time around.

The perception of pain, says Ted Kaptchuk of Harvard Medical School, who helped lead the 2012 study, depends on “what the nonconscious mind anticipates despite any conscious thoughts.”

The placebo effect doesn’t even depend on deception. It can kick in even when people are told they are receiving an inactive drug. For instance, in a 2010 study led by Harvard’s Kaptchuk, scientists recruited 80 people with irritable bowel syndrome, or IBS, and gave half no treatment and half what they were told were “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body, self-healing processes.” It was full disclosure. Even without the deception, the placebo-takers’ IBS symptoms improved over the course of three weeks. That response suggests another avenue for the placebo response: ritual.

The author (Sharon Begley) asks the key question which is how does this placebo effect play out in the 21st century.  With all this technology that we have and the physician shortage, is there a greater opportunity here?  Can we tap into this in a positive way?  She also points out how doctors are using other techniques such as relaxation therapy to address the power of the mind.

Consume Cocoa Like The Kuna (aka Chocolate is Good For You)

For years, we’ve all heard pieces of information about cocoa being good for us.  Here’s a few articles about that:

And from Cleveland Clinic, here’s a key point about selecting your chocolate:

your best choices are likely dark chocolate over milk chocolate (especially milk chocolate that is loaded with other fats and sugars) and cocoa powder that has not undergone Dutch processing (cocoa that is treated with an alkali to neutralize its natural acidity).

It appears in a recent meta-analysis that the data generally supports this fact although some longer terms studies are needed.  One of the most interesting things mentioned in both of the hyperlinked studies above are the Kuna.

The Kuna, an indigenous group of approximately 50,000 people who live predominantly on small islands off the coast of Panama, are virtually free of hypertension and cardiovascular disease. Kuna who migrate to nearby Panama City, however, lose this advantage, a loss that cannot be attributed to changes in salt intake (1) or stress (2). The Kuna who live on the Caribbean archipelago, however, consume a striking amount of natural cocoa drinks, whereas those who migrate to the mainland do not (1).

I also got an e-mail from a PR firm about the meta-analysis saying the following:

Recent research published in The Journal of Agricultural and Food Chemistry found that a mug of hot cocoa had nearly twice the antioxidants as a glass of red wine and up to three times the antioxidants as a cup of green tea. Compared to black tea, cocoa had up to five times the concentration of antioxidants.
 
“The results of this Cornell University study corroborate earlier research showing the extensive health benefits of cocoa,” says Harvard nutritionist and epidemiologist Eric Ding, Ph.D. Dr. Ding was lead researcher of a landmark Journal of Nutrition meta-analysis on cocoa’s multiple benefits for cardiovascular and metabolic health. The study incorporated 24 papers with 1106 participants.
 
“Cocoa flavonoids are protective against heart disease,” says Dr. Ding. “We’ve found that they lower blood pressure, lower bad LDL, raise good HDL, improve insulin sensitivity, and improve blood flow and, in a long term study, lower the risk of heart disease.” Journal of Nutrition meta-analysis on cocoa’s multiple benefits for cardiovascular and metabolic health. The study incorporated 24 papers with 1106 participants.
 
“Cocoa flavonoids are protective against heart disease,” says Dr. Ding. “We’ve found that they lower blood pressure, lower bad LDL, raise good HDL, improve insulin sensitivity, and improve blood flow and, in a long term study, lower the risk of heart disease.”
So, don’t feel bad about enjoying chocolate.  Not only is it good for your mood, but it can be good for your health (if you pick the right kinds).  But, this shouldn’t be an excuse for binging on it since it’s also high in fat.

Guest Post: How Nursing Can Help Reduce Healthcare Costs

Yes, the election has come and gone. No doubt we’re still suffering from the latent effects of election-fatigue, buzzwords still echoing in our heads like bad nightmares; stimulus packages, fiscal cliffs, economic malaise, and the ever-popular budget cuts. But the super-sensitive topic at the crux of our current political polarization is undoubtedly, one of healthcare. It’s hard not to get caught up in all the political hoopla in regards to current policies versus proposed plans and how we seem unable to find that magic bullet to rescue us from this healthcare maelstrom instead of dooming us further into the partisan abyss.

It has been estimated that between 2012-2022, Medicare spending will skyrocket through the current $550 billion to the astronomical tune of $1.064 trillion (that’s trillion with a ‘T’). Medicaid will likely double from $253 billion to $592 billion. Additional costs created by expenditures and subsidies for mandatory healthcare will rise from $25 billion to $181 billion. Where will all this money come from?

To counter rising healthcare costs, the burden will be shouldered by all Americans. But don’t start crying that the sky is falling just yet; there is a remedy that would not only benefit our healthcare needs and reduce costs, but also maintain that all-important mark of quality. How? Let’s take a look at how nursing can be the ultimate solution to remedy our economic woes as well help improve our overall good health.

  • Nurse Practitioner: One of the fastest rising fields of healthcare, Nurse Practitioners (NPs) can receive their training and certification four-five times quicker than a physician. The costs of educating an NP is far less than the cost of putting a medical student through medical school and with quicker training that means seeing more patients earlier and subsequently shorter waiting lines and getting in and out of the doctor’s office and on your way to better health in a much more efficient manner. Nearly 96% of all Nurse Practitioners can write prescriptions and according to healthcare studies, patients ranked them as high as they would their primary doctor.
  • Traveling Nurses: If you can earn your nursing degree, than a host of numerous healthcare opportunities will arise for you. Among them are temporary jobs with flexible schedules, some such assignments include nursing jobs all over our country as well as overseas. Here in the states such a program is called, “Nurse-Family Partnership”. This provides a visiting nurse to make house calls for lower income families that might not have the opportunity otherwise to have high quality healthcare provided for them.
  • Silver Boom: In the next twenty years, the elderly population will not only increase due to aging baby boomers but because of better diagnoses and preventative care, we are ALL living longer and more productive lives. According to the Center for Healthcare Workforce Studies*, by the year 2050 the number of older adults will increase from 12.5% to 20% of the United States population (this is among the population of those 65 years and older).

At the end of the day, healthcare will continue to grow as our population follows along this similar trend. Having nurses filling in those costly gaps will pay off down the road with better care, quicker appointment availability and lower overall costs. And in a climate of ever-changing political landscapes, to have one sector not only reducing costs but composed of those continually seeking higher quality standards would be hard to argue against.

*”The Impact of the Aging Population in the Healthcare Workforce in the United States Summary of Key Findings” – Center for Healthcare Workforce Studies, School of Public Healthy, University at Albany.

Kathryn Norcutt has been an active member of the health care community for over 20 years. During her time as a nurse, she has helped people from all walks of life and ages. Now, Kathryn leads a much less hectic life and devotes most of her free time to writing for RNnetwork, a site specializing in travel nursing jobs.

How Farmers Outmarketed Pharma

When you think of potatoes, where do you want them to come from? Idaho

When you think of citrus, where do you want it to come from? Florida

When you think of US wine, where do you want it to come from? Napa Valley

When you think of generic drugs, where do you want them to come from? [company?, geography?]

This vacuum is a big problem in terms of commoditization. People don’t think of Teva or Ranbaxy or some other generic company. The average consumer probably doesn’t know who they are. And, they’ve competed based on price for years. If I was the CEO of Teva, this would be the number one challenge I would pose to my staff which was how do I get consumers to ask for my generic version of the drug. The next question should be what would we do to justify this?

For the first time, I think that they have a similar problem that brand pharma does which is how to create an offering not just a pill. The quote below from the CEO of Novartis, tees it up well.

“I also started to shift our business away from a transactional model that was focused on physically selling the drugs to delivering an outcome-based approach to add value beyond just the pill. I really believe that in the future, companies like Novartis are going to be paid on patient outcomes as opposed to selling the pill.”

And, I think this reflects what Sanofi has been experimenting with in terms of diabetes for several years. They launched their iBG Star Blood Glucose Meter to get into the meter space. Sanofi also has heavily invested in social media to give them direct engagement and feedback from consumers. Both of these begin to create more consumer branding for them as an entity.

I’ve talked about this several times over the years based on a book that one of the E&Y partners wrote when I was there called BLUR which was about blending products and services to create offerings. I think this notion combined with the lessons learned that commodities like potatoes have gone through in branding their products offer some insights into what pharma has to do to shift their positioning in the value chain. This is part of what I’ll be discussing at the upcoming PBMI conference where this shift to outcomes based contracting and focus for the industry is critical to long-term survival and differentiation.

Guest Post: I’m Ready To Lose Weight!

Guest Blogger Lynn Gieger is a contributor to Everyday Health and its calorie counter and fitness tools.
The signs were all there, but until the doctor commented, “You’re overweight and your weight is negatively impacting your health,” it was no longer easy or healthy to ignore the too-tight belt, too-small jeans, and the steering wheel poking into the stomach.

Now what are you going to do about it?

Ignore the hype of the hundreds of weight loss programs that promise effortless weight loss. If it was that easy, you wouldn’t be in this shape right now, would you?

To truly take charge of your weight and health, start by giving yourself some time to think about why weight loss is important to you. What will be different in your life when you lose weight? Look at the health implications: decreased cholesterol, lower blood pressure, reduced risk of type 2 diabetes, less pressure on your knees and hips. Also think about personal reasons why weight loss is important to you: do you want to get on the floor and play with your grandchildren, go hiking with your kids, dancing with your spouse, or just look smashing? List all of the reasons how losing weight will improve your life to increase your motivation to make changes.

The National Weight Control Registry, established in 1994, tracks over 10,000 people who lost an average of 66 pounds and kept it off for 5.5 years. The NWCR research identifies 3 key steps to lose weight and keep it off:

1. Keep a journal detailing what, when and how much you eat. 78% of the NWCR participants report eating breakfast every day, and the majority decreased both calorie and fat intake to lose unwanted pounds. Use your journal to identify specific places to make changes, such as using lower fat salad dressing, choosing water instead of a high-calorie sweetened beverage, and swapping fruit for chips at snack time. Need help figuring out where to make changes? Find a weight management specialist with the knowledge and skills to streamline your food choices and encourage you to make lasting changes in your eating habits.

2. Keep track of daily exercise. 90% of NWCR participants exercise for an average of one hour each day. Create a habit of daily exercise to burn calories and improve your fitness – plus give you something else to do besides eat. Find a certified fitness expert to get you started or ask at your local gym.

3. Decrease the number of hours of non-work screen time (TV, video games, movies, computer). NWCR recommends less than 10 hours of screen time per week. If Sunday at your house means 6 hours of TV football, change your weekly screen-time habits and guess what – you just found time for exercise!

If you’re stuck and can’t figure out how to get started losing weight, work with a certified wellness coach to help you set realistic goals and hold you accountable.

Avoid a weight loss/gain rollercoaster by clearly identifying why weight loss is important to you and focus on the long-term. It doesn’t matter if it takes you 6 months or 6 years to reach your weight goal: the key is changing your habits so you stay at a healthy weight.

And the next time you see the doctor, think of this comment, “Wow, you’re looking great!”

How To Improve Good Cholesterol (HDL) If Drugs Don’t Work

The Wall Street Journal on 1/8/13 had an article called “New Rules for Boosting Good Cholesterol” which shared the results of a recent study on medications that improve HDL (or Good Cholesterol).

“Not all HDL are created the same” was what Roger Newton, chief science officer of Esperion said.

“If you raise HDL in non-pharmacologic ways, it really does help you” says Steve Kopecky, a Mayo Clinic cardiologist.

The points made in the article can be summarized in the following:

  • Improving good cholesterol is important.
  • People with high HDL face fewer heart attacks (according to the Framingham Risk Score)
  • Multiple trials to improve HDL with drugs have failed
  • People may need to raise good cholesterol by behavior change

This should lead to 3 questions:

  1. What should be my HDL or Good Cholesterol? From the Mayo Clinic on Good Cholesterol:

  1. What can I do to improve my Good Cholesterol without drugs? From the WSJ article:

Activity

HDL Increase

Exercise

4 mg/dL

Drink Alcohol (in Moderation)

2-4 mg/dL

Quit Smoking

5 mg/dL

Lose Weight

1 mg/dL per 3-6 lbs

Eat Fish And Olive Oil

3-5 mg/dL

Avoid Carbohydrates

8 mg/dL

  1. What are my risks and the value of medications? For that, I found two online risk tools.

Here’s a simple one that uses the Farmingham study to estimate your risk of having a heart attack.

Here’s another one from over in Europe that’s focused on the value of statins and hosted by the Cleveland Clinic. It takes more inputs but then gives you several outputs. (A nice algorithm to integrate with something like iBlueButton or your care management system perhaps to warn you of risks without having you input a bunch of data.)

FitBit Review Summary – Device, Apps, And Suggestions

In the spirit of the Quantified Self movement and in order to better understand how mHealth tools like FitBit can drive behavior change, I’ve been using a FitBit One for about 6 weeks now. I’ve posted some notes along the way, but I thought I’d do a wrap up post here. Here’s the old posts.

Those were focused mostly on the device itself. Now I’ve had some time to play with the mobile app. Let me provide some comments there.  And, with the data showing a jump in buyers this year, I expect this will be a hot topic at the Consumer Electronics Show this week.

  • The user interface is simple to use. (see a few screenshots below)

  • I feel like it works in terms of helping me learn about my food habits. (Which I guess shouldn’t be surprising since research shows that having a food diary works and another recent study showed that a tool worked better than a paper diary.) For example, I learned several things:
    1. I drink way too little water.
    2. I eat almost 65% of my calories by the end of lunch.
    3. Some foods that I thought were okay have too many calories.
  • In general, the tracking for my steps makes me motivated to try to walk further on days that I’m not doing good.
  • The ease of use and simple device has helped me change behavior.  For example, when I went to go to dinner tonight, I quickly looked up my total calories and saw that I had 600 calories left.  Here’s what I ate for dinner.  (It works!)

Meal

But, on the flipside, I think there are some simple improvement options:

  1. I eat a fairly similar breakfast everyday which is either cereal with 2% milk and orange juice or chocolate milk (if after a workout). [In case you don’t know, chocolate milk is great for your recovery.] Rather than have to enter each item, FitBit could analyze your behavior and recommend a “breakfast bundle”. (and yes, I know I could create it myself)
  2. Some days, I don’t enter everything I eat. When I get my end of week report, it shows me all the calories burned versus the calories taken in. That shows a huge deficit which isn’t true. I think they should do two things:
    1. Add some type of daily validation when you fall below some typical caloric intake. (Did you enter all your food yesterday, it seemed low?)
    2. Then create some average daily intake to allow you to have a semi-relevant weekly summary.
  3. The same can be true for days that you forget to carry your device or even allowing for notes on days (i.e., was sick in bed). This would provide a more accurate long-term record for analysis.
  4. The food search engine seems to offer some improvement opportunities. For example, one day I ate a Dunkin Donuts donut, but it had most types but not the one I ate. I don’t understand that since there’s only about 15 donuts. But, perhaps it’s a search engine or Natural Language Processing (NLP) issue. (I guess it could be user error, but in this case, I don’t think so.)
  5. Finally, as I think about mHealth in general, I think it would be really important to see how these devices and this data is integrated with a care management system.  I should be able to “opt-in” my case manager to get these reports and/or the data.

The other opportunity that I think exists is better promotion of some things you don’t learn without searching the FitBit site:

  • They’re connected with lots of other apps.  Which ones should I use?  Can’t it see which other ones I have on my phone and point this out?  How would they help me?
  • There’s a premium version with interesting analysis.  Why don’t they push these to me?

I also think that they would want an upsell path as they rollout new things like the new Flex wristband revealed at CES.

And, with the discussions around whether physicians will “prescribe” apps, it’s going to be important for them to be part of these discussions although this survey from Philips showed that patients continue to increasingly rely on these apps and Dr. Google.

Philips_Health_Infographic_12%2012_F3

Finally, before I close, all of this makes me think about an interesting dialogue recently on Twitter about Quantified Self.

Court Decision Allows Pharma Reps To Discuss Off-Label Uses Of Prescriptions

I must admit that I’ve heard very little about this decision from the Federal Appeals Court for the Second Circuit of Manhattan that decided that discussing off-label uses for prescription drugs was an issue of free speech. This could change the way pharmaceutical manufacturers interact with physicians. It could change the job of the pharmaceutical rep. It could change how clinical trials are done. It could change how prescriptions are used. It could also lead to a whole new set of prior authorizations by companies that actually have to actively manage off-label usage as it becomes widespread.

On the other hand, I wonder if this door hadn’t already been opened. Have you looked at some of the peer-to-peer (P2P) healthcare websites out there or the disease based communities (e.g., PatientLikeMe or CureTogether)? Patients are already talking about what medications they are using to treat their diseases and their symptoms. Don’t you think those are leading to requests to the provider and discussions with them about off-label utilization?

And, I’m sure that Dr. Google has helped many patients identify other uses of medications. This process (to the best of my knowledge) is completely un-managed. It’s a popular enough topic that Consumer Reports talked about it earlier this year and even put together the following table on drugs commonly used off-label.

Specific drug, type of drug Examples of off-label use**
Aripiprazole (Abilify), antipsychotic Dementia, Alzheimer’s disease
Tiagabine (Gabitril), antiseizure Depression
Gabapentin (Neurontin), antiseizure Nerve pain caused by diabetes, migraines, hot flashes
Topiramate (Topamax), antiseizure, in combination with phenteramine for weight loss Bipolar disorder, depression, nerve pain, alcohol dependence, eating disorders
Risperidone (Risperdal), antipsychotic Alzheimer’s disease, dementia, eating disorders, post-traumatic stress disorder
Trazodone (Desyrel), antidepressant Insomnia, anxiety, bipolar disorder
Propranolol (Inderal), high blood pressure, heart disease Stage fright
Sildenafil (Viagra), erectile dysfunction To enhance sexual performance in people not diagnosed with erectile dysfunction, to improve sexual function in women taking certain antidepressants
Quetiapine (Seroquel), antipsychotic Dementia, Alzheimer’s disease, obsessive-compulsive disorder, anxiety, post-traumatic stress disorder
SSRI antidepressants such as paroxetine (Paxil) and sertraline (Zoloft) Premature ejaculation, hot flashes, tinnitus (ringing in the ears)
Prazosin (Minipress), high blood pressure Post-traumatic stress disorder
Amitriptyline (Elavil), antidepressant Fibromyalgia, migraines, eating disorders, pain after shingles infection
Bevacizumab (Avastin), certain types of cancer Wet age-related macular degeneration (eye disease)
Statins such as atorvastatin (Lipitor), simvastatin (Zocor), high cholesterol in adults, children with an inherited cholesterol condition Rheumatoid arthritis, to lower cholesterol in children who lack the inherited condition
Clonidine (Catapres), high blood pressure Smoking cessation, hot flashes, attention deficit/hyperactivity disorder (ADHD), Tourette’s syndrome, restless legs syndrome

* Not meant to be a comprehensive list. Many of the drugs listed here are also available as generics.

** Does not imply that use is clinically appropriate or inappropriate, or beneficial or not.

***To find out if a drug’s off-label use is supported by evidence, click on the medication name.

 

I would imagine that pharma is going to tip-toe through this open door not simply crash through it. They’re generally risk adverse so their discussions of off-label utilization will be fact-based (to limit exposure) even if (as we all know) statistics can lie. I would suspect (as I’ve seen on other blogs) that this will ultimately go to the Supreme Court before anyone really takes advantage of it.

I guess I’d also point to the issue that physicians have responsibility here. They prescribe off-label today. Here’s what the FDA says about this:

Good medical practice and the best interests of the patient require that physicians use legally available drugs, biologics and devices according to their best knowledge and judgement. If physicians use a product for an indication not in the approved labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain records of the product’s use and effects. Use of a marketed product in this manner when the intent is the “practice of medicine” does not require the submission of an Investigational New Drug Application (IND), Investigational Device Exemption (IDE) or review by an Institutional Review Board (IRB). However, the institution at which the product will be used may, under its own authority, require IRB review or other institutional oversight.

One way to begin to manage this would be to require the use of diagnosis codes (Dx) on all prescriptions. This would at least great a way of tracking how the medications are being used and allow for better technology oversight across the provider, payer, pharmacy, and PBM.

In the interim, Consumer Reports suggest consumers do the following:

  • When your doctor prescribes a drug, ask if it’s an approved use. If he or she doesn’t know, ask your pharmacist.
  • Check for yourself. Go to DailyMed (dailymed.nlm.nih.gov/) and search for the drug. Then click on the tab for “Indications & Usage” to see if your condition is listed.
  • If it’s an off-label use, ask your doctor if it’s supported by well-designed trials showing significant improvement for people with your condition.
  • Ask your doctor why he or she thinks the drug will work better than approved drugs for your illness.
  • Find out if your health insurer covers payment for the off-label use. Some may require evidence of effectiveness or failure with conventional treatments, especially if the drug is expensive.

Fortune Article Questions Generic Equivalency Of Drugs

A new Fortune article “Are Generics Really the Same as Branded Drugs?” (1/14/13) sets a dangerous tone for something that has become a standard across the pharmaceutical industry.  This is either:

(a) giving consumer credibility to a long-standing rumor with a case study or

(b) a dangerous perspective which will only further activate the conspiracy theory consumers and clinicians.

Let’s start with a few basics from the Generic Pharmaceutical Association:

  • There are over 4B prescriptions filled in the US per year.
  • Of those, over 80% are generic medications.
  • Generic medications saved over $190B last year.

For facts on generics, I would point you to the FDA website.  I posted some of their slides years ago on SlideShare which I put below along with their latest infographic.

The article in Fortune focuses on a case regarding an anti-depressant called Wellbutrin and its generic counterpart.  The article goes on to point out that the active ingredients in the generic (compared to the brand) can vary from 80% to 125%.  (I think a good more detailed explanation of this is available here).

But, the author goes on to point out the risks associated with the fillers (or inactive ingredients) and talks about the issue of NTI (Narrow Therapeutic Index) drugs that no one substitutes for anyways.

One big thing that I was always taught was to understand that the difference in active ingredients between brands and generics was similar to the differences in different lots of the same brand drug.  And, given the fact that traditionally, 50% of generic drugs were made by the brand manufacturers, it would seem difficult to believe that they were simply throwing caution to the wind by producing substandard product.

I would hope that Express Scripts, CVS Caremark, Walgreens, PCMA, and many other groups will come out strongly to address this article. This is the type of article that could be a significant setback to the generic industry which has proven itself under lots of scrutiny over the years to save money and have very few negative impacts with the FDA’s scrutiny.

ucm305899

Glaucoma On The Rise – Infographic For Glaucoma Awareness Month – NIH

I received this from the National Eye Institute of the National Institutes of Health (NIH) along with an infographic which I thought I would post.

I also like the fact that it gives you a few parameters to identify your risk level for this often undiagnosed disease:

  • Over the age of 60
  • People with a family history of glaucoma
  • African Americans over the age of 40

And, you may be able to get a discount as part of Medicare.

*****Press Release******

It’s the first month of the new year, a time when more than 40 percent of American adults make one or more resolutions. What are your resolutions for the new year? Losing weight? Quitting smoking? How about learning more about glaucoma and how you can protect
your sight?

Glaucoma is a group of diseases that can damage the optic nerve of the eye and lead to vision loss and blindness. Primary open-angle glaucoma is the most common form. In this condition, fluid builds up in the front chamber of the eye, and the optic nerve is damaged by the resulting increase in eye pressure. This potentially blinding eye disease currently affects 2.7 million people nationwide, and studies show that at least half of all people with glaucoma do not know they have it.

“While anyone can develop glaucoma, we encourage people at higher risk to get a comprehensive dilated eye exam every one to two years,” said director Dr. Paul Sieving of the National Eye Institute (NEI) of the National Institutes of Health. “Individuals at higher risk include African Americans age 40 and over; everyone over the age of 60, especially Mexican Americans; and people with a family history of glaucoma.”

The prevalence of glaucoma is projected to reach 4.2 million by the year 2030 and 6.3 million by 2050. Last year, NEI invested $71 million on a wide range of studies to understand causes and potential areas of treatment for glaucoma.

“Primary open-angle glaucoma often has no early warning signs,” said Dr. James Tsai, chair of the Glaucoma Subcommittee for the NEI National Eye Health Education Program. “Often, a person will not experience any noticeable vision loss in the early stages of glaucoma. But as the disease progresses, a person may notice his or her side vision decreasing. If the disease is left untreated, the field of vision narrows and blindness may result.”

Glaucoma can be detected in its early stages through a comprehensive dilated eye exam. During this exam, drops are placed in your eyes to dilate, or widen, the pupils. This allows your eye care professional to examine the optic nerve for signs of glaucoma and other vision problems. An eye pressure test alone is not enough to detect glaucoma. “It’s very important that people don’t wait until they notice a problem with their vision to have an eye exam,” adds Dr. Tsai.

If you have Medicare and are African American age 50 or older, are Hispanic/Latino age 65 or older, have diabetes, or have a family history of glaucoma, you may be eligible for a low-cost, comprehensive dilated eye exam through the glaucoma benefit. Call 1–800–MEDICARE or visit http://www.medicare.gov for more information. To learn about other possible financial assistance for eye care, visit http://www.nei.nih.gov/health/financialaid.asp.

“It’s a new year,” said Dr. Sieving. “Make and keep a resolution to maintain healthy vision. Contact your local eye care professional and make an appointment for a dilated eye exam today.”

For more information about glaucoma, visit http://www.nei.nih.gov/glaucoma or call NEI at 301–496–5248.

20130105-133529.jpg

Which Health Apps Show Up On Most Top App Lists?

At this time of year, you’ll see lots of “top apps” lists.  MobiHealth put together a list of the top 80 apps, but I also wanted to look across a variety of lists and see if there were any common apps mentioned. 

We’re still early in this mHealth world, but it is a key topic which will change how physicians interact with their patients as one MD talks about on Kevin MD’s blog

After looking at a recent CNN Money Magazine article called “Tap Here for Better Health”, I also looked at the following lists:

Obviously, each of these writers had different criteria, but there were 8 applications that appeared more than once across these lists:

  1. Lose It
  2. Fooducate
  3. Runkeeper
  4. ZocDoc
  5. Cardiio
  6. Sleep Cycle
  7. Endomondo
  8. My Fitness Pal

If interested, you can also see the list of most helpful apps from the Modern Healthcare survey that Jane Sarasohn-Kahn highlights in her blog.  Most of those seem less “sexy” than the typical lists that you see.

 

Most-important-mobile-apps-Mod-HC-Dec-12-300x225

The apps that show up on these lists have changed over the past few years although Endomondo appears on this 2010 list and on several of these recent lists.

Are Females More Or Less Adherent? Big Data Question

FICO adherence image

Certainly, the push around Big Data should drive more companies to look into predictive algorithms.  You already have Fair Issac (above), ScreenRx by Express Scripts, and RxAnte.

I’d always been under the impression that women were less adherent than men to prescription drugs.  I’d heard several very logical reasons:

  1. As the caregiver, they often took care of their children, spouse, and/or other people first before being adherent themselves.
  2. They took more medications on average which is highly correlated with non-adherence.

But, some researchers recently told me that their data showed women to be more adherent.  And, I then noticed that the infographic that Express Scripts put together showed something similar.  (see zoomed in picture)

Express Scripts Adherence Infographic Zoom

So which is it?  I can find lots of research online to support females being less adherent.  Here’s a few links:

BTW…If you want to see a good presentation on some adherence data from CVS Caremark from a few years ago, you can follow this link to a presentation that was given.  Here’s a more recent one from URAC.

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