Archive | September, 2013

The Connected Pharmacy of 2020

At the conference last week, I was talking about the opportunity for retail pharmacy to play a broader role as the patient’s medical home.  As part of that discussion, I tried to create a vision of a digitally connected location.  Here’s my summary of that…

Imagine that the pill bottle you use is now a smart object (expanding on the RxVitality concept).  It now knows when you are running low on pills.  Since it’s connected to your WiFi signal and to your smart phone, as soon as you’re low, it does the following:

  • Send a new refill request to the pharmacy (or to your physician if you’re out of refills)
  • Puts a reminder in your phone for you to pick up the prescription (action item list, calendar) and updates that once it gets confirmation on time from the pharmacy

As you’re driving by the pharmacy, your smart phone reminds you to pick up the Rx as it knows where you are based on GPS.

When you enter the pharmacy, it has a system to capture information from your devices or phone about your sleeping habits, what you’ve been eating, and your exercise.  All of this information is important for them to actively manage your health.  Additionally, as you enter the pharmacy, they use a technology like FaceDeals to recognize you and do several things:

  • Alert the pharmacy that you’re in the store so they can pull your prescription
  • Pull up your CRM (customer relationship management) profile so they pharmacist and tech can great you by name and link back to other information (i.e., Hi George.  Are you here to pick up your prescription?  By the way, how did those crutches work out?)
  • Offer you a coupon on some new OTCs or medical supplies based on your chronic disease(s)

While you’re shopping (at a grocery or big box pharmacy), you’re linking your smart phone to the smart cart which is helping you navigate the store.  As it confirms your identify via fingerprint or facial recognition, it opens up a link to your medical data.  This allows the cart to help you navigate the store and scans everything you put into the cart to look for drug-food interactions (e.g., grapefruit juice).  It also helps to steer you to better food options (eat this not that) based on your diagnoses (i.e., for a diabetic, I would suggest this other cereal).  All of this is happening on your screen to protect your privacy.

By the time you get to the pharmacy, you stand in front of the register which has a scale embedded in the floor so they can instantly know your weight and compare that to your last measurement.  Since they are now tied into your medical data, the Point of Sale technology also gets relevant alerts that they can talk with you about (e.g., Did you know that your health coverage has changed?  Did you know that you have access to a health coach to discuss your condition?).

As you leave, all of the data they collected is integrated and pushed out to both your personal health record (PHR) along with the electronic medical record (EHR) that your physician uses.  Any new risks identified are also shared with your caregiver or others in your social circle that you’ve identified and opted-in to receive information.  This social connectivity helps to create the village necessary to drive change.

Scary or fascinating?  I prefer to think about this as a fascinating way of leveraging technology and data to make my experience better and improve my outcomes, but I know not everyone will feel that way.

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I Thought I Got To Keep My Doctor In Health Reform

We all remember when President Obama pointed out that you wouldn’t have to change your doctor with health reform.  That’s probably true in the most expensive plans, but you can’t always eat your cake and keep it too.

We know healthcare prices vary from semi-rational to outrageous.  It would be hard to get any concessions if every physician had to be in the network.  So, like we’ve seen in pharmacy with some initial screaming but general acceptance, plans are going to reduce the size of their networks in return for some price concessions.

Should this be a surprise?  No…unless you actually believe politicians.

Will this lead to a different set of issues around monitoring out of network use?  Yes.  This is something plans historically don’t do very well.

What Will Really Happen October 1st For Health Reform?

10/1/13…That is the date that the healthcare exchanges will go-live (or at least are supposed to go live).  As of a week ago, the testing hadn’t even begun.  Will they actually get through all the testing and go-live in time?  It will be a huge failure if they don’t.

On the flipside, if they go live but the experience is horrible and pricing is wrong, will that reflect poorly on the exchanges or on the health insurance companies?  I know several of the large health insurance companies who are ready (or as ready as they can be) are worried about that.  

There are other issues to be sure:

  1. Do people even know that the exchanges exist?  (A recent survey said only 27% of young people did.)
  2. If people know, will they come to buy insurance?  Will they understand the exchanges and that they can get a subsidy?
  3. Will exchanges end up with only the sick or will there be a mix of healthy and sick?  (This will eventually be an issue, but plans will have to underwrite for 2015 exchange pricing before they really understand this.)

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Sorry…Put A Few Posts On The Wrong Blog

To those that get my blog posts e-mailed to them, sorry about any confusion.  I used to maintain a family history blog, and had a few requests to update it.  I posted a few things to the wrong site this morning.  

Retail Pharmacy As The Digital Medical Home

I’m excited to deliver my presentation on the topic about the retail pharmacy as the digital medical home tomorrow at the intersection of three CBI conferences – Point of Care Summit, Retail Strategy Summit, and Strategic Distribution Planning for Specialty Products.  As always, I’m sharing my slides below via SlideShare, and I’ll set up some tweets to give you the cliff note version.

The key here IMHO is that retailers are best positioned to take advantage of this, but the key points are:

  1. Why retail pharmacy?
    • Retail pharmacies have trust from consumers.
    • Easily accessible.
    • Pharmacy is the most used benefit.
  2. What’s the challenge?
    • Successfully engaging the consumer.
    • Integration with the provider so there are process oriented care gaps.
    • Data.
  3. What needs to happen?
    • Focus on the golden moments for engagement.
    • Systemic model for engagement – e.g., Prochaska.
    • Tools and skills to motivate the consumer – e.g., Motivational Interviewing, Incentives.

Is Wellness Really Just About ROI?

Al Lewis and Tom Emerick posted a great article on the HBR blog about the Danger of Wellness Programs.  It reminds me a lot of what my old boss published after she left Healthways, but as the old expression goes – don’t throw the baby out with the bathwater.

I’ve talked about this before in my post on why CVS asking for their employees weight was a good thing, but let me elaborate more.  While the HBR article makes some great points about ROI, the reality is that companies don’t just jump into wellness for the ROI.  It’s about creating a better workforce.  What Al Lewis and his partner ignore are other realities like:

In general, only 12% of people are fully health literate.  Most people are unengaged with their healthcare and overwhelmed with work and life.  That’s why programs like biometrics and health risk assessments are important.  They try to create teaching moments for us to pay attention to our health and realize our risks.

Interview With Authors of Anxious Kids, Anxious Parents

After getting a press release about their new book, I did an e-mail interview with the authors of the book “Anxious Kids, Anxious Parents: 7 Ways to Stop the Worry Cycle and Raise Courageous & Independent Children”.    

A quick bio on the authors Reid Wilson, PhD and Lynn Lyons, LICSW is below:

  • Reid Wilson, Ph.D. is the Clinical Associate Professor of Psychiatry at the University of North Carolina School of Medicine. He is author of Don’t Panic: Taking Control of Anxiety Attacks and the coauthor of Stop Obsessing! How to Overcome Your Obsessions and Compulsions.
  • Lynn Lyons, LICSW, is a licensed clinical social worker and psychotherapist in private practice and a sought-after speaker and consultant. She specializes in the treatment of anxiety disorders in adults and children, including generalized anxiety, phobias, social anxiety, obsessive compulsive disorder, and performance anxiety.

I didn’t get a chance to read the book, but from the teaser I received, I had a few questions which they answered for me.

What percentage of children have a diagnosable anxiety disorder today?  

 

Research estimates that one in five children and adolescents have a diagnosable anxiety disorder. This does not mean that all of these children receive treatment, but that they have symptoms of anxiety that meet the criteria for an anxiety disorder. 

How has the prevalence of anxiety increased over the years?  

 

Although we don’t have exact data on the increase of anxiety disorders in children, we do know that research and understanding of anxiety in children has increased dramatically over the last two decades. More children are diagnosed based on a much greater knowledge and awareness of anxiety disorders such as Obsessive Compulsive Disorder and Post Traumatic Stress Disorder. Anecdotally, adults report greater stress levels, and we know that parental stress, anxiety and depression impacts childhood anxiety. Anxiety is the leading reason that a parent seeks out mental health treatment for a child, and most clinicians who work with anxious children are very busy these days!  

Is there a test to know when someone is clinically anxious or just feels anxious?  (i.e., when should parents seek help?)

First, it’s important to remember that anxiety is normal. It happens to all of us and is very helpful when dealing with danger. The warning system and fight-or-flight reaction is an important part of survival, so should be respected and appreciated. There is no “test” for an anxiety disorder. We look at the symptoms and functioning of a child to determine the diagnosis. Anxiety becomes a disorder when the child spends significant time managing the anxiety, or remains highly distressed due to their fear, or significantly limits their participation in normal life activities. For example, a family might expend a lot of energy making sure that a child doesn’t “freak out,” so the distress might be minimal, but only because everyone is working so hard to avoid any triggers. Or a child may be unable to manage daily events, such as going to school or friends’ houses, sleeping alone, or participating in new activities. Anxious children can also be very rigid, demanding that adults follow anxiety’s rules. When a child cannot handle changes in routine without great distress, and when a family feels that anxiety is in charge of the family’s functioning, then help is needed.   

How does childhood anxiety show up in a kid’s behavior?

 

Avoidance is anxiety’s calling card. When a child consistently avoids, or becomes overly upset when avoidance isn’t possible, then anxiety is often the culprit. Other signs are when they become rigid about how things need to be done, when they have difficulty with new experiences or with uncertainty about how events are going to turn out, or when they begin skipping “fun” events because of fear or worry. Sometimes children are very good at expressing their fear, worries, or nervousness; again, this can be normal. If their worry prevents them from moving forward, and they tend to cry, throw a tantrum, or ask for excessive reassurance, then anxiety is probably in charge. 

How does someone treat childhood anxiety – counseling, medication, other?

One great thing about being in the anxiety business is that it is a very treatable problem. Once you know how it functions, it’s not all that mysterious. Therapy is highly effective when it focuses on teaching children and parents how anxiety operates and then gives them concrete skills to handle anxiety’s predictable tricks. We work with parents and children together to make sure that patterns of avoidance and overprotection are interrupted, and we give kids concrete strategies to deal with anxiety when it shows up. Therapy should be active and experiential, meaning that families should have homework assignments that give them the experience of moving into uncertainty and then handling it. 

Medication can help, but, if given the opportunity, we’d rather work with a family on learning new strategies first. Most kids and parents benefit greatly from psycho-education and skills. Even when medication is used, we don’t recommend it as the only course of treatment for children and teens. 

What are the other impacts of childhood anxiety as someone grows older?

 

Anxiety in childhood is a very strong predictor of both anxiety and depression in later life. The more episodes of anxiety a teen has, the less likely they are to complete college. Most adults with anxiety report that they began having symptoms as a child, so we know that anxiety just doesn’t go away in children if left untreated; it actually gets stronger and leads to other diagnoses and problems. As you can imagine, if avoidance is your best coping strategy, you miss out on many experiences in life. Anxiety impacts relationships, career, and the ability to live independently. Risk of substance abuse is also increased as anxious teens and young adults self-medicate their symptoms. 

What will the book teach parents and/or kids that will help them improve their level of anxiety?

 

Our book focuses on the importance of teaching children and teens how to handle uncertainty and discomfort. We normalize anxiety as a part of growing and developing, and we give parents concrete ways to support moving toward anxiety, rather than avoiding it. We help parents to understand that keeping their anxious child safe and comfortable actually makes anxiety stronger. We offer them a step-by-step plan to deal with anxiety when it (inevitably) shows up. Research tells us that anxious parents tend to have anxious kids. Our goal is to interrupt the transmission of anxiety from one generation to the next by helping parents react differently to their children’s worry and their own. And, actually, the skills we teach are preventative: handling uncertainty, being a problem solver, and knowing how to talk back to worry and move forward into life’s challenges are skills that all children should learn. 

Personal Example Of How Zip Code Affects Health

The Robert Woods Johnson Foundation has been talking about this issue for a while.  Yesterday, they released some great pictures of this within a few cities.

It got me thinking about how where you live influences your health.  Here’s a very personal example from the three houses I’ve lived in as an adult.

  • At my first house, all of my neighbors ran so I eventually started running with them leading up to me running three marathons.  
  • At my second house, all of my neighbors played poker 1-2 times per month which was a great social activity (although not so great on the calorie count those nights).
  • At our new home in Charlotte, I haven’t found a running club or a poker group or even a golf group, but I’ve been invited to play tennis with a group of guys that play “recreational” tennis weekly.  

Each of these are directly influencing several things – activity, diet, sleep, and social interactions.  

I’ll have to hold off judgement on the tennis group since it hasn’t started yet.  I had to ask my kids to start helping me since the last time I played an adult in tennis was in 9th grade with my dad.  I’ve played with my kids for a few years, but they generally play with their opposite hand to prevent beating me too badly.  (which either says something about me or them in terms of play)

World Suicide Prevention Day 2013

Today, September 10th is World Suicide Prevention Day.  For many people, this may just seem like another day that gets used to recognize a cause.  To others, this is a day to acknowledge some of the scary statistics around suicide including:

  • There is one suicide every 40 seconds worldwide.
  • For every “successful” suicide, there are 20 failed attempts.
  • Therefore, there is one attempted suicide every 2-3 seconds.

These are 2011 statistics which were projected to increase 50% by 2020.  

I think a lot of people mistakenly think of suicide as a teenage issue, but it’s not.  Many of you have probably seen articles in the US about suicides in the military which happen almost daily.  The suicide rate among middle-aged Americans has risen dramatically also.  A few years ago with several high profile suicides in the LGBT community there was a big focus on this with the It Gets Better Project.  

If you haven’t been touched by suicide in your life, you’re lucky.  I unfortunately can think of several people I know:

  • My friend from high school who killed himself.
  • My friend from grade school who’s brother killed himself.
  • A kid in my high school, that killed himself.
  • A friend’s ex-husband who just killed himself a few months ago.
  • A former co-worker who killed himself.

People who have attempted suicide usually aren’t very willing to talk about it based on the risk of being stigmatized, but this TED video is by one survivor speaking out.  

 

The key is for people to recognize the signs (when possible) and engage people.  The Cleveland Clinic and WebMD give some good information on the topic.  Here’s a list from the Cleveland Clinic site:

  • Excessive sadness or moodiness — Long-lasting sadness and mood swings can be symptoms of depression, a major risk factor for suicide.

  • Sudden calmness — Suddenly becoming calm after a period of depression or moodiness can be a sign that the person has made a decision to end his or her life.

  • Withdrawal — Choosing to be alone and avoiding friends or social activities also are possible symptoms of depression. This includes the loss of interest or pleasure in activities the person previously enjoyed.

  • Changes in personality and/or appearance — A person who is considering suicide might exhibit a change in attitude or behavior, such as speaking or moving with unusual speed or slowness. In addition, the person might suddenly become less concerned about his or her personal appearance.

  • Dangerous or self-harmful behavior — Potentially dangerous behavior, such as reckless driving, engaging in unsafe sex, and increased use of drugs and/or alcohol might indicate that the person no longer values his or her life.

  • Recent trauma or life crisis — A major life crisis might trigger a suicide attempt. Crises include the death of a loved one or pet, divorce or break-up of a relationship, diagnosis of a major illness, loss of a job, or serious financial problems.

  • Making preparations — Often, a person considering suicide will begin to put his or her personal business in order. This might include visiting friends and family members, giving away personal possessions, making a will, and cleaning up his or her room or home. Some people will write a note before committing suicide.

  • Threatening suicide — Not everyone who is considering suicide will say so, and not everyone who threatens suicide will follow through with it. However, every threat of suicide should be taken seriously.

The Mayo Clinic gives this list of things to do:

  • Encourage the person to seek treatment. Someone who is suicidal or has severe depression may not have the energy or motivation to find help. If your friend or loved one doesn’t want to consult a doctor or mental health provider, suggest finding help from a support group, crisis center, faith community, teacher or other trusted person. You can help by offering support and advice — but remember that it’s not your job to become a substitute for a mental health provider.

  • Offer to help the person take steps to get assistance and support. For example, you can research treatment options, make phone calls and review insurance benefit information, or even offer to go with the person to an appointment.

  • Encourage the person to communicate with you. Someone who’s suicidal may be tempted to bottle up feelings because he or she feels ashamed, guilty or embarrassed. Be supportive and understanding, and express your opinions without placing blame. Listen attentively and avoid interrupting.

  • Be respectful and acknowledge the person’s feelings. Don’t try to talk the person out of his or her feelings or express shock. Remember, even though someone who’s suicidal isn’t thinking logically, the emotions are real. Not respecting how the person feels can shut down communication.

  • Don’t be patronizing or judgmental. For example, don’t tell someone, “things could be worse” or “you have everything to live for.” Instead, ask questions such as, “What’s causing you to feel so bad?” “What would make you feel better?” or “How can I help?”

  • Never promise to keep someone’s suicidal feelings a secret. Be understanding, but explain that you may not be able to keep such a promise if you think the person’s life is in danger. At that point, you have to get help.

  • Offer reassurance that things will get better. When someone is suicidal, it seems as if nothing will make things better. Reassure the person that these feelings are temporary, and that with appropriate treatment, he or she will feel better about life again.

  • Encourage the person to avoid alcohol and drug use. Using drugs or alcohol may seem to ease the painful feelings, but ultimately it makes things worse — it can lead to reckless behavior or feeling more depressed. If the person can’t quit on his or her own, offer to help find treatment.

  • Remove potentially dangerous items from the person’s home, if possible. If you can, make sure the person doesn’t have items around that could be used to commit suicide — such as knives, razors, guns or drugs. If the person takes a medication that could be used for overdose, encourage him or her to have someone safeguard it and give it as prescribed.

Get SMAC’d (Social, Mobile, Analytics, and Cloud) and BYOD

I was reading the mHealth Trends and Strategies 2013 by netcentric strategies, and I thought I would share a few things from the report.  Of course, I like the acronym SMAC which I re-used in the title and in a recent presentation.  

  • Mobile phone use for health information reached 75M in 2012.
  • Tablet activity for healthcare reached 29M in 2012.
  • 50% of people will download mHealth applications (prediction).

“mHealth is not a separate industry, but rather it’s the future of a healthcare industry that’s evolving to care for patients differently, putting them first to deliver services better, faster, and less expensively.”  quote from David Levy, MD, Global Healthcare Leader at PwC

  • Only 27% of MD actively encourage patients to manage their own health through mHealth applications.  (problem)
  • 13% of MDs actively discourage mHealth participation.

There is a whole section on remote patient monitoring with some good points about the system and the financial case. There is another section on preventative technology talking about adherence and compliance.  It makes a key point which I believe is that technology will be welcomed by the 7M long-distance caregivers.  

And, if you haven’t heard the term yet – BYOD.  This stands for Bring Your Own Device which is about letting the user chose the device / interface that works for them but being flexible in terms of normalizing the data and using it within the workflow that you develop.  

It’s a good, quick read.  

The New Grade – A, B, C, D, Fat

We all know childhood obesity is a big issue and many parents don’t realize it.  But, I didn’t realize that for a few years now some schools have been changing the traditional report card to include new letters – BMI.

This is hot topic that I’ve highlighted in a few posts about boy scouts and obesity and in the new categorization of obesity as a disease.  We’ve also seen a huge rise in companies focused on biometrics like BMI.

So, is this movement at schools good or bad?

Here’s a few points to consider:

  • We learn early in life so helping kids to understand the importance of health early is important.
  • Most parents don’t know their kids are overweight and are often overweight themselves.
  • PCPs are encouraged to track BMI on an annual basis and report on it (but most don’t).

On the flipside:

  • Some people would argue that BMI’s not a good measure of health.
  • It doesn’t do much good to just tell people they’re overweight if you’re not going to provide a solution to help them manage their weight.
  • Schools already offer less physical activity and often may not have great food choices.

One other thing I think people overlook is that they assume just because their kids are active or play sports that they can eat whatever they want or that they’re actually getting enough exercise.

OMG – Prescription Coupons Could Cost Consumers More

Talk about an article that seems a few years late to the party…

Anyways, I was reading a link from the PCMA today about an article on philly.com about copay cards.  It stresses several points:

  • The cards are typically only for 90-days.
  • The cards get people started on brand drugs not generics.
  • People are less likely to switch to generics after they use the brand.
  • This costs people more money over time.

I’ve talked about copay cards many times and presented on this topic at the PCMA conference a few years ago.

Let me give some quick thoughts here.

  1. The cards may typically be for only 90-days, but most people that drop off therapy or titrate to other strengths do so in the first 90-days so perhaps this is saving some money.
  2. Of course, it’s for brand drugs not generics.  That’s the business model we’ve created in this country where generics are priced at pennies so there is no marketing to support those products.  It’s the PBMs and pharmacies that do the marketing for generics since they are the ones making money here.
  3. I think it’s a fair generalization that people are less likely to switch, but this is the problem.  If the drugs are the same (per the FDA), why is this an issue?  Is it an educational issue.  Or, is there really a difference?
  4. I’m not sure the consumer cost is the issue.  That’s marketing 101.  Don’t most consumers understand this issue that sales and coupons drive you to build loyalty often to higher priced products.  I think the debate here needs to stay on the payer who pays 70-80% of the drug costs.  They are the ones who really have an issue here since they don’t control the decision made in the market.

This one doesn’t seem to be going away, but I’m not seeing any net new information.


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