Archive | June, 2014

Otis Brawley’s Book – How We Do Harm

Brawley book cover

Let me start by saying…DON’T read this book if you enjoy having your physician up on a pedestal.  It will change your perceptions and skepticism of the system.

DO read this book if you’re frustrated by our US health care system and wonder why we spend so much money without necessarily seeing differences in mortality and outcomes compared to other developed countries.

“Proponents of science as a foundation for health care have not come together to form a grassroots movement, and until this happens, all of us will have to live with a system built on pseudoscience, greed, myths, lies, fraud, and looking the other way.  Patients need to learn that more care is not better care, that doctors are not necessarily right, and that some doctors are not even truthful.”

(Quote from the book pg. 27)

Let me start with an abbreviated bio on Dr. Otis Brawley from the American Cancer Society’s website:

Otis W. Brawley, M.D., F.A.C.P., chief medical officer for the American Cancer Society, is responsible for promoting the goals of cancer prevention, early detection, and quality treatment through cancer research and education.

Dr. Brawley currently serves as professor of hematology, oncology, medicine and epidemiology at Emory University. From April of 2001 to November of 2007, he was medical director of the Georgia Cancer Center for Excellence at Grady Memorial Hospital in Atlanta, and deputy director for cancer control at Winship Cancer Institute at Emory University. He has also previously served as a member of the Society’s Prostate Cancer Committee, co-chaired the U.S. Surgeon General’s Task Force on Cancer Health Disparities, and filled a variety of capacities at the National Cancer Institute (NCI), most recently serving as assistant director.

Dr. Brawley is a member of the Centers for Disease Control and Prevention Advisory Committee on Breast Cancer in Young Women. He was formerly a member of the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection and Control Advisory Committee. He served as a member of the Food and Drug Administration Oncologic Drug Advisory Committee and chaired the National Institute of Health Consensus Panel on the Treatment of Sickle Cell Disease.

Dr. Brawley is a graduate of University of Chicago, Pritzker School of Medicine. He completed his internship at University Hospitals of Cleveland, Case-Western Reserve University, his residency at University Hospital of Cleveland, and his fellowship at the National Cancer Institute.

I would put this book on my must read list for anyone working in healthcare.  I have two other books there:

Here are some things I highlighted as I read the book:

  • People diagnosed with cancer who had no insurance or were insured through Medicaid were 1.6x more likely to die within 5 years than those with private insurance.
  • “No incident in American medicine should be dismissed as an aberration.  Failure is the system.”
  • “Our medical system fails to provide care when care is needed and fails to stop expensive, often unnecessary, and frequently harmful interventions even in situations when science proves these interventions are wrongheaded.”
  • He introduces the concept of the “wallet biopsy” as a term to describe the difference in care we get once it’s determined what type of insurance we have.
  • While he points out and is clearly an advocate for health discrepancies and the issues of the un- and under-insured, he also points out that “wealth in America is no protection from getting lousy care”.
  • He hits on a point that I agree with in medicine and everywhere else which is teaching people to say “I don’t know”.  He later says “If you truly respect the patients you treat, you will not obscure the line where your knowledge stops and your opinion begins.”
  • He makes a key comment “Can the health-care system make itself trustworthy, become accessible and driven by science?”  (This reminds me of another book on trust in the healthcare system.)
  • “In most cancers, the quality of the surgery is the most important factor in the ultimate outcome.”
  • He talks a lot about the motivation of physicians in determining treatment and how that can be misguided over time.  While some of this can be explained away with Defensive Medicine, he points out that many other times this is simply the business of healthcare with people making money off these treatments.  Or, as he also points out, sometimes it’s simply unwillingness to challenge the status quo of over-treating the patient.  [This is something that I’ve heard other oncologists who provide second opinions point out.]
  • I learned about “gomers” which stands for get out of my emergency room which are patients who come to the emergency room just to interact with someone without any real symptoms.  He also introduces several other terms apparently all derived from a book The House of God about an intership at Beth Israel Medical Center in the 70s.
  • He brings up an important issue that us as Americans and many physicians believe to be true which is that “death is a failure of medicine”.  I’ve talked with several physicians about this.  I believe it’s one of the things that contributes to the enormous amount of money we spend on people in their last 90-days of life.
  • He gives a great (but sad) story of the “moral hazard” scenario of a family trying to care for their parent in the last days of their life and all the “senseless acts of medical torture” that they put him through.  This is one of his classic examples of where the physician knows better but is actually instructed to do harm.
  • He talks about one of the physicians he was assigned to work with during a rotation.  I thought this summary of his rules was great:

“You don’t deviate from the science.  You don’t make it up as you are going along.  You have to have a reason to give the drugs you are giving.  You have to be able to quote literature that supports what you are doing.  You have to tell patients the truth.”

  • At one point, he says that he confirms a truth he learned as a kid which is scary – “Doctors try out things just to see whether they will work.”
  • He gives a brief nod to companies using business rules to safeguard patients through technology that requires physicians to document what they are doing and comparing those to guidelines.
  • He spends a lot of time on prevention and survivorship in terms of how people justify some of those numbers.  It’s worthy of an entire post, but the key point is that early diagnosis by itself simply increases the years of survivorship.  It doesn’t actually mean we did anything better.  He also points out that due to all the treatments we give patients some of them die of other issues rather than cancer that “improves” the cancer death statistics.
  • And, for all of my pharmacy friends, he doesn’t miss the opportunity to tell the Nexium story or to talk about Vioxx and what happened in both of those cases.
  • His stories are amazingly similar to some of the physicians that I worked with for the past two years.  He talks about the overuse of radiologic imaging.  He talks about the da Vinci robot.
  • He gives some unique insights into the politics of support groups and government funding which I’d never understood before.
  • A great quote he uses from Willet Whitmore when talking about PSA testing and prostate cancer was:

“When cure is possible, is it necessary, and when cure is necessary, is it possible?”

  • I also liked a quote he gave from another urologist which said:

“There is the kind of prostate cancer that can be cured, but does not need to be cured; there is the kind of prostate cancer that needs to be cured and cannot be.  We all hope there is a kind of prostate cancer that needs to be cured and can be cured.”

  • This leads up to his point that research shows that 1.3M American men were needlessly treated for localized prostate cancer from 1986-2005.  Wow!
  • He was very positive on the US Preventative Services Task Force (USPSTF) which I was glad to hear since that’s the group that several of my physician friends have used before for setting guidelines.

Hopefully, you get the point.  It’s a quick read with a good mix of studies, patient stories, and the history of cancer with a focus on both historical and current issues that face us in this time of transformation in health care.

Here’s a few more articles about Dr. Brawley and his book:

 

As a random point of interest, Dr. Brawley uses several references to teachers and his Jesuit education at The University of Detroit Jesuit High School and Academy in Detroit which is where I also went to school and had some of the same teachers.  Our school was featured a few years ago as the last Catholic college prep school still in the city.

The Era Of The Two-Tier PBM Strategy

After Aetna, Cigna, and Wellpoint all moved into different PBM relationships with CVS Caremark, CatamaranRx, and Express Scripts, it certainly marked the end of much of the debate on whether a captive PBM (i.e., owned and integrated with the managed care company) could compete with the standalone PBMs.  There are really only a few big integrated models left including Humana, OptumRx (as part of UHG) and Kaiser with Prime Therapeutics having a mixed model of ownership by a group of Blues plans but run as a standalone entity.  Regardless of where the latest Humana rumors take them, it made me think about what the market has become with these new relationships.

  1. Scale matters.  All of these relationships and discussions show that there are clear efficiencies in the marketplace.
    1. Drug procurement (i.e., negotiating with the manufacturers (brand and generic) and the wholesalers)
    2. Pharmacy networks (i.e., getting the lowest price for reimbursement with the retail pharmacies)
    3. Rebating (i.e., negotiating with the brand and specialty drug manufacturers for rebates)
  2. Outcomes matter.  If scale was all that mattered, there be no room for others in the marketplace.  But, we continue to see people look at this market and try to make money.  That means that “outcomes” matter in different ways:
    1. Clinical outcomes (i.e., does the PBM have clinical programs or intervention strategies that improve adherence and/or can demonstrate an ability to lower re-admissions or impact other healthcare costs?)
    2. Financial outcomes (i.e., does the PBM have innovative programs around utilization management (step therapy, prior authorization, quantity level limit) or other programs like academic detailing that impact costs?)
    3. Consumer experience (i.e., does the PBM’s mail order process or customer service process or member engagement (digital, call center, etc) drive a better experience which improves overall satisfaction and overall engagement…which drives outcomes?)
    4. Physician experience (i.e., does the PBM engage the physician community especially in specialty areas like oncology to work collaboratively to drive different outcomes?)
    5. Data (i.e., does the PBM use data in scientifically valid but creative ways to create new actionable insights into the population and the behavior to find new ways of saving money and improving outcomes?)

While I’ve been beating the drug of the risks of commoditization to the market for years, I’m going to make a nuanced shift in my discussions to say that there is still a risk of commoditization and driving down to the lowest cost, but we may be quickly approaching that point.  What I’m realizing is that there can be a two tier strategy where you commoditize certain areas of the business and let the other areas be differentiated.  And, that this can be a survival tactic where you either outsource the core transactional processes to one of these low cost providers or figure out how to be one of them while creating strategic differentiation in other areas.  

Maybe you can eat your cake and have it too!

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AIS Quote Of The Day – Will Healthcare Ever Be Like Nordstrom’s?

I was reading my AIS Health Business Daily e-mail this morning.  Today’s quote of the day is below.  It made me wonder.  Think about any healthcare organization.  We have a long way to go to get here.

“The other part … of a great customer experience is to have a seamless interaction. The last thing we want to hear is ‘oh, I can’t help you, that’s his department’ or ‘I can’t help you, it’s his operating division’ or ‘I can’t help you because Sally helped you with that; I’m Sue.’ That’s not going to work. A great customer experience is when it is seamless. Customers look at us as a brand, as Nordstrom, as one. However we’re organized with our people, how we operate, customers don’t care about that. They care about what you stand for and the seamless customer experience.”

— Mike Koppel, Executive Vice President and CFO at Nordstrom Inc., speaking recently at America’s Health Insurance Plans’ Institute 2014 in Seattle.

Getting To Zero Trend In Specialty Pharmacy – CVS Caremark – AHIP

When I was at AHIP last week in Seattle, I had a chance to see Alan Lotvin from CVS Caremark present on specialty pharmacy.  It was one of the best presentations that I’ve seen in a while.  

It was good because I actually heard things that I’d never heard discussed around specialty pharmacy before.  And, as he pointed out, specialty will represent 50% of the pharmacy spend and about $235B in total spend by 2018.  This is where everyone is focused and the opportunity for differentiation exists. 

  1. He talked about how to get to zero trend in specialty.
  2. He talked about the consumer experience in specialty.
  3. He talked about care coordination and its value in specialty.
  4. He talked about the need for a beyond the pill approach by the specialty pharmacy.

So, what does all this mean?  Let me share some highlights:

  • Specialty pricing is starting higher based on government pricing constraints.  You can’t raise price.  It’s easier to start high, discount, and/or come down over time.
  • Pharma is beginning to price based on Quality Adjusted Life Year (QALY).
  • 3.6% of patients drive 25% of costs (not a surprise)…but 43% of their total costs are not from the specialty condition but from their co-morbidities.  (Why treating the patient not the condition is critical.)
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  • Site of care (which is the hot buzz today) can save you 17% or more.
  • Developing an exclusion formulary is important to counteract copay cards and help reduce costs.

o   This article says that CVS Caremark is working on a formulary with 200 brand drugs excluded.

  • They are moving from 12-month contracting with pharma to 2-3 month contracts to really keep on top of market conditions. 
  • Coordinated care can drive lower costs in terms of readmissions and other total medical costs. 
  • You can use generics to replace biologics.  For example, he showed switching out an HIV biologic costing almost $3,000 / month with 3 generics costing $101 per month.  (I’ve never heard anyone else talk about this.)
  • He also reinforced the fact that today’s specialty benefits are not coordinated across medical and pharmacy.  For example, he used the RA example where there are 9 drugs with 4 of them commonly used under the medical benefit and 5 under the pharmacy benefit. 

But, the most important thing was their strategy to get clients to ZERO TREND for specialty pharmacy.  (It reminded me of the program I developed at Express Scripts where we actually guaranteed a 3-year zero trend…if you followed our very aggressive recommendations.)  He outlined the following:

  • 1.5% savings from their formulary
  • 0.5% savings from an exclusive specialty network
  • 1.9% savings from an aggressive generic policy
  • 1.0% savings from innovative pricing
  • 3.6% savings from optimizing site of care
  • 2.5% savings from medical claims editing and repricing
  • 6.0% savings from enhanced prior authorization

He also went on to talk about the consumer experience.  I think a lot of specialty pharmacies are thinking about the same things, but there were several things he shared that were new to me.  It was exciting. 

As I’ve said before, as specialty pharmacies really start to think about the patient and focus on the experience over time, we will start to see more coordination with pharma about going beyond the pill and driving lower total costs.  

Prime Therapeutics Drug Trend Report 2014 Report

The Prime Therapeutics Drug Trend Report was released yesterday.  Interestingly, they start out the report by making the point that what really should matter is net ingredient cost not trend.  I’ve made the point before that trend isn’t a great number to focus on for many reasons.  And, if you’re comparing trend numbers (which we all do), then you need to understand different methodologies.  I think Adam Fein does a good job of summarizing that in his post.  (BTW – This is a tough discussion to have especially when you’re getting spreadsheeted by consultants as part of an RFP.)

As comparisons, you can see my reviews of the other drug trend reports here:

Their report was short and to the point.  Here’s some of the key data points:

  • 25M members
  • 80.6% generic fill rate
  • 12.7 Rxs PMPY
  • Overall drug trend = 3.3%
  • Specialty drug trend = 19.5%
  • Net ingredient cost trend = 2.2%

Prime Trend Drivers DTR 2013

 

  • The net ingredient cost per Rx = $58.99 (this is net of rebates and takes into account acquisition costs and network discounts)
    • They state that this beats the competition by $6.00 per Rx

Prime Net Ing Cost DTR 2013

 

Of course, anything anyone really cares about these days is specialty.  Specialty represents only 0.4% of the scripts they fill but 20.5% of the spend for a commercial account.  (They point out that this is much less as a percentage of scripts than other PBMs which have closer to 1% of their scripts classified as specialty…which could influence trend numbers.)  The chart below shows how some of the things we all did around traditional drugs apply to specialty drugs.

Prime Trad vs Specialty Rx DTR 2013

 

And, they make a few predictions going forward:

Prime Forecast DTR 2013

 

Mail Order Prescriptions Dropped 9.2% – WOW!

For some people running mail order pharmacies, this analysis is no big surprise.  They’re running off to their boss to show them that it’s not just their mail order facility, but it’s an industry issue.  To others, they’re left scratching their head trying to figure out why this is.  If mail order is where all the money is, what does this mean to them?  (The historical PBM model put most profit in generics filled at mail order.)

Per a statistic mentioned in Drug Benefit News from Pembroke Consulting (and discussed here by Adam Fein), mail order prescriptions from 2012 to 2013 (excluding Medicare) dropped 9.2% while retail prescriptions jumped 2.7%.  (This is not new news, but this is a big drop.)

I’ve talked about the issues and challenges of mail order many times:

  1. Retail satisfaction seems to beat mail order satisfaction based on different studies, but at the same time, there are studies showing the exact opposite.
  2. Presentation on the challenges with improving mail order rates
  3. Why clients don’t always save using mail order
  4. Why consumers choose mail

At the end of the day, I simplify the mail order issue down to four major challenges:

  1. Savings are disappearing.  Savings were primarily on brand drugs filled for 90-days.  When you fill a generic at mail and your getting 15-30 days supply for “free” (i.e., no copay), that’s great, but the copay savings is $4-10 every 90-days.  With generic utilization in or around 80%, this is a real issue.
  2. Transparency, coupons, and cash pay.  With apps like GoodRx, it’s easy for consumers to find the lowest cost option for them to fill a prescription.  That might be in a discount program.  It might be to pay cash.  It might be with a coupon.  And, it might be mail order.  They now can figure it out and optimize their spend easier.  Mail isn’t the only option.
  3. High expectations.  As a society, we continue to be more and more of a society that wants an instant response.  Sending prescriptions off to a black box with a multiple day turnaround and difficulty tracking the prescription doesn’t meet our modern expectations.  (A connected model of electronic prescribing may one day change this.)
  4. Cash flow.  As I always point out to people, we (those working in the industry) don’t represent the average American.  While it seems so logical to pay for a 90-day script in order to save money, that means you have to have the cash to pay for 3 months upfront.  Not everyone can do that especially when they have multiple prescriptions…And, no mail order pharmacy that I know of wants to be in the credit business.

Will mail order disappear?  Of course not, but PBMs need to continue to either find ways to improve the consumer experience and make it better or they need to recognize the issues that exist and continue to diversify.  And, with more 90-day prescriptions at retail for the same copay (i.e., CVS Caremark), this will continue to shift expectations.

Chinese Herbal-Therapy Ward At Cleveland Clinic

I think this is really interesting.  Cleveland Clinic has opened a Chinese herbal-therapy ward.  In the US, we’re very much a medicated society.  There’s a pill for almost every ailment you have and some you didn’t even know you had.  Even admitting that Western medicine might not have all the answers is a big step forward especially for such as prestigious hospital such as Cleveland Clinic.

So, what are they doing?  According to what I’ve read, they see patients with chronic pain, fatigue, poor digestion, infertility, and sleep disorders.  The clinic is run by a certified herbalist under the supervision of several classically trained physicians.  Access to the clinic is only on a referral basis, and according to Ohio law, the physician has to continue to oversee the patient’s treatment for a year after their referral.

The clinic is a single room with bright pillows, a tapestry, candles, and a cot.

Compared to China, the herbal formulas here are all encapsulated versus sent home with them to brew.

Of course, one of the worries is drug-herb interactions which requires them to coordinate care using an EMR and have people that have the right training and work with a clinic that can provide them with the right herbs and still meet their safety standards.

A consultation costs $100 which is typically not covered by insurance.  Additionally, follow-ups are $60 and a one-month supply of herbs will cost $100 (on average).

Here’s more on their clinic:

12 Innovation Lessons from 2014 (Fast Company)

Back in March 2014 (yes I’m behind), Fast Company put out a report on the World’s Most Innovative Companies.  I thought the list of 12 trends or lessons from their research was worth sharing.

  1. Exceptional is the Expected…Google is the case study here, but they make a point that for most companies, the best businesses focus on less not more.
  2. Innovation is Episodic…Innovation ebbs and flows so people don’t stay on the list every year.  This is also known as regression to the mean or the Sports Illustrated curse (of being on the cover).
  3. Making Money Matters…This is very true for mHealth.  I’ve seen so many really cool ideas, but if they’re not self-sustaining, that’s a problem.
  4. Sustainability Has Found A New Gear…”Green” is no longer a gimmick.  Companies are innovating and using alternative fuels and recycling as part of that.
  5. Unlocking Global Talent Unlocks Possibility…I can’t believe companies still don’t get this.  To innovate, you need diversity and a culture which allows those different opinions and perspectives to hash it solutions.  (Just look at the graphic at the bottom of this post for Silicon Valley which makes that point.)
  6. Passion is Underrated…While crowdsourcing sounds like old news to many industries.  I think there’s still a huge patient empowerment push that will happen in healthcare.  (Just look at this article in the WSJ.)
  7. Conflict Isn’t Required…This is the perfect Blue Ocean example.  You don’t always have to try to change the establishment but sometimes you have to figure out a whole new way.
  8. Happy Customers Make You Happy…Not much to say here.  Healthcare is about to learn this lesson with exchanges, but we have a long way to go.
  9. Software Beats Hardware…YES!  A great computer with a horrible data entry process which messes up the physician workflow and consumer experience is bad.  We need outside-in design to develop user-friendly software that takes into account workflow and regulation but improves the overall experience and outcomes.
  10. “Made In China” Is A Compliment…I’d expand this point to say that while we’ve outsourced for years for cost that’s building up knowledge and a middle class abroad.  As their expectations and experience rise, we’re going to see more innovation and quality from abroad.
  11. The Biggest Winner In The App Economy Remains Apple…And, now, Apple is taking it’s “moral obligation” and bringing it to healthcare.
  12. Dreaming Big Isn’t Folly; It’s Required…Eliminating cancer.  Changing payment paradigms in healthcare.  Getting patients to take action.  Changing food at schools.  We have to have some BHAGs in healthcare and make them happen.  (Perhaps some of the HealthPeople 2020 initiatives will get us thinking.)

Silicon Valley Workers

Above: Tech Immigrants: A Map of Silicon Valley’s Imported Talent (from VentureBeat article)

 

Curing Camden: Book Review

Curing Camden is a quick read on how different groups collaborated to change the healthcare cost curve in Camden, NJ.  Here’s the official language from the Amazon site, but after reading it, I thought I’d highlight a few things that caught my attention.

As the federal health reform debate played out in the national media spotlight, author Christina Hernandez Sherwood was reporting on the American medical system from the street level. From 2010 to 2012, she wrote a half-dozen stories for thePhiladelphia Inquirer that focused on an innovative healthcare nonprofit: the Camden Coalition of Healthcare Providers. These stories centered on the nonprofit’s role in combating falls, violence, diabetes, and other issues in Camden, New Jersey, a city known nationally as one of the country’s poorest and most violent, but that is now making a name for itself as an innovation leader in the public health sector.

In Curing Camden, all of Sherwood’s articles have been collected into a single book, including the unpublished final installment profiling the nonprofit’s founder. This book takes readers from the living rooms of Camden residents to the halls of the New Jersey State House in Trenton and beyond. Sherwood highlights how Camden could be the first US city to bend the cost curve by lowering healthcare costs while improving care. The ideas revealed in this book could be translated into practice across the country, and Camden could become a national model of 21st century medicine and public health.

The book goes through several core chapters.  The first one is on creating a citywide health record by working with the 3 primary health systems in the city.  The core part of the success here is that they used the framework of opt-out not opt-in which would drive more participation at the consumer level.  This behavioral economics framework called “active choice” has been used by several companies that I’ve worked with in the healthcare space to shift behavior patterns.  This obviously has the opportunity to reduce duplicate testing and improve care coordination.

The second chapter is about create an ACO for Camden with a 3-year Medicare demonstration project.  It’s an interesting discussion about how Dr. Jeffrey Brenner began using data to learn things about the Camden population.  For example he found out that most of the population will vista a hospital at least once in a 2-year period (which is 2x the national rate).  He also found that most of the top reasons for going to the emergency room were all primary care issues.  He makes a great point in the book that while people think that complicated patients simply like going to emergency rooms the reality is that they don’t have better choices.

The third chapter was about protecting against the risk of falling.  From 2002-2009, Camden residents made more than 17,000 trips to the hospital (the number one cause of hospital visits in Camden).  This isn’t a localized issue either.  Falls affect 1 in 3 seniors every year and drive $19B in costs according to the CDC.  In the book, they make an interesting point about the “vicious cycle” of falling which leads to less activity which leads to weaker patients increasing the likelihood of another fall.

The fourth and fifth chapters are about diabetes.  In Camden, almost 13% of adults have diabetes.  These patients can be high utilizers which is something they talk about along with their focus on the 13% of patients that drive more than 80% of the costs in Camden with one patient having over $5M in charges over 5 years.  Of course, people in dangerous communities are at higher risk of obesity due to lack of access to food and safe places to exercise which contributes to the diabetes issues.

The sixth chapter is about violence and helping victims.  Camden’s 77,000 residents experience more than 13 aggravated assaults per 1,000 residents (which is 5x the national rate).  This lead to 9,361 trips to the hospital from 2002-2009.

It’s an interesting read.  They had a lot of grant money, but at the end of the day, it was about several things:

  • Coordination and collaboration across the different systems
  • Localized care – being in the apartment building with a clinic or going into people’s homes
  • Using data to target the areas where they could make a difference
  • Caring to make a change

$83,000 In Savings On 3 Procedures – The Driver Of Transparency & Reference-Based Pricing

At the front of the HealthLeaders Magazine, they have a FactFile every month with data from Truven Health.  The one from March 2014 focused on price variation and transparency.  I thought I’d share a few of the charts.

This first chart shows their projections about the impact of a price transparency tool on cost savings over three years.  (BTW – If you’re looking for information on price transparency tools, I would go to Jane Sarasohn-Kahn‘s blog HealthPopuli and look at her posts on transparency – Part I, Part II, Part III, Part IV, and Part V).  Their projection was $6,786,000 in year 3 for an employer with 20,000 employees (or about 46,000 total covered lives if you assume a ratio of 2.3).

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The other topic in the FactFile is about price variation and potential savings.  They looked at three procedures and the variation in pricing for them.  They then estimated the savings from those three procedures for an Chicago based employers.

As you can see, the variation is dramatic.  What this will eventually lead to is called “reference-based pricing” where payers will agree to pay a fixed amount (or reference price) for a procedure and consumers will have to use transparency tools to figure out which providers will meet that price or pay out of pocket to go elsewhere.  The hope is that this will drive down prices, make consumers aware of differences, and finally help people understand that price and quality are NOT correlated in healthcare.

Here’s a few articles to read on price transparency:

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Will Smart Sports Equipment Lead To Better Athletes?

For those that are part of the Quantified Self movement, this is just a natural extension.  You can now measure your different sports.

  • Swingbyte – a sensor that clips to your golf club to monitor speed, acceleration, arc, and other stats.

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  • FWD Powershot – a sensor that fits into the handle end of a hockey stick and measures speed, angle, and acceleration.

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  • Zepp Baseball Sensor – a sensor stuck to the knob of a baseball bat that tracks the speed and plane of the swing and the angle of impact.

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  • There’s also the Babolat Play which is a smart tennis racket.

Babolat Play

On the one hand, this stuff is fascinating and amazingly cool.  On the other hand, who even knew that dribble force was something for me to be coached on.  It will be interesting to see how athletes and coaches adopt these technologies and how they help improve sports over time.  Will they increase the stress for the average athlete who was never going to be great and was just playing for fun?  Will they improve everyone and help players and coaches really focus where they can make a difference?

19% Higher Risk Of Medication Non-Adherence If The Physician Communicates Poorly

This was just one of the really great data points I got from the Medication Adherence Clinical Reference page from the American College of Preventative Medicine.  It’s worth a read.  

But, let me highlight a few other points:

  • Non-adherence is thought to account for 30-50% of treatment failures.
  • Trust and communication are critical factors in adherence.

I think this is important because a lot of the industry solutions focus on the pharmacy and the consumer.  They don’t (IMHO) go back to the initial discussion with the provider.  How are we helping to enable those conversations to last longer than 99 seconds in the average encounter in which time they have to explain the medication, the side effects, and help the patient feel like the medication is going to make a difference?  (Of course, this always make me think of my favorite placebo effect video.)

 

Additionally, this chart from the Adult Meducation publication was a great list of factors reported to impact adherence.  (Sources: Miller et al., 1997; Nichols-English and Poirier, 2000; Vermiere et al., 2001; World Health Organization, 2003; Krueger et al., 2005; Osterberg and Blaschke, 2005)

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They also share this chart (which I’ve seen a version of many times):

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[Source: National Association of Chain Drug Stores, Pharmacies: Improving Health, Reducing Costs, July 2010. Based on IMS Health data]

 

 

Should Providers Have Private Conversations With Your 12-Year Old?

There was an interesting story which came out of Michigan this past week from Christy Duffy about how her physician’s office was requiring all minors between the age of 12-17 to have a 5 minute private conversation with them (according to the law).  Of course, it appears that they made a mistake per her later post, but I think it serves to make several interesting points.

1. Don’t always assume that someone’s interpretation of the law is right if it doesn’t make sense.  Sometimes, you have to apply common sense and push back or ask questions.

2. There is a gray area between protecting the rights of our kids and protecting our rights.  While the intent of allowing our kids to have honest and open conversations is appropriate, there needs to be some involvement of the parents.

It’s an interesting topic for discussion.  Should our teenagers have access to providers on their own?  Yes.  If a teenager has a health issue, I think we’d all prefer that they talk to a professional rather than Dr. Google or their friends to find the answer.

Should a provider be able to force a private conversation with a minor?  Yes…if they have a legitimate concern about abuse, but I don’t see any other reason.

Should a teenager who’s covered by my insurance and lives in my house be able to block me from having access to their medical records?  Yes.  This is the law, but should providers be having private conversations to offer them this option?  I don’t think so.  I would like them to have those discussions with me and my child to say that here are their options.

Should a teenager have a private conversation with their provider about STDs, HIV, and birth control?  Yes, BUT I’d like to have the conversation at the right age with me in the room initially and then offer the private option.  I don’t think forcing that conversation on a 12-year old would make sense in a private setting.

Ultimately, this comes down to the issue of access to the medical records online.  What I heard was that this would also require the provider to get a cell phone and e-mail address for my kids.  Obviously, if they’re doing something confidentially with the doctor, that’s one thing, but as a matter of record, I disagree.  (I don’t even give out my kid’s Social Security numbers.)  I don’t want my kids to start getting e-mails, phone calls, and letters sent directly to them as early as 12-years old.  And, yes…I do try to shelter them a little.  We talk about all the issues, but in a way that my wife and I want them to learn, not according to some formula driven approach that’s mandated.  But, ultimately, I don’t think a 12-year old is mature enough to make all their own health decisions or to feel like they should.

Obviously, some part of this falls on the parent regardless to create an environment of open dialogue with their kids.  The kids have to feel comfortable talking with their parents which is important for health and many other challenges that our kids have to deal with.  And, unfortunately there’s always bad people in any profession so while sexual abuse by a physician or nurse is rare it’s not unheard of.  Ideally, I think you should have the choice of when to encourage a private conversation and never have it mandated (unless of course the provider suspects abuse).  Unfortunately, with a report of abuse being made every 10 seconds, we have a huge problem in our country.

Our Unreasonable Expectation For Devices And Apps

I was reading an article the other day about devices like FitBit and their use within corporate wellness programs. One of the questions it was asking was why use them when people abandon them after a while.  I found this great chart from Endeavour Partners in their whitepaper which looks a lot like an adherence curve.  They say that 1/3 of people abandon their devices within 6 months which makes it a hard investment for anyone.  Image

 

It’s the same question you might ask around mobile apps.  While this chart shows that Americans install almost 33 apps, the questions is how long they use them.

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(Source: http://www.statista.com/chart/1435/top-10-countries-by-app-usage/)

According to Flurry, most apps peak within 3 months, and they show that health and fitness app retention is only 30% after 90-days. Again, that doesn’t make you want to invest a lot of money in a mobile app.  But, there are lots of reports out there telling us that people want to use mobile to communicate with their providers, track calories, and do lots of other health related tasks.  (see RuderFinn report, see IMS report, see Pew report)

So, what gives?  Do we have unreasonable expectations?  I would say yes.

We live in a ADD culture where people are constantly multi-tasking.  People want things that evolve and constantly change.  It’s the same reason we don’t want the same experience every single day.  It’s the reason that you’ve seen people from gaming coming into healthcare.  They understand how to keep people engaged over time.

Whether you want to picture it as a customer journey or different phases, the reality is that messaging needs to evolve with the consumer.  If you got the same letter every month, at some point, you don’t even pay any attention to it.  At some point, you wouldn’t even open it.

When I worked in healthcare communications, it was the same challenge from a strategy perspective.  How would we coordinate communications across channels?  What would the first message say versus the fifth message?  How do you avoid message or channel fatigue?

It’s the same thing in the digital or device world.  So, I ask the question…do we have unreasonable expectations about these tools by thinking that we can put them out there and sustain use of them?  I think so.  We need an evolving, constantly changing strategy about content, community, functionality, etc. to keep engagement sustained.


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