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DBN Article on Adherence

In today’s Drug Benefit News, I was quoted several times on the issue of incentives and adherence.  Here’s one of the quotes along with one of the quotes from Bob Nease from Express Scripts

Article: Should Patients Be Paid for Adherence? Strategy Could Yield Savings or Cost Hikes

Author: Renee Frojo

Medication nonadherence is recognized by most payers as a major driver of pharmacy costs, but nobody can get their hands on a foolproof solution to the problem. As a result, PBMs and health plans are experimenting with a new method that some critics view as a last resort: paying people to take their drugs appropriately. “There is no silver bullet when it comes to adherence, because it’s not that straightforward,” George Van Antwerp, vice president of the Solutions Strategy Group at Silverlink Communications, tells DBN. “However, it is an issue where everyone is aligned because there are a lot of potential savings.”

 “Some plans will do whatever it takes to get patients to be adherent to their therapy or engaged in better behaviors,” Bob Nease, Ph.D., chief scientist and vice president of marketing at Express Scripts, Inc., tells DBN. While the PBM hasn’t launched its own program yet, Nease says it will be following the trend closely. “The use of lotteries is very interesting and it has potential,” he adds.

Don’t Take OTC Drugs (Cold Medicine) and Drive?

Why don’t we all just stay home or set up a massive public transportation system across the US.  Since over 50% of consumers take a maintenance drug, I can only imagine the percentage of people who take either a maintenance prescription drug or an over-the-counter (OTC) medication.

And, now the government wants to issue a warning about driving while taking medication and throw that in the same bucket as illegal drugs, driving drunk, and texting while driving.  Do they have any studies here?  Don’t medications that make you drowsy require labeling (not that anyone reads it or follows it)?

I guess I’m just confused at someone coming out and making broad statements like this.

Washington (CNN) — Add driving while on drugs — even it’s just cold medicine — to the list of distractions behind the wheel to which authorities are giving special attention.

National Drug Control Policy Director Gil Kerlikowske, a former police chief in Seattle, said drivers need to know they might be impaired if they have taken prescription or over-the-counter drugs, just as with illegal drugs.

“Drugs adversely affect driver judgment, driver reaction time, their motor skills and their memory,” said Kerlikowske, telling reporters the effects can be similar to those of driving under the influence of alcohol.

Father’s Day Numerology

While the male family member has not traditionally been the dominant healthcare figure, will that change over time? 

According to a Numerology page in Fast Company (June 2010) on Father’s Day:

  • There are 66M fathers in the US.
  • There are an estimated 158K stay-at-home dads.  (or 0.2% of all fathers)
  • 7 of the top 15 TV dads come from programs in the 50s and 60s (does that tell us something?).
  • 1 in 4 dads spend less than an hour a day with their kids.
  • 38% of working dads say they’d take a pay cut for more time with their kids.
  • 13% of US companies offer paid maternity leave.
  • There are at least 2M father-son businesses in the US.
  • 10% of the 29M ties sold per year are for Father’s Day…but they are still the least-popular Father’s Day gift (just 1% give ties).
  • Consumers spent an average of $91 on Father’s Day in 2009.

We know that our friends drive our health…we exercise if our friends exercise…we lose weight if our friends lose weight.  I’ve never seen a study comparing “friends” versus family in terms of social influence around healthcare.  But, I certainly believe that you build a culture of health at home.  Parents are important in doing that.  What you eat.  If you exercise.

CVS and Walgreens Reach Resolution

I’ve tried to stay out of this since my initial posts on this, but it has certainly added some excitement to the industry over the past couple of weeks. I can’t remember one topic stirring so many reporters, analysts, sales people, and other potentially affected constituents.

As I’ve predicted from the beginning, both CVS Caremark and Walgreens came to resolution. It was in their mutual interest. I know there are a few sales people at the other PBMs that are disappointed as they hoped for this to be a wedge in several open RFPs. I think it may actually work against the other PBMs depending on the terms.

We know that Walgreens wanted higher reimbursement rates that other pharmacies. My question is whether they were acting like the UAW with the Big 3 auto companies. The UAW would reach agreement with two of them and then strike the 3rd one. Did the other PBMs give Walgreens higher reimbursement rates and then CVS Caremark finally draw the line in the sand? If so, does CVS Caremark have better rates and will they be even more aggressive around pricing in the sales cycle this year?

On the other hand, I know people at the other PBMs that were hoping for either a validation of the limited network concepts that have been around forever with limited adoption or to see them come to terms and hope that they can draw a line in the sand similar to CVS Caremark. For those outside the two companies, it was a win-win scenario while it was a lose-lose scenario for the two players if they didn’t reach resolution.

So, what happens now?

Will there be a Maintenance Choice offering with Walgreens in the network for 90-day scripts? I’m not sure here. Retailers have always struggled to over mail reimbursement rates at retail especially with less foot traffic, but I have to imagine that CVS and Walgreens have similar buying power.

Does this validate the concept of a retailer owned PBM (which as I’ve pointed out before is not unique to CVS)? I’ve talked many times about my support of this concept and think it’s only those with something to gain who are keeping this concept an issue. The independent pharmacies who are losing to mostly chains but also mail and the other big PBMs especially Express Scripts that had made a bid for Caremark before CVS bought them.

Lottery For Taking Your Medicine

Adherence is the big focus these days.  It’s an issue where everyone is aligned – payer, pharmacy, PBM, pharma, patient, MD.  And, there are certainly lots of savings to be gained both hard dollars (less ER visits) and soft dollars (less absenteeism). 

BUT, COME ON…

There are lots of issues around adherence.  Getting people to fill the script after they leave the doctor’s office.  Making the script affordable.  Getting them to take the medication.  Remembering to take it over time.  Dealing with side effects.  Dealing with differences in cultures, conditions, health literacy, etc. 

Now, people are paying you or giving you a chance to “win” money every day just for taking your medication (see NYT article).  So, in my mind, this eliminates the issues of affordability (i.e., you already have the drug) and side effects (i.e., you’re not going to take something that has a meaningful side effect just for money).  So, why do I have to pay you.  Does the dentist pay you to brush your teeth?  Of course not.  Does your auto insurance company pay you not to speed?  Does your life insurance company pay you to not drive drunk?  NO…In all these cases you either pay more money if you do this or your service gets discounted if you don’t. 

If you have a chronic illness, can afford the medication, and have no meaningful reason to not take it, you should be doing your best to take the medication.  Otherwise, you’re driving up the costs of healthcare for you and your friends and your kids.  You do have some social responsibility to try and get better OR you should pay more for your healthcare.  We all have a choice (see the 1,000 pound woman).

Won’t paying people just create a long-term “dependency” where I only want to take my pills when I’m getting paid?  Probably…we certainly used to see that incentives at the call center drove up success rates, but once they went away the success fell below the baseline. 

Will this create an incentive simply to open the pillbox to get paid even without taking the medication?  No one is there making sure it goes down my throat so I’m sure some people will game the system.  (A sentiment shared by John Mack at the Pharma Marketing Blog.)

For the people that are adherent, will you just be wasting money?  Yes…and why should my neighbor get paid for forgetting…I’m going to want the same thing.

Don’t get me wrong.  I’m a fan of incentives, but reward me for the right things otherwise we end up with situations like Enron.  Incent me for managing my BMI, my A1c value, my blood pressure.  I can take medication, work out, or diet to achieve those. 

Give me tools and information.  Help me to understand my drug.  Help me to afford my drug (e.g., value based insurance design or patient assistance programs).  Educate me on my condition.  Have a talking pillbox or medication bottle.  Call me to remind me to refill.  Sign me up for auto-refill. 

I just can’t get on board with this latest twist.  I guess the proof is in the pudding so we’ll see if it makes a difference.  I’d love to be proven wrong here and see us throw money at people and change the healthcare cost curve.

Sensory Friendly Films

I was reading about a great idea this morning in our local county paper – “Sensory Friendly Films”.  This is an idea for families affected by autism or other conditions so that they can take their kids to the movies.  Apparently, our local movie theater (AMC West Olive 16) has partnered up (at the corporate AMC level) with the Autism Society to design this program.

The movies are shown with the lights turned up and the sound turned down.  There are no previews.  Families can bring their own snacks.  And, kids are able to move around and talk during the movie if needed.

There are an estimated 30M people in the world (1.5M in the US) with an autism spectrum disorder.

Prioritizing Social Media Participation

If you haven’t read the article in USA Today titled “A doctor’s request: Please don’t ‘friend’ me“, I think you should.  It makes some great points and is symbolic of the challenge we all face relative to social media.

  • Should we participate?
  • Which tools should we use – MySpace, Facebook, Twitter, LinkedIn, Plaxo, blogging, …?
  • How much time to spend on them?
  • What should I expect from them – leads, contacts, friends, finding old friends?
  • Is this okay to do at work or should I do this at home?
  • Should these sites be blocked at work?
  • What can I or can’t I say?
  • Should I accept invitations from everyone who reaches out to me?

The author of this article talks about some of the more physician specific issues of becoming friends with your patients in Facebook, but it generally begs the question of where do those boundaries exist.

“Having a so-called dual relationship with a patient – that is, a financial, social or professional relationship in addition to a therapeutic relationship – can lead to serious ethical issues and potentially impair professional judgement.”

On the flipside, what if a friend of yours is a physician and you need to be treated.  Is that okay?  I think so.  I know my pharmacist very well.  We’ve even had her and her family over to the house several times.  But, we became friends through our kids and our gym not simply because we have a clinical relationship.  And, while we’ll talk industry trends occassionally, we rarely talk specifics.  Plus, the fact that I help lots of companies drive business away from her pharmacy (retail-to-mail) never sits too well!

So, I’ve selectively added social media sites over the years.  Here’s a quick picture of how I think about it.  I do not accept the majority of invitations that I receive simply based on a few key criteria which vary by tool.  For example, in Facebook, I generally have to view you as someone who I have or would invite to my house in order to be your friend.  In LinkedIn, I have to have connected with you in person or on the phone one or more times before I would become a connection. 

Woman Tries To Eat Herself To Death

I’m not sure how else to describe this woman who willingly wants to weigh 1,000 pounds so she can hold a world record.  She’ll be so unhealthy.  I at first assumed that she must not have kids since this is essentially suicide…but she does.

I wonder if this is a reason to remove someone from health insurance or life insurance.  If she needed an ambulance, I’m not even sure how they would get her out of the house.  She’s already over 600 pounds.

Less Time in Hospital Correlated to More Readmissions

We all want to get out of the hospital as quickly as possible.  A recent study from JAMA that appeared in the WSJ showed that while days in the hospital dropped from 8.6 days in ’93-’94 to 6.4 days in ’05-’06 the readmission rate (within 30 days) went up from 17.3% to 20.1%.  I’d love to see the economics around this. 

  • Do the hospitals make more money in this case? 
  • Do the plans save more money? 
  • Are patients happier?  [Remember that the majority of them got out sooner.]

“From a societal point of view, dollars spent on health care likely increased.”  Harlan Krumholz, Yale University cardiologist and senior author of the study. 

The study author echos a point that we [Silverlink] often make to our clients which is that hospitals (or payers) need to invest more effort and resources to make sure the transition to outpatient status in seamless.  Do they understand what the doctor’s instructions were?  Do they have someone caring for them?  Did they pick up their medications?

Another key lesson learned here is that it’s important to measure what matters and that what’s measured gets improved.

2010 Medco Drug Trend Report

I can’t believe it’s taken me a few weeks to catch up on my notes from a conference call with David Snow and Dr. Rob Epstein from Medco Health Solutions about their 2010 Drug Trend Report. I captured some of Dr. Epstein’s comments in a quick blog post, but I have a lot of respect for David Snow and wanted to capture a few of his comments here and pull out some of the interesting data from the Drug Trend Report.

David Snow mentioned a few things:

  • Reform has to address all three legs of the stool – Access, Quality, and Cost. Right now, it’s focused on access.
  • Of the $2.4T we spend in the US on healthcare, $1T of it was unproductive.
  • One of the big issues in the system is poorly designed systems for the people that deliver care.
  • Pharmacy is ahead of the curve since it’s already wired and uses evidence-based care.
  • We have to focus on the chronic conditions. 96% of the pharmacy spend and 75% of the medical spend is here.
  • Prescriptions are used as first line solutions 90% of the time. (See my comments on why trend shouldn’t matter.)
  • $350B of the waste is due to poor management of chronic solutions.
  • We still have to address medical liability and defensive medicine.

He also answered questions. A few of my notes from the Q&A:

  • Patent expiration doesn’t fully explain the increase in brand pharmaceutical costs. (Traditionally these drug costs go up once the patent expires.) You can correlate the tax on pharma (in reform) to the increase in prices. (Not dis-similar to the increases around Part D if memory serves me.)
  • Adherence is a key issue. The Therapeutic Resource Centers (TRCs) are their answer to this. They drive adherence in the classes that matter and we report to clients on this. (While I think a lot of people viewed the TRCs as marketing strategies when they first came out, I believe they have demonstrated a clinical focus with some case studies and clinical leads over the past 18 months.)
  • The pathway to biosimilars is very fair to the innovator.
  • Class competition in specialty is increasing.

His most interesting comment which I’ll repeat from my earlier post was that if the FDA really understood true adherence they might make different decisions on approving drugs whose effect is tied to a person staying on a medication over time.

I won’t repeat some of the core data elements from my prior post, but here are some new ones from reading the document:

  • Mail order penetration was 34.2% (which I believe is industry leading for the PBM sector with only Walgreens showing a 90-day utilization number that’s higher).
  • Interestingly, they show trend for clients with over 50% mail use (and clients with less than 50% mail use). [Most PBMs would love to have any clients with over 50% mail use.]
    • 0.1% for those with over 50% versus 5.3% of those under 50%

Reported trends are based on 2 years’ data on pharmaceutical spending. Drug trend percent includes 201 clients representing approximately 65% of consolidated drug spending. The sample comprises clients who offer integrated (mail-order and retail) pharmacy benefit options for members. Clients with membership enrollment changes > 50% were excluded from the analysis. Plan spending is reported on a per-eligible per-month (PEPM) basis, unless otherwise specified. An “eligible” is a household, which may include multiple members who are covered under the same plan. Plan spending comprises the net cost to plan sponsors less discounts, rebates, subsidies, and member cost share. Generic dispensing rates and mail-order penetration rates represent the total consolidated Medco client base.

 

  • Diabetes is obviously a critical category for everyone. I found it interesting that they saw fewer patients filing claims for diabetes but more drugs per patient in 2009.
  • Respiratory therapies (driven by those <19 years old) jumped in contribution to trend from 8th to 2nd.
  • In patients aged 35 to 49, antiviral drugs are the greatest contributors to cost – 8.3% of plan pharmacy costs. [Some of this driven by flu although this is not the at risk age group.]  

Antiviral drugs (Formulary Guide Chapter 1.8) include oral treatments for HIV/AIDS, influenza, herpes, hepatitis C, hepatitis B, and injectable treatments for respiratory syncytial virus (RSV), and cytomegalovirus.

  • Utilization growth for ADHD drugs for those age 20-34 grew 21.2%. [Is this for people not diagnosed as kids, people who have adult-onset ADD (if that exists), or just an over-diagnosis of the condition?]
  • Specialty drugs…I’m always surprised that all the PBMs still have to caveat the fact that they only adjudicate some of the claims since some specialty drugs are filled and billed under the medical benefit. That seems like something that should / could be fixed, but I know it’s been tried and is hard since people are making money off them being billed elsewhere.  

 

 

  • Cancer is already a huge driver of specialty costs AND:
    • Much of the spending is still under medical;
    • Most drugs approved in the past 4 years costs over $20,000 for a 12-week course; and
    • There are over 800 drugs in the pipeline.

 

 

Spending growth has outpaced spending for nonspecialty, or traditional medications because:

  • A high proportion of newly approved drugs are designated as specialty.
  • Unique manufacturing processes make specialty drugs expensive to develop.
  • Fewer drugs within a therapeutic category limit competition.
  • There may be only one specialty treatment for an orphan condition.
  • Few drugs are therapeutically equivalent to others in the category, reducing interchange and related cost savings opportunities.
  • It is more difficult to transition existing patients from one specialty drug to another preferred specialty drug because often these drugs are large, unique proteins that are not considered interchangeable.
  • Most small-molecule specialty drugs are relatively new with few generic alternatives.
  • No defined approval pathway exists for follow-on biologics (also known as biosimilars).
  • Drugs used to treat cancer represent a large portion of new drugs in both the pipeline and marketplace; most are specialty drugs and some can cost more than $20,000 for a 12-week therapy course.
  • It was the first time I noticed anyone caveating the specialty trend. They proactively addressed different calculation methods to point out that their method yielded a 14.7% specialty trend, but if you did things differently (as I assume others must), then their trend would have been 12.1%.

 

 

  • Trend in children exceeded trend in other age groups for the second year in a row. (I think this is an interesting perspective and a scary indicator for the future health of our country.)
  • They provided some examples of drugs that had new indications for younger patients approved:
    • WelChol, Crestor—for low-density lipoprotein cholesterol (LDL-C) reduction in children aged 10 to 17 with heterozygous familial hypercholesterolemia.
    • Atacand—for hypertension in children aged 1 to 17.
    • Axert—for acute treatment of pediatric migraine.
    • Protonix—for erosive esophagitis in patients aged 5+.
    • Abilify—for irritability associated with autistic disorder in children aged 6 to 17.
    • Seroquel—for schizophrenia in children aged 13 to 17, and for acute manic episodes in children aged 10 to 17 with bipolar I disorder.
    • Zyprexa—for schizophrenia and for acute mania (bipolar I) in children aged 13 to 17.

 

 

 

  • An interesting perspective that I’ve talked about many times (without the research capabilities to analyze) is the correlation between sleep and chronic disease. They looked at this across states based on drug utilization and found a correlation (not necessarily causation).

 

So what do they say to watch:

  • Continued inflation in brand drug prices.
  • Majority of trend will come from specialty – oncology, orphan conditions.
  • Personalized medicine.
  • Biosimilars.
  • Generic pipeline.
  • Obesity epidemic.

 

  

  • They bring up an interesting issue relative to OTC (over-the-counter) product which is DUR (drug utilization review) which looks for drug-drug type interactions. They talk about the Medco Health Store integrating that data to monitor patients. [Do plans care? Do patients care? Should retail OTC purchases be integrated? How great are the interactions?]
  • They talk a little about obesity although I would love to understand more about how a plan sponsor should manage this.
    • 68% of adults are overweight; 34% obese
    • 32% of children are overweight; 17% obese
    • Medical spending on obesity related conditions is $147B
    • 19.5M adults (24-85) have diagnosed diabetes and other 4.25M are undiagnosed
    • Diabetic medical claims are forecasted to grow from $113B to $336B over the next 25 years.
  • I’m not going to spend a lot of time on personalized medicine here.  (A recent post of mine on this topic.)  They’ve been very active in this space for years talking about it. I think one of their interesting points in the Drug Trend Report is how Comparative Effectiveness will dovetail with Personalized Medicine.
  • Almost 2/3rds of people at risk for CHD in the next 10 years and eligible for lipid lowering drugs (e.g., Lipitor) were still not using them. (A common gap-in-care program run by many companies is to target these people (e.g., diabetics).)
  • Only 29% of patients treated for high cholesterol reach their cholesterol goal.
  • They have a section on wiring healthcare which David Snow has talked about for a while. It’s a critical area to address and has lots of opportunity.
  • They also talk about the concept of collaborative care (aka medical home…aka accountable care organizations).
  • I’m a big believer that poly-pharmacy creates issues (as does poly-physician). I don’t hear much talk about it. I was glad to see them talk about a study they did which identified poly-pharmacy issues, talked to MDs, and ended up with 24% of cases where medications were changed.

 

A Medco survey reported that 81% of participants with a new diagnosis, who received services at a traditional retail pharmacy, either did not receive counseling or were dissatisfied with the prescription drug counseling they received. When given the opportunity to speak with a Medco Specialist Pharmacist, 75% of these patients accepted the offer of immediate telephone support.

 

  • I thought it was really interesting to see a screen shot of their application used by the TRCs to create their Health Action Plans for consumers.

 

 

  • I was also interested in their focus on women’s health and some data on caregivers and the gender differences in healthcare. One of their TRCs is dedicated to addressing these differences.

 

Walgreens vs. CVS More Thoughts

This was definitely the hot topic yesterday. I talked to lots of people about it.

I had a chance to give it some more thought last night. A few things dawned on me.

1. Timing. This was timed well from a Walgreens perspective. Managed Care RFPs are mostly over and employers are making their decisions now on PBM services. Managed Care would have been more likely to focus on the cost and understand how to mitigate the disruption. Employers will be much more sensitive to the disruption. That will be something that CVS Caremark will have to manage.

2. Who wins. Since one analyst told me that Walgreens represents only a single-digit of CVS Caremark’s revenue, the impact may not be huge. On the flip side, it’s likely some downside for Walgreens since they’ll stop serving some portion of CVS Caremark’s business. Consumers aren’t helped here. So, my only conclusion is that the other PBMs (i.e., Medco and Express Scripts) are best positioned to win from this if it causes any CVS Caremark PBM decisions to go their way. At a minimum, it creates FUD (fear, uncertainty, and doubt) which no sales person likes to have to deal with.

3. Validation. If I’m the product manager for Maintenance Choice at CVS Caremark, this seems like pretty strong validation that the offering works. As Adam Fein showed before, it does drive volume to their stores. Obviously, Walgreens was afraid of this taking off and having a larger impact on them.

So…what would I do?

This is interesting since one of my last tasks at Express Scripts was to come up with a strategy in late 2005 around CVS and Walgreens backing out of our mandatory mail network. My strategy (which I ultimately left to pursue) was to respond by opening onsite clinics and building out a pharmacy kiosk system that could be put in grocery stores (only 50% have pharmacies), large employer campuses, and high density sites in big cities. While Express Scripts didn’t choose that path, I still believe there is opportunity there and CVS Caremark could easily implement such a strategy. [It’s starting to get momentum in Canada.] CVS Caremark (or Walgreens for that matter) have the technology and business model to implement on-site pharmacies and to create a central fill using kiosks. If those could mitigate the effect of the Walgreens decision, it could be an interesting response. [BTW – If you’re interested in my pharmacy kiosk business model that I ultimately wrote up and pursued with some angel investors, let me know. I may try to post some of it here later.]

On the other hand, another response would be to look at the top 5 MSA (market service areas) where Walgreens is stronger than CVS. I’m guessing those are NY (post-Duane Reade acquisition), Delaware (post-Happy Harry’s acquisition), St. Louis (CVS just started operating here), and a few others. They could go into those markets and buy up independents or some smaller chains to immediately mitigate this.

There are several responses short of just folding and putting Walgreens in the network. Ultimately, I think it’s about whether CVS and Walgreens see each other as “enemies” or just competitors. Do they want to grow the pie or do they want to put the other out of business (if such a thing were possible)?

More to come I’m sure…

Walgreens and CVS Caremark – Coming to Blows

I’m surprised this took the 3 years to play out. I talked about this back in 2007. Today, Walgreens announced that they would no longer participate with CVS Caremark networks for new networks and renewals. (See the CVS Caremark response here.)

Personally, I’m a little surprised they didn’t limit it just to the Maintenance Choice contracts which is where they have issues (like Mandatory Mail). Walgreens has fought for years against PBMs that implement models that limit choice.

I guess one of the big questions here is whether CVS Caremark allows Walgreens into their Maintenance Choice network. Walgreens (for example) has multiple 90-day networks. One which is just with Walgreens and one that includes other retailers.

Other questions I would have are:
1. Will CVS Caremark pull out of the Walgreen’s PBM network or their 90-day networks?
2. Will other retailers pull out of the CVS network?
3. Will Walgreens be more aggressive with other PBMs or can they only “fight” one at a time?
4. Will this help CVS Caremark focus their retail acquisition strategy to areas where Walgreens is stronger than them really creating a retail battle and less of a PBM battle?

I’m sure in some geographies (e.g., St. Louis, NYC) this may present some challenges where the CVS presence is not as strong, but in the end, most consumers have access to more retail pharmacies than they need and most PBM decisions are heavily influenced by price. If CVS Caremark can offer a price point that takes into account the disruption to the member base of not having Walgreens in the network, they can win. If that hurts them too much or they can’t do it, they’ll have to figure out how to make nice with Walgreens.

It will be interesting!

Do You Brush Your Teeth With Toilet Water?

While I hope not intentionally, this is a discusting reality for most of the world. Since most people flush with the lid up, the germs spread all over your bathroom. (One of the reason I hate those public toilets that auto-flush and cover you in germs all the time.) Here’s a good article on this along with a slightly humorous video below.

I was reviewing this list of worse places for your health that got me thinking about this. Here’s a few other highlights from the list:
* Don’t wear your shoes in the house and don’t store them in your closet.
* Don’t move hot food to the fridge to quickly or you’ll create a ripe environment for bacteria to grow.
* Don’t use the middle stall of a public bathroom.
* Don’t store your medicines in your bathroom.
* Don’t put your purse down on places you eat off. Nasty stuff on the bottom of those purses.
* Don’t use headphones in public areas with lots of background noise…you’ll turn the volume up so loud that you’ll damage your ears.

Behavioral Economics – Affirmative Choice – Organ Donations

You can call the framework whatever you want but forcing people to chose an option works. I think Organ Donations are a great thing and the data is out there to show what states should do to encourage this. In Colorado, 64% of driver’s license and State ID applicants signed up as donors. In Michigan and NY, less than 13% did. The 8 states who have rates in exceess of 50% all do the same thing…the employees at the motor vehicles department ask the people and force them to say yes or no.

Apparently there are some people pushing for “presumed consent” which would require that people opt-out. This is apparently done in several European nations, and while I don’t have an issue with it personally, I’m sure it won’t happen here.

This framework reminds me of the Select Home Delivery option which Express Scripts designed a few years ago, and I believe is the best product idea to come out of the Consumerology concept.

From Donate Life America:
* Top 5 states for participation – Colorado (64%), Iowa (63%), Montana (62%), Washington (57%), and Wyoming (55%)
* Bottom 5 states – New York (11%), Michigan (13%), Arizona (17%), California (25%), and Kentucky (26%)

Should You Spank?

There was an article last month in Time (5/3/10) that caught my eye titled “The Long-Term Effects of Spanking“.  I’ve never been a big fan of spanking, but I don’t have any issues with it either.  I was spanked a few times as a kid, but it was the exception not the rule.  I was surprised in another article to see that 22 states still allow spanking in schools.  I would have an issue with that.

This article talks about a Tulane study published in Pediatrics magazine which says that children that are spanked may act out more in the long run.  Those who were spanked at age 3 were much more likely to be aggressive at age 5.  Apparently, this was the first study to control for issues such as depression, alcohol and drug abuse, spousal abuse, and whether the mother considered abortion.   (All factors which apparently contribute to a child’s aggressive behavior.)  Controlling for those, spanking still was a strong predictor.

“The odds of a child being more aggressive at age 5 increased by 50% if he had been spanked more than twice in the month before the study began.”  Catherine Taylor, Tulane Professor

These children who had been spanked were more likely to be defiant, demand immediate satisfaction of their wants and needs, become frustrated easily, have temper tantrums and lash out physically against other people or animals. 

The American Academy of Pediatrics (AAP) does not endorse spanking under any circumstances.  They recommend time-outs which typically involve denying the child any interaction, positive or negative, for a specified period of time. 

Any interesting discussion topic and one that for many us probably demonstrates the shifting winds of our culture.  I don’t think I’ve ever discussed this with my pediatrician.  I guess I know what her answer would be.

Medco 2010 Drug Trend Report

Today, Medco Health Solutions released their 2010 Drug Trend Report (which looks at 2009 data). I haven’t had time to read the entire report, but here are a few highlights and comments from a conference call:

  • Overall drug trend was 3.7%. [They use their top 200 clients for analysis.]
    • Trend was 0.1% for clients with greater than 50% spend at mail.
    • Trend was 1.7% for Medicare.
    • [I still point out here that the question is whether trend is good or bad.] Dr. Epstein and David Snow pointed out that they work with clients on this to track metrics on adherence at the TRCs (Therapeutic Resource Centers) and report on this. The key here is knowing what classes show measurable impact to overall costs and outcomes by improving adherence and increasing costs.
    • Another point I thought was interesting was a comment that if the FDA saw the actual adherence on some drugs that require sustained utilization to achieve an outcome that they might make different decisions about drug approvals.
  • Inflation for branded drugs was 9.2% which was the highest in a decade. Generic inflation was 0.3%.
    • On a conference call, David Snow validated that this was associated with the tax on brand pharma so yes the high inflation on brand drugs was tied to reform. Someone asked a question about patent expiration (which historically drives prices up), but that doesn’t explain all the inflation here.
  • They saw a 3.4% increase in generic utilization.
  • Prescription utilization was up a minor 1.3%.
    • 5% for children 0-19.
    • 0.2% for seniors.
  • Specialty drug spending continued its rapid growth with a 14.7% increase including a 2.6% utilization increase.
  • Diabetes continues to be the largest driver of drug trend representing 16.7% of all drug spending and grew by 11.1%. [We can expect to see this continue to grow as more pre-diabetics are diagnosed.]
  • H1N1 drove up antiviral spending by 15.7%.
  • Pediatric use of medications grew faster than other groups.
  • 1 in 4 insured kids now take a medication for a chronic condition.
  • Increased utilization in kids occurred in diabetes, asthma, antivirals, ADHD, cancer, and rheumatology drugs.
    • There was a huge increase in diabetes over the decade (5x the adult population) and this was especially true with adolescent girls.
    • It’s amazing to me that you now have kids on lipids (high cholesterol), but it’s clearly an indication of the obesity issue. [We’re just at the tip of iceberg.]

  • ADHD surged for those under 35 – 9.1% increase in use leading to a 23.8% increase in spending.
    • The CDC says that 5M kids age 3-17 have and ADHD diagnosis.
    • [The other issue here is abuse of ADHD drugs.]
  • They also mention Nuvigil as a drug that could gain popularity for treating jet lag.
  • They forecast the drug trend will rise 18% thru 2012 driven largely by diabetes, oncology, and rheumatology.
  • About $46B in brand drug sales are scheduled to go generic by 2012.
  • They don’t expect biosimilars to impact the market until after 2012.
  • Not surprisingly, they showed a high correlation between states with frequent sleep deprivation and high drug utilization. As I’ve talked about many times, lack of sleep drives obesity which is highly correlated with many conditions. They also found a notable overlap of the use of Provigil (as stimulant used to treat daytime sleepiness associated with sleep apnea). [Seems like a drug that could get abused by college students like ADHD.]

“While H1N1 caused a spike in antiviral use among children last year, the far more alarming trend since the beginning of the decade is the increasing use of medications taken by children on a regular basis and in some cases, for conditions that we don’t often associate with youth, such as type 2 diabetes,” said Dr. Robert S. Epstein, Medco’s chief medical officer and president of the Medco Research Institute.  “The fact that one-in-three adolescents are being treated for a chronic condition points to the need for additional health education and lifestyle changes that can address the obesity issue that is likely a driving force behind such conditions as type 2 diabetes and even asthma.”

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Automated Call Nudge – WSJ

Yesterday’s WSJ had an article about some research done at Stanford about comparing automated calls and human interventions.  The goal was to see what motivated people to exercise more.  As you can see in the chart below, at 6-months automated calls produced better results while at 12-months they were below the human interventions.  But, an automated solution is obviously much more cost efficient and scalable.  The one big question I have is how to make the automated calls even more interactive.  There are lots of things we do at Silverlink to use automation to drive behavior.

While many are skeptical, the reality is that automated calls are the best channel in healthcare based on the cost per success ratio.  [Do you know any other channel that can get you a 70% “open” rate?]  You can deliver PHI.  You can track interventions for audit purposes.  You can have real-time access to data.  You can create rules based solutions that dynamically change based on interactions. 

And, this is not the first study Stanford has done on this.  Here’s links to two older studies they did:

Is Bad Debt In Healthcare Inevitable?

It’s an interesting question since there is quite a lot of bad debt.  I’ve certainly believed the default hypothesis which is that people can’t afford their healthcare out-of-pocket costs, but I know I’ve had several instances where I had delayed payment due to misinformation or provider billing errors that I tried numerous times to get fixed.

McKinsey’s new research suggests that I’m the norm (i.e., most people would AND could pay their bills).

  • 90% if <$500
  • 74% if <$1000
  • 62% if >$1000

Don’t Believe The Hype – Copay Waivers

Don’t believe the hype – its a sequel
As an equal, can I get this through to you
 

I talk about it all the time as most people do…non-adherence to prescription drugs is a real issue.  People don’t fill their initial script.  People who do fill their first script drop off after the first several fills.  By 12-18 months after a patient starts therapy, less than 50% of them are still taking their medications.  Here’s a few key articles on this: 

Common barriers to adherence are under the patient’s control, so that attention to them is a necessary and important step in improving adherence. In responses to a questionnaire, typical reasons cited by patients for not taking their medications included forgetfulness (30 percent), other priorities (16 percent), decision to omit doses (11 percent), lack of information (9 percent), and emotional factors (7 percent); 27 percent of the respondents did not provide a reason for poor adherence to a regimen.  Physicians contribute to patients’ poor adherence by prescribing complex regimens, failing to explain the benefits and side effects of a medication adequately, not giving consideration to the patient’s lifestyle or the cost of the medications, and having poor therapeutic relationships with their patients.  (NEJM article) 

Depending on what study you look at cost is certainly an issue, but it typically isn’t the primary issue.  I typically see cost as being a factor in 5-15% of the cases.  I think if you look at how Merck weighs cost in their Adherence Estimator that it is only a small factor.  A lot of this plays out in VBID (Value Based Insurance Design) which while not purely about copay waivers that certainly is an element of most solutions.  

A few friends of mine formed their own company (CareScientific) and had a paper published in AMCP recently.  From that article: 

  

VBID is receiving attention as a tool to increase medication adherence and lower medical costs. However, applying a “plausibility calculation” method to data generated from a recent VBID study involving reduction of drug copayments, this evaluation found that health plan sponsors are highly unlikely to experience net savings by implementing VBID programs, even under generous assumptions, for 2 reasons. First, the price elasticities of medications are too low to generate meaningful increases in medication adherence when copayments are lowered. Second, the potential reductions in the avoidable hospitalization and ER utilization rates across a commercially insured population with varying risk levels are generally not large enough to offset the additional plan costs of lowering copayments to increase medication adherence. 

I would also suggest looking at some of their tools that they’ve developed

So, getting back to how I’m tying in my reference to Public Enemy (rap musicians)… 

When I look at the upside for pharmaceutical manufacturers to grow the pie (get more Rxs through adherence), I often wonder why one of the default solutions is to fund copay waivers.  That happens by employers, health plans, and even the manufacturers.  There are many less expensive ways to get that lift by addressing things like reminders and tailoring information to individuals based on their personalized barriers. 

There are lots of high cost solutions that will make an impact.  The question is how to triage those resources to focus them on the right people.  It’s important to identify adherence risks (pro-active intervention) and adherence gaps (retrospective) and intervene with the patient.  

Here are a few of my other posts on this: 

 

The Facebook and iPod Generation

When I think of the current generation that is coming into the workforce, I think of people who:

  • Grew up with social media all around and are less concerned about privacy
  • Grew up with the ubiquity of technology having an iPod always on and being in constant communication with their mobile phone
  • Grew up with the US in a constant state of war – 9/11, Iraq, Afghanistan
  • Grew up with the idea of constant stimulus – portable video games, TVs in the car
  • Grew up with periods of market instability – technology bubble, 9/11, housing bubble
  • Grew up with a likelihood of living at home after college [and think that’s ok]
  • Grew up with more global awareness via CNN and the Internet
  • Grew up with allergies and general paranoia – no more leaving home as a kid and coming back when the sun set or eating peanut butter at school


I think the more typical perception of many of them is an overly privileged generation who can’t focus on one thing, expect everything (money, position, title, responsibility) regardless of whether they deserve it, don’t follow basic protocols (like a thank you after an interview), have been coddled their whole life, and have no respect for what others have done.  But I think every generation thinks that of the next generation.

I guess the official definitions are: (see good presentation)

  • Traditionalists – born before 1946
  • Baby Boomers – born btwn 1946 and 1964
  • Generation X – born between 1965 and 1981
  • Millennials – born 1982 to 2000

The Millennials are also called Generation Y, GenNext, the Google Generation, the Echo Boom, or the Tech Generation and are 76M strong. With immigration they are likely to surpass the Baby Boom generation in the 2010 census. [Note – Comments derived from reading an exerpt of The M Factor by Lynne Lancaster and David Stillman in the May 2010 Delta Sky Magazine.]


Their book – The M Factor – is focused on this generation. They talk about the fact that this generation is talking about and searching for “meaning” in their work. They’ve been raised by working parents that struggled with life balance and want more out of work for their kids. They see how work has become so engrained in our lives with Blackberries and other tools.

More than 90% of US Millenials said having opportunities to give back thru their company was somewhat to very important when considering joining an organization.

51% of young workers surveyed as part of the Kelly Global Workforce Index were prepared to accept a lower wage or lesser role if their work contributes to something “more important or meaningful”.

The question that a lot of this drives at is how do you leverage the passion and tech savvy Millenials as part of your workforce. They are going to drive changes. They are going to be innovators. And, they’re not going anywhere. Here’s a good blog on Generation Y.

It reminds me of some mock interviews I did a few years ago at my business school. I was stunned by some of the accomplishments of these people. They had founded companies and businesses. They had volunteered in the community. They were well read and had passion for things that I didn’t care about at their age. I was glad to have made it thru school with my peers. But, on the flipside, I talked with my friends who are the Dean of the School and run the Career Center to point out that not one of those people wrote me a thank you or sent me an e-mail. None of them ever asked me to help them find a job leveraging my network.

The article talks about this Millenial generation growing up at a time when the divorce rate had dropped and parents spent more time with their kids and transformed from authority figures to mentors and friends of their kids. This whole concept of “helicopter parents” has been explored in other areas and still amazes me. [Are you a helicopter parent test.] For example, 11% of US Millenials said they would feel comfortable involving their parents in salary negotiations. [If I had the option legally and a parent showed up with their kid for a salary negotiation, I would rescind the offer. If they can’t do that by themselves, how can I trust them to drive my business in pressure situations?]

In healthcare, the best example I always use for a company focusing on this generation or the “Young Invincibles” is Tonik Health which is a Wellpoint brand. I’m always surprised how few people know them. Take a look at their website (below) – the colors, the words, and the positioning is all so different than how most of us think about our health insurer. Here’s a good blog entry on the “millennial patient“.

Why is this relevant to my healthcare communications blog – because segmentation is so key to effective messaging. You have to understand this generation and how to engage them and drive them to take care of their health. Traditional language, modes, techniques, and messages may not work. The article (from the book) talks about their focus on feedback and scoring. They are used to constant [positive] stroking and having a score to evaluate success. They grew up being rewarded for everything. How does that manifest itself in a wellness system that tracks their good deeds (exercise, diet, preventative actions), provides them with rewards, frames their effort as contributing to the greater good, and integrates technology (e.g., connect devices)?

Only 3% of the people they surveyed said that Millenials handled negative feedback well. They haven’t been allowed to fail. This makes me think about one of my favorite quotes from IDEOFail Often To Succeed Sooner. You have to understand how to try, fail, learn, and try again to make improvements.

Here’s some recent research we’d done at Silverlink on the “young invincibles” and “Why I Have Health Insurance”:

Implications of Frugality as the New Black

I have heard some dialogue about consumers freeing up their spending even without their salaries going up or their house value going up (although their portfolio may have recovered by now).  But, the question is how the frugality that was learned in the past year will impact consumers long-term.  Will it change the way they buy?  Will that be true across generations or will this just have a major impact on certain generations that are just coming of age?

An article released by Booz & Company a few weeks ago has some interesting data in it.  For example, in the chart below, it shows 22% of people spending less on healthcare (drugs, supplies).  What does that imply – pill splitting, more generics, more mail order, lower adherence, less preventative care?  So are they more receptive to cost messages from healthcare entities?

Most of the consumers surveyed said they continue to consider saving more important than spending (65 percent). They sacrifice convenience for price (65 percent), frequently use coupons (65 percent), and, to a lesser extent, prefer the best price to the best brand (55 percent).

Maybe it’s time for the PBMs to emphasize convenience more – simplify your life, use mail order…one less errand to run.  I’m still skeptical that this would beat a traditional cost savings message.  BUT, perhaps it’ time to reconsider coupons / incentives.  They’ve been tried with limited upside over the years in pharmacy.  They do drive up results, but they don’t always pay for themselves.  Maybe a lower value incentive would have the same yield thereby increasing ROI. ???

They identify six segments of the population with this frugality filter:

AIS Quote Of The Day – 25 Years Of Health Efforts Wasted

 

“Other than on cancer, we’ve spent 25 years wasting our time on trying to reduce health risk. I think it’s been a disaster….We weigh more than we did 30 years ago, we exercise less than we did 30 years ago and we have more diabetic people than we did 30 years ago….” 

— Dee Edington, Ph.D., director of the University of Michigan Health Management Research Center, at the recent World Health Care Congress in Washington., D.C. [From today’s quote of the day from AIS]

Thoughts On Express Scripts 2010 Drug Trend Report

As one of my favorite annual projects during my time at Express Scripts, I love the drug trend report. It has been a historical benchmarking tool for the industry and become a normal deliverable for many of the PBMs. Here are my initial thoughts after reading this year’s document which looks at 2009 data.

Individuals often are not rational.

  • As driven by their Consumerology initiative over the past few years, Express Scripts has shifted the dialogue around the B2C components of the PBM industry to one of behavior change versus simply plan design. This report continues to reinforce that messaging.
  • Waste has been an ongoing drum beat since my days there. This continues to be the message with a shift to include non-adherence to channel mix and drug mix.
  • They talk about the Healthy People 2010 initiative and that key to closing “the last mile” in achieving our objectives is the ability to influence behavior.
  • One of my favorite charts is below showing the waste by class. Not surprising, plan sponsors should focus on heart disease, depression, high cholesterol, and ulcer disease. [Diabetes is not in the top four but is one of the typical areas of focus.]
  • Key Performance Indicators (KPIs):
    • Overall drug trend – 6.4%
    • Specialty drug trend – 19.5%
    • Traditional (non-specialty) drug trend – 4.8%
    • $800.23 PMPY average drug spend
  • The top five classes are:
  • Specialty drug spend is up to $111.10 (processed under the prescription benefit) with a belief that this is only 50% of the total spend which includes specialty drugs processed under the medical benefit.
  • The top specialty classes include inflammatory conditions, MS, and cancer which represent 67% of total specialty spend.
  • I was surprised to see the member contribution to the drug costs had gone down while the actual dollars had stayed flat.
  • I was also surprised that they found adherence (as measured using Medication Possession Ratio) stayed flat from 2008-2009. I think most of the information available had implied thru survey data that it was going down with the recession.
  • I’m having some difficulty reconciling the MPR analysis below with the waste argument. If 80% MPR is ideal and most classes are above 80% MPR, I’m not sure I see the crisis in the data.
  • One of the key charts that I always copied and hung on my wall is the one below. It shows the classes by rank, the utilization, the average cost, and now the estimated behavioral waste (generics and mail).
  • You should certainly go into the document and look at the class level detail. They’ve included a utilization chart by gender by age which I really like. The sections also give some insight into future pipeline. I think I’ll pull diabetes out into a separate post.
  • It’s interesting that they identify only three segments for non-adherent patients with specialty medications versus more on the traditional side:
    • Active Decliner
    • Refill Procrastinator
    • Sporadic Forgetter
  • They project that utilization will continue to go up at about 3% per year and that trend will be mitigated with new generics coming to market.
  • Another interesting analysis is where the waste is by state:
  • They have some information on their Consumerology approach, but I’ve talked about that before.
  • I liked their simple plan design primer:
  • Towards the end, they talk about some of the changes they’ve made over the past few years to their programs to reflect their consumerism approach:
    • Step Therapy Choice
    • Formulary Rapid Response
    • Call4Generics
    • Select Home Delivery (which is gem of their new programs in my assessment)
    • First Generic Fill Free
    • Select Curascript
  • A simple graphic that points to the importance of understanding the consumer and developing programs to effectively drive behavior is below. [This is very similar to all the work we do at Silverlink with clients to help them drive health outcomes and behavior.]

I like it. Very humanized versus purely statistical document. Good job Emily, Steve, Yakov, Andy, Bob, Brian, and Chris. (That’s the core group that I know well.)

Would You Like Some Food With Your Salt?

This is a good example of too much of a “good thing”.  The recommended daily salt maximum is 2,300 milligrams.  But, men consume 4,300 mg per day and women consume 3,003 per day (National Health and Nutrition Examination Survey).

What’s the problem?  Excessive sodium can lead to high blood pressure which is associated with strokes, kidney damage, and congestive heart failure.  The Institute of Medicine estimated that reducing sodium intake could prevent 100,000 deaths a year and save $18B in medical costs.

And, salt also contributes to the obesity crisis by creating a brain response that craves more and causes people to drink more soft drinks and alcoholic beverages.  Some big claims.

Sugar and Cholesterol

If you have high cholesterol, drink water NOT soda, juices, lemonade, sweetened teas, etc!  That’s my quick summary of the article I read

Of course we all know that sugar intake is linked to obesity which is linked with high blood pressure and heart disease.  I think logically many of us would know that sugar is tied to cholesterol but generally the focus is on reducing fat intake.  I simplistically think of it as the primary driver of my tricyceride levels. 

Based on the study just published looking at over 6,100 adults:

  • Participants consumed an average of 21.4 teaspoons of added sugars a day.
  • 16% of participants total calorie intake was from added sugars (compared with 11% in 1977-78).
  • People with higher levels of sugar intake were more likely to have low HDL and high triglycerides (blood fat).

The American Heart Association says that women should consume no more than 6.5 teaspoons of sugar a day and men no more than 9.5 teaspoons a day.  [A Coke has 16.5 teaspoons in a 20 oz bottle or 10 teaspoons in a 12 oz can.]

HealthEngagement Barometer 2010

Edelman recently published the results of a survey of over 15,000 people across 11 countries.

The study is interesting in terms of people’s opinions. Here’s a few highlights.

  • More than 50% of people believe businesses are doing a poor job of engaging in health.
  • 73% say it’s as important to protect the public’s health as it is to protect the environment.
  • 61% believe they need to do a better job of taking charge of their own and their family’s health.
  • Only the UK reads and shares less information than the US. 41% of people read health information weekly and 33% share health information weekly.

So, what do people mean by how businesses should engage?

One of the things that interested me was the slide about what motivates people to get active in their health.

While 58% of people use some form of digital media to research health, the majority use Google or some search engine. 34% of them (globally) use health company websites. [If this were limited to health plan or PBM websites in the US, that would seem high.]

I wasn’t surprised that fighting cancer was the most important issue, but I was surprised that privacy of information was the least important.

Express Scripts Drug Trend Report 2010

I knew the new report must be out when I had about 40 hits this morning on my blog based on Google searches for it.  Here’s the banner showing some segmentation.  I haven’t had the chance to read it and comment, but I will in the next 2 weeks.  You can search my blog to see my comments on all the PBM drug trend reports from the past few years.

[added later…my comments are now posted here.]

The Adherence Estimator by Merck

Merck did research that was published last year showing that their 3-question Adherence Estimator (TM) was 86% accurate in identifying patients at risk for nonadherence.  Pretty impressive. 

A copy of the questions are below and were on the Tuft’s website which also shows the scoring mechanism.  This is something patients can take to determine their risk or plans, PBMs, pharmacies, MDs, disease management companies, or others could use.