Enabling Healthy Decisions

So, URAC has decided to focus on accrediting PBMs. This caught my eye especially when one of the press releases I saw mentioned communications. With 70% of Americans receiving their pharmacy benefits through PBMs, perhaps this could have an impact. If you go look at the expectations for accreditation, I saw several interesting things:

1. There has to be a continuous improvement plan around quality (is that Six Sigma, Lean, BPM, or just a general plan?)…any option is good.
2. Does the PBM have the capability to disclose and educate members on costs and optimizing their benefit? (what about whether they do it…but key capability)
3. Is the member information at the right reading level and culturally sensitive? It would seem like you would want to require at least some multi-lingual capabilities in letters or via the call center.
4. How is over / under utilization monitored? Does this mean how do they drive compliance which is very complicated…but again a good objective?
5. Does the PBM have a medication therapy management (MTM) process? WOW. This would be great to offer beyond the Medicare Part D. Expensive to help members manage their total set of drugs and provide counseling from a pharmacist.

Overall, I think it has the right objectives. A lot of it is dependent upon communications. How does the PBM mine their information? When and how should they communicate with patients? What information do they push to them? What information do they provide for them? What channels do they use? How do they make a difference?

If taken to the next level, this could be a huge driver of consumerism in the pharmacy space by giving “points” (i.e., accreditation) to those that do it. Hopefully, it is more than simply having the ability to do it, but actually executing successfully on that capability. Then, some of the work I have been doing around data mining, optimization, and channel management of communications will be critical path.

If you don’t read The Healthcare Blog, you should.  It is certainly one of the best collections of information out there.  I constantly monitor it to see what interviews or opinions they have.

This morning I found a link to another blog which talked about Healthcare Transparency.  This is a fascinating topic especially since we talked a lot about this in the PBM world.  Brian Klepper (the blogger) presents a good discussion around a couple of key points (said in my words below):

1. Transparency is only legitimate if everyone understands what’s in the black box whether that is a quality calculation, outcomes data, cost information or any other issue.
2. We have to be pushing for data access so that people can make informed decisions and drive volume to the best value providers (quality/cost) that meet the standards of care.

There has always been a lot of push back from the large companies or individuals about revealing quality information or cost information.  That is what consumerism is about.  Think about mutual funds.  You know their positions, why they make decisions, their objectives, how much the fund manager is paid, etc.

I was doing some research on Guardian the other day when I ran across one of their products called “The Living Balance Sheet”.  This is a web-based, dynamic tool to help you organize, simplify and monitor your financial life.

This made me think…why not have this for healthcare.  In one sense, the Personal Health Record is meant to do this.  (I like the example from ActiveHealth).  In another sense, that only covers the organizing and simplifying part.  I don’t think that PHRs (myPHR, ihealthrecord, Misys, etc.) are meant to mine the data and push information to you.  Their original objective was not to be a virtual coach (from my understanding).

But, this is the opportunity.  Put lots of data in one place.  Add inteligence.  Add the ability to learn.  Blend in best practices.  Begin to weigh options based on costs and quality and possibly impact on your quality of life.

Wouldn’t it be great to log in somewhere and see how you were doing?  Are you making good choices?  How do you compare to your peers?  How can you improve?  Eventually, this could even link into clothes or other objects that push data real-time to the system.

SCENARIO: John – Thanks for logging in.  It appears your blood sugar is high.  You normally have a 10% spike every day at this time, but today you spiked 20%.  We have pulled together a personalized diet plan for you.  This should give you the nutrients required while also keeping your blood sugar low.  Some other options you might evaluate are…  And, if interested, we have benchmarked your  experience with diabetes versus others within your age group.  This can be sorted by geography, income, and other metrics if interested. 

Understanding what to do and its impact on your overall health would be great.  I remember using an interactive tool years ago that told you how old you were based on exercise, smoking, etc.  It was called RealAge.  Having a “score” about your health (e.g., BMI) would be a great Health Balance Sheet.

So, how does one define consumerism from a pharmacy perspective?  Let’s first look at the objective.  The objective of consumerism is to put information, choice, and responsibility in the hands of the patient.  To do this successfully, several things have to be addressed – knowledge, awareness, incentives.

The benefit of pharmacy is the timeliness of the data (real-time).

I believe  consumerism is made up of several different things:

1. Plan designs which include high deductibles and have Health Savings Accounts (HSA)s.
2. Content and tools that helps consumers make choices.  This includes information on plan design, on disease states, on drugs, on quality, on cost, and mostly on their options.  This is for pharmacy, providers, and general healthcare services.  The options here with all the consumer-driven healthcare vendors and the Web 2.0 technologies are significant.
3. Communications to educate and remind them.  I think of this as an event driven architecture where information is pushed to consumers around events when they need or want information.  Doing this effectively and in a timely manner is the key challenge.
4. Incentives and rewards to align the interests of the parties.  If you stay healthy and spend less resources, you should share in the savings.  It is a simple pitch to me.
5. A focus on prevention versus simply treatment.  This includes wellness programs and disease management.

Everyone is trying different things which is what makes this such a dynamic space right now.  Here are a few of the players:

1. WebMD
2. RevolutionHealth
3. ActiveHealth
4. DestinationRx
5. Definity Health
6. Metavante
7. ConnectYourCare
8. CareGain
9. Healthways
10. Lumenos
11. Amisys
12. PrecisionRx
13. RxEOB
14. Subimo
15. iBenefit
16. HealthEnvelope
    

I could go on, but there are numerous companies embracing disease management, wellness, HSAs, VBID, and many of the other concepts that are part of consumerism.  I welcome you to add other vendors to the list.  Thanks.

A study in the New England Journal of Medicine by James Fowler and Nicholas Christakis found some staggering results:

1. When people become obese, the risk of their closest friends becoming obese over the next 2-4 years increases by 171%; risk for casual friends increases by 57%; siblings by 40%; and spouse by 37%.
2. The reverse is true about shedding weight.
3. The weight gain/loss has a more direct affect on friends and siblings of the same gender.

This should teach us all something (or at least give us a hypothesis upon which to start) for marketing wellness and promoting change in the US.  As companies do when they want to drive change in the business community, focus on the influencers and let them drive behavior.  Now the question is whether this works for smoking cessation and other healthcare issues.  But, obesity is correlated with lots of problems – diabetes, heart disease, etc.

The power of social or viral marketing is strong.  Thinking through this as we look to how we help patients is important.

Tuesday’s (7/24/07) USA Today had an article on page 8D talking about Health Literacy.  Based on a study of 3,260 Medicare beneficiaries, the authors of an article published in the Archives of Internal Medicine found that “those with inadequate health literacy were 52% more likely to have died than those with adequate health literacy”.

This gets right to the point of healthcare communications.  It is critical to understand how to deliver information and what words to use.  Unfortunately, this applies to people even with health literacy such as physicians.  I have seen healthcare communications to go to doctors talking about fluoxetine and lovastatin (for example).  Since many doctors don’t know all the chemical names of drugs, they might not know that this was talking about Prozac (fluoxetine) and Mevacor (lovastatin).  When we provided generic samples to physicians, some of them didn’t use our first batch because it only had the generic name on it, and they couldn’t be 100% sure of what it was.

So, with patients this is even more critical.  When you are wrapped up in healthcare, it is easy to think that everyone thinks like you.  For example, a patient doesn’t understand what a renewal prescription is.  This is the term for a refill when there are no open refills on your prescription.  You can’t simply refill.  You have to get your physician to write you a new Rx (i.e., a renewal).

So, literacy has a micro issue which is clarity of terminology and simplicity of messaging to deliver valuable and timely information which consumers can take action on.  It also has a macro issue which is driving literacy in general such that labels, physician’s instructions, and other information is understood.

This could certainly be an argument for voice based communications for which I am a big advocate.  This could also be an argument for multi-lingual communications so you can avoid issues like once a day being interpreted as 11 per day (since once means 11 in Spanish).

Now here is a novel idea. I was shocked to see this little one liner in my Money magazine over the weekend. It didn’t say much else, but there is plenty of information available online.  Basically, Geisinger Health System is offering a 90-day warranty that covers all the follow-up (including re-admission) for heart surgery.

Even if some of this has been done before in healthcare, it is a key step in driving consumerism.  Translating common consumer practices (warranties) into healthcare is an easy model for us to understand.

The WSJ Blog on Healthcare

NY Times Article

The Doctor Weighs In Blog

Have you ever had to challenge your healthcare bill?  A prescription copay.  A reject at the pharmacy.  An overcharge from your provider.  A claim that wasn’t paid for some reason.

It can be a nightmare.  Given that my wife and I are both in healthcare, I think we understand the system and the codes well enough to figure things out.  But, I often wonder how many people overpay.  This is a significant problem.  If it takes me a year to fix something, how long does it take someone who doesn’t understand the system?

As you (the patient) bear more and more responsibility for your healthcare dollars, how will this play out in your relationship with your physician.  Will they negotiate with you?

I keep seeing articles in Money magazine and others encouraging you to do this.  Certainly, it can’t hurt.  Offering to pay them cash versus credit should have some immediate value to them.  A key question would be whether they truly understand the costs of their care.  I doubt they have some true cost accounting approach to help them understand.

And, do we have an established benchmark for negotiations?  I know that 10% off the MSRP for a car is a pretty good negotiation.  I know that 50% of list for furniture or jewelry is pretty good.  What is reasonable for healthcare services?  And, where do we go for quality information and the tradeoffs there?

It is an interesting question.  Without data for both sides, it is a complicated discussion.

CFO magazine had a good article about this a few years ago.  It posed the question differently.  “If all your employees have to research and negotiate their own care, what is the impact on productivity?”  Good question.