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New Blog Post and Whitepaper…and Upcoming Presentation

For those of you that have followed me here, I thought I would share three things with you:

  1. I just had my first blog post published under the Deloitte brand on the Deloitte Center for Health Solutions blog.
  2. I recently helped lead the creation of a whitepaper on what topics health plans and payers should be working with their PBMs to address.
  3. I will be speaking on the topic of specialty pharmacy at the PCMA event in March.  I hope to see some of you there.
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Parkour Running And American Ninja Warrior

If you’ve never watched a video about Parkour running (aka free running), take a look at this video.

As a runner, I find this very interesting.  On the flipside as someone who can’t do a cartwheel, is afraid of heights, and has passed 40, this seems like a great way for me to hurt myself.

But, I find it really interesting that a TV show based on an obstacle course in Japan has really shined a light on this.  American Ninja Warrior is a very interesting show about athletes.  It’s like the Voice for sports.  They share the backstory and then have people compete on very difficult obstacles.  You see NFL players, Olympic athletes, trainers, stuntmen, and people from all walks of live.  I personally find it a great show to run on the treadmill with.  I feel very motivated.

I thought I’d share as this looks like a great type of program for kids to get them into obstacle course running and making exercise fun.  I know a lot of gyms around the country have started to offer these programs.

 

Internet Turns 25 – Looking Back And Forward

happy birthday

Wow!  The Internet turned 25.  Do you remember when you started using computers and technology?  I can.

I think my first computer was the Commodore 64 which we plugged into our home TV for a monitor and used a tape recorder to store files and access programs.

commodore 64

I can remember when we got 3 Macintosh computers to use at school.

first Mac

I can remember when we got our IBM PC Jr.

IBM PC Jr

After that, computers started being a little more common where we had them in high school for typing, but at the same time, people were using electric typewriters more than computers.  (I can’t believe that they still sell electric typewriters – see Wal-Mart ad.)

I can then remember being at the University of Michigan with massive computer labs of Apple computers.  At that time, I still remember using the Gopher technology that had been developed out of the University of Minnesota and pre-dated today’s Internet and HTML.

gopher

This eventually led to all the excitement about physical companies having websites and being able to do amazing things like order pizza online…the rise of e-commerce and eventually the dotcom bubble.

I still smile when I think that one of my first assignments in healthcare was to convince managed care companies to build a website.  I flew all around the country as a consultant with Ernst & Young LLP meeting with teams to convince them of what the Internet could do, why they should build a website, what functionality to put on it, and how to drive members to the website.

And, now, our kids grow up with this as normal.  Everything can be “googled”.  There is no card catalog to look things up or waiting to figure out why someone is late.  Things are instantly available.  (If you’ve never seen the list of what graduates will never remember, here’s a link to their 2017 graduate list.  Always interesting.)

So, I’ll wrap this up with a look at the future from a new report by PEW.  Here’s 15 predictions from their report:

1) Information sharing over the Internet will be so effortlessly interwoven into daily life that it will become invisible, flowing like electricity, often through machine intermediaries.

2) The spread of the Internet will enhance global connectivity that fosters more planetary relationships and less ignorance.

3) The Internet of Things, artificial intelligence, and big data will make people more aware of their world and their own behavior.

4) Augmented reality and wearable devices will be implemented to monitor and give quick feedback on daily life, especially tied to personal health.

5) Political awareness and action will be facilitated and more peaceful change and public uprisings like the Arab Spring will emerge.

6) The spread of the ‘Ubernet’ will diminish the meaning of borders, and new ‘nations’ of those with shared interests may emerge and exist beyond the capacity of current nation-states to control.

7) The Internet will become ‘the Internets’ as access, systems, and principles are renegotiated

8) An Internet-enabled revolution in education will spread more opportunities, with less money spent on real estate and teachers.

9) Dangerous divides between haves and have-nots may expand, resulting in resentment and possible violence.

10) Abuses and abusers will ‘evolve and scale.’ Human nature isn’t changing; there’s laziness, bullying, stalking, stupidity, pornography, dirty tricks, crime, and those who practice them have new capacity to make life miserable for others.

11) Pressured by these changes, governments and corporations will try to assert power — and at times succeed — as they invoke security and cultural norms.

12) People will continue — sometimes grudgingly — to make tradeoffs favoring convenience and perceived immediate gains over privacy; and privacy will be something only the upscale will enjoy.

13) Humans and their current organizations may not respond quickly enough to challenges presented by complex networks.

14) Most people are not yet noticing the profound changes today’s communications networks are already bringing about; these networks will be even more disruptive in the future.

15) Foresight and accurate predictions can make a difference; ‘The best way to predict the future is to invent it.’

 

How Aetna’s Pivoting With Healthagen – #whcc13

Do you know the term “pivot“? It’s all the rage now in terms of describing how companies continue to evolve their models with this rapidly changing business environment.

Of course, Aetna is one of the big healthcare players in the US. They’re not going to abandon a model that’s been working for well over 100 years. But, thanks to some great leadership from people like Mark Bertolini, CEO of Aetna, they’ve created a new business unit called Healthagen (building on the company they bought known mostly for iTriage). The screen shot says it all.

I got the privilege to sit down with Dr. Charles Saunders who runs Healthagen at the World Healthcare Congress in DC (#whcc13).

Charles E. Saunders, M.D., is responsible for leading the strategic diversification of Healthagen’s products, services and global opportunities. He focuses on identifying new growth opportunities and developing market strategies that can help Healthagen and Aetna profitably manage quality and cost for its customers.

Prior to joining Healthagen, Dr. Saunders served as executive in residence at Warburg Pincus, one of the world’s largest and oldest private equity firms. He has held a number of other significant leadership positions during his career, including CEO of Broadlane, Inc., President of EDS Healthcare Global Industry Solutions; Chief Medical Officer of Healtheon / WebMD; Principal of A.T. Kearney; and Executive Director of San Francisco General Hospital Managed Care Programs.

Dr. Saunders received a B.S. in biological sciences from the University of Southern California and an M.D. from Johns Hopkins University. He is board certified in Internal Medicine and Emergency Medicine and has served on the faculty of several universities, including the University of California, San Francisco; Vanderbilt University; and University of Colorado.

I also got to hear him speak right before I talked to him. (As a side note, he is a great presenter which is something that I really respect in a world of people who present too many slides, use notes, talk to the screen, and can lose you quickly.)

He hit on several key themes in his presentation that we then discussed further face-to-face:

  1. Social Caregiver Model
  2. Game Theory
  3. Digital / Mobile

One of my first questions was to really understand Healthagen and what it was set up to do. (As you can see from the screen shot below, they’re doing lots of things in this group.)

He boiled it down nicely to three things:

  1. Physician (provider) enablement
  2. Patient engagement
  3. Population Health Management IT

Our next discussion was really around why and how to create and innovate within a large company like Aetna. He reiterated what I believed that Mark Bertolini championed this new vision along with several of the other senior leaders. But, I think the key was that they recognized that issue of trying to do that internally and were willing to form a group to be different. To minimize bureaucracy for this group. And, to leverage their capital and assets to support this group. Not many big companies do this well. My impression is that Aetna is and will continue to be successful here. (Full disclosure – I own a minor number of Aetna shares and have believed this since I bought them about a year ago.)

Of course, in today’s market, there’s an explosion of innovation with questions on the short-term and long-term ROI of many initiatives and start-ups. With that in mind, Dr. Saunders pointed out that they don’t want to own everything. They want to create a plug and play platform of enablement. iTriage is a great example of this where they brought in a mobile technology with 2M downloads in 2011 and now have over 9.5M downloads of the tool (on top of massive increases in functionality and integration). You can download it here – https://itunes.apple.com/app/itriage-health-doctor-symptoms/id304696939?mt=8.

Certainly, one concern others have historically had in this space was how to own solutions and sell them to their peers (competitors). Dr. Saunders talked about their ability to do this with ActiveHealth and a perception that the industry is over that issue as long as Aetna can continue to demonstrate that they are good stewards of the data and are keeping the appropriate firewalls in place.

We wrapped up the conversation talking about the social caregiver and game theory. I think both are important in our mHealth / digital world. With the sandwhich generation, this is increasingly important. That is where Aetna is focusing…enablement of the caregiver for infants and seniors leveraging a social approach. This reminds me of their recent announcement of a pilot with PatientsLikeMe. We also talked about game theory and the role of that in healthcare which is a common theme from my discussion with Keas this morning and a theme from the overall conference.

It should be interesting to watch Dr. Saunders and his team and how Aetna continues to pivot.

Key Topics At #WHCC13 In DC

I’m at the World Healthcare Congress (WHCC13) in Washington DC this week.  This has always been one of the top 5 events for me to try to come to every year (admitting that there are a few like TED that I haven’t attended due to budget yet).

It’s interesting  how trends start to flow within a conference and how the trends change year to year.  This year, the key themes that I continue to hear are (in no order):

  • Engagement is critical.  Between MD and Patient.  Between social network / influencers and member.  Between employee and employer.
  • We have to get past the barriers to health enablement (i.e., legacy IT systems) and make change happen.
  • Game theory can help improve engagement.
  • Mobile tools are important.
  • Data integration has to happen and employers are doing it themselves.
  • Biometrics are critical path.
  • We can’t solve healthcare if we don’t solve health.  The community.  Our food choices.  Work / life balance.  (I would add sleep and stress.)
  • Rapid innovation.
  • Reform isn’t going to be easy on the employer or the employee.

But, since Twitter is my new note taker…here’s a few sets of tweets for you.

#whcc13 tweets whcc13 tweets3 whcc13 tweets2 whcc13 tweets1

Short Sighted View Of Freedom With NY Soda Ban

pouring-on-the-pounds

There are lots of fundamental issues here:

  • Was the law legal?
  • Does soda make you fat?
  • Should the government be able to steer you to positive choices?
  • Did this impact our freedom?

At the end of the day, I look at it very differently.  I think the proposed ban was great.  I was very annoyed last night to find out it was overturned.

Why?

  1. I don’t see this as any different than moving unhealthy foods to a less obvious place in the food line at school.  It simply was meant to help steer people to make healthier decisions.  We should all be thankful for someone helping us since we generally don’t seem to be able to help ourselves.
  2. Government has to be run like a business.  (It usually isn’t.)  Obesity is a big driver of costs.  It requires more power for public transportation.  It requires bigger chairs.  It requires bigger hospital beds.  It requires bigger ambulances.  And, all of us taxpayers pay for this.
  3. 80% of healthcare costs are driven by personal decisions that we make mostly around diet and exercise.  Since most people will end up on Medicare at some point, we need to change the cost curve in healthcare sooner rather than later.  Otherwise, we either bankrupt our country or we bankrupt Medicare.

So, enjoy your big 64 oz soda now, but when you’re 69 and Medicare has been rolled back to 70 due to funding challenges, you can smile and remember that you got to enjoy all that sugar for years without anyone trying to help you. (I can picture a great political cartoon here of the patient getting a healthcare bill looking over their shoulder from their wheelchair to see a big pile of soda cups!)  Never mind the fact that you’re bankrupt due to your healthcare bills and not able to walk around to keep up with your grandkids.

The Business of Obesity
Source: top-nursing-programs.com

FitBit Review Summary – Device, Apps, And Suggestions

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

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

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

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

Meal

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

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

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

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

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

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

Philips_Health_Infographic_12%2012_F3

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

Are You Going To The 2013 PBMI Conference?

Are you going to this year’s conference (February 18-20th) in Las Vegas? I’ll be presenting again this year, and I hope to see some of you there. If you’ll be there, let me know and we can connect.

This year, I’m going to talk about one of my favorite topics which is how the pharmacy industry needs to transform itself. This touches on several topics which I’ve blogged about multiple times:

  • Health reform and ACOs
  • Turning data into wisdom
  • Predictive models
  • Coordinating medical and pharmacy data
  • The role of the pharmacist in the broader care team strategy
  • Consumer engagement as fundamental to healthcare
  • Outcomes-based contracting
  • Population health management
  • Consumer experience

Do you have a specific example of how you see companies (pharma manufacturers, PBMs, or pharmacies) transforming from a traditional Fee-For-Service (FFS) model to an outcomes based model in terms of payment and how that is changing the way they do business? I’m always interested in learning more.

Here’s the official description from the brochure for the conference.

Pharmacy — Data, COEs, Predictive Models, and Consumer Engagement

George Van Antwerp, Vice President, Product Development, inVentiv Medical Management

ACPE UAN 0221-9999-13-009-L04-P 1.0 Knowledge-based contact hour

Pharmacy is the most used benefit, and for most chronically ill patients, they take multiple medications per day and interact with their pharmacist/pharmacy frequently. With the transformation in healthcare to an outcomes-based focus, PBMs, pharmacies, and pharma are looking at new models and new ways to work with payers, providers, and patients to be part of the care team. We will explore how companies are using this data and technology to intervene, change behavior, and improve outcomes from a broader population health management perspective.

Sandy Hook Tragedy – Gun Laws? Mental Health Impact?

The tragedy at Sandy Hook Elementary School was a shock for everyone.  In a connected world, it doesn’t take six degrees of separation to know someone who lost a child.  I’m only one degree away from several people.  And, for those of us with kids, it really makes you look at your school and their processes.

I wanted to take a moment to say that my thoughts and prayers go out to those families and the community and to capture a few thoughts.

moment of silence

General Thought #1:  While we have a clear gun violence issue in this country (see infographic below), we’ve been slow to make any meaningful changes.  Will this finally push us over the edge?  I’m not sure.  Certainly, those that like to own guns believe it might as you can see the sales of guns have spiked in the past few days.  This seems like an opportunity for Obama to create a legacy for himself by changing this paradigm.

General Thought #2:  The other big question or potential impact here is whether this will change the way schools or society in general deal with mental health issues.  Even at the simplest level, I think about the stigma placed on people on anti-depressants.  People who have depression don’t often openly discuss it, but the reality is that 16% of Americans are taking an anti-depressant (almost 1 in 5).  If you assume there are many others that aren’t diagnosed or aren’t medicated, it becomes a significant population.

Interesting Video: The one thing I saw last night from a 9-year old was the video below which wasn’t made about Sandy Hook but was released and dedicated to them.  It covers the broader topic of bullying and violence including school violence.

Gun Violence in America

Browse more data visualization.

iBlueButton Interview At The mHealth Summit #mhs12

I had a chance to sit down and do several interviews at the mHealth Summit earlier this week in DC. I’m slow to get my interviews posted, but they were all very interesting.

One of the best was with Dr. Bettina Experton (see bio below) of Humetrix. I will admit that reading about iBlueButton doesn’t do it justice. I was confused as to what they were trying to do and why it won an award. And, while explanatory after the fact, I found the graphic below intimidating as a consumer before talking with her.

[For those of you that don’t know what BlueButton is, you should go research it here.]

Dr. Experton explained to me how broad the BlueButton initiative now is. I only knew that CMS was using it, but apparently, there are now 200 plans also using it including Aetna, United Healthcare, and Humana. What Humetrix focused on for this offering was the mobile empowerment of BlueButton allowing the patient to have control of their information in the iOS platform (i.e., your Apple products – iPhone, iPad). They provide a tool for downloading and encrypting the data – prescription, medical claims, lab, and procedures.

iBlueButton

Of course, if you’ve ever seen what this data looks like in the raw form, this wouldn’t seem very helpful. Most of us wouldn’t know what to do with this. But, as Dr. Experton showed me, they’ve rendered the data in a great GUI (graphic user interface) that really brings it to life in a readable and understandable format. For example, they translate the NDC code (used for prescriptions) into the drug name with the chemical name and the dosage. The GUI is very iPod like in terms of simplicity and ease of use.

iBlueButton 2

The iBlueButton app even will pull in patient self-reported data from a PHR (personal health record) and show it in a different color and different section so the provider can understand the sources. Of course, this was another point of confusion for me before we talked which was how would a physician get this and what would they do with it. She showed me a demonstration of the patient opting to share their data and records with the provider in real-time. Of course, this assumes the provider’s office and/or the physician is actually using a device in the presence of the patient, but we know that is changing quickly these days. (See article on survey about MD use of iPad / iPhone.) So, with their tool, I can now store and share my data. The challenge still is integrating this data into the physician’s EMR (electronic medical record), but the iBlueButton app on the provider’s device can do this. It can also print it for those physicians who still want to see the printout in their paper file.

Another thing that you see in the second set of screen shots above is that you can start to report on whether you’re using the prescriptions still that it shows you on. Assuming patients engage, this would be a great tool for medication reconciliation and adherence discussions.

I’m not the Meaningful Use expert, but Dr. Experton pointed out to me that all of this is important since meaningful use requires viewing, downloading, and transmitting capabilities. They provide all of these.

I definitely plan to download iBlueButton and my data, and I hope to use this as a tool to reinforce why any claims provider should be offering you BlueButton access to your data. This is definitely a company to watch.

Bettina Experton, M.D., M.P.H.
President & CEO

Dr. Experton is the founder, President and CEO of Humetrix which she has led over the last 15 years on the HIT innovation path starting with the development of health risk appraisals, chronic care management software, and since the early 2000s with the development of novel mobile device-based solutions which have been deployed worldwide. A physician with over 20 years of healthcare informatics experience, Dr. Experton is the author of multiple information technology patents. At Humetrix, Dr. Experton also conducted groundbreaking health services research on the frail elderly which led to major federal legislation in the area of Medicare and managed care, and has been a national healthcare policy advisor in the US, China, and France. As a healthcare IT advisor to the French Ministry of Health, she made important contributions to the design of the newly launched French government sponsored single web-based individual health record with smart card access made available to French citizens and their physicians. Dr. Experton is an Adjunct Professor of Medicine at the University of California at San Diego, School of Medicine and a permanent member of the Faculty of the School of Medicine in Paris, after graduating Summa Cum Laude where she completed her training in Internal Medicine. In California, Dr. Experton received a Master’s degree in Public Health with a major in epidemiology from Loma Linda University School of Public Health, completed a Pediatrics internship at University of California Davis Medical Center and a Public Health residency with the State of California Department of Health Services.

What I Learned Day One at the mHealth Summit #mhs12

I only had time to attend one day of the mHealth Summit in DC. Overall, it seemed like a well attended event with a good vendor area.

But, what I saw left me with concerns about the maturity of the space.

1. Every vendor has their own portal. There was no idea of convergence or sensitivity to the care manager or provider or patient having to access multiple sites to collect data. Of course, there were a few exceptions.

2. There’s still some heavy lifting for the consumer, but it’s getting better. For example, one food application lets you scan in your food but that calorie counter isn’t integrated into any activity monitor. Another application was trying to monitor social activity for part of their depression algorithm but they weren’t leveraging the data sitting on the phone itself – numbers of calls, movement, etc.

3. There are some really creative solutions being tried but the scale of the studies is small. I was excited to see what was being done with obesity, but the case studies were less than 150 participants.

4. There are a lot of non-healthcare people jumping in which is great from an innovation perspective, but healthcare is tricky and making sure to apply consumer literacy filters to the clinical guidance you get is important. For example, I asked one vendor why he had several chronic diseases covered but ignored high cholesterol. He pointed out that he had a heart disease component, but IMHO I don’t know many people with high cholesterol that would self select into heart disease.

On the other hand, there were some really positive things.

1. The user interface on a lot of these is very elegant.

2. The devices are getting smaller and smaller with a few disposables on the way.

3. The data captured and reporting is really interesting and insightful although I’m not sure how it will all be used by patients, physicians, or companies.

4. Technology is much more scalable than people centric strategies which is critical in the US and globally.

5. Several companies really get it and are focused on device neutral approaches for capturing and disseminating data.

Overall, it reminded me of some of my concerns about the Health 2.0 movement a few years ago in terms of business models and distribution models. But, keep the innovation coming. It’s fascinating and thought provoking. But, there will definitely be a shakeout in the years to come.

Kroger Expansion – Digital, Physical, Strategic, and Specialty Pharma … Oh My!

Since one of my first jobs was at Kroger, I’ve always been intrigued to see what happens with them. (I can even still go back almost 30 years later and still have some of the General Managers at my old store come out and remember me.) So, I was initially intrigued a few weeks ago when the story came out in Drug Store News about their expansion plans.

“Over the course of a day-long investor conference Tuesday, Kroger outlined its future growth strategy. Across its physical store base, Kroger plans to enter one or two as-yet-to-be-named new markets along with boosting presence in existing markets. But Kroger also has significant designs on the multichannel consumer, and outlined for analysts the grocer’s plan to grow its marketshare across the digital landscape as well.”

Kroger has several interesting assets to leverage:

Now, with today’s announcement, they’ve made a jump into the Specialty Pharmacy Space with their acquisition of Axium. It begs the question of what they want to be – a grocer with a pharmacy, a pharmacy with groceries, a health destination, or something new.

Looking at some JD Powers data from 2010, they are positioned in the middle of the pack from a pharmacy satisfaction perspective.

On the other hand, if I look at their positioning from Bruce Tempkin’s analysis, they score well.

I have to believe there’s some great opportunity here. I’m a big believer that the retail assets create large opportunities for them to play in the broader healthcare market.

  • They have broad hours (in some cases 24/7).
  • They are natural destinations for people.
  • They can host clinics.
  • They already have pharmacies.
  • They have food which is a critical part of addressing obesity and for certain conditions like hypertension and diabetes.
  • They have patient specific data around things like home monitoring tests, food products, OTCs, and other products.
  • They are generally located in easy access locations.
  • They have good brand equity.

For example, just look at this press release from Target from a few years ago. This is a broad vision (that I’ve never heard or seen in the market). On the flipside, we know that CVS, Walgreens, and WalMart are spending considerable efforts trying to really “own” this space with their teams. We also know that specialty pharmacy (and even pharma in general) is trying to see how it gets out of its box and become broader players in the health continuum looking beyond just drugs to actual outcomes. (This is why healthcare is so exciting right now!)

Should NY Hold The Marathon This Weekend? (SuperStorm Sandy)

This seems like an interesting question, but one with perhaps a straightforward answer. With NY and NJ devastated by Superstorm Sandy and almost 4M still without power, should NY try to hold their marathon this weekend? Seems like a clear no to me.

I do understand the fact that this is a big revenue event for the city.  I do understand that you want to show your ability to recover from the storm.  BUT, it takes resources – volunteers, police, hotels, food, and other efforts to pull this off.  Wouldn’t those resources be better focused on the people that are still trying to dig out of their homes and get power?

 

Scary Infographic On the Effects Of Soda

The scariest stat in here is that kids ages 1 and 2 are drinking soda on a daily basis.

Now, the fact that we’re fat and drink too much soda isn’t the soda’s company’s fault.  We drink soda of our own free will, but this is a contributor to our obesity and this is why the NY soda law makes sense.  (And, IMHO, this is why the soda companies supported removing their drinks from schools and went into the business of selling non-soda beverages…they know there are issues regardless of what they say.)

Soda Infographic

Discussing Oncology Prevention With Dr. Hawk From MD Anderson #WHCC12

Last week, I had a chance to sit down with Dr. Hawk right after his presentation at the World Health Care Congress (WHCC). Dr. Hawk is the Vice-President and Division Head for Cancer Prevention and Population Sciences at the University of Texas M. D. Anderson Cancer Center. He’s been there since late 2007 when he came from the National Cancer Institute.

My favorite point from talking to him was…

Cancer is a process not an event. Communication is critical.

In his presentation, he talked about several things:

So, after his formal presentation, we talked about several things.

  1. One of the big focus areas for MD Anderson is prevention. As we know from research, many cancers are preventable. And, the promise of personalize medicine and genetic testing is beginning to help us understand these cancers and their treatments even more.
    1. Primary – this would include lifestyle changes such as diet and smoking which help prevent the disease
    2. Secondary – this would include screening and detection to help slow the progression of the disease
    3. Tertiary – this would include the focus on the patient (not the tumor) for treatment and helping them with quality of life
  2. He talked about how cancer is really 200 different diseases to be understood and managed.
  3. He gave a great analogy about how CVD (cardio-vascular disease) evolved and talked about how all the individual risk factors became asymptomatic diseases which have led to all the “know your number” campaigns around lipids and blood pressure.
  4. We talked about cancer as a process which led us into the discussion about palliative care and shared decision making. He made another good analogy here about driving a car. We need to understand the value of wearing our seat belt and having insurance, but we have to make the final decision about whether to do that or not.
  5. We talked about personalized medicine including genomics and epigenetics. We talked about how this impacts dosing and understanding of the tumor. (Interesting in a conversation with another person in this field this week they were telling me about how tumors and viruses change over time and those implications on genetic test results.) We also talked about SNPs and the complications in getting validation in studies due to sample sizes. We wrapped up this topic with discussions on coordinated registries and work that companies like 23andMe are doing.
  6. Our final topic of discussion was around clinical practice algorithms and how evidence-based medicine (EBM) gets implemented. We talked about the use of guidelines and how those allow for monitoring the use of EBM standards. We also talked about the need for integrated EMRs that would allow for benchmarking and linking outcomes to use of guidelines.

This is a fascinating area. Cancer affects most of us either directly or through some family member or friend.

Interview With Laurel Pickering NEBGH At #WHCC12

Yesterday, I sat down with Laurel Pickering, MPH who is the President and CEO of the Northeast Business Group on Health.  This was a great follow-up to the session she moderated with PEBTF and CalPERs and allowed me to validate my list of focus areas for employers(Note: I did not use a tape recorder and have translated our dialogue into the discussion below so while it is based on my discussions with Laurel these should not be considered specific quotes.)

The first thing we discussed was the concept of ACOs (Accountable Care Organizations) and how employers think about them (or similar concepts).  She talked about the fact that most employers don’t understand the ACO framework in specific.  They may have heard something about the idea of a medical home or mention of the ACO, but they are more broadly focused on the conversion to an outcomes-based future.  Initially, there are some leading edge employers and coalitions that you hear talking about these concepts at conferences, but in general, employers are going to look to their payors to lead this effort and think about how to embrace these new quality and payment frameworks.

We then talked about what are the issues that keep her up at night.  In general, we focused on three things:

  1. Reform – What is the future of healthcare reform and how will that impact employers?
  2. Cost – How can we control costs both direct and indirect?  And, what is the role of prevention in cost management?
  3. Engagement – Even if we understand how to control costs, how do we engage consumers to take action?  Is it through incentives, gamification, social media, mobile, or other tools?

We then talked about incentives and paying consumers (employees) for healthcare actions.  She described three phases here:

  • Phase I: Payment for completing and HRA (which many companies have done for several years).
  • Phase II: Payment for completing specific screenings and participating in programs for which the patient is engaged (i.e., respond with the case manager calls you).  (This seems to be a rapidly emerging standard with many employers.)
  • Phase III: Payment tied to achievement of different outcomes (weight loss, BMI, smoking cessation, blood sugar, blood pressure).  (This is a lot further off and much more complicated, but it’s something that people are beginning to look at.)

We wrapped up with two topics – new technologies and ROI.  In today’s environment, everyone is looking at mobile health and telemedicine.  The question of course is how to get these tools used, paid for, and demonstrating the ROI.  From a technology perspective, we talked mostly about the idea of the “digitally naive” (i.e., people under 16 today) for which technology is the norm.  They’ve never experienced life without mobile phones and computers and Google.  As this generation becomes patients, they won’t think twice about using technology as a way to see their physician and monitor their health.

From an ROI perspective, this has become a table stake to play.  Everyone requires some case study for use.  But, we had a great discussion about the flexibility of calculating ROI and how companies do look beyond just the simple avoided medical costs.  They look at presenteeism.  They look at satisfaction.  They look at overall

8 Common Employer Healthcare Themes #WHCC12

I had the opportunity to listen to some heads of HR a few weeks ago and then sit in on an employer session yesterday at the World Healthcare Congress here in DC.  It was interesting the common themes that clearly were emerging from the presentations by PEBTF and CalPERs along with the event I was at before.

  • Incentives
  • Biometrics
  • Evidence-based medicine
  • Steerage of consumers to lower cost “Centers of Excellence”
  • Reference-based pricing to address unwarranted variation
  • Cost / transparency tools
  • Consumer engagement
  • Integrated care

Took A New Job With inVentiv Medical Management

As some of you know, I’ve taken a new job.  I just joined inVentiv Medical Management which is a company focused on reducing care costs and improving health outcomes quality for self-insuring employers, their employees and family members.  One of the exciting new products that they launched before I came is called Accountable Care Solutions.  Here’s a description from the press release:

Powered by a combination of clinical and financial algorithms and evidence-based decision-making rules, inVentiv Medical Management’s Accountable Care Solutions ensure that physician-ordered procedures are the best option from a treatment effectiveness and patient risk perspective. The new suite of solutions includes Comprehensive Oncology Care Management(TM), Comprehensive Cardiovascular Care Management(TM) and Comprehensive Kidney Care Management(TM). These Accountable Care Solutions offer customers – such as third-party administrators, employer groups and reinsurance carriers – best-in-class resources to effectively and efficiently enhance healthcare quality, while reducing overall costs of medical claims and improving patient outcomes.

Why Blending Rx and Dx Data Matters

Yesterday at the PBMI conference, I was listening to a presentation on the blending of pharmacy and medical data. This has been the Holy Grail for a while although companies have struggled to do it well and successfully use it to affect change. That being said, I think it’s one of the biggest focus area for differentiation in the market today. From a large PBM perspective, you can look at the Guided Health efforts at Prime Therapeutics. From a payer software perspective, you can look at Active Health.

Some of the examples from yesterday were interesting data points that you’d never see without digging into both sets of data. For example:

  • 84% of patients using PPIs chronically had no clinical diagnosis to support that
  • 67% of patients taking CNS stimulants had no clinical diagnosis to support that
  • 31% of patients taking atypical antipsychotics had no glucose monitoring
  • 60% of patients taking a psychotropic drug didn’t have a clinical diagnosis
  • Of course, the challenge is not only to identify them but to engage the patient and the provider in the best course of treatment looking at cost, outcomes, and patient experience.

    My PCMA Presentation On Copay Cards

    I’m giving my PCMA presentation in FL right now about copay cards. For those of you that can’t attend, here is my executive summary and a copy of some slides. (My actual slide deck was shorter for presentation but this gives more data to those of you looking online.)

    I focused on three key points:

    1. Copay cards are a direct threat to the PBM model. They can run against the idea of copay differentials and formulary tiers. Since they’re not allowed at mail order, they create a disconnect there. And, eventually, I believe they will be in conflict with rebates (i.e., why pay for both).
    2. The cost numbers to the payer are huge ($32B according to Visante) although this is less than $1 per Rx over that 10 year time period. But, it’s concentrated on 3% of all scripts which makes it a big deal.
    3. There should be a win-win IF they are concentrated on specialty medications with a link to improved adherence and health outcomes.

    There doesn’t seem to be clear data (although another article says it is available) but the general data shows that availability and use of copay cards is growing rapidly.

    Investing in copay cards seems to be based on four myths:

    1. Cost is a large issue in non-adherence. It’s an issue but not the dominant issue.
    2. Costs will influence physician choice. The reality is that they don’t know the costs and see this as a pharmacist issue.
    3. Copay cards are a cost effective way to improve adherence. They get about a 10% improvement in MPR which sometimes produces a positive ROI. There are much lower cost ways to get a similar improvement.
    4. Copay cards can delay conversion to generics. This is still in the air with the Pfizer Lipitor program, but if it works, it will be a lightning rod for PBMs and payers to focus on.

    This topic’s not going away. For now, the easy PBM response is to close down the formulary, move more scripts to mail, and implement prior authorization programs. I would expect this will happen more often unless there is more transparency here around what’s happening and the benefits. Things like ZQuiet can, indeed, help one to stop snoring when used correctly.

    Adam Fein From Last Year’s PCMA Event On Copay Cards

    Just revisiting what Adam Fein talked about last year as I work on my slides for this year. 

    Speaking at the upcoming PCMA Event

    I just got added to the agenda for the February PCMA event so look me up if you’ll be there.  I’ve spoken on the topic of copay cards a few times for AIS in the past.  Since then, there have been a few significant events:

    • The Pfizer Lipitor strategy and push around a copay card.
    • The PCMA study on the impact of copay cards.
    • CVS Caremark’s changes to their formulary of which some were attributed to the existence of copay cards.

    As always, I welcome comments, articles, suggestions, or data to support this discussion.  It is certainly one where there is limited data or facts.  Thanks.

    Presenting at PBMI in February

    I am excited about the opportunity to present at PBMI in February.  I hope many of you will be there.  If you want to meet up, send me a quick note at gvanantwerp at mac dot com.  Thanks.

    Here’s the description of my presentation:

    The PBM industry continues to consolidate through mergers and acquisitions.  At the same time, new PBMs and niche PBMs continue to grow.  While the majority of the green space is gone, there is increasing focus on the individual market through exchanges and the Managed Medicaid market.  But, this maturing of the market has forced PBMs to look at more organic growth opportunities also.  How do you retain business?  How do you innovate?  How can you increase profitability per member?  With a few large market dynamics playing out in 2012, we’ll begin to look at what the future might hold and what we can learn from the past.  It is an interesting time for all PBMs, pharmacies, and manufacturers as they embrace the role of pharmacy in improving overall health outcomes.   

    2011 Blog Overview and Press Hits Update!

    2011 was a great year for the blog with over 120,000 visits and 365 new posts (conveniently averaging 1 per day).  You can see the top posts here.  The blog led to several new opportunities at Silverlink, and it generated numerous press opportunities. 

    The blog now has over 400 people who get an e-mail every time a new post is published.  The content is then syndicated to the 930 people who follow me on Twitter and to my 1252 contacts in LinkedIn.  I’m happy with this for something I do in my spare time.

    In August, I shared my press hits YTD which numbered 25 times.  Since then, I’ve had 27 more which are listed below:

    1. Dec 26th issue of Health Plan Week about Express Scripts and Walgreens
    2. Jan 1st issue of Managed Healthcare Executive on limited networks
    3. Dec 2nd issue of Drug Benefit News on Lipitor
    4. Dec 2nd issue of Drug Benefit News on Prime Therapeutics Retail MTM solution
    5. Dec 2nd issue of Drug Benefit News on PBM Deal Making
    6. November Frost & Sullivan newsletter on consumer engagement
    7. PBMI Report
    8. Nov 11th issue of Drug Benefit News on Pfizer’s Lipitor strategy
    9. Nov 11th issue of Drug Benefit News on the PBMI Report
    10. Oct 28th issue of Drug Benefit News on OptumRx
    11. Oct 28th issue of Drug Benefit News on CVS Caremark case study
    12. AIS webinar on copay cards / coupons
    13. AIS webinar on PBM outsourcing
    14. Oct 7th issue of Drug Benefit News on Outcomes-Based Contracting
    15. PCMA Smart Brief on Oct 5th regarding PBM disclosure of profits
    16. Sept 23rd issue of Drug Benefit News on Mobile Apps
    17. Sept 23rd issue of Drug Benefit News on Anthem study
    18. Drug Channels mention of my post on the Prime Therapeutics Trend Report
    19. PCMA Smart Brief on Aug 11th re: NY bill
    20. Sept 9th issue of Drug Benefit News on the Prime Therapeutics Trend Report
    21. Sept 9th issue of Drug Benefit News on the proposed Express Scripts acquisition of Medco
    22. Sept 9th issue of Drug Benefit News on Generics
    23. Aug 22nd issue of Health Plan Week on Generics
    24. Aug 24th Reuters article on the proposed Express Scripts acquisition of Medco
    25. Aug 19th mention in Health Reform Watch
    26. Aug 19th issue of Drug Benefit News on Part D
    27. Presentation with Aetna at the Care Continuum Alliance on engaging the hard to engage

    Barrett Toan To Speak At PBMI Spring Conference

    Barrett Toan who was the motivating force behind building Express Scripts has been gone for since 2006 when he stepped down as Chairman of the board.  He is now the chairman of Sigma Aldrich here in St. Louis and active in other pursuits.  I was excited yesterday when I heard from Brenda Motheral, the Executive Director at PBMI, that Barrett had agreed to speak at their conference (register here). 

    While I never got to work with Barrett as closely as I would have liked to, I was on several projects with him.  I was always amazed by both his passion for the industry and the patient along with his ability to move from both the macro-vision to digging down into the details.  It should be fascinating to hear his view on where the industry is today and all the changes that have happened.

    And, that should add to the agenda they already have which includes Gilbert Welch, the author of Overdiagnosed, Kjel Johnson from Magellan, Stacy Dow from Whirlpool, and Dr. Troy Brennan from CVS Caremark

    The focus of the agenda this year is on specialty which is obviously front and center for all of us.  The one concern that I have had in the past was around attendee mix.  It always seemed like the PBMs talking to each other, but Brenda told me that so far ~75% of the registrants are plan sponsors and that the actual number of plan sponsors registered already exceeds last year.  This would be a big and very positive change. 

    Brenda also mentioned several other key topics – 340B, MTM, eRx, generics, consumerism, OTC, and Rx and Dx integration.  Of course, I’m sure there will be discussion from their survey which I reviewed earlier, and they will be releasing their new specialty survey at the event.  I’m planning to attend, and I hope to see you there.

    Candy For Cash (or Toys)

    Is this what Halloween looks like at your house?  A big pile of candy!

    Similar to the guns for cash program that many police departments have done, we’ve developed a candy for cash program at my house.  The kids can get as much candy as they want and eat a few pieces tonight.  But, they then have to pick their favorite pieces and can keep about a gallon ziplock full of candy.  For the past few years, we’ve actually taken the candy to ToysRUs and basically given it to the cashier as we buy something.  The kids think it’s actually being used to buy the toys while we both get rid of the candy and gives them some incentive not to rot their teeth and eat unhealthy amounts of sugar for months to come.

    Do You “Give A Spit”?

    R.jpg

    Have you seen this new campaign from BeTheMatch.org?

    Only 2% of the US population is registered.  Are you one of them?  I am.

    There are 10K people who need a transplant.  Whether you organize an event or just get yourself registered, you can help save a life!

    Words Matter: Doodling – We Should Foster It

    As someone who was trained as an architect, I understand the value of sketches in the design process and have always “doodled” as I try to conceptualize what people are describing with words.  With that in mind, I really enjoyed this TED video and think it’s a good message for all of us in the communications field.

    Post ESRX/MHS Merger – How Many Big PBMs Are There?

    This seems to be one of the critical questions in the evaluation of whether the merger should go through.  We’ve always talked about the Big 3 PBMs – Express Scripts, Medco, and CVS Caremark.  If that’s the market, then going from 3 to 2 seems like a huge deal.

    But, I think the market has and is changing.

    • What about OptumRx (formerly Prescription Solutions)?  Once the lives formerly managed by Medco are insourced in 2013, this is going to be > $20B company (I believe) which is part of a huge company (United Healthcare).
    • What about Prime Therapeutics?  They manage over 14M members (I believe) and have been actively bringing in lots of new management from other PBMs as part of their growth strategy.
    • What about SXC and CatalystRx?  They both have shown their ability to win against the “Big 3” and grow.
    • What about “captive PBMs” like Humana and CIGNA?  I think they would both want a bigger crack at the lives outside their insured book of business.
    • What about MedImpact?  They manage 35M lives today.
    There are dozens of other PBMs that have shown success in the market – ReStat, WelldyneRx, Navitus.  I guess it also depends on whether you view the market as just PBMs or you look at it for drug spend in which case cash patients play into the mix and you look at what companies like Walgreens, Walmart, CVS, Target, and RiteAid do.  [One could hypothesize that in a >80% generic world that cash is really the dominant method since insurance discounts matter much less and the role of the PBM or PBA is more around claims coordination for utilization management and DUR.]
    Ultimately, I think it boils down to whether size gets you unfair advantages in pricing and discounts (i.e., rebates, acquisition cost, network discounts).  I would suppose that Worker’s Compensation is an area to look at where there are dozens of smaller WC PBMs competing with Express Scripts – MyMatrixx, PMSI, CypressCare.  What’s their experience been?

    Today’s session in DC will certainly be interesting.

    [As noted before, I both own shares in some of the companies mentioned here and do business with others and/or seek to do business with the companies mentioned here.]

    Anonymous Pharmacy / PBM Survey

    There are lots of big things going on in the industry right now.  I’d love to get some of you to give your opinions.  I figure the easiest way to do this is a few anonymous survey questions.  Please weigh in…

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