Enabling Healthy Decisions

A new book called Quiet: The Power of Introverts in a World That Can’t Stop Talking
recently came out. USA Today had an article about this in January (1/24/12). As an introvert, I find this very interesting and could associate with a lot of the points in the article.

I’ve actually found the Myers-Briggs Type Indicator to be very helpful in understanding my own behavior. I (like most introverts) can be extraverted for a period of time, but it is exhausting. If I don’t have time to recharge by being by myself, I will start to be very quiet…additionally as a thinker, I need to gather information and thoughts before talking too much. But, as the article points out, there is a difference between being shy and being introverted. [On the flipside, I’m a big believer in the IDEO model of ‘fail often to succeed sooner’ so I’ve learned not to overanalyze without acting.]

“Some shy people have social anxiety but are not really introverted, and plenty of introverts are not shy. Introversion has zero relationship with shyness.” Jonathan Cheek, a professor of personality psychology at Wellesley College

I think this list of attributes of an extrovert versus an introvert will help you understand which side of the equation you are more likely to fall on (source):

Extrovert:

• I am seen as “outgoing” or as a “people person.”
• I feel comfortable in groups and like working in them.
• I have a wide range of friends and know lots of people.
• I sometimes jump too quickly into an activity and don’t allow enough time to think it over.
• Before I start a project, I sometimes forget to stop and get clear on what I want to do and why.

Introvert:

• I am seen as “reflective” or “reserved.”
• I feel comfortable being alone and like things I can do on my own.
• I prefer to know just a few people well.
• I sometimes spend too much time reflecting and don’t move into action quickly enough.
• I sometimes forget to check with the outside world to see if my ideas really fit the experience.

On the flipside, shyness (per Wikipedia) is defined as:

In humans, shyness (also called diffidence) is a social psychology term used to describe the feeling of apprehension, lack of comfort, or awkwardness experienced when a person is in proximity to, approaching, or being approached by other people, especially in new situations or with unfamiliar people. Shyness may come from genetic traits, the environment in which a person is raised and personal experiences. There are many degrees of shyness. Stronger forms are usually referred to as social anxiety or social phobia. Shyness may merely be a personality trait or can occur at certain stages of development in children. Shyness has also a strong cultural dimension.

Next week, the FDA has called a meeting to discuss moving more drugs to over-the-counter (OTC) or behind-the-counter (BTC) status. This means that you would no longer need a prescription.

What would this mean to us as a consumer:

• No more need to meet with your physician to get a prescription (new, refill, or renewal).
  • Is this good or bad?
  • Will this drive more use of “Dr. Google”?
  • Will this create an opportunity for more use of home monitoring and home tests?
  • Will this drive screenings at clinics?
• Many pharmacy plans don’t cover products that don’t require a prescription so this may change coverage rules.

Some of the drugs that have been proposed for discussion include:

• High cholesterol
• High blood pressure
• Diabetes
• Asthma
• Migranes
• Allergies

At some point, we’ll just end up with a pharmacy benefit that focuses on specialty drugs. Everything else will be generic, OTC, or BTC.

Pharmacogenomics is the study of how genes affect a person’s response to drugs. It has taken a while for people to really understand how and why different people respond differently to the same medications, but I think it’s now commonly understood that people may react very differently to the same medication. In cases where this is dangerous or has serious side effects or is very expensive, the system is looking for new ways of intervening to leverage genetic testing and screening to determine when medications are appropriate.

But, the tests aren’t cheap and both patients and physicians don’t always understand when to use them. For example, Oncotype-DX is a genetic test for breast cancer that predicts the risk of recurrence. As a recent article in Employee Benefit News (Feb 2012) said, if you knew that you had a 3% chance of the cancer returning in the next decade, would you still choose to have chemotherapy?

The article has quotes from various people debating the use of testing and whether the ROI is there yet. But, I think there are more and more specialty drugs being approved with genetic tests, and it creates unique opportunities. For example, in Hepatitis C, if you knew the variation of the gene that the patient had, you could determine if they needed 24 weeks of therapy versus 48 weeks of therapy.

While oncology is a big focus area here, there are other areas such as Hep C, HIV, cardiovascular disease, RA, and high cholesterol where tests are either developed or being developed.

I was reading an article from PharmaVOICE (February 2012) on Dr. Deborah Dunshire who is the president and CEO of Millennium, the Takeda Oncology Company and thought I would pull a few things in here since I think the topic of “curing cancer” is very interesting.

“Our mission guides us to focus on translational medicine and personalized medicine, which means understanding the genetics of a particular patient’s cancer to guide the combination of therapies. It also drives us to prioritize our portfolio, and if a compound delivering a transformative benefit, we direct resources to another product that can.”

With early screening, more people living with cancer, and more open discussing of our healthcare, most people can now say they know one (or many) people with cancer so it’s an area that most of us can get very passionate about. Additionally, there is constantly new research around genetics in this area. And, from more of a cost perspective, it’s a huge driver of healthcare costs.

She goes on to describe their culture as one of intensity and caring (which sounds like the perfect healthcare environment). Compared to many of the stories you read today about traditional pharma having pipeline challenges and laying people off, this is a motivating interview about the opportunities to improve care for patients through personalized medicine and how bright the future is.

Apparently, the answer to this question is YES. It’s called “cold urticaria“. It’s a fairly new diagnosis, and researchers are not sure how many people have it.

If you have it, you’ll break out in hives after being exposed to cold air or water or even walking into an air-conditioned room. Sometimes, your hands will swell after holding a cold beverage or your lips will swell after eating cold foods.

Although not perfect, there is a test for this which is to hold a melting ice cube on the skin, remove it, and wait for a few minutes to see if hives begin.

Last week, I gave a presentation at the PBMI conference in Phoenix. My presentation was on Organic and M&A Growth within the industry. Of course, Express Scripts’ proposed acquisition of Medco and their dispute with Walgreens were front and center since no discussion could be had without discussing these two topics.

But, the industry is about more than that. I began my talk by addressing some of the topics that PBMs are discussing today from specialty to copay cards to integration of medical and pharmacy data. I leveraged my interview with Mark Merritt about the adaptability of the industry as key to the industries growth. I went on to talk about how the shifts in the industry were creating more opportunities for other players from OptumRx to CatalystRx and even causing some of the captive PBMs to look more aggressively at business in other areas.

And while everyone waits to see what happens with Walgreens, the reality is that Medicare Part D has shown that limited networks can work and that consumers will respond positively to them. Additionally, as many have predicted, consolidation will continue in the industry given the challenges that some of the fundamental traditional metrics are under. Mail order utilization has dropped for the first year ever. More than 50% of all 90-day prescriptions are now filled at retail. Generics continue to grow which is decreasing rebates and allowing for more cash business. The shining star of the industry is specialty.

The three big areas of opportunity are around consumer engagement leveraging data and new technologies (i.e., mobile), adherence (especially relative to Medicare Star Ratings), and new growth in the areas of Medicare and Medicaid.

Here’s a copy of my presentation:

TPAs are Third Party Administrators. You can see their definition in Wikipedia, but essentially they are companies that process claims, help manage risk, and often provide other functions in areas such as Flexible Spending Accounts for self-funded employers.

The key to TA success has always been. That TPAs provide intimate, personalized services to client-employers and plans. This means lots of hand-holding and assistance in understanding and gearing up for new laws, requirements and concepts as they will best fit for that particular employer or workforce.

. (Fred Hunt, past president, Society of Professional Benefit Administrators, Employee Benefit News, Feb 2012)

In general, the complexity of the regulated healthcare industry is good for the TPAs that specialized in helping their clients navigate this maze and create a customized plan that meets their needs. Of course, in this like other industries, TPAs are focused on using technology and other differentiators to demonstrate value for their clients.

I was reading the IBM executive summary called “From social media to Social CRM“, and I thought I would share some of my takeaways. (Note that CRM = Customer Relationship Management)

Social CRM “recognizes the role of business today is to facilitate collaborative experiences and dialogue that customers value.” Exciting! This seems like what many healthcare companies should be doing.

Some of their findings include:

• Nearly 80% of the online customers surveyed have at least one account on a social networking site
• Almost 50% have accounts on media-sharing sites
• Only 5% say they nearly always respond to others comments or post original content [creating a world of voyagers]
• Only 45% use social media to interact with brands…but the majority of those say they need to feel a company is communicating honestly before they will interact

There was a huge gap between why companies use social media and what customers want businesses to use social media for (as shown below):

Additional data points:

• Consumers who engage with a company via social media already have an affinity for the company or brand [key point…self-selection bias and identification of advocates]
• 70% of companies think social media will increase customer advocacy while only 38% of consumers agree
• Less than ½ of companies monitor their brand online
• Only 53% of companies offer social media training to their employees
• Only 27% of companies say they share social media insights across functional areas

As I read on into the details of the study, they share the Best Buy case study which showed $5M in reduced call center calls based on their social media strategy. They also point out that social CRM is about engagement not management which is another key point relevant to a lot of the healthcare discussions today.

Where are you on your social CRM strategy?

In preparation for my presentation on copay cards at the PCMA event on Wednesday, I read Mason Tenaglia’s article in Pharmaceutical Executive called “Letting the Facts Get in the Way“. I think it’s a good article from the manufacturer perspective to discuss copay cards. (You can see comments from Adam Fein here.) Perhaps if Mason and Visante could get together and share data we might actually have a full perspective of the marketplace.

Mason’s article is a frontal attack on the Visante paper on the topic that talks about copay cards increasing costs by $32B over the next 10 years (which by the way is less than $1 per Rx over that time period). But, I’m not sure it really clears up the debate for me. Let me discuss a few points.

• He talks about the APLD (Anonymous Patient Longitudinal Data) from Wolters Kluwer which can identify secondary payers. And, it can tell you if they were new to therapy, changed therapy, or simply were continuing therapy when they used the cards. This sounds great since everyone I’ve ever talked to said they can’t get to this data.
• He proposes that the Lipitor $4 program to extend the brand after a chemically equivalent generic is available is more an anomaly than a standard program. Perhaps. While I agree that the focus of many cards is in specialty (51% according to his estimate), if the Lipitor program works (still TBD), why wouldn’t others jump on board (which would likely increase costs to payers).
• He proposes that copay cards be used for Medicare Part D members (which most people tells me already happens). He also says that they’re the least adherent which is probably true based on total number of prescriptions which has been shown to correlate with lower adherence (not really their insurance).
• He states that most copay cards are used for Tier 2 (formulary) medications. It makes me wonder why the manufacturers pay rebates and use copay cards…which he alludes to in his article.
• He states that formulary access is attributed to marketshare which I think is true in a world of “me-too” products, but if products have new clinical value and better outcomes, they can get placed on a formulary without marketshare.
• He states that copay cards won’t drive up costs in Part D because over ½ of the utilization of brand drugs is by low-income patients where they won’t need a copay card for their $6.60 average copay. I personally disagree. I think that’s a red herring as this group is very price sensitive.
• Without giving away too much of my presentation for Wednesday (which I’ll post the slides and summary that day), he makes a key point but without the key data. “Combined medical and pharmacy costs in Medicare for oncology, rheumatology, and MS might actually be lower as a result of compliant patients.” The key word here is might. While I (like many) believe this to be true, I don’t think there are studies to support this. I agree that IF copay cards could demonstrate improved adherence AND that adherence could demonstrate lower medical costs and better outcomes THEN we would be having a different discussion.

It’s an interesting area. I’ll share a lot more thoughts on Wednesday, but I think Mason’s article is a good one for discussion on the topic.