Enabling Healthy Decisions

The 5/26/14 edition of Forbes has a great article on Novartis called “Will This Man Cure Cancer?”.  It’s an interesting article and Novartis has really ramped up their focus on Oncology with their purchase of Glaxo’s Cancer drugs.  And, they recently got FDA approval for a lung cancer drug of theirs.  

The article talks about Joseph Jimenez’s leadership at Novartis and highlights several interesting things:

• A focus on speed to stop having to turn patients away from a possible cure.
• Cancer drugs already represent $11.2B of Novartis’ $58B in sales.
• Novartis has a 33% stake in Roche which has $31B in oncology sales.
• Gleevec was it’s big breakthrough oncology drug that Jimenez’s predecessor believed in and has been so successful that it’s a $4.6B drug where they’ve been able to quadruple the price.
• It talks about transforming the campus working with architects like Frank Gehry and moving research to Cambridge, MA.

There is some discussion on a new therapy that they’re working on based on some initial trials which uses CARTs (Chimeric Antigen Receptor T-Cells) to attach cancer.  At the same time, Juno Therapeutics is on the same trail and raised $175M in their first round to research it.    

I really liked one quote from Jimenez in the article that seems to imply a focus on the end goal not necessarily whether they win.  

“You look at a company like Celgene, and you know they’re going to figure it out.  And they should figure it out.  It will be good for patients.  We want to beat the competition, but we’re really using the competition to trigger us to get to the patient.”

He goes on to talk about the issue of pricing especially around oncology drugs (but also applicable to specialty drugs in general).  He calls it “a new brutal world” because costs will go up with the aging population and new medicines which will cause more backlash against price.  He talks about looking at how to be innovative about pricing which could be interesting.  

This is definitely worth a read.  They have it nicely packaged up with a slide deck also once you register.  Here’s a few highlights.

Look at the gap between perceived value and satisfaction with clinical programs offered by specialty pharmacies.

Look at the huge jump in plans to educate physicians.  

Look at the different adherence management strategies.  I’m amazed at the low percentage using an outside vendor but the huge perceived effectiveness.  

Look at some of the benefit strategies that companies are planning to use.

This is an interesting one that shows that companies are really going to focus on controlling specialty benefits in the exchange world in the future.  

This shows the variation in terms of coverage (medical versus pharmacy) for different categories of drugs.

There’s more in the deck and report, but these should be enough to tease you to read more.  

I always enjoy Bruce Temkin’s reports and analysis.  He just came out with his latest report on customer service.  

It’s not a healthcare focused report so you have to gleam a few things from his summaries although you can buy the report to see the details by company.  Without doing that, I thought I’d point out a few things from his charts.

1. Humana was the most improved (of all companies) in terms of customer service.  Great job.  Coventry (which was bought by Aetna) had the biggest drop (of all companies) in terms of customer service.  [Perhaps not a big surprise as integrations can always be tough.]

2. As it has in past years, healthcare continues to be at low end of the spectrum in terms of customer service.  While you can divide up the market into pharmacies, physicians, hospitals, PBMs, and insurance companies (with many other players out there), one of the biggest groups which is covered in the survey is health insurance companies.  They fall below airlines and way below other types of insurance companies – i.e., auto / home.

3. Five of the bottom 20 companies he highlights on his blog are all health insurance companies.  [But, you’ll have to click through to see who!]

Seems like a great opportunity for someone to help those and the entire industry to think differently about customer service and consumer engagement.  

“Hubbub is a technology-driven online playground and mobile wellness solution that uses social circles and gamification to motivate and engage people in healthy behaviors.”

Several people have suggested I take a look at what Hubbub Health is doing so I did.  At first glance, there were several things that caught my attention (beyond the interesting teaser description of the company):

• Lots of unconventional language in how they talk (reminds me of the Wellpoint Tonik Healthcare business from years ago)
• A direct to consumer model where you can download the app and use their tool AND a $3 PMPM (per member per month) model for employers which includes additional services like health coaching (most people aren’t in both markets)

Of course the question is whether this is just another one of many mobile companies making a play in healthcare or whether they’ll actually survive for a few years and get traction.  

But, Hubbub isn’t just another one of the many wellness vendors out there.  They’re part of Cambia Health.  You’ve probably still never heard of them, but Cambia is Regence which is a BCBS plan operating in Oregon, Idaho, Utah, and some counties in Washington.  Additionally, they own and/or invest in lots of companies – e.g., HealthSparq, GNS Healthcare, OmedaRx, and Wellero (plus Hubbub).

So, this gives them some instant credibility.  And, it’s an interesting time in the market.  The Population Health Alliance (which used to be the Care Continuum Alliance) recently put out a post looking for contributions around “Return on Value” or VOI (Value on Investment) which is the focus these days in Population Health Management. 

This sounds a lot like what you see in the presentation and white paper by Hubbub.

What was more interesting was some of the foundational elements upon which Hubbub was built like:

• Cognitive Evaluation Theory
  

Cognitive Evaluation Theory (CET) concerns intrinsic motivation, motivation that is based on the satisfactions of behaving “for its own sake.”  Prototypes of intrinsic motivation are children’s exploration and play, but intrinsic motivation is a lifelong creative wellspring. CET specifically addresses the effects of social contexts on intrinsic motivation, or how factors such as rewards, interpersonal controls, and ego-involvements impact intrinsic motivation and interest. CET highlights the critical roles played by competence and autonomy supports in fostering intrinsic motivation, which is critical in education, arts, sport, and many other domains. (source)

 

• Self-Determination Theory

Self-Determination Theory (SDT) represents a broad framework for the study of human motivation and personality. SDT articulates a meta-theory for framing motivational studies, a formal theory that defines intrinsic and varied extrinsic sources of motivation, and a description of the respective roles of intrinsic and types of extrinsic motivation in cognitive and social development and in individual differences. Perhaps more importantly SDT propositions also focus on how social and cultural factors facilitate or undermine people’s sense of volition and initiative, in addition to their well-being and the quality of their performance.  Conditions supporting the individual’s experience of autonomy, competence, and relatedness are argued to foster the most volitional and high quality forms of motivation and engagement for activities, including enhanced performance, persistence, and creativity. In addition SDT proposes that the degree to which any of these three psychological needs is unsupported or thwarted within a social context will have a robust detrimental impact on wellness in that setting. (source)

Those are foundational for a lot of the work in healthcare, and I liked this graphic about motivation. 

Whether the app works and captures my attention is still TBD.  I did download it and register, but I didn’t really get engaged upon registration.  And, the website seemed better than the mobile app, but it still had a few issues in terms of how the large top image dominated most of my screen on my laptop.  

At the end of the day, their key role like anyone in this space is to figure out how to engage the consumer (or patient or member or individual) as validated in a study they use.

In the spirit of the Internet of Things and the Smart Home, I was intrigued by a short article I read about Menssana Research which can identify 2,000 chemical compounds from our breadth…including signs of cancer and radiation exposure.  Pretty cool!

I guess this explains how dogs can detect diseases in humans. 

Of course, my mind jumped to the idea of how you could use existing devices (like Nest) which would be tied into our HVAC system and could monitor the overall air in an entire house and look for risks based on the air.  (like my idea of the smart toilet)  Maybe that’s a little too scary like why an underwriter wants your cell phone data or too much like the Snapshot from Progressive.  And, while on the one hand it’s cool, I’m not always sure we’re ready to know things too much in advance so the question would really be how early is the device identifying people and how accurate is it.  

This statement alone should scare anyone as you think about all the new consumers coming into the healthcare system.  That will only stress the system more leading me to believe we’ll see bigger drops in satisfaction in the years to come.  

This data is from the latest American Customer Satisfaction Index (ACSI).  You can see a blurb on them below along with the full ranking of different industries.  Not surprising, healthcare isn’t at the top, but let me highlight a few of the categories:

• Ambulatory Care = 79
• Health and Personal Care Stores = 79
• Hospitals = 76
• Health Insurance = 73

In general, I found the industries to be very tightly clustered.  I’m going to reach out to them to see how to interpret that.  

About ACSI

The American Customer Satisfaction Index (ACSI) is a national economic indicator of customer evaluations of the quality of products and services available to household consumers in the United States. The ACSI uses data from interviews with roughly 70,000 customers annually as inputs to an econometric model for analyzing customer satisfaction with more than 230 companies in 43 industries and 10 economic sectors, as well as over 100 services, programs, and websites of federal government agencies.

ACSI results are released throughout the year, with all measures reported on a scale of 0 to 100. ACSI data have proven to be strongly related to a number of essential indicators of micro and macroeconomic performance. For example, firms with higher levels of customer satisfaction tend to have higher earnings and stock returns relative to competitors. Stock portfolios based on companies that show strong performance in ACSI deliver excess returns in up markets as well as down markets. And, at the macro level, customer satisfaction has been shown to be predictive of both consumer spending and GDP growth.

I’ve been thinking a lot about the excitement of being an entrepreneur or an innovator and how that compares with being a consultant.  While I could find a few articles out there comparing these two career paths, I thought I would share my observations.  

I think the two have some of the same fundamentals:

1. Self-motivator – In both cases, you have to able to drive yourself.  You’re responsible for your career and your success.  You’re always under pressure to perform, and you’re typically part of a small, core team.  It’s important that you can motivate yourself to push past the finish line.  I think of both like running a marathon.  
2. Quick learner – Your role in both types of organizations is constantly changing.  You’re adapting with the business and the market.  This requires the ability to understand and see trends.  It requires the ability to connect with clients and monitor the market.  It requires the ability to learn new things and to have a desire to learn new things.  
3. Able to pivot quickly – Change is a constant in almost any role in business today, but the pace of change in the start-up world is amazing.  You need to understand this pace of change and how to be a change agent in both these roles.  How do you help people with the organizational change that’s required to make your project a success.  
4. PPTS – No…this isn’t being an expert at PowerPoint although that may be an important skills.  PPTS stands for People, Process, Technology, and Strategy.  You need to understand all four of these areas of the business.  You don’t have to code to be a great consultant or entrepreneur, but you need to understand technology and its impact on business.  
5. Think and do – While there are a few opportunities to just develop strategy and move on or to simply operate an outsourced project, I think you need to understand how to take ideas from concept through implementation.  This means that you understand how to work with the CEO and how to work with the call center agent.  
6. Motivational – Most entrepreneurs and consultants are somewhat evangelistic and they’re always involved in the selling process (in any role).  They are selling and building ahead of the curve which means they have to compel people to act.  They are also working with multiple vendors and cross-functional teams that don’t report to them.  Success is dependent on their people skills and the ability to motivate these different groups.  

Agree?  Disagree?  Thoughts?

After working at Express Scripts for almost 5 years and then selling into the PBM industry for almost 5 years, I’ve had the chance to lead and work on a ton of very interesting projects:

• Electronic prescribing
• Generic sampling
• Generic promotion – DTC, plan design, utilization management
• Formulary support programs
• Mail order promotion – mandatory mail, retail-to-mail, 90-day
• Prilosec and Claritin going from Rx to OTC
• Adherence
• Pill splitting
• $0 copay / VBID

I’ve found that I love business development (working with clients and vendors).  I enjoy bringing ideas from concept through pilots and then determining how to scale them.  I love doing research and presenting.  I enjoy working cross functionally.  I enjoy leading teams and pushing the envelope to get people to think different.  Ultimately, I enjoy solving problems.  I like being the person who’s brought in with a business challenge and can then figure out the solution – do the research, evaluate the options, create a plan, implement the plan, and create a process of continuous improvement.

So, after spending 2 years working in the care management side of healthcare and learning about case management, disease management, claims code editing, and other solutions to manage complex patients with cancer or chronic kidney disease, I’m ready to jump back into the pharmacy industry (specialty, PBM, retail, pharma, payers or related companies).  (And, I’ll be bringing a lot of lessons learned with me.)

I think the industry is going through another inflection point which is what Mark Merritt from PCMA pointed out a few years ago is the core skill – adaptability.  If you think about the trends, I think there are several key things that make this an interesting time to be in the industry.  And, everyone is fighting commoditization by trying to differentiate themselves.

• The focus on specialty will make integration between care management and traditional PBM services critical.
• The complexity of care is driving a huge focus on evidence based medicine (e.g., Best Doctors or Eviti) which will eventually lead to companion diagnostics and personalized medicine.
• Pharma is trying to figure out their role in this new world and will start looking at creative ways to blend product and services (e.g., Merck’s investments in Vree Health).
• The market is full of change with new technologies and new start-ups that will lead to more unique mash-ups, and I still think you could see Google Health come back in some form.
• Medication adherence continues to be such a huge opportunity that no one’s cracked with over 100 vendors that I identified, and no one has figured out how to fully integrate medical and pharmacy benefits to address specialty medications.

And, the fundamentals are good for the industry.

1. The PBMs are big and need to grow so they’ll have to do some creative things.
2. People continue to get older and take more medications.
3. Health reform is forecasted to grow the market by over $200B in the next 10 years.  (from recent CatamaranRx presentation on their investor website)

Of course the question is what to do…

All of these things sound interesting, but here’s what I’m going to focus on:

• A company with an entrepreneurial (or intrapreneurial culture).
• A role working directly with clients (no Ivory Tower role).
• A mission driven organization which wants to change the world and improve outcomes.
• A passionate leader and team that I can learn from.
• A leadership role where I can help a PBM or payer (or a group of them as a consultant) help make this transformation.  Some of the roles that would interest me would be:
  • MD strategy
    • Adherence
    • ACOs
    • Shared risk
    • Evidence-based care
  • Consumer experience
    • Journey mapping
    • Consumer advocate
    • Incentives
    • Gamification
    • Plain language
    • Patient Activation
  • Consumer engagement
    • Multi-channel coordination (print, web, IVR, mobile, SMS, F2F, telehealth)
    • Big data
    • Segmentation
    • A-B testing
    • Social media
  • mHealth / Care coordination
    • Risk and segmentation algorithms
    • Coordination with caregivers and providers
    • Remote monitoring
    • Working with clinics and telehealth
  • Beyond The Pill
    • Obesity
    • Chronic Kidney Disease
    • Oncology
    • Diabetes
  • Innovation and business development

(If you know of something interesting, let me know.)

Short answer = they appear to understand the customer experience.

Obviously some companies like CVS and Walgreens are both retailers and pharmacies.  They are clearly in the healthcare business and with CVS stopping selling cigarettes, they are clearly trying to show their commitment to healthcare.  

Other retailers like Walmart are clearly in the pharmacy business.  They’ve also done lots of different programs around healthcare, and there are always rumors of more.  And, they are also in the grocery business.

Target is an example of a retailer that has gotten into the pharmacy and clinic business and now in the grocery business.

Kroger is a very traditional grocery store company who has had pharmacies (like about 50% of grocery stores) and has made several steps to get into the healthcare space.  

I tee this up because whenever I see the Temkin Experience Ratings I’m always amazed that the grocery chain with the worst experience rating is similar in value to the best healthplan experience.  

I think by now we all understand that the healthcare experience actually matters…and will matter even more in an exchange world where they have more freedom to find a plan that works for them.  

We’ve  seen some companies focus on this (e.g., Cigna with their Chief Experience Officer who is now the Chief Experience Officer at Prime Therapeutics).  You can see PWC’s report on this and also compare different industries to healthcare.  You can go and visit this deck on 13 great healthcare experiences.  At the end of the day, the healthcare experience is one leg of the Triple Aim and is a key opportunity for differentiation.