Enabling Healthy Decisions

On one of those rare days when I have a chance to clean my office, I figured I would post some quick things that are in my “Blog Pile”. In no particular order, here are some of the things I ripped out of magazines, printed, and/or otherwise captured and meant to write about.

• Kids affect your blood pressure
• US obesity rate leveling off
• Find a bright spot and clone it (Switch book)
• Interesting 2×2 grid in Spirit Magazine called “State of Attraction” which shows which states keep people and which states have lots of non-locals
  • 76% of Texans never move
  • 86% of Nevadans were born elsewhere
• Pew Research Interactive tools
• British researchers at Keele university found that swearing can actually help increase your pain tolerance (seems like a story a kid tells parents)
• Biotech was the #1 funded area for VCs in Q2-2009 (Med Devices #3, Healthcare Svcs #14)
• 17% of us respond to spam (come on people)
• A new metric – EVA Momentum
• An Arms Race of Goodness (how are you positioning your company?)
• The Gene Bubble
• Google Wave (seems like lots of buzz, but I haven’t heard much)
• Rebranding Nurses
• Money Matters, but relationships play a part in happiness
• 7 Digital Fitness Coaches
• What Health Reform Means for the States
• Fat Fees and Smoker Surcharges
• Overparenting
• Why Your DNA Isn’t Your Destiny

Anyways, a few things you should read and look at.

Healthcare is by its nature a service business.  Your experience matters.  If you don’t get your script on time from mail order, you’re upset.  If you come back to pick up your script at retail and it requires a prior authorization, you’re annoyed.  If you have to wait to see your physician when you had an appointment, you’re upset.  If your bill is wrong, you’re upset.  If your care isn’t covered due to some loophole, you’re upset. 

But, some companies recover better than others.  And, some companies do a better job of empowering their frontline employees.  Let me just give a few non-healthcare examples to make my point.

• Recently, I stayed at a Marriott property (which by the way is my favorite chain).  This was for personal travel, and I had reserved two adjoining rooms.  They not only didn’t have the adjoining rooms, but they didn’t even have two rooms.  It wasn’t the end of the world, but we crammed into one room.  The staff at the hotel weren’t apologetic and didn’t do anything to note their mistake.  Instead, I had to escalate it to the senior team at Marriott to get resolution.  Now, once I sent the e-mail, it was less than 12 hours before I had gotten e-mails and several calls admitting their mistake and making amends.  But, this could have been solved by the front desk staff.
• In another case, I was at a different Marriott property a few months ago on vacation.  We also had two rooms, but only one of them was ready at the 3:00 check-in time.  The other one was only 30 minutes late, but we’d been waiting around since 11:00 to get into the room.  They immediately sent up a food snack to apologize, AND when the waiter heard my kids say “I wish they’d just brought us some gummy worms”, he was back in 10 minutes with a platter of gummy worms and other candy.  It probably cost them $5 to make us happy, and we quickly recovered from the inconvenience.

Little things do matter.  The best example in healthcare that I’ve ever heard was from a plan in the Boston area.  A spouse called up to ask some questions about a hospital bill they had recieved.  The associate on the phone realized it was for a heart surgery and asked how the patient was doing.  The woman responded that her husband had passed away and she was trying to address his finances.  The associate expressed her regrets and asked the woman to hold for a few minutes.  When she came back, they chose to waive the payment due.  I think that’s overly generous, but it makes the point.

I know at Express Scripts that we empowered many of our call center agents to be able to offer a minor (I think up to $10) coupon or waiver for inconveniences at mail order.  But, all the research shows that companies that recover from service issues are more likely to create loyalty over time.

And, I find it strange that companies don’t follow-up when loyal customers churn.  I had used Avis (for example) for well over a decade and was generally very happy with them.  About 12-months ago, they changed their inventory management model to be more real time which led to more waiting after I got to certain rental lots.  I put up with this for a few times until I was late for a meeting since they didn’t have any cars for me.  I’ve switched the majority of my business now to Hertz which while a little bit more expensive doesn’t have this issue.  But, Avis never reached out to me.

I’m sure this is the politically incorrect way to look at this, but it’s how my mind immediately works. A new drug – Provenge – was approved by the FDA. It’s a vaccine for men with prostate cancer that gives them (on average) four additional months of live.

The drug costs $93,000 for the 3 shots. So, $93,000 for four months or $279,000 for a year [although you don’t really have that option].

I wonder what a life insurance company puts as value on a year of life? Or the courts?

Who should bear the costs of this drug? The insurance company? The individual? Medicare (taxpayers)?

Or, another complexity…I assume the drug doesn’t work if you don’t take all 3 shots. Of course, it’s going to have side effects – fevers, chills, and headaches. Will patients want to spend the last two years of their life with those side effects for the few additional months of life?

What if they get the first shot at $31,000 (1/3^rd of $93K) and decide not to get the additional shots? Assuming that makes the first shot a total waste of money, should they bear some responsibility for that? Could you make them pay $3,100 (10%) for the first shot and nothing for the future shots or some other way to make their costs front loaded?

I’m sure population health is one of those terms that means nothing to a consumer but is actively used within the healthcare system. Disease management is one of the old terms which is subsumed under this phrase. I think wellness is synonymous with it. But lots of older terms like case management fall under it. [In my humble opinion]

I had the chance to sit down with several leaders in the space and talk about their companies while I was in DC earlier this week.

I talked with Rob Webb (CEO of OptumHealth Care Solutions), Mike Tarino (President of DSM Personalized Nutrition), Stuart Slutzky (Chief Mktg Officer at The Vitality Group), and Calvin Schmidt (President of J&J’s Wellness and Prevention Group). There were some definite similarities in what they all were focused on and their thoughts about reform, but each of them certainly had a different perspective. Here’s a few of my takeaways from the conversations.

The Vitality Group:

• They are more of a start-up here in the US, but they have a lot of interesting experience from work in South Africa and the UK. [I’ll admit that while I liked some of their ideas a lot I’m a little more of a skeptic about the easy of leveraging learnings outside the US to our unique environment.]
• He talked about the fact that places like Europe have a greater awareness of the benefits of Wellness so the ROI / sales process is different.
• I liked the fact that in South Africa they developed a discount program with the largest grocery chain. For Vitality members, they get a 15% discount (or 20% if you have completed an HRA). I believe this is just limited to healthy foods which seems like a good motivator.
  • This reminds me of another company Linkwell which is doing some interesting programs here in the US. I talked with their CEO about using grocery data to identify what people buy and rather than trying to radically shift their buying patterns simply move them to a healthier alternative within the same category (e.g., frozen foods).
    
• They have a partnership to expand within China.
• In one of the countries, they have developed a link to life insurance so you get discounts for participation and staying active.
• They link incentives to outcomes based on 14 different risk factors and 30 different factors that they track.
• They’ve integrated with gyms like LifeTime Fitness to track your use of the gym. They’ve also integrated with several devices. The goal is to remove access barriers.
• We talked about the difference in the “value” of points between the US and South Africa. In SA, you earn discounts as your status increases (like an airline). In the US, you earn Vitality Bucks which you can cash in for free stuff.
• They don’t want to focus on certain fixed outcomes because people are different and they want to offer a non-discriminatory path to success.
• We talked a lot about corporate culture, using incentives appropriately, and developing a communication plan for how this is rolled out and engagement is sustained.
• This seems like a lot of work to finalize integrations especially as healthcare can be local in many cases. He said it only takes about 60-days.

DSM Personalized Nutrition:

• This is a newer group within a large global entity.
• They are looking at how to use nutrition to create health from disasters (i.e., Haiti) to Olympic athletes (e.g., faster recovery formula).
• They deliver employer solutions around wellness and how to most effectively drive lifestyle change.
• I asked him naively if nutrition equaled diet. He pointed out that it was broader than that. It was what you eat, how much you eat, when you eat, and the supplements you take.
• As I’ve talked about before, this is a personal area for me. We digressed several times to talk about the challenge of changing diet versus exercising more. (Only about 2% of people can lose weight without changing what they eat…something I learned a few months ago.)
• I asked him who they competed with which is a broad area since there are a lot of companies out there now competing for wellness dollars.
• I asked him about Jenny Craig and Weight Watchers who seem to be moving into the employer space. He said that they were focused on performance not just on weight loss, but he did talk about the Biggest Loser type competitions and challenges that are part of a cultural change.
• One of the most interesting stats was when he asked me what the average calorie intake difference was between someone who was of a healthy weight and overweight…I would have thought about 500 calories. What do you think? (See bottom for the answer)
• I asked him what they do to gain insight into the health today and in the future:
  • Assessments (web)
  • Screenings (in-person)
  • Coaching (phone, in-person)
• He talked about using teachable moments to get commitment to a goal.
• He felt that incentives often create false motivation and therefore create a short-term return, but don’t create sustainable change. He used the term Intrinsic Motivation several times.
• We talked about the BlueZones research about people living long lives.

OptumHealth Care Solutions:

• I first met Rob at this conference a few years ago where I interviewed him.
• I now know a lot more about what they do and we had a good dialogue about several things.
• We talked about their recent partnership with American Well to leverage their technology.
• I asked him how that played into their traditional model of the health coaches and nurses. He described the need to match up the patient with the right physician and make sure to keep them in the care delivery system. This tele-health strategy allows them to do that.
• I hadn’t seen the American Well presentation yet so I immediately jumped to the value of getting a second opinion using this (or bringing a specialist into the dialogue…which is even better). He agreed and talked about how they’ve been able to lower the transplant rate in their population from 16 per 1,000 (which is the norm) to 11 per 1,000.
• We talked about the measurement and payment challenges in the industry where there’s no clear definition of engagement (or more importantly sustained engagement). It’s too easy to manage to an opt-out list or simply send people a letter saying that you didn’t get them on the phone and check the box that they’ve been “engaged”.
• We talked about incentives for a while and the challenge with them. He (like many I talked to at the conference) was quick to point out that they can often be used to cover up the problem of people not being engaged for the right reasons.
• We talked about back surgery and the fact that if you talk to a surgeon about it then you are 17x more likely to get back surgery than if you talk to a chiropractor about it. (Or 5x more likely if you talk to a PCP about it.) We also talked about the fact that most back pain lasts about 5-6 weeks so if you get someone in a stretching program (for example) that last six weeks then the pain will be gone before their done.
• We talked about a Center of Excellence (COE) concept which many people have been discussing both at hospitals along with call centers (e.g., Medco’s Therapeutic Resource Centers).
• Then we had a really interesting discussion on geography and how consumers are so focused on geography which is something they have access to versus quality and affordability which are harder to access and understand. For example:
  • There are >200,000 physician offices in the US
  • There are about 100,000 gas stations in the US
  • There are about 60,000 pharmacies in the US
  • I often think there are too many gas stations so…
• We ran out of time to talk about their eSync platform, but I find this to be an interesting concept.

Johnson & Johnson Health & Wellness Division:

• They have bought a few companies (e.g., HealthMedia) to get into this space and at one point were looking to build a stand-alone $20B company.
• They seem very focused on the employer and creating custom solutions for them that blend technology, science, and engagement.
• He described it as a “holistic, multi-dimensional consumer approach” and talked about creating a seamless experience.
• I liked his five “pillars” that he categorized as important – leadership and communications, programs, policies and practices, marketing communications, and outcomes.
• We talked about ROI and the two areas to be analyzed – productivity and cost reduction.
• We also talked about incentives and looking at carrots versus sticks and how to use carrots to drive participation.
• They’ve developed 1.3M individual plans for consumers to improve their health.
• I asked him whether HealthMedia was one leg in their stool or the platform upon which to build. Interestingly, he said it wasn’t binary that HealthMedia provided them with both a set of solutions along with a platform to build upon.
• I asked him for some insights into consumers. One that I noted was that they found binge eaters were more willing to talk with or interact with a system than with an agent. [This is similar to what we’ve found at Silverlink where consumers with some specialty conditions are more willing to provide information to an automated call than to the nurse…they don’t want to feel like their being judged.]
  
• We talked about health as a strategic imperative and the need to create a top-down leadership culture to effectively change behavior and environmental factors.

[Answer from above…It’s only a 100-calorie a day difference between being healthy and being overweight.]

For the third year, I’ve been able to come to the WHCC big spring event in DC. I would say this is one of the best conferences in terms of total attendance, level of speakers, and level of attendees.

Between recovering from vacation, work (no…the blog doesn’t pay the bills), and interviewing people, I only made it to a few sessions. My notes from them are here.

Kathleen Sebelius (Secretary of Health and Human Services) talked about:

• Reform is not a gov’t takeover but providing an operating framework (paraphrased).
• Some of the immediate changes – no more pre-existing conditions. Moving coverage of dependants to age 26.
• Medicare spends over $1B per day.
• Preventative care incentives…great example on comparing the costs of amputation for a diabetic versus the costs of preventing it. (want to run this model in more detail later)
• There are $56B in uncompensated healthcare costs (to hospitals) which leads to $1,000 in insurance premiums for all of us that are covered.
• She quoted someone saying that healthcare costs are the tapeworm that is eating into American competitiveness in the global marketplace.

Dr. Mehmood Khan (SVP, Pepsi) talked about:

• How a food company can contribute to the health discussion and change in health (e.g., taking full calorie sodas out of the schools).
• The research and work they do internally.
• The fact that we are now seeing both overfeeding and under-nurishment co-existing in the same geography.

Andy Webber (CEO, National Business Coalition on Health) talked about:

• Challenges that employers see:
  • Improving health
  • Transforming the delivery system to focus on outcomes
  • Controlling expenditures
• The healthcare delivery system is a small input into the overall outcomes. He says that jobs and income are the #1 driver in determining outcomes. [Good for pitching a focus on economic growth, but I don’t buy it.]
• Improving population health is a team sport focused on the local level.

Dr. Reed Tuckson (EVP, UHG) talked about:

• Chronic disease is a tsunami to our delivery system.
• We need to understand what is killing people locally and how to solve it.

Nathan Estruth (VP/GM of FutureWorks at P&G) talked about:

• The innovation strategy at P&G (see detailed paper here)
• The Connect & Develop strategy they use where P&G brings the consumer to the table.
• Some of their investments including MDVIP and Navigenics.
• The power of “and” (try to find solutions that do A and B not just optimizing around one component)
• I think the most telling message was that they clearly did not subscribe to the “Not Invented Here” innovation challenge that many companies do. He said they focus on >50% of their innovation coming from outside the company.

Roy Schoenberg (CEO of American Well) talked about:

• The issues around healthcare in the US – access, MD income, PCP shortage, specialty care access, ER abuse, and systems agility.
• Work they are doing with pharmacies, payers, OptumHealth, Ascension (hospital), and the military.
• A very interesting point about retired MDs coming back into the system since they can work on their schedule and without having to have an office.
• Another cool point about the ability to coordinate visit between a PCP and a specialist. They also enable easier referrals. (I think this could be game changing.)
• They can also project care where needed – e.g., Haiti.

General Observations:

• Lots of talk about creating a culture of health and innovation.
• Lots of talk about wellness.
• Most of the people I talked to from the wellness companies were very skeptical of incentives.
• Lots of people trying new things and trying to innovate.