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PBM Competitive Intelligence

TMA, a group that was doing a PBM study, called me with questions a few months ago.  They sent me some of the results of the work last week.  A few interesting observations from them looking at CVS Caremark, Medco, Express Scripts, Wellpoint NextRx, Prescription Solutions, Aetna Pharmacy, and CIgna:

  • Aetna was cited as having the best online capabilities.
  • Express Scripts was cited as having the best generic drug conversion.
  • Medco was cited as having the best disease management.
  • Medco was cited as having the best sales channels.
  • CVS Caremark was cited as having the best practices for implementation.

“As competition among PBMs is forecasted to remain high, customer service will continue to become more and more important as members/patients have greater expectations.”

Call Center Agent vs. Automated Calls

The other day I called some service provider to ask some questions about their product.  It was painfully obvious that the person at the call center was reading from a script.  This made me realize that there are reasons (beyond simply cost) for using automated, speech-recognition technology for calling people versus humans.

It would have been more conversational for me to have talked with an automated phone call where I could answer questions with certain hotwords that dynamically moved me through the path of the call.  Depending on content, I think it is often nice to have the option to transfer out to a call center agent since that role will never disappear.  Some people prefer a human (look at all the grocery store lines) and some exceptions don’t fit into a rules-based decision tree.

But, quality is a huge issue with complex plan designs in healthcare.  How do you teach each call center agent (especially when you have high turnover) to respond and explain things exactly the same?  You can’t unless you force them to read a script which is a bad experience for the member / patient.  We used to have to do lots of secret shopper calls to work with our agents to get them to the right place and meet minimum expectations.  Again, this is something that a computerized system can address.

The thing I always hear about calls is aren’t they like those election calls I get where the voice sounds a little computer-like (aka text-to-speech) or there is a big pause between the person answering the phone and saying hello and the actual recording kicking in or the live person talking.  With the top vendors out there, those are old issues.  There is no pause.  The messages are recorded in human voice.  Ideally, the variable text (e.g., patient’s name or drug name) are part of a custom audio library which is in the same voice.

Avoiding Calls Then Texting

CNet has an interesting article about teens avoiding live calls only to text back the person immediately so they can continue their current activity.  I do it all the time when I am in meetings or on conference calls.

They provide some interesting statistics on text messaging (see below) for this young group.  Not a prime focus for healthcare, but it will be interesting to see how this use of technology applies as they grow older.

More broadly, nearly one out of every two U.S. tweens (or kids between 10 and 13 years old) and 83 percent of teens own a cell phone, according to new research from Chicago-based C&R Research. And with that many kids using mobile devices, the text messages are flying.

The average teen, according to C&R, generates between 50 and 70 text messages a day, or as many as 18,000 a year.

What Driving Teaches Us About Wellness

We all understand the challenges in getting people to take their healthcare seriously which manifests itself most prominently in a obese society which leads to numerous other conditions – heart disease, diabetes, high blood pressure.

I was reading an article earlier today about driving slower to maximize your fuel usage and thought what a great example of how people don’t do what’s best for them. You can reduce your fuel needs by driving slower, but most of us are too hurried to do that. We don’t follow practical, fact-based suggestions. It’s just like the challenges of eating well. It is much easier to go to the fast-food restaurant than to plan your lunch, buy healthy foods, pack a lunch and bring it to work.

Another good link is between using a phone when driving and wellness. Again, we know that people being distracted by their conversations (voice and text) while driving can lead to accidents. Certainly, headsets and voice technology should reduce those distractions (although the data doesn’t support that). For example, when I am driving, I simply press the button on my Bluetooth headset, speak the person’s name, and then the phone calls them. Much less distracting for my eyes on the road…but I am still talking to someone and multi-tasking. So, again, why don’t we do what’s best for us and stay off the phone? It’s generally not efficient…we are pressed for time…we have become a country of multi-taskers. A similar reason to why lots of people don’t exercise…too busy.

“There are limits to how much we can multi-task, and that combination of cellphone and driving exceeds the limits,” says David Strayer, a University of Utah psychologist who has found that by many measures, drivers yakking on cellphones are more dangerous behind the wheel than those who are drunk, whether the conversation is carried on by handset or headset.

Texting – We Are About To Call

I had one of our clients use an interesting banking example the other day. Initially, I was a little skeptical, but after an incident this morning, maybe there is a place.

They said their bank lets you opt-in to receive a text message right before they call you. It says something like “This is your bank. We are about to call you about your account.” Therefore, you are more likely to answer the 800# call you get on your mobile phone.

My immediate question is why doesn’t the 800# have a caller ID that shows who is calling. This can be a significant factor in getting people to answer the phone.

So, late Sunday night, I get a message from an 800#. I don’t listen to it until I get up at 4am this morning to catch a flight. Well, it was from American Airlines saying that they had cancelled my non-stop 6:45 flight and rescheduled me on a flight through Chicago that gets me there over 2 hours later. Since I have a 2-hour drive from that airport, I was a little panicked that I would miss a big presentation. I ran to the PC; found a new flight on Southwest that got me to a smaller, but closer airport; packed a bag since I was now going to spend the night; and went to the airport.

Had American texted me last night, I might have answered the phone and/or I would have read the text before crashing.

McKinsey On Automated Calling Technology

McKinsey and Company published a report called “Using IT To Boost Call Center Performance” in the Spring of 2006 which had a few relevant comments for those of you looking at how to leverage automated communications in the healthcare space. Here are the two primary quotes that I took away:

Customers are getting used to automated transactions – in fact, some prefer them. Our research suggests that more than 60 percent of customers favor an automated option for many types of simple interactions (for example, balance inquiries or payments); the rest said they didn’t mind being presented with an automated option as long as they could connect with a live agent if they wanted one.

Investments in new VR (voice recognition) and IVR (interactive voice recognition) technologies can help automate an additional 5 to 30 percent of incoming calls while maintaining or even enhancing customer satisfaction and revenue.

I always love finding those 3rd party verifications of the value propositions that we see at clients.

Medical Home

I just changed PCPs (primary care physicians) to find a new one who was easier to access and more personable. (Not that I had been to my other PCP in 5 years.) I was very pleased that this new individual has adopted the medical home concept. He wants to be my central point of contact, and he is a big prescriber of Ix (information therapy). It was interesting. Here are a few highlights from my introductory visit.

  • His paperwork asks you to call him before going to the emergency room (ER) or urgent care.
  • He does in-office dispensing using a company I know called Purkinje.
  • He asks you to sign off on leaving you messages and/or who else he can talk to about your care if needed.
  • Every time we talked about something, he would reach over and grab an article from a library on the office wall and give it to me to read.
  • He gives you his e-mail for contact and talks about responding within 30 minutes.

Now, hopefully I don’t need much care, but I feel like I have found a good advocate and involved MD to work with. (He also came highly recommended by several people.)

IDC – Healthcare Communications

Janice Young at IDC just put out a new report titled “Too Much Information? The Irony of the Coming Information Glut and New Technologies that Help Target Communications” which focuses on several fast-follower announcements about what we have been doing at Silverlink Communications. Here are a couple of quotes from the report.

The final mile of the current healthcare information blitz is not just getting at or to the information, though in the very fragmented, silo’d U.S. healthcare system, that is hard enough. But the real solution provides targeted and event-triggered information based on consumer interactions or events, rather than relying on the consumers to search and seek.

These two announcements join Silverlink’s earlier announcement in March 2008 of their new Adaptive HealthComm Science Platform. The Silverlink platform integrates decision support and analytics to create personalized customer communications. Unique to the Silverlink solution are behavior analytics to communications success and affect on customer behavior and outcomes.

Beating The Patient Over The Head

Something that I don’t normally do, but I am going to edit this after the fact to stress what the story really is supposed to be about since someone told me the original text might be offensive to a competitor that I respect.  The point is whether being pushy is worth it in some cases.

The other day a patient asked one of our people about a mail order order pharmacy where they had gotten a call every other day for the past 12 days about refilling their medication. Each message was slightly different – your supply of medication is about to run out, you need to refill your medication, your prescription has run out, etc.  The patient didn’t like the call program.

I found this an interesting debate…how pushy is good if you drive a desired outcome?  Also, we all obviously know that vendors and consultants don’t always make the decision so if a client tells you to do this even if it makes no sense, what do you do?

I think it makes for a good debate and had it with several clinical people:

  • At what cost is a better refill rate okay…especially since this doesn’t mean that they are compliant? Are you willing to drop your patient satisfaction by several points?  (We often used to give clients a report that showed savings per disrupted member or per drop in satisfaction at my prior employer.)
  • If the company is just driving up refills and can they do that without creating more waste?  This was a constant debate at mail.  One trick here is whether you base it on refill dates or days supply.
  • With this frequency of calls is there a chance that you actually get people that would have refilled to just wait for the calls to come and say yes?
  • If people take the call because they know you will keep calling them, is this actually better acceptance of calls or just being an “obnoxious salesperson”?
  • Are you calling people that have refilled at retail due to data latency issues?
  • Do you drive people back to retail?
  • Have you dulled them to future calls by upsetting them on this program?

Now, on a more clinical program, my opinion here might be different. If you could successfully get an overweight individual to diet by constantly reminding them. This might be okay. It’s an interesting debate.

Communication Chicken And Egg

You hear a lot these days about preference based marketing.  The idea is that consumers (or members or patients) select how you interact with them.  In healthcare, this means things like:

  • What types of communications do you want to receive?
  • How do you like to be communicated with – letter, web, live person, automated call, text message?
  • When do you like to be communicated with – day, time?

Of course, companies then have to figure out what rules to use in terms of when to trigger communications.  The next question is how to personalize the communication.

So an interesting question is…does the company have a responsibility to their members to use their data to drive them to actions that are in the member’s best interest?

Do companies always do what’s right…probably not, but I do believe that they want to do the right thing.  They want to drive successful outcomes.  They want patients to be healthy.  They want patients to save money.

Now, my chicken and egg analogy is which comes first the selection of what my preferences are or experiencing the communication.  How do I know whether I want a refill reminder if I have never received one?  How do I know which channel I prefer if I haven’t experienced each of them?  And, since each communication can vary based on messaging and many other variables, can one good or bad experience bias my selection?

Putting Your Kid On Cholesterol Drugs

I was a little surprised to see the news this morning claiming that it was okay to start putting kids as young as 8 years old on cholesterol lowering drugs and starting testing as early as 2 years old.  Talk about an obesity epidemic out of control.  I would think that there were lots of things we could be doing about diet and exercise to address this before setting kids up to be on these maintenance medications for the rest of their life.

Not a clinical opinion, but my personal opinion.  It makes me think of the social commentary delivered in the new movie – Wall-e – where the people don’t know how to walk anymore and just float around getting fatter and fatter.

Medical Bankruptcies

I will give credit to the Health Care Reform Now blog for leading me to this article in The Indianapolis Star, but I think it is a sad reality.

“More and more of the middle class is finding out that even if they have jobs and insurance, they can be wiped out by medical events that are not even catastrophic,” says Dr. Christopher Stack, a retired orthopedist and co-founder of Hoosiers for a Commonsense Health Plan, the state’s chapter of Physicians for a National Health Program. “You can run up a high five-figure bill real easily.”

A Harvard study published in 2005 estimated that about half of all bankruptcies filed in the U.S. have their origins in medical costs, a ratio that jibes with Silver’s and other bankruptcy veterans’ observations here in Indianapolis. While the rest of the world’s industrialized nations provide health coverage to all or nearly all of their populations, the U.S. mass-produces the distinctly American phenomenon of medical bankruptcies.

I am not a big fan of the donut hole in Medicare, but perhaps we need a donut hole type concept for health insurance where people have a maximum out-of-pocket in any one year.  Although I am sure that would beg the question of what was optional versus required surgeries and treatments.  It just seems a shame that we can bankruptcy hard working people with insurance over their medical bills.

What is a Mail Order Pharmacy (Home Delivery Pharmacy)?

My most popular post ever is “What is a PBM?” which made me think that this is probably a relevant post for the average healthcare consumer.  And, given the historical push to mail combined with the current economy, you can expect mail order pharmacy (or home delivery pharmacy) along with 90-day retail pharmacy to be a hotter topic.

At Silverlink Communications, we work with a lot of companies on their retail-to-mail (RTM) communications strategy and execution.  One of the first things I point out to all of them is that over 50% of people don’t usually know what mail order pharmacy is.  So, you have to address awareness at the same time as recruiting new patients.

So, for all of you that receive a letter or call talking to you about moving your prescription to mail order, let me answer a few of your basic questions:

  • Mail order pharmacies are also called home delivery pharmacies since they deliver your medications through the mail and directly to your home (or other address provided).
  • The mail order pharmacy is typically owned by either your managed care company (aka health insurer) or by a pharmacy benefit management company that your insurer contracts with directly to provide this service.
  • There is typically only one mail order pharmacy that you can use (i.e., is considered “in-network”).
  • The service is typically the fulfillment of 90-day prescriptions of medications which you will take on a long term basis (aka maintenance medications).  This is not true for controlled substances which typically only allow a 30-day prescription and for some specialty and injectable drugs.
  • You often have a financial incentive to choose mail order where you will get a 90-day supply for less than it would cost you to buy three 30-day prescriptions at your local pharmacy.  This discount is due to the buying power of the mail pharmacy, the automation which reduces the costs of dispensing the drugs, and the lower distribution costs (i.e., no need to move the drug to all 5,000 retail locations).
  • The drugs are the same drugs you buy at your local pharmacy.
  • You have the same access to a pharmacist but it is over the phone not face to face (which I personally prefer and think is more confidential).
  • You can do your refills over the IVR (interactive voice response) line and over the Internet along with traditional means of live agents and using snail mail.
  • These mail order pharmacies use robotics and other highly sophisticated solutions to dispense the drugs accurately and quickly.
  • Many of the mail order pharmacies that we work with offer services around calling your physician to get new prescriptions and also use our automated outbound calls to provide you with order status (WISMO calls – what is the status of my order) and refill reminders.
  • You shouldn’t typically start a new drug at mail order.  You want to wait until you have had two fills locally to make sure you are titrated to the right strength (i.e., your MD might switch your dosage initially so you don’t want to buy too much supply of a drug you might not use).

Are Involved Patients More Compliant?

This is a study from a few years ago from Harris Interactive and BCG that I found on the BioPlus website.  If I am interpreting it right, it would imply that those that are most involved in their healthcare are most likely to be non-compliant.  It doesn’t seem logical, but perhaps those are the people that want to play doctor and are most likely to think they know better.

Burning Calories – How Many?

I was with a friend and was talking about how many calories you burn per hour. The instructor at the aerobic kickboxing class I have gone to on and off for years always says that I could burn up to 800 calories per hour in the class. When I am on the treadmill, I always try to get it up close to 1,000 calories per hour. I have never been good about tracking calories in, but I always think about how much more I need to work out if I have been eating poorly.

So, if you’re looking for an estimators, here is a calculator and here is a great laundry list of activities from cooking to hiking and biking to broomball or calories burned per hour. I pulled a few common ones from their list here:

Activity (1 hour)

130 lbs

155 lbs

190 lbs

Biking (<10 mph)

236

281

345

Biking (>20 mph)

944

1126

1380

Golf (carrying clubs)

325

387

474

Ice Hockey

472

563

690

Pushing stroller with child

148

176

216

Running (6 mph)

590

704

863

Running (7 mph)

679

809

992

Why Can’t I Go To Any Physician?

In pharmacy, there is a rarely used benefit structure called Therapeutic MAC (Maximum Allowable Cost).  What this does is say that in any class of drugs (e.g., cholesterol lowering drugs) there is a maximum amount of money that will be paid by the plan.  But the individual can get any drug.

That can be controversial since a patient could end up being required to take a more expensive drug by their physician costing them a lot of money.  (Although most pharmacy plans allow for a clinical prior authorization in cases like this where they might pay less.)

My thought is why not do the same thing at least for physician visits.  If my health plan simply published statistics that said they will pay $100 for any visit to a physician’s office.  I could then go to any physician and that physician would know they were going to get $100 for my visit plus whatever they charge me.  It would eliminate a whole process of constantly managing the network and focus patients on the price that their physician charged.

I am sure there is something that I am oversimplifying, but it seems logical.

Would You Pay $100 To Be Told To Take Your Rx?

We know adherence is a serious issue that drives healthcare costs.  And, as I have talked about a little here and a lot with many of our pharmacy clients, it’s not a simple issue.  People aren’t adherent for a variety of reasons – cost, side effects, health literacy, or simply just forgetting (among others).

There are lots of tools out there to help you organize your medications and manage them.  Whose job is it to help you – yours, your physicians, your managed care company, your pharmacy, your pharmacy benefit manager?  Obviously, you (the patient) have the primary responsibility.  After that, your pharmacy is best positioned to help you with this.  But, the managed care company stands to benefit the most by preventing serious medical conditions associated with non-compliance.

So, I was a little surprised to see a new company come up that offers to send you calls, e-mails, or text messages to remind you to take your medications.  And, you can even talk to a pharmacist.

Let’s break this down:

  • Whatever pharmacy you use (mail, retail, specialty) will offer you consultation with a pharmacist for free.
  • I believe most pharmacy benefit management (PBM) companies offer automated e-mail reminders that you set up yourself off their website for free.

I don’t know why I as a consumer would pay for this.  And, it seems pretty high for a managed care charge.  If I went to a client of ours and told them I would send messages to patients for $100 PMPY (per member per year), I think they would choke on that price tag.

So, will it work??  Who knows?  I have been surprised by business models before.

Dental Experience

I am a big believer in the fact that the experience matters for healthcare.  From my architecture days, this means physical space, sequence of events, bedside manner of the staff, clarity of communications, and processing of the claim (at the simplest level).  Everything that the patient experiences as associated with an event drives their satisfaction.

So, I was pleasantly surprised taking my daughter to the dentist a few weeks ago.  We had gone to a “kid’s dentist” before which was an hour away that I thought did a good job (although the kids hated going).  But, this one was over the top.

When you walk in, the entire room is covered with art (e.g., there is a giant Spiderman climbing on the ceiling).  There are video game stations in the corner.  There is a large flatscreen TV playing a slide show of pictures of the kids coming to visit that day.

And, it doesn’t stop there.  Each room is decorated.  The staff talks to the kids (more than the parent).  Every tool and process is explained to the kids in simple terms.  They sometimes give out balloons.

Just something to think about when you try to look at things from an outside-in perspective.  How is the patient experiencing your service?

Genetic Art

I was reading about this company DNA 11 the other day, and I found it a pretty cool concept. They take your DNA and make it into art focusing on the 1% that is unique. According to the article in American Way magazine, prices ranged from $390 to $1,200 with 25 color options or the ability to request a custom color (to match your sofa perhaps).

They can do pets, fingerprints, and lip prints.

A Few New Blogs

I always enjoy coming across new blogs with interesting articles. Here are a few that I found yesterday and added to my blogroll:

The Health As Human Capital Blog (sponsored by a company described as “dedicated to providing better information for better decision-making in health care and business”)

The Doctor Comes To You Blog about the onsite healthcare industry

Medication Non-Adherence Blog by Alex Sicre who comments on my blog often

LinkedIn Question On HealthComm

I think it was earlier this year when LinkedIn rolled out a new feature called questions which allows you to pose questions to LinkedIn users and get answers. I continue to like this tool, and it has been interesting to watch it evolve from a “startup” (when I joined there were less than 2M members) to a tool that well over 10M people use and has gotten lots of press.

I finally decided to pose a question:

Do you have any good (or bad) examples of healthcare communications? I am looking for how your healthplan, disease management company, pharmacy, or PBM communicates with you. What worked or isn’t working? This could include letters, websites, phone calls, social media, etc. Examples might include communications around moving you to a 90-day prescription, moving you to a generic drug, improving your awareness of a disease, addressing compliance and adherence, reducing your out-of-pocket costs, etc.

I received four answers:

Answer One: I had some great success marketing to Medicare members by conducting health and fitness seminars as well as bring in experts to discuss retirement and other topics of interest. Initially, I’d obtain a 3% response through postcards and an additional 1.0% through phone calls. Conducting a series of seminars in one area can also bring in additional attendees (0.5%), through word-of-mouth buzz.

I found seminars to work well because the attendees were getting something of true value for their time (information and a social event with their peers) and I had a captive audience to market. A win, win situation.

Answer Two: My experiences with Blue Cross have been pretty good, there’s the health mag they send out with information articles, etc. I’ve never been able to access the website services though, something to do with the number that CS can never work out though I’ve tried on several occasions. I love my primary doctor and feel she and her partner give excellent care and plenty of information to their patients. They’re the only ones who’ve ever given me a reading list and web printouts! It was just a general question I had, not a condition I suffer from.

In addition to other tasks, I handle the health documents for the children enrolled with us and find that often the doctors have done a very poor job in informing the parents of what to watch for, what a result means, etc. Their offfice staff often do a shoddy job of filling out the forms correctly. Last month I recieved paperwork for a child, the physical form stated passed 20/20 for vision, it was accompanied by a referral from the doctor for a full eye exam as the child had failed the eye test miserably! I once received a normal hearing result for a child we knew was deaf as a door nail. When trying to get an insurance company to cover a needed service or therapy for such is incredibly difficult with that kind of paperwork.

Thanks for the opportunity to raise awareness!

Answer Three:

Aetna sent me a letter suggesting several plan options that may be cheaper than the one I currently have. That was a positive. I wish that I could compare the plans side by side on the website. It is difficult to remember the details of each one as you look at them individually.

Answer Four: As a health promotion practitioner, we are at a time when the national consciousness of health has never been higher. The most important thing we can do at a workplace is create individuals and systems that are health literate. We spend enormous amounts of money in our wrongly terms “health care” system. What we actually have is a “sick care” system, and what is truly missing are incentives and action by companies to recognize the billions of dollars we could save and then return to economy by protecting our workforce with sound health promotion. Our children are contracting early onset adult diabetes and we commonly refer to our bleak situation of the obesity epidemic. Our “health care” system, and thus the traditional “disease management” is from a biomedical chronic disease model.

It is time to work at reducing costs related to health care and absenteeism from a proactive rather than reactive approach. Many companies and organizations provide services that have yielded significant economic returns from building well companies.

According to the the NIH, most people are unhappy with our current system, and unable to continue to straddle the costs of ever increasing health care. We can avoid chronic disease by acknowledging new paradigms of business operations that include well companies. For information, contact www.positivepurposeinc.com

Tier Zero

Frank Koronkiewicz, the Director of Pharmacy, at Blue Cross of Northeastern Pennsylvania (BCNEPA) just launched a new plan where people can get 65 different generics focused on chronic diseases at no copay AND without any premium.  It’s called Tier Zero.

Frank has always been a progressive Director of Pharmacy.  We worked on several programs together at Express Scripts.   You can also find some of their collateral and videos on generics on their website – click here.

It would be interesting to look at the overlap between these drugs and the Wal-Mart list of drugs, but I think you would find that an individual could have a pretty comprehensive benefit of generic drugs between these two solutions with low out-of-pocket (OOP) costs and no increase to their medical premium.  A compelling story to many.

Three Sad Healthcare Stories

First, I think this is a very disappointing article about workplace violence in the healthcare industry.  I certainly could believe (unfortunately) in the verbal violence since people are very emotional about their healthcare and often stressed over the financial implications and unintuitive processes.  But, this story has some scary statistics which are an issue at a time when we need more healthcare service workers.  [Ask your friends in the industry.  I plan to.]

  • Health care workers are 16 times more like to face violence at their job that workers in any other service-oriented profession.
  • More than 50 percent of reports of aggression in the workplace come from the health care sector.
  • Over 9,000 nurses and other health care workers are verbally or physically assaulted on the job every day, according to the National Institute of Occupational Safety and Health.
  • A 5-year survey of 170 university hospitals showed that over half of all emergency room employees had been threatened by weapons.
  • Almost 90 percent of nurses in every specialty said they were verbally assaulted during the past year and almost 75 percent claimed they were physically attacked, according to a study published in The Journal of Emergency Nursing, which related reports of 100 percent verbal and 80 percent physical assault rates for emergency room nurses.
  • Almost half of all psychiatric physician residents reported an assault during their career and other medical residents in the hospital setting reported a 16 percent assault incidence.

The second article which I read which I think is also sad is about the rise in seniors filing bankruptcy. Sometimes, seniors don’t even have enough resources to install stairlifts in their homes. Not only is it disappointing to see people reach retirement only to have their dreams dashed away from them with crashing house prices, rising food prices, rising gas prices, and lower return on their investments, but they are facing huge healthcare costs that are pushing them over the brink.  22.3% of the bankruptcy filings in 2007 were from seniors.  We also know that even without filing this stress can get people to skip medications or not take care of themselves only worsening their health.

The third story which I saw on CNN this morning was about a group of high school girls making a pregnancy pact.  Talk about a need for sex education and health literacy.  It’s one thing to happen by accident and quite another to intentionally put yourself in that challenging situation of getting a high school diploma and raising a child.

Diabetes or Depression: Which Comes First

Since many of us understand the risk of co-morbidities (i.e., two diseases that commonly exist together), I think it makes a lot of sense to ask this question.  Dr. Gupta from CNN had an article earlier this week on his blog about a study that was recently out on the relationship between diabetes and depression.

  • Those that started with depression but no diabetes had a 42% higher risk of developing diabetes during a 3-year period.
  • Patients with type 2 diabetes but no symptoms of depression were 54% higher risk for depression during that same period.

St. Louis – Less Beer More Health

Here in St. Louis there has been a lot of upset people about the potential buyout of Anheuser-Busch by InBev.  Isn’t that business?  Don’t the shareholders want to maximize their return?  Of course, we have lost several big companies to international entities which obviously changes the dynamics, charity support, and other things but isn’t that part of globalization.

So, I was a little surprised (not totally) that the WSJ blog talked about St. Louis moving more toward high growth health care than slow growth manufacturing companies.  St. Louis has been trying to drive a bio-tech focus now for many years, and it has the headquarters (or large presence) of several healthcare companies:

And, there are numerous smaller companies and healthcare start-ups here.  According to the St. Louis RCGA’s information on the BioBelt area here, we have more that 15,000 employees and 400 companies in this life science space.

Brand Prices Up; Generics Down

For those of you who are interested in this type of stuff, I think the AARP Watchdog reports (Brand Report, Generic Report) which track prescription drug prices over time are pretty interesting.  (Note: This is for drugs most commonly used by Medicare recipients, but I think you’ll get the point.)

Why People Choose Mail Order Pharmacy?

I was looking for something else in the Express Scripts Drug Trend Report 2005 when I came across this study referenced on page 209. I should have remembered since I wrote this section (yes I was a contributor see page 332). This is a Morgan Stanley study which talks about why people choose mail order pharmacy. Of course, the primary reason here is savings. The more savings the higher the likelihood of a person moving to mail order. This is a factor of savings per Rx multiplied by the number of maintenance drugs that an individual has that can be filled at mail order (or home delivery). This study shows the frequency of the response. If you focus on the weighted scores, you would see a dramatic cliff after savings. (I.e., 61% of people may choose mail for convenience, but they are much less likely to do it than someone with significant savings) So, why don’t all PBMs communicate exact patient savings to each individual? It’s hard. Given minimums and maximums; deductibles; percentage copays; and other benefit plan designs, the systems are stressed to produce this.

Sprint Response

Just to continue on the Sprint story I posted the other day. The response time to get a live person was 5 days (but only 3 business days). I then received an e-mail and a voicemail message. Interestingly, when I call back the individual’s direct dial number (nice), her voicemail says “from the office of dan@sprint.com”. I am not sure if I will get the context to help relay my story to healthcare, but I look forward to the conversation.

Good afternoon Mr. Van Antwerp,

I am certainly happy to hear that you are enjoying the simply everything plan. I called and left you a message on your voice mail with my contact information. If you would like to call me that would be just fine. I am here Mon-Fri from 8 AM to 4 PM eastern time.

Thank you for your loyalty. We really do appreciate it. Have a great evening.

Sincerely,

Her Name
Sprint

Sell Your Captive PBM – Why?

I was a little surprised by the quote from Lisa Gill from JPMorgan Chase about why health plans should sell their in-house PBMs (Pharmacy Benefit Management):

“I think it makes a lot of sense for PBMs [pharmacy benefit managers] to be sold or spun off as a stand-alone business. The only time it will make sense for a managed care company to actually own a PBM is after they move to real-time [medical] claims processing. And that’s not going to happen near term.”

Maybe I am missing some context here, but I don’t understand.  Why would you have a “captive” PBM (i.e., owned by a managed care company)?

  • Able to align total healthcare interests (e.g., drive Rx usage up to manage ER visits)
  • No conflicts of interest (real or perceived)
  • Able to keep margins of the PBMs (look at the stocks of Medco, Express Scripts, and CVS Caremark)
  • Manage the customer service experience

What does any of this have to do with real-time claims access?

Why would you use a standalone PBM?  (Again an easy decision)

  • Economies of scale on rebates
  • Mail order pharmacy efficiencies
  • Manage capital outlays
  • Get a dedicated focus on pharmacy which as only 10% of the total healthcare spend will be a stepchild under a managed care plan no matter what
  • Best practices being leveraged across companies

And, we all know from bidding on RFPs that managed care companies use this service to win business talking about the integrated solution and underwriting pharmacy with medical.

If you understand the rationale here, help me out.

Express Scripts Jumps Into Worker’s Compensation

Express Scripts has been in the Worker’s Compensation space for years now.  As I suggested several months ago (see #2), buying a worker’s compensation PBM makes some sense.  The margins are good, but it does require a different service model.

That being said, they jumped in last week with the announcement to buy the worker’s compensation PBM business from MSC down in Florida.  It would have been intriguing to see them buy the other ancillary business that MSC has to get their footprint a little bigger.  Now, this can go from being someone of a stepchild for Express Scripts to a major business unit.  As Joe Paduda points out in his blog post, they have good teams at both organizations so they should be able to make some things happen in the market with a focused team, financial resources, and some efficiencies.

Given that fact that PMSI has been on the block, this may create a reason for a Coventry or a CypressCare to step in and buy them to gain more marketshare to take on Express Scripts.