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A Few AIS Quotes Of The Day

June 16, 2008 by George Van Antwerp 0 Comments

I have a few more to post, but I often find their quotes interesting (www.aispub.com).

“Specialty medications require significant education for patients to feel confident self-injecting and achieve a successful outcome. For many patients, injecting a medication into the skin or muscle can be very intimidating. Because of the expense and the complexity of the medication, we cannot assume that the patient is just going to figure it out on their own.” Kari Amundson, director of specialty pharmacy services at Fairview Pharmacy Services, LLC.

“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.” Lisa Gill, a JPMorgan Chase analyst, speaking with AIS’s Health Plan Week about why health plans should jettison their in-house PBM units to shore up ailing profits.

“We went back and asked the 37,000 consumers we surveyed how long they had been with their last health plan, and found that the plans with the highest levels of involuntary turnover had the lowest levels of customer satisfaction.” Jim Dougherty, health care practice leader at J.D. Power Associates.

“The hepatitis C medications are pretty effective, but patients will feel much more sick from the treatment than from the disease, [so] companies that make those drugs are very willing to education patients” to improve their chances of remaining on the medication.” Mark Rubino, chief pharmacy officer at Aetna Inc.

Books / Articles, Healthcare

George Paz (Express Scripts) on Adherence

June 11, 2008 by George Van Antwerp 4 Comments

Paul Levy who is the CEO of a hospital has a blog called Running A Hospital.  He posted a summary the other day of a presentation by George Paz who is the CEO of Express Scripts.  It has some good facts and there are several good comments on there about defining the terms in this area (see my old post) and whether these are reasonable rates of compliance.  There is also a patient commenting about getting nurse calls and reminder e-mails which sounds great but puts them in the 1% of the population for which this happens.

The numbers do seem understated to me – 85% compliance with cholesterol lowering drugs.  That might be the amount of people that get a paper prescription and then fill the drug or it might be the amount of people that get one refill, but I believe by month 6 or certainly by month 12 most compliance rates are closer to 50%.

There is clear value in adherence.  Everyone should (in key therapeutic categories and using evidence-based standards) want to increase adherence to reduce total medical costs.

What surprised me most recently around this was what Kaiser had observed when looking at how doctors shared information with patients (Archives of Internal Medicine, Sept 2006):

  • Only 74% of the time did the physician tell the patient the name of the prescription drug
  • Only 35% of the time did the physician discuss adverse events with the patient
  • Only 58% of the time did the physician explain the frequency and timing of dosing
Healthcare, PBM / Pharmacy, Research, Value Propositions, Weblogs

A Few Blog Entries About The Think Different Event

June 11, 2008 by George Van Antwerp 0 Comments

We wrapped up the road show this week in Hartford and NY.  I missed both events to be at client meetings on the west coast (and now down south).  But, one of the presenters and someone who was in the audience posted entries on their blogs about the event:

Books / Articles, Consumerism, Healthcare, Marketing / Communications

Giving Out Your CEO’s E-mail

June 11, 2008 by George Van Antwerp 2 Comments

From the perspective of soliciting feedback, how many companies post their CEO’s or anybody’s real e-mail these days? Sometimes you can’t even find a number to call on the website. You simply get some generic form to fill out and get feedback. You sent it into the black hole and wonder if you’ll ever hear.

So, given Sprint’s challenges over the years, I think it was (is) a bold move to post the new CEO’s (Dan Hesse) e-mail (dan@sprint.com) at the end of some of their television commercials. I have been using Sprint as a great example of a company building loyalty because they reached out to me recently to move me to a better plan which reduced their revenue in ½. So, to test this e-mail address, I just sent the following. I will let you know what happens.

Dan (or whoever answers these for you):

I have been a loyal customer for 15 years now with Sprint PCS. I am not sure if that puts me in a minority, but I bet it does.

I was recently impressed when you guys called me to make sure I knew about the all inclusive plan (not sure of the actual name) which was something like $99 per month. Especially, since I was spending about $200 per month before. I work for a healthcare technology company and have been using that as an example about how to build loyalty.

I would be very interested (if you can share) how you guys made the decision to “down-sell” people and whether it has had the desired effect (which I assume is less churn).

The NY Times had an article about this on 6/9/08. Apparently, the initial response is an automated reply from Sprint, but most people then hear from someone on his staff (or likely a group of dedicated customer service agents) to address their questions.

“Yeah, we were worried,” said Mike Goff, vice president of advertising and marketing communications for Sprint. The company had a reputation for poor customer service, and soliciting critiques for the new chief to read was a risk. But, Mr. Goff said, Sprint wanted to “show we were serious about our intent to improve our customer service. We knew this was happening at a time when the perception of our customer service in the market was poor, so this is a chance for Dan to hear back from the market.”

The question is whether bold tactics like this can work to help change their image. If so, maybe health plans and PBMs should start posting their Chief Medical Officer, SVP of Customer Service, and CEO’s e-mails and see what happens. I can only image the look on some of their faces of doing something like this. Even though I am sure the reality is that he has a confidential e-mail address that gets used for internal purposes and personal purposes. As the Times article says, I am sure shareholders don’t want to think that the CEO sits in front of his PC all day answering questions.

Books / Articles, Consumerism, Healthcare, Marketing / Communications

Exercise Supercenter – Lifetime Fitness

June 9, 2008 by George Van Antwerp 0 Comments

Have you ever heard of Lifetime Fitness?  I didn’t until they started building this huge facility near my house outside St. Louis.  My first reaction was that somebody had the wrong business model.  A million square foot gym in this economy.  No way.

After an initial run in with an overly aggressive salesperson, my neighbors slowly signed up after their strong marketing push.  Given that I primarily run, it seemed hard to justify, but everyone who I talked to that had been to one of their facilities raves about them.  People compare them to country clubs (other than everyone in casual clothes) where there is great service and quality design and materials.

When you review their website, you get a much different view of the company.  Not your typical gym.  The facilities include a restaurant with healthy foods, a spa, and all of what you’d expect – classes, equipment, pools.  But, they also provide corporate wellness programs.

It finally opened, and I had a chance to go there Sunday.  Very nice.  Lots of staff.  Lots of equipment.  Lots of people (but not too many).  [I have no idea what the breakeven model is for a facility but it has to be 3,000+ members.]  And, a great example of old world social networking was the fact that there were tons of people who we knew and who knew each other there.  It was a destination to be at where hanging out at the pool was a social event by itself.

Since we know that peer pressure can influence wellness, it would be interesting to study the health dynamics in neighborhoods with a Lifetime Fitness versus other gyms and versus no facility.  Could it be the catalyst or tipping point?  It’s only a couple of days in, and I am on the west coast so we will see.

Healthcare

More On Silverlink’s Think Different Event

June 5, 2008 by George Van Antwerp 1 Comment

I am now up in Minneapolis at our 4th Think Different event on how to engage the healthcare consumer.  I talked about the first few speakers the other day, and I finally had a chance to hear the other speakers present.  This week, I had the chance to listen to  James Taylor (of Smart (enough) Systems fame not music) and Fred Jubitz (American Express).  Here are a couple of my takeaways.

[Again, if you are coming to the upcoming events, this might be a little bit of a spoiler.]

A few notes from James’ presentation:

  • He gave a great example of a program they did at Fair Isaac where they compared the standard, baseline program with one that was highly personalized.  What was the improvement – 2,000%!!
  • He gave a good real-life example of the need for channel coordination talking about buying tickets for the Chunnel and how he got different prices on the web and phone which were also different from the prices his father in England got using the same channels.
  • The Chunnel example reminded me of something that someone told me the other day.  They were using the Dell self-service example and pointed out that Dell now uses real-time chat right before you buy.  They have found that this increases the average sale by 15%.
  • The Chunnel example also made me think about how web technology allows us to do a lot of customization by visit, but most companies don’t do this.  At the simplest level, I remember a competitor of Firepond (previous employer) where if I visited their website from work it looked one way and from home looked different.
  • James talked about ATM customization as an easy example.  How much money do you normally take out.  Only showing you services that you have access to.  Some of this is starting to happen, but not much.
  • He also talked about rules creation and how that varies.  I think it is always interesting to trace the evolution of rules and policies within a company.  Are they there because of regulatory issues?  Is it because someone coded the legacy systems that way?  Is it based on a personal interpretation?  Or are they dynamic and regularly reviewed?  One of the worse examples that I have ever seen was a large healthcare company that believed that HIPAA required them to re-code everything as it moved from development to production.  (A very costly error in interpretation.)
  • He also talked about the evolution of interactions:
    • Automate decisions
    • Apply rules
    • Segment customers
    • Predict risk and value
    • Optimize
  • James hammered home the point of never stopping to try to optimize since as the environment and your customer base change the optimal solution might change.

Fred who ran the gold and green cards at AMEX talked about:

  • American Express really wanted to be a lifestyle enabler not a payments company.
  • He talked about the Centurian Card (black AMEX card) which apparently is able to charge $5,000 initiation fee plus a $2,500 annual fee.  (Surprising that people still pay it, but I have heard examples of people buying a plane with their black card so I guess that level of service requires something.)
  • He gave examples of how companies think about cards and showed a lot of affinity cards which made me think about groups and how people like to affiliate with others (e.g., by diseases).
  • He talked about the importance of several things:
    • Know your audience
    • Key metrics
    • Segmentation
    • Personalize
    • Continuous improvement
  • He showed the standard framework for segmentation looking at size of wallet (i.e., how much you charge / spend per year) versus their share of wallet (i.e., how much of that is with AMEX).  Each box on the grid then had a strategy – invest, retain, focus, divest, etc.
  • He showed a lot about how the financial services companies can personalize the web experience, but he pointed out that this took months to develop as they built up your profile.
  • I think a key point he made relative to healthcare is that a lot of a new member’s behavior was determined in the initial months which led to how they used their card.  He gave an example of his blackberry.  The first couple features he learned are all he uses.
    • What are you doing in the initial months to “train” your members or be trained by your healthplan to use the website and leverage other ancillary services (e.g., gym membership) that they might offer?
  • He stressed evolving your segments but not starting over each year or you will lose some of the lessons you have developed.
  • Finally, as you always want to stress, he said to keep it simple.

Additionally, you can see some of Matthew Holt’s comments about the event at The Health Care Blog (here and here) and Les Masterson’s comments in The Health Plan Insider.

Consumerism, Healthcare, Managed Care, Marketing / Communications, PBM / Pharmacy, Research, Technology, Value Propositions

GINA – A Good First Step For Personalized Medicine

June 5, 2008 by George Van Antwerp 1 Comment

Whether you are a patient or a health care company, I think you should be happy about this. GINA is the Genetic Information Nondiscrimination Act of 2008 which was signed into law on May 21st. It is a good step in encouraging individuals to participate in genetic testing without worrying about that information being used against them by an employer or health plan/insurer. It also bans companies from requiring genetic testing.

Based on an e-mail I got from Fulbright (a law firm where a friend practices), they offered the following definitions:

A. Genetic Information = includes the individual’s genetic tests, the genetic tests of family members of the individual, and the individual’s family medical history. Any information related to the individual’s or any family member’s participation in clinical research offering genetic services is included as is the genetic information of any fetus and embryo of an individual or family member of an individual who is pregnant. The sex or age of the individual is not considered genetic information, however.

B. Genetic Test = any analysis of DNA, RNA, chromosomes, proteins, or metabolites that detects genotypes, mutations, or chromosomal changes.

The use of genetic information (i.e., genomics) is a key step in creating personalized medicine. We know people are different and their bodies react differently to different drugs and different treatments. Some (much) of that can be attributed to their genetic make-up and likely to environmental factors.

The future holds a lot of promise once we can delivered personalized therapy that is specific to an individual. But, no one is going to get these tests if they distrust or worry about how the information is used. I have talked about this issue before when looking at companies like 23andme.

Consumerism, Healthcare, Technology, Value Propositions
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Wisdom Of The Crowd – Socializing Wellness

June 5, 2008 by George Van Antwerp 1 Comment

You probably caught the articles last year about how obesity seemed to spread throughout social networks. Now, in an article in the Washington Post (5/27/08), they talk about another example of research showing that smoking is similarly affected by social networks. Theoretically, this research could have significant implications for using social media (i.e., Facebook, MySpace, SecondLife). I can easily imagine blogs out there following people’s efforts to lose weight or quit smoking. I can see a Facebook “badge” or “sticker” congratulating someone for not smoking.

In a study published last week in the New England Journal of Medicine, the team [Nicholas A. Christakis, a medical sociologist at the Harvard Medical School, and James H. Fowler, a political scientist at the University of California at San Diego] found that a person’s decision to kick the habit is strongly affected by whether other people in their social network quit — even people they do not know. And, surprisingly, entire networks of smokers appear to quit virtually simultaneously.

Some of the observations that they found which seem interesting included the way non-smoking spread throughout a interrelated but not always directly related group. I don’t find that too surprising. If everyone quits and it is no longer “cool” or accepted you are marginalized and likely to feel pressure to quit. This was a concern that they noted which might lead to other negative health outcomes for the group that doesn’t change.

In a small group of my friends, I have seen one person’s efforts to lose weight (which included drinking less) impact the broader group. Others lost weight. Less beer is consumed when we get together. And, there is more discussion about the gym and running and other activities. For those who aren’t interested in those topics, they miss out on part of that dynamic.

  • A person whose spouse quit was 67 percent more likely to kick the habit.
  • If a friend gave it up, a person was 36 percent more likely to do so.
  • If a sibling quit, the chances increased by 25 percent.
  • A co-worker had an influence — 34 percent — only if the smoker worked at a small firm.

“It could be your co-worker’s spouse’s friend or your brother’s spouse’s co-worker or a friend of a friend of a friend. The point is, your behavior depends on people you don’t even know,” Christakis said. “Your actions are partially affected by the actions of people who are beyond your social horizon” — but in the broader network.

“People quit in droves — whole groups of people quit together at roughly the same time,” Christakis said. “You can see it ripple through a network. It’s sort of like an ant colony or a flock of birds. A single bird doesn’t decide to turn to the right or the left; the whole flock has mind of its own.”

From a employer, health plan, or even individual perspective, the question is how do we capitalize on this? How can we create wellness programs that leverage this “viral marketing” approach to drive behavior across the “colony or flock” to quickly and efficiently drive change. Certainly, this is where I see an opportunity for some of the Health 2.0 type of companies to play a role in creating communities and enhancing dialogues on key topics to enable this process faster and make the reach broader.

Books / Articles, Consumerism, Healthcare, Innovation, Managed Care, Marketing / Communications, Research, Technology

NCPA Survey on Adherence

June 3, 2008 by George Van Antwerp 0 Comments

I have been talking a lot about adherence lately (or lack of). A friend sent me the results of a survey of 1,000 adults by NCPA (National Community Pharmacy Association) from October 2006. This is now the 3rd study I have read this week with different results. Of course, they all used different channels – web, mail, and phone. And, I am sure that the questions asked were slightly different.

  • While most consumers believe they are highly compliant when it comes to taking their prescription medications (64% said they follow their physician’s instructions “extremely closely”), the survey found they are not as compliant as they believe.
  • Nearly three-fourths (74%) of respondents admitted to non-adherent behaviors in the past.
  • Nearly half (49%) said they had forgotten to take a prescribed medication.
  • Nearly one-third (31%) had not filled a prescription they were given.
  • More than one in 10 (13%) had taken someone else’s prescription medicine.
  • Nearly one-quarter (24%) had taken less than the recommended dosage.
  • Nearly three out of 10 (29%) had stopped taking a medication before the supply ran out.
  • More than one in 10 (11%) substituted an over-the-counter medication instead of filling the prescription they were given.
  • Nearly four out of 10 (38%) had forgotten whether they had taken a medication.
  • Less than half of respondents (48%) said they had consulted their doctor or pharmacist before making these changes.
  • An overwhelming 90% of respondents saw non-adherence as a serious problem.
  • More than eight out of 10 (83%) respondents agree that pharmacists can play a role in improving adherence by helping to make sure patients are taking their prescription medications correctly.
  • More than two-thirds (68%) believe pharmacists are more knowledgeable than other health care professionals when it comes to information about prescription medications.
  • Two-thirds (66%) go to one pharmacy for their prescription medications, which presents an opportunity for pharmacists to advise patients how to take their medications properly.
  • Nearly nine out of 10 (86%) say they would be likely to talk to their pharmacist about their medications.
Books / Articles, Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy, Research, Value Propositions

When Would I Pay More – Z-Lists and Green

June 3, 2008 by George Van Antwerp 0 Comments

The other day, someone was talking to me about the Z-List at Harvard. Basically, Harvard will allow a certain number of students to come in if their parents give $1M. Makes sense, and it allow them to provide lots of other students with aid.

At the grocery store, we pay a premium for organic foods.

We pay a premium for green buildings.

We pay a premium for energy derived from sustainable sources (e.g., wind).

Yet, in healthcare, we are always focused on how to lower premiums and/or ashamed of the constant increases.

  • Is there a place for a premium product with a different service model? E.g., no inbound IVR…you always talk to a live agent
  • Is there a place for more bundled services? E.g., vision, personal health concierge, OTCs
  • Is there a place for a wide open formulary? E.g., every drug is covered for a flat copay of $10
  • What about a preventative care plan that focused on getting you better?

The one that immediately jumped to my mind is pre-existing conditions. I am sure the underwriters could figure it out like Harvard, but why can’t I pay a one-time penalty or annually higher rates to be insured even with my pre-existing condition and maybe I can earn credits for being preventative.

It ultimately gets to the idea of personalized insurance that is specific to me where I weigh my need for simplicity, my financial assets, and my risk profile against the insurance companies underwriting model for risk management.

Consumerism, Healthcare, Managed Care

Variance In Children’s Healthcare

June 3, 2008 by George Van Antwerp 0 Comments

I think state-by-state variance in basic statistics is fascinating. It seems like we should have standardized around some fundamentals by now, but the variances continue to be significant.

In a recent report out by The Commonwealth Fund, it showed some wide variation:

  • Only 46% of kids visit the doctor and dentist at least once a year in Idaho, but 75% of Massachusetts children do.
  • Infant mortality rates are 2.5 times higher in the District of Columbia than in Maine.
  • Kids in South Carolina are 5.7 times as likely to wind up in the hospital for asthma as those in Vermont.
  • The percentage of children who received five recommended vaccinations from ages 19 months to 35 months ranges from 94% in Massachusetts to 67% in Nevada.
  • Utah has the lowest spending per person at $3,972. The District of Columbia has the highest at $8,295.
State

Overall rank
Alabama

14
Alaska

41
Arizona

47
Arkansas

44
California

34
Colorado

34
Connecticut

14
Delaware

37
District of Columbia

31
Florida

50
Georgia

38
Hawaii

7
Idaho

33
Illinois

38
Indiana

22
Iowa

1
Kansas

10
Kentucky

9
Louisiana

48
Maine

3
Maryland

27
Massachusetts

4
Michigan

12
Minnesota

23
Mississippi

49
Missouri

28
Montana

28
Nebraska

13
Nevada

45
New Hampshire

5
New Jersey

42
New Mexico

40
New York

25
North Carolina

31
North Dakota

21
Ohio

6
Oklahoma

51
Oregon

43
Pennsylvania

19
Rhode Island

8
South Carolina

36
South Dakota

16
Tennessee

30
Texas

46
Utah

26
Vermont

2
Virginia

23
Washington

18
West Virginia

20
Wisconsin

11
Wyoming

16
Books / Articles, Healthcare, Research

PBM Satisfaction Survey

June 3, 2008 by George Van Antwerp 1 Comment

It should be out soon, and it will be interesting to see the data. The WilsonRx PBM Satisfaction Survey is the only (I think) independent survey done of the industry. [Although I never remember paying attention to it at Express Scripts.] From what I know, they seem to get a good sample of more than 25,000 responses rating 18 PBMs (Pharmacy Benefit Managers).

Some of the new factors they are including:

  • Overall Medicare costs and availability
  • Annual increases in premiums or costs
  • Overall delivery of pharmacy benefit services
  • Courteousness and helpfulness of PBM plan representatives
  • Ease and timeliness regarding conversations with a PBM representative
  • Ease and ability to access prescription records and order refills
  • Resolution of denied drug claims or appeals
  • Overall quality of care
  • Adequate coverage of treatment medication needs
  • Personalized care for Rx needs

They seem like logical factors, but some of them aren’t controlled by the PBM but by either the self-insured employer or the managed care company (1, 2, 9). Depending on the service model, several others may be done by the managed care company (4, 5, 6, 7). And, I have no idea of how they are going to gauge things like overall delivery (3); quality of care (8); or personalized care (10). I hope they at least look at how responses vary by high utilizers versus low utilizers (of drugs) along with the type of coverage (which I doubt the individual knows whether their pharmacy coverage is through Aetna’s PBM or Medco (for example)).

Walgreens Health Initiatives (WHI) won the award last year and is certainly building a very competitive offering:

  • A goal of 10,000 retail locations
  • Mail pharmacy
  • Specialty pharmacy
  • 90-day at retail
  • On-site (or worksite) pharmacy
  • PBM

“While we already knew from our own surveys that members are highly satisfied with the wide selection of innovative products and services we offer, it was gratifying to have it confirmed by an independent third-party,” according to Richard Ashworth, Pharm.D., MBA, executive vice president for WHI, a wholly owned subsidiary of drugstore giant Walgreen Co.

He believes member satisfaction ultimately boils down to choice and convenience, noting how a 90-day medication option at the retail level serves as an important mail-order alternative for those who prefer face-to-face consultations with a pharmacy team they know and trust. Of WHI’s national retail network of more than 62,000 pharmacies, more than 39,000 offer this option and the number continues to grow.

Walgreens also offers worksite pharmacies on many corporate campuses across the U.S., which encourages employees to be more proactive about their health and, in turn, helps reduce absenteeism and the overall health care spend. Serving just one employer allows pharmacists to focus solely on that particular patient population, maximizing plan design and wellness strategies as part of a tailor-made approach to comprehensive care.

Pharmacists can help engage, educate and empower employees, as well as provide informed feedback on clinical prior authorizations, therapy-specific programs or the impact of formulary changes on medication options. There’s also room for leveraging a company’s core cost-containment strategies by promoting generic utilization, formulary efficiency and other key clinical programs whether or not WHI is the plan’s PBM. (Text from article by Employee Benefit News)

Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy, Research

The Doctor Will See You…IF You Promised Not To Critique Them

June 3, 2008 by George Van Antwerp 1 Comment

It takes a lot for me to get offended, but I find this offensive.  The WSJ Blog mentioned it this morning, and when I clicked through the links, it seems like a total disconnect with the technology world.

Medical Justice Inc. has put together a contract physicians can ask their patients to sign. In it, patients promise not to post anything about their experience, good or bad, without your prior approval. The organization calls it a “vaccine against libel.” (AMA article)

This seems ridiculous to me.  Don’t we all have reputations that we work and go to school to create and protect.  Doesn’t every business have a brand equity that they work to protect.  This is nothing new.  So trying to create a fascist environment where public comment about your services is not allowed is ridiculous.

What’s next?  Hotels that won’t let you stay there unless you don’t rate them.  eBay not allowing feedback on buyers and sellers.  Architects not letting you visit their buildings unless you promise to like them and not comment about them.

This is a new economy which is driven by consumers.  Healthcare is going to be part of that like it or not.  Patients should have choice and should have transparent access to how physicians and other providers perform.  I am not against establishing some standards in terms of how the experience is evaluated, but censoring speech seems like the WRONG way to accomplish this.

Why don’t they focus on helping the physician create a positive experience, be responsive to criticism, and get patients that like them to post their comments.  We all realize that one or two people can be negative about a person or company, but that can be outweighed by a hundred positive reviews.

Consumerism, Healthcare, Marketing / Communications, Technology

Pavlovian Response To Sound

June 2, 2008 by George Van Antwerp 0 Comments

We recently got a new dog (a Tibetan Terrier), and we decided to start training the dog using the clicker method.  I kiddingly commented that it would be great to have something like this to train people.  Apparently there already is such a method, and it can be used as a teaching method for autistic children (for example) along with sports training.

Basically, clicker training is an audio reinforcement for positive behavior…think whistle with dolphins.  TAG Teach is a website where you can learn more.

What I found interesting is how to link this in with sonic branding and the Pavlovian response concept.  Could I create an audio sound that drove behavior?  For example, I have my dry cleaning dropped off and picked up at my house.  They use an automated call to remind me to set it out.  All I have to do is pick up the phone and hear the voice.  Once that happens, I know what to do and hang up on the call.

TAG stands for Teaching with Acoustical Guidance and uses a sound marker to indicate correct performance.

The TAG refers to the distinctive sound made to mark or “TAG” a moment in time. This sound becomes an acoustical binary message, a sort of “snapshot” that is quickly processed by the brain.

A TAG means “yes.” Absence of a TAG means “try again.”

The student no longer has to perform a time-consuming language analysis while attempting complicated movements. The immediacy and clarity of the feedback allows the student to form a mental picture of the movement or position.

TAG points are the individual pieces of a desired response action or position. Students receive a TAG (the click sound) when the points are correctly performed.

The set up for a golf swing may have TAG points for grip, body position, foot placement, and club placement. The swing component may have TAG points for hand, arm, and club position at the top and end of the swing, TAG points for leg position, arm position, and weight transfer during the swing. With a beginning golfer a limited set of key TAG points are defined and executed individually. With an experienced golfer a diagnosis is performed and TAG points are identified based on technique errors requiring correction.

Books / Articles, Healthcare, Marketing / Communications, Research, Technology

Kid’s Cancer Highest In Northeast

June 2, 2008 by George Van Antwerp 0 Comments

I think this is an interesting analysis, but I don’t think it shows any causality just correlation.  The key questions (as reported) are whether there is an issue here (e.g., greater exposure to radiation) or just a difference in reporting or access.

The study was just released by the CDC.  It showed that cancer effects 166 out of every million children or 0.017%.  Rare, but very tragic.

  • The highest rate was in the Northeast with 179 cases per million children.
  • The lowest was among children in the South with 159 cases per million.
  • The rates for the Midwest and West were nearly identical, at 166 cases per million and 165 per million, respectively.
  • The cancer incidence in boys was 174 cases per million, compared with 157 cases per million in girls.
  • In white children, the rate was 173 per million, versus 164 per million in Hispanics and 118 per million in blacks.
  • Teenagers had higher rates than younger kids.
Healthcare, Research

You Only Have To Be Compliant For 10-Days…What Happened?

June 2, 2008 by George Van Antwerp 0 Comments

On the topic of non-compliance, I found this a pretty pathetic statistic:

56% of children on a 10-day course of penicillin for streptococcal infections were no longer receiving the drug by day three. (The Merck Manual of Diagnosis and Therapy)

I guess I expect it with maintenance drugs, but this is for your sick kids where you have already purchased the medication.

Consumerism, Healthcare, PBM / Pharmacy, Research

Deloitte Survey Of Health Care Consumers II

June 2, 2008 by George Van Antwerp 0 Comments

I posted an entry about a month ago about the Deloitte study that was out about consumer segmentation. That was from reading their website.

After someone sent me the PDF on their study, I finally read it on my flight to San Francisco today. It is full of lots of interesting facts based on their web survey of just over 3,000 adults in September 2007. Here are a few additional things that I pulled out (click on the tables to expand their size).

78% of consumers express a preference for customizing their insurance product by selecting the benefits and features they value and, in doing so, increasing or decreasing the overall cost of their coverage (Figure 18). Only 22% prefer selecting from a few pre-packaged products with defined benefits and features.

Books / Articles, Consumerism, Healthcare, Research

Guest Post: Health Researchers Obtain Grants for Video Game Study

May 30, 2008 by George Van Antwerp 0 Comments

12 US research groups were awarded grants this week in order to conduct studies on how interactive video games affect players’ health. There has been a lot of press lately for Nintendo Wii and its many health benefits. It seems that the Wii isn’t the only gaming system to influence a person’s lifestyle choices where health is concerned. Of course, not all games are having a positive influence.

Grants totaling up to $200,000 were given to each research team, all of which are connected with a major US university. The generous donations come from Robert Wood Johnson Foundation (RWJF), a private foundation that is dedicated to improving the health of all Americans.

In regards to the grants, RWJF program officer Chinwe Onyekere stated:

We have been actively working in this area since 2004. Over this time, we have heard repeatedly that there is a need for stronger evidence that games can improve health and healthcare and support the growing realization that games can make a real difference in public healthcare in the United States.

Our vision is that in the coming years we will have a thriving marketplace of well designed, compelling interactive games that draw on this evidence base to become highly engaging and effective tools for improving the health and healthcare of Americans.

The 12 teams are currently working on projects that focus on different age groups and behaviors. Maine Medical Center, for example, was awarded a grant for its study, “Family-Based Exergaming with Dance Dance Revolution (DDR)”. The aforementioned game, DDR, is extremely popular with children and young adults. It involves moving on a small, portable dance floor while a video with instructions plays on the screen.

Research grants were dispersed by RWJF in order to study things like “the potential of physical activity video games to serve as innovative, cost-effective ways to help people recover motor skills after experiencing a stroke” or “health impacts of online mobile mini-games for people with type 2 diabetes.” Another group of 12 research grants will be awarded next year.

By-line: Heather Johnson is a regular commentator on the subject of CNA Classes Online. She welcomes your feedback and potential job inquiries at heatherjohnson2323 at gmail dot com.

Consumerism, Guest Post, Healthcare, Innovation, Research, Technology, Value Propositions

American Cancer Society on YouTube

May 29, 2008 by George Van Antwerp 0 Comments

I think it’s interesting to see how the American Cancer Society is using YouTube to create a call to action both around the election, the uninsured, and other issues.

Consumerism, Healthcare, Marketing / Communications, Technology

Our First Think Different Event

May 29, 2008 by George Van Antwerp 2 Comments

Today was our first Think Different event in Boston. This is a road show we are doing around our new positioning and how health care companies need to get outside the box to improve the effectiveness of their communications. It has four external speakers plus our CEO.

[Spoiler Alert: If you are attending an upcoming session, I may reveal some of the content here.]

I missed ½ the session today due to a client call, but I will be at 3 of the other 5 events. In listening to the first two speakers, I jotted down a few thoughts.

From Kinney Zalesne:

  • She spoke about moving to the Starbucks economy and how we have much more choice today in what we do, who we love, religion, and our gender. Everyone immediately thinks of gender meaning sex change operations, but the point here is that there is a group of people who don’t want to be forced to select a gender identity. Before you discount it, you should know that 100 corporations, 75 colleges, and 8 states now ban discrimination based on gender identity. This was a bit of a surprise to me, but when I was talking with a large health plan about this, they informed me that their new EMR (electronic medical record) allowed for 5 possible gender options.
  • She talked about people basically starving themselves to focus on the theory that has been demonstrated in animals, but not yet in humans which says that by eating 30% less calories you can extend your life by 40%. (Not something I will be doing.)
  • She talked about the Do-It-Yourself (DIY) Doctors which are the people who use the Internet to self-diagnose and treat the MD as an ATM for drugs (i.e., I need a prescription for simvastatin can you please write it for me). I have heard a lot of talk recently about the changing perception of physicians. I haven’t seen the statistics, but one person said that they have lost the most respect over the past 20 years than any other profession. I think Kinney’s point is more about them moving from being a supervisor role (i.e., you should do this) to an advisor role (i.e., thanks for your opinion…I will take it into consideration).
  • Her statistics about 5M working retired (i.e., >65 years old) and 2M working teens (i.e., using the Internet to make money before they leave high school) says a lot about how benefit design will need to change. The implications on needs and flexibility (e.g., imagine two primary addresses for snowbirds) could be significant.
  • In her talk about micro-targeting, my mind drifted to a few thoughts:
    • How has gas prices changed our opinion of other costs? A $15 copay used to be equal to 7 gallons of gas. When it only equals 3 gallons of gas, do we view the $15 differently? [Have you caught yourself saying gas is only $3.75 at this one station near my house?]
    • Just like your segmentation can change in healthcare, it is important to consider the macro-economic and political environment when communicating. Have you listened to all the car advertisements lately…they all talk about gas mileage?
    • If you need a simple example of why personalization matters, think about buying a car. I am not a mechanical person so if I came in and someone talked to me about horsepower and cylinders then I would be turned off. I care about comfort and low maintenance.
    • Finally, getting back to health, I thought about how difficult it is to be successful. Let’s assume there were 10 primary reasons for non-adherence and 3 primary channels for delivering information (live, letter, automated call). In this case, you have 10% chance of hitting the right message and a 33% chance of using the right channel (i.e., a 3% chance to be successful).

From Liz Boehm:

  • She shared a lot of great facts about patient awareness of technology and how adherent they are.
  • She points out a scary fact that while our health care needs are going up with the boomers we simultaneously have an issue with health care workers retiring which will only make things worse in the short term.
  • She showed that 47% of people had visited their health plan’s website. [I will have to push her on this data since I believe they visited, but I think the percentage that log-in and use the site has to be very small. I would estimate 10-15%.]
  • She talked about use of social media and gave an example of a MySpace group on diabetes.
  • I found the discussion on wellness very interesting where she pointed out that things like chocolate, riding an elevator, or for some smoking gives you an immediate positive feeling while dropping your cholesterol by 10 points or even trying to lose 1 pound per week is pretty abstract.
  • I have talked about loss aversion several times, and she talks a lot about it. Using it to make a link to why incentives matter in health care.
  • Talking about motivation, I like her point that it isn’t a reasonable suggestion if you can’t achieve it. It may make good clinical sense to have a BMI of <25, but for someone with a BMI of 31, perhaps setting a goal of 28 is more reasonable and not as discouraging.
  • In her talk about trust, it made me wonder how many people that work for managed care companies and pharmacy benefit management companies reveal that fact at cocktail parties. I am not talking about professional networking events, but your neighborhood events. Do you say who you work for and address their comments about service and/or coverage issues?

I finished my client meeting in time to hear Stan Nowak, our CEO and co-founder, speak and tie together the different points of view with some potential actions that people could take. As he often does, he talked a lot about the power of data and the fact that what’s new to health care is often old in other industries. We are an industry with the most data about people, but the least ability to use it effectively.

It’s also interesting to hear him talk about some of the “data exhaust” that is created by the analysis that the team does. These are facts that get revealed which may be surprising and may be things you never even thought to look for. For example:

  • Patients with emphysema are 40% more likely to engage in a communications program related to additional coverage than patients with migraines.
  • Patients with uncommon names are 18% more likely to complete a healthcare survey than those with common names.
  • Males with depression are 83% less likely to do pill splitting than females with depression.
Books / Articles, Consumerism, Events, Healthcare, Managed Care, Marketing / Communications, PBM / Pharmacy, Research, Silverlink, Technology, Value Propositions

Skin Cancer Widget

May 28, 2008 by George Van Antwerp 0 Comments

I get a lot of solicitations to talk about products on the blog. I also get a lot of general e-mails. The ones I generally respond to are people giving me a heads up about an article, press release, technology, or something else that I just wouldn’t have known about. That doesn’t mean I will do anything about it, but if I have time and find it interesting, I will usually click through the link. And, if it still catches my attention then I will write about it.

This one is fairly self-explanatory, but I found it interesting. VisualDxHealth has built a widget for you to self-diagnose your skin cancer. Which, according to the statistics they sent me, is valuable since 1 in 6 Americans will develop skin cancer and the survival rate is high when found and treated early.

The Recognizing Skin Cancer widget interactively provides information about the different types of skin cancer and includes a visual identification quiz that tests the user’s knowledge about recognizing the signs of these conditions.

Unfortunately, I can’t add widgets and other code to my blog or I would have lots of these types of cool things on the site.

Consumerism, Healthcare, Technology

Wii Fit: Using Technology To Teach Wellness

May 28, 2008 by George Van Antwerp 0 Comments

I talked about the Wii a few months ago when we first got one. At the time, I didn’t know that Wii Fit was coming.

This past weekend we happily bought it, and I enjoyed it. It tells you your BMI. You can do yoga. You can do aerobic exercise (running, hula hoop, step aerobics). You can do agility exercises (downhill skiing, tight rope walking). I was a little skeptical, but I have been fascinated by the Wii so far.

And, I loved the fact that my 6 year old could get into it. She loved that once you put in your height, and it calculates your weight that it changes your Mii (avatar) to reflect your likely dimensions. She spent lots of time on the yoga moves that I probably never could have gotten her to do in a traditional forum.

This creative use of technology gives me a lot of hope for how we can teach our youth, drive rehab programs, and impact people.

Now what I am looking for is when will we see a competition to lose the most weight only using the Wii for training.

Healthcare, Innovation, Technology
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Groups And Microsegments

May 28, 2008 by George Van Antwerp 0 Comments

When I was listening to Kinney Zalesne (Microtrends author) present this morning at our Think Different event, there were several things that crossed my mind:

  1. Which micro-trends am I part of?
  2. How much micro-targeting is too much?
  3. Will consumers self-identify into groups?

Without going back to the whole book, I can think of several micro-trends with which I associate:

  • Marathoning
  • Stay-at-home worker and extreme commuter
  • 30-winker (don’t sleep a lot)
  • DIY Doctor (research my own care)
  • Pet Parent (pamper my dog)
  • Video Game Grown-ups (enjoy playing Wii w/ and w/o my kids)
  • Blogger

It has come up in the past two sessions where I have seen Kinney present. The question is how much is too much. Just because I know that you like cats, subscribe to Popular Mechanics and GQ, and have 3 siblings, should I use that information?

  • I certainly think that more targeting is better although I might not always want you to tell me how much you know about me.
  • You have to be flexible enough to allow for mistakes in interpretation and/or not too presumptuous. (For example, one of our co-founders is from Brazil but has been here for years. He recently started getting all of his communications from a few companies in Spanish. He didn’t opt-in, but they assumed his last name meant he spoke Spanish (which is not what they speak in Brazil BTW).)
  • You have some issues of parity which must be either addressed or are legally required (i.e., you may have to treat everyone in a similar way). I am sure we might all like to drive high satisfaction for healthy members to increase their retention, but this deliberate adverse selection would be an issue and abuse of information.

Finally, there is a lot of discussion about capturing preferences (i.e., I prefer calls over letters) and how to segment populations. I think there is an interesting trend in social media for people to self-identify into groups. For example, I pulled up my LinkedIn profile to look for a second at all the groups to which I belong. The same thing is happening in Facebook. Until recently, this was not a huge driver of activity, but over the past 6 months, I have noticed people forming and joining groups. We want to be associated with certain things. I think if I knew how the information was being used that I would spend a few minutes during enrollment filling out information about how and when to communicate and interact with me. I think I would even reveal my Myers-Briggs category (INTJ) if it helped someone better deliver information to me that would make me healthier.

The younger generation is rapidly becoming used to revealing lots of information about themselves. I don’t think that things are considered as private as they once were.

Books / Articles, Consumerism, Healthcare, Managed Care, Marketing / Communications, PBM / Pharmacy, Research, Value Propositions

Express Scripts Settlement on Statin Switches

May 28, 2008 by George Van Antwerp 0 Comments

I don’t know the insider details, but I am certainly familiar with the original program in 2005/2006 which targeted users of 3rd tier branded cholesterol (statin) drugs to get them to move to a lower cost agent which could either be a brand or generic drug on formulary (obviously wanting it to be the generic).

Apparently Express Scripts settled with 28 states for $9.5M associated with their program.  I would guess there were several issues:

  • Switches within this class might require follow-up physician visits and/or lab work to be done.  That could increase copays for the patient and/or drive up plan costs.  How clearly that was explained could be an issue?
  • Depending on timing some of these switches might have occurred right when Lipitor was moved off formulary.  It would have then been more expensive for the plan sponsor, but I believe all the clients would have signed off on this knowing that they would save money over the initial 12-month period.
  • Depending on when this is from, they moved Lipitor back on formulary for 2008 which might mean some people were bounced around different formulary agents.  (But, I can’t imagine this was already identified and settled.)

It basically appears to be a communication issue.  Was the right information disclosed to the right person at the right time with the right amount of detail?  And, even if it was, is it worth fighting it?

From a patient perspective, I would hope that this doesn’t prevent my health plan / PBM from reaching out to me to tell me how to save money.  I spend a lot on health care each year and hate to believe that there aren’t ways to save money.

From a PBM / plan perspective, I wouldn’t be discouraged.  This just continues to clearly layout the rules about what needs to be done.  There are still plenty of opportunities, but they need to be designed the right way with the right information included in the communications.  There is nothing there that is not achievable or unreasonable.

Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy, Value Propositions

Missing The First Step

May 28, 2008 by George Van Antwerp 1 Comment

When I saw Forrester’s data around Personal Health Records (PHRs), it reminded me of one of the facts we struggled with around increasing mail order utilization…most people didn’t know what it was or whether they had it as a benefit.  (From their Q2 – 2007 Social Technographics Online Healthcare Survey)

So, given all the buzz about PHRs and which one will work and what needs to be included, I wonder if we often miss the first step as people in the industry.

The first step in any “marketing” or communication approach has to be to build awareness.  Although it might sound great to say that I have 80% of chronic drug users that are aware of their mail order benefit using mail order, I am not maximizing the size of the pie.  (I.e., 50% have chronic medication x 50% aware of mail x 80% use mail = 20% penetration)

Consumerism, Healthcare, Managed Care, Marketing / Communications, PBM / Pharmacy, Research, Technology

Are You Going To AHIP Institute 2008?

May 27, 2008 by George Van Antwerp 0 Comments

Are you going to the AHIP (America’s Health Insurance Plans) Institute 2008 event in San Francisco in June?  I will be there and would love to connect.  Just let me know.

Events, Healthcare, Managed Care

Additional Blog Site

May 27, 2008 by George Van Antwerp 0 Comments

I got asked to contribute to the Drug Safety Hub Blog and just posted my first entry there on patient’s awareness of technology solutions around pharmacy.

Consumerism, Healthcare, PBM / Pharmacy, Research, Technology

Book Review: Health Care Reform Now!

May 27, 2008 by George Van Antwerp 3 Comments

Health Care Reform Now! A Prescription For Change is the latest book by George Halvorson (CEO of Kaiser Permanente). I have been talking about it and using quotes from it for a few months. I finished the book a few weeks ago and figured that I better carve out the time to capture my thoughts now.

First, if you are looking for a great book on why healthcare is a big issue in this election, you don’t have to look any further. As someone running one of the biggest healthcare entities in the US, George clearly knows what he is talking about and speaks from a position of authority. I know that he has talked with all of the candidates about their policies.

If you are in healthcare and trying to be a catalyst for change, you have to read the book. It is pointed, opinionated, and supported with lots of facts and examples. If it doesn’t make you want to change what we have, I would be shocked. Some of the examples of mis-alignment are scary.

Some of the facts he shares:

  • Family health insurance rates in CA already exceed the per capita income of 147 countries.
  • General Motors now spends more money on healthcare then on steel.
  • Nearly 50% of the time, patients in the US are receiving less than adequate, inconsistent, and too often, unsafe care.
  • Healthcare costs are unevenly distributed in America.
    • 1% of the population uses 35% of the healthcare dollars
    • 5% uses 60%
  • Care linkage deficiencies abound – and can impair or cripple care delivery.
  • Economic incentives significantly influence healthcare.
  • Systems thinking isn’t usually on the healthcare radar screen.
  • Most of our costs are for chronic diseases – primarily diabetes, congestive heart failure, coronary artery disease, asthma, and depression.
  • Prevention is a lot less expensive than addressing these chronic diseases at their late stages.
  • The US ranks 35th in the world in infant mortality.
  • We could cut the complications of diabetes by 90% with best care and involved patients.
    • We could cut second heart attacks by 40%.
    • We could cut school and work days lost because of asthma by 90%.
  • Incentives work…yet while we have 9,000 billing codes for procedures and services not one of them is for curing someone or improving someone’s health.
  • There is up to a 60% difference in the 5-year mortality rate for breast cancer patients, depending on which hospital’s surgery team did the surgery.
  • 1 in 10 doctors use electronic medical records (EMR) and only 5% of hospitals use computerized physician order entry (CPOE). This means our history exists mostly in paper files with no standards.
  • Almost 50 developing nations have higher immunization rates for preventable childhood diseases than the US.
  • The Institute of Medicine showed that it takes “seventeen years before a proven new technique becomes the standard of care in a given medical specialty.”
  • There were 2,000 published clinical trials in 1985 and 30,000 published in 2005. (Can your provider really keep up without an electronic system?)
  • Diabetes is the number one cause of new blindness (90% preventable) and foot and leg amputations (85% preventable). It is the number one co-morbidity associated with death from heart failure.
  • Asthma causes – 2M emergency room visits, 500,000 hospital stays, 5,000 deaths, and 14M lost school and work days per year.
  • The vast majority of asthma attacks can be prevented.
  • If Americans were 5-10% thinner and walked just 30 minutes per day, the incidence of Type 2 diabetes could be cut by more than half. (Culture and incentives matter)
  • We spend $250,000 every minute on heart disease.
  • More than 15M Americans have depression…and on average, people with depression have 3 other chronic diseases.
  • A 10% reduction in spending for the top 0.5% of patients would create enough savings to fund universal coverage for the uninsured.
  • The most expensive acute conditions are cancer, maternity, and trauma care. (Acute conditions account for 30% of the health care spend.)
  • The median life expectancy across the 117 cystic fibrosis centers is 33, but it is 47 at the highest performing center. (This seems embarrassing that there could be such a difference here.)
  • US employers pay an average of $6,600 Per Employee Per Year compared to $600 in Canada.
  • 4% of people believe they have insurance…but they don’t. (Who are these people?)
  • Government pays 44% of the healthcare bill today; employers 26%; and individuals 30%.

Key Point – I think everyone wishes that we could address the uninsured and underinsured issue here in the US. It is ridiculous. But, I think most people feel it would further complicate the economy and be a downward drag. George presents a good case that today’s model simply cost shifts so that we are paying for care but paying at the high cost of emergency care not preventative care for those people. In the book, they say that this cost represents $922 per employee today in what is paid. Someone has to pay the providers for these real costs that they incur and can’t recoup. We could cover the costs of the uninsured without any real increases in costs.

Some of my favorite quotes:

  • “We don’t really have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited Microsystems, each performing in ways that too often create suboptimal performance both for the overall health care infrastructure and for individual patients.” (introduction)
  • “Performance reporting that actually exists about either processes or outcomes is almost always regarded in the current culture of American health care as an onerous, externally imposed burden, extraneous and irrelevant to the actual business and profession of care delivery.” (pg. 23)
  • “I do not want ‘rules-based’ medicine. I do want accountable care.” (pg. 29)
  • “Process reengineering will not happen on any scale in health care until there is a financial reward for doing just that.” (pg. 33)
  • From the book Escape Fire: Designs for the Future of Health Care by Don Berwick – “A patient with anything but the simplest needs is traversing a very complicated system across many handoffs and locations and players. And as the machine gets more complicated, there are more ways it can break.” (pg 86)
  • “We need highly credible doctors, nurses, and health educators talking to patients in targeted and effective ways to help people make the lifestyle changes necessary to avoid diabetes.” (pg 117)
  • “Health care can be improved. The challenge is to do it consistently and systematically, not incidentally and haphazardly.” (pg 122)
  • “Improving care by 50 percent for diabetics is wonderful, but not as wonderful as reducing the number of diabetics by 50 percent by preventing the disease.” (pg 206)

Comments:

  • He talks about studying the international models and that none of them are the same. They have all been individually developed to fit the culture and needs of the country.
  • He talks about creating a “patient-centered American health care marketplace”.
  • He is careful about not just pushing the Kaiser model of vertical integration. He focuses on virtual integration which is more achievable.
  • More care is not better care.
  • He gives several examples of how following best practices for evidence based medicine improved outcomes but reduced revenues for the providers which is a hard model to sell.
  • He compares HEDIS scores (which measure how often health plans offer care that complies with best practices) with Six Sigma:
    • Average performance for screening for colorectal cancer is 49% (or 1.5 sigma).
    • Recommended treatment of acute depression is 61.6% (average) and 70.8% (90th percentile) which are 1.8 and 2.1 sigma performance.
    • Note: 2-sigma performance means 308,000 cases of non-compliance per million patients…6-sigma means only 3.4 cases per million.
  • He talks about the fact that 5% of patients experience an adverse drug event. I think the PBM industry has consolidated a lot of data to minimize this, but I am surprised more people don’t talk about samples here. Although they are supposed to track samples, I bet most physicians don’t record them in the chart and they certainly aren’t electronically managed to look for potential drug-drug interactions. (In my opinion, there is still opportunity for improvement, but it is at the pharmacy level not the provider level.)
  • He proactively addresses one major excuse about controlling patient behavior. Yes…we can’t control the patients, but we can make sure that the right events happen to align them for success.
  • I like his suggestion that a personal health record could be a more logical first-step than a full blown EMR solution due to costs and ability to execute.
    • “That personal health record data set for each patient should show all care received by that patient, all prescriptions paid for, all tests given, all diagnosis made, and all providers who delivered care to each person as a patient. The information should be in an easy-to-use format and available to each patient on demand, either electronically or on paper.”
  • He provides a good, quick comparison of PHR and EMR:
    • EMR has the exact Rx dosage and level. PHR may just have the name of the drug.
    • EMR will have the x-rays and scans. PHR will just say the date the test was done.
    • EMR will have notes from physician visit. PHR will just know the patient visited.
  • Preventing a CHF (congestive heart failure) crisis might only generate $200 in billable revenue while treating a crisis creates $10,000 – $20,000 in revenue. (And, we really wonder why people aren’t acting preventatively.)
  • Preventative care makes me think of two examples:
    • People have to want to be healthy and manage their risk. I know numerous people who are told to be on bed rest when they’re pregnant that don’t listen to their physicians.
    • People have to know there is not a risk of discrimination. I know a friend with MS who didn’t go see a doctor for several years until she had found a job with good health insurance.
  • He talks a little about it, but I think the issue of helping patients evaluate trade-offs is a big one. Enabling them with information is important, but how do we help them compare two treatments based on both outcomes and the experience (i.e., pain, functionality). Is it always better to simply live longer even if you have limited functionality and are always in pain?
  • He talks about plan design with some very good insight:
    • Deductibles only work if the unit of care being purchased is less than the deductible.
    • Deductibles tend to discourage chronic patients from getting preventative and maintenance care.
    • Percentage copays only work on big dollar differences. Otherwise, paying 10% more of a drug or office visit that costs $20 more is only $2.
  • In talking about plan design, he talks about something that in pharmacy is referred to as Therapeutic MAC. (MAC = maximum allowable cost) This allows patients access to any drug, but the plan only pays for the lowest cost drug which produces equal outcomes. Therefore, a patient might get the first $70 of any office visit covered, and they pay the difference. Then they care about where and when they go to the doctor.
  • For all the talk about price transparency and driving decisions, he makes a great point that this is thrown out the window at times. For example, when you are having a heart attack, you don’t have time to research your options and make tradeoffs.
  • Kaiser saw first-hand what happens after seniors pass a cap on prescription coverage (pg 137):
    • 18% started skipping doses of medication
    • 9% increase in ER visits
    • 13% increase in hospital admissions
    • 22% increase in mortality
  • He talks about 8 developments that have made health care reform possible:
    • Common provider number
    • Computerized databases
    • Electronic claims data portability
    • Government transparency about payment data
    • Universal awareness of the quality issues
    • Buyers are ready for change
    • Internet functionality used for care
    • Lawmakers are ready for reform
  • He talks about blending virtual care and live care with a technology infrastructure which I think makes a lot of sense. I wonder how we change physicians to be more comfortable with the “DIY” (Do It Yourself) patient that comes in with lots of information and suggestions from other caregivers or even getting “second-guessed” by the rules engine of the EMR.
  • He talks about health care needing a Target, Best Buy, or Wal-mart to manages the buy and sell side of health care.
  • (I am going to massively over-simplify this) He talks a lot about having the buyers issue an RFP requiring certain things and creating a new type of entity – the Infrastructure Vendor (IV). “The IV should facilitate and operate electronic connectivity support tools for the patients and caregivers and should demonstrate their effectiveness to the buyers.”
    • He doesn’t see the government playing this role which limits who could do this nationwide.
    • Conceptually, I agree that a technology backbone that connects everyone would be key.
    • It sounds a little too build it, and they will come to me. This is a radically and risky change that would need everyone on board.
    • Some mandated change at a government level has to be required.
    • Could you do this at a state level first?? For example, I know a coalition that got all the employers to agree to a RFP and moved all their business to Humana for one area after they won the RFP.
  • At many points in the book, I kept thinking about the need for SLAs (service level agreements) on outcomes. (I haven’t studied the capitation modes tried in the US years ago, but there seems to be something there about paying a provider a fixed amount per year. Their job is then to act preventatively.)
  • I am a fan of using incentives and penalties in the system with one caveat. I think you need to tie this to genomics. So, someone who has high cholesterol based on their family history and tries to treat it shouldn’t be treated the same way as someone who eats junk food all the time with no family history.
  • I think making people buy-up to different providers or drugs works great for events that can be planned, but not for emergency. It would be possible to tell which one was which with a fully integrated system. Of course, you have to manage people not gaming the system, but that is where there should be incentives for being preventative. Trading off metrics in your design to balance behavior will be key.
  • Another sad fact that he relays toward the end of the book is some of the data pointing to the racial and ethnic disparities in coverage and care in the US.
    • The death rate from asthma for African American children is 4x the death rate for white children.
    • Minority Americans make up ~ 1/3rd of our population but over ½ of the uninsured.
  • One thing I didn’t see or get was whether any of the international models that he studied had a focus on outcomes.
    • I thought one interesting point he made that in a government system where votes are at stake there is a strong focus on primary care which is used by the masses (i.e., more votes) versus specialists which are used by the minority of patients. Another example of how incentives skew solution design.
  • I am always shocked when I see the Federal Poverty Guidelines. How does someone survive on $9,800 or $20,000 for a family of 4? If you ever wonder how all the tasks get done around you and still feel like addressing the uninsured and underinsured is an issue, you should try to live on that income.

My summary after reading the book was:

  • Wow! We have a lot of work to do.
  • We can make a difference pretty easily.
  • There are three things that matter – infrastructure, incentives, and culture.
  • Employers have to be willing to push incentives or penalties to their employees. The strategy of lowering costs without “disrupting” people doesn’t work.

Go read the book. Help make a change.

Books / Articles, Consumerism, Healthcare, Innovation, Managed Care, PBM / Pharmacy, Research, Technology, Value Propositions, Weblogs
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Medco’s Trend Report

May 22, 2008 by George Van Antwerp 0 Comments

Medco‘s Trend Report recently came out for 2008 (which looks back at 2007). Here are some of the graphs and information from it.

“Generic drugs have been a tremendous asset in controlling runaway health care costs,” Medco Chairman and CEO David B. Snow Jr. said. “Generic cholesterol medications have helped contain our drug trend to a new all-time low of 2.0 percent. Patients and our clients are reaping the benefits of generics as we enable them to hold down costs and make prescription drugs one of the few areas where spending trails overall health care inflation.” (Source)

  • Drug trend was 2.0%.
  • They talk a lot about what drives trend by class.
  • It shares a lot of tables and charts. (I pulled out those below that most interested me.)
  • They talk about legislative and technology issues / opportunities such as e-prescribing.
  • They talk about consumer driven health plans (CDH):
    • Lot of plans offering them; low adoption (2.6M members)
    • Mail order use is only 1.2% higher and generic use is only 1.0% higher (so much for easy ways of saving money)
  • They talk about the rapid growth of people using social networking tools to learn about diseases and medications.
    • Which presents risks and opportunities

  • They introduce a new metric…the Generic Opportunity Score.
  • They introduce a new topic to me which is “adjunct therapies”. The key to this topic here is whether plans should consider coverage of over-the-counter (OTC) drugs that are prescribed for use with prescriptions to treat a condition.
  • They talk about Medicare driving a focus on quality.
  • They talk about coverage for the uninsured.
  • They talk about biosimilar drugs (aka – biogenerics).
  • The talk about genomics (i.e., personalized medicine).
  • They talk about BTC (behind-the-counter) and OTC (over-the-counter) trends.
  • They talk about nanotechnology.

I didn’t read it word for word, but it seems to cover the landscape well and give good easy to read metrics with lots of charts.

Books / Articles, Consumerism, Healthcare, Innovation, PBM / Pharmacy, Research, Technology, Value Propositions

Walgreen’s Trend Numbers

May 22, 2008 by George Van Antwerp 0 Comments

I think the next thing I need to do is put all this data side-by-side, but in the interim, here is some recent data from Walgreens:

  • Highly managed plans had a -0.07% pharmacy trend last year. (I think we started this breakout of trend numbers back in 2005 at Express Scripts.)
  • Total drug trend was 5.66% (based on all clients)
  • They had a generic dispensing rate of 61.2% (or 69.6% incuding Medicare)
  • They state that a 1% improvement in generic utilization equals a 2% savings in plan cost

“The outstanding -0.07 percent trend for highly managed plans demonstrates the effectiveness of our cost-containment strategies and illustrates the enormous impact our plan management options can have,” said Richard Ashworth, executive vice president, Walgreens Health Initiatives.

They also say their Trend Report will be available in early summer. (link will be good then)

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