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Specialty Rx Offerings Not Rxs Only

April 6, 2011 by George Van Antwerp 0 Comments

I’ve spoken about this for a while, but I was pleasantly surprised to hear one of the Chief Medical Officers in the industry make this point to a large number of manufacturers. He was talking about lots of the changing dynamics in the industry from personalized medicine to new research. He talked about the challenge of adherence and how we needed to think differently. He even suggested that pharma should start talking with payers much earlier in the pipeline so that their research tracked metrics that the payers cared about.

At the end, one of his summary perspectives was that they should stop thinking about just bringing a drug to market and think about how they bring an offering for the condition to market which centers around a drug. This goes back to what the book BLUR presented years ago. You have to blend products and services to create offerings.

In the case of specialty, you have a very sick patient who often has a symptomatic condition that they are living with everyday that might affect their ability to live or potentially debilitate them. It affects their family. And, there may be additional co-morbidities associated with the condition.

Right now, there are solutions that try to engage these patients especially in clinical trials or when a drug is first launched, but over time, that “energy” decreases. It’s important to think about these specialty patients from an experience perspective.

  1. Diagnosis – What happens after they’re diagnosed? How much do they really remember from the physician encounter? Do they understand the drug they’ve been prescribed? Do they know where to go to find more information? Do they understand what resources are available to support them?
  2. First Fill – Do they understand the drug’s side effects? Do they believe that this is going to help them? Do they know how to get the prescription? Do they understand how to use the specialty pharmacy?
  3. Ongoing Therapy – Do they continue to refill the medication? What are their barriers (cost, convenience, literacy, beliefs, side effects)? Can they afford the medication? What support is there (financial, education, counseling) and how do they access it? Does their physician understand the disease? Have they gotten engaged with a community or support group?
  4. Changes In Condition – As they progress, what should they expect? How do you monitor these changes? Do these changes have an impact on the drug or strength? How does adherence affect this?

This creation of a solution blending services and pharmaceuticals creates some new ways for a manufacturer to differentiate themselves in the marketplace. Imagine the power of going to the physician, pharmacy, or PBM and telling them that you have a solution which does the following:

  • Provides a highly effective drug (cue traditional data)
  • Improves awareness and understanding of the condition for the patient
  • Decreases the likelihood of abandonment
  • Helps the patient with their out-of-pocket costs
  • Increases the patient’s likelihood of refilling
  • Helps the patient become an e-patient and engages their support system
  • Provides ongoing monitoring of changes in their condition

Interested? I have some ideas if you’re a brand manager.

Healthcare, Leadership, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Silverlink, Value Propositions

The Physician As Island Versus Support From Intermediaries

April 6, 2011 by George Van Antwerp 0 Comments

Should physicians have the final say in patient care?

Someone tweeted me this question the other day. It made me start to think…

Logically, individuals trust their physician to act in their best interest and make the best decisions (based on the information they have).  But, this has shifted from the MD as the primary source of knowledge to the MD as a part of a care team.

There are probably more, but I can think of 5 important things that need to be fixed for the physician to be seen as an ‘information island’ where they can make the best decisions without intermediaries (PBMs, managed care, disease management companies) intervening:

1.  They have to be able to not practice defensive medicine.

2.  They have to understand my costs.

3.  There have to be no meaningful differences based on geography or income or race.

4.  They have to adopt best practices quickly.

5.  They have to be able to be paid based on outcomes.

Some of these are systemic changes that have to be addressed (#1 and #5). The other three can be addressed thru technology (as long as physicians are willing to embrace the science of medicine not just the art).  As a quick example, look at Dr. Atul Gawande’s book. – The Checklist Manifesto or look at some of the work by companies like Health Dialogue on shared decision making.

Now, maybe the person that asked the question is taking a more radical stand and physician’s embrace the support these companies provide them, but that hasn’t historically been true.

Books / Articles, Consumerism, Healthcare, Leadership, Marketing / Communications, Methodology, Politics, Value Propositions

The New Kaiser Center For Total Health (#WHCC11)

April 6, 2011 by George Van Antwerp 1 Comment

While I was at the World Healthcare Congress yesterday, I had the opportunity to go into DC to visit the new Kaiser Center for Total Health. This is their showcase in the East to facilitate discussions around improving healthcare. It’s not a replacement for the Garfield facility in CA, but it will create an more accessible forum for dialog with policymakers and international visitors. (NYTimes post about the opening)

It’s one of those fun places where you can go and interact with technology. It’s full of technology like telemedicine and telemonitoring. It provides you with demos of the world’s smallest ultrasound device and connected devices. It showcases Kaiser’s rich history and their MyHealthManager tool.

Their online tools have some great stats:

  • 3.3M members signed up
  • 25.8M test results viewed in 2010
  • 10.7M emails sent to MD’s in 2010

There are a lot of videos where you can hear employees, members, clinicians, and others talk about what they think “total health” is. And, they have a massive interactive mural about their walking initiative.

It seems like this type of interactive, high technology space is becoming an asset at several companies. We used to have this innovative, brainstorming space at E&Y years ago and clients loved it. I believe IDEO has this type of space.

I enjoy it. It’s interesting, inspiring, and creates a dynamic work environment. I look forward to see how this space gets used and what others think.

Events, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Research, Technology

Interview With Dr. David Wennberg At #WHCC11

April 5, 2011 by George Van Antwerp 0 Comments

I had the opportunity to sit down with Dr. David Wennberg (Chief Science & Product Officer, Health Dialog) at the 8th Annual World Healthcare Congress (Twitter hashtag #WHCC11).  David is a fascinating and engaging speaker.  He has lots of publications, works with the Dartmouth Atlas, and leads the Health Dialog Analytic Solutions group. 

David and I began our time talking about “informed choice”.

In this environment, doctors need tools that identify patients lacking evidence-based care. They also need to ensure that patients undergoing surgery have been exposed to informed choice, not just informed consent, when there is more than one legitimate treatment path. With these resources in place, physician groups can ensure that they are in control of their own destiny when it comes to performance evaluations.  (source)

This is an important issue in healthcare.  Giving patients (1) complete information in (2) language that they can understand and helping them (3) frame their options relative to their preferences is at the core of this issue. 

Health Dialog calls this Shared Decision Making and focuses on how to engage targeted consumers and help them make their best decision.  Their customer support personnel go through a certification process and use decision aids to enable the process. 

This led us into a discussion about “trust” (see prior post) and then into a discussion about “embodied conversational agents“.  Obviously, if you’re going to help consumers make decisions, they need to trust you.  We talked about the need to have transparency, the need to for disclosure, and the importance of using clinicians in the engagement and discussion process.  In many cases, nurses and the empathy that they have are critical to this process.

But, I know from prior exposure to Health Dialog that they have figured out ways to blend technology and agents.  They do a lot with data and analytics to really understand the popluation.  They’ve worked hard to avoid the traps that “disease management” has fallen into over the years.  He shared with me some amazing engagement statistics. 

We talked about the value of peer-to-peer videos for people to understand their condition and talked about some recent studies around storytelling and distributing that information via DVD to patients (see more on study).  We went on to talk about how engaging the consumer in the decisions about their care increase success, but that many models have been a challenge to scale.  Health Dialog just published an article in the NEJM called A Randomized Trial of a Telephone Care-Management Strategy which demonstrated an ability to scale the solution and get results. 

At baseline, medical costs and resource utilization were similar in the two groups. After 12 months, 10.4% of the enhanced-support group and 3.7% of the usual-support group received the telephone intervention. The average monthly medical and pharmacy costs per person in the enhanced-support group were 3.6% ($7.96) lower than those in the usual-support group ($213.82 vs. $221.78, P=0.05); a 10.1% reduction in annual hospital admissions (P<0.001) accounted for the majority of savings. The cost of this intervention program was less than $2.00 per person per month.

Before I could even jump to my next question about ACOs, he made the natural transition to the fact that the new ACO regulations mention shared decision making 8 times.  I believe we both agreed that whatever actual form these new practice settings take that they will accelerate the importance of leveraging technology and things like shared decision making to engage the consumer.  The key is to leverage the PCP setting whether it’s the MD or someone on their staff as the foundation for engagement.

This led me to ask him about physician acceptance of technology as part of their practice (more on this later).  He felt that they had moved from resistance to understanding the technology and “guides” can enable them to practice better medicine.

Books / Articles, Consumerism, Events, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Methodology, Research, Technology, Value Propositions

Trust As The Foundation For Healthcare Communications

March 31, 2011 by George Van Antwerp 3 Comments

Trust improves medical outcomes. It is the number one predictor of loyalty to a physician’s practice. Patients who trust their doctors are more likely to follow treatment protocols and are more likely to succeed in their efforts to change behavior. (Introduction of The Trust Prescription)

I just finished reading The Trust Prescription For Healthcare by David Shore. I would recommend it. It definitely framed things in a differently light. I also had a chance to talk with David on the phone and pick his brain a little. He sounds like a great speaker, and I’m looking forward to his new book coming out around building trust as an intermediary (i.e., managed care company or PBM).

A few of my highlights from the book are:

  • Trust can be a differentiator.
  • Trust is good business.
  • The physician to patient relationship is where the baseline of trust exists today. Although he brings up the question of whether that trust erode as you get more and more time pressure.  [I don’t remember the book specifically addressing the pharmacist – patient trust relationship although one would assume it is a similar foundational element.]
  • Trust is critical in healthcare because you’re asking a vulnerable patient to believe you can help them.
  • Profits may be negatively correlated with trust in healthcare (but not in other industries).
  • He pointed out the fact that it’s ironic that while pharmaceutical companies do so much good they get such a bad rap.
  • It was the first time I had seen someone introduce the issue of how healthcare entities are portrayed in TV shows and how while this is generally neutral that managed care organizations in the early 2000’s were portrayed negatively (and probably still are).
  • He talks about the concept of “response shift” which I think it an important phenomenon about how our expectations change over time and the effect of expectations on trust.
  • He talks about how two things happen when trust erodes – government intervention and consumer activism. [Hey…that’s where we are today!]
  • He uses two examples many times which are very relevant:
    • Volvo is known for safety not specifically for making cars. They make sure this is consistent in their branding (e.g., not funding NASCAR races). It gets to the core of defining who you are. [This concept also made me think about the new Dawn campaign about saving wildlife.]
    • You can build trust equity like Johnson & Johnson did which helps you when you have issues. [The question is how long they can draw on this given their current issues.]
  • He holds out a few healthcare power brands but says there are very few – Mayo Clinic, Cleveland Clinic, BCBS, Kaiser, Massachusetts General.
  • He talked about the concept of a Brand Architecture which made me think about some of the recent rebranding efforts at United Healthcare.
  • He talks about how consumer understanding and communications are key to building trust.

Communication in healthcare typically runs into a series of obstacles related to listening, clarity, and confidence.

Some of the interesting research data was [noting that this was a book from 2005]:

  • 56% of consumers say they will pursue something simply because it was made by a company they trust. (Macrae and Uncles 1997)
  • About half of people agree that “doctors are not as thorough as they should be” and “doctors always treat patients with respect”. (National Opinion Research Center 1998)
  • Race was a highly significant variable in trust correlation even when researchers controlled for other variables. (Corbie-Smith, Thomas, and St. George 2002)
  • Patients are more likely to take a drug that they have requested than a drug with which they are unfamiliar. (Handlin et al 2003)

It book made me think of some interesting questions:

  • Does transparency build trust with consumers?
  • Does concierge medicine build trust overall?
  • Does the use of technology by physicians enable or erode trust? [I believe he said that a lot of physicians didn’t think so.]
  • Do non-profit systems have more consumer trust?
  • What does all the news about drug problems, medical errors, and other issues do to the overall trust of the system?
  • What are the trust queues for consumers by type of healthcare entity? (For example, a dirty bathroom at a hospital might make you worried. What’s true for insurers, PBMs, pharmacies, etc.?)

One key point to pull out that he makes is that

Without branding, healthcare becomes a retail industry, and in retail, as in residential real estate, the three most important factors are location, location, and location.

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

You Need An Experience Architect

March 29, 2011 by George Van Antwerp 0 Comments

I’m often asked how my 6 years of architecture school plays into what I do right now.  I have a variety of things that I believe I learned in architecture that help me, but it wasn’t until the other day that it really clicked.  I was reading an interview about a CEO who had been trained as an architect.  She described architecture as building experiences.

All of sudden it hit me…that’s what I do.  I help companies look at an objective and architect the consumer experience to get to that objective.  And, it’s a lot of fun!

So, what are the parallels between healthcare communications and physical architecture?

  • There is no one answer.
  • You have to listen.
  • There is lots of data.
  • You have to use lots of materials. (print, e-mail, web, automated call versus concrete, glass, steel)
  • Each person’s experience is different.
  • Compliance matters. (building codes versus CMS)

Now, unfortunately, I can’t coin the term “experience architect”.  It’s been used by others.  For example, Tom Kelley from IDEO used it as one of his Ten Faces of Innovation.  He says an experience architect is one who:

Is that person relentlessly focused on creating remarkable individual experiences. This person facilitates positive encounters with your organization through products, services, digital interactions, spaces, or events. Whether an architect or a sushi chef, the Experience Architect maps out how to turn something ordinary into something distinctive—even delightful—every chance they get.

Fast Company talks about the Experience Architect in an article from 2005.  More commonly you’ll find articles or references to user experience architect. 

The point is that you need to think about things in this light, and I think the architectural paradigm is helpful in how you construct and embrace the creation of an experience for the consumer whether it’s around shopping, adherence, or managing diabetes.

Books / Articles, Consumerism, Healthcare, Leadership, Marketing / Communications, Methodology, Silverlink

The Changing Pharmacy Marketplace

March 29, 2011 by George Van Antwerp 0 Comments

I had the opportunity to listen to a few executives talk about how the marketplace is changing.  While I don’t think any of it was surprising, it did bring up some interesting discussion points.

The discussion focused on five themes:

  • The fact that the small molecule market is essentially going generic and will be a low cost market.
  • The fact that biologics is the focus and is where innovation and the spend will be.
  • The challenge of wiring healthcare to get that last mile to the physician.
  • The unknown implications of health reform and exchanges.
  • The continued focus on the consumer as central to healthcare.

I thought it was very interesting that several people talked about this evolution from brand to generic to biologics as the “circle of life” where there was a natural redistribution of cost.

I thought the discussion around personalized medicine was interesting especially as it dealt with the non-biologics and looking at where there were still opportunities to differentiate in the small molecule world.

One of the more interesting discussions was on whether bio-similars were really a “generic” type strategy or a new type of innovation.  Given the clinical work and other hurdles that are imagined for bringing bio-similars to the market, it isn’t expected that you’re going to see massive price drops.  And, if they aren’t therapeutically equivalent, then they become another option within the category.  As one person pointed out, the likely scenario is more of a step therapy strategy where if the bio-similars (or bio-betters as one person called them) are less expensive that the original biologic AND there is no difference in likelihood of success with an initial patient then you would simply require patients to start with the bio-similar.

There was some interesting discussion on the use of biologics from a prevention perspective which was only touched on.

One person talked about the blurring of the brand and generic manufacturer demarkations, but I think Teva’s already done that over the past few years. 

There was some discussion of current state tactics around copay cards and how they are used.  The question being whether this is to drive lower consumer costs, avoid switching, or avoid generic substitution.  This led to the classic debate of patient – physician versus payer. 

The biggest thing that scared me was some of the discussion around how DC and politics can play a role in determining care versus allowing for evidence-based standards of care to drive decisions.  As I was taught in consulting, you should make your decisions based on facts not on opinions.

Healthcare, Innovation, Leadership, PBM / Pharmacy

CMS Treatment Of Generic Samples Offers False Hope

March 28, 2011 by George Van Antwerp 1 Comment

It’s interesting but irrelevant that CMS is now proposing that Part D plans can treat generic samples similar to OTC drugs.  Who cares?

Why do I say that?

  1. Generics represent more that 80% of the non-specialty drugs dispensed in many cases.
  2. The technique doesn’t work.

At Express Scripts, I ran a program for a year.  We hired pharmaceutical representatives to detail doctors.  We bought generic drugs and repackaged them.  And, we tracked GFR (generic fill rate) in the six categories for a year. 

Guess what?

In most cases, the GFR for the doctors with the samples barely exceeded the GFR for the doctors without the samples.  In one category, it was even lower.  The GFR was going up too fast in the general market.  If you add in the costs, it was a money loser. 

We even compared our GFR in certain geographies to the published statistics from another company doing generic sampling…our clients GFR without samples was going up faster than their GFR with samples. 

If you want to give away free drugs as a “gift” to make your academic detailing program more effective, have at it, but lets keep reality in mind here.  This is not going to make a difference.  All it’s going to do is drive up administrative costs for PDP plans.

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

Using the “Placebo Effect” in New to Therapy Situations

March 26, 2011 by George Van Antwerp 0 Comments

I was reading a book about trust which pointed out the concept of “remembered wellness“.  This concept is similar to the “placebo effect” in that it shows that patients who trust their physicians and their course of therapy are more likely to have better outcomes (e.g., HIV study).  WOW!!

I’ve talked before about the gap that exists when patients leave their physician’s office with a new diagnosis and we all know that health literacy is a big issue.

So…what are you doing to address this?  I’ve been talking a lot lately about “primary adherence” (i.e., getting people to start therapy) and about engaging patients when they first get a new prescription or a new diagnosis.  This concept of trust only makes this a more pressing issue.

Here’s your worse case scenario:

  • Patient is newly diagnosed with a chronic condition and given a new prescription.
  • They don’t have a great relationship with the physician and/or have limited understanding of the condition (due to literacy, fear, or other issues).
  • They fill the prescription once and stop taking the medication after a few days.

How can you step in here?

  • You can trigger an outreach based on diagnosis code.
  • You can assess their understanding of the condition and help them learn more by addressing their barriers.
  • You can engage them when they fill their first script.
  • You can follow-up with them after the first few days to make sure they stay on therapy.
  • You can enroll them in an adherence program.
  • You can enroll them in a condition management program.

But, the point here is that you need to be doing something that reinforces the decision to manage the therapy and help them to understand and believe in that course of treatment.  If they don’t believe and have trust, they are less likely to get to a successful outcome.

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

Rules Based Communications

March 16, 2011 by George Van Antwerp 1 Comment

After working with data warehouses, configuration engines, and workflow management systems, I’m a big believer in embedding rules into a process. Communications is no different.

Let’s look at a few rules:

  • Don’t communicate with someone more than X times per week.
  • Don’t call these people.
  • Use Spanish for people with that language preference.
  • Send a text message to people who have provided their mobile number and opted in to the program.
  • When applicable, use a preferred method of communication for reaching out to someone.
  • If a caregiver is identified and permission is on file, send the caregiver a copy of all communications to the patient.
  • Call the patient if the amount being billed for their prescription is greater than $75.
  • For patients between these ages, use the following messaging.
  • If the patient hasn’t opened the e-mail after 48 hours, then call them.
  • For clinical information, use this channel of communications.
  • For John Smith, only call them on Tuesdays between 5-6 pm ET.
  • For Medicare recipients, use this font in all letters.
  • For Hispanic consumers, use this particular voice in all call programs.
  • If the patient doesn’t respond after two attempts, send a fax to their physician.
  • For patients with an e-mail on file, send them an e-mail after you leave them a voicemail.
  • For patients who are supported by Nurse Smith, only call them when she is on duty and use her name in the caller ID.

I could go on. But, the point is that communications, like healthcare, is a personalized experience. We have to use data to become smarter (historical behavior, segmentation, preferences). We have to use customization to create the right experience. AND, probably the most difficult thing for lots of companies, we have to coordinate communications across modes (i.e., e-mail, direct mail, SMS, automated call, call center, web).

Ultimately, I believe consumers will get to a point where they can help set these rules themselves to create a personalized profile for what they want to know, how they want it delivered, and ultimately provide some perspective on how to frame information to best capture their attention.

To learn more, you should reach out to us at Silverlink Communications.

Business Tools, Consumerism, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Silverlink, Technology, Value Propositions

Intel Health Video On Using Smartphones and Facebook For Health

March 4, 2011 by George Van Antwerp 1 Comment

(Note: Videos and slides may not appear in your e-mail summary. You may have to visit the website to see them.)

Consumerism, Healthcare, Leadership, Marketing / Communications, Research, Social Media, Technology

Book Review: Drive by Daniel Pink

March 2, 2011 by George Van Antwerp 0 Comments

I just finished the book Drive by Daniel Pink. It’s a great book. I’d recommend it from both a personal and professional perspective because it challenges so much of what we normally think. But, it’s both logical and based on tons of research.

He lays out three reasons why people act:

  1. Food, water, or sexual gratification (Motivation 1.0)
  2. Rewards and punishment (Motivation 2.0)
  3. Intrinsic reward (Motivation 3.0)

The concept of intrinsic reward was new to people. The concept of having this drive challenges all which we believe around incentives. And, his examples reinforce this point. People performed worse on certain tasks when a clear reward was identified.

“When money is used as an external reward for some activity, the subjects lose intrinsic interest for the activity.” Edward Deci

He uses open source collaboration as a great example of this. His example is whether you would have expected Encarta , an encyclopedia by Microsoft, or Wikipedia to succeed. Why wouldn’t a big company with unlimited resources beat out a collection of volunteers?

Business today is based on the whole concept of Motivation 2.0 (i.e., carrots and sticks). He talks about the historical presumption that absent some reward or punishment that people are inert.

“Enjoyment-based intrinsic motivation, namely how creative a person feels when working on the project, is the strongest and most pervasive driver” Lakhani and Wolf

He goes on to explain the difference between algorithmic and heuristic problems. Algorithmic problems can be solved based on a single path while heuristic problems have different options. [It’s like when I went to business school and architecture school.]  He quotes a McKinsey study which says that 70% of job growth in the US is around heuristic work. Therefore, applying a traditional model of motivation to creative work creates a major issue. It turns creative work which we feel passionate about into a disutility (something we won’t do without payment).

Now of course, creative “work” isn’t “play” if the basics aren’t addressed – i.e., fair pay. This has application in lots of areas including how we get kids to learn. Paying kids for specific activities pushes them to focus on completing those but not necessarily learning how to apply the knowledge. I think it’s a key issue which should be getting debated in when, if, or how to use incentives in health care. This is why you may see a short-term improvement that falls off over time.

This will be very relevant as P4P becomes more important. If rewards narrow the focus of solutions and limit creativity, will that be good in that it focuses people on specific processes? Or will it be a problem because in complex cases or cases where there are alternatives, the creativity of solutions and consideration of options will be limited?

But, he’s careful to make sure you don’t think that rewards are always bad. They have to be used appropriately and for the right tasks.

“If we watch how people’s brains respond, promising them monetary rewards and giving them cocaine, nicotine, or amphetamines look disturbingly similar.” Brian Knutson

He lays out “The Seven Deadly Flaws” of using carrots and sticks:

  1. They can extinguish intrinsic motivation.
  2. They can diminish performance.
  3. They can crush creativity.
  4. They can crowd out good behavior.
  5. They can encourage cheating, shortcuts, and unethical behavior.
  6. They can become addictive.
  7. They can foster short-term thinking.

He suggests that for tasks that don’t inspire passion nor requires deep thinking that there are three things that are important:

  1. Offer a rationale for why the task is necessary.
  2. Acknowledge that the task is boring.
  3. Allow people to complete the task their own way.

He talks about how using bonuses can work even for creative tasks when it’s not an “if-then” reward, but it’s a “surprise”. (Which is hard to repeat multiple times.)

He goes on to talk about Type A personalities. Theory X and Theory Y. Type I and Type X. It makes some key points about how we perceive people. Do we believe in the “mediocrity of the masses” or do we believe in people’s interest in succeeding? This is where Motivation 3.0 begins to come in and there is a focus on people’s desire to success or to master something.

He makes a lot of points that remind me of Malcolm Gladwell’s book Outliers.  Mastery is hard work.

“The most successful people, the evidence shows, often aren’t directly pursuing conventional notions of success. They’re working hard and persisting through difficulties because of their internal desire to control their lives, learn about their world, and accomplish something that endures.” (pg. 79)

He talks about how these frameworks can be applied at an organizational level and cites a Cornell University study of 320 small businesses. Those that offered autonomy grew at four times the rate of control-oriented firms and had one-third the turnover. He talks about ROWE (Results Oriented Work Environment) and gives examples of companies that really give their employees freedom. It’s a radical change for many people…imagine a work environment where you set your own hours.

He introduces the concept of “flow” from work by Csikszentmihalyi which was new to me. It describes this state where people are challenged but have an opportunity to stretch to get there.

He talks about mastery as a mindset and how what people believe shapes what people achieve. This belief is critical especially in addressing things like obesity (my opinion) and plays into a lot of what you see on The Biggest Loser. Losing weight (mastering being in shape) is a lot of work, and you have to believe you can do it. You also have have to have some motivation other than financial goals.

There is an interesting discussion of “entity theory” versus “incremental theory” which talks about whether you believe you have a finite intelligence or an opportunity to expand your intelligence. There is lots of talk about education in the book which I think is really important. Are we creating kids that want to “prove their smart” by getting A’s or who are really trying to learn?

“West Point grit researchers found that grittiness – rather than IQ or standardized test scores – is the most accurate predictor of college grades.”

He has a whole chapter on purpose. I think this is key to healthcare. He talks about autonomy and mastery, but without purpose, we don’t have balance. Think about someone who is obese. They want to be autonomous and master being in shape, but when you listen to them talk, it is typically a focus on being there for their family that motivates them to actually take action.

He made me wonder about linking health outcomes to lower costs (i.e., value based). If I know that my healthcare premiums go down if I manage my BMI or cholesterol or get certain tests done, am I just checking a box or am I really changing my lifestyle in a sustainable way?

Books / Articles, Consumerism, General Business, Healthcare, Leadership, Research, Value Propositions

The MBA Oath

February 27, 2011 by George Van Antwerp 0 Comments

This is a little off topic, but I think it applies well within health care.  Health care is a profession where managers (like clinicians) should feel a responsibility to improve the lives of their members while making money.  With that in mind, I wanted to highlight this effort.  To learn more, go to mbaoath.org to learn about the history and efforts of this group (along with a new book).

THE MBA OATH

As a business leader I recognize my role in society.

•  My purpose is to lead people and manage resources to create value that no single individual can create alone.

•  My decisions affect the well-being of individuals inside and outside my enterprise, today and tomorrow.

Therefore, I promise that:

•  I will manage my enterprise with loyalty and care, and will not advance my personal interests at the expense of my enterprise or society.

•  I will understand and uphold, in letter and spirit, the laws and contracts governing my conduct and that of my enterprise.

•  I will refrain from corruption, unfair competition, or business practices harmful to society.

•  I will protect the human rights and dignity of all people affected by my enterprise, and I will oppose discrimination and exploitation.

•  I will protect the right of future generations to advance their standard of living and enjoy a healthy planet.

•  I will report the performance and risks of my enterprise accurately and honestly.

•  I will invest in developing myself and others, helping the management profession continue to advance and create sustainable and inclusive prosperity.

In exercising my professional duties according to these principles, I recognize that my behavior must set an example of integrity, eliciting trust and esteem from those I serve. I will remain accountable to my peers and to society for my actions and for upholding these standards.

This oath I make freely, and upon my honor.

Books / Articles, Business Tools, Leadership

Get Wellness Article in Time – Silverlink, Aetna, Hypertension

January 14, 2011 by George Van Antwerp 0 Comments

The recent issue of Time magazine includes an article called “Get Wellness” about wellness.  It talks about having MDs “prescribe” wellness (think Information Therapy or Ix) and the fact that Medicare enrollees will be eligible for wellness visits begining 1/1/11. 

The new wellness benefit tasks doctors with creating “personalized prevention plans,” which ideally will be tailored to each patient’s daily routine, psyche and family life. And if that sounds more like a nanny-state mandate than medicine, consider that some 75% of the $2.47 trillion in annual U.S. health care costs stems from chronic diseases, many of which can be prevented or delayed by lifestyle choices.
The article goes on to talk about the challenge this may create for physicians.  Can they act as nutritionists?  Can they change behavior? 
 
Of course, MDs won’t be the only one’s focusing here (although some of that could change with ACOs and PCMHs).  Disease management companies and managed care companies have focused here for a long time.  The focus in many ways these days is how to reduce costs in these traditionally nurse-centric programs with technology but without impacting outcomes and participation.  There is one example in the article from some work we are doing at Silverlink around hypertension. 
 
Some firms, in trying to bring down health care costs, have hired health coaches to reach out to the sedentary or overweight to get them moving more. Others use interactive voice-response systems to keep tabs on participants’ progress. In a study, Aetna set out to see whether it could reduce hypertension — and the attendant risks of stroke, heart attack and kidney failure — among its Medicare Advantage members. More than 1,100 participants were given automated blood-pressure cuffs and told to call in with readings at least monthly. They also got quarterly reminders to dial in. When they did so, an automated system run by Silverlink Communications provided immediate feedback, explaining what the readings meant and where to call for further advice. Alerts were also sent to nurse managers when readings were dangerously high. The result: of the 217 people who started out with uncontrolled hypertension and stuck with the program for a year or so, nearly 57% got their blood pressure under control.
Books / Articles, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Methodology, Research, Silverlink, Technology, Value Propositions

DBN: 2011 Pharmacy Predictions

January 8, 2011 by George Van Antwerp 0 Comments

Drug Benefit News (which is a must read publication) just came out with a summary of opinions from people about the new year (DBN, 1/7/11).  Here are a few highlights:

  • Focus on clinical programs to help MCOs hit their MLR targets
  • PBM consolidation and need for smaller PBMs to innovate (as my whitepaper discusses)
  • Potential for generic only formularies as generic fill rate is in the 70-80% range
  • Focus on specialty drug costs including the claims processed under the medical benefit (Express Scripts big push right now)
  • Outcomes based contracting (i.e., Merck and Cigna)
  • Direct contracting (i.e., Caterpillar, Delta)
  • Continued pharma shift to niche markets as brand oral solids make up <20% of claims
  • Health reform fallout
  • Continued streamlining and focus on MA and PDP
  • Continued innovation (i.e., Wal-Mart and Humana model)
  • Limited or restricted networks take off (finally)
  • Cost plus pricing
  • Modernizing Medicaid management and controlling costs

I was one of the people interviewed for the article.  My comments from the article are:

The things that I’m monitoring and think will affect the industry include mobile health, behavioral science application, preference-based marketing, risk based contracting, and integration with home monitoring devices. Rising costs will push several things such as increased management of the specialty benefit, more focus on adherence, and an increased understanding of how consumers impact health outcomes and how to best engage them. In 2011, innovations and changes in benefit design could include limited networks, more and more utilization management especially step therapy and 90-day retail or mail.

The biggest area of discussion in Medicare Part D right now is the Star Ratings. There are questions for PBMs about how they support the MA metrics and there are now specific PDP metrics. Understanding what those are, how to track them, how to influence them, and how to improve them will be a major focus in 2011.

Books / Articles, Healthcare, Leadership, PBM / Pharmacy, Research, Silverlink

CVS Caremark: Causal Link Between Adherence And Overall Costs

January 6, 2011 by George Van Antwerp 2 Comments

I’ve argued many times that prescription costs should (in many cases) go up not down.  But, the evidence to support that has often been anecdotal or from studies that people have struggled to replicate. 

CVS Caremark just released the results of their study “Medication Adherence Leads to Lower Health Care Use and Costs Despite Increased Drug Spending” in the January issue of Health Affairs.

  • Looked at pharmacy and medical claims
  • 135,000 patients
  • Patients with with one of more of the following – congestive heart failure, diabetes, hypertension, and dyslipidemia

“There have been many studies through the years that suggest adherence can save on health care costs, but the issue has not been central to health care cost discussions because those studies did not establish a causal link. We took the research further and what we found is that although adherent patients spend more on medications – as much as $1,000 more annually – across the board they spend significantly less for their overall health care costs”  by Troyen A. Brennan, MD, MPH, EVP and Chief medical Officer of CVS Caremark (source)

The savings associated with being adherent were:

  • Congestive heart failure = $7,823
  • Diabetes = $3,756
  • Hypertension = $3,908
  • Dyslipidemia = $1,258

It will be interesting.  Will this replace the “Sokol study” that everyone has historically quoted?  Will this lead to a rush of adherence programs for key conditions such as those studied here?  Will others try to replicate this study? 

I for one hope this changes the conversation from “prove the ROI” to show me how to best improve adherence across categories and segments of the population.  (To learn more about how Silverlink works with clients on adherence, you can go to our microsite.)

Books / Articles, Healthcare, Leadership, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Value Propositions

Humana and Concentra

January 4, 2011 by George Van Antwerp 0 Comments

I’d forgotten about this deal until someone sent me a note about 2010 earnings for Humana and the fact that this was Humana’s 11th acquisition over the past 5 years.  (Can you name them all?)

Given the push for ACOs and PCMHs and clinics, I think the acquisition of Concentra which owns 300 clinics and almost 250 on-site facilities is an interesting one.  It will give Humana another tactic for managing care and creating stickiness with employers.  I also think that clinics have a lot of opportunity to coordinate with pharmacy and improve adherence, therapeutic conversion, and use of mail order.  (See some of Joe Paduda’s comments here.)

With the Concentra staff, I’d be interested in seeing a deal with American Well or another company where they could be leveraged further in a virtual consultation setting with the option of driving them to a physical facility for follow-up. 

The other potential here is to leverage the clinics to improve HEDIS scores and STAR ratings. 

I think there is more to come here and with similar deals.

Blogroll, Healthcare, Leadership, Managed Care, Value Propositions

CVS Buys Universal American PDP Plan

January 3, 2011 by George Van Antwerp 0 Comments

I guess everyone’s on vacation since I haven’t seen much talking about this deal that was announced at the end of last year – CVS buying Universal American’s PDP plan.  The one post I saw was from someone who didn’t seem to have a clue. 

The reality here is that this is a good deal (IMHO).  I’m not speaking specifically on the price since I haven’t looked the financials, but more from the business strategy.  CVS Caremark has been actively moving forward over the past few years with new management (Per Lofberg and others), organizational changes, big wins (Aetna), success with their plan design, and many other research studies supporting their value proposition. 

Doubling down in one of the big areas of growth from both a population and a reform perspective makes a tons of sense.  Why wouldn’t you?  And, with the Star Ratings creating bonus opportunities, this is the time to jump in and focus on improving your quality metrics to get the bonus. 

[Note: I both work with CVS Caremark and own their stock.]

Books / Articles, Healthcare, Leadership, PBM / Pharmacy, Value Propositions

Save $30B in Medicaid (over next decade)

December 28, 2010 by George Van Antwerp 1 Comment

The big assumption around savings is always that you’ll have to cut benefits. What if that wasn’t true? Why wouldn’t the government be making those changes?

A new report by The Lewin Group explores this. 73% of Medicaid spending is based on fee-for-service plans that are administered by state officials. Not a big surprise to those of us that believe in the private market over big government, but they leave a lot of money on the table compared to Medicare and managed Medicaid.

The savings come from four areas:

  1. Generic Drug Dispensing: Medicaid FFS is less effective at encouraging the dispensing of generic drugs in place of brands. The generic dispensing rate in Medicaid FFS averages 68%, compared to an average 80% generic dispensing rate in Medicaid MCOs. While some of this difference is attributable to demographic differences between the Medicaid FFS and MCO populations, much of the generic dispensing difference persists when looking within each demographic subgroup.
  2. Dispensing Fees: At $4.81 per prescription, the national average dispensing fee that Medicaid FFS programs pay to retail pharmacies is more than double the average dispensing fees paid by Medicare Part D payers, Medicaid managed care organizations (MCOs), or health plans in the commercial sector.
  3. Ingredient Costs: The rate at which retail pharmacies are reimbursed for the actual medication ingredients (pills, capsules, etc) is also higher, on average, in Medicaid FFS programs than in Medicare Part D or the commercial sector.
  4. Drug Utilization: The number of prescriptions dispensed per person is typically higher for similar demographic subgroups in Medicaid FFS programs than in Medicaid MCOs for similar demographic subgroups due to less effective controls on polypharmacy, fraud, waste, abuse, and other factors in the FFS setting.

Their study estimates that converting all the FFS Medicaid to a Managed Medicaid model that relies on the typical PBM process would save almost 15% (or about $30B over the next decade).

The report also includes lots of comparative data (state by state) which shows the discrepancies across the US in terms of cost of FFS Medicaid.

Books / Articles, Healthcare, Leadership, Politics, Research, Value Propositions

My AHIP Podcast On Adherence

December 14, 2010 by George Van Antwerp 0 Comments

I did a podcast with AHIP on adherence.  I was hoping to embed it here, but I couldn’t so here’s the link.

http://www.ahiphiwire.org/Innovations/Feature.aspx?doc_id=722249

Consumerism, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Silverlink, Social Media, Value Propositions

Pharmacy 2011 – 11 Things To Consider

December 2, 2010 by George Van Antwerp 0 Comments

I pulled together (in Prezentation Zen style) 11 Things to Consider in the Pharmacy industry.  It’s certainly a matter of opinion, but it’s a point of view meant to cause you to think.  I spend a lot time with clients thinking about the industry, and I thought this was a fun way to put some of those thoughts out there. 

I divided these up into two areas:

The Consumer:

  1. Patient Centric approach is critical path. (i.e., create an experience)
  2. Be proactive not reactive. (think Obesity)
  3. Literacy and health disparities need to be addressed. (simple and direct)
  4. People are different…act appropriately. (mass customization)
  5. Genomics are fascinating…but can be confusing. (and healthcare in general is already very confusing)

Business Strategy:

  1. The pharmacist role has to change from refills to outcomes. (see prior post)
  2. Blend high touch and automation in specialty. (they have the same needs about information)
  3. Integrate your physician and consumer strategies. (the HIT focus will make this more pressing)
  4. You need a STAR strategy for your PDP. (hottest topic in Medicare right now)
  5. Mobile is here to stay. (but may not be a business model unto itself)
  6. Social media will change the conversation. (so what are you doing)
Blogroll, Consumerism, General Thoughts, Healthcare, Leadership, Marketing / Communications, PBM / Pharmacy, Silverlink, Technology

Wal-Mart and Humana for Medicare Part D

November 23, 2010 by George Van Antwerp 0 Comments

Again, I’m a little late on this story (too much work), but I was thinking about it after the CMS news recently that they were going allow plans with a 5-star rating to have an open enrollment season all year round.  That’s a huge deal. 

(If you’re don’t know what the Star Ratings are about,  see the Kaiser Family Foundation piece on What’s In The Stars or if you’re working on improving your Star Ratings, you can see Silverlink’s Star Power solution.)

Humana Walmart-Preferred Rx Plan

If you missed it earlier this year, Humana announced that they were partnering with Wal-Mart to offer the lowest national plan premium for 2011 for standalone PDP plans (see details).  Consumers who select the plan will get a lower copayment when they use Wal-Mart pharmacies.  (I’ve talked about limited networks before so it will be interesting to see if this gets more to be offered in the marketplace.)

“The basics of the preferred network – tight formulary and a low premium – offer an affordable value proposition for patients.”  William Fleming, Vice President of Humana Pharmacy Solutions (from Drug Benefit News on 10/8/10)

This creates a network with 4,200 preferred pharmacies and 58,000 non-preferred pharmacies.  Personally, I’m still surprised more people haven’t gone to the $0 copay for prescriptions at mail which Humana offers in this plan (for tier-one and tier-two).  United Healthcare has recently rolled out a program called Pharmacy Saver which has some similar attributes to the Humana plan. 

So, has it made a difference?  We won’t know yet.  I would expect it would.  The economy is still tight.  Seniors are budget conscious.  Humana has good brand equity.  Wal-Mart, especially in certain geographies, is frequented heavily by this population.

Medicare open enrollment is from November 15th thru December 31st.  This certainly caught everyone’s attention when it launched.  (You can see some of Adam Fein’s comments when it first was announced and here’s a more recent AP article on the topic.)  In a few months, we will know a lot more.

Blogroll, Books / Articles, Consumerism, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, PBM / Pharmacy, Silverlink, Value Propositions

CVS Caremark Insights 2010

November 17, 2010 by George Van Antwerp 0 Comments

I’m catching up on a few things this week. One of those is sharing my notes from the CVS Caremark Insights 2010 publication (their drug trend report). While this year’s report outlines all of the traditional things you would expect – trend, spend by condition, market conditions, generic pipeline, I really thought the exciting information was at the end where they really begin to stitch together the retail / PBM model. I’ve talked about why I believe in this model so strongly in the past (you can also see some of their executive’s comments here). And, I think my perceptions about the future of pharmacists create lots of opportunity for a combined entity. I also think they hint at some of the insights they gained from research around non-adherence and around abandonment which is important and creates a foundation for them around predictive modeling and focused interventions.

  • I like that this year’s publication starts with a letter from Per Lofberg (the new President). He has brought them a renewed perspective on the PBM within the overall CVS Caremark enterprise which I think has been very helpful for them in this year’s sales cycle. [I personally haven’t met him yet, but I’ve heard a lot of good things about him.]
  • This introduction talks about:
    • Generics, specialty, and genetic testing as key trends
    • Controlling costs thru – plan design, clinical strategies, and negotiations with the manufacturers and retailers
    • Executing flawlessly
    • Improving outcomes
  • I like the fact that they introduce the outcomes focus early on. I think that linking themselves to outcomes given their unique footprint (retail, PBM, clinic) is critical for long-term differentiation.
  • Much like I see at Prime, CVS Caremark is a company that is blending its long-term team with some new leadership from outside the company and from the retail side of the business to drive innovation and change. I believe the clients and market has seen some of those changes already.
  • A quarter of their clients maintained a gross trend of less than 3%.
  • I found it interesting at the beginning of the document where they talk about the recession and macro-economy where they mention the effect that the COBRA subsidy had on health consumption.
  • They say that their member contribution is 15.7% which seems really low to me, but that is pulled down by the Medicare average.
  • As everyone has talked about, one of the big drivers of cost this past year was significant price inflation (9.7%) for brand drugs.
  • Their generic dispensing rate (GDR) in Q1-2010 was 70.4%.
  • Their average specialty trend was 11% with a best-in-class trend of 7.3% which seems really low.
  • Not a big surprise, the top classes are similar to other PBMs with large commercial populations. Here’s the list of the top 10 categories:
  • They mention later on their managed Medicaid lives (which I didn’t even know that they had). I think this should be a good growth area along with their Medicare Part D (PDP) lives.
  • They introduce a new methodology which I like which looks at trend by group – employers, health plans, TPA, and Medicare. There are differences in each so being able to compare to a relevant peer group is valuable.
  • They also talk about another change which is looking at book-of-business (BOB) which represent their top clients which represent 65% of total drug spend.
  • Their average gross trend was 3.4% (or 2.4% if you exclude specialty).
  • Digging into the best-in-class numbers is interesting. For example, for employers, 78.6% of their days supply was filled at preferred channel pricing (mail order or 90-day retail). I assume this is essentially for just maintenance drugs, but it seems really high (which is good) and is a new metric for me to think about.
  • They talk about 77.7% of hypertensives (in employers) being optimally adherent (which I assumes means having and MPR > 80%). This seems pretty good, but I don’t have an industry number to compare to.

“With overall goals of reducing health care cost and improving member outcomes, health plan respondents in our 2010 benefit planning survey placed high value on proactive member outreach (93 percent), multi-channel access for members (87 percent) and opportunities for face-to-face consultation (73 percent)—all factors that can help keep members on prescribed therapies and satisfied.” (page 14)

  • For each segment, they give the distribution of trend numbers. Here’s the one for health plans:
  • The best-in-class Medicare and Medicaid number for Generic Dispensing Rate are high and set a high goal:
    • 78.2% Medicare Part D
    • 86.8% Medicaid

Member retention is critical and involves a balance of copay levels, premiums and drug coverage as well as less tangible factors. Member satisfaction plays a significant role in loyalty and re-enrollment. High-performing plans focus on effective member communication and outreach as well as added-value services such as the CVS ExtraCare Health card.

  • They talk about using a split generic tier design for Medicare to allow for different member copays for higher priced generics. I think this makes a lot of sense, but I don’t know all the details or member data and feedback to really understand how it plays out.
  • I’ve never spent much time on Managed Medicaid, but they give a few numbers here:
    • Their average age is 17.6.
    • The average PMPY spend is $288.
  • Several times they use the term “evidence-based” which I really like. I recently was using that term to refer to communications and talking about how to leverage data to create “evidence-based” communications to consumers.
  • They provide a nice 2-page summary of reform.
  • They put out a short list of recommendations:
    • Prepare to take advantage of pending new generics; evaluate plan design and communication strategies for quick mobilization when new launches are pending. (This will be a big year for this with Lipitor.)
    • Many specialty pipeline products are for orphan diseases and will have narrow indications; have plans in place to ensure appropriate utilization. (This will continue to be a bigger and bigger issue.)
    • If you haven’t already done so, investigate the use of genetic testing to help guide treatment decisions. (Given their relationship with Generation Health this is an area that I expect to hear a lot more about in future Insights publications.)
    • Newer, more expensive pharmaceuticals may offer little advantage over existing products in the class; consider step therapy or preferred product strategies. (I think Utilization Management (UM) activities like Step Therapy (ST) will be a continued focus for the next few years especially as biologics allow these “traditional” techniques to be applied to specialty.)
    • Use wellness and preventive programs to identify people at high risk for chronic disease and help them lower their risk profile. (This is an area that I would have liked them to talk more about. As I’ve said many times, this is an opportunity for them to shine and differentiate.)
    • Members with chronic disease who are non-adherent tend to have higher health care costs; evaluate your population’s adherence levels and the support you provide to help people stay adherent. (Differentiation in this area is a huge opportunity. I think they are doing some interesting work in this area as they’ve talked about in some recent press releases – Rx abandonment, barriers to diabetes care, US Airways program, and behavioral research.)
  • They provide a forecast on trend for overall, non-specialty, and specialty. Here’s their forecast for the overall trend.

  • They give a clear chart on the generic opportunity and likely impact on overall generic fill rates for 2010-2012.

  • They go on to talk about specialty drugs which could be as much as 50% of the total spend by 2013…a scary prospect.
  • They have a good “state of the union” for specialty in the deck:
    • As of January 2010, 57 percent of all late-stage pipeline drugs fell into the specialty area.
    • 71 percent of applications for supplemental indications are for specialty products.
    • The number of new specialty drugs approved in 2009 was more than double the number of 2008.
    • Provenge, the first therapeutic vaccine—which utilizes the patient’s own DNA and stimulates the immune system to fight prostate cancer—was approved early in 2010.
    • Potential approvals 2010-2012 include four new products for multiple sclerosis (all oral), three for hepatitis C, and three for cystic fibrosis.
    • 18 of the products pending approval in 2010 target orphan diseases, which currently have few or no treatments.
    • While health care reform legislation provides for a pathway for approval of biosimilars, it also mandates a 12-year minimum exclusivity period for brand innovators with the possibility of additional exclusivity in 12-year increments for the development of new uses.
  • They then talk a little about pharmacogenomics (PGx). Again, I expect this to be a much bigger area in the future. It’s interesting. It’s changing rapidly. BUT, there is a huge education mountain for patients and MDs.

For a 1M member population, ~$12M is spent each year on 18 drugs that are administered to patients who do not respond and/or who are more likely to experience drug-induced medical complications.

  • I think some of the hidden gems begin on page 27 where they talk about their study on electronic prescribing:
    • 22.1% never filled their first claim. (why – samples?)
    • They found that those who had an eRx were most likely to fill than those with a paper Rx. (I personally would have bet on the other…i.e., that I have something physical in my hand that it would serve to remind me to go to the pharmacy.)
  • Another study towards the end was on abandonment (which they recently released more information on). It showed that copay, income, and whether it was an NRx (new start on Rx) were predictors of abandonment.
  • They also share work done around adherence focused on complexity of therapy – number of Rxs, number of MDs, number of pharmacies, and synchronization of refills. They talk about using this to score patients and predict risk of non-adherence. (I look forward to seeing more here since this seems very interesting especially in terms of focusing resources and developing a triage model.)
  • They shared the results of a deep dive on reasons for abandonment of prescriptions. Being able to respond and position messaging around these reasons is important.
  • They share some of the work from their Pharmacy Advisor program:
    • IVR messaging improved the odds of refills by up to 70.6% when members answered the phone.
    • Early IVR refill reminders were 2x as effective for first fill persistency rates at mail as compared to reminders after refill due dates.
    • Physician directed fax alerts about gaps in care nearly doubled gap closure rates.
    • Pharmacist interventions were most effective at improving adherence.
    • Members in VBID (value based insurance design) in which copays were lowered or eliminated were more likely to initiate therapy, less likely to discontinue therapy, and had better adherence.

“Diabetes is one of the most prevalent and expensive chronic diseases in the nation, costing the U.S. an estimated $174 billion a year,” said Troyen Brennan, MD, MPH, EVP and Chief Medical Officer of CVS Caremark. “The Pharmacy Advisor program improves clinical care because we are able to identify and address pharmacy-related care issues that if left unattended could result in disease progression and increased health care costs. We are also better able to engage the member in their care through multiple contact points, providing counsel that can improve adherence and help members optimize their pharmacy benefit and find the most cost effective options.” (quote from press release)

  • They talk about a pilot program they did in Polk County were patients signed a contract for care and was focused on diabetes care. It had some great results:
    • Reduction in blood glucose levels from 52% under or equal 7% at the beginning to 72% after one year.
    • 30% reduction in hospitalizations.
    • 24% reduction in ER visits.
    • Only 3.4% of enrolled members had poorly controlled diabetes (compared to national average of 29.4%).
    • Improved patient care – identification of potential adverse events, streamlined medication regimens, and formulary support.
    • (I personally would think this would get other plans (or PBMs) to partner with them on regional strategies where they have a strong retail presence.)
  • This also coincided with their announcements about their Pharmacy Advisor program which officially launches in January 2011. I’m very interested to see the uptake here which I would imagine will parallel the success of Maintenance Choice. This is a program which leverages their Consumer Engagement Engine (see image from last year’s report) and their retail presence to engage consumers.

Overall, it was an easy read without a lot of fluff. It cuts to the chase and gives you a good perspective on how they think. You begin to get a feel for what they are doing differently, but I imagine that you’ll continue to see a lot more research and case studies come out in the next year about some of the work they are doing.

(Note: In the sense of disclosure, CVS Caremark is a stock that I own.)

Books / Articles, Consumerism, Healthcare, Innovation, Leadership, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Technology, Value Propositions

Prime Therapeutics 2010 Drug Trend Insights Report

November 12, 2010 by George Van Antwerp 1 Comment

I am way behind this year in getting thru the Drug Trend Reports and posting my comments.  I think I still have to do both the CVS Caremark report and the Walgreens report…and if I can get it, the SXC report also.  (You can see my thoughts from the Medco and Express Scripts Drug Trend Reports earlier.)

A few things I’ve found interesting this year were that Medco reached out via their PR group to engage me and several other bloggers in the space.  And, Prime Therapeutics has always been very active in engaging me around my thoughts on their report (see comment from last year) and continued to be proactive in discussing it with me and sending me a hard copy to read on the plane.

Overall, I think their Drug Trend Report continues to improve year after year.  It’s interesting in that this year I found the tone slightly more aggressive in talking about them versus their competition.  Certainly, Prime is going thru some changes (if you haven’t noticed).  They brought Eric Elliott on board who I think very highly of after hearing him speak and engaging him on a few topics.  Eric has brought in a set of core people from Aetna, Cigna, Express Scripts, and other places to complement an existing management team that really understands the market and how to work with the Blues owners.  [I personally think of them (and MedImpact or SXC) as a dark horse would could consider bidding on the Walgreen’s PBM lives while everyone is pretty focused on it being either Express Scripts or Medco.]

  • If you don’t know, Prime works with 17 BCBS plans who are either owners or clients.  They managed $9.1B of drug spend in 2009 and had 15M members.
  • Their overall trend was 3.4% which is good.  Everyone’s trend was generally low this year although I continue to question if this is the right metric for the industry.  I also wonder if they will embrace the outcomes based rebating that Eric did with Merck at Cigna.
  • Early on they talk about one of the ways they manage trend being through adherence and not manufacturer programs.  I might be out on a limb here, but I believe manufacturer funding on adherence programs (especially in specialty) is a good thing. 
  • They are always quick to point out that they report drug trend across their entire book of business not a random set or using any other cut of the data. 
  • They share some early analysis looking at medical claims where they identified that 1/3 of people with diabetic complications had no recent diabetes prescriptions.  A gap-in-care intervention opportunity. 
  • They also shared a study that I hadn’t seen published that members using a 90-day supply of medication (retail or mail) were 40% less likely to stop taking their drugs than those using a 30-day supply.  That’s a big difference. 
  • Interestingly they source a study saying that their members get Rx refills a day faster than competitors.  Again, that’s a big difference.
  • Generics were 67%.  (in 2009)
  • They talk about their MAC list (Maximum Allowable Cost) which is used to manage the cost of generics in the payment terms with the retailers.  They are the only PBM that I’ve ever seen do this. 
  • Their average costs per Rx were:
    • $145.51 Brand
    • $18.21 Generic
    • $62.40 Overall
  • They talk about the need to establish out-of-pocket (OOP) maximums for higher cost drugs.  I AGREE!
    • 1 in 6 cancer patients with high OOP costs abandon treatment
    • Capping OOP at $100 reduces abandonment to 4.9%
  • They (like others) discuss the impact of rising drug prices primarly around brand products. 
    • I had an interesting discussion with a reporter at the NY Times yesterday on this where he talked about manufacturers essentially paying the entire copay (20% of a $100,000 drug) to keep it getting filled. 
  • They projected that the GFR (generic fill rate) would exceed 70% by the end of 2010 which I suspect will happen (if it hasn’t already). 
  • It was interesting that they layout their pharmacy benefit for their employees.  That would be an interesting one to come across PBMs.  How do they treat their employees?  What do they recommend?  Do they take their own advice?
    • Generics were 10% with a $4 min and $10 max
    • Mandatory generic policy
    • Step therapy
  • Specialty medications had a 13% trend while representing less than 1/2 percentage of the overall prescriptions processed…but they did account for 12% of the cost.
  • Prime’s members filled 11.8 prescriptions per year (2.5% increase in utilization).
  • Prime’s Medicare trend was -5.6% with utilization of 48.2 Rxs PMPY.  The average age for their Medicare lives is 73 (compared to 33 in the commercial lives).
  • As I’ve talked about before, I like the way they break out their “Focus” drugs which are drugs used to cover diabetes, high blood pressure, high cholesterol, respiratory disorders, and depression.  These are categories with clear value propositions around adherence and are often co-morbidities. 
  • The average specialty drug cost $2,117.07.
  • Here’s some of their top drugs based on spend:

  • A few facts…
    • 7 in 10 Americans die from chronic illness.
    • As many as half of all patients don’t adhere to their prescription regimens.
    • More that $100B is spent each year on avoidable hospital admissions due to non-adherence.
    • Adherence to high blood pressure treatment alone could prevent 89,000 premature deaths in the US annually.
  • They shared that 70.5% of their 683,000 members using a statin in the second half of 2009 had an MPR (medication possession ratio) of 80% or higher (which is considered clinically adherent).  They talked about using copay waivers, value-based benefit design, and member education to drive up MPR.  [I’d love to see how the 3 compared in terms of results and ROI.]
  • They talked about an MD intervention program around respiratory illness that got 10% of members to return to therapy.  [I’m a big believer that PBMs need to integrate their MD and consumer intervention strategies since 1+1 can equal 3 in some cases.]
  • They then go thru different therapy class (drug categories) to discuss each one.  In the gastrointestinal disorders (think Prevacid, Protonix, Prilosec), I was surprised they didn’t talk about a strategy to drive OTC (over-the-counter) use.  [Although with some of the new rulings about what can be considered part of your flexible spending accounts, it may change how people compare the costs of OTCs to copays.]
    • I’m still a big fan of step therapy in this category using OTCs then H2s then generic PPIs then brand PPIs, but I know step therapy with OTCs can be a pain. 
  • Specialty drugs accounted for 21% of the $300B in 2009 drug spend (National)…by 2030, it’s estimated that specialty will account for almost 50% of drug expenditures.
  • They talk about Ampyra (a new MS drug) but don’t talk about how they are managing that.  [From my NCPDP meeting last week, RegenceRx was talking about more aggressively managing this.]
  • They share the research from PhRMA that there are 861 drugs in the pipeline for oncology.
  • Here’s a nice graphic on designing the right benefit…

  • They provide some best practices around plan design which did prompt some questions for me:
    • They talk about value-based benefits when MPR is less than 80% for diabetes, high blood pressure, and high cholesterol.  I’m good with this as long as it’s not selectively offered to just those with low MPR (i.e., rewarding those who aren’t taking their medications).
    • They talk about requiring prior auth (PA) before a non-preferred drug is dispensed.  Does this mean the formulary is essentially closed?
    • They talk about using co-insurance to deter the use of brand-name and non-formulary drugs.  I’ve always been a skeptic here since the patient doesn’t know the cost of the medication so I believe that flat copays are much easier to understand the difference, but there might be research that I’ve missed on this one.
    • They talk about reaching out to MDs on generic utilization.  This should work but is tough.  I had an academic detailing team at Express Scripts and a generic sampling team.  I’d love to know what the success rate was and if MDs impressions of generics have changed over the past 5 years. 
  • For tiers, they share data that suggests that the copay savings needs to be $25.50 per month for a patient to choose a generic over a brand (and I might assume one brand over another).  As they point out, that’s much larger than the $13 difference which exists today.
Books / Articles, Healthcare, Leadership, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Value Propositions

Todd Park (HHS CTO) On Unlocking Innovation Mojo (#mhs10)

November 8, 2010 by George Van Antwerp 0 Comments

I came out to the Mobile Health Summit (Twitter hashtag #mhs10) in DC today, and I had the opportunity to interview Todd Park who is the Chief Technology Officer (CTO) for the US Department of Health & Human Services (HHS). Todd is a great resource for the country and perhaps a surprising bureaucrat (in the nicest sense of the word) given his background as a consultant and then co-founder of athenahealth.

It was an interesting discussion starting around what his role is. The CTO role is a new role in the US government which he describes as an internal change agent who is responsible for working with HHS leadership. He described his objective as forming virtual start-ups to advance new solutions. [A radical departure for those of us that view government as a monolithic organization which is slow to change and full of red tape.]

He said that one of the first questions people ask when they see the new initiatives such as HealthCare.gov is who were the consultants he brought in from Silicon Valley to do the work. He says that it was all internal people. We talked about that being a cultural change which he described as “creating the right vision” and a “work pathway”. That sounds exactly like what one might see a change agent being responsible for – better leveraging internal assets by changing the framework for service delivery.

We talked about several of the initiatives that HHS has worked on lately:

  1. HealthCare.gov which is a focused on helping consumers find public and private options for healthcare. He said this was a 90-day implementation. I think if you go to the site you’ll see a few things:
    1. Easy navigation
    2. Content for multiple personas
    3. Links to social media
    4. Videos, widgets, blog postings, iPhone app, etc.

    This is much like what you would expect from a direct-to-consumer company or your health plan.

  2. The Open Health Data Initiative which is focused on taking data which HHS has and making it available for use by companies for FREE. The idea is to stimulate an eco-system around the data and enable better health thru better decisions. He uses the NOAA framework as an example for how they share data to sites like weather.com. He then mentioned that they had done a brainstorming session earlier this year to think about what could be done with this data (some of which was new to everyone). You can learn more and see the 2-hour YouTube video here, but a talk by Todd Park at another event is below.

     

  3. The Blue Button Initiative which was launched in October and focuses on getting Medicare members and veterans to get a copy of their own data to print, download, share, upload, etc. Already more than 100,000 have downloaded their data. This should certainly be an enabler for PHR adoption.

We then went on to talk about HHS as a “reservoir of innovation mojo” which needs to collaborate with the public sector. In Todd’s words, he sees government as needing to be a catalyst and enabler. When he joined, his idea was not to fly in like aliens and change HHS, but to come in and find ways to unlock the mojo which already existed.

I asked him if he sees this as being a model for the private sector. Obviously, one of the challenges we have everywhere is figuring out the right way to balance co-opetition and competition. If we’re going to “solve” our obesity epidemic, we need to have some collective knowledge and insights rather than constantly re-creating learnings in a microcosm. On the flipside, companies want to create intellectual property and sustainable differentiation. It’s not easy to balance.

But, Todd mentions that several companies are already following in the “blue button” model such as Gallup / Healthways which is making their Well Being Survey data available publicly (for FREE) for the top 200 cities.

Of course, there is a lot of work to do here. I asked him about what the government was doing to address some things at a national level (e.g., obesity) where in my mind we almost need a reframing such as that which happened with littering, smoking, or wearing our seat belts. He brought up three things that were happening:

  1. National Quality Initiatives
  2. HealthyPeople 2020
  3. Community Level Dialogues

One of the other things that we talked about was the challenge of making changes to health outcomes with the health literacy levels in the US. I suggested that we need to address this systemically as I believe we need to address financial literacy…beginning in the schools and the home. He talked about needing to making learning fun through educational games. He mentioned that the First Lady had been promoting the creation of apps to accomplish this as part of a competition. (This made me think of the iTots article in today’s USA Today.)

We closed with a quick discussion on other things that he’s monitoring that will drive healthcare innovation. He talked a lot about improvements in the provider payment system – think Accountable Care Organizations (ACOs) and Patient Centered Medical Homes (PCMH). The goal with these is the change from “pay for volume to pay for value”.

Talking to Todd gives you a positive view on what government can do. I can see him motivating his team and his prior teams to follow his vision and embrace change.  I’d have to agree with Matthew Holt’s article on Todd Park from earlier this year.

Books / Articles, Consumerism, Events, Healthcare, Innovation, Leadership, Politics, Research, Technology, Value Propositions

The Future Of Pharmacists

November 3, 2010 by George Van Antwerp 0 Comments

I went into yesterday’s NCPDP presentation expecting that I would be an outlier in proposing a radical model for pharmacists … but others had the same ideas before I spoke. I think everyone has talked about pharmacists wanting to do more counseling with their patients for years. Some of this is fulfilled with Medication Therapy Management (MTM) which began to be a compensated service under Medicare.

But, there is a huge gap in terms of what pharmacists are trained to do and what they actually do. I remember initially running into this concept when I worked on my pharmacy kiosk model. Some people saw this as a horrible thing that would replace the pharmacist. I actually saw it as a way to free up their time to focus on the patients that needed counseling not on people filling an antibiotic or getting a refill for the 30th time. In that case, I ended up going to talk to the Head of the St. Louis College of Pharmacy to see his thoughts. I remember him talking about the gap between what the students learn and the reality of what they do.

Most pharmacists (unfortunately) become high paid pill counters for much of their day. As someone said yesterday, “I didn’t go to school to learn to count in 5’s.” Another person pointed out yesterday that the top questions at the pharmacy are “How much will this cost”, “How long do I need to take this”, and “where’s the bathroom”. These aren’t things that require clinical knowledge.

There was a healthy discussion yesterday about expecting more from pharmacy technicians. For refills (which are 55% of prescriptions filled), why can’t they handle the process with oversight from the pharmacist.

Which I think brings us around full circle…

We’ve gone from a shortage of pharmacists to an overabundance of pharmacists. This has changed the paradigm. How do we leverage them?

At the same time, we have a shortage of PCPs which is likely to get worse with more insured people. Why can’t pharmacists step in here?

The change in flu shots may be the beginning. Will this be the start of all immunizations for people over 7 (as one person suggested yesterday) moving to the pharmacy? Given the profit on these, that would be a boom for the pharmacies, but it would certainly get pushback from the physician groups.

I would also suggest that the pharmacist could act as a PCP in helping manage care. Think about conditions like diabetes where the pharmacist in certain settings would have a unique ability to help the patient select food or look at devices. They could become a much more active “floor” resource for people shopping.

And, my radical idea that another presenter suggested yesterday was to look at focusing the pharmacist on new fills and initial titration. This of course would blow up the financial model in pharmacy. Why not pay them $10 or $15 per new fill and for the next 2 fills (of maintenance drugs) and then move everything to mail order, kiosks, central fill, and/or pharmacy technicians. We could write rules into the system to flag the technician to ask questions of people on statins every 12 months about getting lab work done or muscle pain.

At the end of the day, I would argue that pharmacy needs a radical overhaul like the entire healthcare system, BUT since it only represents 10-15% of total healthcare spend, some would argue that improving it be 25% (which would be huge) would only impact 2-4% of our healthcare spend. The problem with this is it’s like the PBM trying to justify adherence without looking at the impact on total health, absenteeism, and other factors.

Today, prescriptions are first line therapy for 90% of diagnosis. Over 50% of patients take 1 or more maintenance drug. And, most patients drop off their maintenance prescriptions by the end of year one. This costs us $300B a year.

Finding a new role for pharmacists and pharmacies, and giving them a better seat at the table is an imperative for change not an option. At the same time, there is a role for integrating technology into what they do to automate the simplier, repetive tasks. I’m not sure who’s the champion here, but I was emboldened by the fact that I wasn’t a radical at the conference.

Events, Healthcare, Leadership, PBM / Pharmacy, Politics

Your Personal Brand

October 12, 2010 by George Van Antwerp 1 Comment

Years ago, one of the articles that changed my approach was by Tom Peters called The Brand Called You. It’s a great article if you haven’t read it.

Here’s a good presentation I just stumbled upon with some similar messaging…

General Thoughts, Leadership

Stop By The Silverlink Booth At The Forum 2010 (DMAA)

October 7, 2010 by George Van Antwerp 0 Comments

Next week in DC is The Forum 2010 which is the annual event for The Care Continuum Alliance (formerly known as The Disease Management Association of America).  If you’re there, you should stop by the Silverlink booth and attend the presentations that we’re giving with some of our clients and other industry leaders. 

  Aligning Employee, Employer & Provider Research to Maximize Value-Based Benefits
October 13, 1:00 – 2:00 p.m.
Jan Berger, MD, MJ, Chief Medical Officer, Silverlink Communications
Cheryl Larson, Vice President, Midwest Business Group on Health (MGBH)
   
  Improving Statin Adherence through Interactive Voice Technology & Barrier-Breaking Communications
October 13, 2:15 – 3:15 p.m.
Ananda Nimalasuriya, MD, Chief of Endocrinology & Complete Care, Kaiser Riverside
George Van Antwerp, MBA, General Manager, Pharmacy Solutions, Silverlink Communications
   
  Addressing Colorectal Screening Disparities in Ethnic Populations
October 14, 12:30 – 1:30 p.m.
R. Reid Kiser, MS, National Director, Clinical Excellence Special Projects and Reporting, UnitedHealthcare
Jack Newsom, MBA, MS, ScD, Vice President, Analytics, Silverlink Communications
   
  Addressing an Epidemic – Improving Diabetes Care with Personalized Communications
October 14, 3:00 – 4:00 p.m.
Jan Berger, MD, MJ, Chief Medical Officer, Silverlink Communications
William Shrank, MD, MSHS, Instructor, Harvard Medical School and Associate Physician, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital
Consumerism, Events, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Silverlink, Technology, Value Propositions

Mobile / Social Media Stats c/o HubSpot

September 9, 2010 by George Van Antwerp 0 Comments

I’ve never met the people over at HubSpot, but I like the information that they’re making available.  (Thanks SF for the suggestion.)

Here’s a few graphics from a recent post on their blog about mobile infographics.  (BTW – I love infographics)

In another area of their site, they have some interesting data on how blogging and social media drives leads.  Here are three of them that I found interesting.

Blogroll, Leadership, Marketing / Communications, Methodology, Research, Social Media, Technology, Value Propositions

NCPDP Nov 2010 Event: The New Economy And …

August 24, 2010 by George Van Antwerp 0 Comments

On November 2nd, NCPDP is hosting an educational event called “The New Economy and It’s Impact on Healthcare, Pharmacy, and the Patient.” Sounds pretty cool! It’s a topic we all talk about.

What does the new sense of frugality mean? What will new forms of insurance mean? How will pharmacy evolve? Will MTM work? Will MTM become a product for commercial? How is the consumer’s behavior changing relative to information and compliance?

The agenda includes yours truly along with people from:
* Kaiser
* Walgreens
* AARP
* Sanofi-Aventis
* North Carolina Association of Pharmacists
* Eaton Apothecary
* American Society of Consultant Pharmacists
* RegenceRx

Consumerism, Events, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, PBM / Pharmacy, Research, Silverlink, Technology, Value Propositions
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