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DBN Article on Adherence

June 24, 2010 by George Van Antwerp 0 Comments

In today’s Drug Benefit News, I was quoted several times on the issue of incentives and adherence.  Here’s one of the quotes along with one of the quotes from Bob Nease from Express Scripts. 

Article: Should Patients Be Paid for Adherence? Strategy Could Yield Savings or Cost Hikes

Author: Renee Frojo

Medication nonadherence is recognized by most payers as a major driver of pharmacy costs, but nobody can get their hands on a foolproof solution to the problem. As a result, PBMs and health plans are experimenting with a new method that some critics view as a last resort: paying people to take their drugs appropriately. “There is no silver bullet when it comes to adherence, because it’s not that straightforward,” George Van Antwerp, vice president of the Solutions Strategy Group at Silverlink Communications, tells DBN. “However, it is an issue where everyone is aligned because there are a lot of potential savings.”

 “Some plans will do whatever it takes to get patients to be adherent to their therapy or engaged in better behaviors,” Bob Nease, Ph.D., chief scientist and vice president of marketing at Express Scripts, Inc., tells DBN. While the PBM hasn’t launched its own program yet, Nease says it will be following the trend closely. “The use of lotteries is very interesting and it has potential,” he adds.

Books / Articles, Healthcare, Marketing / Communications, PBM / Pharmacy, Silverlink, Value Propositions

Does Age Matter in Adherence?

June 22, 2010 by George Van Antwerp 0 Comments

Certainly age could be a confounding factor for many reasons – health literacy, length with a condition, co-morbidities, number of medications, tolerance for side effects – but I like this chart that the people at Vitality (aka GlowCaps) (www.rxvitality.com or www.roseology.com) just put out.

Of course, like any survey, there is sample bias so I would hesitate to extrapolate this, but I would say something like…

“for people who have and use a refill reminder device in their homes for hypertension medications, older people are more likely to be adherent.”

Of course, I’d love to know their MPR (medication possession ratio) before using the device.  Which had the higher lift? 

Healthcare, Innovation, Marketing / Communications, PBM / Pharmacy, Research, Technology

Good Social Media Deck (Prezentation Zen style)

June 17, 2010 by George Van Antwerp 0 Comments

Consumerism, Marketing / Communications, Research, Social Media, Technology, Value Propositions

Lottery For Taking Your Medicine

June 17, 2010 by George Van Antwerp 1 Comment

Adherence is the big focus these days.  It’s an issue where everyone is aligned – payer, pharmacy, PBM, pharma, patient, MD.  And, there are certainly lots of savings to be gained both hard dollars (less ER visits) and soft dollars (less absenteeism). 

BUT, COME ON…

There are lots of issues around adherence.  Getting people to fill the script after they leave the doctor’s office.  Making the script affordable.  Getting them to take the medication.  Remembering to take it over time.  Dealing with side effects.  Dealing with differences in cultures, conditions, health literacy, etc. 

Now, people are paying you or giving you a chance to “win” money every day just for taking your medication (see NYT article).  So, in my mind, this eliminates the issues of affordability (i.e., you already have the drug) and side effects (i.e., you’re not going to take something that has a meaningful side effect just for money).  So, why do I have to pay you.  Does the dentist pay you to brush your teeth?  Of course not.  Does your auto insurance company pay you not to speed?  Does your life insurance company pay you to not drive drunk?  NO…In all these cases you either pay more money if you do this or your service gets discounted if you don’t. 

If you have a chronic illness, can afford the medication, and have no meaningful reason to not take it, you should be doing your best to take the medication.  Otherwise, you’re driving up the costs of healthcare for you and your friends and your kids.  You do have some social responsibility to try and get better OR you should pay more for your healthcare.  We all have a choice (see the 1,000 pound woman).

Won’t paying people just create a long-term “dependency” where I only want to take my pills when I’m getting paid?  Probably…we certainly used to see that incentives at the call center drove up success rates, but once they went away the success fell below the baseline. 

Will this create an incentive simply to open the pillbox to get paid even without taking the medication?  No one is there making sure it goes down my throat so I’m sure some people will game the system.  (A sentiment shared by John Mack at the Pharma Marketing Blog.)

For the people that are adherent, will you just be wasting money?  Yes…and why should my neighbor get paid for forgetting…I’m going to want the same thing.

Don’t get me wrong.  I’m a fan of incentives, but reward me for the right things otherwise we end up with situations like Enron.  Incent me for managing my BMI, my A1c value, my blood pressure.  I can take medication, work out, or diet to achieve those. 

Give me tools and information.  Help me to understand my drug.  Help me to afford my drug (e.g., value based insurance design or patient assistance programs).  Educate me on my condition.  Have a talking pillbox or medication bottle.  Call me to remind me to refill.  Sign me up for auto-refill. 

I just can’t get on board with this latest twist.  I guess the proof is in the pudding so we’ll see if it makes a difference.  I’d love to be proven wrong here and see us throw money at people and change the healthcare cost curve.

Blogroll, Books / Articles, Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy, Value Propositions

Prioritizing Social Media Participation

June 15, 2010 by George Van Antwerp 0 Comments

If you haven’t read the article in USA Today titled “A doctor’s request: Please don’t ‘friend’ me“, I think you should.  It makes some great points and is symbolic of the challenge we all face relative to social media.

  • Should we participate?
  • Which tools should we use – MySpace, Facebook, Twitter, LinkedIn, Plaxo, blogging, …?
  • How much time to spend on them?
  • What should I expect from them – leads, contacts, friends, finding old friends?
  • Is this okay to do at work or should I do this at home?
  • Should these sites be blocked at work?
  • What can I or can’t I say?
  • Should I accept invitations from everyone who reaches out to me?

The author of this article talks about some of the more physician specific issues of becoming friends with your patients in Facebook, but it generally begs the question of where do those boundaries exist.

“Having a so-called dual relationship with a patient – that is, a financial, social or professional relationship in addition to a therapeutic relationship – can lead to serious ethical issues and potentially impair professional judgement.”

On the flipside, what if a friend of yours is a physician and you need to be treated.  Is that okay?  I think so.  I know my pharmacist very well.  We’ve even had her and her family over to the house several times.  But, we became friends through our kids and our gym not simply because we have a clinical relationship.  And, while we’ll talk industry trends occassionally, we rarely talk specifics.  Plus, the fact that I help lots of companies drive business away from her pharmacy (retail-to-mail) never sits too well!

So, I’ve selectively added social media sites over the years.  Here’s a quick picture of how I think about it.  I do not accept the majority of invitations that I receive simply based on a few key criteria which vary by tool.  For example, in Facebook, I generally have to view you as someone who I have or would invite to my house in order to be your friend.  In LinkedIn, I have to have connected with you in person or on the phone one or more times before I would become a connection. 

Books / Articles, Healthcare, Marketing / Communications, Social Media, Value Propositions

Less Time in Hospital Correlated to More Readmissions

June 14, 2010 by George Van Antwerp 0 Comments

We all want to get out of the hospital as quickly as possible.  A recent study from JAMA that appeared in the WSJ showed that while days in the hospital dropped from 8.6 days in ’93-’94 to 6.4 days in ’05-’06 the readmission rate (within 30 days) went up from 17.3% to 20.1%.  I’d love to see the economics around this. 

  • Do the hospitals make more money in this case? 
  • Do the plans save more money? 
  • Are patients happier?  [Remember that the majority of them got out sooner.]

“From a societal point of view, dollars spent on health care likely increased.”  Harlan Krumholz, Yale University cardiologist and senior author of the study. 

The study author echos a point that we [Silverlink] often make to our clients which is that hospitals (or payers) need to invest more effort and resources to make sure the transition to outpatient status in seamless.  Do they understand what the doctor’s instructions were?  Do they have someone caring for them?  Did they pick up their medications?

Another key lesson learned here is that it’s important to measure what matters and that what’s measured gets improved.

Books / Articles, Healthcare, Managed Care, Marketing / Communications, Research, Silverlink, Value Propositions

2010 Medco Drug Trend Report

June 9, 2010 by George Van Antwerp 2 Comments

I can’t believe it’s taken me a few weeks to catch up on my notes from a conference call with David Snow and Dr. Rob Epstein from Medco Health Solutions about their 2010 Drug Trend Report. I captured some of Dr. Epstein’s comments in a quick blog post, but I have a lot of respect for David Snow and wanted to capture a few of his comments here and pull out some of the interesting data from the Drug Trend Report.

David Snow mentioned a few things:

  • Reform has to address all three legs of the stool – Access, Quality, and Cost. Right now, it’s focused on access.
  • Of the $2.4T we spend in the US on healthcare, $1T of it was unproductive.
  • One of the big issues in the system is poorly designed systems for the people that deliver care.
  • Pharmacy is ahead of the curve since it’s already wired and uses evidence-based care.
  • We have to focus on the chronic conditions. 96% of the pharmacy spend and 75% of the medical spend is here.
  • Prescriptions are used as first line solutions 90% of the time. (See my comments on why trend shouldn’t matter.)
  • $350B of the waste is due to poor management of chronic solutions.
  • We still have to address medical liability and defensive medicine.

He also answered questions. A few of my notes from the Q&A:

  • Patent expiration doesn’t fully explain the increase in brand pharmaceutical costs. (Traditionally these drug costs go up once the patent expires.) You can correlate the tax on pharma (in reform) to the increase in prices. (Not dis-similar to the increases around Part D if memory serves me.)
  • Adherence is a key issue. The Therapeutic Resource Centers (TRCs) are their answer to this. They drive adherence in the classes that matter and we report to clients on this. (While I think a lot of people viewed the TRCs as marketing strategies when they first came out, I believe they have demonstrated a clinical focus with some case studies and clinical leads over the past 18 months.)
  • The pathway to biosimilars is very fair to the innovator.
  • Class competition in specialty is increasing.

His most interesting comment which I’ll repeat from my earlier post was that if the FDA really understood true adherence they might make different decisions on approving drugs whose effect is tied to a person staying on a medication over time.

I won’t repeat some of the core data elements from my prior post, but here are some new ones from reading the document:

  • Mail order penetration was 34.2% (which I believe is industry leading for the PBM sector with only Walgreens showing a 90-day utilization number that’s higher).
  • Interestingly, they show trend for clients with over 50% mail use (and clients with less than 50% mail use). [Most PBMs would love to have any clients with over 50% mail use.]
    • 0.1% for those with over 50% versus 5.3% of those under 50%

Reported trends are based on 2 years’ data on pharmaceutical spending. Drug trend percent includes 201 clients representing approximately 65% of consolidated drug spending. The sample comprises clients who offer integrated (mail-order and retail) pharmacy benefit options for members. Clients with membership enrollment changes > 50% were excluded from the analysis. Plan spending is reported on a per-eligible per-month (PEPM) basis, unless otherwise specified. An “eligible” is a household, which may include multiple members who are covered under the same plan. Plan spending comprises the net cost to plan sponsors less discounts, rebates, subsidies, and member cost share. Generic dispensing rates and mail-order penetration rates represent the total consolidated Medco client base.

 

  • Diabetes is obviously a critical category for everyone. I found it interesting that they saw fewer patients filing claims for diabetes but more drugs per patient in 2009.
  • Respiratory therapies (driven by those <19 years old) jumped in contribution to trend from 8th to 2nd.
  • In patients aged 35 to 49, antiviral drugs are the greatest contributors to cost – 8.3% of plan pharmacy costs. [Some of this driven by flu although this is not the at risk age group.]  

Antiviral drugs (Formulary Guide Chapter 1.8) include oral treatments for HIV/AIDS, influenza, herpes, hepatitis C, hepatitis B, and injectable treatments for respiratory syncytial virus (RSV), and cytomegalovirus.

  • Utilization growth for ADHD drugs for those age 20-34 grew 21.2%. [Is this for people not diagnosed as kids, people who have adult-onset ADD (if that exists), or just an over-diagnosis of the condition?]
  • Specialty drugs…I’m always surprised that all the PBMs still have to caveat the fact that they only adjudicate some of the claims since some specialty drugs are filled and billed under the medical benefit. That seems like something that should / could be fixed, but I know it’s been tried and is hard since people are making money off them being billed elsewhere.  

 

 

  • Cancer is already a huge driver of specialty costs AND:
    • Much of the spending is still under medical;
    • Most drugs approved in the past 4 years costs over $20,000 for a 12-week course; and
    • There are over 800 drugs in the pipeline.

 

 

Spending growth has outpaced spending for nonspecialty, or traditional medications because:

  • A high proportion of newly approved drugs are designated as specialty.
  • Unique manufacturing processes make specialty drugs expensive to develop.
  • Fewer drugs within a therapeutic category limit competition.
  • There may be only one specialty treatment for an orphan condition.
  • Few drugs are therapeutically equivalent to others in the category, reducing interchange and related cost savings opportunities.
  • It is more difficult to transition existing patients from one specialty drug to another preferred specialty drug because often these drugs are large, unique proteins that are not considered interchangeable.
  • Most small-molecule specialty drugs are relatively new with few generic alternatives.
  • No defined approval pathway exists for follow-on biologics (also known as biosimilars).
  • Drugs used to treat cancer represent a large portion of new drugs in both the pipeline and marketplace; most are specialty drugs and some can cost more than $20,000 for a 12-week therapy course.
  • It was the first time I noticed anyone caveating the specialty trend. They proactively addressed different calculation methods to point out that their method yielded a 14.7% specialty trend, but if you did things differently (as I assume others must), then their trend would have been 12.1%.

 

 

  • Trend in children exceeded trend in other age groups for the second year in a row. (I think this is an interesting perspective and a scary indicator for the future health of our country.)
  • They provided some examples of drugs that had new indications for younger patients approved:
    • WelChol, Crestor—for low-density lipoprotein cholesterol (LDL-C) reduction in children aged 10 to 17 with heterozygous familial hypercholesterolemia.
    • Atacand—for hypertension in children aged 1 to 17.
    • Axert—for acute treatment of pediatric migraine.
    • Protonix—for erosive esophagitis in patients aged 5+.
    • Abilify—for irritability associated with autistic disorder in children aged 6 to 17.
    • Seroquel—for schizophrenia in children aged 13 to 17, and for acute manic episodes in children aged 10 to 17 with bipolar I disorder.
    • Zyprexa—for schizophrenia and for acute mania (bipolar I) in children aged 13 to 17.

 

 

 

  • An interesting perspective that I’ve talked about many times (without the research capabilities to analyze) is the correlation between sleep and chronic disease. They looked at this across states based on drug utilization and found a correlation (not necessarily causation).

 

So what do they say to watch:

  • Continued inflation in brand drug prices.
  • Majority of trend will come from specialty – oncology, orphan conditions.
  • Personalized medicine.
  • Biosimilars.
  • Generic pipeline.
  • Obesity epidemic.

 

  

  • They bring up an interesting issue relative to OTC (over-the-counter) product which is DUR (drug utilization review) which looks for drug-drug type interactions. They talk about the Medco Health Store integrating that data to monitor patients. [Do plans care? Do patients care? Should retail OTC purchases be integrated? How great are the interactions?]
  • They talk a little about obesity although I would love to understand more about how a plan sponsor should manage this.
    • 68% of adults are overweight; 34% obese
    • 32% of children are overweight; 17% obese
    • Medical spending on obesity related conditions is $147B
    • 19.5M adults (24-85) have diagnosed diabetes and other 4.25M are undiagnosed
    • Diabetic medical claims are forecasted to grow from $113B to $336B over the next 25 years.
  • I’m not going to spend a lot of time on personalized medicine here.  (A recent post of mine on this topic.)  They’ve been very active in this space for years talking about it. I think one of their interesting points in the Drug Trend Report is how Comparative Effectiveness will dovetail with Personalized Medicine.
  • Almost 2/3rds of people at risk for CHD in the next 10 years and eligible for lipid lowering drugs (e.g., Lipitor) were still not using them. (A common gap-in-care program run by many companies is to target these people (e.g., diabetics).)
  • Only 29% of patients treated for high cholesterol reach their cholesterol goal.
  • They have a section on wiring healthcare which David Snow has talked about for a while. It’s a critical area to address and has lots of opportunity.
  • They also talk about the concept of collaborative care (aka medical home…aka accountable care organizations).
  • I’m a big believer that poly-pharmacy creates issues (as does poly-physician). I don’t hear much talk about it. I was glad to see them talk about a study they did which identified poly-pharmacy issues, talked to MDs, and ended up with 24% of cases where medications were changed.

 

A Medco survey reported that 81% of participants with a new diagnosis, who received services at a traditional retail pharmacy, either did not receive counseling or were dissatisfied with the prescription drug counseling they received. When given the opportunity to speak with a Medco Specialist Pharmacist, 75% of these patients accepted the offer of immediate telephone support.

 

  • I thought it was really interesting to see a screen shot of their application used by the TRCs to create their Health Action Plans for consumers.

 

 

  • I was also interested in their focus on women’s health and some data on caregivers and the gender differences in healthcare. One of their TRCs is dedicated to addressing these differences.

 

Books / Articles, Healthcare, Innovation, Leadership, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Technology, Value Propositions
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Walgreens vs. CVS More Thoughts

June 8, 2010 by George Van Antwerp 2 Comments

This was definitely the hot topic yesterday. I talked to lots of people about it.

I had a chance to give it some more thought last night. A few things dawned on me.

1. Timing. This was timed well from a Walgreens perspective. Managed Care RFPs are mostly over and employers are making their decisions now on PBM services. Managed Care would have been more likely to focus on the cost and understand how to mitigate the disruption. Employers will be much more sensitive to the disruption. That will be something that CVS Caremark will have to manage.

2. Who wins. Since one analyst told me that Walgreens represents only a single-digit of CVS Caremark’s revenue, the impact may not be huge. On the flip side, it’s likely some downside for Walgreens since they’ll stop serving some portion of CVS Caremark’s business. Consumers aren’t helped here. So, my only conclusion is that the other PBMs (i.e., Medco and Express Scripts) are best positioned to win from this if it causes any CVS Caremark PBM decisions to go their way. At a minimum, it creates FUD (fear, uncertainty, and doubt) which no sales person likes to have to deal with.

3. Validation. If I’m the product manager for Maintenance Choice at CVS Caremark, this seems like pretty strong validation that the offering works. As Adam Fein showed before, it does drive volume to their stores. Obviously, Walgreens was afraid of this taking off and having a larger impact on them.

So…what would I do?

This is interesting since one of my last tasks at Express Scripts was to come up with a strategy in late 2005 around CVS and Walgreens backing out of our mandatory mail network. My strategy (which I ultimately left to pursue) was to respond by opening onsite clinics and building out a pharmacy kiosk system that could be put in grocery stores (only 50% have pharmacies), large employer campuses, and high density sites in big cities. While Express Scripts didn’t choose that path, I still believe there is opportunity there and CVS Caremark could easily implement such a strategy. [It’s starting to get momentum in Canada.] CVS Caremark (or Walgreens for that matter) have the technology and business model to implement on-site pharmacies and to create a central fill using kiosks. If those could mitigate the effect of the Walgreens decision, it could be an interesting response. [BTW – If you’re interested in my pharmacy kiosk business model that I ultimately wrote up and pursued with some angel investors, let me know. I may try to post some of it here later.]

On the other hand, another response would be to look at the top 5 MSA (market service areas) where Walgreens is stronger than CVS. I’m guessing those are NY (post-Duane Reade acquisition), Delaware (post-Happy Harry’s acquisition), St. Louis (CVS just started operating here), and a few others. They could go into those markets and buy up independents or some smaller chains to immediately mitigate this.

There are several responses short of just folding and putting Walgreens in the network. Ultimately, I think it’s about whether CVS and Walgreens see each other as “enemies” or just competitors. Do they want to grow the pie or do they want to put the other out of business (if such a thing were possible)?

More to come I’m sure…

Blogroll, Books / Articles, Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy, Politics, Technology, Value Propositions

Walgreens and CVS Caremark – Coming to Blows

June 7, 2010 by George Van Antwerp 0 Comments

I’m surprised this took the 3 years to play out. I talked about this back in 2007. Today, Walgreens announced that they would no longer participate with CVS Caremark networks for new networks and renewals. (See the CVS Caremark response here.)

Personally, I’m a little surprised they didn’t limit it just to the Maintenance Choice contracts which is where they have issues (like Mandatory Mail). Walgreens has fought for years against PBMs that implement models that limit choice.

I guess one of the big questions here is whether CVS Caremark allows Walgreens into their Maintenance Choice network. Walgreens (for example) has multiple 90-day networks. One which is just with Walgreens and one that includes other retailers.

Other questions I would have are:
1. Will CVS Caremark pull out of the Walgreen’s PBM network or their 90-day networks?
2. Will other retailers pull out of the CVS network?
3. Will Walgreens be more aggressive with other PBMs or can they only “fight” one at a time?
4. Will this help CVS Caremark focus their retail acquisition strategy to areas where Walgreens is stronger than them really creating a retail battle and less of a PBM battle?

I’m sure in some geographies (e.g., St. Louis, NYC) this may present some challenges where the CVS presence is not as strong, but in the end, most consumers have access to more retail pharmacies than they need and most PBM decisions are heavily influenced by price. If CVS Caremark can offer a price point that takes into account the disruption to the member base of not having Walgreens in the network, they can win. If that hurts them too much or they can’t do it, they’ll have to figure out how to make nice with Walgreens.

It will be interesting!

Books / Articles, Events, Healthcare, Marketing / Communications, PBM / Pharmacy, Value Propositions

Behavioral Economics – Affirmative Choice – Organ Donations

June 3, 2010 by George Van Antwerp 1 Comment

You can call the framework whatever you want but forcing people to chose an option works. I think Organ Donations are a great thing and the data is out there to show what states should do to encourage this. In Colorado, 64% of driver’s license and State ID applicants signed up as donors. In Michigan and NY, less than 13% did. The 8 states who have rates in exceess of 50% all do the same thing…the employees at the motor vehicles department ask the people and force them to say yes or no.

Apparently there are some people pushing for “presumed consent” which would require that people opt-out. This is apparently done in several European nations, and while I don’t have an issue with it personally, I’m sure it won’t happen here.

This framework reminds me of the Select Home Delivery option which Express Scripts designed a few years ago, and I believe is the best product idea to come out of the Consumerology concept.

From Donate Life America:
* Top 5 states for participation – Colorado (64%), Iowa (63%), Montana (62%), Washington (57%), and Wyoming (55%)
* Bottom 5 states – New York (11%), Michigan (13%), Arizona (17%), California (25%), and Kentucky (26%)

Books / Articles, Consumerism, Healthcare, Marketing / Communications, Value Propositions

Text4Baby (or Bebe)

June 3, 2010 by George Van Antwerp 0 Comments

This seems to be one of the more successful texting programs in the healthcare space.  This public-private partnership with sponsors like J&J and Pfizer is leveraging texting technology to try to address the US infant mortality rate (with is 30th worldwide).

With 25% of people not having a landline and more and more people (especially younger generations) depending upon the mobile phone, this makes a lot of sense.  In general, the sick population for the healthcare companies are not the younger generations, but this is typically different for pregnancy.  What I didn’t know until reading an article about this is that Hispanics and African Americans are 2.5x as likely at Whites to put off prenatal care until the 3rd trimester or skip it altogether. 

So what do you do?  Text BABY (or BEBE) to 511411 and punch in your due date.

Who writes the content?  The National Healthy Mothers, Healthy Babies Coalition.

Is there a charge?  No.

What is the content?  You get up to 3 texts a week until the baby’s first birthday.  They talk about seeing their doctor.  Keeping their appointments.  Get immunizations.  Put babies on their backs to sleep. 

What do they hope to learn?  Will users have different outcomes?  Will they go to more appointments?  Will they stop smoking?  Will the incidents of low birth weight and pre-maturity decline?

Consumerism, Healthcare, Innovation, Marketing / Communications, Social Media, Technology, Value Propositions

Some of my notes from RESULTS2010

May 28, 2010 by George Van Antwerp 0 Comments

This week was our [Silverlink Communication’s] annual client event – RESULTS2010 (click here to see the final agenda). I’ve talked about this before as one of the best events.  It was great! Educational. Fun. Good networking.  

Here’s a few of my notes along with a summary of the twitter feed (using hashtag #results2010). Unfortunately, the two of us twittering were also fairly involved so there are some gaps in coverage. And, my notes are sporadic due to the same issue.

Overall themes:

  • Communications are critical to driving behavior change.
  • We have to address cost and quality.
  • Reform creates opportunity.
  • Systemic problems require systemic solutions.
  • Measure, measure, measure.
  • Automated calls – while not the whole solution – work in study after study.
  • People are different.
  • There is a gap in physician – patient interactions. 

Notes:

  • Reform basics – guarantee issue, requirements for coverage, income related subsidy.
  • Independent payment advisory board has an aggressive goal – get Medicare spending to equal GDP growth + 1% each year.
  • ½ of the $1 trillion needed to pay for health reform comes from Medicare savings / reform…the rest from taxes.
  • Everyone’s fear is that MCOs become “regulated utilities” that just process claims…unlikely.
  • Need to address underuse, misuse, overuse, and limited coverage.
  • Need to measure quality and cost at the person level.
  • CMS pilots around shared savings are working – outcomes improved.
  • Medicare Part D only got one complaint per thousand for therapeutic interchange programs / drug switching.
  • The decision around defining MLR (medical loss ratio) and what fits in there is critical.
  • Healthcare is like anything else…it’s not great and needs to change, but don’t touch mine cause it works ok. [frog in the pot]
  • How do we make each healthcare decision an informed decision.
  • Decision aids.
  • Pull, push, or pay – 3 ways to drive awareness.
  • Moving from information about your care to information being care.
  • The incentive rebound effect…what happens when you take away an incentive.
  • Social interaction affects our behavior.
  • Solving for how to change consumer behavior cost effectively and in a sustainable manner is a good challenge to work on.
  • How do we move people from desires to action? From “I’d like to exercise” to actually doing it.
  • The fact that some European programs take 3-5 years to see an impact makes me wonder what that means for our US investment strategy given the member churn across plans.
  • Great examples of ethnographic interviews
  • Good McKinsey data on people’s perceptions – Annual Retail Healthcare Consumer Survey.
  • Inform / Enable / Influence / Incentivize / Enforce
  • One way of categorizing – willingness to change versus barriers to change (rational, emotional, psychological).
  • Attitudinal segmentation – cool…but how to scale?
  • Provider staffs attitudes are important.
  • Design – delivery – measurement
  • Readiness to coach
  • A culture of health
  • Have to mix up your tools (incentives, channels)
  • “Communication Cures”
  • The chief experience officer is a new role in plans and PBMs.
  • The only experience you have with health insurance is via communications. Make it count.
  • Loyalty is a result of cumulative experiences.
  • People have to trust you so they listen to your message
  • Communication maturity model
  • Price is what you pay; value is what you get. (Warren Buffett quote…he wasn’t there)
  • Shifting paradigms:
    • Consumption to sustainability
    • Possessions to purpose
    • Retirement to employment
    • Trading up to trading off
    • Perceived value to real value
  • Simple…less is more
    • 1/3 of people feel their lives are out of control.
  • Inflamation causes 80% of diseases (really)?
  • If only 10% of outcomes are driven by costs, why do we spend 100% of our time trying to fix that problem. [tail wagging the dog] [It’s the same point on adherence.]
  • There are 45M sick days per year from 5 conditions – hypertension, heart disease, diabetes, depression, and asthma.
  • Have to look at clinical efficacy and elasticity of demand.
  • Commitment, concern, and cost.
  • Five components – plan design, program, community, communication, and provider engagement.
  • Need a multi-faceted approach to create a culture of health.
  • MDs much more likely to talk about pros than cons.
  • There would be 25% less invasive procedures if patients fully understood the risks.
  • Foundation of Informed Decision Making
  • Huge gaps in patient view versus physician views around breast cancer.
  • Preference-sensitive care
  • Dartmouth Atlas
  • Genomics tells you the probability of being on a disease curve, but not where you are in the potential severity.
  • Only 60-70% of women get at least one mammogram their entire life.
  • Statin study – barriers to adherence:
    • 37% didn’t know to stay on the Rx
    • 27% side effects
    • 15% convenience
    • 15% MD instructions
    • 11% cost
  • In healthcare, we’re all taught to speak a language that no one else understands.
  • It takes a village.
  • Challenge – Use communications to cure cancer.
  • Collaboration. Innovation. Evaluation.
  • Adherence is a great example of where everyone’s interests are aligned.
  • There is no magic bullet for adherence.
  • You need a multi-factorial approach to address adherence…Physicians are rather ineffective at addressing adherence.
  • Evidence-based plan design works to impact adherence (although I think another speaker said no).
  • You have to think about operant conditioning. (Look at dog training manuals and kid training manuals – very similar)
  • Think about all the failure points in the process.
  • What is the relative value to the patient.
  • Reward system has to reward at the failure points not just at the end of the process.
  • Using a point system successfully increased the use of a select (on-site) pharmacy by 57% at one employer.
  • 75% of PBM profits are from dispensing generics…that’s why Wal-Mart was able to be a threat to the industry.
  • Drugs only work in 20-80% of people.
  • There are people with a gene that doesn’t break down caffeine.
  • 3% of people are ultrafast metabolizers of codeine (which turns to morpheine in the body)…that can be a problem.
  • Epigenetics – turning DNA switches on and off.

“Tweets”

Rebecca from ProjectHEALTH closes #results2010 with a remarkable talk on this crucial program; they work with 5,000 families/year.

Reid Kielo, UnitedHealth: 93% of members validated ethnicity data for HEDIS-related program using automated telephony #results2010

25% of Medco pt take a drug with pharmacogenetic considerations. Robert Epstein, CMO Medco #results2010

Bruce Fried: the “California model” of physician groups facilitate efficiencies that improve delivery; an oppty for M’care #results2010

Bruce Fried on Medicare: 5 star ratings have strategic econ. importance, med. mgt. and cust serv. key #results2010

Fred Karutz: members who leave health plans have MLRs 2 standard deviations below the population. #results2010

Fred Karutz: Market reform survival – retain the young and healthy #results2010

Poly-pharmacy has negative impact on adherence. #cvscaremark
#results2010

1 in 3 boys and 2 in 5 girls born today will develop diabetes in their life. SCARY! #results2010

20% of all HC costs associated with diabetes. #results2010. What are you doing to manage that?

Messages to prevent discontinuation of medication therapy far more effective than messages after discontinuation. CVS #results2010

25-30% of people who start on a statin don’t ever refill. #CVSCaremark
#results2010

Maintenace of optimal conditions for respiratory patients increased 23.4% with evidence-based plan design. Julie Slezak, CVS. #results2010

Value-based benefits help control for cost sensitivity for medications; every 10% increase in cost = 2% – 6% reduction on use. #results2010

Pharmacists who inform patients at the point of dispensing are highly influental in improving adherence. William Shrank #results2010

The game of telephone tag in HC is broken. Pt – MD communications. #results2010

37% of Pts were nonadherent because they didn’t know they were supposed to keep filling Rx. #results2010

Last mile: 12% of Americans are truly health-literate; they can sufficiently understand health information and take action. #results2010

Only 12% of people can take and use info shared with them. #healthliteracy
#results2010
#DrJanBerger.

We need to improve the last mile in healthcare… clear, effective conmunication. Jan Berger #results2010

#McClellan used paying drug or device manu based on outcomes as example of “accountable care”. #results2010

72% of those with BMI>30 believe their health is good to excellent; as do 67% of those w/ chronic condition. #McKinsey
#results2010

Are incentive systems more likely to reward those that would have taken health actions anyways (i.e., waste)? #McKinsey
#results2010

Only 36% of boomers rate their health as good to excellent. #results2010

27% of people believe foods / beverages can be used in place of prescriptions. #NaturalMarketingInstitute
#results2010

Why do we spend so much time on impacting health outcomes thru the system when that only explains 10%. #Dr.JackMahoney #results2010

Using auto calls vs letters led to 12% less surgeries & 16% lower PMPM costs in study for back pain. #Wennberg
#HealthDialog
#results2010

MDs are much more likely to discuss pros with patients than cons. #Wennberg
#HealthDialog
#results2010

Should physicians be rewarded as much for not doing surgery? How do economics influence care decisions? #results2010

Physicians were 3x as concerned with aesthetics than breast cancer patients in DECISIONS study. #results2010

Fully-informed patients are more risk-averse; 25% fewer of informed pts in Ontario choose angioplasty. #results2010

Patients trust physicians over any other source (media, social connections) but only receive 50% of key knowledge. #results2010

Informing Patients, Improving Care. 90% of adults 45 or older initiate discussions about medication for high BP or cholesterol. #results2010

What is #results2010? #Silverlink client event.

#results2010 – #Aetna Medicare hypertension program leads to 18% moved from out of control to in control using auto calls (#Silverlink) …

About 2 of 3 medicare pts have hypertension. #results2010

John Mahoney describes how he connects payors, providers, and care via research. #results2010

As information becomes commoditized in healthcare, sustainability enters the vernacular. #results2010

Segmentation innovations of today will be tomorrow’s commodities. Measurement and learning must be “last mile” IDC insights #results2010

Plans are strategically investing in bus. intel to reach wide population for wellness, not just the low-hanging fruit. #results2010

The single most significant future market success factor is measurable results. Janice Young, IDC Insights. #results2010

Knowing our attendees’ preferences could have fueled segmented, precise invitations to #results2010. Dennis Callahan from Nielsen Media.

Drivers of those sereking alternative therapies: stress, lack of sleep and energy, anxiety, inflammation. #results2010

Only 2% of people don’t believe it’s important to lead a healthy lifestyle. Their behavior could’ve fooled me. #results2010

Are purity and simplicity the new consumption? Steve French of Natural Marketing Institute explores. #results2010

Gen Y is the most stressed out generation. #results2010

Less is more. 54% say having fewer material possessions is more satisfying. Natural Mktg Institute #results2010

Loyalty is a result of a cumulative set of experiences. Individual intervention ROI is sometimes difficult. #results2010

Sundiatu Dixon-Fyle of McKinsey; understand how beliefs shape an individual’s ability to change behavior. #results2010

Don Kemper: each of 300M HC decisions made each year need to be informed. #silverlink
#results2010

Medicare Part D: 40% lower cost than projected, seniors covered through tiered coverage powered by communication. #silverlink
#results2010

Mark McClellan: Brookings is engaging private insurers to pool data to understand quality of care. #silverlink
#results2010

Mark McClellan at RESULTS2010; bend the curves, provide quality care efficiently. HC reform >> insurance reform. #silverlink
#results2010

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

Who Is Dr. Obvious?

May 25, 2010 by George Van Antwerp 0 Comments

As someone pointed out to me today, there is now a character called Dr. Obvious which is featured on the Medco site – www.medcopharmacy.com.  He’s also on Twitter and Facebook.  So, who is he?  What’s the twist here? What’s the Institute for the Incredibly Obvious?

You might get some idea by watching the video on Facebook or some of the videos on YouTube.

Here’s one on automated refills (which is the push for most pharmacies – retail and mail).

 


Consumerism, Healthcare, Innovation, Marketing / Communications, PBM / Pharmacy, Social Media, Value Propositions

Reframing Death – A Good Example

May 22, 2010 by George Van Antwerp 0 Comments

Anyone who works in communications knows that framing is a critical concept to grasp.

Here’s a simple statistic presented two ways:

  • An astonishing 40% of people were offended by the action
  • A majority of people had no issues with the actions taken

Another great example I like is using graphics to frame things.  Here’s a picture of how much a simple drink compares to in terms of donuts.

So, I was intrigued a few weeks ago when I was at my cousin’s funeral (Fr. Tom McDevitt) by how well the priest did at framing his passing.  (You can listen to the entire podcast of the funeral here…I’d start around 16:25 if interested.)  There were several times that I wanted to pull out my BlackBerry and tweet a few things (but I thought that might be inappropriate).  The priest (or actually priests) did a great job of turning his life into lessons for all the people there and framing this out as a celebration (which it certainly felt like with 80 priests and 3 bishops there…I counted).  He talked about how he found the good in everything.  He talked about how he continued to learn.  He talked about how he kept doing things even if he didn’t feel good trusting that he would die when it was appropriate.  He talked about dealing with forgiveness and not holding grudges…it only punishes the person with the grudge.

This has always been the way my family views funerals.  It’s a time to reconnect and remember people especially in today’s day and age where families are so busy and so far flung.  But, at the same time, death is a challenge for most of us.  We miss the people that we loved and knew.  Fr. Tom had been one of the cousins that I’d stayed in touch with over the years, and he had married my wife and I and baptized one of our kids.  But, you still learn a lot about a person at their funeral.  I was amazed at all the things he did and people he touched.

It seems to surprise people, but I’ve know a lot of people that have died over the years:

  • In high school, one classmate killed himself, one friend killed himself, my friend’s brother killed himself, and my friend’s mom tried to kill him (due to her chemical imbalance).  Additionally, another guy I knew got killed in a fight…And, a kid got paralyzed in a lacrosse game and eventually died dramatically affecting my friend who collided with him.
  • When I was 30, two co-workers of mine died of brain aneurisms (who were about the same age).
  • I come from a large family and have seen 12 aunts and uncles die.  But, only one grandparent since 3 of them were dead before I was born.
  • A few years ago, a person I worked with killed themselves.
  • Another time a co-worker’s dad got shot on a hunting trip.
  • Last year at my daughter’s school, one kid died of cancer, another kid drown, and an older brother of a kid got hit by a car and died.
  • And, to top it off, I worked at a cemetary for 2 years when I was younger.

My point is that I have seen death and consider it a very normal part of life.  One of the quotes from Fr. Tom’s was “It’s a great day to live.  It’s a great day to die.”  Do you live your life that way?  Understanding and finding the value in what you do and enjoying life is important.  While I appreciate the challenge of communicating difficult information and dealing with death, I think we all have a need to think more about how to frame things and understand them.

Healthcare, Marketing / Communications, Value Propositions

Medco 2010 Drug Trend Report

May 19, 2010 by George Van Antwerp 1 Comment

Today, Medco Health Solutions released their 2010 Drug Trend Report (which looks at 2009 data). I haven’t had time to read the entire report, but here are a few highlights and comments from a conference call:

  • Overall drug trend was 3.7%. [They use their top 200 clients for analysis.]
    • Trend was 0.1% for clients with greater than 50% spend at mail.
    • Trend was 1.7% for Medicare.
    • [I still point out here that the question is whether trend is good or bad.] Dr. Epstein and David Snow pointed out that they work with clients on this to track metrics on adherence at the TRCs (Therapeutic Resource Centers) and report on this. The key here is knowing what classes show measurable impact to overall costs and outcomes by improving adherence and increasing costs.
    • Another point I thought was interesting was a comment that if the FDA saw the actual adherence on some drugs that require sustained utilization to achieve an outcome that they might make different decisions about drug approvals.
  • Inflation for branded drugs was 9.2% which was the highest in a decade. Generic inflation was 0.3%.
    • On a conference call, David Snow validated that this was associated with the tax on brand pharma so yes the high inflation on brand drugs was tied to reform. Someone asked a question about patent expiration (which historically drives prices up), but that doesn’t explain all the inflation here.
  • They saw a 3.4% increase in generic utilization.
  • Prescription utilization was up a minor 1.3%.
    • 5% for children 0-19.
    • 0.2% for seniors.
  • Specialty drug spending continued its rapid growth with a 14.7% increase including a 2.6% utilization increase.
  • Diabetes continues to be the largest driver of drug trend representing 16.7% of all drug spending and grew by 11.1%. [We can expect to see this continue to grow as more pre-diabetics are diagnosed.]
  • H1N1 drove up antiviral spending by 15.7%.
  • Pediatric use of medications grew faster than other groups.
  • 1 in 4 insured kids now take a medication for a chronic condition.
  • Increased utilization in kids occurred in diabetes, asthma, antivirals, ADHD, cancer, and rheumatology drugs.
    • There was a huge increase in diabetes over the decade (5x the adult population) and this was especially true with adolescent girls.
    • It’s amazing to me that you now have kids on lipids (high cholesterol), but it’s clearly an indication of the obesity issue. [We’re just at the tip of iceberg.]

  • ADHD surged for those under 35 – 9.1% increase in use leading to a 23.8% increase in spending.
    • The CDC says that 5M kids age 3-17 have and ADHD diagnosis.
    • [The other issue here is abuse of ADHD drugs.]
  • They also mention Nuvigil as a drug that could gain popularity for treating jet lag.
  • They forecast the drug trend will rise 18% thru 2012 driven largely by diabetes, oncology, and rheumatology.
  • About $46B in brand drug sales are scheduled to go generic by 2012.
  • They don’t expect biosimilars to impact the market until after 2012.
  • Not surprisingly, they showed a high correlation between states with frequent sleep deprivation and high drug utilization. As I’ve talked about many times, lack of sleep drives obesity which is highly correlated with many conditions. They also found a notable overlap of the use of Provigil (as stimulant used to treat daytime sleepiness associated with sleep apnea). [Seems like a drug that could get abused by college students like ADHD.]

“While H1N1 caused a spike in antiviral use among children last year, the far more alarming trend since the beginning of the decade is the increasing use of medications taken by children on a regular basis and in some cases, for conditions that we don’t often associate with youth, such as type 2 diabetes,” said Dr. Robert S. Epstein, Medco’s chief medical officer and president of the Medco Research Institute.  “The fact that one-in-three adolescents are being treated for a chronic condition points to the need for additional health education and lifestyle changes that can address the obesity issue that is likely a driving force behind such conditions as type 2 diabetes and even asthma.”

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

Automated Call Nudge – WSJ

May 19, 2010 by George Van Antwerp 0 Comments

Yesterday’s WSJ had an article about some research done at Stanford about comparing automated calls and human interventions.  The goal was to see what motivated people to exercise more.  As you can see in the chart below, at 6-months automated calls produced better results while at 12-months they were below the human interventions.  But, an automated solution is obviously much more cost efficient and scalable.  The one big question I have is how to make the automated calls even more interactive.  There are lots of things we do at Silverlink to use automation to drive behavior.

While many are skeptical, the reality is that automated calls are the best channel in healthcare based on the cost per success ratio.  [Do you know any other channel that can get you a 70% “open” rate?]  You can deliver PHI.  You can track interventions for audit purposes.  You can have real-time access to data.  You can create rules based solutions that dynamically change based on interactions. 

And, this is not the first study Stanford has done on this.  Here’s links to two older studies they did:

Books / Articles, exercise, Healthcare, Marketing / Communications, Research, Silverlink, Technology, Value Propositions

Is Bad Debt In Healthcare Inevitable?

May 17, 2010 by George Van Antwerp 0 Comments

It’s an interesting question since there is quite a lot of bad debt.  I’ve certainly believed the default hypothesis which is that people can’t afford their healthcare out-of-pocket costs, but I know I’ve had several instances where I had delayed payment due to misinformation or provider billing errors that I tried numerous times to get fixed.

McKinsey’s new research suggests that I’m the norm (i.e., most people would AND could pay their bills).

  • 90% if <$500
  • 74% if <$1000
  • 62% if >$1000

Books / Articles, Consumerism, Healthcare, Marketing / Communications

Don’t Believe The Hype – Copay Waivers

May 11, 2010 by George Van Antwerp 0 Comments

Don’t believe the hype – its a sequel
As an equal, can I get this through to you 

I talk about it all the time as most people do…non-adherence to prescription drugs is a real issue.  People don’t fill their initial script.  People who do fill their first script drop off after the first several fills.  By 12-18 months after a patient starts therapy, less than 50% of them are still taking their medications.  Here’s a few key articles on this: 

Common barriers to adherence are under the patient’s control, so that attention to them is a necessary and important step in improving adherence. In responses to a questionnaire, typical reasons cited by patients for not taking their medications included forgetfulness (30 percent), other priorities (16 percent), decision to omit doses (11 percent), lack of information (9 percent), and emotional factors (7 percent); 27 percent of the respondents did not provide a reason for poor adherence to a regimen.  Physicians contribute to patients’ poor adherence by prescribing complex regimens, failing to explain the benefits and side effects of a medication adequately, not giving consideration to the patient’s lifestyle or the cost of the medications, and having poor therapeutic relationships with their patients.  (NEJM article) 

Depending on what study you look at cost is certainly an issue, but it typically isn’t the primary issue.  I typically see cost as being a factor in 5-15% of the cases.  I think if you look at how Merck weighs cost in their Adherence Estimator that it is only a small factor.  A lot of this plays out in VBID (Value Based Insurance Design) which while not purely about copay waivers that certainly is an element of most solutions.  

A few friends of mine formed their own company (CareScientific) and had a paper published in AMCP recently.  From that article: 

  

VBID is receiving attention as a tool to increase medication adherence and lower medical costs. However, applying a “plausibility calculation” method to data generated from a recent VBID study involving reduction of drug copayments, this evaluation found that health plan sponsors are highly unlikely to experience net savings by implementing VBID programs, even under generous assumptions, for 2 reasons. First, the price elasticities of medications are too low to generate meaningful increases in medication adherence when copayments are lowered. Second, the potential reductions in the avoidable hospitalization and ER utilization rates across a commercially insured population with varying risk levels are generally not large enough to offset the additional plan costs of lowering copayments to increase medication adherence. 

I would also suggest looking at some of their tools that they’ve developed. 

So, getting back to how I’m tying in my reference to Public Enemy (rap musicians)… 

When I look at the upside for pharmaceutical manufacturers to grow the pie (get more Rxs through adherence), I often wonder why one of the default solutions is to fund copay waivers.  That happens by employers, health plans, and even the manufacturers.  There are many less expensive ways to get that lift by addressing things like reminders and tailoring information to individuals based on their personalized barriers. 

There are lots of high cost solutions that will make an impact.  The question is how to triage those resources to focus them on the right people.  It’s important to identify adherence risks (pro-active intervention) and adherence gaps (retrospective) and intervene with the patient.  

Here are a few of my other posts on this: 

 

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

Do People Self Diagnose?

May 10, 2010 by George Van Antwerp 0 Comments

I think we all venture a guess on why we feel bad – cold, flu, rash.  And, at least from my perspective, that might lead to an OTC (over-the-counter) medication.  BUT, apparently 30% of people use that self-diagnosis to self-prescribe and borrow medication from friends and family.  That has some more significant risks associated with it and can lead to an incomplete medical record if something happens to you (i.e., a severe side effect). 

According to the recent survey:

  • 3/4th of those that borrowed a medication did it to avoid seeking formal medical care
  • 1/3rd of those who tried to avoid a medical visit (or 1/4th of those that borrowed a medication) ended up at the physician anyways
  • 25% of those that borrowed a medication experienced a side effect (or believed they did)

I think we all know that borrowing medications is wrong.  The only time I would think you might be okay is you were prescribed the identical chemical entity and strength and had a friend that had changed medications and had some extra.  Since the reality is that there is a lot of excess medication out there given all the non-adherence.

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

The Facebook and iPod Generation

May 5, 2010 by George Van Antwerp 1 Comment

When I think of the current generation that is coming into the workforce, I think of people who:

  • Grew up with social media all around and are less concerned about privacy
  • Grew up with the ubiquity of technology having an iPod always on and being in constant communication with their mobile phone
  • Grew up with the US in a constant state of war – 9/11, Iraq, Afghanistan
  • Grew up with the idea of constant stimulus – portable video games, TVs in the car
  • Grew up with periods of market instability – technology bubble, 9/11, housing bubble
  • Grew up with a likelihood of living at home after college [and think that’s ok]
  • Grew up with more global awareness via CNN and the Internet
  • Grew up with allergies and general paranoia – no more leaving home as a kid and coming back when the sun set or eating peanut butter at school


I think the more typical perception of many of them is an overly privileged generation who can’t focus on one thing, expect everything (money, position, title, responsibility) regardless of whether they deserve it, don’t follow basic protocols (like a thank you after an interview), have been coddled their whole life, and have no respect for what others have done.  But I think every generation thinks that of the next generation.

I guess the official definitions are: (see good presentation)

  • Traditionalists – born before 1946
  • Baby Boomers – born btwn 1946 and 1964
  • Generation X – born between 1965 and 1981
  • Millennials – born 1982 to 2000

The Millennials are also called Generation Y, GenNext, the Google Generation, the Echo Boom, or the Tech Generation and are 76M strong. With immigration they are likely to surpass the Baby Boom generation in the 2010 census. [Note – Comments derived from reading an exerpt of The M Factor by Lynne Lancaster and David Stillman in the May 2010 Delta Sky Magazine.]


Their book – The M Factor – is focused on this generation. They talk about the fact that this generation is talking about and searching for “meaning” in their work. They’ve been raised by working parents that struggled with life balance and want more out of work for their kids. They see how work has become so engrained in our lives with Blackberries and other tools.

More than 90% of US Millenials said having opportunities to give back thru their company was somewhat to very important when considering joining an organization.

51% of young workers surveyed as part of the Kelly Global Workforce Index were prepared to accept a lower wage or lesser role if their work contributes to something “more important or meaningful”.

The question that a lot of this drives at is how do you leverage the passion and tech savvy Millenials as part of your workforce. They are going to drive changes. They are going to be innovators. And, they’re not going anywhere. Here’s a good blog on Generation Y.

It reminds me of some mock interviews I did a few years ago at my business school. I was stunned by some of the accomplishments of these people. They had founded companies and businesses. They had volunteered in the community. They were well read and had passion for things that I didn’t care about at their age. I was glad to have made it thru school with my peers. But, on the flipside, I talked with my friends who are the Dean of the School and run the Career Center to point out that not one of those people wrote me a thank you or sent me an e-mail. None of them ever asked me to help them find a job leveraging my network.

The article talks about this Millenial generation growing up at a time when the divorce rate had dropped and parents spent more time with their kids and transformed from authority figures to mentors and friends of their kids. This whole concept of “helicopter parents” has been explored in other areas and still amazes me. [Are you a helicopter parent test.] For example, 11% of US Millenials said they would feel comfortable involving their parents in salary negotiations. [If I had the option legally and a parent showed up with their kid for a salary negotiation, I would rescind the offer. If they can’t do that by themselves, how can I trust them to drive my business in pressure situations?]

In healthcare, the best example I always use for a company focusing on this generation or the “Young Invincibles” is Tonik Health which is a Wellpoint brand. I’m always surprised how few people know them. Take a look at their website (below) – the colors, the words, and the positioning is all so different than how most of us think about our health insurer. Here’s a good blog entry on the “millennial patient“.

Why is this relevant to my healthcare communications blog – because segmentation is so key to effective messaging. You have to understand this generation and how to engage them and drive them to take care of their health. Traditional language, modes, techniques, and messages may not work. The article (from the book) talks about their focus on feedback and scoring. They are used to constant [positive] stroking and having a score to evaluate success. They grew up being rewarded for everything. How does that manifest itself in a wellness system that tracks their good deeds (exercise, diet, preventative actions), provides them with rewards, frames their effort as contributing to the greater good, and integrates technology (e.g., connect devices)?

Only 3% of the people they surveyed said that Millenials handled negative feedback well. They haven’t been allowed to fail. This makes me think about one of my favorite quotes from IDEO – Fail Often To Succeed Sooner. You have to understand how to try, fail, learn, and try again to make improvements.

Here’s some recent research we’d done at Silverlink on the “young invincibles” and “Why I Have Health Insurance”:

Blogroll, Books / Articles, Consumerism, Healthcare, Managed Care, Marketing / Communications, Research, Silverlink, Social Media, Value Propositions

Implications of Frugality as the New Black

May 5, 2010 by George Van Antwerp 0 Comments

I have heard some dialogue about consumers freeing up their spending even without their salaries going up or their house value going up (although their portfolio may have recovered by now).  But, the question is how the frugality that was learned in the past year will impact consumers long-term.  Will it change the way they buy?  Will that be true across generations or will this just have a major impact on certain generations that are just coming of age?

An article released by Booz & Company a few weeks ago has some interesting data in it.  For example, in the chart below, it shows 22% of people spending less on healthcare (drugs, supplies).  What does that imply – pill splitting, more generics, more mail order, lower adherence, less preventative care?  So are they more receptive to cost messages from healthcare entities?

Most of the consumers surveyed said they continue to consider saving more important than spending (65 percent). They sacrifice convenience for price (65 percent), frequently use coupons (65 percent), and, to a lesser extent, prefer the best price to the best brand (55 percent).

Maybe it’s time for the PBMs to emphasize convenience more – simplify your life, use mail order…one less errand to run.  I’m still skeptical that this would beat a traditional cost savings message.  BUT, perhaps it’ time to reconsider coupons / incentives.  They’ve been tried with limited upside over the years in pharmacy.  They do drive up results, but they don’t always pay for themselves.  Maybe a lower value incentive would have the same yield thereby increasing ROI. ???

They identify six segments of the population with this frugality filter:

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

Why Is Pharmacy So Important For Healthcare Communications?

May 2, 2010 by George Van Antwerp 0 Comments

I’ve talked about pieces of this before, but I really believe that pharmacy is the cornerstone of a successful healthcare communication strategy.

Pharmacy is the most used benefit.  On average people have over 12 pharmacy claims per year.  And, if you take out the people that don’t have any, the number rises to around 20 pharmacy claims per year.

That’s 20 opportunities to intervene at a logical event and educate the patient about their condition, talk to them about saving money, stress the importance of adherence, capture feedback from them, drive them to take an action, etc.

Additionally, pharmacy is a very tangible event that consumers can control.  They get to choose (in most cases) their pharmacy – retail, mail, specialty.  They can talk with physicians about the options – generics versus branded.  It’s a space with lots of DTC (direct-to-consumer) information.

I don’t think most of us (even those in the healthcare field) would feel as open to debating one surgery versus another type or talking about the quality differences between one location and another.  The data’s not as accessible and therefore we’re more dependent upon the system to drive us to good decisions.

Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy

Thoughts On Express Scripts 2010 Drug Trend Report

May 1, 2010 by George Van Antwerp 0 Comments

As one of my favorite annual projects during my time at Express Scripts, I love the drug trend report. It has been a historical benchmarking tool for the industry and become a normal deliverable for many of the PBMs. Here are my initial thoughts after reading this year’s document which looks at 2009 data.

Individuals often are not rational.

  • As driven by their Consumerology initiative over the past few years, Express Scripts has shifted the dialogue around the B2C components of the PBM industry to one of behavior change versus simply plan design. This report continues to reinforce that messaging.
  • Waste has been an ongoing drum beat since my days there. This continues to be the message with a shift to include non-adherence to channel mix and drug mix.
  • They talk about the Healthy People 2010 initiative and that key to closing “the last mile” in achieving our objectives is the ability to influence behavior.
  • One of my favorite charts is below showing the waste by class. Not surprising, plan sponsors should focus on heart disease, depression, high cholesterol, and ulcer disease. [Diabetes is not in the top four but is one of the typical areas of focus.]
  • Key Performance Indicators (KPIs):
    • Overall drug trend – 6.4%
    • Specialty drug trend – 19.5%
    • Traditional (non-specialty) drug trend – 4.8%
    • $800.23 PMPY average drug spend
  • The top five classes are:
  • Specialty drug spend is up to $111.10 (processed under the prescription benefit) with a belief that this is only 50% of the total spend which includes specialty drugs processed under the medical benefit.
  • The top specialty classes include inflammatory conditions, MS, and cancer which represent 67% of total specialty spend.
  • I was surprised to see the member contribution to the drug costs had gone down while the actual dollars had stayed flat.
  • I was also surprised that they found adherence (as measured using Medication Possession Ratio) stayed flat from 2008-2009. I think most of the information available had implied thru survey data that it was going down with the recession.
  • I’m having some difficulty reconciling the MPR analysis below with the waste argument. If 80% MPR is ideal and most classes are above 80% MPR, I’m not sure I see the crisis in the data.
  • One of the key charts that I always copied and hung on my wall is the one below. It shows the classes by rank, the utilization, the average cost, and now the estimated behavioral waste (generics and mail).
  • You should certainly go into the document and look at the class level detail. They’ve included a utilization chart by gender by age which I really like. The sections also give some insight into future pipeline. I think I’ll pull diabetes out into a separate post.
  • It’s interesting that they identify only three segments for non-adherent patients with specialty medications versus more on the traditional side:
    • Active Decliner
    • Refill Procrastinator
    • Sporadic Forgetter
  • They project that utilization will continue to go up at about 3% per year and that trend will be mitigated with new generics coming to market.
  • Another interesting analysis is where the waste is by state:
  • They have some information on their Consumerology approach, but I’ve talked about that before.
  • I liked their simple plan design primer:
  • Towards the end, they talk about some of the changes they’ve made over the past few years to their programs to reflect their consumerism approach:
    • Step Therapy Choice
    • Formulary Rapid Response
    • Call4Generics
    • Select Home Delivery (which is gem of their new programs in my assessment)
    • First Generic Fill Free
    • Select Curascript
  • A simple graphic that points to the importance of understanding the consumer and developing programs to effectively drive behavior is below. [This is very similar to all the work we do at Silverlink with clients to help them drive health outcomes and behavior.]

I like it. Very humanized versus purely statistical document. Good job Emily, Steve, Yakov, Andy, Bob, Brian, and Chris. (That’s the core group that I know well.)

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

How Does Adherence Fall Off?

April 29, 2010 by George Van Antwerp 0 Comments

This is a nice simple graphic from a new Medco document that’s out – Case For Smarter Medicine.  We all know adherence is an issue especially in the first 3 months (for those that ever fill even their drugs one time), but this gives us a good picture of how it drops off over the first 12 months. 

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

The Best Healthcare Conference

April 28, 2010 by George Van Antwerp 1 Comment

In today’s budget conscious economy, people are constantly evaluating where to spend their time and money from a conference perspective.  Some conferences are good networking events.  Some of requirements to work in an industry.  Some are educational.  Some give you new ideas on how to run your business.  Some are in great fun locations with fun events.  Very few fit all of those.

I think our Silverlink Communications client event called RESULTS2010 does all of those.  [Hint – the conference is called RESULTS since that’s what we focus on with our customers.]  It takes on all the key issues we see in the market.  It brings in industry experts and clients to talk about what they are doing to address these issues.  Those problems are framed out by our industry experts that have line experience with these roles.  [Our leadership team comes from places such as Express Scripts, CVS Caremark, Gorman, and HCSC and our team includes people from McKesson, Humana, United Healthcare, IMS, DigitasHealth, Medco, and WebMD.  I challenge anyone to find a more knowledgeable vendor team.]  It gives people a chance to network and talk to their peers.  And, there’s some fun mixed in there.

This year’s event is focused on THE HEALTH CONSUMER.  I’m pretty sure it’s the only conference focused on communicating with consumers in healthcare.  The objective is to provide clients with ideas about how to educate, support, and motivate consumers to take actions which support health outcomes. 

Honestly, it was the original event that convinced me to come to Silverlink.  I was a consultant at my first event working with the company.  I met 75 users who were passionate about the company and had great first hand experience using the technology to make a difference in their companies.  I was able to ask them about the competition and understand why they choose Silverlink for their member communication partner.

So, what does this year’s event have in store:

  1. An amazing list of external speakers including Mark McClellan, David Wennberg, Don Kemper, Jack Mahoney, and Janice Young.
  2. A long list of client case studies – 14 so far.
  3. Specific tracks to cover our different client groups and allow for smaller discussion versus formal presentations – Pharmacy, Population Health, Medicare, and Managed Care.
  4. Industy experts on key topics such as consumer engagement, use of data in healthcare, consumer data, behavior change models and incentives, pharmacy economics, pharmacogenomics, medicare market dynamics, and the evolving retail healthcare model.
  5. Adherence experts such as Dr. Will Shrank from Harvard and Valerie Fleishman who led the NEHI adherence study that is widely quoted.
  6. Several fun events including golf, morning runs, and a few special sports related surprises.

There are several more speakers who you would know and I’m very excited to have come and speak…BUT, I want to leave something inside the package for you to want to rip it open and learn more.

How much does it cost?  Nothing (as long as you’re a Silverlink client).

Where is it?  Boston (a great city).

How do I learn more?  Well…if you work for a large managed care company, a population health company, or a pharmacy / PBM, you may already be a client.  We have over 80 clients today.  So, if you’re not on our invite list, think you might be a client, and want to learn more, let me know.  I’m at gvanantwerp at silverlink dot com.  [spelling it out avoids spam]

This year’s event is in late May so I hope to see many of you there!

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

HealthEngagement Barometer 2010

April 20, 2010 by George Van Antwerp 0 Comments

Edelman recently published the results of a survey of over 15,000 people across 11 countries.

The study is interesting in terms of people’s opinions. Here’s a few highlights.

  • More than 50% of people believe businesses are doing a poor job of engaging in health.
  • 73% say it’s as important to protect the public’s health as it is to protect the environment.
  • 61% believe they need to do a better job of taking charge of their own and their family’s health.
  • Only the UK reads and shares less information than the US. 41% of people read health information weekly and 33% share health information weekly.

So, what do people mean by how businesses should engage?

One of the things that interested me was the slide about what motivates people to get active in their health.

While 58% of people use some form of digital media to research health, the majority use Google or some search engine. 34% of them (globally) use health company websites. [If this were limited to health plan or PBM websites in the US, that would seem high.]

I wasn’t surprised that fighting cancer was the most important issue, but I was surprised that privacy of information was the least important.

Books / Articles, Healthcare, Marketing / Communications, Research, Social Media

Express Scripts Drug Trend Report 2010

April 20, 2010 by George Van Antwerp 0 Comments

I knew the new report must be out when I had about 40 hits this morning on my blog based on Google searches for it.  Here’s the banner showing some segmentation.  I haven’t had the chance to read it and comment, but I will in the next 2 weeks.  You can search my blog to see my comments on all the PBM drug trend reports from the past few years.

[added later…my comments are now posted here.]

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

The Adherence Estimator by Merck

April 19, 2010 by George Van Antwerp 0 Comments

Merck did research that was published last year showing that their 3-question Adherence Estimator (TM) was 86% accurate in identifying patients at risk for nonadherence.  Pretty impressive. 

A copy of the questions are below and were on the Tuft’s website which also shows the scoring mechanism.  This is something patients can take to determine their risk or plans, PBMs, pharmacies, MDs, disease management companies, or others could use. 

Books / Articles, Consumerism, Healthcare, Innovation, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Research

Ingrid Lindberg, Chief Experience Officer, Cigna

April 15, 2010 by George Van Antwerp 3 Comments

This was definitely my favorite and most interesting presentation and discussion from the World Health Care Congress in DC.  Ingrid presented and subsequently spent some time talking with me.  She has what I would consider one of the coolest jobs – transforming a large company to be consumer centric and radically changing the way they think, speak, and act. 

From her presentation, here were a few notes:

  • There are 337 languages spoken in the US today. (health literacy issue?)
  • Only 23% of people understand what their health insurance policy means.
  • Most patients appear to be unaware of their lack of understanding in physician instructions and are inappropriately confident.
  • 35% of consumers spend less than 30 minutes reading their health benefit information.
  • Only 7% of people trust their insurer.
  • Trust translates to loyalty and satisfaction.
  • It’s a mix of quantitative and qualitative research.
  • They spent time monitoring sites like – www.pissedconsumer.com.  (do you?)
  • Their senior staff has to spend time listening to member calls each week.
  • They spent lots of time on ethographic research and identified 6 personas that they use for defining products – Busy Mom, Skeptic, CareGiver, Controller, Athlete, and Bargain Shopper.
  • They identified the #1 dissatisfier was language.  Plans talk to them in a language they don’t understand.  (For example, consumers think of providers as the insurer not a physician.)
  • Consumers didn’t want to be called members since it’s not a health club.  They didn’t want anyone other than their physician to call them patient.  They’ve elected to go with “customer”.
  • She talked a lot about how they’ve changed their EOB (explanation of benefits) and their plan overview to address things like what’s not covered.  She talked about how customers think of the EOB as the “this is not a bill form”.
  • They identified 10,000 separate letters that could go out to a customer.  They’ve re-written 9,000 of them. 
  • She talked about changing their call centers to 24/7 and the fact that they’ve now taken their 1M call in what used to be considered “after hours”.
  • She talked about re-designing their IVR to offer you a self-service option (press 1) or a talk to agent option.
  • She talked about their website and YouTube channel – www.ItsTimeToFeelBetter.com.
  • She talked about their understanding level being around 70% while the industry average is around 15% [of communications sent out].
  • This was in a 15 minute presentation and summarized only 2 years of work. 
  • She also shared some metrics that they use and improvements such as a 8 point improvement in one year of “values me as a customer”. 

And, they’ve shared some of this information in their press kit.  There is also an IBM white paper about some of the technology they’ve implemented.

I think the following slide from her deck sums it up well.

Then I sat down with Ingrid to talk with her.  I had a thousand questions which I limited to about 10.  This is a topic I love and is why I love what I do – work with companies to help them develop consumer communication strategies and implement those strategies to improve the consumer experience and drive better health outcomes. 

  1. How long did it take?  This is about a 3-5 year effort which is complicated by the fact that people in these types of roles typically only last about 28 months.
  2. Did you do it all internally?  No.  They worked with Peppers & Rogers on a Touchpoint Map and used an IBM tool called Moment of Truth.  They also worked with IBM on a new desktop solution.  BUT, she was quick to talk about the fact that those were enablers while the majority of work had to be done by internal change agents since this is a cultural change.  She said that now almost 80% of Cigna people are using their recommended language and are aware of the changes made by her group.
  3. Why haven’t others followed?  It’s hard work. 
  4. How do you deal with consumer preferences?  This is one of my favorite topics to debate.  Should you offer consumers options on how you communicate even if you know that they might not pick one that is the most effective.  For example, I might say to send me an e-mail, but they get lost, they can’t contain PHI, etc.  She said that you have to ask but you have to navigate the path.  She seemed to agree with me that there are some communications where you want to ask (e.g., order status at mail) and others where you want the right to contact them (e.g., drug-drug interaction).  She talked about the fact that it’s all in the framing (e.g., if we have a message for you that could affect your safety, is it okay if we ignore your do not call request?).
  5. Are you changing Cigna’s physician communications also?  Yes.  The changes have become the “language of Cigna”.  Physicians are people, and they are also trying to educate physicians on what they’ve learned about how to communicate with customers.  She mentioned that the most difficult groups to change were the people that were knee deep in this healthcare language – internal people and consultants. 
  6. Based on my discussion with Andy Webber, I asked her if she thought that today’s fragmented environment would allow for a coordinated consumer experience.  She agreed that it’s difficult and that the consumer sees everything as their benefit.  They don’t see the piecemeal parts.  She mentioned that one of their clients had held a “vendor fair” to kickoff the plan year where she presented their learnings and all the vendors were told to use them immediately.  [Maybe that’s part of the solution.]

We then bounced around on a couple of interesting topics:

  • We talked about the fact that lots of companies are hiring non-healthcare people to help them better understand the consumer.  These include consultants, database people, marketing people, and innovators.  My personal opinion is that you need people that have worked in or around healthcare AND outside healthcare.  They also need to have consulting and line management experience.
  • She talked about their war room (she used another term) where they had a current state and future state (of patient experience) and showed all the 10,000 current communications as a waterfall. 
  • We talked a little about some of the things we’d done at Express Scripts when I was there including changing the way we referred to members at the call center to patients and the impact that had. 
  • I shared with her that our biggest difficulty was making web changes at Express Scripts which I thought would be the easiest to do.  She shared that changes on the web were one area where they were lagging and is difficult. 
  • She talked about trying to get innovation from customers by understanding what they want and giving it to them.
Consumerism, Events, Healthcare, Innovation, Leadership, Managed Care, Marketing / Communications, Methodology, Research, Silverlink, Value Propositions

BOB vs. ERP Concept For Patient Experience

April 13, 2010 by George Van Antwerp 0 Comments

I had a quick dialogue with Andrew Webber (President and CEO of the National Business Coalition on Health) earlier today at the WHCC (see #whcc10 twitter feed).  I wanted to talk with him about how we create a unified consumer experience in today’s healthcare environment. 

Today, a consumer gets messages from their employer, their physician, their pharmacy, their PBM, their managed care company, their hospital, their disease management company, healthcare sites such as WebMD, and probably several other places.  Very little of that is coordinated, and it’s certainly not always consistent in messaging and direction.

Mr. Webber explained that the employers need a “supply chain management” solution to share data across vendors and develop a consistent message.  We talked about how the Accountable Care Organization (ACO) concept will try to get us back to some type of solution where there is a primary “owner” of the relationship and that this would be with the trusted key in the solution – the MD. 

We talked about the fact that the employers have created this system which pushed the BOB (best-of-breed) over a consolidated, centralized solution.  And, we discussed the fact that employers continue to love these “boutique solutions” that develop niche plays (think Health 2.0 companies) which address an acute need.  They create great case studies but are often difficult to scale.

It made me think of some old IT models I worked on where clients had to decided whether to pick an ERP system like SAP or go with the best-of-breed and manage the infrastructure to connect them.  I think the current employer based system even went a step past this.  In the IT world, the company had to manage a connected infrastructure (think enterprise data warehouse and service oriented architecture).  BUT, in healthcare (or benefits), that infrastructure doesn’t exist.  Each entity owns their piece of it completely with limited interaction and connectivity.

This was the first time where I could see the point of a “employee centric model” versus an “employer centric model”.  I’m not sure I believe it could effectively be done, but it reminded me of a company that was trying to create a web-application that was a type of next generation PHR (personal health record) where the member could consolidate communications, designate preferences, and would adapt general (vanilla) communications to the consumer based on behavior, preferences, demographics, etc.

Consumerism, Healthcare, Innovation, Marketing / Communications, Technology
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