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REMS: A Few Learnings

June 30, 2011 by George Van Antwerp 0 Comments

I just finished reading Assessing the Impact of Risk Evaluation and Mitigation Strategies (REMS) Requirements on the Pharmaceutical Supply Chain by the Center For Healthcare Supply Chain Research. 

If you don’t know what REMS is, here is the FDA page on REMS.  Essentially, they are programs that the manufacturer is required to provide to mitigate risks associated with certain drugs. 

This study does a good job of describing the REMS landscape and sharing some challenges and opportunities.  As someone who was less familiar with this than many of you in the industry, I found it a good foundational piece which got my mind thinking. 

Overall REMS can be required to include five distinct elements:

  1. A medication guide
  2. A communication plan to healthcare professionals
  3. An ETASU (Elements to Assure Safe Use)
  4. An implementation system
  5. A timetable for submission of assessments of the REMS (required in all cases)

“As part of the REMS submission to the FDA, a manufacturer also must show that the strategy elements will not unduly burden patient access (particularly where patients have life-threatening diseases or difficult access to healthcare providers of the drug).”

Definitely, that access issue is key.  These programs add time and hurdles which need to be seamlessly worked into the workflow for physicians and pharmacies and show improvement in outcomes or reduction in risk.  And, ideally that should happen with cost in mind. 

Given the infrequency that some generalists might have with some specialty products, this can create communication and compliance challenges.

For distributors, this creates both a burden but also a financial upside as they charge to manage and implement the REMS.  On the flipside, for physicians, this creates extra effort which isn’t reimbursed.  As the study broke out different perspectives from constituents in the process, this along with several others from providers caught my attention:

  • Do the REMS requirements hold the physician liable for safety?
  • Will the perception of risk impact the likelihood of the patient starting or continuing on therapy?

Certainly from a communications perspective, REMS have led to the buildout of “hubs” that provide services around these drugs in the areas of data management, patient counseling, call center, registry, and content management. 

The study estimates the economic impact of these programs on both the distributor and the provider (physician, nurse, and pharmacy).  For example, they estimate that a pharmacist at a specialty pharmacy spends 100-165 minutes per patient per month for those on drugs with a REMS requirement. 

They pose a question towards the end around generics and biologics which gets at the heart of the cost / benefit tradeoff for bringing a product to market which requires a REMS when part of your value proposition is a lower cost. 

Anyways, for those of you interested in the topic, it’s a good read. 

 

Books / Articles, Healthcare, Methodology, PBM / Pharmacy, Research, Value Propositions

Enchantment Infographics (by Guy Kawasaki)

June 28, 2011 by George Van Antwerp 0 Comments

I’ve had the privilege to hear Guy Kawasaki speak and have read a lot of the stuff he’s written over the years.  I haven’t read the new book Enchantment, but these infographics might get me to go out and do that.

I’d love to think about similar graphics which blend his work and the work of David Shore on trust in healthcare…how to you engage and build trust as a healthcare entity!

Books / Articles, Business Tools, General Thoughts, Leadership, Marketing / Communications, Methodology

Is The PBM A Fiduciary? I Don’t Think So.

June 20, 2011 by George Van Antwerp 2 Comments

I’m not a lawyer, but with the potential repealing of the Maine law regarding PBMs, it’s time to think about this question.

Here’s a definition from USLegal.com:

A fiduciary duty is an obligation to act in the best interest of another party. For instance, a corporation’s board member has a fiduciary duty to the shareholders, a trustee has a fiduciary duty to the trust’s beneficiaries, and an attorney has a fiduciary duty to a client.

A fiduciary obligation exists whenever the relationship with the client involves a special trust, confidence, and reliance on the fiduciary to exercise his discretion or expertise in acting for the client. The fiduciary must knowingly accept that trust and confidence to exercise his expertise and discretion to act on the client’s behalf.

Just looking at this definition, it raises a few eyebrows:

  1. Can the PBM be responsible to its shareholders and to the clients?
  2. Does the PBM act on behalf of the client?

The fiduciary relationship basically makes the PBM into a cost-plus model where profits and costs are know. There are already lots of transparency standards for clients to leverage in designing their PBM contracts.

I struggle to see a comparable fiduciary business relationship out there. Suggestions?

On the second point, the whole PBM model around benefit design and interventions has been set up as consultative where the PBM provides ideas and models for the payer to select from. They don’t get to chose what’s best for them. I’m not sure that the lobbyists for the original plan would want this. If I’m a PBM with a mail order pharmacy, I believe that this is the best model to save money, drive adherence, and avoid errors. So, as a fiduciary, wouldn’t I have to put in a mandatory mail program with mandatory generics lots of utilization management programs and a closed formulary? That’s what’s best financially in most (all cases).

I’m all in favor of disclosure of conflicts of interest. PBMs should explain how they make money to their clients so it’s clearly understood.

In this older post on another blog, a physician talks about physicians having some fiduciary responsibility, but I don’t think this goes far enough. If the physician has a fiduciary responsibility to the patient, wouldn’t they have to disclose their profit based on different choices:

  • If you choose this medication and fill it from my in-office dispensing, I make $X versus you choosing this other drug.
  • If you get this procedure done, I get a referral from my colleague plus I make $X on performing the surgery.

Of course, maybe the issue is that Maine (and others) have tried to use fiduciary to focus on the financial controls around the PBM business model instead of the business practices about helping payers understand their decisions (the legal breakdown on MDs seems more business focused):

  • This will affect X% of the population.
  • This will save you $X compared to your other options over here.
  • This will be a win-win for us because we make money as your GFR goes up.
  • We charge manufacturers an administrative fee for managing the rebate contracts and will keep that.

When the DC regulation around PBM fiduciary responsibility went to court, it was struck down. Will Maine finally end up in the same bucket? Will others follow?

I guess the question for people to ask is what has happened to Maine’s pharmacy costs in the past few years. Has there been an advantage (or disadvantage) to this law?

Books / Articles, Healthcare, Methodology, PBM / Pharmacy, Politics, Value Propositions

Less Likely To Take Your Statin After Surgery

June 7, 2011 by George Van Antwerp 0 Comments

A recent study looked at people who were hospitalized for heart disease. It then tracked people’s use of statin medications (e.g., Lipitor) for the next year and looked at their adherence based on whether they had surgery or were simply discharged with a prescription.

SURPRISE – 70% of people who had surgery stayed on their statins for a year while 79% of those who didn’t have surgery stayed adherent. (thanks to Box Cutters for sharing this)

This begs a whole lot of questions:

  • How did they get the people to be so adherent in the first place? (this seems higher than the national statistics)
  • Did the surgery patients feel like they were “cured”? (see post on similar issue)
  • Was the statistical difference true at a location or prescriber level also? (i.e., was it simply that some locations or prescribers always wrote a script and talked about adherence or was it really a patient difference?)
  • Were the patients who had surgery sicker to begin with and therefore on more medications (which would reduce their likelihood of being adherent)?

On the other hand, this is perhaps another warning flag on the whole hospital readmissions issue where we have to address issues of health literacy, follow-up, discharge process, support network, and medication reconciliation.

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

The Customer Experience Matters Healthcare Nuggets

June 2, 2011 by George Van Antwerp 1 Comment

Are you focused on the customer experience?  If yes, then you should know who Bruce Temkin is and look at his research.

I follow his research mostly through his blog, and you can find teasers of information on healthcare by what he posts.  I thought I’d pull together a few of those things here:

1. In his loyalty ratings, Walgreens was one of the top 20 companies recommended to friends while Cigna, Aetna, Humana, Anthem, and BS of CA were all in the bottom 20.  [I’m not sure this should surprise us.  I would expect CVS was close to the top with Walgreens.  I’d assume many people don’t “recommend” their insurance companies in general.  I’ll have to try to find out if the PBMs appear on here.]

2. In his forgiveness rankings, retailers like CVS, Walgreens, Walmart, and RiteAid scored well.  TriCare scored very well.  Medicare and Medicaid had good scores, and Kaiser was the only health plan in the top 70.  [This is a key issue for retention and important in the retailization of healthcare…you will make mistakes so the question is how much good will you have to overcome those mistakes.]

3. In his loyalty rankings, you find out that African Americans are much more loyal to their health plans than Hispanics or Caucasians.  [How does this change your engagement strategy?]

4. Bruce even goes on to quantify the value for different industries.  For healthcare, he estimates that a $1B company could improve it’s topline by $179M / year by improving its customer experience.

5. In his experience ratings, he shares some specifics on health plans (see below):

And, I suggest you read some of his thoughts on changing how we analyze data.  I think his points about “contextual insights” make a lot of sense.

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

Pharmacy Reimbursement Needs To Be Re-Aligned With Effort

May 28, 2011 by George Van Antwerp 0 Comments

I know this is not a popular topic, but I really believe that reimbursement on a per Rx basis in misaligned.  Today, a pharmacy (retail, mail, specialty) is paid based on either a discount off a standard price (e.g., AWP) or based on a MAC (maximum allowable cost) list.  They may also receive a dispensing fee.  According to the latest PBMI Benefit Design Report, those dispensing fees are:

  • $1.62 retail
  • $2.33 mail (noting that only 21% of their surveyed employers pay dispensing fees at mail)
  • $3.26 specialty

And, the reimbursement rate is the same whether it’s a new Rx or a refill.  Does anyone out there believe that the amount of effort to fill a new Rx and a refill is the same?  Why not pay differently?

An industry number that has held up anecdotally when I’ve talked to lots of people is that 40% of new Rxs require some type of work to become a “clean Rx”.  That might mean that they are subject to a utilization management program (step therapy, prior authorization, quantity level limit).  It might mean that there is a DUR issue such as a drug / drug interaction which has to be addressed.  It might mean that the drug isn’t covered.  It might mean that the cost is too much based on formulary tier.

Additionally, the first few times a patient fills a drug is when they have questions.  When do I take the drug?  Are there any side effects?  Should I avoid any foods?  Should I eat with my meal?  Are there alternatives?

Once the patient has titrated to the right strength and is taking their medication on a regular basis, the job is pretty much to count the pills and get them to the patient in a timely manner.  It has been my argument for a while that if we could fix this reimbursement misalignment then you would see a better coordination between retail and mail order.

The right model in my mind shifts reimbursement dollars through dispensing fees or some other payment structure to compensate for these cognitive services on the initial fill and acknowledge where the effort is.  I believe this would allow for a “mail at retail” type model of central fill or a kiosk model at the store or encourage retailers to better support mail order efforts when appropriate.

Everyone is aligned (at some level) with getting patients to:

  1. Start on the appropriate medication
  2. Understand their medication and their condition
  3. Make appropriate choices that lower overall costs to the payers
  4. Stay on their medications
With that said, it seems like there is an opportunity here.  It won’t be easy, and I don’t hear anyone talking about it…but I’ll continue on my soapbox for now.
Healthcare, Leadership, Methodology, PBM / Pharmacy, Research

Highlights From The CVS Caremark Insights Report 2011

May 26, 2011 by George Van Antwerp 0 Comments

CVS Caremark has been on a roll lately releasing lots of research especially in the adherence area. They just released another study this week that said:

In a study published online this week in the Journal of the American Pharmacists Association (JAPhA) the researchers said,”Approximately one-half of caregivers reported they are more likely to forgo their own medications than the medication needs of their caregivees, especially if cost was a problem, and that caring for their family members was more important than caring for themselves.” The researchers added, “Our findings indicate care-giving status may be an important characteristic for providers to identify and that caregivers may represent a fertile target for adherence interventions to improve chronic disease management and prevent chronic disease.”

But, today, I want to focus on their drug trend report called Insights which was released a few weeks ago. The report begins with a focus on change pointing out a few facts which will change our healthcare experience. Here’s part of the introductory letter by Per Lofberg, the President of Caremark Pharmacy Services.

We all know change is a constant, in this industry and in life, but the change we face over the next several years is monumental and unprecedented. The sweeping nature of the health care reform legislation makes it difficult, as even the government admits, to predict how the system and its stakeholders will respond. Regardless of how much is unknown and “still to be determined” about reform, all of us continue to face the urgent, ongoing need to reduce health care spending and simultaneously improve health outcomes.

They take a different approach than Express Scripts (see review of this year’s drug trend report) and Medco in their drug trend reports which are more encyclopedic in their breakdown of class by class. CVS Caremark poses questions by group and then presents data to address those questions.  They focus on health reform and overall changes to the market dynamic.  [Both Adam Fein and I review most/all of these reports every year so I’d encourage you to look at both of our blogs if you want historical facts or comments about comparing the drug trend reports.]

  • Employer: Benefit costs are hurting our profitability. Something’s got to change.
    • Only 6% of employers believe their company will be better off as a result of healthcare reform.
  • Health Plan: How do I compete, comply, and control costs in this new world?
    • 120M members will be seeking or changing coverage between 2012-2016.
  • Physician: My practice is already stretched to the limit.
    • The US will have about 159,000 fewer doctors than it needs by 2025.
  • Consumer: Where do we go from here?
    • In 2010, 1 in 4 households reported having trouble paying medical bills.

Key Statistics:

  • Overall trend = 2.4%
  • Non-specialty trend = 0.8%
  • GDR for 2010 was 71.5%
  • Specialty trend = 13.7%

Specialty now makes up 14.2% of their BOB (book of business) overall spending…[something that some people are predicting will be close to 40% in under 5 years].

I really like how they breakout the charts by type of client (employer, health plan, and TPAs) since they have different approaches to trend management. Here’s the health plan one:

They talk about some of the future trend influencers:

  1. Economy
  2. Aging population
  3. Chronic condition prevalence
  4. Changing condition guidelines
  5. Health care reform
  6. Adherence
  7. Generic launches
  8. Specialty growth
  9. Brand price increases
  10. Less predictable events – weather, flu impact

Like others…they are saying that GDRs (generic dispensing rates) of 80% are now possible by 2012! Talk about a change in the past decade and why there is so much pressure on the manufacturers.

They mention it in the publication, but they’ve also issued some press about their effort to target the specialty spend that happens under the medical benefit. They estimate that 80% of the drug spend in the medical benefit is from specialty drugs with cancer representing 46% and three other categories representing more than 2%:

  • Anemia and neutropenia
  • Osteoarthritis and RA
  • Immune disorders

Given their broad footprint, they pose an answer rather than a question from the next constituent – the pharmacist:

I know I can make a real difference for people.

One of the big areas of focus for leveraging that F2F relationship is adherence:

They provide an updated statistic on average Rxs PMPY of 12.6.

One of their big studies from the year was the one that was published around savings related to adherence:

I’ll end with a statement they highlight at the end:

“Every member interaction is an opportunity to improve outcomes for the plan and the member.”

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

Pharmacy Kickoff At #RESULTS2011

May 24, 2011 by George Van Antwerp 0 Comments

I’m currently presenting at our client event (see twitter hashtag #results2011 for real-time comments). My presentation is an extension of my white paper on the future of the PBM / pharmacy industry along with a blend of data from our annual client survey and Silverlink Communications best practices with a focus on our work around medication adherence. It also builds on my thoughts from NCPDP that I shared late last year.

Here are a few of the points I touch on:

  • Avoiding being commoditized by adding value
  • Keys to success with a focus on:
    • Evidence-based approaches
    • Consumer engagement
    • Patient experience
    • Cross-channel coordination
  • Adherence and other priorities
  • How to use SMS to drive self-service
  • An approach to condition management in hypertension and diabetes
  • Focus on the “un-engaged” but don’t forget about the engaged consumers
  • Case studies and research around adherence
  • Timing and sequencing of direct mail, automated calls, and e-mail
  • Measuring “trust”

Here’s a teaser of some of the slides I’m presenting:

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

Walmart: Good or Bad for the PBMs

May 23, 2011 by George Van Antwerp 4 Comments

I think this is a question many of my PBM friends would like to know. Fortunately, a few of the Walmart people that read my blog and are part of their Health and Wellness group agreed to sit down and talk about their strategy.

Let’s start with setting some background:

  • Walmart was the first to introduce the concept of $4 generics which originally caught the market off guard and has created lower generic costs and free antibiotic programs at several pharmacies. [I would also argue that it highlighted the fact that generic copays were getting too high.]
  • Walmart was the first to work directly as a pharmacy to create a limited network contract direct with an employer (Caterpillar).
  • Walmart has partnered with Humana on a limited network offering for Medicare.
  • Walmart came out with a direct to consumer mail order pharmacy offering.

If you follow the industry, you know that all of these things were potential game changers (if they’ve worked).

This creates some tension:

  • Is Walmart simply a catalyst for change in the healthcare space?
  • Does Walmart (pharmacy) want to disintermediate the PBM?
  • Is Walmart able to make money where others can’t?
  • Does Walmart get more foot traffic such that pharmacy can be a loss leader?

Here is the Q&A [interpretive not literal] from my dialogue with Marcus Osborne (Sr. Director, Business Development, Healthcare, Walmart) and Tom Hill (Director, Health Services Development, Walmart).

What is Walmart’s Health & Wellness strategy?
Walmart wants to help consumers “save money and live better”. That is our DNA and our fundamental approach to the market. Pharmacy has presented a unique challenge since consumers often have the same copay regardless of which pharmacy they went to. Even when it’s a percentage copay, the savings differential might not be much to the consumer. Walmart was disconnected from the consumer in the traditional pharmacy pricing approach. That has driven us to look at unique ways that we can create savings.

How does Walmart decide what “offerings” to bring to market?
Walmart looks at ideas that focus on our EDLP (Everyday Low Price) concept and leverage our supply chain efficiencies. We are constantly looking at non-store operational opportunities to work directly with key companies. We currently have over 20 direct relationships with managed care companies and PBMs where we are working with them to drive down consumer costs in the pharmacy and broader healthcare area.

Obviously healthcare is bigger than pharmacy. What other things are you doing to drive healthy eating, management of critical conditions, or other programs? We’re constantly looking at what’s needed in the healthcare sector and where to invest. We focus on our two key advantages:

  • Willing to trade profit for volume
  • Value of the total “box” [store]

A good example is the work we’ve done around “Healthy Mom Healthy Baby” in Medicaid. We looked at the issues of high pre-term labor and the high rates of injury post-birth. We felt like we had a moral and cost imperative to take action. As part of this, we worked with several managed care groups to redefine the entire process and look at our unique assets. Our solution includes:

  • Free pregnancy tests
  • Free pre-natal vitamins
  • Rewards for free diapers and other supplies tied to physician visits and other health activities
  • Free car seats
  • Leveraging our physicians and clinics

[I was impressed…this was a broad solution that looked at a lot of their assets.] We’ve also created several diabetic specific solutions; a smoking cessation program with Healthways; weight management programs; and women’s and men’s health programs. The focus is on payers that are at risk for their healthcare spending with more to come from clinics.

Will Walmart become a PBM?
No. We’re not looking to go into the PBM market. We’re supply chain experts. We see value in the PBM model. [We talked a little about the fact that “you are what your profits say you are” meaning that the PBMs have painted themselves into a profit corner where their profit comes from generics at mail order so any threat to that is a challenge.]

If the Caterpillar model was so successful, why haven’t others adopted it?
The reality is that over 400 employers have contracted directly with Walmart for a limited network model similar to Caterpillar. They are all seeing significant savings.

Does Walmart see the market through “different glasses” than others?
No. We still want to have the pharmacy be a profit center. We’re not looking to bottom out the market, but we are willing to trade lower profits per transaction in return for more market share. At Walmart, it’s not about maximizing revenue/Rx or profit/Rx…it’s about total revenue and total profitability. [A very different strategy than other CFOs which would say you can’t expect volume to make up for lower profitability.] Obviously, we also have the opportunity to get non-pharmacy sales associated with food traffic. One thing that may be is different is the fact that we believe scale should drive down costs. In pharmacy, the biggest players are always trying to command a premium. We think it should be the other way around. We also have been able to get our cost-to-fill to be the same at retail and mail so we’ve become channel ambivalent.

Have these programs improved market share in any significant ways? You have to look at the programs separately, but overall we’ve seen our market share increase from 6% overall [when the $4 generic program launched] to 10% now. The network design strategy has had great success. We look at three types of programs:

  • Incentive based networks
    (Caterpillar 1.0) where all the pharmacies are in the network, but there is a lower copay to go to certain pharmacies. If only 15% of pharmacies are preferred, their market share doubles. If Walmart is the only preferred pharmacy, their market share goes up 4x.
  • Limited networks where some pharmacies are removed from the network. If you drop the network significantly, they’ve seen their share go up 2-3x.
  • Limited networks with preferred pharmacies where you some pharmacies are removed from the network, but within the remaining pharmacies, there are still incentives to go to certain stores (Caterpillar 2.0). In these cases, they’ve seen their share go up 10x.

The $4 generics program has helped increase market share by an estimated 150 basis points. In many cases, companies that initially jumped to offer similar programs have dropped them. They couldn’t sustain them.

The Medicare program with Humana has been very significant and successful [as demonstrated by Humana’s huge jump in Medicare lives].

The direct-to-consumer (DTC) programs for mail have been pretty limited and haven’t had a huge impact, but they’ve been offered in markets where we have no stores (e.g., Detroit and NY) and therefore almost no share to begin with so any share is a gain.

People complain about the pharmacy location within the store. Would you ever consider a direct access point to the pharmacy which didn’t involve going through the entire store? This is a very hot topic. We did a lot of research about store design and what goods should be located next to each other, but in the end, we’re considering moving the pharmacy closer to the front entrance. Right now, 25% of the stores have a drive-through pharmacy which gets utilized at a very high rate. But, this does lose the pharmacist face-to-face benefit. [At the end of the conversation, my take is that they are looking at lots of scenarios here and trying to figure out the balance of convenience to the pharmacy only consumer and how to optimize the entire footprint.]

The partnership with Humana really seemed to help them grow their Medicare lives this year. How did this come about? We both were looking for new solutions to leverage the fact that scale matters and how to operate within the CMS parameters. We felt like there was an opportunity to do something different and began speaking with plans about some limited network ideas. We know that Walmart is over-indexed in the 65+ category based on store visits per week. Based on that, we were looking at what we could do to offer them more value as compared with our traditional, core customer of 35-50 year old females. Through a series of conversations, the partnership was born. We’re very happy with the relationship and believe they are also.

Limited networks have been around for a long-time with limited adoption. Do you think their time has finally come? What has changed? They have been around, but historically the networks weren’t limited enough to create enough savings to overcome the “costs” of disruption to the payer. Based on our experience at Caterpillar, we believe that you will see a transitional period where companies first move to incentivized networks and then 1-2 years later move to limited networks. [Something I would compare to the transitions which have happened in formulary over time.] The one area where we do see limited networks happening more rapidly is in the area of Managed Medicaid. [This plays into the focus of PCMA and others on the PBM opportunity around Managed Medicaid.]

It was a great discussion. I learned a lot. They allowed me to ask them a lot of questions about their programs and approach that honestly had led to some skepticism in the past. It sounds like they’ve brought together a great team with a broad vision of what they can do in pharmacy and in health and wellness overall. It has gotten my mind thinking about ideas, and I look forward to learning more.

[BTW – You can sign up to get posts like this e-mailed to you whenever I write them.  A registration link is in the right hand column.]

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

PBM Mobile Applications – CVS, Humana, Medco, Express, Catalyst, Prescription Solutions

May 21, 2011 by George Van Antwerp 4 Comments

This week, Medco released their mobile application that they’ve been working with Verizon on.  Not a big secret in my mind since I’ve been hearing about it since last Fall.  I’ve talked about CVS Caremark’s application (CVS mobile), Humana’s application, and CatalystRx’s application.  So, this made me wonder why I hadn’t heard about one from Express Scripts.  It seems unlikely that they wouldn’t have one.

There doesn’t seem to have been a lot of fanfare, but they launched one in March.  Here’s a quick summary of it:

The new Express Rx mobile app works across multiple platforms, and is now available for a free download at both the Apple iPhone App Store and at the Android Market (simply search ‘Express Rx’).  In addition, members using a Blackberry or other smartphone device with web browsing capability can access our mobile optimized website at http://m.esrx.com.

With our new mobile app and mobile optimized website, Express Scripts members will be able to securely access the following functions:

  • Start Home Delivery – transfer available maintenance medications to the Express Scripts Pharmacy
  • Order Refills – select and schedule prescriptions to be refilled from the Express Scripts Pharmacy
  • Check Order Status – check to see if an Express Scripts Pharmacy order has shipped, the ship date and by what method
  • Find a Pharmacy – locate a nearby retail pharmacy using the GPS technology built into a smartphone
  • Drug Information – access Drug Digest database to look up drug information, common uses and possible side effects

The app consists of three features: My Rx Choices, which delivers on-demand, personalized out-of-pocket costs, interactions and other information for any prescription drug; My Medicine Cabinet, which allows patients to view the medications they’re on, including prescription and over-the-counter drugs, and set reminders for themselves; and Prescription ID Card, which allows convenient access to a member’s prescription drug card.

Of course, Walgreens also has a mobile application as does Walmart.  Neither of them are PBMs, but they are both critical players in the pharmacy space.
Next on my list to check out is Prescription Solutions.  They also have a mobile application which does:
  • Refill mail service pharmacy prescriptions
  • View your prescription history
  • Set up text message medication reminders
  • Check the status of and track orders
  • Locate a pharmacy by ZIP Code
  • Search your formulary by generic or brand name drug, status, or class
As one might expect, mobile web or mobile apps are quickly becoming the norm.  The key to look at is what is the functionality.  Is it simply putting their websites on a phone or are they developing other technologies that take advantage of the mobile environment (e.g., location based services or enhanced reality).  I’ll share some thoughts on those in another post.
Books / Articles, Consumerism, Healthcare, Innovation, Leadership, Marketing / Communications, Methodology, PBM / Pharmacy, Press, Social Media, Software, Technology

CVS Caremark Pilots New ePA Technology

May 18, 2011 by George Van Antwerp 0 Comments

CVS Caremark announced earlier this week that they were launching a pilot to improve the prior authorization process. They are partnering with Navinet, Allscripts, and Surescripts to do this. This should be an interesting pilot to monitor. They plan to share the transactions and the results with the market to hopefully drive industry standards.

“CVS Caremark understands the opportunities that innovations such as electronic prior authorization provide to prescribers and patients looking to embrace a more efficient and effective way to share critical prescribing information,” said Troyen A. Brennan, M.D., M.P.H., chief medical officer of CVS Caremark. “The prior authorization process is currently evolving to keep pace as prescribers transition towards electronic prescribing and electronic patient records to better manage their patients’ pharmacy care. This pilot is an important step toward demonstrating how the industry can integrate ePA with e-prescribing to streamline and speed up processing of prior authorizations to ensure that members have quick access to care that is medically appropriate and cost-effective.”

Books / Articles, Healthcare, Innovation, Methodology, PBM / Pharmacy, Technology

Summary Of Big 3 PBM Drug Trend Numbers

May 18, 2011 by George Van Antwerp 1 Comment

All of the big 3 PBMs have now reported their drug trend for 2010.  How do they compare?  [acknowledging that methodologies are different]

  1. CVS Caremark = 2.4% (0.8% without specialty)
  2. Express Scripts = 3.6% (1.4% without specialty)
  3. Medco = 3.7% (1.1% without specialty)

Now, I’ll reiterate my points from the past which are:

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

Why Aren’t We More Focused On Rx-OTC Interactions?

May 16, 2011 by George Van Antwerp 0 Comments

The pharmacy system in the US does a good job of catching drug-drug interactions at the POS (point-of-sale) when the claims are all processed by a PBM or all the drugs are filled within the same pharmacy.  But, with 68% of adults taking both a prescription drug and either an OTC (over-the-counter) or dietary supplement (per JAMA Jan 2009), do we need a broader safety net to catch all those?

I was looking at an old Medco deck from last year.  It estimated that there are 30B combinations if you look at 80,000 prescription doses, 300,000 OTC products, and 75,000 dietary supplements. 

Of course, when you go to the pharmacy, you fill out some basic information.  You do the same at your physician.  But, how often are those updated?  Do you have an easy way to register new products you’re trying? 

On the flipside, the question is what percentage of these 30B combinations are important versus just noise?

There are some significant examples here…

For example, Proton Pump Inhibitors (PPIs) increase the risk of major cardiovascular events by more than 50% for patients taking Plavix, but you can now buy several PPIs over-the-counter.  How would the pharmacy or PBM know?

Healthcare, Methodology, PBM / Pharmacy, Technology

Your Refill Logic Has To Be Dynamic

May 15, 2011 by George Van Antwerp 0 Comments

I signed up for an auto-refill program recently.  It quickly made me realize how stockpiling happens.  (Stockpiling is where a patient ends up with a large supply of their medication over time…typically due to refilling too soon.)

Imagine the following:

  • I get a 90-day supply of a medication.
  • At day 75, I get a refill of the medication.  (I have 105 days left at this point.)
  • 75 days later, I get my next refill.  (I now have 120 days left at this point.)
  • 75 days later, I get my next refill.  (I now have 135 days left at this point.)
The problem here is what I would call “static refill logic”.  The auto-refill program is triggered to fill the drug 75 days after it was last filled.
What is needed is “dynamic refill logic” which calculated days supply on hand.  This isn’t easy, but it makes a lot of sense.  The risk (if I’m a mail pharmacy) is that without this, I get gaps-in-care and/or create a short-term retention issue.
Imagine the following:
  • You ask me to refill, but I have 30 days on hand so I say no.
  • Now I forget to refill on time and I have a choice – (a) skip my medication for a few days or (b) go back to retail.  Neither is ideal for the mail pharmacy.
BUT, all of this could have been fixed if the logic was dynamic and they called to confirm my refill when I had just a few weeks left (i.e., enough to be thinking about refilling but also enough to have time to get it shipped to me).
BPM / Process, Consumerism, General Thoughts, Healthcare, Marketing / Communications, Methodology, PBM / Pharmacy, Technology, Value Propositions

Are Limited Distribution Deals Good For Patients?

May 14, 2011 by George Van Antwerp 0 Comments

People with complex conditions such as RA, cancer, hemophilia, MS, HepC, and other diseases that are treated with specialty drugs (often injectibles) are subject to several unique complexities in filling their prescriptions:

  • Potentially significant cost burdens
  • Limited locations at which to fill their medications
  • Prior authorization requirements
  • Scheduling complexities for delivery or home infusion or coordination with their physician’s office
But, there can also be another complexity called “limited distribution” which is where the manufacturer has only allowed the drug to be filled by a select list of pharmacies.  So, imagine the following situation:
  • You are a patient with multiple co-morbidities.
  • You have several chronic oral medications along with several specialty drugs that you have to fill.
  • You fill one of your chronic medications at retail since you forgot to refill it in time one month at mail and just haven’t gone back since the saving is minimal (as it’s a generic).
  • You have two other oral, chronic medications that you fill at mail order.
  • You fill two of your specialty medications at the preferred specialty pharmacy under your benefit (i.e., limited network).
  • You fill your last two specialty medications at two other specialty pharmacies since both of them are limited distribution products neither of which have contracts with the preferred specialty pharmacy in your network.
You now have to coordinate between five pharmacies.  What ever happened to people worrying about poly-pharmacy?  Is it an issue?
Now, this is important since complexity of therapy (# of drugs and # of pharmacies) appears to be a key factor influencing likelihood of adherence, but I never hear anyone worry about it anymore.
So, I ask…are the limited distribution deals which limit access to a specific specialty drug an undo burden on the patient or is the value of specialized care and monitoring more valuable to the patient?
Healthcare, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Value Propositions

How To Improve Use Of A Preferred Pharmacy

May 9, 2011 by George Van Antwerp 1 Comment

One of the key questions from PBMs, pharmacies, specialty pharmacies, and payers is…
 

How can we drive utilization of a preferred channel (retail, mail order, specialty)?

 
I’ve worked on 15+ different “retail-to-mail” type programs (or even just 30-day to 90-day).  They typically follow a pretty standard profile:
  • Identify who to target
    • Plan design (does the member save?  the payer?)
    • Maintenance drugs
    • Categories (is titration an issue?)
  • Score individuals for prioritized outreach
    • Likelihood to convert (drug, prior experience, costs)
  • Create personalized messaging
    • What’s In It For Me (WIIFM) – cost, convenience
  • Create business rules
    • What’s the best channel?
    • What’s the best time to call or e-mail? 
  • Engage people and quickly transfer them to an agent who can answer their questions
    • How do I get started?
    • How much will I save?
    • Why should I do this?
    • Who are you?
  • Make the process easy…call or fax their provider and get a new prescription for the new pharmacy
  • Implement a process of continuous improvement
    • What works?
    • What could be better?
    • Are their differences within certain sub-segments?
    • How can I test and validate my assumptions?

At the end of the day, this approach can also be used for formulary support and many other programs.  The important things are:

  1. Engage the consumer in a dialogue about their options
  2. Be clear about the value of change
  3. Make the process easy
  4. Answer their questions
Healthcare, Marketing / Communications, Methodology, PBM / Pharmacy, Silverlink, Value Propositions

15 Things You Should Know About Prescription Non-Adherence

May 5, 2011 by George Van Antwerp 1 Comment

One question I frequently get is “what should I know about adherence”. This is then followed by “so what should I do about it”.

Here’s my starter list of what you need to understand about medication adherence.

  1. It’s a $290B problem.
  2. Patients fall off therapy quickly.
  3. There are a lot of reasons for non-adherence…it’s not just about reducing out of pocket spend. AND, to make it more complex, there are variations by gender, culture, medication, condition, trust, copay levels, etc.
  4. There are lots of predictors of non-adherence (old study, Express Scripts, Merck tool), but generally the best predictor is past behavior.
  5. Interventions can improve adherence (CVS Caremark study, Express Scripts study, Silverlink data). BUT, physicians generally don’t see non-adherence as an issue they can address. (see also White Coat adherence)
  6. Patients don’t think they’re non-adherent (see “Rx Adherence Hits The Ignorance Wall” by Forrester that says only 8% of people think they are regularly non-adherent).
  7. Adherence reduces total healthcare costs (CVS Caremark study, Sokol study).
  8. Communications matter (misperceptions, physician-patient gap, health literacy, what physicians tell patients).
  9. There are lots of cool technologies that will work for different people (talking bottles, monitoring devices, iPhone reminders, websites, pill boxes). BUT, improved labeling and bottle design may not be the answer (analysis of Target improvements).
  10. Starting on generics (or lower cost drugs) improves the probability of adherence.
  11. Pharmacist involvement is key and impactful (CVS Caremark study, Ashville).
  12. 90-day prescriptions lead to better medication possession ratio (Walgreens study, CVS Caremark study, Kaiser study, Express Scripts study).
  13. Complexity of therapy (e.g., number of prescriptions) increases the likelihood for non-adherence.
  14. Electronic prescribing gives us new visibility into primary adherence and should also create opportunities to improve this issue.
  15. It’s an area where everyone wins and there’s lots of research…but there’s no silver bullet.
Blogroll, Books / Articles, Healthcare, Innovation, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Silverlink, Value Propositions

Looking Forward To The Silverlink Client Event – RESULTS2011

April 30, 2011 by George Van Antwerp 3 Comments

One of my favorite events every year is the Silverlink Communications client event in May in Boston.  Our marketing team does a great job of pulling together a mix of clients and external speakers to really motivate and challenge the audience.  It’s not much of a sales event, but it does a great job of pushing a lot of key topics for discussion.  (See prior posts – last year’s event, notes from RESULTS2010, and notes from RESULTS2009.)

This event was one of the things that originally convinced me to join Silverlink back in 2007.  Sitting and talking with clients about their experiences with the company, their shared passion for results and outcomes, and their interest in collaborating to improve outcomes for consumers was motivating.

This year should be no different.  This year’s theme is – “Seeing Healthcare Through The Eyes Of The Consumer“.  There are presentations on sustaining engagement, obesity, diabetes, health literacy, social media in healthcare, adherence, loyalty and retention, health reform, STAR, HEDIS, and many other topics.

Some of the speakers include:

  1. Dr. Atul Gawande (Harvard, The New Yorker, Author)
  2. Thomas Goetz (WIRED Magazine)
  3. Dan Buettner (Author, The Blue Zones)
  4. Mark Merritt (PCMA)
  5. Dr. Will Shrank (Harvard)
  6. Jim Wilson (WilsonRx)
And many other executives from across healthcare.
It promises to be another banner event.  I’ll share some summarizes as time allows via Twitter and eventually after the event.
I guess with attendance maxed out and the hotel sold out it’s time for me to buckle down and work on my presentation!
Books / Articles, Consumerism, Events, Healthcare, Leadership, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Silverlink

Interview With Dr. Victor Strecher (Founder of HealthMedia) From #WHCC11

April 19, 2011 by George Van Antwerp 1 Comment

While I didn’t get to meet Victor at the World Healthcare Congress in DC, I got a chance to do a phone interview with him last week. For those of you that don’t know who he is, here’s a quick bio:

Victor J. Strecher, PhD, MPH
Professor, Health Behavior & Health Education; Director, Health Media Research Laboratory; Director, Cancer Prevention and Control, University of Michigan School of Public Health;
Chairman & Founder, HealthMedia, Inc.
Dr. Victor J. Strecher graduated in 1983 with an M.P.H. and Ph.D. in Health Behavior & Health Education from the University of Michigan. After positions as Assistant and Associate Professor in the School of Public Health at the University of North Carolina, Dr. Strecher moved back to the University of Michigan, where he became Professor of Health Behavior & Health Education and Director of Cancer Prevention and Control in the University of Michigan’s Comprehensive Cancer Center.

Dr. Strecher also founded the University of Michigan’s Center for Health Communications Research (CHCR): a multidisciplinary team of behavioral scientists, physicians, computer engineers, instructional designers, graphic artists, and students from a wide variety of disciplines. For over a decade, Dr. Strecher’s center has conducted research studies and demonstration projects of computer-tailoring and interactive multimedia programs.

In 1998, Dr. Strecher founded HealthMedia, Inc.– a company designed to create interactive health communications solutions for medical care, employer, pharmaceutical, and government settings. The intention of HealthMedia, Inc. is to bring the highest quality science, operational capabilities and creativity to the marketplace.

My key takeaways from the conversation were:

  1. We have to focus on intrinsic motivators in healthcare.
  2. A little help at the right time is a lot better than a lot of help at the wrong time.
  3. Selecting physicians based on organic chemistry scores without weighing empathy may be a issue.
  4. You have to listen to the patient, assess their needs, and provide them with tailored information.
  5. Social media has to embrace “collaborative filtering”.
  6. Most behavior change companies are hitchhikers while some like PBMs are tollbooths. It’s better to be a tollbooth.
  7. Choice has to expand over time.

Intrigued? You should be. Dr. Strecher was a fascinating person to talk with (see some of his insights). We only spent 30 minutes together, but I could easily imagine sitting with him in at my alma mater (University of Michigan) and talking for hours about healthcare communications and how this can impact the country and our outcomes.

We started off by talking about the shift in focus to the consumer over the past decade and how even while this has happened we (healthcare companies) have been guilty of seeing the patient from our perspective not from their perspective. This took us down the path of talking about motivation and what gets people to take action. We focused on the fact that health (in and of itself) isn’t a big motivator, but being healthy to see your kids or grandkids certainly is. We talked about how financial rewards aren’t the right (or only answer) and how there is a need to really understand and articulate intrinsic motives (see write-up on Drive by Daniel Pink).

We talked about his company HealthMedia (owned by Johnson & Johnson) and what they do to collect information on motivation. We talked about the use of stories (a topic that keeps coming up) and providing the right amount of help at the right time. He talked about how HealthMedia monitors consumers, provides them with coaching, and continuously evaluates their goals. He also talked about how they use online technology and mobile technology to get the right connection at the right time.

This led us into a discussion about how important behavior is in health outcomes. He mentioned that 70% of cancers are related to behavior – scary. But, at the same time, we don’t chose candidates for medical school based on their abilities to engage patients or show empathy. We choose them based on their organic chemistry scores. (As a physician, he could say that while I’d probably get tomatoes thrown at me for that comment.)

At this point, I really wanted to understand what HealthMedia has learned to get people off the couch and engaged. It all sounded a little too theoretical to me. He talked about their core process:

  1. Listen to the issues. Assess the patient using branching technology and feedback to them.
  2. Try to figure out what they need using a software algorithm.
  3. Tailor information to them based on what you’ve learned (e.g., if they are concerned about gaining weight when quiting smoking, help them with that). And, I thought a key point here was to help them prioritize their actions rather than giving them a laundry list of things to do.

But, one of the keys in getting them to engage is to work through their intermediaries – employers and payers. For example, while you might encourage consumers to take an HRA for a financial reward, you may need a “health champion” at the employer site to really motivate people at a personal level. Or in another example, he talked about how Kaiser uses Epic and how HealthMedia integrates there. This creates an opportunity for “information therapy” which can be given to the consumer as a follow-up action from their encounter.

We went on to talk about social media which is one of those big topics in healthcare today. Obviously, there is lots of research that talks about the “peer pressure” effect on weight and smoking and other topics. (He mentioned the book Connected here.) But, how to you build trust (see recent post on this) and route consumers to the relevant information. He brought up a concept which was new to me called “collaborative filtering”. My interpretation of this is essentially having an expert monitor and guide consumers to relevant information within the social media realm. You want to find relevance in the data which means it has to be from “friends” who have experience with the topic.

I was asking him about the challenge of building trust given how many companies are out there and the amount of information which consumers are bombarded with. This is when he created the great visual of most companies as being hitchhikers in the behavior change world while others like PBMs are tollbooths. The tollbooths create a pause in the process which is triggered around an event. This event is an opportunity to get the consumer engaged. Of course, in general, these “golden moments” (my phrase) aren’t taken advantage of as much as they could be.

But, if they were, consumers would understand what they want and how a particular behavior maps to those desires. This would lead to improvements in adherence and other outcomes.

We wrapped up by talking about preference-based marketing and the impact of choice. He had some great points here which is an area of interest for me since there’s not much research. He pointed out that choice is instrumental since it appeals to autonomy. BUT, not everyone wants autonomy. Too much choice can be overwhelming. In summary, he suggested that less choice is best early on when the consumer is overwhelmed (e.g., newly diagnosed), but as they become more of an engaged patient over time, more choice is better.

Books / Articles, Healthcare, Leadership, Marketing / Communications, Methodology, Press, Research, Social Media, Technology

QR Codes – The Ultimate Opt-In Tool

April 14, 2011 by George Van Antwerp 0 Comments

You probably are starting to see them more (those 2D barcode boxes).  They’re called QR codes.  Here’s a few articles about them:

I find this a fascinating area.  Imagine a few examples here:

  1. You want to get a member to opt-in to a program (e.g., auto-refill).  You can put a QR code on their invoice.
  2. You want to offer an educational video about a condition.  You can put a QR code on the Rx label.
  3. You want to get consumers to opt-in to a SMS program.  You can put a QR code on a mailing.
  4. You want to offer a physician access to the clinical studies about a drug.  You can fax them some information with QR codes on it. 
  5. You want a patient to learn more about a condition.  You could put up DTC materials in the provider’s office with QR codes. 

I think you get the point.  I expect this will grow rapidly especially as the smart phone market grows and more and more people have cameras in their phones (devices). 

One of the biggest uses right now in pharmacy is from Walgreens where they allow you to order a refill by scanning the QR code on their bottles using their mobile app.

Blogroll, Books / Articles, Consumerism, General Thoughts, Healthcare, Innovation, Marketing / Communications, Methodology, PBM / Pharmacy, Technology

The CVS Caremark Drug Trend Report (Insights) Is Out

April 14, 2011 by George Van Antwerp 0 Comments

The new CVS Caremark Insights 2011 report (Drug Trend Report) is out.  I haven’t read it yet, but here’s the summary from the press release:

  • 2.4% overall trend
  • 13.7% specialty trend
  • GDR of 71.5%

“The continuing increase in the use of expensive specialty drugs, as well as the growing prevalence of chronic disease, calls for innovative health care solutions such as an integrated pharmacy home to help patients deal with complex therapy regimens and stay adherent,” says Troyen A. Brennan, MD, MPH, Executive Vice President and Chief Medical Officer of CVS Caremark. “Developing a pharmacy home was one of the recommendations raised by our recent research conducted with Harvard Medical School and Brigham & Women’s Hospital. That work and this report make it clear we must devise better ways to serve the chronically ill. This trend report shows we are making headway in that fight.”

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

Real-Time PBM “Pricing” From Prescription Solutions

April 13, 2011 by George Van Antwerp 1 Comment

I don’t do a whole lot in the PBM pricing world these days, but I remember some of the process and the underwriting steps.  That being said, I was really impressed with the new Prescription Solutions online Pharmacy Benefit Advisor Tool (go to http://mybenefitpreferences.com). 

You go through a few basic steps to get an idea of how much you (payer) could save (with a very nice GUI). 

  1. Rank the features that matter to you – net cost, compliance, shifting cost to the consumer
  2. Rank the importance of different clinical programs
  3. Make some trade-offs in programs (A is more important than B)
  4. Enter some baseline data

Now, in reality, PBM pricing is never that simple, but what it effectively does is help articulate the savings that different decisions can create in a real-time setting.  It also forces some dialogue around issues – adhererence versus drug cost…which matters more to you?

I also think it could be a great way to help consumers understand the costs and savings associated with certain decisions.  I would also guess that the sales team at Prescription Solutions will find it helpful especially in the smaller, self-funded world.

Business Tools, Healthcare, Innovation, Marketing / Communications, Methodology, PBM / Pharmacy, Technology, Value Propositions

The Express Scripts 2010 Drug Trend Report – Waste and Intent Focused

April 11, 2011 by George Van Antwerp 2 Comments

As I’ve talked about in the past, after working on the Express Scripts Drug Trend Report (recent copy here), I really enjoy getting the chance to read through them every year (see 2009 review or 2008 review). Over time, they’ve become less about the clinical side of the business and more about the programs used to engage the consumer with consolidated class specific data still included.

This year’s report is similar, but it is built around a new study that Express Scripts just completed with Harris Interactive. It comes to a rather surprising but interesting conclusion –

We discovered that the majority of people want to engage in the same behaviors plan sponsors seek to promote, but these desires often remain dormant. That is, there is a persistent intent–behavior gap. The key is structuring interventions that close the gap between what patients already want and what they actually do.

What’s the key point here? The point is that this says that consumers really want to move to generics and move to mail order, but they don’t do it. Is it that simple? I’d love to think so. And, for generics and mail order, I’m more likely to believe that inertia is a large factor. BUT, as I’ve talked about before, adherence has lots of complicating dimensions.

They focus on the gap between the physician and the optimal outcomes. This is certainly a major factor, but beyond consumer intent, there are issues of health literacy and physician beliefs that have to be addressed. Regardless, the point is correct…how do we engage and motivate consumers to change behavior especially if they are pre-disposed to change (when presented with the right facts).

They did continue to build on last year’s focus on WASTE. They estimate that the waste in 2010 was over $403B as broken down below:

As adherence is a key issue here, they highlight the difference in adherence rates between retail pharmacy and mail pharmacy.

The focus of the report and the early press I’ve seen has been on the following chart. What it shows is some of the data from the Harris study saying that 82% of people would chose a generic (that are on a brand) and (depending on copay savings) 55-71% would chose retail.

One topic that I was glad was in the survey was limited networks. This is a topic everyone’s talking about from ReStat to Wal-Mart to Walgreens to CVS. Here’s what the research said with some explanation for what it means:

Of note is that about 40% said they would be willing to switch retail pharmacies to save their plan (or employer, or country) money. This fi gure is not as low as it fi rst appears because before a plan implements a more narrow retail network, a large fraction of members already use these pharmacies and therefore don’t have to switch pharmacies. It is not unusual, for example, for a client using a broad network to have 70% of prescriptions processed through pharmacies that are in the narrow network; members currently using these pharmacies do not have to make any changes. When a narrow network is implemented, if 40% of the users of the remaining 30% of prescriptions would willingly move to a lower-cost network pharmacy (as suggested by the survey), we estimate that the resulting overall market share within the narrow network would rise to 82% {70 % + (30% x 40%)}. (page 14 of the DTR)

All of this tees up their family of “Select” offerings (see Consumerology page) which builds on the success of Select Home Delivery and applies the concept of “Choice Architecture” from the book Nudge.

They talk about some of their work with adherence and their Adherence IndexSM. This metric is certainly one that has the industry’s attention as people wonder about the predictive value, how this is used, and how to craft solutions around such an index. My perception has been looking at studies like this one by Shrank and colleagues that past behavior remains the best predictor of future behavior, but I’m happy to be wrong.

So…what were the trend numbers?

  • 1.4% in the traditional (non-specialty drugs)
  • 19.6% in specialty
  • 3.6% overall

One of the other lists that I always find helpful to have is what are the top 15 drug classes and the PMPY spend.

Of course, in today’s world, you really want to know this for specialty medications:

So, as always, I would recommend you read the report. Lots of great information in here. Interesting research. Good thoughts on consumer behavior and how to change it.

I think this week is their Outcomes conference which was always a good event.

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

Increasing Specialty Drug Refill Rates

April 9, 2011 by George Van Antwerp 0 Comments

Adherence is one of the primary topics of discussion today both within pharmacy and (after reform) within other areas of healthcare.  Adherence drives costs.  Adherence impacts productivity.  And, with a few rare exceptions (CBO type budget analysis looking only at fiscal year returns), everyone’s interests are aligned on the value of improving adherence.

For now, let’s skip over the traditional pharmacy market which is rapidly becoming generic. Let’s look at specialty where the average cost is $1,800 per month and can run into the $10,000’s.

So, what if I told you there were simple solutions that could improve your monthly refill rate on your drugs by 20-40%?  What if that also reduced the gaps-in-care and improved patient awareness of their condition?  What if that also incorporated a feedback mechanism to the care team?

How much would that we worth?  What about all that for $2 / month per member?  Much less that copay waivers or many other solutions out there on the market.

Sound interesting…Go learn more at Silverlink.

Healthcare, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Silverlink, Technology, Value Propositions

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

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

Data: Should You Be Paranoid?

April 4, 2011 by George Van Antwerp 0 Comments

I think we all know or are quickly realizing that everything we do leaves a trail of breadcrumbs.  That trail is a series of data points which now can be aggregated to create a record of you.  What you do?  What you buy?  What ads you respond to?  Who your friends are?  The list goes on. 

The question of course is whether you should be paranoid and worried about it. This video below shows you the extreme scenario of how data could be abused.

In a more balanced view, Time Magazine had an article call Your Data, Yourself which just appeared on March 21, 2011.

Oddly, the more I learned about data mining, the less concerned I was. (Joel Stein, author of article)

The article talks about a variety of companies that collect and sell data:

  • Google Ad Preferences
  • Yahoo!
  • Alliance Data
  • EXelate
  • BlueKai
  • RapLeaf
  • Intellidyn

The author makes a key point…a lot of the things we get for free are free because people collect and sell our data.  Otherwise, these “free” business models wouldn’t exist.  Would you pay for all the content and other things you get today or do you just want to understand what happens to your data?

On the other hand, the author shows you how data put together adhoc can paint erroneous pictures of you.  Should you care?  Do you want to fix this?  Can you control it?

This is all important since there is some do-not-track legislation being discussed.  (See Joe Manna’s post on this for some additional perspective)  Several people bring up the good question…

While we say that we don’t like to know that our data is being used to target ads at us, do we really want to have to sort through all the irrelevant advertisements?

Of course, we all become a lot more sensitive around healthcare data.  But, somehow, I doubt many of us think about what happens when we use our work PC to research a condition (see article on 10 ways to monitor your employees).

The article also suggests some sites for protecting yourself:

Don’t expect this one to go away.  With issues like the data breach at Epsilon, people are concerned.  Additionally, as data gets co-mingled and your credit score is used to determine health programs (for example), there may be limits about what and how information is used.

Blogroll, Books / Articles, Consumerism, General Thoughts, Healthcare, Marketing / Communications, Methodology, Politics, Technology, 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

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
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