Archive | PBM / Pharmacy RSS feed for this section

Updated Share of Revenue Growth Chart

November 21, 2010 by George Van Antwerp 0 Comments

Adam Fein was kind enough to send me an updated chart of the one I posted yesterday that comes from his new report “The 2010-11 Economic Report on Retail and Specialty Pharmacies” which will be available December 7th here – http://www.pembrokeconsulting.com/industry-reports.html.

One of the interesting things that isn’t clear in the industry is that while mail order made significant gains in the past decade, the IMS numbers show negative growth over the past few years. On the flipside, mail order numbers and new users are still a big focus across the PBMs.  It begs the question of whether mail order growth without intervention programs is negative and only those with an effective retail-to-mail strategy can replace and potentially grow mail faster than people organically leave.

It also begs more discussion on the topic of retention which while a hot topic for a while hasn’t manifested itself in many rigorous programs as of yet (to my knowledge).

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

Legitimate Online Prescribers

November 20, 2010 by George Van Antwerp 0 Comments

From an article in USA Today, it sounds like tele-prescribing or virtual prescribing is making some steps forward.  It’s no longer a scam business set up to allow people to skirt the system but a legitimate set of online companies leveraging technology to make it easier for patients.  It will be interesting to see how this plays out.

With big companies and start-ups working in this space, it will likely take the same route as the clinics have taken in getting physician support although most of these described in the article seem to have physician involvement.  Will they protest their peers?

Eventually, this won’t even be a debate as we can use home monitoring devices that plug into our computer or smartphone or iPad app to tell temperature, blood pressure, and other key statistics.  I can see some cool scenarios being explored about how to allow the physician to do a virtual physical exam to complement the patient reported data.  I can also believe that an online record of the patient’s symptoms will be easier to pull into an EMR / PHR than the physician’s notes.

The one thing the article doesn’t bring up is why the physician isn’t accessing a PHR (personal health record) to conduct the exam.  I would think that should be a requirement for patients to use this.  Make them go thru the step of pulling their history into an online tool and adding data about OTCs and allergies.  Then, the virtual consultation would have a physician with all (most) of the data readily available.

You match that with some specific symptoms, some realtime data, and you have a recipe for improved care.

The three companies that the article mentions are:

 

Books / Articles, Consumerism, Healthcare, Innovation, Managed Care, PBM / Pharmacy, Technology

MD or RPh for info on prescriptions

November 18, 2010 by George Van Antwerp 0 Comments

If you have detailed questions on prescriptions, would you talk to your physician or your pharmacist?  I’d certainly talk to my pharmacist.  That’s their job while the physician is there to diagnose and treat.  I don’t think they can keep up with all the 10,000+ prescriptions in the market. 

But, apparently, I’m not the norm (not a big surprise on most things).

Healthcare, PBM / Pharmacy, Research

How Generic Prices Drop With Number of Manufacturers

November 18, 2010 by George Van Antwerp 2 Comments

Here’s another great analysis by my friends at Barclays Capital (contact Meredith Adler).  It’s amazing to see the correlation of these two variables:

  1. Generic price as a percentage of the brand price and
  2. Number of generic manufacturers in the market.

It begs the question of why those last few manufacturers get into the market.

Healthcare, PBM / Pharmacy, Research

Brand Prices vs. Generics Over Time

November 18, 2010 by George Van Antwerp 0 Comments

It’s amazing to look at the increasing gap over time between the price of a brand drug and the price of a generic drug.  There are a few things going on:

  • More specialty drugs
  • Less blockbuster drugs and therefore more research costs per new brand drug
  • More generic competition

But, regardless of the logic behind it, it is dramatic.

(Note: Research from Meredith Adler and team at Barclays.)

Healthcare, PBM / Pharmacy, Research

CVS Caremark Insights 2010

November 17, 2010 by George Van Antwerp 0 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

$ESRX – Continued Growth

November 16, 2010 by George Van Antwerp 0 Comments

Some people think I should be impartial on my blog. But, no one really wants to read posts that are just PR recast for the sake of driving hits to the blog. One of the things I did a lot at Express Scripts was to see new research, try to find flaws in it, point out the flaws, and then try to find ways to innovate around them. I enjoy doing that here. With a lot of my clients, I get to do that in meetings where they respect my bluntness around what they are or aren’t doing. In other cases where I’m not included in those dialogues, I may play out some of those thoughts here. Hopefully, it’s a helpful perspective.

I have a fine path to walk which is to protect the confidentiality that I have with lots of PBMs while at the same time providing a fresh perspective on the industry. I hope all of you view it that way. I know all the analysts and competitive intelligence people enjoy what I talk about and lots of industry veterans find the views worthy of discussion. But, I think of few people take the intellectual challenges personally. Don’t.

One thing that a few analysts have asked about is my thoughts on why Express Scripts stock has done so well (see below). The short answer is FOCUS. But, I’ve certainly learned from talking to them that I see things differently. I’m often looking at the edges of the strategy and the innovation versus focusing on what the day to day operations are doing. At the end of the day, the analysts and the street are pretty focused on achieving the quarterly numbers.

Some of the things that they do that have made them successful are listed below.

  1. Focus. They have been one of the few companies that have really stayed the course on the PBM core business model – processing claims and mail order. I’ve talked to a bunch of the Wall Street analysts to gain their perspective. They look at things differently. While I may find much of the ancillary activities and strategy more interesting, George Paz (CEO) has been great at keeping them focused on what matters and constantly improving the key metrics.
  2. Integration. One of the best things they’ve done repeatedly is buy PBM assets and integrate them into the core system and existing business processes. This drives efficiency and scale which is critical to the core model.
  3. Research. From early on under Barrett Toan, the company brought in a group of statisticians and researchers. They focused on using data to research interesting topics and publish them. Eventually, this got better integrated with product management, and this now gives them a core team around which to build on for segmentation and predictive models. (Note: This research focus has become the norm in multiple PBMs now.)
  4. Consumerology. While I could talk on this one for days, this was an important move. They claimed the space before anyone truly realized it was the competitive battlefield for PBMs. They found a way to rapidly test things and package them up for the market to digest. (Although I’m disappointed that the Consumerology blog seems to have died with no new postings since May.)
  5. Generics. They realized early on that there was more money to be made from generics than from rebates and pushed hard for this. (Although I’ll admit to a few ugly meetings between me and the rebate team early on.) This positioned them well (“we save when you save”) and allowed them to have a leading generic fill rate (GFR) for years (although others have made up much of that ground).
  6. Intense Culture. The company has successfully adapted and rallied around numerous challenges with a relentless focus. For those that like this culture and can adapt on the fly, it creates a highly intensive environment of competitive people. They’ve created a GE culture of rewarding the high performers and creating competition for upward mobility. And, there is a hyper focus on a few key competitors – Medco and CVS Caremark… a lot of my friends didn’t even know who the other PBMs were.
  7. Worker’s Compensation. This business unit struggled to find a home forever, but some core people continued to push it based on the margins it represented. They seem to have doubled down with their acquisition of MSC a few years ago and have brought their lower cost approach to the market to win business.
  8. Medicaid. They seem to be one of the few PBMs that have traditionally played in the managed Medicaid business. Given the increase in lives that may come into Medicaid via healthcare reform, this could create a large growth opportunity.
  9. Golden Handcuffs. When you have a stock that’s growing like this, what do you want to do…tie people to the stock. The executives have huge investments in the stock and traditionally got lots of options. People that have been there for years have lots of options. This has definitely reduced turnover.
  10. Small Risks. They have also tried a lot of things under the radar. If it wasn’t for an analyst, I wouldn’t even know that they had started a GPO with Krogers. And, they barely talk at all about their work in China. The view there has definitely been that when you try something new to manage the risk.

All the PBMs are doing interesting things. The market has become very dynamic compared to some of the “me-too” days of old. Everyone is finding their space and claiming it. The next few years will continue to be interesting.

[A point of clarification and disclosure – I do not own any individual Express Scripts stock although it may be held by some of the funds that I have invested in.]

General Thoughts, Healthcare, PBM / Pharmacy

Prime Therapeutics 2010 Drug Trend Insights Report

November 12, 2010 by George Van Antwerp 1 Comment

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

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

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

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

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

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

The Future Of Pharmacists

November 3, 2010 by George Van Antwerp 0 Comments

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

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

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

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

Which I think brings us around full circle…

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

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

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

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

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

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

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

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

Events, Healthcare, Leadership, PBM / Pharmacy, Politics

Technology Challenges (and Opportunities) For Pharmacy

November 1, 2010 by George Van Antwerp 0 Comments

Here’s the presentation that I’m going to deliver tomorrow (11/2/10) at the NCPDP education event in Portland.  The question posed was what are the busines models needed to survive and thrive in the new economy.  My mind immediately jumped to what are the challenges in the industry, what are the trends that got us to where we are, and how can pharmacies (or PBMs) think about turning these challenges into opportunities.

At the end of the day, I think there is still lots of white space for pharmacies to leverage technology to build relationships with their clients (consumers / customers / patients).  I think technology makes that scalable. 

One bias that I also have long-term is that (with the right economic model) retail pharmacies should focus on the acute drugs and new prescriptions and get compensated for the initial education and titration with the patient and the physician.  After that, maintenance drugs which are essentially just refills should be handled by the lowest cost option – kiosks, central fill, mail order.  I think that would encourage a different payment model centered around cognitive services and encourage greater collaboration between retail and the mail order pharmacies. 

Business Tools, Events, Healthcare, PBM / Pharmacy, Silverlink, Technology

Mississippi Specialty Pharmacy Settlement

October 29, 2010 by George Van Antwerp 0 Comments

I just saw this.  I wonder if this will have any implications on the Mandatory Specialty model that has been prevalent.

Vital Care of Meridian, a franchise of Vital Care Inc., (“Vital Care”) has won a significant partial summary judgment motion in a matter against the Mississippi State and School Employees’ Life and Health Plan (the “Plan”), a state insurance plan that covers certain state employees, and its pharmacy benefit manager (“PBM”). The lawsuit is currently in progress on remaining issues, but a major issue in the lawsuit was whether Mississippi’s “Any Willing Provider” statute (“Statute”) applies to the Plan. The Plan and the PBM awarded sole provider status for specialty pharmacy services to a single specialty pharmacy, to the exclusion of Vital Care and other specialty pharmacies in Mississippi. The Plan and its PBM argued that the Statute did not apply to them for a variety of reasons, but those arguments were rejected by the Mississippi Chancery Court. It is thought that this case will likely serve as precedent for several other similar cases across the country.  (Court Order)
Healthcare, PBM / Pharmacy

Express Scripts Model – DBN Article

October 29, 2010 by George Van Antwerp 0 Comments

I was quoted in yesterday’s Drug Benefit News with one of my favorite people – Dr. Steve Miller from Express Scripts.  This was a follow-up to talk about their predictive model for adherence.  Steve confirmed what had previously been reported that it is 85% accurate in predicting the 10% of people least likely to be adherent.  He says that the model takes into account past behavior, demographics, condition, and the drug.  Those sound like a lot of the right variables.

The article teases us with information that CVS Caremark is planning to publish a study in the upcoming months on their model.  Medco Health Solutions comes across as more of a skeptic in the article talking about efforts from 20 years ago that were difficult and expensive to execute. 

My quotes were very consistent with what I’ve shared on the blog – fascinating, somewhat skeptical, more concerned about the group that is somewhat adherent than those that are the bottom 10%, implementation of behavior change is more important that the model. 

“Everybody’s trying similar efforts in terms of how to predict adherence…but there hasn’t been a model that has proven itself as being a good predictor.  Maybe Express Scripts has cracked the code…I would assume that if you can accurately predict who is going to be adherent that will be a good tool.”

However, attempting to change behavior in the top 10% of patients likely to be nonadherent will be tough, Van Antwerp contends. “The industry is still waiting for that proof,” he maintains. “If we can predict that patients are adherent but can’t change behavior, then the model doesn’t do us much good.”
Books / Articles, Healthcare, Innovation, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Silverlink, Technology, Value Propositions

Predictive Model + Segmentation + Intervention

October 21, 2010 by George Van Antwerp 0 Comments

I was fielding a few questions today about the predictive model from Express Scripts.  The concept of predictive modeling is one that everyone is working on and holds great allure.  BUT, it is only a piece of the puzzle.  In the dialogue, I identified three key tenets for success.

  1. Predictive Model – Can you predict who is likely to act in certain ways – be adherent, log-in to the member portal, use mail order, switch to generics, pick up the phone?
  2. Segmentation Model – Once you can predict people, can you develop a segmentation model about how to get them to take action based on different attributes – gender, age, past behavior, preferences, income, other?
  3. Intervention Strategy – If you can predict who is most likely to act and know what type of segment they fall into, do you have a cost-effective intervention strategy to get them to take action…right message at the right time using the right channel?  For adherence, this could be reminders, coaching, devices, or other tools.  (As many people say, a less sophisticated strategy executed perfectly is better than a complex strategy executed less than perfectly.)

And, then you need to study and refine these on an ongoing basis especially since topics like adherence may be affected by macro-economic trends (e.g., economy), patient beliefs (e.g., fatalism), and other attributes (e.g., plan design) on top of the attributes in your models. 

I do believe we’re early in the days of modeling and that the access to data and greater availability of informatics resources will increase the development and focus on these models.

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

“One Walgreens” Advertisement

October 20, 2010 by George Van Antwerp 0 Comments

I liked the simplicity of the Walgreens’ ad that I saw this morning in a magazine (although I don’t like the tagline about “there’s a way to stay well” since there is a healthcare company named StayWell).

It provides this series of data points:

70,000 healthcare professionals

25,000 certified immunizing pharmacists

7,560 community pharmacies

1,670 physicians, nurse practitioners, and physician assistants

900 infusion nurses

700 worksite health centers and convenient care clinics

125 medical facility and specialty pharmacies

100 infusion and respiratory centers

1 Walgreens

Marketing / Communications, PBM / Pharmacy

PBMs and Social Media

October 20, 2010 by George Van Antwerp 1 Comment

I always get pulled into the discussions about what PBMs are doing, should be doing, or could be doing in social media. For now, let’s just look at the current state – i.e., who is doing what.

I’m going to focus on the big channels – Twitter, Facebook, YouTube, and blogging.

 

Twitter

Other (Facebook, YouTube, Blogs)
CVS Caremark @CVS_Extra

@CVS_Health

@CVSCaremarkFYI

 http://www.youtube.com/user/CVSPharmacyVideos

http://www.facebook.com/CVS
Medco @DrObviousPhD

@LibertyMedical

@Medco

 http://www.youtube.com/DrObviousPhd

http://www.facebook.com/DrObviousPhD
Walgreens @Walgreens

@WalgreensNews

@WalgreensHealth

 http://www.facebook.com/Walgreens
Express Scripts @BobNease

@EScripts

 http://www.consumerology.com/blog
MedImpact @MedImpact  

 

To make it easy, I created a Twitter list on my profile of the PBMs, pharmacies, and several other key resources in this area – http://twitter.com/#!/gvanantwerp/pharmacy-pbm.

I welcome your links to other PBM or pharmacy social media assets. I looked under CatalystRx, Prime Therapeutics, and SXC also. I also checked Cigna Pharmacy, Humana Pharmacy, Prescription Solutions, and Kaiser Pharmacy. I couldn’t find more, but I’m sure there’s a few I missed.

The question of course is how to judge if these are successful. Is it the number of followers or fans? I would argue no. The goal of social media is to create a dialogue and engage the patients or consumers. Given the traditional focus on the PBM on the business-to-business relationship and the pharmacy on the business-to-consumer relationship, there is an interesting question of how the mail order pharmacies (owned by the PBMs) make that leap. Can social media create a forum for discussion about plan design, drug trends, and other things in straightforward language that engages consumers? Will consumers be willing to use these channels to interact with the PBMs or only with their pharmacist? This could be an area where companies like Walgreens or CVS Caremark who have a large physical footprint can leverage a real-world connection with consumers to a virtual one easier than others.

As you can see, there are not a lot of people doing a lot yet. This area will change a lot in the next 5 years.

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

Quote Regarding Number of Pharmacies

October 16, 2010 by George Van Antwerp 2 Comments

“We have more than 60,000 drug stores in America, 38,000 grocery stores, and about 13,000 McDonalds. How difficult is it for someone to find a McDonalds hamburger if they want one?…Not hard. So why do we need 64,000 drug stores within our network?”

— Michael Jacobs, national clinical practice leader at Buck Consultants, told AIS’s DRUG BENEFIT NEWS.

 

Books / Articles, Healthcare, PBM / Pharmacy

CVS Adds Mobile Application

October 15, 2010 by George Van Antwerp 0 Comments

Communications continue to evolve.  Mobile health in the form of applications has either crossed the chasm or is crossing the chasm.  I expect in 5 years that most communications in healthcare for people under 45 will start with a mobile application.  It may “escalate” to other modes, but using a secure application on the ubiquitous mobile phone will be a primary starting point to engage them.

Caremark rolled out their mobile application earlier this year.  Now CVS has rolled out there application.  Several other companies have rolled out their applications also.  Humana’s application is out (mobile site).  Another big PBM is piloting their mobile application with one employer right now. 

So, what does the CVS mobile application do:

  • Find nearby CVS/pharmacy locations using the GPS-based store locator with integrated driving directions and maps;
  • Refill prescriptions from a personalized prescription history for pickup at any CVS/pharmacy;
  • Transfer prescriptions from another pharmacy to CVS/pharmacy;
  • Access the Drug Information Center to retrieve critical details about medication management, including instructions for use, dosing information, side effects and relevant safety warnings;
  • View and manage sales circular to create a custom shopping list and identify money-saving deals each week; and
  • Schedule a flu shot at any local CVS/pharmacy location.

Consumerism, Healthcare, Marketing / Communications, PBM / Pharmacy, Social Media, Technology

Total Medical Costs Lower For Diabetics At Mail

October 15, 2010 by George Van Antwerp 0 Comments

I can’t believe I missed this one earlier this year especially since a friend of mine is one of the authors…BUT this is an important one for the industry showing that not only did adherence improve moving from retail to mail order pharmacy but as pharmacy costs when up the corresponding medical costs went down MORE!

I’m just going to paste the abstract from the Journal of Medical Economics below:

Objective: To compare long-term diabetes medication adherence and healthcare costs in patients using mail order pharmacy versus retail pharmacy.

Methods: The MarketScan database was used to identify patients who filled prescriptions for oral anti-diabetes medications in a retail pharmacy for at least 6 months before switching to mail order pharmacy for at least 12 months. These patients were matched to others who used retail pharmacy continuously for at least 18 months. A propensity score was used to create matched groups of patients comparable on probability of switching to mail order, weighted Poisson regression was used to analyze differences in medication adherence, and Tobit regression was used to compare costs.

Results: A total of 14,600 patients who switched to mail order were matched to 43,800 patients who used retail pharmacy continuously. The average adjusted adherence in retail pharmacy was 63.4% compared to 84.8% after switching to mail order. Per-member-per-month total healthcare and total medical costs were on average $34.32 and $37.54 lower in the mail order group, respectively. Diabetes-related medical costs were on average $19.14 lower in the mail order group, while pharmacy costs were $14.13 higher.

Limitations: Limitations include a patient population under the age of 65, no information on pharmacy benefit design, and limited follow-up time relative to that necessary to identify long-term diabetes complications.

Conclusions: After adjusting for measured confounders of medication adherence and disease severity, individuals who switched to mail order pharmacy had higher medication possession ratios and trended toward lower total and diabetes-related medical costs over time.

Press release about it here.

Here’s a slide showing the values:

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

Why Mail Order Is Better (ESRX)

October 15, 2010 by George Van Antwerp 0 Comments

I was looking at the latest investor decks from Express Scripts on their site and found this slide in the presentation from the William Blair Growth Stock Conference.  It does a nice job of comparing the two channels although I’m sure that my retail friends would hotly debate this topic.

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

Changing Rxs (or Doses) Without Asking Basic Question

October 14, 2010 by George Van Antwerp 0 Comments

I’ve talked about this with many clients.  Since physicians don’t always engage patients in the basic dialogue around adherence, how can they decide to increase doses or change prescriptions simply if the patient’s condition isn’t becoming better?  This has to drive waste in the system. 

The reality is that a physician may get a lab value that shows that their patient’s cholesterol (or A1c or…) is higher than it was last time.  They know the patient is on a certain dose of the medication.  They instinctively think to increase the dose or change the medication.  BUT…they don’t always ask the patient about their adherence to the medication.  This is attributed to multiple reasons:

  • They don’t see adherence as their issue.
  • They assume the patient is adherent.
  • They assume the patient would tell them if they weren’t adherent.
  • They assume if they ask that the patient would lie to them and say they were adherent.

I’d heard about a study done about a decade ago that had looked at this, but it had never been published.  I was excited to see that Medco had published some research on this topic today. 

There were some interesting things in the research also.  It was another validation on the fact that men are more adherent than women.  And, it showed that people with multiple conditions were more adherent.  I would expect that there is a curve around this that people with a few medications and those with lots of medications are least likely to be adherent, and those somewhere in the middle are most adherent.  (But, I’ve never looked at the data with this question in mind.)

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

Some Medicare Survey Data

October 13, 2010 by George Van Antwerp 1 Comment

The Medicare Part D prescription drug coverage has been a great validation for the PBM industry. It has shown the ability of the traditional tools to manage spend and provide an affordable benefit.

With that said, a new survey conducted on behalf of the Medicare Today coalition shows more reinforcing data:

  • 84% of beneficiaries are satisfied with their coverage.
  • 80% said their Part D premiums and co-pays are affordable
  • 94% said that they understand how their plan works and know how to use it
  • 65% said that they don’t feel a need to shop for a new plan during open enrollment
  • Only 20% were aware of the new discounts on brand-name medications that are available when they hit the donut hole next year [If I was pharma, I would make the PDP plans educate consumers on this.]

“The Medicare Part D program continues to defy its doubters,” said Mary R. Grealy, president of the Healthcare Leadership Council and co-chair of Medicare Today. “At its outset, critics said health plans wouldn’t participate in Part D, but today seniors have ample choices of affordable plans. They said the program would cost too much, but the last Medicare trustees report reported costs are 41 percent below initial expectations. And they said seniors would find the program too confusing, but it remains enormously popular.”

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

Predicting Non-Adherence

October 12, 2010 by George Van Antwerp 0 Comments

There is lots of buzz over yesterday’s article in the WSJ about Express Scripts being able to predict who will be adherent.  Today’s blog post on the Corporate Research Blog added some details (or further confused me).  It says that the model is 80% accurate in predicting the 10% of people who are least likely to be adherent.

Is that all it does?  For sake of this post, let’s assume it does.  That seems much less interesting and much easier to do.  In talking with a leading researcher in this area that has looked at the correlation of 9,000 variables to adherence, he told me that nothing was highly correlated, but the most correlated metric was past behavior.  Where they adherent in the past on other medications?  Did they take preventative action (e.g., get flu shots, mammograms)? 

Several people have been looking at how credit scores can be used to predict adherence.  Given errors in credit scores, this may be deceptive even if it works.

But, back to the issue.  If you know who’s least likely to be adherent, so what?  Do you give up on these people?  They aren’t likely to chance behavior.  Do you try harder or have a different strategy with these people?  If you succeed and move them to taking their medications 40% of the time (using a proxy like a 40% medication possession ratio), does it make a difference? 

I would think it’s better to focus on the people who are likely to be adherent and how to enable them to move from 40-70% MPR to >80% MPR.  We often work with clients to stratify their population and have different intervention strategies (channel, messaging, level of effort, etc.) across where they fit in the model (value, likelihood to engage, likelihood to change).

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

Analysts On The PBM Marketplace (ESRX, MHS, CVS)

October 8, 2010 by George Van Antwerp 0 Comments

I continue to get the chance to talk with more and more analysts about the PBM marketplace (see list of PBMs by claims processed).  It teaches me a lot from how they think about and analyze events versus how I see things.  I heard several of them speak the other day.  Here’s my spin on what they collectively said.

  1. The general dynamics are good.  Prescription utilization has continued to go up slightly even with the bad economy.  Mail use has stagnated but still offers value to the market.  The PBM model has continued to be validated and shown proven savings.  There is less client churn.  There is potential growth in covered lives around Medicaid.  There are more generics coming to market.  Specialty continues to grow and with biosimilars will offer opportunities for the PBM.  (see prior post on health reform and the PBMs)
  2. There is a short-term market (pre-2014) and a long-term market (post-2014) positioning for PBMs.  In the short-term, the flow of new generics into the market will drive the bottom line so mail order penetration and ability to convert members to generics thru plan design and education will be important. 
  3. The long-term is a little unknown pending how health reform plays out.  It’s possible (probable) that exchanges do happen.  It’s possible that employers push employees into the exchanges (although the recent waivers impact this).  Then, a government focus and a managed care focus becomes much more important that PBM success in the self-funded market.
  4. The PBMs are making different moves today but the value of those will be obfuscated until post-2014.  Express Scripts is staying very focused on the core PBM business with some moves in China.  CVS Caremark is pursuing an integrated retail-PBM model which leverages the pharmacist and focusing on pharmacogenomics and MinuteClinic.  Medco is leveraging their Therapeutic Resource Centers (TRCs) as a phone-based care model and focusing on pharmacogenomics, several international investments, and several new service companies. 
  5. The managed care companies have looked to outsource PBM (e.g., Wellpoint and Aetna), but if health reform were to drive consolidation in the managed care industry (such that there were 3 large players like in the PBM marketplace), it’s possible that the managed care companies would carve pharmacy back in.  It was interesting that they saw the 10-12 year deals as enough time for the reform and the exchanges to play out giving the managed care companies time to see whether they want to carve these assets back in at that time. 
  6. The PBM tools have been effective but pharmacy is still only 15-20% of healthcare spend.  They saw an opportunity to pull more things under the PBM (e.g., specialty spend in medical, devices) and the opportunity to leverage experience in pharmacy in other areas of healthcare. 
  7. They also talked about the potential Accountable Care Organization (ACO) impact.  Will they become insurers?  How will they be structured?  The final models that prove themselves legally, financially, and clinically will impact the industry.

Some quick thoughts for you.

Healthcare, PBM / Pharmacy, Value Propositions

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

October 7, 2010 by George Van Antwerp 0 Comments

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

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

Pharma Manufacturers Need To “Blur” The Rx

October 5, 2010 by George Van Antwerp 0 Comments

Years ago when I was at Ernst & Young as a consultant, several of the partners wrote a book called BLUR.  The concept (that I took away) was that products and services were being combined into offerings.  That one could not stand without the other.  A quick example for me is General Motors with OnStar, but there are numerous examples out there.

In pharmacy, I think this has been the standard around specialty drugs for years.  Manufacturers produce the drugs and sell them to a pharmacy for distribution.  With that, they provide educational materials, adherence programs, or other “services”.

I think going forward that there is going to be increasing need to differentiate even oral solids (traditional small molecule products) that are less expensive and focus on chronic conditions.  Formularies are only going to get more narrow.  Comparative effectiveness is going to push companies to compare overall outcomes of products.  Why not find a way to wrap a similar service strategy around these medications in a more technology driven, scalable manner?

It seems like a great way to show that not only is your product effective when taken, but that patients on your product are more engaged with their condition and more likely to stay adherent.

Healthcare, Innovation, Marketing / Communications, PBM / Pharmacy, Silverlink, Value Propositions

White Coat Adherence

September 27, 2010 by George Van Antwerp 0 Comments

Do you brush your teeth more before you go to the dentist?

Are you more likely to take your medications the week before you go back for your physician visit?

YES!

But, do we make that clear to the physician? No. When the physician asks if you’re taking your medications, the answer is yes. That’s not a lie. What they need to know is how many pills are left since you last filled your medication? How many pills did you start with? How many did you lose?…

You get the picture. I like the term here that our Chief Medical Officer used – “white coat adherence”.

Now, let’s imagine that the physician orders a blood test for your cholesterol and your LDL hasn’t dropped, there are three scenarios:
1. They go back and really push you on your adherence (or diet and exercise);
2. They believe you but they assume the medication dose isn’t strong enough and increase your dose; or
3. They believe you but they assume the medication isn’t working and change your medication.

These are minimally issues for the healthcare system – wasted costs – but there is also the potential for giving you an unnecessarily high dose or changing you to a riskier medication since the default one didn’t work.

How do we address this? It’s not easy. This involves a few things:
1. Improving physician access to data (i.e., adherence data);
2. Improving physician – patient communications; and
3. Helping patients stay adherent and understand the impact of their medication (and lifestyle decisions) on their health.

I continue to see more and more data on the physician patient gap in communications. This is from a few years ago, but a study showed that 40 to 60% of patients could not correctly report medication expectations 10 to 80 minutes after physicians provided information, AND more than 60% of patients misunderstood prescription directions immediately after doctor visits. (source)

Pretty scary!

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

Auto-Renewal / Auto-Refill Article In Drug Benefit News

September 23, 2010 by George Van Antwerp 1 Comment

Per my prior two posts on this, Drug Benefit News (DBN) published an article today on this topic. Renee talked with me along with several other people to get a perspective on the topic.

Here are a few quotes from the article:

“Auto-refill for prescriptions is all the focus lately,” says George Van Antwerp, General Manager of Pharmacy at Silverlink Communications. “Everyone from the big PBMs to the local pharmacies are encouraging this.” This is because auto-refill programs address one of the common patient-reported issues with adherence — forgetfulness — allowing insurers to “minimize gaps in care.” Auto-renewals, on the other hand, are not considered common practice and many payers are hesitant to implement the service.

Express Scripts, Inc. is one of the few PBMs developing an auto-renewal program, which it will offer through home delivery. “Renewals are much more problematic than refills for patients when procrastination occurs,” Bob Nease, Ph.D., chief scientist at Express Scripts, tells DBN. “If you procrastinate on getting a renewal, it’s not just a matter of calling the pharmacy. You have to get a new prescription with a physician. And if you talk to physicians, they pull their hair out over this issue.”

Others contend that auto-refill and renewal programs may up plan costs by increasing medication waste. The concern is that auto-renewals may result in “provisions of medications that may not be a current active medication therapy or where the patient may have experienced an adverse effect and their drug therapy may have been modified by their physician,” contends Andy Szczotka, senior vice president of corporate clinical services at HealthTrans. “This may lead to potential medication waste and increased member and plan sponsor costs.”

“This is all done under the assumption that you’re improving adherence,” [Jerry] Shipkin [from SXC] says. “But I have not seen solid evidence that this improves adherence.”As an alternative, SXC sends its members auto-reminders with phone calls or e-mails to inform patients about their upcoming refill. “This is a more patient-friendly program,” Shipkin argues. “When you measure patient adherence on this program, it’s just not significantly lower than what you might get on an auto-refill program when you calculate the reversal.”

Van Antwerp contends that auto-reminders aren’t enough. “Everyone does auto-reminder programs,” he says. “In my mind, that’s the minimum that a pharmacy or PBM should do.”In addition, he argues, “anything can lead to accumulation if the patient is not using their medication and refilling their drug on a regular basis.” However, “how many patients do that?” he asks. “Drugs cost money.” While it could drive up more prescriptions, “no one’s going to pay for — and/or pick up — scripts they don’t need,” he maintains.

CVS Caremark Corp. claims its “Ready-Fill” program is “a convenience our members love,” according to Bari Harlam, the PBM’s senior vice president of marketing. The program includes auto-refills and auto-renewals. “There are a lot of people that have trouble being adherent, and this is a service that we offer to our consumers that helps do the work for them,” she tells DBN.

CVS Caremark members enrolled in the program receive notifications about their refill a few days before it’s shipped, and have the option of cancelling the refill. The PBM also calls its members’ physicians to request additional refills. “The physicians’ offices view this as part of the normal workflow, and retail and mail pharmacies are always reaching out to them for particular medications,” Harlam says.

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

JD Power Pharmacy Satisfaction Study

September 23, 2010 by George Van Antwerp 3 Comments

The study came out yesterday. I pulled the data from the executive summary into a powerpoint for all you visual people like me. Some interesting statistics on the value of pharmacy satisfaction and retention. Maybe this will create the business case for more tracking and focus on impacting satisfaction in pharmacy. I think we’ve seen that over the past few years for managed care with individual insurance.

Before you peek, who (pharmacy type) do you think gets the highest average ranking in satisfaction?

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

DEA National Take-Back Day (Prescriptions)

September 23, 2010 by George Van Antwerp 0 Comments

This topic continues to get more attention.  Don’t leave your old medications around for your kids to use.  Don’t flush them down the toilet and into our water supply.  Turn them in for safe disposal.

WASHINGTON, D.C. – The Drug Enforcement Administration and government, community, public health and law enforcement partners today announced a nationwide prescription drug “Take-Back” initiative that seeks to prevent increased pill abuse and theft. DEA will be collecting potentially dangerous expired, unused, and unwanted prescription drugs for destruction at sites nationwide on Saturday, September 25th from 10 a.m. to 2 p.m. local time. The service is free and anonymous, no questions asked.  

For more information, visit: http://www.deadiversion.usdoj.gov/takeback/  

Events, Healthcare, PBM / Pharmacy, Value Propositions

Pharmacists As Answer To PCP Shortage

September 21, 2010 by George Van Antwerp 1 Comment

I think all of us are aware that there is a physician shortage.  Obviously, with several trends, this is a big issue:

  • More patients being covered
  • Increasing prevalence of chronic conditions
  • Increasing complexity of care and the healthcare system
  • Ongoing need for more cognitive care
  • Trends towards accountable care organizations

A few years ago, there was a lot of worry about a pharmacist shortage.  Everything I’ve seen recently seems to say that the pharmacist shortage has been avoided even with increased prescriptions being filled per year.  I believe some of that is associated with more schools.  Some of it is associated with technology enhancements. 

But, will the same happen with MDs…I doubt that it’s that simple. 

If we look at the most trusted professions, pharmacists are usually in the top 5-10 with nurses and physicians.  Combine that with the fact that that medications are the first line strategy for treatment about 90% of the time, and I have to ask why there isn’t more dialogue about leveraging the pharmacist to address the PCP shortage. 

Let’s look at some of the pros about the pharmacist / pharmacy as a central health management resource:

  • Easy access (60,000 pharmacies across the US and typically a pharmacy within 2.5 miles of a consumer)
  • Broad hours (some 24×7)
  • Good integrated data
  • Experience with health management thru MTM
  • Trained in motivational interviewing and other patient mgmt skills

It’s obviously not apples-to-apples, but there seems to be a way to leverage the trend for clinics with NP or PAs and pharmacists into a solution to address the PCP shortage.

Healthcare, PBM / Pharmacy
Newer Entries
Older Entries