Archive | PBM / Pharmacy RSS feed for this section

Why Do People Think Adherence Is So Easy?

I think we all know that medication adherence is a big deal. The most common number quoted is the $290B waste number from NEHI. There are numerous studies that confirm the value of non-adherence even one that just came out.

The amount of money spent on trying to improve adherence is huge! Pharma has worked on. Retail pharmacies have worked on it. Providers have worked on it. Insurance companies have worked on it. Employers have worked on it… And all of these have happened across the world.

At the same time, you see people get so excited about things don’t make any sense to me.

Let me take an easy example. A few months ago, a company called MediSafe put out a press release around moving medication adherence on statins up to 84.25%. Nothing against the company, but I read the press release and reached out to them to say “this is great, but it’s only 2 months of data…most people drop therapy after the first few months so who care…call me back when you get some good 12 month data.”

But, a lot of people got all excited and there was numerous press about this – see list of articles about them.

Now, tonight, I see another technology getting similar excitement. Fast Company talks about the AdhereTech technology which integrates a cellular phone with a pill bottle. And, it costs $60 a month. In my experience, companies wouldn’t even spend $2 a month to promote adherence so $60 is just impractical. The argument is that this is good for high cost specialty drugs that are oral solids not injectables. But, this isn’t a new idea. Glowcaps already built this model with a very slick interface and workflow.

And, I don’t know about you, but I think this would be obnoxious. And, I love data and am part of the QuantifiedSelf movement. I’m not sure I understand the consumer research here. I would have to believe all of the following to buy into this model.

  • Non-adherence people are primarily not adherent due to no reminders to take their medication on a daily basis.
  • People with chronic conditions that require high cost specialty drugs are going to change behavior because some bottle sends them a text message.
  • Manufacturers or some other healthcare company is willing to pay $60 a month for this service.
  • There won’t be message fatigue after a few months (weeks) of messaging.
  • Pharmacies would be have to be willing to change their workflow to use these bottles.

Yes. Will this work for some people…sure. But, if it helps 10% of people, then my cost is really $600 per success.

Should we be working on better solutions to address adherence…of course.

But, let’s stop trying to figure out some gimmick to fix adherence. Let’s look at root cause.

For example:

  • People don’t know why they’ve been given a medication.
  • People don’t understand their disease.
  • People can’t afford their medication.
  • People don’t know what to expect in terms of side effects.
  • People don’t see value in improving adherence.
  • People don’t know they have to refill their medications.
  • People aren’t health literate.

We have a lot of problems.

How Walgreens Became One Of The More Innovative Healthcare Companies

While we are generally a society focused on innovation from start-ups (and now all the incubators like Rock Health), there are a few big companies that are able to innovate while growing.  That’s not always easy and companies often need some catalyst to make this happen.  Right now, there are four established healthcare companies that I’m watching closely to track their innovation – Kaiser, United/Optum, Aetna, and Walgreens.  (Walgreens has made the Fast Company innovation list 3 of the past 4 years.)

I think Walgreens is really interesting, and they did have a great catalyst to force them to really dig deep to think about how do we survive in a big PBM world.  It seems like the answer has been to become a healthcare company not just a pharmacy (as they say “at the corner of Happy and Healthy”) while simultaneously continuing to grow in the specialty pharmacy and store area.

Let’s look at some of the changes they’ve made over the past 5 years.  Looking back, I would have described them as an organic growth company with a “not-invented-here” attitude.  Now, I think they have leapfrogged the marketplace to become a model for innovation.

  1. They sold their PBM.
  2. They re-designed their stores.
  3. They got the pharmacist out talking to people.
  4. They got more involved with medication therapy management.
  5. They increased their focus on immunizations increasing the pharmacists role.
  6. They formed an innovation team.
  7. They invested heavily in digital and drove out several mobile solutions including innovations like using the QR code and scanning technology to order refills.
  8. They’ve reached out to partner with companies like Johns Hopkins and the Joslin Diabetes Centers.
  9. They increased their focus on publications out of their research group to showcase what they could do.
  10. They started looking at the role the pharmacy could play and the medications played in readmissions.
  11. They partnered with Boots to become a much more global company.
  12. They offered daily testing for key numbers people should know like A1c and blood pressure even at stores without a clinic.
  13. They created an incentive program and opened it up to link to devices like FitBit.
  14. They partnered with The Biggest Loser.
  15. They increased their focus on the employer including getting into the on-site clinic space.
  16. They created 3 Accountable Care Organizations.
  17. They partnered with Novartis to get into the clinical trials space.
  18. They developed APIs to open their system up to developers and other health IT companies.
  19. They formed a big collaboration with AmerisourceBergen which if you read the quote from Greg Wasson isn’t just about supply chain.

    “Today’s announcement marks another step forward in establishing an unprecedented and efficient global pharmacy-led, health and wellbeing network, and achieving our vision of becoming the first choice in health and daily living for everyone in America and beyond,” said Gregory Wasson, President and Chief Executive Officer of Walgreens. “We are excited to be expanding our existing relationship with AmerisourceBergen to a 10-year strategic long-term contract, representing another transformational step in the pharmaceutical supply chain. We believe this relationship will create a wide range of opportunities and innovations in the rapidly changing U.S. and global health care environment that we expect will benefit all of our stakeholders.”

  20. They jumped into the retail clinic space and have continued to grow that footprint physically and around the services they offer with the latest jump being to really address the access issue and help with chronic conditions not just acute problems.

With this service expansion, Take Care Clinics now provide the most comprehensive service offering within the retail clinic industry, and can play an even more valuable role in helping patients get, stay and live well,” said Dr. Jeffrey Kang, senior vice president of health and wellness services and solutions, Walgreens. “Through greater access to services and a broader focus on disease prevention and chronic condition management, our clinics can connect and work with physicians and other providers to better help support the increasing demands on our health care system today.” (from Press Release)

This is something for the whole pharmacy (PBM, pharma, retail, mail, specialty) industry to watch and model as I talked about in my PBMI presentation (which I’m giving again tomorrow in Chicago).  It reminds me of some of the discussions by pharma leaders about the need to go “beyond the pill”.

 

Why CVS Caremark Asking For Your Weight Is Good For You

I continue to annoyed by all the fear-mongering in the industry around what CVS Caremark is “doing to their employees”.  What about focusing on how they are helping their employees to get better?  (If interested, you should read some of the information they have on their blog.)

Our “Plan for Health” combines an evolving, best-practice approach to health coverage with preventive care and wellness programs. Our colleagues will be more accountable for taking control of their health and associated costs. The first step is getting to know your numbers by getting a health screening and completing an online wellness review each year. If colleagues complete both by the May 1, 2013 deadline, they will avoid paying an additional $600 for the 2013-2014 plan year. (from the CVS Caremark blog)

I was hopeful to hear someone come out strongly and speak about it yesterday on CBS, but instead the CEO of Mercer just talked about “soft” programs that depend upon consumers being proactive around their health.  I would rather hear about the value of screenings and how it helps employees.  In talking with one friend of mine at a biometrics company, he told me that in one case almost 40% of the people that they identified with diabetes (or pre-diabetes) and hypertension (or pre-hypertension) didn’t know they had the disease (or were at high risk).  That to me is a valuable insight to the individual especially when coupled with a program to help them learn and manage their disease (or risk).

For example, companies for years have been using Health Risk Assessments (HRAs) to try to baseline employee health and use that to accomplish several things:

  1. Help the employee to understand their risks
  2. Identify people who should be in coaching programs to improve their health
  3. Learn about their population and how to improve their health benefits

Use of biometrics is the right evolution from the HRA.  People have tried HRAs for years with some success.  Companies pay as much as $600 for people to take this online survey that has no necessary link to reality.  Most HRAs aren’t linked to lab values.  Most HRAs aren’t linked to claims data.  Most HRAs don’t necessarily trigger enrollment in health programs.  They are supposed to activate the employee to be proactive which doesn’t work for many sick consumers especially those in the “pre-disease” phase.  (Here’s a good study that does show some increased activation.)

As I mentioned the other day, this use of biometrics and link between incentives and participation (and ultimately outcomes) is normal and will ultimately improve the link between the workplace and the employee around health.

Let’s take a broader look at insurance to help set some context:

  • For life insurance, you have to disclose certain data and depending on the policy level you have to do other things like get a physical and have blood work drawn.  That effects your costs and their underwriting.  
  • For car insurance, if you get in accidents, your costs go up.  In some case, you can have a monitoring device put on your car to lower your costs.  (like getting blood work done)
  • For home owners insurance, your costs go up if you live in a flood zone or a earthquake zone.  It also goes up if you have lots of claims.

Whether we want to admit it or not, we do determine a lot of our healthcare costs based on decisions we’ve made or had made for us since we were kids.  Some of these are conscious and some are subconscious.  And, obesity which is a large driver of many of these chronic conditions and has an impact on your likelihood of having cancer.  So, a company asking for your BMI and other data to help understand your risks for healthcare costs (of which they typically pick up 80%) doesn’t seem unusual.

Certainly, some are environmental such as those that live in “food deserts” like Detroit.  In other cases, workplace stress can affect our health.  We’re just starting to get smarter about “sitting disease” and it’s impact on our health.  Or, we may take medications that affect our blood pressure (for example).  It’s certainly important to understand these in context of your lab values and discuss a holistic strategy for improving your health with your physician and any care management resources which are provided to you (nurse, social worker, nutritionist, pharmacist).

This idea of learning more about employees in terms of biometrics, food, sleep, stress, social interaction, and many other data points is going to be more and more of a focus.  Companies want to learn how their employees do things.  They want to understand their health.  They want to improve their health.  They want to invest in their workforce to improve productivity, innovation, and ultimately job satisfaction.

While the glass half-empty people won’t see this and there are some companies that don’t always act this way, I generally believe that companies are trying to act in a way to increase their top line and most intelligent executives understand the correlation between health and wealth and the link between employee satisfaction and growth.

Ultimately, healthcare costs are estimated to put a $240,000 burden on us after we retire (even with Medicare) so if someone wants to help me become healthier and thereby save me money which improves my ability to retire and enjoy life I’m happy for them to do.

A Frustrating Pharmacy Experience Highlights Service Challenges #Fail

We all talk about the challenge of consumer engagement in healthcare.  If we can’t get consumers to engage, we’ll never get them to change behavior or be preventative.

But, as the recent Times article highlights, sometimes engagement still leads to failure which can be very frustrating.  As I think about my recent experience within the pharmacy system, I’m reminded of a comment that I re-tweeted yesterday.

In this case, I have connections which I suppose I could escalate this to, but it seems wrong that the only way to resolve my customer service issue is to call in personal favors from Express Scripts and CVS.

 

 

But, maybe that’s what I’ll have to do.  At this point, the only way I seem to be able to get my medication is to pay cash which seems like a total system failure.  (Thankfully, I can use the GoodRx app to figure out which pharmacies have the lowest cash price for me.)

So, here’s the scenario…

  • On 12/31/12, I requested a refill for my 90-day retail script that was getting filled at my local CVS store.  
  • I got busy and couldn’t go to pick it up until 1/2/13.
  • Obviously, my plan design changed on 1/1/13, and I was no longer eligible for 90-day retail scripts at CVS.
  • I asked the pharmacist to run it as a 30-day script.  They tried numerous times, but for whatever reason, they couldn’t get the 30-day script to go through.
  • I asked them to transfer the script to my local Schnucks (grocery store) pharmacy.
  • I filled the January 30-day script and a February 30-day script.
  • When I came back for my March refill, they were getting a RTS (refill-too-soon) reject from the PBM – Express Scripts.
  • The local pharmacist and I both jumped on our phones and talked to the pharmacy help desk and customer service at Express Scripts and got the same answer…”You should have another 59 days supply based on the 90-day Rx you picked up at CVS on 12/31/12.”
  • I tried explaining to the customer service rep that I never picked it up.  They said that I’d have to solve that with CVS since they show it in the Express Scripts system…which by the way had me very upset that it became my issue to resolve a problem between the pharmacy and the PBM.  The rep went on to explain to me that they don’t talk to retail pharmacies to resolve issues like this.  (This became one of very few times when I was shouting and upset on a customer service call.)
  • My local pharmacist called the CVS store that said they show the original claim, but it shows that they didn’t fill it.  They agreed to try to reverse it again.
  • One complicating factor here which I think is making this worse is that the 2012 plan was with Medco which has since been bought by Express Scripts.  As a new client to Express Scripts, I would assume Medco sent them an open refill file probably on 12/31/12 or 1/1/13.  A reversal after that day might never come over to Express Scripts.
  • So, I posted the above tweet out of frustration over a week ago.  Express Scripts’ social media team quickly followed-up and assigned someone to work the case…BUT, it’s still not fixed.
  • I talked to Express Scripts yesterday, and it was still something they were trying to resolve with CVS.
  • I talked with CVS who confirms that they never filled the script and show it never paid by Express Scripts.  They blame it on an issue with their software vendor that somehow the reversal was caught in the system.  They said it could get resolved in the next 48 hours.

Who knows when this will resolve itself, but everyone seems to be able to blame someone else here.  Never mind that the patient (me) can’t get their medication.  As someone who tries to look at this from the average consumer’s perspective, this is a nightmare and total customer experience failure.  I understand the system.  I understand plan design.  I know the pharmacists.  I know the teams at Express Scripts and CVS.  Even with all that, I’m stuck having to go outside the system, pay cash for my prescription, and hope that my paper claim will get processed and hit my deductible in my plan design.

fail-stamp

 

2013 PBMI Presentation On Pharmacy Need To Shift To Value Focus

Today, I’m giving my presentation at the PBMI conference in Las Vegas.  This year, I choose to focus on the idea of shifting from fee-for-service to value-based contracting.  People talk about this relative to ACOs (Accountable Care Organizations) and PCMHs (Patient Centered Medical Homes) from a provider perspective.  There have been several groups such as the Center For Health Value Innovation and others thinking about this for year, but in general, this is mostly a concept.  That being said, I think it’s time for the industry to grab the bull by the horns and force change.

If the PBM industry doesn’t disintermediate itself (to be extreme) then someone will come in and do it for them but per an older post, this ability to adapt is key for the industry.  While the industry may feel “too big to fail”, I’m not sure I agree.  If you listened the to the Walgreens / Boots investor call last week or saw some of things that captive PBMs and other data companies are trying to do, there are lots of bites at the apple.  That being said, I’m not selling my PBM stocks yet.

So, today I’m giving the attached presentation to facilitate this discussion.  I’ve also pre-scheduled some of my tweets to highlight key points (see summary below).

 

Planned PBMI Tweets

Only 50% Of Healthcare Companies Respond To Twitter Messages – Test Results

12 Of 23 Companies

As I mentioned a few weeks ago (2/2/13), I wanted to test and see if healthcare companies would respond to consumers via Twitter. To test this, I posted a fairly general question or message on Twitter to see the response (see below). Of the 23 companies that I sent a message to, only 12 of them ever responded even after 6 of them received a 2nd message. Those results are shared below. What I also wanted to look at was the average time to respond along with which group was more likely to respond.

  • PBMs – All of the 3 PBMs that I reached out to responded. (This could be biased by my involvement in this space since two of them e-mailed me directly once I posted a comment.)
  • Pharmacies – Only 2 of the 4 retail pharmacies that I reached out to responded.
  • Disease Management Companies – Only 1 of the 3 that I reached out to responded. (I was surprised since Alere often thanks me for RT (re-tweeting) them, but didn’t respond to my inquiry.)
  • Managed Care – 5 of the 7 companies that I reached out to responded. (For Kaiser, they responded once I changed from @KPNewscenter to @KPThrive.)
  • Health Apps or Devices – Only 1 of the 5 companies that I reached out to responded. (This continues to surprise me. I’ve mentioned @FitBit on my blog and in Twitter numerous times without any response or comment.)
  • Pharmaceutical Manufacturers – Only 1 of the 3 companies that I reached out to responded. (This doesn’t surprise me since they are very careful about social media. @SanofiUS seems to be part of the team that has been pushing the envelope, and they were the ones to respond. I thought about Tweeting the brands thinking that those might be monitored more closely, but I didn’t.)

I will admit to being surprised. I’m sure all of these companies monitor social media so I’m not sure what leads to the lack of response. [I guess I could give them the out that I clearly indicated it was a test and provided a link to my blog so they could have chosen not to respond.]

Regardless, I learned several things:

  1. Some companies have a different Twitter handle for managing customer service.
    1. @ExpressRxHelp
    2. @AetnaHelp
    3. @KPMemberService
  2. Some companies ask you to e-mail them and provide an e-mail.
  3. Some companies tell you to DM (direct message) them to start a dialogue.

From a time perspective, I have to give kudos to the Prime Therapeutics team that responded in a record 2 minutes. Otherwise, here’s a breakout of the times by company with clusters in the first day and approximately 2 days later.

Company

Response Time (Hrs:Min)

Prime Therapeutics

0:02

Aetna

1:12

LoseIt

1:19

Healthways

2:07

Walmart

3:01

Express Scripts

8:35

Kaiser

29:22

BCBSIL

47:32

OptumRx

47:39

BCBSLA

48:18

Sanofi

53:30

I guess one could ask the question of whether to engage consumers via Twitter or simply use the channel more as a push messaging strategy. The reality is that consumers want to engage where they are, and there are a lot of people using Twitter. While it might not be the best way to have a personal discussion around PHI (Protected Health Information) given HIPAA, it certainly seems like a channel that you want to monitor and respond to. It gives you a way to route people to a particular phone number, e-mail, or support process.

As Dave Chase said in his Forbes article “Patient engagement is the blockbuster drug of the century”, this is critical for healthcare companies to figure out.

The CVS Caremark team told me that they actively monitor these channels and engage with people directly. I also talked with one of the people on the Express Scripts social monitoring team who told me that they primarily use social media to disseminate thought leadership and research, but that they actively try to engage with any member who has an actionable complaint. They want to be where the audience is and to quickly take the discussion offline.

If you want to see the questions I asked along with the responses, I’ve posted them below…

How Quickly Do Healthcare Companies Respond To Twitter Comments? (Test)

I was intrigued by this test done over in the UK to look at how quickly retailers responded to comments via Twitter (you can see an infographic about similar US data below).  Obviously, more and more consumers are using social media.  And, we know that comments can go viral quickly especially when they’re negative.

“A recent Spherion Staffing Services survey shows that when consumers have a good customer service experience, 47 percent are likely to tell a company representative; 17 percent will express their opinions via social media; and 15 percent will write a review. The same survey from 2010 showed that only 40 percent of consumers were likely to share a great experience with a company representative—proving that consumers are becoming more vocal with companies they interact with. If consumers have a poor experience, 36 percent are willing to write a complaint directly to the company, and one in four will express their opinions on social media. Nineteen percent, the same statistic as last year, will choose to write a review online.” (December 2011 Study)

Of course, some people actively monitor their social media feeds while others view them more as a PR channel.  It also depends on whether the feed management is outsourced or insource and whether it’s monitored by marketing, operations, customer service, sales, or some combined team.

Here’s a good post on measuring response and activity within Twitter accounts.

So, what I’ve decided to do is a Twitter test similar to the one above.  I’m going to post the following to different categories of healthcare companies and see how quickly they respond.

  1. To retail pharmacies:  Are you using social media to handle customer service?
  2. To PBMs:  Are you using social media to handle customer service?
  3. To Managed Care: Where’s the best place to find out about your Medicare products?
  4. To mHealth companies:  Can you share examples of how employers are promoting your products?
  5. To pharma:  Are you doing any value-based contracting with PBMs?
  6. To device companies:  Can you share examples of how employers are promoting your products?

Who do you think will be the fastest to respond?  Will the bigger companies simply have more resources to monitor and staff their teams or with more digital companies be more in tune with social media?

KeepingUpWithTwitter_2

Why We Need Whole Patient Adherence Programs

While prescription adherence continues to be a $290B+ problem, we still address the problem in a drug by drug approach due to silos within our healthcare value chain.

For example:

  • Generic drugs (about 80% of the prescriptions filled) are the lowest cost and most profitable drugs (to the suppliers).  For these medications, you’ll usually have several programs:
    • Refill reminder calls, text messages, letters
      • From the PBM
      • From the retail pharmacy
      • From the mail pharmacy
  • Auto-refill programs
  • Brand drugs are usually higher cost and profitable (to the manufacturers).  For these, you have pharma funded programs such as:
    • Messaging attached to your bill at the pharmacy
    • Letters sent to your house by the pharmacy
    • Specialty drugs which are the highest cost and typically profitable (across the supply chain).  For these, companies often take a higher touch approach:
      • Pharmacy techs calling you
      • Nurses calling you

Additionally, there is additional effort made to keep you adherent if:

  • You’re a Medicare Advantage member in one of the categories where adherence is measured for the STAR metrics program
  • You’re have a condition where adherence is a key metric for HEDIS or some other quality program

For those of us that have studied adherence, you know that this is a multi-factorial issue meaning that there are numerous things that impact your adherence.  Some people will respond to nudging.  Some people need to better understand their disease.  Some people need co-pay relief or patient assistance programs.  Some people need a different medication.

But, the two things we don’t need are:

  • Being treated like a disease not a patient
  • Getting 4, 5, 10 different communications from different parties on different schedules

So, what’s the answer.  There isn’t a silver bullet (which is what we’d all like).  I believe the best alternative is to drive adherence through the disease management and case management companies.  These nurses are treating the patient.  They are discussing their multiple co-morbidities with them.  They are talking about and understanding their barriers.  They should be able to help “prescribe” information and tools to help them with their adherence.

Of course, the issue here is engagement.  If we’re only getting 10% of the patients with chronic illnesses to participate in our programs (which is about the national average – I believe), what about the other 90%.  This is where a care coordination program that incorporated the provider and the pharmacy into a technology solution which pushed gaps-in-care and messaging through the EMR and pharmacy system to drive coordinated solutions is the answer.

I don’t know when this will happen, but I don’t believe we’re going to put a dent in adherence until we think differently about this problem.

CVS Caremark Adherence Study – Is Facebook The Solution To Adherence?

A new study funded by CVS Caremark as part of their ongoing research into medication adherence was recently published.

“Association Between Different Types of Social Support and Medication Adherence,” December 2012 issue of American Journal of Managed Care

In this, researchers reviewed 50 peer-reviewed articles about studies which directly measured the relationship between medication adherence and four categories of social support, including:

  • Structural support – marital status, living arrangements and size of the patient’s social network
  • Practical support – helping patients by paying for medications, picking up prescriptions, reading labels, filling pill boxes and providing transportation
  • Emotional support – providing encouragement and reassurance of worth, listening and providing spiritual support
  • Combination support – any combination of the three support structures detailed above

According to the study, greater practical support was more often linked to improved medication adherence, with 67 percent of the studies evaluating practical support finding a significant association between the support and medication adherence.

It drives some interesting questions as you dig into the actual research.  I sent several questions to Troyen A. Brennan, MD, MPH, who is the Executive Vice President and Chief Medical Officer of CVS Caremark, and heads the research initiative that conducted the study.  Here are his responses:

1. How will this research change CVS Caremark’s approach to medication adherence such as your Adherence to Care program? 

CVS Caremark’s Adherence to Care program is all about engaging patients more consistently and directly to ensure they are following their medication regimes. We understand that our patients’ social networks and communication preferences are diverse, and we know that multi-dimensional interventions help to change behaviors. Given these factors, this research can be an important reference point as we develop new approaches to our adherence programs, challenging us to look beyond traditional engagement strategies in an effort to most effectively support patients on their path to better health. We are planning to test some interventions along these lines in 2013.  As a pharmacy innovation company, we want to make sure we are anticipating patient needs and remaining relevant to them especially given the changing face of social communication and networks.  

2.  The data points required to assess these support factors aren’t readily available in the eligibility file or claims file.  Are you collecting that data at the POS or during the enrollment process and using it in any way to determine the correct intervention cadence or level of effort at an individual level?

While this may not be the standard today, it is clear from the research that a patient’s social network and resulting support can be important factors in helping them take their medications as directed. This research can help us and others in the industry think about how best to incorporate new approaches to identify and leverage social networks for greater medication adherence.  For now, we will rely on POS as a way to collect this type of information.

 

  • 3.  To me, it appeared the data was less conclusive than I would like.  There were lots of conflicting data points and qualitative data.  Do you plan to refine this testing within your population to look at differences across disease states and relative to other factors?

 

This study relied on a comprehensive analysis of current literature linking medication adherence to social support networks – so we recognize that there are limitations in being able to draw concrete conclusions on certain factors, such as disease-specific conditions. Regardless, we still believe these findings – which look at clinical, peer-reviewed studies – contribute to the knowledge base in our field. As with all of the research we conduct, we challenge our teams to consider how we might be able to use the information to find practical supports for patients, while at the same time contributing to awareness about the implications of adherence on the broader health care landscape. The best way to understand this research is as hypothesis generating, which we can use in the design of real interventions that we can then test definitively in subsequent studies.

4.        Some of these social factors might be correlated with depression.  Was there any screening done to look at how depression as a co-morbidity might have affected adherence rates?

The methodology of this study relied on literature review and analysis of fifty peer-reviewed research articles which directly measured the relationship between medication adherence and forms of social support. A full review of the medical conditions associated with these studies can be found in Appendix 1. While depression, alone, was not one of the conditions featured in these studies, several did look at mental health conditions and the linkage between adherence and social networks. We did not however stratify by existence of depression—it may be a factor we have to take into account in future studies.

5.   The one thing that I read between the lines was the need for a caregiver strategy.  This has been missing in the industry for years.  Does CVS Caremark have an approach to engaging the caregivers?

 

Our study found that practical support such as picking up prescriptions, reading labels and filling pill boxes – all within the realm of a given caregiver’s role – were the most significant in driving greater adherence. Considering this finding, and acknowledging the role caretakers have in the lives of our patients, there is certainly space for us to develop solutions that engage caretakers more effectively. Recent analyses of “buddy” programs do suggest such interventions do work- -we just need to consider how to scale it.

 

  • 6.        With all this talk about social networks, it naturally leads you to a discussion about Facebook (or Google+).  Neither of them have big focuses in the healthcare space.  In your opinion, will these tools offer an intervention approach for changing behavior around medication or will that be occur at the disease community level in tools like PatientsLikeMe or CureTogether where there’s no social bond but a connectivity around disease? 

 

 The role of social media has changed the way we communicate and connect with one another dramatically over the past decade. What we can say, based on this particular study, is that the more practical the support, the more significant the impact on medication adherence. Perhaps further studies looking into solutions that effectively combine online/social media platforms to complement practical support would help clarify their impact on medication adherence.

If interested, here are some of their other presentations on adherence:

How Farmers Outmarketed Pharma

When you think of potatoes, where do you want them to come from? Idaho

When you think of citrus, where do you want it to come from? Florida

When you think of US wine, where do you want it to come from? Napa Valley

When you think of generic drugs, where do you want them to come from? [company?, geography?]

This vacuum is a big problem in terms of commoditization. People don’t think of Teva or Ranbaxy or some other generic company. The average consumer probably doesn’t know who they are. And, they’ve competed based on price for years. If I was the CEO of Teva, this would be the number one challenge I would pose to my staff which was how do I get consumers to ask for my generic version of the drug. The next question should be what would we do to justify this?

For the first time, I think that they have a similar problem that brand pharma does which is how to create an offering not just a pill. The quote below from the CEO of Novartis, tees it up well.

“I also started to shift our business away from a transactional model that was focused on physically selling the drugs to delivering an outcome-based approach to add value beyond just the pill. I really believe that in the future, companies like Novartis are going to be paid on patient outcomes as opposed to selling the pill.”

And, I think this reflects what Sanofi has been experimenting with in terms of diabetes for several years. They launched their iBG Star Blood Glucose Meter to get into the meter space. Sanofi also has heavily invested in social media to give them direct engagement and feedback from consumers. Both of these begin to create more consumer branding for them as an entity.

I’ve talked about this several times over the years based on a book that one of the E&Y partners wrote when I was there called BLUR which was about blending products and services to create offerings. I think this notion combined with the lessons learned that commodities like potatoes have gone through in branding their products offer some insights into what pharma has to do to shift their positioning in the value chain. This is part of what I’ll be discussing at the upcoming PBMI conference where this shift to outcomes based contracting and focus for the industry is critical to long-term survival and differentiation.

How To Improve Good Cholesterol (HDL) If Drugs Don’t Work

The Wall Street Journal on 1/8/13 had an article called “New Rules for Boosting Good Cholesterol” which shared the results of a recent study on medications that improve HDL (or Good Cholesterol).

“Not all HDL are created the same” was what Roger Newton, chief science officer of Esperion said.

“If you raise HDL in non-pharmacologic ways, it really does help you” says Steve Kopecky, a Mayo Clinic cardiologist.

The points made in the article can be summarized in the following:

  • Improving good cholesterol is important.
  • People with high HDL face fewer heart attacks (according to the Framingham Risk Score)
  • Multiple trials to improve HDL with drugs have failed
  • People may need to raise good cholesterol by behavior change

This should lead to 3 questions:

  1. What should be my HDL or Good Cholesterol? From the Mayo Clinic on Good Cholesterol:

  1. What can I do to improve my Good Cholesterol without drugs? From the WSJ article:

Activity

HDL Increase

Exercise

4 mg/dL

Drink Alcohol (in Moderation)

2-4 mg/dL

Quit Smoking

5 mg/dL

Lose Weight

1 mg/dL per 3-6 lbs

Eat Fish And Olive Oil

3-5 mg/dL

Avoid Carbohydrates

8 mg/dL

  1. What are my risks and the value of medications? For that, I found two online risk tools.

Here’s a simple one that uses the Farmingham study to estimate your risk of having a heart attack.

Here’s another one from over in Europe that’s focused on the value of statins and hosted by the Cleveland Clinic. It takes more inputs but then gives you several outputs. (A nice algorithm to integrate with something like iBlueButton or your care management system perhaps to warn you of risks without having you input a bunch of data.)

Court Decision Allows Pharma Reps To Discuss Off-Label Uses Of Prescriptions

I must admit that I’ve heard very little about this decision from the Federal Appeals Court for the Second Circuit of Manhattan that decided that discussing off-label uses for prescription drugs was an issue of free speech. This could change the way pharmaceutical manufacturers interact with physicians. It could change the job of the pharmaceutical rep. It could change how clinical trials are done. It could change how prescriptions are used. It could also lead to a whole new set of prior authorizations by companies that actually have to actively manage off-label usage as it becomes widespread.

On the other hand, I wonder if this door hadn’t already been opened. Have you looked at some of the peer-to-peer (P2P) healthcare websites out there or the disease based communities (e.g., PatientLikeMe or CureTogether)? Patients are already talking about what medications they are using to treat their diseases and their symptoms. Don’t you think those are leading to requests to the provider and discussions with them about off-label utilization?

And, I’m sure that Dr. Google has helped many patients identify other uses of medications. This process (to the best of my knowledge) is completely un-managed. It’s a popular enough topic that Consumer Reports talked about it earlier this year and even put together the following table on drugs commonly used off-label.

Specific drug, type of drug Examples of off-label use**
Aripiprazole (Abilify), antipsychotic Dementia, Alzheimer’s disease
Tiagabine (Gabitril), antiseizure Depression
Gabapentin (Neurontin), antiseizure Nerve pain caused by diabetes, migraines, hot flashes
Topiramate (Topamax), antiseizure, in combination with phenteramine for weight loss Bipolar disorder, depression, nerve pain, alcohol dependence, eating disorders
Risperidone (Risperdal), antipsychotic Alzheimer’s disease, dementia, eating disorders, post-traumatic stress disorder
Trazodone (Desyrel), antidepressant Insomnia, anxiety, bipolar disorder
Propranolol (Inderal), high blood pressure, heart disease Stage fright
Sildenafil (Viagra), erectile dysfunction To enhance sexual performance in people not diagnosed with erectile dysfunction, to improve sexual function in women taking certain antidepressants
Quetiapine (Seroquel), antipsychotic Dementia, Alzheimer’s disease, obsessive-compulsive disorder, anxiety, post-traumatic stress disorder
SSRI antidepressants such as paroxetine (Paxil) and sertraline (Zoloft) Premature ejaculation, hot flashes, tinnitus (ringing in the ears)
Prazosin (Minipress), high blood pressure Post-traumatic stress disorder
Amitriptyline (Elavil), antidepressant Fibromyalgia, migraines, eating disorders, pain after shingles infection
Bevacizumab (Avastin), certain types of cancer Wet age-related macular degeneration (eye disease)
Statins such as atorvastatin (Lipitor), simvastatin (Zocor), high cholesterol in adults, children with an inherited cholesterol condition Rheumatoid arthritis, to lower cholesterol in children who lack the inherited condition
Clonidine (Catapres), high blood pressure Smoking cessation, hot flashes, attention deficit/hyperactivity disorder (ADHD), Tourette’s syndrome, restless legs syndrome

* Not meant to be a comprehensive list. Many of the drugs listed here are also available as generics.

** Does not imply that use is clinically appropriate or inappropriate, or beneficial or not.

***To find out if a drug’s off-label use is supported by evidence, click on the medication name.

 

I would imagine that pharma is going to tip-toe through this open door not simply crash through it. They’re generally risk adverse so their discussions of off-label utilization will be fact-based (to limit exposure) even if (as we all know) statistics can lie. I would suspect (as I’ve seen on other blogs) that this will ultimately go to the Supreme Court before anyone really takes advantage of it.

I guess I’d also point to the issue that physicians have responsibility here. They prescribe off-label today. Here’s what the FDA says about this:

Good medical practice and the best interests of the patient require that physicians use legally available drugs, biologics and devices according to their best knowledge and judgement. If physicians use a product for an indication not in the approved labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain records of the product’s use and effects. Use of a marketed product in this manner when the intent is the “practice of medicine” does not require the submission of an Investigational New Drug Application (IND), Investigational Device Exemption (IDE) or review by an Institutional Review Board (IRB). However, the institution at which the product will be used may, under its own authority, require IRB review or other institutional oversight.

One way to begin to manage this would be to require the use of diagnosis codes (Dx) on all prescriptions. This would at least great a way of tracking how the medications are being used and allow for better technology oversight across the provider, payer, pharmacy, and PBM.

In the interim, Consumer Reports suggest consumers do the following:

  • When your doctor prescribes a drug, ask if it’s an approved use. If he or she doesn’t know, ask your pharmacist.
  • Check for yourself. Go to DailyMed (dailymed.nlm.nih.gov/) and search for the drug. Then click on the tab for “Indications & Usage” to see if your condition is listed.
  • If it’s an off-label use, ask your doctor if it’s supported by well-designed trials showing significant improvement for people with your condition.
  • Ask your doctor why he or she thinks the drug will work better than approved drugs for your illness.
  • Find out if your health insurer covers payment for the off-label use. Some may require evidence of effectiveness or failure with conventional treatments, especially if the drug is expensive.

Are Females More Or Less Adherent? Big Data Question

FICO adherence image

Certainly, the push around Big Data should drive more companies to look into predictive algorithms.  You already have Fair Issac (above), ScreenRx by Express Scripts, and RxAnte.

I’d always been under the impression that women were less adherent than men to prescription drugs.  I’d heard several very logical reasons:

  1. As the caregiver, they often took care of their children, spouse, and/or other people first before being adherent themselves.
  2. They took more medications on average which is highly correlated with non-adherence.

But, some researchers recently told me that their data showed women to be more adherent.  And, I then noticed that the infographic that Express Scripts put together showed something similar.  (see zoomed in picture)

Express Scripts Adherence Infographic Zoom

So which is it?  I can find lots of research online to support females being less adherent.  Here’s a few links:

BTW…If you want to see a good presentation on some adherence data from CVS Caremark from a few years ago, you can follow this link to a presentation that was given.  Here’s a more recent one from URAC.

Are You Going To The 2013 PBMI Conference?

Are you going to this year’s conference (February 18-20th) in Las Vegas? I’ll be presenting again this year, and I hope to see some of you there. If you’ll be there, let me know and we can connect.

This year, I’m going to talk about one of my favorite topics which is how the pharmacy industry needs to transform itself. This touches on several topics which I’ve blogged about multiple times:

  • Health reform and ACOs
  • Turning data into wisdom
  • Predictive models
  • Coordinating medical and pharmacy data
  • The role of the pharmacist in the broader care team strategy
  • Consumer engagement as fundamental to healthcare
  • Outcomes-based contracting
  • Population health management
  • Consumer experience

Do you have a specific example of how you see companies (pharma manufacturers, PBMs, or pharmacies) transforming from a traditional Fee-For-Service (FFS) model to an outcomes based model in terms of payment and how that is changing the way they do business? I’m always interested in learning more.

Here’s the official description from the brochure for the conference.

Pharmacy — Data, COEs, Predictive Models, and Consumer Engagement

George Van Antwerp, Vice President, Product Development, inVentiv Medical Management

ACPE UAN 0221-9999-13-009-L04-P 1.0 Knowledge-based contact hour

Pharmacy is the most used benefit, and for most chronically ill patients, they take multiple medications per day and interact with their pharmacist/pharmacy frequently. With the transformation in healthcare to an outcomes-based focus, PBMs, pharmacies, and pharma are looking at new models and new ways to work with payers, providers, and patients to be part of the care team. We will explore how companies are using this data and technology to intervene, change behavior, and improve outcomes from a broader population health management perspective.

Infographic: Improving Primary Care With Pharmacists

This is an infographic on an interesting program out of USC which received money from the CMS innovation fund.

Infographic Expanded Role Of Pharmacists

Updated: What Is A PBM? Pharmacy Benefit Manager

The short answer is that a PBM is the company hired by your employer (either directly or through your health insurance company) to manage your pharmacy benefits.  When you use your pharmacy card at the retail pharmacy to get a prescription, the pharmacy interacts with your PBM electronically to find out if the drug is covered and the copay to you the consumer.

*****************

Back when I first started blogging, I used a lot of my experiences at Express Scripts to shape some of my perspectives about the PBM or Pharmacy Benefit Manager industry.  It took me a few months before I realized that some people reading the blog didn’t know what a PBM was.  That led me to my all time most popular blog post – “What Is A PBM?

Since that was over 5 years ago, I figured it was time for an update.

The market has shifted in the past 5 years especially with Express Scripts purchase of Medco to become the largest player in this space.  Walgreens has also divested their PBM to CatalystRx which was then bought by SXC and the new entity renamed CatamaranRx.  At the same time, you’ve seen United Healthcare insource their PBM business from Medco to combine it with their old Pacificare PBM to create OptumRx.  You’ve also seen Humana’s PBM business and mail order business – RightSourceRx – grow significantly.

There are other big PBMs which I didn’t mention such as CVS Caremark which after years of rumors about them splitting back up seems to have proven their case as an integrated, retail-owned PBM.  There is MedImpact which has 32M lives according to the latest PBMI market share report, and Prime Therapeutics which is a PBM owned by several of the BCBS plans.  Additionally, Aetna, Cigna, and several other managed care companies also have their own PBMs.

While I would have argued that the PBM wasn’t typically known to consumers 5 years ago, I think that the very public dispute between Walgreens and Express Scripts has changed some of this.

But, what a PBM does is relatively simple:

  • Process pharmacy claims (i.e., when you go to your retail pharmacy, the pharmacist enters your prescription and electronically submits it for adjudication. The claim is routed to the PBM where it is checked for eligibility and then to see if it pays and what copayment you owe.)
  • Set up pharmacy benefits (i.e., based on the plan selected by your employer or payor, the PBM codes what drugs are covered and the copayment structure).
  • Administer rebates…since large pharma companies (e.g., Pfizer) pay rebates for having their drugs on formulary (aka preferred drug list), someone has to manage the negotiations and billing of this.
  • Set up clinical programs (i.e., most PBMs have a clinical committee which evaluates new drugs and looks at market data to help employers choose coverage options).  This also includes programs to look for drug-drug interactions and pharmacy adherence.
  • Establish a retail pharmacy network (i.e., work with retailers to get them to agree to discounts on drugs) and are a big part of SureScripts which is the hub to enable electronic prescribing between physicians, pharmacies, and PBMs.
  • Communicate with patients and physicians (i.e., look at pharmacy claims data and help find ways to save money or identify clinical issues to inform the patient or physician about).
  • Provide cross pharmacy data for drug-drug interactions…this is a critical function since many people use more than one pharmacy for claims.
  • And, last but not least, most PBMs provide a mail order and often specialty pharmacy where they ship prescriptions to patients.

The PBM’s clients are employers who are self-insured, government entities (i.e., state employees, Department of Defense), unions, TPAs (third party administrators), and managed care companies (i.e., BCBS of).

PBMs are sometimes referred to as middlemen, but I will point to a few other posts on this:

In general, if you’re looking for more information on PBMs, I would point you to several sources:

The only other blogger who really offers any coverage of this space is Adam Fein which his blog – Drug Channels.

What Do MDs Tell Patients About Their Rx … with only 99 seconds?

As part of a new study mentioned on The Doctor Weighs In, it shows that physicians spend an average of 10 minutes and 10 seconds with patients in an average visit.  Of that, 99 seconds (or 16% of the time) they are discussion prescriptions.  The big question is what are they discussing.

MD Rx discussions

A 2006 study showed the following:

74 percent of the doctors mentioned the trade or generic name of the medicine, and 87 percent stated its purpose. Sixty-six percent said nothing about how long to take the medicine, 45 percent did not say what dosage to take and 42 percent failed to mention the timing or frequency of doses. Physicians mentioned adverse side effects only 35 percent of the time.

Of course, research on the physician and patient dialogue around prescriptions should also include looking at these studies:

That is asking a lot of the money spent by the manufacturers on the physicians.

Detailing to physicians, nurse practitioners, and physicians’ assistants cost $12 billion, accounting for more than half of that promotional spending (see Figure 1). Drug companies spent another $3.4 billion sponsoring professional meetings and events and about $0.4 billion placing advertisements in professional journals. Pharmaceutical manufacturers spent the rest of their promotional budgets, $4.7 billion in 2008, on direct-to-consumer advertising.

Diabetes Innovation – mHealth; Quantified Self; Business Model

I’m not a diabetic, but I’ve been researching the topic to understand the space and what innovation is occurring around diabetes. This is a space where there are lots of applications, tools, devices, communities, and research. The ADA estimates the total US cost at $218B with very high prevalence. If you expand that on a global scale, the costs and impact is staggering.

  • Total: 25.8 million children and adults in the United States—8.3% of the population—have diabetes.
  • Diagnosed: 18.8 million people
  • Undiagnosed: 7.0 million people
  • Prediabetes: 79 million people*
  • New Cases: 1.9 million new cases of diabetes are diagnosed in people aged 20 years and older in 2010.

So, what’s being done about it? And, what opportunities exist? I think you’ve certainly seen a lot of innovation events being sponsored by pharma and others.

You’ve seen a shift from drug to engagement for a few years as evidenced in this old post about Roche – http://www.diabetesmine.com/2009/10/a-visit-to-the-roche-new-concept-incubator.html

You’ve seen a proliferation of diabetes apps. (A prime opportunity for Happtique.)

From my traditional PBM/Pharmacy focus, you’ve seen several efforts there:

Obviously, Medco (pre-Express Scripts acquisition) thought enough of this space to buy Liberty Medical.

I pulled some screen shots and examples into a deck that I posted on SlideShare. I’d welcome people’s thoughts on what’s missing or what are the key pain points from a diabetes perspective (e.g., not integrated devices).

While I was doing my research, I found a few interesting things worth sharing.

Several interesting studies:

Some good slide decks:

Additionally a few videos:

I also posted some diabetes infographics on my blog – https://georgevanantwerp.com/2012/12/13/more-diabetes-infographics/

And, while I started to pull together a list of diabetes twitter accounts below, you can follow @AskManny’s list with 360 people already tagged in it. https://twitter.com/askmanny/diabetes

My starting twitter List:

My Top 11 Healthcare Predictions For 2013

It’s always fun to predict what will happen in the next year. No one is ever right, but you can hope to be directionally correct. With that in mind, here’s a few of my thoughts for what will happen in 2013…

  1. Reform (PPACA aka ObamaCare) will happen. While the Republicans will fight it, with Obama’s re-election and the Supreme Court decision. Reform will continue to happen. The states will mess up the Exchanges which will create many issues, but private exchanges will come to the “rescue”.
  2. Big Data” will be a focus at every healthcare company. What data to store? How to mine the data? What data to integrate? How to bring in unstructured data such as physician’s notes? What to do with consumer reported and consumer tracked data from all the different devices?
  3. Physicians will emerge back in the power seat. With Accountable Care Organizations and Patient Centered Medical Homes, consumers are finally becoming more aware of all the shortcomings in our sick care system. They trust their physicians although somewhat blindly given ongoing challenges with evidence-based care and quality which are often the result of our Fee For Service system (too little time) combined with an abundance of new research happening concurrently.
  4. mHealth will be the buzz word and exciting space as entrepreneurs from outside healthcare and people with personal healthcare experiences will attempt to capitalize on the technology gap and chaos within the health system. This will create lots of innovation, but adoption will lag as consumers struggle with 15,000+ apps and the sickest patients (often older patients) are the slowest to adopt.
  5. Device proliferation will go hand in hand with mHealth and with the Quantified Self movement. This will create general health devices, fitness devices, diabetes solutions, hypertension solutions, and many other devices for wellness and home monitoring for elderly patients. Like mHealth, this will foster lots of innovation but be overwhelming for consumers and lead to opportunities for device agnostic solutions for capturing data and integrating that data for payors and providers to use.
  6. The focus on incentives will shift in two ways. Technology vendors will begin to look more and more at the gamification of healthcare and how to use gaming theory and technology to drive initial and sustained engagement. At the same time, the recent ruling will allow employers to shift from rewards to “penalties” in the form of premium differentials where patients who don’t do certain things such as take biometric screenings or engage with a case manager will pay more. In 2014 and 2015, this shift will be from penalties with activity to penalties tied to outcomes.
  7. Consumer based testing will drive greater regulation. With the focus on home based testing (e.g., HIV or High Cholesterol) and the increased interest in genetic testing especially when tied to a medication, the FDA and other government agencies will have to address this market with new regulations to close gaps such as life insurance companies being able to force disclosure of genetic testing in order to get coverage (even though the testing isn’t necessarily deterministic).
  8. Clinics will prepare for 2014. With the increase number of consumers being covered in 2014, there will be an access challenge for patients to see a provider. This will drive buildout and utilization of health clinics such as TakeCare or MinuteClinic. Clinics will have to look at how to adapt their workflow to create a patient relationship which will create potential integration points with TeleHealth and bring back up the issue of whether they should or could replace the traditional Primary Care Provider (PCP) relationship or not.
  9. Telemedicine will hit a tipping point and begin to Cross the Chasm. They now have better technology and adoption within major employers. This will start to create more and more business cases and social awareness of the solution. With utilization, we will see great adoption and the increasing use of smart phones for healthcare will drive telemedicine into an accelerated growth stage.
  10. Transparency solutions will continue to be a hot area with CastLight and Change Healthcare leading the way. Their independence and consumer engagement approaches based on critical moments (i.e., pointing out how to save money on Rxs just before a refill) and using multiple channels will show high ROI which will also increase broader healthcare awareness making them part of the population health solution.
  11. Generics will no longer be a talked about issue. With generic fill rates running so high across different groups and being front page news, PBMs, pharmacies, and pharma will truly begin to move forward to embrace the specialty market with a clear vengeance (at least in the US).

There are still a few longer term trends that I’m watching, but I don’t think that 2013 is the primary year for them.

  1. The evolving role of pharmacists within the Medical Home and with vaccines.
  2. A significant shift from mail order to 90-day at retail fulfilled by massive central fill facilities.
  3. Pharma co-opetition where they begin to collaborate at the disease state level realizing the a rising tide is good for all boats.
  4. Integration of data from all types of solutions and actions into workflow triggers that automatically create new events within the care management infrastructure using Service Oriented Architecture and Business Process Management.

Kroger Expansion – Digital, Physical, Strategic, and Specialty Pharma … Oh My!

Since one of my first jobs was at Kroger, I’ve always been intrigued to see what happens with them. (I can even still go back almost 30 years later and still have some of the General Managers at my old store come out and remember me.) So, I was initially intrigued a few weeks ago when the story came out in Drug Store News about their expansion plans.

“Over the course of a day-long investor conference Tuesday, Kroger outlined its future growth strategy. Across its physical store base, Kroger plans to enter one or two as-yet-to-be-named new markets along with boosting presence in existing markets. But Kroger also has significant designs on the multichannel consumer, and outlined for analysts the grocer’s plan to grow its marketshare across the digital landscape as well.”

Kroger has several interesting assets to leverage:

Now, with today’s announcement, they’ve made a jump into the Specialty Pharmacy Space with their acquisition of Axium. It begs the question of what they want to be – a grocer with a pharmacy, a pharmacy with groceries, a health destination, or something new.

Looking at some JD Powers data from 2010, they are positioned in the middle of the pack from a pharmacy satisfaction perspective.

On the other hand, if I look at their positioning from Bruce Tempkin’s analysis, they score well.

I have to believe there’s some great opportunity here. I’m a big believer that the retail assets create large opportunities for them to play in the broader healthcare market.

  • They have broad hours (in some cases 24/7).
  • They are natural destinations for people.
  • They can host clinics.
  • They already have pharmacies.
  • They have food which is a critical part of addressing obesity and for certain conditions like hypertension and diabetes.
  • They have patient specific data around things like home monitoring tests, food products, OTCs, and other products.
  • They are generally located in easy access locations.
  • They have good brand equity.

For example, just look at this press release from Target from a few years ago. This is a broad vision (that I’ve never heard or seen in the market). On the flipside, we know that CVS, Walgreens, and WalMart are spending considerable efforts trying to really “own” this space with their teams. We also know that specialty pharmacy (and even pharma in general) is trying to see how it gets out of its box and become broader players in the health continuum looking beyond just drugs to actual outcomes. (This is why healthcare is so exciting right now!)

Less Than 20% Trust A Pharmacist To Help Them Make Healthcare Decisions – Surprising?

Whenever you go to the pharmacy, they always ask you if you have questions and make you sign off that you were offered counseling.  It begs the question of whether anyone actually does.  I just got this survey data e-mailed to me, and I wanted to share it since it was surprising to me and from RxAlly

I also found it surprising that people don’t think their pharmacist can help them make healthcare decisions.  This is certainly relevant in the Medicare world where AARP and others have partnered with pharmacists traditionally.  Additionally, I think it limits some of the longer term opportunities for pharmacy, pharmacists, and PBMs.  I’ve always thought that given their frequency of patient intervention that there would be lots of opportunities to leverage the pharmacist at the POS to close care gaps and be very engaged in the overall care and driving health outcomes. 

Only 15 percent of U.S. adults have ever discussed a medication maintenance regimen with a pharmacist and only 49 percent have discussed any new medication with a pharmacist. Less than 20 percent (18%) of U.S. adults trust a pharmacist most to help guide and inform healthcare decisions for themselves and their families. A majority of people trust their doctor most (72%), followed by friends and family (36%), spouses or significant others (36%) and the internet (22%).

Source: RxAlly
http://rxally.com/rxally-news.html

Express Scripts Study: 89% Of Consumers Don’t Know How Adherent They Are

So much for self-reported data.  In the recent Drug Trend Report by Express Scripts, they mention a study they did looking at patient self-reported adherence and comparing it to actual adherence.  (I can’t believe no one had done this before.)  89% of the consumers incorrectly reported that they were taking the medication as prescribed.  For years, I’ve used two separate studies to point out that this gap had to exist, but it was not done on the same population. 

This is critical to any care manager or anyone else talking to the patient.  If you trust their perspective on adherence, you’re likely overestimating it.  In some cases, this might not be materials, but some of the gaps are significant.  Therefore, integrating pharmacy data to get to a true MPR (medication possession ratio) or PDC (percentage of days covered).

Change.org Petition Regarding Pharmacists

Someone posted a link to this in LinkedIn.  For those of you in the pharmacy world, pharmacists, PBMs, and even medical professionals that work with them, this seems very relevant.  We all know the value that pharmacists bring to the over all care team.  With that in mind, I signed the petition and thought I would share it here.

(BTW – I’ll admit that I thought the Medicare legislation did recognize pharmacists.)

**************************

Recognize pharmacists as health care providers!!!

Greetings,

I just signed the following petition addressed to: Congress.

—————-
Recognize pharmacists as health care providers!!!

Despite overwhelming evidence of the positive impact pharmacists can have on patient health, pharmacists are not recognized as healthcare providers under the Social Security Act and, therefore, cannot be paid by Medicare for therapy management and patient consultation services. The Social Security Act does recognize other healthcare professionals such as dieticians, nurse practitioners, physician assistants, nurse midwives, and clinical social workers.

By changing the compensation structure allowed under Medicare, we can ensure that patients have access to the medication expertise of pharmacists. Studies have shown that when a pharmacist is directly involved in patient care, patients have fewer adverse drug reactions, experience improved outcomes, and healthcare costs are reduced.

The perils of adverse effects from taking multiple medications affect all age groups. According to a recent survey, just over half of all Americans take at least 2 medications each day and nearly one-third take 4 or more medications each day. For the Medicare population, medication use is even higher — nearly half of Americans aged 65 and older take at least 4 medications each day.

This is a critical safety issue!!
—————-

Sincerely,

George Van Antwerp

When Is It Good To Pay 300% Profit For A Medication?

Another interesting discussion at this Oncology event was about physician reimbursement for drugs.  In Oncology, one historical source of revenue (~50%) for physicians has been the medications they dispense and administer in their offices.  And, depending on who you believe, this has some degree of influence on what drugs they dispense.

The problem that was discussed is that today’s reimbursement model is ASP (Average Selling Price) plus 6% mark-up.  This assumes that everyone buys at some price near that average which by definition means that not everyone does.  One of the presenters suggested that physicians lose money on about 20-25% of the drugs they dispense and that it would need to be ASP + 12% for them to be positive on every drug.  (I don’t know the math here and am simply sharing the dialogue as I found it very intriguing.)

The examples that they kept talking about in several presentations were that for a generic drug that costs $40 then their margin is theoretically $2.40 (6%) versus for a brand drug that’s $4,000 where their margin is $240 (or 6%).  The suggestion was that if generics were reimbursed at 200-400% of ASP then it would take this economic factor out of the oncologists influence (when conscious or subconscious). 

It’s an interesting debate.  (Here’s some comments from another conference on this topic.)

On the flipside, some of this may go away with oral oncolytics being more common in the future (and therefore being more likely to be controlled by the PBM) although companies will look to enable in-office dispensing of these drugs also to help the physician from losing this income. 

The other strategy being pushed has been called “brown bagging” where the patient is directed to obtain their medications from a specific specialty pharmacy and then bring those to the oncology practice for them to use.  This eliminates the “buy-and-bill” approach but is not something that the physicians like (from what I know). 

At the end of the day, I don’t really care.  I think there are several key principles that if met would make me neutral to any solution:

  1. Are decisions made in the patient’s best interest or do financial implications impact clinical decisions?
  2. Is the safety of the patient impacted in any way?
  3. Is the patient experience impacted negatively in any way?

Shifting Spend In Pharmaceutical Spending

Pharmaceutical manufacturers are dealing with massive shifts in their industry – less blockbuster drugs, more generics, emergence of different global markets, a greater payor emphasis on outcomes and adherence, less interaction with sales reps, more use of biologics, and the emerging biosimilar opportunity.

All of that is causing a massive shift in where they invest.  In some cases, you’re seeing manufacturers invest in devices (e.g., Sanofi diabetes device) or into education and content at a disease (not drug) level or even in mHealth (e.g., Boehringer and Healthrageous). 

With that in mind, I found this Booz & Company survey interesting in highlighting how their shift in spending is changing.

$WAG and $ESRX Reach New Pharmacy Deal!

Wow!  Finally! 

Those are my immediate reactions.  I just saw the news that Walgreens and Express Scripts have reached a new pharmacy deal effective 9/1/12.  I’m sure there are lots of consumers that will be happy about that and a few competitive PBMs that will be disappointed. 

A few things that this makes me think about:

  • The Walgreen’s shareholders will be happy.
  • Both parties can claim some victory by holding out so long.
  • I imagine that the limited network was working ok, but there wasn’t huge adoption.  It was probably also an issue in RFPs and with consultants.
  • Other PBMs were likely using this in selling against Express Scripts so they’ll be disappointed.
  • Obviously, the Medco contract with Walgreens was the big catalyst here.  Letting that transition to a point where they didn’t get any Medco or Express Scripts patients would be a disaster.
  • Will this change Walgreens collaboration with the NCPA against the PBMs and mail order or is that just the natural conflict here?

The biggest battle now will be around customer retention and winback.  Can Walgreens get their old Express Scripts patients to come back?  Can CVS and others hold on to the patients?  This will really test the theory about customer loyalty in the pharmacy space. 

The other interesting thing here is that this pushed Walgreens to really re-evaluate their strategy and market positioning.  Will they emerge as as stronger and different company because of this 9 month period.  I would think so, but that is still TBD.

The Express Scripts 2011 Drug Trend Report – Full of Infographics

Those of you that have been readers for a few years know that I love to read and summarize these reports. They provide a huge set of aggregated data and summarized information that is useful in creating business cases and identifying trends.

This year is no different although the graphics within the Express Scripts Drug Trend Report continue to get better … ala infographics (as they even posted one recently on their blog).

So, what caught my eye this year…

  • There was one ex-Medco person who signed off on the intro letter…and interestingly (compared to other DTRs), no George Paz signature.
  • They have a big picture of their Research & New Solutions Lab upfront (see below). It reminds me of the NOCs (Network Operations Centers) that I had at my past 3 employers. [Maybe one day before I move out of St. Louis they’ll take me on a tour.]

  • I was definitely interested to hear what they would say about Walgreens. They tackled it early on in the document.

Our 2011 retail-network negotiations marked another milestone in our heritage of independence from pharmacies and alignment with our plan sponsors. One retail pharmacy chain, Walgreens, was unwilling to offer rates and terms consistent with those of the market, and instead opted to leave our pharmacy network at the beginning of 2012. Although we remain open to Walgreens being part of our pharmacy network in the future, the positive reaction we received from plan sponsors and members during the process of transitioning patients to other pharmacies confirmed what our prior analyses had shown: the vast majority of the U.S. has an oversupply of pharmacies, suggesting that networks can be tightened significantly while maintaining sufficient patient access.

  • 17.6% of the total Rx spend was for specialty
  • 47% of specialty medications are processed under the medical benefit
    • 78% for oncology
  • They talk a little about evaluating genetic tests and when to recommend a test. It’s definitely an evolving space, and it will be interesting to see the Medco influence here in terms of what they recommend.
  • They talk about $408B in waste from adherence, generics and mail order. All consumer behaviors. (see last year’s report focused on waste)
  • They show the breakdown of waste by state where the South is the biggest problem. It looks a lot like the Diabetes Belt although it also includes the SouthWest.

  • Not surprisingly, diabetes, cholesterol, and hypertension represent 3 big opportunities.

 

 

  • FINALLY…For years, I’ve been comparing two older studies to make the point that people think their adherent when there’s no way that perceived adherence can match reality. The most exciting thing to me was that they actually looked at perceived and actual adherence on the same patients.

For example, patients in the least-adherent group in the survey of Express Scripts members had an average actual MPR of 24.3%. The average perceived MPR reported by patients in this group, however, was 90.6%. We therefore found a staggering 66% gap between perceived MPR and actual MPR.

  • They talk about how this data is being used to predict non-adherence with some crazy high reliability. (Meaning only that it sounds too good to be true.) Regardless, they’re right in using data to identify behavior gaps (current and future) and developing personalized interventions to address barriers.

  • The overall drug trend was 2.7%
    • 17.1% specialty trend
    • 0.1% traditional drug trend
  • Here’s the breakout by class of specialty spend

  • Actual member out-of-pocket and percentage of cost actually went down $0.14.  Surprised?

  • Perhaps most interesting (and new) is a huge section on Medicare and Medicaid trends. Obviously this shows their focus here in an area that CVS Caremark has also been focusing on.

I’d also point you to Adam Fein’s breakdown of this report (in a more timely manner).

Highlights From The Prime Therapeutics Drug Trend Report

It’s been a busy year, and I’m getting a late start on reviewing the drug trend reports as I’ve done in the past. I’ll try to get to the CVS Caremark and Express Scripts reports next week.

As I mentioned last year, the Prime Therapeutics Drug Trend Report takes a more aggressive stand and how they compare to the competition. I’ll give a lot of that credit to Eric Elliot’s presence there as the CEO.

“Smart car buyers know that the actual cost of a car does not always align with the price on the window; the same is true for pharmacy benefits. Yet plan sponsors continually focus on “sticker price” measures such as brand-name discounts or manufacturer rebates — metrics that can be manipulated to make a deal look more attractive.”

The one thing which is noticeably different this year is that the document has more of a care management sound to some of the programs they talk about with an emphasis on total healthcare cost savings. Again, I attribute that to both being owned by the Blues and having several people in the management team that came from payers. Buried towards the back, they call themselves “total health focused” versus their competitors.

As always, here’s a few things that caught my attention:

  • A $4.73:$1 ROI for using the local pharmacist to address gaps-in-care.
  • 1.3% trend increase.
  • 74.7% generic fill rate.
  • 20.1% specialty trend increase.
  • 15.4% of client’s pharmacy spend is for specialty drugs which cost on average $2,654.
  • 0.4% of Rx claims processed are for specialty drugs.
  • Their Rxs PMPY have gone up to 12.4 which I think is closer to industry.
    • This is an interesting one. I pointed out a few years ago that they were below average which I wasn’t sure if this was due to plan design, member mix, or client mix.
    • They seem to be going up even though some industry data suggests a downturn in Rxs filled which again is something I can’t explain.
    • It could simply be more people >50 years old are staying in the insured mix…and they use more drugs.
  • Their average net costs per Rx were:
    • $165.33 brand
    • $17.95 generic
    • $57.53 combined
  • They breakdown specialty spend by category and also show how it’s growing and is projected to grow as a percentage of total drug spend.
  • Of course, another big piece of the specialty picture is how the spend breaks out between medical and pharmacy benefits. This is why blending data to understand the complete picture is important.
  • I thought the list of specialty drug management tools was a good starting point although I expected to see more here about how to integrate with the payers especially around categories like oncology and what BCBS of Florida is doing around an oncology ACO solution.

 

Drug Trend Reports: Quick Summary Of Big Three PBMs

“Comparative” is a very loose word to use here since each PBM has a slightly different approach to their analysis.

But, while it’s truly impossible to compare apples to apples and I will continue to argue that trend may be an irrelevant metric, I know may consultants and others are focused on these metrics.

With that in mind, I pulled the trend numbers (overall and specialty) along with the generic fill rate from the Express Scripts, CVS Caremark, and Prime Therapeutics trend reports.

 

Overall Rx Trend

Specialty Trend

GFR

CVS Caremark

2.2%

19.1%

74.1%

Express Scripts

2.7%

17.1%

75.0%

Prime Therapeutics

1.3%

20.1%

74.7%

Notes:

  • I used the CVS Caremark health plan overall and specialty trend data which I thought would be most comparable to Prime’s data.
  • Express Scripts reports their overall trend (without specialty) being 0.1%.
  • CVS Caremark provides a break out of trend along with best practices by sector (see below).

     

Healthcare Transparency, Out-Of-Network Claims, and Technology Solutions

Another big focus area these days is around the creation of transparency solutions to enable consumers to make better cost decisions about their healthcare.  While several companies have sprung up to work directly with consumers, the large payers have begun to rollout their own solutions.   And, as you can see from the Towers Watson and National Business Group on Health 2012 Survey, this issue of transparency was the 3rd biggest focus area for 2013. 

If you havent’ heard much about the topic, here’s several articles about the challenge of price discrepancies and surprise bills to consumers:

Here’s what UHG and Aetna are doing:

A few of the companies to look at are:

Companies like GoodRx are creating solutions in this area. 

You also might enjoy this infographic from Change Healthcare.

 

If you don’t believe this is a big issue in terms of price differentials, take a look at this data from the Healthcare Blue Book.  This shows a huge swing in prices which depending on your plan design can directly impact your out-of-pocket spend. 

Test or treatment Low Fair High
Brain MRI $ 504 $ 560 $ 2,520
Chest X-ray 40 44 255
Colonoscopy 800 1,110 3,160
Complete blood count 15 23 105
Hip replacement 19,500 21,148 43,875
Hysterectomy 8,000 8,546 16,480
Knee replacement 17,800 19,791 42,750
Knee arthroscopy 3,000 3,675 7,350
Laminectomy (spine surgery) 8,150 11,744 25,760
Laparoscopic gallbladder removal 5,000 6,459 12,480
Tubal ligation 2,865 3,183 5,729
Transurethral prostate removal 4,000 4,409 8,875
Ultrasound, fetal 120 169 480
Vasectomy 700 1,003 2,100
%d bloggers like this: