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The Transtheoretical Model And Setting Goals

There’s a good article in Time (9/17/12) called “Goal Power” by Dr. Oz.  I found it interesting on a few fronts.

“Getting people to make meaningful changes in their lives is much more complicated than explaining to them what to eat for dinner, how often to exercise and which kinds of tests they should get from their doctors.  The psychology of health is every bit as complex as the biology, and to create seismic shifts in behavior, we have to probe the subconscious.”

1. The topic of goals and objectives and their importance relative to healthcare behavior change is a repeating theme.

  • A month ago, I was at a presentation by Dr. Victor Strecher who founded HealthMedia.  He was talking about the importance of getting people to articulate their goals or objectives for changing.  (E.g., I want to become healthy to see my daughter get married.)
  • I had a pharmacy client who was looking into this as part of an adherence program a few years ago.

2. The topic of behavior change and behavioral economics has been a very popular theme with Nudge and many other publications and programs over the past few years.

3. Obesity, which is part of the focus of his article, is widely becoming recognized as the greatest public healthcare challenge of the 21st century.  And, it is a very complex issue tied to sleep, stress, social network, and many other factors.

4. He introduces the transtheoretical model (also known as the Prochastka model or the Stages of Change), which is widely known in the academic and health areas, into the public domain which surprised me.

(Here’s the abstract from what one widely quoted paper on this.)

The transtheoretical model posits that health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations. Basic research has generated a rule of thumb for at-risk populations: 40% in precontemplation, 40% in contemplation, and 20% in preparation. Across 12 health behaviors, consistent patterns have been found between the pros and cons of changing and the stages of change. Applied research has demonstrated dramatic improvements in recruitment, retention, and progress using stage-matched interventions and proactive recruitment procedures. The most promising outcomes to data have been found with computer-based individualized and interactive interventions. The most promising enhancement to the computer-based programs are personalized counselors. One of the most striking results to date for stage-matched programs is the similarity between participants reactively recruited who reached us for help and those proactively recruited who we reached out to help. If results with stage-matched interventions continue to be replicated, health promotion programs will be able to produce unprecedented impacts on entire at-risk populations.

5. He references two of the big studies that looked at social pressure an its influence on health.  Something that peer-to-peer healthcare and social network tools can create for us by developing support communities and “buddies” to support our change.

  • 2012 study in the journal Obesity about weight loss.
  • 2008 study in the NEJM about smoking

6. He references Dr. Nicholas Chrisakis who co-authored the book Connected which is being manifest in the company called Activate Networks.

Overall, for those of us that work in the healthcare field, these are all critical topics that we constantly talk about.  It’s nice to see it brought to the “popular press”.

Comparing Obese States With Less Obese States

You can’t really call any state “non-obese” these days with every state having at least 20% of their population considered obese and 12 states having over 30% of their population obese.

 

 

But, in a separate study, I found it interesting to compare some metrics from the most obese to least obese states.  Not surprising.

 

 

One of the things that I do always find interesting is whether people consider themselves to be obese.  People generally don’t.  I’ve spoken about it before, but I sometimes think healthcare providers need to be more direct with people to let them know that they are obese and this in going to increase their chances of dying sooner (2x more likely to die prematurely) and having other health problems.

Digital Dimension Of Healthcare Paper – Global, mHealth, Halvorson

I was just skimming the Digital Dimension of Healthcare whitepaper which has as one of its authors – George Halvorson from Kaiser.  There’s not a lot of new information in here if you’re well read on the space, but I like their framing of a fourth space for health delivery along with their two dimension matrix of opportunities.

The other piece that I’ll pull out here is the Six Principles that they identify:

  1. Set the direction, and commit to it
  2. Balance patient confidentiality and information sharing
  3. Empower patients
  4. Adapt payment systems
  5. Reduce barriers to regulatory approval and licensing
  6. Accelerate the healthcare evidence base

Would You Pay $100 A Month For A Diabetes Application?

An article in MobiHealthNews caught my attention this morning when it talked about 2 payers agreeing to pay $100 a month for Welldoc’s diabetes application. This is fascinating to me since (a) I’m always interested in how people price and value services and (b) I’d love to bundle something like this into our diabetes offering. 

This of course begs the key question which is what is the value of the application.  We’re all familiar with the fact that diabetes drives significant costs within our healthcare system.  Here’s a quick summary from the ADA.

The national cost of diabetes in the U.S. in 2007 exceeds $174 billion. This estimate includes $116 billion in excess medical expenditures attributed to diabetes, as well as $58 billion in reduced national productivity. People with diagnosed diabetes, on average, have medical expenditures that are approximately 2.3 times higher than the expenditures would be in the absence of diabetes. Approximately $1 in $10 health care dollars is attributed to diabetes. Indirect costs include increased factors such as absenteeism, reduced productivity, and lost productive capacity due to early mortality.

Of course, diabetics also spend a lot of money on out-of-pocket costs themselves.  $6,000 from one study mentioned here.

But, I think the key question here is what assumptions make this a good investment.  Let’s me walk through my thought process.

  • At $100 per month, you pay $1,200 per year per member.
  • BUT, members won’t actively stay engaged with the application all year long so you have to assume some percentage of engaged members.  (A key question is whether you pay only for actively engaged members or all members enrolled in the program.)  And, how long does a patient have to use the application to achieve the results?
    • If 20% are engaged, the cost per engaged member would actually be $6,000 ($1,200 divided by 20%). 
    • If 60% are engaged, the cost per engaged member would be $2,000.
  • The next question is how you estimate the value of the application.  Based on their study, they saw a 1.9 point drop in A1c which is a good one-year drop and a good outcome metric to focus on (see article).  So the question becomes…what is the value of a 1.9 point drop in A1c?  This is a question I was looking for earlier.
    • This pharmacist based study talks about a 0.8% reduction in A1c leading to $1,200 in total savings.
    • This CVS study showed a $3,756 annual savings for an adherent diabetic versus non-adherent.  (But, adherence wasn’t shown in the Welldoc study.)
    • The President from Welldoc quotes a savings of $3,500-$4,000 per point drop in A1c, but I couldn’t find the study to support that.  (I e-mailed their PR people about this.)
    • And, a few weeks ago at a mHealth conference, I heard someone say the value was $7,000 per point reduction in A1c.

As you can see from this tweet, I was looking for this study yesterday and mentioned DiabetesMine to see if Amy might know, but she didn’t.

 

So, my conclusion is that this is worth it if:

  1. The value is closer to the $3,500 point.
  2. You pay based on actual engagement or utilization…or you only give it to people who actually use it versus the overall population. 
  3. The application improves adherence.

I hope to figure this out since this was the first FDA approved device and looks very promising.

Vaccine Excemptions By State

This is an interesting map from Every Child By Two which is a pro-immunization advocacy group.  And, per the article in USA Today, this discussion around vaccines is heating up with kids coming back to school and the biggest epidemic of whooping cough in 50 years.

I’ll also pull up this video that I posted last year which I thought to be a fun presentation of this topic.

2 New Health Infographics

I found this list of data visualization winners and grabbed two to share here.  Although I like their first place winner on cancer, I found it to hard to read on the site.  These use bigger fonts and images with less detail which I personally think is important.

Chronic Kidney Disease (CKD) Action Plan Poster

I was at my physician’s office yesterday and noticed this great poster on the wall from the Renal Physicians Association (RPA).  I reached out to them and got a PDF of the poster – RPA Toolkit Action Poster FINAL.  (Note: It’s meant to be a poster on the wall not a graphic in a blog post so it’s here for you to go look at, but it’s not easy to read and digest here.  Use the link to get to the PDF.)

The key points are that it shows you stages of CKD based on GFR along with the action you should take.  It also highlights the risk factors for CKD and the possible complications.



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).

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.

P4P, PCMH, ACO…The Concept Is The Same

Healthcare is very good at creating TLAs (Three Letter Acroynms). The Accountable Care Organization (ACO) and the adjacent models are no different.

You have:

These are of course governed by:

And, they were significantly impacted by the SCOTUS (Supreme Court of the United States) decision regarding PPACA (Patient Protection and Affordability Care Act).

But, at the end of the day, the goal here is the same. We need a solution that addresses:

  • Cost, Quality, Care (the Triple Aim)
  • Our existing infrastructure
  • Our unique healthcare environment in the US
  • The challenges of changing patient behavior

We all know that the healthcare system is not sustainable without change. What will happen to health reform with the election is still TBD, but at the end of the day, change is needed. PPACA might not be perfect, but it was better than a lot of options (IMHO). As I said before, I would focus on phased change:

  • Improve access for all Americans
  • Build out connectivity and technology
  • Develop a new payment model
  • Integrate payment with outcomes

The Core Of The ACO – The Provider

While my other post talked about the IT priorities of the ACO, I believe that a large part of the ACO (Accountable Care Organization) effort driven by CMS is about creating a provider-centric approach to care management. While medicine certainly began as a provider to patient relationship, that has changed over the years to a managed care driven relationship. This peaked years ago with the HMO backlash that led to the revised system that most of us have grown accustomed to operating within.

Then, with the discussions around exchanges, Medicare, and the individual market, we’ve seen a shift to a more patient-centric approach to healthcare focused on the patient experience and understanding their behavior. Is anyone necessarily wrong – no. But, there needs to be a balance. I personally think that the ACO approach is trying to build some of that with a Kaiser type of framework. Physicians would be at the heart of the solution with technology, process, and financial support from managed care companies and medical management companies. And, they would have to partner with the patient to really affect behavior and ultimately health outcomes.

Will it work? Who knows. There have been a lot of smart people who have spent a lot of time and energy trying to figure out health outcomes and cost with limited effect in any scalable way.

There have been a few initial articles about ACO success:

There have also been a few people talking about ACO 3.0 and the future of how ACOs will evolve from what we know today.

Of course, most of this is focused on the CMS ACO model while others are using the “ACO” moniker as a framework for pay-for-performance (P4P) within the physician world.

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Building Accountable Care Solutions

Right now, it’s a little bit of the Wild West in terms of building Accountable Care Solutions (ACS’s)…which is not necessarily bad.

You have physicians building ACOs. You have hospitals building ACOs. You have managed care companies buying physician groups to have ACOs. You have managed care companies providing technology to providers to have ACOs. You have consultants helping design ACOs. You have technology companies building components of ACOs. Eventually, my prediction is that you’ll end up with some type of franchise model on ACOs that providers can leverage. Perhaps it’ll be like the Medicine Shoppe model for pharmacies.

But, as I read through all the literature and try to have opinions on this space, there are a few core things I keep coming back to:

  • Leveraging Evidence-Based Medicine (EBM) guidelines
  • Consumer engagement and behavior change
  • Quality tracking and reporting
  • Technology enablement
    • Patient registries to collectively manage similar patients
    • Gaps-in-care identification
    • Risk modeling
  • Coordination of data and care across PCP, specialists, hospitals, pharmacy, clinics, and labs
  • “Care coordinator” role (probably a blend of human and automation)
  • Sharing value and risk

While traditional providers have been focused on actual diagnosis and care, they haven’t focused on most of this. This is a fundamentally different business (at least at the individual physician level). Even the one that most naturally fits with the practice of medicine – Evidence Based Medicine – is a challenge given the pace of change and information. Plenty of studies have documented this challenge.

So, while everyone is now using this term that our team started using last year, the reality is that ACS’s are complex solutions that take a holistic view of the patient and their care and manage using EBM with an integrated solution that blends technology and face-to-face care with a focus on specific health outcomes.

To borrow from Ernst & Young, here’s a framework they propose on their website about Accountable Care:

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

Five Critical Components Of An ACO

The Advisory Board out of Washington DC has jumped headfirst into the pool around ACOs. They have some great information on their website and like any other consultants, provide some great frameworks to leverage.

One that I found helpful lays out the 5 critical IT components for developing an ACO (see image below):

  1. Network Interconnectivity (Practice Management System and Electronic Medical Record integrations in my words)
  2. Clinical Knowledge Management (Evidence-Based Medicine in my words)
  3. Patient Activation (or Engagement)
  4. Financial Operations
  5. Population Risk Management (or Medical Management or Population Health Management)

I think this is a good starting point for understanding what technology you need to provide an ACO (and theoretically make money doing it).

[To see more about our physician directed Accountable Care Solutions at inVentiv Medical Management, click here. Or contact me if you’re interested in how we’re applying these to support ACO and “ACO-like” organizations in their efforts to engage consumers and drive health outcomes.]

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).

     

Interview With Michael Graves On Healthcare Design

When I was in architecture school, Michael Graves was one of those architects that we studied.  Everyone wanted to be like him designing cool building like this one below.  Since then, he’s gone on to be even more famous both from an architecture perspective and a design perspective (even having his own Target line).

But, since he was left paralyzed from the chest down in 2003, he’s had an incredible focus on redesigning healthcare from the perspective of the patient.  [I would put him in a similar e-patient category as e-Patient Dave, but while Dave is focused on technology and data, Michael is focused on furniture and spatial experience.)

I was thrilled to get the chance to talk with him yesterday to see how this effort was taking off, and on a personal note, to see if this idea of architecture influencing outcomes would be generally accepted.  My general takeaway after talking with him was that he’s getting a very positive response as he talks to people about it, but you’re not seeing a sea-change in terms of clients focusing on this or his fellow architects embracing this.  But, as someone in healthcare, this isn’t surprising.  We know it takes physicians 17 years to adopt new standards…why should it take the administrators of those physicians any less.

At the same time, there is a huge focus on the patient experience and on outcomes these days.  Both of those can be improved through a focus on the physical experience.  I asked him whether he was seeing interest from both inpatient and outpatient facilities.  He indicated that the dialogue is all happening around hospitals which isn’t surprising given their investments in new facilities and the industry shift around ACOs and PCMHs.  But, any of us that have sat in a physician’s office looking at posters from the drug companies, outdated magazines, or just an overly sterile room, know that these things don’t relax you or make you comfortable.

Michael tells a story that I’d seen in other articles about how he first came to understand all the problems with the physical space in the hospital.  He wanted to shave one day and realized that he couldn’t see himself in the mirror and he couldn’t reach the water to turn it on.  It was all designed by someone that hadn’t put themselves in the patient’s shoes (or wheelchair) to understand their perspective on the space.

Since “evidence-based medicine” is all the buzz in the healthcare area, I asked him about the term “evidence-based design” which is used in several articles and on his website.  As he pointed out, it’s basically about just using common sense, but I do think there’s more there (to eventually sell this).  To me, this implies a level of rigor linking more practical furniture and spatial redesign to clinical outcomes and patient satisfaction.  These are the things that are going to motivate the CFO to open the purse strings to make a change.  Unfortunately in our healthcare system, there aren’t a lot of changes made just because the patient wants them or they make sense.  Otherwise, we’d have a healthcare system not a sick care system.

The final topic we discussed was moving beyond furniture to look at art and color and other things that could effect the patient’s experience.  He told me that he’s also a painter (which I didn’t know) and mentioned that one of his clients had bought some of his art and furniture for their facility.  He also reinforced a study that I’d seen before about not using abstract art but focusing more on natural scenes within the patient setting (also mentioned below).

Here’s a few articles from other interviews and a link to the work he’s doing with Stryker on medical equipment / furniture.  You can also see a press release on his upcoming presentation at the end of this post.

And, while Michael is focused on the furniture and spatial experience, there are others focused on the art, colors, and other aspects of the hospital experience.  I found this text from The Atlantic from a few years back that even talks about some of the studies that have been done.  [Maybe case managers should be asking for specific rooms in facilities!]

Such “evidence-based design,” which draws its principles from controlled studies, is the great hope of professionals who want to upgrade the look and feel of medical centers. Much of this research follows a seminal 1984 Science article by Roger S. Ulrich, now at the Center for Health Systems and Design at Texas A&M. He looked at patients recovering from gallbladder surgery in a hospital that had some rooms overlooking a grove of trees and identical rooms facing a brick wall. The patients were matched to control for characteristics, such as age or obesity, that might influence their recovery. The results were striking. Patients with a view of the trees had shorter hospital stays (7.96 days versus 8.70 days) and required significantly less high-powered, expensive pain medication.

Along similar lines, a 2005 study compared patients recovering from elective spinal surgery whose rooms were on the sunny side of a ward with those on the dimmer side. Those in the sunnier rooms rated their stress and pain lower and took 22 percent less pain medication each hour, incurring only 80 percent of the pain-medication costs of the patients in gloomier rooms. Other studies, with subjects ranging from the severely burned to cancer patients to those receiving painful bronchoscopies, have found that looking at nature images significantly reduces anxiety and increases pain tolerance. Not all distractions are good, however. Ulrich and others have found that inescapable TV broadcasts and “chaotic abstract art” can increase patients’ stress.

Press release about his upcoming presentation:

World-Renown Architect Becomes Healthcare Advocate After Rare Illness Leaves Him Paralyzed

Michael Graves to speak at medical conference about his passion for healthcare design


Michael Graves, the award-winning architect and product designer famous for his collection of home products sold at Target, will address the country’s top healthcare professionals during a special reception at the 2012 Health Forum and the American Hospital Association Leadership Summit next month.  He will give a personal account about how paralysis fueled his desire to improve healthcare design.

Graves, who was recently named the 2012 recipient of the Richard H. Driehaus Prize and applies his design philosophy to designing better hospitals and home care environments, will be the featured speaker immediately following the welcome reception of the 2012 AHA Summit, at the San Francisco Marriott Marquis, at 7 p.m., Thursday, July 19.

In his lecture, “People First: Redesigning the Hospital Room,” Graves will discuss his own experience with a sinus infection that left him paralyzed from the chest down and how undergoing hospitalization and rehabilitation in inadequately designed hospital rooms has inspired his healthcare designs.

Graves talk will focus on design solutions for Stryker Medical, including a collection of hospital patient room furniture that addresses common hospital problems such as infection control, patient falls and clinician back.

“We are thrilled to have such a highly-acclaimed and gifted architect speaking before the healthcare community about ways of improving the hospital setting,” said Harold Michels, senior vice president of the Copper Development Association (CDA), the organization hosting the dinner event with Graves.  “This is a can’t-miss event that will certainly have hospital CEO’s and healthcare advocates talking about way after it’s over.”

Graves has said that spending months in hospitals during his recovery in 2003 opened his eyes to poorly designed patient rooms, and made him realize the patient experience could be improved by design.  He immediately began to sketch ideas for improving hospital buildings, room and furniture.

The event is being presented by CDA’s Antimicrobial Copper team, which is working to advance the message that copper surfaces intrinsically kill disease-causing bacteria.  On display will be a variety of antimicrobial copper products, which can play a pivotal role in healthcare facilities by killing bacteria that cause hospital-acquired infections and by reducing costs.

Laboratory testing has demonstrated that antimicrobial copper surfaces kill more than 99.9% of the following HAI causing bacteria within 2 hours of exposure:  MRSA, VRE, Staphylococcus aureus, Enterobacter aerogenes, Pseudomonas aeruginosa, and E. coli O157:H7.

Graves is internationally recognized as a healthcare design advocate, and in 2010, the Center for Health Design named Michael Graves one of the Top 25 Most Influential People in Healthcare Design.  Graves regularly gives lectures to major healthcare advocacy groups, including AARP, the Healthcare Design Conference, Medicine X and TED MED.

About Michael Graves & Associates

Michael Graves & Associates has been in the forefront of architecture and design since AIA Gold Medalist Michael Graves founded his practice in 1964. Today, the practice comprises two firms run by eight principals. Michael Graves & Associates (MGA) provides planning, architecture and interior design services, and Michael Graves Design Group (MGDG) specializes in product design, graphics and branding. MGA has designed many master plans and the architecture and interiors of over 350 buildings worldwide, including hotels and resorts, restaurants, retail stores, civic and cultural projects, office buildings, healthcare, residences and a wide variety of academic facilities. MGDG has designed and brought to market over 2,000 products for clients such as JC Penney, Target, Alessi, Stryker and Disney. Graves and the firms have received over 200 awards for design excellence. With a unique, highly integrated multidisciplinary practice, the Michael Graves Companies offer strategic advantages to clients worldwide. For more information, visit www.michaelgraves.com.

About the Copper Development Association

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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

A Few Diabetes Facts From Express Scripts

Here’s a summary of some of the data from the latest Express Scripts Drug Trend Report relative to Diabetes.

  • 26M Americans have diabetes
  • 15% of Americans (or 39M) will have diabetes by 2020
  • Diabetes costs $194B per year (health spending) and that is expected to rise to $500B by the end of the decade
  • 41% of diabetes are non-adherent to their medications
  • 60% of diabetics using insulin don’t regularly self-monitor their blood glucose levels
  • The drug costs are $81.12 PMPY (based on high utilization of metformin (a generic)) with 14.91 Rxs per user per year (which seems low since the average diabetic takes 5 medications from what I know)

This gives you some data, but I pulled this data from an older blog post of mine from the ADA…

I found this list of diabetes fact from the American Diabetes Association in an article I was reading:

  • 25.8M children and adults in the US have diabetes (8.3% of the population).  This includes 7.0M who haven’t yet been diagnosed.
  • 1.9M new cases of diabetes were diagnosed in people 20+ in 2010.
  • 215,000 or 0.26% of all people under 20 have diabetes.
  • In 2007, diabetes was listed as the underlying cause of death on 71,382 death certificates and as a contributing factor on another 160.022 death certificates.
  • Adults with diabetes have heart disease death rates 2-4x higher than adults without diabetes.
  • The risk for stroke is 2-4x higher for people with diabetes.
  • Diabetes is the leading cause of blindness among adults ages 20-74.
  • Diabetes is the leading cause of failure accounting for 44% of new cases in 2008.
  • Total cost of diagnosed diabetes in the US was $174B in 2007.

And, depending on if you focus on pre-diabetics, the population becomes even larger.  I expect with more and more companies doing onsite biometric screening that the population in diabetes management programs will increase significantly over the next few years.  The keys will be treating them differently based on risk, disease understanding, and patient preferences to make the programs cost effective.

NY Law On Soda Is Simply A Nudge To Be Healthy

I know we can all complain about the government telling us what to do, but at the end of the day, they’re not saying we can’t drink soda.  As far as I know, you can still have unlimited refills in NY.  They are simply reframing one aspect of drinking soda to try to nudge us into being healthier.  Ultimately, this should be a good thing for us for several reasons.

  1. We eat or drink whatever is put in front of us.  Just look at this research.
  2. Soda and other sugary drinks are generally not good for us.  Just look at the infographic below.
  3. We have an obesity problem in this country (in case you didn’t know it).
  4. Obesity drives diabetes, kidney problems, hypertension, and many other problems that are driving up our healthcare costs and turning us into the first generation to potentially live shorter lives than our parents.
  5. Nudging people into behavior change works.

A Few Basics On Health Risk Assessments

Like many of you, I’ve heard a lot about HRAs (Health Risk Assessments) for years.  A few times I’ve even taken them.  And, depending on your employer, you may even get paid to complete one.  But, what are the basics about HRAs that you should know?

  1. What is a HRA?  An HRA is a series of questions that can be administered over the Internet or by the phone or by a nurse to help collect patient reported data to help screen patients for chronic conditions or risk of developing a chronic condition based on their behaviors or other data.  Additionally, they often lead to either immediate feedback on behaviors to address or lead to the patient being engaged into a program with a wellness, disease management, or case management. 
  2. Should employees be incented to take an HRA?  Incentives are basically used to increase response rates to the HRA.  Not surprisingly, several studies show that incentives work, but education about the need to take the HRA is also important.  In some cases, employers are even linking participation to premiums.  Additionally, here’s a list of the top incentives used based on a 2010 study. 
  3. How should an HRA be used?  An HRA is a key component of an overall care management strategy.  Like claims analysis, the objective of the HRA is a screening mechanism to identify patients who should be included in wellness, disease management, or care management program. 
  4. Are HRAs valuable?  There have been studies over the years that have shown a 2:1 or 3:1 ROI for wellness programs and a ROI for case management.  HRAs are valuable in identifying more patients who should be enrolled in these programs. 
  5. Should you combine biometrics with HRAs?  Here’s a good study that shows that blending lab work with HRA data significantly increases the likelihood of identifying patients with diseases especially kidney disease. 

Of course, no HRA is valuable if:

  • You can’t get enough members to actually take the HRA.
  • You don’t have an engagement strategy to get the members to participate in the program.
  • You don’t continue to follow-up and help the member manage their condition.
  • The member doesn’t get engaged in their healthcare. 

Regenerative Medicine – TEDMed Video On Printing A Kidney

It takes a lot to wow me, but this is an amazing video from TED.  It shows several different innovations within the field of regenerative medicine

Given the growth in chronic kidney disease due to diabetes and obesity, the need for kidney transplants is only going to go up.

2/3rds of Pharmacy Spend to be in Specialty by 2016

I found this chart to be very interesting.  According to the latest CVS Caremark projections, over 60% of healthcare spending on drugs will be on specialty drugs by 2016.  That’s a huge shift!  A lot of it still sits in the medical side which no PBM has really figured out how to manage, but it creates great opportunity for those that can integrate medical and pharmacy claims to analyze the data and leverage it for cost and care management programs.

9 Leading Trends In Rx Plan Management

This a Medco report (now Express Scripts) that they recently released.  It lays out what’s on the minds of clients (payers) in terms of prescription management.  Not a lot of surprises here.  (But, if you’re looking at this, you might also note that the URL www.drugtrendreport.com is now up with the new branding and Express Scripts drug trend report.)

Only 20% of Americans Perceive Themselves To Be In Poor Health

Should we be surprised?  It always looks worse around us than what we think about ourselves.

BUT, this has huge implications.  If we’re trying to get people engaged in their care at a pre-disease point (i.e., pre-diabetic) or trying to engage them earlier in their chronic kidney care continuum, this matters.  They’re likely to ignore the outreach about wellness and disease management if they don’t think it applies to them.  I guess it’s like thinking that you’ll win the lottery.  Or thinking that the last dose of chemotherapy (even though you’re about to die) might just save you.

But, if you dig into the data, you do see some differences by age and by income (per Thomson Reuters 2010 PULSE Healthcare Survey):

  • 35.5% of those making >$100K think of themselves in excellent health versus 11.1% of those making less than $25K.
  • Only 1.1% of those making >$100K think of themselves in poor health versus 14.3% of those making <$25K.

(While we know that there are healthcare discrepencies tied to income, this wouldn’t explain this great of a gap in self-perception.)

  • 61.7% of those <35 perceive themselves to be in very good or excellent health versus 40.7% of those >65 (but a lot of that could be explained away since they are much more likely to have symptomatic diseases at that age)

(comments in parenthesis are my perspective not from the study)

Discussing Oncology Prevention With Dr. Hawk From MD Anderson #WHCC12

Last week, I had a chance to sit down with Dr. Hawk right after his presentation at the World Health Care Congress (WHCC). Dr. Hawk is the Vice-President and Division Head for Cancer Prevention and Population Sciences at the University of Texas M. D. Anderson Cancer Center. He’s been there since late 2007 when he came from the National Cancer Institute.

My favorite point from talking to him was…

Cancer is a process not an event. Communication is critical.

In his presentation, he talked about several things:

So, after his formal presentation, we talked about several things.

  1. One of the big focus areas for MD Anderson is prevention. As we know from research, many cancers are preventable. And, the promise of personalize medicine and genetic testing is beginning to help us understand these cancers and their treatments even more.
    1. Primary – this would include lifestyle changes such as diet and smoking which help prevent the disease
    2. Secondary – this would include screening and detection to help slow the progression of the disease
    3. Tertiary – this would include the focus on the patient (not the tumor) for treatment and helping them with quality of life
  2. He talked about how cancer is really 200 different diseases to be understood and managed.
  3. He gave a great analogy about how CVD (cardio-vascular disease) evolved and talked about how all the individual risk factors became asymptomatic diseases which have led to all the “know your number” campaigns around lipids and blood pressure.
  4. We talked about cancer as a process which led us into the discussion about palliative care and shared decision making. He made another good analogy here about driving a car. We need to understand the value of wearing our seat belt and having insurance, but we have to make the final decision about whether to do that or not.
  5. We talked about personalized medicine including genomics and epigenetics. We talked about how this impacts dosing and understanding of the tumor. (Interesting in a conversation with another person in this field this week they were telling me about how tumors and viruses change over time and those implications on genetic test results.) We also talked about SNPs and the complications in getting validation in studies due to sample sizes. We wrapped up this topic with discussions on coordinated registries and work that companies like 23andMe are doing.
  6. Our final topic of discussion was around clinical practice algorithms and how evidence-based medicine (EBM) gets implemented. We talked about the use of guidelines and how those allow for monitoring the use of EBM standards. We also talked about the need for integrated EMRs that would allow for benchmarking and linking outcomes to use of guidelines.

This is a fascinating area. Cancer affects most of us either directly or through some family member or friend.