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Highlights From the Takeda / PBMI 2011-2012 Prescription Drug Report

November 7, 2011 by George Van Antwerp 0 Comments

PBMI puts this out each year with funding support from Takeda. It is another one of those great annual reports full of lots of trend data for you to digest. Let me pull out a few of the things that stood out to me, but I recommend you read the entire thing yourself:

  • Use of 4-tier plans grew by 25% in 2011.
  • Specialty copays increased by 37% (to $84).
  • Plans continue to offer 90-day mail at a lower copay multiple than 90-day retail.

  • Nearly 60% of plans allow 90-day retail prescriptions. [Wow! This was a shocker to me.]
  • 30% of respondents require specialty medications to be filled by their PBM. [Which seemed low to me.]

 

  • Only 5% of respondents said they give their PBM responsibility for plan design.
  • 18% of plans have mandatory mail (although the statistic is 26% for respondents who have pharmacy provided as a carve-out).
  • 21% of plans have a limited retail network.
  • 36% of plans have copay waivers.
  • 7% of plans cover some form of genetic testing.
  • In general, there was an equal view of all the forces impacting benefit plans.

 

  • 64% of plans are focusing on member education to help them control costs. [exactly what we do at Silverlink everyday!]

Here’s a key chart on average copays for 3-tier plan designs.

 

Another summary they show from some external research is below:

 

Adam Fein recently pointed this out, but the use of MAC pricing at mail is pitifully low at 18% versus 42% for 30-day retail.  (More from Adam on the report.)

I’m always interested in the overall use of programs by plans which is summarized here. Interestingly, there were three areas which carve-in did much less than carve-out – outbound phone calls, retro DUR, and therapeutic substitution.

 

They also include a summary of several research studies on adherence with a quote from me:

“In working with healthcare companies around adherence, our focus is always on how to best use data and technology to personalize interventions in a scalable way,” said George Van Antwerp, 2011-2012 Prescription Drug Benefit Cost and Plan Design Report Advisory Board member. “Medication adherence is a multi-faceted issue. While there is no silver bullet, technology can help deliver different messages to consumers based on the complexity of their condition, specific medications, and their plan design (for example). But, while technology can provide the initial nudge, the care team has to work together to address health literacy and build an understanding of the condition, the medication, and value of adherence.”

Another data point that I often use from here is the average number of Rxs PMPM:

 

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

Calling In Sick – A Few Statistics For You

November 6, 2011 by George Van Antwerp 0 Comments

I found a survey from MiracleWorkers.com interesting so I thought I would share some statistics from it:

  • 37% of healthcare employers say that workers call in sick more often during the winter holidays.
  • 28% of healthcare workers have admitted to “playing hooky” from work this year.
  • Sick days are spread out by quarter with 34% being taken in Q1, 10% in Q2, 30% in Q3, and 26% in Q4.
  • 14% of people are now using a text message to let their boss know they’ll be sick.
  • They had some great (and unbelievable) examples of the excuses used:
  1. Employee’s 12-year-old daughter stole their car and they had no other way to work.  Employee didn’t want to report it to the police.
  2. Employee said a refrigerator fell on him.
  3. Employee was in line at a coffee shop when a truck carrying flour backed up and dumped the flour into her convertible.
  4. Employee fell out of bed and broke his nose.
  5. Employee’s child stuck a mint up his nose and had to go to the ER to remove it.
  6. Employee had a headache after going to too many garage sales.
  7. Employee drank anti-freeze by mistake and had to go to the hospital.
  • 17% of healthcare employers said they have fired a worker for calling in sick when they weren’t.
  • 30% have checked up on an employee, citing the following examples:
  1. 80% required a doctor’s note
  2. 50% called the employee
  3. 18% had another employee call the employee
  4. 10% drove by the employee’s home

 

Healthcare, Research

One Challenge Of Medicare OEP – Satisfaction

November 5, 2011 by George Van Antwerp 0 Comments

We’re in the Medicare open enrollment period right now.  This is a highly competitive time for MA and PDP plans to compete for new members and to get members to switch to their plans.  I’ve talked about the Star Ratings process before.  I’ve talked a little about the limited network offerings before.

This time, I wanted to focus on a recent study by Medicare Today that was put out on satisfaction.  It shows:

  • 95% say their current Part D plan works well, with 94% saying it is easy to use.
  • 82% say their Part D plan offers good value.
  • 67% say they have lowered their prescription drug spending.
  • 34% say they used to skip or reduce their prescription medicine doses to save money, but now no longer have to do so.
  • Two of every three seniors said they are unlikely to shop around.
Those are impressive statistics.  They certain point to the battlegrounds being around new Medicare eligible participants and retention (not acquisition) for existing PDP or MAPD members.
Books / Articles, Healthcare, Managed Care, Marketing / Communications, PBM / Pharmacy, Research, Silverlink, Value Propositions

Did You Know PhRMA Has A YouTube Channel?

November 4, 2011 by George Van Antwerp 1 Comment

I just ran across this, and I figured I would share it.  PhRMA is the Pharmaceuticals Research and Manufacturers of America.  They represent they pharma and biotech companies.

Here’s a few of the videos from the site.  One on Part D and one on adherence.

Healthcare, Leadership, Marketing / Communications, PBM / Pharmacy, Research, Social Media, Value Propositions

My Eight PBM Predictions For 2012

November 3, 2011 by George Van Antwerp 0 Comments

I recently heard one of the key CEOs in the PBM industry say that his crystal ball for 2012 was fuzzy, and he wasn’t sure what was going to happen.  (Not particularly reassuring.)  That being said…it’s an exciting time, and I’m going to take my pass at predictions anyways.

  1. The proposed Express Scripts acquisition of Medco will take place although they will be required to sell off some specialty assets.  This will create a new specialty player and will also trigger further consolidation and acquisitions.  You will also see many of the Medco people go to new healthcare companies throughout the industry to drive change.
  2. The contract dispute between Express Scripts and Walgreens will get resolved shortly after 1/1/12, but it will serve as the trigger for limited networks as multiple clients will keep Walgreens out of the network since they’ve addressed most of the disruption and achieved savings.  But, you will also see several companies quickly add Walgreens back into their network.
  3. Star Ratings will trigger a bigger focus on adherence across the industry and begin to create outcomes-based performance measures that the commercial business starts to see in their PBM contracts linking payment to performance.
  4. Lipitor will be a disruptive item throughout the year with aggressive Pfizer rebating, the overhang from it potentially going OTC, and the pricing of the initial generic.
  5. Innovation will finally begin to shift to the specialty space with this being the primary area of concern from a trend management and clinical perspective.  Clients will expect innovative ways of engaging patients and improving outcomes which will push closer links between pharma and PBMs around key drugs and complex conditions.  The focus on specialty spend in medical will continue, but the increasing percentage of infusion drugs will challenge this and push specialty to look for more ways of engaging with the physician.
  6. The “retailing of healthcare” through storefronts will manifest itself in different ways in pharmacy with greater focus on specialty at retail, pharmacists as part of the ACO/PCMH concept, MTM, and ultimately through exchange based partnerships with large payers.
  7. Integration of medical, pharmacy, and lab data will be a huge focus on PBMs create targeting algorithms and databases for segmentation, targeting, and ultimately engaging consumers around specific health behaviors.
  8. Telemedicine in the form of telemonitoring will link into the retail pharmacy clinic strategy as they extend their pharmacy relationship from an event based relationship to an ongoing monitoring relationship around key conditions like diabetes.

Two things that I expect to continue to be areas of focus will be the development and execution of a mobile strategy and continued exploration in the area of personalized medicine and genomics.

The one outlier which I’m not sure of yet is Medicaid pharmacy.  It’s been a hot topic lately, but I’m still unsure of whether that will radically change in 2012 or not.

[Interested in sharing your opinions on 2012 in a formal way?  I’m going to reach out to several companies and ask their thought leaders or executives to do an “interview” with me about their predictions for 2012.  Let me know if you’d like to participate.]

[And, don’t forget that you can sign up to have these posts e-mailed to you whenever I write them by signing up for my e-mail list on the right side of the blog.  Thanks for reading.]

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

Diabetes Facts From the ADA – Total Costs in US = $174B

November 3, 2011 by George Van Antwerp 0 Comments

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.

No wonder this is such a focus in the Medicare Star Ratings!

Healthcare, Managed Care, PBM / Pharmacy, Research

Three Pillars of Adherence (NEHI)

November 1, 2011 by George Van Antwerp 4 Comments

I was digging through some adherence materials, and I stopped on the NEHI graphic from their report “Thinking Outside The Pillbox” which first quantified the impact of non-adherence at $290B (a number which everyone uses now).

I don’t remember every posting it on the blog so I’m sharing it now.  I think it hits on the key topics that we all talk about:

  1. We have to get it right from the beginning with the drug regiment.
  2. Cost can be an issue so if possible address it.
  3. But, the biggest issues are with understanding (literacy), side effects, creating a habit, and many other things that require education and ongoing intervention and support for the patient.

[Note: NEHI has now releasesdd their roadmap on Medication Adherence which I’ll review in a subsequent post.]

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

Hospital Social Media Stats

October 28, 2011 by George Van Antwerp 2 Comments

Here’s some interesting stats from Ed Bennett that were shared in PharmaVOICE (Oct 2011) based on 1,188 hospitals that are using social media.

  • 548 YouTube channels
  • 1,018 Facebook pages
  • 788 Twitter accounts
  • 458 LinkedIn accounts
  • 913 Foursquare
  • 137 Blogs
  • 3,952 hospital social networking sites

My one pet peeve is the “emergency room” locations that publish their wait time via Twitter.  If it’s really an emergency, shouldn’t I be going in to get care not focusing on wait times?  And, aren’t the wait times variable based on how urgent my need?

Books / Articles, Healthcare, Research, Social Media

Predicting Medication Adherence

October 27, 2011 by George Van Antwerp 0 Comments

Is there a secret sauce?  (Hint: past behavior)

It always important to be skeptical, but there are certainly attributes like the number of Rxs, gender, condition, copay amount, and other factors that contribute to the likelihood of a consumer being adherent.

But, one of the big discussions is around how to use other variables.  FICO, the company that creates credit scores, has created an adherence score.  In today’s WSJ, they shared this image about predicting adherence.  Interesting…

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

What’s The Average Prescription Copay? (AIS Survey)

October 25, 2011 by George Van Antwerp 0 Comments

AIS conducts a quarterly survey on behalf of Drug Benefit News.  For the second quarter of 2011, the average copays were:

  • 1st Tier – $10.28
  • 2nd Tier – $26.66
  • 3rd Tier – $44.65

 

Healthcare, Methodology, PBM / Pharmacy, Research

Basic Attributes Of The 7B People In The World

October 25, 2011 by George Van Antwerp 0 Comments

There was an article in the 10/31/11 Time magazine about the global population.  I found this list of basic statistics interesting:

  • 19% of the world’s population lives in China.
  • 33% of the world’s population is Christian.
  • 50.4% of the world’s population is male.
  • 50.5% of the world’s population lives in a town or city.
  • 29 is the median age of the world’s population.
  • $10,290 is the per capita gross world income.
  • 73% of the world’s population does NOT use the Internet.
Books / Articles, Healthcare, Research

Infographic: Allergy Myths

October 23, 2011 by George Van Antwerp 0 Comments

Healthcare, Infographic, Research

Will The Stars Align To Drive Adherence?

October 22, 2011 by George Van Antwerp 0 Comments

We all know that adherence to prescriptions is a problem.  People don’t start on their medications.  People don’t stay on their medications.  But, another problem also exists which is finding the ROI on adherence.  While the ROI is clear to the manufacturer or even to the pharmacy, it’s often less clear to the payer.

This is not true in every category.  Diabetes and several other conditions have been shown to have an ROI associated with intervention programs that improve adherence.  But what about all the others.

In the short-term, I expect you’ll see the CMS Star Ratings and bonus payments drive behavior in three critical categories that are now measured in the 2012 for MAPD and PDP plans.  (see technical notes on 2012 measures)

If you’re not familiar with the Star Ratings system, you should read this.  In 2012, there were three new adherence measures added.  Not only are they now part of the evaluation process, but they were weighted more heavily than some of the operational measures.  A  good indication of focus on quality of care.

Getting more Stars is important since it is linked to bonus dollars that the plans can get.  And, there aren’t many Five Star Plans.  Only 9 plans received 5-Star Ratings for 2012 (see article).  [Interestingly, I think one of the unique assets that Express Scripts is buying in the proposed Medco acquisition is one of the 4 Five-Star PDP plans.]

“The Medicare star quality rating system encourages health plans to improve care and service, leading to better patient experiences across the board,” Jed Weissberg, a senior vice president at Kaiser Permanente.  (from 5-star article above)

The adherence measures focus on diabetes, high cholesterol, and hypertension and use Proportion of Days Covered (PDC) rather than MPR for their measurement.  Certainly, one of the things we’re seeing at Silverlink with our Star Power program is that many of these Star Measures can be influenced by communications.  Adherence is certainly one of those big areas of opportunity for plans to focus on.

While the benefit is obvious to the plan in terms of reimbursement, the big question is whether consumers care about Star Ratings or just focus on lowest price point and access to pharmacies or specific medications.  A Kaiser study that was done seems to indicate that the answer is no.

Conducted by Harris Interactive, the survey showed that only 18 percent of Medicare-eligible seniors said that they are familiar with the government’s rating system. Of those that are familiar, less than one-third have used the system to select their health plan. Moreover, only 2 percent of respondents were aware of how their current plans rates. 

Since we’re in open enrollment for Medicare right now (see Medicare.gov to evaluate options), perhaps we’ll get some data in early 2012.  2012 will also be the first year for the 5-Star plans to be able to market all year round and not be limited to the OEP (open enrollment period).

But, one of the things I found interesting as I looked on the Medicare.gov site to “select” a plan in my area is that there is an option to “Select Plan Ratings” but even I wasn’t sure what that was.  It’s not intuitive to the consumer that this is a quality rating for them to pay attention to.  And, it appears that the default order of options which is presented to you is based on price.

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

Infographic: Word Of Mouth Advertising

October 22, 2011 by George Van Antwerp 0 Comments

As healthcare moves toward a more retail model, word of mouth advertising becomes more important.  This is already true in terms of physician’s influence on prescription use or in some cases distribution location.  It’s also important from a Medicare perspective.  But, this will continue to increase in importance in the future with health reform.

I also believe that clients will require satisfaction scores as part of their SLAs (service level agreements) in many cases in the future and/or tie bonus dollars to this.  Will you be prepared?  Do you understand your customers’ satisfaction with you?  Do you know how to impact it?

Books / Articles, Consumerism, Healthcare, Infographic, Marketing / Communications, Methodology, Research, Silverlink, Social Media

Managing Stress As One Of 65M Caregivers

October 21, 2011 by George Van Antwerp 0 Comments

65 million Americans are caregivers which can be a stressful job.  I think more and more companies that I consult with are looking at how to engage the caregivers as part of the overall health team.  With that in mind, I thought I would share this quote.  Managing stress as a caregiver is important so you don’t burn out.

“When you have a bad job in a toxic workplace, you feel trapped, but you can always try to find another job,” said Sharon Brothers, a veteran social worker who is now executive vice president of Caregiver Village (www.caregivervillage.com), an omnibus Internet community and resource hub for caregivers that includes expert forum hosts and even an online caregiver game. “Caregivers, however, can’t just find another role. They are caring for a loved one, so the stress they live with is real and the boss they report to is themselves. They feel trapped by their love and obligation to their family members, which makes it exponentially more difficult for them to get a break, because they feel guilty whenever they try to take one.  In fact, studies show that being a family caregiver is one of the most stressful ‘occupations’ in the country today.”

Books / Articles, Healthcare, Marketing / Communications, Research

Did IOM Overlook Literacy and Prevention With Their EHB Recommendations?

October 16, 2011 by George Van Antwerp 0 Comments

“The ACA requires that certain insurance plans—including those participating in the state purchasing exchanges—cover a package of diagnostic, preventive, and therapeutic services and products that have been defined as “essential” by the Department of Health and Human Services (HHS).

This package—commonly referred to as a set of essential health benefits (EHB)—constitutes a minimum set of benefits that the plans must cover, but insurers may offer additional benefits. The EHB are intended to cover health care needs, to promote services that are medically effective, and to be affordable to purchasers.”

The Institute of Medicine (IOM) put out a report recently about Essential Health Benefits (EHBs). While I haven’t fully digested the report and its implications, I noticed two things:

  1. There was no one from the pharmacy community on the committee.
  2. They seem to overlook the value of health literacy.

While I know observation #2 is an opinion that could be heavily debated, let me share my logic here.

If you look at the criteria for EHB selection (see below), they call out that it must “be a medical service, not serving primarily a social or educational function.” I would argue that it is risky to ignore education and its correlation with health. There are many educational functions around prevention which are important. Additionally, there is a lot of research these days around the social value of different networks and tools and their relevance to overall health.

This is Health Literacy Month so you can go visit several sites to see more about this topic. You could also look at research on social aspects of health from Pew. Or, I might even draw upon research around pets and their value in healthcare.

I’m sure the panel didn’t mean it to be interpreted this way, but we know how our government works. These comments become “law” and hard to overcome. I would think some clarification to say something more like the following would be better.

“Be a medical service or a program whose educational or preventative objectives have been demonstrated to improve health outcomes.”

Other articles on the report include:

Books / Articles, Healthcare, Leadership, Marketing / Communications, Research, Value Propositions

How Concentrated Are State Healthcare Markets?

October 14, 2011 by George Van Antwerp 0 Comments

Kaiser Family Foundation just put out a new report on the concentration of health insurers within each state.  It’s interesting since it has relevance on the state health exchanges.

 

Books / Articles, Healthcare, Managed Care, Research

Using Hypothetical Questions To Influence Decisions

October 13, 2011 by George Van Antwerp 1 Comment

Most people don’t realize how questions can be persuasive, according to new research from the University of Alberta. Hypothetical questions usually start with the word “if,” meaning the information may or may not be true. Our brains process that information like the “if” isn’t even there, says study author Sarah Moore, Ph.D., a marketing professor at Alberta’s School of Business. “As a result, people accept the data you present at the beginning of a question as fact,” Moore says.

This is from an article in Men’s Health.  It made me think about lots of ways that hypotheticals could be used to drive consumer behavior in healthcare:

  • If you were able to avoid having your kids home with the flu shot this year, would you take them to get a flu shot?
  • If you were able to save $50,000 in healthcare costs over your lifetime, would you make sure to take your medications everyday?
  • If you were able to spend more time with your family rather than waiting in line at the pharmacy, would you be more likely to use 90-day prescriptions?
  • If you didn’t have to take any sick days next year, would you go in for your annual physical exam?
  • If you decreased your likelihood of losing your foot to amputation due to diabetes, would you go get a foot exam every year?

This fits well with a lot of the behavioral economics frameworks that companies are using today.

Books / Articles, Consumerism, Healthcare, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Silverlink, Words Matter

Patient Reasons For Participating (or not) in Genetic Test

October 13, 2011 by George Van Antwerp 0 Comments

Medco just put out a study that I found very interesting since it shares data around patients opting-in to a genetic test around use of statins.

In the big picture, it showed that those got the genetic test were more adherent.  Perhaps this points to a better belief in the therapy post-genetic test (similar to the placebo effect).

But, what first grabbed my eye was data on the consumers:

  • 53.8% participated in the study since they believed in the utility of genetic testing
  • Only 6.7% of those that declined cited privacy issues
  • Only 8.8% of those that declined cited anxiety about the results

This could be very promising for something that is complex but is certainly part of the future of medicine.

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

Infographic: Patient Education

October 9, 2011 by George Van Antwerp 0 Comments

This is a topic I often bring up in discussing adherence with clients.  We have to partner with MDs as a pharmacy community to address this.  There are fundamental gaps at the beginning of the process where patients don’t understand their disease or their drug.  Without that, it’s hard to believe that taking your medication will make you better or to understand that this is a lifelong process in some cases.

Healthcare, Infographic, Marketing / Communications, PBM / Pharmacy, Research, Silverlink

Flu Shots, Myths, Appointments, and Public Health

October 5, 2011 by George Van Antwerp 0 Comments

I talked about Flu Shots last week, but I came across a few other things when I was following up on the post.  One is a site called Faces Of Influenza by the American Lung Association.  It does a good job of making this public health concern personal by highlighting lots of personal stories.

They also provide a list of myths and address those.

The other thing that this got me thinking of is whether people want appointments.  In general, flu shots have become a walk-in, adhoc business.  Which is nice from a consumer perspective (as long as there’s not a wait), but I have to imagine it’s difficult for the pharmacy to plan their data around.

I know that CVS is now offering apointments as an option for flu shots.  It would be interesting to see what percentage of people choose this option and their demographic attributes.

Healthcare, Marketing / Communications, PBM / Pharmacy, Research, Silverlink, Sponsor

Words Matter: Doodling – We Should Foster It

September 30, 2011 by George Van Antwerp 0 Comments

As someone who was trained as an architect, I understand the value of sketches in the design process and have always “doodled” as I try to conceptualize what people are describing with words.  With that in mind, I really enjoyed this TED video and think it’s a good message for all of us in the communications field.

Events, General Thoughts, Leadership, Marketing / Communications, Methodology, Research, Social Media, Value Propositions, Words Matter

EveryBodyWalk.org Infographic

September 30, 2011 by George Van Antwerp 0 Comments

Some of you have probably seen some of the efforts by Kaiser to encourage walking.  Here’s an infographic that they put out as part of their EverybodyWalk efforts.

exercise, Healthcare, Leadership, Managed Care, Marketing / Communications, Research

Coordinated Versus Integrated PBM

September 24, 2011 by George Van Antwerp 0 Comments

I’ve long held what would appear to be conflicting positions:

A. I believe that a standalone PBM offers the unique ability to be laser focused on pharmacy and should therefore optimize your benefits from a carve-out perspective.

B. I also believe that ideally that focus could be achieved within an integrated benefit where you could leverage pharmacy strategically to drive down the bigger overall area of costs – medical.

So, my initial reaction when I heard about the study below Anthem was that this finally showed a clear savings from the integrated PBM model.

According to a separate analysis Anthem conducted of members in its affiliated health plans, enrollees with both medical and pharmacy benefits managed by Anthem have medical costs that are $8 to $16 lower per employee per month compared with those without Anthem’s pharmacy program. (from Drug Benefit News)

I haven’t seen the original study which I’d like to read in more depth, but on the surface, this is interesting.  After further retrospect, I wonder if the issue isn’t necessarily integrated versus coordinated.

Can a standalone PBM act as an integrated PBM?  What would need to happen for that to be true?

  • They would need to coordinate benefit design across both areas (pharmacy and medical) which is easier when the managed care company is the buyer of PBM services not the individual employers.
  • There would need to be integration of pharmacy and medical benefits into a predictive model and an outcomes model.
  • The PBM would need to be tied to outcomes in some type of P4P model.
I’m sure there’s lots of PBMs out there on both sides of the fence who could (and will) argue this story better.  I’m just thinking through my initial reaction to think about what this study really means.
Books / Articles, Healthcare, PBM / Pharmacy, Research, Value Propositions

Pharmacy Adherence (Waste) And The Need for MD-RPh Collaboration

September 22, 2011 by George Van Antwerp 0 Comments

I spent the day today at the NEHI adherence event in DC. I pulled out a few of my takeaways below, but while I was riding on the plane to get here, a few things were running thru my head:

  • The focus on budget and the estimates that adherence costs us $290B a year here in the US.  (or as one person pointed out that’s $1.2T in a presidential term)
  • The recent report estimating that chronic conditions could cost us $47T worldwide over the 20 years which is leading to the UN talking about healthcare for only the second time ever.
  • The discussion by George Paz from Express Scripts the other day about how PBMs drive value by eliminating waste (see Drug Trend Report). A large piece of waste is adherence and certainly one of the forecasted benefits of the combined Express Scipts and Medco entity is the intersection of Consumerology with the Therapeutic Resource Centers (TRCs).
  • The ongoing dialogue around motivational interviewing, commercial MTM, and blending face to face interventions with technology to “nudge” behaviors.
  • The huge opportunity which I believe exists in leveraging technologies like Surescripts to create data exchanges with physicians around MPR and barriers.
  • The exciting fact that the new STAR measures for Medicare include more adherence metrics that are weighed more heavily than some of the operational metrics.

Fortunately, these were a lot of the topics that were discussed.  Here some of the discussion topics:

  • The fact that there’s no “easy button” for adherence.
  • How adherence is a foundational building block for quality.
  • The role of HIT in sharing data bi-directionally across the care team.
  • Upcoming evidence around VBID.
  • The role of the pharmacist and need for them to collaborate more with the physician to discuss and manage adherence.
  • The fact that the adherence solution has to be multi-factorial.
  • The need to optimize the drug regiment and individualize care (aka patient-centered care).
  • The role of the caregiver.
  • Opportunities around PCMH, readmissions, MTM, and eRx.
  • The need for patient engagement.
  • The need for the patient to believe in the therapy and that it will make them better.
  • Good discussion on the role of the PCMH (patient-centered medical home) versus the pharmacy as the foundation for adherence.
  • Discussion on whether physicians could address adherence if time wasn’t an issue.  Do they have the training and skills?
  • Social media as an emerging factor.
  • Reaching the consumer when they have time and are receptive to information.
  • Helping prepare the consumer for the encounter (i.e., checklist or list of questions).
  • What happens when the patient waits in line and then is rushed themselves in the encounter.
  • The role of technology in complementing the physician and patient.
  • How to share data across team members.
  • The need for ROI data on interventions.
  • The value of having a Dx on the Rx.
  • The need to vary incentives and not keep doing the same thing.
  • If prevention is long-term and adherence is short-term, should the physician focus more on adherence and less on screening and other preventative measures.
  • The need for – sufficient accountability, information, and skills.
  • Adherence as a solution that needs to be localized.
  • Patient centered or disease centered solutions.
  • The governments role in improving adherence via policy and funding demonstration projects through CMS.
  • STAR ratings and the bonus payments as an incentive to motivate research and programs in this area.

Overall, it was a good discussion with a very engaged panel and audience.  We didn’t come to any answers, but you certainly got to think about the topic, identify some projects that should be done, and identify some research questions. 

I look forward to pulling out a few of the topics in more depth.  They align well with the communications platform and intervention strategies that Silverlink provides for our clients around adherence.

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

State By State Use of Rxs per Capita, Age, and Gender

September 15, 2011 by George Van Antwerp 0 Comments

(Note: This is retail only data so it’s not comprehensive, but it should be directionally accurate.)

The Kaiser Family Foundation puts out lots of data.  One of their sites shows state by state analysis.  Here is a map of utilization by state. 

As you can see on the site, the top 5 states are (i.e., highest utilizers of prescription drugs):

  • WV
  • KY
  • AL
  • TN
  • MS

The bottom 5 are:

  • AK
  • CO
  • UT
  • NM
  • WA

For age breakdown, the data showed:

  • 0-18 = 3.8 average Rxs
  • 19-64 = 11.3
  • 65+ = 31.1

For gender, the averages were 9.5 Rxs for males and 14.4 Rxs for females. 

Note: All this data is available online at http://www.statehealthfacts.org/. 

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

Primary Adherence – Technology, Kaiser Study, and EHRs

September 13, 2011 by George Van Antwerp 0 Comments

I think we all know that primary adherence is a real issue.  Depending on what you read, you see that anywhere from 20-30% (or more) of patients don’t start therapy.  They are prescribed a drug, but they never fill it.  This is due to lots of reasons:

  • They get a sample.
  • The drug costs too much leading to abandonment.
  • They don’t feel like they need the prescription.
  • They feel better.
  • The doctor tells them only to fill it if something else doesn’t work.

These issues vary based on whether it’s an acute drug or a maintenance drug.  It also varys by drug class. 

I’ve always been surprised that pharmaceutical manufacturers focus so much on ongoing refills leading to improved MPR rather than focusing on primary adherence which would grow their market significantly.  One of the big reasons for this has been visibility.  Without electronic prescriptions and mapping those to claims data, it was hard to identify who had a prescription and didn’t fill it.  You could do something with data out of the PPMS (Physician Practice Management System) or through more complicated processes to get data out of their notes, but it wasn’t easy. 

So, this new study by Kaiser caught my attention. 

If you are a diabetic, have high cholesterol, or high blood pressure and you receive medical care at an integrated healthcare system that has electronic health records (EHRs) linked to its own pharmacy, then you are more likely to collect your new prescriptions than people who receive care in a non-integrated system, a Kaiser Permanente study shows.

That’s a strong sell for an integrated model, but perhaps more realistically for the use of EHRs.  You can also see some of the data from Surescripts around this topic of electronic prescriptions and adherence. 

This creates a great opportunity for pharmacies, PBMs, payers, and pharmaceutical manufacturers to leverage technology to improve primary adherence.  By identifying people who don’t fill a prescription they receive, companies can help determine which of those are intentional and which of those should be addressed.  This should help address the overall costs attributed to non-adherence and be a business driver for all these entities. 

[Note: If you’re interested in working on primary adherence, let me know.  We have several approaches for this at Silverlink.]

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

Walgreens and Express Scripts: The Plot Thickens ($ESRX, $WAG)

September 8, 2011 by George Van Antwerp 2 Comments

Remember when this “conflict” was first announced a few months ago.  If you’re like me, you probably assumed this would be over in 30-days like the Walgreens – CVS Caremark dispute last year.  What’s different?  I’m not sure.  It seems like both sides are well dug in.  (From my poll a few days ago of 22 of the readers of this blog, 65% felt this would get resolved by 1/1 and 25% felt that it would never get resolved.)

Now, it seems like both sides are continuing to take significant steps towards no resolution.

Express Scripts has apparently launched a pilot program to move share from Walgreens stores now using coupons.  I believe the pilot was with Lowes and is about to expand to the Department of Defense.  Additionally, I’ve heard that Express Scripts has sent out letters to their clients preparing them for a limited network starting 1/1/12 without Walgreens.

On the flipside, I’ve heard that Walgreens has begun putting signage out encouraging consumers to talk to their plans about excluding them from the network and for Medicare members to chose plans that aren’t run by Express Scripts.  Walgreens also put out a whitepaper about what happens when you remove them from the network.  This has some really interesting data in it.

Key Statement: Excluding Walgreens from a pharmacy network will result in little to no savings for most sponsors and patients, and in some cases will raise costs, while causing significant patient disruption and risking gaps in care, and increasing administrative costs on plan sponsors.

  • As part of this document, they are encouraging payers to consider directly contracting with them and/or creating a custom network (if their PBM contracts allow for that).
  • They state that their costs are comparable to other retailers or within 2% of their costs.
  • They show some data from another PBM (not named) that modeled out network savings for them based on a limited network taking into account their drug costs, generic fill rate, and 90-day rates.  It shows a jump in costs versus savings.

  • They share data that their Generic Fill Rate (GFR) is 1.4% higher than the rest of the Express Scripts retail network which the paper says translates to $2 per Rx in cost.
  • They say that 90-day retail generates a 6-8% savings compared to 30-day retail based on the pricing that they offered to Express Scripts.

Ultimately, I still believe resolution will occur before the end of the year.  While both parties are dug in, I believe it’s a lose-lose situation for this to stay unresolved.  That being said, there are lots of things that could occur here:

  • This creates a wave of direct contracting between payers and pharmacies.
  • This validates the integrated model of CVS and Caremark.
  • This creates a large number of limited networks.
  • This creates greater use of the Walgreens discount card and/or cash business at Walgreens especially for lower cost generics.
  • Alienating Walgreens creates a disruptive force in the FTC review of the proposed Medco acquisition.
  • Another PBM jumps in to do a creative deal with Walgreens which limits their long-term ability to work with Express Scripts.
  • Express Scripts ends up in a shotgun relationship with CVS.
  • The terms of PBM contracts get changed going forward based on new terms regarding retailers.
  • Walgreens becomes a much more vocal voice in the retail world through NCPA and other organizations.

Between this and the proposed Express Scripts acquisition of Medco, the landscape in the PBM market could be radically different by early 2012.

[Note: As the stock market has dropped, I have continued to buy stock in the PBM industry including several of the specific companies mentioned in this post – MHS, ESRX, WAG and CVS.]

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

Infographic: Hazards of Hospitals

September 1, 2011 by George Van Antwerp 1 Comment

Scary infographic from http://www.MedicalBillingandcodingCertification.net.

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

Highlights From the Prime Therapeutics 2010 Drug Trend Report

September 1, 2011 by George Van Antwerp 0 Comments

I just finished reading the Prime Therapeutics Drug Trend Report. As I highlighted the other day, their overall drug trend was 2.9%. Like in the past few years, they have jumped up to offer a report comparable with the other big PBMs. And, as we saw with last year’s report, the new management team is aggressive in using this to highlight research, their competitive differentiation, and point out why they are a competitive force in the market.

More interesting that just their success in drug trend was their “adjusted drug trend” for the other PBMs. You don’t often see this in your face marketing in this space, but they clearly want to show not only that their trend was better but that their methodology is better. (I don’t have the time to compare methodologies at this point.)

Fortunately, they don’t stake the argument on trend since as I’ve pointed out before – trend can be misleading. Sometimes higher trend is good as when it indicates better Medication Possession Ratio or better success at reducing gaps-in-care. They focus on five things in the document:

  • Savings
  • Safety
  • Guidance
  • Satisfaction
  • Partnership

Their Generic Fill Rate (GFR) for 2010 was 69.2% which was lower than the 71% reported by Medco and the 71.5% reported by CVS Caremark. (I couldn’t find the Express Scripts numbers for whatever reason.)

The report focuses on some of the differences in the Prime model (client ownership, not public) and how that plays out in transparency and alignment.

They are now at 12 Rxs PMPY which to me still seems a little low. (I’ve mentioned this is prior reviews, but I don’t understand why their population usage is different.) To validate my hypothesis, I looked at the PBMI report from last year which shows PMPM utilization ranges by respondents (not industry averages).

I do think their example around implementing a generics-formulary along with their new benefit plan guaranteeing cost at $47 per Rx are very interesting. They remind me of the GenericsWork product I launched at Express Scripts and should offer some clients a great way to save money. They key, as I learned, was really understanding how to manage member disruption and gain buy-in to the offering.  [Amazingly, a quick Google search led me to a cached image of the PDF from my product from 2004.]

They give some good MTM numbers:

  • $1.29 in return for every $1 spent
  • $86 in savings to the payer over a 10 year period per MTM encounter

They also announce a new offering for 2012 which they call the GuidedHealth care engine. There’s a little information in the document, but it sounds intriguing.

One of those typical charts that we all like to look at shows the drug classes that contributed most to driving trend.

I think their equation about overall cost…

Optimal cost = (medical cost + pharmacy cost) x health outcomes

One of my favorite charts is below which recognizes that there are two cost curves to focus on. The one for the relatively healthy which is often highly pharmacy focused cost versus the chronically ill that drive the majority of overall costs and is heavily medical and specialty medications.

Another study they share in here looks at the likelihood of hospitalization tied to adherence. Very interesting.

$7.60 PMPY savings for a limited network. Those are big numbers that they share from a case study around a client limiting their retail network by excluding one chain.

Their drug trend report looks at another hot topic – 90-day prescriptions. They share their results of a statin study looking at waste in 90-day retail and mail and 30-day retail and estimate the cost impact of the waste.

Another hot topic is the mix of specialty drug spend between medical and pharmacy. They share a chart looking at several of the large specialty drug classes.

At the end of the report, they give suggestions to clients on a spectrum of management (low to high). They also predict a few things in the next five years:

  1. A return to double digit trend increases after this generic wave;
  2. A generic fill rate in excess of 90%;
  3. Specialty drugs accounting for 40% of spend;
  4. Healthcare spending will increase 8-10% per year;
  5. The role of genetic testing will be validated; and
  6. Up to 25% of employers will drop benefit coverage.
Books / Articles, Healthcare, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Research, Value Propositions
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