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Using Gilligan To Drive Colonoscopies

While I do applaud the creative concept here, I wasn’t overly impressed with the creative itself.  At the end of the day, the question for me is results.  Did it pay for itself?  Did it get more people to get colonoscopies (in the target audience) than otherwise would have?  I’m unsure of that.

Here’s what I did find in a HealthLeaders article…At the end of the day, I’d want to compare that to a program we did at my last company for UHG in this area.

The campaign also netted 44 colonoscopy appointments. Of those 44 appointments, 13 were current Good Samaritan patients and 31 were new to the hospital. Forty-three of the 44 scheduled an appointment through the call center and one booked online. Of those who called, 27 cited the radio spot as how they found out about the service. More than half of the patients were in the target group of 50–59 year olds, with 24 female and 20 male.

Silverlink Infographic On Healthcare Communications

Here’s an infographic from my previous company – Silverlink Communications.

Uping The RxAnte: An Adherence Predictive Model

Those of you that have heard me speak know that I look at this topic of predicting adherence both from an area of fascination along with the eye of a skeptic.  While I love the concept of predicting someone’s adherence and therefore determining how to best support them from an intervention approach, I also believe that the general predictors are pretty straightforward:

  1. Number of medications
  2. Plan design (i.e., cost)
  3. Gender
  4. Health literacy and engagement (see PAM score research)

And, this is a hot topic (see post on FICO adherence score).  You can see my prior posts on some different studies, on the Merck Estimator, and some notes from the NEHI event on this topic.  It generated a good dialogue on Kevin MD’s blog when I talked about paying MD for adherence.

I had a chance to talk with Josh Benner the CEO of RxAnte the other day.  It sounds very interesting, and they have an impressive team assembled.  In general, they’re focused on:

  • Predictive modeling
  • Decision rules
  • Monitoring and managing claims to track adherence
  • Evaluating effectiveness of interventions
  • And creating a learning system

There are definitely some correlations to the work we do at Silverlink Communications around adherence.  We’re helping clients determine a communication strategy that might include call center agents, direct mail, automated calls, e-mail, SMS, mobile, or web solutions.  We’re looking at segmentation and prioritization.  We’re looking at past behavior and messaging.  The goal is how to best spend resources to drive health outcomes from primary adherence to sustaining adherence.  This is a challenge, and we all need to build upon the work that each other is doing to improve in this area.  We have a huge problem globally with adherence.

The New Post-Recession Consumer

I’m always fascinated by segmentation, and I think understanding how market events like the Great Recession have changed the fundamentals of the game is important. In November 2011, Money Magazine shared some data from a survey they did. Here are some of the results.

  • 53% of Americans aren’t sure their kids will better off then they are.
  • 67% are worked their quality of life will suffer in retirement.
  • 80% say they’re eating at home more.
  • 75% say time with family is more important than ever.

“Big periods of economic upheaval can define a generation. Not so much because of the depth of this recession, but because of its prolonged nature, it will have lasting impact.” Paul Flatters, Managing Director of Trajectory Partnership. (How The Economy Changed You by Dan Kadlec)

  • 85% spend more time looking for deals before they buy. (hence the couponing craze)
  • 57% are building an emergency fund.
  • 51% are pessimistic about the US economy in the next 12 months.
  • 61% are pessimistic about government officials spurring growth.

I don’t know about you, but I see a ton of nuggets in here about positioning generic drugs, preventative health, adherence, mail order, and many other cost savings actions in healthcare.

Who’s the 1% in healthcare?

As we all have known, healthcare costs are driven by the minority. According to the Agency for Healthcare Research and Quality, the top 1% account for 22% of healthcare spending in the US or about $90,000 per year. (USA Today article)

So, what are the characteristics of these people:
– White, non-Hispanic
– Female
– In poor health
– Elderly
– Users of publicly funded healthcare

Only about 20% of the high cost consumers stay in that bucket for two straight years…which I think is good. But, I guess you have to look at what percentage die during that period since a lot of costs are concentrated at the end-of-life.

Obviously it’s critical to develop solutions to engage and manage these patients earlier in the process. As data gets better, our predictive algorithms around conditions will improve and we’ll be able to intervene and prevent or delay cost in the system. The key of course is doing that in a way that fully engages the healthcare team and the caregivers.

Presenting at PBMI in February

I am excited about the opportunity to present at PBMI in February.  I hope many of you will be there.  If you want to meet up, send me a quick note at gvanantwerp at mac dot com.  Thanks.

Here’s the description of my presentation:

The PBM industry continues to consolidate through mergers and acquisitions.  At the same time, new PBMs and niche PBMs continue to grow.  While the majority of the green space is gone, there is increasing focus on the individual market through exchanges and the Managed Medicaid market.  But, this maturing of the market has forced PBMs to look at more organic growth opportunities also.  How do you retain business?  How do you innovate?  How can you increase profitability per member?  With a few large market dynamics playing out in 2012, we’ll begin to look at what the future might hold and what we can learn from the past.  It is an interesting time for all PBMs, pharmacies, and manufacturers as they embrace the role of pharmacy in improving overall health outcomes.   

2011 Blog Overview and Press Hits Update!

2011 was a great year for the blog with over 120,000 visits and 365 new posts (conveniently averaging 1 per day).  You can see the top posts here.  The blog led to several new opportunities at Silverlink, and it generated numerous press opportunities. 

The blog now has over 400 people who get an e-mail every time a new post is published.  The content is then syndicated to the 930 people who follow me on Twitter and to my 1252 contacts in LinkedIn.  I’m happy with this for something I do in my spare time.

In August, I shared my press hits YTD which numbered 25 times.  Since then, I’ve had 27 more which are listed below:

  1. Dec 26th issue of Health Plan Week about Express Scripts and Walgreens
  2. Jan 1st issue of Managed Healthcare Executive on limited networks
  3. Dec 2nd issue of Drug Benefit News on Lipitor
  4. Dec 2nd issue of Drug Benefit News on Prime Therapeutics Retail MTM solution
  5. Dec 2nd issue of Drug Benefit News on PBM Deal Making
  6. November Frost & Sullivan newsletter on consumer engagement
  7. PBMI Report
  8. Nov 11th issue of Drug Benefit News on Pfizer’s Lipitor strategy
  9. Nov 11th issue of Drug Benefit News on the PBMI Report
  10. Oct 28th issue of Drug Benefit News on OptumRx
  11. Oct 28th issue of Drug Benefit News on CVS Caremark case study
  12. AIS webinar on copay cards / coupons
  13. AIS webinar on PBM outsourcing
  14. Oct 7th issue of Drug Benefit News on Outcomes-Based Contracting
  15. PCMA Smart Brief on Oct 5th regarding PBM disclosure of profits
  16. Sept 23rd issue of Drug Benefit News on Mobile Apps
  17. Sept 23rd issue of Drug Benefit News on Anthem study
  18. Drug Channels mention of my post on the Prime Therapeutics Trend Report
  19. PCMA Smart Brief on Aug 11th re: NY bill
  20. Sept 9th issue of Drug Benefit News on the Prime Therapeutics Trend Report
  21. Sept 9th issue of Drug Benefit News on the proposed Express Scripts acquisition of Medco
  22. Sept 9th issue of Drug Benefit News on Generics
  23. Aug 22nd issue of Health Plan Week on Generics
  24. Aug 24th Reuters article on the proposed Express Scripts acquisition of Medco
  25. Aug 19th mention in Health Reform Watch
  26. Aug 19th issue of Drug Benefit News on Part D
  27. Presentation with Aetna at the Care Continuum Alliance on engaging the hard to engage

Will Patient Reported Data Augment Claims Based Models?

On the one hand, it seems fairly obvious that patient reported data (use of OTCs, exercise, food intake) is important in understanding their healthcare.  On the other hand, the historical bias has been to use historical claims to predict future costs.  At a minimum, I think that studies around tools like PAM (Patient Activation Measure) have shown that patient reported information is important in understanding their literacy and attitudes on healthcare.  This data is critical in designing effective healthcare engagement programs.  [One of the reasons that Silverlink has stressed our focus on using data for segmentation and personalization for years.] 

That’s why I found one of the latest studies by Kaiser to be really important.  They used both claims data and patient reported data to evaluate inpatient admission rates and costs.  And, as explained below, this data increased the predictive power of their model. 

The research determined that self-reported information about being in poorer health was a key determinant in predicting higher inpatient admissions and for being in the top tier for costs. Higher admission rates and costs were associated with patients who self-reported:

  • Lower score for general self-rated health
  • Yes to “do you need help with one or more activities of daily living?”
  • Yes to “do you have a bothersome health condition?”

The addition of this self-reported information to a claims history model explained an additional 2.8 percent of variance in admissions and 4 percent in cost.

Cost and Outcomes Drive Better Use of Data

Overall, I would describe healthcare companies as trying to figure out how to drive the best outcomes at the lowest cost while maintaining a positive consumer experience.  This isn’t easy.  One area of opportunity that companies increasingly look at is how to use data to become smarter. 

  • Can I build a predictive model of response curves?  Who’s likely to respond?  Who’s likely to take action?
  • Can I develop a segmentation model that works?  How will I customize my communications after the segmentation?
  • Can I rank and prioritize my outreaches?  Should I do that based on risk or based on potential value? 

Ultimately, I think this is driving companies to be a lot smarter and to look at how they use both medical and pharmacy data.  For example, I’ll point to both CVS Caremark and Prime Therapeutics in press releases from earlier this year. 

“The ActiveHealth CareEngine offers evidence-based information that can be used to improve the health care of our members and enables us to take our programs to the next level by seamlessly incorporating medical data,” stated Troyen Brennan, EVP and chief medical officer of CVS Caremark. “This agreement will enhance our existing programs to identify issues related to gaps in care, potential drug-to-drug interactions and duplicative care — information that is important to bring to the attention of the member’s physician.”  (article that this is sourced from)

Smart use of medical and pharmacy data is one of the most powerful tools we have to improve outcomes and increase value for our members and clients,” said David Lassen, PharmD, Chief Clinical Officer at Prime. “Through ongoing partnership with health plan clients, Prime is uniquely positioned to view the entire spectrum of patient care, and we can leverage that information to help manage cost and to improve outcomes. We are very excited to collaborate with Corticon on the development of this clinical platform.” (press release)

The next step will be to integrate PRO (patient reported outcomes) from sources like connected devices and PHR (personal health records) that might show blood pressure, workouts, calories, or other data points that could help companies determine when to intervene and how to add value to drive an outcome.

Additionally, another key is continued work in the outcomes-based contracting world and bonus areas such as Star Ratings where the financial value is tied in the short-term to outcomes.  This creates a burning platform for smarter use of data and use of a broader set of data to understand and impact care.

What’s A PAM Score?

PAMTM is the Patient Activation Measure which was developed by Dr. Hibbard, Dr. Bill Mahoney, and colleagues. It helps you gauge how much people feel in charge of their healthcare. To find out more, you can go to InsigniaHealth’s website.

Given the focus on health engagement across the industry these days, I think this is an important tool to consider. It’s been used broadly and has been validated in a lot of published studies. The questions lead people to be assigned to one of four different activation levels.

You can collect and use the PAM score for segmentation, developing customized messaging, measuring program success, and/or identifying at risk populations.

A few other interesting points from one of their FAQ documents were:

  • Patients who are more activated are more likely to adopt positive behaviors regardless of plan design.
  • People with higher activation levels are more likely to choose consumer directed plans.
  • People with low activation often feel overwhelmed with the task of taking care of themselves.
  • You increase the level of success in by breaking down change into smaller steps where the consumer has a greater likelihood of success.

Which PBMs Have The Highest Mail Order Penetration?

I was looking at some data from earlier this year (Q1 – 2011) from the AIS quarterly survey of PBMs. I thought this was a nice summary of mail order penetration by PBM. As you can see, it identifies some areas of opportunity:

  • Will Express Scripts’ mail penetration go up with the potential acquisition of Medco? Or, will Medco’s go down?
  • Will anyone be able to match the Medco mail penetration?
  • Will Aetna’s mail penetration go up to the CVS Caremark penetration rate?
  • How will Prime Therapeutics, SXC, and CatalystRx increase their mail penetration?

Overall, the mail penetration of the industry has dropped to 16.3% which is the lowest it’s been since 2004 when it was 12.9% (according to AIS). [Note: These are based on adjusted Rxs.]

Reprint: Getting Aligned For Consumer Engagement

(This just appeared in the publication by Frost  & Sullivan and McKesson called “Mastering the Art and Science of Patient Adherence“.  It was written by me so I’m sharing it here also for those of you that don’t get that publication.)

According to the 15th Annual NBGH/Towers Watson Health Survey, employees’ poor health habits are the number one issue for maintaining affordable benefits. Since studies have shown that 50-to-70 percent of healthcare costs are attributed to consumer choices and adherence is one of those issues, the topic of how to engage consumers isn’t going away.

The challenge is getting the healthcare industry to use analytics and technology tools when engaging the consumer in a way that works for each individual and builds on their proven success in other industries. Healthcare has an enormous amount of consumer data ranging from demographics to claims and behavior data. Consequently, there is great opportunity to use this data to engage consumers in their health to improve clinical outcomes. While on the one hand, it’s like motivating consumers to buy a good, the reality is that healthcare is both personal and local which complicates the standard segmentation models.

This is a dynamic time where people are experimenting with different strategies for engagement. For instance, in medication adherence, people are trying everything from teaming those who have chronic conditions with community pharmacists to make sure they are taking their medications correctly to technology that monitors when the pill actually enters your body. But, there are still fundamental gaps in the process which can be addressed using interactive technology to complement the pharmacist interventions.

Consumer engagement in healthcare is increasingly moving to new channels with 59 percent of adults in the U.S. looking for health information online and 9 percent using mobile health applications according to Pew Research Center. Additionally, there is more and more participation in social media or peer-to-peer healthcare applications. Modes like SMS, which companies are starting to leverage in programs like Text4Baby or the diabetes reminder program recently launched by Aetna, are gaining popularity. Companies like Walgreens have also begun exploring the use of SMS and Quick Response (QR) codes for medication refills.

At the end of the day, consumers want preference-based marketing where they can elect how to best engage them, but that doesn’t mean that’s the most likely channel to get them to take action.They want you to learn from their past responses to improve your future outreach, but they are also skeptic about how their data is used. You have to put yourself in their shoes to create the optimal consumer experience. You have to deliver the right message to the right consumer at the right time using the right sequence and combination of channels.This is not easy.

So, if you’re going to optimize your resources and build the best consumer experience, you need an approach which is dynamic and personalizes each experience. For example, we found that creating the right sequence and timing around direct mail and automated calls improved results by as much as 100 percent in a pharmacy program. Or, in another case, at Silverlink Communications, we found that using a male voice in an automated call to Latinos got an 89 percent better engagement rate around colonoscopies. We also know that using a peer pressure message does not work in motivating seniors to take action in both a retail-to-mail program and a cancer screening program, but does work for those younger than 55-years-old?

You have to make simple messaging relevant to them—why should I get a vaccination, why is medication adherence important, how can you address my barriers? Only an ongoing test and learn approach to consumer insights will suffice, and those that figure this out will become critical in the ongoing fight for mindshare and trust. But, this isn’t a stand-alone opportunity. We have to partner with providers to improve engagement, adherence, and ultimately outcomes in different forms. We have to offer them a platform for engagement that is built upon consumer insights and provides a unique consumer experience to them based on their disease, their demographic attributes, and their plan design. All of these factor into their behavior and are important in “nudging” them towards healthcare engagement and ultimately, better health.

“Code Lavender” – Focusing On The Patient Experience

If you don’t know it yet, the consumer “experience” is rapidly becoming the hot topic. I’ve talked about it a lot beginning with companies like Cigna that have hired and staffed a consumer experience team and Chief Experience Officer. But, as the WSJ pointed out earlier this week in their article “A Financial Incentive For A Better Bedside Manner“, this is getting quantified in the provider world. One might argue that experience has always mattered more in the provider world since it’s easier to switch hospitals or physicians than insurance companies, but that is likely to continue to change as the individual insurance world and Medicare continue to create competition for the individual.

For payers, you can already see this individual market playing out with the growth of retail stores which is where the experience begins. In other cases, the PBMs and payers have to rely on many cases on their call centers as the front-end of the consumer experience. Additionally, with pharmacy being the most used benefit, this is another critical area. And, we know that pharmacy satisfaction is highly correlated with overall payer satisfaction.

But, let me pull a few things that caught my attention in the WSJ article:

  • CMS will begin withholding 1% of their payments and tying payment to quality standards for medical care AND patient satisfaction surveys known as HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Services). This will go up to 2% in 2017.
  • The survey is a 27-question survey sent to a random sample of discharged patients (about 25% of the 36M patients admitted in 2010 with a pretty low response rate of 7%). It asks about cleanliness, quiet, communications, and an overall satisfaction based on something similar to the Net Promoter Score (i.e., would you recommend the hospital to friends and family).
  • 67% of patients give their hospitals the top two ratings on a scale of 1-10 (which I actually think is pretty good).
  • Only 60% say that doctors and nurses always communicated well about medications (which was higher than I expected).

Cleveland Clinic Chief Executive Delos “Toby” Cosgrove, a heart surgeon by training, says he had an epiphany several years ago at a Harvard Business School seminar, where a young woman raised her hand and told him that despite the clinic’s stellar medical reputation, her grandfather had chosen to go elsewhere for surgery because “we heard you don’t have empathy.”

  • The Cleveland Clinic calls their program HEART—for hear the concern, empathize, apologize, respond and thank. They also use the term “Code Lavender” for patients or family members who need immediate comfort.

I look forward to watching how this transforms over time. I know I’ve seen this play out in the dentist’s offices for my kids. The waiting rooms have video games and other things to keep them and their siblings busy, but I do agree with the article that this may unfairly bias the wealthier hospitals.

Sustained Patient Engagement Around Hypertension: Silverlink and Aetna

At Silverlink, we had a great opportunity to work with one of our clients and publicize it. This morning, Aetna released a joint press release with us about our hypertension program.

As companies continue to look at new ways to use technology to engage patients around chronic diseases, solutions like this offer companies a unique way to blend multiple channels into an overall consumer experience that improves engagement and outcomes.

From the press release:

The program also achieved high levels of engagement, with nearly 60 percent of participants continuing to actively monitor their blood pressure by using a free blood pressure monitor and submitting readings on a monthly basis. The frequency of participants’ cholesterol (low-density lipoprotein (LDL) cholesterol) screening also improved 5 percent.

“By helping our Medicare members manage their high blood pressure, we are hoping to help prevent heart disease, strokes and even deaths,” says Randall Krakauer, MD, FACP, FACR, Aetna’s national Medicare medical director. “Our nurse case managers work closely with our members and do a tremendous job providing them with the information, tools and support they need to help them control and improve various chronic conditions, including hypertension. The results of our program with Silverlink demonstrate that an automated program can further support and engage members in managing their own health conditions.”

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

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:


One Challenge Of Medicare OEP – Satisfaction

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.

Three Pillars of Adherence (NEHI)

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.]

Predicting Medication Adherence

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…

Will The Stars Align To Drive Adherence?

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 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 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.

Infographic: Word Of Mouth Advertising

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?

Increasing The Value Of Your Refill Reminder Call

The other day, I got a refill reminder call from my pharmacy. The call came to my home number and simply stated that your prescription is ready.

Thanks…BUT what prescription. Mine? My wife’s? My kid’s?

If mine, was it the one I stopped taking? Or was it the second fill or an anti-biotic that we switched since it wasn’t working?

Did they even have the right phone number? (They never said anyone’s name in the message.)

I was confused and annoyed. I don’t think this type of message is helpful.

IMHO…the ideal refill reminder call should be something like the following:

  • This is pharmacy X calling for George Van Antwerp. Please have him call us back.
  • Thanks for calling back in. Please enter (or say) your prescription number or date of birth.
  • We have a prescription for drug X ready to refill for you. Will you be coming to pick it up in the next 2 days?
  • (If no) Do you intend to refill it?
    • (If no) Why not? (and then address the barrier)
    • (If yes) When should we call you back to remind you?

This would minimize me calling the pharmacy to follow-up on the call. It would cut down on abandonment. It would also address adherence by capturing and addressing any barriers in the interactive call.  [Of course, you have to manage HIPAA and several other constraints to achieve this, but it is possible.]

Creating an interactive and effective communication is the type of work we do at Silverlink (campaign design, scripting, segmentation, behavioral economics, communication execution, analytics). Like many others, we’re seeing refill reminders move from blast calls to interactive calls and expanding to SMS, mobile apps, and e-mail. Ultimately, it’s about figuring out the patient’s preference and the right way to “nudge” them to refill at the lowest cost per success. And, it works. You can see more at our adherence site –

  • What voice should you use?
  • When should you call?
  • Should you e-mail then call?
  • Should you call then send a text?
  • Should you talk about their condition and stress the value of adherence?
  • What’s important to the patient about being adherent?
  • What is their previous pattern of refills?

Using Hypothetical Questions To Influence Decisions

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.

Infographic: Patient Education

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.

Flu Shots, Myths, Appointments, and Public Health

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.

Diabetes And Medicare Star Ratings

Do you know what the Medicare Star Ratings are?  If not, you might want to review the Kaiser Family Foundation brief from last year.

Basically, the star ratings provide individuals with a quality rating across numerous dimension on a Medicare plan.  And, they are helping to drive the pay-for-performance (P4P) focus across healthcare.  This year’s changes include several adherence metrics and have brought the total diabetes measures up to 7.  And, if you happen to be one of the few 5-star Medicare plans, you will be able to have open enrollment all year not simply during the AEP period from 10/15-12/7.

Here’s a quick summary of the seven (lots of opportunities to work with communications to improve ratings and outcomes):

Measure Summary
Cholesterol Screening Percentage of diabetics with an LDL  test
Eye Exam Percentage of diabetics with an eye exam
Kidney Disease Monitoring Percentage of diabetics with a kidney function test
Blood Sugar Controlled Percentage of diabetics with an A1c test showing their blood
sugar under control
Cholesterol Controlled Percentage of diabetics with an acceptable LDL value in their cholesterol test
Treatment Percentage of diabetics with both a diabetic medication and a hypertension medication that are getting an ACEI or an ARB
Adherence to Oral Rxs An average Proportion of Days Covered (PDC) greater than 80%

We all know the statistics on diabetes so hopefully this will help to improve outcomes.  If you’re interested in how Silverlink helps plans with Star Ratings – go here.

Do Medicare Participants Know Open Enrollment Period Has Changed? No.

A recent study showed that only 37% of Medicare participants knew that the AEP (Annual Enrollment Period) had changed. It now closes on 12/7 not 12/31. That could cost people money if they don’t review their ANOCs (Annual Notification of Changes) and take action.

Another article in US News & World report emphasizes that with some comments from Silverlink’s Chief Medical Officer (Dr. Jan Berger):

Berger breaks down the Medicare coverage decision into five steps, all of which are addressed in the annual statement:

1. What are the primary financial implications of your plan for 2012, including the premium, annual deductible, and co-pays?

2. How well does the plan accommodate your preferred medical providers? Are your doctors participating in the plan? Your preferred hospital?

3. What are the costs and availability of your medications in the plan?

4. How convenient is the plan in geographic terms? Are the participating doctors, medical facilities, and pharmacies nearby and easy for you to get to?

5. What is the star rating of your health plan, and how does it compare with other plans offered in your service area? Quality ratings of health plans ranging from one star (worst) to five stars (best) are relatively new. Medicare has been emphasizing them, and the health reform law has provisions that will penalize plans for substandard rankings. The current star rating process will go live on Medicare’s website on October 12, an agency spokesman says.

Sandwiches and Caregivers During AEP

October 1st marked the beginning of the Medicare marketing period leading into the enrollment period known at AEP (Annual Enrollment Period) which begins on 10/15. [For more on how Silverlink is helping clients with AEP – click here.] More to come on this topic, but for right now, I was just reading an article about the sandwich generation which made me think about this.

Traditionally, we think of sandwich generation as those that have young kids and parents to care for. Increasingly, that “young kids” age is getting stretched out as kids move back in post-college or even as they lose their jobs later in their career.

Perhaps, some of this will be good as we go through more integration of multiple generations into single households as other cultures experience, but it certainly is creating financial stress for the baby boomers. As you think about your marketing, this is just another wrinkle.

For example, according to Strategic Business Insights’ MacroMonitor, 39% of households headed by 60-64 year olds had primary mortgages compared with 22% in 1994. And, as we know, it’s often harder to get out of those houses these days as many people are unwater or can’t sell their homes.

How does this change our caregiver strategy as a healthcare provider? (assuming you even have a caregiver strategy)

On this caregiver point, here are some statistics from the National Family Caregivers Association:

More than 65 million people, 29% of the U.S. population, provide care for a chronically ill, disabled or aged family member or friend during any given year and spend an average of 20 hours per week providing care for their loved one.
Caregiving in the United States;
National Alliance for Caregiving in collaboration with AARP; November 2009
The value of the services family caregivers provide for “free,” when caring for older adults, is estimated to be $375 billion a year. That is almost twice as much as is actually spent on homecare and nursing home services combined ($158 billion).
Evercare Survey of the Economic Downturn and Its Impact on Family Caregiving;
National Alliance for Caregiving and Evercare. March 2009
The typical family caregiver is a 49-year-old woman caring for her widowed 69-year-old mother who does not live with her. She is married and employed. Approximately 66% of family caregivers are women. More than 37% have children or grandchildren under 18 years old living with them.
Caregiving in the United States;
National Alliance for Caregiving in collaboration with AARP. November 2009
1.4 million children ages 8 to 18 provide care for an adult relative; 72% are caring for a parent or grandparent; and 64% live in the same household as their care recipient. Fortunately, most are not the sole caregiver.
National Alliance for Caregiving and the United Hospital Fund, Young Caregivers in the U.S., 2005.
51% of care recipients live in their own home, 29% live with their family caregiver, and 4% live in nursing homes and assisted living.
Caregiving in the United States;
National Alliance for Caregiving in collaboration with AARP. November 2009
36% of family caregivers care for a parent and 7 out of 10 caregivers are caring for loved ones over 50 years old.
Caregiving in the United States;
National Alliance for Caregiving in collaboration with AARP. November 2009

Do You Have A Communications Waterfall?

For those of us that have ever worked in IT, the idea of a waterfall based design always implies a less than optimal strategy.  But, I’m beginning to see an applicability of this framework for communications.

Let’s look at a scenario for a prescription refill where you’re trying to optimize for the lowest cost intervention.

  • Identify targets for an intervention
  • First push a message to all those that have downloaded your mobile application (~10%)
  • Second push a message to all those that have opted into your SMS reminder system (~6% with some overlap)
  • Third push a reminder to those that you have an e-mail address on file
  • Fourth send a reminder using an automated outbound call with the option to refill during the call
  • Fifth (maybe) use agents to reach out to the patient
As you go through this “communications waterfall”, there are several things to think about:
  1. How do you leverage permission-based or preference-based marketing here?
  2. How do you integrate your channels so that if you send an e-mail which isn’t opened after 48 hours (and the message is important) that it automatically escalates to the next channel?
  3. How do you cross-promote across channels to drive greater use of the self-service channel?
  4. What permissions do you need to use each channel?
  5. What are the HIPAA / PHI limitations within each channel?
  6. What is the correlation between preferences and behavior?
  7. If you know that certain segmentation and messaging increase the likelihood of action, how do those insights manifest themselves in each channel and does that change your interest in using a particular channel?
  8. What data do you want and can you get from each channel to understand the response curves?

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

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.

Flu Shots: Stock It And They Will Come?

This is the hot topic. Everyone wants you to get a flu shot because it’s good for your health and a profit making opportunity.

  • The CDC recommends flu shots for everyone over 6 months of age.
  • Pharmacies have big expectations about volume but “unfortunately” (from the perspective of nudging people to act) the disease does not seem to be too prevalent yet.

According to the CDC (and thanks to Larry Marsh’s team at Barclays Capital for sending out in their Flu Clues report):

We highlight that 0.8% of patient visits to physicians were due to flu-like illness, which is down 20bps from last week’s data. We note that this is well below the peak of 8.0% in early 2010. The 0.8% rate is below the national baseline average of 2.5%. Next we note that 6.0% of all reported deaths were due to pneumonia and the flu, 10 bps below last week, and below the epidemic threshold of 6.4% for week 37.

Traditionally, only about 40% of US adults will get a flu shot meaning there’s lots of opportunity for growth in vaccinations.  Tim Martin from the WSJ has talked about this in a few recent articles – Flu Shots Are A tough Sell This Year and People Have Big Plans For Flu Shots.  In the second article, he quotes a recent survey showing almost 2/3rds of adults plan to get the shot this year.  BUT WHY?  (other than the fact that those who respond to survey’s around flu shots may be more likely to take action)

You can also look at the Google flu trends data (again thanks to Larry Marsh and team for pointing this out) which shows online searches down for flu topics:

Like last year, the number of locations for getting a flu shot has expanded exponentially driven predominantly by pharmacies (which BTW is a good thing for them in demonstrating additional value).  You’re even seeing some creative programs building on last year’s programs. One new one I’ve seen is Walgreens use of Foursquare for donating flu shots.

Of course, if we can’t convince healthcare workers to get flu shots then it’s going to be really hard to convince the average consumer.

I would expect MA plans to work with their PDP provider or pharmacy partner to drive members to get flu shots. Since flu shots are a STAR measure, it’s important for plans to reach out and get consumers to get a flu shot.

But why should I get a flu shot if my likelihood of getting the flu is down?  That is the question.

That’s why I’m skeptical about some of the “generic” marketing efforts.  I think everyone knows that they “should” get a flu shot and now finding a location for one is easy.  BUT, we need to make it relevant to them especially those of us in healthcare.  Ideally, their pharmacist and physician are talking to them about it, but if not, how do “we” (as healthcare companies) engage them.

We have to make the “pitch” relevant to them. For families, make them understand the importance of keeping the family healthy and their kids in school. For pregnant moms, help them understand that it’s important and why.  For people who work, stress the importance of not missing work. For people with chronic conditions, focus on their additional risk.  For the elderly, explain the risks to them.

A recent Walgreens study quantified some of the costs of the flu:

A new Walgreens survey examining the effects of influenza on people’s everyday lives and the economy, suggests that last flu season resulted in 100 million lost works days, along with nearly $7 billion in lost wages and 32 million missed school days, among many other findings released today. These findings, the first of a two-part Walgreens Flu Impact Report series, underscore the ramifications the flu and ill-timed illness can have beyond people’s health – from missed work and lost income to parenting challenges.

According to the Centers for Disease Control and Prevention (CDC), on average 13 percent of the U.S. population gets the flu every year, with active flu seasons seeing closer to 20 percent, or more than 62 million Americans.

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