Enabling Healthy Decisions

A typical struggle that a large company has is how to deal with mid-market companies or average customers.  Typically national clients or repeat customers get great attention, but it is hard to give this same customized attention to an average customer even if they might be your next big customer.

This challenge is exasperated by the difference between your average customer service or account management professionals and your top performers.  How do you embed the DNA of the top performers in that of the average employee.

When I was at Express Scripts, I used to half-kiddingly suggest creating an “automated pharmacist”.  All of our clients from individual groups of 200 people to the Department of Defense with 9M members all wanted a pharmacist to provide them with personalized recommendations based on their member demographics and triggered by market events – e.g., Prilosec goes OTC (over-the-counter), Zocor loses patent, a new drug comes to market.  There was no easy way to do this.

Additionally, all of us who use the healthcare system want more personalized attention from our physicians, nurses, pharmacists, physical therapists, etc.  But, of course, we don’t want to pay a retainer to have them on call.  We just want them to somehow manage to give us proactive advice.

Any professional services firm (e.g., accountants, lawyers) has this same challenge.  When something changes (e.g., long-distance excise tax), how and when do they communicate this change to all of their clients and help them assess the impact of this change on their business.

Companies with distributors or retail branches have similar challenges from communicating downstream or upstream changes across the different constituents to help them prepare in advance.  For example, if your advertising company calls and tells you the ad copy will be 2 days late which means the collateral will be printed 3 days late which means that the supermarkets installing your new display have to shift schedules to have it set up 4 days later…

Well…it didn’t hit me until this morning, but Business Process Management (BPM) technology could help here.  We could map these processes til the cows come home, but that won’t do any good.  Streamlining these processes, capturing the rules, embedding logic into the process, codifying best practices, and integrating these human and system centric solutions can create this automated intelligence.  It is not artificial intelligence but it can help manage your clients and create real personalized value.

Let’s stick with the pharmacy example:

• Image that Claritin announces it is going over-the-counter
• This trigger from the Pink Sheets kicks off an internal process
• The process queries the claims database to identify the number of patients with Claritin claims
• The internal process sends an e-mail to all the account teams within your PBM (pharmacy benefit manager – e.g., Express Scripts, Medco, Pharmacare, Caremark, Argus) or MCO (managed care company – e.g., Aetna, Cigna, Wellpoint, BCBS)
• Based on rules or election by the account teams a subsequent e-mail is sent to each of the clients
• The client can opt-in to a communication to their members
• This approval triggers a mail merge of a pre-approved letter which is sent to all the affected members (patients)

This is a service that every client wants.  They want the hand holding, but it is hard for large companies to give this to every client.  There is not time enough to have all these discussions, talk about customizing the letters, wait on customer approvals, or manage things through e-mail when people are busy and unavailable.  A BPM approach to this embeds the logic and creates a personalized flow triggered off key events that can initiate dormant processes that are waiting in the background.

What a perfect opportunity.  CVS (retail pharmacy chain) owns Pharmacare (pharmacy benefit management company) and owns MinuteClinic (onsite medical clinics).  Right now, if you went to a clinic or physician or hospital, you have created one customer record.  At your retail pharmacy, you have another customer record.  The PBM that processes your pharmacy claims has another customer record of you.  And, the health plan with which you are affiliated has a fourth customer record of you.

There has been talk for years about Personal Health Records (PHR) or Electronic Health Records (EHR).  Although some of the technology exists, the integration and adoption challenges are barriers.  That being said BPM offer some of the core benefits.  The patient can be viewed as having one customer record that follows their path of care.  Each constituent along the way adds information and can view information based on HIPAA guidelines and role based security.

If such a solution made sense, this would create a great opportunity for CVS.  They could capture patients at their clinics and learn about them.  This information could follow the prescription to the retail pharmacy where they could learn more about the patient.  Eventually, they could use the diagnosis data to help inform the treatment suggestions or pharmacy-patient dialog about side-effects.  This data could then be integrated at the PBM level to capture other data from mail pharmacy use and other retailers.

CVS could see where people stop taking therapy.  MinuteClinic could see where people don’t fill prescriptions.  Triggers could be created to generate automatic outbound calls or e-mails or care management calls for follow-up.  But, each event is part of a case management framework so they have history and information to build upon each other.

If you leverage some model like this from a CDHC (Consumer Driven Health Care) perspective, you enable the patient to manage their care by setting reminders for refills, electing to have information pushed to them based on diagnosis codes, seeing reports about costs versus payments, and having the ability to track status of open items – labs, payments, prior authorizations, etc.  In a competitive industry built around complexity, there is a way to simplify it for the patient.