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Smart People Doing Stupid Things

I was reading a post on the Foghound blog which made me think of an article I saw this morning on medical administrators using homeless people to defraud the government.  Lois points out eight things that smart people do that are stupid – impulsiveness, indulgence, and tempting fate (for example).

Why is it that seemingly intelligent people so easily and frequently seem to skirt the law to try to make money.  Do they think they are above the law?  Are they that greedy?  Do they believe (like the common criminal) that they won’t get caught?

It’s cases like this one with the homeless that cause distrust in the system.

Other Contributors

I have had a few guest posts over the past year, but I have now invited my team at Silverlink to contribute to the blog so don’t be surprised if you see a few other contributors in the near future.  Each of them owns a market area within healthcare (Medicare, Medicaid, Loyalty, Payor, Population Health, Clinical, Individual) and has great experience and ideas.

Gas Prices Helping PBMs

Unfortunately, the WSJ Health Blog beat me to it, but I think it’s an interesting perspective that apparently David Snow (CEO of Medco) talked about.  High gas prices cause people to reconsider things…like driving to the pharmacy or paying for brand drugs.  That would mean that mail order penetration should go up and people should use more generics.

It seems logical, but I am trying to reconcile it with two other economic realities…people not filling their prescriptions or skipping doses to save money and the fact that mail order requires upfront payment for the longer supply.  I have always struggled with why someone doesn’t offer a credit card for their mail order pharmacy so that you can save money and spread the payment over three months.  In tough economic times, that cash flow can be an issue.

And, for the first time in over a decade, it appears that the growth in prescriptions actually fell as reported on the 16th in the WSJ.

The burden on consumers has increased sharply. The average copay for a preferred drug on an insurance company’s tiered system rose 67% to $25 in 2007 from $15 in 2000, according to the Kaiser Family Foundation. Out-of-pocket costs to cover family insurance premiums were $3,281 per employee last year, up nearly 84% from 2001.

Consumers appear to be skimping on medicines as a result. An April poll from the Kaiser foundation showed 23% of patients who responded didn’t fill a prescription in the last year because of cost, up from 20% in 2005; 19% split pills or skipped doses, up from 16% in 2005. A report last month from the nonpartisan Center for Studying Health System Change in Washington, D.C., said 20% of respondents in a 2007 survey of 18,000 people had put off or gone without medical treatment in the previous year, compared to 14% in 2003.

Data from IMS Health show growth in prescription volume for the first five months of this year slowed to 1.5%, the lowest rate at least since 1996. From 2003 to 2007, annual volume growth averaged 3%. In December 2007, total prescriptions dipped by 2.1%. The decline was 0.2% in April and 0.1% in May.

New Drug Trend Blog

In a new blog called DrugTrendsToday by DestinationRx, you can find some good initial posts and some good data such as the following on generic Zocor (aka simvastatin).  What this shows you (that I have blogged about before) is the massive difference between AWP and actual cost for a generic.  In this case, the AWP is $136, but Costco pays 2% (or $2.72) for the drug.  This huge difference is only true on generics, but unfortunately, the industry has come to depend on generic pricing as the profit engine to subsidize the brand pricing which is some cases is a loss leader.

One Year Blogging “Anniversary”

It was last July that I started this new blog originally called The Patient Advocate and now Patient Centric Healthcare. I pulled in some of the content from my old blog on Business Process Management (my focus during my non-compete days). I thought I would spend a minute and capture some statistics from this first year.

It has been interesting to hear from and meet some of the readers. Additionally, I have enjoyed some of the opportunities it has created. I had a chance just the other day to do an analyst briefing on PBMs to one of the big investment firms on Wall Street.

And, one of my favorite things was that I got a signed book from George Halvorson the other day with a personal note about my comments on his book on my blog.

But, for all those that ask…it is a lot of work. I do it primarily because I enjoy it. I am not sure if these stats are just stats or indicate that it has been a successful effort.

Medical Bankruptcies

I will give credit to the Health Care Reform Now blog for leading me to this article in The Indianapolis Star, but I think it is a sad reality.

“More and more of the middle class is finding out that even if they have jobs and insurance, they can be wiped out by medical events that are not even catastrophic,” says Dr. Christopher Stack, a retired orthopedist and co-founder of Hoosiers for a Commonsense Health Plan, the state’s chapter of Physicians for a National Health Program. “You can run up a high five-figure bill real easily.”

A Harvard study published in 2005 estimated that about half of all bankruptcies filed in the U.S. have their origins in medical costs, a ratio that jibes with Silver’s and other bankruptcy veterans’ observations here in Indianapolis. While the rest of the world’s industrialized nations provide health coverage to all or nearly all of their populations, the U.S. mass-produces the distinctly American phenomenon of medical bankruptcies.

I am not a big fan of the donut hole in Medicare, but perhaps we need a donut hole type concept for health insurance where people have a maximum out-of-pocket in any one year.  Although I am sure that would beg the question of what was optional versus required surgeries and treatments.  It just seems a shame that we can bankruptcy hard working people with insurance over their medical bills.

Three Sad Healthcare Stories

First, I think this is a very disappointing article about workplace violence in the healthcare industry.  I certainly could believe (unfortunately) in the verbal violence since people are very emotional about their healthcare and often stressed over the financial implications and unintuitive processes.  But, this story has some scary statistics which are an issue at a time when we need more healthcare service workers.  [Ask your friends in the industry.  I plan to.]

  • Health care workers are 16 times more like to face violence at their job that workers in any other service-oriented profession.
  • More than 50 percent of reports of aggression in the workplace come from the health care sector.
  • Over 9,000 nurses and other health care workers are verbally or physically assaulted on the job every day, according to the National Institute of Occupational Safety and Health.
  • A 5-year survey of 170 university hospitals showed that over half of all emergency room employees had been threatened by weapons.
  • Almost 90 percent of nurses in every specialty said they were verbally assaulted during the past year and almost 75 percent claimed they were physically attacked, according to a study published in The Journal of Emergency Nursing, which related reports of 100 percent verbal and 80 percent physical assault rates for emergency room nurses.
  • Almost half of all psychiatric physician residents reported an assault during their career and other medical residents in the hospital setting reported a 16 percent assault incidence.

The second article which I read which I think is also sad is about the rise in seniors filing bankruptcy. Sometimes, seniors don’t even have enough resources to install stairlifts in their homes. Not only is it disappointing to see people reach retirement only to have their dreams dashed away from them with crashing house prices, rising food prices, rising gas prices, and lower return on their investments, but they are facing huge healthcare costs that are pushing them over the brink.  22.3% of the bankruptcy filings in 2007 were from seniors.  We also know that even without filing this stress can get people to skip medications or not take care of themselves only worsening their health.

The third story which I saw on CNN this morning was about a group of high school girls making a pregnancy pact.  Talk about a need for sex education and health literacy.  It’s one thing to happen by accident and quite another to intentionally put yourself in that challenging situation of getting a high school diploma and raising a child.

Express Scripts Jumps Into Worker’s Compensation

Express Scripts has been in the Worker’s Compensation space for years now.  As I suggested several months ago (see #2), buying a worker’s compensation PBM makes some sense.  The margins are good, but it does require a different service model.

That being said, they jumped in last week with the announcement to buy the worker’s compensation PBM business from MSC down in Florida.  It would have been intriguing to see them buy the other ancillary business that MSC has to get their footprint a little bigger.  Now, this can go from being someone of a stepchild for Express Scripts to a major business unit.  As Joe Paduda points out in his blog post, they have good teams at both organizations so they should be able to make some things happen in the market with a focused team, financial resources, and some efficiencies.

Given that fact that PMSI has been on the block, this may create a reason for a Coventry or a CypressCare to step in and buy them to gain more marketshare to take on Express Scripts.

George Paz (Express Scripts) on Adherence

Paul Levy who is the CEO of a hospital has a blog called Running A Hospital.  He posted a summary the other day of a presentation by George Paz who is the CEO of Express Scripts.  It has some good facts and there are several good comments on there about defining the terms in this area (see my old post) and whether these are reasonable rates of compliance.  There is also a patient commenting about getting nurse calls and reminder e-mails which sounds great but puts them in the 1% of the population for which this happens.

The numbers do seem understated to me – 85% compliance with cholesterol lowering drugs.  That might be the amount of people that get a paper prescription and then fill the drug or it might be the amount of people that get one refill, but I believe by month 6 or certainly by month 12 most compliance rates are closer to 50%.

There is clear value in adherence.  Everyone should (in key therapeutic categories and using evidence-based standards) want to increase adherence to reduce total medical costs.

What surprised me most recently around this was what Kaiser had observed when looking at how doctors shared information with patients (Archives of Internal Medicine, Sept 2006):

  • Only 74% of the time did the physician tell the patient the name of the prescription drug
  • Only 35% of the time did the physician discuss adverse events with the patient
  • Only 58% of the time did the physician explain the frequency and timing of dosing

Book Review: Health Care Reform Now!

Health Care Reform Now! A Prescription For Change is the latest book by George Halvorson (CEO of Kaiser Permanente). I have been talking about it and using quotes from it for a few months. I finished the book a few weeks ago and figured that I better carve out the time to capture my thoughts now.

First, if you are looking for a great book on why healthcare is a big issue in this election, you don’t have to look any further. As someone running one of the biggest healthcare entities in the US, George clearly knows what he is talking about and speaks from a position of authority. I know that he has talked with all of the candidates about their policies.

If you are in healthcare and trying to be a catalyst for change, you have to read the book. It is pointed, opinionated, and supported with lots of facts and examples. If it doesn’t make you want to change what we have, I would be shocked. Some of the examples of mis-alignment are scary.

Some of the facts he shares:

  • Family health insurance rates in CA already exceed the per capita income of 147 countries.
  • General Motors now spends more money on healthcare then on steel.
  • Nearly 50% of the time, patients in the US are receiving less than adequate, inconsistent, and too often, unsafe care.
  • Healthcare costs are unevenly distributed in America.
    • 1% of the population uses 35% of the healthcare dollars
    • 5% uses 60%
  • Care linkage deficiencies abound – and can impair or cripple care delivery.
  • Economic incentives significantly influence healthcare.
  • Systems thinking isn’t usually on the healthcare radar screen.
  • Most of our costs are for chronic diseases – primarily diabetes, congestive heart failure, coronary artery disease, asthma, and depression.
  • Prevention is a lot less expensive than addressing these chronic diseases at their late stages.
  • The US ranks 35th in the world in infant mortality.
  • We could cut the complications of diabetes by 90% with best care and involved patients.
    • We could cut second heart attacks by 40%.
    • We could cut school and work days lost because of asthma by 90%.
  • Incentives work…yet while we have 9,000 billing codes for procedures and services not one of them is for curing someone or improving someone’s health.
  • There is up to a 60% difference in the 5-year mortality rate for breast cancer patients, depending on which hospital’s surgery team did the surgery.
  • 1 in 10 doctors use electronic medical records (EMR) and only 5% of hospitals use computerized physician order entry (CPOE). This means our history exists mostly in paper files with no standards.
  • Almost 50 developing nations have higher immunization rates for preventable childhood diseases than the US.
  • The Institute of Medicine showed that it takes “seventeen years before a proven new technique becomes the standard of care in a given medical specialty.”
  • There were 2,000 published clinical trials in 1985 and 30,000 published in 2005. (Can your provider really keep up without an electronic system?)
  • Diabetes is the number one cause of new blindness (90% preventable) and foot and leg amputations (85% preventable). It is the number one co-morbidity associated with death from heart failure.
  • Asthma causes – 2M emergency room visits, 500,000 hospital stays, 5,000 deaths, and 14M lost school and work days per year.
  • The vast majority of asthma attacks can be prevented.
  • If Americans were 5-10% thinner and walked just 30 minutes per day, the incidence of Type 2 diabetes could be cut by more than half. (Culture and incentives matter)
  • We spend $250,000 every minute on heart disease.
  • More than 15M Americans have depression…and on average, people with depression have 3 other chronic diseases.
  • A 10% reduction in spending for the top 0.5% of patients would create enough savings to fund universal coverage for the uninsured.
  • The most expensive acute conditions are cancer, maternity, and trauma care. (Acute conditions account for 30% of the health care spend.)
  • The median life expectancy across the 117 cystic fibrosis centers is 33, but it is 47 at the highest performing center. (This seems embarrassing that there could be such a difference here.)
  • US employers pay an average of $6,600 Per Employee Per Year compared to $600 in Canada.
  • 4% of people believe they have insurance…but they don’t. (Who are these people?)
  • Government pays 44% of the healthcare bill today; employers 26%; and individuals 30%.

Key Point – I think everyone wishes that we could address the uninsured and underinsured issue here in the US. It is ridiculous. But, I think most people feel it would further complicate the economy and be a downward drag. George presents a good case that today’s model simply cost shifts so that we are paying for care but paying at the high cost of emergency care not preventative care for those people. In the book, they say that this cost represents $922 per employee today in what is paid. Someone has to pay the providers for these real costs that they incur and can’t recoup. We could cover the costs of the uninsured without any real increases in costs.

Some of my favorite quotes:

  • “We don’t really have a health care delivery system in this country. We have an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited Microsystems, each performing in ways that too often create suboptimal performance both for the overall health care infrastructure and for individual patients.” (introduction)
  • “Performance reporting that actually exists about either processes or outcomes is almost always regarded in the current culture of American health care as an onerous, externally imposed burden, extraneous and irrelevant to the actual business and profession of care delivery.” (pg. 23)
  • “I do not want ‘rules-based’ medicine. I do want accountable care.” (pg. 29)
  • “Process reengineering will not happen on any scale in health care until there is a financial reward for doing just that.” (pg. 33)
  • From the book Escape Fire: Designs for the Future of Health Care by Don Berwick – “A patient with anything but the simplest needs is traversing a very complicated system across many handoffs and locations and players. And as the machine gets more complicated, there are more ways it can break.” (pg 86)
  • “We need highly credible doctors, nurses, and health educators talking to patients in targeted and effective ways to help people make the lifestyle changes necessary to avoid diabetes.” (pg 117)
  • “Health care can be improved. The challenge is to do it consistently and systematically, not incidentally and haphazardly.” (pg 122)
  • “Improving care by 50 percent for diabetics is wonderful, but not as wonderful as reducing the number of diabetics by 50 percent by preventing the disease.” (pg 206)


  • He talks about studying the international models and that none of them are the same. They have all been individually developed to fit the culture and needs of the country.
  • He talks about creating a “patient-centered American health care marketplace”.
  • He is careful about not just pushing the Kaiser model of vertical integration. He focuses on virtual integration which is more achievable.
  • More care is not better care.
  • He gives several examples of how following best practices for evidence based medicine improved outcomes but reduced revenues for the providers which is a hard model to sell.
  • He compares HEDIS scores (which measure how often health plans offer care that complies with best practices) with Six Sigma:
    • Average performance for screening for colorectal cancer is 49% (or 1.5 sigma).
    • Recommended treatment of acute depression is 61.6% (average) and 70.8% (90th percentile) which are 1.8 and 2.1 sigma performance.
    • Note: 2-sigma performance means 308,000 cases of non-compliance per million patients…6-sigma means only 3.4 cases per million.
  • He talks about the fact that 5% of patients experience an adverse drug event. I think the PBM industry has consolidated a lot of data to minimize this, but I am surprised more people don’t talk about samples here. Although they are supposed to track samples, I bet most physicians don’t record them in the chart and they certainly aren’t electronically managed to look for potential drug-drug interactions. (In my opinion, there is still opportunity for improvement, but it is at the pharmacy level not the provider level.)
  • He proactively addresses one major excuse about controlling patient behavior. Yes…we can’t control the patients, but we can make sure that the right events happen to align them for success.
  • I like his suggestion that a personal health record could be a more logical first-step than a full blown EMR solution due to costs and ability to execute.
    • “That personal health record data set for each patient should show all care received by that patient, all prescriptions paid for, all tests given, all diagnosis made, and all providers who delivered care to each person as a patient. The information should be in an easy-to-use format and available to each patient on demand, either electronically or on paper.”
  • He provides a good, quick comparison of PHR and EMR:
    • EMR has the exact Rx dosage and level. PHR may just have the name of the drug.
    • EMR will have the x-rays and scans. PHR will just say the date the test was done.
    • EMR will have notes from physician visit. PHR will just know the patient visited.
  • Preventing a CHF (congestive heart failure) crisis might only generate $200 in billable revenue while treating a crisis creates $10,000 – $20,000 in revenue. (And, we really wonder why people aren’t acting preventatively.)
  • Preventative care makes me think of two examples:
    • People have to want to be healthy and manage their risk. I know numerous people who are told to be on bed rest when they’re pregnant that don’t listen to their physicians.
    • People have to know there is not a risk of discrimination. I know a friend with MS who didn’t go see a doctor for several years until she had found a job with good health insurance.
  • He talks a little about it, but I think the issue of helping patients evaluate trade-offs is a big one. Enabling them with information is important, but how do we help them compare two treatments based on both outcomes and the experience (i.e., pain, functionality). Is it always better to simply live longer even if you have limited functionality and are always in pain?
  • He talks about plan design with some very good insight:
    • Deductibles only work if the unit of care being purchased is less than the deductible.
    • Deductibles tend to discourage chronic patients from getting preventative and maintenance care.
    • Percentage copays only work on big dollar differences. Otherwise, paying 10% more of a drug or office visit that costs $20 more is only $2.
  • In talking about plan design, he talks about something that in pharmacy is referred to as Therapeutic MAC. (MAC = maximum allowable cost) This allows patients access to any drug, but the plan only pays for the lowest cost drug which produces equal outcomes. Therefore, a patient might get the first $70 of any office visit covered, and they pay the difference. Then they care about where and when they go to the doctor.
  • For all the talk about price transparency and driving decisions, he makes a great point that this is thrown out the window at times. For example, when you are having a heart attack, you don’t have time to research your options and make tradeoffs.
  • Kaiser saw first-hand what happens after seniors pass a cap on prescription coverage (pg 137):
    • 18% started skipping doses of medication
    • 9% increase in ER visits
    • 13% increase in hospital admissions
    • 22% increase in mortality
  • He talks about 8 developments that have made health care reform possible:
    • Common provider number
    • Computerized databases
    • Electronic claims data portability
    • Government transparency about payment data
    • Universal awareness of the quality issues
    • Buyers are ready for change
    • Internet functionality used for care
    • Lawmakers are ready for reform
  • He talks about blending virtual care and live care with a technology infrastructure which I think makes a lot of sense. I wonder how we change physicians to be more comfortable with the “DIY” (Do It Yourself) patient that comes in with lots of information and suggestions from other caregivers or even getting “second-guessed” by the rules engine of the EMR.
  • He talks about health care needing a Target, Best Buy, or Wal-mart to manages the buy and sell side of health care.
  • (I am going to massively over-simplify this) He talks a lot about having the buyers issue an RFP requiring certain things and creating a new type of entity – the Infrastructure Vendor (IV). “The IV should facilitate and operate electronic connectivity support tools for the patients and caregivers and should demonstrate their effectiveness to the buyers.”
    • He doesn’t see the government playing this role which limits who could do this nationwide.
    • Conceptually, I agree that a technology backbone that connects everyone would be key.
    • It sounds a little too build it, and they will come to me. This is a radically and risky change that would need everyone on board.
    • Some mandated change at a government level has to be required.
    • Could you do this at a state level first?? For example, I know a coalition that got all the employers to agree to a RFP and moved all their business to Humana for one area after they won the RFP.
  • At many points in the book, I kept thinking about the need for SLAs (service level agreements) on outcomes. (I haven’t studied the capitation modes tried in the US years ago, but there seems to be something there about paying a provider a fixed amount per year. Their job is then to act preventatively.)
  • I am a fan of using incentives and penalties in the system with one caveat. I think you need to tie this to genomics. So, someone who has high cholesterol based on their family history and tries to treat it shouldn’t be treated the same way as someone who eats junk food all the time with no family history.
  • I think making people buy-up to different providers or drugs works great for events that can be planned, but not for emergency. It would be possible to tell which one was which with a fully integrated system. Of course, you have to manage people not gaming the system, but that is where there should be incentives for being preventative. Trading off metrics in your design to balance behavior will be key.
  • Another sad fact that he relays toward the end of the book is some of the data pointing to the racial and ethnic disparities in coverage and care in the US.
    • The death rate from asthma for African American children is 4x the death rate for white children.
    • Minority Americans make up ~ 1/3rd of our population but over ½ of the uninsured.
  • One thing I didn’t see or get was whether any of the international models that he studied had a focus on outcomes.
    • I thought one interesting point he made that in a government system where votes are at stake there is a strong focus on primary care which is used by the masses (i.e., more votes) versus specialists which are used by the minority of patients. Another example of how incentives skew solution design.
  • I am always shocked when I see the Federal Poverty Guidelines. How does someone survive on $9,800 or $20,000 for a family of 4? If you ever wonder how all the tasks get done around you and still feel like addressing the uninsured and underinsured is an issue, you should try to live on that income.

My summary after reading the book was:

  • Wow! We have a lot of work to do.
  • We can make a difference pretty easily.
  • There are three things that matter – infrastructure, incentives, and culture.
  • Employers have to be willing to push incentives or penalties to their employees. The strategy of lowering costs without “disrupting” people doesn’t work.

Go read the book. Help make a change.

Incentives and Communications

Everybody looking at the healthcare system understands that incentives and alignment of goals is a critical component for successful change.

  • Providers need to be motivated to focus on wellness and prevention.
  • Individuals need to be motivated to care about the cost of care and to act in a healthy manner.
  • Pharmacists need to be motivated to take the extra action of moving patients to lower cost agents, resolving administrative edits, and counseling patients.
  • Hospitals need to be motivated to focus on Six Sigma type process initiatives.
  • Health Plans need to be motivated to invest in long-term care initiatives that prevent people from getting sick.
  • PBMs need to be motivated to drive optimal prescription use even if that includes more over-the-counter (OTC) drugs.
  • Employers need to be motivated to offer benefit plans to cover their employees which are simple to understand and align employees with healthy outcomes.
  • Pharmaceutical manufacturers need to be motivated to drive adherence across clinical conditions and to bring new drugs to market that represent significant improvements in therapy (better outcomes, less side effects, easier deliver methods).

With that in mind, I am glad that Silverlink Communications announced this morning that we are partnering with IncentOne to incorporate incentives into our communication programs.  Going forward, incentives will offer us another lever to improve outcomes in our programs that we conduct for clients.

“If applied appropriately in healthcare, incentives are an influential lever to motivate healthcare behaviors, arguably the most powerful force for changing the economics of healthcare,” said Stan Nowak, CEO and co-founder of Silverlink. “We’re excited to be partnering with IncentOne to design highly flexible, personalized and incentive-driven outreach that enables health plans to better connect with and engage their members to drive healthcare behaviors and reward them at the same time.”

“This is a truly integrated technology partnership that seamlessly connects healthcare consumer participation to incentives,” said Michael Dermer, CEO at IncentOne. “Silverlink and IncentOne together can deliver complementary solutions that drive participation and ultimately cost savings in healthcare. The combination of our expertise in finding the right incentives and Silverlink’s personalized communications to drive consumer behavior delivers the ability to implement more effective programs.”

Matthew Holt (author of The Healthcare Blog) did a podcast with both the CEOs yesterday that you can listen to to learn more.

You can also look at a study by Hewitt Associates of large employers which covers several related topics:

  • 2/3rds plan to offer incentives to motivate sustained health care behavior change.
  • 67% will utilize health care data and measurements to drive their organization’s health care strategy.
  • 74% of employees think their employer should help them understand how to use their health plan better.
  • 12% of employees think employers should help them become healthier.
  • Employee decisions on healthcare were influenced by cost:
    • Nearly one-third (30 percent) said they did not go to the doctor when they were sick because of cost.
    • 27 percent didn’t fill a prescription given by a doctor.
    • Almost one in five (19 percent) stopped taking medications before their prescription ran out, and of those, 18 percent did so due to finances.

Certainly, there are numerous examples of incentives being used to drive behavior.  Moving patients to evaluate mail order pharmacy has been a solution where coupons have been used over th years.  Driving therapeutic conversions have used incentives in the form of copay waivers.  Getting patients to complete health risk assessments (HRAs) and other tools have given incentives.

The interesting component will be the personalization of incentives.  While I may enjoy a $10 gift card to the dog store, my wife may enjoy a $10 gift card to the spa.  Flexibility of incentives and alignment of incentives with what drives behavior will be important.

Doctors Won’t Trust PHRs

One step forward and two steps backwards is my reaction to this comment…if it’s true.

Steve Leiber — who runs Healthcare Information and Management Systems Society, the trade group for health IT — told the WSJ Health Blog that physicians won’t trust PHRs.  As John Sharp mentions on the eHealth Blog, this points to the need for PHR certification especially around data sources (i.e., payor claims data, patient self-reported).

Wow.  I just assumed that was part of any legitimate PHR.  I have asked the question of several vendors and always thought I got the answer that you could tell where the data came from.  I would certainly think some data in an emergency situation is better than none especially if you have some understanding of the source and date of the information.

If PHRs just become a tool for patients with no use in the medical community, they are doomed for extinction or will simply be marginalized.  We need solutions that bring us together.

E-mailing Your Physician – A Likely Trend?

This seems to be a topic hotly debated right now. I certainly would love to e-mail my physicians. Between travel and phone calls, we end up playing tag for days. Additionally, I love e-mail for its ability to provide me with a trail of what we discussed. Of course, there are lots of issues not least being reimbursement:

  • The studies show that visits go down when they use e-mail. Will they willingly reduce revenue?
  • If it is simply replaces the call, that is probably easy to justify. If it becomes more clinical in nature (i.e, an e-visit), what new issues does this bring in?
  • Is it secure? Is security any different than the phone today?
  • Is it your physician responding or someone on staff? Do you care?

“People are able to file their taxes online, buy and sell household goods, and manage their financial accounts,” said Susannah Fox of the Pew Internet & American Life Project. “The health care industry seems to be lagging behind other industries.” Doctors have their reasons for not hitting the reply button more often. Some worry it will increase their workload, and most physicians don’t get reimbursed for it by insurance companies. Others fear hackers could compromise patient privacy — even though doctors who do e-mail generally do it through password-protected Web sites.

There are lots of blog posts on this so I will point you to a few of them rather than starting a whole new discussion:

From a corporate perspective, I then have to ask whether health plans and PBMs should (or could) communicate with the physician through e-mail. Again, more efficient, allows them to track history (no more he said she said), accessible anytime, and can link to more information. My general opinion is that there must be a mechanism to parse the e-mails into buckets (general patient exchange, e-visit, payor information). They should get paid for the e-visit. The other two are just a new channel for what they do today. (There are separate arguments for whether they should get paid for those functions, but let’s not let that detract from solving one issue at a time.)

Silverlink Coming To A City Near You

I am really excited about a new initiative at work.  We have pulled together a great set of speakers and are doing a road show around the country.

The speakers include:

The topic of the event is Healthcare Communications: Think Differently and is about how to engage the new healthcare consumer and drive behaviors in scale.  Very much like what a lot of the talks were about at the World Healthcare Congress.  It’s not simply getting data and information, but it is about making that information actionable.  That is exactly what this 1/2 day session will be about.

The meetings will be in Boston, NY, Hartford, Minneapolis, Oakland, and Westlake (CA).  Click here to find out more information and to get registered.  We hope to see you there.

Putting Faces On Fellow Bloggers

I had a chance to meet up face-to-face with several of the other bloggers at WHCC 2008 which was great.  Some of them were also Twittering during the conference (here’s an example).  We shared one common thought which was that this was exhausting.

Also a few of us shared thoughts with at least one friend about blogging out of passion versus blogging purely for a corporate reason (see types of blogs).  Not sure any of us could do the second.

Blogger’s Block

I never really knew what it was like to have writer’s block.  I didn’t have pressure to write or some big manuscript.  I occasionally suffer from block in being creative, but that is usually worked through by focusing on something else or going for a good run.

This week has been so busy with several big meetings that it has been hard to free up my mind to write.  I have posted a few basic posts, but nothing significantly thought provoking.  I often get asked about blogging and how I manage to come up with content every day.  Usually, it is so easy since I am watching TV, reading the news, and reviewing news clippings.  I don’t think I have done any of the three all week.

Here’s to clearing my mind and trying to share some thoughts.

Blogging Next Week – WorldHealthcareBlog

Next week, I will be posting my blogs to this site and to the WorldHealthcareBlog as part of my press efforts at the conference in DC.  I look forward to meeting lots of industry people there and have set up a bunch of interviews to talk about topics such as:

  • Gaining mindshare with the patient / member / consumer / customer
  • Mass personalization
  • PHR adoption
  • Consumerism
  • Patient segmentation
  • Getting ready for the individual market
  • Building trust with patients

Several Good Entries On Other Blogs

I was doing some blog surfing this morning and found a few entries worth going out and reviewing:

On EverythingHealth:

On HealthCareReformNow!:

On e-patients:

On The Sentinel Effect:

On Running a Hospital:

And to wrap up, on the Forrester Marketing Blog, you can get links to all the information being captured at their event on Engagement.

Questions On Health Care Policy For McCain

Elizabeth Edwards (wife of former presidential candidate John Edwards) provides some thoughts on John McCain’s healthcare plan on the The Wonk Room blog.  It will be interesting to see if his team engages in the conversation and provides a response.  Regardless, I think the key points are good ones for any candidate to answer:

  1. How are we going to address pre-existing conditions?  We can’t exclude or gouge people that have chronic diseases.  On the other hand, it is often the fact that they don’t manage these diseases that drive up costs.  Would it be reasonable to charge them more if they didn’t take responsibility for their disease?
  2. What is the long-term market mechanism to make sure that the solution doesn’t increase costs?
  3. Will this really be cheaper for everyone in America?  Does the estimate include all the patient’s out-of-pocket costs for healthcare – copays and deductibles?  If the plans being proposed talk about shifting away from employer sponsored, do you really think that those dollars are going to be shifted to higher wages?   

These are my generalizations of her questions.  The Kaiser Family Foundation has put out a PDF which compares the plans of the three candidates – Clinton, Obama, and McCain.

Healthcare As A Non-Profit Industry

I am a big believer in the fact that our healthcare system needs to be more focused on outcomes, but I am not ready to jump on the bandwagon of making healthcare a non-profit industry. I had to throw in my comments on one of the entries on The Health Care Blog to talk about this.

A couple of the key points that I think are worth repeating are:

We need to address healthcare as a profession. We are facing a shortage of PCPs, RNs, and RPhs over the next decade.

I don’t think it’s a bad thing to see more business school people getting into healthcare. This new perspective can only help. It doesn’t mean that the industry will become less health focused.

I think ROI is an important metric even in healthcare. The reality is we don’t have good data to look at ROI in any holistic way in healthcare. We don’t know outcomes. We don’t know the impact of outcomes on absenteeism and other metrics. We don’t have an activity-based costing system to understand the costs of treatment.

The author says that “by law, a corporation’s first obligation is to make a profit for its shareholders. Its customers come second.” I am not sure that A makes B true. There is lots of proof out there in the business world that shows that a focus on customers sometimes at the short-term expense of profits will drive a sustainable business model.

I think we just need a different system with passionate leadership (from whatever background) who understand the long-term management model and are committed to impacting outcomes through financially aligned incentives. This likely may need to be a combination of public and private especially when you realize that 1% of the population drives 35% of the cost meaning that a small focus can make a big difference.

Patient Ping-Pong: Cholesterol

As if it’s not already difficult for patients to navigate their benefits, DTC advertising, and all the healthcare information on the web, it seems we are structurally trying to make it more difficult. With the recent news around Vytorin and Zetia, the drugs used to treat high cholesterol have gone through some dramatic changes over the past few years. (Here is the formal study.)

In an editorial by the New England Journal of Medicine:

“Until such data are available, it seems prudent to encourage
patients whose LDL cholesterol levels remain elevated despite
treatment with an optimal dose of a statin to redouble their
efforts at dietary control and regular exercise. Niacin, fibrates,
and resins should be considered when diet, exercise, and a statin
have failed to achieve the target, with ezetimibe [Vytorin] reserved for
patients who cannot tolerate these agents.”

For several years, Lipitor was clearly the market leader with Zocor as a close second. Even with one drug (Mevacor) available generically, most plans (other than Kaiser) had single digit utilization. Kaiser was able to drive significant use of generic Mevacor as a first-line agent. When Zocor was going to lose it’s patent protection in 2006, most plans began moving Lipitor to the 3rd tier and introducing programs to move Lipitor patients to Zocor (generic name simvastatin). These included step therapy programs along with simple copay incentives by having a large copay differential between the 1st or 2nd tier and the 3rd tier.

Then, last year, Pfizer, which makes Lipitor, began to offer aggressive discounting to encourage some plans to actually encourage Lipitor utilization over generic Zocor. All the while, Vytorin and Zetia were gaining marketshare to capture a $5B piece of the market. Now, with the recent study, the authors are suggesting that these patients should be on generic Zocor or another drug in the statin class. I am sure there are some clinical nuances here, but the quote above seems to limit them.

And, of course, patients should discuss this with their physicians. They shouldn’t stop taking their drugs. And, generally, when you switch drugs, you want to get lab work done in this class. So, are we asking patients to change drugs again? Do they incur an office visit copay? Do they need to pay for the lab test?

Talk about confusing. And, at the same time, the Improve-It study around Vytorin and Zetia is enrolling more patients. Seems counterintuitive to the data just released.

I’m not a pharmacist, but after working in the industry, if I can’t figure out what to do, how can your average patient. At this rate, healthcare will be as confusing as our taxes.

Note: There are a handful of entries on this out at the WSJ Health Blog.

Convergence: The White Space Between Ford and Starbucks

I recently read a great book called Microtrends. If you haven’t seen it, I highly recommend it for its interesting analysis of trends and the way it makes you think. For example, it talks about how people are drinking more water and more caffeine drinks. It talks about how people have much shorter attention spans yet there is a rise in knitting and books are getting longer. It talks about obesity and young vegans. It plays on the power to see small trends (i.e., 1% of the population) and how they can impact the overall framework. (You can read my detailed notes here.)

One of the frameworks that the authors use is to compare the world as moving from a Ford economy (one choice) to a Starbucks economy (personalization). As healthcare typically lags other industries, I think we this analogy works to show where healthcare was and where we are going over time. Historically (at least in the modern era), we had one choice for healthcare coverage which was offered through our employer. Over time, that has changed to where most people have more than one option for healthcare coverage from their employer. And now, more and more people are losing coverage and the fastest growing segment is individual health insurance.

We have evolved to personal healthcare, but we aren’t yet to personalized healthcare which I think will be largely driven by genomics and some radical change to our healthcare system. Unfortunately, I think we are stuck somewhere in between right now where to personalize your healthcare you need to go to a series of providers or tools which aren’t integrated. There are a few scenarios out there where there is some integration of medical, pharmacy, lab, and other data (Kaiser jumps to mind). But, even in an integrated environment, they haven’t yet fully digitized the offering and created a seamless patient experience (to the best of my knowledge).

As George Halvorson says in his latest book, Health Care Reform Now!, “We have an expensive plethora of uncoordinated, unlinked, economically segregated, operationally limited Microsystems, each performing in ways that too often create suboptimal performance both for the overall health care infrastructure and for individual patients.”

In a likely scenario, you have the following for a sick patient who is actively managing their health:

  • A primary care physician and their staff to interact with
  • A specialist and their staff to interact with
  • A pharmacist (or likely multiple pharmacists)
  • A specialty pharmacy and their nurse
  • A managed care company (and possibly Medicare) which offers a member portal and tools
  • A PBM which offers a member portal and tools
  • A disease management company and their health coach
  • Health portals or information sites (e.g., WebMD, RevolutionHealth)
  • A gym and potentially a trainer
  • A series of vitamins and OTCs that no one has visibility to (other than maybe their grocery frequent buyer card program)
  • One or more disease specific communities that they participate in (i.e., some of the Health 2.0 companies)
  • Blogs and news feeds they subscribe to for information on their disease

The reality is that they have to go out and build a series of interactions to create this semi-personalized offering with no hope of the data being integrated, getting consistent messages, or any true learnings being generated. Each party has a 1:1 relationship with them (best case) and knows a piece of the puzzle. Without an integrated infrastructure, aligned incentives, and a mechanism to engage each patient according to their preferences, we have a very difficult challenge (as an industry) and each patient bears the brunt of this.

Until we can create physical or virtual convergence (i.e., integration of data and tools into one framework), we won’t be able to move from buying coffee at one store and skim milk at another store and our muffin at another store to a Starbucks world where we have one interface to select and personalize our healthcare experience. I wish I had the answer. Unfortunately, as more and more people are talking about, it seems like we have to make a radical change to be successful. Evolution from the status quo will likely not work. Much like GE had a program in the dotcom days called where they encouraged their leadership to figure out how to develop a new model, that is what healthcare needs with the support to initiate the skunkworks organization which might eventually become the norm.

Another Health Blog Ranking System

I have followed and used the ranking system for healthcare blogs for the past few months as a way of identifying new blogs.  [Side note…My rankings move dramatically week to week.  Last week, I was 121 (my personal best).  This week, I dropped to 249.]  It is a good tool to see an objective rating system.

I recently stumbled upon another blog ranking site at  I haven’t studied it as well, but it is another good tool to see a list of healthcare blogs.

BTW – If you are a fellow blogger, I have started a healthcare bloggers group in LinkedIn.   

Where Is “The Best Care”?

In a great post on the HealthBeat Blog, Maggie Mahar talks about research from The Commonwealth Fund called “Aiming Higher: Results from a State Scorecard on Health System Performance.” It provides a comparative state-by-state study of care in the U.S. (States in white are in the top quartile…ND, SD, NE, MN, IA, WI, ME, VT, RI, MA, HI.)


As she points out, the researchers used 32 indicators which look at “Access”, “Quality”, “Potentially Avoidable Use of Hospitals and Cost of Care”, and “Healthy Lives”.

She also goes on to talk about the lack of connection between quality and cost of care. She talks about research from Dartmouth Medical School that supports the data from this study.

“If insurance rates nationwide reached that of the top states, the nation’s uninsured population would be halved,” the Commonwealth report observes. “If all states could approach the low levels of mortality from conditions amenable to care achieved by the top state, nearly 90,000 fewer deaths before the age of 75 would occur annually. Matching the performance of the best states on chronic care would enable close to four million more diabetics across the nation to receive basic recommended care and avoid preventable complications, such as renal failure or limb amputation. By matching levels achieved in the best-performing states, the nation could save billions of dollars a year by reducing potentially preventable hospitalizations or readmissions, and by improving care for frail nursing home residents. If annual per-person costs for Medicare in higher-cost states came down to median rates or those achieved in the lowest quartile of states, the nation would save $22 billion to $38 billion per year. While some savings would be offset by the costs of interventions and insurance coverage expansions, there would be a net gain in value from a higher-performing health care system.”

As the economy continues to be challenged and with the election coming, this will certainly be an issue that those planning the future of our healthcare system need to analyze. There are lots of opportunities for improvement to the system, but we have to realize the challenge of aligned incentives within the system and external to the system. I predict it would take three election cycles (12 years) for us to make fundamental change. How we get politicians aligned and committed to something that outlasts them may be as difficult as changing the system itself.

Fast Friday: First Edition

The good and bad of loving information is that you get a lot of it and hate to throw it away until you skim it and take some notes. But, I am getting backed up so I think I am going to start a Friday edition that will be less thorough and more a data dump of things that I have set aside. I welcome feedback on whether this is interesting, helpful, or just dumping.

  • ChangeNow4Health – I stumbled upon this website which interesting has a Humana copyright at the bottom. [Simplify, Prevent, Educate]

How do we go about fixing the nation’s health care system? Where do we start? ChangeNow4Health believes we begin with small first steps. We’re looking for changes we can confidently make in the short term, using existing resources in creative ways … changes that will result in genuine improvement.

    Facebook Application To Drive Blood Donations

    I must admit I am pretty conservative so it was with some reluctance that I finally joined Facebook.  After the Health 2.0 conference formed a group out there, I decided to join earlier this week.  First, my brother reached out to me.  Then, a roommate of mine from college who I hadn’t talked to in almost 20 years contacted me.

    Then, I became mildly interested.  So, I spent a few hours early this morning playing around.  But, I was most interested to find a post on Vijay’s Consumer Focused Healthcare blog about a non-profit using Facebook as a way to drive blood donations.  Will it work?  I don’t know, but it is a worthy cause and an interesting use of social technology.

    When a patient is in need of blood that isn’t available, it becomes a life and death situation. Historically the Red Cross will make efforts to alert the public during a shortage. But there may be a better way – leverage the social networks to get the word out. If shortages of a certain type of blood occur in a certain zip code, having a database of willing donors in that zip code to contact may be the most efficient way to solve the problem quickly.

    That’s where Takes All Types (TAT), a non-profit organization, comes in. Users install their just-released Facebook application, tell it their location and blood type, and say how often they are willing to be contacted to donate blood (maximum is every 57 days). If a shortage occurs, they’ll contact you via the methods that you authorize (Facebook, email, text message, etc.)

    Value Based – Impact on Pharma

    Kip has a good posting about the impact of value-based benefit design on the manufacturers.  He doesn’t allow comments so I will post some thoughts here.

    For many firms, this will require a significant, even scary change in thinking and tactics; payor-centric communications; comfort with a massive increase in transparency; and a greater willingness to partner. Therefore, while the financial risks of moving to a value-based world are daunting, ultimately the greatest challenges are intellectual.

    Value-based drug benefit designs will pose the greatest challenges to manufacturers with product lines (or pipelines) dominated “me too” drugs; rigid, risk-adverse organizational silos; and out-dated, prescriber-centric communications.

    While I certainly think the industry has been tip-toeing towards value based benefits for a while, it still will beg several key questions:  [Note: When I think about value based, I think about a grid showing outcomes mapped out versus costs similar to a quality over price analysis.]

    1. How do you value certain things – less pain, convenience, minor variations in outcomes, extension of life?
    2. How does genomics play in here when you realize that a drug may be better for one patient but worse for another?
    3. How do you communicate this to patients without making benefits more difficult to understand?
    4. Can patients “buy-up” to pay the difference to allow them to get an alternative that keeps the company neutral?
    5. Will we ever get standards and clean data?  We can’t even agree about whether anti-depressants work.

    I agree it’s a key trend and one to watch, but I think the implemented reality will be radically different than the solutions out there.

    Convergence: MiCoach

    As a runner, I found this interesting new product c/o The Hospital Impact blog.  The video is pretty engaging on the MiCoach.  It blends a GPS technology with an MP3 player with a personal coach with a phone and links it to a website for tracking.  If I wasn’t a runner, I would have some skepticism, but those are all relevant things.

    When I run, I have a GPS on my wrist, my iPod, and often (for long distances) a phone in my pack.  I then download my running to my PC which has some great reporting tools but limited analysis tools.  The personal coach response will vary by person as different people respond to different “encouragement”.  I may have to put this on my wish list to try out at some point.

    Now, of course it requires specific shoes, which I think is an issue for runners.  I have been using the same brand of shoes for 4 years.  And, I go out of my way to get them.  There is no store in St. Louis that sells them so I have to order them every 3 months or so.

    I was also somewhat confused on the website about how to get the products.  There was no buy here function (unless I missed it).

    But, I think the key here is the idea of device convergence and the blending of clothes with technology.  Just one sign of the many interesting things to come.

    Did the Government Admit Vaccine:Autism Link?

    I caught some sensational header about this the other day. Rather than engage in a debate about it, I wanted to simply post a link to an autism blog which appears to have a well written piece about the article, the settlement, and some of the issues.

    Health 2.0: My Notes

    I am just flying back from the Health 2.0 conference out in San Diego. I feel like there is a ton of information that I want to share so kudos to Matthew and Indu for the great job. (And, if you make it to the end of this post, you must really like the topic.)

    I decided the best way to do this is in three posts: (1) Notes; (2) Companies; and (3) Observations. [Some people were doing live blogging which I just couldn’t do and keep focused.]

    Here are a few of the other blog postings about the event:

    So, let me begin here with my notes from the conference which began Monday with some informal sessions (user driven) and a deep-dive on a new vendor American Well. [I missed this event since it was so packed that it was standing room only in the hallway, and I was 5 minutes late getting off a conference call. That being said, they were in there for 3 hours so there must be something pretty interesting.] Tuesday was pretty much packed from breakfast (7:00) until I got back from dinner (11:00).

    Matthew Holt:

    • Talked about his Health 2.0 picture of search, social networks, and tools. And, at the end of the conference, he showed a preliminary sketch of the model for the fall Health 2.0 conference where each of these are blown out into smaller segments.
    • Talked about the challenge of wrapping context around transitions. [In a side conversation, I thought someone else made a great point of saying that one of the biggest challenges will be how to drive change.]
    • Talked about the four stages of Health 2.0. I was soaking it in versus scribbling notes madly so all I got were phase 1 (user-generated content) and phase 2 (users as providers). But, I believe the later phases do (or should) show these models integrating into the establishment.

    Susannah Fox (Pew Internet & American Life Project):
    [Who by the way was a very good speaker and refreshingly gave a 30-minute presentation w/o any slides.]

    • Talked about an early 2000/2001 quote from the AMA on not trusting the Internet and a push to the physician. [That seems to have softened a bit over the years.]
    • Said that 40% of adults in America have a high school education or less which gets right to the issue of health literacy.
    • Talked about validity of online data. Researchers want to see date and source, but patients don’t look for that.
    • Talked about an article in a cancer magazine about misinformation which said the most highly correlated factor was a discussion around alternative medicine. Those sites often had misinformation on them.
    • She set the tone for the day by using the concept of a seven word expression to summarize your talk. Her’s was “Go Online. Use Common Sense. Be Skeptical.”
    • Pointed out that only 3% of e-patients report bad outcomes based on online data. [I think this whole discussion around what patients want in terms of research versus experiential data from their peers is very interesting.]
    • Talked about the white space between a “physican is omnipotent model” (my words) versus a “patient self-diagnosis world”. That is where we have to find a solution.
      • [A person from Europe who I talked with said that not only is their model different but the fact that they hold the physician on a pedestal makes some of these things impractical there.]
    • Talked about a new term for me – “participatory medicine”.
    • Said that Pew had classified people into three groups not on the concept of do you own a mobile device (for example) but on how you use it (e.g., do you feel like the device interrupts your life when it buzzes you, do you require help in setting up your devices).
      • 1/3 of Americans are “elite tech users” who own lots of devices
    • There is still minority distrust of some of these online tools. Some of this is generational.
      • The memory of the syphilis experiment is failing.
      • There is limited discussion of faith in these discussion areas which is important.
      • The older generation typically has less technical skills.
    • Her next seven word expression was “Recruit Docs. Let E-Patients Lead. Go Mobile.”
    • She described African American and Latino users of mobile devices as leveraging it as a Swiss Army knife versus a spoon. [I hope I use it more as a spork…which I assume is evolutionary over the spoon.] They use it more than TV or computers.

    Patient Videos:

    • One of the most engaging segments was a series of video clips from patients.
      • The founder of (I’m Too Young For This) spoke about being diagnosed with cancer at an early age and how he overcame the physical challenges and has become a go to destination for people about cancer.
      • The founder of Heron Sanctuary in Second Life talked about how she has limited mobility in real-life and her ability to create a world in second life where she can help people and gave examples of how people are using this virtual reality tool.
      • A young woman with RSD talked about how she has used ReliefInsite to manage her disease and pain. She also had the same issue of being “too young” to have RSD and the challenges of finding a physician to help her and believe her.

    The format for most of the day was to have 3-4 founders or executives from companies get up and talk for 4 minutes on their company. Then a panel of people would comment and questions would get asked. On the one hand, it was a compelling, fast-based approach that kept your attention. [No nodding off at this conference.] On the other hand, it was heavy on marketing and light on really drilling down on the problem. [Although I am not sure that was the purpose or even achievable without making this a multi-day conference.]

    So…here were a few of my quick notes on some of the companies. I will post another one trying to look at some screen shots and other observations. If you didn’t get mentioned here, it’s likely because I was simply watching or distracted. Hopefully, I catch everyone on the Health 2.0 Company post.

    • WEGO Health – allows consumers to rank content…i.e., directed search…gave example of search for some health topic that returned 98,000 links on Google, but only 50 here…option to score after consumer uses the link
      • Seems interesting. How often is it updated? How do you build awareness? Can it be part of a broader search engine? Seems like a likely acquisition to be another option like images or desktop from a search criteria within Google.
    • HealthCentral – biggest brand you don’t know (or something to that effect)…have 40+ sites around specific disease states…6M unique visits per month…new VC money…100 “expert patients” found to create initial communities…ability to create inspirational cartoons that summarize your story…good GUI
      • I really liked some of the features they demonstrated (in 5 minutes). They talked about creating micro-communities (e.g., spouses of people with a disease).
      • The idea of “recruiting” 100 “expert patients” to build an active community was one of the best I saw.

    In preparation for discussion on patient-MD solutions, someone shared that only 2-3% of MDs allow appointments to be booked online. There was discussion that patients don’t really look to the Internet to find a physician or hospital. They look at what’s in-network and they ask their friends. There was an example given for Yelp which is used to rank restaurants, but allows people to review the physician. [A comment I heard later was when will we see a site ranking the sites that rank physicians.]

    • Carol (company name) – talked about mall concept in that people shop for something like a physical or allergy test not necessarily a specific type of MD…provide cash prices and insured prices
      • Seemed interesting. I will have to think more about how I search.
    • – I talked about this company on the blog a few weeks ago…still like the graphics…saw a few other features that I hadn’t noticed such as customizing the search criteria and using slider bars so that you get weighted recommendations

    I thought there was a good discussion on why would an MD participate in a ranking site.

    • Help them sub-specialize (i.e., I want to treat knee pain not neck pain).
    • Allow them to attract the right type of patient that matches their style and focus.
    • Ego…allowing them to manage comments.

    IDEO, the famous industrial design, company facilitated a lunch workshop and talked at the conference. For simplicity, I will blend both notes here. (see old post about IDEO book)

    • Talked about user-centric design which is key. At lunch asked us to come up with a solution to address the problems of diabetes patients. Showed us four interviews with diabetics. But the stress was not on solving what we thought was their problem, but trying to actually listen to what they say and do in order to find something. Key point.
    • Talked about empathic research showing that we don’t say what we think, do what we should logically do an online car loan, or even do what we think we do.
    • Talked about a book called Thoughtless Acts.
    • Gave examples of project with Bank of America that showed how most people round up their credit card payments so they started a “Keep the Change” campaign which allowed them to attract 2M new members.
    • Walked through an example of creating the Humalog pen for Eli Lilly.
    • Talked about creating a new bike design.
    • All of them were common in the framework they use and their focus on the person/user/patient/member.
    • Lunch was an interesting workshop where you listened to the videos, identified issues, brainstormed solutions, picked a solution to “pitch”, and then shared your idea with your neighbor. At our table…
      • Saw problem largely as educational / informational
        • Don’t know what to expect
        • Don’t know where to get information
        • Don’t understand lifecycle and treatment plan options
        • Don’t know what to do with the pump
      • Talked about everything from portal to device solutions
      • Settled on an iPump concept that would blend an iPod with an insulin pump and foster a community around it to develop cases (e.g., a belt that it fit into as part of a formal dress), videos to download to it on education, connectivity to trigger auto-refills, etc.

    Then we had several discussions by physicians that were blending the old model of house calls with technology. Seems very cool (for those that can afford it). Although one example was relevant, it missed the masses. One showed a trader who was too busy to leave the trading floor, but he had a sore throat so the physician came to his office, took a culture, and gave him an antibiotic.

    • One great point that they made was the benefit of seeing the patient’s environment (i.e., home) in helping them manage a disease.
    • I loved the fact that they would send me an e-mail with my notes from the visit rather than trying to scribble things down while they are talking.
      • Of course, this begs the question of literacy and teaching physicians how to communicate in simple, non-medical language.
    • Another great point was the issue of technology as a good unidirectional solution. For example, if the physician wants to know whether something works, an e-mail is very efficient if it does. Leaving a voicemail so that you play tag back and forth only to realize the patient is feeling better is a waste of time.
    • Jay Parkinson referred to himself as the “Geek Squad” for healthcare (think Best Buy computer technicians). Great analogy. He also showed this seemingly very intuitive and easy to use EMR called Myca which I believe he has built.
    • Somebody tied this back to the physician ranking discussion by asking how this new flexibility of business model would be captured and tracked on those sites (e.g., does MD respond to e-mail).
    • I can remember if I jotted this down or one of them said it but I have “More Time. Save Money. Less Costs.” I think this was in response to a question I e-mailed in about how these new models were affecting the compensation and lifestyle of the physicians.

    Phreesia talked about their tablet solution (i.e., electronic clipboard) for the physician’s office. They had an interesting statistic that 49M Americans move each year so address data is constantly changing. (Not to mention plan coverage, drug use, etc.) They are getting 200-300 new MDs a month to sign-up for this.

    I don’t see myself using it, but this is an interesting option. Organized Wisdom talked about their product LiveWisdom which allows users to leverage a live person (I assume MD or RPh or RN.) via chat to address questions they might otherwise contact their MD about. They pay $1.99 per minute.

    • As they admitted, they are limited in scope and often have to refer the patient to an MD. They seemed to me limiting, but creating an opportunity to partner with American Well who helps you find an MD, sees if they have time to talk, and launches an interactive video session and chat session with the MD right then for a pre-agreed upon rate.

    There were two patients there that were involved in lots of feedback sessions. The first was a woman who has lost 144 pounds (w/o going on The Biggest Loser) and has become an online advocate and support mechanism for lots of people using DailyStrength. The second was Amy Tenderich who is a very active diabetic and blogs at DiabetesMine.

    Amy’s story was great. Her blog is very engaging and as Matthew said it is “thought by many to be the #1 blog for patients“. I had a chance to talk with her and her husband and heard a lot about how it started and the response. It is a great story, and she is very knowledgeable and was willing to really push the patient-centric agenda at the conference.

    Someone made the point about linking patient costs to compliance with their care plan which I have blogged about before. I completely agree that the patient should be rewarded for using self-service options (web vs. live agent) and for staying compliant.

    ReliefInsite talked about their solution and shared that 1 in 6 Americans suffer from chronic pain. No matter what the CEO said, he couldn’t do better than the opening patient video which used their solution. (Which he said was a surprise to him.)…seemed like a good, interactive tools with nice reporting.

    Emmi Solutions showed their online educational tool which had videos built in a conversational tone and used animation to help people understand procedures and their disease. Seemed great. Said that informed patients are less likely to sue.

    MedEncentive is one that I will have to spend more time looking at. It plays to the incentive question and rewarding patients and MDs. They talked about a 10:1 ROI and said the medically literate patients have less hospital visits.

    [Completely off topic, but from the conference, I heard someone talking about CouchSurfing which is apparently a “network” where you allow people (that you don’t know) to come sleep on your couch. I thought that died with hitchhiking in the 60s.]

    A consultant from Mercer commented that some large employers with physicians on staff are more effective [at health and cost management] than small health plans. Not sure if that was a complement to employers or an insult to health plans.

    BenefitFocus which automates the set-up of your benefits (imagine no more paperwork to enroll) had a great video showing the future with personal consultants (via hologram), biometric signature, and other cool things. [I have heard good things about them for years although they never returned my phone calls several years ago even with name dropping one of their biggest investors.]

    Virgin Healthmiles was there and talked about their pedometer which is tracked online. They also have an employer kiosk for tracking weight and body fat. Offline, he also told me that they are rolling out connections which will be on the treadmills and other machines at participating gyms. I am a big fan of what they are doing. I believe he said they recommend 7,000 steps a day per person (and think he told me that 2500 is a mile).

    Stan Nowak (my boss) presented the Silverlink story talking about using technology to engage patients, the importance of capturing data, extreme personalization, and showed recent success improving compliance by 3x by rapidly doing a series of pilots.

    • I am not sure I have figured out our seven word description but here’s a few attempts:
      • Patients Are Different. Personalization Matters. Be Proactive.
      • Preference Based Communications Engage Patients & Drive ROI.
      • Segment. Learn. Interact. Empower. Use Communications Appropriately.

    iMetrikus talked about their solution which connects over 50 biometric devices today into backend healthcare systems. They charge $3 PMPM which caused me to raise an eyebrow. It is a great solution and integration is a nightmare, but that seems like a lot of money. But, I am all about ROI. If I can get better return on this than on another project and it exceeds my cost of capital, why wouldn’t I do it.

    iConecto didn’t present but had a booth and introduced a section. But, I love the concept of using play (e.g., Wii) to drive health.

    To be fair, I will even include my notes about Eliza Corporation (our competition). Their CEO and our CEO did a podcast with Matthew the weekend before which you can listen to here. The messaging is fairly similar (although I have a strong bias about why us). She talked about tailoring [of messaging] being the new black. She talked about using clinical and demographic data to drive programs. They are a good company, and it was well done. [I was even flattered that several of their employees said that they read my blog.] Both companies commented on how they feel old (~7 years) compared to a lot of the companies presenting here (~2 years).

    • One thing that I find strange is for two companies that pretty evenly split the healthcare marketplace for Strategic HealthComm is that we are located within 10 miles of each other near Boston.

    At one point, there was a discussion around ROI especially on new technologies and how to get that first big project. One of the panelists said that a 1:1 ROI over two years would be sufficient. [Not true for any company that I have worked at or consulted to.]

    The final panel discussion and closing statements had a lot of good content:

    • Discussion of the patient as a provider and what that could mean.
    • Discussion of importance of sharing information across solutions.
    • The concept of citizen (European) versus patient.
    • From the Wired magazine participant, discussion around fidelity versus flexibility:
      • Disk versus MP3
      • HDTV versus Tivo
      • Microsoft versus Google
    • Importance of moving upstream in care
      • Disease management
      • Wellness
      • Prevention
      • Diet
    • As part of upstream discussion, talked about involving the food companies and used the analogy of inviting the oil companies to a green conference. [I wondered where the MCOs were, the hospital networks, and the politicians.]
    • The author of the book “Demanding Medical Excellence” (who I believe is part of the Health 2.0 staff talked about “random acts of doctoring” and the issue of solving healthcare for the few or the masses.
    • Indu talked about building a new system versus extending and improving the existing system. [A great question]
    • I think it was Matthew that brought up the issue of designing for credibility.

    Wow! If you made it through this thesis, good for you. I hope it’s helpful. It is certainly easier than me trying to find my notes two months from now or sending a bunch of e-mails to people on sections they might find interesting.

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