My Healthcare Experience

While you can see an highlighted version of my experiences in my LinkedIn profile, here’s a longer list of projects I’ve worked on in the healthcare area:

  • Led the development of a health plan commercial go-to-market strategy to determine how to avoid pharmacy carve-out by PBMs.
  • Led the identification of new opportunities around opioid management and medication adherence to enhance the product roadmap for a health plan.
  • Led the creation of a playbook around how a health plan could enhance their detailing of providers in value-based contracts with them focused specifically on pharmacy.
  • Led a rapid response research team to support the evolving COVID-19 pandemic to help a large health care company to prepare for and think through key issues ranging from supply chain to virtual health.
  • Led the evaluation of how AI could augment the role of the pharmacist for a health plan.
  • Led the evaluation of how digital pharmacy could disrupt a mail pharmacy business and identification of potential tactics to respond.
  • Led the evaluation of medical pharmacy savings for a regional health plan to help them determine a clinical strategy and improve their medical rebates from $300K/year to $7M/year while still protecting their opportunities for biosimilar promotion.
  • Led the evaluation for a regional health plan to help them refine their specialty pharmacy strategy with a focus on their top therapeutic areas ultimately identifying $44M in savings.
  • Led the evaluation of the specialty pharmacy and home infusion business for an Integrated Delivery Network (IDN) to identify the best opportunities for growth.
  • Led the evaluation and audit of a PBM’s prior authorization results to determine if a health plan should insource this work.
  • Led the development of a presentation on the future of pharmaceutical rebates for the Board of Directors of a national PBM.
  • Led the development of a business case around a new analytics business to present to the Board of Directors of a public company.
  • Led the development of a pitch book for a pharmacy services company to raise their next round of capital.
  • Led the development of a pharmacy turnaround strategy in specialty and retail which included go to market, M&A, operations, pricing, and prioritization of investment options leading to over $250M in immediate opportunity and identifying another $1B+ in potential savings.
  • Led the design of a Stage-Gate process for evaluating and bringing new value based contracts and solutions to market for a regional health plan.
  • Led the development of a 3-year strategic plan for pharmacy for a health plan preparing them for synergy discussions with a potential acquirer, leading to two joint ventures, and identifying over $8B in opportunity over the next 5 years.
  • Led the business and process work streams for a tax efficient procurement strategy for pharmacy evaluating the current supply chain leading to the identification of over $200M in savings.
  • Led the team responsible for addressing multiple CARs and ICARs from CMS for a Medicare plan to avoid sanctions.
  • Led the team responsible for capturing pricing information from two legacy systems and helping transition to standardized pricing to avoid over $100M in penalties associated with a corporate integrity agreement.
  • Led the team responsible for the due diligence of a retail pharmacy chain leading to a successful $1.9B acquisition.
  • Led the team responsible for evaluating the Revenue Cycle processes for a Long Term Care (LTC) pharmacy business to identify $40M in savings.
  • Led the team responsible for developing a Medicare Star adherence program including development of a beneficiary segmentation leading to identification of several quick hits which improved program success immediately and prevented $10M+ in performance guarantee payouts.
  • Led the team responsible for benefit set-up and testing for a PBM welcome season leading to the lowest performance guarantee payouts in years.
  • Reviewed PBM RFPs for a health plan to help them determine whether to insource or outsourced their pharmacy function.
  • Developed a specialty pharmacy fact book to improve internal awareness of specialty pharmacy trends and key strategic areas.
  • Served as the Subject Matter Advisor for several projects including:
    • Evaluation of how to bring a digital therapeutic to market
    • Development of a direct-to-patient model for a pharmaceutical manufacturer
    • Evaluation of a new approach to revenue cycle management for a digital pharmacy
    • Global scenario planning around market access and pricing for a pharmaceutical manufacturer
    • Benchmarking the PBM functionality of a health plan against the market to prioritize their investments
    • Development of a payer strategy for a retail pharmacy chain
    • Analysis of Medicare pharmacy functionality and needs for several BCBS plans
    • Development of an oncology Center of Excellence (COE) for a hospital system
    • Development of a PBM growth strategy
    • Multiple M&A due diligence projects
    • Helping a pharmaceutical company evaluate and understand alternative payment models (i.e., value-based care)
    • Helping a health plan develop and assess the pharmacy market place to develop a 5-year investment plan tied to competitive differentiation
    • Helping a client understand how to collaborate with PBMs around the issue of opioid abuse
  • Developed an M&A strategy for a national health plan to help them identify and prioritize targets leading to a significant PBM acquisition and a specialty pharmacy acquisition.
  • Developed a point of view for a large pharmaceutical distribution company to help them rethink their approach to the oncology market.
  • Worked with a lab services company focused on opioid abuse to help them position themselves with state Medicaid agencies, worker’s compensation companies, and pharmacies.
  • Developed the product roadmap for our care management platform with a deep dive on disease management and population health management.
  • Managed a small team of product managers and analysts to develop and deploy new solutions while firefighting issues within the legacy environment as part of a cost and care management turnaround funded by private equity.
  • Developed a member portal with content from Healthwise, an HRA from ADAM, connectivity to IncentOne, and integration with Change Healthcare.
  • Designed and implemented a biometric screening program for an 8,000 employee group which included onsite screenings and outcomes-based incentives meeting the new PPACA requirements.
  • Conducted RFIs and RFPs to determine a 24×7 NurseLine vendor and to evaluate Specialty Pharmacies and telemedicine partners.
  • Developed a member satisfaction survey process achieving 30-39% response rates and incorporating the Net Promoter Score (NPS).
  • Designed a global pilot program for diabetes management linking remote patient monitoring to pharmacy interventions.
  • Part of the core team to develop several “beyond the pill” approaches for pharmaceutical manufacturers to create new strategies.
  • Presented at the PBMI conference (twice) on my views on the PBM and pharmacy industry.
  • Presented at the CBI conference on my views on how retail pharmacy could create a broader role with health reform.
  • Reviewed and provided feedback on the PBMI annual publication (twice).
  • Developed two different webinars for AIS on use of copay cards within the industry and the potential implications for their growth.
  • Presented at PCMA on copay cards and a potential industry response.
  • Presented at the DMAA (now CCA) with Kaiser on a statin adherence program and great results using barrier survey’s administered using outbound IVR.
  • Presented at the Care Continuum Alliance (CCA) with Aetna on using multi-channel engagement for diabetics.
  • Worked with Silverlink (a healthcare communications company) to develop a PBM product strategy for them including positioning, value propositions, and market analysis.
  • Designed Silverlink’s first expansion from IVR into call center and sold that service to United Healthcare.
  • Wrote an eBook with Dr. Jan Berger on consumer engagement in healthcare.
  • Built up and managed a team of subject matter experts to help document best practices and begin to build out solution frameworks for our sales team to use in areas such as Medicare, adherence, retail-to-mail, disease management, retention, and clinical interventions.
  • Developed a “commercial MTM” solution for a United Healthcare by which they were able to double their effectiveness in pill splitting and offer a turnkey solution to clients for engaging consumers about savings opportunities – formulary, mail order, pill splitting.
  • Developed new content, business rules, and process designs collaboratively with our analytics group and clients to improve program effectiveness – e.g., improving retail-to-mail success by 300% over 90-days for CVS Caremark.
  • Developed multiple whitepapers and thought leadership pieces to be used in client marketing efforts, press interviews, and sales processes.
  • Worked with Optum to develop a joint offering for pharmaceutical manufacturers about how to leverage technology and clinical staff to improve adherence (based on Medication Possession Ratio).
  • Led the PBM, pharmacy, and pharmaceutical sales efforts (sales, account management) and contributed to program development leading to over 400% growth in my first 4 years and increasing the average client contract from <$100,000 commitment to over $1M.
  • Developed and launched a company (CentralScript) to develop a self-service pharmacy kiosk where patients could scan in their prescriptions, talk with a pharmacist via video conferencing, and get their prescription dispensed real-time.  Presented idea to VCs, raised $500,000, and developed management team before determining regulatory hurdles were too much given other business priorities (e.g., clinics) within the pharmacy marketplace at the time (2006).
  • Managed the e-prescribing (eRx) vendor relationship for Express Scripts including looking at how the vendors (e.g., Allscripts) were going to work with RxHub (the Express Scripts JV) and developing collateral for clients around e-prescribing.
  • Developed and managed a generic sampling program for Express Scripts where we provided 7-day samples of six different generic drugs (e.g., fluoxetine, lisinopril) to approximately 1,000 physicians in PA and FL.  This was a pilot program to determine whether Medco’s program (GenericsFirst) had a material effect on dispensing or was simply a marketing ploy.
  • Became the generic drug champion for Express Scripts which meant that I evangelized generic drugs to our clients, did press interviews, developed materials for clients and patients, sat on the generic committee, and even created collateral for Barrett Toan to present at the Generic Pharmaceutical Association’s national meeting.
  • Developed the Express Scripts Step Therapy Rapid Response program which provided letters to patients that were rejected at the POS (point-of-service) and never filled a drug in the therapy class.  This became a very popular offering with clients.  The research that led to this was published in JMCP.
  • Worked with one of our clients (Connecticare) to productize a Zero Dollar Copay program which encouraged patients on select brand drugs to move to the therapeutically equivalent generic drug (e.g., Nexium to omeprazole) in return for having their copays waived for up to six months.  This program won the PBMI Innovation Award.
  • Developed GenericsWork which was Express Scripts’ most comprehensive trend management program where the company was willing to do risk based pricing.  This blended formulary design, copayments, utilization management programs, and communications into an off-the-shelf offering for plans.  The pilot client dropped their pharmacy spend by 20% in year one.
  • Managed the implementation of the Express Scripts Client Pledge.  This was a high level set of guiding principles that Express Scripts put out the align ourselves with the clients.  My job was to make sure that the SOPs (standard operating procedures) and systems supported what we promised.
  • Managed the Drug Choice Management program at Express Scripts which was the controversial program which shifted appropriate utilization from higher cost drugs to lower cost brand drugs.  Under my leadership, this program was shifted to a brand-to-generic substitution program focused on therapeutic alternatives (not chemical alternatives) and worked with our procurement and finance teams to optimize the targeting algorithm.
  • Led the internal team responsible for presenting Express Scripts Senior Staff with a recommendation on how to respond to the Medco Settlement where they agreed to a long list of legal and systemic changes to address perceived and real issues of transparency.
  • Led the team responsible for mail promotion (i.e., encouraging patients to move their maintenance prescriptions from retail stores to Express Scripts’ mail order pharmacy).  This included development of a strategy, review and creation of materials, campaign design and management, modification of the targeting algorithm, client upsells, and reporting.  In 2005, we targeted 10M patients, increased the success rate by 25%, and moved $300M in prescriptions to mail order which was 10x more profitable.
  • Conducted several webinars at Express Scripts for internal audiences on our product offerings and for external audiences around generics, plan design, and mail order.
  • Championed the internal push at Express Scripts for the creation of a single view of the patient which although not funded became the catalyst for several smaller projects (and ultimately came to fruition after I left as their Consumerology program).
  • Business lead on the CRM committee for Express Scripts’ internal technology for patient targeting and letter fulfillment for clinical and trend management programs.
  • Led the rollout of Express Scripts mandatory mail offering internally and externally which was the first time Express Scripts had gone to market pushing mandatory mail order.
  • Led the rebranding of mail to home delivery in order to soften the offering and address perceived concerns.
  • Contributed content to Express Scripts Drug Trend Report in 2003, 2004, and 2005 and presented to clients at our annual Outcomes conference which was for our top 900 clients.
  • Led the transition of clients and patients from Claritin and Prilosec to their OTC (over-the-counter) alternatives.  This included addressing the call centers, retail pharmacies, internal staff, adjudication system, clients, and plan design to minimize the disruption and maximize the patient and client savings while optimizing Express Scripts profit.
  • Part of the core team responsible for addressing the CVS and Walgreen opt-out of Express Scripts mandatory mail network and creating numerous options for how to respond.
  • Helped finalize the CDHC strategy (as a consultant in late 2006) that was presented to Sr. Staff at Express Scripts including doing competitive intelligence and researching topics such as rewards and incentives to drive wellness.
  • Developed the Express Scripts roadmap and several innovative solutions for rapidly shifting marketshare from Lipitor to Zocor to prepare for Zocor’s patent expiration in 2006.  This has been a story they have presented to the street based on how successful it was at moving marketshare.  (See control room concept)
  • In order to address the worker’s compensation challenge of capturing the first fill of a prescription and eliminating the third party billers, developed a joint venture with an eRx company to build and take to market a worker’s compensation eRx solution for Express Scripts.
  • Part of the core Express Scripts team charged with looking for process improvements at mail order and producing a 3-year roadmap for improvement.
  • Created and presented a 5-year vision for the pharmacy landscape to BCBS MA, Express Scripts’ biggest client at the time.
  • Co-led the development of Express Scripts options on how to respond and redirect the company in preparation for the adoption of fiduciary legislation at the state level.
  • Led the development of the Ernst & Young LLP point-of-view (POV) on how the Internet was going to affect managed care.  This became our key offering in the managed care space where I worked with several E&Y partners to evangelize this POV to MCOs across the US (Aetna, Pacificare, Wellmark, BCBS SC, and others).  This led to several engagements including one at BCBS of KC where I worked with the implementation team.
  • Hindsight is 20-20, but one of our more exciting projects out of this was a 3-day Accelerated Solution Environment project with United Healthcare on CDHC (Consumer Drive HealthCare) back in 1999.
  • Actively worked with Firepond (while at E&Y) to co-sell a broker configuration tool to the MCOs including CareFirst.
  • Worked with the Mallinckrodt Institute of Radiology on an Activity Based Costing model comparing the cost and outcomes of two different treatments.  We subsequently published the article in the International Journal of Radiation Oncology Physics in 1996.

3 Responses to “My Healthcare Experience”

  1. George, I hope you’re doing well. I read your blog entries fairly often, but I just haven’t replied. I think you have some good insights, which are very educational for me. Thanks.

    You caught my attention on the commentary around healthcare workers and the increbile ‘smoking’ issue … it’s hard to believe.

    Woud you be willing to let me buy lunch for us one day and ‘pick your brain’ on the healthcare market? Let me know what availabilites you may have next week or the following week.

    Thanks, and have a great weekend.


  1. Leaving The Start-Up World To Join Deloitte Consulting | Enabling Healthy Decisions - July 21, 2014

    […] My Healthcare Experience […]

  2. Getting Back Into The PBM Industry | Enabling Healthy Decisions - May 5, 2014

    […] My Healthcare Experience […]

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: