Why Aren’t There More Collaborative Practice Agreements?

March 7, 2011 by George Van Antwerp 1 Comment

Collaborative practice agreements (aka collaborative drug therapy management) are legal documents between a specific pharmacist and physician to allow the pharmacist to have more direction in the care of the patient relative to their medications. Given the challenge of the physician to keep up with all the mediations and their lack of access to plan design information and full drug history, I’m surprised that these documents haven’t become more popular.

My guess is that the logistics of a one-to-one legal document around standards of care is complex to scale (see how to set up). But, I always think about how easy this could be for addressing formulary management. The physician could agree to which drugs they considered therapeutically equivalent. They could then tell the pharmacist to choose the drug which was lowest cost for the patient.

Books / Articles, Healthcare, Methodology, PBM / Pharmacy

Is Royal Pains Good Or Bad For Concierge Medicine?

March 7, 2011 by George Van Antwerp 0 Comments

I really enjoy the show Royal Pains which highlights a physician providing concierge medicine to the super wealthy in the Hamptons. The physician (Hank) and his staff doing an amazing job of diagnosing complex conditions based on a mix of science and deep dives with the patient to really understand their condition, their symptoms, and their environment.

On the one hand, it shows the power of building a relationship between the patient and the physician. It also shows how convenient it can be to have the physician coming to your house and monitoring you.

On the other hand, the type of attention and care shown here with all the technology being available within the home seems unreasonable. The cost to participate would be outrageous (I think).

So, it makes me wonder whether this is beneficial for the whole movement that companies like MDVIP or people such as Dr. Jay Parkinson are providing.

Healthcare, Methodology

Physicians Want A Long-Term Patient Relationship

March 7, 2011 by George Van Antwerp 1 Comment

In a recent survey by Consumer Reports, 76% of physicians say that a longer-term relationship with their patients would be very helpful.

Is that feasible in today’s environment with consumers more likely to move cities and states?

Assuming it is, this would seem to make EMRs more important especially as they could act as a CRM system for the physician. The average physician probably supports about 2,000 active patients (“physician panel“). It would be difficult for them to remember and personalize their experiences without some mechanism for capturing notes about the patient. Certainly this can and has been done on paper for years, but technology would make this much more efficient.

“A primary-care doctor should be your partner in overall health, not just someone you go to for minor problems or a referral to specialty care,” said Kevin Grumbach, M.D., professor and chair of the department of family and community medicine at the University of California at San Francisco.

The article says that there is research that supports the fact that patients who stick with one physician over time have less healthcare issues and lower healthcare costs. I would assume that it therefore holds that patients who like their physician begin to trust their physician and therefore stay with their physician longer.

Physicians said that respect was the second thing that could help patients get better care. Does that mean that disrespect causes you to get worse care or simply that you’re less likely to engage the physician in a dialogue and understand their recommendation?

There were lots of surprises to me in the data:

  • 33% of patients track their changes and activity between visits. I’m guessing those are the chronically ill patients with complex diseases not the average patient.
  • 80% of MDs thought that patients would be better off with a family member or friend joining them for the visit…but only 28% of patients have someone with them.
  • Only 8% of MDs thought that online research was very helpful with the majority of them thinking it provided little to no value.
  • 9% of patients had e-mailed their physician in the past year.
  • ¼ of patients indicated some level of discomfort with their physician’s willingness to prescribe medications.
Books / Articles, Consumerism, Healthcare, Managed Care, Marketing / Communications, Research, Value Propositions

What’s Your Fitness Personality?

March 7, 2011 by George Van Antwerp 0 Comments

If you don’t read Experience Life magazine from Lifetime Fitness, I would recommend getting it or following them on Twitter. They put out some very interesting articles on expercise and food.

One that I found interesting was about Fitness Personalities. By using the Myers-Briggs test as a framework, Suzanne Brue developed 8 different categories (I’m a white). Given the difficulty of making exercise a lifetime habit for many of us, this could be a helpful framework for understanding what works, what doesn’t work, and with some rationale for why.

Here’s the quick summary:

  • Blues are safety-conscious, and good at creating their own space and concentrating in a gym.
  • Golds are traditional, conservative, and like to share their exercise experiences and results with others.
  • Greens are nature lovers who enjoy outdoor activities.
  • Reds like to live in the moment and compete in team sports.
  • Whites prefer to plan, hate to be rushed and are visionary types who enjoy calm spaces.
  • Saffrons like to express themselves as individuals and are attracted to spontaneous, engaging activities.
  • Purples are routine-oriented and enjoy repetition.
  • Silvers like exercise to be disguised as fun.
Books / Articles, exercise, Healthcare, Marketing / Communications, Methodology, Research

Online Company Looking For Pharmacy Partner For Customer Acquisition

March 7, 2011 by George Van Antwerp 0 Comments

A friend I met years ago when I looked at the Duane Reade pharmacy kiosk is now at Everyday Health. He recently asked if I new anyone in the pharmacy area (independent, chain, mail, specialty) that might be interested in partnering with them to drive new customer acquisition based on their online content.

I figure there are several people that might be interested. I asked him to write up a brief note and provide some contact information. Here it is for anyone who’s interested.

Everyday Health is online health network that connects more than 27MM monthly users to in-depth medical content for health condition prevention and management, as well as lifestyle content in pregnancy, diet, fitness, and much more. Our network of 25 sites consists of our flagship, everydayhealth.com, in addition to many well-known health brands such as What to Expect When You’re Expecting, South Beach Diet and Jillian Michaels.

Everyday Health is currently exploring the local health frontier and trying to determine how our organization can better leverage relationships with local doctors, dentists, pharmacies and hospitals. For pharmacies, we’re wondering if there is any value in driving Rx’s to a given storefront and whether there would be economic upside for doing so.

We’d like to connect with people with experience in marketing acquisition of patient Rx’s and/or anyone who can help clarify the above opportunity. Email Dan Wilmer in Everyday Health Business Development at dwilmer at everydayhealth.com.

Healthcare, Marketing / Communications, PBM / Pharmacy

Intel Health Video On Using Smartphones and Facebook For Health

March 4, 2011 by George Van Antwerp 1 Comment

(Note: Videos and slides may not appear in your e-mail summary. You may have to visit the website to see them.)

Consumerism, Healthcare, Leadership, Marketing / Communications, Research, Social Media, Technology

Who Should Decide Rx Location – Payer Of Course

March 4, 2011 by George Van Antwerp 7 Comments

Today’s NYTimes article “Pharmacists Fight The Rise Of Mail Order” begs an interesting question. Who should have the right to determine choice?

As the retail pharmacies imply, should they be able to legislate that payers (employers, government, insurance companies, unions) have to allow consumers to come to their location? That seems strange to me.

If the shoe were on the other foot and payers didn’t allow their members to go to mail order, would retail allow the PBM to ask the legislature to change that? (Maybe someone can show me examples of a PBM arguing for mail having to be an option with a client that doesn’t offer mail order.)

Maybe I’m missing something here. Doesn’t the person who is paying the majority of the bill (~80%) have the right to direct care to the lowest cost channel? If someone has an issue with that, shouldn’t it be the consumers talking with their employers?

Shouldn’t competition play out in pricing and value proposition not in the government?

I’ve never heard Chrysler go to the government and say that they had to stop a large employer from limiting their choice of cars for their executive to team to Ford products.

If my employer offers me a discount to Sam’s Club, can CostCo go and argue that with the legislators?

Wouldn’t that turn our whole free-market economy upside-down?

In my opinion, payers should be able to choose their network which could include a limited number of retail locations if that met their expectations on price, outcomes, access standards, and satisfaction. It could include mail or not. BUT, it’s their choice based on the options they have and their management of their spend. Why does government have a role here?

Healthcare

Daniel Pink Video On Drive

March 4, 2011 by George Van Antwerp 0 Comments

I was just visiting Daniel Pink website and saw this video on his book. Good summary plus I love the RSA Animate videos.

RSA Animate — Drive: The surprising truth about what motivates us from Daniel Pink on Vimeo.

Books / Articles, Healthcare

You Have Cancer…Blah Blah Blah

March 3, 2011 by George Van Antwerp 0 Comments

After you get diagnosed with a serious disease like cancer or even a chronic condition like diabetes, do you remember anything the physician says?  Someone once told me that patients remember something like 12% of what the physician says after that (I couldn’t find the source).  Another person shared with me that their physician told them to go home and call them later to talk about all their questions. 

This is the extreme example, but a situation that repeats itself day after day.  Patients learn that they have a disease.  In some cases, they’ve been searching for an answer to their symptoms for a while, and there is a sense of relief followed by anxiety.  In other cases, they had a minor problem which leads to identification of a much more serious issue. 

I talk about this because in some cases we start this patient on a course of therapy that they don’t understand or a drug which has side-effects they didn’t expect.  Health literacy is a big enough issue, but not understanding the receptiveness of the patient based on environmental issues such as shock is a big deal. 

We (as a healthcare system) have to continue to help close this gap to educate consumers and leverage the broader care team including physician, pharmacist, and caregivers to help patients understand their condition and the next steps they need to take.  Trisha Torrey does a good job of laying out a series of steps for you to take beginning with acknowledging your fear.

Books / Articles, Consumerism, Healthcare, Marketing / Communications

Congressional Statements Regarding MTM

March 3, 2011 by George Van Antwerp 0 Comments

In the new Medication Therapy Management Empowerment Act of 2011, there is a nice summary at the beginning of why this is important:

    Congress finds the following:
  1. Medications are important to the management of chronic diseases that require long-term or lifelong therapy. Pharmacists are uniquely qualified as medication experts to work with patients to manage their medications and chronic conditions and play a key role in helping patients take their medications as prescribed.
  2. Nonadherence with medications is a significant problem. According to a report by the World Health Organization, in developed countries, only 50 percent of patients with chronic diseases adhere to medication therapies. For example, in the United States only 51 percent of patients taking blood pressure medications and only 40 to 70 percent of patients taking antidepressant medications adhere to prescribed therapies.
  3. Failure to take medications as prescribed costs over $290,000,000,000 annually. The problem of nonadherence is particularly important for patients with chronic diseases that require use of medications. Poor adherence leads to unnecessary disease progression, reduced functional status, lower quality of life, and premature death.
  4. When patients adhere to or comply with prescribed medication therapy it is possible to reduce higher-cost medical attention, such as emergency department visits and catastrophic care, and avoid the preventable human costs that impact patients and the individuals who care for them.
  5. Studies have clearly demonstrated that community-based medication therapy management services provided by pharmacists improve health care outcomes and reduce spending.
  6. The Asheville Project, a diabetes program designed for city employees in Asheville, North Carolina, that is delivered by community pharmacists, resulted over a 5-year period in a decrease in total direct medical costs ranging from $1,622 to $3,356 per patient per year, a 50 percent decrease in the use of sick days, and an increase in productivity accounting for an estimated savings of $18,000 annually.
  7. Another project involving care provided by pharmacists to patients with high cholesterol increased compliance with medication to 90 percent from a national average of 40 percent.
  8. In North Carolina, the ChecKmeds NC program, which offers eligible seniors one-on-one medication therapy management consultations with pharmacists, has saved an estimated $34,000,000 in healthcare costs and avoided numerous health problems since implementation in 2007 for the more than 31,000 seniors receiving such consultations.
  9. Results similar to those found under such projects and programs have been achieved in several other demonstrations using community pharmacists.
Healthcare, Methodology, PBM / Pharmacy, Politics, Value Propositions

Book Review: Drive by Daniel Pink

March 2, 2011 by George Van Antwerp 0 Comments

I just finished the book Drive by Daniel Pink. It’s a great book. I’d recommend it from both a personal and professional perspective because it challenges so much of what we normally think. But, it’s both logical and based on tons of research.

He lays out three reasons why people act:

  1. Food, water, or sexual gratification (Motivation 1.0)
  2. Rewards and punishment (Motivation 2.0)
  3. Intrinsic reward (Motivation 3.0)

The concept of intrinsic reward was new to people. The concept of having this drive challenges all which we believe around incentives. And, his examples reinforce this point. People performed worse on certain tasks when a clear reward was identified.

“When money is used as an external reward for some activity, the subjects lose intrinsic interest for the activity.” Edward Deci

He uses open source collaboration as a great example of this. His example is whether you would have expected Encarta , an encyclopedia by Microsoft, or Wikipedia to succeed. Why wouldn’t a big company with unlimited resources beat out a collection of volunteers?

Business today is based on the whole concept of Motivation 2.0 (i.e., carrots and sticks). He talks about the historical presumption that absent some reward or punishment that people are inert.

“Enjoyment-based intrinsic motivation, namely how creative a person feels when working on the project, is the strongest and most pervasive driver” Lakhani and Wolf

He goes on to explain the difference between algorithmic and heuristic problems. Algorithmic problems can be solved based on a single path while heuristic problems have different options. [It’s like when I went to business school and architecture school.]  He quotes a McKinsey study which says that 70% of job growth in the US is around heuristic work. Therefore, applying a traditional model of motivation to creative work creates a major issue. It turns creative work which we feel passionate about into a disutility (something we won’t do without payment).

Now of course, creative “work” isn’t “play” if the basics aren’t addressed – i.e., fair pay. This has application in lots of areas including how we get kids to learn. Paying kids for specific activities pushes them to focus on completing those but not necessarily learning how to apply the knowledge. I think it’s a key issue which should be getting debated in when, if, or how to use incentives in health care. This is why you may see a short-term improvement that falls off over time.

This will be very relevant as P4P becomes more important. If rewards narrow the focus of solutions and limit creativity, will that be good in that it focuses people on specific processes? Or will it be a problem because in complex cases or cases where there are alternatives, the creativity of solutions and consideration of options will be limited?

But, he’s careful to make sure you don’t think that rewards are always bad. They have to be used appropriately and for the right tasks.

“If we watch how people’s brains respond, promising them monetary rewards and giving them cocaine, nicotine, or amphetamines look disturbingly similar.” Brian Knutson

He lays out “The Seven Deadly Flaws” of using carrots and sticks:

  1. They can extinguish intrinsic motivation.
  2. They can diminish performance.
  3. They can crush creativity.
  4. They can crowd out good behavior.
  5. They can encourage cheating, shortcuts, and unethical behavior.
  6. They can become addictive.
  7. They can foster short-term thinking.

He suggests that for tasks that don’t inspire passion nor requires deep thinking that there are three things that are important:

  1. Offer a rationale for why the task is necessary.
  2. Acknowledge that the task is boring.
  3. Allow people to complete the task their own way.

He talks about how using bonuses can work even for creative tasks when it’s not an “if-then” reward, but it’s a “surprise”. (Which is hard to repeat multiple times.)

He goes on to talk about Type A personalities. Theory X and Theory Y. Type I and Type X. It makes some key points about how we perceive people. Do we believe in the “mediocrity of the masses” or do we believe in people’s interest in succeeding? This is where Motivation 3.0 begins to come in and there is a focus on people’s desire to success or to master something.

He makes a lot of points that remind me of Malcolm Gladwell’s book Outliers.  Mastery is hard work.

“The most successful people, the evidence shows, often aren’t directly pursuing conventional notions of success. They’re working hard and persisting through difficulties because of their internal desire to control their lives, learn about their world, and accomplish something that endures.” (pg. 79)

He talks about how these frameworks can be applied at an organizational level and cites a Cornell University study of 320 small businesses. Those that offered autonomy grew at four times the rate of control-oriented firms and had one-third the turnover. He talks about ROWE (Results Oriented Work Environment) and gives examples of companies that really give their employees freedom. It’s a radical change for many people…imagine a work environment where you set your own hours.

He introduces the concept of “flow” from work by Csikszentmihalyi which was new to me. It describes this state where people are challenged but have an opportunity to stretch to get there.

He talks about mastery as a mindset and how what people believe shapes what people achieve. This belief is critical especially in addressing things like obesity (my opinion) and plays into a lot of what you see on The Biggest Loser. Losing weight (mastering being in shape) is a lot of work, and you have to believe you can do it. You also have have to have some motivation other than financial goals.

There is an interesting discussion of “entity theory” versus “incremental theory” which talks about whether you believe you have a finite intelligence or an opportunity to expand your intelligence. There is lots of talk about education in the book which I think is really important. Are we creating kids that want to “prove their smart” by getting A’s or who are really trying to learn?

“West Point grit researchers found that grittiness – rather than IQ or standardized test scores – is the most accurate predictor of college grades.”

He has a whole chapter on purpose. I think this is key to healthcare. He talks about autonomy and mastery, but without purpose, we don’t have balance. Think about someone who is obese. They want to be autonomous and master being in shape, but when you listen to them talk, it is typically a focus on being there for their family that motivates them to actually take action.

He made me wonder about linking health outcomes to lower costs (i.e., value based). If I know that my healthcare premiums go down if I manage my BMI or cholesterol or get certain tests done, am I just checking a box or am I really changing my lifestyle in a sustainable way?

Books / Articles, Consumerism, General Business, Healthcare, Leadership, Research, Value Propositions

Social Media Analysis – The Involved Patient

March 2, 2011 by George Van Antwerp 1 Comment

I just finished reading a whitepaper by ListenLogic Health.  They do social media analysis for pharmaceutical companies on what patients think.  There is some interesting data in there looking at what people talk about based on age.  They also show several charts about information searched for or discussed by stage.  I pulled out one chart from their whitepaper to share:

They also share some data on what patients say they want from physicians.  This is things like explaining their data better, helping them understand their options, and all basically focus on engaging them.

Books / Articles, Healthcare, Research, Social Media

Can We Use Technology To Address Gaps In Resources – YES!

March 1, 2011 by George Van Antwerp 0 Comments

Dr. Joseph Kvedar writes a great piece about the psychology of persuasion and the possibility of using technology to engage consumers and drive behavior change.  This is an important topic as we look at addressing healthcare as a country.  Since behavior and consumer choice drive a significant portion of our healthcare costs, we have to think more about how to engage patients – what is the right message?  what is the right channel?  what is the right time to deliver the message?

We can deploy technology in smarter to ways to engage consumers in new ways that leverage our limited resources in better ways – i.e., get good and scalable outcomes without increasing costs.  That is what we do everyday at Silverlink Communications with our clients whether it’s around HEDIS, adherence, condition management, or many other programs. Recently, there was an article in Time Magazine that talked about some work we did with a Medicare population for Aetna.

I also think you can look at the research Stanford has published on the topic over the past decade.  You can also look at some of the data from the CVS Caremark Pharmacy Advisor program. While it certainly showed the value of having pharmacists involved, it also showed some positive results from automation.

The reality is that combining automation and live resources can be very powerful. Technology can screen and triage people to connect the at risk population with critical resources. This can allow resources to support as many as 4x as many consumers.

Blogroll, Books / Articles, Healthcare, Innovation, Marketing / Communications, Research, Silverlink, Technology, Value Propositions

Words Matter: Have You Drugged Your Kid Today

March 1, 2011 by George Van Antwerp 0 Comments

I think I’m going to start a series tagged to “words matter” where I call out some of the examples that I notice. The first one is the story about a teacher getting fired for her bumper sticker on her car. (Something I never thought would happen.) Her bumper sticker said “Have You Drugged Your Kid Today”.

First off, I think people are entitled to their opinions.

Second, I think we all would agree that there are certainly times when patients are given medications rather than ask to change.

Whether kids are over-medicated today versus the past is hard to know. We are certainly more aware of conditions these days, but I think this is a hot topic. Just look at some of the articles on the topic.

It’s not like the teacher was taking some massively controversial position. She wasn’t teaching the kids. She was simply expressing an opinion on a hotly debated topic in a quick sound bite which she put on her car in the form of a bumper sticker.

Books / Articles, Events, Healthcare, Politics, Words Matter

The Benefit’s Package Blog Carnival

February 28, 2011 by George Van Antwerp 3 Comments

I appreciate the submissions that I got for this week’s Benefit’s Package Blog Carnival.

Adam Fein of Drug Channels submitted a post that was near to my heart since it is a study that everyone has been talking about (in the pharmacy space). He wrote up a summary of the research that CVS Caremark published about choice of retail versus mail and what they were seeing. Like adherence, past behavior is a good indicator of future behavior. In this case, people who had used mail before, were more likely to use it again.

In Dave Kerrigan’s submission, he talks about the need to Percolate the Perks. He brings up a great point around how to sustain engagement. The reality of differentiating your benefits, keeping people aware of them, and getting people to use them is a real challenge. Some of the ideas he brings up are relevant across the spectrum of engaging consumers.

Building on engagement, one of the things that scares a lot of people is being misdiagnosed or given the wrong treatment (or getting surgery on the wrong body part). Evan Falchuk talks about this in his blog post on Third Place Health Care. The opportunity to get a 3rd party opinion is one that I think lots of people would like to access. And, interestingly, Jennifer Benz also talks about this in her submission about Boosting 401k Participation. Her post talks about what’s happened from a tax perspective and stressing that with the consumer.

While I’m not sure of the relevance from a health benefits perspective, I did get an interesting submission from the Action For Better Healthcare blog on what Geisinger is doing around making facilities more efficient. This plays into a lot of the green architecture efforts that are ongoing (see a blog and book from a classmate of mine from architecture school). But, I found another post on the blog more interesting –an interview they posted with Karl Rowe which is interesting given the Kaiser research that many people think healthcare reform is already repealed.

Next up, I thought the Free Range Communication blog does a great job of breaking out highlights from the recent SHRM report. A lot of topics of focus to the HR community are very health centric, and a lot of the trends around aging, increased use of caregivers, more people with chronic conditions, etc. are all very relevant. For those of you looking for similar data around pharmacy benefits, I just pulled out some data from another report from PBMI here.

Dr. Liu wrote on Why Consumer Driven Healthcare Will Fail and also had a piece on the recent Consumer Reports story about What Doctors Wish Their Patients Knew. He draws some parallels around CDHC and 401k plans which I think is very relevant.

Another post from this past week that I liked was Dr. Val’s write-up on Tabloid Medicine. Given the fiasco around vaccines and the false research, this should be a hot topic.

I also liked an AMA story about Secret Shoppers and Susannah Fox’s video and writing on Healthcare Out Loud. A few other things from this week were a brief summary of some of the work Sanofi-Aventis is doing in social media, a paper on The Connected Patient by Jane Sarasohn-Kahn, and some research on storytelling and hypertension.

Healthcare

The MBA Oath

February 27, 2011 by George Van Antwerp 0 Comments

This is a little off topic, but I think it applies well within health care.  Health care is a profession where managers (like clinicians) should feel a responsibility to improve the lives of their members while making money.  With that in mind, I wanted to highlight this effort.  To learn more, go to mbaoath.org to learn about the history and efforts of this group (along with a new book).

THE MBA OATH

As a business leader I recognize my role in society.

•  My purpose is to lead people and manage resources to create value that no single individual can create alone.

•  My decisions affect the well-being of individuals inside and outside my enterprise, today and tomorrow.

Therefore, I promise that:

•  I will manage my enterprise with loyalty and care, and will not advance my personal interests at the expense of my enterprise or society.

•  I will understand and uphold, in letter and spirit, the laws and contracts governing my conduct and that of my enterprise.

•  I will refrain from corruption, unfair competition, or business practices harmful to society.

•  I will protect the human rights and dignity of all people affected by my enterprise, and I will oppose discrimination and exploitation.

•  I will protect the right of future generations to advance their standard of living and enjoy a healthy planet.

•  I will report the performance and risks of my enterprise accurately and honestly.

•  I will invest in developing myself and others, helping the management profession continue to advance and create sustainable and inclusive prosperity.

In exercising my professional duties according to these principles, I recognize that my behavior must set an example of integrity, eliciting trust and esteem from those I serve. I will remain accountable to my peers and to society for my actions and for upholding these standards.

This oath I make freely, and upon my honor.

Books / Articles, Business Tools, Leadership

The Cost Of Chronic Pain

February 26, 2011 by George Van Antwerp 2 Comments

The March 7th edition of Time Magazine has a whole section on chronic pain including a fascinating timeline of how pain has been managed over the years.  It’s just in recent history that pain has moved from being a side effect to being a condition to be management.

An article by Dr. Oz provides some statistics on pain:

  • The annual price tag of chronic pain is $50B.
  • Lower-back pain is one of the most common complaints affecting 70-85% of adults at some point.
  • 7M people are either partially or severely disabled because of their back pain.
  • Lower-back pain accounts for 93M lost workdays every year and consumes over $5B in costs.
  • 40M Americans suffer from arthritis pain.
  • 45M Americans suffer from chronic headaches.
  • People with chronic pain are twice as likely to suffer from depression and anxiety.

One of his key suggestions – if you’ve worked with your physician for six months and its not resolved – go see a specialist.

He also points you to the American Chronic Pain Association for communication tools in helping you verbalize your pain.

In his article and in the other articles, it talks about stretching as a way to alleviate pain.  Obviously, there are medications that can help with pain relief although some of them can be abused and addictive.  And, both Dr. Oz and the other articles mention acupuncture as a potential solution.

You can also go to the American Chronic Pain Association to learn more.

From a management space, one of the areas where chronic pain is a big area of focus is in Worker’s Compensation.  For more about this space, you can follow Joe Paduda’s blog.  You can also follow some of the Worker’s Compensation PBMs such as:

Blogroll, Books / Articles, Healthcare, Managed Care, Marketing / Communications, PBM / Pharmacy, Research, Value Propositions

Pharmacy Benefit Data From PBMI

February 25, 2011 by George Van Antwerp 1 Comment

I had a chance to read through the new 2010-2011 Prescription Drug Benefit Cost and Plan Design Report that PBMI puts out and is sponsored by Takeda Pharmaceuticals. Here are some of my highlights:

  • Percentage of the pharmacy claims costs paid by the beneficiary
    • Retail = 25.3%
    • Mail = 20.1%
    • Specialty = 15.9%
  • Average difference between retail and mail copayments (see chart):
    • Non-preferred brands = $18.38
    • Preferred brands = $7.15
    • Generics = $3.61
  • 5.1% of employers are covering genetic tests to improve drug therapy management
    • 68.8% of them are covered under the medical benefit
  • 43.0% of employers are restricting maintenance medication dispensing to select pharmacies (retail or mail) [much higher than I expected]
  • They give examples of the percentage of respondents using the following value-based tools:
    • 31.7% – reduced copayments in select classes
    • 19.7% – incentives to motivate behavior change
  • I was surprised to see a significant drop in the percentage of clients requiring specialty medications to be dispensed at their PBM’s specialty pharmacy.
    • 2009 = 53.8%
    • 2010 = 40.0%
  • There was a similar drop from 15.7% to 11.5% of employers restricting coverage of specialty drugs under the medical plan.
  • Given all the focus on medication adherence, I was disappointed to see that only 24.2% of employers were focused on maximizing compliance in specialty. [Maybe they haven’t seen all the studies on this topic.]
  • They have some nice comments on Personalized Medicine and the critical questions to address.
  • I was also surprised that less than 1% of employers were using onsite pharmacies or pharmacists.
  • They provided the following data on average copayments for 3-tier plan designs with dollar copayments:
    • Generics at retail = $9.45
    • Generics at mail = $19.06
    • Preferred at retail = $25.93
    • Preferred at mail = $53.63
    • Non-preferred at retail = $46.43
    • Non-preferred at mail = $98.25
  • The average pharmacy discounts (based off AWP) were:
    • Retail brand = 17.5%
    • Retail generic = 46.6%
    • Retail 90-day = 19.8%
    • Mail brand = 23.3%
    • Mail generic = 53.5%
    • Specialty = 18.7%
  • The one number that seemed off to me was the Rxs PMPM which they had as 2.29 for active employees. That would mean 27.48 PMPY which seems closer to Medicare. [I typically use 12 Rxs PMPY for commercial and 30 Rxs PMPY for Medicare as a quick proxy.]
  • For the first time, they showed the percentage of employers excluding coverage of non-sedating antihistamines (e.g., OTC Claritin) and proton pump inhibitors (e.g., Prilosec OTC). Both classes have had lots of blockbuster drugs go OTC (over the counter) so it makes sense to exclude coverage.
    • NSAs = 44.7%
    • PPIs = 30.6%
  • They provide a nice summary of how employers are using UM (utilization management) tools.

The report has tons of data on different scenarios, different plan designs, rebates, and many other topics. I’d encourage you to go online and read thru it.

BTW – The respondent group of employers included 372 employers representing 5.8M lives including both active and retired. The average group size (active only) was 9,736 which is a decent size employer group. And, 12% of the respondents were part of a union bargaining agreement.

Books / Articles, Healthcare, Managed Care, Marketing / Communications, Methodology, PBM / Pharmacy, Research

Mail Order Savings Continue To Go Down

February 25, 2011 by George Van Antwerp 3 Comments

One of the questions I often get is why don’t consumers move to mail as much as they used to.  There are several reasons why, but I think this chart from the PBMI 2010-2011 Prescription Drug Benefit Cost and Plan Design Report does a good job of summarizing one issue – less savings.  This shows how the savings of moving from retail to mail has gone down over the past 10 years. 

Books / Articles, Healthcare, PBM / Pharmacy, Research, Value Propositions

Engaging The Distracted Consumer

February 23, 2011 by George Van Antwerp 4 Comments

It’s not a surprise to any of us that most people are much more distracted today then they were in the past. Remember the days when there were no mobile phone, no video games, no DVDs in the car…it seems so peaceful. On the flipside, it seems so unproductive. I can’t imagine not multi-tasking.

Ultimately, there are three questions that come to mind:

  1. Do we learn more this way?
  2. Does this affect our social relationships?
  3. Does this change our productivity keeping in mind quality?

I don’t know the answers to these (although I have opinions). But, I started thinking about this when I was reading an article in Time (Wired For Distraction). The author talks about “continuous partial attention” which is a key complication in the world of health engagement.

On the one hand, I can’t tell you how many times I hear people say how critical multi-tasking is. BUT, there are times (IMHO) that you have to buckle down and focus. I remember a few years ago when I had to essentially just focus on one big project for a month. It was hard, but the project was successful. At the end of the day, there is a difference between being used to distractions and dealing with multi-tasking.

Is this a prevalent issue? Yes. You don’t have to look any farther than those advertisements on TV with the father walking around the soccer field on his BlackBerry or phone. Or look at all the efforts to get people to stop texting while they drive.

“Constant distraction affects not only how well kids learn but also how their brains absorb new information.” (Time, 2/22/11, pg. 56)

I think the study mentioned in the article from UCLA in 2006 makes the point:

  • Multi-taskers and focused learners deploy different parts of their brain
  • Multi-taskers use their striatum which is focused on building procedural memory
  • Focused learners use the hippocampus which helps people apply knowledge

So, what do you want for your kids – them to be good at routine tasks or them to be good creative thinkers. Does that play into Michelle Obama’s decision not to let her kids use Facebook?

But, apply this to the healthcare challenges we face…

  • Are people using the devices during their physician visit further limiting what they retain?
  • When you send someone a direct mail piece, an e-mail, or a phone call about their healthcare, are they really hearing the information? Or are they listening to TV and reading e-mail? Or taking a phone call while watching a soccer game?

Given the health literacy issues we face, this lack of focus when we’re delivering critical information to an overwhelmed patient is a real cause for concern. Maybe there are simple answers:

  • Appeal to the basic research on learning which shows that people learn the most when you leverage multiple ways of delivering information – verbal and written; or
  • Simplify the message; or
  • Leverage plain language; or
  • Ask the person to pause to listen to the message; or
  • Increase your attempts to change behavior (without annoying the consumer).

We know the message matters, the channel matters, the person or entity delivering the message matters, and now I’m suggesting that the environment in which the information is received matters.

Healthcare

Chocolate Good For Cholesterol?

February 23, 2011 by George Van Antwerp 1 Comment

Just another one of the many confusing messages in healthcare. Is red wine good or bad? Is this drug good for me? How do I weigh the side effects? How much should I work out? Should I stretch before I work out? Is BMI critical if I have muscle mass? Am I genetically doomed? Should I provide feedback on my physician or will I get sued? Do I have to take my drug every day or just most days?

Well, I’m sure in this case moderation is important, BUT Japanese investigators have found that polyphenols in cocoa attach to genes in the liver and intestines which activate the ones that produce good cholesterol (HDL) and help suppress bad cholesterol (LDL).

Great news for those of us that love sweets!

Healthcare

CatalystRx Engaging Patients With Avatars

February 21, 2011 by George Van Antwerp 0 Comments

Last week, I got to see one of the more interesting presentations I’ve seen in a while. CatalystRx presented on some of the work they are doing with a mobile application to be released later this year. The application uses an avatar (well technically an “embodied conversational agent“) to engage with the consumer. I’m not sure how well that will work with a senior population, but the technology (shown in a video demo) was very cool.

The application is based on lots of research (and designed by the people who made Happy Feet). For example, they talked about:

  •  
    •  
      • The importance of finding the right balance between too cartoonish and too human. They referenced some Disney research about size of the eyes versus the size of the head which creates a positive memory trigger due to similarities to baby’s faces.
      • Creating a “trusted advisor” for the patient (using David Shore’s book – Trust Crisis in Healthcare).
      • The importance of the face and how it shows emotion (both human and avatar).
      • How small talk engaged the consumer and builds trust even when it’s an avatar telling first person stories.

Some of the research comes from Chris Creed and Russell Beale’s work.

Recent research has suggested that affective embodied agents that can effectively express simulated emotion have the potential to build and maintain long-term relationships with users. We present our experiences in this space and detail the wide array of design and evaluation issues we had to take into consideration when building an affective embodied agent that assists users with improving poor dietary habits. An overview of our experimental progress is also provided.

The application helps patients to:

  • Make decisions
  • Identify pharmacies
  • See prescription history
  • Get reminded about refills
  • Get information about generics and formulary compliance
  • Receive personalized interventions

Obviously, mobile solutions as a way to engage patients using a secure environment for delivering PHI is a holy grail (for those that download and stay engaged). This was an interesting and promising variation on some of the solutions out there. I look forward to learning more and seeing it once it’s fully available.

Books / Articles, Healthcare, Innovation, Marketing / Communications, PBM / Pharmacy, Research, Social Media, Software, Technology, Value Propositions

Dr. Atul Gawande On Using Checklists

February 17, 2011 by George Van Antwerp 0 Comments

Dr. Atul Gawande wrote The Checklist Manifesto.  Here’s a video of him on the Colbert Report talking about using lists.

Do you use checklists?

I do. I’m a big believer in the fact that they help you organize your thoughts. I also believe that in today’s day and age with all the information coming at us and the pace of change that you need to use a list to optimize on the best practice. I recently gave my team a checklist of things to do each week. It’s basically what I think about on each Friday to make sure I can wrap up the week and that I’m prepared for the next week.

Healthcare

PCMA Interview – The Core PBM Skill: Adaptability

February 17, 2011 by George Van Antwerp 2 Comments

Last week, I had a chance to talk with Mark Merritt, President of PCMA, over the phone.  I reached out to Mark as a follow-up to my whitepaper on the future of the PBM to get his thoughts on where the market was going.  It was a great discussion as I appreciate Mark’s perspective.  He spends his days working on behalf of PBMs navigating the changing tides of Washington.  He also previously worked with the health plans so he has an appreciation for their perspective as well.

My first question to Mark was about how the PBM model will change in the next 5-10 years.

He reinforced for me that the PBM will continue to drive value.  While some had forecasted PBMs becoming commoditized 5-6 years ago, they have continued to grow and demonstrate value time after time.  But, he admitted that the exact model they hold in the future is unknown.  PBMs have focused on affordability and access and with that mantra, they have continuously changed and adjusted.  They’ve evolved from claims processes to trend managers.  They’ve moved from mail order companies to add specialty pharmacies.  They’ve moved from focusing on rebates to focusing on generics.  And, at the same time, they’ve launched new technologies such as electronic prescribing and been critical to the Medicare Part D solution. 

He went on to talk about how the relationship with payers has evolved and how PBM clients have become more educated about how to partner with the PBM and not simply look at them as a transactional service where the lowest price is all that matters.  [I felt like his comments reinforced a lot of my thoughts about how the PBM needs to be more focused on patient engagement and condition management.  Drug trend is not the only answer…outcomes matter.]

We then went on to talk about how PBMs are developing a consumer brand. 

Mark talked about consumer branding as a company by company decision since there are a variety of factors to consider.  [In my experience, some clients don’t want the PBM to be a “brand” in the consumer’s mind.]  We talked about how historically pharmacy has been an after-thought to medical, but that specialty drugs may change that paradigm.  We also talked about how an increased focus in preventative medicine would push pharmacy to the forefront where prescription drugs are often first-line therapy for most diagnoses. 

We also then talked a little about the difference between the claims processing business of the PBM and the mail or specialty pharmacy.  Where the PBM has a pharmacy – patient relationship, their “brand” and awareness to the consumer is [and needs to be] different.  They have to be able to engage the consumer to provide them with information and help them understand their drugs, their condition, and help them stay adherent.  We wrapped up this section talking about how patient engagement improves savings whether it is on generics, mail order, or overall medical costs.

Finally, we discussed Medicaid growth and some of the research that PCMA has been disseminating around the potential savings with more managed Medicaid and greater use of pharmacy management tools.

My Summary

The summary for me was a reinforcement of why the PBMs have survived.  They focus on the patient [while making money].  They evolve to the place where the market needs a solution.  They leverage technology.  They invest in understanding consumer behavior.  And, there are enough of them that clients can find a PBM that fits their needs whether it’s claims processing, mail order, trend management, transparency, limited networks, retail connectivity or some other point of differentiation. 

Healthcare

Trying to Limit eRx Functionality

February 16, 2011 by George Van Antwerp 0 Comments

When I first worked on electronic prescribing (eRx) back in 2001, there were grandiose expectations for the technology. A decade later, we’re finally starting to see adoption happen with over 20% of new Rxs (NRxs) written electronically according to several people. (see article or go to Surescripts for more data)

The holy grail of this technology is not simply to get a clean prescription sent electronically, but to minimize the more that 40% of NRxs which fall into the exception process for drug-drug interactions, step therapy rejects, or other follow-ups. (see prior post) That doesn’t even take into account the amount of times that cost is an issue for the patient leading to further work effort by the pharmacy and/or patient to get a new prescription. Obviously, cost is one of the issues which is driving the increased abandonment rate at the pharmacy.

Whether or not physicians should or will take on this additional responsibility at the point-of-care (POC) has always been a question…of course CMS incentives help. BUT, I was disappointed to hear from PCMA that some manufacturers are trying to limit the eRx functionality. They don’t want physicians to be able to:

  • See lower cost alternatives
  • See drug-drug interactions based on the patient’s history
  • See lower cost pharmacy alternatives

That seems a little bitter to me. The manufacturers were one of the biggest advocates of the technology early on to the point where they saw lots of opportunities for promoting their brands. Fortunately, the vendors didn’t sell out as a vendor the retail pharmacies use for messaging did years ago. That vendor allowed the manufacturers to buy out a therapeutic class and didn’t allow any plan specific messaging to be delivered to the consumer which was very frustrating.

Healthcare

Genetics 101 Parts 1-4

February 16, 2011 by George Van Antwerp 0 Comments

I found these 4 videos from 23andMe on YouTube, and I thought I would share them.  They answer:

  1. What are genes?
  2. What are SNPs?
  3. Where do your genes come from?
  4. What is a phenotype?
Books / Articles, Healthcare, Marketing / Communications, Research, Social Media, Technology

(Community) Pharmacy 101

February 15, 2011 by George Van Antwerp 0 Comments

The NCPA blog talks about educating Congress about their value.  They also share their slide deck . 

I’m not sure I see how this is community pharmacy specific, but I agree that this is a good educational deck of what pharmacists do (retail, mail, specialty). 

  1. It’s more than counting pills.
  2. Immunizations.
  3. Address adherence.
  4. Educate patients and serve to support patient centered care and address MD shortage.
  5. Medication management

I was surprised at the low numbers of non-Rx discussions they have per day and the low number of physician discussions.  It would be good to benchmark those based on average store volume.

Blogroll, Healthcare, Marketing / Communications, PBM / Pharmacy, Value Propositions

Social Networking For Pharmacists

February 15, 2011 by George Van Antwerp 0 Comments

Drug Store News has partnered up with Skipta to form a pharmacists social networking site.  Interesting.

1. Why Skipta versus some other forum?  [Personally I prefer less places to log in not another one]

2. Will pharmacists use it?  [TBD]

3. Is it good to have a private social networking location?  [Probably if used appropriately]

4. Wouldn’t it be great to use this to facilitate pharmacist and MD dialogue on key topics – adherence?

I’m not sure what else to say on this yet.  Obviously, pharmacists have the same issues as doctors – do you friend your patients, what liability do you have for what you say in these channels, is it considered medical advice, etc.

Healthcare, PBM / Pharmacy, Social Media, Technology

Benefits Package Blog Carnival – Call For Submissions

February 14, 2011 by George Van Antwerp 0 Comments

Next week (2/21/11), I’ll be hosting the 6th edition of the Benefits Package Blog Carnival. You can see last week’s edition at BeyondHealthcareReform.com.

If you’re interested in participating, please send your blog post to me at gvanantwerp at mac dot com. I’d appreciate submissions by Friday night (2/18), but I’ll try to include any I receive by Sunday night (2/20).  Please include the name of your blog, the link to the blog post, and your name. Think about submissions that are interesting to people in the benefits space especially thoughts about how they can engage their population to more effectively manage their health.

Thanks.

Healthcare

NCPA Twisting Reality Again

February 9, 2011 by George Van Antwerp 11 Comments

I continue to be frustrated by NCPA (National Community Pharmacists Association). While I agree that the pharmacist – patient relationship is important, they continue to blatantly misrepresent the facts to make their point. On Tuesday, they sent a letter to Kathleen Sebelius, Secretary of HHS, stating the following:

While we strongly support your efforts to provide the states with measures to drive pharmaceutical program costs down, we respectfully disagree with the statement that mail order is a potential cost-savings program strategy. Experience has shown that mail order pharmacies almost never deliver the savings they promise and are often ultimately more expensive than community pharmacies. In 2009, retail pharmacies drove a 69% generic dispensing rate (GDR) while the three dispensing services of the largest PBMs – Medco Health Solutions, Inc.; Express Scripts, Inc.; and CVS Caremark – had GDRs under 58% for the exact same time period – leaving potential savings on the table resulting from increased brand usage.

Either they are naïve or they think HHS is. You can’t compare the GDR at retail pharmacies to the GDR at mail order pharmacies without significant adjustment for acute medications and seasonal medications that aren’t appropriate for mail order. Historically, those medications have had higher generic utilization than other conditions (e.g., antibiotics).

On the other hand, maybe they aren’t a history fan. The only independent study that I’ve seen comparing the two channels specifically on this issue was published in 2004 by Harvard in Health Affairs. It looked at claims from 5 PBMs across both channels, made the adjustments, and concluded that while retail had a slightly better GDR than mail, it had a lower generic substitution rate. It also pointed out that the majority of the different was attributed to the statin class which was over-represented in the mail order channel (and at the time was mostly brand prescriptions).

Or, maybe they haven’t looked at the chain GDR versus the independent GDR…In this presentation, you see what I would expect – chain GDR > independent GDR. Combine that with the percentage of scripts dispensed (i.e., weighted average) and the normalized GDR from the Health Affairs study probably would favor PBMs over independents.

Since PBMs make over 50% of their profits on generic at mail, it wouldn’t make sense for them to sub-optimize this area. Given the changes in drug mix over the past 7 years (i.e., more generics), I would hypothesize that if this study were done again you would see mail order matching or exceeding retail GDR especially GDR for independents.

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