Enabling Healthy Decisions

In an interesting, if not over my head conversation, Robert Goldberg (VP of the Center for Medicine in the Public Interest) talks about comparative effectiveness which effectively looks at the costs of treatments versus the outcomes.  From a business perspective, this makes all the sense in the world.

On the flipside, I certainly understand his key arguement which points out that generalizations don’t work.  A drug that doesn’t work generally might work for a certain minority segment.  I pulled a few quotes below, but you can read the whole Washington Times editorial here.  This is why genomics is so important.  Once we understand how drugs and treatments vary by genes and understand what genes each person has, we will be much more effective at treatment and outcomes.  (I am not so sure about cost, but we will table that for now.)

• “opposed approval of Bidil, which reduced deaths from stroke among blacks by 43 percent but is making money peddling the ALLHAT regimen to doctors even though it increases stroke related death among blacks by 40 percent”
  
• “The comparative effectiveness crowd hates gene testing because it identifies individual differences that screw up their ability to make sweeping judgments about what’s best for everyone.”

Next year’s election for president should have healthcare as a key issue.  It has certainly become a front page issue.  Do you focus on universal coverage?  Do you focus on the uninsured?  Do you focus on errors?  Do you focus on quality?  Do you focus on consumerism?

It will be very interesting.  If interested, I am not going to summarize everyone’s opinions, but here are a few links that will provide you with more information:

• Summary of positions w/ links to their websites
• Their voting records
• A few of the candidates at a Kaiser event in April 2007
• Washington Post article
• NY Times Table with key quotes on their proposals for expanding coverage and funding

I was reading a blog by the CEO of Harvard Pilgrim earlier and found the point below pretty interesting:

50% of health status is determined by healthy behavior. 4% of health care spending supports healthy behavior.

I think it leads to a critical issue which we all face (patients, providers, insurers) in healthcare which is how to drive healthy behavior.  Ideally, we would want to understand and have visibility to actions that could lead down the wrong path.

Not all very realistic, but imagine:

• Buying groceries that aren’t good for you triggering a message.
• Stopping at a fast food restaurant for drive-thru triggering a message using RFID or Bluetooth technology.
• A reminder in your car before you leave for work that you need to take your prescription.
• Exercise reminders pushed into your Outlook and linked to an online analysis tool.
• Genetic based testing suggestions linked to a home based device which tracks blood pressure, blood sugar, and other key metrics.

I am sure there are a lot of innovative ideas, but the point here is that we need to think about how to create opt-in communication options or online tools or devices that integrate non-claims data with health suggestions to figure out how to prevent treatment.

Here are a few charts from the California Healthcare Foundation 2007 report on healthcare costs. They show some interesting data.

This first one shows annual out-of-pocket spending by consumers on healthcare. As you would expect, it has gone up in real dollars, but it has gone down as a percentage.

Here is a chart that shows how the yearly growth in healthcare costs has compounded itself over time compared to the CPI.

This next chart has always been interesting to me. When I was at the PBM, we talked so much about drug costs, but the reality is that they are a minority of the total costs.

This chart comparing our spending to other countries is always a little scary since our average age and (I believe) our typical outcomes aren’t very different from these other countries. But, it is important to look at both together. Spending more if it made us live longer and healthier lives might be worth it.

We used this chart several times in my past. It shows how private insurance has begun to pay for drugs compared with consumers over time.

I happened to have the chance to catch almost an hour of this forum the other day and see John Edwards and Hillary Clinton talk with Lance about Cancer and healthcare reform. It was pretty interesting.

There are several good blog entries covering this in more detail (see below):

• Today Blog
• Live Strong Blog

Here are a few of the things I heard / noted:

• Talk about mandating preventative care. Interesting. I never thought about this as a mandate. Could we really do this? Would it make a difference?
• Clinton talked about EMRs (Electronic Medical Records) to help people like Katrina victims and others. Good compelling example. Horrible to have a loss and not know your medical history or what drugs / strengths you are on.
• Debate about whether to include the HMOs at the table for healthcare reform or not. Is it possible to exclude them? Unless the government is going to force something down everyone’s throat, they need the current players to help them understand history and create a transition plan.
• I think it was Edwards that made a point about universal healthcare not being free. I assumed he meant that the money came from somewhere, but I don’t remember him articulating anything specific.
• They disagreed about whether to take money from the healthcare companies. Do any of us citizens really think they aren’t influenced by somebody (money or not)?
• Both seemed focused on technology which I agree is important.
• Lance asked a great question around why the cancer death rate is highest in 15-40 year olds. Great answer (I think by Edwards) pointing out that they don’t go for regular checkups and therefore the disease is often ignored until it is too late.
• Some discussion about providing good care for veterans and the poor. Important point. Can we really have someone go off and fight for us and then not care for them when they come back? That is a shame. Plenty of us aren’t volunteering for the army.
• Interesting discussion on ROI for cancer investment. I am not sure where the numbers came from by they were throwing around studies that $200B in productivity costs are incurred each year due to cancer. How much would we have to invest to recoup some of that?
• Edwards made a point (that I always talk about).  He said that he and his wife while very educated can’t understand communications regarding their health benefits.  Simplicity people.  Clear messaging.  It seems so easy.
• I was also surprised to hear Michael Moore’s movie Sicko brought up several times in the discussions.

There was a study done a few years ago that showed that given the projected rates in prescription drug utilization there would be as many as 150,000 too few pharmacists by 2020.  The studies looked at automation as a solution.  They looked at opening more pharmacy schools.

But, there are numerous constraints.  Here are few links about the study.

• US Pharmacist summary
• A good powerpoint on the study and implications
  • With no changes, we will move from one Rx per 5 minutes at retail to one per 2.5 minutes.  And, in the hospital, we will move from one Rx per 3 minutes to one per 2 minutes.
• CBS News Story

It is an important issue since your prescription benefit is your most highly used benefit.  If you haven’t seen the 20/20 story on pharmacy errors from earlier this year, it is worth a read.  It is a little controversial since it shows a much higher error rate than I have ever seen and is certainly biased towards the negative.  But, it is an important discussion.

The question is how to leverage this important asset – pharmacists – as a key point in the patient care continuum without sacrificing quality.  Automation.  Virtualization.  Central Fill.  There are some options, but figuring out the new economics and division of labor to help open up time for more patient care will be a change.