Enabling Healthy Decisions

I have no idea how someone who doesn’t understand the internal working of the healthcare system gets things done.  I have trouble when I understand it.

A few months ago, I had an issue with a prior authorization for an Rx for my son.  I paid cash and then knew to send it in via a paper claim.  It was still rejected.  Fortunately, I know you can appeal twice and then formally a third time.  It took two appeals and several “discussions” with the call center staff, but I got it fixed.

Today, it happened again.  I had changed something on our plan and eligibility got mixed up so my Rx rejected.  When I called, the managed care company said my family was all eligible.  When I explained what happened, they informed me that prescriptions were a different eligibility file that they weren’t looking at.  (Like I should know to ask this.)

They then explained that my employer must have submitted the wrong paperwork.  I said that was impossible since I did the paperwork myself.  I also explained to the agent that since the managed care eligibility was right then it was a data entry issue on the pharmacy side for them.  She tried three times to tell me to talk with my employer.  (Only because I understand the process did I refuse.)

She finally went away for 20 minutes.  (I was sure she was just sitting there laughing at me.)  When she came back, she admitted that they had made an error and needed to fix the eligibility data.  Of course, it couldn’t be done tonight, but it could be done in the morning.

If I didn’t know how data was sent and the processes, I would have been chasing my tale with my employer and TPA for days.  I feel for all of you that don’t know these things.

I was reading a new blog tonight on healthcare research.  Boring…NO.  This is a good blog call Health as Human Capital Foundation.

One of the entries was about misalignment of incentives.  It is an interesting point.  It made me think of a typical call center metric called First Call Resolution.  This measures how many customer issues are resolved the first time they call the call center.  Wouldn’t it be wonderful if this was true in healthcare?  How many people have had to go to their primary care physician, a specialist, another specialist, etc. to try and figure out what’s wrong with them?

Since many in the industry miss the semantics here, I am sure those of you that are consumers could benefit from a couple of points here.

If you are on a brand drug, there are two types of generic opportunities to consider.  One is a chemical substitution.  In this case, the patent has expired on the brand and the same chemical entity is available in a generic form.  In many cases, unless your physician marks DAW (dispense as written), you will get the generic drug (or pay for chosing the brand drug).  The only time I would ever hesitate to do this is on NTI (narrow therapeutic index) drugs where the active ingredients are titrated to your blood – e.g., coumatin.

The other type of generic savings opportunity is a therapeutic substitution.  In this case, there is a generic drug that is therapeutically equivalent to your drug but NOT the same chemical entity.  For example, if you take Lipitor, you might have the same ability to manage your high cholesterol using generic Zocor which became available about a year ago.  In most drug classes (or for most conditions), there is a generic drug available.  Many of these were the former blockbuster drugs in this category. 

It is worth talking to your physician or pharmacist about this.  Additionally, it is worth going to your managed care or PBM website and using their online tools to look up chemical and therapeutic switch opportunities. 

There is a new study out about consumer directed health plans by Watson Wyatt and RAND Corporation.  The multi-year study was jointly funded by the California HealthCare Foundation and the Robert Wood Johnson Foundation.  Copies of the research brief, “The CDHP Implementation Experience with Large Employers,” are available at http://www.watsonwyatt.com/cdhp.

Not surprisingly, it points out that companies need to educate employees about how to be responsible for their care and give them tools on cost and quality.  These need to be easy to use and easy to understand.

Here are a few of the key points:

• Most employers that offer a consumer-directed health plan say communicating with workers about these plans is their greatest challenge.
• Nearly all of the respondents — 90 percent — cited employee communication as their greatest challenge in introducing the consumer-directed health plan (CDHP) and during the plan’s first year.
• Employers, on average, began communicating information about the new plan to workers four months prior to open enrollment.
• The study found that employers are generally pleased with Web-based, out-of-pocket cost calculators for employees.
• Just 2 percent rated cost information about health care providers as excellent, and 5 percent rated it as good.
• Only 10 percent rated information on the quality of care as good; none rated it as excellent.

“Employers have high expectations for CDHPs,” said Roland McDevitt, director of health research at Watson Wyatt and co-author of the study. “While their early experiences are favorable, the success of the plans will ultimately hinge on whether employers can provide employees with decision support tools that will empower them as engaged consumers.”

Why don’t insurance companies cover selective OTCs (over-the-counter)?  I always heard clients talk about opening pandora’s box.  If I cover one OTC then I have to cover aspirin and vitamins.  Hopefully, us consumers aren’t stupid enough to look a gift horse in the mouth.

But, I like to make rational economic arguements.  So, let’s look at the math around Proton Pump Inhibitors (PPIs) such as Nexium.  If a client covers these, they probably pay somewhere around $100.

• The AWP (average wholesale price) of the drug might be $150.
• Their cost might be 15% discount off AWP.
• The member might pay $22.
• They might get a 10% rebate from the manufacturer.

But, whatever the assumptions, it has to be cheaper for them to give the OTC product which might cost $20, to the members for free.  Why not?

I can’t weigh in on the quality of care issue that surrounds the mini-clinics that are popping up all over the country (but here are a few facts). But, from a convenience perspective, I like the concept. They still aren’t open enough hours for me. Why not focus on 5-9am and 5-11pm which always seems to be when things go wrong.

I came across a good article with some facts on the trend from 8-11-07:

• 7% of people have tried a clinic
• There are 400 today in the US – projected to go to 700 by the end of 2007 and 2,000 by the end of 2008
• 40-50% of clinics accept insurance from companies like Humana, United, and Aetna

There is even a Convenient Care Association that you can go to learn about the industry.

At the Health Business Blog, David mentions a site called Healthcare311.com where you look up the nearest clinics. At least I think it is supposed to. It crashed for me multiple times.

One of the key programs we used at Express Scripts to manage trend was Step Therapy.  What this means is that a patient is required to use a less expensive drug (typically a generic) prior to using a more expensive drug.  A day-to-day example of this is with antibiotics.  Anyone with kids knows that you start your child on a generic antibiotic and if that doesn’t work you escalate to a stronger (and more expensive) product.

Step Therapy has two challenges.  One, consumers got “rejected” at the Point-of-Sale (POS) (i.e., the pharmacy) and were upset they couldn’t get the drug their doctor prescribed.  Two, how do you handle programs like this (that are effective) with CDHC where the consumer is responsible for managing their own money and edits are typically frowned upon.

Patients generally don’t understand plan design and edits and don’t know what to do.  As you can see from the Express Scripts 2004 Drug Trend Report (pg. 121), a material amount of people filed no claim (great savings) but did take action (i.e., no negative clinical outcomes identified).  We developed a rapid response program to inform them what to do to get their drug covered which seemed to help.

But, what do you do in a consumer driven plan where you just have a high deductible.  I for one advocated that I would like edits that forced me to save money.  Perhaps, I needed an override code, but I wanted to know when and how to save money.  Left to my own devices and having to research every prescription would be a burden.

I think this still remains to play out, and I am sure there are lots of opinions here.

After posting the note on Sermo yesterday, I began wondering about a patient’s ability to influence their physician.  The best study I have seen on this topic was around Direct-to-Consumer (DTC) advertising on brand drugs.  The FDA did a study a few years ago that showed how that information influenced the physician-patient relationship.  It is a good read (if you like studies).

But, what do you do when you know about some type of online resource for your physician?  Can you influence them to go out and research your disease state?  Will you even push your physician on his or her knowledge?

I think this is definitely influenced by generational issues.  This is a sweeping generalization, but I generally see older people have more deference towards people like physicians.  I think some of that is beginning to change as people bear more costs and responsibility for their healthcare.  But, younger people (who are not the sick ones generally) have a greater willingness to challenge those in authority (good and bad).

We faced this issue a lot at Express Scripts in trying to drive generic drugs and mail order.  Eventually, we created a “Physician Kit” that the patient could complete online and print to take to their physician.  It was presented by the physician, but it had the backing of the provider. 

I was looking for something else on the Aetna site and stumbled across this picture in their latest investor presentation (Morgan Stanley Global Healthcare Unplugged). For those of us looking at consumerism, I think this is a good snapshot for competitive intelligence.

It hits all the key buzzwords – optimizing health, quality, affordability, literacy, transparency, and evidence based.  The proof is always in the actions, but this is what you want your MCO to be discussing.  The key challenge in all of this is bringing information to the consumer in digestible amounts and in a format and language that they can understand.

I was pleasantly surprised this morning to learn about RxWiki.com.  This is a website by pharmacists to provide consumer information about drugs, OTCs, and other products.  Certainly, for those practicing pharmacy (versus in the ivory tower), they should have some good first hand experiences to share with patients.

I think about when I first started seeing advertisements for Alli (diet drug).  When I asked a pharmacist about it, he said it was great as long as you eat no fat.  He said you couldn’t make it from taking one bite of a McDonald’s hamburger in your car into the bathroom at McDonald’s fast enough to avoid an accident.  Doesn’t sound appealing to me.  Why not just give up fat?

I wonder if we will ever see a MDWiki (somebody already has the URL).  These collaborative tools are great for allowing people to share information with the general public.  Hopefully, they have the right disclaimers so they don’t ever have some frivolous lawsuit because I think consumerism is only going to take off when information is generally available with some quality assurance process.  We need to trust the information but have it relayed to us in straightforward, non-legalese.