Tag Archives: Healthcare

Healthcare Companies Sitting On Lots Of Cash…What Will They Do With It?

In the September 8-15 edition of Time Magazine, they have a whole article about data and numbers.  One of the pages is on which companies have the most cash.  Apple is number one and the one you always hear about.  As we’ve all seen, there are lots of rumors about Apple, Google, and Amazon and what they’re doing that is health related. 

At the same time, I was intrigued to see all the health related companies on the list:

  • Medtronic – $13.7B
  • Abbott Labs – $8.1B
  • Merck – $27.3B
  • Pfizer – $48.8B
  • Johnson & Johnson – $29.2B
  • Abbvie – $9.9B
  • Eli Lilly – $12.7B
  • Amgen – $23.1B
  • Bristol-Myers Squibb – $8.3B

You have several other non-healthcare companies which are doing things in healthcare that are also on the list:

  • Walmart – $8.7B
  • GE – $14B
  • Procter & Gamble – $8.5B
  • Qualcomm – $31.6B

If you look at the Rock Health recent report, you can imagine how these companies could leverage all this money to really change healthcare.  They could fund companies.  They could buy companies.  They could invest in orphan drugs.  They could create new technology standards.  They could educate consumers.  They could push technologies like the Internet of Things. 

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Express Scripts 2013 Drug Trend Report

I always enjoy reviewing the PBM Drug Trend Reports.  Even though these past two years I’ve been focused more on the care management side of healthcare, I continue to see these two paths colliding in interesting ways in the near future. 

Here’s my big takeaways from the report some of which you can get in their Executive Summary

(I’d also encourage you to look at Adam Fein’s review…where he unfortunately beat me to the punch again.)

  • Overall trend was 5.4% which they did a nice job of breaking out according to different lines of business.
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  • They also showed the breakout of trend comparing specialty drug trend versus traditional oral solid medications. 

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  • Specialty trend was up 14.1% based on a 2.5% increase in utilization and an 11.6% increase in unit cost.
  • A key point is that specialty now makes up 27.7% of the total drug spend for a payer (and that doesn’t even count the ~50% of specialty drugs billed under the medical benefit).
  • Diabetes was the standout category within traditional drug classes with increased utilization and price increases.  [Which isn’t surprising to those of us working on the clinical side that see huge innovation and investment in the diabetes area – Omada Health, Telcare, and Welldoc (for example).]
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  • While they make a key point with data that member cost share is going down and actual out-of-pocket costs are only going up marginally, I think it ignores the reality that consumers are feeling the pain of out-of-pocket spending more especially with all the High Deductible plans out there.
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  • They do reinforce their previous messaging around waste and also introduce their Health Decision ScienceTM approach.  (I personally would have liked to see more on this.  How is the blending of Consumerology and the Therapeutic Resource Centers impacting utilization, adherence, waste, clinical outcomes, patient satisfaction, or other key metrics?)
  • As always, you can dig into their forecasts by drug class.  I choose cancer as one area to look at.  (While this is focused on the basics, I would have loved more about what’s going on around cancer.  How are genetic tests impacting use?  What about survivorship?  How do Centers of Excellence affect outcomes, drug selection, pricing, and adherence?)
  • On top of being able to drill down on Medicare and Medicaid, you can also look at a Worker’s Compensation specific version of the drug trends.  This is interesting since that business is different than the traditional PBM market and is an area that Express Scripts has gone aggressively after in recent years. 
  • One thing I couldn’t find in the document (which is hard to read in the current format) is the average number of Rxs PMPM or PMPY which is just a good stat that I personally track. 
  • One note I will offer on methodology is the definition of specialty drugs.  This could lead to some differences between PBMs as we try to compare their trend numbers.  Here’s the definition Express Scripts offers:

“Specialty medications include injectable and noninjectable drugs that are typically used to treat chronic, complex conditions and may have one or more of the following qualities: frequent dosing adjustments or intensive clinical monitoring; intensive patient training and compliance assistance; limited distribution; and specialized handling or administration. – See more at: http://lab.express-scripts.com/drug-trend-report/appendix/methodology#sthash.dhJhFIZs.dpuf” 

 

#mHealth and Innovation – 2 Recent Reports

We all know that healthcare is clearly one of the darlings in the market right now.  One doesn’t have to look any further than these stories:

You can see companies building innovation teams and innovation labs within healthcare.  You see lots of new entrants trying to figure out how contribute in this space (e.g., Qualcomm Life).  But, some of these just become ivory towers where they pontificate and put out cool ideas.  Others disappear because they can never be commercialized.  Others fall into the “fast fail” bucket of companies, and only a portion of those actually innovate well.

Of course, it begs the question of “What is innovation?”  Is it:

  • Something completely new
  • Something re-engineered
  • The same thing delivered differently
  • Combining of multiple things (i.e., product with services)
  • Solving old problems with new technology

With that in mind, I was reading two reports which I thought I’d share with some initial reactions.

The Boston Consulting Group report “Fulfilling the Promise of mHealth Through Business Model Innovation”.

This is a nice report, but it’s a little too high level for me.  It has some great frameworks about what to do and some nice graphics, but it’s not operationally practical (although that may not have been the purpose).  Here’s a few things I highlighted:

  • “Mobile Health – The use of mobile applications and devices to deliver medical information, access or record data, or provide clinical services – has the potential to revolutionize patient care.”  [good definition]
  • “The gap between the current market size and five-year projections is significant.”  [so is it a warranted gap or will it get closed…I think it will be a challenge to meet expectations.]
  • Their big example of success is Welldoc’s BlueStar “mobile prescription therapy”.  [it’s an interesting product with some interesting studies, but I’m not sold yet…will the Rx process work for a device?  Can they justify their price?  Will buyers do more than pilot?]
  • They hold out 3 barriers – entrenched behaviors, reluctance to pay, and fragmented infrastructure.  [I would agree but how do I work through these…they provide some thoughts.]
  • They talk about creating a “must-have app” that would consolidate multiple offerings into a single solution.  [I don’t even think this silver bullet approach should be considered…It won’t happen.]
  • They seem to fall into the traditional trap that people other than the payers and employers will fund these programs (telcos, pharma, device companies).  [Everyone wants that, but I think that’s the wrong framework.]
  • They talk about an option of creating and charging a premium for mHealth offerings because some of them “deliver objectively better outcomes or lower costs compared with traditional health-care offerings”.  [Really?  That’s great news, but I wouldn’t consider that a fact.  I’d say we’re seeing some promising studies.]
  • They talk about “an orchestrated ecosystem” and integration of data.  [This would have been a perfect time to highlight what Vladic is doing or what Dossia is doing.]

There were some things missing that I personally would have called out.

  • What about learnings from prior models like electronic prescribing?
  • What about things like EMR integration and the difficulties there?
  • What about the issue of privacy and security?
  • What about the fact that people abandon devices and apps very quickly?
  • What about learnings from gamification or incentive management?
  • What about prescribing apps to patients? (like Happtique or IMS)
  • What about the whole issue of FDA approval of apps and devices?
  • What about what the large companies are doing – Aetna, Cigna, CVS, Walgreens, WalMart?  I think understanding their view of this market is so critical.

Triple Tree report “Connected Health”. 

It starts with a great tag line from IBM – “Does Your Kid Have Better Technology Than Your Business?”  They reference Steve Case’s framework from a presentation he made (see below):

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What I liked about this report is that it’s based on lots of real world examples.  (It’s still not operationally helpful, but these are investors not consultants so it met my expectation.)  They certainly could have gone deeper to explain why certain companies they highlight got acquired such as Diversinet, Epocrates, BodyMedia, CardioCom, Healthagen, Vitality, and ConsultADoc.  But, if I look at their list of companies, I see a lot of the innovative companies that I would have on my list – Proteus Digital Health, Healthrageous, iTriage, TelaDoc, Telcare, Eviti, Change Healthcare, and Asthmapolis.  (I know Healthrageous shut down – see postmortem – but I think they had some great vision.)

I also think they’re list of major inhibitors to growth was very believable:

  • Physician adoption
  • ROI
  • Regulatory hurdles
  • Security and governance
  • Lack of standards

The report shares an interesting stat that 45% of the companies that applied for their rewards were led by MDs in 2009 while it’s only 21% now.  To me that shows the movement of IT and business executives into the healthcare space.

Triple Tree does talk about remote monitoring and CMS which I think is important.  While the Veteran’s Administration was mentioned in the BCG report, I think that the government efforts here and influence was generally overlooked.

Overall, two interesting reports.  Worth a read although I would choose the Triple Tree report over the BCG one if I had time to only read one.

Two other places that I would recommend going if this topic is interesting are:

Why Healthcare Needs A “Google Health”

Most people know that Google tried to jump into the healthcare space with Google Health a few years ago.  Google Health was (from Wikipedia):

Google Health was a personal health information centralization service (sometimes known as personal health record services) by Google introduced in 2008 and cancelled in 2011.  The service allowed Google users to volunteer their health records – either manually or by logging into their accounts at partnered health services providers – into the Google Health system, thereby merging potentially separate health records into one centralized Google Health profile.

Personally, if they wanted to build that, they should just go buy Dossia, and they would be there.  Looking backwards, you can read the announcement to cancel Google Health here, and there’s lots of articles out there about why it failed.

While they haven’t had a dedicated health team officially, they continue to have several health related projects:

  1. Helpouts is a video service that is HIPAA compliant meaning it could eventually compete with Teladoc, MDLive, and American Well.
  2. Calico is a newer company focused on aging which has lots of people wondering as they add well known executives to the core team.  
  3. They just came out with their smart contact lens to help diabetics test their blood sugar.
  4. Google has an app called My Tracks and an API to tap into some of the sensors in the phone that could be used for fitness apps.  
  5. Google X staff recently met with the FDA leading to some speculation.  
  6. Of course, there is also lots of discussion about how Google Glass could be used in healthcare.  (I personally think about the Checklist Manifesto as a perfect opportunity.)
  7. And, I would also point to the intelligent home (per their acquisition of Nest) as a venture which will lead them down the path of health at some point.

You could also look at the companies that Google Ventures is investing in from the health space:

I could have easily seen them investing in something like Theranos which stands to change the biometrics space.  

So…it’s not like they’re ignoring the space which isn’t unusual for many companies outside of healthcare.  Healthcare is hard.  Healthcare has lots of regulatory constraints.  In general, many companies want to avoid having to deal with some of those issues which can constrain the rest of their businesses.

But, let’s look at the critical and hot topics in healthcare right now:

  • BigData – how to use data; how to build predictive models
  • Engagement – how to personalize communications and engage consumers to take action from mass customization to segmentation to even gamification
  • Mobile and devices – how to use technology to track your steps, monitor your health, and collect data (see post about why your underwriter wants your mobile data)
  • Social – how to use social pressures and peers to create better health
  • Connectivity – how to connect devices, caregivers, pharmacies, providers, and others into a shared platform for care
  • Security – how to securely manage data
  • Transparency – collecting and aggregating pricing data to help consumers make intelligent decisions
  • User experience – creating user journeys and user interfaces to improve the overall consumer experience (perhaps changing the model like Uber (a Google Ventures investment))

Do those things sound like the competencies of any one company?  To me, they all sound like things that Google is good maybe even great at.  Additionally, the founders of Google have the big, picture and long-term vision that’s critical in healthcare.  Driving change in healthcare isn’t about meeting specific quarterly numbers.  It’s about seeing the world in a new light where you want to drive change and improve things like childhood obesity.  It doesn’t happen overnight.  

I wish I knew more about Google.  Someday, I’d love to work with them on some of these opportunities.  If so, I could see this being a perfect fit in the Google X world.  I could see them making a change as a core focus, as investors, or simply by creating enabling tools.  But, at the end of the day, this is why I think health needs Google to have a focus here.  It’s almost 20% of our GDP and something that impacts most people on a daily basis.  

CarePass Updates – Medication Adherence and Stress

A few weeks ago, I had a chance to follow-up with Martha Wofford, the VP of CarePass about their latest press release.  This was a quick follow-up interview to our original discussion.  As a reminder, CarePass is Aetna’s consumer facing solution (not just for individuals who they insure) which integrates mHealth tools and data to help consumers improve their engagement and ultimately health outcomes.

“Many Americans have a lower quality of life and experience preventable health issues, adding billions of dollars to the health care system, because people do not take their prescribed medications. There are a myriad of reasons why medication adherence is low and we believe removing barriers and making it easier for consumers to take their medications is important,” said Martha L. Wofford, vice president and head of CarePass from Aetna. “As we continue to add new areas to CarePass around medication adherence and stress, we seek to provide people tools to manage their whole health and hopefully help people shift from thinking about health care to taking care of their health.”   (from press release)

As part of this update, we talked about one of my favorite topics – medication adherence.  Obviously, this is a global problem with lots of people trying to move the needle.  In this case, they’ve included the Care4Today app from Janssen.  This tool does include some functionality for the caregiver which is important.  It also links in charitable contributions as a form of motivation.  We talked about the reality that adherence is really complex, and people are different.  This may work for some, but adherence can vary by individual, by condition, and by medication.  But, they hope that this is a tool that may work to nudge some people.

I was also glad to see them taking on the issue of stress by adding the meQ app.  This is a key struggle, and Martha pointed out to me that 1/4 of adults are either stressed or highly stressed.

“When people are under chronic stress, they tend to smoke, drink, use drugs and overeat to help cope.  These behaviors trigger a biological cascade that helps prevent depression, but they also contribute to a host of physical problems that eventually contribute to early death…” – Rick Nauert, PhD for National Institute of Mental Health, 5/2010

She mentioned that they’ve gotten a great reception to this program, but they have a lot more to learn.  They’re still in the early period of getting insights and interconnecting all of their efforts.  We also talked about some of the upcoming opportunities with the caregivers (or the sandwhich generation).  I personally think the opportunity to improve aging in place through a smart home strategy with remote monitoring is going to be huge of the next 10 years.

I did interview the Janssen people as a follow-up which I’ll post separately, but I also thought I’d include this video interview of Martha that I found.

2014 Healthcare Predictions and Trends

Happy New Year!  2013 has been an interesting year in healthcare with 2014 promising many more exciting developments.  A few of the biggest stories from 2013 include:

  • Healthcare.gov – the politics, the drama, and the missteps
  • Healthcare transparency and costs – new companies, new revelations, and an entire Time magazine focused on it
  • Healthcare engagement – ongoing focus on how to get consumers to engage
  • mHealth and QuantifiedSelf – apps and devices proliferate
  • Investment – a huge jump in VC and angel funding for healthcare
  • ACOs – do they work or not
  • Big Data – so much data…so many opportunities

Here’s my predictions for 2014:

  1. Transparency – The race to bring cost data to the forefront of the consumer mindset will move from a radical concept to an expectation.  With increased out-of-pocket costs and HDHPs, consumers will expect access and information to cost data.  They will look for systems that can predict what they need and push data to them in a timely fashion using location based services and predictive algorithms. 
  2. Exchanges – With big companies trying the private exchanges and moving their employees to the federal exchange, we’ll see the market holding its breadth to see what happens.  If this drives success on both sides of the equation – employers and payers, you can expect a large jump in this direction later in the year.   
  3. Mobile – The traditional member website will continue to die a slow death without mobile optimization in place.  More and more consumers will access the healthcare system through a smart phone or device like an iPad.  This will drive healthcare companies to figure out how to embrace user design and member experience in new ways as they strive to provide the sustainable app that consumers use more than a few times. 
  4. Providers – Providers will continue to cautiously embrace pay-for-performance, value-based healthcare, and models like ACOs and PCMHs.  They will want them to work, but they will continue to look for the Tipping Point in which their overall panel is part of these programs.  Providers will also begin to modify their workflows using technology based on Meaningful Use and the ubiquity of technology. 
  5. Engagement – Consumer engagement in healthcare will continue to be the elusive Holy Grail.  Companies will try behavioral economics, incentives, and mass personalization to try and get consumers to understand healthcare and take actions to improve their health.  There will be more shifting to include caregivers and embrace social media (e.g., Facebook) and peer-to-peer networks.  We will start to see documented case studies and results in terms of improved outcomes. 
  6. Devices – While 2013 was the year of device proliferation, we will see the number of people (early adopters and QuantifiedSelf groupies) maxing out.  I expect some further consolidation and a dip in adoption rate as we move into the period of disillusionment.  Devices will be less about a standalone solution and look at how they integrate with the smart phone and existing systems (at work and home).  Like smart pills and smart clothes, this will lead to increased data and integration into daily life.  This will require collaboration with providers and employers to figure out how to come through this period.
  7. Value-based – CMS will continue to be a big driver in pushing new payment models around healthcare as they struggle to figure out how to slow the tidal wave of costs coming in Medicare and Medicaid.  This will meet up with some of the progress in the commercial space with ACO and PCMH models leading to an evolving path in terms of how drive value.  This won’t be the breakthrough year, but we’ll see meaningful progress. 
  8. Investments – I don’t see any slowdown in healthcare investments.  Our health issues aren’t going away in the US or abroad.  China is just emerging with a long list of health issues and technology is creating new solutions in 3rd World countries. 
  9. Pills Plus – With pharma struggling with how to reinvent itself, they are going to look at new solutions like Merck is doing with Vree Health.  This will cause them to look at many of these trends and how they wrap services, technology, and incentives around their medications.  
  10. Specialty Care – Specialty pharmacy will continue to be a big growth driver with novel innovations coming down the pipe.  But, these pharmacies will realize that they can’t work in a vacuum.  They have to do a better job at integrating care management into their services and partnering with Case Management companies to holistically treat the patient. 
  11. Metabolic Syndrome – The overall global issues of obesity and diabetes will become a huge weight around the shoulders of the healthcare system.  While the focus will continue to be on the complex cases requiring massive dollars, the majority of people will be struggling with a chronic disease.  Metabolic Syndrome will become a big focus for payers, employers, and health services companies as they try to find ways to prevent further complications. 
  12. Prevention – While I don’t expect a huge shift here, I think we’ll start to hear more voices on the perimeter yelling about why we only spend 5% of our dollars on prevention.  They’ll point out other models outside the US spending more with better outcomes.  Health Reform will begin to enable some change here, but it will be slow. 
  13. Community Based Care – With more people coming back into the healthcare system with Health Reform, there will be a greater need for location based access to healthcare.  This will involve clinics but will be much broader.  Companies will need to look at how they embrace community resources like churches to engage the disengaged and poor who don’t trust the system and have limited access to the traditional channels.  

New/Old Accusations About PBMs And Their Margins

PBMs (or Pharmacy Benefit Managers) are big business.  Just look at a few of the names and their place on the Fortune 500 list:

Not surprisingly, none of those are non-profits.  There is real money being made here.  It’s all part of the mark-up game in healthcare.  The question of course is does the money being made justify the profits.  For example, I’m happy to pay my banker lots of money as long as he’s earning me more than he’s making (and significantly more).

This is a complicated question.  (see past posts on What’s Next, Why People Don’t Save With Mail, and Growing Mail Order)  I’ve also presented on this topic several times in the past pointing out that the model needs to change, and re-iterating the fact that PBMs made a mistake by putting all their profits in the generic space.  I’ve always said that disintermediation would happen by focusing on generics at mail which is where all the money was at Express Script (8 years ago).  [People remind me that some of this has changed and is different across PBMs.]

The new Fortune article by Katherine Eban called “Painful Prescription” certains shows a dark story.  It focuses exactly on one of these scenarios which is the gap between acquisition cost and client cost.  The article talks about paying $26.91 for a drug but selling it to the client at $92.53.  I’m always reminded of the fact that at one time we used to buy fluoxetine (generic Prozac) for about $0.015 per pill.  On the flipside, we had brand drugs that we bought for more than we got reimbursed and lost money.  It was strange model.

So, here’s my questions:

  1. Do you want transparency?  If so, there are lots of “transparent PBMs” and many larger PBMs will do transparent deals.  You can also follow the Caterpillar model.  (Don’t forget that pharmacy represents less than 20% of your total healthcare spend so you can find yourself down the rabbit hole here trying to shave 2% of spend on 20% or 0.4% of your costs with a lot of effort.)
  2. Are you focused on anamolies like this one or average profits per Rx?
  3. Do you have the right plan design in place?
  4. Do you have a MAC (maximum allowable cost) list both at retail and mail order for generics?
  5. Are you getting the rebates and any admin fees from pharma for your claims passed through to you at the PBM?
  6. If you pay the PBM on a per Rx basis (i.e., no spread allowed), what are they doing to keep your drug costs down year over year (i.e., they have no more incentive to push down on suppliers)?
  7. Are you benchmarking your pricing?  Look at reports from places like PBMI.  For many smaller clients, I often wonder if the savings they find you is worth the costs.

I’m sure there’s more since I’ve been out of the industry for a few years, but while I don’t intend to be the defender of the industry, I do like to bring some balance to the conversation.

CarePass, Another Aetna Innovation – What’s Your Healthy?

Have you seen the new “What’s Your Healthy?” campaign?  Here’s a few shots.

BTW – My healthy is keeping up with my kids in sports and moving down a belt notch.

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As many of you know, I consider Walgreens and Aetna to be two of the most innovative healthcare companies today (out of the big, established players).  [And, full disclosure, I own stock in both.]  I’ve talked about Walgreens (see Walgreens post on innovation) several times along with Aetna (see Healthagen post).

That being said, the new campaign along with the press caught my attention.  I was glad that I was able to get some time with Martha Wofford who is the VP and head of CarePass.

“We want to make it easier for everyone to engage in their health and hopefully shift from thinking about health care to taking care of their health,” said Martha L. Wofford, vice president and head of CarePass from Aetna. “CarePass helps consumers connect different pieces of health data to create a fuller, more personalized picture of their health.”

I spent some time talking with Martha and team about their initiative.  Here’s some highlights that stuck out to me.

  • There use of goals was really easy and intuitive.  If you log-in to the CarePass site and get started, you have 3 options or you can create your own (see below).  We spent some time talking about the importance of making these relevant to the individual not focusing on “healthcare goals” like adherence or lowering you blood sugar.  Most of us don’t think that way.  As they described them, they picked “motivation centric goals”.
    Aetna Carepass goals
  • I was also really interested in how they picked which apps to recommend.  There are so many out there, and many of you know that I’ve been fascinated by the concept of curating apps or prescribing apps to people.  They had a nice, simple process:
    • Which apps are most popular?
    • Does the app have “breadth”?  (i.e., national applicability)
    • They also spent more time pre-screening apps which collect PHI to understand them before listing them on the site.
    • They’re using the consumers goals to recommend apps to them.
  • The other big question I had is why do this.  It certain helps build the Aetna brand over time, but there’s not direct path to revenue (that I see).  They described their efforts as “supporting the healthcare journey” through connected data.  Ultimately, it’s about making Aetna a preferred consumer brand which may be very relevant in the individual market and exchange world in the not too distant future.
  • I like the idea of companies being “app agnostic” as I call it.  Walgreens is doing this.  Aetna is doing this.  I plan on doing this in my day job.  This allows the consumer to pick the app that works for them and as long as the data is normalized (or can be normalized) and the app provides some type of open API (application programming interface) it’s much easier to integrate with.
  • We talked a little about what’s next.  Metabolic syndrome is something they brought up.  This is something that Aetna’s been talking about in several forums for a while now.  They launched a new offering earlier this year.  (I still hate the term metabolic syndrome from a consumer perspective, but it seems to be sticking in the healthcare community.)
  • We also talked about new goals to come around smoking cessation, medication, and stress.
  • Another discussion I have with lots of people is how this data gets used.  (see a good article about what’s next for QuantifiedSelf)  I personally really want to see my data pushed to the care management team to monitor and send me information.  (Eat this not that type of suggestions)  Martha talked about how the data belongs to the member and they have to choose to push it to the coach.  She also talked about how they’re integrating with their PHR (Personal Health Record) first and then looking at others.  (see old interview with ActiveHealth)

In summary, CarePass is a nice additional to your #QuantifiedSelf toolkit.  As you can see from the screenshots below, the GUI (graphic user interface) is simple.  It’s well designed.  Integration with your apps is easy.  It provides you with goals and motivation.  They help you navigate the app world.  And, it helps you bring together data from multiple sources.  Once it can pull in all my Rx, medical and lab data along with my HRA data and my device data, it will be really cool!  But, I know that I’m a minority in that effort.  I’m really intrigued by the lifestyle questions they ask and wonder how those will ultimately personalize my experience.

Carepass lifestyle questions Carepass dashboard

So, what apps do they share?  Here’s a screenshot, but you really should log-in and try the site and see the full list.  It’s simple and worth the effort.

Carepass apps

As an added bonus, I’m adding a presentation I gave with Aetna at the Care Continuum Alliance two years ago.  I was searching for my past interviews with Aetna people and found this online so I added it to SlideShare and put it here.

Pharmacy Non-Adherence Infographic

While I’ve moved most of the infographics I find to my Pinterest account, I wanted to capture and share this one from Stephen Wilkin’s blog since it hits so many of the points that I try to make with people.

patient-non-compliance-infographic3

Personalized and Relevant Messages are Key to Successful Patient Engagement

Guest Post From The President of TeleVox Software

It shouldn’t come as a surprise to anyone that we live in a society yearning for instant gratification. We expect to get information in the blink of an eye, the answers we need within minutes and material goods delivered prior to the date that was promised. But what may surprise you is that even through the desire to have this information so quickly, the importance of providing a personalized message remains one of consumers’ biggest wishes. For instance, studies show that tailoring the message to the needs of patients as well as personalizing the messages are key to successful high-tech patient engagement. In fact, according to a recent TeleVox Healthy World Report, Technology Beyond the Exam Room: How Digital Media Is Helping Doctors Deliver the Highest Level of Care, 50 percent of patients expect information to be personalized to their specific needs. In the age of instant feedback and heightened technology, it is interesting to know that patients still desire a personalized approach in terms of their healthcare.

The days of simply setting forth wellness plans based solely on numbers and stereotypes are past us. Patients are looking for communications that are relevant to their lives, and it is their expectation that healthcare professionals will take time to engage in this level of personalization. Know Your Health also found that 53 percent of patients expect communications to be relevant to them as individuals. Relevant patient engagement can include personalized interactions, individualized treatment plans, and follow up. Patients thrive on a feeling of importance, ranging from a doctor knowing their name and medical history when they walk in to a follow-up call or email after the appointment to continue that personal connection.

Think about this: According to the same report, 21 percent of the population will refuse information if it is not tailored specifically to them. And, further, 13 percent of patients surveyed report they will ignore information sent their way if it doesn’t have their name on it. Why would providers want to miss out on connecting with an important part of the population by simply not including their name on any communication to the patient?  Including this step can ensure patient engagement is successful and save valuable resources, as the information conveyed will have a better chance of being received by patients.

Finally, taking time to connect with patients outside of their yearly exams or scheduled check-ups is another important link in ensuring that patients make positive decisions that ensure a healthy future. 68 percent of the population would like to receive educational tips that will help them live a better life via email throughout the year. Many Americans are concerned with the direction of the overall health and well-being of the country, but still aren’t taking steps to get where they need to be. However, healthcare providers can take steps to tailor messages that are relevant and personalized to patients to ensure successful high-tech patient engagement, and ultimately a healthier America.

Scott Zimmerman is a regularly-published thought leader on engaging patients via ongoing communication between office visits. He is the President of TeleVox Software, Inc, a high-tech Engagement Communications company that provides automated voice, email, SMS and web solutions that activate positive patient behaviors by applying technology to deliver a human touch. Scott spearheads TeleVox’s Healthy World initiative, a program that leverages ethnographic research to uncover, understand and interpret both patient and provider points of view with the end goal of creating a healthy world–one person at a time. Zimmerman possesses 20 years of proven performance in the healthcare industry, with domain knowledge in the surgical, interventional and pharmaceutical arenas. Prior to joining TeleVox, Scott served for nine years at GE Healthcare in a variety of cross-functional and global leadership roles in sales, services, quality, marketing, pricing, finance and product development. Scott is a graduate of the John M. Olin School of Business at Washington University in St. Louis.

How Aetna’s Pivoting With Healthagen – #whcc13

Do you know the term “pivot“? It’s all the rage now in terms of describing how companies continue to evolve their models with this rapidly changing business environment.

Of course, Aetna is one of the big healthcare players in the US. They’re not going to abandon a model that’s been working for well over 100 years. But, thanks to some great leadership from people like Mark Bertolini, CEO of Aetna, they’ve created a new business unit called Healthagen (building on the company they bought known mostly for iTriage). The screen shot says it all.

I got the privilege to sit down with Dr. Charles Saunders who runs Healthagen at the World Healthcare Congress in DC (#whcc13).

Charles E. Saunders, M.D., is responsible for leading the strategic diversification of Healthagen’s products, services and global opportunities. He focuses on identifying new growth opportunities and developing market strategies that can help Healthagen and Aetna profitably manage quality and cost for its customers.

Prior to joining Healthagen, Dr. Saunders served as executive in residence at Warburg Pincus, one of the world’s largest and oldest private equity firms. He has held a number of other significant leadership positions during his career, including CEO of Broadlane, Inc., President of EDS Healthcare Global Industry Solutions; Chief Medical Officer of Healtheon / WebMD; Principal of A.T. Kearney; and Executive Director of San Francisco General Hospital Managed Care Programs.

Dr. Saunders received a B.S. in biological sciences from the University of Southern California and an M.D. from Johns Hopkins University. He is board certified in Internal Medicine and Emergency Medicine and has served on the faculty of several universities, including the University of California, San Francisco; Vanderbilt University; and University of Colorado.

I also got to hear him speak right before I talked to him. (As a side note, he is a great presenter which is something that I really respect in a world of people who present too many slides, use notes, talk to the screen, and can lose you quickly.)

He hit on several key themes in his presentation that we then discussed further face-to-face:

  1. Social Caregiver Model
  2. Game Theory
  3. Digital / Mobile

One of my first questions was to really understand Healthagen and what it was set up to do. (As you can see from the screen shot below, they’re doing lots of things in this group.)

He boiled it down nicely to three things:

  1. Physician (provider) enablement
  2. Patient engagement
  3. Population Health Management IT

Our next discussion was really around why and how to create and innovate within a large company like Aetna. He reiterated what I believed that Mark Bertolini championed this new vision along with several of the other senior leaders. But, I think the key was that they recognized that issue of trying to do that internally and were willing to form a group to be different. To minimize bureaucracy for this group. And, to leverage their capital and assets to support this group. Not many big companies do this well. My impression is that Aetna is and will continue to be successful here. (Full disclosure – I own a minor number of Aetna shares and have believed this since I bought them about a year ago.)

Of course, in today’s market, there’s an explosion of innovation with questions on the short-term and long-term ROI of many initiatives and start-ups. With that in mind, Dr. Saunders pointed out that they don’t want to own everything. They want to create a plug and play platform of enablement. iTriage is a great example of this where they brought in a mobile technology with 2M downloads in 2011 and now have over 9.5M downloads of the tool (on top of massive increases in functionality and integration). You can download it here – https://itunes.apple.com/app/itriage-health-doctor-symptoms/id304696939?mt=8.

Certainly, one concern others have historically had in this space was how to own solutions and sell them to their peers (competitors). Dr. Saunders talked about their ability to do this with ActiveHealth and a perception that the industry is over that issue as long as Aetna can continue to demonstrate that they are good stewards of the data and are keeping the appropriate firewalls in place.

We wrapped up the conversation talking about the social caregiver and game theory. I think both are important in our mHealth / digital world. With the sandwhich generation, this is increasingly important. That is where Aetna is focusing…enablement of the caregiver for infants and seniors leveraging a social approach. This reminds me of their recent announcement of a pilot with PatientsLikeMe. We also talked about game theory and the role of that in healthcare which is a common theme from my discussion with Keas this morning and a theme from the overall conference.

It should be interesting to watch Dr. Saunders and his team and how Aetna continues to pivot.

Key Topics At #WHCC13 In DC

I’m at the World Healthcare Congress (WHCC13) in Washington DC this week.  This has always been one of the top 5 events for me to try to come to every year (admitting that there are a few like TED that I haven’t attended due to budget yet).

It’s interesting  how trends start to flow within a conference and how the trends change year to year.  This year, the key themes that I continue to hear are (in no order):

  • Engagement is critical.  Between MD and Patient.  Between social network / influencers and member.  Between employee and employer.
  • We have to get past the barriers to health enablement (i.e., legacy IT systems) and make change happen.
  • Game theory can help improve engagement.
  • Mobile tools are important.
  • Data integration has to happen and employers are doing it themselves.
  • Biometrics are critical path.
  • We can’t solve healthcare if we don’t solve health.  The community.  Our food choices.  Work / life balance.  (I would add sleep and stress.)
  • Rapid innovation.
  • Reform isn’t going to be easy on the employer or the employee.

But, since Twitter is my new note taker…here’s a few sets of tweets for you.

#whcc13 tweets whcc13 tweets3 whcc13 tweets2 whcc13 tweets1

#WHCC13 Interview: Content + Community + Competition = Keas

I had the opportunity to sit down this morning with Josh Stevens who is the CEO of Keas.

“Keas is the most engaging wellness program in the workplace. Keas promotes healthy behavior and teamwork with interactive media that delivers relevant, individualized content to hundreds of thousands of employees. Keas has a proven track record of supporting corporate HR in increasing retention, productivity, teamwork, collaboration, and competitiveness. By rewarding people for achieving simple exercise and nutrition goals, employee health is improved and overall healthcare costs are decreased.”

He is a passionate believer in using fun and social to drive change in healthcare with a focus initially on wellness and then moving upstream to other challenges like disease management.

As CEO of Keas, the market leader in corporate wellness, Stevens is responsible for leading the development and market adoption of the company’s breakthrough wellness platform and applications.

Stevens has over 20 years of experience in product, sales, marketing, and is a recognized leader in driving high-value product experiences that deliver customer delight and investor’s valuation growth.

Prior to Keas, Stevens was Vice President of e-commerce at YouSendIt, Senior Vice President of strategy and business development at TicketsNow, and General Manager of e-commerce at AOL. Prior to his GM role at AOL, Stevens held a variety of leadership positions in business development, product marketing, product management, and corporate strategy.

Some of you may have seen Keas over the years. They were founded by Adam Bosworth who was responsible for Google Health at one point. They’ve gone through a few evolutions, but it seems like they’ve hit on a working model leveraging several principles that we discussed:

  1. Being intellectually nimble
  2. Developing holistic and integrated solutions
  3. Using content, community, and competition to drive engagement
  4. Building social networks around health
  5. Integrating into the consumer’s experience to be seamless (e.g., single sign on)
  6. Recognizing that change is dependent upon corporate culture changing also
  7. BYOD (bring your own device) meaning that they can integrate with anyone with an open API
  8. Realizing that while some people (like me) might want to focus on data in a Quantified Self manner, we’re only 15% of the population

While Josh isn’t a healthcare native, that seems like a good thing. I’ve seen a lot of people try to come into healthcare from the outside. Most of them fail because they get overwhelmed by the regulation or frustrated by the challenges or stick too much to what they personally think should work. In the hour we spent together, I didn’t get that sense.

I’m looking forward to learning more about Keas and trying out the tools myself. One of the most fascinating points was that they get people to engage 15 times per month. I told him that that was a ridiculous number in healthcare. We went on to talk about his hiring a team from the gaming industry and that they were used to being tied to repeat visits not simply getting people to download the tool.

IMHO – if you could get 50% of people to engage twice a month with a tool (and sustain that engagement rate), you would be a hero.

As I’ve talked about in my posts about CVS and as I tweeted earlier today from the conference, companies need to engage the worker at the workplace to transform healthcare. Josh gets that key point.

“Today’s employees spend most of their daily lives at work and companies can have a huge impact on improving overall health by creating a culture of wellness at work. That culture starts with Keas’ fun, engaging platform, which helps employees become healthier, more productive and more engaged at work, and in life.” (press release)

Why CVS Caremark Asking For Your Weight Is Good For You

I continue to annoyed by all the fear-mongering in the industry around what CVS Caremark is “doing to their employees”.  What about focusing on how they are helping their employees to get better?  (If interested, you should read some of the information they have on their blog.)

Our “Plan for Health” combines an evolving, best-practice approach to health coverage with preventive care and wellness programs. Our colleagues will be more accountable for taking control of their health and associated costs. The first step is getting to know your numbers by getting a health screening and completing an online wellness review each year. If colleagues complete both by the May 1, 2013 deadline, they will avoid paying an additional $600 for the 2013-2014 plan year. (from the CVS Caremark blog)

I was hopeful to hear someone come out strongly and speak about it yesterday on CBS, but instead the CEO of Mercer just talked about “soft” programs that depend upon consumers being proactive around their health.  I would rather hear about the value of screenings and how it helps employees.  In talking with one friend of mine at a biometrics company, he told me that in one case almost 40% of the people that they identified with diabetes (or pre-diabetes) and hypertension (or pre-hypertension) didn’t know they had the disease (or were at high risk).  That to me is a valuable insight to the individual especially when coupled with a program to help them learn and manage their disease (or risk).

For example, companies for years have been using Health Risk Assessments (HRAs) to try to baseline employee health and use that to accomplish several things:

  1. Help the employee to understand their risks
  2. Identify people who should be in coaching programs to improve their health
  3. Learn about their population and how to improve their health benefits

Use of biometrics is the right evolution from the HRA.  People have tried HRAs for years with some success.  Companies pay as much as $600 for people to take this online survey that has no necessary link to reality.  Most HRAs aren’t linked to lab values.  Most HRAs aren’t linked to claims data.  Most HRAs don’t necessarily trigger enrollment in health programs.  They are supposed to activate the employee to be proactive which doesn’t work for many sick consumers especially those in the “pre-disease” phase.  (Here’s a good study that does show some increased activation.)

As I mentioned the other day, this use of biometrics and link between incentives and participation (and ultimately outcomes) is normal and will ultimately improve the link between the workplace and the employee around health.

Let’s take a broader look at insurance to help set some context:

  • For life insurance, you have to disclose certain data and depending on the policy level you have to do other things like get a physical and have blood work drawn.  That effects your costs and their underwriting.  
  • For car insurance, if you get in accidents, your costs go up.  In some case, you can have a monitoring device put on your car to lower your costs.  (like getting blood work done)
  • For home owners insurance, your costs go up if you live in a flood zone or a earthquake zone.  It also goes up if you have lots of claims.

Whether we want to admit it or not, we do determine a lot of our healthcare costs based on decisions we’ve made or had made for us since we were kids.  Some of these are conscious and some are subconscious.  And, obesity which is a large driver of many of these chronic conditions and has an impact on your likelihood of having cancer.  So, a company asking for your BMI and other data to help understand your risks for healthcare costs (of which they typically pick up 80%) doesn’t seem unusual.

Certainly, some are environmental such as those that live in “food deserts” like Detroit.  In other cases, workplace stress can affect our health.  We’re just starting to get smarter about “sitting disease” and it’s impact on our health.  Or, we may take medications that affect our blood pressure (for example).  It’s certainly important to understand these in context of your lab values and discuss a holistic strategy for improving your health with your physician and any care management resources which are provided to you (nurse, social worker, nutritionist, pharmacist).

This idea of learning more about employees in terms of biometrics, food, sleep, stress, social interaction, and many other data points is going to be more and more of a focus.  Companies want to learn how their employees do things.  They want to understand their health.  They want to improve their health.  They want to invest in their workforce to improve productivity, innovation, and ultimately job satisfaction.

While the glass half-empty people won’t see this and there are some companies that don’t always act this way, I generally believe that companies are trying to act in a way to increase their top line and most intelligent executives understand the correlation between health and wealth and the link between employee satisfaction and growth.

Ultimately, healthcare costs are estimated to put a $240,000 burden on us after we retire (even with Medicare) so if someone wants to help me become healthier and thereby save me money which improves my ability to retire and enjoy life I’m happy for them to do.

How The CVS Program Will Change The Employer – Employee Contract

Have you heard that CVS Caremark is requiring employees to go get biometrics and going to take action on it? OMG!

I’m not sure I understand why people are all upset. Let’s look at the facts:

And, by the way, have we forgotten how much healthcare costs have gone up over time and who pays that bill. It’s either the employer or the government. Both of those things impact our pay as individuals either in terms of lower raises to cover healthcare costs, shifting healthcare costs to us, or taxes. It’s not sustainable so the person who pays the bill has to step in since we’re not. (Which is also why I support the NY ban on soda.)

Now, let’s look at our healthcare system where in the current fee-for-service model, there isn’t an incentive for physicians to address this.

For now, people should be happy. They’re only being required to do the biometrics. The penalty isn’t linked to whether they’re fat or have high blood pressure or smoke or have high cholesterol or have diabetes. A recent study by Towers Watson shows that while 16% of employers do this type of outcome based incentive program today (2013) that this is going to jump to 47% in 2014. So, this will be the norm.

And, guess what…sticks often work better than carrots in some cases.

And, healthcare costs are making us uncompetitive globally as a country.

  • The cost of healthcare is greater than the cost of steel in a car.
  • The cost of healthcare is greater than the cost of coffee in a Starbuck’s cup of coffee.

And, health reform is allowing (even enabling) this to happen. It says that you can treat people differently and create up to a 50% differential in costs associated with their health. (Not a legal definition so read the fine print.)

But, what I think all of us (consumers and employers) will need to realize is that moving to this (which I agree with) will change the employer and employee relationship in several ways.

  1. You can’t put these programs in place without something to help me manage my obesity, cholesterol, and/or other chronic condition. This will drive wellness and disease management programs to be more engaging and successful.
  2. This will put pressure on employers to create a culture of health since we spend so much time at work and work contributes to our health conditions.
    1. Need more time to be active. Less sitting. Treadmill desks. Standing meetings. Nap time. Walking breaks. Use of devices to track steps. Incentives. Gym discounts. Healthy food discounts.
    2. Need less stress.
    3. Need more sleep.
    4. Better food choices at work.
  3. This will drive a lot of the new tools and run counter to some trends about limiting dependent coverage since you can’t address obesity without engaging the entire family and the social network.
  4. This will also create a whole exception process by which people who gain weight due to certain drugs have to be excluded. People who can’t exercise may have to be excluded. People may have to see short-term goals (i.e., dropping BMI from 35 to 32). Physicians will have to be engaged.
  5. Coaching will have to expand to include dieticians, social workers, and others to help people beyond the historical nurse centric coaching model.

If none of this motivates you, then just think about the “gift” we’re giving our kids and maybe that will be a wake-up call why someone has to do something here. (As I shared the other day, I struggle with my weight so don’t think I’m some super skinny, high metabolism person who thinks this is easy.)

What’s Your #Moment4Change?

I’ve being doing a lot of work lately on how to tackle the obesity problem in the US. This has been great personally as it has forced me to look at lots of research to understand all the tools out there.

  • Diet
  • Exercise
  • Coaching programs
  • Devices
  • Social networks
  • Physicians
  • Centers of Excellence

It’s also made me look at different drivers of obesity including sleep and stress. The new report out showing that sitting is a huge problem (even if you exercise) is very eye-opening also.

For years, I’ve talked about my challenges is managing my weight which lead to some fluctuations, but at the end of the day, I think a lot of this boils down to a “Golden Moment” or a “Moment4Change”. Even people who do this every day (e.g., doctors or sports coaches) are often overweight. We have to have something which prompts us to change our life. We aren’t generally motivated by dropping our HDL. We’re motivated by being able to play with our kids or living long enough to see our kids get married.

In my life, there have been several Moment4Change points so I thought I would put this out there to hear what’s motivated others:

  • In 2002, I went to the doctor for the first time in a decade. He saw some health risks in my blood work and sent me to another physician. He told me I was obese. (Something less than 50% of physicians actually tell their overweight patients.) I was shocked. I was 215 pounds and 5′-10″. After 2 days of agony, I decided that I couldn’t accept that diagnosis and proceeded to lose 40 pounds in the next 60 days (all through exercise and social motivation through a running group).
  • Last fall after letting much of that weight creep back on over the decade, I decided to do a 5K with one of my kids. I’d run 3 marathons and was running several days a week (although at an average pace of 9 minute miles). I got killed as my kid ran at a 7:30 pace in their first race ever. Not only did I feel old, but I felt like I wasn’t being much of a role model. That motivated me to change. Now, after using the FitBit (see several comments), I’ve had good success losing 25 pounds in 3 months and seeing my cholesterol drop 120 points in that same time frame.

So, I’m interested. What has motivated you to changed? And, how do you measure success? I suggested that while women may use the “skinny jeans” test that men might be more likely to use the “belt buckle” test.

 

 

I think this image below from the AON Hewitt 2012 Health Care Survey is a good one about the fact that 80% of our costs are driven by 8 behaviors.

I also thought that this presentation at the FMI by The Well which was a GSW project was right in line with this.

Why It’s So Hard To Improve Consumer Engagement In Healthcare?

I spend a lot of my personal and professional time trying to figure out how to better engage consumers in healthcare.  If you can’t engage them, you can’t improve outcomes.

Never mind the fact that people experience about 5,000 messages a day so you have to cut through that clutter.

Even if we do cut through the clutter, people are busy living their lives.  They’re worried about their family.  They’re worried about the economy.  They’re trying to keep food on the table.  They are generally overwhelmed with too little sleep and too much stress.

But, let’s even assume that you can cut through the clutter and get them to listen, you still struggle with getting a person at a time when they are open to change.  These “golden moments” require them to see value in the change and feel like the short-term effort is worth the long-term gain.  This “value exchange” doesn’t often exist.  And, with 30% variance in the healthcare system, people often don’t trust the system.

Even with all that in mind, people still don’t engage.  They don’t get flu shots.  They don’t fill their medications.  They don’t understand the messages that are delivered to them.

Here’s a quick image I created for a presentation later this week.

Consumer

A few of the sources for this are:

Healthcare Fails Again In Experience Survey

The fact that most people would rate their experience with their health insurer low isn’t a big surprise to most of us in healthcare.  But, with the Triple Aim and other quality metrics, the customer experience is becoming an increasingly important metric.  Several recent surveys have talked about this as one of the top priorities for hospital systems.  And, as use of CAHPS continues to grow, this will be more closely linked with incentives.

“Patient experience is on the radar of hospital executives, especially since Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores will soon affect reimbursement,” said Jason Wolf, executive director of the Beryl Institute. “However, the data shows that executives are still grappling with how to implement change within their organizations.” (source)

Like in years past, health insurers just barely nudge out TV service providers to prevent being the bottom of the industry in Bruce Temkin’s Benchmarking work.  While I’d love to see healthcare broken out into hospitals, physicians, pharmacies, insurance companies, PBMs, and care management companies, I think we can assume some similar concerns would fall out.

Healthcare companies need to find ways to address this.  I think there are several key first steps:

  1. Defining your customer;
  2. Mapping their experience;
  3. Creating personas or segments to think about (i.e., healthy, sick, insured);
  4. Identifying influences on their experience (some of which you might not control);
  5. Determining what matters versus doesn’t matter;
  6. Capturing baseline metrics; and
  7. Building a continuous improvement process.

Temkin Group 2013 Satisfaction Temkin Group Satisfaction

 

Less Than 1/3rd Of Health Insurers Very Confident In Their Big Data Value To Consumers

With all the discussions these days on Big Data and how to use information to create insights and wisdom, I was really shocked when I looked back at this PWC survey from 2011.  In it, less than 1/3rd of health insurers were very confident in their use of informatics to add value around case management, disease management, wellness, and consumer health tools.  WHAT???

This seems crazy to me.  In this interconnected world where everyone is talking about connected devices, mHealth, and ENGAGEMENT, health insurers are in the optimal position to leverage their data to provide insights, to provide transparency, to create algorithms, to be preventative in their actions, etc.  Maybe their technology platforms are too old?  Maybe they’re too silo’d?  I’m not sure.  But, I find this an interesting arbitrage opportunity.

With a system that integrates data from claims, labs, patient reported sources, HRAs, and biometrics, you can add value by creating a personalized patient experience that adapts with their needs.

Clinical Informations for Care Mgmt

New mHealth App – Interactive HRA – Recommendations – Zuum

In the Winter 2012 Innovate Magazine from Barnes-Jewish Hospital and Washington University Physicians, they talk about a new iPad app that they developed that calculates disease risk and offers a customized plan.

I just downloaded it and used it.  Here’s my quick summary:

  • Nice GUI (graphical user interface)
  • Easy to use HRA (health risk assessment)
  • Cool interactive tool (you can see how your risk for certain diseases changes with your changes in behavior)
  • Content seems to be well written with basic health literacy taken into account
  • Links out to more research and content
  • Messaging feature (which I guess will push me updates and other messages over time)

Overall, it seems like a nicer than normal HRA with the ability to interact with it.  My question would be how it integrates with my care team and how it gets used over time.  If this integrated into my other devices and monitored my data, it would seem more valuable than a standalone app, but I certainly think it’s great for a one-time use.

If you’re interested in downloading it, you can go to iTunes here.

Zuum 2 Zuum 1

17 Healthcare Blogs You Should Read

This is just a list of my favorites.  Feel free to add your own recommendations.  I broke them into 3 categories.

(BTW – I’m sure I missed a few of you so I’m sorry.)

1. Key Foundational Blogs To Follow

2. One’s I Read Frequently

3. Good Blogs That I Use For Certain Topics

I’ll also give a shout out to a new blog that has started that I have high hopes for based on their initial content – http://hoopayzblog.com/.

Favorite Health Infographics In Pinterest

While I’m sure I’ll still integrate some health infographics into my blog posts, I’ve decided to use a different tool for simply sharing the infographics that I like.  I built a Pinterest account and put 70+ infographics in there to get it started.  Most of those are ones that I’ve used before in the blog, but there are some new ones.  Enjoy.

http://pinterest.com/gvanantwerp/health-infographics/

Healthcare Infographics

 

Court Decision Allows Pharma Reps To Discuss Off-Label Uses Of Prescriptions

I must admit that I’ve heard very little about this decision from the Federal Appeals Court for the Second Circuit of Manhattan that decided that discussing off-label uses for prescription drugs was an issue of free speech. This could change the way pharmaceutical manufacturers interact with physicians. It could change the job of the pharmaceutical rep. It could change how clinical trials are done. It could change how prescriptions are used. It could also lead to a whole new set of prior authorizations by companies that actually have to actively manage off-label usage as it becomes widespread.

On the other hand, I wonder if this door hadn’t already been opened. Have you looked at some of the peer-to-peer (P2P) healthcare websites out there or the disease based communities (e.g., PatientLikeMe or CureTogether)? Patients are already talking about what medications they are using to treat their diseases and their symptoms. Don’t you think those are leading to requests to the provider and discussions with them about off-label utilization?

And, I’m sure that Dr. Google has helped many patients identify other uses of medications. This process (to the best of my knowledge) is completely un-managed. It’s a popular enough topic that Consumer Reports talked about it earlier this year and even put together the following table on drugs commonly used off-label.

Specific drug, type of drug Examples of off-label use**
Aripiprazole (Abilify), antipsychotic Dementia, Alzheimer’s disease
Tiagabine (Gabitril), antiseizure Depression
Gabapentin (Neurontin), antiseizure Nerve pain caused by diabetes, migraines, hot flashes
Topiramate (Topamax), antiseizure, in combination with phenteramine for weight loss Bipolar disorder, depression, nerve pain, alcohol dependence, eating disorders
Risperidone (Risperdal), antipsychotic Alzheimer’s disease, dementia, eating disorders, post-traumatic stress disorder
Trazodone (Desyrel), antidepressant Insomnia, anxiety, bipolar disorder
Propranolol (Inderal), high blood pressure, heart disease Stage fright
Sildenafil (Viagra), erectile dysfunction To enhance sexual performance in people not diagnosed with erectile dysfunction, to improve sexual function in women taking certain antidepressants
Quetiapine (Seroquel), antipsychotic Dementia, Alzheimer’s disease, obsessive-compulsive disorder, anxiety, post-traumatic stress disorder
SSRI antidepressants such as paroxetine (Paxil) and sertraline (Zoloft) Premature ejaculation, hot flashes, tinnitus (ringing in the ears)
Prazosin (Minipress), high blood pressure Post-traumatic stress disorder
Amitriptyline (Elavil), antidepressant Fibromyalgia, migraines, eating disorders, pain after shingles infection
Bevacizumab (Avastin), certain types of cancer Wet age-related macular degeneration (eye disease)
Statins such as atorvastatin (Lipitor), simvastatin (Zocor), high cholesterol in adults, children with an inherited cholesterol condition Rheumatoid arthritis, to lower cholesterol in children who lack the inherited condition
Clonidine (Catapres), high blood pressure Smoking cessation, hot flashes, attention deficit/hyperactivity disorder (ADHD), Tourette’s syndrome, restless legs syndrome

* Not meant to be a comprehensive list. Many of the drugs listed here are also available as generics.

** Does not imply that use is clinically appropriate or inappropriate, or beneficial or not.

***To find out if a drug’s off-label use is supported by evidence, click on the medication name.

 

I would imagine that pharma is going to tip-toe through this open door not simply crash through it. They’re generally risk adverse so their discussions of off-label utilization will be fact-based (to limit exposure) even if (as we all know) statistics can lie. I would suspect (as I’ve seen on other blogs) that this will ultimately go to the Supreme Court before anyone really takes advantage of it.

I guess I’d also point to the issue that physicians have responsibility here. They prescribe off-label today. Here’s what the FDA says about this:

Good medical practice and the best interests of the patient require that physicians use legally available drugs, biologics and devices according to their best knowledge and judgement. If physicians use a product for an indication not in the approved labeling, they have the responsibility to be well informed about the product, to base its use on firm scientific rationale and on sound medical evidence, and to maintain records of the product’s use and effects. Use of a marketed product in this manner when the intent is the “practice of medicine” does not require the submission of an Investigational New Drug Application (IND), Investigational Device Exemption (IDE) or review by an Institutional Review Board (IRB). However, the institution at which the product will be used may, under its own authority, require IRB review or other institutional oversight.

One way to begin to manage this would be to require the use of diagnosis codes (Dx) on all prescriptions. This would at least great a way of tracking how the medications are being used and allow for better technology oversight across the provider, payer, pharmacy, and PBM.

In the interim, Consumer Reports suggest consumers do the following:

  • When your doctor prescribes a drug, ask if it’s an approved use. If he or she doesn’t know, ask your pharmacist.
  • Check for yourself. Go to DailyMed (dailymed.nlm.nih.gov/) and search for the drug. Then click on the tab for “Indications & Usage” to see if your condition is listed.
  • If it’s an off-label use, ask your doctor if it’s supported by well-designed trials showing significant improvement for people with your condition.
  • Ask your doctor why he or she thinks the drug will work better than approved drugs for your illness.
  • Find out if your health insurer covers payment for the off-label use. Some may require evidence of effectiveness or failure with conventional treatments, especially if the drug is expensive.

Infographic: How Patients Learn In The Digital Age

 

I found this infographic here – http://www.hitconsultant.net/2012/07/25/how-patients-learn-in-the-digital-age-infographic/.

How-Patients-Learn-in-the-Digital-Age-Infographic-1

Updated: What Is A PBM? Pharmacy Benefit Manager

The short answer is that a PBM is the company hired by your employer (either directly or through your health insurance company) to manage your pharmacy benefits.  When you use your pharmacy card at the retail pharmacy to get a prescription, the pharmacy interacts with your PBM electronically to find out if the drug is covered and the copay to you the consumer.

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Back when I first started blogging, I used a lot of my experiences at Express Scripts to shape some of my perspectives about the PBM or Pharmacy Benefit Manager industry.  It took me a few months before I realized that some people reading the blog didn’t know what a PBM was.  That led me to my all time most popular blog post – “What Is A PBM?

Since that was over 5 years ago, I figured it was time for an update.

The market has shifted in the past 5 years especially with Express Scripts purchase of Medco to become the largest player in this space.  Walgreens has also divested their PBM to CatalystRx which was then bought by SXC and the new entity renamed CatamaranRx.  At the same time, you’ve seen United Healthcare insource their PBM business from Medco to combine it with their old Pacificare PBM to create OptumRx.  You’ve also seen Humana’s PBM business and mail order business – RightSourceRx – grow significantly.

There are other big PBMs which I didn’t mention such as CVS Caremark which after years of rumors about them splitting back up seems to have proven their case as an integrated, retail-owned PBM.  There is MedImpact which has 32M lives according to the latest PBMI market share report, and Prime Therapeutics which is a PBM owned by several of the BCBS plans.  Additionally, Aetna, Cigna, and several other managed care companies also have their own PBMs.

While I would have argued that the PBM wasn’t typically known to consumers 5 years ago, I think that the very public dispute between Walgreens and Express Scripts has changed some of this.

But, what a PBM does is relatively simple:

  • Process pharmacy claims (i.e., when you go to your retail pharmacy, the pharmacist enters your prescription and electronically submits it for adjudication. The claim is routed to the PBM where it is checked for eligibility and then to see if it pays and what copayment you owe.)
  • Set up pharmacy benefits (i.e., based on the plan selected by your employer or payor, the PBM codes what drugs are covered and the copayment structure).
  • Administer rebates…since large pharma companies (e.g., Pfizer) pay rebates for having their drugs on formulary (aka preferred drug list), someone has to manage the negotiations and billing of this.
  • Set up clinical programs (i.e., most PBMs have a clinical committee which evaluates new drugs and looks at market data to help employers choose coverage options).  This also includes programs to look for drug-drug interactions and pharmacy adherence.
  • Establish a retail pharmacy network (i.e., work with retailers to get them to agree to discounts on drugs) and are a big part of SureScripts which is the hub to enable electronic prescribing between physicians, pharmacies, and PBMs.
  • Communicate with patients and physicians (i.e., look at pharmacy claims data and help find ways to save money or identify clinical issues to inform the patient or physician about).
  • Provide cross pharmacy data for drug-drug interactions…this is a critical function since many people use more than one pharmacy for claims.
  • And, last but not least, most PBMs provide a mail order and often specialty pharmacy where they ship prescriptions to patients.

The PBM’s clients are employers who are self-insured, government entities (i.e., state employees, Department of Defense), unions, TPAs (third party administrators), and managed care companies (i.e., BCBS of).

PBMs are sometimes referred to as middlemen, but I will point to a few other posts on this:

In general, if you’re looking for more information on PBMs, I would point you to several sources:

The only other blogger who really offers any coverage of this space is Adam Fein which his blog – Drug Channels.

Diabetes Discussion – Clinical vs Technical vs Plain Language

One of the big issues in healthcare communications which is a rate limiting factor on health engagement is the language we use with patients. Here’s my attempt to talk about diabetes using different frameworks to drive home why this is important.

A clinical discussion:

You have diabetes mellitus. Because of that, you’re at increased risk for multiple co-morbidities including atheroscelerosis, hypertension, periodontal disease, retinopathy, neuropathy, and renal disease. Diabetes is considered a progressive disease. As our first line, I’m going to start you on monotherapy. Based on comparative effectiveness, this has the best clinical end points and lowest DUR issues. You will also need to maintain glycemic control and modify your physical activity level and caloric intake to minimize the long-term probability of getting ESRD and to lower your risk of myocardial infarction.

A mHealth discussion:

Based on our predictive algorithm and quantified self-tracking, I’m 90% confident that you have diabetes. To manage your diabetes, there are numerous widgets for assessing your risk along with online tools leveraging embodied conversational agents to support your efforts to self-monitor your condition. There are also apps which you can download which use gamification and location based services to address your intrinsic motivation to change. These tools will leverage the Trans Theoretical Model to understand your readiness for change and tailor messaging to you. Additionally, there are clinical staff available to help address your symptoms post-encounter.

A plain language discussion:

As you know, diet and exercise are important to maintain a healthy lifestyle. The test I had you take confirms that you have diabetes. Diabetes is a manageable disease, but it can lead to other health problems including gum disease, high blood pressure, and problems with your heart. We are going to start you on a prescription called metformin which will help to manage your diabetes, but you will still need to make some lifestyle changes. There are lots of technology tools on the Internet and your smart phone that can help you. I’d be happy to show you a few. They will help you track your calories, your exercise, and provide you with reminders about taking your medication. They can also help you learn about diabetes and answer some of your questions.

(And the above is at 7.8 grade level which is still too high for Medicaid and many programs.)

Here’s a summary from the CDC on Health Literacy…

What is Health Literacy?

The Patient Protection and Affordable Care Act of 2010, Title V, defines health literacy as the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions. This definition is almost identical to Healthy People. The only difference is the addition of “communicate” to the legislative definition.

Why Does Health Literacy Matter?

Every day, people confront situations that involve life-changing decisions about their health. These decisions are made in places such as grocery and drug stores, workplaces, playgrounds, doctors’ offices, clinics and hospitals, and around the kitchen table. Obtaining, communicating, processing, and understanding health information and services are essential steps in making appropriate health decisions; however, research indicates that today’s health information is presented in ways that are not usable by most adults. “Limited health literacy” occurs when people can’t find and use the health information and services they need.

  • Nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely available in our healthcare facilities, retail outlets, media and communities.1
  • Without clear information and an understanding of the information’s importance, people are more likely to skip necessary medical tests, end up in the emergency room more often, and have a harder time managing chronic diseases like diabetes or high blood pressure.2

What Needs to Be Done to Improve Health Literacy?

We can do much better in designing and presenting health information and services that people can use effectively. We can build our own health literacy skills and help others—community members, health professionals, and anyone else who communicates about health—build their skills too. Every organization involved in health information and services needs its own health literacy plan to improve its organizational practices. The resources on this site will help you learn about health literacy issues, develop skills, create an action plan, and apply what you learn to create health information and services that truly make a positive difference in people’s lives.

References

1 Kutner, M., Greenberg, E., Jin , Y., & Paulsen, C. ( 2006 ). The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics.

2 Rudd, R . E., Anderson, J . E., Oppenheimer, S., & Nath , C. (2007). Health literacy: An update of public health and medical literature. In J. P. Comi ngs, B. Garner, & C. Smith. (E ds.), Review of adult learning and literacy (vol . 7) (pp 175–204). Mahwa h, NJ: Lawrence Erlbaum Associates.

Diabetes Infographic

Our marketing team at inVentiv Medical Management created this infographic that I thought I would share.

Diabetes infographic inVentiv

My Top 11 Healthcare Predictions For 2013

It’s always fun to predict what will happen in the next year. No one is ever right, but you can hope to be directionally correct. With that in mind, here’s a few of my thoughts for what will happen in 2013…

  1. Reform (PPACA aka ObamaCare) will happen. While the Republicans will fight it, with Obama’s re-election and the Supreme Court decision. Reform will continue to happen. The states will mess up the Exchanges which will create many issues, but private exchanges will come to the “rescue”.
  2. Big Data” will be a focus at every healthcare company. What data to store? How to mine the data? What data to integrate? How to bring in unstructured data such as physician’s notes? What to do with consumer reported and consumer tracked data from all the different devices?
  3. Physicians will emerge back in the power seat. With Accountable Care Organizations and Patient Centered Medical Homes, consumers are finally becoming more aware of all the shortcomings in our sick care system. They trust their physicians although somewhat blindly given ongoing challenges with evidence-based care and quality which are often the result of our Fee For Service system (too little time) combined with an abundance of new research happening concurrently.
  4. mHealth will be the buzz word and exciting space as entrepreneurs from outside healthcare and people with personal healthcare experiences will attempt to capitalize on the technology gap and chaos within the health system. This will create lots of innovation, but adoption will lag as consumers struggle with 15,000+ apps and the sickest patients (often older patients) are the slowest to adopt.
  5. Device proliferation will go hand in hand with mHealth and with the Quantified Self movement. This will create general health devices, fitness devices, diabetes solutions, hypertension solutions, and many other devices for wellness and home monitoring for elderly patients. Like mHealth, this will foster lots of innovation but be overwhelming for consumers and lead to opportunities for device agnostic solutions for capturing data and integrating that data for payors and providers to use.
  6. The focus on incentives will shift in two ways. Technology vendors will begin to look more and more at the gamification of healthcare and how to use gaming theory and technology to drive initial and sustained engagement. At the same time, the recent ruling will allow employers to shift from rewards to “penalties” in the form of premium differentials where patients who don’t do certain things such as take biometric screenings or engage with a case manager will pay more. In 2014 and 2015, this shift will be from penalties with activity to penalties tied to outcomes.
  7. Consumer based testing will drive greater regulation. With the focus on home based testing (e.g., HIV or High Cholesterol) and the increased interest in genetic testing especially when tied to a medication, the FDA and other government agencies will have to address this market with new regulations to close gaps such as life insurance companies being able to force disclosure of genetic testing in order to get coverage (even though the testing isn’t necessarily deterministic).
  8. Clinics will prepare for 2014. With the increase number of consumers being covered in 2014, there will be an access challenge for patients to see a provider. This will drive buildout and utilization of health clinics such as TakeCare or MinuteClinic. Clinics will have to look at how to adapt their workflow to create a patient relationship which will create potential integration points with TeleHealth and bring back up the issue of whether they should or could replace the traditional Primary Care Provider (PCP) relationship or not.
  9. Telemedicine will hit a tipping point and begin to Cross the Chasm. They now have better technology and adoption within major employers. This will start to create more and more business cases and social awareness of the solution. With utilization, we will see great adoption and the increasing use of smart phones for healthcare will drive telemedicine into an accelerated growth stage.
  10. Transparency solutions will continue to be a hot area with CastLight and Change Healthcare leading the way. Their independence and consumer engagement approaches based on critical moments (i.e., pointing out how to save money on Rxs just before a refill) and using multiple channels will show high ROI which will also increase broader healthcare awareness making them part of the population health solution.
  11. Generics will no longer be a talked about issue. With generic fill rates running so high across different groups and being front page news, PBMs, pharmacies, and pharma will truly begin to move forward to embrace the specialty market with a clear vengeance (at least in the US).

There are still a few longer term trends that I’m watching, but I don’t think that 2013 is the primary year for them.

  1. The evolving role of pharmacists within the Medical Home and with vaccines.
  2. A significant shift from mail order to 90-day at retail fulfilled by massive central fill facilities.
  3. Pharma co-opetition where they begin to collaborate at the disease state level realizing the a rising tide is good for all boats.
  4. Integration of data from all types of solutions and actions into workflow triggers that automatically create new events within the care management infrastructure using Service Oriented Architecture and Business Process Management.

FitBit One Goes To The Gym – Last Challenge

I’ve shared a few tests with you about my FitBit One which included comparisons against my Garmin and versus a pedometer. Today, I got to take it to the gym with me and tested it for distance and calorie count relative to several pieces of equipment from LifeFitness – treadmill, stationary bike, and elliptical. For the treadmill, I also looked it two ways: (1) running at an 8 minute mile pace and (2) walking at a 15 minute mile pace at a 15% slope.

As you can see before, the FitBit was much better aligned on distance with the treadmill, but it was not as aligned on calorie count. I’m have no hypothesis here. I will say that I was surprised that the uphill walking didn’t somehow register as steps. I say that because I went on an outside run the other day up and down hills, and the FitBit did a great job of tracking my uphill runs and translating that into floors climbed.

As a side note, I think this does a nice job (if you believe the equipment calorie count) on showing how a slow walk up a steep slope can burn lots of calories compared to a fast run.

Stay Moving Avoid Sitting Disease

A clinician was talking to me he other day about “sitting disease“. They said that our increasingly sedentary lifestyles are causing all kinds of problems – not least of them being obesity.

With that in mind, I thought I’d share this article and Infographic…

Office workers can exercise at their desk to get into better shape

Stuck working in an office with no time to hit the gym on a regular basis? There are ways to burn off a few calories during office hours, says Selen Razon, a physical education professor at Ball State.

“Studies have shown that long periods of inactivity — including sitting at your desk — increase the risk of cardiovascular disease and cancer,” she says. “I suggest that people do a few simple exercises to get their bodies moving and then stretching and toning at your desk. Moving a little goes a long way.”

Razon suggests:
• Start exercising before arriving at your desk by first parking your car as far away from the building as possible and then walking.
• Take the stairs whenever possible.
• Do exercises at your desk, including flexing arms, legs and abs on 30-second intervals.
• Get rid of a chair and sit on a medicine/fitness ball while working. Sitting on a ball will tone and strengthen your abs.
• Stand up and/or take short walks every 20 minutes at desk. Studies show even simple frequent standing breaks significantly decrease your chances of getting diabetes.
• Exchange the typical desk for one that allows you to stand, which burns more calories.
• Bring gadgets to the office. Hand grippers and stretch cords are relatively cheap and can provide great outlets for keeping active while you look at your screen.

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