On the Express Scripts Consumerology Blog, I noticed a new entry this morning from Bob Nease (Chief Scientist) about changing behavior.  It points to two things - motivation and self-efficacy.  (What’s in it for me and do I believe I can be successful.)

There is an interesting study from the University of Michigan that he discusses, and he also provides some detail on one of their web pilots.  What the web study showed is that a simpler message led to more “click throughs”.  This is very similar to what we see in the voice channel of communications.

If I call you and tell you there is an opportunity to save money with your health benefit, you are likely to go to the next step or transfer to hear more.  On the other hand, if I tell you a lot in the message, I might get a much lower click-through (or continuation or transfer) rate.

Since ultimately, I care about conversion in the claims data (i.e., did the patient really change behavior) these metrics are nice proxies but don’t mean much.  I care about did the patient and their physician actually act on the recommendation or the opportunity to save money.  I posted that as a comment on the blog so hopefully Bob can add that detail.

We have clearly seen this in some of our programs where we would rather qualify them on the phone and then transfer them leading to a higher close rate than simply drive up transfers.

Anyone who works with drug manufacturers knows that once a drug gets closer to its patent expiring, they are going to look for creative ways of extending the patent life – new approvals (e.g., pediatric dosing), an extended release (XR) version, or a me-too drug for example. And, as a product manager, who can blame them.

As the payor or the public, this is a greedy action that they take. In another WSJ article from the other day (”How a Drug Maker Tries to Outwit Generics”), it deals out the strategy that Cephalon (the manufacturer) is taking relative to its narcolepsy drug Provigil. I give them credit for a well thought through plan (although I am not sure I would have made it public).

Over the past 4 years, they have raised the price by 74% (now $8.71 per tablet). At the same time, they are preparing to bring a longer acting version of the drug called Nuvigil to market. So what does this price increase accomplish:

• They are maximizing revenue and profit in the waning years of the patent (which expires in 2012).
• They are going to launch Nuvigil in 2009 at a much lower price which will encourage most payors to exclude coverage of the higher priced (and older) Provigil and shift utilization to Nuvigil.
• When the patent expires in 2012, anyone still on Provigil will be quickly moved to the generic version, but most of the market share will have shifted to Nuvigil so they can then begin to raise the price on that drug with less dramatic market share erosion.

This wouldn’t work in a lot of drug classes because there already is a generic available and dramatic price increases would drive utilization to the generic alternatives. But, if you are one of the only brand drugs to treat a condition, you have a lot of pricing upside.

From this month’s publication of Adler’s Drug Store Counter by Meredith Adler from Barclays Capital, I found two telling things.

She highlights the drug trend and generic fill rate numbers from the big PBMs (as I have done before). What it made me think about is that with Medco and CVS Caremark having lower generic fill rates, they actually have a better opportunity for lower trend in subsequent years (with the right programs to close the gap).

In another chart, she shows how different areas of the healthcare market are increasing in cost. Pharmacy is increasing at the fastest rate (as it has several of the past few years). Fortunately, it typically only represents about 15% of the healthcare costs, AND it is the easiest to influence. Patients have a lot more opportunity to research and talk with their physician about prescriptions than discussing whether a particular blood test is appropriate.

I was just talking with someone yesterday about what happens as the retail clinic concept (e.g., Minute Clinic) and virtual consultations (e.g., American Well) take off. Given that primary care physicians (aka General Practitioners) have seen increased reimbursement pressure, will these trends finally make that the least desirable job coming out of medical school? [Which would be a shame in my opinion.]

In a survey done by The Physician’s Foundation in May, they had 12,000 responses from US physicians that confirmed this. [They define primary care physicians (PCPs) as family practitioners, general internists, pediatricians, and OB/GYNs.]

• 78% said there is a shortage of PCPs.
• 49% said that over the next 3 years they plan to see less patients or stop practicing.
• 60% said they would not recommend medicine as a career.

Here my democrat tendencies come out.

The Council for Excellence in Government did a Gallup Poll of 1,000 adults in June to see who would be willing to pay more in taxes to cover the uninsured. I was surprised by the results:

• 50% age 18-36 would be willing to pay more
• 45% age 40-64 would be willing to pay more
• 31% age 65 and older would be willing to pay more

Maybe I know something different, but I believe there is research that shows that if the uninsured were covered that would reduce the healthcare costs paid by the insurers today.

For example…If someone is uninsured and goes to the hospital today, they are treated and the bill is never paid. Those costs are “peanut buttered” across the hospitals billable events to keep them whole. So, in most cases, we (consumers) are either paying directly or indirectly (through the insurance companies) a higher cost per incident to cover the uninsured. And, since they are uninsured, they are less likely to take preventative action (which is less expensive) and more likely to end up in higher cost events (e.g., the emergency room).

So, would I pay more in taxes to improve the general health of the country and cover the uninsured knowing that I would basically get that money back (perhaps with some time lag) through lower healthcare premiums? YES. Happily.

This is a topic that has been around for a while. Before the Medicare Prescription Drug Plan (PDP) and a significant number of drugs losing their patents, you used to hear about people driving to Canada to get their prescriptions at reduced prices.

I believe this is one of the things that Obama talked about in his plans to lower healthcare costs. I haven’t studied up on it in a few years, but I got to work with our General Counsel at Express Scripts on our position for this several years ago. At the time, a lot of our clients were asking what they should do and what we would do.

Here were my conclusions (updated with the general market conditions above):

• There is certainly a window of opportunity to import brand drugs from other countries (e.g., Canada) into the US and reduce costs.
• That window will be short-lived as the US is the biggest prescription drug market based on high prices and the manufacturers will simply increase global prices putting pressure on those governments to not allow re-importation.
• There is some increased risk of “counterfeiting” but that could be managed with some of the drug pedigree things being discussed and implemented.
• Brand drugs are cheaper in other countries because they negotiate as a country and have larger buying power and give higher probability of market share to the approved manufacturer. [Which isn't likely to happen in the US anytime soon.]
• (One of my biggest ah-hah moments…) This is only relevant for brand drugs which now represent less than 40% of all drugs dispensed in the US. Generic drug prices are cheaper in the US than anywhere else for the exact same reason – competition.

As a corporation, we couldn’t encourage this activity back then, but we could process paper claims as out of network for our clients if they included those locations as part of their benefit.

So, I think it’s an outdated suggestion that will ultimately hurt the other countries for our short-lived benefit. Hopefully, Obama brings some people onto his team that look at these facts not at playing to the general public’s perception. [And, yes…I would happily volunteer to help us fix the healthcare system no matter how painful of an experience.]

If you ever read the label on your prescription drugs (or more likely the PI (Product Insert)), you will learn about all kinds of potential side effects ranging from mild things like headaches to much more serious but rarer conditions. The WSJ had an article earlier this week called “Power of Suggestion: When Drug Labels Make You Sick” which talks about the “nocebo effect” where knowing about potential risks makes you more likely to experience them.

“Women in the multi-decade Framingham Heart study who thought they were at risk for heart attacks were 3.7 times as likely to die of coronary conditions as women who didn’t have such fears – regardless of whether they smoked or had other risk factors.”

“In a 1960s test, when hospital patients were given sugar water and told it would make them vomit, 80% of them did.”

Richard Kradin, author of “The Placebo Response and the Power of Unconscious Healing” says that about 25% of people who get placebos (i.e., a sugar pill) complain about side effects in clinical trials.

The article tees up the question of what to do with this information. Should the information be for the physician only? [I don't think so.] Should the physician walk the patient through the information and the key side effects? [I think they should for any serious effects or have some type of follow-up mechanism to see how the patient feels on any chronic medication.]

I guess part of the challenge is talking with the patient about normal symptoms they are having before taking the drug. Are you drowsy? Do you have frequent headaches? Then at least they might be able to understand if they are side effects or the “nocebo effect”.

Yesterday, I had a brief (5 minute) opportunity to present on a webinar by the Center for Information Therapy (Ix).  Similar to the Health 2.0 conferences, they talked about some trends and then asked 5 companies to talk about how they were delivering information to patients/members.  The companies that presented were:

• Silverlink Communications (me)
• Enhanced Medical Decisions
• Kranes
• Healthwise
• bWell-Informed

As one of the moderators observed, it is interesting to see how information is being delivered using different modes.  Certainly web is great if you get people there, but as I think I have spoken about before, one of the challenges is that some of the patients at the highest risk aren’t engaged so you have to have an outbound strategy to engage them.  You can’t depend upon them engaging without being prompted.

I think we are all still waiting on the final business models to find the profitable solutions. I think many of the tools are great. Some are even amazing in what they can do. But, ultimately most of these are businesses, so how are they making money?

In a recent report by Manhattan Research, they define Healthcare 2.0 consumers as “adults who have read health-related blogs, access message boards, or participated in health-related chat rooms.” It also includes people who have contributed content through comments to a blog entry, writing, or creating and posting videos or pictures.

It seems a little easy to become a Healthcare 2.0 consumer using this definition and without much stickiness.

“Healthcare in the US is an expensive commodity and, as a result providers are always seeking to streamline operations. Allowing members to manage their own healthcare portfolio services online helps them to achieve this, as well as raising levels of customer satisfaction. It’s a win-win situation,” said David Lavenda, vice president of marketing and product strategy at WorkLight.

See study here.

See WorkLight press release on this here.

If there are 60M “users”, there is a great install base to build upon.  I think we are all hoping to see how some of these companies make their models work and blend with the establishment to change the industry.

Based on different statistics I saw today, it is clear that a healthcare strategy for reaching the Hispanic community is needed. Just looking at what I see being done:

• Some companies are building out a “language flag” in their databases to allow members to choose the language for communication.
  • This works a lot better than “guessing” based on their last name.
• Some companies are offering Spanish and English versions of print documents.
  • It may exist, but I haven’t seen any companies allowing a member to “toggle” their website between English and Spanish.
• Some companies doing calls offer patients the ability to choose Spanish during the automated call (i.e., Spanish on the fly).
  • These could be offered to every member or only to members in zipcodes with a high concentration of Spanish speakers.
• An older solution which exists many places is hiring call center staff that are bi-lingual.
  • And many companies use the AT&T language line to support less common languages.

But, the key is that you should have some strategy and be working towards improving it and understanding the differences in that population segment.