Health IT

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care

Scaling the Limits of Scale: The PBM Path to Value-Based Health Care
Scale has its limits, as the nation’s two largest pharmacy benefit managers (PBM) are discovering.  Express Scripts and CVS Caremark each process more than a billion prescriptions a year.   That is not enough for big customers Anthem and Aetna.  Both are likely to alter dramatically or not renew long-term contracts set to end in 2019 with the PBM behemoths.

PBM Optionality for Anthem, Aetna

Anthem and Aetna say they now have “optionality” because Cigna and Humana, which they are respectively acquiring, both have PBMs.  That optionality goes well beyond the scale Aetna would enjoy as the fourth largest PBM.  It can put the pharmacy benefit, integrated within each organization, on the path to value-based health care.

Both the Humana and Cigna PBMs align well with the quality and outcomes focus of value-based health care.  Humana’s PBM primarily supports the company’s Medicare Advantage (MA) and Part D programs, with MA accountable care arrangements delivering better outcomes than traditional Medicare.

Meanwhile, Cigna has pioneered outcomes-based reimbursement arrangements with pharmaceutical manufacturers.  Previously overseeing Cigna’s PBM was none other than Aetna CEO Mark Bertolini; Cigna CEO David Cordani will serve as chief operating officer of the new Anthem.

In their sights is UnitedHealth Group (UHG), which brought its PBM business inside from Medco at the start of 2013, trigging Express Scripts’ anticipatory acquisition of Medco in 2012.    UHG says its OptumRx PBM focuses “on connecting total condition spend and pharmacy’s impact across benefits,” a process it calls “synchronization.”

More explicitly than Anthem, Aetna has said it will integrate Humana’s PBM, along with its “growing health care services business,” even characterizing it as an “Optum-like business.”

Value beyond Scale

UHG’s Catamaran acquisition earlier this year, while adding scale, also significantly included Catamaran’s RxClaim processing platform.  OptumRx plans to integrate the adjudication platform with its medical and pharmacy claims synchronization.  UHG promises to create value “beyond the scale … resulting from integration,” by linking “demographic, lab, pharmaceutical, behavioral and medical treatment data” to encourage healthy decisions and improve compliance with pharmaceutical use and care protocols.”

In fact, the very tools used to leverage scale to get lower prices, such as formulary exclusions, can potentially work against reducing total costs.  In securing a substantial discount from AbbVie for Viekira Pak, Express Scripts excluded Gilead’s Harvoni from its 2015 formulary.  Viekira Pak is a four pill a day regimen to Harvoni’s adherence-friendly one pill for curing hepatitis C.

Not surprisingly, given their focus on overall costs, Aetna, Anthem, UHG and Cigna all included Harvoni on their formularies and do not publish exclusion lists like Express Scripts and CVS Caremark.  Instead, they typically establish clinically based prior authorization criteria.

For the latest high-cost drugs to hit the market, Express Scripts is following the health plans on their value path.  Instead of excluding one of two new anti-cholesterol drugs, known as PCSK9 inhibitors and list priced at $14,000 per year, it announced coverage for both this week.

As the health plans did with Harvoni, Express Scripts will implement rigorous prior authorization procedures.  The company says it negotiated good pricing with Amgen for Repatha and with Sanofi and Regeneron Pharmaceuticals for Praluent, enabling it to cover both drugs.  Perhaps it also heard from customers unhappy with price-driven drug exclusions.

Wanting More, Customers Become Competitors

Clearly, some very big customers – Aetna, Anthem and UHG – want something more than scale from traditional PBMs like Express Scripts and CVS Caremark.  Beyond scale, they want a pharmacy benefit that contributes to reducing total costs through better outcomes, consistent with achieving overall value-based payment goals.

Building PBM paths to value-based health care for themselves, Anthem, Aetna and UHG will also sell against volume-based models like those of Express Scripts and CVS Caremark, and against health plans that fail to integrate pharmacy and medical claims for actionable intelligence.

Employers and the Limits of Scale

Their strategy blueprint could easily have come from the Harvard Business Review article “The Limits of Scale.”  Hanna Halaburda and Felix Oberholzer-Gee argue that, when rapidly scaling companies neglect to take into account differences among their customers, performance declines.  On that premise, they suggest how challengers and incumbents can take advantage of customer differences.

Among PBM customers with differences are employers, which provide health coverage for 147 million Americans.   The National Business Coalition on Health is uneasy with the growing use of exclusionary formularies.  It advises members to “base selection criteria for formularies on clinical outcomes to ensure that pharmaceutical costs do not decrease at the expense of rising medical costs.”

Employers are becoming more actively engaged in managing the pharmacy benefit, even developing their own formularies and negotiating directly with pharmacy retailers.  Caterpillar’s Daren Hinderman told an NBCH panel last year, “I don’t want to have a conversation [with PBMs] on rebates; I want to have a conversation on how I can keep my employees more compliant with medications they need to stay healthy. We decide what’s best for our employees. It’s a transparent process.”

NBCH also urges members to “verify that pharmacy and medical benefits are aligned, and link data between the two in order to evaluate cost and outcomes across both types of benefits and the entire health-care spectrum, not just through the lens of pharmacy.”  As Dr. Mark Fendrick of the University of Michigan Center for Value-Based Insurance Design told the NBCH panel, “I’d prefer to spend more on statins than on stents.”

Obstacles on PBM Value Path

Mapping the PBM path to value-based health care is one thing, building it is another.  Aetna and Anthem still must face a gauntlet of government and legal reviews before they can complete their acquisitions and commence integrating the Humana and Cigna PBMs.

OptumRx must complete its integration of Catamaran, which in turn is still integrating the data platforms of its acquisitions.  Furthermore, OptumRx and Catamaran both use different versions of the RxClaim platform and, for Catamaran, medical claims synchronization remains down the road (or path).

Meanwhile, the Catamaran acquisition has roiled a PBM industry where many participants use Catamaran’s RxClaim platform – including Cigna!  They were content to compete with Catamaran, despite using its technology.  However, will they be similarly comfortable with OptumRx and UHG in the technology driver’s seat?

Much like UHG’s acquisition of Catamaran and its technology, Rite-Aid did the same when it acquired EnvisionRx.  The PBM had previously acquired Laker Software, also a claims platform supplier for many PBMs.  Again, the comfort question arises, in this case over Envision and Rite Aid as the drug retailer pursues its path to value-based health care via innovative alliances with health care providers.

Making the Laker and RxClaim platforms particularly valuable has been the PBM industry’s reliance on a hodge podge of decades-old, antiquated platform technologies.  With each acquisition, scaling PBMs have patched together instead of invested in their platforms to maximize short-term synergies, at the cost of limited flexibility and lower efficiency.

PBMs Miss Technology Revolutions

Meanwhile, multiple revolutions have coursed through the systems development world since the PBM industry acquired its mainframes and data centers in the late 1980’ – early 1990’s.   When relational databases followed soon thereafter, PBMs adopted them for after-the-fact data analysis, but not broadly for real time use with claims processing platforms, which now are antiquated and fragmented.

More recently, graphical user interfaces have greatly streamlined the programming of business intelligence applications.  It is now easier for more people, more efficiently to translate their expertise into innovative systems.  No longer must visionaries exclusively funnel their solutions through highly specialized programmers and coders.  Now, the visionaries’ can become coders, their hands on the programming controls, unleashing new applications across the entire economy, including the PBM industry.

PBM Platform for Value-Based Health Care

One such visionary has developed a PBM solution for value-based health care.  His name is Ravi Ika.  “The solution is holistic, unlike that of any other existing PBM.  It reduces overall pharmacy cost, converts specialty from ‘buy & bill’ to ‘authorize and manage,’ and lowers avoidable drug-impacted medical costs,” explains Ika.

Before turning his attention to the PBM industry, he created a comprehensive, integrated payer platform now provided by ikaSystems, which he founded to transform the payer operating model.  Spanning all payer departments and business lines, it decreased administrative costs for health insurers by as much as 50% and reduced avoidable medical costs.

In 2013, Ika launched RxAdvance, a full service PBM, which similarly operates on an integrated, end-to-end platform – one designed specifically for value-based health care.   Combining pharmacy, medical, and lab data, the platform – called PBM Collaborative Cloud– enables real-time engagement.  This engagement occurs with physicians at the point of care, pharmacists at the point of sale, and patients via mobile cloud.  It also engages payers clinical and pharmacy staff through their workflows.

Better decisions by these stakeholders – driven by platform-generated, actionable intelligence – can reduce avoidable drug-impacted medical costs, optimize utilization, facilitate better specialty drug management, and decrease overall pharmacy costs.

PBM Processes Reimagined

“We started with a clean slate,” observes Ika, who says he and his team reimagined PBM processes to streamline workflow before building the platform.  Redefining the human role, they automated as much as possible while, on the other hand, increasing opportunities for engagement, what-if modeling, and informed decision-making.  The platform also enables market and regulatory changes configurable by the business user, as well as system-driven compliance management.

Ika built the platform from the ground up using a unified data model.  In information technology parlance, that means the platform’s standards are universal enough to encompass a large scope of data and types of data with high scalability.

In PBM language, the platform includes everything from pharmacy claim adjudication, formulary management, benefit design, enterprise reporting and analytics, to pharmacy network and rebate contracting, medication adherence and therapy management, specialty management, transparency, compliance, and adverse drug event management.

From Existing to Ideal Formularies

For example, the platform includes algorithm-driven artificial intelligence to manipulate, with plan sponsor engagement, the complex and interdependent variables associated with formulary management.  Incorporating habitual member and prescriber utilization patterns, in addition to other data, it derives an ideal formulary with optimal financial and clinical outcomes.  The system then maps a transition plan from an existing formulary.  The platform also accommodates an unlimited number of formularies and supports real time dynamic modeling and changes coupled with full transparency.

Better Medication Therapy, Adherence Outcomes

For medication therapy management (MTM), the platform taps patient medical claims and disease conditions, against which the system overlays a prescription listing for easy use by prescribers.  In addition, each new prescription triggers a dynamic analysis to determine patient eligibility for a comprehensive medication review (CMR), which the system prepopulates for efficient prescriber use.

After the CMR, RxAdvance advisors rely on system alerts to intervene with patients to ensure medication adherence.  For high-risk patients, RxAdvance will install an electronic, patent-pending pill station at their residences and resupply it with disposable pre-filled pill trays.

Integrated with and wirelessly connected to the company’s platform, the device assists with monitoring adherence and vital signs.   The company says the device has improved adherence to more than 93%, including patients with multiple chronic conditions who are taking an average of 15 medications a day.

The Centers for Medicaid and Medicare Services (CMS) recently underscored the PBM need for physician-led, point-of-care MTM capability when it announced a new Medicare Part D MTM model.  Currently, highly fragmented PBM MTM relies on pharmacists “chasing” patients without closing the loop with prescribers, thus failing to secure meaningful health outcomes, according to Ika.

Ika points to the RxAdvance specialty management program as another example of his platform’s capabilities.  As it does for MTM, the platform integrates prescriptions, medical claims and disease conditions to create an action plan for all stakeholders.  Case managers use a dashboard to prioritize their outreach to patients, prescribers and pharmacists.  Because the platform integrates medical, pharmacy and lab information, it helps facilitate appropriate utilization.

Risk Sharing

One of the hallmarks of an organization configured for value-based health care is its ability to share risk.  The RxAdvance unified data model platform enables it to share risk for both pharmacy and avoidable drug-impacted medical costs.  For pharmacy, it is prepared to assume both up and down side risk based on its cost management performance against a risk cap set below a national benchmark projected increase.

The company can also compute a baseline trend for avoidable drug-impacted medical costs using prior years’ medical claims data.  RxAdvance and its client then set a target and, if the PBM lowers actual avoidable drug-impacted medical costs, it will share in the savings.  According to Ika, this sort of risk sharing is unique in the PBM market.

Ika reports that RxAdvance is currently implementing full PBM services for three clients, replacing national PBMs.  “The Collaborative PBM Cloud platform is making for a very smooth launch,” he notes.

RxAdvance has gotten a head start along the PBM path to value-based health care, scaling the limits of scale.

Telemedicine: Bad for Antibiotic Stewardship?

telemedicine2Sandy Walsh is a breast cancer activist and, assuming she is like one in seven adult Americans each year, a sinusitis “survivor” too.

She served as the first-ever consumer advocate on the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) panel that recently updated the adult sinusitis clinical practice guideline.

Patient Education and Watchful Waiting

Novel, too, was the panel’s emphasis on patient education and its expansion of watchful waiting (without antibiotic therapy) as an initial management strategy.  The latter now applies to all patients with uncomplicated acute bacterial rhinosinusitis (ABRS) regardless of severity.  The prior guideline limited the antibiotic-free approach only to patients with “mild” illness.

Patients may not even need to see a doctor.  “For the first time we’ve really made it crystal clear how to self-diagnose your own bacterial sinus infections without going to the doctor, with a high degree of accuracy,” Dr. Richard Rosenfeld told National Public Radio.  He led the AAO-HNS guideline panel.

Not seeing a doctor for a sinus infection might actually have its advantages.  The doctor a patient sees, not the patient’s condition, largely determines treatment, according to an Annals of Internal Medicine study published this month.  Physician preference or “style” largely determined antibiotic use, not patient related factors like fever, age, setting, or comorbid conditions.

Telemedicine and Antibiotics

What happens when telemedicine makes physicians more accessible, convenient and less expensive to “see” for ailments like sinusitis?   Antibiotic prescribing rates for acute respiratory infections were similar regardless of whether the encounter was face-to-face or via telemedicine, according to a JAMA Internal Medicine study published this month.

That the prescribing rates were similar represents an improvement – of sorts.  A study published two years ago, also by JAMA Internal Medicine, found that telemedicine physicians were more likely to prescribe an antibiotic.

Other research shows that acute respiratory tract infections account for 75% of all outpatient antibiotic prescribing.  Half those prescriptions are unnecessary because a large portion of those infections are likely viral, not bacterial.

Even more troubling, telemedicine physicians in the 2015 study were more likely to use broad-spectrum antibiotics, raising concerns because “overuse increases costs and contributes to antibiotic resistance.”  The study suggests telemedicine physicians may have been prescribing more conservatively due to limited diagnostic information.

To decrease antibiotic prescribing, the study’s authors want telemedicine operators to change physician behavior with timely feedback.  They also recommend “direct education to patients to influence demand.”

Do It Yourself for Patients

Sandy Walsh, the consumer advocate, is ready with patient education — specifically “do-it-yourself” diagnostic tools for sinusitis sufferers.  She and her co-authors have written a plain language, adult sinusitis summary, including patient information sheets, based on the new AAO-HNS clinical practice guideline.   The summary, already available online, will appear in the August issue of Otolaryngoly – Head Neck Surgery.

According to Dr. Rosenfeld, the key to this “do it yourself” approach is learning how to tell whether the infection is viral or bacterial.  As he told NPR, if you have been sick less than 10 days and you are not getting worse, it is most likely viral and an antibiotic would have no effect.

If you do not improve or get worse in 10 days, it is probably bacterial.  Still, Dr. Rosenfeld advises that, even then, an antibiotic would play little role in what is largely a battle between your body and the infection.  “There’s a good chance you’re going to get better on your own,” says Dr. Rosenfeld.

Integrate Telemedicine and Education

Telemedicine providers would do well to follow Dr. Rosenfeld’s example.  Fully integrate patient education as first line therapy for sinusitis, help patients learn how to diagnose and care for themselves, and reserve antibiotics for true need.   Make telemedicine good for antibiotic stewardship.

And, get the help of consumer advocates like Sandy Walsh!

As Insurers Merge, What’s Next for Healthcare? Watch Gretzky!


Remember that quote from hockey great Wayne Gretzky, “I skate to where the puck is going to be, not where it has been.”  To see where healthcare is going, watch Gretzky.  Watch the successful organizations that always seem to be in the right place at the right time. Watch Ascension Health.

The nation’s largest not-for-profit health system, Ascension popped up in a recent New York Times story on health insurer consolidation.  It had become an insurer, too, when it acquired Michigan-based U.S. Health and Life Insurance in February.

Ascension Health as Insurer

Ascension plans to continue the small insurer’s focus on serving small, self-insured employers, according to a filing with Michigan regulators.  Although 20 states have licensed the insurer, Ascension plans to concentrate on Michigan, where the health system’s footprint is biggest, as well as in Illinois, Indiana and Wisconsin.

Longer range, the system has the much more ambitious vision of coupling its new insurance asset with a newly formed Ascension Care Management subsidiary to provide employers with population health services. Ascension then can take provider direct contracting with employers to a new level.

Generally, organizations like the Mayo Clinic and the Cleveland Clinic have contracted with national employers for single-price orthopedic and cardiac surgeries.  Ascension, on the other hand, is ready to provide capitated care arrangements directly to employers for all their employees, not just surgical patients. Modern Healthcare reports that risk based contracts, including capitated arrangements with payers, already cover about 1.9 million Ascension patients.

Being a Healthcare Gretzky

To be a Gretzky, a healthcare provider must be able to assume risk. However, not every provider capable of assuming risk will be as good as Gretzky.  There is more to being a Gretzky, including focused scale, powerful information technology and clinical leadership.

Focused Scale

Surely, Ascension’s size is its most striking characteristic.  However, size alone does not make Ascension a Gretzky.  Instead, Ascension brings a distinguishing focus to its size, one that recognizes healthcare in the U.S. as a confederation of 50 state markets plus the District of Columbia.

For example, in Michigan, Ascension has allied with CHE Trinity Health Michigan to form Together Health Network for joint managed care contracting and, potentially, offering narrow network coverage products on the state’s public insurance exchange.

The network, which does not involve an asset merger, covers nearly all of the state, with 75% of the population no more than 20 minutes from a participating hospital or physician practice. Reinforcing that coverage, Ascension has also agreed to acquire Crittenton Hospital Medical Center in Southeast Michigan.

On the other hand, Ascension has scaled back in Arizona, where it has entered into a joint venture with Tenet and Dignity Health, resulting in Tenet operating Ascension’s Carondelet Health Network.  Ascension had not been a major presence in the market.

Ascension is also configuring horizontally for the nation’s diverse healthcare payment models.  In a recent article, CEO Tony Tersigni observed that Medicare resembles Canada, our under-65 model is closer to France, Germany or Japan, veterans, military and Native American healthcare is a lot like the British National Health Service and, for the uninsured, rural India or Cambodia provide the best comparison.

Consistent with this mental map, Ascension last year announced establishment of Ascension Health Senior Care, now the nation’s second largest not-for-profit long-term care provider in the nation.  Consisting of 34 facilities serving more than 5,500 patients, the unit shares best practices and establishes consistent standards.

Once again, like Gretzky, Ascension has positioned itself well. At this week’s White House Conference on Aging, the Obama Administration announced a proposed rule updating, for the first time in nearly 25 years, the quality and safety requirements for nursing homes and skilled nursing facilities.

Powerful Information Technology

Ascension is not waiting for national data to achieve “drastically reduced hospital readmissions.”  Instead, in almost real time, it spots patterns in 30-day readmissions using admission, discharge and transfer (ADT) data across the care continuum. The immediacy enables Ascension to evaluate and adjust interventions on a local level.

“We are highly engaged with supporting the technology that would enable rapid identification and management of those conditions, so we are working very hand-in-glove with our clinical leaders,” Ascension Information Services (AIS) vice president Mary Paul recently explained to HealthITAnalytics.

The system has identified three key risk factors for readmissions – medication management, access to primary care and socio-economic factors.  ““We can predict fairly well which patient is likely to get in trouble from their clinical situation, but their social determinants are just as important,” Chief Quality and Nursing Officer Ann Hendrich told the publication.

Meanwhile, 2,500 AIS employees are also working to standardize and consolidate across 1,900 sites of care in 23 states, according to CIO Mark Barner.  They are shrinking more than 4,000 software applications to a much smaller number and consolidating 37 disparate interface engines into one.  Ascension is using the Athenahealth ambulatory electronic health record application and cloud based applications for ambulatory physician practice management.

Clinical Leadership

Ascension Health has been at the forefront of the patient safety movement for more than 20 years.  In connection with a 2002 commitment to 100% access to safe, effective care, Ascension adopted a goal of clinically excellent care with no preventable injuries or deaths by July 2008.  The Joint Commission Journal on Quality and Patient Safety published a series of articles charting the system’s journey toward clinical transformation.

Ascension continues its leadership through its Hospital Engagement Network (HEN).  Selected by and with funding from CMS, Ascension’s HEN is developing advances in ten areas, including sepsis, hospital acquired infections, patient safety culture, home healthcare models, hospital acquired kidney failure, and safe patient handling.  Ascension will share the advances with hospitals throughout the nation.

The Ascension HEN has already identified, documented, refined and shared best practices in ten additional areas, including urinary tract infections, adverse drug events, pressure ulcers, fall injuries and central line associated blood stream infections. For example, Ascension developed a protocol for reducing catheter induced urinary tract infections, which account for 30% of hospital-acquired infections, by limiting catheter use.

In another example, Ascension has dramatically reduced induced or C-section deliveries before 36 weeks, which often result in higher complications for babies and mothers.  In February 2012, Ascension’s early-elective delivery rate was about 3.5%, already substantially lower than the national average of 10% to 15%.  Now, it is even lower, at 0.6% after shared data with physicians and stepped up patient education efforts.  (For additional advances in obstetrical care, see three Ascension-authored articles in the January 2014 edition of Health Affairs.)

Last month, Ascension told the White House Forum on Antibiotic Stewardship that it wants to “set the pace for the nation in antimicrobial stewardship.” It has pledged to establish facility-based antimicrobial stewardship programs in all Ascension hospitals that will include both a pharmacist and a physician with antimicrobial expertise.  The system also said it would reduce the use of three broad-spectrum or niche antimicrobials by at least 10% reduction during the first 12-18 months.

What’s Next for Ascension?

One of the best ways to project where a Gretzky organization will be next is to watch the Gretzky’s within it.  In Ascension’s case, that would include Chief Quality and Nursing Officer Ann Hendrich, who joined Ascension in 2003, after leading the development of an innovative coronary care unit at Methodist Hospital in Indianapolis.

That she would be a Gretzky to watch at Ascension was clear from an observation she made in her application to be a Robert Wood Johnson Executive Nurse Fellow in 1998.  Hendrich wrote, “The opportunity to take shell space and not replicate the present and familiar but integrate environmental design, technology and a new care delivery model is imperative.”

In her dozen years at Ascension, Hendrich has played a key role in cementing Ascension’s clinical leadership.  Given the system’s accomplishments, especially in clinical quality and patient safety, Ascension merits the recognition usually afforded the great healthcare brand names like Mayo, Cleveland Clinic, MD Anderson and Kaiser.

Establishing a strong national brand is “what’s next” for Ascension.  The need and the opportunity are clear and, to track how Ascension intends to build its brand, look to the recent arrival of another Ascension Gretzky, Nick Ragone.  A lawyer and author, Ragone most recently led the Washington office of Ketchum, a global public relations agency.

As Ascension’s chief communications officer, he will “enhance the strategic identity of Ascension,” according to the 2014 announcement of his arrival. His initial focus has been internal, engaging 153,000 employees, as it should be for any brand-building exercise.  Ragone is supporting an enterprise-wide “One Ascension” initiative, which is integrating and establishing best practices throughout the once highly decentralized system.

Meanwhile, Ragone is preparing to take his branding initiative on the road:  He is looking for a brand strategy director to “lead work around the definition and development of the Ascension brand, both internally and externally.  The Director will be responsible for developing the value of the Ascension brand and driving strategies to build brand equity for Ascension, its Subsidiaries and Health Ministries.”

Epilogue as Prologue

Earlier this month, Modern Healthcare editor Merrill Goozner interviewed Ascension CEO Anthony Tersigni.  He asked Tersigni about Aetna buying Humana and Anthem pursuing Cigna.  Tersigni shrugged off the big deals, saying, “Ascension is preparing to take on risk itself for self-insured employers as the system strives to manage population health while encountering an increasing number of patients in high-deductible plans.”

Spoken like a true healthcare Gretzky.

Smartphone Spring: The Great HealthIT Democratization

A great democratization of health information. That’s what the nation’s departing HealthIT Czar, Farzad Mostashari saw on the horizon last week when he bade farewell to his team at the Office of National Coordinator (ONC).

Over the next 12-months, he wrote in a valedictory email, individuals will become empowered to download their own health information. Investors will continue to pour venture capital millions in new health management tools. The landscape is changing, forever, he observed.

Meanwhile, the mobile devices that Ernst and Young Chief Technology Officer Mal Posting calls – in speaking of mHealth — “the nerve endings at the end of a vast information network” are spreading far beyond the hands of the advantaged.

As I noted in my recent post on self-service medicine, BI Intelligence forecasts that the next 100 million new smartphone users will be older and/or lower income.  Currently, about 60 percent of the US population owns a smartphone, according to Pew Internet and ownership growth is accelerating from 572,000 to 583,000 per week.  By the end of 2013, there will be about 13 million new smartphone users in the US.

In fact, smartphone makers are racing to introduce lower price handsets to satisfy demand from consumers and service providers who want to add more subscribers.  While much of the growth in low-price handsets has been in emerging markets like China and India, US demand is picking up.

For example, Nokia recently introduced its Lumia 625 priced at $290, which is a third of the cost of its highest end model.  Notably, Nokia touts the phone as the first “accessibly priced” 4G device so, although introduced first in emerging markets, it appears designed for use in developed markets with 4G networks like the US.

But, Nokia has some catching up to do.  Even cheaper still is the new Moto X from Google’s Motorola division, introduced this month and costing $199 on a two year contract.  Motorola says it will be rolling out even cheaper smartphones, especially for emerging markets and prepaid use in the U.S.

Other smartphone makers are quite active too. Lower cost versions of Samsung devices, such as the Galaxy S4 mini, are heading for emerging and prepaid developed markets.  However, the company is facing stiffer competition at the low end of the market from local and smaller producers.. And rumors of a low cost Apple iPhone abound.  In fact, recent news reports suggest that, at Apple’s anticipated September 10, introduction of a new high end model, it will also launch a new lower cost smartphone.

Lower cost smartphones and more affordable prepaid service plans are playing off each other, resulting in further cost reductions and enhancements for both.  According to a study by the NPD Group, 32% of all smartphone sales were for prepaid models by the beginning of 2013. As a result all the major carriers are rolling out more affordable prepaid smartphone plans, even on their fast 4G and LTE networks.

What about app pricing?  It’s going down, too.  According to the mobile analytics firm Flurry, the average app price has fallen significantly over the past four years. Meanwhile, the number of free and ad-supported titles continues growing.  Currently, 90 percent of all apps are free.  Of those that are not, iPhone apps average 19 cents and those for Android, the most popular operating system on lower cost phones, average 5 cents.

Clearly the smartphone spring is well underway.  In the United States and globally, it’s helping to drive the democratization of information.  Presumably, the smartphone spring will also drive the democratization of health information. In fact, there currently are 15,000 medical apps on the market, growing 25 percent annually.  The question is, will the smartphone spring ultimately bring on a health information spring.

The potential is there, especially with widespread accessibility.  But, as I noted in my most recent post – “App or Apt” — smartphones, their apps and related technology must be adapted to users, especially patients.   In that post, I shared suggestions from the Wireless Innovation Council and Mobiquity.  These included individualized solutions, appropriate interventions and outcomes for each user, personalized communications, and low effort data collection.

Additional guidance has also come from Dr. David Lee Scher, an expert on mobile and digital health and formerly a cardiac electrophysiologist:

  • An app must address a specific problem to be considered useful.  Otherwise, it will not be used.
  • Technology design must include physician input.
  • Final app construction must fully consider usability and the user experience with the focus on specific users accomplishing specific tasks.
  • Knowing the healthcare landscape is critical to creating a strategy for adoption.
  • Build to regulatory specifications.

Expansion of global smartphone ownership beyond the current 1.08 billion out of 5 billion cellphones, by itself, will not automatically lead to widespread use in healthcare.  The key, as I said, will be the extent of integration that truly adapts to the healthcare system, especially the people in that system, particularly patients.

One vision of such full integration has healthcare apps included as a mandatory requirement of some insurance plans.  At the risk of higher premiums, patients could be required – for example — to access an app before going to see their doctors.  Diabetics might need to check glucose levels and send the results to a remote monitoring station.

As explained by Merrill Matthews of the Institute for Policy Innovation and Edward M. L. Peters, CEO of Open Connect Systems, “this innovative approach focuses on information, rather than “brick and mortar” services. As information and technology get ever cheaper, policyholders and insurers can take advantage of them directly, thereby reducing costs and improving health outcomes.”

“Not everyone would take advantage of such a policy, but if health insurers were able to offer one at a significantly lower price, millions of Americans might jump at the chance. In an age of near-constant connectivity, where people use apps to manage everything from travel directions to dinner recipes to bank accounts, insurance policies that encourage consumers to embrace technology and information may be the key to bending down the health care cost curve,” they concluded.

Meanwhile, in the world’s biggest democracy, the Indian government is pushing smartphone makers to produce Made in India smartphones costing less than $100.  Said one government official:  “A fully-functional smartphone is no longer an object of desire but an instrument of empowerment,” with telemedicine one of uses.

But, the same rule requiring adaptive integration applies on the subcontinent, just as it does to healthcare in the US or anywhere.

Ovum analyst Shiv Putcha cautions that equipping the population with cell phones is not enough.  He says the government would have to develop a “broadband ecosystem” with mass mobile content and applications development in local languages so that people even in rural India would use the mobile platform to go online.

1.2 billion people, speaking 447 different languagesHoli smartphone spring!

App or Apt: What does the learning patient need?

My 90-year old dad, now two months with a new aortic valve courtesy of Penn Medicine, was puzzled – and perhaps impatient.  “My energy still escapes me,” he asked, wondering when the new valve would make a difference.  The doctors had said give it time, but he still puzzled.  Maybe it’s the meds, some new, others with different dosages.

So, he started reading the fine print, going line by line through the labels, information sheets and other documents accompanying each of nearly a dozen medications.  He also took another look at the materials provided by the Penn team.  He’s keeping track of when he takes each medication and how he feels throughout the day.

His conclusion so far:  Each medication has a purpose despite any side effects, and that he’ll give it time as the doctors advised.  And, he’ll continue with cardiac rehab, walking the block to the sessions and increasing his time on the treadmill with each session.  He’ll also take his research and “charting” with him when he next sees his internist and cardiologist to get their advice.

What he’s done is exceptional, as I’ll explain below, but not unexpected.  You see, he’s a Greatest Generation naval veteran of the 1944 Battle off Samar in the Philippines.  After the war and some time back home in Ohio, he enlisted in the Air Force, where he was a sergeant and a flight engineer.  Reading, following and documenting detailed procedures was part of the job.  Now, he’s surrounded by books.

How he learned about his medications was “apt” for him.  There’s no “app” for it.  In fact, he’ll have nothing to do with new-fangled computers, smartphones or tablets, though he likes emails that emerge on hard copy from a printer at his home.

Here’s the point:  Successfully helping a patient learn doesn’t start with the information or the knowledge.  Neither does it start with the teacher or the tool, be it a website, app or flashcard.  Instead, it begins with and must be apt for, ie. adapted to, the patient.  Unfortunately, this fundamental principle of adult learning – it’s all about the learner, not the teacher – is too often neglected.

Therefore, starting with the patient, here’s what adapting to the patient will need to consider.  It’s sobering.

  • Only a little more than one in ten Americans are considered health literate at the proficient level, according to the National Assessment of Adult Literacy.
  • 90 percent of adults have difficulty following routine medical advice largely because it is often incomprehensible to average people, according to studies cited by Orca Health.
  • Patients at all literacy levels, but particularly those with the lowest literacy skills, have difficulty understanding medication directions and warning labels, according to studies cited by the Institute of Medicine.
  • The National Assessment of Adult Literacy found that only 30 percent of subjects with a bachelor’s degree or higher were considered proficient.
  • According to a study in the Journal of the Royal Society of Medicine, 40 to 80 percent of information patients receive is forgotten soon after an appointment, and roughly half of what they do remember is inaccurate.
  • Patients ask an average of 0 – 2 questions during doctor visits, according to studies cited by Orca Health.
  • Viewing rates for web based educational tools are low.  In a recent study published by the Journal of the American Medical Association Internal Medicine, only 6% of patients in the study viewed the online material.

Clearly, most of the nation is on a steep learning curve.  Successfully helping the learning patient up this curve starts with and requires adaptation to the patient.  Here are some examples:

  • Move away from the discharge data dump, following the example of the University of Nebraska Medical Center (UNMC).  Instead, UNMC focuses on active learning based on patient teach back and teaching sheets.
  • Prepare more extensively for primary care patient visits by adding nurses to counsel and spend more time with patients, ordering labs so discussion of them can be part of the visit and looking patients in the eye to motivate healthier behaviors.  Such team based care has proven quite successful at the Red Cedar Clinic in Menomonie, WI.
  • Pick the right time, being aware of patient readiness, and add a human touch advised Jessie Gruman, president of the Center for Advancing Health, in advice for providers recently shared with the New York Times.  Too much information doesn’t help a patient learn.
  • Speak slowly and plainly, encourage questions, rely on pictures and other visuals, keep information digestible and ask patients to teach back, as suggested CareNovateMag based on information from and the Federal Health Resources and Services Administration.
  • Initiate face-to-face patient conversations with clinical pharmacists in community health centers to reduce emergency room visits like Health Partners of Western Ohio.
  • Use pharmacists as discharge process leaders like the University of North Carolina does in an initiative to improve anti-coagulant safety.
  • Rely on videos and pictures, engage in conversations and resolve patient issues or concerns when using social media, according to Nucleus Medical Media.
  • Tell stories when blogging for health behavior change, as suggested by a study published in the Journal of Medical Internet Research.  Doing so is the most effective way to engage the reader and establish credibility across a broad spectrum.  Otherwise, the reader wants the blogger to be like him or her to sustain attention, thus making the range for potential engagement much narrower.
  • Look to the Kahn Academy, which has begun producing patient videos.  Rishi Desai, Kahn medical fellow and Robert Wood Johnson Pioneer grantee calls in “flipping the visit.”   They help patients learn before doctor visits, freeing time for doctors to listen to patients.  This is instead of “teaching” during an appointment with a hurried lecture.
  • Prepare patient education materials that reflect knowledge and respect for the audience, feedback during preparation.  Make them simple, interactive and easy to digest, suggests internal medicine physician Erin Marcus in an article posted on KevinMD.

Now, to the question in the title:  App or apt?  Ultimately, it’s not an either or question. There can, should be and likely are apt apps.  A recent report from the Wireless Innovation Council and Mobiquity outlined best practices for creating behavior changing mobile health apps.  The practices, all aptly tailored for the individual user, include individualized solutions, appropriate interventions and outcomes for each user, personalized communications, and low effort data collection.  Suggested as individualized solutions are self-logging, gamification, social feedback, self-measurement, auto-analytics, notifications, alerts and reminders.

In fact, the health self-management app Boston Medical Center is offering its lower income community – about which I wrote in my last post – just might be such an “apt app.”  Take a look at the check in screen to see why Dr. Robert Sokolove says this app, which relies on peer support, is sort of a Facebook for patients.

Self Service Medicine: It’s Clinical Now!

Self-service medicine – it’s now more than using an appointment-scheduling kiosk, conversing with a phone robot or ordering electronic prescriptions.  Already mastered by many, these essentially administrative tasks – the equivalent of supermarket self-checkout – are looking a lot like false summits to patients climbing the healthcare learning curve.

In truth, the climb continues.  Patients are learning that self-service medicine now includes self-diagnosis, self-medication, self-entered histories, self-care, self-management and self-monitoring, with the latter sometimes relying on clever gadgets attached to app-equipped smartphones.  The clinical realm clearly is no longer off limits to patient self-service.

Not too long ago, clinicians frowned on patients arriving for appointments with print-outs in hand, having researched and self-diagnosed their symptoms on the Internet.   Now, some physicians are encouraging patients to prepare for appointments by consulting reliable symptom checkers, as reported recently by the Wall Street Journal.  These include the widely used WebMD, as well as symptom checkers available from the Mayo Clinic, the American Academy of Pediatrics, and companies such as A.D.A.M, iTriage and Isabel.

Why the turnabout?  As Dr. George Reynolds, chief information officer of Omaha’s Children’s Hospital and Medical Center told the Journal, “We are giving them a much better tool than just googling a bunch of stuff.”  Dr. Mark Graber, president of the Society to Improve Diagnosis in Medicine, observed that “suggesting a range of possibilities to your M.D. might help prevent the premature closure errors that underlie so many diagnostic errors.”  Isabel founder and chief executive officer, Jason Maude, explained that “patients are experts on their symptoms and doctors are experts on working out their probably causes.”

Driving self-diagnosis and self-service medicine into the mainstream will be additional factors closely aligned with self-service expansion throughout the economy.  These include saving time during office visits, more productive consultations and potentially better clinical outcomes, for example in helping doctors think of something they hadn’t considered and preventing diagnostic errors.   In other words, self-service medicine such as self-diagnosis helps drive down provider cost and increases quality.

Inspired by Mary Meeker’s annual Internet trends presentation, HealthPopuli author Jane Sarasohn-Kahn recently observed, “the more consumers can do for themselves in remote monitoring, on-time efficacious care, and safe aging at home, the more providers can manage their risk for that patient’s conditions” within the context of value based healthcare and risk management.  So the more Medicare and commercial insurers (e.g. UnitedHealth Group) move away from fee for service to value or population based reimbursement, the more self-service medicine will grow.

Here are some additional examples:

    • According to Physicians Practice, patient entered histories can effectively address problems with traditional physician-patient interviews identified in a Mayo Clinical Proceedings article.  The Mayo review noted that 50% of psychiatric problems are missed, about 50% of patient problems go unaddressed and patient and physician do no% t agree on the primary complaint 50% of the time.  And, there’s less work for providers.  As Physicians Practice observed:  “Whether you are writing a note, using dictation, or typing into an EMR, documenting the subjective part of the note can be time consuming.  Why not have patients tell (i.e. document) their own stories?
      • The 2013 TEDMED conference in Washington, DC, featured “The Smartphone Physical” exhibit, where attendees saw how a special cell phone case doubled as a one-lead EKG, an attachment snapped pictures of the inside of a subject’s eye and another attachment produced a “picture perfect” magnification of the inner ear.  Harvard medical student Ravi Parikh wrote in the Washington Post that smartphone medical applications cost less, produce better quality results and more fully engage patients – once again, the factors driving expansion of self service medicine. As the curator of the exhibit, Johns Hopkins medical student Shiv Gaglani told Parikh:  “Some of the smartphone devices are already being used by patients to collect and store their data, so when they see their clinicians they can have productive and informed conversations.”

Underlying each of these examples of self-service medicine, from self-diagnosis to self-service physicals, is a technology platform for use on the Web but typically also available via a smartphone.   So, with the growth of self-service medicine, how many people, unable to own smartphone or access such a device or the Web, will find themselves on the wrong side of a healthcare “digital divide?”

Not as many as might be feared.  According to the Pew Internet Project, 85% of U.S. adults use the Internet, 91% own a cell phone and 56% own a smartphone.  Of these, 31% of cell phone owners and 52% of smartphone owners have used their phone to look up health or medical information.  Notably, Pew, observes that young people, Latinos and African Americans are significantly more likely than other groups to have mobile Internet access.

However, some are concerned that smartphone prices may go up, hampering widespread access, due to a pending decision by the International Trade Commission in a battle between Apple and Samsung over Samsung smartphone imports.  The controversy is arcane, involving Apple’s claimed exclusive rights to the rounded rectangular touchscreen design.  If the ITC rules in Apple’s favor, the concern is that prices could go up.  That could impact the next 100 million new smartphone users, who BI Intelligence predicts will be older and/or lower income.

Meanwhile, Boston’s safety net hospital, Boston Medical Center (BMC) will offer low-income patients access to the OneHealth online and mobile platform to promote self-management of chronic diseases, offer peer support and engage them in between office visits.  As BMC’s Dr. Robert L. Sokolove told MobiHealthNews, “Many of our patients can’t use a desktop because they don’t have a desk, but they do have smartphones.”

Patients Have Stopped Going to the Doctor

Patients have stopped going to the doctor.  Instead, the doctor is going to patients, intercepting them at work, at home and in grocery stores, malls, offices, shopping centers, drug stores, big box stores and on farms. In person and electronically, they’re showing up where patients live, work, shop and play.

They’re not alone.  They’ve got the whole team and more:  Nurse practitioners, physician assistants, nurses, pharmacists, community health workers, self-management trainers, iPhone app, cell phone text reminders, etc.

“Location, location, location,”

That’s how Direct Primary Care (DPC) pioneers Dr. Randy Robinson and Mason Reiner explained it in their recent Physician News Digest article:

“In today’s intense working environment where 85.8% of males and 66.5% of females work more than 40 hours per week, DPC addresses the burden of traveling for care. By locating near commercial centers, and integrating email, text messaging, and telemedicine capabilities into the practice, DPC can deliver convenient, time-efficient, high-quality care – a benefit for patients as well as employers.

When a hemoglobin A-1c lab test for a patient comes back grossly elevated, scheduling a 15-20 minute conversation about proactive diabetic management is a necessity. The only difference, utilizing DPC, the physician is in his or her office and the patient is at work as well as on a break. The vast majority of effective primary care is knowledge transfer, communication, and continuity.  The physical point of service is no longer necessary for billing purposes.”

Their characterization of primary care bears repeating:  “The vast majority of effective primary care is knowledge transfer, communication and continuity.” In other words – mutual learning for both the learning physician (about the patient) and the learning patient (about his or her condition). They emphasize that care will neither be patient centric nor physician centered but relationship centered.

The movement of care closer and closer to the patient can only accentuate this relationship-based learning.  In fact, the greatest long term value will come from patients learning to better care for their health and manage their conditions and from physicians and clinicians avoiding the inefficiency and misdirected care that can come from limited knowledge of their patient’s complete situation in context.

How can this closer relationship and mutual learning occur when, paradoxically, patient and physician are located miles apart, but joined by a high definition, telemedicine connection? In fact, patients and physicians are saying that virtual doctor visits may be better than in-person visits.  Reasons include greater convenience, a virtual waiting room that’s better than a real one, greater patient engagement from screen sharing, more convenient record keeping and a feeling by patients that their doctors pay more attention to them during virtual visits.

America’s military medical services have been using telemedicine extensively.  In fact, they are beginning to move from fixed base connections to using smart phones.

In Cleveland, physicians are examining patients remotely in connection with initiatives at University Hospitals, Cleveland Clinic and other institutions, according to a story in this week’s Cleveland Business.   Telemedicine candidates could include people in poor, urban centers or those in rural communities, according to the report.

One 77 year old patient was quoted in the story, saying “it was essentially the same experience as a visit to the doctor, but there was (my doctor) sitting at his desk, and here I was in my apartment.  It was amazing and very enlightening to me. The quality of the image is amazing.”

Meanwhile, in California, big agricultural companies have begun operating free clinics for workers on the farm. As California Healthline reported, “Paramount Agribusinesses, partnering with Kaiser Permanente, recently opened a 1,500-square-foot health and wellness center at its clementine plant in Delano and a temporary facility at its almond-processing plant in Lost Hills.”

“We’re backing up the healthy products we create by offering our employees much better than standard coverage,” said Danny Garcia, director of human resources at Paramount Citrus, according to the publication.

In Indianapolis, three employers are sharing a clinic set up in the Cumberland Crossing shopping center. Interviewed by Indiana Business, Dan Marchetti, Chief Financial Officer of Urschel Laboratories explained: “We see this as being both conveniently accessible and a great cost-savings to our workforce and their families.  Urschel is a global leader in food cutting machinery.

For rural areas across the country, Wal-Mart expects to install primary care clinics in its stores within five years. According to the Advisory Board’s Lisa Bielamowicz, MD, about a third of provider’ patients shop at Wal-Mart on a weekly basis. “It’s the cheapest place to buy groceries and ammunition, and it could become your most formidable competitor,” Dr. Bielamowicz said, as reported by Becker’s Hospital Review.

Already well known are clinics established by Walgreens, Target and CVS in their stores.  At Walgreens, the role of nurse practitioners will be expanded up the full level of education and licensure.

Taking medicine to patients is more than a US phenomenon; it is occurring worldwide, especially in developing countries.  The UN has just launched a campaign to recruit a million health care workers in sub-Saharan Africa. Already, these grassroots health advocates equipped with smart phones and other technology are making a difference in Rwanda and Tanzania. They are helping patients learn about and to manage their conditions – and to know when higher level care is needed.  And, in Zambia physicians from around the world are seeing patients via telemedicine connections.

So, whether you’re in the most remote areas of Africa, miles away from but connected the Cleveland Clinic, at an Indianapolis shopping center clinic, Dr. Robinson’s direct primary care practice in Elkins Park, Pennsylvania, or any number of pharmacy based clinics….you’ve stopped going to the doctor because the doctor, nurse or other clinician has come to you.

And, that means there’s a lot of learning to do.

Thank you for reading.