IMS Institute on the Global Oncology Market

By Clive Riddle, June 2, 2016

The IMS Institute for Healthcare Informatics this week released their new study: Global Oncology Trend Report: A Review of 2015 and Outlook to 2020, which examines the current and future global oncology market. Their 42-page report tells us that “more than 20 tumor types are being treated with one or more of the 70 new cancer treatments that have been launched in the past five years, with the sustained surge in innovative therapies driving the global oncology market to $107 billion in 2015. However, many of these drugs are not yet available to patients in most countries, and even when registered they may not be reimbursed under public insurance programs.”

The study finds that growth in global spending on oncology therapeutics and supportive care drugs increased 11.5 percent on a constant-dollar basis last year, with more than 500 companies actively pursuing oncology drug development around the world. Collectively, they are advancing nearly 600 new molecules through late-stage clinical development, most frequently for non-small cell lung cancer and breast, prostate, ovarian and colorectal cancers.

And as for the future, “annual global growth in the oncology drug market is expected to be 7.5 – 10.5 percent through 2020, reaching $150 billion. Wider utilization of new products—especially immunotherapies —will drive much of the growth, offset by reduced use of some existing treatments with inferior clinical outcomes. Payers also are expected to tighten their negotiation stance with manufacturers and adopt new payment models in an effort to drive greater value from their expenditures on these drugs.”

The report also shares that:

• The pipeline of oncology drugs in clinical development has expanded by more than 60 percent during the past decade, with almost 90 percent of the focus on targeted agents.
• The median time from patent filing to approval for oncology drugs in 2015 was 9.5 years, down from 10.3 years in 2013.
• Of the 49 oncology New Active Substances analyzed that were initially launched between 2010 and 2014, fewer than half were available to patients by the end of 2015 in all but six countries: the U.S., Germany, UK, Italy, France and Canada.
• Targeted immunotherapies are available in most developed countries, but none of the emerging markets outside of the European Union has yet registered these treatments.
• Of the drugs approved in 2014 and 2015 by a set of developed countries analyzed, only the U.S., France and Scotland have more than half included on reimbursement lists at the end of 2015.
• The annual growth rate in cancer drug costs has risen from 3.8 percent in 2011 to 11.5 percent in 2015, at constant exchange rates. Growth in the U.S. market increased from 2.0 percent to 13.9 percent in the same period.
• The U.S. now accounts for about 45 percent of the global total market for therapeutics, up from 39 percent in 2011, due in part to the strengthening of the U.S. dollar and more rapid adoption of newer therapies.
• In the U.S., cancer drugs now make up 11.5 percent of total drug costs, up from 10.5 percent in 2011
• Net price growth in the U.S. on existing branded oncology drugs have averaged an estimated 4.8 percent in 2015, compared with 6.4 percent invoice price growth
• In the U.S., cancer drugs dispensed through retail channels now account for more than one-third of total costs, up from 25 percent ten years ago and typically covered by pharmacy benefits. This reflects a shift in the mix of new therapies toward oral medicines, eliminating the need for injection or infusion in a physician’s office or outpatient facility.
• Nearly 40 percent of the total costs of targeted therapies in the U.S. are now for oral formulations, up from 26 percent in 2010.
• Only 17 percent of U.S. oncologists are in independent practices, unaffiliated with some type of integrated delivery network or corporate parent, down from 28 percent in 2010.
• Average total treatment costs for patients in commercial insurance plans with a cancer diagnosis who are receiving active treatment reached $58,000 in 2014, up 19 percent from 2013.
• Patients with commercial insurance who were treated in 2014 with cancer drugs received by injection or infusion were responsible for more than $7,000 of costs on average, compared to $3,000 for those patients receiving only oral medicines.
• Some type of coupon or patient cost offset was used for more than a quarter of cancer drug retail prescriptions filled by patients with commercial insurance in 2015, up from 5 percent in 2011 and reflecting efforts by manufacturers to reduce patient out-of-pocket costs. The average cost offset has averaged about $750 per prescription over the past five years.

Blue Shield of California Releases Executive Pay Report

By Claire Thayer, May 31, 2016

This week, Blue Shield of California released its first report on executive pay, thanks in part to a state audit that raised questions on the amount of executive pay and large cash reserves, along with mounting public pressure to be more transparent on executive compensation.  It pays to meet incentive plan goals - the CEO’s compensation jumped 40% in less than two years in doing so. 

The report includes components of the executive compensation program –including base salary and incentives tied to short and long term goals. Compensation paid to their top ten executives is listed, details on the CEO's individual pay package, along with comparison of how their exec pay ranks compared to their peers (Centene, Aetna, United, Anthem, Humana and Kaiser).

For further reading:

Blue Shield of California 2015 Executive Compensation Summary [May 2016]

Blue Shield ‘Lifts The Veil’ On Executive Pay [Kaiser Health News, May 26, 2016]

Blue Shield reveals executive compensation [BenefitsPro, May 27, 2016]

Practicing in an Age of Uncertainty

By Kim Bellard, May 27, 2016

If you've ever had a hard time trying to decide what's best for your health, perhaps you can take comfort in the fact that physicians often aren't so sure either. 

Or perhaps not.

A new study in Annals of Surgery, and nicely reported on by Julia Belluz inVox, focused on surgical uncertainty.  The researchers sent four detailed clinical vignettes to a national sample of surgeons, seeking to get their assessment on the risks/benefits of operative and non-operative treatment, as well as their recommendations. You'd like to think there was good consensus on what to do, but that was not the case.

In one of the vignettes, involving a 68 year-old patient with a small bowel blockage, there was fairly universal agreement -- 85% -- that surgery was the best option.  In the other three vignettes, though, the surgeons were fairly evenly split about whether to operate or not, even on something as common as appendicitis. 

So, there may be a "right" answer but you might as well flip a coin in terms of getting it, or there may just not be a right answer.  Both options are troubling.

The authors believe that surgeons are less likely to want to operate as their perception of surgical risk increased and the benefits of non-operative treatment increased, and more likely to want to operate as their perception of surgical benefit increased and non-operative risk increased.  The problem is that surgeons vary dramatically -- literally from 0 to 100% -- on their perceptions of those risks.

Most surgeons based their estimates of risks/benefits on their experience, their training, and -- if you're lucky -- on whatever literature might be available, but it is doubtful that we can usually expect an objective, quantifiable assessment. 

The American College of Surgeons has developed a "surgical risk calculator" to help surgeons better gauge these risks, using data from a large dataset of patients.  However, an earlier related study from the same team of researchers found that it doesn't make much difference.  The calculator did narrow the variability of surgeons' assessment of risk, but: "Interestingly, it did not alter their reported likelihood of recommending an operation."

Oh, well.

It is not just surgeons who aren't always sure of the right course of action, of course.  A study in the American Journal of Managed Care found that 62% of physicians reported that they found the "uncertainty involved in providing patient care disconcerting."  The discomfort with uncertainty did not vary appreciably between type of specialty.

Then there is the example of PSA tests.  In 2008 the US Preventive Services Task Force recommended routine PSA tests not be given to men over 75, and in 2012 broadened that recommendation to all ages.  Yet data suggest that the group least likely to need the tests -- men over 75 -- had the smallest declines in rates of testing.  Almost 40% of this age group are still getting the test, which is not far from the previous rates. 

As one researcher told The New York Times,   "That’s just insanity...bad medicine, poor use of health care resources and poor decision-making.”

There's all too much of that in our health care system.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

How are health plans meeting behavioral health needs of members?

By Claire Thayer, May 23, 2016

There’s been a lot of awareness about mental health lately, especially during the month of May – officially recognized as Mental Health Month, via Mental Health America .  In the spirit of this awareness, AHIP recently released a new 28-page issue brief on behavioral health benefits and mental health coverage from collective case studies of 11 member health plans. This new issue brief, Ensuring Access to Quality Behavioral Health Care: Health Plan Examples, identifies innovative approaches to these key areas:

• Awareness and Education
• Identification and Outreach
• Timely access to care
• Quality measurement
• Evidence-based clinical criteria
• Care Coordination and integration
• Programs targeting opioid use

Health Plans profiled in the report include:

• Anthem
• Beacon Health Options
• Blue Shield of California
• CareFirst
• Cigna
• Health Care Service Corporation
• Health Partners
• Highmark
• Humana
• Kaiser Permanente
• Wellcare

To read this complete Issue Brief: Ensuring Access to Quality Behavioral Health Care: Health Plan Examples

Patients Happy With PCPs But Not Always Following Their Advice Due to Costs

By Clive Riddle, May 19, 2016

The Physicians Foundation has just released a 74-page report with results from their Physicians Foundation Patient Survey conducted by Harris Poll. The report findings state that “95 percent of patients surveyed are satisfied or very satisfied with their PCP’s ability to explain information in a manner they understand, while 96 percent feel their physicians are respectful of them. Moreover, 93 percent were satisfied or very satisfied with how well their PCP listened to them during their most recent exam, with 92 percent noting high levels of satisfaction relative to how well their doctor knew their medical history.”

But the report notes that “patients who saw a primary care physician for their most recent routine exam are not fully adhering to treatment plans, avoiding routine check-ups or opting not to take prescription medication due to rising healthcare costs.”

They cite that “ sixty-two percent of U.S. adults are concerned with being able to pay for medical treatment if they get sick or injured. Almost half (48 percent) are not confident they could afford care should they become seriously ill. In addition, more than a quarter of U.S. adults (28 percent) have skipped a medical test, treatment or follow-up or avoided a visit to the doctor for a medical problem in the past 12 months because of costs. Twenty-seven percent of patients have avoided filling a prescription in the past 12 months, noting costs as a primary factor.”

Who do patients feel are driving these costs? The report says that “59 percent of patients surveyed say it’s the cost of prescription drugs. One-third (33 percent) of patients cited fraud as another contributor factor, followed by social conditions and poverty (28 percent), government mandates (26 percent) and an aging population (25 percent).”

Rip Hollister, MD, a Physicians Foundation board member tells us “patients recognize that there is an array of stakeholders and external influences that affect treatment options and, in effect, clinical autonomy. Historically, treatment plans have been developed between the doctor and patient. Yet, patients understand that there are now many other parties ‘in the room,’ so to speak, which complicates and challenges the manner in which physicians practice medicine.”

In this regard, the report cites how much patients felt each of the following stakeholder groups, as a whole, impacts treatment options available to them:

• Health insurance companies (83 percent)
• Physicians (79 percent)
• Pharmaceutical companies (68 percent)
• Federal legislature (60 percent)
• State legislatures (54 percent)

Walgreens raising awareness on mental health with online screening tools and telehealth services

By Claire Thayer, May 10, 2016

Walgreens and Mental Health America have forged an ambitious initiative to screen 3 million people for mental issue, by the end of 2017. Walgreens is well positioned to step up to expand mental health services and treatment options and has announced it will offer access to 1,000 therapists and psychiatrists via MDLive’s subsidiary, Breakthrough.

Walgreens new dedicated mental health “answer center” is designed to help connect people to Mental Health American’s Online Screening Program— free, scientifically-based online screenings for a number of conditions including depression, anxiety, bipolar disorder, PTSD and others.

The National Alliance on Mental Illness reports that getting access to services for treatment of mental health illness continues to be a concern:

• Approximately 60 percent of adults, and almost 50% of youth ages 8 to 15 with a mental illness received no mental health services in the previous year.
• African American and Hispanic Americans used mental health services at about one-half the rate of whites in the past year and Asian Americans at about one-third the rate.
• One-half of all chronic mental illness begins by the age of 14; three-quarters by age 24.
• Despite effective treatment, there are long delays−sometimes decades−between the first appearance of symptoms and when people get help.

Further reading:

• Walgreens To Expand Mental Health Services [Forbes, May 10, 2016]
• Walgreens hopes to screen 3 million on mental health by next year [MedCity News, May 10, 2016]
• Mental Health America, Walgreens Team Up on Mental Health Screenings and Campaign
• National Alliance on Mental Illness: Facts and Numbers

Hot Healthcare M&A Market Starting to Cool

By Clive Riddle, May 6, 2016

Irving Levin Associates reports that healthcare merger & acquisition activity, which has been relatively overheated, is starting to cool a little. Lisa E. Phillips, editor of Irving Levin’s Health Care M&A News tells us “the slowdown in deal volume in the first quarter of 2016 might simply be fatigue setting in after a record-setting year in 2015. Also, some buyers are still figuring out where the best opportunities are, as the shift to value-based reimbursements gains momentum.”

Health Care M&A News states that “health care merger and acquisition activity began to slow down in the first quarter of 2016. Compared with the fourth quarter of 2015, deal volume decreased 7%, to 351 transactions. Deal volume was also down 7% compared with the same quarter the year before. Combined spending in the first quarter reached $79.5 billion, an increase of 87% compared with the $42.5 billion spent in the previous quarter.”

Here’s a snapshot the publication provided of the quarter’s activity:

How big was 2015?  Bigger than 2014, which was also a huge year.  Irving Levin’s Lisa Phillips says “health care mergers and acquisitions posted record-breaking totals in 2015. The services side contributed 62% of 2015’s combined total of 1,503 deals, which is even higher than 2014, when services deals accounted for 58% of the deal total.” A separate Irving Levin publication, the Health Care Services Acquisition Report, cites that “deal volume for the health care services sectors rose 22%, to 936 transactions versus 765 in 2014. The dollar value of those deals grew 183%, to $175 billion, compared with $62 billion in 2014. Merger and acquisition activity in the following services sectors—Behavioral Health Care, Hospitals, Laboratories, MRI & Dialysis, Managed Care, Physician Medical Groups, Rehabilitation and Other Services—posted gains over their 2014 totals. The exception was the Home Health & Hospice sector, which declined 33% in year-over-year deal volume.”

In the hospital sector, for 2015, they report that “activity remained strong in 2015, up 3% to 102 transactions, compared with 99 transactions in 2014. An average of 2.6 hospitals were involved in each transaction, compared with an average of 1.8 in 2014 and 3.3 in 2013.” Philips noted that “several deals resulted from the mega-mergers of 2013,” and that “we’re seeing more sales resulting from bankruptcies, especially in states that have not expanded Medicaid coverage.”

Getting on the Blockchain Bandwagon

By Kim Bellard, April 28, 2016

Face it: health care IT infrastructure is a mess.  After spending tens of billions of dollars to "incent" providers to move to EHRs, they're using them but are not very happy with them. We now have millions of electronic records that are still way too siloed, and all too often incomplete.

Enter blockchain.

To the extent most people think of blockchain at all, it is in relation to one of its most prominent users, Bitcoin.  Bitcoin, which has its passionate advocates and equally passionate skeptics, is not synonymous with blockchain.  Blockchain is the technology that allows Bitcoin to operate, but they are no more one and the same than Salesforce.com and Oracle are.

In layman's terms -- and, trust me, when it comes to this I definitely am a layman -- blockchain is a set of distributed records, or databases, that are shared by multiple parties and which can only be updated by a majority of those parties.  There is no central authority, no central database.  It reminds me of the Internet's distributed networks, which help assure its robustness. 

Equally important, in blockchain once a record is stored (or "transcribed"), it can't be tampered with.  For better or for worse, Bitcoin has demonstrated that blockchain does, in fact, assure anonymity, privacy and security. 

Blockchain is starting to become more visible even outside of Bitcoin.  Businesses are being told they need a "blockchain czar.  Wall Street is starting to embrace it.  Britain looking into using it for manage the distribution of public money
 
Some people think it is the greatest thing since sliced bread -- or, in modern terms, since the Internet.  IBM's Jerry Cuomo says: "Blockchain has the potential to become the technological foundation for all electronic transactions conducted over the Internet."

If they are even remotely right, blockchain is something that we better be paying attention to, and what industry needs its advantages more than health care?

We're already beginning to see blockchain show up more in health care.  For example, Gem just announced Gem Health, As they say: "We need a modern infrastructure that unlocks new channels for services to connect, while balancing the need for strong data privacy and security.  Blockchain technology is that infrastructure."

Philips is onboard, with the Philips Blockchain Lab joining the Gem Health network.

It's not going to be easy.  Health care has had a hard time agreeing to things like ICD-10 or HL7, much less interoperability standards.  In CIO, Peter B. Nichol points out the need for foundational protocols, such as the Linux Foundation's Hyperledger project is working on  If we thought getting providers to use EHRs was hard, picture trying to get the health care industry onto a entirely new technology platform like blockchain. 

True to form, the "HIT standards mandarins" are already showing resistance to blockchain.

However, Mr. Nichol also enumerates a number of companies already jumping on the blockchain bandwagon for healthcare uses, including not just Gem but also Tierion, Factom, HealthNautica, and Guardtime.  It is something that any organization involved in health care can ignore only at their own risk.

Look, I'm no technology seer.  I don't know if blockchain is going to totally revamp how we store and update data, as its proponents claim.  What I do know is that, when it comes to health care, our current approaches are not getting us to the interoperability that we need, or are doing so only at glacial speeds, and that they allow our electronic data to be increasingly vulnerable.   

If not blockchain, what?

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Cyber attacks – a new reality for health care organizations

By Claire Thayer, April 20, 2016

The healthcare industry as a whole is at a critical juncture in its efforts to curb medical identity theft, data breaches and health care fraud. More than any other industry, health care is now leading the way for the highest number of records breached - 84.4 million alone in the first half of 2015. Hospitals, health plans, health systems and provider organizations are all doubling down on efforts to address vulnerabilities related to cyber attacks. And, the sooner the better – as consumers are starting to take notice - about 50% say they wouldn’t hesitate to find another healthcare provider if they were concerned about the security of their medical records.

Cyber threats now have the full attention of the c-suite. A recent HIMSS Cybersecurity Survey finds:

• 87% of healthcare leaders indicated that information security had become a critical business priority
• 66% of healthcare organizations experienced a significant security incident
• 57% of healthcare organizations have allocated a full-time resource to address cybersecurity
• 81% of respondents believe more innovative and advanced tools are needed to combat security threats

These and issues pertaining to identity management in health care are the focus of a recent MCOL infographoid, co-sponsored by LexisNexis Healthcare, highlighted below:

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.

Health Systems Advised to Tread Carefully When Considering Provider-led Health Plans

By Claire Thayer, April 18, 2016

McKinsey & Co released an in-depth paper that explores both growth and evolution of provider-led health plans and offers key questions health systems should think about when evaluating their current plans or considering offering stepping into to provider-led plan market space. Here are some of the highlights gleaned from this paper.

The authors point out that overall, the growth in enrollment of provider led plans has increased 6% since 2010, growing from 12.4 million in enrollment to 15.3 million in 2014. While during this same time period, growth in the number of provider-led health plans was modest, increasing just 3% from 94 plans in 2010 to 106 in 2014. The enrollment growth was most pronounced in the Medicaid, Medicare Advantage and Individual Markets

The authors point to 4 important questions that are critical for health systems to consider when evaluating provider-led health plan (PLHP) offerings:

• How can consumerism benefit a PLHP
• When is growth through a PLHP most likely
• Is an alternative type of administrative infrastructure possible?
• What can be gained through granular analytics?

For further reading:

Article Summary: The market evolution of provider-led health plans [McKinsey & Company]

Full Article: The market evolution of provider-led health plans [McKinsey & Company]

Ten Things to Know About The Comprehensive Primary Care Plus (CPC+) model

By Clive Riddle, April 15, 2016

1.  CPC+ is a CMS five-year initiative starting in January 2017 to create a national advanced primary care medical home model that aims to strengthen primary care through a regionally-based multi-payer payment reform and care delivery transformation.

2. CPC+ will be implemented in up to 20 regions and can accommodate up to 5,000 practices, which would encompass more than 20,000 doctors and clinicians and the 25 million people they serve.

3. The multi-payer approach involves Medicare partnering with commercial and state health insurance plans to support primary care practices in delivering advanced primary care.

4. Advanced primary care has five key components:

• Services are accessible, responsive to an individual’s preference, and patients can take advantage of enhanced in-person hours and 24/7 telephone or electronic access;
• Patients at highest risk receive proactive, relationship-based care management services to improve outcomes;
• Care is comprehensive and practices can meet the majority of each individual’s physical and mental health care needs, including prevention. Care is also coordinated across the health care system, including specialty care and community services, and patients receive timely follow-up after emergency room or hospital visits:
• It is patient-centered, recognizing that patients and family members are core members of the care team, and actively engages patients to design care that best meets their needs:
• Quality and utilization of services are measured, and data is analyzed to identify opportunities for improvements in care and to develop new capabilities.

5. CPC+ lists five patient care objectives to help primary care practices:

• Support patients with serious or chronic diseases to achieve their health goals;
• Give patients 24-hour access to care and health information;
• Deliver preventive care;
• Engage patients and their families in their own care; and
• Work together with hospitals and other clinicians, including specialists, to provide better coordinated care

6. CPC+ will include two primary care practice tracks with incrementally advanced care delivery requirements and payment options. Practices in both tracks will receive up-front incentive payments that they will either keep or repay based on their performance on quality and utilization metrics. Practices in both tracks also will receive data on cost and utilization.

7. Track 1 practices will receive a monthly care management fee in addition to the fee-for-service payments under the Medicare Physician Fee Schedule for activities.

8. Track 2 practices will be expected to provide more comprehensive services for patients with complex medical and behavioral health needs. Track 2, practices will also receive a monthly care management fee and, instead of full Medicare fee-for-service payments for Evaluation and Management services, will receive a hybrid of reduced Medicare fee-for-service payments and up-front comprehensive primary care payments for those services. Track 2 practices’ vendors will sign a Memorandum of Understanding (MOU) with CMS that outlines their commitment to supporting practices’ enhancement of health IT capabilities.

9. CPC+ was developed through the ACA enacted Center for Medicare and Medicaid Innovation, and is an outgrowth of the Comprehensive Primary Care (CPC) initiative, a model tested through the Center for Medicare & Medicaid Innovation that began October 2012 and runs through December 31, 2016

10. CMS will accept payer proposals to partner in CPC+ from April 15 through June 1, 2016. CMS will accept practice applications in the determined regions from July 15 through September 1, 2016. CMS will select regions for CPC+ where there is sufficient interest from multiple payers to support practices’ participation in the initiative.

Here’s where you can find out more:

• CMS April 11^th 2016 CPC+ Press Release
• CMS CPC+ Fact Sheet
• CMS CPC+ FAQs
• JAMA April 11, 2016 Article: Medicare’s Vision for Advanced Primary Care

52% of healthcare IT leaders evaluating cloud-based solutions for population health management

By Claire Thayer, April 12, 2016

A recent HIMSS Media survey of healthcare IT leaders identifies five key challenges in using connected health IT applications to support population health management:

• Care Coordination – 23.5%
• Financial investment in IT – 21.4%
• Data Management – 18.4%
• Patient Engagement & Adherence – 14.3%
• Cohort identification and risk stratification – 12.2%

With the growing consumer interest in all things mobile, it’s not a surprise to see that many of these health IT leaders are giving serious considerations to population health platforms that support telehealth systems with back-end integration services.  Notably, 52% are evaluating cloud-based solutions and more than half say they intend to adopt mobile wellness monitoring apps for their population health management needs.

Identity Crisis: The Need for Improved Healthcare Identity Management

by Clive Riddle, April 8, 2016

This week, Kathy Bardeen from LexisNexis spoke in a HealthcareWebSummit webinar on Mastering Identity Management in Healthcare.  The issue with that inaccurate and missing demographic information and inadequate authentication systems and processes threaten business integrity and success, financial outcomes, and member engagement. On top of that, there is the looming specter and fear of hacking, healthcare identify theft and fraud.

Kathy cited recent medical identity theft breaches with OPM data, UCLA Health and Anthem, along with these concerns:

• Nearly 40% of consumers would abandon or hesitate using a health organization if it is hacked
• 50% if consumers agreed they would find another healthcare provider if their medical records were stolen
• Between 8-14% of medical records have erroneous information tied to an incorrect identity
• Only about ten percent of health insurers use two-factor authentication and encryption to protect data
• Individual can spend an average of $13,500 to resolve applicable medical identity fraud cases
• Insurers spend $2pmpm or more for multiple years of credit monitoring for members affected by data breaches

Kathy tells us healthcare organizations need to handle identities as a journey that starts with Identity Checks, progresses with Identity Management and then Identity Insights. Here’s her definitions:

• Identity Checks involve facilitating the authentication, verification and resolution of identities engaging with the organization, identifying possible fraud risks, and allowing for point of need identity information searches.
• Identity Management leverages a systematic approach to maintaining, enhancing and augmenting member identity profiles with current, correct and previously unavailable information.
• Identity Insights involves understanding individuals and their relationships within and outside of the healthcare ecosystem and gaining insight into socioeconomic factors impacting health outcomes, costs and overall risk.

Kathy shares these best practices in Risk Mitigation in Identity Checks, Identity Management and Identity Insights:

• Risk Mitigation in Identity Checks should involve: evaluating systems and process to minimize the transmission and storage of PHI/SPII data whenever possible; executing a robust algorithm for unique ID assignment that will maintain consistency and persistence over identity evolution; and deploying a multi-layered approach for identity management that grows with business objectives as well as an ever changing identity landscape.
• Identity Management should involve: implementing an ongoing maintenance program to ensure integrity of identity records as this data erodes; executing the identity management program with a frequency and focus that matches the business processes and programs leveraging this data; and leveraging an authoritative, reliable data source(s) to augment and update identity information.
• Identity Insights should drive analytics from identity insights to solve for large complex problems as well as target improvements to existing programs; and maximize the value of the identity management data asset across different areas of the business.

This webinar is now available for free on an on-demand basis for qualified applicants.

The Biosimilar Opportunity

By Clive Riddle, April 1, 2016

Biosimilars hold considerable future opportunity for helping address rapidly rising prescription costs. They also hold considerable opportunity for pharmaceutical companies seeking to offer them, as well as challenges for pharmaceutical holders of brand drugs that they would impact.

PwC listed Biosimilars as one of their top ten health industry issues of 2016. They stated that “Finally entering the US market, biosimilar drugs have the potential to be as disruptive as generic drugs following the Hatch-Waxman Act of 1984. The first US biosimilar - Sandoz’s Zarxio, which prevents infections in cancer patients – received FDA approval in 2015, and entered the market at a 15% discount. At least four biosimilar applications are pending FDA review in 2016, with another 50 in the FDA review process.”

PwC also another challenge in that U.S> consumers don’t know what the heck a Biosimilar is: citing a survey in which only 17% of consumers chose a correct definition of Biosimilar when offered multiple choice answers.

Biosimilars are of course much further along the path in Europe, but in addition to consumer confusion and provider and purchaser lack of familiarity as well, there is of course continued regulatory morass as well as lobbying from pharmaceutical companies trying to protect specific brand drug turf. The NCSL (National Conference of State Legislatures) has a page dedicated to the topic of State Laws and Legislation Related to Biologic Medications and Substitution of BioSimilars.

In addition to monitoring and summarizing this activity, NCSL provides easy to understand background information. They tell us “Biologic medicines are much more complex than traditional chemically synthesized drugs. Biologics are manufactured from living organisms by programming cell lines to produce the desired therapeutic substances and consist of large molecules….Regulating biologics raises new issues for both state and federal policymakers. Because of their complexity, biologic drugs are much more difficult to replicate than the chemically produced generics for other drugs. The cell lines used and modifications in the manufacturing process affect biologic medicines. As a result, truly identical “generic” versions are currently virtually impossible to produce. However, once patents expire for the existing brand-name biologic drugs, “biosimilar” medicines can be produced, which is an occurrence that raises regulatory issues in the states. Currently, there is concern that traditional statutes regulating ‘generic drugs’ may be misapplied to new products that are not identical. This has led to a recent move to amend older state laws to address the medical and chemical characteristics of these ‘biologics,’ as well as any future generic-style ‘follow-on biologics’ or ‘biosimilars.’ “

This week the IMS Institute for Healthcare Informatics released a 36 page report: Delivering on the Potential of Biosimilar Medicines -The Role of Functioning Competitive Markets, telling us that “Greater acceptance of biosimilar medicines in a growing number of therapy areas and an active pipeline of 56 new products in clinical development are expected to deliver total savings of as much as $110 billion to health systems across Europe and the U.S. through 2020.”

IMS offer considerable research into Biosimilar adoption and issues in Europe, and counsels that “As these medicines also become available in the U.S., stakeholder education and incentives will play a vital role in ensuring biosimilars deliver their full potential.” Their report finding include:

• Considerable variations across the EU in payer policy approaches are limiting the biosimilar opportunity.
• Biosimilars use in the EU and U.S. may yield total savings of $56-110 billion over the next five years.
• Patient access to biologic treatments has grown by as much as 100 percent following the availability of biosimilars.
• Intensifying competition and greater choice are expected as new biosimilars reach the market.
• Capturing the benefits of biosimilar medicines requires a balance between controlling price and ensuring a sustainable, competitive marketplace.

IMS emphasizes the need for education and incentivization in order for Biosimilars to fulfill their potential.  They tell us that “Payers need to ensure that they are keeping themselves informed. The variation in policies adopted, as well as in biosimilar prices and uptake, across the EU, suggests that some payers do not understand the potential offered by biosimilar medicines. Physicians need to trust that biosimilar medicines offer a safe and efficacious alternative to original biologics…..Patients are expected to accept new technologies, about which they may have only limited information….Payers need to ensure that doctors see a tangible benefit to prescribing biosimilar medicines. Physicians need to understand that prescribing biosimilar products delivers clinical benefits across the market as a whole, and that the cost-savings that result from biosimilar uptake enable more patients to access needed treatment.”

Aligning Wellness Program Incentives to Increase Use of Digital Health Apps

By Claire Thayer, March 29, 2016

A recent HealthMine survey of 500 insured consumers finds that half of those surveyed are enrolled in a wellness program and one-third received their health device/app as a benefit of their wellness program.  Of those now using digital health tools, most were for tracking fitness and nutrition purposes. Pharmacy and medication tracking apps were used by 28% and 14% of those surveyed; patient portal by 22%, and about 10% indicated they were using apps for prescriptions / medical provider price comparisons.  A bit surprisingly, only 7% were using disease management apps:

More on these findings, including biggest motivators to use digital health apps, are published at HIT Consultant.

Medication Adherence and Out of Pocket Costs

By Clive Riddle, March 25, 2016

While out of pocket costs impact consumer demand and utilization for healthcare services in various degrees for all aspects of care, the relationship is perhaps the most direct for prescriptions. This direct relationship is due to both the relatively lower average cost per prescription compared to the per unit cost of most other health care services, along with the behavioral economics implications that a prescription typically delivers delayed results, while most other healthcare services provide perceived potentially immediate results.

In this context, Truveris, a pharmacy benefits solutions provider, has just released study results examining medication adherence based upon out of pocket prescription costs. They found that “85 percent of prescriptions are filled when the price at the register is around $30. Once the cost of a prescription surpasses $50, the rate starts a notable decline, dropping to 76 percent. The number of prescriptions filled drops even further, to 65 percent, when the cost is $90 and above.”

Kristin Begley, Chief Pharmacy Officer at Truveris tells us “as healthcare costs continue to burden Americans, there is ample evidence of increased prescription costs leading to discontinuation of medications in order to save money. We’re seeing a troubling trend that when drug prices reach a certain level, consumers are simply walking away, not filling the prescriptions and, in effect, gambling on their health. This should be an urgent wake-up call across the healthcare spectrum.”

Taking things a step further, a Geisinger study published in the February 2016 issue of The American Journal of Managed Care “shows that instituting a zero prescription co-pay for its chronically ill employee population resulted in a positive cost saving and return on investment.”

The Geisinger study found “that a zero co-pay drug program for its chronically ill employee population was associated with positive cost savings and a return on investment of 1.8 over five years….More than 200 prescription medications were selected to be eligible for the $0 co-pay program; those selected were designated for chronic conditions like high blood pressure, cholesterol and diabetes management and were preventative in nature. Geisinger researchers say that VBID implementation within the context of a wider employee wellness program targeting the appropriate population can potentially lead to further positive cost savings.”

Under the Influence

By Kim Bellard, March 18, 2016

A new analysis by ProPublica found that doctors who receive money from drug companies do, in fact, tend to prescribe more brand name drugs, and that the more money they got, the more brand name prescribing they did.

ProPublica looked at prescribing patterns from five specialties -- cardiovascular, family medicine, internal medicine, ophthalmology, and psychiatry -- with the restriction that individual physicians had to have had at least 1,000 Part D prescriptions in the study period (2014).  Overall, about three-fourths of physicians took some money from a drug company, although there was wide variation by specialty and geography -- e.g., nearly 9 of 10 cardiologists took payments, just as around 90% of physicians took such payments in Nevada, Kentucky, Alabama, and South Carolina. 

Conversely, in Minnesota and Vermont the percentage was closer to 25%.

The amount of the payments appeared to have an impact.  Internists who received no payments had brand-name prescribing rates of about 20%, while those getting more than $5,000 had rates of around 30%.

The defenses from physician organizations and the drug industry make for fun reading.  Dr. Richard Baron, the president and chief executive of the America Board of Internal Medicine, protested that doctors almost have to go out of their way to avoid taking these kinds of payments.

The president of the American College of Cardiology suggested the patterns were re-enforcing; the more they learn about a drug, the more they tend to use it, and the more they use it, the more drug companies pay them to be speakers and consultants.

Seriously, these are their defenses?

We've been learning a lot more about how pervasive industry payments -- not just pharmaceutical companies but also medical device and other health care suppliers -- are since the advent of the Open Payments initiative.  We're talking about over $6.5b in payments in 2014, made to over 600,000 physicians and 1100 hospitals.  I wrote about this last summer, and the new ProPublica analysis certainly should rattle any remaining doubts anyone might have had about the potential impact of such payments. 

True to form, last fall the AMA called for a ban on DTC advertising.   That's right, they don't seem disturbed about the $6.5b physicians are getting, but they think that the ads that we see are bad.  There's a certain logic to that; it has long been suspected that these ads help drive consumer demand.

Austin Frakt, of The New York Times, recently challenged this conventional wisdom.  For one thing, he notes that while drug ads do cause an increase in sales for the advertised drug, they also increase sales of other drugs in the same class, using Prozac as an example.  Seeing drug ads may help "normalize" the condition being treated, making getting treatment for it more acceptable, and may also help encourage patients to continue with existing prescriptions.  

Mr. Frakt points out that it is not only the drug companies who benefit from drug advertising, but also physicians.  Every $28 in drug advertising results in an additional doctor visit; someone has to do the prescribing, after all.  And, of course, the DTC spending is dwarfed by the direct-to-physician "promotions" -- Mr. Frakt estimates drug companies spend seven times more on these than on DTC advertising. 

So we're back to the ProPublica analysis. 

It simply is not plausible to maintain that these efforts are not influencing physicians' decisions, and that they may not always be in the best interests of patients.  As Bloomberg put it last summer: the payments "seek to convince doctors that second choice is OK."
 
Well, I don't know about you, but that is not OK with me. 

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Telemedicine and Virtual Visits preferred by close to one-third of consumers

By Claire Thayer, March 17, 2016

Telehealth, quite simply refers to the use of electronic technology to deliver health care and health information between patients and their providers. Use of mobile devices and smartphones for vitual visits and remote patient monitoring alone goes a long ways in terms of enhancing patient engagement. The American Telemedicine Association reports that up to 15 million people used telehealth services in 2015, a 50 percent increase from 2013. 

A new Accenture survey finds that nearly one-third (29 percent) of consumers said they prefer virtual doctor appointments to face-to-face doctor appointments,  compared with just under one-quarter (23 percent) in the 2014 survey.

The survey further finds that both physicians and consumers alike believe that virtual visits provide benefits for patients, such as:

• lower costs:  58% of consumers vs. 62% of doctors
• convenience:  52% of consumers  vs. 80% of doctors
• timely access to care: 42% of consumers vs. 49% of doctors

For providers, plans and health systems evaluating incorporation of telemedicine into overall care delivery systems, ECG Management Consultants offers a few key questions to take into consideration:

• What operational and care delivery challenges is your organization looking to solve?
• How far do your patients live from sites of care?
• What are the demographics and health needs of your organization’s patient population?
• Which services will your contracted health plans reimburse for?
• What is your organization’s capacity and ability to build telemedicine services internally?
• Which companies are the right partners to support your telemedicine services?
• What is the level of technology adoption in your organization, and what are the technology habits of your patient population?

HIMSS: Only 3% of Providers Believe Their Organization is Highly-Prepared for Transition to Value-Based Payment Model

By Claire Thayer, March 14, 2016

The clock is ticking! There’s a lot of incentive for hospitals and physicians to transition to value-based care.  With the onset of the Affordable Care Act, HHS has set a goal of tying 30% of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.  HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs. Last week it was announced that  more than 30 percent of Medicare payments are now made through alternative payment models tied to quality outcomes.

The 2016 HIMSS Cost Accounting Survey finds that while the transition from fee-for-service to pay-for-value has been referred to as one of the greatest financial challenges the U.S. healthcare system currently faces,  a mere 3% of respondents believe their organization is highly prepared to make the transition from fee-for-service to a value-based payment system.

The Top 3 Needs in transitioning to a value-based payment system, identified in the HIMSS Survey:

• Tools to track and evaluate quality of care
• Better communication between disparate providers
• Consistent definition of quality by specific type of disease

Retail Clinics: Trying to Reconcile Cost Per Visit, Utilization, Access and Convenience

By Clive Riddle, March 10, 2016

The March issue of Health Affairs features a paper presenting study findings on retail clinic:  Retail Clinic Visits For Low-Acuity Conditions Increase Utilization And Spending. The title would seem to say it all regarding their findings. The study involved retail clinic use by 3 million Aetna members, from 2010 to 2012 for 11 low-acuity conditions. 

Here’s what the authors had to say in part in their abstract: “We found that 58 percent of retail clinic visits for low-acuity conditions represented new utilization and that retail clinic use was associated with a modest increase in spending, of $14 per person per year. These findings do not support the idea that retail clinics decrease health care spending.”

Kaiser Health News, in covering the story, notes that “The study doesn’t contradict earlier research that found retail clinics provide care that costs 30 to 40 percent less than similar care provided at a physician’s office and that the treatment for routine illnesses was of similar quality. But it suggests those savings are more than offset by increased use of medical services.”

But for some who embrace this perspective, but also are critics of increased consumer cost-sharing including high deductible plans that can limit access, is this perhaps a bit contradictory from a policy standpoint? If you are concerned the increased access and use of such services drives up costs, should you be concerned about cost savings measures that decrease potential access and use?

Interestingly, a Policy Brief in last month’s Health Affairs  on High Deductible Health Plans features the lead-in: “As high-deductible health plans become increasingly prevalent in both group and individual markets, it remains to be seen how they will affect health care access and outcomes.”

Is it a paradox that high-deductible health plan consumers are target audiences for retail care clinics?

Last month, NPR, Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health released the 42-page study: Patients’ Perspectives on Health Care in the United States which addressed retail clinic and urgent care use among many things. 92% of survey respondents rated retail clinic costs as reasonable, and 74% rated urgent care costs as reasonable, compared to 77% rating their personal doctor visit costs as reasonable and 58% rating emergency room costs as reasonable.

Granted, the study published in Health Affairs didn’t dispute the lower cost per visit – they just conclude that the retail supply creates demand and thus drives up costs. But what about access, and what happens to overall costs when access isn’t adequate? Isn’t that the critique of high deductible plans – that high out of pocket costs become a barrier to access?

The argument put forth in Health Affairs is your out of pocket costs might be higher per visit, but ultimately lower overall, by always sticking with your personal doctor because you will see them less.

And see them less you very well may. Another aspect of access addressed in the NPR study: 22% said they could not see their regular doctor at some point in the past two years when they needed health care, with the number one reason the doctor did not have any available appointment times (followed by care was needed at night or on the weekend.)