Patients Switch Doctors Based on Service, Not Just Care or Costs – Think “Text”

There’s more evidence of shopping behavior among patients: there’s new data showing that patients-as-consumers switch healthcare providers not due to quality of care or costs, but because of lack of service.

I discovered one key verb and feature patient-consumers expect from doctors: it’s the ability to text, for appointment reminders, alerts, treatments, and communicating with the practice.

SolutionReach, in the business of patient engagement, conducted a survey among 500 consumers asking about primary care providers, communication experience and satisfaction levels. The company presented the research results in a webinar on 29 June 2017. The research was also written up in a report, The Patient=Provider Relationship Study, which mines the data for generational differences across patient cohorts by age.

The first table orders the features patients told SolutionReach they want versus those they have. The highlighted areas show the greatest gaps in service, all related to texting.

Here are some other key findings:

• Over all patients, only 32% are completely satisfied with their medical provider
• Due to dissatisfaction, 12% of patients say they have left their doctor’s practice, and 34% are considering leaving
• Generationally, 42% of Millennials are likely to switch doctors in the next couple of years; 44% of Gen X patients; and 20% of Boomers
• Dissatisfaction with practice logistics is driven mainly by convenient location, ease of making an appointment online or by phone, receiving reminders about upcoming appointments, and ease in getting that appointment.

“Patients are not leaving because of poor quality care,” SolutionReach concluded. Poor experience is driving at least one-third of patients to seek a new provider practice.

Health Populi’s Hot Points: The findings here are part of a larger growing market for retail health and healthcare, where patients, flexing consumer muscles, are feeling empowered to make more decisions on their own behalf. While cost continues to be a major factor in healthcare decision making, service levels are highly tied to communication, access, convenience and transparency.

My recent take on West’s research into patient experience in healthcare reinforced this consumer demand.

Note the last chart, which features data from the 2017 Temkin Experience Ratings which I’ve written about here in Health Populi. Health plans rank at the bottom, and retail, fast food, and financial services at the top. The latter create the high benchmark for customer service that legacy healthcare stakeholders — hospitals, physicians, pharma, and health insurance — are expected to meet.

Remember: the last-best consumer experience people have is the benchmark against which they compare future experiences across all industries, whether banking, food, hospitality, or package delivery. If patients are paying more for healthcare, they expect that higher benchmarked experience.

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Should Republicans support Unions?

I’m not talking about civil unions (that topic is for another blog)…but instead actual trade unions. Compared to Democrats, Republicans have been relatively pro-business and anti-union for many years.  However, The Atlantic has an article making the case that Republicans should become more pro union.  Perhaps not pro-union in the traditional US union setting but maybe more like German works councils.

Why would Republicans do that?  First, Republicans may for ethical or political reasons decide that some support for lower income individuals is necessary.  If that is the case, then two of the most prominent methods of providing social support or the government.  The problem with unions is that only employed individuals and their families receive union benefits. Unions also often provide financial rewards more based on seniority rather than performance.  In theory, government provision of social support programs (e.g., health insurance, unemployment insurance) could be done fairly for all individuals regardless of employment status.  Government provided benefits, however, have two key problems.  First, politicians may decide to enact programs for political reasons rather than maximizing social welfare.  Second, there is often no hard budget constraint or at the least much less financial discipline.  Firms have an incentive that any benefits provided to unions and their workers is done in a cost effective manner; governments have similar incentives, but the budget constraint is not as strong.  For instance, it is very difficult for governments to roll back benefits in tough times without significant backlash; it is also difficult for businesses to do this as well, but they have a financial reason to make these hard choices.

I am not advocating for or against an increasing role of unions in the workplace, but the proposition that Republicans could actually become the pro-union party would be an interesting turn of events.

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Health Policy Institute offers unmatched, usable information

Wise words on State vs. Federal Administration of Medicaid

Yuval Levin has an interesting article in The Nation on Obamacare and the Senate’s most recently proposed bill, the Better Care Reconciliation Ace.  There has been a lot of arguments on both sides of the aisle about Better Care especially in terms of the provisions to decrease Medicaid funding and devolve more power to the States.  Mr. Levin believes that this is generally a good idea, but his comments below suggest that more of us should be less certain in our beliefs and more open to the possibility the opposition–whether Democrat or Republican–actually has some valid points.

In its scope and structure, this redesigned waiver would be unlike anything else in American federalism — which also means we don’t know how it would work.  Those of us inclined to look favorably upon a bottom-up, experimental mindset in policy design will be inclined to think the best of the possibilities here. I am very much in the grip of this prejudice myself. Those inclined to think the state governments are filled with bumbling fools while Washington overflows with subtle expertise will think the worst of this idea. But these different expectations are all rooted in roughly equal ignorance, and the results will probably be mixed enough to leave us all feeling mostly confirmed in our presuppositions in time — just as the performance of Obamacare has.

Do read the full article.

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Student loan-repayment options for dental residents

Access to credible information on schizophrenia patients’ medication adherence by prescribers can change their treatment strategies

Below is the abstract for my most recent publication titled “Access to credible information on schizophrenia patients’ medication adherence by prescribers can change their treatment strategies: evidence from an online survey of providers“.  It is work with Suepattra G May, Anshu Shrestha, Charles Ruetsch, Nicole Gerlanc, Felicia Forma, Ainslie Hatch, Darius N Lakdawalla, and Jean-Pierre Lindenmayer.  The video abstract is also posted below.

Objective: Overestimating patients’ medication adherence diminishes the ability of psychiatric care providers to prescribe the most effective treatment and to identify the root causes of treatment resistance in schizophrenia. This study was conducted to determine how credible patient drug adherence information (PDAI) might change prescribers’ treatment decisions.
Methods: In an online survey containing 8 clinical case vignettes describing patients with schizophrenia, health care practitioners who prescribe antipsychotics to patients with schizophrenia were instructed to choose a preferred treatment recommendation from a set of predefined pharmacologic and non-pharmacologic options. The prescribers were randomly assigned to an experimental or a control group, with only the experimental group receiving PDAI. The primary outcome was the prescribers’ treatment choice for each case. Between-group differences were analyzed using multinomial logistic regression.
Results: A convenience sample (n=219) of prescribers completed the survey. For 3 nonadherent patient vignettes, respondents in the experimental group were more likely to choose a long-acting injectable antipsychotic compared with those in the control group (77.7% experimental vs 25.8% control; P<0.001). For 2 adherent but poorly controlled patient vignettes, prescribers who received PDAI were more likely to increase the antipsychotic dose compared with the control group (49.1% vs 39.1%; P<0.001). For the adherent and well-controlled patient vignette, respondents in both groups made similar treatment recommendations across all choices (P=0.099), but respondents in the experimental arm were more likely to recommend monitoring clinical stability (87.2% experimental vs 75.5% control, reference group).
Conclusion: The results illustrate how credible PDAI can facilitate more appropriate clinical decisions for patients with schizophrenia.

Source:

• hafrin J, May SG, Shrestha A, Ruetsch C, Gerlanc N, Forma F, Hatch A, Lakdawalla DN, Lindenmayer JP. “Access to credible information on schizophrenia patients’ medication adherence by prescribers can change their treatment strategies: evidence from an online survey of providers“. Patient Preference and Adherence. 27 June 2017 Volume 2017:11 Pages 1071—1081. DOI http://ift.tt/2tjlTkE

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Costs of Healthcare Top Americans’ Financial Concerns: It’s Financial Health Matters Day

Americans are most worried about healthcare costs among all financial concerns; most people in the U.S. also believe the Federal government should ensure that all people have health coverage.

Two polls published in the past week point to the fact that most U.S. health citizens are concerned about health care for themselves and their families, driving a growing proportion of people to favor a single-payer health system.

The first line chart illustrates a dramatic trajectory up of the number of American identifying healthcare costs as their #1 financial problem, rising from 10% of people in 2013 to 17% in 2017.  Note this proportion nearly reaches the 19% of public concern for healthcare costs in 2007 just before the Great Recession hit, the Gallup Poll found. Gallup surveyed 1,009 U.S. adults over 18 the week of June 7, 2017.

The relative low of 10% of people most concerned about healthcare costs was felt in 2013 as people grew more confident in health security: the Affordable Care Act was being implemented, and 2013 was a significant year of Medicaid expansion, with health insurance exchanges taking effect on January 1, 2014.

The poll found that, after healthcare cost concerns, the most important financial problems families in the U.S. face today are:

• Too much debt, and not enough money to pay those debts, 11%
• Lack of money, low wages, 10%
• College expenses, 10%
• Cost of owning/renting a home, 9%
• High cost of living, 8%
• Retirement savings, 6%
• Taxes, 5%.

Most Americans believe that the government is responsible to ensure health coverage for everyone in the nation, according to a poll from Pew Research Group conducted about the same time as the Gallup Poll in early June 2017.

Most Americans believe that the Federal government is responsible for ensuring that all Americans have health care coverage, according to a new poll from the Pew Research Center conducted between June 8 and 18. This represents an increase of 18 percentage points over the 2013 support, and approaches the largest percent for Federal government healthcare support seen back in Pew’s survey from 2006.

Over 33% of Americans, across all political parties, support a single payer health plan for the United States, up 5 percentage points since January 2017.

Support for single payer healthcare varies by political ID: 52% of Democrats support a single payer plan and 12% of Republicans, in this poll. The proportion of Democrats supporting a single payer plan grew 9 percentage points since January 2017 and 19 percentage points since 2014.

While only 1 in 10 Republicans support a single national health plan, 57% of Republicans still support the Federal government sponsoring Medicare and Medicaid for seniors and the poor, Pew’s research found.

Age is a predictor for single-payer support: nearly one-half (45%) of America’s youngest voters, ages 18 to 29, support a national single payer health plan.

Health Populi’s Hot Points:  Today is Financial Health Matters Day, a project of the Center for Financial Services Innovation (CFSI). Clearly, healthcare financial health matters to Americans, which underpins a growing sense of healthcare insecurity in America.

The sentiment is expressing itself in the number of people in the U.S. supporting a single-payer healthcare system, noted by the Pew survey.

Follow Financial Health Matters Day on Twitter using hashtag #FinHealthMatters.

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Trials in Health Policy

Scientists often use randomized controlled trials (RCT) to examine whether certain treatments have a causal effect on patient outcomes.  For social scientists, however, conducting an RCT is more difficult.  Nevertheless, there have been a number of health policy trials.

In a recent NEJM paper, Newhouse and Normand (2017) review some of these trials.  A summary is below:

Trials that vary prices paid by patients:

• RAND Health Insurance Experiment. This experiment randomized people between full coverage (i.e., no cost sharing) and various cost sharing insurance schemes.  The study found that for the average patient, reduced cost sharing did not affect health outcomes, but health did improve for patients with more severe initial health limitations or those that were low income. The study also found that paying providers using prepaid (i.e., capitation) plans compared to fee-for-service physicians reduced hospitalizations).
• Oregon Health Insurance Experiment. In 2008, Oregon initiated a limited expansion of its Medicaid program for low-income adults through a lottery drawing of approximately 30,000 names from a waiting list of almost 90,000 persons. Selected adults won the opportunity to apply for Medicaid and to enroll if they met eligibility requirements.  Comparing outcomes of lottery “winners” and “losers”, the authors found that emergency department use increased among lottery winners and overall healthcare utilization also incrased.
• Post–Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE). Study made drugs free after acute myocardial infarction. The group in the free drug arm had 4-6% higher adherence and fewer major vascular events and revascularization.

Trials that vary reimbursement.

• RAND Health Insurance Experiment. This experiment also randomized people between traditional fee-for-service practices and an HMO where physicians were salaried employees and the HMO received a flat per-member, per-month payment.  Their study found that patients in the HMO had fewer hospitalizations compared to those in FFS practices.
• Randomization for treatment of LDL cholesterol (LDL-C) . Physicians in the incentives arm were eligible to receive bonus payments when their patients met LDL-C goals and in the control arm no incentative payments were made.  The physician incentives did lead to a reduction in LDL-C.

The article also provides a summary of some of the key decisions researchers need to make when designing a health policy trial.  These decisions include:

• What Inducement, if Any, Should Be Offered to Participants?
• How Many Sites Should There Be?
• How Long Should the Experiment Run?
• How Should Individual Patients or Families Be Assigned to Treatments?
• To What Degree Should Groups of Special Interest Be Oversampled?
• What Baseline Physiological Characteristics, if Any, Should Be Measured?

Source:

• Newhouse, Joseph P., and Sharon-Lise T. Normand. “Health Policy Trials.” New England Journal of Medicine 376, no. 22 (2017): 2160-2167.

 

 

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The associateship interview: Come prepared with smart questions

Dental referrals to other specialists: How your mouth can show symptoms of non-oral disease

You already know what cavities are, and probably knew that cavities—or tooth decay—is caused by bacteria. The great majority of us have had at least one dental restoration (the process you undergo to remove and replace a part of a tooth damaged by decay). It’s an almost universal experience.

 

There have been studies which have linked oral decay and an increased risk of respiratory infections, bloodstream infections, heart issues, diabetes, pregnancy complications, osteoporosis and arthritis. And while it’s unlikely—or, at least, still unproven—that tooth decay has any causal relationship with these diseases, the lifestyle factors which create the former are also risk-factors for developing the latter.

 

With this information in mind, getting your regular dental check-ups twice per year can also be a larger “health check” to step back and evaluate your lifestyle choices, and watch out for factors that can lead to other problems.

Signs of gum disease

 

When your gums are healthy, their color is that of a light pink, not unlike raw salmon. When their color is a darker red, this could be a sign of higher blood circulation and inflammation. Swelling and bleeding are the first obvious signs of gum disease. You might also notice your gums become smaller, as they recede and leave your teeth unprotected. Receding gums also correlate with teeth becoming more prone to decay. If you only notice bleeding occur during or after brushing, start by switching to a softer toothbrush or changing the way you brush. If these small changes eliminate the bleeding, you might not have developed full-blown gum disease yet, but probably have sensitivities you need to discuss with your dentist.

 

On the other hand, when bleeding is frequent and lasts for several minutes, it’s possible you might need treatment for chronic inflammation of your gums. Swelling should be treated as soon as possible, because your oral health will be more susceptible to bacteria, disease and decay if your gums aren’t healthy.

 

Infection can permeate your dental tissues all the way up to the top of the root, and cut through deeper teeth tissues as well. This is why it’s important not to procrastinate fixing tooth decay; restoring teeth while the decay is accessible gives you the best shot at blocking further spread of disease.

 

How to prevent the spread of infectious gum disease

 

Gum disease can be genetic, meaning the infection will activate again and again. If you have these genetic predispositions, it’s important to undergo regular professional cleanings, at least once every six months. Regular cleanings aren’t just about keeping your teeth clean, after all—they’re also about keeping track of your gums. Gum disease can lead to other serious maladies—oral and other—including oral cysts, heart disease, trouble controlling blood sugar, and even premature delivery among pregnant women, according to the National Institute of Dental and Craniofacial Research.

 

Oral disease as an indicator of other problems

 

In addition to the health of your teeth and gums, dental checkups monitor the condition of your tongue, saliva and breath. Bleeding wounds and other oral problems are mostly benign and can easily be remedied, but some of these irregularities can be an indicator of other diseases. Just as oral disease can lead to illness elsewhere by weakening your immune system, other illnesses can also manifest themselves through diseases in your mouth. For example, kidney failure and liver disease can show symptoms of bad breath, due to imbalances of enzymes in proper digestion.

 

Your body is connected system-by-system, and it’s natural that symptoms of a disease might show in unexpected places. By caring for your teeth and treating oral disease, your dentist might also indirectly help you detect other problems, and advise you to consult with the appropriate specialist or general practitioner. Start with regular cleanings, and you’ll be on your way to more proactive action toward your greater health.

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Medicare’s value-based purchasing fail?

Value-based payment is the latest hot topic.  One question remains, however, does it work?  Does paying for quality improve quality.  A study by Zuckerman et al. (2016) finds that the hospital readmissions reduction program (HRRP) did appear to reduce re-hospitalization rates among the targeted conditions.

What about the hospital value-based purchasing program (HVBP).  Beginning in fiscal year 2013, the Affordable Care Act mandated that Medicare payments to acute care hospitals be tied to some performance metrics.  Initially the incentive payment was 1% of total reimbursement, but by FY2017, this figure has climbed to 2%.  A question is, did HVBP improve patient outcomes?

According to a study by  Ryan et al. (2017):

Our results are consistent with those from studies that have shown that HVBP did not increase quality with regard to clinical process or patient experience in its first 9 months 15 and more recent research indicating that HVBP did not reduce mortality over the first 30 months of the program.

The authors reached this conclusion by running a difference-in-difference analysis of acute care hospitals.  They compared differences in these key outcomes before and after the implementation of HVBP for acute care hospitals subject to bonuses and penalties and compared them against critical access hospitals (CAH), which were not subject to the HVBP financial incentives.

What would have worked? To be honest, that is not known.  However, the authors hypothesize that:

…alternative incentive designs — including those with simpler criteria for performance and larger financial incentives — might have led to greater improvement among hospitals.

 

Sources:

• Zuckerman, Rachael B., Steven H. Sheingold, E. John Orav, Joel Ruhter, and Arnold M. Epstein. “Readmissions, observation, and the hospital readmissions reduction program.” New England Journal of Medicine 374, no. 16 (2016): 1543-1551.
• Ryan, Andrew M., Sam Krinsky, Kristin A. Maurer, and Justin B. Dimick. “Changes in Hospital Quality Associated with Hospital Value-Based Purchasing.” New England Journal of Medicine 376, no. 24 (2017): 2358-2366.

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Artificial Intelligence, AI, Is Becoming the New Operating System in Health – Accenture

Artificial Intelligence, AI, can help drive the Triple Aim in healthcare, reducing cost, improving quality, and expanding access, according to Artificial Intelligence: Healthcare’s New Nervous System from Accenture.

Acquisitions of AI developers in health will be fast-paced, growing at a compound annual growth rate of 40% – “explosive” in the word of Accenture – moving from $600 mm in 2014 to $6.6 billion in 2021.

What these AI startups will do is to enable machines to sense, comprehend, act and learn, Accenture foresees, to augment administrative and clinical tasks which could free up healthcare labor (say, doctors, other clinicians, and accountants) to work at their highest-and-best-use.

The most impactful AI-driven application would be robot-assisted surgery, generating $40 billion of value, annually, by 2026. Next in AI-health value-creation include virtual nursing assistants (valued at $20 bn annually), administrative workflow support ($18 bn), fraud detection ($17bn), and medication error reduction ($16 bn).

Together, the ten AI applications Accenture studied could generate at least $150 bn worth of value in U.S. healthcare, shown in the second chart.

Health Populi’s Hot Points:  AI is a relatively new-new thing, but it’s getting a lot of attention and coverage beyond wonky health-tech media. Newsweek pronounced AI as a “cure for America’s sick-care system” in the magazine last month, highlighting many examples where algorithms, big data, and cognitive computing could help stem the cost-curve in US healthcare. Addressing diabetes care, mining electronic health records databases, and capitalizing on what’s known about genomes were some specific areas Newsweek identified.

We should be mindful of the history of medical tech innovation, and how the adoption of new-new healthcare things has often resulted in disparities. This WIRED UK interview with the World Health Organization’s Director-General warns of the potential for nation-to-nation health disparities when it comes to uneven AI adoption. We don’t have to go so far globally to imagine that AI could also result in digital health divides in the U.S.

That would be ironic and costly, indeed, given the nature of the burden of chronic disease in America which is largely driven by social determinants of health. AI can go a long way to identifying gaps in health citizens’ access to these contributors to health (such as food deserts, sick buildings, financial ill health). Will AI applications be deployed in these areas along with healthcare system factors? That’s a huge opportunity that would support Newsweek’s bullish forecast for AI as a cure for American healthcare.

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Will Better Care deliver better care?

The Senate’s new health care bill, the Better Care Reconciliation Act of 2017, proposes a number of changes to the Affordable Care Act.  The Kaiser Family Foundation has a detailed breakdown of the bill and compares it with the Affordable Care Act that President Obama passed and the American Health Care Act that was proposed by the House of Representatives. How should we evaluate these changes?

From an economist’s point of view, there are generally two dimensions over which one evaluates economic policy: efficiency and equity.   Efficiency asks whether the bill will increase market efficiency and improve overall social welfare.  Efficiency is not everything.  As a society we value providing support for the least fortunate among us.  Whereas maximizing efficacy is generally a good thing, equity depends on societal preferences.  No redistribution would provide little support to the poor, complete equity would lead to a communist society with little incentives for innovation or hard work.

Now back to the Better Care bill.

In terms of efficiency of health insurance markets, there is little to like.  The bill keeps in place premium subsidies for the working poor, but the value of these subsidies drops from 70% of the plan’s actuarial value to 58%.  Additionally, provisions to reduce cost sharing provisions for the poor  have been stripped.  Thus, fewer people are likely to buy insurance, particularly healthy people.  Second, the bill eliminates the individual mandate.  Thus, fewer people are likely to buy insurance, particularly healthy people.  Third, the employer mandate will be repealed meaning that fewer employers will offer insurance.   Many people may claim that the Obamacare health insurance exchanges were suboptimal.  For instance, community rating gives health insurers an incentive to provide poor care to the sickest patients to get them off their plan.  Nevertheless, a suboptimal but functional insurance market is better than one likely to go into a premium death spiral, which is likely what we have with the Better Care plan.

In terms of overall societal efficiency–taking into account things besides health care–there are some small things to like.  Taxes are lowered, which is a positive due to the deadweight loss taxes create.  For instance, distortionary taxes on specific services (e.g., health insurers, pharmaceuticals, medical devices) are dropped.  Allowing individuals to buy health insurance at 58% of actuarial value will allow more people to buy insurance, and still have funds left over for other expenses (even though some of those expenses will inevitably be out-of-pocket health care costs not covered by insurance).

In terms of equity, the plan is certainly bad for the poor.  Medicaid expansions will be rolled back over time (although not as quickly as in the AHCA).  As described above, premium and cost sharing support will decrease.   As described by Axios, the biggest winners of the bill are young healthy people who either no longer need to buy health insurance or who can buy less generous but less expensive (58% actuarial value) coverage.  The biggest losers are the poor and elderly, who will face some combination of higher premiums, or more cost sharing.  Better Care does provide some funds to States to set up high risk pools–which could be separate from the general health insurance exchanges and thus could drive down premiums–through the State Stability and Innovation Program.

In short, despite some tax cuts, there is a serious risk that the health insurance exchanges  collapse and poor and near elderly individuals are left with either no insurance or much less generous insurance.

Politically, this was much less of a repeal and replace, rather just more of the same.  According to Megan McArdle:

I called the House health care bill “Obamacare Lite,” but compared to the Senate bill, the House was offering a radical new taste sensation. The Senate bill touches very little of the underlying architecture of Obamacare; all it does is eliminate the insurance mandates, cut spending and give states somewhat more autonomy in how those dollars are spent. Repeal Obamacare, you say? They’re barely even worrying it.

 

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Health Wonk Review is up

Joe Paduda has posted  this week’s version of the Health Wonk Review (HWR) – The double edition at Managed Care Matters.  Check it out.

I also found this very honest discussions of effects of concussions in the NFL from former player and Hall of Famer Warren Sapp.  The video is below and the article here.

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Shopping Food for Health: the 2017 U.S. Grocery Shopper Trends

Wellness is at the grocery store, the vast majority of U.S. health citizens say. 8 in 10 U.S. shoppers are concerned about the nutritional content in the food they eat.

As grocery shoppers look for more fresh and less processed foods, grocery stores are seen as trusted allies for meeting wellness needs. Grocers are coupling the growth of more healthy packaged foods in the middle of the store with more fresh and prepared food options that consumers see as healthier than restaurant meals, according to U.S. Grocery Shopper Trends 2017 from FMI (the Food Marketing Institute) and Hartman Group.

While “my primary” food store falls below trust in wellness supported by “my family,” doctors, “my friends,” farmers, and health clubs, my personal grocer rank higher as an ally for wellness than health insurers, drug stores, restaurants, media, food manufacturers, and the many celebrity chefs on food TV shows — along with government, entertainment, and fast food — lowest of the wellness-ally food chain (pun intended).

What’s important to note in the first bar chart is the red-lines, which consumers believe are industry segments that “work against me” for wellness. Here it’s where fast food, entertainment, government, food manufacturers, and health plans rank “higher,” meaning they are perceived as militating against consumers’ personal wellness strategies.

Consumers who seek wellness at the grocery store look for product claims to support health missions: most frequent claims sought are for low sugar, low sodium, no artificial ingredients, whole gain, no trans fats, high fiber, no preservatives, no added hormones, natural, and non-GMO. Low calorie and no/low-fat are lower down the scale of importance.

“Transparency is the currency of trust in the digital age,” FMI and Hartman Group recognize. And transparency is important for health-oriented grocery shoppers, for whom finding out what’s in products, where they’re sourced, and how they’re made play intimately into wellness values. People seeking healthy lifestyles look to grocers for inspiration to inform and support healthy living. Key “food culture” factors for these shoppers are:

• Avoiding negative ingredients
• Seeking positive nutrition
• Favoring minimal processing, and
• Allying with the store in wellness.

An emerging trend in food stores is the presence of a “grocerant:” that is, a restaurant located in the grocery store. Eating in grocery stores has gained more traction among consumers while restaurant sales have been struggling. More grocery stores are also preparing ready-to-eat items like rotisserie chickens, salads, and sushi to provide families greater convenience while enabling them to eat-at-home, which is perceived as a more healthy option than eating out. Two in three U.S. households with kids bought prepared meal items at least sometimes, according to the FMI/Hartman Group survey.

This study was conducted among 2,145 U.S. primary shoppers age 18 and over in February 2017.

Health Populi’s Hot Points:  This research was published within days of the news that Amazon would purchase Whole Foods. Virtually every vertical market analyst has opined on how the Amazon/Whole Foods combination would impact their sector: for example,

• A take on how banking will be affected by the Amazon/Whole Foods deal
• A look at transportation in the context of the acquisition
• How the deal will affect real estate
• Insights into the deal’s impact on retail
• Here are thoughts on the deal’s impact on retail grocers — the most direct impact.

Health and wellness are also a part of this deal’s halo effect. I wrote about Amazon’s foray into prescription drugs and the pharmacy market just two weeks ago here in Health Populi. Add food and storefronts into the mix, and you have further building blocks for retail pharmacy storefronts on Main Streets throughout the U.S. You also have an approach to food-as-medicine in local stores, which can be staffed by nutritionists and health coaches on the ground for people who seek face-to-face high-touch advice.

Of course, Amazon’s core competence is ecommerce, so these services can also, inevitably, be deployed through mobile apps and web-based services.

Underneath all of this is data. As food data can mash up with pharmacy data and consumer-generated data through wearable tech and the Internet-of-Things at home and in the car, Amazon will play a growing role well beyond the stuff we buy. They’ll be an integral part of our health and wellness.

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Are you satisfied? – Practice setting and dentist job satisfaction

The six CE topics new dentists want to explore

Mid-week Links

• U.S. ranks poorly in differences in self-reported health by income.
• FDA pulls opioid off the market.
• Medicaid reform.
• Follow the money.
• Value frameworks and IVI
• Insurers now joining Obamacare?

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Global Drug Sales Forecasts Fall For Next Five Years

Total prescription drug sales have been trimmed, based on calculations of EvaluatePharma which forecasts a $390 bn drop in revenues between 2017 and 2022.

“Political and public scrutiny over pricing of both new and old drugs is not going to go away,” EvaluatePharma called out in its report.

The intense scrutiny on pharma industry pricing was fostered by Martin Shkreli in his pricing of Daraprim (taking a $13.50 product raising the price to $750), Harvoni and Sovaldi pricing for Hepatitis C therapies, and last year’s EpiPen pricing uproar.

A May 2017 analysis of prescription drug costs by AARP judges that, “Nothing stops drug companies from charging the highest price the market will bear.”

Projecting a compound annual growth rate of 6.5% between 2017 and 2022, EvaluatePharma identifies the following drivers and brakes on drug sales over the next five years:

Drivers fostering Rx revenues include:

• Additional sales from Orphan drugs, accounting for 32% of total growth
• 27 new FDA approvals in 2016, with the pace picking up in 2017
• $522 mm average value of new approvals in 2016, above 2010-2015 averages
• A 13% compound annual growth rate for oncology therapies to reach $192 bn in 2022.

The brakes on worldwide prescription drug sales grow are expected to be:

• $194 bn sales at-risk due to patent expirations between 2016-22
• 54% sales erosion due to biosimilars expected for top-selling biologic therapies
• $4 bn average R&D spend per new molecular entity (NME) since 2006, increasing pressure of pharmaceutical companies’ productivity.

Health Populi’s Hot Points:  “Many patients will feel as though the cost of medicines is still rising because the amount they must personally pay ‘out of pocket’ is linked to the list price of drugs and does not factor in discounts,” the Financial Times noted in its coverage of the EvaluatePharma forecast.

“Although Donald Trump has yet to directly intervene on US drug costs, the threat remains ever present and some pharma companies have announced their own pre-emptive strikes, by publicly announcing caps to price hikes,” the report asserts.

Notwithstanding some (not all) pharma companies’ efforts to rationalize or moderate prescription drug pricing, American voters are fully supportive of the Federal government allowing Medicare to negotiate lower prices for medications, shown in the Kaiser Health Tracking Poll from April 2017.

The issue of drug pricing is, for most Americans, part of a larger discussion on health care reform that is not being addressed through the AHCA discussions or as aggressively by the White House as President Trump had committed during his campaign. Remember Candidate Trump’s pronouncement — “I’m going to bring down drug prices,” Mr. Trump said, quoted on the TIME website naming him Person of the Year. “I don’t like what’s happened with drug prices.”

The President has, for now, decided on a strategy to ease regulatory drug approval hurdles in the FDA as a tactic to lower drug prices, discussed in the New York Times here. This could be akin to an expectation of trickle-down price reductions. But it may not produce as direct an impact on consumer-facing drug prices as voters  — Democrats, Independents, and Republicans alike — desire.

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ADA-endorsed student loan program rebrands to Laurel Road

Can physician quality be captured by a single composite measure?

Value-based payment for providers is often predicated on being able to measure physician quality with a single composite measures.  For instance, Medicare’ s Value-Based Payment Modifier (Value Modifier) combines a variety of individual quality metrics across domains to create a single quality score.  Payment to physicians is adjusted based on a combination of physician quality and resource use.

The question remains, however, whether these composite scores do a good job of measuring quality.  Martsolf, Carle, and Scanlon (2017) notes that this may not always be the case.

However, the creation of such global composite measures is not without risk. When multiple indicators measuring distinct aspects of quality are inappropriately combined into a single measure, the resulting composite measure is not useful or even completely uninterpretable. For example, when indicators measuring unrelated constructs are included in a single score, the high score on some indicators could “hide” low scores on other indicators or vice versa. In this case, the composite measure does not provide a clear quality signal. Inclusion of invalid composite measures could actually hurt quality reporting by leading to physician practice misclassification.”

To take a simple example, Physician A could be excellent at diagnosing a condition but poor at treatment and Physician B could be excellent at treatment but poor at diagnosis.  If this information where known to patients, and all patients went to Physician A for diagnosis and Physician B for treatment, they would both be excellent at treating the patients they do even though a composite score could rank both physicians as average. This example captures cases where quality is multidimensional.  Quality metrics also must be reliable as well and accurately capture underlying physician quality when measured across a reasonable sample size of patients.

While this argument is theoretical, the Martsolf, Carle, and Scanlon (2017) paper examines whether “HEDIS process indicators [can] be used to measure a single construct for the purpose of creating an internally valid global composite measure of physician practice quality.”  The authors use physician quality scores from the Puget Sound Health Alliance’s (PSHA) Community Checkup scorecard.  Their analytical approach was as follows:

We used measurement models (e.g., confirmatory factor analysis) to investigate the “ dimensionality” of 19 specific physician practice quality indicators. In this case, dimensionality refers to the extent to which multiple indicators can be used to assess a single construct or multiple constructs. Specifically, the measurement model approach is used to assess the extent to which a single factor accounts for the observed covariance among indicators. Models that “fit well” do a good job of reproducing the observed covariance matrix.

Using this approach, the authors’ results “…did not support the psychometric validity of a single unidimensional composite.”  The implications of these results are very interesting.  Although many payers and researchers have argued for a single quality measure for physicians and other providers, in practice this single measure may work poorly.  Thus, tying reimbursement to quality–if quality is measured using HEDIS process measures–is problematic.  In the words of the authors:

Our results may call into question efforts to create and use single unidimensional measures of physician practice quality, as using such measures can lead to spurious conclusions about quality by hiding important aspects of quality and to increased physician misclassification by exacerbating the measurement error inherent in any given measure. Particularly, performance on an invalid global measure of physician practice quality may obscure practices’ performance on more specific areas of clinical care.

For more details, do read the whole article.

Source:

• Martsolf, Grant R., Adam C. Carle, and Dennis P. Scanlon. “Creating Unidimensional Global Measures of Physician Practice Quality Based on Health Insurance Claims Data.” Health services research 52, no. 3 (2017): 1061-1078.

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Everything You Need to Know About Milk Teeth

Although they only enjoy an ephemeral existence, milk teeth are the main protagonists in the story of a child’s development. Affecting a child as much physically as psychologically, milk teeth deserve special attention and care.

Legends about milk teeth

We’ve long nurtured certain narratives around milk teeth. The legend of the Tooth Fairy is ubiquitous in almost every part of the world. Children place their lost tooth under the pillow, where it can be collected by the Tooth Fairy in exchange for a small amount of money. In Turkey and Greece, the milk tooth is thrown on the rooftop, and the child makes a wish. A similar ritual is performed in India, Korea and Vietnam, although the exact tradition is applied only to the lower baby teeth, while the upper ones are put under the carpet.

When do baby teeth grow?

Milk teeth—also known as deciduous teeth, baby teeth, temporary teeth and primary teeth—are the first to represent a set of teeth in the mouth of young humans and mammals. The development of primary teeth is initiated in embryo stage of pregnancy, and ends few months after the appearance of the last milk tooth in the baby’s mouth.

There are 20 teeth in deciduous dentation, five on each side of each jaw. The first teeth that grow in the mouth are the lower incisors, appearing in the jaw six months after birth. The last ones are the second milk molars, which come in between the 22^nd and 33^rd months.

Even though most milk teeth appear between the 6^th and 33^rd month of life, it is not uncommon to witness their growth half a year before or after this interval.

Milk teeth play a leading role in later oral health. They are also crucial for the proper development of facial bones, muscles, gums, tongue, etc. And, of course, milk teeth are saving the place in the jaw for permanent teeth.

Common misconceptions about milk teeth

1) “Cavities on milk teeth should not be treated, because they’re going to fall out anyway.” It’s important to be aware that primary teeth play a role in speech development and food chewing. They are also part of facial aesthetics, so their role in the socialization of a child is not to be neglected. Untreated milk teeth are also the source of chronic infections that can affect rudiments of permanent teeth.

2) “Children can brush teeth on their own.” The subtle movements required for proper tooth brushing continue developing until a child is eight years old. Parents should control how often and how well the kids scrub their milk teeth, especially with younger children who are usually impatient with this habit.

3) “Feeding on a bottle doesn’t harm a baby’s oral health.” The second biggest factor in the development of cavities is the consumption of carbohydrates, especially over long periods of time. In most cases, a baby’s bottle is saturated with carbohydrates, which leads to baby bottle syndrome: cavity decay that quickly affects all teeth.

4) ”We won’t take our baby to the dentist unless there is a visible dental condition.” Children need to have regular dental check-ups, no matter how perfect their teeth look. It’s also important to start early with positive discussions about going to the dentist so the child doesn’t develop dentophobia.

Remember: no child is born with fear of the dentist; dentophobia is learned.

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The Future of Oncology Treatment and Value Assessment

Value frameworks are all the rage of late.  But are payers really using them?

According to my colleague Jeremy Schafer, the answer is yes.  From an article in Drug Topics:

“Value assessment may become more important as the health-care market shifts to outcomes and value-based reimbursement models,” said Jeremy Schafer, PharmD, MBA, Senior Vice President and Director for Payer Access Solutions at Precision for Value… “Our research has also found that payers currently not using value frameworks either anticipate doing so in the future or are relying on internal cost-effective analyses within their organizations…The most common way payers are using value frameworks is in choosing preferred therapies, comparing products within a class, and policy/pathway development.”

The articles continues to notes a number of limitations of the current value framework, such as their ability to accurately capture a treatment’s effect on patient quality of life as well as the medication’s convenience factor (e.g., injection vs. oral).  Schafer even cites the work of the Innovation and Value Initiative, where I serve as the Director of Research.

New initiatives around value, such as one currently under development from the Innovation and Value Initiative, may also help to add transparency by allowing pharmacists and other stakeholders to measure value from a variety of perspectives within a single tool. They may also allow value measurement to be adjusted based on different methodological assumptions.

Do read the whole article.

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Consumer Experience Is An Integral Part of the Healthcare Experience

Patient satisfaction should be baked into healthcare provider service goals, according to Prioritizing the Patient Experience from West, the communications company.

West is in the business of improving communications systems, and has a vested interest in expanding comms in health. This research polled patients and providers to assess how each healthcare stakeholder perceives various patient satisfaction issues, which when done well are grounded in sound communications strategy and technologies.

Patient satisfaction is directly linked to the bottom lines of healthcare organizations, West contends, due to two key drivers:

1. Evolving payment models are increasingly tying patient satisfaction to reimbursements; and,
2. Increased consumer choice requires providers to meet patients’ expectations, delivering positive care experiences to retain patients and engender positive word-of-mouth from patient-to-patient.

West’s survey found that patients will take action when they are dissatisfied: namely, shopping around for new healthcare providers, or postponing seeing their current doctors or clinics. The younger the patient, the more likely this form of healthcare consumerism will take hold.

Cost still trumps other aspects of healthcare, with 50% of patients seeking healthcare providers who accept their insurance and 49% seeking advance knowledge of healthcare costs.

Other key experience factors beyond cost include consumer expectations of shorter waiting times, high level of expertise to treat illnesses, scheduling ease, improved interpersonal or communication skills, and friendly staff in the provider’s office. Overall, “slow healthcare” is in demand, with unhurried appointments during face-to-face visits in-demand.

More patients dealing with managing chronic health conditions have even higher expectations of healthcare providers for clearer communication, remote health monitoring, and between-visit support for an additional payment (e.g., $10 per month).

Health Populi’s Hot Points:  Underpinning reliable communications are three components: connectivity; technologies; and, smart user-centered design.

First, a patient or provider must have access to connections: broadband/WiFi, and faster is better for healthcare. This is the theme of new research from Ericcson, From Healthcare to Homecare, studying the crucial role for 5G networks that enable healthcare communications backbones that are efficient, resilient, and redundant to support, say, real-time robotic surgery, eICU remote monitoring, and virtual stroke care/support at the point of patient trauma.

Second, stakeholders must have access to technologies that range from broad-based platforms that integrate fragmented and siloed providers to mobile apps in patients’ hands.

Finally, the key role of user-centered design to ensure clinicians’ workflow is realistic and productive, and patient-targeted comms and tech are grounded in consumers’ values, cultural mores, and life-flows. The chart illustrates that a first-generation of consumers recognizes the role that digital technology can play to streamline their self-care.

All of this depends on connectivity, to which I’ve been referring as a social determinant of health for years. The FCC has recognized this through the agency’s Connect2Health initiative. Now, networks must proliferate to not only the last mile, but to the last un-connected U.S. health citizen to their preferred healthcare platform: the mobile phone.

 

 

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Your patients’ top fluoride questions — explained!

Does more spending improve outcomes?

A number of studies have claimed that increased health expenditures may result in no better, or even worse outcomes.  For instance, a paper by Fisher et al. (2003) looking at patients with acute myocardial infarction, colorectal cancer, or hip fracture finds that “Quality of care in higher-spending regions was no better on most measures and was worse for several preventive care measures.”  This analysis, however, examined variation in spending and quality by hospital referral region (HRR) and could suffer from the ecological fallacy.

A recent paper by Watson et al. (2017) examines the effect of increased spending out outcomes at the individual level among patients in neonatal wards.  The authors use the National Neonatal Research Database (NNRD).  The data contain information from infants treated in neonatal units in England between 2009 and 2013.  Costs were estimated based on Helathcare Reseource Group (HRG) codes and costs per intensive care cot day were estimated.  The key outcome variable was overall mortality and a secondary outcomes were in-hospital mortality and moribidity free survival.  The key explanatory variable cost per intensive care cot day.  The regression also controlled for the baby’s gender, gestational age, birth weight, and mother’s receipt of steroids as well as year, ward, and ward-year fixed effects. To control for the potential endogeneity, the authors also ran a fixed-effects instrumental variables (FE-IV) regression using patient distance to the nearest hospital as a instrument for the unit providing the treatment.

Using this approach, they found:

…a £100 increase in the cost per intensive care cot day (sample average cost: £1,127) is estimated to reduce the risk of mortality of 0.38 percentage points (sample average mortality: 11.0%) in neonatal intensive care. This translates into a cost per life saved in neonatal intensive care of approximately £420,000.

Their estimates for their secondary outcome also suggest that “reductions in the mortality rate are accompanied by equivalent rises in morbidity.”

Source:

• Watson, Samuel, Wiji Arulampalam, and Stavros Petrou. “The effect of health care expenditure on patient outcomes: Evidence from English neonatal care.” Health Economics (2017).

 

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Pharmacy and Outpatient Costs Will Take A Larger Portion of Health Spending in 2018

Health care costs will trend upward by 6.5% in 2018 according to the forecast, Medical Cost Trends: Behind the Numbers 2018, from PwC’s Health Research Institute.

The expected increase of 6.5% is a half-percentage point up from the 2017 rate of 6.0%, which is 8% higher than last year’s rate matching that of 2014.

PwC’s Health Research Institute has tracked medical cost trends since 2007, as the line chart illustrates, when trend was nearly double at nearly 12%. The research consider medical prices, health care services and goods utilization, and a PwC employer benefit cost index for the U.S.

The key points of the forecast are that:

Employers’ medical costs have settled into a “new normal” in the words of PwC, rising at single-digits below 6% over the past several years.

Medical prices are a greater driver of overall healthcare costs compared with utilization (use) of medical services, shown in the second chart

Pharmacy and outpatient costs will consume more of employers’ health spending in 2018 than in 2008. Pharmacy will grow to 18% of employer health spending in 2018, up by 20% since 2008. Outpatient costs will comprise 19% of health spending in 2018, increasing by 18% over the past ten years.

Inpatient costs will remain a flat share of spending at 30% since 2008, and spending on physicians will drop from 35% of share to 29% — a fall of 16%.

The opportunity for payors to lower costs based on branded prescription drugs coming off-patent will erode given fewer medicines moving to cost-saving generics in 2017. PwC points out that it takes as long as 24 months for the market to benefit from a fall in a drug’s price once going off-patent.

Health Populi’s Hot Points:  The cost growth of prescription drugs as a component of total healthcare spending takes center-stage in PwC’s 2018 trend projections. Two important studies out this week speak to the public perceptions on branded pharmaceutical costs, as well as a global perspective on the role of medicines in rich countries’ primary care systems.

9 in 10 U.S. consumers are concerned (somewhat or very) about the high cost of prescription drugs, according to a survey from CVS published this week. The poll was conducted among 2,195 registered U.S. voters in April 2017. While costs are seen as too high, one in two consumers also believes that there aren’t enough drugs on the market to treat the diseases they face. Most Americans support faster market entry of lower-cost drugs (e.g., generics) to substitute for more expensive brands, in favor of speeding up FDA approvals for biosimilars.

The second point is that in developed countries where health care universally covered, prescription drug spending is lower based on the encouragement of lower-cost alternative medicines and treatments. The result is lower overall pharmaceutical spending, according to a new study sponsored by The Commonwealth Fund published today. The research looked at 10 high-income countries’ spending on prescription drugs used in primary care in six common drug categories: hypertension, pain, cholesterol, non-insulin diabetes treatment, depression, and GI disorders (e.g., ulcer and heartburn). The nations with single-payer healthcare were more successful at maintaining lower costs. The key approach is that these countries leveraged greater purchasing power in negotiating drug prices with manufacturers, thus driving lower prices paid.

In the Kaiser Health Tracking Poll conducted last September 2016, 4 in 5 consumers support allowing the U.S. Federal government to negotiate prices for prescription drugs for Medicare. See the third chart: Federal negotiation for drug prices gets positive nods from Democrats (93%), Independents (85%) and Republicans (68%) alike. This is one of the few areas that receives tri-partisan support in America in 2017.

This is not a new wake-up call for the pharma industry, which has instituted a public marketing campaign to “Go Boldly” and communicate the sector’s commitment to new-new drug development. The industry should remember American health policy history, which PwC notes in the report: political and public scrutiny of pharma companies put downward pressure on the growth of drug costs in the 1990s under the President Clinton years, discussed here in a 1993 New York Times analysis. Read it and learn.

 

 

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ADA Foundation awards celebrate leaders

Quotation of the day: Health as capital

The thought that health is a form of capital goes way back to the 19th century.  Max von Pettenkofer compares health and economics and health states with capital in the following quotation:

Just as the effort to obtain greater profits, an not merely fear of losses, is the driving force in economics, so too it must be in hygiene as a doctrine of health.  Hygiene (as a subject) must establish and investigate all the influences exerted on the organism by its natural and artificial environment, in order to increase its well-being through this knowledge.  Health really is a form of property or capital, which is to be sure usually inherited, but which must also be acquired by its owner and can be increased as well as reduced.

This is quoted  from Death in Hamburg by Richard J. Evans, p. 242.

Pettenkofer–a Bavarian innovator– even called the subject of hygiene “health economics” to make the parallel even more explicit.

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Working with my father

Can financial incentives increase the effectiveness of weight loss programs?

As an economist, I would say “of course”!  Increasing the price (the reward for weight loss) generally leads to an increase in supply (of efforts to lose weight).  However, there is evidence that in some cases, adding a financial incentive can actually reduce effort.  For instance, Uri Gneezy and Aldo Rustichini (2000) found that adding a financial penalty when parents were late to pick up their children at daycare lead to an increase in the number of parents who arrived late to pick up their children.  As summarized by the Freakonomics podcast, some incentives were “…completely incompatible with money. Like, for example, avoiding the guilt of inconveniencing the day care workers.”

So, does paying for weight loss fall in the traditional economic realm where paying more leads to more effort or the Israeli daycare phenomenon?  According to a study by Finkelstein et al. (2017), the answer is the former.

We conducted a parallel-group randomized controlled trial from October 2012 to October 2015 with 161 overweight or obese individuals randomized to either control or reward arm in a 1:2 ratio. Control and reward arm participants received a four month weight loss program at the LIFE (Lifestyle Improvement and Fitness Enhancement) Centre at Singapore General Hospital. Those in the reward arm paid a fee of S$165.00 (1US$ = 1.35S$) to access a program that provided rewards of up to S$660 for meeting weight loss and physical activity goals. Participants could choose to receive rewards as guaranteed cash payments or a lottery ticket with a 1 in 10 chance of winning but with the same expected value. The primary outcome was weight loss at months 4, 8, and 12. 161 participants were randomized to control (n = 54) or reward (n = 107) arms. Average weight loss was more than twice as great in the reward arm compared to the control arm at month 4 when the program concluded (3.4 kg vs 1.4 kg, p < 0.01), month 8 when rewards concluded (3.3 kg vs 1.8 kg, p < 0.05), and at month 12 (2.3 kg vs 0.8 kg, p < 0.05). These results reveal that a payment/rewards program can be used to improve weight loss and weight loss maintenance when combined with an evidence-based weight loss program.

The world of sports also finds that financial incentives lead to weight loss.

The Finkelstein et al. 2017 study did find that weight loss was more persistent after the incentives ended (month 12), but it would be interesting to see if the financial incentives also lead to long-run weight loss multiple months after the incentives had ended.   If that was the case, then clearly neoclassical economics could not purely explain the result.  If that was the case, once the financial incentives were taken away individuals should go back to their preferred weight.  There may, however, be a status quo bias.  Getting people to change behavior may be costly and thus financial rewards are needed.  Once this behavior change has been made and turned into habit, however, perhaps the cost of continuing the healthier behaviors is lower and this a new optimal weight (which would likely fall between the weight with  financial incentives and pre-intervention weight) could be reached.

HT: Marginal Revolution.

Source:

• Finkelstein, Eric A., Kwang-Wei Tham, Benjamin A. Haaland, and Aarti Sahasranaman. “Applying economic incentives to increase effectiveness of an outpatient weight loss program (TRIO)–A randomized controlled trial.” Social Science & Medicine (2017).
• Gneezy, Uri, and Aldo Rustichini. “A fine is a price.” The Journal of Legal Studies 29, no. 1 (2000): 1-17.

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Organized dentistry: It’s all in the family

Mid-week Links

• ACA and healthcare spending.
• Risk adjustment and the ACA.
• Value framework harmonization?
• Is value-based pricing coming for drugs?
• “…it also caused mutations to more than a thousand other unintended genes“

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Helping People On A Path to Better Health with CVS @Retail

“Helping people on their path to better health” is the mission-mantra of CVS Health. Re-branded from its previous identity as CVS/pharmacy, the organization convened a Health Innovation Summit with its vendor partners whose products fill the front-of-store shelves to empower, inspire and support consumers to manage health and wellness for themselves and their families.

I was grateful to provide the first talk for the day, setting the day’s context with a discussion of the evolving retail health/care landscape with the consumer at the center. The consumer is, at any point in a 24-hour day, a person wearing many hats (a worker, a parent, a social animal, a community volunteer, with a spiritual life); a patient, sometimes; and, a payor, bearing more costs for healthcare.

Steve Laughlin who leads IBM’s global consumer distribution effort then discussed the growing role of data in retail, and how the company’s cognitive computing and analytics engines can work in health to anticipate emerging epidemics and health trends in communities. Key retail trends to watch for are direct-to-consumer, hyper-personalization, re-imagined stores (brick & mortar) and new business models. “Just doing efficiency” doesn’t work in retail anymore; the sector must re-build the sort of intimacy it once had with customers when we purchased meat from the butcher, hand-picked and pinched produce at the green grocer, and worked across the counter with the department store make up consultant for best advice on skin care. “The last best experience anyone has anywhere becomes their expectation everywhere,” Steve has learned, asserting the importance of customer experience in retail. This is highly relevant for health/care, as well.

Helena Foulkes, President CVS Pharmacy, shared some of CVS Health’s latest innovation news to address consumers’ retail pain points coming out of the CVS digital learning lab based in Boston. CVS Pay addressed the challenge for a consumer whose family may have several famly members filling prescriptions at the same time. The company developed technology to consolidate all of these separate patient transactions onto one bar code requiring one swipe at the point of purchase. Another project, CVS curbside, has the scenario of mom or dad driving home from work, stressed out with kids in the back seat of the car. Mom/Dad needs to pick up 3 things at the store without getting out of the car, so CVS will provide curbside delivery with underlying technology that knows when the consumer is driving up to the store. This “concierge” approach was discussed later in the day by a Kimberly-Clark representative who made the case for Boomer healthcare that’s served up with a high degree of customer service.

Google’s health leader, Ryan Olahan, covered the “10x Mindset,” and how companies need to think and go beyond incremental thinking and goal-setting to truly innovate health and healthcare. 40% of Google Ventures funding is going toward healthcare, so the company continues to have a strong focus in the sector. One in 20 Google searches is health-related. Now that 86% of consumers do health information searches on Google, a growing cadre of people are looking for good (I’d say evidence-based) health content on YouTube. There can be 2 million views of a teenager talking about her experience with acne treatments, but for scientific content, not nearly so many. Olahan, who is the father of several children, showed a provocative slide showing curves of search frequencies for “baby crying” and “baby formula.” Interestingly, at 4 am, Ryan noted, moms aren’t looking for information about formula but for how to ease a baby’s cries. This is an opportunity for health ecosystem players in the “Mom and baby business” to provide helpful advice in that targeted, lonely early am timeframe when a Mom can feel quite alone, frustrated and worried.

 

 

 

 

 

 

Under Armour’s first product was a compression garment, launched over 20 years ago. Since then, the company has been morphing from a strictly athletic garment manufacturer to an organization committed to supporting consumers in being the best athlete they can be.

The brand’s mission is, according to Chris MacAuley, VP of Connected Fitness, “To make all athletes better through passion, design, and the relentless pursuit of innovation.” Chris played a wonderful video featuring some of UA’s history, focusing first on its Baltimore Harbor HQ and incorporating a video of Bill Clinton waxing lyrically, “Baltimore’s great shining jewel of a company is Under Armour.” The company has played an important and pivotal role in Baltimore’s economic development, bringing jobs back to the city. “We’re not going anywhere,” a company leader asserts on the video, stating the UA’s commitment to Baltimore. [I will note that financial wellness, jobs, and a strong local economy help foster positive determinants of health for people in a community].

The company’s mantra among consumers is “I Will” or more specifically, “I Will What I Want.”

As we were convening at an “Innovation Summit,” Chris explained that UA’s definitely of “innovation” is simple and practical: it’s the process of going from invention to adoption. And with wearables, sustained adoption is a major success factor. So UA’s community of 210 million registered users of its apps, logging 2.5 million workouts a day and countless food choices and recipe shares, makes it among the largest databases of healthy people data on the planet. The company believes it’s the largest connected health and fitness community in the world, which makes its database extremely powerful. Its scale is huge: the community has lost 200 millions pounds to-date, and realizes an 88% success rate for weight loss among people who log for 7 days straight.

The money quote here is Chris’s statement that UA’s is “community of people who share with us their greatest fear as and vulnerabilities.”

UA launched a sleepwear line this year (which I favorably reviewed at CES 2017 in Las Vegas in January). The company worked with Johns Hopkins to develop a sleep recovery system to track and understand personal sleep patterns: sleep volume, consistency and quality.

A fun story: Tom Brady is the celebrity endorser of the UA sleep line and Chris learned that Tom takes sleep very seriously indeed: he goes to bed by 9 pm at night. As Chris opined, “It’s hard to be great.”

Another innovation of interest to me and my health-everywhere ecosystem paradigm is UA’s work with Marriott, the hotel chain. UA has worked with Marriott’s Residence Inn hospitality brand to develop local running routes outside of the hotels to help travelers maintain healthy lifestyles while working on the road. I covered the health-hospitality convergence just last week in Health Populi, and this Marriott/Residence Inn program is part of that market trend.

Two panels discussed health innovations from consumer pharma, technology, and direct-to-consumer genomics companies, all of which are operating or undergoing consumer testing in the market. It was encouraging to see that each of these efforts had done their homework on consumer demands and design considerations, whether focused on helping people age with independence (the wearable watch, UnaliWear) or manage pain for greater mobility (which is the goal of the inspiring pioneer, BraceUnder). Bayer talked about value beyond the pill (thus, their development of the Aleve-branded pain management device), and Kimberly-Clark, how Boomers can life with gusto using well-designed personal care products.

The day’s content generated many conversations about partnering, experimenting, and risk-taking for the benefit of expanding health beyond healthcare legacy players. For CVS Health, it provided scores of ideas for innovative products, strategies, and plans.

Health Populi’s Hot Points:  The necessity and importance of collaboration and partnering cannot be over-stated for building a health/care system that pays attention to the social determinants of health. The U.S. does trauma and intensive sick care pretty well compared with other developed countries. But when it comes to noncommunicable diseases such as cardiovascular (heart), metabolic (diabetes), respiratory conditions (like COPD) and some cancers borne through lifestyle choices (such as lung), it takes more of it-takes-a-village approach to prevent the onset of disease and then address, early, the onset of such diseases.

Today, I heard about innovative collaborations across the pharmacy channel, over-the-counter medicines, and digital technologies both wearables and platforms (e.g., Facebook, Google). I used the Optum ad shown here as my last slide in my talk about the health/care ecosystem. Breaking down internal corporate silos, and partnering for an “us” versus a “you plus me” with the consumer ruthlessly focused at the core of the partnership is the required approach. Some retail health players will be open to going deep and doubling down on this strategy, particularly those players who will share patient/consumer data for the ultimate benefit of that patient. My ask: companies, please do not hoard the patient data for just your own company’s benefit.

 

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As dentists, we step into the public spotlight (whether we want to or not)

What can you learn from quality or cost outliers?

Many researchers have pointed to (positive) cost or quality outliers and made the claims that if only all physicians, or hospitals, or regions could be like these high quality or low cost providers/regions, then the health care system would be much more efficient.  Research teams such as the Dartmouth Atlas are famous for finding these conclusions.  My own research has also investigated these questions (here, here and here).

Describing variation in quality or cost, however, does not mean that the solution is to make everyone like the best providers.  For instance, the Mayo clinic has some of the best physicians in the world.  It is not possible for all hospitals to hire the best physicians, since clearly there is a limited number of these “best” physicians.  However, oftentimes, you can learn from these outliers using qualitative data collection methodologies.

What people can learn from so-called “positive deviance” analysis is exactly the topic of a recent HSR study by Rose and McCullough (2017). Their study describes how to sample sites for positive deviance analysis, how many sites to examine, how to collect data, and many other practical challenges. For instance, the authors provide an example why surveying both positive and negative deviants is important.

…we had expected to find that the staff at the best-performing sites would be distinguished by their willingness to go “above and beyond” for their patients, but in fact, we found that this was equally true at the high- and the low-outlier sites…meaning that simply exhorting providers to go the extra mile for their patients would not be an effective approach.

On the other hand, if there are specific processes or organizational structures that can be identified by positive deviants, these could potentially be adapted by both negative deviants as well as the typical organizations. When idiosyncratic factors, talent, or effort are key drivers of variability, then policy and management interventions to improve outcomes and reduce cost at negative deviant sites are less likely to succeed.

The authors do a good job of showing both the utility of positive deviant analysis (e.g., looking for potential causes for improved outcomes) as well as its limitations (e.g., negative deviants may face resource, organizational or legal constraints and thus may not be able to implement the practices of positive deviants).

For more information on studies using the positive deviance approach, check out the Positive Deviance Initiative.

Source:

• Rose, A. J. and McCullough, M. B. (2017), A Practical Guide to Using the Positive Deviance Method in Health Services Research. Health Services Research, 52: 1207–1222. doi: 10.1111/1475-6773.12524

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Healthcare Cost Concerns Trump All Others Across the Generations

Patients, evolving into health consumers, seek a better healthcare experience. While most people are pretty satisfied with their medical care, cost and confusion reign. This is the topline finding of a study from Oliver Wyman appropriately titled, Complexity and Opportunity, a survey of U.S. health consumers’ worries and wants. Oliver Wyman collaborated on the research with the FORTUNE Knowledge Group.

Consumers’ biggest healthcare concerns deal with costs: rising insurance premiums; greater out-of-pocket costs for care not covered by insurance; and, the growing costs of prescription drugs together rank as the top 3 healthcare concerns in this study.

After costs, consumers cite government and corporate control and restrictive networks as top issues, but ranking much lower than the top three cost concerns.

Underneath the overall theme of cost worries, there are clear differences across generations, the research learned. Two groups stand out in this research based on their interest in adopting innovative healthcare approaches: Millennials and Caregivers.

Millennials are most open to trying out new healthcare offerings and are more interested in new-new products and services. Younger people see healthcare as more “shoppable” informed by their ecommerce experiences via Amazon and Uber, for example.

This study unearthed some insights into Millennials managing chronic conditions, 60% of whom are very interested in new healthcare formats which may require out-of-pocket payments such as retail clinics, home visits by a doctor, and same-day appointments.

Caregivers, defined in the report as people responsible for the care of someone else, are much more keen in accessing additional healthcare services (34% of caregivers) than people without caregiving roles (14% of non-caregivers). Caregivers tend to be more concerned about access issues such as restrictive provider networks and lack of choice for insurance plans.

It follows, then, that caregivers were found to be more likely to be willing to pay a third party to help with medication management for their loved ones, and for the ability to contact medical professionals via a 24-hour helpline or via computer.

The survey was conducted online among 2,016 health-insured US consumers in October and November 2016.

Health Populi’s Hot Points: A new survey from Bankrate published earlier this month also focuses on health consumers’ cost concerns. Over 1 in 2 people were found to be worried (35% ‘very,’ 21% ‘somewhat’) about their ability to afford health insurance in the future.

In Worried Sick About Healthcare? You’re Not Alone, Bankrate portrays a cadre of health citizens with high anxiety about health care costs. The largest group of financially unwell health consumers are the Millennials, Bankrate observed, 31% of whom said they have avoided seeking health care services due to costs.

Consumers in other generational cohorts also avoided health care due to costs, albeit in fewer numbers: 25% of Gen X, 23% of Boomers, and only 8% of the Silent Generation. The latter low number reflects the fact that most seniors in America are covered by Medicare which enjoys relatively high consumer-member satisfaction.

Patients-as-consumers are recognizing their right and financial incentive to shop for health care service when they are shoppable. This requires time and information (e.g., an unexpected medical trauma would not allow time to compare variations in provider quality and prices).

Sam Myers of Balderston Capital wrote an essay on the consumerization of health care on 5th June in TechCrunch, talking about “the new over-the-counter” medicine. Going beyond packaged medicines that have switched from brands (the classic “OTC” scenario), the new OTC segment includes direct-to-consumer lab testing, online tele-mental health consults with therapists, and new primary care models like MesDocteurs in France, Kry and MinDoktor in the Nordic nations, and PushDr. and Doctor Care Anywhere in the UK, along with Omada Health in the U.S.

In yesterday’s Health Populi, I wrote about consumers’ search for innovation in healthcare. We are seeing green shoots of such innovation of care that’s tech-enabled, coupled with high-touch. This paradigm will be one of the best practices for consumer-directed healthcare that’s truly consumer-driven and -desired.

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Really, Though—Which Toothbrush?

Really, Though—Which Toothbrush?

You probably remember the ads. A model stood smiling in her bathroom, teeth whiter than her robes or sparkling vanity. There were flashes of digitally animated rows of teeth getting brushed to perfection by a full-headed toothbrush. To say the ads were satisfying would be an understatement.

Toothbrush ads these days focus more on the lifestyle built around good oral hygiene than the act of brushing itself. But if you were watching TV in the 1990s and 2000s, you were probably bewitched more than once by the animated close-ups of toothbrush heads scouring away every molecule of plaque and food.

The funny thing is, there was never a compelling argument made for which toothbrush is really better. How do all the options compare?

Toothbrush bristles: hard, medium, or soft

You aren’t the only one who’s wondered about this—there have been formal studies done, too. Research has shown that medium and hard-bristled toothbrushes do remove more plaque, but soft-bristled toothbrushes still work effectively.

Hard and medium bristled toothbrushes do cause more of the tiny abrasions to your gums that lead to other types of gum damage. However, if you’re careful when brushing, you can use hard and medium bristles to get a more gratifying clean around molars and pre-molar areas.

All shapes and sizes

There’s been study around the size and shapes of toothbrush bristles, too, especially with the boom of fancy designs and built-in gum stimulators. Most brushes today have varying lengths of bristles, but does it really make a difference?

Some soft-bristled toothbrushes achieve their “softness” with tiny, split-end bristles that dance and sweep over the surface of each tooth. Hard or medium-bristled brushes are more effective with varying heights of bristles, which—in combination with their stiffness—helps you clean uneven surfaces and tight spaces.

The shape and size of a toothbrush head make for more options, with brushes ranging from rectangular bases to pointy-tipped diamonds. Unsurprisingly, the diamond-head design is better for getting those hard-to-reach spaces. Smaller-headed toothbrushes might feel less effective, but they do allow for better dexterity in reaching and cleaning every tooth.

The gummy question

The rubbery gum stimulators along the sides of certain toothbrushes offer many benefits, though you’ll have trouble finding them on a toothbrush that costs less than $6. Not only are these rubber protuberances good for poking out big pieces of leftovers, but they also give you a warning tickle if you’re getting aggressive too close to your gums. Just think of the rumble strips on the highway—it’s the same idea.

Gum stimulators are also good for promoting blood flow to keep your gums healthy. In the end, toothbrushes with varied bristle heights and other features do have their advantages, tempting though it is to throw that $1 flat-head toothbrush in your cart. Take a good look before buying your brush—the more you get from your oral hygiene routine, the more likely you are to keep it.

The real debate: electric spin versus manual

There’s a big debate on electric versus spin toothbrushes, but we’d better start simply comparing “manual” and “other.” Do you want a brush that spins or oscillates on its own, or one you move yourself?

The clear advantage to any spin or electric option is that the brush does the moving for you, and much faster than you could comfortably keep up yourself. This friction offers such a quick brush (and polish) that you might not be able to resist the squeaky-clean feel these brushes give you.

When it comes to head size and varying bristle length, however, manual brushes come out ahead. Half this article was just devoted to the wonder that is the manual toothbrush market with all its variety. There must be be some effective toothbrushes behind all that demand!

Manual brushes also have the advantages that they don’t use batteries or need to be charged, and are easier to travel with.

Really, though, which toothbrush? This question comes back to you. Why is there demand for such variety in a toothbrush? Because some of these features really do make a difference. Depending on what you like, your oral hygiene and your lifestyle, the answer will be clear enough once you take a good look at the options.

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