Misdirection Can Be Fatal 

by Laurie Gelb, March 17, 2009

ETHEX has initiated a retail-level recall of tablets found after the fact to have been manufactured in non-cGMP conditions. A Blues plan finally sent out a one-page masterpiece of misdirection, one that I'm confident was replicated similarly nationwide, to patients for whom one of the affected scripts was reimbursed. Unfortunately, in this case, misdirection could potentially be fatal, so a communication like this is worth delving into.

First, the letter is dated February 2009, though received in March. ETHEX PR is dated Jan. 28, so there's been a communication delay.

The salutation, despite the fact that these letters are obviously databased from PBM records, is the time-honored "Dear Valued Member." So what would cue a member that this letter, unlike several others received this quarter, should actually be read? The outer envelope holds no clue, either.

The sentence announcing the recall is in bold. That seems scary and necessitating action, doesn't it? But no.

We read that these prescriptions were no longer processed by the PBM as of January 30. If I were comparing this with recalls for cars or food, that would mean that I should take it back and get something fixed or refunded, yes?

Not here. Of course, use of the word "recall" isn't the plan's doing, but there remains the responsibility to explain it.

About halfway down the page, we read "...it is recommended that you continue to take them [the medications] in accordance with your prescriptions, as the risk of suddenly stopping needed medications may increase your risk for side effects."

Side effects -- not quite the term that most clinicians would characterize as the risk of suddenly d/c'ing nitrates or beta blockers. So this letter is presuming that the patient knows why s/he is on each medication (and remember, each of these is listed only under its full generic name). Alas, if the good ship Argo...and since the letter lists each of the recalled tabs, without specifying which one(s) were filled for the patient, it would be easy to skim this long, complex list and not see the connection. Another form letter gone astray, one might think.

But let's say the patient does recognize one of these meds. She should be thinking that she should do nothing, right? Side effects and all that. But the very next sentence advises: "Your physician is in the best position to help you slowly discontinue use of the medication..."

Wait a second. So the member is supposed to "discontinue?" That sounds like "stop?" But that logic fails when there's no mention of getting a replacement supply, because, of course, the letter is not really recommending that anyone d/c her meds. It's just saying that if you wanted to, you should let your doc in. In fact, it's not saying anything at all, but merely palming patients off on the Ethex customer service number or the MedWatch URL.

The closing: "Thank you for your attention to this matter," once again suggests that you should do something, but by this time, we're immune to confusion (and conclusions). Time to cue up the David Bowie song, "Changes."

This letter mentions five different organizations by name: the plan, its PBM, its pharmacy "consultant," ETHEX and the FDA. However, nowhere does the letter explain any of their responsibilities, roles, accountability or possible usefulness in sorting out any of the letter's contents.

Some of the recalled tabs may be over-generous with the active ingredients. Nowhere in this letter does this fact appear. What to do about refills when shortages for some of the compounds in question have been news for months is nowhere addressed (some patients have been switched over to immediate release vs. extended release metoprolol, for example). Even if the PBM is fully stocked, that reassurance is not made. Nor are terms like cGMP explained. Nor is it identified which drug(s) on the list may apply to the patient (we call it a mail merge with a form field). A single-spaced missive that fills a page, this letter raises more questions than it answers, yet it hints delicately at clinical implications.

When you read polls about distrust, mistrust and misunderstanding of the health insurance industry, remember this letter. A patient who is on a recalled med, based on the PBM's data, is sent a letter in a 8.5 x 11" envelope, signed by a PharmD. There's bold face type and mention of the FDA. It seems serious and worth reading, (well, if you get past the first sentence regarding "changes to prescription drugs in the marketplace"). But, in the end, it's not only unhelpful, it's anxiety-producing or a sedative, depending on which sentences one reads. The tone is cold, formal, impenetrable and replete with jargon. Health plan as robot? We are here.

What would the LA Times think and write about a physician who sent this letter? A hospital? What would you think? Need a plan somehow avoid any visible role in medication management beyond formulary access? The plan will certainly assume a broader role when it comes to hospitalization, surgery, medical devices, etc. and patients know this very well.

So to the Blues plan and your sisters and brothers: After the next recall, if you can't acknowledge the facts for whatever reason (and remember, there's more than one general counsel in the sea), please send your members somewhere that offers actual answers. For example, see the simple language about this recall at the Facts & Comparisons Web site: http://www.factsandcomparisons.com/News/ArticlePage.aspx?id=8294. Ironically, this para is written for HCPs, but is simpler than many of your letters to members.

And next time, don't delay. Spring for a mail merge that produces a personalized salutation and short name rx info. A member with a condition serious enough to justify a drug that you're paying for deserves personhood, not to mention the fact that you might want to converse with that person in the future. Names of drugs and people are a good start. Run your next effort by some real patients, please, and if you can't come to grips with the fact that these are sick people, you might want to think about finding a vertical with lower stakes.

Thank you for your attention to this matter.


The Challenge to Healthcare Marketing

By Lindsay Resnick. March 12, 2009

Political change, economic volatility and competitive rivalry will bring the
unexpected this year. Be prepared to aggressively track what's working (or
not) in terms of your business tactics and prepare to move quickly based on
emerging market indictors. Be agile.


It appears health reform is set to take off in 2009. The new administration
has made this their top domestic priority under a battle cry of "How can we
afford it.how can we afford not to" With America's aging demographic,
soaring unemployment, expanding uninsured population, and unprecedented
levels of uncompensated care, there's broad agreement on the need for major
health system overhaul. Of course, the devil's in the details.

Recessionary conditions also mean that healthcare companies that are able to
demonstrate an ability to lower costs will continue to thrive. Leading this
watch-list are those promoting medical travel, chronic care management,
limited benefit individual medical plans, and retail medicine. Personal
healthcare budgeting is shifting along with the number and complexity of
delivery choices. There's a healthcare squeeze on consumers and it will only
get tighter.

Expect to see the Health 3.0 movement continue to advance through web-based
consumer connectivity, personalized health care delivered in clinically
relevant settings, and financing mechanisms structured around
consumer-centric business models. The new digital customer will be an
activated consumer with any time-any place-any device connectivity,
supported by "information everywhere" tools. They will have the confidence
and smarts to be empowered healthcare purchasers. Be proactive.


Making sure your business can turn it up in a downturn relies on a marketing
strategy built on data, dialogue and differentiation.

Customer segmentation allows companies to know your most profitable
customers. It enables smart marketers to define what messages and vehicles
are most effective in reaching your best prospects. Understanding
demographic, lifestyle and value-based attributes provides an important
competitive edge.

Search engines are defining brands, changing sales processes and influencing
just about everything in our lives. Newspapers, magazines, and traditional
television audiences are shrinking. They're being replaced by social
networks, wikis, blogging and online video content. It's a media insurgency,
and consumers have grabbed an important new role. They are now broadcasting
opinions, turning fads into trends, and getting information from customized
information outlets where monologues are turned into dialogues. Tomorrow's
marketers will quickly figure out how their efforts fit into the new media

Healthcare is a price-driven, fragmented marketplace where differentiation
is king. A sustainable growth strategy takes targeted outreach, value
positioning and tactical savvy. Figure out how to articulate your value
proposition in a way that separates your company from healthcare's "sea of
sameness." Then, select in-market tactics (direct response, new media
advertising, grassroots PR, etc.) that will be most effective for getting in
front of the right people at the right time. Start a relationship with your
prospects and build a customer base of brand loyalists. Be memorable.

Everyone agrees 2009 will be a tough year. Companies will be hard pressed to
balance budget pressures with customer acquisition and retention
expectations. Competitors will work hard to steal your customers. But, where
there are challenges there's opportunity. Keep a sharp eye on trends that
impact your business, and keep a closer eye on your customers. Keep products
and services relevant so they can withstand economic pressures. And, keep
your marketing data driven, differentiated and built around a relationship
with your customers. Of course, a little luck will go a long way! Be


Employers Committed to Active Employee Health Benefits for 2010

by Clive Riddle, March 9, 2009

Are employers going to shed health benefits from their employee compensation packages as the recession deepens? Last week, Hewitt Associates released results from a January 2009 employer survey, in their report: Survey Findings: Challenges for Health Care in Uncertain Times 2009.

Commenting on the survey results, Jim Winkler, Hewitt’s head of Health Management Consulting, said "in today's environment, employers are under pressure to cut health care expenses, but they realize that short term cost management tactics do not address the underlying drivers of health care cost. This leaves them with two options: making a long-term commitment to improving the health of employees and their families, or exiting health care altogether. Most companies believe that investing in the long-term health of their population is the most effective way to mitigate costs and create a more productive and engaged workforce."

However, in keeping with survey results and company headlines, Hewitt found retiree health benefits are not as sacred. While less than 1% of the 340 large employers surveyed plan to eliminate health benefits for their active populations, 13% indicated plans to eliminate benefits for their retirees next year.

Furthermore, while employers thus remain committed to offering benefits to actives, they intend to make a number of reductions and adjustments in order to cope with the economic downturn. Hewitt found that:

  • 49% intend to reduce the number ofplans and options offered
  • 65% plan on increasing the level of employee cost sharing with insurance premiums
  • 30% intend to reduce, and 6% eliminate incentive programs; while 24% will reduce and 2% eliminate wellness programs, often just recently put in place
  • Another 26% plan on reducing retiree health benefits, in addition to the 13% who will eliminate them
  • 13% will reduce, and 6% eliminate health benefits for part time employees

On the other hand, despite the downturn, many employers are looking to enhance certain programs and initiatives for 2010:

  • 40% will increase consumer driven plan offerings
  • 33% will increase wellness programs
  • 20% will increase incentive programs
  • 13% will increase their overall health benefits package

Because the impact of the recession didn’t hit until the 2009 benefit year was already put into place, whatever employers are going to change as a result of the recession, their changes are coming in 2010 versus having already implemented them in 2009.


Health Care Stakeholders Weigh In On the Obama Budget

By Clive Riddle, February 27, 2009

So how do some key stakeholders view the health care implications of President Obama’s FY 2010 budget?

AHIP (America’s Health Insurance Plans) applauds the health care agenda, sort of. As the voice of the health plan industry, AHIP is compelled register very deep concerns over cutting Medicare Advantage payments to plans. Will we return to the Medicare health plan market withdrawals of a decade ago? Karen Ignagni, AHIP President, states:

“We have strongly supported recent efforts by the Administration and Congress to strengthen the health care safety net, expand coverage for kids, conduct comparative effectiveness research, and invest in health information technology. Our Board of Directors has offered a comprehensive proposal that starts with us playing a leadership role in advocating for market reforms and addresses the core issues of cost, access, and quality. Health plans will continue to be constructive participants in the health care reform discussion. We recognize that to achieve reform of this magnitude, every stakeholder group will be expected to contribute and will be challenged to innovate, perform better, and be held accountable for results.“As policymakers evaluate the entire Medicare program, including Medicare Advantage, as part of health care reform, it is vital that seniors continue to have access to the benefits and services they rely on. Medicare Advantage plans provide care coordination, disease management, and prevention programs for seniors and reward clinicians for delivering quality care to patients. Unfortunately, this proposal would force seniors enrolled in Medicare Advantage to fund a disproportionate share of the costs to reform the health care system. A cut of this scale would jeopardize the health security of more than ten million seniors enrolled in Medicare Advantage and would turn back the clock on innovative payment incentives to improve the quality of care that patients receive.”

The AHA (American Hospital Association) commends the President, sort of. They are quite concerned that “half of the reserve fund would come from savings in health care programs, including proposals to bundle Medicare payments for hospital and post-acute care ($17.84 billion in savings), reduce payments to hospitals with certain readmission rates ($8.43 billion), and link a portion of inpatient hospital payment to performance on specific quality measures ($12.09 billion). The budget outline also cites the need to address physician self-referral to facilities in which they have a financial interest."

AHA President and CEO Rich Umbdenstock states, "We commend President Obama for making health reform a top priority in his budget blueprint. However, we are concerned about any cuts that would affect the work hospitals do for their communities during this economic downturn. We remain ready to work with the president and Congress to strengthen health care in America."

The AMA (American Medical Association) offers applause without the reservations in bold print. They like the rollback of planned physician Medicare payment cuts. Nancy H. Nielsen, MD, President, American Medical Association states “President Obama’s budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40 percent over the next decade. Looming widespread physician shortages coupled with aging baby boomers highlight the urgent need for permanent Medicare physician payment system reform to preserve seniors’ access to health care. “The AMA is committed to working with the administration and Congress to develop reforms that will reward and preserve access to high-quality care for seniors and all Americans.”

AARP (the Amer) not only applauded the budget, but now tells Congress to step up and act on it. AARP CEO Bill Novelli states “We are making it clear to our leaders that they need to work with the president in a bipartisan fashion to complete the plan for reform and finance reform in a fiscally—and morally—responsible way. They must make sure that any savings from Medicare and Medicaid are dedicated to reforms that strengthen the quality, efficiency and performance of our health care system, including these critical lifeline programs.”

AARP also announced key priorities to be included in health reform legislation in 2009, including: Making affordable health care coverage options available to everyone, especially people ages 50-64 who are among the fastest growing group of uninsured; Keeping Medicare affordable by rewarding doctors and hospitals for quality rather than the quantity of care; Promoting prevention and healthy behaviors; Eliminating fraud, waste and abuse; and Improving care coordination for people with chronic conditions and helping them stay in their homes and out of institutions.

The National Business Group on Health is pleased and concerned: they are “very pleased to see such emphasis on making health care affordable for all American” but don’t like new taxes and Medicare Advantage cuts.

Helen Darling, President of the National Business Group on Health states "with respect to proposed financing schemes for health reform, we have concerns that the funding mechanism could be subject to constant political pressures. The proposed 10-year $634 billion health-care fund - paid for through new taxes and particularly cuts to Medicare Advantage beneficiaries - approximates the annual portion of health spending that is estimated to be wasteful, redundant, or even harmful. We believe there are other ample opportunities to reduce costs through eliminating overuse of services, preventing serious adverse avoidable medical errors, and combating waste. As legislation is crafted in the coming months, we strongly encourage policymakers to look at the root causes of higher health care costs and use health reform as an opportunity to make lasting structural reforms - many of which have been discussed previously by both the President and congressional leadership - that will yield long-term savings and improve patient care and safety."

So, what does your spokesperson have to say about the ten year $634 billion health care fund, and the budget?




The Path to Reform as laid out by the Commonwealth Fund


By Clive Riddle , February 19, 2009


The Commonwealth Fund Commission on a High Performance Health System today published their report, the Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, which the Commonwealth Fund in a press release distributed today bills as a proposal for “a comprehensive set of insurance, payment, and system reforms could guarantee affordable health insurance coverage, improve health outcomes, and slow the growth of health spending by $3 trillion by the end of the next decade” and “details the Commission’s recommendations for an integrated set of policies and assesses the impacts of specific policy actions from 2010 to 2020, compared to the status quo.”


The Commonwealth Fund is a major policy stakeholder organization in Washington, and has the ear of various key Democratic party health care leaders. Not that the eventual Administration or Congress reform proposal would mirror the Commonwealth Fund’s report by any means, but it has significant potential to influence the discussion, and thus bears reading.


 Here’s some projected results the report touts would be ultimately achieved via their proposed package:


  • Insurance reforms would extend coverage to everyone within two years, with only 1 percent uninsured throughout the next decade. The number of uninsured, currently 48 million and estimated to increase to 61 million by 2020, would instead under the proposal decrease to 19.7 million in 2010, 6.3 million in 2011 and stabilize at 4 million for the rest of the decade
  • Combined with payment and system reforms initiated in 2010, the integrated approach to reform could slow the growth of national health spending by a cumulative $3 trillion by 2020.
  • Spending would still go up but at a slower rate. The U.S. is expected to spend $42 trillion on health care over the next 11 years, with spending rising 6.7 percent per year, the proposal package would lower this rate to 5.5 percent per year.

So how would such lofty results be achieved? Here’s a verbatim summary as provided in the 122 page report:

  • National Health Insurance Exchange. Offers businesses and individuals a choice of private plans and a new public plan, phased in by size of firm with all eligible by 2014. Premium of the public plan would be community rated within broad age bands. Benefits are similar to the standard option in the Federal Employees Health Benefits Program. The plan would use Medicare’s claims administrative structure and reformed payment methods and rates.
  • Individual Mandate. All individuals are required to obtain coverage.
  • Affordability. Premiums are capped at 5 percent of income for low-income individuals and 10 percent of income for those in higher-income tax brackets.
  • Shared Financial Responsibility. Employers are required to provide coverage or contribute to a trust fund. The example used in the model included 7 percent of payroll, up to $1.25 an hour.
  • Medicaid/SCHIP Expansion. All individuals with incomes up to 150 percent of the federal poverty income level are eligible for Medicaid acute care benefits. Medicaid provider payment rates are raised to Medicare levels. The federal matching rate is increased to offset state costs.
  • Medicare. The two-year waiting period for coverage of the disabled is eliminated. Medicare beneficiaries are offered a supplement with the same acute care benefits as in new public plan and premium affordability provisions.
  • Insurance Market Reforms. Require community-rate premiums (age bands permitted) and guaranteed issue and renewal of policies. Premium and insurance information would be publicly available on the Web.
  • Enhance Payment for Primary Care. Increase Medicare payments for primary care by 5 percent and apply differential updates for primary care and other care.
  • Encourage Development and Spread of Patient-Centered Medical Homes. Provide payment per patient in addition to fee-for-service to practices qualified to provide patient-centered care. Reduced premiums and cost-sharing available to patients who designate a primary care practice as their medical home. Shared savings would be distributed on the basis of performance.
  • Bundled Payments for Acute Care Episodes. Expand acute care payment to include services during the hospital stay and 30 days post-discharge in a global fee. The policy would be phased in, starting with inpatient services in 2010, then post-acute care in 2013, and hospital inpatient and outpatient physician care in 2016.
  • Correcting Price Signals. Modify payments by: 1) slowing the rate of Medicare payment updates in geographic areas with high costs; 2) reducing prescription drug costs by having Medicare pay Medicaid prices for drugs used by dually eligible beneficiaries and determining Medicare payments for unique drugs with effective monopolies based on prices paid in other countries; and 3) resetting benchmarks for Medicare Advantage plans in each county to projected per-capita spending under traditional Medicare.
  • Accelerate the Adoption and Use of Health Information Technology. Require all providers to report key health outcomes electronically by 2015 to qualify for payment updates. Provide funding to support health information networks and assistance for safety-net providers and small practices through a 1 percent assessment on insurance premiums and Medicare outlays.
  • Center for Medical Effectiveness and Health Care Decision-Making. Create a mechanism to develop information on the clinical and cost-effectiveness of alternative treatment options. Fund the Center with a .05 percent assessment on insurance premiums and Medicare and Medicaid spending. Use the information in benefit designs with higher out-of-pocket costs or differential pricing depending on comparative effectiveness and include physician–patient shared decision
  • Reduce Tobacco Use. Increase federal taxes on tobacco products by $2 per pack of cigarettes. Use revenues to fund public health programs and insurance expansion.
  • Reduce Obesity and Alcohol Use. Establish a new tax on sugar-sweetened soft drinks of 1 cent per 12-ounces to finance state obesity prevention programs, and increase the federal excise tax on alcohol by 5 cents per 12-ounce can of beer, with proportionate increases on other alcohol products. Use funds for prevention and insurance expansion.

The Commonwealth Fund Commission on a High Performance Health System was established by the organization in 2005, to “seek opportunities to change the delivery and financing of health care to improve system performance, and to identify public and private policies and practices that would lead to those improvements. It also explores mechanisms for financing improved health insurance coverage and investment in the nation's capacity for quality improvement.”


So who has a seat at the table for the Commission. Not all major stakeholders. Integrated hospital/medical group systems, large non profit health plans, some progressive employers, and like-minded associations, policy institutions and academic institutions are well represented. For profit health plans and health care providers, non-integrated private providers, public agencies and dissimilar institutions are not. Here’s the list of the Commission members:

  • James J. Mongan, M.D. (Chair), President and CEO, Partners HealthCare System, Inc.
  • Maureen Bisognano, Executive Vice President and COO, Institute for Healthcare Improvement
  • Christine K. Cassel, M.D., President and CEO, American Board of Internal Medicine and ABIM Foundation
  • Michael Chernew, Ph.D., Professor, Department of Health Care Policy, Harvard Medical School
  • Patricia Gabow, M.D., CEO, Denver Health
  • Robert Galvin, M.D., Director of Global Health Care, General Electric Company
  • Fernando A. Guerra, M.D., Director of Health, San Antonio Metropolitan Health District
  • Glenn M. Hackbarth, J.D., Consultant
  • George C. Halvorson, Chairman and CEO, Kaiser Foundation Health Plan, Inc.
  • Robrrt M. Hayes, J.D., President, Medicare Rights Center
  • Cleve L. Killingsworth, Chairman and CEO, Blue Cross Blue Shield of Massachusetts
  • Sheila T. Leatherman, Research Professor, School of Public Health, University of North Carolina
  • Gregory P. Poulsen, Senior Vice President, Intermountain Health Care
  • Dallas L. Salisbury, President and CEO, Employee Benefit Research Institute
  • Sandra Shewry, President and CEO, California Center for Connected Health
  • Glenn D. Steele, Jr., M.D., Ph.D., President and CEO, Geisinger Health System
  • Mary K. Wakefield, Ph.D., R.N., Associate Dean for Rural Health and Director, Center for Rural Health, University of North Dakota
  • Alan R. Weil, J.D., Executive Director, National Academy for State Health Policy
  • Steve Wetzell, Vice President, HR Policy Association