Thursday, March 31, 2011

Being Happy, Being Smart

We have a good friend who has met the financier Warren Buffett. Her description of him: down to earth, interested in people, happy. If you look at his pictures, Mr. Buffett looks like a pleasant individual.

A few years ago, we had the excellent good fortune of meeting E.O. Wilson, the evolutionary biologist and two-time Pulitzer Prize winner—for science writing, no small feat. Our description of him is very similar to that of our friend’s description of Mr. Buffett’s. He too, looks like a pleasant individual.

We forgot to mention, of course, that they’re both brilliant in their respective fields.

Another brilliant man who always seems to have a smile on his face: Bill Clinton.

We combed through Google for all these photos because of a Harvard Business Review blog that talked about whether happy people are dumb. Duh!

The author, a former Harvard teaching fellow, says it is unhappy people who aren’t living up to their potential. We need to release that dopamine to let us enjoy and be happy, and to get the secondary benefits: dopamine turns on the brain’s learning centers. Without the dopamine, it’s tougher for us to learn. The higher the level of positive emotion, the more you learn, the more you create.

“Doctors primed to be positive come to the correct diagnosis 19% faster when primed to be positive as opposed to negative. Salespeople have 37% higher levels of sales when optimistic. … A meta-analysis of employees … reveals that nearly every single business outcome improves when a brain is positive. Happiness is a significant advantage,” author Shawn Achor says.

Being happy isn’t being na├»ve, or ignorant. In fact, the Greek playwright Sophocles said wisdom is the supreme part of happiness.

There’s nothing dumb about that.

Tuesday, March 29, 2011

The Pooled CME Model: A True Gift

Industry members, the American Gastroenterological Association (AGA) has handed you a gift, even though you might be insulted by its recent proposal that you adopt a centrally funded CME model. From our back-of-the-envelope calculations, we can’t figure out how pharma loses with this proposition, only gains from it—including some public credibility.

But first, for those who don’t know what happened recently: The AGA proposed at a recent meeting that its pharma supporters contribute to a general fund for its CME activities. AN AGA education committee would determine the curriculum. But, “If required … AGA would guarantee companies to produce one program in a therapeutic area of interest to the supporter,” according to the Medical Marketing and Media article.

Industry members who heard the proposal weren’t exactly in love with the idea.

But, if they thought about it, they could at least grow to like it. One well known study has shown that physicians aren’t exactly aware of when industry has paid for the CME courses they’re taking, although they seem to be aware of the drug ads in the journals.

If the former is true, and it’s true that industry expects to recoup $3.56 for every dollar it invests in CME, then what difference does it make what the money pays for? Pharma only wins here. It is helping educate physicians, and it can say to its critics, “See, we are supporting well done CME and not involved in influence-peddling.”

Industry shouldn’t fear the change here—pharma should fear that it’s passing up a great opportunity to deal with a meddlesome transparency issue.

ACOs and Fierce Communication

So here’s a question to ponder while you’re reading our carefully honed prose: How do you attract patients to sign up for an accountable care organization?

Last week, Cigna announced that its two ACO pilots were doing, at least preliminarily, what they should be doing: improving patients’ health and saving money. The giant insurer is so happy with the results that it is planning a national expansion of its ACO program this year.

Here’s why they’re happy: At its multi-specialty medical group practice division in Phoenix, the average annual savings per patient was $336; ambulatory surgery was down 11%; preventive care visits, overall, were up 3%, and up 12% for adults. And, its partner in New Hampshire is “closing gaps in care 10% better than the market.”

A few years ago, Cigna jumped on the ACO bandwagon. The goal: “Achieve the ‘triple aim’ of improved quality, lower medical costs and improved patient satisfaction by creating a care model anchored in the principles of the patient-centered medical home that also builds in accountability by rewarding physicians for results.”

In its press release Cigna says its collaborative ACO model is big on communication. Its doctors and nurses speak frequently with its customers’ doctors and nurses, “to help with coordination of patient care.” Cigna’s program also includes disease management programs and lifestyle management programs, including stress management.

Cigna doesn’t say how its customers reacted to the idea of participating in an ACO. That notion is even more interesting for Medicare patients. How will Medicare—by law, mandated to start pilot programs by next January—attract its seniors, normally an independent, privacy-loving lot? According to the new healthcare law, the pilot ACOs will take care of all the healthcare needs of at least 5,000 Medicare patients for three years, minimum.

FierceHealthcare says the success of these ACOS will require “fierce communication strategies,” like physicians doing things they don’t normally get paid for—contacting patients by e-mail, instant messaging and so on.

But as usual, it comes down to communication. We somehow doubt that it will matter what the medium is: word of mouth, Twitter, radio, smoke signal. If the ACO healthcare providers are communicating among themselves, sharing information about a patient’s well-being, and that patient’s health is improving, along with his quality of life, then that patient will spread the word.

And that can be pretty fierce, don’t you think?

Friday, March 25, 2011

Patience and Effective Disease Management Programs

The McKinsey Quarterly recently did its usual fine job, explaining in detail how other countries are running effective disease management programs. McKinsey says a successful disease management program has these common denominators: many participants; simple rules to follow; is patient-focused; has clearly defined measures; and aligned incentives. Sounds doable, right?

And then it got to the kicker.

“Any group thinking of sponsoring a disease management program must also realize that a large program takes years, not months, to get completely off the ground. It took Germany more than six years to fully implement its program for type 2 diabetes.”

Kind of dooms the notion of a successful disease management program happening in this country. Americans are not exactly the most patient of people.

Need proof? In a survey published Jan. 21, 2009, 79% of Americans were “optimistic” about this country’s future under the leadership of its new president, Barack Obama. By July 30, 53% said they didn’t like how Mr. Obama was handling the economy. Four months later, his job approval rating had fallen below 50%.

If we’d gain a little patience and let providers develop some effective disease management programs, can you imagine what the savings to lives and the bottom line would be? Isn’t that worth a little patience?

Maybe if we thought of a disease management program as a bottle of fine wine, aging to a perfect maturity....

Saturday, March 19, 2011

The VA Shouldn't Hold Its BREATH

What a mess. In 2009, the Department of Veterans Affairs abruptly halted a study called the BREATH study, designed to help 413 veterans manage their advanced COPD, because of unspecified safety concerns.

Apparently the deadly type of safety concerns.

The VA, keeping mum about what happened until it publishes in a peer-reviewed journal, had all the right intentions. It wanted to help the sick vets cope with this chronic lung illness by teaching them how to manage it–-with the hope of then keeping them out of the hospital.

But apparently the trial backfired. While the study’s researchers wouldn’t give details, one told the Pittsburgh Tribune-Review, “If someone were to start a disease management program, I would suggest they probably not do it just yet, until the information is available," said Dennis Niewoehner, a pulmonary doctor in Minneapolis, a co-chair for the trial.

Forgive us, Dr. Niewoehner, but we disagree. One, the VA should tell healthcare providers now what happened. There may be a clinical trial going on that could benefit from your knowledge. And two, stalling the start of a disease management program until a paper is published is not right. For those with chronic diseases, every minute has got to be torture.

What is ironic is that maybe the VA should have waited to start its study. Just recently, a review was published in Current Opinion in Pulmonary Medicine on COPD and older adults. The researchers looked at various areas, including comorbidities and disease management.

Older adults with this disease have an average of nine other comorbidities, including depression, cardiovascular diseases and chronic renal failure. What they found was that research suggests that “aging is a determinant of the progression of disease and that management of this population requires different metrics and strategies.” According to the summary information of the VA study, the study group received an education program, an “action manager," plus care. They also received telephone calls. The control group received standardized care.

Since we have no clue as to what went wrong with the study, we can only speculate, but the take-away message is that patient monitoring and management could have potentially signaled these problems sooner. While we think publishing what goes wrong is as important as publishing what goes right, we also believe the use of monitoring technologies like MedAdherence can help providers manage patients with many comorbitities remotely, and possibly better.

Let us know what you think.

Tuesday, March 15, 2011

Adopting EMRs: Can Challenges Be Overcome?

A recent Wall Street Journal article talks about the biggest challenges that electronic medical record (EMR) adoption faces: the physicians and HCPs using the system. One challenge that's easy to understand is finding the necessary funding -- $7.5 million of a $250 million investment is allocated for training.  Man, that is a lot of money!

Is there a better way?  We think so, but the real issue is the change that needs to occur in the training of medical personnel.  It also requires a perception change that may make the practice of medicine even less desirable today.  The WSJ article quotes one consulting firm that compares "the switch to the commercial airline industry's move from analog to digital flight decks because both involve highly skilled professionals learning a new technology quickly."  Maybe that is why the cost is so high, but does it have to be?

The Healthcare Channel (HCC) highlighted this point in one of its recent blog posts and suggested that physicians not be paid until they document moving forward. While HCC suggests in a harsh manner that it is physicians' incompetence, we think it is really a fear of the unknown.

We believe EMRs can offer significant advancement in medical care. It is clear that gaps in medical care are caused by events or issues between visits, episodes or conversations. We think technology can positively change care and as HCC suggests, accountable care organizations will need to use EMRs to achieve business objectives and margin targets.

In the end, change is often difficult. When people are faced with change or proving why they should not, most people get busy with the proof.

Friday, March 11, 2011

Getting Patients and Physicians to use EMR's & PHRs

Physicians are missing an amazing opportunity to help ensure that their patients maintain their treatment regimens. That opportunity, of course, is online. Their patients are online; many of these patients want their doctors online; but their doctors, for various reasons, continue to resist.

According to a story in FiercehealthIT, meaningful cyberspace connections aren't happening between patient and physician, regardless of the Web tool – patient portal or personal health record.

Patient portals, according to the article, are primarily used administratively, paying bills and requesting appointments. As for personal health records-–few people have them--but a survey by the California HealthCare Foundation found that more than half of those queried said they’d like a PHR provided by their doctor. Which means they want real data in their files. Which means they’d need to get it from an electronic medical record ….

A report from the business technology consultant CSC says that’s not likely to happen, because EMRs are “the least prevalent” sources of data available today.

Writes FiercehealthIT: “The common denominator between the situation with patient portals and PHRs is that most doctors and hospitals still are not making much clinical data available to patients."

A Health Affairs study might add some insight. In a national survey of physicians conducted in 2008 and 2009, 64% said they hadn’t used a patient’s electronic personal health record. The reasons: patients’ privacy concerns, data accuracy and liability issues, and lack of payment for reviewing or using the records.

Legitimate concerns, but concerns that should be worked out. These records, if maintained accurately, could lead to better health–-at least that’s what the California HealthCare Foundation found. Physicians would have more holistic pictures of their patients.

Can we all agree that would make sense?

Monday, March 7, 2011

Pharma: Know Thine Enemy

Mindless habitual behavior is the enemy of innovation. 
Harvard Business Professor Rosabeth Moss Kanter 

Might we suggest that pharma begin thinking about investing serious money into healthcare that does not only involve drugs? We keep tripping over stories and studies of how non-traditionalists are stepping into the healthcare space using social media.

We found this interesting.

One group of researchers has published two papers on smoking cessation; both papers involved the same number of subjects, 27. Another group took a look at the 47 apps, designed to help smokers quit smoking, all of which are currently sold for iPhones only.

The two groups of researchers found different results.

In the first paper  the researchers first used fMRIs on the subjects, all heavy smokers, to learn which parts of the brain were fighting, or giving in, to the urges to smoke. Their description of this battle: “A war that consists of a series of momentary self-control skirmishes.”

The researchers theorized that by mapping the brain areas where these skirmishes are fought, they could predict which of the subjects would have more success at quitting–-because these brain areas were more active. The motivation they used on these subjects was text messages, eight messages a day for three weeks.

“We are really excited about this result because it means that the brain activation we see in the scanner is predictive of real-world outcomes across a much longer time span than we thought,” said one researcher. “The tasks that we use in the laboratory are simplified models of these real-world processes–-but they seem to be valid models.”

In the apps paper, the researchers checked out the 47 smoking cessation apps, just to see how effective they might be. They looked at how each app approached smoking cessation and its adherence to the U.S. Public Health Service's 2008 Clinical Practice Guidelines for Treating Tobacco Use and Dependence.

The conclusions? The apps had “low levels of adherence to key guidelines in the index. Few, if any, apps recommended or linked the user to proven treatments such as pharmacotherapy, counseling, and/or a quitline.”

What an opportunity for pharma; it’s tailor-made.

Friday, March 4, 2011

Can the NIH Innovate Faster than Industry?

So it’s come to this: The federal government plans to entice industry with basic bench, and maybe even clinical trial results, to spur drug development.

Concerned that so few promising drugs are in the pipeline, that let alone meet FDA standards, the NIH is setting up a new research shop. Anticipating that penny-pinching Republican House members may give him a hard time about his idea, NIH chief Frank Collins is willing to “cannibalize other parts of the health institutes to bring more resources to the new center,” says the Times.

“There are some people that would say this is not the time to do something bold and ambitious because the budget is so tight,” he told the Times. “But we would be irresponsible not to take advantage of scientific opportunity, even if it means tightening in other places.”

For those who need a recount: The FDA approved 21 drugs in 2010, 25 in 2009, and 24 in 2008. No drugmaker, says Fiercebiotech, had more than one drug approved last year. The approval rules are getting tougher: We all saw what happened with the obesity drugs. Collins said in the Times article that industry’s “productivity has been declining for 15 years.”

It doesn’t look like many drugs will be approved this year: The Street said in January that 26 were in the queue and one’s already been rejected: Contrave, the obesity drug.

Industry is all tied up in what it considers a bad situation. While profits are increasing for some members, companies choose to focus on patent expirations, tough regulators – on both sides of the Atlantic – the new U.S. health care reform, and no doubt myriad other issues.

Fiercebiotech penned the apt phrase: A wave of impatience has crashed over the drug development and discovery business.

How did we get here? Another phrase is apt: The perfect storm.

Pharma’s past behavior forced overregulation, which added more costs to R and D. And since no one in discovery appears willing to give up its quest for innovation – read blockbuster – the costs of discovery continue to rise. So mergers and acquisitions make sense, which in our experience has drained talented R and D personnel.

So, academic researchers and advocacy groups may be the ones who drive new innovation, but it's doubtful they'll have enough funds to see any product through all the regulatory challenges. It appears to us no one is reconciling the priorities with the limited dollars available.

In our opinion: Drug research is too inefficient.

Industry critics continue to scream that pharma spends way too much on marketing and has no reason to cry poor mouth. This may be true: But the fact remains that collaboration in pharma is still a business, and pharma must answer to a board of directors, shareholders and its own future. As for the NIH, do we have evidence that research dependent on the federal government for basic bench research is the way out of this mess?

We believe both parties can find new ways to conduct research and conduct clinical trials. We just began working with a company that's ready to break down some of those challenges. We suggest this type of communication, knowledge management and performance measurement tool can help all parties involved in research. 

A comment from researcher Hugo Geerts posted on the Fiercebiotech article regarding the huge dependency on animal studies is another excellent point to consider.

His suggestion: Pharma should use more computer-based mechanistic disease modeling.