Medicare Part D

Profitceuticals

While public and private interest groups wring their hands about the ever-increasing cost of drugs, one drug list publisher quietly wields monumental impact on pricing.  First DataBank, a unit of Hearst Corp., publishes a benchmark list of pharmaceutical prices that health plans and state Medicaid programs use as a guide.

As reported in the Wall Street Journal on Oct. 6, First DataBank reached a legal settlement in a case of price gouging. Implicated was McKesson, who is the only company that First DataBank "surveys" to arrive at price averages. As a result of the settlement, prices on many of the most common drugs will be lowered.

This is an egregious example of unmonitored pricing, one which when addressed does more to help alleviate pricing than all the excuses of pharma executives.

Posted by Shawn Whalen on October 8, 2006 at 4:34 PM
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Medicare Part D: A New Perspective

Healthcare is pretty serious stuff, so when I saw a hilarious piece on Comedy Central's "The Colbert Show" about Medicare Part D I wanted to share it. Check it out here
and click the "Explanation: Medicare" link three rows down. A good laugh.

Onto serious matters...

Posted by Shawn Whalen on April 12, 2006 at 10:18 PM
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Managed Care: Changing the Anti-CDH

Many years ago when I was in college, Harvard Community Health Plan was my HMO. I have only one memory of them. I didn't need much healthcare then and I don't recall why I was there (probably a general check up). What I do recall is sitting in the waiting room for almost 40 minutes, complaining, and being shown to the examination room. Then waiting another half hour. Being an impatient youth, I hopped off the table and walked down the hall to the offices. I found my doctor in his office, on the phone on a social call. I knew that because I stood in his doorway for a good minute before he noticed me and asked if he could help me. I told him he should have been helping me an hour ago and stalked off out of the building never to return. No surprise, Harvard Community Health Plan went bankrupt and had to be bailed out by the fine commonwealth of Massachusetts (who says socialist medicine doesn't exist in this country?) Today Harvard Pilgrim is a highly rated managed care plan, though I can't personally vouch for it.

Even if the doctor was to blame in my example, I like so many consumers was left with a bad taste for the HMO itself. How health plans treat their members is often the antithesis of the spirit of consumer directed healthcare (CDH). Health plan members often first hear from their health plan for a denied claim or payment request. No wonder they don't have a good reputation.

As media have widely reported, the Federal government kick-started CDH with proposals for HSAs, calls for more technology adoption and launching Medicare Part D. Pundits point out that consumers are gaining risk and increased responsibility, often without the tools and knowledge to make them informed decision makers. An often overlooked part of the solution is health plans, who have a stake with all parties and are a center point of communications.

Many health plans are not up to the task. MCOs have been marketing to employer groups and providers for so long that member/consumer communications have suffered. Take for example Medicare Part D. The often-reported difficulties of Part D are a microcosm of the broader challenges facing healthcare. The ill-prepared senior population had to grapple with a complex issue. Government and managed care's education efforts were weak, and the result was mass confusion and low enrollment.

What are the smart health plans doing to counter this? My uncle recently told me about his conversation with his health plan. They had called to remind him of drug and medical issues around his chronic condition and to check on open reimbursement issues. I was surprised - was he sure it wasn't his doctor or a nurse? No, it was indeed his health plan and the call had been automated, using the voice of a nice older woman. Apparently his MCO, one of the top three in the country, uses automated voice services. My uncle doesn't use the Web, and probably ignores letters as junk mail, so in his case the good old fashion telephone was the delivery mechanism for value-added, interactive information that improved his health while likely helping the MCO's bottom line.

This anecdote is echoed in the sophisticated member communication being done by such payors as Aetna, Unicare, Oxford Health Plans/United and others. An article in Healthcare Informatics explores how these vendors are closing the "information gaps" with their members. It's as much a trust gap as information gap. Aetna's MedQuery program sends e-mails and phone calls to members who have not complied with doctor recommendations. Unicare in Massachusetts followed up with members with chronic conditions, resulting in a much higher rate of best practice guideline adoption. These are smart moves by insurers that can ultimately improve outcomes while at the same time lower costs.

Managed care is due for an overhaul of their member communications. As my client Silverlink's CEO Stan Nowak says, the best plans of the future will be healthcare guides for their members, assisting them through the whole healthcare life cycle. Communications should be proactive and coordinated among the many departments of the MCO. The proper dose of value added data should be delivered at the right moment, instead of a deluge of information that goes unheeded. As so many other industries have proven, technology solutions exist to make this happen. Efficiency in operations can result in better healthcare.

Posted by Shawn Whalen on April 10, 2006 at 4:14 PM
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