Eichert on Changes

Penn’s Databases

Czajkowski on Sharing

Chiang, of the Feds

Smith Bio

Innovative Health Marketing

Corrections or additions?

These stories by Barbara Fox were published in U.S. 1 Newspaper on

March 25, 1998. All rights reserved.

The Quest for Rational Healthcare Decisions

Pharmaceutical and biotech companies develop them,

contract research organizations test them, the federal government

approves them, managed care organizations pay for them, physicians

prescribe them, nurses administer them, and patients take them. But

can anyone really be sure what are the "right" drugs or treatment

procedures from the standpoint of cost compared with successful results?

No. There are no good answers, says Marilyn Dix Smith, a pharmacist

who — after her father died — dedicated her life to finding

those answers, to standardize the data gathering practices of researchers

and hospitals so that physicians and patients can make rational and

appropriate healthcare decisions.

In 1995, along with William F. McGhan (a professor at Philadelphia

College of Pharmacy and Science) and Alan Bakst (of Smith-Kline Beecham)

she co-founded the Association for Pharmoeconomics and Outcomes Research,

now known as the International Society for Pharmacoeconomics and Outcomes

Research (ISPOR). Based at 20 Nassau Street, the organization’s aim

is to translate research into practice to ensure that society allocates

scarce health care resources wisely, fairly, and efficiently.

ISPOR involves the scientific community, the practice community (nurses,

pharmacists, physicians), the managed care organizations, and the

purchasers. "We are plucking out from each type of organization

those people who are interested in looking at economic and clinical

outcomes," says Smith. ISPOR is trying to stimulate its members

to generate the data for comparing drugs or surgical interventions

or new biotech interventions — to compare their costs with clinical

outcomes such as mortality, suffering, and quality of life.

"Just about the time that this idea was born, my father became

extremely ill and died, and I experienced the health care system first

hand," says Smith. "I saw all its inadequacies, even in the

big teaching hospitals. It became my personal goal to look not only

at economics but also the outcomes."

"Quite frankly the world relies on the pharmaceutical companies

for research, but then everything stops. Who is gathering data that

pulls it all together? And is this data collected in a form that will

help everyone make good health care decisions?" asks Smith. She

hopes ISPOR and/or its members will set the guidelines for collecting

the information — what form it should be in, what should be collected,

and how it should be analyzed.

The databases must be standard, so apples can be compared to apples,

says Smith, who has a Ph.D. in pharmaceutical science. "We all

have a standard way of counting the mortgage interest we can deduct

from our income tax. We want to set the same kind of accounting rules

for health care decisions."

Top Of Page
Eichert on Changes

John Eichert, of Hastings Healthcare Group on Titus Mill Road,

heralds such technology-based changes. Physicians have typically made

decisions based on anecdotal experience, says Eichert. "We are

moving from a totally disorganized cottage industry full of bright

entrepreneurial physicians to an organized system connected by infrastructure

that won’t be complete for 10 years. Until the infrastructure is there

to share information in real time it will be difficult for physicians

to get the benefit of `best practices.’"

His 100-employee firm is a leader in helping pharmaceutical

clients set up both intranets and databases that are useful for managed

care decisions. For Janssen Pharmaceutica, Hastings helped organize

collective intellectual capital about stroke management into an internal

database, and it has hired one of Janssen’s outcomes research experts,

Patricia Deverka, to expand Hastings’ presence in pharmaco-economics

research.

Hastings has also partnered with the National Conference of State

Legislators and Strategic Health Policy International to assemble

its own database, Medicaid KNet, for the Medicaid portion of managed

care. Just completed, it covers regulatory, legislative, and policy

changes that affect decisions on how to market products in the Medicaid

marketplace.

Hospitals are assembling databases on a larger scale. For instance

David Shulkin, chief medical officer of the University of Pennsylvania

Health System, has pulled together "best clinical practice"

databases for 18 conditions (with the goal of increasing this to 40)

and has disseminated them to several hundred physician groups.

"If Smith can create a community of knowledge and experience,

it will be valuable. But it can be difficult; there is not a culture

of sharing in medicine," says Eichert. For a scientific discovery

or drug to be accepted there must be open discussion and "peer

review." In contrast, "best practices" in disease management

do not have to be shared. If a woman has a particular kind of breast

cancer, she will get whatever combination of radiation, surgery, or

drugs has been deemed best by the doctors at her hospital.

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Penn’s Databases

Shulkin has decided not to shelter his databases as proprietary information

because, as an academic institution, Penn aims to advance the field.

Nevertheless, other hospitals may keep their "best practice"

management discoveries to themselves in order to differentiate themselves

from competitors. "Medicine traditionally shares clinical experience

through peer review, but actually implementing clinical care is more

of a business competition," says Eichert.

"You need to connect the knowledge gained through the outcomes

of the research world, the clinical research world, and the real world

of the Main Street doctor practicing medicine," summarizes Eichert.

"It is very important that knowledge in the marketplace be shared,

and the best way to share it is through technology."

But Smith believes that, even though databases may be kept private

to promote a particular hospital group, they must still be held to

high standards of accounting. "Our organization will not force

anyone to share," says Smith, "but someone should at least

be able to standardize how they counted when they make their claim."

Top Of Page
Czajkowski on Sharing

"That would be a hot commodity as well as a useful resource,"

says Ron Czajkowski, vice president of the New Jersey Hospital Association

(http://www.njha.com). "The chase for good data is a

hugely competitive field, and everyone has their notion of what good

data is. Some of the chase is being funded by insurance companies,

business, various consumer groups, universities, and by hospitals

themselves. If somebody could come up with a one-stop shopping formula

it would be hugely valuable."

Czajkowski ruefully remembers how a dozen New Jersey hospitals were

upset when the NJHA published unflattering statistics about Caesarean

section rates. These member hospitals pressured the NJHA to keep results

of the next studies secret. Yet the reason why some of them looked

bad in the statistics was not because they were doing anything wrong,

but because their "counting process" differed from their competitor’s.

When they changed "oranges to apples" their "apples to

apples" figures made them look much better.

As for those who looked bad no matter how the count was made —

they learned some valuable lessons and had an opportunity to change

their procedures.

"Even though some of our members disagree, we have a commitment

that sharing data is going to help us improve," says Czajkowski.

Top Of Page
Chiang, of the Feds

ISPOR is on the verge of receiving its first foundation grant, but

it has had ongoing federal support for its professional meetings from

the Agency for Health Care Policy and Research. "It is a new field

and a new professional association as well," says Yen-Ping Chiang,

Smith’s contact at AHCPR. "Standardization of many things certainly

would be the ultimate goal, and at this stage we are still trying

to explore ways how to get there. ISPOR’s work certainly is one of

the important elements."

"People involved in ISPOR discuss what it takes to move the field

forward. Most of ISPOR’s members come from industry and these individuals

will produce the studies," says Chiang.

Chiang also cites, as possible contributors to the standardization

process, the Pharmaceutical Research and Manufacturers of America

(which represents about 100 of the biggest research-based pharmaceutical

and biotechnology companies http://www.pharma.org) plus a

new organization of managed care firms, which he cannot yet name.

Clinical economics will not be subject to federal regulations but

will, he hopes, be governed by a consensus on a common data set. "To

the extent that the marketplace can winnow out useful from non-useful

information, that will be sufficient," says Chiang.

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Smith Bio

At the hub of all these possibilities is Marilyn Dix

Smith, the great great niece of Dorothea Dix, the visionary social

reformer who founded Trenton Psychiatric Hospital. Smith grew up in

Ohio, where her father was a farmer. With a B.S. and a Ph.D. in pharmaceutical

science from Ohio State, Smith has had a 20 year pharmaceutical career,

including working in retail pharmacies as well as for Abbott Labs,

Lederle Laboratories, and American Hospital Corporation. Formerly

a Dayton resident, she lives in South Jersey with her husband, and

they have four grown children, two in college.

"I said I need to dedicate my new career to making change happen.

It has been an uphill battle — you have to have people believe

in what you do, and I believe in it."

Her strategy: not to make a big splash "but to get people to feel

committed and marching together." The strategy is working. Three

people started from scratch with no funding, and 35 showed up for

the first meeting. Uwe Reinhardt, the noted Princeton health economist,

was the keynote speaker for the second annual meeting, and the third

annual will be in Philadelphia from May 27 to 30. The organization’s

first international meeting is set for Cologne, Germany, in December.

This is truly a grass roots group that nevertheless has high-placed

members. There are 2,000 members, ranging from students to such experts

as Michael Drummond, a British health economist, and Harvard’s Milton

Weinstein. Individual memberships cost just $75, and income from institutional

memberships has been limited to 20 percent of the budget to remove

any taint of bias. It has all been done without major funding, though

a government grant has been obtained, and applications have been made

for foundation grants. A journal will be published soon. In January

APOR changed its name and merged with another organization that had

better funding but lacked leadership.

"These are great times because you have information technology

at your finger tips, means of communicating with the Internet and

the written word, and we are capable of doing so much without a large

support team," says Smith. She has two assistants: Jennifer Olson,

director of meetings and conventions, and Natalie Palyvoda, manager

of member services.

"It’s risky to take on a whole new initiative. There’s not an

umbrella that’s going to catch you," says Smith. "But as more

people get involved, everyone gets excited about what we are doing.

We have students from pharmacy schools calling to ask about starting

student chapters."

What helped fuel her inner fire: the hospital sent a letter addressed

to her father, three months after he died, asking him to come in for

a visit. "My father was a data point who was lost," says Smith.

"Two days after the funeral, my mother and I were faxing out press

releases on the existence of the organizations. It was her therapy.

We honor our mentors and parents by what we do, and I have done some

good things, but I need to do more. There have to be systems using

large databases to find out what are the right treatments and what

are the wrong treatments."

International Society for Pharmacoeconomics and Outcomes

Research, 20 Nassau Street, Princeton 08540-6627. Marilyn Dix Smith,

executive director. 609-452-0209; fax, 609-452-7473. E-mail: econhealth@aol.com.

Home page: http://www.ispor.org.

Top Of Page
Innovative Health Marketing

Steven Gross of DevCom makes his living by netting

out what is truly important about a product and showcasing that in

an unusual way. For some conditions (edema and arthritis, for example)

he invented a diagnostic gadget and sold the trademarked invention

to a drug company to be used as a marketing tool.

For the makers of DHA (a little known food additive for infants),

he took an even more innovative approach; he created an unusual concept

— it called for founding an organization named "Pregnant Physicians

for DHA" and arranging for women physicians to appear on television

talk shows. It’s a very persuasive image — a pregnant woman doctor

who says she is taking DHA and plans to feed it to her newborn child.

Gross now positions his firm, not as mere a device-invention company,

but as a full service marketing communications firm that specializes

in the healthcare industry. He started DevCom in Paoli, Pennsylvania,

in 1982, moved it to the Carnegie Center in 1993, and bought a two-building

property at 114 Main Street in Kingston. DevCom moved there last month

and occupies 3,150 square feet.

His move resulted — in "small world" fashion — from

a Friday night encounter at the bar at Lahiere’s, where he met the

building’s owner, psychologist Leonard Blank.

"I love being in Kingston," says Gross. "In our 16 years

in business, this is the first time we have moved into a location

where I personally designed every square inch." Extensive renovations

were accomplished by a Freehold-based firm, Cavanaugh’s. Gross delights

in the high tech conference room complete with motorized 100-inch

projection screen connected to networked and individual PCs. He admits

that until now, his firm has been the one to "come calling"

on clients. "But our plan is to invite them to a `day in the country’

and have a working session in our AV conference room."

Picture an Oprah Winfrey show with five pregnant pediatricians (Gross

hasn’t reached the Winfrey pinnacle yet, but 50 broadcast stations,

including CNN and Fox News, have carried DHA concept on talk shows

or news programs).

DHA stands for docosahexaenoic acid, a fatty acid that Gross terms

"brain food," because 15 percent of the brain consists of

good fatty acid. A New Zealand study has correlated a lower IQ from

babies not breast fed or breast fed babies where the mother was on

a low fat diet.

But in the United States DHA has not been accepted for inclusion in

infant formula. Though it is available "over the counter,"

it is not universally known to pediatricians, so Gross needed a way

to plant DHA in mothers’ minds — to tell them that it is safe

and comes recommended by physicians to improve infant intelligence.

He created the concept for a public relations campaign that involved

sending a mailing to the American Academy of Pediatrics. Within two

weeks, one of the DHA experts, Barbara Levine, director of the Nutrition

Information Center, associate professor at Cornell University Medical

College, was making an appearance on Good Morning America. The organization

has gathered 1,400 members, of which more than 200 are pregnant physicians.

One of the Pregnant Physicians for DHA doctor-members,

Jane Oski, was the daughter of the late Frank A. Oski, the chief of

pediatrics at Johns Hopkins, who spent the last two years of his life

trying to educate the FDA and the pediatric community on the importance

of DHA and another fatty acid, ARA, on infant neural development.

DHA Neuromin dietary supplements (as compared to vitamins) are marketed

by such manufacturers as Solgar, Solaray, Source Naturals, and Nature’s

Way. All are sourced from Devcom’s Maryland-based client, Martek Biosciences,

which cultures algae to produce a DHA that Gross says is the "purest

in the world." Firms who take their DHA from fish are taking it

from the secondary source, says Gross, and they do not use the term

Neuromin on the bottle. He also notes that infants are not supposed

to eat fish until they are two years old.

"But if you extract the DHA from cultured algae you don’t have

anything bad, and you can replenish the levels that women should be

taking while they are pregnant," says Gross.

Generally recognized as a safe substance, DHA is supposed to improve

night vision, has been found to lower triglycerides, has not been

found to affect HDLs, and is being studied for its effect on Alzheimer’s

Disease. "When I was on the regimen, my night vision was radically

enhanced," says Gross. He believes there is a correlation between

children with ADD (attention deficit disorder) and low DHA levels,

and that American women, with their low-fat diets, have the lowest

DHA levels in the world.

More traditional to Devcom’s business is a just-trademarked device,

the "edemeter," which takes the guesswork out of measuring

fluid retention, usually determined by pressing your thumb into a

swollen ankle and counting how long it takes for the indentation ("pit")

to resolve. The inexpensive hand-held edemeter has a timer that measures

the recovery. The fancy version comes with a built-in pressure gauge.

"When it hits a certain predetermined level of pressure it automatically

clicks on the timer, independent of the person doing the test,"

Gross explains.

"We would sell this as a trademarked invention to a drug company

with an anti-hypertensive product that doesn’t cause edema," says

Gross. When a sales person goes to a doctor’s office, he or she demonstrates

the edemeter, perhaps using it on the physician’s own ankle, then

pivots to a conversation about the product. "It penetrates communication

barriers in a much more sophisticated way than a presentation, and

it lets the product rise or fall on its own merits."

Gross grew up with a medical legacy; his father was an award-winning

biochemist who died at age 44 during his heart transplant operation.

He majored in biology and chemistry at St. Peters College, Class of

1968, worked at Merck, Sharp & Dohme in sales and advertising for

10 years, then went to the food and pharmaceutical division at FMC

Corporation. "Over the years I had created several inventions

that we call medically relevant brand reminder items that have some

functionality for physicians," says Gross, adding with pride that

many are listed in the FDA’s 510K register (U.S. 1, November 24, 1993).

Gross brings his avocation to his work; with his brother Dave, a casino

music director, he can create his own synthesized musical scores.

He plays seven instruments. As a serious violinist, he is vice president

of the Princeton Music Club (he’s hosting the June meeting), and has

done a deluxe annual report, pro bono, for the New Jersey Symphony.

He’ll use that report plus the annual report of the New Jersey American

Heart Association as a showcase.

"The way we sell our product is by showing `before and afters.’

You don’t have to be a rocket scientist or a specialist to see that

they are very dramatic," says Gross.

— Barbara Fox

DevCom, 114 Main Street, Kingston 08528. Steven

Gross, CEO. 609-924-4666; fax, 609-924-3999. E-mail: DevCom@adv.com.

Selling to Managed Care

It’s a new world out there, in managed care, and a

new division of a familiar marketing firm aims to help pharmaceutical

firms stake out their claims. MediMedia Managed Care does health care

marketing and communications services and is particularly focused

on helping pharmaceutical companies sell to managed care organizations.

It moved onto Phillips Boulevard last fall and is expanding now to

20 employees.

Bradley Kozar, the president and COO of the division, was one of the

earliest to devote his efforts to marketing a drug company’s products

to managed care organizations. "I had a more bullish attitude

about it than most," says Kozar. "Though the traditional routes

to success were in sales, product management, or market research,

I saw managed care as an opportunity rather than as a threat to success."

"Managed care has created bigger winners and bigger losers, and

I am comfortable with that scenario," says Kozar. "If you

understand the marketplace and develop the right relationships based

on trust, credibility, and getting close to the customers, and you

have the right programs and services, there is a tremendous opportunity

for those who do it right. You become the winners."

"A company like mine tries to assist the pharmaceutical firm to

develop the most appropriate managed care, clinical, pharmacoeconomic,

and quality of life message — that differentiates the product

and sells the HMO on the merits of the product," says Kozar, who

usually represents the more expensive brand names that compete with

the cheaper generics.

"Brad has been active in managed care for many many years and

is considered an expert in managed care marketing," says John

Eichert, president and CEO of the 100-employee Hastings Healthcare

Group on Titus Mill Road. "He is a very smart guy, and he has

lots of good contacts in the managed care world."

Indeed, says Kozar, those relationships help facilitate

all the marketing moves. To position a product he might convene a

customer advisory board of 10 to 12 medical directors. Then he has

to help get it listed on an HMO’s "formulary" so it can be

prescribed. Then he needs to encourage "pull through," i.e.

give sales representatives the tools they need to encourage the physicians

to use the product.

"Having held some of the positions that my clients have, having

been responsible for creating contracts for a drug company, and having

created a managed care division, I have credibility very few people

have," says Kozar.

Kozar grew up in a family of six kids in Bedford, a suburb of Cleveland,

where his father was a middle manager. He majored in interpersonal

communications at the University of Toledo, Class of 1980, and interned

as a staff assistant to Howard Metzenbaum, the senator from Ohio.

Kozar spent eight years at Marion Laboratories, leaving in 1988 as

marketing manager of managed care markets. He has also directed institutional

and managed healthcare for Ortho Biotech (a Johnson & Johnson division.

He helped create Johnson & Johnson Healthcare Systems. He also managed

marketing activities for Emron Inc., a full-service managed healthcare

education, research, marketing, and communications firm. Most recently

he was the managing director of Medicom Excel, publishers of managed

care trade publications.

He is married to a physician who had to sell one practice and extricate

herself from another in order to accommodate the moves required by

his career. "She had faith that through hard work and by making

some moves I could be a fairly substantial contributor," says

Kozar. They live in Flemington and have two children.

MediMedia is most familiar to clinical physicians as a provider of

Triple i prescription pads, customized with the doctor’s name and

number, and sponsored by a drug appropriate to the physician’s specialty.

It also provides CliniForms, patient record charts appropriate to

a specialty. In California it offers prescription and formulary guides

(a book for HMO physicians with the approved and recommended drugs)

and plans to release them in other states soon.

Veterinary Learning Systems, a sister organization, has been at this

address on Phillips Boulevard since the early 1990s. The animal healthcare

division of MediMedia International Group, VLS is a publisher, video

producer, and seminar developer that employs 44 people. The parent

company is now based on Park Avenue in Manhattan but will move to

Teterboro this spring. A sister company, MediMedia Infoscan, publishes

formulary guides and is located in Horsham, Pennsylvania. Kozar can

tap Infoscan’s database of nearly 800 managed care formularies. He

claims Infoscan’s is the largest and most up-to-date database of managed

care formularies in the nation.

Optimism and interpersonal skills, says Kozar, are among the keys

to success in the managed care world. "Coming from a family of

five boys you had to learn to talk your way out of some things,"

Kozar admits. "My parents clearly always preached that hard work

was key. That you should be a positive person, and that everyone has

their own problems, so don’t be a complainer."

"My father used to say the A students are the doctors and attorneys

of the world, and the lawyers are your B students. But it’s the B-minus

students and C students with a broad focus — who have more than

just book knowledge — who run the world."

"Coming from a big family, I believe that if we are positive,

enthusiastic, and solution oriented, we are going to win more than

we lose," says Kozar. "I don’t want people to bring just complaints

to me. Managed care doesn’t have to be doom and gloom if you know

how to differentiate your product."

— Barbara Fox

MediMedia Managed Care, 425 Phillips Boulevard,

Suite 100, Trenton 08618. Bradley Kozar, president, COO. 888-724-2302;

fax, 609-882-6202.


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