Stakeholder Mapping

I’ll Take a Tube of Toothpaste and a Tetanus Shot: Five Factors Reshaping Retail Healthcare Delivery

The recent approval of CVS Health’s merger with Aetna is being heralded as nothing less than potentially “transformational” to the health care system. Innovative ideas to help streamline care and encourage cost effectiveness are not new as illustrated by the undefined collaboration between Amazon, Berkshire Hathaway and JP Morgan, nevertheless here is the joining of the consumers, delivery and payer stakeholders. Observers have remarked on the impact that this union may have on the role of the MinuteClinic, i.e., the retail clinics owned and managed by CVS Health. Will there be incentives for Aetna members subscribers to favor these clinics over traditional practices? If so, will their service offerings need to further expand?

A relatively recent phenomenon (the first clinic was established in 2000), their use has been driven by convenience. Where else can you get a flu shot while picking up laundry detergent and cotton swabs or quickly get that sinusitis checked out without an appointment? They have progressed significantly since their inception. For example, they were originally fee-for-service, but the majority of clinics now have negotiated contracts with major insurers.

While this sets up retail clinics as a go-to for wellness services and to manage simple acute illnesses, can they take it to the next level that being chronic disease management?

These contemplations have elicited the realization that retail clinics in general have not been on industry’s radar screen. To help get us up to speed and fully realize their potential in therapy development and commercialization, we provide five facts about retail clinics.

  1. Retail clinics are staffed by non-physicians

The simple premise behind retail clinics management is filling the need for a convenient way to get non-critical acute illnesses such as influenza and sinusitis quickly, along with wellness measure like those pesky booster shots that we put off until the last minute – no appointment necessary. According to the National Urgent Care Center Accreditation (NUCCA), retail clinics are a level IV – the lowest level of care. In essence, requirements include that providers must be certified in basic life support, provide basic on-site lab, offer no radiology or suturing and must post service limitations. Most noteworthy is how they are staffed. In accordance with level IV, retail clinics are staffed mainly by mid-level practitioners with the vast majority being nurse practitioners, with remote medical supervision by a licensed physician. This makes sense as it is a less expensive option and an on-site physician would essentially be overkill.

  1. Over 90% of retail clinics are managed by only five operators

The U.S. has approximately 2000 retail clinics. Five operators mainly represented by retail pharmacies followed by a supermarket and a big box store, run 92% of them. The remainder to a lesser extent, are run by physicians groups and delivery systems.

 Location and Market Share of Retail Clinics by Chain, 2017

 Clinic Location Clinic Operator Market Share
CVS Health (retail pharmacy) MinuteClinic 55%
Walgreens Walgreens Healthcare Clinic; Advocate 18%
Kroger The Little Clinic 11%
Walmart Care Clinic; Clinic at Walmart 4%
Rite Aid RediClinic 3%
HEB RediClinic 2%
All others 8%

Adapted from Drug Channels.

According to the Center for Financial Research & Analysis, CVS Health is the largest operator of retail health care clinics in the U.S. As of December 2017, CVS Health operated over 1100 retail clinics in 33 states under the MinuteClinic name including 15 newly opened ones. Furthermore in 2015 CVS Health acquired Target’s pharmacy business, consisting of 1,660 locations and 80 in-store health clinics, for approximately $1.9 billion. The 79 clinics purchased were re-branded as MinuteClinic. CVS Health is working on opening 20 new clinics within Target stores by the end of 2018. Additionally, CVS Health and Target plan to develop five to 10 small-format stores over a two-year period following the close of the transaction.

  1. Evolution from simple acute care and vaccines to chronic conditions is already taking place

There is already a movement by the retail clinic industry into the more complicated realm of chronic diseases. This wider scope of practice at certain retail clinics is facilitated through affiliation with larger health care systems which provide specialized physician oversight. Many now care for and manage patients with chronic conditions, such as hypertension, diabetes, and asthma. For almost a decade, CVS Health has been affiliating with the Cleveland Clinic and Target (now CVS Health MinuteClinics) has recently struck up an agreement with Kaiser Permanente. Though these are currently regional partnerships, by way of the integration of the clinics into their system and thus physician engagement, they have allowed for improved access to and coordination of care. This is germane to monitoring to manage chronic conditions while maintaining links to other clinical systems.

  1. Physicians groups may not necessarily be fans of retail clinics expanding beyond uncomplicated care and vaccines

While medical groups certainly see a role for retail clinics as they were originally intended, there is resistance against their expansion into areas such as chronic care. The American Academy of Family Physicians (AAFP) officially opposes the expansion of services offered by retail clinics, specifically those related to chronic disease management, as they fear fragmentation of care. They cite that the protocol-based decision and diagnostic models used in most retail clinics (they point out that they are non-physician led), may result in a missed opportunity to address more complex patient needs.

This view is bolstered in a 2017 article from the American Journal of Managed Care which cites that while there is strong user satisfaction demonstrated by a relatively high rate of return visits, people who use retail clinics are less likely to return to their primary physicians for subsequent visits. This raises continuity of care concerns.

There should be sensitivity toward the fact that retail clinics as viable competitors to physician practices, if services are greatly expanded to chronic disease monitoring and beyond.

  1. Adults on either end of age spectrum will likely fuel growth

The retail clinic trend lends itself to convenience with expanded care options created through strategic collaborations. This is expected to stimulate interest in retail clinics by adults on both ends of the age spectrum – millennials and seniors. In fact, a recent article in Forbes notes that millennials are largely ditching their primary physicians and opting for real-time care provided on their schedules.

On the other end of the spectrum, retail clinics are taking steps to further focus their services toward seniors. Most notably, Walgreens “Take Care” clinics and Humana is piloting a program in Kansas City markets, targeted to Humana’s Medicare Advantage patients. Jointly, the two companies will offer geriatrics-focused acute and chronic care, health navigation services, and health education. Notably, retail clinics are already offering the free Medicare wellness visits.

The CVS Health-Aetna merger is being regarded as transformational for the health care industry as the clinic and payer are now one. This is as disruptive as it gets. CVS Health will now have the ability to convert more of its brick-and-mortar locations into front-line clinics for basic medical services and monitoring of chronic conditions. CVS Health has said that by deepening its knowledge of and relationships with patients, CVS says that the combination could help Americans stick with medication regimens and stay out of the hospital. This indeed makes sense as minute clinics are situated where people shop on a daily basis and you can’t beat their proximity to pharmacists. This has the potential to increase a patient’s likelihood to actually fill their prescription and be more informed about it.

This may set the tone for other comparable non-traditional marriages. We are already seeing limited partnerships between Target’s MinuteClinics and Kaiser and Walgreens and Humana. If the model works, it is only going to grow.  While industry has been doing a good job of connecting with patients, nurse practitioners and pharmacists, there is a huge opportunity to better engage them within the ecosystem of the retail clinic.

Snowfish has pioneered a unique approach of mapping the disease state ecosystem including non-traditional competitors and key stakeholders designed to meet the needs of the particular product. To learn more, please feel free to contact us at

Melissa Hammond, GNP is Managing Director at Snowfish a strategic consulting firm that has almost two decades working exclusively with the pharmaceutical, biotech, and medical device industries. Please go to or call +703-759-6100 to learn more about our services.

Posted by Dave Fishman  |  0 Comment  |  in Brand Management, Medical Affairs, Stakeholder Mapping, Strategic Partnering

As Companies Tackle “Age-Related Diseases”, How Much Do We Know About Geriatricians?

It is encouraging to hear the news of further investment  – $1B to be exact – into extending research collaboration between AbbVie and Calico focused on developing innovative therapies for “age-related diseases”. This partnership is evidence of the growing industry movement to embrace the differences across the lifespan and focus on therapies which can be tailored to this unique and medically complex population.

Such development initiatives underscore a very important stakeholder group  – geriatricians. While they are in high demand by patients, who are realizing their value,  their numbers are relatively meager as geriatrics does tend to have the appeal of other specialty tracks. Thus there is a low likelihood that an industry professional will come in contact with a geriatrician and it is often not clear what they bring to the table and how they differ from other clinicians such as internists and primary care.

According to the American Geriatrics Society, a geriatrician is “a medical doctor who is specially trained to meet the unique healthcare needs of older adults. Illnesses, diseases and medications may affect older people differently than younger adults and older patients often have multiple health problems and take multiple medications.”  Truly, this definition does not do this specialty justice. In fact, geriatrics is probably one of the most complex areas in which to practice.

As we age, common conditions tend to present “atypically”, therefore practitioners must have incredibly astute assessment skills and instincts. For example, a patient with a urinary tract infection may not necessarily have burning, but might have a dehydration and confusion. Similarly, an MI might present mild discomfort in the upper abdomen rather than crushing chest pain. Therapy options are also limited to some extent; there are certain drugs that have a high risk to benefit ratio in the elderly. So too, they must play detective when a drug reaction or interaction is suspected.

Due to the nature of their patient population, geriatricians often veer well beyond the realms of what is considered “medicine”. They must take a holistic approach to disease management and prevention. It is not unusual that a potential crisis is averted by maintaining or improving function through the incorporation of nutrition, hydration, psychiatric modalities, physical therapy, and referrals to social work. We think of geriatricians playing a critical role in the identification and management of dementia. What is often neglected is that their training readies them to take on the challenge of treating other chronic conditions in the presence of dementia.

In reference to training, there is no shortage of fellowship programs with 139 in the U.S. alone. In the U.S., geriatrics is not even a specialty, but rather a subspecialty of internal medicine. A residency in internal medicine with a one to two year fellowship for geriatrics is required for certification. In the EU, the training path differs by country with the norm being two to three years of geriatric concentration. Unlike in the U.S, 19 countries within the EU recognize geriatrics as a specialty.

As said before, geriatrics does not have the draw enjoyed by other specialties. Reasons range from funding and reimbursement to its perceived lack of “sexiness” by medical students and trainees. That said gaps are slowly being filled by non-physician clinicians such as nurse practitioners and physician assistants. Another trend is the geriatric concentration with certain specialists. Witness the geriatric psychiatrist, geriatric cardiologist, geriatric nephrologist, geriatric oncologist and even the geriatric emergency physician. This is driven on the appreciation that many of the patients seen in these specialty practices are older or elderly and the appropriate knowledge base is critical to ensure optimal management. Other innovative solutions such as continuing education for non-geriatric clinicians are also well established.

Given the steady focus in the development of therapies for age-related diseases, it is more imperative than ever to partner with this very important stakeholder group. With a solid grasp on the role and qualifications of geriatricians, industry professionals can develop innovative ways to involve and provide value to them. Additionally, there are endless opportunities to assist non-certified clinicians to practice geriatric medicine through effective therapy development and education along with linking clinicians up with valuable resources.

Melissa Hammond, MSN, GNP is Managing Director at Snowfish and a well-recognized industry expert in geriatrics. She can be contacted at

Snowfish has pioneered this unique approach of building custom stakeholder landscapes designed to meet the needs of the particular product. Individuals and policies are able to be assessed across multiple groups and companies are able to plan their pre-launch and launch activities on a very detailed level. To learn more, please feel free to contact us at

Snowfish can be reached at (703) 759-6100 or via e-mail at  We are also on the web at

Posted by Melissa Hammond  |  0 Comment  |  in Management Consulting, Medical Affairs, Product Development, Stakeholder Mapping

5 Reasons Why You Don’t Use Prescription Data to Identify Your KOLs

Over the years we have heard a number of concerns regarding KOLs from company employees:

“I am worried that if he is asked how to use it, what will he say”?

“She is not loyal to us”.

“I don’t know why he is up there [speaking], he never prescribes our product”.

These are the concerns of anxious sales representatives, marketing professionals and even medical affairs directors when referring to certain speakers that I have worked with earlier in my career in medical communications. That put quite a damper on what were essentially excellent scientifically strong and intellectually stimulation educational presentations. In any case, the point is that when it came to KOLs, there appeared to be a greater interest in brand loyalty than in diverse experience, credibility and linkages to other individuals and groups. Such loyalty was measured in terms of prescriptions.

Since then for many in our industry, thankfully the definition of a KOL has gone beyond someone with allegiance to a particular product. Yet it is not uncommon to run into our colleagues who ask why we can’t just use prescribing data to identify KOLs, particularly beyond the national level. The rationale is that this will help to uncover the true clinicians – those who can speak from their vast patient-facing experience. While there is some validity to this, there are even more reasons why the process for KOL identification should not include prescription data, period. We have outlined the top five reasons for avoiding prescribing data in your KOL mapping efforts.

     1. Is not a measure of expertise

Prescription data is a measure of just that, prescriptions. That said, it only tells us the specific products that a clinician uses for their patient and the volume. It does not signify if the individual has expertise in a given area or even if they treat a lot of patients (see #4). To that point, we do hear that especially at the regional/local levels, it is critical that the KOL speaks from their experience.  There are more effective – and less expensive – means to do this.

     2. It has not been a great indicator of a KOL

In our 15+ years of experience in KOL mapping, we have found that prescription volume has not been an accurate marker of an ideal KOL. In fact, there is an inverse relationship between these two once you are at the national level.  Alternatively, KOLs at any level are found to have multi-faceted profiles with demonstrated abilities to take their expertise outside of their own practices and link with their communities.

     3. Can lead to malalignment with the organizations objectives

By labeling a KOL based off one set of data (prescription data) can lead to a host of problems.  Medical Affairs might be looking for KOLs to shed light on a disease state at an advisory board but soon realize their knowledge is limited. Marketing is looking for a KOL that can communicate issues to a wider audience but realize they have no public speaking or writing experience. This becomes even more apparent when a company use one set of KOLs for a variety of disparate tasks. We have always advocating using a unique profile we’ve develop to ensure the right match within an organization.

     4. May not represent who you think it does

It is well established that a good deal of the care delivered is no longer exclusively through physicians. With over 280,000 in the US alone, the role of nurse practitioners (NPs) has been expanding significantly and they have been functioning at a much higher capacity than ever before.  This includes varying levels of prescriptive privileges in all 50 states and the District of Columbia with NPs writing an average of 23 prescriptions a day per the American Academy of Nurse Practitioners.  What is not always realized is that a fair share of these treatments is not captured under the NP themselves, but rather a physician with whom they work with.

Consequently, while a particular physician may show up as having an incredibly large prescription volume for a particular product or class of therapy, the reality is that they have five NPs, all of whom are using the physician’s number for their own prescriptions. They are then captured under the physician and not the NP. On the flip side, when trying to use this to map NP KOLs, this data will likely misrepresent them as low-volume clinicians who do not see many patients.

The bottom line is that prescription data may not even be an accurate picture of an individual’s clinical experience. There are better sources.

     5. May open company up to media or government scrutiny.

For this very reason, prescription data should be considered a proverbial third rail in KOL identification. Due to activities years ago by some players that were less than savory, our industry is still shaking off a reputation that suggests that anyone tied to it is biased. Most recently, reports by CNN and other news outlets have tied money paid to clinicians for speaking and consulting, to their prescription patterns. While these reports tend to inspect the prescriptions following such payments, it is just as likely to trigger a red flag if it is found that a KOL who is also an established high prescriber is receiving significant honoraria for a number of activities.

Therefore, while the intent may not be to only collaborate with KOLs who are product loyalists, use of prescription data to identify them may nonetheless send the wrong message and impair the credibility. It can also open the company up to some unwanted attention.

Overall, the definition of a KOL has evolved, with the ideal being one who is a trustworthy and capable expert who can convey their knowledge to others in order to improve patient care. So too have the methods for identifying them. With the multi-faceted approach which combines multiple and varied sources, such as what Snowfish provides, credible KOLs can be effectively mapped and engaged for all types of innovative programs. Whereas prescription data has value for many functions such as sales and marketing, for the reasons stated, it should be omitted from KOL mapping efforts.

Snowfish has pioneered this unique approach of building custom stakeholder landscapes including KOL identification and mapping, designed to meet the needs of the particular product. To learn more, please feel free to contact us at

Melissa Hammond, GNP is Managing Director at Snowfish a strategic consulting firm that has almost two decades working exclusively with the pharmaceutical, biotech, and medical device industries. Please go to or call +703-759-6100 to learn more about our services.

Posted by Dave Fishman  |  0 Comment  |  in Management Consulting, Medical Affairs, Product Development, Stakeholder Mapping

Stakeholder Deep Dive: Is there more than a doctor in the house?

Doctor BookA recent Snowfish post discussed the virtues of stakeholder engagement and the advantages afforded to companies who invest in mapping their own stakeholder landscapes. While we touched upon the endless number of stakeholder categories, the nuances within them was way more than a single article could handle. We will be publishing a series of posts which will take a deeper dive inside these categories to understand the individual entities which make up the fabric of a strong network.

The first broad group is the providers. They generally include the places that people go to get care along with the individuals that work within these organizations. They deliver care for a particular condition and are often instrumental in providing or referring for a particular therapy. They may conduct research related to the disease or therapy. They may treat patients fitting a particular profile. In fact providers were THE original “key opinion leaders (KOLs)” and “centers of excellence (CoEs) and mainly limited to physicians, researchers, and research institutions. Everyone else was considered an “influencer” of the physician or only tangential to the elite institutions.

Non-physicians stakeholders are no longer “influencers” only

Indeed those “influencers” have been realized to be way more critical than originally thought and are important facets of the provider stakeholder category. This multifaceted group has grown to include nurse practitioners, nurses, disease state educators, disease navigators, pharmacists, and even administrators, medical directors, quality improvement/assurance, and ethics professionals. Taking it down to more granular level, the majority of these groups of professionals may be divided into general versus specialist.

Clinical settings are as diverse as the individuals that work in them.

Depending upon the therapy and target population, clinical settings may be quite diverse. Outpatient clinics, group practices, and pharmacies join conventional hospitals and research centers on the list of potential stakeholders. Also of consideration are nursing homes, assisted living facilities, rehabilitation centers, and mobile health teams. These may be general or specialty focused, urban or rural, private or public, standard or innovative care model.

Identifying the right provider stakeholders

In the vast universe of providers there is only a subset that would be considered true stakeholders for a given disease. Thorough research of the stakeholder category and specific target groups coupled with the objectives for the therapy lend itself to developing the profile of the individuals and organizations to include. This is followed by mapping of the providers using critical inputs which should include factors related to expertise, and focus in the particular disease state.

Objective measures such as disease state specific clinical articles, trials, treatment staff, guidelines, affiliations, membership, etc. should be incorporated. In addition, subjective measures such as hospital survey rankings, KOLs, Medicare rankings, press releases, should also be used. The net result is a very select list of providers for engagement.

Given how care has evolved, it is clear that provider stakeholders are no longer limited to physicians and hospitals. Many other professionals and organizations must be engaged. The complexities of the provider landscape can only be addressed through a systematic mapping and targeting of the most important stakeholders and entities within them.

Snowfish has pioneered this unique approach of building custom stakeholder landscapes designed to meet the needs of the particular product. Individuals and policies are able to be assessed across multiple groups and companies are able to plan their pre-launch and launch activities on a very detailed level. To learn more, please feel free to contact us at

David Fishman, MBA is President at Snowfish a strategic consulting firm that has almost two decades working exclusively with the pharmaceutical, biotech, and medical device industries. Please go to or call +703-759-6100 to learn more about our services.

Posted by Dave Fishman  |  0 Comment  |  in Management Consulting, Product Development, Stakeholder Mapping