By KIM BELLARD

It’s Cyber Monday, and you’ve probably been shopping this weekend. In-stores sales on Black Friday rose 2.2% this year, whereas online sakes rose almost 8%, to $9.8b – over half of which was via mobile shopping. Cyber Monday, though, is expected to outpace Black Friday’s online shopping, with an estimated $12b, 5.4% higher than last year. 

Lest we forget, Amazon’s Prime Day is even bigger than either Cyber Monday or Black Friday.  

All that shopping means lots of deliveries, and here’s where I got a surprise: according to a Wall Street Journal analysis, Amazon is now the leading (private) delivery service. The analysis found that Amazon has already shipped some 4.8 billion packages door-to-door, and expects to finish the year with some 5.9bn. UPS is expected to have some 5.3bn, while FedEx is close to 3bn – and – unlike Amazon’s numbers — both include deliveries where the U.S. Postal Service actually does the “last mile delivery.” 

Just a few years ago, WSJ reminds us, the idea that Amazon would deliver the most packages was considered “fantastical” by its competitors. “In all likelihood, the primary deliverers of e-commerce shipments for the foreseeable future will be UPS, the U.S. Postal Service and FedEx,” the then-CEO of Fed Ex said at the time. That quote didn’t age well.

Amazon’s growth is attributed in part to its contractor delivery program, whose 200,000 drivers (usually) wear Amazon uniforms and drive Amazon-branded vehicles, although they don’t actually work for Amazon, and a pandemic-driven doubling of its logistics network. WSJ reports: “Amazon has moved to regionalize its logistics network to reduce how far packages travel across the U.S. in an effort to get products to customers faster and improve profitability.”

It worked.

But I shouldn’t be surprised. Amazon usually gets good at what it tries. Take cloud computing.  Amazon Web Services (AWS) in its early years was considered something of a capital sink, but now not only is by far the market leader, with 32% market share (versus Azure’s 22%) but also generates close to 70% of Amazon’s profits. 

Prime, Amazon’s subscription service, now has some 200 million subscribers worldwide, some 167 million are in the U.S. Seventy-one percent of Amazon shoppers are Prime members, and its fees account for over 50% of all U.S. paid retail membership fees (Costco trails at under 10%). There’s some self-selection involved, but Prime members spend about three times as much on Amazon as nonprime members.

The world’s biggest online retailer. The biggest U.S. delivery service. The world’s biggest cloud computing service. The world’s second largest subscription service (watch out Netflix!).  It’s “only” the fifth largest company in the world by market capitalization, but don’t bet against it. 

I must admit, I’ve been a bit of a skeptic when it comes to Amazon’s interest in healthcare. I first wrote about them almost ten years ago, and over those years Amazon has continued to put its feet further into healthcare’s muddy waters.

For example, it bought online pharmacy Pillpack in 2018. “PillPack’s visionary team has a combination of deep pharmacy experience and a focus on technology,” said Jeff Wilke, Amazon CEO Worldwide Consumer. “PillPack is meaningfully improving its customers’ lives, and we want to help them continue making it easy for people to save time, simplify their lives, and feel healthier. We’re excited to see what we can do together on behalf of customers over time.”

PillPack still exists as an Amazon service, but has broadened into Amazon Pharmacy. PillPack focuses more on people with chronic conditions who like the prepacked pills, while Pharmacy offers home delivery to other customers.  At its introduction, Doug Herrington, Senior Vice President of North American Consumer at Amazon, said: “PillPack has provided exceptional pharmacy service for individuals with chronic health conditions for over six years. Now, we’re expanding our pharmacy offering to Amazon.com, which will help more customers save time, save money, simplify their lives, and feel healthier.”

Amazon Pharmacy has since introduced RxPass, a $5/month subscription service for many common generic drugs, but it still hasn’t cracked the top ten U.S. pharmacies, so there’s work to be done. One pharmacy analyst writes: “Perhaps one day Amazon will be a true disrupter. For now, Amazon is choosing to join the drug channel not fundamentally change it.”

PillPack’s co-founders have recently left.   

Earlier this year, after all the fumbling around with Haven and Amazon Care, Amazon bought One Medical. “We’re on a mission to make it dramatically easier for people to find, choose, afford, and engage with the services, products, and professionals they need to get and stay healthy, and coming together with One Medical is a big step on that journey,” said Neil Lindsay, senior vice president of Amazon Health Services.

Then this month Amazon sought to entice Prime members to join One Medical by offering membership for $9/month, or $99 per year. “When it is easier for people to get the care they need, they engage more in their health, and realize better health outcomes,” said Mr. Lindsay. “That’s why we are bringing One Medical’s exceptional experience to Prime members—it’s health care that makes it dramatically easier to get and stay healthy.”

Of course, One Medical is only in 25 metro markets, with some 200 doctors office, and it doesn’t contract with every insurance plan. Plus, One Medical CEO Amir Dan Rubin is already on his way out of the door. Scaling will not be easy.

Amazon’s success with its healthcare ventures is hard to tell.  HT Tech reports that monthly active users of the One Medical app are up 16% since the acquisition, and that Amazon claims Amazon Pharmacy doubled its active customers from 2022 to 2023. Still, Lisa Phillips, an analyst with Insider Intelligence, scoffed: “It really hasn’t made a big dent. I don’t think anybody is scared of it anymore.”

Maybe. Healthcare is hard, and usually confounds outsiders who aren’t familiar with its byzantine structures. But I look at it this way: Amazon has been delivering its own packages for less than 10 years, and now it is bigger than UPS and FedEx. That’s not nothing. So for the first time I’m starting to think that maybe Amazon can make its mark in healthcare. 

Amazon the biggest healthcare company in ten years?  Don’t bet against it.

By HANS DUVEFELT

I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but was unaware of the additional risperidone-furosemide risk. Epocrates only has a nonspecific warning to monitor blood pressure when prescribing both drugs.

This is only today’s example of an interaction I didn’t have at my fingertips. I very often check Epocrates on my iPhone for interactions before prescribing, because – quite frankly – my EMR always gives me an entire screen of fine print idiotic kindergarten warnings nobody ever has time to read in a real clinical situation. (In my case provided by the otherwise decent makers of UpToDate.)

I keep coming back in my thoughts and blogging about drug interactions. And every time I run into one that surprised me or caused harm, I think of the inherent, exponential risks of polypharmacy and the virtues of oligopharmacy.

One conclusion I have come to is that too often the benefit of our prescribed medication is actually too small to justify the drug. The way drugs are approved today is pretty much that they have to bring a 20% or so advantage over placebo for a certain outcome. Other than the drug versus placebo, all other factors are ignored or “controlled for”, which is easier said than done.

But this whole premise seems wrong to me: If pill A is 20% better than placebo at lowering blood pressure, but salt restriction, weight loss, exercise, and stress reduction are twice as powerful as pill A, why are we so stuck on prescribing pill A? If a Mediterranean diet lowers cardiovascular risk as much as atorvastatin, why isn’t that a blockbuster/no-brainer intervention?

The health of our nation is not great, in spite of all the pills at our disposal. And the more pills we prescribe, the more we risk interactions: antidepressants and cholesterol pills with blood thinners, gout medicines with cholesterol pills, mood stabilizers with cardiac medications, and on and on and on.

May we all take a step back and look at the big picture of what we are doing and where we are heading.

Donald W Light from the Harvard Center of Ethics wrote in 2014:

Few people know that new prescription drugs have a 1 in 5 chance of causing serious reactions after they have been approved. That is why expert physicians recommend not taking new drugs for at least five years unless patients have first tried better-established options, and have the need to do so.

Few know that systematic reviews of hospital charts found that even properly prescribed drugs (aside from misprescribing, overdosing, or self-prescribing) cause about 1.9 million hospitalizations a year. Another 840,000 hospitalized patients are given drugs that cause serious adverse reactions for a total of 2.74 million serious adverse drug reactions. About 128,000 people die from drugs prescribed to them. This makes prescription drugs a major health risk, ranking 4th with stroke as a leading cause of death. The European Commission estimates that adverse reactions from prescription drugs cause 200,000 deaths; so together, about 328,000 patients in the U.S. and Europe die from prescription drugs each year. The FDA does not acknowledge these facts and instead gathers a small fraction of the cases.

There are obviously more recent statistics out there, but this piece struck me because it was published in a forum about ethics. Think about that for a moment: We are subjecting our patients to known and unknown risks of harm with every prescription we issue.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

David Medvedeff, CEO Aspen RxHealth, tells me about the new role of pharmacists in managing chronically ill patients. Aspen RxHealth has put together a network of independent pharmacists and a tool that allows them to select patients, call them and consult with them for their pharmacy issues. It’s kinda like the original Teladoc model but for pharmacists, while the clients are health plans keen for their patients to avoid problems with polypharmacy. They’ll be doing 200K+ consults this year and just raised $23m.

Health system pharmacists are frustrated with the lack of time they spend connecting with patients. Why? Jennifer Tryon, Chief Pharmacy Officer for Wake Forest Baptist Health breaks it down for us by talking specifics about the outdated processes and old-school tech that are underpinning many health systems’ medication management programs — and holding back their pharmacists as a result. When she’s sourcing innovative new solutions for her pharmacy at Wake Forest Baptist Health, what are the pressing priorities that are getting her attention (and her budget)? Jennifer’s description of the challenges and opportunities for innovation in the health system pharmacy and medication management space is a MUST watch for anyone looking to learn more about taking their tech into this space.

Filmed at the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in Las Vegas, December 2019.

From the point at which a medication arrives at a hospital’s receiving dock to the time it’s given to a patient, Omnicell systems are relied on to “store it, package it, barcode it, order it, issue it, and charge it.” Now, CEO Randy Lipps wants to automate ALL OF IT — getting medications from dockside to bedside, without the help of human hands. The Autonomous Pharmacy is not only Omnicell’s bold vision for the future of medication management for hospitals that brings in robotics and software to improve the safety and accuracy of every aspect of the drug delivery process, but as Randy says, it’s an “industry movement” to free the hospital pharmacist from the “basement pharmacy” and allow them to truly practice at the top of their license. Although integrating new tech into healthcare systems is never easy, this CEO says that it’s less the tech — and more the lack of urgency in shifting our mindset as an industry — that’s slowing us down. What exactly needs to change? Bold visions require big plans…

Filmed at the American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in Las Vegas, December 2019.

Well, it’s official: CVS has stopped selling cigarettes and other tobacco products.

The sales ban will cost the multi-billion dollar pharmacy chain about $2 billion a year in profits.  But the hope is that the move will provide a more consistent health promotion message to consumers (it has changed its corporate name to CVS Health) and lead to new business (for example, through visits to its in-store health clinics).

But will this move have any effect on smoking in the population? It’s difficult to say at this point.

The impact of the ban on overall tobacco sales nationwide will probably be negligible.  Only a very small percentage of consumers buy their tobacco at pharmacies and there are plenty of retail options available beyond the local pharmacy.

CVS is also banning the sale of electronic or e-cigarettes. Advocates from this industry are predictably agitated: “It’s smoking that causes all the health problems, not the smokeless alternatives.” Others argue that e-cigarettes and other smokeless alternatives are effective aids for those wishing to quit-smoking.

Well, not exactly: the short and long term toxicity of e-cigarettes is still largely unknown (though they are probably safer than smoked cigarettes) and there is no evidence that e-cigarettes help smokers quit or reduce their smoking. Now, it’s possible that CVS will reverse course on the sale of e-cigarettes if the evidence base evolves to support the e-cigarette industry’s claims. But for now the position it is taking is conservative and is consistent with the Food and Drug Administration’s position that e-cigarettes should be regulated like a tobacco product.

There is the renewed promise of CVS helping smokers quit. The chain sells a variety of medications that can help smokers with quitting (for example, nicotine skin patches) and now will be supplementing those medications with a “robust smoking cessation program.” It’s not entirely clear what this smoking cessation program will look like or who will deliver it, but the few randomized clinical trials that have evaluated pharmacist-delivered smoking cessation interventions have shown that they are effective at helping people quit.

Overall, the ban on tobacco product sales is probably most significant for what it symbolically represents. CVS is the first national pharmacy chain to stop selling tobacco products; smaller pharmacies and chains, and some select localities have already banned the sale of tobacco products in pharmacies. Other national chains are currently evaluating their tobacco sales policies and may or may not make a change. It is likely that they are waiting to see what happens to CVS before making a decision.

So, right now, the only thing that we know for sure is that CVS has stopped selling tobacco products. We’ll have to wait to see whether any tangible public health benefits emerge from its decision.

William G. Shadel is a senior behavioral scientist and associate director of the Population Health Program at the nonprofit, nonpartisan RAND Corporation. 

Alex Savic is CEO of Alensa NextWidgets, based in Zurich, Switzerland. Alex is a repeat presenter at Health 2.0 and will be presenting an update on the NextWidgets platform at Health 2.0 Europe in Paris April 6-7, 2010. NextWidgets allows pharmacies to sell their products online directly to consumers through widgets placed on relevant content publisher websites.

Indu Subaiya: Alex, tell us a bit about yourself and our background, and what Alensa is all about.

Alex Savic: I’ve been working in the generics industry since 2000, traveling a lot to India and Eastern Europe to meet with manufacturers and inspect manufacturing facilities. Alensa was mostly in the API and finished formulations business then. So to branch out, in 2006 we started working on an e-commerce platform for pharmacies which has since evolved into the NextWidgets platform.Indu: What specific insights did you gain working in the pharmaceutical industry that led you to see the opportunity for an e-commerce platform for pharmacies?

Alex: Around 2005 we looked at the success of online pharmacies in the US and also of DocMorris in Europe and saw a potential to create a platform that would allow any pharmacy to establish themselves online and offer e-commerce to their customers. Still today, only a small fraction of pharmacies are engaged online, despite the high demand for Internet healthcare services from users.

Indu: Do you mean sites like Drugstore.com in the US?

Alex: That is definitely a good example – it was one of the case studies we looked at.

Indu: But your platform allows individual pharmacies to sell directly to consumers. Why did you take that angle?

Alex: We thought that we should create software that could empower any pharmacy owner to compete online. It’s quite a challenge for small to medium-sized pharmacies to allocate resources to an Internet project, so most of them don’t. By providing a hosted and managed platform we felt we could get more pharmacies on board. What’s interesting is that we’ve created a platform now that can be used by both large and small merchants

Indu: Tell me a little bit about the market for pharmacies in Europe. What percentage of the market is dominated by large chains and what percentage is made up of smaller, “mom and pop” operations.

Alex: It is different for each individual country but mostly it is still independently owned pharmacies that make up the majority. What I find fascinating about e-commerce is that the physical size of your chain is not as important, other competitive advantage factors come into play. I put together some stats for the pharmacy market in Europe—it’s clearly a fragmented, diverse market:

Indu: Your NextWidgets platform plays an interesting role connecting content and community sites with the drugstore vendors. Tell us how that works and how the use of widgets across a network of sites benefits both sets of parties.

Alex: NextWidgets is a shopping widget platform which means we take the pharmacy store and miniaturize it to the size of a traditional banner ad. When the ad is clicked on, it expands into a small shop where the user can make purchases without leaving the publishers page. This allows content publishers to offer products relevant to the content and earn a sales commission. It’s a really simple way for publishers to provide e-commerce functions on their site and increase engagement with visitors. On the other side, the pharmacy benefits from increased distribution.

What’s really exciting at the moment is that we’re launching the same functionality for Facebook fan pages. Many publishers have huge fan communities on Facebook and so this is an added way to generate revenue off-site.

Indu: So give me an example of a publisher, an example of a drugstore and take through how the economics works for both sides.

Alex: An example in the US is OverstockDrugstore.com from Utah. Their store can now we seen on healthworldnet.com website and the Sugarstats Facebook fan page, both branded to fit the publishers requirements.

Indu: So healthworldnet.com gets a commission each time someone makes a purchase from a widget it hosts?

Alex: Currently we are working on a commission model, where we pay any publisher a commission on each sale. This is a purely performance based model which is often a challenge since many publishers only work on a fixed price (CPM) model. In many ways it comes down to publishers requirement for e-commerce functionality, and if it’s required to make the site more interesting, then it’s a good proposition. On the Facebook side, it’s an easier proposition, there is only upside to using the widget on Facebook.

Indu: Does the content site benefit from increased traffic/search optimization because of the widget?

Alex: The widget does not offer publishers traffic/SEO benefits – it’s purely a contextual shopping functionality

Indu: So as a consumer today, what types of products can I buy through NextWidgets’s modules? Is it shampoo and razors? Or can I get chemotherapy prescriptions filled?

Alex: In the example of OverstockDrugstore.com we have some 9500 products which are currently all non-prescription. We are also planning to enable a sign-up form for a new program that OverstockDrugstore.com is launching for low-price prescription filling service for diabetics.

Indu: So how many pharmacies are now online with Alensa and how many publishers are hosting widgets? In which countries is the service available?

Alex: We currently have OverstockDrugstore.com in the US, OneClickPharmacy.co.uk in the UK, www.stauffacher-apotheke.ch in Switzerland and Apothekapharmacity.rs in Serbia. We hope to have France and Germany covered within this year. On the publisher side, we have only started the marketing effort so please stay tuned for more on that at Health 2.0 in Paris Here’s a bit more on the Facebook widget for OverstockDrugstore.com:

Indu: Are there any regulatory issues that impact ecommerce for pharmacies?

Alex: In the US there are no issues. In Europe there are some countries where online pharmacy business in not allowed such as Poland, Hungary and I believe Spain and Portugal.

Indu: Do you think those regulations will change?

Alex: Many countries in Europe have been dragging their feet about liberalizing the pharmacy market. I believe they will change but it could take years. The interesting thing is that the free trade of goods principle allows online pharmacies in countries that allow them such as the UK, to sell into the countries that don’t legally, but within those countries themselves, there cannot be any local online pharmacies. Which is a strange situation indeed. Pharmacies online still have the lowest penetration rate of any online industry

Indu: What plans are coming up for NextWidgets/Alensa?

Alex: Even the best technology is worthless if you don’t market it, which is our task for the next half of the year, with the goal to get many more merchants and especially many publishers to try the system. Of course we have to optimize the technology further as well. For example we are working hard on getting our crawler & contextual matching engine ready to demo at Health 2.0. Beyond that we look forward to officially launching the iPhone/Android version of the widget. We have a couple of more innovative ideas about how this technology can be extended which we will be ready to present next year.

Indu: Thanks very much and see you at Health 2.0 Europe , in Paris on April 6th!

Alex: Thanks, we’re looking forward to presenting.