* The Asheville Project * * The Asheville Project * An Ounce of Prevention An Ounce of Prevention

Really IS Worth a Pound of Really IS Worth a Pound of Cure Cure

Barry A. Bunting, Pharm.D.

Clinical Manager of Pharmacy Services

Mission Hospitals

Asheville, NC

Barry A. Bunting, Pharm.D.

Clinical Manager of Pharmacy Services

Mission Hospitals

Asheville, NC

THE HJ THE HJ PKKKHHROJECTPKKKHHROJECT

SINCE WE LAST MET:SINCE WE LAST MET:

There are over 50 employers in 12 states that have implemented similar models for their employees We have over 1400 people enrolled in our community Programs are offered for diabetes, asthma, high blood pressure, high cholesterol, and depression We have published data on asthma Others have now published data on diabetes West Virginia offers this model for all state employees and they have over 3000 people with diabetes enrolled The largest employer in Los Angeles offers the program

WHY AREN’T WE WHY AREN’T WE DOING BETTER?DOING BETTER?

PATIENT BARRIERSPATIENT BARRIERS COST ACCESS KNOWLEDGE DEFICITS LACK OF MOTIVATION TO CHANGE COMPLIANCE/ADHERENCE ISSUES DENIAL/FATALISM/LOW EXPECTATIONS LACK OF FEEDBACK ON HOW THEY ARE DOING LACK OF HELP WITH THEIR DAY-TO-DAY DECISIONS

PAYER BARRIERSPAYER BARRIERS

FREQUENTLY LACK UNDERSTANDING OF COST DRIVERS BELIEF THAT DISCOUNTS ARE THE WAY TO CONTROL HEALTH CARE COSTS BELIEF THAT CONTROLLING HEALTH CARE COSTS IS OUT OF THEIR CONTROL HAVEN’T SEEN CONVINCING EVIDENCE THAT AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE SKEPTICISM OF PREVENTIVE/DISEASE MANAGEMENT PROGRAMS

PHYSICIAN BARRIERSPHYSICIAN BARRIERS

TOO MANY GUIDELINES NOT ENOUGH TIME TIME PRESSURES CAN RESULT IN TRIAL & ERROR VS. EVIDENCE BASED APPROACHES BUSINESS DEMANDS DICTATE HIGH VOLUME NOT HIGH-TOUCH INABILITY TO KNOW IF PATIENT IS FOLLOWING THEIR PLAN INABILITY TO SIGNIFICANTLY INFLUENCE PEOPLE’S BEHAVIOR

IDENTIFYING IDENTIFYING BARRIERS IS THE BARRIERS IS THE

EASY PART!!EASY PART!!

WHAT DO WE WHAT DO WE DODO ABOUT ABOUT THEM?????THEM?????

WHAT IF:WHAT IF: Health plans invested in long-term health rather than sick- care? The cost of medications suddenly became a non-issue? Patients were incentivized to adhere to their tx plan? Patients received as much self-care education as they needed for as long as they needed? Patients had easy access to a knowledgeable health care provider to ask even their “little” questions? Patients were monitored frequently for key outcomes? Patients who were not “succeeding” were quickly identified & referred to their physician w recommendations?

WHAT IF:WHAT IF:

Physicians were informed when their patients were not adhering to their treatment plan? Patient’s had a person health coach to whom they were accountable? Patient’s & their health care providers were educated in guideline therapy, not just their physician? Physicians were educated on guideline therapy one patient at a time?

MODEL SUMMARY:MODEL SUMMARY:

FREQUENT FACE-TO-FACE CONTACT WITH A PERSONAL HEALTH “COACH” (specially trained community pharmacists/educators).

FINANCIAL INCENTIVES TO ENCOURAGE PARTICIPATION.

INTENSE SELF-CARE EDUCATION.

EMPLOYER/HEALTH PLANEMPLOYER/HEALTH PLANCOMMITMENTCOMMITMENT

Notifies employees wellness programs are available.

Agrees to pay for self-care classes & face-to face care manager sessions.

Agrees to waive co-pays for disease related medications/ supplies/education as an reward for active participation.

PATIENT’S PATIENT’S COMMITMENTCOMMITMENT

Agrees to attend self-care education classes. Goes to a pharmacy or health education center they

choose from a list of participating locations. Meets with a pharmacist or educator 1x/month for 20-

30 minutes. Has lab work done at baseline & repeat Q 6 months at

no cost to them.

PHYSICIANPHYSICIAN

INVOLVEMENTINVOLVEMENT

Informed their patient has voluntarily agreed to participate. Asked to share their treatment goals for the patient. Informed when patient is not adhering to the plan. Given suggestions on management options. Are educated one patient at a time on guideline compliance. Provided outcomes information on their patient.

““ASHEVILLE ASHEVILLE PROJECT” STATUSPROJECT” STATUS

> 1400 INDIVIDUALS CLOSELY MONITORED BY TWO DOZEN PHARMACISTS & EDUCATORS IN THE ASHEVILLE AREA

- 560 IN HTN/LIPID PROGRAM

- 410 IN DIABETES PROGRAM

- 295 IN ASTHMA PROGRAM

- 155 IN DEPRESSION PROGRAM

EACH PLAYER DOES EACH PLAYER DOES WHAT THEY ARE GOOD WHAT THEY ARE GOOD

ATAT Physicians diagnose & implement treatments plans. Educators educate. Patients are coached to comply w treatment plan. Patients self-manage 24-7. Patients are regularly assessed, monitored, and --- Changes recommended when Tx plan isn’t working. Convenient access to knowledgeable resource. Employers encourage participation by providing incentives. Patients TAKE their medications safely, and effectively. USES RESOURCES ALREADY AVAILABLE IN YOUR COMMUNITY.

DIABETES GROUP DIABETES GROUP DATADATA

DIABETES STUDYDIABETES STUDY

5 Year Hemoglobin A1c Averages5 Year Hemoglobin A1c Averages

ADA GOALADA GOAL ____________________8

6.66.7

6.97.3

6.7

5

6

7

8

9

Prior to Program 1st yr Program 2nd yr Program 3rd yr Program 4th yr Program 5th yr Program

LDL CHOLESTEROL LDL CHOLESTEROL DIABETES STUDYDIABETES STUDY

121

108

113

106104

95

70

80

90

100

110

120

130

LDL (AVG) PRIOR TO PROGRAM & EACH OF 5 YEARS OF PROGRAM

ADA GOAL <100 __________

Prior to Program 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr

HDL CHOLESTEROLHDL CHOLESTEROLDIABETES STUDYDIABETES STUDY

4042

4744 43

45

5457

61

54 54

62

0

10

20

30

40

50

60

70HDL (AVG) PRIOR TO PROGRAM & EACH OF 5 YEARS OF PROGRAM

MALESADA Goal >45

FEMALESADA Goal >55

Prior to Program

Prior to Program1st Yr 1st Yr2nd Yr 2nd Yr 3rd Yr3rd Yr 4th Yr 5th Yr 4th Yr 5th Yr

SICK DAYSSICK DAYSDIABETES STUDYDIABETES STUDY

6

8.5

7.37.7

6.4

12.6

0

2

4

6

8

10

12

14

Prior to Program 1st yr 2nd yr 3rd yr 4th yr 5th yr

AVERAGE SICK DAYS/YEARPRIOR TO PROGRAM & EACH YEAR FOR

5 YEARS OF PROGRAM

OUTCOMES:OUTCOMES:PATIENT GOALSPATIENT GOALS

70%

93%

75%

36%

27%

65%

99%

23%

10%

79%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PATIENT RESPONSE TO QUESTIONS ABOUT THEIR DIABETES/BEHAVIOR BEFORE AND AFTER PARTICIPATION IN PROGRAM

A1c in last 6 mo. Foot exam in last 6 mo. On ACE Inhibitor Self-testing blood sugar at home

Smoke

DiabetesDiabetes

Diabetes related ED visitsDiabetes related ED visits

3% *

1%0%

2%

4%

6%

8%

10%

National Wellness Participants*TPA data 2.2 million

DiabetesDiabetes

Hospitalizations related to diabetesHospitalizations related to diabetes

13%

9%0%

10%

20%

30%

40%

50%

National Wellness Participants

Total Diabetes Healthcare CostsTotal Diabetes Healthcare CostsMission Hospitals & City of AshevilleMission Hospitals & City of Asheville

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Prior to Program 1st Yr 2nd Yr 3rd Yr 4th Yr 5th Yr

Prior to program & each year of the program for 1st 5 years

Avg

. / D

iab

etes

pat

ien

t / Y

ear

Other RxDiabetes RxMedical Claims

$7,042

$4,669$4,288

$4,677

$4,129$4,371

Avg. U.S. $7,808U.S. 7,239

U.S. $7,485 U.S. $7,762

U.S. $8,088U.S. $8,468

CARDIOVASCULAR CARDIOVASCULAR GROUP GROUP DATADATA

PATIENTS W ELEVATED BPPATIENTS W ELEVATED BP(( 140/90) 140/90)

National Avg. vs. Our Enrollment Baseline vs. Post National Avg. vs. Our Enrollment Baseline vs. Post

ProgramProgram

66%

50%

25%

0%10%20%30%40%50%60%70%80%90%

100%

National Avg. (NHANES)Baseline (n=223)Follow-up (n=223)

n = 111

n = 56

PATIENTS W STAGE 2 OR 3 PATIENTS W STAGE 2 OR 3 HYPERTENSIONHYPERTENSION

(( 160/100) 160/100)At Enrollment vs. Post ProgramAt Enrollment vs. Post Program

n = 223 (paired)n = 223 (paired)

22%

<1%

0%

20%

40%

60%

80%

100%

BaselineFollow-up

n = 48

n = 2

UNPUBLISHEDUNPUBLISHED DATA DATACARDIOVASCULAR RISK CARDIOVASCULAR RISK

GROUPGROUP 1186 historical patient-yrs vs. 1261 study patient-yrs Events (Heart attacks, strokes, mini-strokes, unstable angina)

98 historical events vs. 48 events during study 165 ED/Hospital Visits vs. 81 23 Heart Attacks vs. 6 Cost/event > $14,0000/event vs. $9900/event Cardiovascular medical claims cost decreased by 46% Event cost $1.3 million vs. <$500,000

CEREBRO-VASCULAR RISK CEREBRO-VASCULAR RISK REDUCTIONREDUCTION

7

21

3 4

28

7

91

47

0

20

40

60

80

100

Stroke (bleed) Stroke (clot) All Strokes All Cerebro-Vascular

Rate/ 10,000 covered lives National (Acordia) vs. Mission Hospitals

CARDIO-VASCULAR RISK REDUCTIONCARDIO-VASCULAR RISK REDUCTION

54

1128

14

101

32

370

184

0

50

100

150

200

250

300

350

400

Heart Failure Heart Attack Angina All related CV

Rate/ 10,000 covered lives National (Acordia) vs. Mission Hospitals

SIGNIFICANT OUTCOMESSIGNIFICANT OUTCOMES

Net decrease in total health care costs avg. >$2000/pt/yr (diabetes)

Diabetes: missed work hours decreased by 50%

Net decrease in total health care costs avg. $ 725/pt/yr in direct costsfor asthma & an additional $1230/pt/yr in indirect cost savings (absenteeism, presenteeism).

Asthma: missed work decreased 10.8 days/yr to 2.6 days/yr

ROI (calculated by employer, diabetes) of 4:1

10% of covered lives enrolled in programs (13,000 covered lives)

SIGNIFICANT OUTCOMESSIGNIFICANT OUTCOMES• Mission’s Hospital’s total health plan costs rose 0% in 2004, decreased by 1% in 2005, and decreased 3% in 2006

• City of Asheville’s total health plan costs rose 0% in 2004, 0% in 2005,and decreased by 2.6% in 2006

• Mission & City of Asheville have saved >$6 million

• State of West Virginia offers program for all state employees w diabetes(3000 people enrolled), expanding to blood pressure and cholesterol

• North Dakota state legislature recently approved funding for diabetesprogram for state employees

CONCLUSION:CONCLUSION:

An Ounce of Prevention An Ounce of Prevention Really is Worth a Pound Really is Worth a Pound

of Cure!of Cure!

THETHE CHALLENGE CHALLENGE

HOW MUCH LONGER HOW MUCH LONGER WILL WE BE ABLE TO WILL WE BE ABLE TO

AFFORD HEALTH AFFORD HEALTH CARE?CARE?

DOES IT COST LESS TO DOES IT COST LESS TO KEEP PEOPLE WELL KEEP PEOPLE WELL

THAN IT DOES TO FIX THAN IT DOES TO FIX THEM WHEN THEY THEM WHEN THEY

BREAK?BREAK?

QUESTIONS ?QUESTIONS ?