Better Health, Lower Health Costs: An Overview of the Asheville Model

Right Care Initiative Scott Sproull, Vice President

GlaxoSmithKline

People in America having one or more chronic diseases:

• 69% elderly

• 50% middle aged

• 25%+ young adult

• 45% of the uninsured

1.Rundall T, et al. As good as it gets? Chronic care management in nine leading U.S. physician organizations. BMJ 2002;325:958-961. 2. Anderson G, Knickman J. Changing the chronic care system to meet people’s needs. Health Aff. 2001; 20 (6): 146-160; Hoffman, C., Rice, D. & Sung, H., Persons with chronic conditions: their prevalence and costs. JAMA. 1996; 276 (18): 1473-1479.

Chronic Disease – Common and Costly

49%49% 75%75% Percent of Health Care expenditure on chronic diseases:

• $5,300 per person spent on chronic disease

• $1.6 trillion overall

1995

The problem is growing: Obesity in America

(*BMI 30, or about 30 lbs overweight for 5’4” person)

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

2005

Source: CDC, “Overweight and Obesity: Obesity Trends: U.S. Obesity Trends 1985–2005” (2006)

Traditional Payer Response to Rising Costs

Aggressive cost-control strategies– Cutting pharmacy budget– Restricting health services (coverage, formularies)– Cost-shifting to employees (higher co-pays for

physician visits and medicines)

Impact of Cost Shifting

The Asheville Project - Diabetes

Program Specifics Employees participated in a diabetes education program.Waived co-pays on prescription medications and medical supplies.Offered employees incentives to participate.

Impact of Program Annual average insurance claims decreased by $2,704 per patient in the first follow-up year and by $6,502 per patient in the fifth year.

Savings on annual direct medical costs ranging from $1,622 - $3,356 per patient.

Absenteeism was cut by more than half – from 12.6 days to 6.2 days a year.

Increased productivity valued at $18,000 per year.

The Asheville Project – Diabetes

The Value of Medicines and Coordinated Care

0

1000

2000

3000

4000

5000

6000

7000

8000

Baseline +5 Years

Insurance Rx - Diabetes Rx - Other

Reduced Healthcare Costs

$7,250

$4.679

-35%

0

2

4

6

8

10

12

14

Baseline +5 Years

Reduced Sick Days

12.6 Days

6.4 Days

-50%

Improved Behavior

93%

79%

65%

99%

10%

75%

36%

27%

70%

23%

A1C

FootExam last

6 Mos.

ACEInhibitor

Self-Diagnose

bloodsugar

Smoking

PrePost

test last 6 mos

The BRiDGE Project – Lancaster County, PA

Applying the Asheville Principles to Other Employers

0

5000

10000

15000

20000

25000

Baseline 1 Year

Medical Medication Network Services

Reduced Healthcare Costs

$19,318

$13,506

-30%

Other Improvements

93%

98%

67%

83%

58%

69%

55%

38%

74%

38%

CurrentEye Exam

CurrentFoot

Exam

LDL < 100

A1C < 9

A1C < 7

PrePost

$21,961

-39% Vs Projection

Vs Baseline

Diabetes Ten City Challenge

Health improved:Percent improvement in patients achieving national HEDIS goals:• 23% Blood Glucose (HbA1c<7)• 39% Blood Pressure (<130/80 mmHg)• 11% Cholesterol (LDL-C <100 mg/dL)

Prevention increased:• Flu vaccinations increased from 32% to 65%• Eye exams increased from 57% to 81%• Foot exams increased from 34% to 74%

Key elements:• Pharmacist Health Coach• Removed barriers to care by waving co-pays • Patient self management• Community based coordinated care

Charleston/Spartanburg (SC), Chicago (IL), Colorado Springs (CO), Cumberland (MD), Dalton (GA), Honolulu (HI), Los Angeles (CA), Milwaukee (WI), Pittsburgh (PA), Tampa Bay (FL)

Actual

Projected7.24% Total Cost / patient

Average total per patient health care costs went down by $1079 compared to projected costs.

Economic Evaluation of first-year data

$14,909

$13,830

19.44% Tot. PrescriptionCosts

19.24%Tot. Medical Costs

Health care costs dropped:

J Am Pharm Assoc. 2009; 49:3; e52-e60 (May / June 2009)

Medication Adherence

Source: 3 Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521-530.

Program SpecificsEducation on cardiovascular and cerebrovascular (CV) risk reduction.

Employees met regularly with trained community pharmacists who act as their health coach and partner.

Waived co-pays on prescription medication.

Impact of ProgramCV medication use increased nearly threefold.

Rate of CV events dropped from 77 per 1,000 to 38 per 1,000.

CV-related medical costs decreased by 46.5% ($1,362 PPPY to $734 PPPY).

Total program showed a 12.6% positive return

Source: 1 Source: The APhA Foundation, Asheville Cardiovascular Group Data - HealthMapRx, slides 2 and 12, 2007.

The Asheville Project - Cardiovascular

Summary of Asheville Experience – Considerations for California

It works in multiple therapeutic areas and is scalable

It demonstrates positive clinical and economic outcomes through peer-reviewed studies

Critical program requirements:– Coordinate care/multi-discipline approach (decreases variation in care)– Lower barriers to care through incentives (increases participation)– Health coach fuels patient self management (behavior modification)– Measure the program with clinical outcome endpoints

DTCC HEDIS Indicators

J Am Pharm Assoc. 2009;49:e52–e60. doi:10.1331/JAPhA.2009.09015

Principles of Value-Based Health Management

An approach to improve health, save on healthcare with other economic potential. The three principles of value-based health management:

1. Reduce Barriers: Barriers to access keep people from getting the care they need like high co-pays, coinsurance and limited formulary coverage

2. Coordinate Patient Care: Leverage the knowledge of multiple sources to educate, guide and monitor patients.

3. Focus on Prevention: Provide beneficiaries access to preventive care

APPENDIX

The storm of diabetes is brewingDiagnosed Diabetes Among Adults

1995 2005

Sources: CDC, National Diabetes Surveillance System; Diabetes Prevalence by State 2005; American Diabetes Association, Diabetes Statistics; CDC, SEARCH for Diabetes in Youth Fact Sheet (2006) (youth type-2 diabetes)

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DTCC – University of Southern California

USC is the largest private employer in the City of Los Angeles, with over 17,000 employeesUSC provides incentives to patient participants in the form of waived co-pays for diabetes-related medications and supplies Services are provided by USC clinical pharmacists:

– Patient counseling and education– Self-management training– Medication therapy management

Additional resources:– Diabetes nurses and Certified Diabetes Educators– Dietitians and lifestyle coaches– Local Endocrinologists

USC Media Contact: National Media Contact:– Kukla Vera– kvera@pharmacy.usc.edu

Toll of diabetes calls for new approach

Every day in the US, diabetes causes an estimated:

- 220 amputations

- 33-66 people lose their eyesight

- 121 people start treatment for end-stage kidney disease

Results of Type 2 diabetes in children increased as much as 10-fold over the past 20 years

Source: CDC, “Complications of Diabetes in the United States,”; Ludwig DS & Ebbeling CB, “Type 2 Diabetes Mellitus in Children Primary Care and Public Health Considerations,” JAMA. 2001;286:1427-1430.

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