The Asheville Project An Ounce of Prevention Really IS Worth a Pound of Cure

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The Asheville Project An Ounce of Prevention
Really IS Worth a Pound of Cure

• December 7, 2007
• Rhode Island Business Group on Health
• Barry A. Bunting, Pharm.D.
• Clinical Manager of Pharmacy Services
• Mission Hospitals
• Asheville, NC

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THE HJ PKKKHHROJECT
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WHY ARENT WE DOING BETTER?
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PATIENT 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

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PURCHASER 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
• HAVENT SEEN CONVINCING EVIDENCE THAT AN
  OUNCE OF PREVENTION IS WORTH A POUND OF CURE
• SKEPTICISM OF PREVENTIVE/DISEASE MANAGEMENT
  PROGRAMS

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PHYSICIAN 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 PEOPLES
  BEHAVIOR

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IDENTIFYING BARRIERS IS THE EASY PART!!

• WHAT DO WE DO ABOUT THEM?????

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WHAT IF

• A health plan 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?

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WHAT IF

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

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MODEL SUMMARY

• INTENSE SELF-CARE EDUCATION.
• FREQUENT FACE-TO-FACE CONTACT WITH A PERSONAL
  HEALTH COACH (specially trained
  pharmacists/educators).
• FINANCIAL INCENTIVES TO ENCOURAGE PARTICIPATION.

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EMPLOYER/HEALTH PLANCOMMITMENT

• 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.

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PATIENTS COMMITMENT

• 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.

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PHYSICIANINVOLVEMENT

• 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.

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ASHEVILLE PROJECT STATUS

• gt 1400 INDIVIDUALS CLOSELY MONITORED BY TWO DOZEN
  PHARMACISTS EDUCATORS FOR 9 EMPLOYERS IN THE
  ASHEVILLE AREA.
• - 560 IN HTN/LIPID PROGRAM
• - 410 IN DIABETES PROGRAM
• - 295 IN ASTHMA PROGRAM
• - 155 IN DEPRESSION PROGRAM

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EACH PLAYER DOES WHAT THEY ARE GOOD AT

• USES RESOURCES ALREADY AVAILABLE IN YOUR
  COMMUNITY.
• Physicians diagnose implement treatments
  plans.
• Educators educate.
• Patients are coached to comply with treatment
  plan.
• Patients self-manage 24-7.
• Patients are regularly assessed, monitored, and
  ---
• Changes recommended when Tx plan isnt working.
• Convenient access to knowledgeable resource.
• Employers encourage participation by providing
  incentives.
• Patients TAKE their medications safely, and
  effectively.
• Outcomes improve.
• Health care costs decrease.

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DIABETES GROUP DATA
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DIABETES STUDY5 Year Hemoglobin A1c
Averages ADA GOAL __________
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LDL (BAD) CHOLESTEROL DIABETES STUDY
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SICK DAYSDIABETES STUDY
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Total Diabetes Healthcare CostsMission Hospitals
City of Asheville
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CARDIOVASCULAR GROUP DATA
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CARDIOVASCULAR RISK GROUP(submitted for
publication Nov. 2007)

• LDL (bad cholesterol) average decreased by 19
  points
• Patients at blood pressure goal increased from
  40 to 67
• 1261 historical patient-yrs vs. 1261 study
  patient-yrs
• Events (heart attacks, strokes, mini-strokes ,
  unstable angina)93 historical events vs. 50
  events during the 6 year study
• 155 ED/Hosp. visits vs. 82
• 23 heart attacks vs. 6
• Cardiovascular related medical costs decreased by
  47
• 53 decrease in risk of a cardiovascular event
  happening
• Cost/event 14,343/event vs. 9931/event
• Event cost 1,333,899 vs. 496,550

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CEREBRO-VASCULAR RISK REDUCTION

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CARDIO-VASCULAR RISK REDUCTION

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SIGNIFICANT OUTCOMES

• Net decrease in total health care costs avg.
  gt2000/pt/yr (diabetes)
• Diabetes missed work hours decreased by 50
• Net decrease in asthma related health care costs
  avg. 1950/pt/yr (direct and indirect cost
  savings)
• Asthma related workdays missed decreased from
  avg. of 10.8 days/yr to 2.6 days/yr
• ROI for the diabetes and the asthma programs of
  41
• Significant improvement in depression scale
  scores

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SIGNIFICANT OUTCOMES

• Missions Hospitals total health plan costs rose
  0 in 2004,
• decreased by 1 in 2005, and decreased 3 in
  2006
• City of Ashevilles total health plan costs rose
  0 in 2004, 0 in 2005,and decreased by 2.6 in
  2006
• Mission City of Asheville have saved gt6
  million
• 60 employers in 12 states with similar programs
• 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

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CONCLUSIONAn Ounce of Prevention Really can be
Worth a Pound of Cure!
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THE CHALLENGE
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DOES IT COST LESS TO KEEP PEOPLE WELL THAN IT
DOES TO FIX THEM WHEN THEY BREAK?
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HOW MUCH LONGER WILL WE BE ABLE TO AFFORD HEALTH
CARE?
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QUESTIONS ?