Transcript Chronic Care Improvement Program for Tennessee

Enhancing Care Management of the Chronically Ill
Through Medication Management and Adherence
Harry Leider, MD, MBA, FACPE
Chief Medical Officer
XLHealth and Care Improvement Plus
Background on XLHealth
• Founded in 1998 as a DM company focused on diabetes
• Participated in BIPA and MHS CMS DM demos
• In 2006, launched a Chronic Care Special (C-SNP)
Needs Plan pilot in Maryland
– Traditional health plan structure, plus Part D, plus DM programs
• In 2007, withdrew from DM vendor business and
launched Chronic Care Special Needs Plans in 6 states
– 65,000 seniors
– All have either: heart failure, diabetes, COPD, ESRD
• We now have full financial risk for each member
– Averages $15,000 per member
2
Leveraging medication data and use
is a critical part of our business
1. Our members average 6 chronic medications
2. Medication spending is over 18% of our total medical
spend
3. Providing access to key meds is a important aspect of
our health plan value proposition to seniors
4. Achieving adherence with key medications drives
outcomes in our DM programs
3
Objectives
1. To provide an overview of how chronic care plans can
use medication “benefit design” to improve enrollment
and DM outcomes
2. To examine how medication utilization data can be
leveraged to improve DM outcomes
3. To examine new technology-based tools for improving
medication adherence
4. Questions and Discussion!
4
Plan Formulary Design:
Our Concept of “Tier 5” drugs
A growing concern about
shifting costs of drugs to
patients and reducing
access….
• While we do have traditional co-pays in our Part D plan
• Our member have access to our “Tier 5 drugs” at zero cost through the
“donut hole”
• Examples include:
– Beta-blockers (brand), TZDs, spironolactone, nsulin, diuretics, ACE
• The objective: improve access and adherence
5
The Value of Drug Utilization Data
1. To enhance patient identification
2. Basic risk stratification for DM Programs
3. More sophisticated predictive modeling
4. Targeting opportunities for care management
6
The Value of Drug Utilization Data
1. Patient Identification/basic risk stratification for DM
Programs
•
•
Spironolactone: severe Heart Failure
Oral Steroids in adults with COPD
7
The Value of Drug Utilization Data
2. Basic Risk Stratification Principle:
Patients with chronic illness who are not on key
medications have an increased risk of
hospitalization and death…..
8
Medication Management in Diabetes: 7-Year Outcomes
50
45%
CVD Mortality
40
Diabetes + prior MI
30
20%
20
14%
10
6%
Diabetes w/o prior MI
0
No Rx
Statin
HTN
ASA
Relative
Risk
25%
25%
20%
Fibrate
Glucose
TZD
Control
Metformin
Adapted from Haffner SM, et al. N Engl J Med. 1998;339:229-234.
20%
15%
9
The “Quick Hits” in Diabetes
• ASA
• Lipids
• ACE/ARBs
• BP control
• Beta-blockers in patients with prior MI
• Glycemic control in patients with HgbA1C > 9 or 10*
10
Is it all about “Better Living
Through Chemistry?”
• What about changing lifestyle issues?
• These issues are important BUT are very hard to
change!
• Getting patients to diet, lose weight, exercise, and stop
smoking after MANY years of bad habits is very difficult!
• Strategy:
– Focus first on the quick hits! (mostly medications)
– Then work on lifestyle issues
11
3. Medications and Predictive Modeling
12
ArchimedesTM: Predictive Model
• Based on 18 high quality diabetes outcomes studies
• Predicts 30 year risk of heart attacks, strokes, kidney failure,
amputations, eye disease
• Model requires
–
–
–
–
–
–
Demographics information
Risk factors
Lifestyle issues
Some physical measurements (BP)
Some lab data (LDL, HDL, total cholesterol, alb/creat)
Meds for diabetes, hypertension, and hyperlipidemia
• You can change risk factors and see the impact on risk of a future
outcome!!!
13
www.diabetes.org/diabetesphd/default.jsp
Patient Profile: Harry 2
74 y.o. black male, obese, Type II DM, hypertensive (not controlled),
moderately elevated lipids
14
Health History
Risks in addition to
demographics, BP, and Lipids
15
Current Meds for DM, HTN, Lipids
(insulin added to the model)
16
Overview: 30 Yr. Risk of
Major Health Outcomes
17
Heart Attack risk (baseline):
45% over 10 years (on ACE already)
18
Impact of Aggressive Lipid
Management and Aspirin
Risk over 10 years reduced from 45% you 25% !!!!
19
Additional Impact of Control of
Moderate Hypertension
Minimal additional impact of control of moderate
hypertension after ASA and lipid control
20
Impact of Increased Glycemic
Control
MI risk decreased further from 25% to 20% over 10 years
21
Impact of smoking cessation
(after other risk factors modified)
Risk of MI reduce >5% by smoking cessation even after lipid
and HTN control, use of ASA and tight glycemic control
22
Improving Adherence and
Outcomes
• Medications are the most powerful interventions in many
chronic conditions
• Two key drivers of outcomes
– Putting patients on key drugs
– Optimal levels of adherence
• Key barriers to adherence:
– Patient’s can’t afford the medications
– Failure to take the medications regularly
23
Health Care Costs
Negatively Impact Adherence
24
Generics Can Reducing Drug Costs
and Improve Adherence
25
IVR Generic Switching
Outreach
End of Campaign Summary
January 2008
26
Generic Switching Outreach
Goals
 Encourage
members to switch to a generic
alternative/equivalent of the drug they have been
prescribed
Targets
 XLHealth
members who are currently taking either a
cholesterol drug or PPI
27
Generic Switching Outreach
Outreach Process Overview
 Confirm
target member
 Explain
that there are low cost alternatives for
current medications
 Review
specific savings with members who allow
IVR to mention the name of drug they are taking
 Review
general savings with those members
who do not allow the script to mention the names
of the drug they are taking
 Review
the generic alternatives/equivalents for
the drug the member is currently taking
 Offer
to transfer the member to a representative
28
Generic Switching Outreach
Key Outcomes:
Total Population:
We received 16,105 records; 4.43% of
records were scrubbed, leaving us with a Target Population of 15,391
members to reach out to.
Targets Reached:
We were able to reach 58% of target
members. Typically, we see about 50% for a campaign with two rounds
of outbound calls.
Yes to Continue: Close to our benchmark of 75%, 70% of the
target members reached asked to continue with this call, showing
the great interest in hearing more information about savings
Hang Up Rate:
At 5%, as compared to our benchmark of 10%
or less, we feel that this, once again, shows a strong member affinity
towards XLHealth and Care Improvement Plus.
29
ImforMedix Med-eMonitor
♦Simple - used successfully by Seniors with 5th Grade Education
♦ Manages 25 medications per patient and delivers education,
questionnaires, behavioral prompts, reminders
♦Branching logic captures critical health information
♦Customized – Web-based individualized care plan
30
XLHealth/InforMedix/ADT
Workflow Process
31
Confidential and Proprietary
Remote Monitoring Process:
32
Confidential and Proprietary
Summary
• Medications play a critical role in a chronic care SNP
(and in all DM programs)
• A specific opportunity in the C-SNP model is innovative
benefit design to reduce co-pays and improve access
• “Driving” patients to generics is important to increase
adherence and reduce costs
• Drug data can help identify and risk stratify patients for DM
programs
• New technologies are showing promise for improving
medication therapy and adherence
33
Discussion and Questions?
34