Transcript Barry Bunting

* The Asheville Project *
An Ounce of Prevention Really
IS Worth a Pound of Cure
Barry A. Bunting, Pharm.D.
Clinical Manager of Pharmacy Services
Mission Hospitals
Asheville, NC
THE HJ
PKKKHHROJECT
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
DOING BETTER?
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
PAYER 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 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
BARRIERS IS THE EASY
PART!!
WHAT DO WE DO ABOUT
THEM?????
WHAT IF:

Health plans invested in long-term health rather than sickcare?

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:

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:

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 PLAN
COMMITMENT

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
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.
PHYSICIAN
INVOLVEMENT

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 PROJECT”
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 WHAT
THEY ARE GOOD AT

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
DATA
DIABETES STUDY
5 Year Hemoglobin A1c Averages
9
ADA GOAL __________
8
8
7
7.3
6.9
6.6
6.7
6.7
6
5
Prior to Program
1st yr Program
2nd yr Program
3rd yr Program
4th yr Program
5th yr Program
LDL CHOLESTEROL
DIABETES STUDY
LDL (AVG) PRIOR TO PROGRAM & EACH OF 5 YEARS OF PROGRAM
130
ADA GOAL <100 __________
121
120
113
108
110
106
104
100
95
90
80
70
Prior to Program
1st Yr
2nd Yr
3rd Yr
4th Yr
5th Yr
HDL CHOLESTEROL
DIABETES STUDY
HDL (AVG) PRIOR TO PROGRAM & EACH OF 5 YEARS OF PROGRAM
70
62
61
57
60
54
47
50
40
42
44
43
54
54
45
40
30
20
MALES
ADA Goal >45
FEMALES
ADA Goal >55
10
0
Prior to
Program 1st Yr
2nd Yr 3rd Yr
4th Yr 5th Yr
Prior to
Program 1st Yr
2nd Yr 3rd Yr 4th Yr
5th Yr
SICK DAYS
DIABETES STUDY
AVERAGE SICK DAYS/YEAR
PRIOR TO PROGRAM & EACH YEAR FOR
5 YEARS OF PROGRAM
14
12.6
12
10
8.5
8
7.3
7.7
6.4
6
6
4
2
0
Prior to Program
1st yr
2nd yr
3rd yr
4th yr
5th yr
OUTCOMES:
PATIENT GOALS
PATIENT RESPONSE TO QUESTIONS ABOUT THEIR DIABETES/BEHAVIOR BEFORE
AND AFTER PARTICIPATION IN PROGRAM
100%
93%
99%
90%
80%
79%
75%
70%
70%
65%
60%
50%
40%
36%
30%
27%
23%
20%
10%
10%
0%
A1c in last 6 mo.
Foot exam in last 6 mo.
On ACE Inhibitor
Self-testing blood
sugar at home
Smoke
Diabetes
Diabetes related ED visits
10%
8%
6%
4%
3%*
2%
0%
1%
National
*TPA data 2.2 million
Wellness Participants
Diabetes
Hospitalizations related to diabetes
50%
40%
30%
20%
13%
10%
0%
9%
National
Wellness Participants
Total Diabetes Healthcare Costs
Mission Hospitals & City of Asheville
U.S. $8,468
U.S. $8,088
$8,000
Avg. U.S. $7,808
$7,042
U.S. $7,485
U.S. $7,762
U.S. 7,239
Avg. / Diabetes patient / Year
$7,000
$6,000
$4,669
$5,000
$4,288
$4,677
$4,371
$4,129
$4,000
$3,000
$2,000
$1,000
$0
Prior to Program
Other Rx
Diabetes Rx
Medical Claims
1st Yr
2nd Yr
3rd Yr
4th Yr
Prior to program & each year of the program for 1st 5 years
5th Yr
CARDIOVASCULAR GROUP
DATA
PATIENTS W ELEVATED BP
( 140/90)
National Avg. vs. Our Enrollment Baseline vs. Post Program
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
66%
50%
n = 111
25%
n = 56
National Avg. (NHANES)
Baseline (n=223)
Follow-up (n=223)
PATIENTS W STAGE 2 OR 3
HYPERTENSION
( 160/100)
At Enrollment vs. Post Program
n = 223 (paired)
100%
80%
60%
40%
20%
0%
Baseline
Follow-up
22%
n = 48
<1%
n=2
UNPUBLISHED DATA
CARDIOVASCULAR RISK GROUP







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 REDUCTION
Rate/10,000 covered lives National (Acordia) vs. Mission
100
Hospitals
91
80
60
47
40
28
21
20
7
0
3
Stroke (bleed)
4
Stroke (clot)
7
All Strokes
All CerebroVascular
CARDIO-VASCULAR RISK REDUCTION
400
Rate/10,000 covered lives National (Acordia) vs. Mission
Hospitals
370
350
300
250
200
184
150
101
100
50
54
28
0
Heart Failure
11 14
Heart Attack
32
Angina
All related CV
SIGNIFICANT 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 costs

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)
for asthma & an additional $1230/pt/yr in indirect cost savings
(absenteeism, presenteeism).
SIGNIFICANT 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 diabetes
program for state employees
CONCLUSION:
An Ounce of Prevention
Really is Worth a Pound of
Cure!
THE CHALLENGE
HOW MUCH LONGER
WILL WE BE ABLE TO
AFFORD HEALTH CARE?
DOES IT COST LESS TO
KEEP PEOPLE WELL THAN
IT DOES TO FIX THEM
WHEN THEY BREAK?
QUESTIONS ?