USING BENEFIT DESIGN AND COLLABORATIVE PRACTICES John P. Miall, Consultant APhA Foundation

1. 1100 15th Street, NW, Suite 400 Washington, DC 20005 USING BENEFIT DESIGN AND COLLABORATIVE PRACTICESJohn P. Miall, ConsultantAPhA Foundation 

2. APHA FOUNDATION: WHO WE ARE The APhA Foundation is a non-profit organization affiliated with the American Pharmacists Association (APhA) The APhA is the national professional society of pharmacists in the United States established in 1852 with over 53,000 members The mission of the APhA Foundation is “To improve the quality of consumer health outcomes.”

3. The Origin: Asheville, NC

4. It’s the System That Needs Care Over half of all healthcarevia managed care Largest increase in 6 yearsin costs It’s evolution not revolution Giving patients the resources tobe well Buy VALUE Taiwanese healthcare system

5. HealthMapRx (Asheville)

6. Frequency/Severity Matrix

7. Diabetes-Related Comorbidities 2–4 times greater risk of heart disease 60–65% have hypertension 2–4 times greater risk of stroke 60–70% have some degree of nervoussystem damage Leading cause of adult blindness Leading cause of ESRD (40% new cases) >50% lower limb amputations

8. Diabetes-Related Indirect Costs 8.3 sick-leave days annually 1.7 sick-leave days for employeeswithout diabetes $47 billion in productivity forgonedue to disability, absence, andpremature mortality

9. Align The Incentives / Improve The Outcomes Labs without co-pays Glucose meters Patient Education Pharmacist fees for counseling Disease Specific Rx co-pay waivers

10. How They Do It “Patient making better food choice. Blood glucosemuch improved. 2 x 1.5c cm wound RLE. Referredto physician for evaluation and therapy.”

11. DIABETES

12. APPROPRIATE MEDICATION

13. Clinical Outcomes:Avg. Glycosylated Hemoglobin

14. City of Asheville Total Diabetes Medical Costs 1996 3.0 6310 1997 2.8 6487 1998 3.4 6708 1999 3.7 6956 2000 4.2 7248 2001 4.7 7588 2002 5.0 79671996 3.0 6310 1997 2.8 6487 1998 3.4 6708 1999 3.7 6956 2000 4.2 7248 2001 4.7 7588 2002 5.0 7967

15. Direct Medical Costs Over Time*

16. Mission Employees with Diabetes On cholesterol &/or blood pressure medication People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.

17. LDL CHOLESTEROL(Asheville Diabetes Patients)

18. HDL CHOLESTEROL(Asheville Diabetes Patients)

19. Outcomes: Patient Goals(Asheville Diabetes Patients)

20. Current Data on Asheville

21. Average Annual Diabetic Sick-Leave Usage (City Of Asheville)

22. Sick Leave Usage By Time In Program(City Of Asheville)

23. DIABETES IN WORK FORCE(City Of Asheville) Average of 1000 employees over 5 years 60 to 100 diabetics expected 32 = average annual percentage of workers with lost time injuries for 5 years 1.97 to 3.2 = expected number of lost time injured workers in average year with diabetes

24. CITY INDEMNITY INJURIES BY YEAR(City Of Asheville)

25. DIABETES MANAGEMENT INDEMNITY CASES(City Of Asheville)

26. Total Employer Spend (Mohawk Carpets, Dublin, GA.) Baseline, Year 1 & Year 2 compared to Projected Costs

27. Clinical – HEDIS 2003 Indicators …Averages through 25 Sept. 06http://web.ncqa.org/Portals/0/Publications/Resource%20Library/SOHC/SOHC_07.pdf NCQA Commercial Accredited Plans A1c Testing = 88% A1c Control (< 9) = 42% Lipid Profile = 83% Lipid Control (< 130) = N/A% Lipid Control (< 100) = 43% Flu Shots = 36% Eye Exams = 55% PSMP Pilot Sites – (Aggregate) A1c Testing = 100% A1c Control (< 9) = 95% Lipid Profile = 100% Lipid Control (< 130) = 83% Lipid Control (< 100) = 52% Flu Shots = 70% Eye Exams = 81%

28. ASTHMA

29. ASTHMA SEVERITY CLASSIFICATIONBaseline vs. Last F/Un = 103 (paired)

30. AsthmaProgram patients with ED visits People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.

31. AsthmaProgram patients with Hospitalization People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.

32. Asthma Care Events (ED & Hospitalization)3 yr Historical Trend & Projection

33. Asthma Care Events (ED & Hospitalization)Historical Projection vs. Actual

34. Asthma People with Severe/Moderate Asthma People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.

35. Asthma Missed/Non-Productive Days/Year People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.

36. Asthma People with Severe/Moderate Asthma People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.

37. AsthmaOn long-term “controller” medication People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.People with SBPs of 140 or more are considered to be at Stage 1 or higher hypertension. Sixty percent of our folks upon enrollment had Stage 1 or worse hypertension. This is significant, because we enrolled people who knew they had hypertension and were presumably being treated for it (rather ineffectively, it would seem). In our population at least, baseline standard care did not seem to be making the grade.

38. AshevilleCardiovascularGroup Data

39. Cardiovascular events thru 2006

40. The Asheville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemiaBarry A. Bunting, Benjamin H. Smith and Susan E. Sutherland: J Am Pharm Assoc. 2008;48:23-31 Objective: Assess clinical and economic outcomes of a community-based, long-term medication therapy management (MTM) program for hypertension/dyslipidemia over 6 years (2000-2005). Design: Quasi-experimental, longitudinal, pre-post study. Setting: 12 community pharmacy and hospital pharmacy clinics in Asheville, N.C. Patients/Other Participants: Patients covered by two self-insured health plans; educators at Mission Hospitals; 18 certificate-trained pharmacists. Interventions: Cardio/cerebrovascular (CV) risk reduction education; regular, long-term follow-up by pharmacists (reimbursed by health plans) using scheduled consultations, monitoring, and recommendations to physicians. Main Outcome Measures: Changes in blood pressure, lipids, percent at BP and lipid goals, percentage with Stage 1 or Stage 2 hypertension, CV-related emergency department/hospital events, CV events, changes in CV-related costs. 620 patients in financial cohort, 565 patients in clinical cohort

41. PATIENTS W ELEVATED BP (? 140/90)National Avg. vs. Our Enrollment Baseline vs. Post Program 

42. PATIENTS W STAGE 2 OR 3 HYPERTENSION (? 160/100)At Enrollment vs. Post Program  n = 223 (paired)

43. Cardiovascular Risk GroupLDL Cholesterol Another criteria that can be used to classify patients into these same severity levels is to look at the DBP. So a person may be classified as Stage 2 or worse based on either a very high SBP or DBP, or both. Here we see those enrollees who had Stage 2 or worse based solely on a very elevated DBP. The good news is that we didn’t have a lot of these. The even better news is that now we have only three. And those that are still elevated are receiving focused case management in this program Another criteria that can be used to classify patients into these same severity levels is to look at the DBP. So a person may be classified as Stage 2 or worse based on either a very high SBP or DBP, or both. Here we see those enrollees who had Stage 2 or worse based solely on a very elevated DBP. The good news is that we didn’t have a lot of these. The even better news is that now we have only three. And those that are still elevated are receiving focused case management in this program

49. The Asheville Project: Clinical and economic outcomes of a community-based long-term medication therapy management program for hypertension and dyslipidemiaBarry A. Bunting, Benjamin H. Smith and Susan E. Sutherland: J Am Pharm Assoc. 2008;48:23-31 SBP decreased from average of 137.3 mmHg to 126.3 mmHg DBP decreased from average of 82.6 mmHg to 77.8 mmHg Patients at BP goal increased from 40.2% to 67.4% LDL decreased from average of 127.2 mg/dL to 108.3 mg/dL Patients at LDL goal increased from 49.9% to 74.6 23 MIs in the historical period and 6 MIs in the study period CV event rate (77/1000 person-years) was decreased to almost half (38/1000 person-years) in the study period Average cost/event historical vs. study period was $14,343 vs. $9,931 CV medication use increased nearly three fold CV-related medical costs decreased by 46.5% CV-related medical costs decreased from 30.6% of total health care costs to 19% 53% decrease in risk of a CV event and >50% decrease in risk of a CV-related ED/hospital visit was observed.

50. AshevilleDepression Group Data

51. Asheville Initial Participant PHQ-9 Results*

52. PHQ-9 Score Summary* Changes from baseline 71% of participants have had improvements 15% have had no change 14% have had worsening Score Ranges Baseline: 1 to 27 Latest follow-up: 1 to 27 Average Scores Baseline: 11.6 (moderate) Latest follow-up: 7.1 (mild) Severely Depressed (Scores >= 20) Baseline: 39 Latest follow-up: 15 Minimally Depressed (Scores <= 4) Baseline: 22 Latest follow-up: 49

53. Medication Persistence – Visit 1 to 6

54. Summary of Initial Depression Group Data Follow-up PHQ-9 scores indicate that depression control has improved significantly during the first 12 months of the program implementation Medication persistence has improved significantly between Visit 1 and Visit 6: Anti-anxiety medications: 24% to 56% (2.3x) Anti-depressant medications: 59% to 85% (1.4x)

55. Summary of Asheville Project Economic Outcomes Net decrease in total health care costs avg. >$2000/pt/yr (diabetes) Net decrease in total health care costs avg. $ 725/pt/yr (asthma) Diabetes: missed work hours decreased by 50% Asthma: missed work hours decreased by 400% ROI (calculated by employer, diabetes) of 4:1 CV event rate (77/1000 person-years) was decreased to almost half (38/1000 person-years) in the study period. Average cost/event historical vs. study period was $14,343 vs. $9,931 Mission’s total health plan costs rose 0.1% in 2004, and decreased by 1% in 2005, and decreased 3% in 2006. Mission & City of Asheville have saved >$6 million in 8 yrs

56. www.aphafoundation.org

58. APhA Foundation Patient Care Programs Across the Country

59. HealthMapRx Programs Active: Diabetes Cardiovascular Health Pending: Asthma Depression

60. Conclusions Pharmacists have had the opportunity toserve on the frontline of patient care, andhave made a difference. Physicians with patients in the programhave recognized the positive impact on care. Collaboration plus innovation leads toreduced healthcare costs. Ashevillesm.wmv Employers benefit by lowering oreliminating barriers to care.