The Past : US Model of DM Future: Global Experience - Catalyst for Change

1. The Past: US Model of DMFuture: Global Experience - Catalyst for Change

2. Whoops… China Delegation Members “caught in the act” at KFC!!! [“What happens in Beijing…..stays in Beijing”] Behaviors are Hard to Change…….. Two Fish Sandwiches Bucket for Four of KFC Extra Crispy! Large Coke Local KFC Restaurant in Beijing, China

3. Healthcare Crisis…. • Bottom-line.…we are trying hard…lack of transparency • We have the knowledge and technology • Changing healthcare is very difficult • The rewards are HUGE but political as it is a matter of how to allocate resources & requires major policy changes • Must benefit and tap into global lessons learned. The answer is “global collaboration” to correct decades of lifestyle problems….together we can do it. • Disease management is a merely a “catalyst for change”

4. The Disease Management Value Proposition • Improving the health of populations • Enhancing patient satisfaction and care experience • Enhancing physician satisfaction and delivery experience • Reducing total health care demand/cost • Improving work force productivity “ A successful Disease Management Program satisfies all 5 points of the value proposition.” Source: Healthways

5. Disease ManagementSo…..How are we doing? DM and Wellness Initiative in the United States and around the world!

6. DM Challenges…. Short Term Challenges… • Utilize Behavior Change Science • Better Leverage technology • Enhance our initiatives for co-morbid depresssion • Must Measure results better…it is complicated • Better Align financial reimbursement • Develop more integrated programs - fragmentation of the industry…lack of portability • Need to lower cost vs. current high cost call-center based DM programs • Shift to consumer empowerment/financial incentives • Engage/re-structure primary care practice • Tap into the learnings of other countries • Continue to raise the bar Long Term Challenge… • Re-engineer our systems to better address the needs of the chronically ill

7. Changing the Definition of DM…. Chronic Disease Management “ An Systems Approach to Improving Patient Outcomes” Todd/Nash, 1997 “ An Integrated Approach to Improving Health Status”

8. The Global Expansion of DM DM and Wellness Initiatives around the world!

9. Argentina Australia Belgium Brazil Germany India Japan Netherlands New Zealand Developing Programs Countries with DM Programs… Existing Programs • Chile • South Korea • Hong Kong • China • Thailand • Canada • Singapore • South Africa • Spain • United Kingdom • Norway • Poland • Sweden • Taiwan • United States

10. Australia Germany Singapore Over $400Million being spent on demonstration projects [Choice: build new expensive Hospitals or keep people out of them] – New DM Association formed DM legislated with reimbursement for sick funds that provide DM; barriers from existing reimbursement structures National initiative initiated in 2000 – leveraging public sector infrastructure Disease Management…Expanding Around the World

11. United Kingdom South Africa Argentina India Several models tested in early 2000…major development but framgented Private sector programs achieving good results; combing with wellness Private hospital initiatives with good use of technology/EMR Several pharma-backed DM pilots being tested Disease Management…Expanding Around the World

12. Spain Brazil Japan Government initiated CHF pilot being developed & tested in Barcelona; COPD in wings Favorable private sector system. Free standing DMO & health plan models. Ministry of Health Interest; private sector pilots; New DM Association, book, newsletter; A mandate for DM in 2008 Disease Management…Expanding Around the World

13. Netherlands Italy Taiwan Poland Academia-driven assessment of DM programs in progress; private & public sector interest; several major national initiatives US Company pilots being developed…early stages Pilot programs in several disease states Physician-based model being developed and tested for “proof of concept” Disease Management…Expanding Around the World

14. Criteria for Success…. Lessons Learned from Global Experience • The barriers are similar to those in the US • Attempting to adjust/adapt programs to fit the current reimbursement/policy environment is stifling DM expansion/success

15. Success Criteria… Areas of Opportunity • More rapid adoption of behavior change science • More aggressive leveraging of technology • Clearer/more validated methods of measuring performance • Enhanced integration of DM into the existing system • The next frontier: absenteeism & productivity • Strategies for policy and reimbursement change

16. …. Leveraging the Science of Behavior Change

17. Self-monitoring Stimulus control triggers Contingency management Stress management Social support Challenging irrational beliefs Cognitive rehearsal Motivational Interviewing Goal setting Relapse prevention/ recycling Attributional retraining Health Belief Model Transtheoretical (Stages of Change) Model Motivational Interviewing Social Cognitive Theory Solution Focused Therapy Self-regulation Theories / models of behavior change STRATEGIES MODELS Source: Health Media

18. Intensity Frequency Duration Changing Patient Behaviors… We Must Better Leverage the principles and Models of Behavior Change Basic Ingredients of Behavior Change

19. 0 -1 -2 -4 -4 Dietary Fat (g) -6 -8 -10 -10 -12 Tailored Tailored Untailored Untailored No Message No Message Message Message Message Message It Takes More Than Education to Change Behavior • Behavioral Interventions • Interactive • Primary goal = improve outcomes • Directly addresses drivers of behavior • Demonstrated educational principles • Focuses on relationships among all influencers - Patient - Physician - Pharmacist - Care partners - Other providers Patient Education • Passive • Primary goal = educate/inform • Assumes knowledge changes behavior • One-dimensional • Generally focused only on patient Message Tailoring Increases Effectiveness Reprinted with permission of Hastings Healthcare Group

20. Factors Related to Behavior Change Acceptance Emotion Quality of life Knowledge Stage of change Demographics (Gender/Ethnicity/Age..) Side effects Personal/Family health history Doctor/patient relationship Medication history Bio-medical measures Motivation Self confidence Prior attempts at addressing issue Hobbies/interests/employment Priorities/Perception of risk Social support Stress/Depression Cost Time with condition Symptom management Refill convenience Treatment complexity Co-morbidities Habit Expectations and beliefs Goals Triggers Lifestyle issues

21. Leveraging of Technology

22. Disrupting like the Roomba…

23. 283 (16 % of Year 1 High-Risk) 1708 (2.2% of Total) 1819 (2.3% of Total) Year 1 Year 2 Patients who had an asthma related hospitalization in both Year 1 and Year 2. Predictive Modeling Finding the future high Utilizers….

24. 1.0 0.8 0.6 0.4 0.2 0.0 70 20 30 40 50 60 80 Measurement Breakthroughs Probability Modern Psychometric Methods Computerized Dynamic Health Assessments Dynamic Health Assessments On the Internet

25. An Opportunity…PRO Outcome Measurement ToolsNew outcome instruments can be used both for health outcome assessment and for patient identification, segmentation and prediction

26. SF Survey Standardization Makes it Possible to Interpret Treatment Outcomes Physical limitations Cut in half (28 to 13%) Costs reduced 1/3; Both hospital & total Asthma Before Rx Asthma After Rx Congestive Heart Failure Chronic Lung Disease Average Adult Average Well Adult 34 38 46 55 30 40 50 Physical Component Summary (PCS) Source: Adapted from Ware, Kosinski & Keller, 1994; Okamoto et al., 1996

27. 75% of chronic disease is the result of unhealthy lifestyle…and is preventable! The Ultimate Solution..is Disease Prevention

28. Individuals Can Maintain Low-Risk Health Status even as they Age A Health Plan, Employer, or government can Help its Members/Citizens Maintain Low-Risk Health Status The Major Economic Benefit is in Paying Attention to Individuals with Low-Risk Health Status Wellness Research Suggests:

29. At the End of the Day… ……The Good News IS… • The scientific knowledge exists…today • A relative small annual reduction in chronic disease • death would achieve major economic and social • results. • The good news is: • - The Causes are Known • - The Way Forward is Clear • - It’s Will Only Take Unique Leadership and an • Action Plan • Leadership and comprehensive, integrated action is • the answer • China is well position to demonstrate this type of • leadership and action

30. Effective Global Interventions… • Poland – 7% decline in deaths from heart disease • Finland – 65% reduction in death rate from heart disease plus major decline in deaths from lung cancer with 7 year increase in male life expectancy • Philippines – decline in adolescent smoking from 33% to 22% • Singapore – Smoking rate decreased from 23% to 15% • South Africa – 33% reduction in tobacco use • Zambia – major drop in sales of branded soft drinks

31. Effective Global Interventions…. • Sao Paulo, Brazil – regular physical activity increase from 55% to 60% in 2003; 96% increase in older high risk group • United States – Schools meeting EAT SMART guideline increase from 10% to 50% • South Africa Nurse Based DM program achieved improved disease control in 68% of hypertensive, 82% of diabetics and 84% of asthmatics • Russia – 85% reduction in admissions from high blood pressure • New Zealand – National Food Industry Accord to reduce obesity

32. Effective Interventions in China… • Tianjin, China – Results: average salt intake was significantly lowered with decreases in systolic blood pressure • China Disease Prevention Project [1995] in 7 cities – Results: reduction in smoking from 59% to4 44% plus increase in high blood pressure detection and a 15% decrease in strokes • MOH – 32 demonstration projects across the country – Results: Prevelence of adult smoking reduced from 29% to 13% in Shanghai plus increase in planned regular physical activity from 41% to 84%in Shenyang

33. Different forms of effective interventions • Legislative Controls - Tax and Price Interventions and indoor smoking bans • Improved Environments – footpaths increases rates of walking by 30-50% • Advocacy/Communications – Awareness & social change • Community & School Based programs – cost of US$0.03 to US$0.06 per capita generates 0.1% to 0.4% of disease burden • Vending machines – Access to better foods • Workplace Interventions – Johnson & Johnson wellness program generated improvements in 8 of 13 risk categories • Comprehensive Disease Management Program – now in 21 countries and expanding

34. Recommendations to “Get Started” • Organize stakeholders to identify obstacles and build support of “change.” • Look for “champions” • Initiate “pilot” programs…worry about changing the system later….small steps! • Customize to meet the needs of your country • Don’t overlook how difficult DM is to implement • Tap into the experience of other countries • Short-term, reinforce “validity” of the concept and explore different models • Long-term, use DM to re-engineer the system versus as a band-aid.

35. In Summary… • The crisis of chronic disease and erosion of lifestyle is a one • We need to work together…. • There are very important “lessons learned” around the world, including the United States • Countries can demonstrate true regional and global leadership in both disease management and wellness initiatives

36. About IDMA… The Challenge... the MissionThe challenge of the unprecedented personal and economic burden of a rapidly aging population with its inherent problem of how to better manage chronic disease has been described as the "next global crisis." This world-wide problem requires world-wide collaboration.The missionof IDMA is to create an international forum of disease and health management stakeholders in order to share knowledge and to build a collective experience on how to better promote healthy lifestyles and to enhance the management of chronic disease.

37. DM Resources… • www.DMAlliance.org or Wtodd@DMalliance.org • www.DMAA.org • www.WHO.org • Australia, Japan and Germany DM Associations…see IDMA website. • DM Conference in 2007 [Eastern Europe, South Africa, Brazil, Canada, and perhaps Hong Kong] • Copy of this presentation at www.DMalliance.org/China in 10 days ALSO: IDMA World DM e-Report - Complimentary Weekly e-Newsletter at www.DMAlliance.org [reaches 8,000 chronic disease stakeholders in 62 Countries.

38. Disease Management ColloquiumPhiladelphia, PA May 7-9, 2007 International DM and Approaches Lucia S. Rosenberg Vice President of Product Development U. S. Preventive Medicine lrosenberg@uspreventivemedicine.com Warren E. Todd, MBA Executive Director International Disease Management Alliance wtodd@dmalliance.org