CDC’s 6|18 Initiative: Partnering with Employers to Accelerate Evidence into Action

1. CDC’s 6|18 Initiative:Partnering with Employers to Accelerate Evidence into Action Office of the Associate Director for Policy and Strategy Centers for Disease Control and Prevention

2. Collaboration between public health, health care purchasers, payers, and providers to support the adoption of evidence-based interventions | 6 18 Evidence-based interventions that can improve health and save money High-burden health conditions www.CDC.gov/sixeighteen

3. Six High-burden Health Conditions • High-burden • Costly • Preventable • Scalable • Purchasers & Payers

4. Health/economic costs of Chronic Diseasehttps://www.cdc.gov/chronicdisease/about/costs/

5. Asthma’s Impact on the Nation • Over 24 million affected • 1 in 12 children • 1 in 14 adults • Annual impact • 1.6 million emergency department visits • 439,000 hospitalizations • 10.5 million school days missed • $14.7 billion in direct costs • $5 billion in lost productivity (missed work or school days • Each day, about 10 people die of asthma Sources: www.cdc.gov/asthma/most_recent_data.htm; Nurmagambetov T et al., Ann Am ThoracSoc, 2018

6. Uncontrolled Asthma Among People with Current Asthma — United States, 2006–2010 38% of children 50% of adults Source: www.cdc.gov/asthma/asthma_stats/uncontrolled_asthma.htm

7. Antibiotic Resistance Annual excess direct healthcare cost: $20 billion Additional annual cost of lost productivity: >$35 billion www.cdc.gov/drugresistance/threat-report-2013/

8. Are We Reducing Inappropriate Antibiotic Use? IQVIA pharmacy dispensing data gis.cdc.gov/grasp/PSA/indexAU.html Outpatient antibiotic prescribing rates to children decreased by 13% Outpatient antibiotic prescribing rates to adults have been stable

10. 6|18 Initiative Goals: Employers • Identify and highlight case study examples of employers • Innovative employers currently using any of the 6|18 interventions in current benefits • Innovative thought leaders who may be willing to consider benefit changes on 6|18 interventions

11. Blood Pressure Control: The EVIDENCE “There is strong evidence that team-based care can improve blood pressure control when a pharmacist is included on the team” – The Health & Human Services Community Preventive Services Task Force. • 75 million U.S. adults have high blood pressure, of these… • 11 million are unware (64 million are unware) • 57 million are treated (18 million are untreated) • 41 million (54%) are controlled (34 million (46%) are uncontrolled) • Twenty to thirty percent of prescriptions are never dispensed and 50% of medications for chronic disease are never taken as prescribed • In U.S. medication non-adherence =125,000 deaths and $100 to $300 billion.

12. Medication Therapy Management Services https://www.cdc.gov/dhdsp/pubs/docs/pharmacist-resource-guide.pdf

13. Outcome Measures - Community Pharmacy MTM 45% 35% 15% 25% 20% N/A • Outcomes • Reduction in inpatient hospital admissions • Reduction in preventable hospital admission or readmission • Reduction in emergency department visits • Increase in use of primary care physicians • Adherence to prescribed medication • Disease control (blood pressure, glucose, and cholesterol, weight loss, and smoking cessation) Community Pharmacy Enhanced Network - https://cpesn.com/

14. Medication AdherenceAction Steps for Health Benefit Managers https://millionhearts.hhs.gov/files/Medication-Adherence-Action-Guide-for-PHPs.pdf

15. Working Adults and Asthma, 2011-2016 • Of an estimated 160.7 million working adults, 6.8% are currently asthmatics • Within the past year: • 44.7% experienced an asthma attack • 9.9% had an asthma-related ED visit Patel O, Syamlal G, Wood J, Dodd KE, Mazurek JM. Asthma Mortality Among Persons Aged 15–64 Years, by Industry and Occupation — United States, 1999–2016. MMWR Morb Mortal Wkly Rep 2018;67:60–65. DOI: http://dx.doi.org/10.15585/mmwr.mm6702a2 Industries of interest

16. Working Adults and Work-Related Asthma (WRA) • Katelynn E. Dodd & Jacek M. Mazurek (2018) Asthma medication use among adults with current asthma by work-related asthma status, Asthma Call-back Survey, 29 states, 2012–2013, Journal of Asthma, 55:4, 364-372, DOI: 10.1080/02770903.2017.1339245

17. Value-Based Health Management and Asthma Medications: H-E-B Case Study • Only 37% of patients adhered to prescribed inhaled corticosteroids Copayments Copayments Use of necessary asthma medications Emergency department visits and hospitalization days

18. Value-Based Health Management and Asthma Medications: H-E-B Case Study • Main components: • Average copayment is $20-30 What happens when you lower copayments to $5? Disease management(asthma education) 10% increase in the number of people using their asthma medication as prescribed Decreased copayment for select asthma controller medication Decrease in overall medical costs • Offset any additional costs for pharmacies that spent more on medications Am Health Drug Benefits. 2010;3(6):394-402.www.AHDBonline.com

19. Overview of the National Diabetes Prevention Program 1 At the core of the National Diabetes Prevention Program (National DPP) is a CDC-recognized, year-long lifestyle change program that offers participants: To successfully implement these lifestyle change programs, the National DPP relies upon a variety of public-private partnerships with community organizations, private and public insurers, employers, health care organizations, faith-based organizations, and government agencies. Together, these organizations work to: 2 http://www.cdc.gov/diabetes/prevention/pdf/ndpp_infographic.pdf

20. National DPP: Economic ImpactWhen individuals develop type 2 diabetes, their health expenses increase dramatically; participation in the National DPP saves money by avoiding these additional costs. Cost of Diabetes Treatment An increase in costs of $8,010 per individual who develops diabetes over a 3-year period Year 1: $2,470; Year 2: $3,190; Year 3: $2,3501 Cost of the National DPP lifestyle change program Average annual cost of $500 per participant2 Over the course of 15 months, Medicare-eligible individuals who participated in the Y-DPP avoided $2,650 in healthcare costs3 • https://www.preventdiabetesstat.org/ • https://www.cdc.gov/diabetes/prevention/employers-insurers/manage_costs.html • https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/Downloads/Diabetes-Prevention-Certification-2016-03-14.pdf

21. National DPP Customer Service Center Overview NationalDPPCSC.cdc.gov Purpose:Provide a hub of resources, training, and technical assistance for CDC-recognized program delivery organizations and other National DPP stakeholder groups Find Resources and Info Provide Feedback and Input Receive Technical Assistance • Engage with technical assistance coordinators and subject matter experts via the CSC or email • View the status of and update existing technical assistance requests • Submit feedback on your satisfaction with technical assistance, resources, and the service center site • Share success stories and suggest additional resources • Quickly and easily find resources and events relevant to your needs (FAQs, toolkits, training videos, webinars, etc.) • Discuss opportunities and challenges with the National DPP community

22. $ Increase Program Coverage & ReimbursementMany public and private insurers are offering the National DPP lifestyle change program as a covered benefit. • Colorado • Delaware • Kentucky • Louisiana • Maine • Maryland (partial payment) • Minnesota • Tennessee Commercial Insurers State Coverage Over 3 million public employees/dependents in the following 17 states have the National DPP as a covered benefit: Many commercial health plans provide some coverage for the National DPP. Examples include: • New Hampshire • New York • Rhode Island • Vermont • Washington • Oregon (Educators) • California • Texas • Connecticut (DoT) • AmeriHealth Caritas • Anthem • BCBS Florida • BS California • BCBS Louisiana • Denver Health Managed Care: Medicaid, Medicare, Public Employees • Emblem Health: NY • GEHA • Highmark Medicare coverage began April 2018 • Humana • Kaiser: CO & GA • LA Care: Medicaid • MVP’s Medicare Advantage • Priority Health: MI • United Health Care: National, State, Local, Private, and Public Employees The following states have approved coverage for Medicaid beneficiaries: • Minnesota • Montana • Vermont • New Jersey • California

23. Examples of Employer Action

24. Aetna and CDC 6|18 Collaboration Using the Core Elements to Target Inappropriate Prescribing

25. Feedback: Collaboration and Acceleration Opportunities • Recommendations on operationalizing these interventions with employers? • Joint collaboration with brokers/disease management companies? • Other potential collaborations with CDC’s 6|18 Initiative?

26. For more information visit www.cdc.gov/sixeighteen or contact sixeighteen@cdc.gov

27. Supplemental Slides

28. 6|18 InitiativeEvidence-based Interventions CONTROL HIGH BLOOD PRESSSURE REDUCE TOBACCO USE • Implement strategies that improve adherence to blood pressure medications and lipid-lowering medications, for example, through • low-cost medication fills and fixed dose medication combinations • calendar blister packs or other medication packaging • care coordination by primary care teams. • Provide home blood pressure monitors to patients with high blood pressure and reimburse for the clinical support services required for self-measured or home blood pressure monitoring (SMBP) or (HBPM). • Increase access to tobacco cessation treatments, including individual, group, and telephone counseling and Food and Drug Administration (FDA)-approved cessation medications (in accordance with Public Health Service Clinical Practice Guidelinesand the U.S. Preventive Services Task Force recommendations). • Remove barriers that impede access to covered cessation treatments, such as cost-sharing and prior authorization. • Promote increased use of covered treatment benefits by tobacco users.

29. 6|18Initiative Evidence-based Interventions REDUCE TOBACCO USE IMPROVE ANTIBIOTIC USE • Reimburse providers for the full range of contraceptive services (e.g., screening for pregnancy intention; counseling; insertion, removal, replacement, or reinsertion of long-acting reversible contraceptives, and follow-up) for women of childbearing age. • Reimburse providers for the actual cost of FDA-approved contraceptive methods. • Unbundle payment for LARC from other postpartum services. • Remove administrative barriers to receipt of contraceptive services (e.g., pre-approval step therapy restriction, barriers to high acquisition and stocking costs). PREVENT UNINTENDED PREGNANCY • Require antibiotic stewardship programs in all hospitals and skilled nursing facilities, in accordance with CDC’s Core Elements of Hospital Antibiotic Stewardship and The Core Elements of Antibiotic Stewardship for Nursing Homes. • Reduce inappropriate antibiotic prescribing by incentivizing providers to follow CDC’s Core Elements of Outpatient Antibiotic Stewardship.

30. 6|18 InitiativeEvidence-based Interventions PREVENT TYPE 2 DIABETES • Use the 2007 National Asthma Education and Prevention Programas medical management guidelines. • Promote strategies that improve access and adherence to asthma medications and devices. • Expand access to intensive self-management education by licensed professionals or qualified lay health workers. • Expand access to home visits by licensed professionals or qualified lay health workers to provide targeted, intensive self-management education and reduce home asthma triggers. CONTROL ASTHMA • Expand access to the National Diabetes Prevention Program, a lifestyle change program for preventing type 2 diabetes.