1. 1 Million Hearts FMI Webinar May 10, 2012 John M. O’Brien, PharmD, MPH, Senior Advisor U.S. Department of Health & Human Services | CMS Innovation Center

2. Million Hearts™ National initiative co-led by CDC and CMS Partners across federal and state agencies and private organizations 2 Goal: Prevent 1 million heart attacks and strokes in 5 years Goal: Prevent 1 million heart attacks and strokes in 5 years http://millionhearts.hhs.gov/pharmacies.html

3. Heart Disease and Strokes Leading Killers in the United States  Cause 1 of every 3 deaths  Over 2 million heart attacks and strokes each year  800,000 deaths  Leading cause of preventable death in people <65  $444 B in health care costs and lost productivity  Treatment costs are ~$1 for every $6 spent  Greatest contributor to racial disparities in life expectancy Roger VL, et al. Circulation 2012;125:e2-e220 Heidenriech PA, et al. Circulation 2011;123:933–4 3

4. Status of the ABCS A spirin People at increased risk of cardiovascular events who are taking aspirin 47% B lood pressure People with hypertension who have adequately controlled blood pressure 46% C holesterol People with high cholesterol who are effectively managed 33% S moking People trying to quit smoking who get help 23% MMWR: Million Hearts: Strategies to Reduce the Prevalence of Leading Cardiovascular Disease Risk Factors — United States, 2011, Early Release, Vol. 60 4

5. Key Components of Million Hearts COMMUNITY PREVENTION Changing the context CLINICAL PREVENTION Optimizing care Focus on ABCS Health information technology Clinical innovations TRANS FAT 5

6. Community Prevention Reducing the Need for Treatment: Tobacco Comprehensive tobacco control programs work  Graphic mass media campaign  Smoke-free public places and workplace policies  Free or low-cost counseling and medications 6

7. Community Prevention Reducing the Need for Treatment: Sodium  Menu labeling requirements in chain restaurants  Food purchasing policies to increase access to low sodium foods  Public and professional education about the impact of excess sodium  Publishing info on sodium consumption About 90% of Americans exceed recommended sodium intake About 90% of Americans exceed recommended sodium intake CDC, MMWR 2011;60:1413–7 7

8.  IOM: Reduce intake as close to zero as possible  FDA in 2003: Requires labeling of trans fats content  Replacing it is feasible, does not increase cost, or change flavor or texture  Monitor and publish trans fat levels in the population  Encourage food industry to eliminate trans fats IOM, Institute of Medicine FDA, Food and Drug Administration 8 Community Prevention Reducing the Need for Treatment: Trans Fat

9.  Have you stopped selling tobacco products?  Do you offer smoking cessation assistance to your customers, patients, and/or employees?  Do you use unique labels to increase awareness of sodium and trans fats?  Do you offer wellness counseling tours or other unique prevention services? 9 Community Prevention Check-in

10. Clinical Prevention Optimizing Quality, Access, and Outcomes  Focus on the ABCS  Fully deploy health information technology  Innovate in care delivery 10

11.  Focus on the ABCS  Simple, uniform set of measures  Measures with a lifelong impact  Data collected or extracted in the workflow of care  Link performance to incentives Clinical Prevention Optimizing Quality, Access, and Outcomes 11

12. Baseline: Alignment of Clinical Quality Measures MH CQMsPQRSMU PQRS CV Prevention Measures Group ACOs HRSA UDS NQF Aspirin UsePQRS #204 S1 opt NQF #0068 BP Screening BP ControlPQRS #236 S1 opt, YesNQF #0018 Chol Control – Pop Chol Cont – DMPQRS #2 S1 opt NQF #0064 Chol Cont – IVDPQRS #241 S1 opt NQF #0075 Smoking CessationPQRS #226 S1 core Yes (2011) NQF #0028

13. Six Month Progress: Alignment of Clinical Quality Measures MH CQMsPQRSMU PQRS CV Prevention Measures Group ACOsHRSA UDSNQF Aspirin UsePQRS #204 S1 opt, S2 core (prop) Yes Yes (2012) NQF #0068 BP ScreeningPQRS #317Yes BP ControlPQRS #236 S1 opt, S2 core (prop) Yes NQF #0018 Chol Control – PopPQRS #316 S2 core (prop) TBD* Chol Cont – DMPQRS #2 S1 opt, S2 opt (prop) Yes NQF #0064 Chol Cont – IVDPQRS #241 S1 opt, S2 opt (prop) Yes NQF #0075 Smoking CessationPQRS #226 S1 core, S2 core (prop) Yes Yes (2011)NQF #0028

14.  Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients  When an ACO succeeds both in both delivering high- quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program  50% one-sided, 60% two-sided Medicare Shared Savings Program

15. Quality is defined by 33 pay-for-reporting or pay-for- performance measures, including:  Patient/caregiver experience (7 measures)  Care coordination/patient safety (6 measures)  Preventive health (8 measures)  At-risk population: Diabetes, Hypertension, Ischemic Vascular Disease, Heart Failure, Coronary Artery Disease Expenditures are defined as Part A & B spending Medicare Shared Savings Program

16. The Pioneer ACO Model  Designed for more advanced organizations  Alternative payment models possible (5/50, 10/60, 15/75, population-based payments possible in years 3-5)  32 sites listed at innovations.cms.gov

17. ACOs & Part D  ACOs & Part D sponsors have expressed an interest in working together  CMS has an interest in PDPs playing a greater role in managing the care of FFS beneficiaries and having greater accountability for overall health outcomes  CMS encourages these entities to form appropriate business arrangements that support improve pharmacy care coordination

18. Incentives Under the ACO Rule ACOs in good standing and their suppliers may provide items for free or at less than market value if:  There is a reasonable connection between the items or services and the medical care of the beneficiary.  The items or services are in-kind and either are preventive care items or services or advance one or more of the following clinical goals: adherence to a treatment regime; adherence to a drug regime; adherence to a follow-up care plan; or management of a chronic disease or condition.

19.  Fully deploy health information technology (HIT)  Registries for population management  Point-of-care tools for assessment of risk for CVD  Timely and smart clinical decision support  Reminders and other health-reinforcing messages  Coming Soon? ONC smartphone app challenge 19 Clinical Prevention Optimizing Quality, Access, and Outcomes

20.  Innovate in care delivery  Embed ABCS and incentives in new models  Health Homes, Accountable Care Organizations, bundled payments  Interventions that lead to healthy behaviors  Mobilize a full complement of effective team members  Pharmacists, cardiac rehabilitation teams  Health coaches, lay workers, peer wellness specialists  Coming soon: Team Up. Pressure Down: The Pharmacy Outreach Projects 20 Clinical Prevention Optimizing Quality, Access, and Outcomes

21.  Do you have a store clinic?  Do you offer blood pressure & lipid testing?  Do you measure or report data back to other providers?  Do you enter into collaborative practice agreements or practice team-based care with other other professionals?  Are you reimbursed by any insurers for MTM or other pharmacist services?  Do you provide these benefits for your employees & their dependents? 21 Clinical Prevention Check-in

22. Public-Sector Support  Administration on Aging  Agency for Healthcare Research and Quality  Centers for Disease Control and Prevention  Centers for Medicare and Medicaid Services  Food and Drug Administration  Health Resources and Services Administration  Indian Health Service  National Heart, Lung, and Blood Institute  National Prevention Strategy  National Quality Strategy  Office of the Assistant Secretary for Health  Substance Abuse and Mental Health Services Administration  U.S. Department of Veterans Affairs 22

23.  Academy of Nutrition and Dietetics  Alliance for Patient Medication Safety  America’s Health Insurance Plans  American College of Cardiology  American Heart Association  American Medical Association  American Nurses Association  American Pharmacists’ Association  American Pharmacists Association Foundation  Association of Black Cardiologists  CVS/Pharmacy  Georgetown University School of Medicine  Kaiser Permanente  Medstar Health System Private-Sector Support  National Alliance of State Pharmacy Associations  National Committee for Quality Assurance  National Community Pharmacists Association  National Consumers League  Samford McWhorter School of Pharmacy  SUPERVALU  The Ohio State University  UnitedHealthcare  University of Maryland School of Pharmacy  Walgreens  WomenHeart  YMCA of America  Maryland Dept of Health and Mental Hygiene  New York State Dept of Health 23

24. Med, Pharmacy, Nursing Students Raise Awareness via Events, Contests, & Social Media Med, Pharmacy, Nursing Academy develops team-based care (TBC) QI module, teaches TBC Med, Pharmacy, Nursing post-grads practice TBC, measure and improve quality Care & reimbursement models, state law support TBC, reward ABCS outcomes Partners Support Progress With Action

25. A Network of Networks

26. State Activity  Existing HDSP, CTG, etc work  Nebraska ABCS Advisory Group  CIMRO and Nebraska HDSP meeting regularly to discuss collaboration on initiatives in an ABCS Advisory Group  Purpose: To bring together partners, programs, policies, and campaigns to create a positive impact across the spectrum of prevention utilizing the ABCS of clinical prevention to prevent heart attack and stroke.  First Meeting – January 25 th  Approximately 25 partners in attendance  Maryland and New York Alignment Efforts

27. A Network of Networks

28. State Medical, Pharmacy, Nursing, etc Associations Schools of Medicine Pharmacy,Nursing, Public Health, etc Patient & Science Advocacy Groups (WomenHeart, AHA) Employers & Insurers Action-Oriented and Results-Focused State Nodes: Harvesting, Spreading, and Providing Technical Assistance on Quality Improvement in the ABCS Corporate Partners SMDsSHOs

29. What Improvement Could Look Like A State Department of Public Health, QIO, School of Pharmacy, and other partners align efforts to reduce health disparities in hypertension in a county of 11,000 people. Other schools/counties in their state test their approach in other locations. A nearby statewide initiative is launched. A national partner achieves results in a HTN primary care learning collaborative. An IPA in another state launches a QI initiative in 14 practices

30. Tools and “lessons learned” are harvested by QIO & HDSP coordinating centers from leading locations and those involved in testing change. Technical assistance is deployed by the coordinating centers to EACH state node. QIOs, HDSPs, RECs, and other partners support learning via LANs and webinars. Local knowledge combines with national experience What Improvement Could Look Like

31. Measuring Progress Measurement & Reporting Short-term, Intermediate, and Long-term metrics reported by the field Awareness > Activity > Improvements > Outcomes Results Drive Technical Assistance High performers analyzed to identify best practices Low performers investigated to discover barriers to success Technical Assistance Refines Local Improvement Strategy Best practices become change practices others may use High performers mentor others using their tools and methods Barriers to success overcome with assistance by those who’ve faced similar challenges

32. Metrics Across the 5 Year Million Hearts Initiative Metrics of engagement and involvement of partners are needed to build MH levers and activities Metrics of the levers and activities are needed to measure short and intermediate outcomes Metrics of short and intermediate outcomes are needed to reach our goal of preventing a million heart attacks and strokes by 2017 2012-2017 2013-2017

33. InterventionBaselineTarget Clinical target A spirin for those at high risk 47%65%70% B lood pressure control 46%65%70% C holesterol management 33%65%70% S moking cessation 23%65%70% Sodium reduction ~ 3.5 g/day20% reduction Trans fat reduction ~ 1% of calories50% reduction Getting to Goal Unpublished estimates from Prevention Impacts Simulation Model (PRISM) 33

34. Million Hearts in May  Kicking off the initiative’s early focus on BP  Highlight high performers’ use of Million Hearts pillars  Team-based care  HIT to enable PI, medication adherence, disparity reduction  Focus on and incenting of ABCS  Reductions in sodium, trans-fat, tobacco use  QI module for interdisciplinary care  Video Challenge to “Beat Down High Blood Pressure”  Ignite partners across country to control BP

35. 37 of 65 Million Americans with Hypertension Are Un-Controlled Small SBP Reductions Can Save Many Lives 35 National Health and Nutrition Examination Survey (NHANES), 2005-2008 Whelton, PK, et al. JAMA 2002;288:1882 Stamler R, et al, Hypertension 1991:17:I-16

36. The Future State  Lower sodium foods are abundant and inexpensive  BP monitoring starts at home and ends with control  Data flows seamlessly between settings  Professional advice when, where, how, and from whom it is most effective  No or low co-pays for medications  High performance on BP control is rewarded Green BB, et al. JAMA 2008;299:2857-67 Adding web-based pharmacist care to home blood pressure monitoring increases control by >50% 36

37. How Can You Support Million Hearts?  Sign the pledge at: http://millionhearts.hhs.govhttp://millionhearts.hhs.gov  Be deputized ambassadors of Million Hearts and speak to:  Reducing disparities  Increasing the use of team-based care  Support behavior change and medication adherence  Engage with the Million Hearts network and state nodes  Participate in the app challenge and Team Up Pressure Down!  Encourage the improvement model to your colleagues working in heart health  Share with us what you’re working on, what works, and what you’ve learned

38. Join Us: Take the Pledge 38 http://millionhearts.hhs.gov John.O’Brien@cms.hhs.gov 443-821-4183