1. * 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

2. THE HJ PKKKHHROJECT

3. SINCE WE LAST MET: X There are over 50 employers in 12 states that have implemented similar models for their employees X We have over 1400 people enrolled in our community X Programs are offered for diabetes, asthma, high blood pressure, high cholesterol, and depression X We have published data on asthma X Others have now published data on diabetes X West Virginia offers this model for all state employees and they have over 3000 people with diabetes enrolled X The largest employer in Los Angeles offers the program

4. WHY AREN’T WE DOING BETTER?

5. PATIENT BARRIERS X COST X ACCESS X KNOWLEDGE DEFICITS X LACK OF MOTIVATION TO CHANGE X COMPLIANCE/ADHERENCE ISSUES X DENIAL/FATALISM/LOW EXPECTATIONS X LACK OF FEEDBACK ON HOW THEY ARE DOING X LACK OF HELP WITH THEIR DAY-TO-DAY DECISIONS

6. PAYER BARRIERS X FREQUENTLY LACK UNDERSTANDING OF COST DRIVERS X BELIEF THAT DISCOUNTS ARE THE WAY TO CONTROL HEALTH CARE COSTS X BELIEF THAT CONTROLLING HEALTH CARE COSTS IS OUT OF THEIR CONTROL X HAVEN’T SEEN CONVINCING EVIDENCE THAT AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE X SKEPTICISM OF PREVENTIVE/DISEASE MANAGEMENT PROGRAMS

7. PHYSICIAN BARRIERS X TOO MANY GUIDELINES NOT ENOUGH TIME X TIME PRESSURES CAN RESULT IN TRIAL & ERROR VS. EVIDENCE BASED APPROACHES X BUSINESS DEMANDS DICTATE HIGH VOLUME NOT HIGH-TOUCH X INABILITY TO KNOW IF PATIENT IS FOLLOWING THEIR PLAN X INABILITY TO SIGNIFICANTLY INFLUENCE PEOPLE’S BEHAVIOR

8. IDENTIFYING BARRIERS IS THE EASY PART!! WHAT DO WE DO ABOUT THEM?????

9. WHAT IF: X Health plans invested in long-term health rather than sick- care? X The cost of medications suddenly became a non-issue? X Patients were incentivized to adhere to their tx plan? X Patients received as much self-care education as they needed for as long as they needed? X Patients had easy access to a knowledgeable health care provider to ask even their “little” questions? X Patients were monitored frequently for key outcomes? X Patients who were not “succeeding” were quickly identified & referred to their physician w recommendations?

10. WHAT IF: X Physicians were informed when their patients were not adhering to their treatment plan? X Patient’s had a person health coach to whom they were accountable? X Patient’s & their health care providers were educated in guideline therapy, not just their physician? X Physicians were educated on guideline therapy one patient at a time?

11. MODEL SUMMARY: X FREQUENT FACE-TO-FACE CONTACT WITH A PERSONAL HEALTH “COACH” (specially trained community pharmacists/educators). X FINANCIAL INCENTIVES TO ENCOURAGE PARTICIPATION. X INTENSE SELF-CARE EDUCATION.

12. EMPLOYER/HEALTH PLAN COMMITMENT X Notifies employees wellness programs are available. X Agrees to pay for self-care classes & face-to face care manager sessions. X Agrees to waive co-pays for disease related medications/ supplies/education as an reward for active participation.

13. PATIENT’S COMMITMENT X Agrees to attend self-care education classes. X Goes to a pharmacy or health education center they choose from a list of participating locations. X Meets with a pharmacist or educator 1x/month for 20-30 minutes. X Has lab work done at baseline & repeat Q 6 months at no cost to them.

14. PHYSICIAN INVOLVEMENT X Informed their patient has voluntarily agreed to participate. X Asked to share their treatment goals for the patient. X Informed when patient is not adhering to the plan. X Given suggestions on management options. X Are educated one patient at a time on guideline compliance. X Provided outcomes information on their patient.

15. “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

16. EACH PLAYER DOES WHAT THEY ARE GOOD AT X Physicians diagnose & implement treatments plans. X Educators educate. X Patients are coached to comply w treatment plan. X Patients self-manage 24-7. X Patients are regularly assessed, monitored, and --- X Changes recommended when Tx plan isn’t working. X Convenient access to knowledgeable resource. X Employers encourage participation by providing incentives. X Patients TAKE their medications safely, and effectively. X USES RESOURCES ALREADY AVAILABLE IN YOUR COMMUNITY.

17. DIABETES GROUP DATA

18. DIABETES STUDY 5 Year Hemoglobin A1c Averages ADA GOAL __________

19. LDL CHOLESTEROL DIABETES STUDY

20. HDL CHOLESTEROL DIABETES STUDY

21. SICK DAYS DIABETES STUDY

22. OUTCOMES: PATIENT GOALS

23. Diabetes Diabetes related ED visits

24. Diabetes Hospitalizations related to diabetes

25. Total Diabetes Healthcare Costs Mission Hospitals & City of Asheville

26. CARDIOVASCULAR GROUP DATA

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

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

29. UNPUBLISHED DATA CARDIOVASCULAR RISK GROUP X 1186 historical patient-yrs vs. 1261 study patient-yrs X Events (Heart attacks, strokes, mini-strokes, unstable angina) 98 historical events vs. 48 events during study X 165 ED/Hospital Visits vs. 81 X 23 Heart Attacks vs. 6 X Cost/event > $14,0000/event vs. $9900/event X Cardiovascular medical claims cost decreased by 46% X Event cost $1.3 million vs. <$500,000

30. CEREBRO-VASCULAR RISK REDUCTION

31. CARDIO-VASCULAR RISK REDUCTION

32. SIGNIFICANT OUTCOMES X Net decrease in total health care costs avg. >$2000/pt/yr (diabetes) X Diabetes: missed work hours decreased by 50% X Net decrease in total health care costs avg. $ 725/pt/yr in direct costs for asthma & an additional $1230/pt/yr in indirect cost savings (absenteeism, presenteeism). X Asthma: missed work decreased 10.8 days/yr to 2.6 days/yr X ROI (calculated by employer, diabetes) of 4:1 X 10% of covered lives enrolled in programs (13,000 covered lives)

33. 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

34. CONCLUSION: An Ounce of Prevention Really is Worth a Pound of Cure!

35. THE CHALLENGE

36. HOW MUCH LONGER WILL WE BE ABLE TO AFFORD HEALTH CARE?

37. DOES IT COST LESS TO KEEP PEOPLE WELL THAN IT DOES TO FIX THEM WHEN THEY BREAK?

38. QUESTIONS ?