1	The Asheville Program John Miall
2	It’s the System That Needs Care Over half of all healthcare via managed care Largest increase in 6 years in costs It’s evolution not revolution Giving patients the resources to be well Buy VALUE Taiwanese healthcare system
3	Frequency/Severity Matrix
4	UN-Managing Care “Kaiser physicians know what things need to be done for diabetic patients, but due to the constraints of modern medical practice they seldom have the time to do them….” Managed Care News 1999 Apr. “Ultimately, all care is managed by patients.” Dan Garrett, Exec. Dir. NCAP
5	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 nervous system damage Leading cause of adult blindness Leading cause of ESRD (40% new cases) >50% lower limb amputations
6	Diabetes-Related Indirect Costs 8.3 sick-leave days annually 1.7 sick-leave days for employees without diabetes $47 billion in productivity forgone due to disability, absence, and premature mortality
7	In the Beginning “Partnering” with physicians, hospital system, NCAPh, NCCPC, UNC School of Pharmacy Invitation to all pharmacists in community Responses of independents vs. chains Two weekends (32 hours) of training by physicians and diabetes educators Compensation after results Fee schedule $2,400 first year, ongoing average of $48.02 per monthly visit through 2002.
8	Patient Incentives and Care Model Patient selection / recruitment Patient education — Mission + St. Joseph’s Diabetes Center Matching patients to pharmacists Incentives: Labs without co-pays Glucose meters PBM co-pay waivers The operative word in health care is “care” (Madge testimonial)
9	How They Do It “Patient making better food choice. Blood glucose much improved. 2 x 1.5c cm wound RLE. Referred to physician for evaluation and therapy.”
10	APPROPRIATE MEDICATION
11	Clinical Outcomes: Avg. Glycosylated Hemoglobin
12	City of Asheville Total Diabetes Medical Costs
13	Direct Medical Costs Over Time¹ ¹Cranor CW, Bunting BA, Christensen DB. The Asheville Project: Long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:173-84.
14	Average Annual Diabetic Sick-Leave Usage (COA)
15	Sick Leave Usage By Time In Program
16	DIABETES IN WORK FORCE 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
17	CITY INDEMNITY INJURIES BY YEAR
18	DIABETES MANAGEMENT INDEMNITY CASES
19	Patient Self-Management Program^sm Baseline A1c = 7.9 Visit 1 Percentages Influenza Vaccination 40% current Foot Exam 28% current Eye Exam 34% current Blood Pressure 73% current Lipid Profile 49% current A1c @ 10 months = 7.1 Visit 6 Percentages Influenza Vaccination 75% current Foot Exam 80% current Eye Exam 80% current Blood Pressure 92% current Lipid Profile 94% current
20	Clinical – HEDIS 2003 Indicators …Averages through 25-Sep-04 (n=256) NCQA Commercial Accredited Plans A1c Testing = 85% A1c Control (< 9) = 68% Lipid Profile = 88% Lipid Control (< 130) = 60% Lipid Control (< 100) = 31% Flu Shots = 48% Eye Exams = 49% PSMP Pilot Sites – (Aggregate) A1c Testing = 100% A1c Control (< 9) = 94% Lipid Profile = 100% Lipid Control (< 130) = 78% Lipid Control (< 100) = 49% Flu Shots = 77% Eye Exams = 82%
21	Humanistic – Pharmacist Care …Aggregate through 25-Apr-04 Overall Satisfaction with Diabetes care Baseline survey (prior to enrollment) 227 patients 57% of responses 8 - 10 6-month follow-up 223 patients 87% of responses 8 - 10 10-point scale
22	Cycle of Incentive Alignment for Collaboration
23	Conclusions Pharmacists have had the opportunity to serve on the frontline of patient care, and have made a difference. Physicians with patients in the program have recognized the positive impact on care. Collaboration plus innovation leads to reduced healthcare costs. Employers benefit by lowering or eliminating barriers to care.