Unlikely Allies: Community Collaborations Galvanize the Asheville Project

OCTOBER 01, 2007
Katherine Heller, PharmD

Joe is a community pharmacist who still likes his job despite the hectic dispensing pace, limited time for patient counseling, insurance problems, and irate phone calls. He really likes the times when he makes a difference in people?s lives. In pharmacy school, he heard about plans to pay pharmacists for direct patient care activities? even in retail and chain settings. Lately, Joe has heard more about medication therapy management, the Asheville Project, and how pharmacists are providing and getting paid for these services.

Every field of study has its mavericks. Physics hails Isaac Newton and the funny yet brilliant Albert Einstein. Community pharmacy hails the dynamic, visionary team behind the Asheville Project?Daniel Garrett, RPh,MS, FASHP, and Barry A. Bunting, PharmD.Together, these pharmacists not only gathered a collaborative and synergistic health care team, but they also found what at the time was unthinkable?an employer group willing to pay pharmacists for cognitive services.

The Asheville Project continues to exceed performance expectations each year since its inception in 1997. How has it been able to reach that crucial ?tipping point? and not only launch, but flourish? The support structures fostering its success include strong pro-pharmacy legislation, backlash against skyrocketing health care costs, innovative employer partners, and an established health-systems community hospital coordinating a multidisciplinary health care team.

Pharmacists Lobby for Legislation

A key component in the success of the Asheville Project is the fact that many hardworking and innovative North Carolina pharmacists secured health care provider status long before the 2003 Medicare Modernization Act. State pharmacy leaders, led by Garrett and the North Carolina Center for Pharmaceutical Care, created the Clinical Pharmacist Practitioner (CPP) credentialing program and lobbied the legislature for recognition of those with CPP status as health care providers. Much more than a certificate training program, qualifying for a CPP demands significant pharmacy training, as well as a letter from an area physician willing to establish a collaborative practice.

The move to CPP status fostered collaborative disease management opportunities for area pharmacists, which included the ability to bill for cognitive services. Although not all pharmacists who provide care for Asheville Project patients are CPP-credentialed, the CPP program established precedence for pharmacists to be recognized as central to direct patient care throughout the state.

What Is the Asheville Project?

  • A disease management and prevention program for patients with chronic conditions such as diabetes, asthma, hypertension, and depression
  • Launched in 1997, it successfully improves patient outcomes and lowers health care costs
  • Pharmacists are paid to act as health care coaches?they regularly monitor patient?s condition, review medications, and develop a treatment plan in conjunction with the patient and the physician
  • 10 years after its inception, Asheville is being replicated across the country as a proven model for a collaborative, cost-effective approach to managing chronic disease

Health Care Costs Skyrocketing

Joe sees Mary, the local hospital?s pharmacy director, hunched over her latte, looking worriedly at some reports. He notices that, despite the energy and noise in the coffeehouse, she appears slightly deflated. As Joe approaches Mary, she looks up and appears relieved at the distraction. ?Hey Joe, have a seat. Sorry if I?m distracted. We just got the medical bills from my husband?s heart attack. It?s so difficult. I am a medical professional and know better, but I thought we were healthy and didn?t need to go see our doctor unless something went wrong. I don?t know how we can afford the bills. The insurance premiums were killing our budget, so I went for a higher-risk plan last year. I guess that didn?t pay off!?

Joe nods, ?I know what you mean. I thought our corporate guys were the only ones raising premiums until I went job hunting last year. It seems all the companies are having a hard time keeping costs down.?

Originally, health benefits were a relatively low-cost hiring incentive for competitive companies to lure and retain employees. In today?s market, competitive health benefits are an expected standard, with employers becoming insurance providers for the majority of Americans. With annual, doubledigit percentage increases in health care expenditures, companies are struggling with a decreasing profit margin directly related to the increasing cost of providing health benefits to their employees and families.

Initial cost-containment measures include high-deductible, tiered copay systems that decrease access to medical care and medications and discourage engagement in the health care system prior to an event. Employees are not taking preventive measures in an effort to avoid initial costs, a strategy that can lead to significantly higher costs in the long run if detecting an underlying condition is delayed and/or the condition is left uncontrolled. Employers are facing all-time-high claims costs and increasing absenteeism, compounding profit-margin problems.

The Asheville Solution

So how do pharmacists fit into this complex, national health care crisis? Dr. Bunting, Asheville?s project coordinator and an employee of Mission St. Joseph?s Hospitals, had an idea: ?What pharmacists need to realize is that dispensing fees are being cut for the same reason as national health care costs are rising. Our current system of care is focused on treatment. Where we really need to be focused is on prevention, especially with specific types of patients with chronic medication use. That?s what made John Miall, the City of Asheville?s risk manager, so visionary. He understood what even we, as pharmacists, are still trying to grasp.?

The City of Asheville was identified as a self-insured employer group, progressive payer, and potential partner. ?With a simple handshake agreement between Dan and John over a cup of coffee, the Asheville Project was born,? says Dr. Bunting. ?John really had nothing to lose; the pharmacists were willing to work for free. John?s biggest concern was getting the employees engaged. He?s the one who came up with the idea to waive copays.?

Identifying innovative employer groups in a target area, combined with community-based networking opportunities, assisted in the successful marketing of the Asheville Project demonstration model. Overall, encouraging the employer group to actively engage in the design and setup allows for better targeting of its needs and a more effective model.

Joe nods, ?We need to find something else, Mary. The current health care system isn?t working. It breaks my heart to see what our patients do to their health, simply because they haven?t had a qualified health care professional really give them some time. What if pharmacists were able to step in and give a little more guidance? I?ve been reading about the Asheville Project. It?s a community-based, wellness model where pharmacists, physicians, and other health care providers collaborate to improve patient care, resulting in decreased overall health care costs. I?d like to talk to you about using your pharmacy department at the hospital to support this type of initiative in our area.?

Mission St. Joseph?s Crucial Role

Enter Garrett, Mission St. Joseph?s director of pharmacy and state pharmacy association committee chair. More than 10 different pharmacy organizations joined forces and met for 3 years to create the backbone of what would become the Asheville Project. ?We had membership from a pharmacy benefit management company owned by pharmacists, the Moses Cone Health System, the University of North Carolina, Campbell University, as well as 2 industry partners?Glaxo- SmithKline and Burroughs Wellcome. I mostly provided the leadership and connection of people, while Barry focused on project design and administration,? noted Garrett.

When asked about the role of the hospital in supporting the Asheville Project, Dr. Bunting said, ?Superficially, the program appears pharmacist-centric. It really isn?t.? As director of pharmacy at Mission St. Joseph?s, the largest employer group in Asheville, Garrett accessed and engaged extensive health care resources creating a connectivity of care in the community. The certificate training program was developed with industry funding and involved physician champions in the diabetes care specialties. ?He pulled all the ?-ologists? together, which in one move improved physician buy-in and awareness, and raised the perceived quality of the program,? recounts Dr. Bunting. ?We?re fortunate to have a medical director employed by the city. That allows us to require biannual [hemoglobin] A1C and lipid panels. The results are sent to his office, so we don?t have any trouble tracking clinical outcomes like some Asheville Project spin-offs are now facing.?

Asheville Model Benefits Hospital?s Bottom Line

Joe leans in, ?What if we could improve patient engagement; connectivity of institutional and community health care resources; clinical and humanistic outcomes for our patients and their families, not to mention improving the economic outcomes for every party involved in the process? Would you and the hospital be interested in supporting such an initiative??

Mary sets down her latte. ?I can tell this is more than a casual question, Joe, but I?ve got to be able to sell this to our finance division. How would the hospital benefit? The pharmacy department is no longer the moneymaker we were just a few years ago. The hospital has already maximized our costcontainment opportunities.?

Clearly, the case for community pharmacy to partner with an area health-systems hospital is an easy one to make, but what are the benefits to the hospital? Community hospitals can be an area?s largest employer group. A hospital could design a program and enroll its own employees in addition to serving other employer groups, potentially resulting in increased cost savings and profits through increased utilization of the institutional providers? services for third-party billing.

All employer groups are affected by the national increases in health care costs. Hospitals are assaulted by payers identifying significant inpatient cost increases. Offering enrollment to area businesses may improve the hospital?s ability to assist employers to offset the necessary cost of care through improved preventive efforts. By serving the community that supports them, hospitals develop a stronger public relations portfolio. This type of local partnering may garner local and national interest.

Over the past 3 decades, hospital pharmacy departments have experienced an ebb and flow in their chief executive officer- or chief financial officer-perceived impact on the overall organizational budget. Historically, pharmacy departments were subject to cost-containment measures based almost exclusively on drug-acquisition cost. Costcontainment measures included reduced dispensing fees, smaller increases in physician and hospital fees, and tighter formulary management, all in addition to negotiating for the biggest drug discount offered by each pharmaceutical company for the privilege of being on the formulary.

Beginning in the 1970s, hospital pharmacists began to demonstrate value-added cost savings by flexing their ?clinical? muscles. Medication management interventions became more standard practice, from the relatively simple? such as intravenous to oral interchange?to more complex services such as anticoagulation, pharmacokinetic drug monitoring, and total parenteral nutrition. With its success in improving outcomes and decreasing the overall cost of care, the pharmacy department began to drive much of the institution?s budget, allowing decentralization and specialization.

Increased health care costs affect individuals as well as employers. Every company, even the most successful hospital with a tenacious and proactive pharmacy department, feels the toll, yet costshifting and cost-containment measures are reaching maximal utilization. The time for value-driven preventive efforts is at hand.

Diabetes Education Program Is Strong Motivator

Before he was diagnosed with type 2 diabetes and high blood pressure, Mike Rhinehart admits he paid little attention to his health. Thanks to his employer?s implementation of a health management program?based on the project pioneered by the City of Asheville?Rhinehart is not only health-conscious, he feels great.

?My A1C was 7.1 when I started, and it?s 5.7 now,? he recounts, adding that his blood pressure levels are now back to normal. ?I have gone from 256 pounds down to 216 pounds. I have stopped smoking. I am 60 years old, and I am more flexible than I have been in about 10 years because I exercise once or twice a week. I feel better just generally.? A swing shift worker, Rhinehart adds that it is now easier for him to get through the night shifts, and work in general is less taxing.

These changes took place gradually, and Rhinehart states that, because of this, they weren?t that difficult to make. ?I worked with the program, my coach, and one of the paramedics down in the mill who monitors my glucose levels. He reads my meter and then puts out a report for me to give to my doctor,? he says. ?I didn?t lose 40 pounds overnight.?

Rhinehart notes that the mandatory diabetes education program served as a strong motivator for him to turn things around. ?The program works,? he says. ?They teach you to read labels. I didn?t pay any attention to labels on food; whatever was there and cheap, I bought.? Now, Rhinehart shops for quality over price. ?If I have to pay a little more for it because it suits my needs, I will do that, because it?s my health. I care about my health now probably more than I ever have. The program that I went to at the hospital really opened my eyes about what diabetes can do, and what it can lead to.?

Asheville: Sparking a Proliferation of Wellness Programs

The Asheville Project has become a model for wellness programs, as companies seek alternative ways to contain health care costs while still protecting the health of employees.

?Employee wellness programs can greatly benefit both employers and employees. These creative programs are a great way to promote better health, which ultimately improves quality of life and lowers the cost of health care for everyone involved,? said Senator Richard Burr (R, NC), a champion of the Asheville model which began in his home state 10 years ago. He praised the project?s disease management benefits in a speech to his Senate colleagues earlier this year, citing the project as a prime example of patients working with a pharmacist to control their diabetes. ?If we can teach people how to control disease, then the number of times they access health care is going to be less,? he said.

The ?Reducing Corporate Health Care Costs 2006 Survey,? conducted by the Human Capital Practice of Deloitte Consulting and the Deloitte Center for Health Solutions, looked at 152 large employers across the country. The survey found that 74% of the respondents offer some type of disease management program, with 63% offering one through their health plan and 11% offering a program through a specialty carrier. Diabetes, asthma, and cardiovascular disease top the popular programs. Of the respondents, 90% offer a diabetes program and 77% offer an asthma program.

Aside from disease state management programs, the survey also indicated that survey respondents offer wellness programs. Of the respondents, 93% reported they offer some kind of wellness program. The flu shot program (74%) is the most popular program. While 45% offer a smoking cessation program, 40% of respondents offer an on-site workout facility, diet group, or subsidized gym program.

The Keys to Success

The Asheville Project has flourished largely because of its supportive structure anchored by a health-systems hospital. Indeed, all of the resources fundamental to the project?s success were catalyzed by having a health-systems hospital pharmacy director at the initiative?s core. Projects the size and scope of Asheville require substantial and supportive administrative effort, and a true health-systems hospital offers not only financial and business stability, but also a level of health care resource connectivity that may not be afforded by an acute care hospital.

Through its focus on quality, connectivity, and value of care, Asheville provides a model for how communities and employers can develop their own collaborative initiatives to improve health care and contain costs.

Keeping Employees Healthy and on the Job

Ed Lamb

Mr. Lamb is a freelance pharmacy writer living in Virginia Beach,Va, and president of Thorough Cursor Inc.

When the Asheville Project launched in 1997, Lynn Hollifield, BSN, RN, COHN-S, was the sole occupational health nurse for the City of Asheville. ?I used to be the local ?Ask-a- Nurse,?? recalled Hollifield, who is now the health services manager for city employees and oversees a small staff. ?The disease management programs have shifted diabetes care from my workload, so we?ve been able to expand in other areas, like an on-site physician clinic, OSHA compliance, and smoking cessation.?

As much as having pharmacists take over many of the tasks of caring for patients with chronic health conditions has helped Hollifield, she praises the Asheville Project most for improving patients health by ?hooking them up with other providers who can provide the most expertise and targeted care like pharmacists, physicians, specialists, dietitians, and diabetes educators.?

As the program has expanded, Hollifield has seen benefits for enrollees, the city, and herself and her colleagues. ?I never really see diabetic crises anymore, and it has been many years since kidney transplant was needed for a current employee,? she said.

According to Hollifield, one notable Asheville success involved a ?brittle diabetic? who was facing the possibility of going on disability. ?Through the patient management program, this man was able to get a GlucoWatch (Animas Technology) and continue working. I went to the training session where he learned how to use the watch, and he couldn?t be happier,? Hollifield said.

She also told the story of an employee who had frequently had to miss work because of ?really bad asthma attacks.? Hollifield said, ?He never carried his inhaler until he enrolled in the program,? she continued. ?He was scared of his asthma because his grandmother had died of asthma, but he just could not remember to keep his inhaler on him. One day after he was in the program, he started having an attack, and he did have his inhaler. ?He made a special visit to tell me, ?I didn?t have to go to the emergency room like before,?? she said.

Hollifield summed up her 10 years of involvement with the Asheville Project by saying, ?This is probably one of the most revolutionary approaches to chronic disease care, and it works.?

A Win-Win for Physicians, Too

Ed Lamb

Mr. Lamb is a freelance pharmacy writer living in Virginia Beach,Va, and president of Thorough Cursor Inc.

As the Asheville Project completes its 10th year, J. Paul Martin, MD, who was a key physician member of the multidisciplinary group that founded it, reflected on the benefits of the program.

Martin was?and is?the medical director of health services for the City of Asheville and the medical director for staff health services at Mission St. Joseph?s Hospital, the two self-insured employers that are the principal underwriters of the Asheville Project. In both positions, Martin identifies patients who could benefit from having pharmacists become more involved in their care and refers those individuals for enrollment in the program. Beneficiaries have a pharmacist regularly monitor their condition, review their medications, and develop a treatment plan in conjunction with them and their physician. Over time, the pharmacist may make recommendations for therapeutic changes.

?It?s a phenomenal resource for everybody,? Martin said. ?As a referring physician, I know that this program will help patients get the care they need. The primary physician is freed up to spend time on resolving problems, and the patient can develop a personal relationship with the pharmacist. It?s a win?win for everybody.?

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