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When the City of Asheville launched the Asheville Project back in 1997, those behind it aimed to achieve some ambitious goals. Through proactive, preventive health care, they strove to make people healthier, thereby decreasing health care costs for their employers and boosting productivity at the same time.
?There has been a lot of research done over the years on improving people?s blood pressure and blood sugar control, and pharmaceutical manufacturers have done lots of research proving that their drugs work,? notes Barry A. Bunting, PharmD, clinical manager of pharmacy and Asheville Project coordinator at the Diabetes and Health Education Center at Mission Hospitals in Asheville, NC. ?However, very few had taken the next step, asking the question: what happened to health care costs??
To address this, Asheville Project organizers found in the City of Asheville a self-insured employer who was willing to waive its employees? copays in exchange for their willingness to attend educational seminars on their condition, as well as regular counseling sessions with their pharmacist. As their health coach, the pharmacist would monitor their progress, ensuring that the patients were adhering to the instructions they had received on the administration of their medications, while noting any problems the patients were experiencing. Patients were also coached on diet and exercise?-2 key factors in managing health.
For diabetes alone, the City of Asheville reports a 4 to 1 net return on investment?-for every dollar invested in the model, the City saves $4:
?The model is really simple,? Dr. Bunting declares. ?People meet with a pharmacist in an appointment-based counseling session. When that happens, they do better: they get on the best medication, they take their medication, and that frequent contact not only improves the clinical outcomes, it helps to control health care costs.?
Diabetes seemed like a prime candidate for this proactive approach to health management, and in the beginning that was the first condition the Asheville Project targeted. The pilot group, comprised of City of Asheville employees, consisted of 47 patients.
Since then, 80 employers in 14 different states have implemented the Asheville model. ?We have never made a cold call on anyone,? relays Daniel Garrett, RPh, MS, FASHP, senior director of medication adherence programs at the American Pharmacists Association Foundation in Washington, DC. ?Every new site has joined the program because they were interested and wanted to learn more.? Today, diabetes, asthma, hypertension, high cholesterol, and, most recently, depression have been incorporated into the model. In Asheville alone, an estimated 1400 patients are following the program, and thousands of others are following similar models across the country.
For their coaching sessions, patients?-depending on their condition?-are required to supply information they gather at home between their visits, for example, blood pressure and sugar levels.
?What this program really does is promote patient adherence to taking their medicine and to the behaviors that are needed for any of the chronic conditions that the Asheville model is now being used for,? Garrett explains. ?In the end, it?s patients who take care of themselves 24 hours a day, 7 days a week. In the end, it?s patients who remember to take their medicine, exercise, eat right, and manage stress in their life.? The patient is at the center of the program, and as health coach, the pharmacist?s role is to direct patients toward making the right choices to manage and improve their health.
For most patients first enrolling in the program, the primary incentive is the decrease in out-of-pocket health care costs. ?That is generally what entices people to enroll,? Dr. Bunting says. ?From there, they start getting great information that helps them improve their health. They get coaching, and they get a caring relationship.? Many participants acknowledge that while they enjoy the cost savings, their coaching relationship has become a vital part of their lives.
Garrett concedes that the Asheville model requires pharmacists to step away a bit from the conventional approach to pharmacy. ?It?s a different model than what pharmacists are used to,? he says. ?It certainly doesn?t involve counting by 5?s really fast and processing insurance claims. It?s a different mindset, it?s done by appointment, and it?s done in a private counseling area.?
All of this requires community pharmacists to re-engineer their workflow, using technicians in the automation and dispensing process. ?The biggest thing they have to do is change their mindset as to their role as a clinician as opposed to someone who is in a dispensing role,? Garrett says.
In this new role, pharmacists must delegate administrative tasks to someone else in their organization in order to maintain efficiencies. ?The biggest mistake that I have seen pharmacists make is spending too much of their personal time on things that somebody else could be doing, such as scheduling,? Dr. Bunting notes. ?If the pharmacist has to spend hours a month on the phone or emailing their patients to schedule them, that?s a waste of their time. They need to plan for someone else to do that.? If not, pharmacists will soon find their workloads overwhelming.
Modeled after the Asheville Project and Project ImPACT: Hyperlipidemia (the American Pharmacists Association [APhA]?s cholesterol management program that took place between 1996 and 1999), the APhA?s Diabetes Ten City Challenge is designed to fight diabetes and reduce health care costs through its patient self-management program. In 2006, the APhA Foundation approached employers in 10 cities across the United States to participate in the program, provided they met certain criteria. Participating employers were required to launch the program in 2006, providing they had self-insured health plans with a minimum of 5000 employees and/or beneficiaries; provided incentives, such as waived copays for diabetes medication and testing equipment; appointed an in-house coordinator to administer the program; and demonstrated a willingness to speak out about the program within their communities. Participating sites are:
The beauty of the Asheville model is that it can be adapted to suit the specific needs of a community depending on its resources. At some sites, the pharmacists? network is set up through the state pharmacy association; in others, it is made up of a private network of pharmacists. At one site, the pharmacists? network is handled through a pharmacy benefits manager. Although the model originally had patients visiting their pharmacist health coaches at the store, an increasing number of employers are inviting pharmacists to conduct their monitoring sessions onsite, at the workplace.
Thorough documentation is crucial to the success of the Asheville model, Garrett underscores. ?Our goal when we started this back in 1997 was to turn this from an academic exercise into a business enterprise,? he says. In order for this to happen, pharmacists must supply the data that demonstrate the value of the program. ?We?re not trying to sell this to a bunch of academics; we are dealing with Fortune 500 companies and city, county, and state governments. What really sells the program is the patient care and how patients respond. In order to justify the continued support for waiving the copays and paying the pharmacists, you have to have the hard data.? So far, the Asheville model is demonstrating significant value, not only in diabetes management, but in other areas, as the program has expanded to include more chronic conditions.
A recent study of a community-based medication therapy management program for asthma at 12 pharmacy locations in Asheville, reported in the Journal of the American Pharmacists Association, concluded that both objective and subjective measures of asthma control improved (Figure 1) and resulted in both direct and indirect cost savings (Figure 2): ?Patients with asthma who received education and long-term medication therapy management services achieved and maintained significant improvements and had significantly decreased overall asthma-related costs despite increased medication costs that resulted from increased use.?1
?What?s in it for the employer is a healthier, more productive employee and control of health care costs,? Bunting says. It also sends a positive message to employees, he adds, that we care about you enough to invest in your health.
?In the old health care system, we assumed that people would go to the doctor, the doctor would write a prescription, and then patients would get the prescription filled and comply with whatever the doctor told them to do,? Garrett explains. ?What we are learning is that if you want to have true change in health care, it needs to be supported by the system. The patient is at the center of the system and not the provider.?
Bunting observes that the Asheville model is growing bigger than pharmacy. Health care educators receive the opportunity to expand their educational reach and to be compensated in exchange. With this extra support, physicians are assisted in achieving the care goals they have set out for their patients. ?They still want to be in charge of their care, and this doesn?t usurp that in any way,? Dr. Bunting explains. ?They get more information that allows them to make more informed decisions, and their patient receives more education that the physician wouldn?t have the time to do.? Under the Asheville model, the treatment plan is enforced because patients adhere much better to what their doctor is asking of them.
Dr. Bunting emphasizes that the Asheville model illustrates that preventive care can work, and when it does, health care costs can be controlled and, in some cases, reduced. ?The whole country needs to shift its focus from fixing people when they break to keeping them from breaking,? he says. In its current state, the primary care system places the majority of the burden on the doctors, who, he says, are overwhelmed. ?There are a lot of barriers: cost of medications, time that they are able to spend with patients, and so on.?
In this way, the Asheville model assists in preventing these health conditions from getting out of hand, immobilizing the patient, and racking up costs. ?In the United States, we do not have a health care system; we have a sick care system,? Garrett says. ?What the Asheville model does, and what the people who have chosen to replicate it have done, is say, ?We are going to do something different.??
In her role as patient service supervisor with Mission Hospitals, Regina Humphries counsels patients suffering from a number of conditions. When Humphries herself was first diagnosed with asthma, high blood pressure, high cholesterol, and diabetes, however, she had a difficult time accepting it.
?I was very much in denial,? Humphries admits. As a patient in Mission Hospitals? wellness program, she received the coaching she required to deal with her condition. ?My case manager would call, even when I didn?t have to see her to say, ?How are you doing? When you left the office a couple of days ago, you weren?t at a point where I was satisfied with you.? She would talk with me, for however long I needed, to smooth out some of the edges.?
This moral support went a long way for Humphries, who couldn?t believe all of these health conditions were happening to her. ?She would tell, without breaking any confidentiality, stories of other patients who were going through the same thing, so that I didn?t feel like I was by myself,? she says. ?She was very encouraging. I could call her any time, and she was quick in calling me back. And she didn?t seem to get frustrated when I would complain if a medication was making my stomach upset or causing me not to feel well.?
Humphries touts the feeling of community that the wellness program offers, transforming patients from being victims to proactive participants in the management of their health. ?You feel valued,? she says. ?When you go into this mentoring program with whomever?a pharmacist, or whomever is your coach?this is one of the places where everything is laid out on the table. They make you feel like you have this disease, you are not of this disease.?