Katherine Heller, PharmD

Joe is a community pharmacist who stilllikes his job despite the hectic dispensingpace, limited time for patient counseling,insurance problems, and irate phone calls.He really likes the times when he makes adifference in people?s lives. In pharmacyschool, he heard about plans to pay pharmacistsfor direct patient care activities?even in retail and chain settings. Lately, Joehas heard more about medication therapymanagement, the Asheville Project, andhow pharmacists are providing and gettingpaid for these services.

Every field of study has its mavericks. Physicshails Isaac Newton and the funny yet brilliantAlbert Einstein. Community pharmacy hailsthe dynamic, visionary team behind theAsheville Project?Daniel Garrett, RPh,MS, FASHP, andBarry A. Bunting, PharmD.Together, these pharmacistsnot only gathered a collaborative and synergistichealth care team, but they also found whatat the time was unthinkable?an employergroup willing to pay pharmacists for cognitiveservices.

The Asheville Project continues to exceedperformance expectations each year since itsinception in 1997. How has it been able to reach that crucial ?tipping point? andnot only launch, but flourish? The support structures fostering its success includestrong pro-pharmacy legislation, backlash against skyrocketing health care costs,innovative employer partners, and an established health-systems community hospitalcoordinating a multidisciplinary health care team.

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

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

A disease management and prevention programfor patients with chronic conditionssuch as diabetes, asthma, hypertension, anddepression

Launched in 1997, it successfully improvespatient outcomes and lowers health carecosts

Pharmacists are paid to act as health carecoaches?they regularly monitor patient?scondition, review medications, and developa treatment plan in conjunction with thepatient and the physician

10 years after its inception, Asheville is beingreplicated across the country as a provenmodel for a collaborative, cost-effectiveapproach to managing chronic disease

Joe sees Mary, the local hospital?s pharmacy director, hunched over herlatte, 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 upand appears relieved at the distraction.?Hey Joe, have a seat. Sorry if I?m distracted.We just got the medical bills from myhusband?s heart attack. It?s so difficult. Iam a medical professional and know better,but I thought we were healthy anddidn?t need to go see our doctor unlesssomething went wrong. I don?t know howwe can afford the bills. The insurance premiums were killingour budget, so I went for a higher-risk plan last year. I guessthat didn?t pay off!?

Joe nods, ?I know what you mean. I thought our corporateguys were the only ones raising premiums until I went jobhunting last year. It seems all the companies are having ahard time keeping costs down.?

Originally, health benefits were a relatively low-cost hiringincentive for competitive companies to lure and retain employees.In today?s market, competitive health benefits are anexpected standard, with employers becoming insuranceproviders for the majority of Americans. With annual, doubledigitpercentage increases in health care expenditures, companiesare struggling with a decreasing profitmargin directly related to the increasingcost of providing health benefits to theiremployees and families.

Initial cost-containment measures includehigh-deductible, tiered copay systemsthat decrease access to medical careand medications and discourage engagementin the health care system prior to anevent. Employees are not taking preventivemeasuresin an effort to avoid initialcosts, a strategy that can leadto significantly higher costs inthe long run if detecting anunderlying condition is delayedand/or the condition isleft uncontrolled. Employersare facing all-time-high claimscosts and increasing absenteeism, compounding profit-marginproblems.

So how do pharmacists fit into this complex, national healthcare crisis? Dr. Bunting, Asheville?s project coordinator and anemployee of Mission St. Joseph?s Hospitals, had an idea: ?Whatpharmacists need to realize is that dispensing fees are being cutfor the same reason as national health care costs are rising. Ourcurrent system of care is focused on treatment. Where we reallyneed to be focused is on prevention, especially with specifictypes of patients with chronic medication use. That?s whatmade John Miall, the City of Asheville?s risk manager, so visionary.He understood what even we, as pharmacists, are still tryingto grasp.?

The City of Asheville wasidentified as a self-insuredemployer group, progressivepayer, and potential partner.?With a simple handshakeagreement between Dan andJohn over a cup of coffee, theAsheville Project was born,?says Dr. Bunting. ?John reallyhad nothing to lose; the pharmacists were willing to work forfree. 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, combinedwith community-based networking opportunities, assistedin the successful marketing of the Asheville Project demonstrationmodel. Overall, encouraging the employer group toactively engage in the design and setup allows for better targetingof its needs and a more effective model.

Joe nods, ?We need to find something else, Mary. The currenthealth care system isn?t working. It breaks my heart tosee what our patients do to their health, simply becausethey haven?t had a qualified health care professional reallygive them some time. What if pharmacists were able to stepin and give a little more guidance? I?ve been reading aboutthe Asheville Project. It?s a community-based, wellnessmodel where pharmacists, physicians, and other healthcare providers collaborate to improve patient care, resultingin decreased overall health care costs. I?d like to talk to youabout using your pharmacy department at the hospital tosupport this type of initiative in our area.?

Enter Garrett, Mission St. Joseph?s director of pharmacy andstate pharmacy association committee chair. More than 10 differentpharmacy organizations joined forces and met for 3years to create the backbone of what would become theAsheville Project. ?We had membership from a pharmacy benefitmanagement companyowned by pharmacists, theMoses Cone Health System, theUniversity of North Carolina,Campbell University, as well as2 industry partners?Glaxo-SmithKline and BurroughsWellcome. I mostly providedthe leadership and connectionof people, while Barry focused on project design and administration,?noted Garrett.

When asked about the role of the hospital in supporting theAsheville Project, Dr. Bunting said, ?Superficially, the programappears pharmacist-centric. It really isn?t.? As director of pharmacyat Mission St. Joseph?s, the largest employer group inAsheville, Garrett accessed and engaged extensive health careresources creating a connectivity of care in the community. Thecertificate training program was developed with industry fundingand involved physician champions in the diabetes care specialties.?He pulled all the ?-ologists? together, which in one moveimproved physician buy-in and awareness, and raised theperceived quality of the program,? recounts Dr. Bunting. ?We?re fortunateto have a medical director employed by the city. Thatallows us to require biannual [hemoglobin] A1C and lipid panels.The results are sent to his office, so we don?t have any troubletracking clinical outcomes like some Asheville Project spin-offsare 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 careresources; clinical and humanistic outcomes for our patientsand their families, not to mention improving the economicoutcomes for every party involved in the process? Would youand the hospital be interested in supporting such an initiative??

Mary sets down her latte. ?I can tell this is more than a casualquestion, Joe, but I?ve got to be able to sell this to ourfinance division. How would the hospital benefit? The pharmacydepartment is no longer the moneymaker we were justa few years ago. The hospital has already maximized our costcontainmentopportunities.?

Clearly, the case for community pharmacy to partner with anarea health-systems hospital is an easy one to make, but what arethe benefits to thehospital? Communityhospitals can be anarea?s largest employergroup. A hospitalcould design a programand enroll itsown employees in addition to serving other employergroups, potentially resulting in increased cost savings andprofits through increased utilization of the institutionalproviders? services for third-party billing.

All employer groups are affected by the national increasesin health care costs. Hospitals are assaulted by payers identifyingsignificant inpatient cost increases. Offering enrollmentto area businesses may improve the hospital?s abilityto assist employers to offset the necessary cost of carethrough improved preventive efforts. By serving the communitythat supports them, hospitals develop a stronger publicrelations portfolio. This type of local partnering may garnerlocal and national interest.

Over the past 3 decades, hospital pharmacy departmentshave experienced an ebb and flow in their chief executiveofficer- or chief financial officer-perceived impact onthe overall organizational budget. Historically, pharmacydepartments were subject to cost-containment measuresbased almost exclusively on drug-acquisition cost. Costcontainmentmeasures included reduced dispensing fees,smaller increases in physician and hospital fees, and tighterformulary management, all in addition to negotiating for thebiggest drug discount offered by each pharmaceutical companyfor the privilege of being on the formulary.

Beginning in the 1970s, hospital pharmacists began todemonstrate value-added cost savings by flexing their ?clinical?muscles. Medication management interventionsbecame more standard practice, from the relatively simple?such as intravenous to oral interchange?to morecomplex services such as anticoagulation, pharmacokinetic drugmonitoring, and total parenteral nutrition. With its success inimproving outcomes and decreasing the overall cost of care, thepharmacy department began to drive much of the institution?sbudget, allowing decentralizationand specialization.

Increased health care costsaffect individuals as well asemployers. Every company,even the most successful hospitalwith a tenacious andproactive pharmacy department,feels the toll, yet costshiftingand cost-containmentmeasures are reaching maximalutilization. The time forvalue-driven preventive effortsis at hand.

Diabetes Education Program Is Strong Motivator

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

?My A1C was 7.1 when I started,and it?s 5.7 now,? herecounts, adding that hisblood pressure levels arenow back to normal. ?Ihave gone from 256pounds down to 216pounds. I have stoppedsmoking. I am 60 years old,and I am more flexible thanI have been in about 10 yearsbecause I exercise once ortwice a week. I feel better justgenerally.? A swing shift worker, Rhinehart adds that it is noweasier for him to get through the night shifts, and work in generalis less taxing.

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

Rhinehart notes that the mandatory diabetes education programserved as a strong motivator for him to turn thingsaround. ?The program works,? he says. ?They teach you to readlabels. I didn?t pay any attention to labels on food; whatever wasthere and cheap, I bought.? Now, Rhinehart shops for qualityover price. ?If I have to pay a little more for it because it suits myneeds, I will do that, because it?s my health. I care about myhealth now probably more than I ever have. The program that Iwent to at the hospital really opened my eyes about what diabetescan do, and what it can lead to.?

Asheville: Sparking a Proliferation of WellnessPrograms

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

?Employee wellness programs can greatly benefit bothemployers and employees. These creative programs are a greatway to promote better health,which ultimately improves qualityof life and lowers the cost of healthcare for everyone involved,? saidSenator Richard Burr (R, NC), achampion ofthe Ashevillemodel whichbegan in hishome state 10years ago. Hepraised theproject?s disease management benefits in a speech to hisSenate colleagues earlier this year, citing the project as a primeexample of patients working with a pharmacist to control theirdiabetes. ?If we can teach people how to control disease, thenthe number of times they access health care is going to beless,? he said.

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

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

The Asheville Project has flourished largely because of itssupportive structure anchored by a health-systems hospital.Indeed, all of the resources fundamental to the project?s successwere catalyzed by having a health-systems hospital pharmacydirector at the initiative?s core. Projects the size andscope of Asheville require substantial and supportive administrativeeffort, and a true health-systems hospital offers not onlyfinancial and business stability, but also a level of health careresource connectivity that may not be afforded by an acutecare hospital.

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

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

When the Asheville Project launched in 1997, LynnHollifield, BSN, RN, COHN-S, was the sole occupational healthnurse for the City of Asheville. ?I used to be the local ?Ask-a-Nurse,?? recalled Hollifield, who is now the health servicesmanager for city employees and oversees a small staff. ?Thedisease management programs have shifted diabetes carefrom my workload, so we?ve been able to expand in otherareas, like an on-site physician clinic, OSHA compliance, andsmoking cessation.?

As much as having pharmacists take over many of thetasks of caring for patients with chronic health conditions hashelped Hollifield, she praises the Asheville Project most forimproving patients health by ?hooking them up with otherproviders who can provide the most expertise and targetedcare like pharmacists, physicians, specialists, dietitians, anddiabetes educators.?

As the program has expanded, Hollifield has seen benefitsfor enrollees, the city, and herself and her colleagues. ?I neverreally see diabetic crises anymore, and it has been manyyears since kidney transplant wasneeded for a current employee,?she said.

According to Hollifield, onenotable Asheville success involveda ?brittle diabetic? who was facingthe possibility of going on disability.?Through the patient managementprogram, this man was ableto get a GlucoWatch (Animas Technology) and continue working.I went to the training session where he learned how touse the watch, and he couldn?t be happier,? Hollifield said.

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

Hollifield summed up her 10 years of involvement with theAsheville Project by saying, ?This is probably one of the mostrevolutionary approaches to chronic disease care, and itworks.?

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

Martin was?and is?the medical director of healthservices for the City of Asheville and the medical directorfor staff health services at Mission St. Joseph?sHospital, the two self-insured employers that are theprincipal underwriters of the Asheville Project. In bothpositions, Martin identifies patients who could benefitfrom having pharmacists become more involved in theircare and refers those individuals for enrollment in theprogram. Beneficiaries have a pharmacist regularlymonitor their condition, review their medications, anddevelop a treatment plan in conjunction with them andtheir physician. Over time, the pharmacist may makerecommendations for therapeutic changes.

?It?s a phenomenal resource for everybody,? Martinsaid. ?As a referring physician, I know that this programwill help patients get the care they need. The primaryphysician is freed up to spend time on resolving problems,and the patient can develop a personal relationshipwith the pharmacist. It?s a win?win for everybody.?

Articles

Dr. Heller is an assistant professor of
pharmacy practice and administration
at Lloyd L. Gregory School of Pharmacy,
West Palm Beach, Fla.