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Pharmacy program with DM component targets CKD

Navigator catches patients before dialysis

The money spent to care for patients on dialysis and those with chronic kidney disease (CKD) is staggering—yet health plans are slow to tackle the issue without knowing whether DM programs are cost-effective.

A recent study published in the Journal of the American Medical Association (JAMA) highlighted the prevalence of CKD among adults in the United States. According to the authors, who were led by Josef Coresh, MD, PhD, of Johns Hopkins University in Baltimore, 13% of Americans have CKD in part because of the prevalence of diabetes and hypertension. CKD also elevates the risk of cardiovascular disease and kidney failure and leads to more expensive healthcare costs. Studies have shown the average dialysis patient incurs costs of about $70,000 per year.

“Estimation of the prevalence of earlier stages of CKD in the U.S. population and ascertainment of trends over time is central to disease management and prevention planning, particularly given the increase in the prevalence of obesity, diabetes, and hypertension, the leading risk factors for CKD,” the study states.

The researchers found that the prevalence of CKD stages 1–4 increased from 10% in 1988–1994 to 13.1% in 1999–2004. Most of those with CKD are in the early stages of the disease, meaning there is still an opportunity to stop the slide into dialysis.

Authors of the JAMA report said that greater awareness is needed.

“The high prevalence of CKD overall, and particularly among older individuals and persons with hypertension and diabetes, suggests that CKD needs to be a central part of future public health planning,” they wrote.

Given the increasing number of Americans afflicted with CKD and the costs associated with dialysis care, Diplomat Specialty Pharmacy of Swartz Creek, MI, developed a program called CKD Navigator, which combined DM with a medical management approach. McLaren Health Plan (an HMO covering about 52,000 Michigan residents) of Flint, National Kidney Foundation of Michigan in Ann Arbor, and corporate sponsor Genzyme of Cambridge, MA, joined the pilot program.

The CKD Navigator pilot showed:

The managed group enjoyed a $300 per patient per month savings in combined medication and medical costs compared to the control group

The managed care group enjoyed a $150 per patient per day savings in combined medication and medical costs because of delaying the onset of dialysis

An ROI of about 5:1

Though the pilot program shows savings, its effect on health and quality of life is unknown. Organizers say the program’s short length of time (six months) and small patient sampling (less than 100) does not allow them to accurately gauge the program’s health effects.

“It is solid enough to get some good financial metrics, but not big enough yet to pull in some lifestyle information,” says Ron Alexander, Diplomat’s vice president of clinical services.

Slippery slope

Phil Hagerman, president and CEO of Diplomat Specialty Pharmacy, says the company is interested in targeting those with CKD because of the costs associated with kidney disease and dialysis care. Similar to hypertension, CKD is a silent condition that people often don’t realize is ravaging their bodies until it’s too late. The goal is to help patients in early stages of CKD before they descend down the slippery slope of dialysis, says Hagerman.

CKD Navigator reached out to patients in Stages 3 and 4. Those in Stage 3 often feel healthy and don’t realize how close they are to dialysis. By stabilizing those in Stage 3, health plans could save patients from dialysis, which could mean the difference between a patient living a long, productive life and spending six months in a hospital, says Hagerman. “We believe that with Stage 3, you have the best opportunity to get the most bang for your buck,” he adds. Hagerman says dialysis is a tremendous trigger event, both in terms of quality of life and finances. Once a patient goes on dialysis, baseline costs skyrocket. “We realized that if we can stop the movement to dialysis, we believe that the return on investment is one of the greatest in any of the disease states.”

When selecting McLaren members to take part, and without knowing members’ glomerular filtration rate (GRF), which measures fluid filtered by the kidneys, pilot organizers searched for patients with comorbidities who were taking certain medications that would suggest they were suffering from CKD. Almost 100 members were chosen for the project—50 in the managed group and about 40 in the control group. All were Michigan residents, and the majority was in the Medicaid population.

Three Diplomat nurses, trained in motivational interviewing and medication therapy management techniques, took part in the program. They made at least one call per month to those in the managed group.

Nurses coached patients and conducted a full medication review during 20-minute calls, during which they were able to form a bond with patients, according to Alexander. After nurses contacted the patients, they created plans of action and faxed them to the individual physician offices. The doctors reviewed and changed care if needed.

Alexander says the three keys to the Diplomat program were communication with the patient, medical therapy management, and physician intervention. Gaining physician trust is often the difference in creating a successful DM program. Alexander says after the PCPs knew Diplomat wasn’t trying to take away their patients or move them to nephrologists, they were receptive to CKD Navigator.

Alexander says PCPs are important to a successful CKD program. “The primary care physician is still the pilot. We’re just trying to be the navigator out there trying to help them.”

Breakdown of the savings

Diplomat Specialty Pharmacy’s CKD Navigator pilot showed combined medication and medical costs savings of $300 per patient per month for the managed care group in a chronic kidney disease study. Here is how the savings were achieved:

Average combined prescription and medical costs for the control group were $999 per month

Average combined prescription and medical costs for the managed care group were $639 per month

That equaled an average savings of $360 per month per patient

The total average savings was $300 per month per patient when the pilot services’ costs of $60 per patient per month were added to the equation

Kidney function test largely unknown

Growing numbers of Americans know their BP numbers and cholesterol figures, but most don’t recognize the letters GFR. Through education programs, some groups are trying to change that. Maurie Ferriter, National Kidney Foundation of Michigan’s director of programs and services, says most people with chronic kidney disease (CKD) don’t realize they have the disorder. Instead, many people go to their doctor or an ER complaining of dehydration and thinking they have the flu—only to find themselves on dialysis. “It doesn’t reach out to bite you in the butt, so to speak, until you’re just about ready for dialysis,” says Ferriter.

The GFR, which stands for glomerular filtration rate, measures fluid filtered by the kidneys. The relatively new test is a gauge similar to cholesterol tests and is considered the best way to measure kidney function. Patients are given a GFR number, which places them into a CKD stage. “GFR is not only a marker of kidney disease, but it’s the easiest, simplest one,” says Phil Hagerman, president and CEO of Diplomat Specialty Pharmacy in Swartz Creek, MI.

With more people diagnosed with the disease, why do so few Americans understand CKD or know their GFR? There are various reasons, including the newness of the GFR test, overworked doctors, and a skeptical DM industry. “When the doctors out there practicing in the world were trained, we didn’t know what we know now about CKD,” says Ferriter. The managed care industry’s resistance was evident in the reaction to Diplomat’s Navigator program. Though Ferriter calls the program “one of the greatest breaths of fresh air” in the dialysis industry, larger health plans were not ready to commit to take part in the pilot without knowing the monetary benefit. However, there is good news on the CKD front. Education is reaching physicians, legislators, and managed care companies. Hagerman says managed care companies now better understand the costs associated with CKD. After the ROI success of its CKD Navigator program, Diplomat is reaching out to sign up other health plans in the Michigan/Ohio area. Officials hope to have 1,000 patients in the CKD Navigator program by the middle of this year. Hagerman says as Diplomat continues highlighting savings in larger populations, he expects larger health plans will show interest.

“We have shown the savings. Now we want to go back and see what this means to the patients as well,” says Ron Alexander, Diplomat’s vice president of clinical services.