DTCC saves money, improves clinical measures and prevention
Pharmacists have taken on a greater presence on the healthcare team in programs such as the Asheville Project and Medicare’s Medication Therapy Management, which have shown that pharmacist coaches can help improve patient health and reduce costs.
The final economic and clinical results for the Diabetes Ten City Challenge (DTCC) concur with those findings and show that combining pharmacist coaches with value-based insurance design helped diabetic patients manage their chronic disease.
According to the study that was published in the May/June Journal of the American Pharmacists Association, average healthcare costs for those involved in the project were reduced by $1,079 per patient annually, and the participants saved an average of $593 per year on their diabetes medications and supplies because DTCC employers waived copays. (See Figure 1 on p. 3.)
The program also improved patients’ key clinical measures, including lowering A1C and cholesterol levels to achieve American Diabetes Association and National Cholesterol Education Program goals and lowering diastolic/systolic blood pressure levels to below the 130/80 goal. The project also fostered improvements in preventive care measures, including flu vaccinations and current foot and eye exams. (See Figures 2 and 3 on p. 4.)
The results show that pharmacist coaches could affect chronic disease, reduce adverse drug events, and improve medication compliance, says William M. Ellis, CEO of the American Pharmacists Association (APhA) Foundation in Washington, DC, who coauthored the study.
Pharmacist coaches can meet with patients longer than doctors, who are stretched for time, and they can help fill a gap left by physician shortages.
“Physicians today are asked to do so much in an office visit in a really short amount of time,” Ellis says. “The things they have to cover with a patient are really more than I think can be done in a lot of office visits. To have the extra support of a pharmacist to reinforce those things is valuable ... I think the opportunity for more one-on-one interaction with the pharmacist is an area where there is a huge opportunity in healthcare that can certainly pay dividends down the road.”
DTCC built upon the foundation of the Asheville Project, a successful pharmacist-driven diabetes program implemented in the city of Asheville, NC. Through DTCC, the APhA Foundation expanded the pharmacist coach model nationally to prove it can be replicated in diverse geographies and various employer types. (See Figure 4 on p. 5 for a list of locations.)
According to the study, the APhA Foundation found that successful pharmacist coaching programs feature the following:
- An employer that invests in incentives for patients and providers to improve health and lower costs
- Receptiveness of healthcare providers who support community-based collaborative care
- Employers who are more involved in program implementation and have an open culture with their employees
- A local network of pharmacists with the motivation, training, and time to help patients manage their care
- Health plans willing to provide claims data for analysis
“This whole area, I think, is emerging from pharmacy networks that are based on drug distribution to the emergence of pharmacy networks that will be based on patient care,” says Ellis.
Pharmacist coaches plus value-based design
The DTCC program included the following:
- Employer-funded, collaborative health management programs using community-based pharmacist coaches
- Evidence-based diabetes care guidelines
- Self-management strategies designed to keep patients with diabetes healthy and productive
- A value-based insurance design that lowered or eliminated copays for diabetes medications and services
DTCC was offered in community independent pharmacies, community chain pharmacies, ambulatory care clinics, and on-site workplace locations. The sites provided:
- Private areas for patient consultation
- Management support so pharmacists were free to take part in patient care activities
- Internet access for recording and tracking patient care
- Participation in a local and/or regional pharmacist service delivery network that contracted directly with the participating employer
The employers that took part were self-insured, so they were at risk for both medical and prescription costs for their employees and beneficiaries. The employers/health plans created incentives for patients and pharmacists, including waived copays for medications and certain supplies, and pharmacists were paid for their services.
During regularly scheduled appointments, pharmacists “applied a prescribed process of care that focuses on clinical assessments and progress toward clinical goals and work with each patient to establish self-management goals. In addition, they worked with other healthcare providers and could recommend adjustments in the patients’ treatment plans when appropriate,” according to the study.
These private visits allowed patients to ask questions, and the pharmacists were able to identify problems and teach self-management skills.
The APhA Foundation focused on diabetes because of the number of Americans with the disease and diabetes’ influence on other health problems. According to the American Diabetes Association, nearly 18 million Americans have been diagnosed with diabetes, and another 5.7 million people are unaware they have the disease.
Diabetes is more than a health concern; it affects the nation’s economy. In 2007, the direct cost of diabetes was $174 billion, which is about $1 for every $5 spent on healthcare, according to the DTCC final study.
The disease also affects productivity. Diabetes accounted for 120 million lost workdays and reduced productivity by $58 billion in 2007, according to the study.
Northwest Georgia Healthcare Partnership
The Northwest Georgia Healthcare Partnership (NGHP), based in Dalton, led one of the 10 DTCC sites. The nonprofit includes healthcare providers, business, industry, payers, government, and educators, who look to improve the health of residents in Whitfield and Murray counties.
Nancy Kennedy, executive director of NGHP, says the organization recognizes gaps in healthcare, offers solutions, attains funding to test possible solutions, and then evaluates those programs’ return on investment and their effects on the community.
NGHP recruited four local employers to participate: Hamilton Health Care System, Dalton Utilities, city of Dalton, and Whitfield County. The Georgia Pharmacists Association coordinated the Northwest Georgia program, which featured 11 independent and community pharmacists.
Kennedy says an important part of the DTCC is that pharmacists are not replacing doctors or diabetes educators. Instead, they are there to help patients between doctors’ appointments and update the physicians about their patients’ health.
Similar to many parts of the nation, Northwest Georgia is facing a primary care physician shortage. Through visits with patients, the pharmacists are able to provide face-to-face case management.
In effect, pharmacists go from dispensing prescriptions to being educators. Patients feel a close bond with pharmacists and aren’t afraid to ask them medical questions, says Kennedy. Having that friendly relationship also allows for more honest communication.
“That accountability, face-to-face accountability, with someone in your community that you know, that you see on a regular basis, to me is what makes this program so phenomenal and strong,” says Kennedy.
One of the businesses that participated in Northwest Georgia, Hamilton Health Care System, contracted with the Georgia Pharmacists Association to provide the pharmacist coaches, who met with employees in conference rooms.
The health system project was not merely a freebie for diabetics. The patients had to follow their prescription regimen, exercise regularly, and maintain a proper diet to remain in the program.
Both employees and employers “have skin in the game, so to speak,” says Jason Hopkins, HR director at Hamilton Health Care System. “That helps both the investment we put forth to these individuals, but also, in theory, motivates them to comply.”
Although Hamilton did not achieve great financial savings and probably broke even in the DTCC, Hopkins says, the health system should realize preventive savings through diabetics taking better care of themselves.
Faced with rising health costs, many businesses are reactive. They pass rising costs onto employees by increasing copays and deductibles. That works to a certain extent, but employers must draw the line, Hopkins says.
“What this tells the healthcare community is that one, you can incentivize your associates to take better care of themselves—that’s what the healthcare providers want to see. But from the industry standpoint, I think this proves to them that they don’t have to push off more cost onto their employees. They can actually pay more but ultimately in the long run see better financial outcomes because [employees] are taking better care of themselves,” he says.
What is next for concept and DTCC?
Although DTCC showed positive results, most pharmacies could not offer the same level of services at this point. To have more pharmacist coaches, Ellis says the following should happen:
- Pharmacies will need to redesign their areas to create private consultation rooms
- Widespread implementation of electronic health records, which could lead to better data exchange
- Employers should understand pharmacy coaching programs bring long-term savings and not view them solely as an expense
- Payers will have to change the way they reimburse pharmacists to include payment for providing coaching services
Ellis says pharmacists add value to the healthcare system by providing evidence-based treatments that can improve patients’ health. Better health means lower employer costs and increased productivity.
“We’re at a point now in healthcare that a lot of people are looking at the healthcare system in total and looking at how can we revitalize it, how can we change it, how can we improve it. This is an example of the promising practices that could lead to a reformed healthcare system in this country,” says Ellis.
The APhA Foundation is now looking to expand the tenets of the DTCC to other disease states, including hypertension, low back pain, asthma, and chronic obstructive pulmonary disorder.
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