The Asheville Project Now: Employers Nationwide Adopt Cost-saving Health Care Model

When the City of Asheville launched theAsheville Project back in 1997, those behind itaimed to achieve some ambitious goals.Through proactive, preventive health care,they strove to make people healthier, thereby decreasinghealth care costs for their employers and boosting productivityat the same time.

?There has been a lot of research done over the years onimproving people?s blood pressure and blood sugar control,and pharmaceutical manufacturers have done lots ofresearch proving that their drugs work,? notes Barry A.Bunting, PharmD, clinical manager of pharmacy andAsheville Project coordinator at the Diabetes and HealthEducation Center at Mission Hospitals in Asheville, NC.?However, very few had taken the next step, asking thequestion: what happened to health care costs??

To address this, Asheville Project organizers found inthe City of Asheville a self-insured employer who was willingto waive its employees? copays in exchange for theirwillingness to attend educational seminars on their condition,as well as regular counseling sessions with their pharmacist.As their health coach, the pharmacist would monitortheir progress, ensuring that the patients were adheringto the instructions they had received on the administrationof their medications, while noting any problemsthe patients were experiencing. Patients were also coachedon diet and exercise?-2 key factors in managing health.

• Employee absenteeism has reduced by 50%
• Fewer workers? compensation claims are beingprocessed
• Employees are saving an average of $400 to $600 peryear thanks to incentives such as waived copays

A Simple Model, Replicated Nationwide

?The model is really simple,? Dr. Bunting declares. ?Peoplemeet with a pharmacist in an appointment-based counselingsession. When that happens, they do better: they geton the best medication, they take their medication, andthat frequent contact not only improves the clinical outcomes,it helps to control health care costs.?

Diabetes seemed like a prime candidate for this proactiveapproach to health management, and in the beginningthat 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 haveimplemented the Asheville model. ?We have never madea cold call on anyone,? relays Daniel Garrett, RPh, MS,FASHP, senior director of medication adherence programsat the American Pharmacists Association Foundation inWashington, DC. ?Every new site has joined the programbecause they were interested and wanted to learn more.?Today, diabetes, asthma, hypertension, high cholesterol,and, most recently, depression have been incorporatedinto the model. In Asheville alone, an estimated 1400patients are following the program, and thousands of othersare following similar models across the country.

For their coaching sessions, patients?-depending ontheir condition?-are required to supply information theygather at home between their visits, for example, bloodpressure and sugar levels.The Patient-Coach Connection

?What this program really does is promote patientadherence to taking their medicine and to the behaviorsthat are needed for any of the chronic conditions that theAsheville model is now being used for,? Garrett explains.?In the end, it?s patients who take care of themselves 24hours a day, 7 days a week. In the end, it?s patients whoremember to take their medicine, exercise, eat right, andmanage stress in their life.? The patient is at the center ofthe program, and as health coach, the pharmacist?s role isto direct patients toward making the right choices to manageand improve their health.

For most patients first enrolling in the program, theprimary incentive is the decrease in out-of-pocket healthcare costs. ?That is generally what entices people toenroll,? Dr. Bunting says. ?From there, they start getting greatinformation that helps them improve their health. Theyget coaching, and they get a caring relationship.? Manyparticipants acknowledge that while they enjoy the costsavings, their coaching relationship has become a vital partof their lives.

Garrett concedes that the Asheville model requirespharmacists to step away a bit from the conventionalapproach to pharmacy. ?It?s a different model than whatpharmacists are used to,? he says. ?It certainly doesn?tinvolve counting by 5?s really fast and processing insuranceclaims. 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-engineertheir workflow, using technicians in the automationand dispensing process. ?The biggest thing they have to dois change their mindset as to their role as a clinician asopposed to someone who is in a dispensing role,? Garrettsays.

In this new role, pharmacists must delegate administrativetasks to someone else in their organization in order tomaintain efficiencies. ?The biggest mistake that I haveseen pharmacists make is spending too much of their personaltime on things that somebody else could be doing,such as scheduling,? Dr. Bunting notes. ?If the pharmacist hasto spend hours a month on the phone or emailing theirpatients 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.

The Diabetes Ten City Challenge

Modeled after the Asheville Project and ProjectImPACT: Hyperlipidemia (the American PharmacistsAssociation [APhA]?s cholesterol management programthat took place between 1996 and 1999), the APhA?sDiabetes Ten City Challenge is designed to fight diabetesand reduce health care costs through its patient self-managementprogram. In 2006, the APhA Foundationapproached employers in 10 cities across the United Statesto participate in the program, provided they met certaincriteria. Participating employers were required to launchthe program in 2006, providing they had self-insuredhealth plans with a minimum of 5000 employees and/orbeneficiaries; provided incentives, such as waived copaysfor diabetes medication and testing equipment; appointedan in-house coordinator to administer the program; anddemonstrated a willingness to speak out about the programwithin their communities. Participating sites are:

City of Colorado Springs

City of Milwaukee, Wis

Hawaii Business Health Council, Honolulu

Midwest Business Group on Health, Chicago, Ill

Northwest Georgia Healthcare Partnership

Pittsburgh Business Group on Health, Pa

Tampa Bay Area, Fla

Charleston/Spartanburg, SC, area

University of Southern California

Western Maryland Health System, Cumberland, Md

Flexible to Meet Service Needs

The beauty of the Asheville model is that it can beadapted to suit the specific needs of a community dependingon its resources. At some sites, the pharmacists? networkis set up through the state pharmacy association; inothers, it is made up of a private network of pharmacists.At one site, the pharmacists? network is handled through apharmacy benefits manager. Although the model originallyhad patients visiting their pharmacist health coaches atthe store, an increasing number of employers are invitingpharmacists to conduct their monitoring sessions onsite,at the workplace.

Thorough documentation is crucial to the success ofthe Asheville model, Garrett underscores. ?Our goal whenwe started this back in 1997 was to turn this from anacademic exercise into a business enterprise,?he says. In order for this to happen,pharmacists must supply the datathat demonstrate the value of the program.?We?re not trying to sell this to abunch of academics; we are dealingwith Fortune 500 companies and city,county, and state governments. Whatreally sells the program is the patientcare and how patients respond. Inorder to justify the continued supportfor waiving the copays and paying thepharmacists, you have to have the harddata.? So far, the Asheville model isdemonstrating significant value, notonly in diabetes management, but inother areas, as the program has expandedto include more chronic conditions.

A recent study of a community-basedmedication therapy managementprogram for asthma at 12 pharmacylocations in Asheville, reportedin the Journal of the American PharmacistsAssociation, concluded thatboth objective and subjective measuresof asthma control improved (Figure 1)and resulted in both direct and indirectcost savings (Figure 2): ?Patientswith asthma who received educationand long-term medication therapymanagement services achieved andmaintained significant improvementsand had significantly decreased overallasthma-related costs despite increasedmedication costs that resulted fromincreased use.?¹

?What?s in it for the employer is ahealthier, more productive employeeand 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 inyour health.

?In the old health care system, we assumed that peoplewould go to the doctor, the doctor would write a prescription,and then patients would get the prescription filledand comply with whatever the doctor told them to do,?Garrett explains. ?What we are learning is that if you wantto have true change in health care, it needs to be supportedby the system. The patient is at the center of the systemand not the provider.?

Bunting observes that the Ashevillemodel is growing bigger than pharmacy.Health care educators receive the opportunityto expand their educational reachand to be compensated in exchange.With this extra support, physicians areassisted in achieving the care goals theyhave set out for their patients. ?Theystill want to be in charge of their care,and this doesn?t usurp that in any way,?Dr. Bunting explains. ?They get more informationthat allows them to make moreinformed decisions, and their patientreceives more education that the physicianwouldn?t have the time to do.?Under the Asheville model, the treatmentplan is enforced because patientsadhere much better to what their doctoris asking of them.

Dr. Bunting emphasizes that the Ashevillemodel illustrates that preventive carecan work, and when it does, health carecosts can be controlled and, in somecases, reduced. ?The whole countryneeds to shift its focus from fixing peoplewhen they break to keeping themfrom breaking,? he says. In its currentstate, the primary care system placesthe majority of the burden on the doctors,who, he says, are overwhelmed.?There are a lot of barriers: cost ofmedications, time that they are able tospend with patients, and so on.?

In this way, the Asheville modelassists in preventing these health conditionsfrom getting out of hand, immobilizingthe patient, and racking upcosts. ?In the United States, we do nothave a health care system; we have a sickcare system,? Garrett says. ?What the Asheville model does,and what the people who have chosen to replicate it havedone, is say, ?We are going to do something different.??

For more information, contact American Pharmacists AssociationFoundation: www.aphafoundation.org or Mission Hospitals: www.missionhospitals.org

Patients Take on Proactive Roles

Regina Humphries, Patient ServiceSupervisor, Mission Hospitals

Carolyn Heinze

In her role as patient service supervisor with MissionHospitals, Regina Humphries counsels patients sufferingfrom a number of conditions. When Humphries herselfwas first diagnosed with asthma, high blood pressure, highcholesterol, and diabetes, however, she had a difficult timeaccepting it.

?I was very much in denial,? Humphries admits. As apatient in Mission Hospitals? wellness program, shereceived the coaching she required to deal with her condition.?My case manager would call, even when I didn?t haveto see her to say, ?How are you doing? When you left theoffice a couple of days ago, you weren?t at a point where Iwas satisfied with you.? She would talk with me, for howeverlong 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 werehappening to her. ?She would tell, without breaking anyconfidentiality, stories of other patients who were goingthrough the same thing, so that I didn?t feel like I was bymyself,? she says. ?She was very encouraging. I could callher any time, and she was quick in calling me back. Andshe didn?t seem to get frustrated when I would complain ifa medication was making my stomach upset or causing menot to feel well.?

Humphries touts the feeling of community that thewellness program offers, transforming patients from beingvictims to proactive participants in the management oftheir health. ?You feel valued,? she says. ?When you gointo this mentoring program with whomever?a pharmacist,or whomever is your coach?this is one of the placeswhere everything is laid out on the table. They make youfeel like you have this disease, you are not of this disease.?