Agenda. Expanding Access to Care for Women and Exploring Health Delivery Models. Cheryl Pegus, MD, MPH Chief Medical Officer.

Transcription

1 Expanding Access to Care for Women and Exploring Health Delivery Models Cheryl Pegus, MD, MPH Chief Medical Officer November 2011 Agenda Background Areas to Focus On New Models/New Tools Walgreens 2 1

2 Demographics for Women Women outnumber men by nearly five million in the U.S. (156.8M vs M) 1 Nearly twice as many women as men are 85 and older 1 66% white; 15% Latina; 13% African-American 2 Age and Sex Composition: 2010; 2010 Census Briefs 03.pdf Accessed 11/18/2011 U.S. Census Bureau, Population Estimates nat detail.html. Accessed 11/18/ Health Insurance Coverage for Women Ages (2009): Employer-Sponsored insurance covers 59% of women Medicaid covers 12% Individually purchased insurance is used by 6% of women Medicare and other government health insurance cover only 3% of women under 65 20% are uninsured 1 Women s Health Insurance Coverage. The Kaiser Family Foundation. December

3 Women and Healthcare 5 Women and Healthcare Women are 2x as likely as men to die within the first few weeks after suffering a heart attack Since 1984, more women than men have died each year from heart disease Women who develop gestational diabetes during pregnancy may have a 50% chance of developing type 2 diabetes 61% of adults with arthritis are women (28.3 million) Women are more likely than men to experience delays in emergency care for cardiac symptoms 6 3

4 Top 10 High Cost Diseases for Women 1. Heart disease ($316 billion) 2. Cancer ($124 billion) 3. Diabetes ($116 billion) 4. Back problems ($100 billion) 5. Hypertension ($76.6 billion) 6. Mental disorders ($57.5 billion) 7. COPD and asthma ($49.9 billion) 8. Trauma ($27 billion) 9. Hyperlipidemia (over $26 billion) 10. Osteoarthritis (over $11 billion) 7 Women and Healthcare Utilization In 2010, annual insurance premiums averaged $5,049 for individuals and $13,770 for families Maternity care and delivery were the two most expensive conditions billed to private insurance in 2008, totaling $50.2B 1 Out-of-Pocket Expenses: Americans Shoulder the Burden of Growing Health Care Costs. Health Care Reform.gov 2 United States Maternity Care Facts and Figures. April (NHANES [ ], NCHS and NHLBI) 8 4

5 Out-of Pocket Healthcare Costs Greater for Women 9 Several Risks Drive Health Status and Costs in Women Self: Increasing age Heredity Smoking High cholesterol High triglycerides High blood pressure Overweight and obesity Physical Inactivity Stress Environment 10 5

6 Access The number of U.S. medical school students going into primary care has dropped 51.8% since 1997, according to the American Academy of Family Physicians (AAFP). 78 million baby boomers born from 1946 to 1964 turned 65 in 2011, and will require increasing medical care By 2020: 45,000 fewer primary care physicians and 46,000 fewer surgeons and medical specialists than we need Under the Patient Protection and Affordable Care Act (ACA), 16 million low-income individuals will gain Medicaid coverage by 2019, creating new demands for health care services 1 Lloyd, Janice. Doctor Shortage Looms As Primary Care Loses its Pull. Updated 8/18/2009. Accessed November 15, Access to Affordable Care Services Shortage of Primary Care Physicians Population to provider ratio calculated for each census tract Ratio of more than 3,500:1 = HPSA designation 12 6

7 Poor Access to Healthy Foods: Food Deserts Many areas lack easy access to healthy foods: fruits, vegetables, whole grains and low-fat milk. Limited access can lead to poor diets, higher levels of obesity and other diet-related diseases Source: 13 Obesity Among women age 20 and older, the following are overweight or obese (BMI of 25.0 kg/m2 and higher): 59.3 percent of non-hispanic whites 70.8 percent of non-hispanic blacks 75.1 percent of Mexican Americans Obese (BMI of 30.0 kg/m2 and higher): 32.8 percent of non-hispanic whites 51.0 percent of non-hispanic blacks 43.4 percent of Mexican Americans 1 (NHANES [ ], NCHS and NHLBI.) 14 7

8 Impact of Obesity on Women s Health More than 80% of people with type 2 diabetes are obese or overweight (BMI of 27 or greater) Obesity and physical inactivity may account for 25-30% of several major cancers colon, breast ( postmenopausal), endometrial, kidney and cancer of the esophagus 32% higher risk of developing heart disease if overweight and 81% higher risk if obese (BMI-CHD Collaboration Investigators) 87% of spine care professionals agree that obesity plays one of the most significant roles in back pain Obesity during pregnancy increases the risk of gestational diabetes; pre-eclampsia; sleep apnea; thromboembolic events Care for Women New Models/New Tools Policies E-tools Access in your community Healthy choices for diets Proven Outcomes 16 8

9 Preventive Services under the ACA 1 Diet Counseling Immunizations: Vaccines for Adults Obesity Screening and counseling Tobacco use screening and cessation interventions Depression screening Type 2 diabetes screening if hypertensive Breast and Cervical cancer screening Osteoporosis screening Colorectal cancer screening for over 50 Annual well-women visits Review of medical history Review of current medications Biometric screening (BP, BMI, Height, Weight) Lab screenings based on medical history and visit information Testing for STIs Breast feeding support and counseling 1 Preventive Services Covered by Private Health Plans under the Affordable Care Act. The Kaiser Family Foundation. September Value of Prevention An investment of $10 per person per year in proven communitybased programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within five years. For every $1 spent on preconception care programs for women with diabetes, health costs can be reduced by up to $5.19 by preventing costly complications in both mothers and babies. 2 For every $1 spent on Pap tests for low-income elderly women, $5.90 is saved on medical care costs. 1 Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings Stronger Communities February Accessed November 20, Diabetes Prevention and Control; Accessed November Contraceptive Needs and Services: National and State Data Update 2008 The Guttmacher Institute May Accessed November 20,

10 mhealth Point of care tools can reduce risk and errors Remote monitoring and self-assessment can reduce office visits Healthcare market is making significant investments in mhealth Experts predict that by reducing emergency care, hospitalizations and nursing home care, this technology could have savings of $21 billion per year Ref: Accenture Mobile Healthcare Report, New Models for Care Convenient care (retail) clinics offer a new model for ambulatory care Significant growth since introduction in 2000 Services provided by Nurse Practitioner (NP) or Physician Assistant (PA) Emphasize convenience with high-quality care and lower costs Health Care on Aisle 7; The Growing Phenomenon of Retail Clinics by Ateev Mehrotra, John L. Adams, Katrina Armstrong, et al, Rand Corporation

11 Role of the Nurse Practitioner According to the American College of Nurse Practitioners, a Nurse Practitioner is nurse who has completed a Master s Degree Program and is specially trained to: Complete Health histories Perform physical examinations Diagnose and treat many common acute and chronic problems Interpret laboratory results and X-rays Prescribe and manage medications and other therapies Provide health teaching and supportive counseling with an emphasis on prevention of illness and health maintenance Refer patients to other health professionals as needed. 21 New Models of Care: Appropriate, Cost-effective Care Condition (N) Percent of Percent of Percent of urgent Convenient Care emergency care center visits Clinic visits department visits Percent of emergency department visits not requiring emergency department care Any time of day When alternative site is typically open N 1,100,000 1,235 31,197 Upper respiratory infections 60.6% 33.3% 9.8% Rhinosinusitis, laryngitis 26.1% 18.7% 5.0% 81.1% 48.4% Pharyngitis 22.2% 8.1% 2.3% 93.9% 56.7% Ear infections 12.3% 6.5% 2.5% 95.7% 53.0% Preventive care 21.6% 0.0% 3.8% Dermatological conditions 0.7% 9.7% 7.8% Cellulitis or abscess 0.6% 5.1% 2.5% 66.7% 45.7% Burns 0.1% 0.6% 0.4% Lacerations 0.0% 4.0% 4.8% 50.0% 31.8% Musculoskeletal conditions 0.1% 21.5% 19.4% Strain and fractures 0.0% 14.5% 8.9% 50.0% 34.0% Back pain 0.0% 0.5% 2.8% Joint and muscle problems 0.0% 3.0% 2.7% 87.5% 58.3% Contusions 0.0% 3.6% 5.0% 50.0% 33.4% Total of listed conditions by site 83.0% 64.5% 40.8% Excerpted from: Weinick RM, Burns RM, Mohratra A. Many Emergency Department Visits Could be Managed at Urgent Care Centers and Convenient Care Clinics. Health Affairs. 29 No. 9 (2010)

12 New Models of Care: Convenient Care Clinics Offer an Alternative to the ED % of all ED visits could take place at alternative sites. Potential $4.4 billion in annual cost savings. 23 Convenient Care Clinic Visits are Often Covered by Health Insurance Saperstein Associates, Inc. The Retail Clinic Patient Study. Commissioned by Boehringer Ingelheim Pharmaceuticals, Inc

13 Payers Play an Important Role in Educating Consumers on When to Use ER, Urgent Care or Convenient Care Clinics 1 (1) 25 Employers Increasingly Appreciate Convenient Care Clinic Solutions Healthcare Trends in America; A Reference Guide from BCBSA, 2010 Edition 26 13

14 Individuals Increasingly Willing To Consider Using Convenient Care Clinics or Pharmacies 27 Pharmacist Interventions Improve HEDIS and Quality Scores Clinical outcome Asheville Project Diabetes Program 1 Ten City Challenge Diabetes Program 2 PharmacistCare Diabetes Program 3 Before After %change Before* After %change Before After %change HbA1c (%) % % % % of patients with optimal HbA1c 41.8% 60.0% +43.5% 70.3%* 91.2% +29.7% 78.0% 94.0% 20.5% LDL mg/dl % % % % of patients with optimal LDL-C 37.2% 58.1% +56.2% 43.8%* 57.7% +31.7% 38.0% 49.0% 28.9% HDL mg/dl % Note: The definition for optimal clinical results can vary from study to study. * The asterisked comparisons are with HEDIS benchmark statistics, not Ten City data. 1. Cranor et al (2003): "The Asheville Project: Long-Term Clinical and Economic Outcomes of a Community Pharmacy Diabetes Care Program 2. Fera et al (2008): The Diabetes Ten City Challenge: interim clinical and humanistic outcomes of a multisite community pharmacy diabetes care program 3. Garrett et al (2005): "Patient Self-Management Program for Diabetes: First-Year Clinical, Humanistic, and Economic Outcomes 28 14

15 The Role of the Community Pharmacist Pharmacists are well positioned to offer the community and the healthcare system a range of services beyond simple dispensing and medication counseling. Pharmacists are now engaged in: Medication adherence Drug safety monitoring and identification of drugdrug interactions Education, patient counseling and chronic care management Participation in multidisciplinary clinical care teams Medication Therapy Management (MTM) and drug utilization review Formulary management Immunizations Biometric screenings and wellness education Diabetes education; HIV COEs 29 What is Walgreens Doing? 30 15

16 Food Oasis Initiative July 20, 2011: Walgreens announces at the White House that it is committing to convert or open at least 1,000 food oasis stores nationwide over the next 5 years. Food Oasis stores provides a wide selection of fresh foods in markets that are food deserts - often low-income areas with depressed businesses, including limited grocery options. More than 45% of our stores are located in areas that don t have access to fresh food Current Food Oasis stores in Chicago, Indianapolis and San Francisco Source: Rafael Malipica 31 Walgreens: 350+ Convenient Care Retail Clinics Take Care Clinics SM Open 7 days a week, weeknights until 7:30 pm, weekends until 5:00 pm No appointment necessary Conditions Treated Respiratory Illness Minor Injuries Vaccinations Physicals Screenings Top Reasons or Utilization Upper Respiratory Infections Sinus Infection Sore/Strep Throat Ear Infections Bladder Infections Patient services at Take Care Clinics SM are provided by an independently owned professional corporation 32 16

17 Walgreens 8,500 Points of Care Retail Existing Retail Approved Take Care Clinics Take Care Worksites Hospital On Sites Specialty Home Infusion/RT Mail 33 Access via Multi-Channel Network Close Wherever You Are locations Best corners in America 63% of consumers live within 3 miles Serves nearly half of the 43% of US population in medically underserved areas 34 Pick Up in an Hour Scheduled prescription pickup 50+% traffic growth in 2 years On the Go iphone, Android and Blackberry Pharmacy and retail purchasing Text message to refill with alert when Rx is ready When You Need Us Take Care Health Systems 370+ On-site Health & Wellness Centers At Employer Locations, 350+ Take Care Health Clinics Located At Select Pharmacies 7 days a week and weeknights 17

18 You can t manage what you didn t measure 35 Pharmacist Wellness Programs: Clinical Outcomes In a recent study, Walgreens pharmacists successfully identified at-risk patients receiving flu immunizations, and increased immunization rates for pneumococcal disease by 68% Average cost associated with a hospitalization due to complications of flu is $15,000 per patient, age 65 years and older, and up to $50,000 for at-risk adults ages Taitel M, Cohen, E, Duncan, I, Pegus, C. Pharmacists as providers: Targeting pneumococcal vaccinations to high risk populations. Vaccine (2011), doi: /j.vaccine

19 Walgreens Peer-Reviewed Outcomes Addressing Immunization in Medically Underserved Communities Access to preventative health: The impact of a community pharmacy on influenza immunizations Medically underserved areas (MUAs) during the influenza season. Over 43% of the U.S. population resides in a MUA. Nationwide, over one-third of Walgreens flu immunizations were administered in pharmacies located in MUAs. In states with the largest MUAs, Walgreens provided up to 77.1% of its flu shots in these areas. Murphy, PA, Frazee, SG, Cantlin, JP, Cohen, EC, Rosan, JR, and Harshburger, DE Access to preventative health: The impact of a community pharmacy on influenza immunizations. Accepted for Publication in Journal of American Pharmacists Association, Walgreens Pharmacist-led Diabetes Education Program at the Worksite Program Goals Achieve and maintain HbA1c 7.0% Enhance patient adherence and self-care Program Design Initial one hour consultation with pharmacist Monthly 1:1 follow-up consultations Incentives for participation i Outcomes included: 330 patients contacted/185 enrolled 91% remained actively engaged HbA1c values decreased from 7.72% to 7.05% HDL value increased from mg/dl to mg/dl 58% of patients achieved goal 7.0% for HbA1c versus 48% at inception 100% patient satisfaction rate Frazee SG, Raulerson W, Schwab H, Broome R, Davis J, Patwardhan A, Murphy P. Improving Health Outcomes and Reducing Cost in Chronic Disease Management: Impact of a Pharmacist Led Diabetes Education Program at a Workplace Pharmacy. Health & Productivity Management November 2010 Vol 8, No 1-2, pg

20 Reducing Hospital Admissions: Stage D Heart Failure Patients Participating in a Home Inotropic Infusion Program The intervention effect was a significant reduction in admission rates by per patient per year (t = , p =.001). For the 236 patients participating in the program, the admission savings was $17,187 per patient and for the whole group sums to almost $4.1 million. Taitel, M., Meaux, N. Hospital admission reductions among Stage D heart failure patients participating in a home inotropic infusion program. Heart Lung. 2011;40(4): Convenient Care Clinics Improve HEDIS Scores 1 1 Retail Clinician, September 2010 Δ = 18.02% Δ = 4.85% 40 20

21 Newer Models: Walgreens Collaboration with Northwestern Memorial Physicians Group on Coordinated Healthcare Program Construct: Collaborative, coordinated care model designed to improve patient outcomes and enhance physician decision-making. Focus on 4 chronic disease states- Hyperlipidemia, Hypertension, Diabetes, Asthma. Walgreens and Northwestern Memorial employees with NMPG as their primary care provider. Patient interventions: NMPG physicians designed an intervention plan for each disease state. Pharmacist interventions include a series of questions designed to maximize adherence and educate patients on their disease. Results of all counseling interventions shared electronically with patient s physician. Provides physicians greater insight into patient behaviors and facilitates focused physician-patient interactions. Outcomes Study: Study compliant with IRB requirements. Outcomes analysis will address clinical outcomes and patient satisfaction Walgreens Press Release June 13, Women s Health Today Expanding Access Utilizing and Exploring New Delivery Models Proven Outcomes 42 21