pegus ncsl ff11.ppt

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Expanding Access to Care for Women and Exploring Health Delivery Models

Cheryl Pegus, MD, MPHChief Medical Officer

November 2011

Agenda

• Background

• Areas to Focus On

• New Models/New ToolsWalgreens

©2011 Walgreen Co. All rights reserved.2

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Demographics for Women

Women outnumber men by nearly five million in the U S (156 8M vs 151 9M)1five million in the U.S. (156.8M vs. 151.9M)

• Nearly twice as many women as men are 85 and older1

• 66% white; 15% Latina; 13% African-American2

Age and Sex Composition: 2010; 2010 Census Briefshttp://www.census.gov/prod/cen2010/briefs/c2010br‐03.pdf Accessed 11/18/2011

U.S. Census Bureau, Population Estimateshttp://www.census.gov/popest/national/asrh/2008‐nat‐detail.html. Accessed 11/18/2011


Health Insurance Coverage for Women

• Ages 18-64 (2009):Employer-Sponsored insurance covers 59% of womencovers 59% of women

Medicaid covers 12%

Individually purchased insurance is used by 6% of women

Medicare and other government % fhealth insurance cover only 3% of

women under 65

20% are uninsured


1Women’s Health Insurance Coverage. The Kaiser Family Foundation. December 2010http://www.kff.org/womenshealth/upload/6000-09.pdf

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Women and Healthcare


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)• 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


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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)


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

1Out-of-Pocket Expenses: Americans Shoulder the Burden of Growing Health Care Costs. Health Care Reform.gov http://www.healthreform.gov/reports/out_of_pocket/index.html2United States Maternity Care Facts and Figures. April 2011. http://transform.childbirthconnection.org/resources/datacenter/factsandfigures/

3(NHANES [2005-2008], NCHS and NHLBI)


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Out-of Pocket Healthcare Costs Greater for Women


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


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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)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 needsurgeons 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

1Lloyd, Janice. Doctor Shortage Looms As Primary Care Loses its Pull. http://www.usatoday.com/news/health/2009-08-17-doctor-gp-shortage_N.htm. Updated 8/18/2009. Accessed November 15, 2011


Access to Affordable Care ServicesShortage of Primary Care Physicians

Population to provider ratio calculated for each census tractRatio of more than 3,500:1 = HPSA designation


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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 diseasesother diet-related diseases

Source: http://www.ers.usda.gov/data/fooddesert/fooddesert.html


Obesity

• Among women age 20 and older, the following are overweight or obese g g(BMI of 25.0 kg/m2 and higher):

59.3 percent of non-Hispanic whites70.8 percent of non-Hispanic blacks 75.1 percent of Mexican Americans

• Obese (BMI of 30.0 kg/m2 and higher): g )

32.8 percent of non-Hispanic whites51.0 percent of non-Hispanic blacks43.4 percent of Mexican Americans

1 (NHANES [2005-2008], NCHS and NHLBI.)


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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)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


2012 Care for WomenNew Models/New Tools

• Policies

• E-tools

• Access in your community

• Healthy choices for diets

• Proven Outcomes


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Preventive Services under the ACA1

• Diet Counseling• Immunizations: Vaccines for Adults• Obesity Screening and counselingObes ty Sc ee g a d cou se g• 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 historyReview of current medicationsReview of current medicationsBiometric screening (BP, BMI, Height, Weight)Lab screenings based on medical history and visit information

• Testing for STIs • Breast feeding support and counseling


1Preventive Services Covered by Private Health Plans under the Affordable Care Act. The Kaiser Family Foundation. September 2011http://www.kff.org/healthreform/upload/8219.pdf

Value of Prevention

• An investment of $10 per person per year in proven community-based programs to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country moreprevent 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, y p p y ,$5.90 is saved on medical care costs.


1 Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings Stronger Communities February 2009 www.healthyamericans.org Accessed November 20, 20112 Diabetes Prevention and Control; www.diabetesatwork.org Accessed November 21 20113 Contraceptive Needs and Services: National and State Data Update 2008 The Guttmacher Institute May 2011 www.guttmacher.org, Accessed November 20, 2011

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mHealth

• Point of care tools can reduce risk and errors

• Remote monitoring and self assessment can reduce office visits• 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, 2010


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 2010.


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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: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

therapiestherapies• Provide health teaching and supportive

counseling with an emphasis on prevention of illness and health maintenance

• Refer patients to other health professionals as needed.


New Models of Care: Appropriate, Cost-effective Care

Percent of emergency department visits not requiring emergency

department care

When

Condition (N) Percent of

Convenient Care Clinic visits

Percent of urgent care center visits

Percent of emergency

department visits

Any time of day

When alternative site

is typically open

N 1,100,000 1,235 31,197Upper 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%

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) 1630-1636

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%


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New Models of Care: Convenient Care Clinics Offer an Alternative to the ED

• 13.7-27.1% of all ED visits could take place at alternative sites.

• Potential $4.4 billion in annual costin annual cost savings.


Convenient Care Clinic Visits are Often Covered by Health Insurance

Saperstein Associates, Inc. The Retail Clinic Patient Study. Commissioned by Boehringer Ingelheim Pharmaceuticals, Inc. 2009.


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Payers Play an Important Role in Educating Consumers on When to Use ER, Urgent Care or Convenient Care Clinics1

(1)


Employers Increasingly AppreciateConvenient Care Clinic Solutions

Healthcare Trends in America; A Reference Guide from BCBSA, 2010 Edition


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Individuals Increasingly Willing To Consider Using Convenient Care Clinics or Pharmacies


Pharmacist Interventions Improve HEDIS and Quality Scores

Clinical outcome Asheville ProjectDiabetes Program1

Ten City ChallengeDiabetes Program2

PharmacistCareDiabetes Program3g g g

Before After %change Before* After %change Before After %changeHbA1c (%) 7.7 6.9 -9.0% 7.6 7.2 -5.3% 7.9 7.1 -10.1%

% 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 109.0 99.7 -8.5% 96.3 93.3 -3.1% 113.4 104.5 -7.8%% 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 46.0 47.9 4.1%

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”

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.


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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 drug-

drug interactions• Education, patient counseling and chronic care

management• Participation in multidisciplinary clinical care teams• Medication Therapy Management (MTM) and drug py g ( ) g

utilization review• Formulary management• Immunizations• Biometric screenings and wellness education• Diabetes education; HIV COEs


What is Walgreens Doing?

30 ©2011 Walgreen Co. All rights reserved.

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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 yearsnationwide 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 freshin areas that don t have access to fresh food

• Current Food Oasis stores in Chicago, Indianapolis and San Francisco

Source: Rafael Malipica


Walgreens: 350+ Convenient Care Retail Clinics

Take Care ClinicsSM

• Open 7 days a week, weeknights until 7:30 pm, weekends until 5:00 pm

No appointment necessary• No appointment necessary

• Conditions TreatedRespiratory IllnessMinor InjuriesVaccinationsPhysicalsScreenings

• Top Reasons or Utilization• Top Reasons or UtilizationUpper Respiratory InfectionsSinus InfectionSore/Strep ThroatEar InfectionsBladder Infections

Patient services at Take Care ClinicsSM are provided by an independently owned professional corporation


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Walgreens 8,500 Points of Care

Retail ‐ Existing

Retail ‐ Approved

Home Infusion/RT

SpecialtyTake Care Clinics

Take Care Worksites

Hospital On‐Sites Mail


Access via Multi-Channel Network

Pick Up in an Hour

Scheduled prescription

i k

Close Wherever You Are

7500+ locationsBest corners in

On the Go

iPhone , Android and Blackberry

When You Need Us

Take Care Health Systems 370+ On-site

H lth & W llpickup50+% traffic growth

in 2 years

America63% of consumers live

within 3 milesServes nearly half of

the 43% of US population in

medically underserved areas

Pharmacy and retail purchasing

Text message to refill with alert when Rx

is ready

Health & Wellness Centers At Employer

Locations,350+ Take Care Health Clinics Located At Select

Pharmacies7 days a week and

weeknights©2011 Walgreen Co. All rights reserved.34

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“You can’t manage what you didn’t measure”


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 p ppatient, age 65 years and older, and up to $50,000 for at-risk adults ages 18-49

Taitel M, Cohen, E, Duncan, I, Pegus, C. Pharmacists as providers: Targeting pneumococcal vaccinations to high risk populations.Vaccine (2011), doi:10.1016/j.vaccine.2011.08.051


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Walgreens Peer-Reviewed OutcomesAddressing Immunization in Medically Underserved Communities

• Medically underserved areas (MUAs)

“Access to preventative health: The impact of a community pharmacy on influenza immunizations”

y ( )during the 2009-2010 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, 2012.


Walgreens Pharmacist-led Diabetes Education Program at the Worksite

Program GoalsAchieve and maintain HbA1c ≤7.0%Enhance patient adherence and self-care

Program DesignInitial one hour consultation with pharmacistMonthly 1:1 follow-up consultationsI ti f ti i ti

Outcomes included:

• 330 patients contacted/185 enrolled• 91% remained actively engaged• HbA1c values decreased from 7.72% to 7.05%• HDL value increased from 42.75 mg/dL to 44.38

Incentives for participation

gmg/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 32-36.


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• The intervention effect was a significant reduction in admission

Reducing Hospital Admissions: Stage D Heart Failure Patients Participating in a Home Inotropic Infusion Program

grates by 0.295 per patient per year (t = -3.223, p = .001).

• For the 236 patients participating in the program, the admission savings was $17,187 per patient and for the whole grouppatient 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):366.

Convenient Care Clinics Improve HEDIS Scores1

Δ = 18.02% Δ = 4.85%

1Retail Clinician, September 2010


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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. p y gFocus 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 g y pphysician. 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, 2011

Women’s Health Today

• Expanding Access

• Utilizing and Exploring New Delivery Models

• Proven Outcomes


pegus ncsl ff11.ppt

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