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Conference Summary

2013 NCAHC Annual Conference


The NCAHC 2013 Annual Conference focused on Treatment Adherence and Communication in the Age of ACOs and Healthcare Reform. Individuals from various segments of North Carolina's health care communities convened at the Embassy Suites in Cary, NC to hear from local and national experts on such topics as the use of social media and communication tools in patient engagement, value based insurance design, motivational interviewing, and employee wellness.  There was also a panel discussion focused on the impact of healthcare reform on treatment adherence.  Near the end of the meeting, the Eagle Award was presented to staff from Moose Pharmacy in Concord, NC for their commitment to improving patients’ health by helping patients find the best management strategies through specialized educational programs.

We invite you to read our post conference newsletter and watch our site for information on our 2014 conference.
 

8:45 – 9:15 AM
Welcome, NCAHC Overview and Organizational review – TJ Gouveia-Pisano, NCAHC President
9:15 – 10:15 AM
Leveraging Social Media & Technology in Medication Adherence - Lauren Whitt, PhD
10:30 – 11:30 AM

Sustained and Targeted Medication Adherence Improvements Associated with Value Based Insurance Design - Joel Farley, PhD
11:45 – 1:00 PM
Panel Discussion & Working Lunch
Patient care & engagement perspectives moving forward under ACO control - Thomas Warcup, DO;  Lauren Whitt, PhD; Troy Trygstad, PharmD; Joel White; Moderator: Rob Nauman

1:00 - 2:00 PM
An Introduction to Motivational Interviewing and Health Behavior Change - Bruce Berger, Pharm D,

2:15 – 3:15 PM

Understanding and Enhancing Communication between Patients and their Healthcare Providers -Julie (TJ) Gouveia-Pisano, BSPharm, Pharm D,
BCPS; Terri Cardwell, RPh, PharmD,
MHA and Debbie Kame, RN, BSN

3:30 – 4:30 PM
Highway to Health Research Study – Outcomes & Lessons Learned - Whitney Davis, MPH and Angie Wester, RN
4.45 PM Communications:
Eagle Award presentation – Moose Pharmacy

 

Julie (TJ) Gouveia-Pisano, BSPharm, PharmD, BCPS
Director Medical Outcomes Specialist
Pfizer Inc.
President, NCAHC

Bio | Slides | Presenter's Disclosures

Summary

TJ Gouveia-Pisano, President, kicked off the 2013 Annual Conference with a big thank you to new members and enhanced member participation in 2013. During her presentation, she highlighted accomplishments from this past year including:

  • Publication of the Report on NC Statewide Prescription Medication Adherence
  • Successful completion of the Ask Me 3 Initiative in collaboration with Novant Health
  • Participation in the Script Your Future campaign

In addition, TJ reminded participants of the resources that are available on the NCAHC website, including the Prescription Drug Coverage Resource Center, the Medication Adherence and Safety Resource Center, educational presentations from monthly member meetings and copies of the quarterly newsletter.

Going forward, the Alliance will focus efforts on three strategic priorities:

  • Structural Enhancement – membership growth and engagement; formalization of operations
  • Increased adherence awareness – current initiatives and compilation of impact practices
  • Financial growth/stability – develop budget and secure funding to support staff and initiatives

 

Dr. Lauren Whitt
Wellness Director and Adjunct Professor
University of Alabama

Bio | Slides

Summary

Leveraging Social Media and Technology in Medication Adherence

This presentation addressed how social media can be used as a vehicle to drive behaviors. Behavioral science is driven by what we like and what we want. Engagement marries experience with expectation. Dr. Whitt suggested that "point of decision prompts" are times when one has the greatest chance of influencing behaviors. Specifically, communication is key to medication adherence. Some ways to communicate are through traditional reminders, counseling, and more recently through mobile devices. In fact, the hour of day that social media is used can have a huge influence on when communication is obtained. Timing can vary based upon whether you are communicating with an individual or an organization. Social media should have purpose, be personal, and allow people to connect. Technology has a way to give us immediate gratification, and therefore is a very effective way to communicate if it is quick, unique, personalized, and done clearly.

 

Joel Farley, PhD
Associate Professor, Division of Pharmaceutical Outcomes and Policy
UNC School of Pharmacy

Bio | Slides

Summary

Designing Medication Copayments to Improve Adherence and Health Outcomes: The Role of Value Based Insurance Design

Healthcare spending in the United States has increased at an unsustainable rate and prescription costs have typically outpaced general healthcare spending. Managed care plans have tried to control prescription costs through copayment increases, under the assumption that cost sharing will lead patients to seek less expensive alternatives to care. However, copayment increases have been linked with poor medication adherence and health outcomes.

Blue Cross Blue Shield of North Carolina (BCBSNC) conducted a study to explore the impact of Value Based Insurance Design (VBID) on medication adherence, health outcomes and health expenditures. VBID sets copayments low for high value services to promote adherence and high for low value services to discourage use. As part of this program, BCBSNC targeted six therapeutic classes of medication including ACE-Inhibitors, Diuretics, Calcium Channel Blockers, β-Blockers, Statins, and Oral Anti-Diabetic Medications (ADM). For these medications, the copayment for generics was waived and brand name copayments were reduced to that of preferred agents. Patients in this group were compared to patients taking Cholesterol Absorption Inhibitors (CAI) and Angiotensin Receptor Blockers (ARB) at the normal copayment levels.

The goal of the study was a 5% increase in medication adherence and improved health outcomes. Over the course of two years, the intervention group did see a modest increase in adherence (between 2-5% depending on the medication). Although the results were statistically significant, questions were raised about the clinical significance. A 2% adherence improvement equals only 7 extra days of treatment per year. In addition, reductions in cost-sharing revenue and increases in prescription expenditures off-set any cost savings from the program.

This study and others like it indicate that the effect of VBID appears to grow over time. However, there are many factors other than cost that contribute to medication adherence. Value Based Insurance Design shows promise as a tool to improve medication adherence for chronic health conditions, particularly when used in combination with other interventions.

 

Panel Discussion: Moving Forward Under Accountable Care Organization Control

NCAHC organized a panel of speakers who were asked to discuss changes in patient care and treatment adherence that could occur under the Affordable Care Act (ACA) and/or within Accountable Care Organizations (ACOs).

Moderator:

Panel Guests:
Thomas Warcup, DO
Lauren Whitt, PhD
Troy Trygstad, PharmD
Joel White

Robert Nauman, BA


Carolina Advanced Health
University of Alabama
Community Care of North Carolina
Council for Affordable Health Coverage

Introductions and opening comments:

Each speaker was asked to introduce themselves and respond to the initial question: What changes do you see the healthcare reform act (ACA) having on medical care in your organization?

Troy Trygstad, PharmD, MBA, PhD, is the director of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina, a parent organization of fourteen regional care management networks. He remarked that people are buying into the inevitability of reform, shifting from inpatient to outpatient. The ACA has been a catalyst for an increase in ambulatory care. Organizations have to ask themselves "Where is my place in the market?"

Lauren Whitt, PhD is the Wellness Director for the University of Alabama, which is the largest employer in the state. As an employer, UAB is questioning what the new standards of care are – they want a better/healthier patient rather than how much can be billed. They are interested in a tight circle of care.

Joel White is the President of The Council for Affordable Health Coverage (CAHC), a Washington, DC-based coalition of insurers, employers, patients, consumers, pharmaceutical manufacturers and providers united in the belief that health costs are too high and must come down so that American living standards can start growing again. They are part of Prescriptions for A Healthy America, a campaign focused on improving medication adherence. Mr. White remarked that the old way no longer works – there is a cultural shift away from fee for service. The ACA payment and delivery reform indirectly affects adherence. For example, hospitals may contract with pharmacists to reduce 30 day readmissions.

There is a greater focus on cost savings - cost and outcomes are an opportunity to focus on adherence.

Tom Warcup, DO is the Medical Director of Carolina Advanced Health, a collaborative partnership between UNC Healthcare and Blue Cross Blue Shield of NC. The practice has 1400 chronically ill patients. Their goal is to reduce hospitalizations and this has been demonstrated. They employ a team-based model of care including a pharmacist, psychologist, and nutritionist. It is fee for value, not fee for service. The model is different because it is an open system versus a closed system like Geisinger Health in Pennsylvania. Quality of life and mortality are why medications are important. The ACA will create demand for practices like Carolina Advanced Health, which target chronically ill patients.

The second question posed was: How does your organization envision driving patient engagement in their own care going forward?

Dr. Warcup referenced being able to manage patients in the gap – and that motivational interviewing plays a role. His practice uses texting to push info out to patients, and patients can also provide information back to the office. The key is to reach out to patients prior to their decline. Activated patients have many teachable moments.

Mr. White addressed the need to educate and advocate for change in policy to promote interventions. Patients are looking for help – a recent survey on adherence indicated that 92% of respondents wanted clear communication with their care provider. The ACO model drives patient experience scores and could affect cost savings. The key is to make it easy, e.g., synchronize a patient's prescriptions so they can refill all of them once per month. Culturally, providers need to go to where the patient is. Use technology to communicate with patients.

Dr. Trygstad noted that context is important. Patients are like snowflakes – each one is unique. You can have patients with the same income living in the same neighborhood but they will all be different. Interventions need to be patient specific - find what makes each patient tick. Use multiple modalities. Prior to payment reform, risk began and ended at the office door. Now risk follows patients wherever they go. Providers need to transcend the walls of their practice.

The discussion then switched to Care Transitions.

Dr. Trygstad emphasized that patient handoffs are difficult across geographic areas. For example, about a third of patients in NC get care in Florida in the winter. How do we use the existing infrastructure to gather data when patients cross such borders? An ACO is still responsible for those patients. They must create provider of care "social networks".

Dr. Whitt suggested that providers need to know all the programs that employers are using so those tools can be reinforced by the care provider. Employers often have tons of resources to help patient and family members that the provider shouldn't minimize.

Dr. Trygstad stated that two entities are driving change - employers and tax payers because together citizens are the largest payer of healthcare. The least of amount coordination often occurs between care managers. CCNC has 124 patients with 92 different medical homes. A key issue is determining who is the "quarterback" for each patient.

Mr. White referenced the longitudinal view on patient care and the need for interoperability of electronic health records. This fix is key to managing transitions across providers. Current EHR incentive program is misaligned.

Dr. Warcup shared that it is a challenge get providers to look at EHRs. In his practice, 12% of patients break geographic barriers so care management and telehealth are important. We need a true handoff to primacy care provider/PCMH so no mixed messages from hospital trying to do their job. We often have care managers stepping on care managers. Patients get mixed messages. A recent study indicated that 40% of Latinos use their smart phone as a computer.

The next question posed was: What skill sets will healthcare professionals need in the future that they currently do not have to make this effort successful?

Dr. Whitt indicated that patients must trust where and who they are getting information from. They need to trust the person and know the reasons why the information is important. Patients will trust in rank order: nurse, pharmacist, physician - nurses are the front line defense in conversation with patients.

Mr. White said providers should meet with the hospitality industry because they will be paid on patient experience. They need to consider things like timeliness and parking. Efforts must be specific, culturally relevant and convenient.

Dr. Warcup joked that physicians need acting classes to learn how to demonstrate empathy. The PCP has to be a trusted advisor. S/he needs to be liaison and understand data, show empathy, become trusted. Employers align with PCMH who live this culture. Healthcare is shifting to a customer service industry.

Dr. Trygstad emphasized the ability to delegate tasks. The PCP in a PCMH needs to be the ultimate delegator. They also need to learn to create relationships at all levels and all scopes of work.

The final question posed was: Where are the connections for early wins?

Mr. White – Policy including: 1) Medication synchronization 2) Medicare silos – need bridge to create positive incentive D plans to drive adherence and 3) Decrease barriers to those wanting to provide help to providers (legal barriers).

Dr. Warcup – Team-based care works. PCP directs the team and delegates out tasks; work up to level of licensure. Employers are at the table (being killed on premiums) - tremendous amount if leveraged to tier it out to drive employees to PCMH practices (e.g., co-pay difference).

Dr. Whitt – UAB offers multiple medical plans to its employees – lowest cost plan involves going through PCP. This helps create a central hub.

Dr. Trygstad - e-prescribing – slow at first then after incentive, adoption took off! Follow the money - doctors in performance-based model earn more money than traditional FFS practices.

Each panelist was asked to provide one take-away message for the audience.

Dr. Whitt - Understand there are many unknowns – many changes will come before we all buy in to ACO/PCMH. Patients won't buy it until they trust it.

Mr. White - Strength in numbers. We all need to get in the same boat. Change policy on reimbursement.

Dr. Warcup - Change the culture. Move away from Fee for Service . Get on board or go overboard. Transparency has held us back. Gatekeeper is essential - PCP sends patient to best.

Dr. Trygstad – Focus on efficiency: can't spend $20 million to save $10 million. Sprinkle stuff across population but focus on smaller groups for savings.

 

Bruce Berger, PhD
President, Berger Consulting, LLC and Emeritus Professor, Auburn University

Bio | Slides

Summary:

Motivational Interviewing and Health Behavior Change

Dr. Berger provided an energetic and enlightening talk about what motivational interviewing (MI) is and why health care providers (HCPs) are still having problems actually getting patients to adhere to therapies. MI was developed to help influence patients who are ambivalent or resistant to change. Adherence is personal and related to sense making. Humans are "sense makers". If a patient senses that he feels okay, then he believes he is okay and won't make a behavior change. Patients make sense of two things simultaneously: 1) What is going on with my health? (issue resistance) and 2) What is going on with this health care provider? (relational resistance). Relational resistance is more damaging than issue resistance. A provider must first develop rapport before any changes can happen.

Motivational Interviewing is concerned with assessing and then addressing a patient's motivation for change. It is the provider's job to assess motivation only, not to motivate their patients. No doctor can empower their patients. Patients drive the bus – providers may be able to influence "the route". Dr. Berger provided examples from a recent program he did with Biogen Idec on their drug Avonex, which had a low retention rate. He found that patients didn't understand the side effects, why they had flare ups (the drug would not cure their MS) and how to give injections (imbuing them with confidence). He also shared some great videos which exemplified what providers often do with patients and what could be done using MI with patients.

 

Debbie Kame, RN, BSN
Disease Management Program Specialist
Novant Health Medical Group

Bio | Slides

Julie (TJ) Gouveia-Pisano, BSPharm, PharmD, BCPS
Director Medical Outcomes Specialist
Pfizer Inc.
President, NCAHC

Bio | Slides

Terri Cardwell, RPh, PharmD, MHA
Senior Director, Clinical Improvement
Novant Health Medical Group

Slides

Summary

A Novant Health & NCAHC Initiative to Understand and Enhance Communication between Patients and Their Healthcare Providers

"The single biggest problem in communication is the illusion that it has taken place." George Bernard Shaw

The opening remarks of the presentation highlighted the scope of the problem of health literacy and non-adherence with multiple statements including: nothing affects health status more than literacy skills and patients' health literacy is central to their ability to adhere.

The Ask Me 3™ program was described as a patient education program designed to improve communication between patients and healthcare providers, encourage patients to become active members of their health care team, and promote improved health outcomes.

This presentation summarized the results of a five-month initiative designed to understand and enhance communication between patients and their healthcare providers. The initiative was conducted with two Novant Health patient populations, the Safe Med and COMPASS programs. This project included both a pre- and post-survey, each of which included questions about demographics, perception of health status and likeliness of asking questions of their providers. At the time of the post-survey, participants also received Ask Me 3™ educational materials and a wallet card as a reminder to ask these questions at every office visit. The post-survey also included a question about how likely patients were to ask specific questions about their health problems and treatment plan after receiving the Ask Me 3 ™ materials.

The most important finding of the survey is that despite their previous beliefs about asking questions, the majority of all patients (70%) said they were more likely to ask specific questions to their healthcare providers after receiving the Ask Me 3™ Wallet Card and educational materials. This benefit was expressed by all sub-groups (64%-80%), of which the highest percentage was among the group of patients that rated themselves as having fair to poor health status.

Novant Health's ongoing and future patient engagement strategies, including Ask Me 3™ & Teach-Back, were described as well. Teach Back is an educational method that asks the learner to explain or demonstrate the trained task. The teacher can modify the message until the learner is able to recall and comprehend the information. Novant Health experienced a 44% increase among heart failure patients in understanding their care plan after initiating the Teach Back method. This also led to a significant reduction in preventable readmissions among heart failure patients.

 

Whitney Davis, MPH
Director, Research & Evaluation
NC Prevention Partners

Bio | Slides

Summary

Angie Wester, RN
Clinical Business Analyst
NC State Health Plan

Bio | Slides

Summary

Highway to Health Research Study: Outcomes and Lessons Learned

Attendees of the NCAHC Annual Conference received a sneak peek at results from the Highway to Health study conducted by NC Prevention Partners and the NC State Health Plan. The purpose of the study was to increase the percentage of employees practicing healthy behaviors, specifically in the areas of tobacco use, physical activity and nutrition. The NC Department of Transportation served as the intervention group and the Department of Corrections (now Public Safety) was the control group. The study lasted three years and involved 24 locations across the state.

This study was unique in that it targeted organizational as well as individual level intervention activities. Leaders were engaged in assessing and changing policies to address the wellness environment within the agency. In addition, employees were offered activities and tools targeted at changing individual health behaviors. Organizational level policies focused on enforcing the tobacco-free policy, offering programs to support good nutrition, and increasing opportunities to participate in physical activity during the work day (e.g., activity breaks, designated walking routes, changing facilities). Employees were also provided information about their wellness benefits and participated in wellness screenings.

Results from the study are very promising, particularly given the target audience of mostly male employees working in the field. The intervention had a modest impact on the intervention group, specifically related to BMI. The study also identified employees with high blood pressure and diabetes. At the organizational level, the intervention group had a higher percentage of sites make positive changes on communication of benefits and providing support for healthy eating and physical activity than the control group.

 

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