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NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation ACTIVE Diabetes Program Organization Overview • MemorialCare is a nonprofit integrated delivery system with five top hospitals and two affiliated medical groups, as well as surgical and outpatient centers and a health plan • The health system is dedicated to driving healthcare innovation through both its care delivery efforts and its strategic investment company, MemorialCare Innovation Fund • As a member of CMS’s Next Generation ACO model and other value-based care initiatives, Memorial- Care is driving forward evidence-based medicine and care coordination Background The CDC estimates that 29.1 million people in the US have diabetes. The disease’s economic toll on the US hit a record-high $245 billion in 2012, representing a 41% increase from just 5 years earlier. Direct medical costs, including hospital care, office visits, and medications, represented $176 billion of the total. MemorialCare’s ACTIVE Diabetes Program was developed in 2012, in response to the unmet needs of physicians in treating complex diabetes patients. The program was originally funded with a grant from Blue Shield of California, as part of an ACO initiative between Blue Shield, Hoag Hospital and Greater Newport Physicians (GNP). When GNP became affiliated with MemorialCare, ACTIVE became fully funded by MemorialCare. Ultimately, the program aims to address barriers that prevent complex diabetic patients from achieving their wellness goals, by providing them with individualized and multidisciplinary care, while also reducing the care burden on the primary care physician (PCP) by enabling other clinicians to practice at the top of their licensure. Program Details The specific objectives of ACTIVE are to: • Engage poorly controlled diabetic patients • Lower these patients’ key risk factors, namely A1c levels and blood pressure • Reduce risk of macrovascular complications (e.g. cardiovascular) by assuring appropriate use and adherence of statin therapy • Increase the rate of annual, preventative diabetic monitoring, including diabetic eye exams, foot exams, and nephropathy screenings To accomplish these goals, ACTIVE has implemented a team-based approach to caring for this subset of MemorialCare’s diabetic population. PCPs that have signed a collaborative agreement can then refer their poorly controlled patients into the program, where they are managed by the ACTIVE team, which includes: • Clinical pharmacist, who leads the ACTIVE care team in selecting the most clinically appropriate, cost-effective medications for each individual patient An Initiative of the 79 | ACTIVE Diabetes Program
NDHI NAT IONAL DIALOGUE FOR Healthcare Innovation • Clinical social worker, who plays a critical role in addressing psychosocial barriers that hinder necessary behavioral changes • Dietitian, who provides healthy diet and exercise programs and helps patients manage roadblocks to lifestyle modification The program manages over 350 diabetic patients from Health Maintenance Organizations (HMOs), and another 100 patients receive dietician counseling. Value Delivered • Improved quality of care for diabetic patients: –– ACTIVE’s program results greatly surpassed its goals in the first year of program operation, a remarkable accomplishment for a patient population that has historically been poorly controlled despite high physician effort -- For example, the initial program goal for A1c improvement was set as 30% reduction, and actual A1c improvement was 69% –– The program continues to exceed the Integrated Healthcare Association (IHA) 90 th percentile in three out of four key measures and comes very close to meeting the 4 th measure • Lower healthcare costs: –– On average, ACTIVE reduced overall medical costs by $1200 per patient annually compared to a cohort of poorly controlled diabetics patients not enrolled in the program (this includes inpatient stays and ED visits) –– After subtracting the cost of the program, there is a small, positive ROI of $90 per patient per year • Enhanced patient and physician experience: –– Patient satisfaction surveys rated the program 4.98 out of a 5.0 points –– The recurring comment from patients is that they wish they had been referred sooner Path Forward • MemorialCare plans to expand the ACTIVE program, both within the HMO patient population and into its affiliated CMS and commercial-led Accountable Care Organizations (ACOs) • MemorialCare would also like to offer ACTIVE for Preferred Provider Organization (PPO) plan members and Medicare Fee-For-Service (FFS) patients, but there are barriers to successful implementation in these settings: –– PPO and FFS patients have a different relationship with the health system: -- Patients often have higher costs, reducing their motivation to seek care -- When they do seek care, these patients do not need to designate a single PCP and may move in and out of network for services –– Medicare does not recognize pharmacists as providers, so ACTIVE has limited reimbursement potential -- MemorialCare currently takes on the full financial responsibility of this program, because of its cost-effectiveness for managing high-risk patients in a capitated environment -- However, this investment puts undue financial burden on MemorialCare in a FFS environment, due to the upfront program costs and its long-term cost-reduction impact • MemorialCare advocates for several regulatory changes that would enhance this program: –– Reimbursement of pharmacist-led programs without additional costs to the patient, rather than requiring a physician to lead the program, which adds unnecessary costs –– CMS recognition of pharmacists as providers, and national expansion of pharmacists’ practicing abilities to allow prescriptive privileges –– Implementation of a national standard for EMR interoperability between different health systems, to enable real-time health data sharing and care coordination ACTIVE Diabetes Program | 80
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Foreword The U.S. healthcare indust
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