Asheville Project Succeeds Against Chronic Disease

Published June 1, 2006

When 43-year-old Brenda Mills of North Carolina was diagnosed with adult-onset diabetes late last year, she was devastated. Her mother was diagnosed with it in her 60s, and Mills knew people who had lost their legs and gone blind from it.

Fortunately, Mills lives in and works for the city of Asheville, the location of a 10-year-old diabetes disease management model that has proven so successful it’s now being tested in several cities nationwide.

Concerned Caregivers

In January, Mills found herself at the center of a circle of caregivers focused on helping her manage her diabetes: the doctor who discovered her blood sugar was up when she took her annual physical last December, a nutritionist who helps her understand food’s effects on her body, a diabetes educator who teaches her about the different risk factors she has and how to take care of herself through medication, and a pharmacist with whom she meets monthly.

The pharmacist acts as a personal coach, reviewing her treatment protocol and goals, keeping her accountable, and making sure her doctor is informed. If any red flags come up, the doctor may then have Mills come in to see him.

Because Mills’ copayments for all diabetes-related visits, equipment, and medications are waived, the result is better health at a lower cost–and one woman who feels empowered by the process, not defeated by her disease.

“They set me up on a program so I don’t crave carbs anymore, I’m not hungry anymore,” Mills said. “I’ve lost 13 pounds in nine weeks. My cholesterol was 255, and I got it to 176 and I got the LDL significantly down. I’m excited about this.”

Common Experience

Mills’ experience is far from unique. Since the Asheville Project, as it is known, was launched as a pilot program in 1997, thousands of people in the Asheville area have taken control of their diabetes and high cholesterol, hypertension, and asthma as the model has been expanded to include other diseases over the years. Six employers and more than 1,100 people currently participate in the Asheville area.

The program is now being replicated nationwide through the Diabetes Ten City Challenge (DTCC), sponsored by the American Pharmacists Association Foundation (APhA) with support from drug manufacturer GlaxoSmithKline. In late April, the University of Southern California–the largest private employer in Los Angeles, with 12,000 employees and their dependents insured through its PPO–became the sixth group to take up the challenge since it was launched in October 2005. (Look for a story on the DTCC in an upcoming issue of Health Care News.)

But in 1996, the city of Asheville, which offers its own insurance program to municipal employees, didn’t have a proven model to follow as it struggled to bring its high health care costs down.

“We basically did it out of frustration,” said John Miall, the former city risk manager who now acts as a DTCC consultant selling the model to employer groups nationwide. “We had tried everything we knew to do to control our health care costs, so what could this hurt?”

Impressive Results

According to the Centers for Disease Control and Prevention, chronic diseases make up 75 percent of the annual national health care bill. Diabetes alone affects 18.2 million people and costs $132 billion a year, including lost productivity and disability. So instead of simply paying for city employees’ disease, Miall and project co-founder Daniel Garrett, APhA’s senior director of medication adherence programs, invested in their wellness by creating circles of care around each diabetic, like the one Mills enjoys now.

“I said I wasn’t going to pay pharmacists for these services until we saw results,” Miall said. “But to everyone’s surprise, that happened fairly quickly–in six months.”

Ever the scientists, Garrett and Miall collected baseline information in 1996 before launching the project in 1997. The results were dramatic. In 1996, the city spent an average of $6,127 a year on each of its 48 diabetic employees. At the end of 1997, the claims for the group had been cut in half, to $3,554 per patient. The average sick time among the diabetic employees dropped from 12.6 days per employee each year to six and has remained at six or below since 1999.

And even though the number of city employees in the program had grown to 140 by the time Miall retired last year, the savings continued to hold true. The pharmacy visits cost the city an average of just $48 per patient per month.

“This was a tremendous learning curve for us. The whole health care system is geared to the sick,” Miall explained. “The only time you pay a provider is when someone is sick. This changed that whole model. We had a protocol written by local physicians, saying that if the pharmacists saw certain trigger points, they were to pick up the phone and call the physician. So that first year, pharmacists called physicians about 200 times more than they had in the year before. Those early, frequent interventions helped catch some ulcers on the feet that could have been devastating.”

Proven Savings

The model works well for employers, too, said Claudia Muse, executive director of the Western North Carolina Health Coalition in Asheville, who has watched the project since its inception. In her 40 years in the disease management industry, she said she’s never seen anything as successful.

“I had seen a lot of disease management programs–most were the case-management type, where you’d have a nurse or social worker assigned, and they were telephonic,” Muse explained. “There wasn’t good data to show there was really good savings to payers. They might see it on a case-by-case basis, but it never translated to the bottom line.”

That wasn’t the case in Asheville. Garrett and Miall scrupulously counted every dollar spent on disease management for each patient, year after year–a refreshing difference from the way most companies handled it, Muse said.

“One of the things I always saw was savings calculated in ways that could be called smoke and mirrors–they tried to guess what the costs would have been if they hadn’t intervened, and then they count that as savings,” Muse explained. “Most of them, especially with the for-profit insurance and disease management companies, tend to [exaggerate] them and then tell the employer, ‘Look what we’ve done for you.’ But in Asheville it’s clear, it’s clean, it’s proven.”

New Vision

With a successful 10-year track record behind it, the Asheville Project model is “the trend of the future,” Miall said. New cities see even better initial results than Asheville did, and in six years, no one on the Asheville program suffered a lost-time injury, which is “unheard of,” Miall noted.

For all its trendiness, the Asheville Project is nothing more than good old-fashioned health care, Miall said. It’s something the APhA hopes will eventually change the way health care is delivered nationwide.

Each year, health care costs rise, Miall said, and when they do, providers “increase deductibles and copays, and justify it on the basis of ‘people need to take more responsibility for their health.’ So in Asheville, we just turned the clock back and said, ‘We’ll pay for face-to-face interventions more often.’ It’s just a return to basics.”

Necessary Change

It’s the simple things that often prove most effective and least costly–and the more health care evolves in this country, Miall said, the more providers need to keep that in mind.

“I’m not anti-Blue Cross, but the moral is, if the current health care system was designed to keep hospitals and physicians in business, we should be throwing a party. It’s been hugely successful,” Miall said. “But if the goal is to get our people healthy and keep them that way, it doesn’t line up. Our expectations have changed. That’s what this is about. It’s not a bad thing–it’s just that the world was different [when managed care was created during the Great Depression].

“There’s a point where you just have to change what you’re doing. This prevents sick people from being sick. People with chronic diseases can be relatively healthy and productive,” Miall noted.

Karla Dial ([email protected]) is managing editor of Health Care News.