the past: us model of dm future: global experience - catalyst for change
TRANSCRIPT
The Past: US Model of DMFuture: Global Experience - Catalyst for Change
Whoops… China Delegation Members
“caught in the act” at KFC!!![“What happens in Beijing…..stays in Beijing”]
Local KFC Restaurant in Beijing, China
Bucket for Four of KFCExtra Crispy!
Two FishSandwiches
Large Coke
Behaviors are Hard to Change……..
Healthcare Crisis….
• Bottom-line.…we are trying hard…lack of transparency• We have the knowledge and technology• Changing healthcare is very difficult• The rewards are HUGE but political as it is a matter of
how to allocate resources & requires major policy changes
• Must benefit and tap into global lessons learned. The answer is “global collaboration” to correct decades
of lifestyle problems….together we can do it.• Disease management is a merely a “catalyst for
change”
The Disease Management Value Proposition
• Improving the health of populations
• Enhancing patient satisfaction and care experience
• Enhancing physician satisfaction and delivery experience
• Reducing total health care demand/cost
• Improving work force productivity
“ A successful Disease Management Program satisfies all 5 points of the value proposition.”
Source: Healthways
Disease ManagementSo…..How are we doing?
DM and Wellness Initiative in the United States and around
the world!
Short Term Challenges…
• Utilize Behavior Change Science• Better Leverage technology• Enhance our initiatives for co-morbid depresssion• Must Measure results better…it is complicated• Better Align financial reimbursement• Develop more integrated programs - fragmentation of the industry…lack of
portability• Need to lower cost vs. current high cost call-center based DM programs• Shift to consumer empowerment/financial incentives• Engage/re-structure primary care practice• Tap into the learnings of other countries• Continue to raise the bar
Long Term Challenge…
• Re-engineer our systems to better address the needs of the chronically ill
DM Challenges….
Changing the Definition of DM….
Chronic Disease Management
“ An Integrated Approach to Improving Health Status”
“ An Systems Approach to Improving Patient Outcomes”Todd/Nash, 1997
The Global Expansion of DM
DM and Wellness Initiatives around the world!
Countries with DM Programs…
• Argentina• Australia• Belgium• Brazil• Germany• India• Japan• Netherlands• New Zealand
Developing Programs• Canada• Singapore• South Africa• Spain• United Kingdom• Norway• Poland• Sweden• Taiwan• United States
Existing Programs• Chile • South Korea• Hong Kong• China• Thailand
Disease Management…Expanding Around the World
• Australia
• Germany
• Singapore
• Over $400Million being spent on demonstration projects [Choice: build new expensive Hospitals or keep people out of them] – New DM Association formed
• DM legislated with reimbursement for sick funds that provide DM; barriers from
existing reimbursement structures
• National initiative initiated in 2000 – leveraging public sector infrastructure
Disease Management…Expanding Around the World
• United Kingdom
• South Africa
• Argentina
• India
• Several models tested in early 2000…major development but framgented
• Private sector programs achieving good results; combing with wellness
• Private hospital initiatives with good use of technology/EMR
• Several pharma-backed DM pilots being tested
Disease Management…Expanding Around the World
• Spain
• Brazil
• Japan
• Government initiated CHF pilot being developed & tested in Barcelona; COPD in wings
• Favorable private sector system. Free standing DMO & health plan models.
• Ministry of Health Interest; private sector pilots; New DM Association, book, newsletter;
A mandate for DM in 2008
Disease Management…Expanding Around the World
• Netherlands
• Italy
• Taiwan
• Poland
• Academia-driven assessment of DM programs in progress; private & public sector interest; several major national initiatives
• US Company pilots being developed…early stages
• Pilot programs in several disease states
• Physician-based model being developed and tested for “proof of concept”
• The barriers are similar to those in the US
• Attempting to adjust/adapt programs to fit the current reimbursement/policy environment is stifling DM expansion/success
Criteria for Success….Lessons Learned from Global Experience
• More rapid adoption of behavior change science
• More aggressive leveraging of technology
• Clearer/more validated methods of measuring performance
• Enhanced integration of DM into the existing system
• The next frontier: absenteeism & productivity
• Strategies for policy and reimbursement change
Success Criteria…Areas of Opportunity
…. Leveraging the Science of Behavior
Change
Theories / models of behavior change
• Self-monitoring
• Stimulus control
• triggers
• Contingency management
• Stress management
• Social support
• Challenging irrational beliefs
• Cognitive rehearsal
• Motivational Interviewing
• Goal setting
• Relapse prevention/ recycling
• Attributional retraining
• Health Belief Model• Transtheoretical (Stages
of Change) Model• Motivational Interviewing• Social Cognitive Theory• Solution Focused
Therapy• Self-regulation
STRATEGIES MODELS
Source: Health Media
Changing Patient Behaviors…
Duration
Frequen
cy
Inte
ns
ity
We Must Better Leverage the principles and Models of Behavior Change
Basic Ingredients of Behavior Change
It Takes More Than Education to Change Behavior
Patient Education Passive Primary goal =
educate/inform Assumes knowledge
changes behavior One-dimensional Generally focused only on
patient
Behavioral Interventions Interactive Primary goal = improve outcomes Directly addresses drivers of behavior Demonstrated educational principles Focuses on relationships among all
influencers - Patient - Physician
- Pharmacist - Care partners
- Other providers
Reprinted with permission of Hastings Healthcare Group
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Message Tailoring Increases Effectiveness
Priorities/Perception of risk
Social support
Stress/Depression
Cost
Time with condition
Symptom management
Refill convenience
Treatment complexity
Co-morbidities
Habit
Expectations and beliefs
Goals
Triggers
Lifestyle issues
Acceptance
Emotion
Quality of life
Knowledge
Stage of change
Demographics (Gender/Ethnicity/Age..)
Side effects
Personal/Family health history
Doctor/patient relationship
Medication history
Bio-medical measures
Motivation
Self confidence
Prior attempts at addressing issue
Hobbies/interests/employment
Factors Related to Behavior Change
Leveraging of Technology
Disrupting like the Disrupting like the Roomba…Roomba…
1819(2.3%
of Total)
1708 (2.2%
of Total)
Year 1
Year 2
Patients who had an asthma
related hospitalization in both
Year 1 and Year 2.
283(16 % ofYear 1
High-Risk)
Predictive Modeling Finding the future high Utilizers….
MeasurementBreakthroughs
Modern Psychometric Methods
Computerized Dynamic Health Assessments
Dynamic Health AssessmentsOn the Internet
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20 30 40 50 60 70 80Pro
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An Opportunity…PRO Outcome Measurement Tools
New outcome instruments can be used both for health outcome assessment and for patient
identification, segmentation and prediction
SF Survey Standardization Makes it Possible to Interpret Treatment Outcomes
3034 38
40 5055
Congestive Heart Failure
Chronic Lung
Disease
Average Well Adult
Source: Adapted from Ware, Kosinski & Keller, 1994; Okamoto et al., 1996
Asthma Before
Rx
Asthma After Rx
46
Average Adult
Physical Component Summary (PCS)
Physical limitationsCut in half (28 to 13%)
Costs reduced 1/3;Both hospital &total
The Ultimate Solution..is Disease Prevention
75% of chronic disease is the result of unhealthy lifestyle…and is preventable!
Wellness Research Suggests:
• Individuals Can Maintain Low-Risk Health Status even as they Age
• A Health Plan, Employer, or government can Help its Members/Citizens Maintain Low-Risk Health Status
• The Major Economic Benefit is in Paying Attention to Individuals with Low-Risk Health Status
At the End of the Day… ……The Good News IS…
• The scientific knowledge exists…today
• A relative small annual reduction in chronic disease death would achieve major economic and social results.
• The good news is: - The Causes are Known - The Way Forward is Clear - It’s Will Only Take Unique Leadership and an Action Plan
• Leadership and comprehensive, integrated action is the answer
• China is well position to demonstrate this type of leadership and action
Effective Global Interventions…
• Poland – 7% decline in deaths from heart disease• Finland – 65% reduction in death rate from heart
disease plus major decline in deaths from lung cancer with 7 year increase in male life expectancy
• Philippines – decline in adolescent smoking from 33% to 22%
• Singapore – Smoking rate decreased from 23% to 15%• South Africa – 33% reduction in tobacco use• Zambia – major drop in sales of branded soft drinks
Effective Global Interventions….
• Sao Paulo, Brazil – regular physical activity increase from 55% to 60% in 2003; 96% increase in older high risk group
• United States – Schools meeting EAT SMART guideline increase from 10% to 50%
• South Africa Nurse Based DM program achieved improved disease control in 68% of hypertensive, 82% of diabetics and 84% of asthmatics
• Russia – 85% reduction in admissions from high blood pressure• New Zealand – National Food Industry Accord to reduce obesity
Effective Interventions in China…
• Tianjin, China – Results: average salt intake was significantly lowered with decreases in systolic blood pressure
• China Disease Prevention Project [1995] in 7 cities – Results: reduction in smoking from 59% to4 44% plus increase in high blood pressure detection and a 15% decrease in strokes
• MOH – 32 demonstration projects across the country – Results: Prevelence of adult smoking reduced from 29% to 13% in Shanghai plus increase in planned regular physical activity from 41% to 84%in Shenyang
Different forms of effective interventions
• Legislative Controls - Tax and Price Interventions and indoor smoking bans
• Improved Environments – footpaths increases rates of walking by 30-50%
• Advocacy/Communications – Awareness & social change• Community & School Based programs – cost of US$0.03 to
US$0.06 per capita generates 0.1% to 0.4% of disease burden• Vending machines – Access to better foods• Workplace Interventions – Johnson & Johnson wellness
program generated improvements in 8 of 13 risk categories• Comprehensive Disease Management Program – now in 21
countries and expanding
Recommendations to “Get Started”
• Organize stakeholders to identify obstacles and build support of “change.” • Look for “champions”• Initiate “pilot” programs…worry about changing the system
later….small steps! • Customize to meet the needs of your country• Don’t overlook how difficult DM is to implement• Tap into the experience of other countries• Short-term, reinforce “validity” of the concept and explore
different models• Long-term, use DM to re-engineer the system versus as a band-
aid.
In Summary…
• The crisis of chronic disease and erosion of lifestyle is a one
• We need to work together….
• There are very important “lessons learned” around the world, including the United States
• Countries can demonstrate true regional and global leadership in both disease management and wellness initiatives
The Challenge... the Mission
The challenge of the unprecedented personal and economic burden of a rapidly aging population with its inherent problem of how to better manage chronic disease has been described as the "next global crisis." This world-wide problem requires world-wide collaboration.
The mission of IDMA is to create an international forum of disease and health management stakeholders in order to share knowledge and to build a collective experience on how to better promote healthy lifestyles and to enhance the management of chronic disease.
About IDMA…
• www.DMAlliance.org or [email protected]• www.DMAA.org• www.WHO.org• Australia, Japan and Germany DM Associations…see IDMA website.• DM Conference in 2007 [Eastern Europe, South Africa, Brazil,
Canada, and perhaps Hong Kong]• Copy of this presentation at www.DMalliance.org/China
in 10 days
DM Resources…
ALSO: IDMA World DM e-Report - Complimentary Weekly e-Newsletter
at www.DMAlliance.org [reaches 8,000 chronic disease stakeholders in 62
Countries.
Disease Management ColloquiumPhiladelphia, PA May 7-9, 2007
International DM and ApproachesLucia S. Rosenberg
Vice President of Product DevelopmentU. S. Preventive Medicine
Warren E. Todd, MBAExecutive Director
International Disease Management [email protected]