the past: us model of dm future: global experience - catalyst for change
TRANSCRIPT
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The Past: US Model of DMFuture: Global Experience - Catalyst for Change
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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……..
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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”
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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
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Disease ManagementSo…..How are we doing?
DM and Wellness Initiative in the United States and around
the world!
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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….
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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
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The Global Expansion of DM
DM and Wellness Initiatives around the world!
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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
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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
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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
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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
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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”
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• 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
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• 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
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…. Leveraging the Science of Behavior
Change
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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
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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
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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
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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
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Leveraging of Technology
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Disrupting like the Disrupting like the Roomba…Roomba…
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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….
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MeasurementBreakthroughs
Modern Psychometric Methods
Computerized Dynamic Health Assessments
Dynamic Health AssessmentsOn the Internet
0.0
0.2
0.4
0.6
0.8
1.0
20 30 40 50 60 70 80Pro
ba
bil
ity
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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
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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
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The Ultimate Solution..is Disease Prevention
75% of chronic disease is the result of unhealthy lifestyle…and is preventable!
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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
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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
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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
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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
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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
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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
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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.
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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
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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…
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• 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.
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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]