Pfizer - Florida Healthy State Program

The Healthy State program guarantees to save the state $33 million over 2 years. The combined results to date include a 15% decrease in patient hospital days per 1000, and a 7% decrease in emergency department visits per 1000.

Situation

Medicaid programs often impose access restrictions on pharmaceuticals, to manage drug spending, such as:

• Step therapy or fail first (requiring a generic or preferred brand before allowing a patient access to other medicines within therapeutic class);
• Preferred drug lists;
• Prior authorization;
• Therapeutic substitution within class (substituting different drugs, or chemical entities, within a therapeutic class of drugs);
• Hard limits on the number of medications per month (automatically deny scripts above the limit);
• Soft limits on the number of medications per month (requiring approval for new scripts after the limit is reached);
• Annual spending caps.
  

Efforts focused solely on pharmaceutical spending reductions can lead to worse health outcomes, such as an increase in hospitalizations or medical visits.

• Medicaid programs should aspire to focus on total health management, abandoning cost containment measures based solely on budget silos that are often ultimately self-defeating.

A study of Medicare +Choice beneficiaries whose annual drug benefits were capped at $1000 found worse outcomes for patients subject to the cap (ER visits, non-elective hospitalizatins, and mortality were all higher). Patients subject to the cap who were taking anti-hypertensives, anti-hyperlipidemics, or anti-diabetics also had lower adherence.(Hsu et al, NEJM 2006,354(22):2349-59).

• After one state introduced a preferred drug list (PDL) that restricted access to certain anti-hypertensives, there was a jump in outpatient hospital visits and physician office visits (Murawski & Abdelgawad, AJMC, 2005,11:SP35-42).
  

Data has demonstrated that Medicaid access restrictions disproportionately impact patients and physicians located in poor neighborhoods.

• The administrative burden to physicians of dealing with Medicaid preferred drug lists and prior authorization for cardiovascular medicines alone are estimated to cost $1000 per physician practice per year; over $2000 for practices with numerous Medicaid patients (Ketchum & Epstein, 2006, Pharmacoeconomics Special Issue, forthcoming).
• Physicians who treat a large number of Medicaid patients tend to be located in minority neighborhoods. So the administrative burden for physicians in minority neighborhoods will be especially high (Headen & Masia, AJMC 2005, 11:SP21-26).
• High administrative costs may discourage physicians from accepting Medicaid patients, and discourage them from prescribing the optimal therapy for their patient.

Different patients respond to the same drug differently.

• Patient response to a drug varies, as does patients’ ability to tolerate side effects (Burroughs et al, J of the Natl Medical Association, 2002, 94(10 Suppl):1-26).
  

It is important to maintain patient choice over medications. Allowing physicians and patients to select the optimal drug for each patient can increase adherence and improve outcomes.

Solution

In 2001, Florida’s Agency for Health Care Administration (AHCA) and Pfizer Inc partnered to create a statewide disease management program — the first and largest of its kind in Medicaid — to address multiple chronic diseases with a community-based care network at its core. Initially designed as a two-year pilot, Florida: A Healthy State provided education and support to fee-for-service Medicaid beneficiaries with asthma, diabetes, heart failure and/or hypertension, with the goal to lower the state’s healthcare costs through improved beneficiary health. Due to the program’s success from both a clinical and financial perspective, Florida’s disease management efforts continue in partnership with Pfizer and now encompass three additional disease states: ESRD, COPD, and sickle cell. PHS believes that disease management creates sustainable improvement only when each of the steps in the process below are achieved. Though we focus our activities on coaching and educating participants about their health, we continuously monitor the impact of our interventions on participant behaviors and clinical, utilization, and cost metrics.

Coaching and education

• In 2005, program participants received by mail over 400,000 health education pieces. These are multi-lingual, culturally relevant, and readable at a fourth grade level.
• Annually, our nurse care managers make over 65,000 direct contacts with intensively care managed participants. These contacts are educational conversations and clinical assessments occurring face-to-face or on the telephone that ultimately empower the beneficiary to become a more proactive health manager.
  

Behavior changes

• Peak flow meters are an important tool helping asthmatics monitor their symptom severity. At baseline (initiation of care management) 32% of asthmatics used a peak flow meter at home. At the most recent follow-up assessment, 64% were using them at home. (n=1,218)
  

By closely monitoring their weight, congestive heart failure (CHF) patients can quickly identify changes in their “comfortable” weight,. At baseline, 13% weighed themselves daily, while at follow-up 46% did so. (n=718)

• Diet changes can significantly reduce blood pressure and its health risks. 61% of hypertensives followed a special diet after care management versus 49% before.
• Care management improved certain self-care metrics to near perfect, with 99% of diabetics checked their feet for problems at their most recent follow-up.

Clinical changes

• The percent of asthmatics classified as mild or intermittent based on NHLBI guidelines more than doubled from 21% at baseline to 45% at follow-up
• Over 77% of CHF patients improved or maintained their New York Heart Association (NYHA) disease severity classification at follow up.
• Diabetics with normal HbA1c levels under 7.0 increased, from 43.9% to 50.0% at follow-up.
• Hypertensives with blood pressure under 140/90 increased from 52.6% to 68.7% at follow-up.

Utilization

The above behavioral and clinical outcomes have had a major effect on utilization. Care managed beneficiaries have shown significant drops in more severe, emergent, and expensive utilization categories such as ER visits and hospitalizations, along with increased utilization in preventive areas such as outpatient visits and prescription drugs.

The net effect of the health improvements and utilization changes described above is considerable cost savings to Florida’s Medicaid system. Since program inception in 2001, Florida: A Healthy State has and generated $139.5 million in savings and investment, helping Medicaid beneficiaries improve their health through improved self-care skills and previously unavailable health care resources.

Better Health & Lower Cost

Spending cuts that target pharmaceutical use can actually sometimes worsen health outcomes and increase overall costs. The results of Florida’s Medicaid program show that access to pharmaceuticals, even growth in prescriptions, can occur alongside overall cost reductions due to reductions in ER visits and hospitalization. If patients and their doctors have the freedom to select the best drug for their specific circumstances, patients are more likely to be adherent. Patients with chronic conditions must adhere to their drug therapy in order to achieve the long-term health benefits of prevention (such as reducing the risk of nerve damage or blindness in diabetics, or heart attacks in high cholesterol patients). Medicines are a key component of managing chronic conditions and reducing the risk or preventing high cost complications in the future.