Innovations Exchange (continued)

Tom Snedden: Good afternoon, everybody. My name is Tom Snedden, and I'm the director of the Pennsylvania PACE Program, which is Pennsylvania's senior pharmacy benefit. You have my contact information here on the first slide. If you have any questions about the program or the initiative I'm about to talk about, feel free to contact me. This is a very truncated version of our Academic Detailing Program, so if you need any more detailed information on the program after the initiative that can't be answered in a short question, again, feel free to let me know.

Just for the sake of preface, when I put these slides together, I presumed that everybody would know what academic detailing was. Maybe that's not a fair presumption. So that everybody does understand, this is outreach medication education from a noncommercial source of evidence-based information about medication choices for physicians. I doubt there's anybody on this call that isn't familiar with the practice of pharmaceutical companies sending representatives to physician offices to talk with physicians about the products that their company manufactures. That's commonly referred to as "detailing."

This particular initiative that we have undertaken actually, starting 5 years ago this month, is what we call "academic detailing," wherein we have staff who do nothing but call on physicians across Pennsylvania to provide them with a noncommercial source of evidence-based education about all drugs that might be available in a particular therapeutic class. When you look at this slide, what you're seeing is a number of significant therapeutic classes that are widely used among elderly patients to treat many disease states that have to do with cardiovascular issues, arthritis, gastrointestinal issues, and depression.

I'm sure that many of you on the call have heard of medications that are associated with these classes like Nexium and Prilosec and Plavix and Lipitor and Crestor. These modules all provide extensive education in treating these particular disease states with these medications and cover each and every medication that might be available within the class to treat these various disease states. This next slide is a continuation of the modules that include osteoporosis, and we have one planned on insomnia, atrial fibrillation.

You also see here these first four modules. These modules—falls and mobility, cognitive impairment, chronic obstructive pulmonary disease, and incontinence—were identified as areas about 2 years ago, 3 years after we started the medication detailing initiative, that were of particular interest to physicians we visited. Many of their older patients experienced problems with falls and cognitive issues, COPD, and incontinence, which quite frequently led to their patients having to be admitted to some kind of long-term care facility like a nursing home or an assisted living facility or, in some cases, just short stays in hospitals. What we did was put together these educational modules that our staff use to go out and educate physicians about how they can prevent things like falls and cognitive impairment and incontinence, COPD in their elderly population.

These modules, I think anybody on the call would find very interesting to look at, and you can do that if you just go to rxfacts.org. These modules have been developed by staff at Harvard Medical School, and they are very user friendly, very attractive, very easy to work with, and very informational. You don't have to be a physician or necessarily a health-care professional to glean a lot of useful information from these modules. I'd recommend them to anybody on the call.

In the 5 years since we introduced this initiative into the PACE Program and Pennsylvania generally, we have had considerable contact with prescribers or physicians across the State. We particularly focused this activity in areas of the State that have high populations of elderly State residents and high enrollments in the PACE Program, which are areas like Philadelphia and Pittsburgh, Allentown, Erie, and Harrisburg, Pennsylvania. This represents a considerable number of physician contacts that I think have not only benefited people in the PACE Program but also have benefited patients of these physicians who actually have no State coverage at all, just private paying customers or people under commercial plans.

On the next slide, we show the cumulative number of visits to physicians in Pennsylvania, which, by the end of this year, we expect to be a considerable number of people, 7,620 people, and this raises the question about our physicians receiving this initiative.

We're very careful in making these visits to ensure that we get fairly comprehensive feedback from physicians about how they feel about our contact, our approach, the material that we are presenting to them and its utility to them. Most importantly, would they like to see it continue and would they be interested in a repeat visit to cover other modules that we have in the program? I think rather than reading through all of this, you can see that the physicians have been pretty happy with what we've done here.

To me having been the director of this program for 25 years and having done a lot of different initiatives that have affected Pennsylvania physicians and pharmacies, I don't think I've ever been involved in an initiative where I didn't get a few negative comments from physicians. But I can honestly say in the case of this initiative, I have never had any doctor complain to me about what we were doing here.

This next slide is just a continuation of the evaluation input that we're getting back from the physicians, and again, it's all highly positive, off the chart kinds of comments. This leads to another question about what kind of impact this is having beyond the fact that physicians seem to like it. We have done a couple of studies on assessing to what extent some of these modules have actually changed physician prescribing practices relative to the specific therapeutic class we were trying to educate people on and relative to how it may have resulted in a measurable change in prescribing.

The first module that we developed back in the fall of '05 and the one that we started off detailing exclusively through the fall of '05 and well into 2006 was the COX-2s, which today are represented by Celebrex. But at the time, some of you may recall there was another product called Vioxx, and there were a few others that aren't out there today. What we determined, relative to this impact study, was that even though the COX-2s came under considerable public health scrutiny back in '05 and '06—in fact, Vioxx was withdrawn from the market over it—the module that we had in place to effect changes in prescribing patterns appeared to work quite well in dropping the use of the COX-2s below what the trend was for a control cohort that we had set up.

So we're satisfied, at least with respect to the COX-2s, and we did a similar study on the proton pump inhibitors—the Nexiums and Prilosecs—that modules in our educational intervention are having some measurable impact in a positive way on physician prescribing choices within these classes. Now in the years that we've done these interventions, we've been contacted by a number of States who were curious about all of these things: what we educate on, how physicians respond to these things, how it changes behavior. It all seems in my conversations with other States that it comes back to the bottom line.

On this slide, I have tried to give people here a sense of what it saves. When we looked at the proton pump inhibitors and we isolated the analysis on specific physicians who were being detailed with the PPI module, we were able to identify some very discrete causally related savings with respect to our educational intervention. This slide details for you what we found those savings to be.

This, of course, is just for one of the classes. We have not been able to do this in all of the classes. I think it's fairly safe to say, with respect to the bottom line here—what does it cost and what does it save—that Pennsylvania is saving more than it is spending on this initiative. Currently, we spend 1.5 million a year, one-and-a-half million a year to pay for the direct cost of this intervention. I believe that we save probably multiples of that number, but I think it's absolutely safe to say that we're saving at least what we're spending.

To sum up, this is a very truncated version of our Pennsylvania Academic Detailing Initiative. You can E-mail me if you want further details, or I can direct you to our PACE Care's Web site, and/or you should go to rxfacts.org to look at the modules, and I hope this is helpful to everybody. Thank you.

Margie Shofer: Thanks, Tom. We have entered our next question-and-answer period, and as I said before, there are two ways you can ask a question of our presenters. You can submit a question by typing your inquiry into the Q&A box located on the left-hand toolbar of your screen, or you can ask a live question by raising your hand, and we will unmute your line, and you will be able to ask your question.

Tom, I have a question for you. I understand that other States have had to end their academic detailing program, so I'm wondering how you have managed to sustain yours when other States have had difficulty doing so.

Tom Snedden: I would have to say that this initiative and the PACE Program itself have the good fortune, unlike any other State in the country, to be funded out of the Pennsylvania State Lottery. Pennsylvania, which has had this lottery now for nearly 40 years, is the only State in the country that dedicates its lottery proceeds exclusively to programs for older people. That's about a billion dollars a year in net revenues that come to largely the Pennsylvania Department of Aging to use to pay for programs like PACE.

Aside from that, I'd say that the PACE Program, the drug benefit that we provide older State residents, has been around now for 25 years, and it has an enrollment of close to 400,000 people, and it's probably one of the most widely popular programs in the entire State budget. People just don't think of cutting back on PACE spending.

With respect to this particular initiative, which is also funded exclusively out of the lottery, I think that most people in Pennsylvania who are familiar with this program know that it's very important to do all that we can to protect people in the program from drug method metrics, which, among older people anywhere is a big, big problem. The misuse or overuse of prescription drugs is absolutely epidemic. We have, for better than 20 years here in the PACE program, put a real premium on protecting people against those kinds of issues. This particular initiative is part and parcel of doing that. We have that insurance to protect the initiative.

Margie Shofer: This is a follow-on question, since you mentioned that the funding came from lottery ticket sales. Does that mean that there was legislation required for this program?

Tom Snedden: No. There was no legislation required for this Academic Detailing Initiative. Of course, there is a State statute to set up the authorization and funding for the PACE Program, but the authorization for the Academic Detailing Initiative was actually an administrative fiat. It wasn't done by statute or regulation.

Margie Shofer: O.k. Thanks. I have a question for DeAnn. Have any other State departments of public health adopted your program or parts of your program? Basically, what has been the spread, and can you assist with adoption?

DeAnn Decker: That's a good question. I don't know if other State departments of public health have been involved, other single-State authority agencies. Sometimes they're housed in the department of substance abuse or the department of mental health. That is usually who has taken on the NIATx project. If they want help with adoption of NIATx, go ahead and E-mail me, and I can talk to people at NIATx, and we can look at what to do to give you the tools to get it started.

Margie Shofer: Thanks and another question for you. How has NIATx worked outside the field of substance abuse? I know you mentioned a couple other areas.

DeAnn Decker: Yeah. It has been great. For gambling, they have just had tremendous success in increasing admissions and getting clients in sooner and keeping them. They have really disseminated and saturated our entire State in the gambling treatment centers here in Iowa. We have done some in the mental health field, but they are in a different agency, so we have tried to do some training with them and some joint work. It hasn't moved as fast as we wanted, but we've done some of that.

Like I said, we've done some with prevention, which is a little bit of a different game because it's not a client that comes in, so it's been a little bit of a different thing. We continue to look at the different ways we can spread that model into all of the things that we're doing. I was talking to the tobacco gal the other day too, so I'm just looking at different areas to start using the process improvement model.

Margie Shofer: Great. Thanks. Another question for Tom. How have the pharmaceutical companies responded to the Academic Detailing Program? Have they been supportive?

Tom Snedden: I'd have to characterize it more as amusement at this point. I wouldn't say they've been necessarily supportive, but they haven't opposed it, which worries me, because if it's going be really effective, they ought to be upset. I'd have to say they've just been watchful and not wanting to be critical or necessarily at least publicly supportive.

Margie Shofer: That's really interesting news, and I think other States would be interested in hearing more because I'm sure that's a concern of most folks.

Tom Snedden: I've found in my 25 years here dealing with the pharmaceutical industry, if you take the approach that you're doing this to protect the patient and you do it in a way that is noncommercial, unbiased, educational, particularly working through a medical school, then it's hard for the industry to oppose that.

We started back in 1991 with probably one of the most aggressive online real-time drug utilization review intervention programs in the country. It's still that way today. I have never had the industry protest privately or publicly about that, as long as they felt that we were doing it to protect patient health and safety.

Margie Shofer: Now that you're talking about this, do you involve them in any way?

Tom Snedden: No. In fact, I go out of my way to keep them out of it.

Margie Shofer: O.k.

Tom Snedden: In fact, the meetings we had to develop and implement our online drug utilization review criteria are not even open to the public. If once they see the criteria they are concerned about how those criteria were set, I do allow them to come in and meet with us, but I restrict it to clinical staff of the company. There can't be marketing staff. There can't be government affairs staff. It has to be physicians and pharmacists that are working for the company.

Margie Shofer: That makes sense.

Tom Snedden: It does. But I think my advice to any State that wanted to do this in such a way that would neutralize or co-opt the pharmaceutical manufacturers is just to do it in a way that is exclusively focused on patient safety. There's just no arguing that.

Margie Shofer: Yeah, that makes sense.

Tom Snedden: The industry may not wildly support it, but they're not going to oppose it.

Margie Shofer: That's good to hear. DeAnn, I have another question for you. How do you continue NIATx when there's no funding involved?

DeAnn Decker: We have continued to use the NIATx principles in any of the grants and contracts we get. We try to put in some access and retention measures. We try to find ways of building it into other things. If we have extra money or anything that's kind of an incentive funding or some set-aside that's extra, we use that to maybe incentivize new providers to learn and do change projects. We try to use anything we can to kind of incentivize the folks to keep looking at where they're at, a lot of times, to refresh themselves. Even if they've been involved in it a while, it's good to go back and relook at your front desk and your customer service and try to keep looking at those processes to make sure they haven't gone back to where they were before you made the change. We continue to look at it and build it into other projects where we can, and in this time where there's not a lot of extra money anywhere.

Margie Shofer: Another question for you. How has this program affected the cost of running the clinics? Do the efficiencies result in cost savings?

DeAnn Decker: Yeah. There is some information on the Web too, about some specific things. Prairie Ridge did a project, I think it was in '06, and it was called the "40% solution." They really started targeting clients that were payers or trying to find funding streams that paid such as Medicaid client fees like the sliding fees, and they tried to look at third-party collections.

Actually, there's a case study in a book from Prairie Ridge. Basically, in 2004, they had revenues of 627,000, and within 2 years, by doing this change project, they had increased their revenues to $1,008,367. They increased their revenues within 2 years by 40% just by trying to find clients who were paying and different ways of billing Medicaid and trying to find different clients that were coming in that were actually paying rather than using the block grant funding that's kind of the capitated amount. Yeah, it was a great change project, and that's really when we tried to increase admissions. You're not only getting clients in and doing good services for clients but you're also increasing revenues too.

Margie Shofer: That's great.

DeAnn Decker: Yeah.

Margie Shofer: Another question for Tom. Are you planning anything different in the foreseeable future with respect to academic detailing?

Tom Snedden: No. I think we've got a pretty full plate here at the moment and not planning anything different at all.

Margie Shofer: I think that wraps up our questions. I want to thank you all for the thoughtful questions and your participation in this Web conference today on the Health Care Innovations Exchange. We hope this discussion was helpful to you.

If you have questions about follow-on technical assistance opportunities, please do not hesitate to submit them to the quality tools E-mail address. I just want to remind everyone that technical assistance for this project is available until November 29, and at that point, this project ends.

If you have any comments or questions about the Innovations Exchange, please send an E-mail to the same address. I want to thank you all for joining us. I want to thank our terrific speakers, and this concludes the Web conference. We look forward to hearing from you. Thanks and goodbye.