Dennis Helling, PharmD, DSc, FCCP, FASHP

Executive Director Pharmacy Operations & Therapeutics

Kaiser Permanente Colorado

Clinical Professor

University of Colorado School of Pharmacy

Costing and Payment From An

Individual Perspective

Copyright © 2011 Kaiser Permanente

3

Our Numbers

8 regions serving 9 states and the

District of Columbia

8.9 million members (as of 2/11)

15,000 physicians (we hire just 11%

of MD applicants in California)

164,000 employees (including 45,000

nurses)

35 medical centers (with hospitals)

454 medical offices (ambulatory care

buildings)

$44 billion operating revenue (2010)

Kaiser Permanente

Kaiser Permanente Colorado (KPCO) Non-profit health plan serving ~500,000

members in Colorado

20 medical offices and 4 behavioral health

>5,000 employees & >800 physicians

Integrated care delivery system

Electronic medical record since 1998

NCQA Medical Home accreditation

MTM services provided by virtual & physically integrated pharmacy teams

A Few Patients Cost A Lot

0%

20%

40%

60%

80%

100%

0% 20% 40% 60% 80% 100%

Percentage of patients

Pe

rce

nta

ge

of

he

alt

h c

are

ex

pe

nd

itu

res 1% = 27%

patients costs

70% = 11%

patients costs

20% = 0.35%

patients costs

6

Rand Study:

Barely 50% of care

in synch with care

guidelines

7

Acute

Care

25%

Chronic Care

Total Cost of Care In America

Chronic Care vs. Acute Care

75%

8

80%

Co-morbidities

20%

Single Disease

KPCO Pharmacy Department

Pharmacy Personnel (>800) 400 pharmacists

300 technicians & administrative support

50 supervisors & managers

50 interns

>4.5 million prescriptions annually

Department budget ~$250 million

Clinical Pharmacy Services

~200 staff members 100 Clinical pharmacy specialists

60 Clinical pharmacists

13 Pharmacy technicians

6 Residents (PGY2)

1 Research Fellow

5 Research specialists

~100 BCPS, BCPP, BCOP

KPCO Clinical Pharmacy Services

Anticoagulation (25) Float Pool (4) Research (5)

Cardiac Risk (22) Pharmacogenomics Research Fellow

Call Center (38) Primary Care (35) Residents PGY2 (6)

Drug Information (2) Medication Safety (2) Therapeutic Initiatives

Travel Clinic (3)

Specialties (23)

Asthma / Allergy Hospital (1) Neurology

Cardiology/Heart Failure (2) Infectious Disease Oncology (2)

Continuing Care (3) Memory Clinic Palliative Care (3)

Diabetes/Endocrinology Behavioral Health (3) Transplant

GI Nephrology Weight Mgmt

Affordability

Interregional Initiative Performance (2010)

Strong partnership with the Medical Group on Drug Use

Initiatives results in Program leading performance

KPCO ranks 1st, 2nd, 3rd

on 13 of 15 National Drug

Use Initiatives

Top performing region

for the past 10 years!

01

234

5678

91011

1213

CO NW OHIO SCA GA GH HI MAS NCA

Na

tio

na

l In

itia

tiv

es

1st 2nd 3rd

December 2010 YTD COGS PMPM Comparison

20

25

30

35

40

CO Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7

CO

GS

PM

PM

12/10 YTD AVG

KP AVG COGS

December 2010 YTD

Interregional Comparison – COGS PMPM

Clinical Pharmacy Services

Impact on Clinical Care

Best Quality – HEDIS Sustained Outcomes

The Pharmacy Department has led KPCO’s efforts in achieving benchmark performances on

many long-standing medication-related HEDIS measures

Use of High-risk Medications in the Elderly

KPCO ranked #1 in Program 2007 / 2008 / 2009 / 2010

National rankings not available for Medicare metrics

Chronic Renal Failure – Potentially harmful drug-disease interactions in the elderly

Achieved 56% reduction in high-risk patients receiving potentially harmful medications

KPCO ranked #1 in Program 2008 / 2009 / 2010

Diabetes Measures

BP control <140 KPCO ranked #1 in Program & #2 in Nation

LDL control <100 KPCO ranked #1 in Program & #1 in Nation

#1

#1

#1

CMS 5 Star Ratings – Pharmacy Contribution

The Pharmacy Department positively contributes to KPCO’s

CMS 5 Star Ratings

Below are highlights of Medicare Part C measures:

3 HEDIS Metrics – Pharmacy “ownership”

Monitoring of Patients Taking Long-term Medications 5

Rheumatoid Arthritis Management 5

Osteoporosis Management in Women After Fracture 3

Other Metrics – Pharmacy influence

HTN control

Improving bladder control

Reducing fall risk

Quality Bonus Payments

• “CMS 5 Star Ratings”• 5 Stars = 5%

• 4 – 4.5 Stars = 4%

• 3.5 Stars = 3.5%

• 3 Stars = 3%

Clinical Pharmacy Cardiac Risk Service (CPCRS)

Centralized telepharmacy model with computerized

tracking system 21 clinical pharmacy specialists & 1 technician

800-1,000 patients per clinical pharmacist

Currently manage >14,000 patients with CAD In addition, also managing >800 patients with

peripheral vascular disease (PVD)

Stroke patients 1,500

Pharmacist’s Role

Focus on optimizing long-term medication

management for patients with CAD

Cholesterol-lowering therapy

Hypertension therapy

Tobacco cessation therapy

Aspirin or other anti-platelet therapy

Diabetes therapy (selected)

Early CCCS

intervention

(< 90 days post-event)

Any CCCS

intervention

All-cause

mortality

89% reduction 76% reduction

Cardiac-related

mortality

88% reduction 73% reduction

CCCS Significantly Reduces Risk of Death

Pharmacotherapy 2007;27(10):1370-1378

CCCS Results/Outcomes

Benchmark performance in related HEDIS

effectiveness of care measures

Improved morbidity & mortality* 135 deaths/year avoided

266 major cardiac events/year prevented

CCCS patients Nearly 90% less likely to die from CAD related

complications or any cause

ROI: ~$60/day ($21,900/year) lower total healthcare

expenditures

*Based on data provided by National Committee for Quality Assurance (NCQA)

Pharmacotherapy 2007;27(10):1370-1378

Clinical Pharmacy Call Center (CPCC)

Centralized telepharmacy service

29 clinical pharmacists & 9 technicians

>200,000 medication related phone calls per

year including: >12,000 new member transitions

>6,000 Medicare MTM interventions

>3,000 SNF discharge transitions

Am J Health-Syst Pharm 2005;62:401-10.

New Member Transition Program

Value to KPCO Transition ~12,000 new members each year

Clinical Pharmacists able to convert > 90% of NF

drugs to formulary alternative prior to first MD

appointment

~$5 million/year drug costs avoided due to

improved formulary adherence

Save ~1 MD appointment per patient transitioned

Reduce demand for physician time and help

improve access

High satisfaction – patients, providers, care teams

Safe Transition Results/Outcomes

Clinical Outcomes 78% in mortality 60 days post-discharge

36% in ED visits

Increased ambulatory care visits (good thing!)

Identify & correct drug-related problems in >90% of patients

Other Outcomes High physician & patient satisfaction

Improved collaboration & documentation

Potential cost savings

Pharmacotherapy 2008;28(4):444-52.

Clinical Pharmacy Anticoagulation Service (CPAS)

Centralized telepharmacy service Cares for ~8,000 patients

Staffing 22 clinical pharmacists/specialists

3 pharmacy technicians

~500 patients per clinical pharmacist

CPAS Services

Warfarin therapy

Outpatient management of deep vein thrombosis (DVT)

High-risk pregnancies

Bridge therapy for surgical procedures

DVT prevention following orthopedic surgery

Management of excessive anticoagulation

Available by pager 24/7

Anemia Growth Factor Service

CPAS Results/Outcomes

CHEST 2005;127:1515-22. J Thromb Thrombolysis 2003; 15:113-8.

Arch Intern Med 2000;160:2926-32.

3.3%

63.5%

5.2%

55.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Complications INR Control

CPAS Usual Care

C

P

A

S

CPAS Results/Outcomes

CPAS-monitored patients 40% less likely to suffer

any bleeding, clotting or fatal complication

1 warfarin complication prevented for every 52

CPAS patients 269 complications prevented each year (one per

day)

Reduced complications attributable to more

therapeutic INRs

One major bleed prevented for every 20 episodes

of INR ≥6 55 major bleeds prevented each year (1 per week)

CHEST 2005;127:1515-1522; J Thromb Thrombolys 2003;15:113-118;

Arch Intern Med 2000;160:2926-2932

Cost Justification for Clinical Pharmacy

Services

• Quality now pays big!

• Drug use initiatives ↑

• Cost of goods ↓

• MD time saved

• Improved clinical outcomes• ↓Clinical events, ↓ER visits, ↓Mortality