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
