Pharmacist-run asthma program slashes costs

Data show 47% drop in expenditures

Asthma is an excellent candidate for disease management programs: It’s a high-cost, high-prevalence disease with a low rate of patient compliance and wide variations in practice styles. There’s a lot of room for improvement, and a unique program in California is making sure pharmacists get a chance to show it can be done.

WellPoint Pharmacy Management, a pharmacy benefits management company in Calabasas Hills, CA, that manages benefits for 12 million lives across the country, began a pilot asthma disease management program last year for 500 patients in California. Preliminary data show a 47% decrease in total expenditures, a 17% increase in quality of life for children and an 11% quality of life increase for adults.

"Pharmacists can play a significant role in managing asthma," says William Waugh, PharmD, director of disease management for WellPoint. "The pharmacist in the managed care organization can analyze claims to influence and improve the way asthmatics are being treated, and the pharmacist out in the community can improve treatment by counseling patients and looking for asthmatics who are getting out of control."

Studies have shown that only 30% of severe asthmatics have peak flow meters and that only 23% use them, Waugh says. Fifty percent of patients who are counseled on how to use their inhalers forget the information within two months. The pharmacist — who sees patients every month, much more often than the physician — can play a key role in helping patients comply with doctors’ orders and ultimately keep themselves away from the emergency department and into a better quality of life.

"The pharmacist reinforces the education the patient gets from the physician," Waugh says. "We all know that a lot of physicians, especially internists, are very busy and don’t have the time to spend with their patients to go over everything. Pharmacists fill in that gap."

WellPoint analyzed total expenditures for asthma in the Blue Cross California population by type of service: hospital, emergency department, physician, pharmacy. They found that the top 20% of asthmatics accounted for 80% of the total costs. The average annual cost per patient in that top 20% was $1,200 — a figure WellPoint thought could be reduced by helping patients understand the need to comply with doctors’ orders and how to use their inhalers and peak flow meters.

WellPoint’s asthma program includes:

Patient education.

Each patient receives an asthma education kit that includes a video, a booklet, and a peak flow meter with instructions on how to use it. Patients learn, among other things, how to avoid asthma triggers by cleaning air conditioning vents and avoiding feather pillows.

Case management.

A case manager calls patients each month, asking a series of questions including how many days of school or work they’ve missed and whether they’ve been hospitalized. If there has been a hospital admission, the case manager discusses what the patient could do to prevent another one. The program reaches about 85% of patients each month, Waugh says.

Pharmacist education.

Continuing education programs are offered throughout California for pharmacists to be certified as asthma educators. They learn the best ways to counsel asthmatics and receive reading materials. Patients in the program are asked to see one of the certified pharmacists once a quarter to get counseling. The regular visits not only provide continued reinforcement for patients, but they also give pharmacists a chance to identify patients whose symptoms are getting out of control.

Physician education.

Treatment guidelines developed by a group of allergists, pulmonologists, emergency department physicians, obstetrician/gynecologists, pediatricians, pharmacists, nurse educators, and case managers are sent to all physicians with patients in the program. A WellPoint pharmacist analyzes how each physician uses medications and sends individualized reports that show how they’re doing compared with their family practice peers and with a benchmark group of specialists.

When collecting baseline data for the program, WellPoint found 90% of the claims came from family practice physicians instead of specialists. New guidelines from the National Heart, Lung, and Blood Institute in Bethesda, MD, recommend that if a primary care provider can’t get a patient’s asthma under control within a reasonable period of time, the patient should be referred to a specialist, and Waugh says encouraging appropriate referrals is one goal of the program. "The patient would be better off — and the insurance company would be far better off — spending the money upfront on a specialist office visit than having to spend it in the emergency room," he says.

Even though pharmacy costs are an obvious concern of the program, they are just one piece of the puzzle. To improve costs, managed care companies must get away from component management, Waugh says. "It’s kind of like if you squeeze on one end of a balloon, it will bulge out on the other end," he says. "If you just try to control pharmacy costs, you’re shooting yourself in the foot because what you’ll end up doing is increasing costs on the medical side. You have to be willing to spend more in one area to save in another."

[Editor’s note: For more information on pharmacists in asthma management, contact William Waugh, WellPoint Pharmacy Management, 27001 Agoura Road, Suite 325, Calabasas Hills, CA 91301. Telephone: (818) 878-2654.]