The Past: US Model of DMFuture: Global Experience - Catalyst for Change

Whoops… China Delegation Members

“caught in the act” at KFC!!![“What happens in Beijing…..stays in Beijing”]

Local KFC Restaurant in Beijing, China

Bucket for Four of KFCExtra Crispy!

Two FishSandwiches

Large Coke

Behaviors are Hard to Change……..

Healthcare Crisis….

• Bottom-line.…we are trying hard…lack of transparency• We have the knowledge and technology• Changing healthcare is very difficult• The rewards are HUGE but political as it is a matter of

how to allocate resources & requires major policy changes

• Must benefit and tap into global lessons learned. The answer is “global collaboration” to correct decades

of lifestyle problems….together we can do it.• Disease management is a merely a “catalyst for

change”

The Disease Management Value Proposition

• Improving the health of populations

• Enhancing patient satisfaction and care experience

• Enhancing physician satisfaction and delivery experience

• Reducing total health care demand/cost

• Improving work force productivity

“ A successful Disease Management Program satisfies all 5 points of the value proposition.”

Source: Healthways

Disease ManagementSo…..How are we doing?DM and Wellness Initiative in the United States and around

the world!

Short Term Challenges…

• Utilize Behavior Change Science• Better Leverage technology• Enhance our initiatives for co-morbid depresssion• Must Measure results better…it is complicated• Better Align financial reimbursement• Develop more integrated programs - fragmentation of the industry…lack of

portability• Need to lower cost vs. current high cost call-center based DM programs• Shift to consumer empowerment/financial incentives• Engage/re-structure primary care practice• Tap into the learnings of other countries• Continue to raise the bar

Long Term Challenge…

• Re-engineer our systems to better address the needs of the chronically ill

DM Challenges….

Changing the Definition of DM….Chronic Disease Management

“ An Integrated Approach to Improving Health Status”

“ An Systems Approach to Improving Patient Outcomes”Todd/Nash, 1997

The Global Expansion of DM

DM and Wellness Initiatives around the world!

Countries with DM Programs…

• Argentina• Australia• Belgium• Brazil• Germany• India• Japan• Netherlands• New Zealand

Developing Programs• Canada• Singapore• South Africa• Spain• United Kingdom• Norway• Poland• Sweden• Taiwan• United States

Existing Programs• Chile • South Korea• Hong Kong• China• Thailand

Disease Management…Expanding Around the World

• Australia

• Germany

• Singapore

• Over $400Million being spent on demonstration projects [Choice: build new expensive Hospitals or keep people out of them] – New DM Association formed

• DM legislated with reimbursement for sick funds that provide DM; barriers from

existing reimbursement structures

• National initiative initiated in 2000 – leveraging public sector infrastructure

Disease Management…Expanding Around the World

• United Kingdom

• South Africa

• Argentina

• India

• Several models tested in early 2000…major development but framgented

• Private sector programs achieving good results; combing with wellness

• Private hospital initiatives with good use of technology/EMR

• Several pharma-backed DM pilots being tested

Disease Management…Expanding Around the World

• Spain

• Brazil

• Japan

• Government initiated CHF pilot being developed & tested in Barcelona; COPD in wings

• Favorable private sector system. Free standing DMO & health plan models.

• Ministry of Health Interest; private sector pilots; New DM Association, book, newsletter;

A mandate for DM in 2008

Disease Management…Expanding Around the World

• Netherlands

• Italy

• Taiwan

• Poland

• Academia-driven assessment of DM programs in progress; private & public sector interest; several major national initiatives

• US Company pilots being developed…early stages

• Pilot programs in several disease states

• Physician-based model being developed and tested for “proof of concept”

• The barriers are similar to those in the US

• Attempting to adjust/adapt programs to fit the current reimbursement/policy environment is stifling DM expansion/success

Criteria for Success….Lessons Learned from Global Experience

• More rapid adoption of behavior change science• More aggressive leveraging of technology• Clearer/more validated methods of measuring

performance• Enhanced integration of DM into the existing

system• The next frontier: absenteeism & productivity• Strategies for policy and reimbursement change

Success Criteria…Areas of Opportunity

…. Leveraging the Science of Behavior

Change

Theories / models of behavior change

• Self-monitoring • Stimulus control • triggers• Contingency management• Stress management• Social support• Challenging irrational beliefs • Cognitive rehearsal • Motivational Interviewing • Goal setting• Relapse prevention/ recycling• Attributional retraining

• Health Belief Model• Transtheoretical (Stages

of Change) Model• Motivational Interviewing• Social Cognitive Theory• Solution Focused

Therapy• Self-regulation

STRATEGIES MODELS

Source: Health Media

Changing Patient Behaviors…

DurationFreq

uency

Inte

nsity

We Must Better Leverage the principles and Models of Behavior Change

Basic Ingredients of Behavior Change

It Takes More Than Education to Change Behavior

Patient Education Passive Primary goal =

educate/inform Assumes knowledge

changes behavior One-dimensional Generally focused only on

patient

Behavioral Interventions Interactive Primary goal = improve outcomes Directly addresses drivers of behavior Demonstrated educational principles Focuses on relationships among all

influencers - Patient - Physician - Pharmacist - Care partners - Other providers

Reprinted with permission of Hastings Healthcare Group

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Message Tailoring Increases Effectiveness

Priorities/Perception of riskSocial supportStress/DepressionCostTime with conditionSymptom managementRefill convenienceTreatment complexity Co-morbidities HabitExpectations and beliefsGoalsTriggersLifestyle issues

AcceptanceEmotionQuality of lifeKnowledgeStage of change Demographics (Gender/Ethnicity/Age..)Side effectsPersonal/Family health historyDoctor/patient relationshipMedication historyBio-medical measuresMotivationSelf confidencePrior attempts at addressing issueHobbies/interests/employment

Factors Related to Behavior Change

Leveraging of Technology

Disrupting like the Disrupting like the Roomba…Roomba…

1819(2.3%

of Total)

1708 (2.2%

of Total)

Year 1

Year 2

Patients who had an asthmarelated hospitalization in bothYear 1 and Year 2.

283(16 % ofYear 1

High-Risk)

Predictive Modeling Finding the future high Utilizers….

MeasurementBreakthroughs

Modern Psychometric Methods

Computerized Dynamic Health Assessments

Dynamic Health AssessmentsOn the Internet

0.0

0.2

0.4

0.6

0.8

1.0

20 30 40 50 60 70 80Prob

abili

ty

An Opportunity…PRO Outcome Measurement Tools

New outcome instruments can be used both for health outcome assessment and for patient

identification, segmentation and prediction

SF Survey Standardization Makes it Possible to Interpret Treatment Outcomes

3034 38

40 5055

Congestive Heart Failure

Chronic Lung

Disease

Average Well Adult

Source: Adapted from Ware, Kosinski & Keller, 1994; Okamoto et al., 1996

Asthma Before

Rx

Asthma After Rx

46

Average Adult

Physical Component Summary (PCS)

Physical limitationsCut in half (28 to 13%)

Costs reduced 1/3;Both hospital &total

The Ultimate Solution..is Disease Prevention

75% of chronic disease is the result of unhealthy lifestyle…and is preventable!

Wellness Research Suggests:

• Individuals Can Maintain Low-Risk Health Status even as they Age

• A Health Plan, Employer, or government can Help its Members/Citizens Maintain Low-Risk Health Status

• The Major Economic Benefit is in Paying Attention to Individuals with Low-Risk Health Status

At the End of the Day… ……The Good News IS…

• The scientific knowledge exists…today

• A relative small annual reduction in chronic disease death would achieve major economic and social results.

• The good news is: - The Causes are Known - The Way Forward is Clear - It’s Will Only Take Unique Leadership and an Action Plan

• Leadership and comprehensive, integrated action is the answer

• China is well position to demonstrate this type of leadership and action

Effective Global Interventions…

• Poland – 7% decline in deaths from heart disease• Finland – 65% reduction in death rate from heart

disease plus major decline in deaths from lung cancer with 7 year increase in male life expectancy

• Philippines – decline in adolescent smoking from 33% to 22%

• Singapore – Smoking rate decreased from 23% to 15%• South Africa – 33% reduction in tobacco use• Zambia – major drop in sales of branded soft drinks

Effective Global Interventions….

• Sao Paulo, Brazil – regular physical activity increase from 55% to 60% in 2003; 96% increase in older high risk group

• United States – Schools meeting EAT SMART guideline increase from 10% to 50%

• South Africa Nurse Based DM program achieved improved disease control in 68% of hypertensive, 82% of diabetics and 84% of asthmatics

• Russia – 85% reduction in admissions from high blood pressure• New Zealand – National Food Industry Accord to reduce obesity

Effective Interventions in China…

• Tianjin, China – Results: average salt intake was significantly lowered with decreases in systolic blood pressure

• China Disease Prevention Project [1995] in 7 cities – Results: reduction in smoking from 59% to4 44% plus increase in high blood pressure detection and a 15% decrease in strokes

• MOH – 32 demonstration projects across the country – Results: Prevelence of adult smoking reduced from 29% to 13% in Shanghai plus increase in planned regular physical activity from 41% to 84%in Shenyang

Different forms of effective interventions

• Legislative Controls - Tax and Price Interventions and indoor smoking bans

• Improved Environments – footpaths increases rates of walking by 30-50%

• Advocacy/Communications – Awareness & social change• Community & School Based programs – cost of US$0.03 to

US$0.06 per capita generates 0.1% to 0.4% of disease burden• Vending machines – Access to better foods• Workplace Interventions – Johnson & Johnson wellness

program generated improvements in 8 of 13 risk categories• Comprehensive Disease Management Program – now in 21

countries and expanding

Recommendations to “Get Started”• Organize stakeholders to identify obstacles and build support of “change.” • Look for “champions”• Initiate “pilot” programs…worry about changing the system

later….small steps! • Customize to meet the needs of your country• Don’t overlook how difficult DM is to implement• Tap into the experience of other countries• Short-term, reinforce “validity” of the concept and explore

different models• Long-term, use DM to re-engineer the system versus as a band-

aid.

In Summary…• The crisis of chronic disease and erosion of

lifestyle is a one• We need to work together….• There are very important “lessons learned”

around the world, including the United States• Countries can demonstrate true regional and

global leadership in both disease management and wellness initiatives

The Challenge... the Mission

The challenge of the unprecedented personal and economic burden of a rapidly aging population with its inherent problem of how to better manage chronic disease has been described as the "next global crisis." This world-wide problem requires world-wide collaboration.

The mission of IDMA is to create an international forum of disease and health management stakeholders in order to share knowledge and to build a collective experience on how to better promote healthy lifestyles and to enhance the management of chronic disease.

About IDMA…

• www.DMAlliance.org or Wtodd@DMalliance.org• www.DMAA.org• www.WHO.org• Australia, Japan and Germany DM Associations…see IDMA website.• DM Conference in 2007 [Eastern Europe, South Africa, Brazil,

Canada, and perhaps Hong Kong]• Copy of this presentation at www.DMalliance.org/China in 10 days

DM Resources…

ALSO: IDMA World DM e-Report - Complimentary Weekly e-Newsletter at www.DMAlliance.org [reaches 8,000 chronic disease stakeholders in 62Countries.

Disease Management ColloquiumPhiladelphia, PA May 7-9, 2007

International DM and ApproachesLucia S. Rosenberg

Vice President of Product DevelopmentU. S. Preventive Medicine

lrosenberg@uspreventivemedicine.com

Warren E. Todd, MBAExecutive Director

International Disease Management Alliancewtodd@dmalliance.org