The Asheville Project manages health issues on the front end

Polly McDaniel knew her health could be better when she took a job with Asheville city government a year and a half ago. Her blood pressure was high, she was overweight and she has clinical depression.

But McDaniel hardly knew where to start to improve her health. She wanted to exercise, but her knees were in terrible shape, and she had little time between work and family obligations.

But the city has a program that helps employees like McDaniel manage chronic conditions: The Asheville Project began a little over 20 years ago, on Feb. 1, 1997, and it has helped to reduce health care costs dramatically.

“It’s not just about my blood pressure or my depression,” McDaniel says. “I meet with someone regularly, and she talks to me about everything.”

The Asheville Project was initiated to try to reduce costs and help people be healthier despite chronic illness, says John Miall, who was the city’s risk manager at the time.

“It boiled down to how we want to spend our health care dollars,” Miall says.

The idea was that if people could be incentivized to manage chronic health conditions, they would be healthier, and the city’s costs would be much lower. For example, glucose testing supplies are a few thousand dollars a year, but the cost of limb amputation, strokes, renal failure or blindness — all common complications of diabetes — can reach hundreds of thousands of dollars per person.

The idea was to offer to cover the cost of medications and testing supplies if employees agreed to follow the protocols necessary to manage their diabetes.

“That first year, all we did was diabetes, and the health plan spent 32 percent less on people with diabetes in the first year alone,” Miall says. “I call that stunning results.”

When cardiovascular conditions were added (high blood pressure and high cholesterol), the cost of care dropped 51 percent over three years, Miall says.

In the first 14 years of the Asheville Project, not one employee had to go on dialysis because of diabetic kidney failure.

Others began to take notice, and Miall traveled across the country, telling other cities and companies how to set it up. Mission Health, which helped to develop the project with the city, adopted it in 1999. Buncombe County government also has adopted it.

Currently, the project deals with a number of chronic conditions: diabetes and prediabetes; asthma and chronic obstructive pulmonary disease; depression; high cholesterol; and hypertension. Mission has added people who are on long-term blood-thinner therapy. Complications of these illnesses are expensive, so preventing or even delaying the onset of complications can save millions of dollars for a large employer.

The project pairs patients with community pharmacists, who meet with them regularly to discuss concerns. At first, the city recruited local pharmacists, and some still work with the project, but since it has grown, the city contracts with Piedmont Pharmaceutical Care Network.

Caroline Lewis is regional director for PPCN, a pharmacist and McDaniel’s consultant.

“The fact is, you have to treat the whole person,” Lewis says. “You can ask whether the person is taking the prescribed medication and taking it correctly, but you also want to know the person is getting regular eye exams and dental care, that they’re doing something to reach or maintain a healthy weight, that they’re getting exercise.”

“We talk about everything,” McDaniel says of her medical consultations through the Asheville Project. “We talk about my stress levels, my ability to exercise — anything I’m concerned about.

McDaniel says she was having trouble sleeping several months ago and talked about it with Lewis.

“We looked at what I might be doing, and it turned out I was drinking a lot of iced tea,” McDaniel says. “She told me to go for decaffeinated tea, and the problem went away as soon as I made the switch.”

While doctors spend an average of five to seven minutes with a patient, PPCN pharmacists spend 30 to 60 minutes. Initially, the appointments are monthly, and later, if the person’s condition is stable, they meet quarterly.

Lori Brown, a pharmacist and director of clinical operations at Mission, says some 1,200 employees are on the rolls now, and as with the city of Asheville, other clinicians have been added to the mix, including dietitians, diabetes nurse educators, licensed clinical social workers and nurse case managers, all of whom work with patients’ primary care physicians to improve outcomes.

The caregivers can help patients set priorities in their care.

“For example, diabetes affects every system in the body, and someone who’s newly diagnosed may not even know where to start — they need to learn about diet and medication, controlling blood pressure, getting an eye exam. There’s a lot to learn, and it can be confusing,” says Brown.

The Asheville Project caregivers can help people sort it all out.

Many times, Brown says, it’s not the lack of knowledge that keeps people from being effective in managing their health; often it’s the other curveballs in life, such as a late meeting at work that doesn’t leave time for cooking a healthy dinner. Children’s activities or caring for an elderly parent can also put a person’s focus elsewhere. Caregivers associated with the project can help patients learn ways to think about their health despite all their other obligations.

Lewis says that often the biggest piece of the puzzle is helping people learn the skills they need to manage their health — how to buy and cook healthier foods, work in some exercise time and practice stress-reduction techniques.

The other big piece, Miall says, is making sure medications are taken correctly, and people can’t do that if they can’t afford them or don’t understand the instructions. Many people still don’t understand that antibiotics must be taken to completion or that they can’t save a few to use next time they get sick.

“One thing to note here is that up to 40 percent of prescribed medications are never filled,” Miall says. “Another one-third are not taken to completion or not as directed.”

Sometimes, people cut pills in half because they struggle to afford their prescriptions, Miall says. Under the terms of the Asheville Project, the medications are paid for if the person complies with the treatment regimen. The pill-cutting problem goes away.

One employee told Miall he used to cut glucose testing strips in half to try to save money, but they often didn’t work properly. Once he was in the program, he never had to worry about the cost again.

“People shouldn’t have to choose between their medications and food,” Miall says.

The program reduces costs, but Lewis says what’s even more important is that it reduces suffering.

As of the end of 2015, 88 percent of those enrolled in the Asheville Project either improved or were at goal for LDL cholesterol levels; 86.5 percent were either improved or at goal for blood pressure levels; and 88.9 percent of people with diabetes or prediabetes showed improvement in A1C, a long-term blood glucose measurement.

At Mission, Brown says that studies early on showed more people were seeing the doctor and getting prescriptions, but costs declined by about $2,000 per patient nonetheless.

“Emergency care is much, much more expensive,” Brown says.

Since McDaniel enrolled in the program, she has been able to lower her blood pressure and manage her depression. She has had a knee replacement and has scheduled surgery for her other knee. She has lost about 5 percent of her body weight and plans to get into a regular exercise routine as soon as she has recovered from her second knee replacement.

“I’ve made positive changes, and I’ve managed to lower my stress levels,” McDaniel says. “I feel better, and I know I’ll continue to do so.”