The line from peddling pills to 'disease management'
By Andrew Jack
Published: April 17 2009 03:00 | Last updated: April 17 2009 03:00
As Maureen describes how the severe pain in her joints makes it hard to do housework, Amanda Cooper listens sympathetically at the other end of the line while gently steering the conversation in a new direction. Glancing at the case notes on her computer screen, she says: "You know, you should try to move around regularly because of your arthritis, to keep the blood flowing and get oxygen to the heart."
The two women have never met but are talking by telephone as part of a pioneering programme designed to help people with diabetes, cardiovascular and other health conditions. In the course of a 20 minute chat, they touch on exercise, taking medicines and diet, with the patient taking the lead.
The conversation is part of a growing practice of "disease management" that could help patients and cut healthcare costs, while generating income for pharmaceutical companies - if they can overcome considerable regulatory and practical difficulties. "It's all about moving from a paternalistic health system to one in which patients do things for themselves," says Andrew Donald, chief operating officer of the Birmingham East and North primary care trusts, who was persuaded of the potential for such programmes during a US study tour in 2003.
Ms Cooper and 11 colleagues work in a call centre near Birmingham alongside local employees of NHS Direct, the nationwide service that provides medical advice to telephone inquiries. Ms Cooper's team, by contrast, actively calls patients identified as needing extra support. "Your objective is to empower people to look after themselves," says Pam Bradbury, who runs both services.
Pfizer, the world's biggest pharmaceutical company, which provides the training and know-how behind the programme, hopes to learn lessons from earlier less successful ventures in the US, Italy and the UK.
In recent years, many healthcare companies - including insurers and pharmaceutical manufacturers - have focused on such disease management programmes. The drug companies hope to boost sales of their products, and justify high prices, by improving patient outcomes and reducing costly hospital admissions and doctors' consultations, measures against which healthcare funders test them.
Eli Lilly of the US has funded groups working to encourage diabetes patients to manage their condition and to take their medicines. Johnson & Johnson made two recent acquisitions to build a "fourth pillar" of health promotion alongside its pharmaceuticals, diagnostics and consumer health units.
Pfizer's Health Solutions division, which was established when it launched a project in Florida in 2001, has gone further still. It used telephone counselling to support healthier lifestyles for nearly 150,000 patients on Medicaid, the government-backed health insurance programme for the poor. It agreed to pay the costs, provide some free medicines and save the Florida administration nearly $40m (£27m) over four years or pay the difference.
The results were mixed. The scheme was partly undermined by the state government keeping Pfizer's higher-priced patented medicines on its list of approved drugs for reimbursement rather than cheaper generic alternatives, without imposing big price discounts. Critics argued that the state would have saved more money simply by imposing the discounts. They also questioned the speed and extent of enrolment of patients and the true benefits and cost savings.
But Pfizer persisted and launched modified versions elsewhere, while dropping any direct link between the programme and its medicines.
In the south of Italy, Project Leonardo involved more than 1,000 patients. Recognising that face-to-face contact is important, it installed nurse-advisers in clinics to talk directly to patients. In Haringey, a relatively poor part of north London, where Pfizer launched TeamHealth for 740 patients with heart disease or diabetes in 2003, the programme was conducted by telephone.
Pfizer has tried to apply the rigour of a quasi-medical clinical trial to test outcomes. However, the results were disappointing. Patients liked the service, but there was no statistically significant change in expensive hospital admissions and other consultations. Pfizer concluded this was partly because of the short timescale in which the programme sought returns, as well as its use of staff who spoke only English in an area where it is not the first language of many patients.
The company drew on these experiences when devising OwnHealth with the NHS in Birmingham, working by phone and providing bilingual staff to talk to the large Asian community.
A bigger challenge is how far case managers like Ms Cooper can make a difference, when so many factors outside their control determine health.
"You're dealing with the interaction of health and social care," says Richard Mendelsohn, director of chronic disease systems for the two Birmingham primary care trusts. "That means jobs, access to material support, housing, people dealing with drugs, prison, and [feeling safe] to go out and exercise."
Even so, Mr Donald has extended the service to 2012, involving more patients and support for a wider range of conditions. Results for the first year are showing promise, with a decline in cholesterol and obesity, a reduction of nearly half in hospital admissions and emergency visits, and visits to family doctors down by a third, he says.
John Proctor, head of Pfizer Health Solutions in the UK, points to an expansion of the Birmingham project to 30,000 patients by 2011, talks with other primary care trusts and a pilot programme with cancer survivors in London. "I'm pretty confident we've been vindicated," he says.
Copyright The Financial Times Limited 2009
Comments