Quality Purchasing: A Strategy to Constrain Health Costs

Gerald M Shea, Ass’t to the President, AFL-CIO

Leonard Davis Institute of Health Economics

November 7, 2003

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

All Health Services Gross Domestic Product

Per capita percent changes in health spending and GDP

Divergent trends in financing employer health benefits:

1. Cost-shifting to individuals and families

2. Quality purchasing and cost management thru care improvement

Cost-Shifting

• Increased premium contributions and higher deductibles and co-pays

• Some abandonment of coverage

• Leveraging consumers by putting more of their own money at risk coverage

52% 49%

57%

65%

46%

71%

0%

20%

40%

60%

80%

100%

Single Coverage Family Coverage* Preferred Provider Non-PreferredProvider

Preferred Drugs Non-PreferredDrugs

Workers' PremiumContributions

Prescription Drug CopaymentsPPO Deductibles**

$508

$334 $1,619

$2,412

$175

$275

$340

$561

$13

$19

$17

$29

Increases in Out-of-Pocket Costs Averaged Over 50 % from 2000 to 2003

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2000, 2003. *Family coverage is defined as health coverage for a family of four. **Average deductibles include covered workers who do not have a deductible or report a $0 deductible.

Chart#2

Cost-Sharing Trends

• Percentage of premiums paid by workers relatively steady since mid-nineties at about 15% for individuals and 27% for families

• Dollars contributed for family coverage up 400% in same period

• PPO deductibles doubled for workers in firms of less than 200 since 2000

• One-third of firms predict offering high deductible plan in next two years. Almost as many predict offering health reimbursement accounts (Kaiser Family

Foundation/Health Research and Educational Trust 2003 Health Benefits Survey)

Most Large Firms Expected to Boost Worker Premiums in 2003

7%

21%

29%

37%

28%

7%

26%

35%

38%

29%

12%

91%

64%

32%

17%

14%

8%51%

20%

14%

8%

1%

3%

0%

1%

2%

1%

0%

0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Drop Coverage Entirely

Restrict Employee Eligibilityfor Coverage

Offer a High Deductible Plan

Increase the AmountEmployees pay for

Deductibles

Increase the AmountEmployees pay forPrescription Drugs

Increase The AmountEmployees Pay for Health

Insurance

Very Likely Somewhat Likely Not Too Likely Not At All Likely Don't Know

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2003.

32

Chart #28

Increasing Cost-Sharing Reduces Use of Essential Care

• Rand (1986) showed decreased likelihood of receiving effective care for acute conditions among both high and low income in cost-sharing plans

• Tamblyn et al (2001) found that cost-sharing reduced use of essential drugs per day among elderly (9%) and low-income (14%) and was associated with large increase in emergency room visits – 43% for elderly, 78% for low-income

12.0%

18.0%

14.0%

8.5%

0.8%

5.3% *

8.2% *

10.9% *12.9% *

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Health Insurance PremiumsWorkers EarningsOverall Inflation

Source: KFF/HRET Survey of Employer-Sponsored Health Benefits: 1999, 2000, 2001, 2002, 2003; KPMG Survey of Employer-Sponsored Health Benefits:1993, 1996; The Health Insurance Association of America (HIAA): 1988, 1989, 1990; Bureau of Labor Statistics, Consumer Price Index (U.S. City Average of Annual Inflation (April to April), 1988-2003; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1988-2003.

*Estimate is statistically different from the previous year shown at p<0.05: 1996-1999, 1999-2000, 2000-2001, 2001-2002.

^ Estimate is statistically different from the previous year shown at p<0.1: 2002-2003.

Note: Data on premium increases reflect the cost of health insurance premiums for a family of four.

Char #1

2

13.9%^

3.1%

2.2%

Insurance Premium Rose Six Times Faster than Overall Inflation in 2002

Quality Purchasing/Care Management

• Risk reduction

• Patient centered care

• Clinical best practices

• Disease prevention

• Disease management

The Cost/Quality Nexus

Improved processes of care produce:

• Better health outcomes

• More satisfied patients

• More satisfied caregivers

• Reduced costs

Purchasing Quality Health Care

• “Quality improvement may well be the unifying force for health care reform”

• “Systematizing quality improvement has the potential to improve health and health care more than any foreseeable technological or scientific breakthrough in the next 20 years, including finding cures for diabetes, heart disease or cancer” (Dr. Ken Kizer, CEO, National Quality Forum)

Growing Cognizance of Safety/Quality Problems &

Associated Costs

• Rand Study – 1986

• Harvard Medical Practice Study – 1991

• IOM Reports – 1999 & 2001

• Rand Study – 2002

• Zhan & Miller – 2003

Health Costs & 2003 Collective Bargaining

In a year of bargaining in large contracts covering 1.5 million workers, health costs

have been center stage.

2003 Bargaining

NYC 2002 150,000 Various

Nationwide Building Contractors

2002-3 50,000 SEIU

Master Freight

3.03 65,000 IBT

Rubber 4.03 77,000 USW

Washington Contractors

5.03 32,300 Bld Trades

GE 6.03 48,000 Various

2003 Bargaining, cont’d

Telecom 8 – 11.03 113,000 CWA & IBEW

Auto 9.03 330,000 UAW +

So. Cal Grocers

10.03 80,000 UFCW+

Advertisers 10.03 130,000 SAG & AFTRA

Wal-Mart Workers Earn 20% Less than Other Retail Workers, 2002

$8.00

$10.04

Wal-Mart Workers Average Retail Trade Workers

Source: UFCW News Release, October 10, 2003; BLS, January 2003.

Wal-Mart Workers Pay Greater Share of Premiums than Other Private Sector Employees

42%

25%

14%

Wal-Mart Workers Average Worker - SingleCoverage

Average Worker -FamilyCoverage

Source: UFCW analysis; Kaiser Family Foundation, Employer Benefits Survey 2003.

Fewer Wal-Mart Workers Are Insured UnderTheir Employer Plan Than Other Workers in

Large Firms (2001)

41%

66%

Wal-Mart Average Worker

Source: Commonwealth Fund, October 2003; Wall Street Journal, September 30, 2003.

Wal-Mart Spends Less Than ½of What the Average US Employer

Spends on Health Benefits$7,954

$4,834

$3,500

US Employers Wholesale and RetailStores

Wal-Mart

Source: Mercer, Wal-Mart, Kaiser Family Foundation, (Wall Street Journal, 9/30/03).2002

“What you get for that (worker premium payments, deductibles and co-pays) is an outstanding

catastrophic medical plan.”

Wal-Mart V-P Mona Williams (Mn. Star-Tribune)

Share of Uninsured Working at Large Firms Jumped from 1987-2003

1987

61%14%

25%

2001

12%

32%

57%

Small (<100)Medium (100-499)Large (500+)

Source: The Commonwealth Fund.

U.S. Businesses that Provide Health Benefits

are at a Competitive Disadvantage • In the global economy,

US companies are at a disadvantage compared to other industrialized nations with social insurance systems and to developing countries without insurance systems

• Domestically, companies that provide health benefits are at a disadvantage compared to companies that do not and to companies that provide catastrophic-only coverage

Real Health Expenditures Per CapitaCanada, United States and OECD Countries, 2001

in U.S. Dollars, PPP

Notes: Health expenditure per capita expressed in economy-wide purchasing power parity, United States dollars.

Source: Source: Health Data:Table 9: Total Expenditure on Health, Per capita US $ PPP, Organization for Economic Cooperation and Development (OECD), http://www.oecd.org/document/16/0,2340,en_2649_34631_2085200_1_1_1_1,00.html.

$301

$586

$629

$893

$911

$1,1

06

$1,5

11

$1,6

00

$1,6

13

$1,7

10

$1,8

41

$1,9

35

$1,9

84

$1,9

92

$2,0

60

$2,1

70

$2,2

12

$2,2

70

$2,3

50

$2,4

90

$2,5

03

$2,5

61

$2,6

26

$2,6

43

$2,7

19

$2,7

92

$2,8

08

$2,9

20

$3,2

48

$4,8

87

Turke

y

Mexico

Pola

nd

Kore

a

Hungary

Cze

ch R

epublic

Gre

ece

Spain

Portu

gal

New

Zeala

nd

Finla

nd

Irela

nd

Japan

Unite

d K

ingdom

Avera

ge

Austria

Italy

Sw

eden

Austra

lia

Belg

ium

Denm

ark

France

Neth

erla

nds

Icela

nd

Luxe

mbourg

Canada

Germ

any

Norw

ay

Sw

itzerla

nd

Unite

d S

tate

s

2004 Presidential Election Offers Rich Set of Policy Options

• Individual coverage schemes vs expanded use of group coverage

• Requirements on individuals and on employers

• Strengthening existing group coverage through tax credits, employer requirements, employee requirements and expanded public programs

• Individual tax credits, employer tax credits and public subsidies.

• Switch to social insurance model?

• Cost containment vs open market, e.g., prescription drugs

• Emphasis on quality purchasing

The Bottom Line: Cost & Coverage 

Candidate Federal Costs (Billions)

Newly Insured **(Millions)

 Representative Richard Gephardt* Senator John Kerry Governor Howard Dean General Wesley Clark Senator John Edwards Senator Joseph Lieberman

 $2500 $ 895 $ 932 $772 $590 $747 

30.9 – 43.6 26.7 30.2 31.8 21.7 31.6 

State Rebellion

• At least seven states and numerous cities are now actively considering programs to import drugs from Canada to save costs in Medicaid, other public programs for low-income, and public employee programs.

• 22 state labor federations are working on comprehensive reform initiatives.

“In my opinion the pharmaceutical corporations and

the lobbyists have an absolute stranglehold on Washington.”

Mayor Michael J. Albano, Springfield, Mass.

State & Local Initiatives

• Coverage Expansion/ Cost Containment (see outline in handouts)

– California

– Maine

– Wisconsin

– Oregon

– Nevada

• Buy Canadian– Illinois– Minnesota– Iowa– Michigan– Wisconsin – Ohio– West Virginia– Many cities, starting

with Springfield, Mass

The Toughest Policy Challenge: Cost Containment

• Eliminate cost-shifting (thru universal coverage)

• Shrink bureaucracy

• Constrain payments

• Restrict usage

• Buy only high quality care

• Reinsurance for high cost cases

Traditional Cost Control Policy Options Come Up Short

• Strong regulatory mechanisms, whether public, e.g., global budget, or private, e.g., managed care, constrain cost growth but are not politically acceptable in U.S.

• Market competition could be useful if achievable, but also brings distortions in delivery systems that drive up utilization and costs, e.g., technology.

Quality Purchasing and Care Management involves cultural change and industrial change

• Personal responsibility from consumers• Patient-centered health care organizations• New partnership between clinicians and patients• Standardized performance measures• Real time public reporting of quality performance• Computerized information systems and decision

tools

EVOLUTION OF A EVOLUTION OF A HEALTHCARE QUALITY HEALTHCARE QUALITY

MANAGEMENT SYSTEM: MANAGEMENT SYSTEM: A Work in ProgressA Work in Progress

Kenneth W. Kizer, MD, MPH, Kenneth W. Kizer, MD, MPH, President and CEO, National Quality President and CEO, National Quality

Forum September 29, 2003Forum September 29, 2003

PrefacePreface

We have spent considerable effort over the past four years conceptualizing and implementing a quality measurement and reporting system.

However, to achieve optimal value the quality measurement and reporting system should be part of an overarching quality management system.

We have yet to conceptualize a coherent vision of an overall healthcare quality management system.

Three of the cornerstones of a healthcare quality management system are accreditation, regulation and education.

HEALTHCARE QUALITY IMPROVEMENT IS NOT A

NEW QUEST

The Quest for Health Care Quality

• 1910 - Flexner report• 1914 – Codman• 1918 – Hospital Standardization Program• 1951 – JCAHO • 1972 – PSROs• 1970s – Criteria mapping, sentinel events, tracer

approach, Williamson’s health accounting system, staging methodology, PEP, others

The Quest for Health Care Quality

• 1980s – TQM, CQI• 1982 – PROs• 1991- NCQA• 1994 – Indicator Measurement System

(JCAHO)• 1998 – IOM National Roundtable,

Presidential Commission, RAND• 2000 – NQF, Leapfrog, other• 2003 – Public reporting of performance,

pay for performance, IT modernization

Quality Improvement and Health Care Culture: The Past

• Combination of art and science

• Highly individualistic

• Competitive

• Ad Hoc organization

• Focus on perfection (not excellence)

Quality Improvement and Health Care Culture: The Future

• Focus is on continuous learning and process redesign in an environment in which:– Healthcare’s complexity and high risk nature are widely

understood;– Performance and outcomes are continuously measured and

evaluated;– Knowledge and skills are actively managed; – Errors are readily identified and evaluated;– Collaboration and teamwork are the norm;– Care is highly coordinated and care needs are anticipated; and – Performance is consistent and predictable.

Forces Behind Purchaser Initiatives

• Rising health costs• Growing understanding that quality in

health care can be:Accurately measuredRoutinely assessedSystematically improved

• Recognition that overall health status is declining as health costs are rising

Quality Purchaser Initiatives

• The Leapfrog Group• Medicare – Hospital Quality Incentive

Demonstration Project• Pittsburgh Regional Health Initiative• Central Florida Employers Coalition• UAW- Autos Community Health Initiative• Iowa Medicaid• Pacific Business Group on Health• BCBS of Illinois

Regulation and Accreditation

• Quality Assurance and Performance Improvement programs made a CMS COP

• OIG and DOJ make quality of care a top priority under the False Claims Act

• MedPAC recommends linking hospital payment to quality of care (2003)

• State regulations (e.g., CA nurse-patient ratios)• JCAHO Patient Safety Goals

Ten Percent of the US Population Account for 70% of Health Costs

In addition to maintaining health and preventing illness, care management focuses on high-leverage intervention

opportunities.

Why did this work?• Early recognition of limited benefit and

oncoming advertising blitz

• Clinical research with Palo Alto VA and development of validated NSAID GI Risk SCORE Card

• Subsequently automated by reference to pharmacy, health plan, laboratory, hospital and outpatient online records

• Close monitoring and clinician feedback

Value and EvidenceCOX-2 Market Share

KP vs. National

5%

46%

95%

54%

0%

20%

40%

60%

80%

100%

K-P National

COX-2's Other NSAIDs

Initiative Case Study

• Statins– Conversion program from brand simvistatin

to a therapeutically equivalent dose of generic lovastatin of existing simvastatin patients

– Requires absolute physician confidence in safety and appropriateness of the switch

– In the process, identify patients who are not at goal and get them there

– Overall, significant improvement in care and improvement in cost-effectiveness of the drug benefit

Value and Brand CompetitionCholesterol Medication Market Share

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

KP CA U.S.

A B C D

KP uses almost 100% of our preferred products for cholesterol

KP Preferred

KP Preferred

Value as Appropriate Use

25% Overall Decrease in Utilization of Antibiotics over 2 years

No Increase in Outpatient Visits

No Increase in Hospitalization Rates

Quality Campaign to Drive Appropriate Use of Antibiotics in Outpatient Respiratory Infections

14

Kaiser’s Physician Tool Kit

• Pilot studies of computerized support tools show improved ability for timely care interventions: – Reduced death rate from end-stage renal

disease 31% (So. Cal) – Cut heart disease rate approx 50% (Ohio) – Reduced bleeding complications by 79% from

anti-coagulation therapy (Colorado)– Cut nurse paperwork time 50%

RxHealthValue

A Purchaser and Provider Perspective on the

Prescription Drug Marketplace

Sharon Levine, MD, The Permanente Medical GroupAnthony Barrueta, Kaiser Foundation Health Plan

April 7, 2003Washington, D.C.

A Complex Demand Market

– Physicians prescribe, pharmacists dispense, patients use and insurance pays for drugs

– Patients are insulated from cost and are being stimulated, without full information, to seek specific drugs from physicians

– Physicians, plans and pharmacies are disaggregated

• Incentives are misaligned• Physicians do not practice as groups• Physicians must use multiple formularies • makes purchaser cooperation difficult

– Lack of comparative data

Regulatory Lessons

• Drug cost increases are a function of price and utilization– Prices are affected by regulation directly

and indirectly• Market vs Administered pricing

– Utilization requires clinical cooperation• Old vs New• New vs Better• Targeting use appropriately• Impact of advertising and objective research

– Some are good and some lack value• Pharmacoeconomic value is important

Key Areas of Concern• In 2001, five classes of drugs (16 drugs total)

represented fully 22 percent of total US Rx spending (Total = $154 billion)

• SSRI antidepressants (4 drugs/ $8.1 b)• Proton pump inhibitors (4 drugs/ $8.5 b)• LS antihistamines (3 drugs/ $4.4 b)• Lipid lowering statins (3 drugs/ $8.7 b)• Cox-2 anti-inflammatories (2 drugs/$4.4 b)

• All ripe for clinically and economically sound management

• The Goal is to Assure Value

Finding Value

• Prudent purchasing flows from prudent prescribing

• Physician cooperation is key to maximizing clinical and economic value for patients

• In an inherently dysfunctional market, physicians hold the key to stimulating price competition

• Physicians’ clinical concerns must take precedence over pure economics

The Kaiser Permanente Model

– Physicians practice as a group• they have access to comparative cost and

effectiveness information• Cooperative group practice with a culture of

fiduciary responsibility to the membership

– Drug Information Service• Supports formulary decisionmaking• Clinical information provided to physicians

– Key issue -- how can this be applied in the broader physician community?

Clinical Guidelines Case Study

• Cox-2 inhibitors• “Appropriate” treatment for between 4 and 5

percent of NSAID-using arthritis patients– In that group, benefit is reducing risk of GI

bleeding from 1 in 75 to 1 in 200

• 50+ percent of new NSAID prescriptions in US are for Cox-2s

• KP use is approximately 5 percent– Result of careful application of patient criteria with

support of physicians

April 7, 2003Rx Health Value

Congressional BriefingBruce Bradley

Director Health Plan Strategy and Public Policy, GM

Purchaser Management of Prescription Drugs: Quality and Cost

•1.2 million covered lives• 180,700 employees ($ 1.5 Billion)• 423,000 retirees ($ 3 Billion)

•$4.5 Billion Spending• $1.5 Billion Prescription Drug

•256 Health Plans (160 HMOs and PPOs)•30 million Transactions with

• 4,300 Hospitals• 36,000 Pharmacies• 241,000 Physicians

General Motors 2002 Health Care

• GM believes the way to reduce health care cost is to improve quality…i.e. preventing over use, under use and misuse of the health care system and provide people with the information on quality to make smart health care choices.

Summary

In other words, get the WASTE out so the dollars can be put to better use!

Generic Drugs

– Joint UAW-GM ongoing communications program• Employee and retiree education• Educated our own leadership on generic drugs• Physician education

– Generics First program• Provides generic samples to physicians• Breaking down barriers, preconceived notion of generics• Medco Health implementing program on behalf of GM

– Next stage…pilot Rx vouchers– For each 1% shift from a brand drug to a generic

drug, there is a $3.5 million savings

Antibiotic Resistance– MARR (Michigan Antibiotic Resistance Reduction)

• Up to 40% of antibiotics prescribed in doctor’s offices are for viral infections, like colds, which are not treatable with antibiotics

• Business/community/provider coalition of S.E. Michigan• Developed common approach to decreasing antibiotic

resistance due to overuse • Using CDC guidelines• Educates physicians and consumers on when it is

appropriate to prescribe and ask for antibiotics• 5% reduction in overall rate of antibiotic use for acute

respiratory tract infections since 1998

Enhanced Physician Education

• Pilot Program– Hired vendor to meet with physicians to

improve appropriate use– Modeled after Pharmaceutical company sales

reps (detailers)– Face to face enhanced physician education for

those who fall out compared to their peers. Mailing will also occur.

– Pilot in Michigan, Indiana and Ohio

Appropriate Use– Implemented UAW-GM disease-focused

programs• Partners for Healthy Aging

– Educate older adults on the safe use of prescription medications

– Provide written drug information in easy-to-understand language

– Physician profiling– Therapeutic Interchange Program

2

Putting the Patient at the Center: VA’s Personal Putting the Patient at the Center: VA’s Personal

Health Record, MyHealth Record, MyHealthHealtheeVetVet (and Beyond) (and Beyond)

Jonathan B. Perlin, MD, PhD, MSHA, FACP

Deputy Under Secretary for Health

Veterans Health Administration

Department of Veterans Affairs

“Heal th Care’s Information Revolution: Putting People at the Center of Progress”

FACCT – Foundation for Accountabil ityWashington, DC – October 14, 2003

j. Perlin, Veterans Health Administration -October, 2003 4

2003: Who is “VA”Veterans Health Administration

VHA is agency of the Department of Veterans Affairs 3 Administrations: Veterans Health, Veterans Benefits, NationalCemetery

4.9 million patients, ~ 6.9 million enrollees Increased from 2.5 million patients / enrollees in 1995 (+96% / 7 yrs)

~ 1,300 Sites-of-Care, including 162 medical centers or hospitals, > 700 clinics, long-term care, domiciliaries, home-care programs 51 million Ambulatory Care visits, 600,000 hospitalizations

~ $25 B Budget: ~ $19B from 1995 –1999 (+ 32% / 7 yrs)

~185,000 Employees (~15,000 MD , 50,000 Nurses, 33,000 AHP) 21,000 feweremployees than 1995

Affiliations with 107 Academic Health Systems Additional 25,000 affiliated MD’s; 100,000 trainees / year 60% (70% MDs) US health professionals have some training in VA

j. Perlin, Veterans Health Administration -October, 2003 5

Who Are Our Patients ?

Older 49 % over age 65

Sicker Compared to Age-Matched Americans

3 Additional Non-Mental Health Diagnoses 1 Additional Mental Health Diagnosis

Poorer ~ 70% with annual incomes < $26,000 ~ 40% with annual incomes < 16,000

Changing Demographics 4.5% female overall

Females: 22.5% of outpatients less than 50 years of age

Computerized Provider Order Entry (CPOE), one of the Leapfrog Group’s “Top 3 Safety Strategies”

Outside of VA, CPOE < 8% nationally, < 30% among Academic Medical Centers

Nationally, 92% of all VA Rx’s Now CPOE

Ultimate Goal: 100%

VA is the Benchmark for CPOE

j . P e rlin , V e te ra n s H e a lth A d m in is t ra t io n - O c to b e r, 2 0 0 3 15

P n e u m o c o c c a l V a c c in a t i o n R a t e s

j. Perlin, Veterans Health Adm inistration - October, 2003 12

0

10

20

30

40

50

60

Hypertension Control in US

Percent Patient's BP < 140/90

VA Best US US Avg

j. Perlin, Veterans Health Administration -October, 2003 34

From Health Care Delivery To Patient-Centered Care

Patient-Centered Care CoordinationSupport patients with safe, high-quality care,

in health and disease, at the time & place, and in the manner patient desires

Patient is locus of control and care is seamless across diseases and locationsCare extends from hospital & clinic to home &

community

Imperative to Care for an Aging Population

j. Perlin, Veterans Health Administration -October, 2003 24

MyHealtheVet

Internet-based, secure Personal Health Record.Provides veterans with copies of key parts of theirVA

health informationVeterans can view, retain, and update theirpersonal

health data (BP, Blood Sugar, Wt, etc.)Comprehensive, Personalized Health Education

Information Personalized Health Assessments

Activate & Empower patients as partners with health care providers in achieving optimal health, through the sharing of health information

j. Perlin, Veterans Health Administration -October, 2003 35

CARE COORDINATION

The Clinic (Care Coordinator)Becomes Aware that the

Patient Is Beginning to

“Get Into Trouble,”

Proactively, The PatientIs Called To Come Into Clinic

. . .

Or Visited at Home!

Before S/He “Crashes”

j. Perlin, Veterans Health Administration -October, 2003 36

Home-TelehealthTechnologies

Voice Telephone-Based Data Still Images Physiologic Monitoring

Blood Sugar Weight Oxygen Respiratory Rate Stethescope

j. Perlin, Veterans Health Administration -October, 2003 42

Improved Clinical OutcomesCompared to Usual Care, Care Coordination Resulted in . . .

Blood Pressure Improvement:

62% greater reduction in systolic bp(p=0.015)

38% greater reduction in diastolic bp(p=0.050)

Diabetes Care (HbA1c) Improvement:

Regression analysis showed significantly greater decrease in HbA1c