November 15, 2016
Recent trends suggest that type 2 diabetes will reach epidemic-like proportions with projections showing that one-third of Americans may be affected by the disease by 2020. Are you concerned that diabetes could reach epidemic proportions in the United States?
If one defines an “epidemic” as a widespread occurrence for a given event, I would say that type 2 diabetes has already reached epidemic proportions. With the almost 30 million Americans (nearly 10%) who suffer from diabetes right now and another 86 million Americans (close to 30%) who have what used to be called “pre-diabetes” (such that their risk of developing type 2 diabetes is 70% over a 10-year time period), we are already in a crisis. Yes, I am concerned and I think that, from a public health standpoint, we all should be.
Do you feel that there needs to be more of an emphasis placed on preventive diabetes treatment in managed care organizations?
That’s an interesting statement. I think that what many people don’t realize is that there already is a large emphasis placed on preventive diabetes treatments in managed care organizations. For example, we work very hard in conjunction with our members to improve their health so that they don’t develop diabetes in the first place. We provide education to our members, whether individually or in larger groups, to teach them what they need to know to make good health promoting choices. We encourage and reward movement and activity because even mild exercise has been shown to promote health and wellness. We partner with certain grocers to promote and reward healthy food choices. And, to help prevent the potential complications associated with diabetes, we put our money where our mouth is by investing in companies that successfully address the challenges of living with diabetes, like Livongo and Omada Health, so that our members can achieve their best health.
How can managed care organizations be employed to avert a health care resource disaster related to diabetes?
In my opinion, a key area where managed care organizations can play an important role in averting a health care resource disaster is through the use of analytics. We have a tremendous amount of data that we capture from various sources: claims data, lab data, demographic data, and—in cases where we can perform health information exchange with our providers—certain electronic medical records data. The ability for us to mine that data for the gold nuggets of information and knowledge that it can provide to help us see patterns that might otherwise not be seen is incredible. Moreover, we can use that data to create predictive models that allow us to determine a given individual’s risk so that we can contact that person and address their needs prior to that person’s needing even more resources. Furthermore, we work with our provider partners by providing them that data on their patients so that they, too, can intervene much earlier than they would have if they didn’t know about the patient’s situation. This is a big deal when we think of, for example, a diabetic member who carries an increased risk of heart attack and stroke.
Analytics, then, allows for a more effective deployment of health care resources throughout the health care system. And, as Professor Regina Herzlinger first opined back in 2003, managed care organizations are the ideal group to function as “health infomediaries” for those exact reasons.
How can treatment guidelines and other research help payers implement better diabetes management plans?
That, too, is an interesting question. I say that for two reasons: first, guidelines are just as their name implies—they are meant to provide guidance to a clinician in addressing the needs of his/her patients. They are not to be looked at as unchangeable or otherwise set in stone. Second, guidelines can be tested as to their efficacy for a given patient population. For example, when we look at guidelines for the management of diabetes, they are fairly straightforward: (1) Begin with lifestyle changes and; (2) if that doesn’t work, begin metformin; and, (3) If metformin doesn’t help control the patient’s symptoms, consider additional second-line therapies by individualizing therapy to that patient’s needs.
Since we know that the clinician is going to make the best decision, with respect to the medical care for that person’s individual needs, we realize that there will be a great deal of variation in how individual patients are treated. Therefore, going back to the last question and my enthusiasm for analytics, we can use the data we have to see which treatments are most effective for the population of people with diabetes on the whole as well as if there are certain treatments that may be better for various subgroups of patients. In other words, we can help research move forward so that individual members/patients can achieve better health in managing their diabetes.
What factors need to be considered when developing benefit plan designs with diabetes in mind?
There are several key factors that we take into account and, ultimately, all fall under promoting the Triple Aim. First, whether one is speaking about people covered under commercial plans or under Medicare Advantage plans, we need to address the elephant in the room: cost. We need to keep the benefit plan designs affordable, especially when it comes to the cost of medications, because we all know that if someone can’t afford his/her diabetes medication, they won’t get it and such medication nonadherence helps no one.
Second, we need to be aware of the quality of care that our members with diabetes receive from their physicians and other providers. We share data with our providers as to key metrics that are a hallmark of what the medical evidence supports as quality care—and it’s more than just A1Cs. We find that those who use the data to promote quality improvement within their own practices continue to improve and that those who either ignore or push back on the data do not. Ultimately, those providers who continually show a lack of improvement in addressing the severity adjusted care they provide for members with diabetes have higher costs of care and jeopardize the affordability of plans for everyone. The more efficient and effective physicians would be the ones promoted by the greatest number of plans we have.
Last, we need to take into account the patient experience. We want our plans to work for our member with diabetes. We have to ensure that they have access to providers who know how to take good care of people with diabetes and that the members understand what is, and what is not, covered under their plan. For example, one of the physician groups in my market knows that their patients may have limited assets when it comes to getting appropriate diabetes education. So that group provides classes for our members/their patients and creates a specified diet plan that they expect their patients to follow. The best part is that patients lose weight, they feel better, they save money and they have a tremendous experience. I think that’s wonderful and I have learned not to underestimate the power of pickles!
Can accountable care organizations (ACOs) impact the way diabetes care is managed?
Absolutely. ACOs understand especially well that there must be communication within a given part of the ACO as well as between different parts of the ACO. They understand the connections between various aspects of diabetes: nutrition, prevention, heart health, eye health, etc. and they make sure that each member of the team taking care of someone with diabetes reinforces both the importance of taking care of diabetes from a holistic standpoint as well as from their individual niche. And, given that many ACOs are at financial risk for the care they provide, they understand that the costs of prevention, both financial as well clinical, are significantly less than the many costs of dealing with a medical issue.
Given that they are on the front lines of care, ACOs can and do play a role in creating care pathways that are both more efficient as well as more effective for the patients.
Have diabetes prevention programs initiated by the CDC been effective?
Overall, I would say that, yes, they have. The CDC has long been involved in addressing many of the lifestyle issues associated with how folks develop diabetes through their diabetes prevention programs. And, more importantly, they have been tracking results. Through their efforts, we now have further proof that programs that promote increased exercise and other lifestyle interventions do, indeed, work. And that leads to the development of plan benefits that cover diabetes prevention programs for, in example, the Medicare aged population.
How can managed care organizations help members overcome socioeconomic barriers that may be affecting their quality of care or participation in preventive services?
We can certainly help address socioeconomic barriers. However, to address them, we need to know about them. In my opinion, one of the best things we can do is get involved in the local community at the grassroots level to find out those barriers first hand. Humana has been a leader in that realm. A couple years ago, our CEO outlined a Bold Goal: we want to improve the health of the communities we serve 20% by the year 2020. To do that, we need to get actively engaged within our communities, identify and understand the resources available to achieve that goal, and forge connections with other groups who want the same thing. In my local market of Jacksonville, Florida, we have made a lot of connections in the community and have helped introduce different organizations, who may not have known that the other existed, to one another in an effort to promote the developing of solutions for the community as a whole. Of course, that includes specifically individuals with limited resources due to their socioeconomic status. We are about to host a Clinical Town Hall in November 2016 that will bring together hundreds of individuals who want to work together to improve the whole Jacksonville community’s health. Managed care organizations can certainly function as Malcolm Gladwell’s “connectors” and can leverage their data, their relationships, and their passion for promoting good health such that they do well by doing good.
With diabetes awareness increasing, and managed care organizations stepping up to improve care, is there a more hopeful outcome possible for the future of diabetes in America?
Most definitely. The key here is acting upon what we know, promoting prevention, and becoming involved in the community at large. Doing nothing is not an option.
Is there anything else you’d like to add?
When I have given presentations about diabetes, I reference the following quote: “There are entirely too many diabetic patients in the country. Statistics for the last thirty years show so great an increase in the number that, unless this were in part explained by a better recognition of the disease, the outlook for the future would be startling.”
This quote, while being incredibly applicable to today, was actually written by Elliot Joslin in JAMA in 1921. Here we are 95 years later and we need to ask ourselves: what has changed?
Managed care organizations must continue to find ways to better care for our members with diabetes and I am confident that that is exactly what we’re doing.