tackling diabetes three approaches

Published as a supplement to

Supported by

NOVEMBER 2015

Tackling Diabetes: Three Approaches

Combating diabetes among seniors, veterans, and American Indians and Alaska Natives

requires new strategies

2 Tackling Diabetes: Three Approaches

If you want to see what the melting pot

of America looks like, visit the Bronx,

New York. Here—in one of New York

City’s five boroughs—you’ll hear accents

from Bangladesh, India, Pakistan, Ghana,

and other places around the globe.

Unfortunately, you’ll also find a high

prevalence of diabetes in the Bronx,

says Joel Zonszein, MD, director of the

Clinical Diabetes Center at the Univer-

sity Hospital of the Albert Einstein College of Medicine, a division of Monte-

fiore Medical Center.

More than 14% of the population in the Bronx has diabetes, according to

an April 2013 data brief from the New York City Department of Health and

Mental Hygiene. Case in point: A 50-year-old man who used to work as a

doorman in New York City. He’s been on disability since the age of 38—that’s

because of his worsening diabetes, congestive heart failure, obesity, and

smoking history. His leg has been removed below the right knee, he experi-

ences moderate kidney disease, and he frequently spends long periods of

time as an inpatient for treatment of his congestive heart failure.

The cost to this man and his family—both in terms of his ability to work

and function—is enormous. And the future’s not bright—that is, if nothing’s

done about it.

More than 9% of the U.S. population has diabetes today, according to the

2014 National Diabetes Statistics Report from the Centers for Disease Con-

trol and Prevention.

“That number could jump to three in 10 [people] if nothing’s done to stop

this chronic disease in its tracks,” says Zonszein.

A supplement supported by BOEHRINGER-INGELHEIM PHARMACEUTICALS, INC., Copy right 2015 and pub-lished by Advanstar Com mu ni cations, Inc. No portion of this program may be reproduced or transmitted in any form, by any means, without the prior written permis-sion of Advanstar Communications, Inc. The views and opinions expressed in this material do not necessarily reflect the views and opinions of Advanstar Communica-tions, Inc. or Managed Healthcare Executive®.

Supported by

Published as a supplement to

NOVEMBER 2015

Tackling Diabetes: Three Approaches

Combating diabetes among seniors, veterans, and American Indians and Alaska Natives

requires new strategies

In the Bronx, New York City,

14% of the population has diabetes.

Source: New York City Department of Health and Mental Hygiene

29.1 million people or 9.3% of the U.S. population has diabetes.

Source: Centers for Disease Control and Prevention: National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014.

—Diagnosed— 21.0 million people

—Undiagnosed— 8.1 million people

Aine Cryts is a freelancer based in Boston. She is a frequent contributor to Managed Healthcare Executive on topics such as diabetes, oncology, hospital admissions and readmissions, senior patients, and health policy.

Edmund J. Pezalla, MD, MPH, is vice president and national medical director for pharmaceutical policy and strategy, Aetna. He has more than 20 years of experience in managed care and related areas. He received his medical and under grad uate degrees from Georgetown University and trained in general medicine and pediatrics at the Bethesda Naval Hospital. He holds an MPH from the University of California, Berkeley.

Ann Bullock, MD Acting Director Division of Diabetes Treatment and Prevention Indian Health Service

Helena Duffy, NP Adult Health Montefiore Medical Center

Dianne Howard Director, Risk and Benefits Management Palm Beach County School District West Palm Beach, Florida

Sachin H Jain, MD Chief Medical Officer CareMoreHealth System

Sharon Movsas Diabetes Education Program Coordinator Montefiore Medical Center

Karen Mulready Director, Product Development UnitedHealthcare

William Yancy, MD Research Scientist Center for Health Services Research in Primary Care Durham VA Medical Center

Joel Zonszein, MD Director, Clinical Diabetes Center University Hospital, Albert Einstein College of Medicine Montefiore Medical Center

3Published as a promotional supplement to Managed Healthcare Executive®

The challenge of tackling seniors’ type 2 diabetes“The main problem these last few years is that many

patients have this disease but they don’t go to have it

checked,” says Zonszein. “They may feel well with type

2 diabetes, but [the disease is] silent ... Many people

live with these problems and don’t go to see the doctor,

which results in the late diagnosis of diabetes and these

other diseases.”

Even if seniors do see a doctor, that doctor visit often

doesn’t translate into patients taking action to combat

the disease’s progression, he says. “We need these pa-

tients to make lifestyle changes, we need them to eat

better and exercise. We need them to take medications

for their blood pressure or diabetes or high cholesterol,”

he says.

Another issue is that some patients don’t take their

medications because they’re afraid of the side effects

and/or are deterred by the costs. “In the Bronx, it’s even

more complicated by the fact that the patient population

watches a lot of TV. Unfortunately, we have a lot of law-

yers [in TV commercials] announcing the side effects of

diabetes medications,” he says.

Zonszein believes that the solution to many of these

problems is patient education about diabetes treat-

ment. Montefiore Medical Center’s program is called

the PROMISED (Proactive Managed Intervention Sys-

tem for Education in Diabetes) Diabetes Self-Manage-

ment Education Program and involves diabetes educa-

tion in a group setting. These sessions are led by

certified diabetes educators who coach and educate el-

derly patients.

“It’s too much for primary care physicians to teach

and manage diabetes for these patients,” says Sharon

Movsas, diabetes education program coordinator at

Montefiore. “It’s very time consuming. And it’s unrealis-

tic that a primary care physician can spend that much

time with their patients.”

One of the most important goals of the group classes

is to teach patients to partner with their doctor, says

Helena Duffy, NP, who teaches in the diabetes educa-

tion program. “In the past, the doctor was seen as an

authority who would tell you what to do. In the class,

patients learn about the need to be involved in creating

their own plan.”

Many of the patients have developed, or will develop

other conditions that go along with diabetes, such as

stroke, cardiovascular disease, cognitive impairment,

and depression, says Movsas. To help, diabetes edu-

cators assist seniors with simplifying their medication

regimens, educate them about what each medication

is for, and provide tips on how to remember to take

their medications.

Most people come into the class with the goal of get-

ting off medication, says Movsas. “At the end of the

class, one of our goals is to make sure that they’re able

to make better decisions about medication. Many of

them actually come out of the class, and we see their

LDL [low-density-lipoprotein] cholesterol levels going

down tremendously because they’ve started to take

their statin, whereas before the class started they were

scared that it would hurt their liver or their kidneys. It

really makes a huge difference in outcomes.”

Covered by most insurance plans, diabetes education

classes at Montefiore include five two-hour sessions

that take place once a week. As a follow-up, participants

are also eligible for medical nutritional therapy each year.

Group sessions for veterans with type 2 diabetesMore than seven in 10 veterans who receive VA care are

either overweight or obese, according to the Office of

Research & Development at the U.S. Department of

Boehringer-Ingelheim Supplement — Tackling Diabetes: Three Approaches — MHE November 2015

Bronx section: Figure


American Population with Diabetes

2010 2012

Mill

ions

of P

eopl

e

35302520151050

25.829.1

The percentage of Americans age 65 and older with diabetes remains high, at 25.9%, or 11.2 million seniors with diagnosed and undiagnosed diabetes.

Source: National Diabetes Statistics Report, 2014


program also includes the opportunity for veterans to

have their feet monitored for any signs of sores and

to receive regular eye exams. Many of the veterans who

arrive for these group appointments are overweight and

have A1c1 levels of 8 or above. At this point, more than

100 veterans have been through the program.

Yancy started working with the first group of partici-

pants about eight months ago and intends to work with

an additional 100 veterans in this research study.

Driving innovation in care among the Native American populationMore than 5 million people self-identify as American

Indian and Alaska Native, according to the U.S. Census

Bureau. The Kaiser Family Foundation highlights that

Native Americans experience significantly higher rates

of poverty than the overall population—41% versus

25%.

American Indians and Alaska Natives are also more

likely than any other racial group to have had either an

alcohol or drug abuse disorder in the past year—and

those substance abuse disorders often complicate the

treatment of diabetes. A 2011 report from the Indian

Health Service (IHS) notes that the rate of alcohol-

related deaths among this population is 519% higher

than for any other race in the country. IHS is an agency

within the Department of Health and Human Services

that is responsible for providing federal health services

to American Indians and Alaska Natives. As if that’s

not enough, more than 16% of Native Americans also

struggle with diabetes.

Veterans Affairs (VA), and that’s leading to high rates of

diabetes among veterans. According to the VA, 24% of

veterans have diabetes.

“It’s just not efficient to provide one-on-one diabetes

education with veterans. We bring groups of [about 10]

patients together and teach them about diabetes,” says

William Yancy, MD, a research associate at the VA Med-

ical Center in Durham, North Carolina. They also get to

know each other and come to rely on each other for

social support,” he says. These group appointments

take place every one or two months; veterans also

meet individually with a clinician who might adjust their

medications.

As with seniors, veterans involved in group diabetes

appointments really care about getting off their diabetes

medication, says Yancy, who also serves as director of

the Duke Diet and Fitness Center at Duke University.

“We don’t necessarily get them off their medications.

We do get them to change their diets and increase their

physical activity so they don’t need to take as much of

their medications.”

These group appointments are part of a VA-funded

research study, and the veterans involved are primarily

middle aged or elderly, although there are some young-

er veterans in their 20s and 30s who participate. The


American Indians/Alaska Natives Figure 1

Source: IHS Diabetes Care and Outcomes Audit

IHS Diabetes Care and Outcomes AuditMean A1c: 1996 to 2014

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Mea

n A

1c (%

)

Audit Year

10.0

9.5

9.0

8.5

8.0

7.5

7.0

6.5

6.0

The estimated number of veterans with diabetes: nearly one in four.

Source: The U.S. Department of Veterans Affairs


clinicians can see how they are doing in terms of meet-

ing the standards of care. Now that most physicians use

electronic health records, Bullock says the team can

audit many more charts. The 2015 audit, which looks at

treatment provided in 2014, included a review of more

than 116,000 medical charts of people with diabetes

across the country at IHS, tribal, and urban Indian health

organizations.

The IHS Diabetes Care and Outcomes Audit for 2015

revealed that key outcome measures for Native Ameri-

cans with diabetes showed achievement at or near na-

tional targets.

Some findings include:

• A1c1 mean: 8.1

• Blood pressure: 65% have blood pressure lower

than 140/90 mm Hg

IHS also reports a decrease in end-stage renal dis-

ease (ESRD) among Native Americans. Between 2000

and 2011, ESRD incidence rates decreased 43%, more

than for any other racial group in the country.

Ann Bullock, MD, acting director of the division of di-

abetes treatment and prevention with IHS, credits the

U.S. Congress with continuing to fund programs around

the country that help to treat Native Americans with di-

abetes. That’s since the Balanced Budget Act of 1997,

when Congress established the Special Diabetes Pro-

gram for Indians (SDPI) and provided $150 million over

five years for the prevention and treatment of diabetes

in American Indians and Alaska Natives. Funds have

been reauthorized through fiscal year 2017. Since the

SDPI started, there has been a 10% reduction in the

average A1c1 levels among Native Americans, accord-

ing to a January 2015 report from IHS.

This funding provides support for 336 community-

directed diabetes programs in 35 states that implement

evidence-based diabetes treatment and prevention pro-

grams. An additional 66 demonstration projects suc-

cessfully completed a six-year program that translates

the results of diabetes prevention and cardiovascular

disease risk reduction research into what IHS calls “di-

verse, real-world Indian health settings.”

Since the 1990s, IHS has also produced the Diabetes

Care and Outcomes Audit, an audit of patients’ medical

charts during which Bullock and others look at the stan-

dards of care and consider how well providers are meet-

ing those standards. The team reviewing the medical

charts looks at blood sugars, blood pressures, and cho-

lesterol and whether patients are taking an aspirin a day

if they should be, for example.

Bullock says that the findings aggregate on a national

level but are also fed back to individual sites of care so


American Indians/Alaska Natives Figure 2


Rates of Diagnosed Diabetes by Race/Ethnic Background

Non-Hispanicwhites

AsianAmericans

Hispanics Non-Hispanicblacks

American Indians/Alaska Natives

Perc

ent o

f pop

ulat

ion

Race/Ethnic Background

20

15

10

5

0

7.69.0

12.8 13.2

15.9

Alcohol-related deaths among American Indians and Alaska Natives

are 519% higher than any other race in the country. More than 16% of Native Americans also struggle with diabetes.

Source: Indian Health Service (IHS)


market for 10 years. I typically spend 20 minutes on the

phone with insurance companies per patient per medi-

cation to get them approved.

Managed Healthcare Executive: What are some of

the unique care coordination approaches you have

taken for managing these patients effectively?

Zonszein: First, every Monday morning, we meet as an

interdisciplinary team to discuss our most challenging

diabetes cases. That’s where we feature these patients’

vitals on a white board.

The meetings result in a total breakdown in the silos

that often exist in the treatment of diabetes. That’s be-

cause the entire care team—which includes nurses and

physicians and pharmacists—is at the same table dis-

cussing one patient at a time. The outcome of those

meetings is a consultation letter that’s sent to the pa-

tient’s primary care provider; then our team focuses on

outcomes follow-up.

The second part is a structured group education pro-

gram, which involves patients meeting with various

healthcare practitioners on a regular basis. We set con-

crete goals for patients, such as setting up an appoint-

ment with a nutritionist. We ask patients what they’re

eating. We hold them accountable with their medica-

tions and help them switch if they experience side ef-

fects.

Managed Healthcare Executive: How are

you measuring success with the diabetes

education program?

Zonszein: These diabetes patients’ A1c1 levels improve

by 10%, one year after their participation in the diabetes

education program—from 43% to 53% achieving their

A1c1 goal of less than 7. One year after participating in

the education program, diabetics’ ability to get their LDL

cholesterol under 100 improves by 14%—from 53% to

67% at their goal.

The Bronx. It’s a place many immigrants call home.

This New York City borough is also host to a higher

than average prevalence of diabetes. More than 14% of

its residents have the chronic disease, according to an

April 2013 data brief from the New York City Department

of Health and Mental Hygiene. Joel Zonszein, director

of the Clinical Diabetes Program at the University Hos-

pital of the Albert Einstein College of Medicine, a divi-

sion of Montefiore Medical Center, is in the thick of

things every day, attempting to engage Bronx patients

in their diabetic care.

Here, he discusses the unique challenges associated

with diabetes care in that area, as well as some of the

successful approaches to caring for these patients that

health plans and providers across the country may want

to emulate.

Managed Healthcare Executive: What are you

finding out about the populations that you

serve in the Bronx and their unique health

management challenges?

Zonszein: We’re seeing a major problem with diabetes

among Bangladeshis now living in the Bronx. We also

have a lot of people from India, Pakistan, Yemen, and

Ghana, all of whom are at very high risk for diabetes.

The main problem we’ve seen in the Bronx is that

many patients have the disease, but they don’t go to the

doctor to check for it because they feel well. Type 2 dia-

betes is typically accompanied by obesity, high blood

pressure, and high cholesterol levels.

We have a lot of people with Medicare, Medicaid, and

limited resources. The newer medications for diabetes

can seldom be prescribed because insurance compa-

nies create artificial barriers that impede our patients’

access to those medications.

Patients in the Bronx are being treated with what I

call “20th century” medications—not 21st century

medications. When a patient goes to the clinic, it’s very

difficult to prescribe a medication that has been on the

Q&A

Empowering Diabetes Patients in the BronxPlans and providers across the country should pay attention to these successful strategies

By Aine Cryts


Diabetes Health Plan, Howard says 19% of its medical

and pharmacy costs were related to diabetes treatment.

“It all boils down to dollars and cents,” she says. “It gets

your attention when your claims keep going up.”

As much as $34 million of the $170 million the school

district was spending on healthcare each year was relat-

ed to diabetes care for employees. Those costs were

highest among employees who were overweight and

experiencing metabolic challenges and comorbidities.

On the payer side, a two-year study by UnitedHealth-

care evaluated how the Diabetes Health Plan impacted

620 enrollees. The study found that these enrollees cost

Dianne Howard, director of risk and benefits man-

agement at Palm Beach County School District in

West Palm Beach, Florida, helped save her employer

about $4 million over two years after deciding that the

district would participate in UnitedHealthcare’s Diabe-

tes Health Plan. As a result of her decision, Palm Beach

County School District’s employees with diabetes are

healthier, too.

The Diabetes Health Plan, launched by UnitedHealth-

care in 2009, provides special medical and pharmacy

benefits to diabetic and prediabetic employees for com-

panies that elect the plan. According to the payer, enroll-

ees receive the following:

• No or reduced cost for diabetes-related doctor visits;

• No or reduced cost for select diabetes-related medi-

cations and supplies;

• Reminders for important tests and exams; and

• A personal scorecard to help them keep track of re-

quired doctor visits, lab tests, and wellness programs.

The program’s goal is to help enrollees prevent com-

plications by receiving evidence-based care from their

physician, while addressing conditions related to diabe-

tes, including blood pressure, obesity, and depression.

UnitedHealthcare’s nurses also work with members to

develop a personal action plan to help them manage the

disease.

Positive results As a result of the Diabetes Health Plan, the Palm Beach

County School District’s prediabetes and diabetes em-

ployees experienced a 17% decrease in emergency room

visits in just the first year; at the same time, the hospital

readmission rate went down .4%, says Howard.

More good news: Primary care visits among this em-

ployee population went up 3.6%, says Howard. “That’s

a good thing,” she says, “because that increase in pri-

mary care visits means employees are actively manag-

ing their disease.”

In 2010, before the school district participated in the


Pre-diabetes Figure 1


Estimated Diabetes Costs in the United States

Indirect costs (disability, work loss, premature death)

Direct medical costs

2012 Total (direct and indirect)

After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than among people without diabetes.

$245 billion

$176 billion

$69 billion

FEATURE

Treating Diabetes and Prediabetes, One Member at a TimeNew program finds that member perks lead to higher engagement, lower costs

By Aine Cryts

In 2012, 86 million Americans age 20 and older had prediabetes; this is up from 79 million in 2010.

Source: Centers for Disease Control and Prevention: National Diabetes Statistics Report: Estimates of Diabetes

and Its Burden in the United States, 2014.


January, UnitedHealthcare identifies the appropriate

employees based on high blood pressure and high-

cholesterol measurements. “Over the last couple of

years, we’ve started to look at the progression of dia-

betes, which has caused us to focus on how we can

really prevent prediabetes,” says Howard.

Onboarding prediabetic employees presents its own

challenges. “What we’ve found is most people don’t

know they’re prediabetic,” says Karen Mulready, direc-

tor of product development at UnitedHealthcare. When

enrollees find out they’re prediabetic, they then have a

conversation with their physician and are told to watch

their blood sugar. They’re also educated about fitness

and nutrition, she says.

UnitedHealthcare finds out which employees are eli-

gible to be included in the prediabetes and diabetes

plans by conducting a historical claims review, accord-

ing to Mulready. Once employees are identified, the

payer sends them a letter informing them of their partic-

ipation in the program.

Enrollees meet with a nurse who shows them how to

check their blood sugar, according to guidelines set by

the American Diabetes Association. They are also re-

quired to visit their doctor, get their eyes checked, and

have their A1c1 levels monitored, says Mulready.

“We’re asking members to be compliant with evi-

dence-based medicine,” she says. Patients see their

less, were more compliant with evidence-based guide-

lines, and demonstrated greater management of their

disease than those who did not participate. The study’s

findings were released in 2013.

The specific findings are:

• Costs grew 4% more slowly for enrolled employees;

• 75% of enrolled employees were compliant with evi-

dence-based medicine guidelines, compared to 61%

of unenrolled employees; and

• 21% of enrollees experienced a reduction in their

health risk scores (which are used to measure expect-

ed healthcare costs for an individual or a population).

• UnitedHealthcare says 35 employers nationwide

have chosen to provide the plan to their employees.

The Diabetes Health Plan today includes approxi-

mately 22,000 enrolled members with diabetes and

prediabetes.

How it works Howard says the program is administered by United-

Healthcare. The only way she finds out which employ-

ees are involved in the Diabetes Health Plan is when

her team receives a question about the plan from an

employee.

Employees are automatically enrolled in the program,

although they can choose to opt out. Howard says some

prediabetic and diabetic employees do opt out of the

program—generally because of their fears about being

labeled with a chronic disease and the impact that could

have on their ability to get health insurance in the future.

In the prediabetes program that was introduced in

In the United States, people with diabetes are twice as likely as the

average person to have depression. Source: Eqede LE, Zheng D, Simpson K. “Comorbid depression is associated with increased health care use and expenditures

in individuals with diabetes.” Diabetes Care. 2002;25(3):464-470.

In 2009–2012, of adults aged 18 years or older with diagnosed diabetes, 71% had blood pressure greater than or equal to 140/90 mm Hg or used prescription medications to lower high blood pressure.


In 2011, about 282,000 emergency room visits for adults aged 18 years or older had hypoglycemia as the first-listed diagnosis and diabetes

as another diagnosis. Source: Centers for Disease Control and Prevention:

National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014.


next year to enroll, she wants to make sure they “value”

the program and participate fully.

Onboarding employees hasn’t always been easy, says

Howard. The school district received some negative

feedback the first year it participated, largely because

of the introductory materials employees received about

the program. The school district continues to work

closely with UnitedHealthcare to ensure the intro-

ductory letters patients receive at home are “more

approachable” and address any potential privacy con-

cerns. Today, Howard says, the response from employ-

ees is mostly positive—in great part because their

copays have gone down. “Everybody likes it when they

can save money.”

physician to have their blood sugars taken, and that in-

formation is integrated and automated within the pay-

er’s systems. Enrollees, who receive online and written

communications by mail from UnitedHealthcare

throughout the year, can track their progress online.

If school district employees don’t comply with at least

three of the plan’s requirements, they’re pulled out of

the program—and then they have to wait a full year to

get back into it, says Howard. “We do that because

those employees aren’t going to get better [if they don’t

adhere to the plan requirements]. That’s when we get

the calls from employees, because they don’t want their

copays to go up,” she says.

While school district employees have to wait until the

If health plan members are aware

of their health statistics, they can

know if they are, or are not, in the

appropriate health ranges. It is a first

step toward empowering members

to take charge of their health.

But most people do not know

their biometrics, according to a re-

cent HealthMine survey of 561 con-

sumers. Specifically, the survey

found that 83% of consumers do not

know, or track, their blood glucose

level. The cost of ignorance about di-

abetes is colossal, adding up to $322

billion per year, according to the

American Diabetes Association. That

figure includes loss of productivity

due to illness and disability. That

means American consumers—even

those who are healthy—are each

paying $1,000 a year for diabetes.

“Chronic illness is a huge cost to

health plans but averting it and man-

aging it down to the individual level

can improve the health of the group

and lower overall costs,” says Bryce

Williams, CEO and president of

HealthMine.

The survey also found:

• 81% of people don’t know their

cholesterol level;


body mass index; and


blood pressure.

Williams offers three ways health-

care executives can help manage

members’ blood glucose levels:

1. Help identify those at risk for dia-

betes.

2. Help avert diabetes by encourag-

ing members to maintain a regi-

men of diet and exercise.

3. Ensure adherence to the proper

medications.

Williams also says health plans

should implement programs to help

members know and track their

average blood sugar over time with

an A1c test and know their health

status.

“Follow recommended preventive

health actions and find out risks,”

Williams says. “Aggregate both clini-

cal and wellness data across many

sources to present it in one mean-

ingful way to the individual.”

He also recommends a rules-

based expert system that measures

individual health data against clinical

criteria, then automatically recom-

mends personalized health actions

for each member. Results of the clin-

ical analysis highlight the riskiest as-

pects of health, he says.

“Empower members with knowl-

edge and guidance of what to do

and when to do it,” Williams says,

adding that plans should provide

health support articles, videos, tools,

and support forums. “Guide mem-

bers and motivate toward improve-

ment.”

Finally, plans should help track

members’ progress and provide re-

wards for successes, says Williams.

“Track both positive behaviors and

positive outcomes and reward those

[members] that make the effort [to

improve] with points, redeemable

for things such as gift cards, fitness

devices, entries into large sweep-

stakes, and discounts on the costs

of healthcare.”

Blood glucose awareness: The first step to lowering diabetes costs


ence an amputation rate that is 66% lower than the

Medicare fee-for-service average. In addition, the aver-

age A1c1 level for members in the program is 7.07; 7.0

is considered to be good clinical control of diabetes.

Managed Healthcare Executive: Why

is the program designed this way?

Jain: Physicians don’t have the time to deliver all the

coaching and education they need to empower patients

to manage their own diabetes—and that’s a central piece

of this work. We have primary care doctors within the

Medicare Advantage plan who refer patients to the Care-

More Care Center. CareMore is reimbursed by Medi-

care through its Medicare Advantage plans per enrollee.

The CareMore Diabetes Program includes diabetic

foot care with an on-site podiatrist, access to wound

care-certified nurse practitioners, and transportation to

CareMore Care Centers.

Managed Healthcare Executive: The prediabetes

program is a more recent addition to CareMore

Care Centers. What’s the status on that program?

Jain: The measures for identifying members for the

pre diabetes program include a body mass index consid-

ered to be obese, physical inactivity, family history, and

A1c1 levels. We start ed our planning in March 2015 and

went live in June 2015.

We started on June 1 to identify our at-risk patients—

from among the 100,000 people we insure nation-

wide—and we identified 2,000 patients whose hemo-

globin A1c1 levels were at the prediabetic stage. That’s

who we’re targeting with our program. It’s based now in

California and Arizona.

We don’t have a lot of data on the diabetes prevention

program yet. However, we’re already hearing from pa-

tients who are getting their A1c1 levels returning to the

normal range after just three months in the program.

The number one challenge facing diabetic patients is

health literacy, says Sachin Jain, MD, chief medical offi-

cer at Cerritos, California-based CareMore Health System

(a subsidiary of Anthem), which operates Medicare Advan-

tage plans and CareMore Care Centers to care for the

plans’ patients in an outpatient setting. “[Seniors] don’t

necessarily understand that many of their behaviors that

can lead to diabetes are under their control—and that they

can modify these behaviors,” says Jain, a former senior

adviser at the Centers for Medicare & Medicaid Services.

For this reason, CareMore has created an innovative

diabetes program, designed to move the needle on diet and

exercise among seniors with diabetes. Here’s more on

the program, what it entails, and how it is helping patients.

Managed Healthcare Executive: How does the

CareMore program seek to improve the type

of care seniors with diabetes receive?

Jain: During patients’ visits at an outpatient CareMore

Care Center, physicians can help address some of the

root issues related to diabetes. That involves providing

education about diet, managing their medications, and

checking their blood sugar.

Physicians can also provide exercise guidance to se-

niors. For instance, physicians can identify and recom-

mend that seniors work out at the Nifty at Fifty gyms

that are located at or near the CareMore Care Centers.

At these senior-appropriate gyms, seniors can be sure

they’re working out at the appropriate tolerance.

According to internal CareMore studies, the patients

who take part in CareMore’s diabetes program experi-

Q&A

CareMore’s Sachin Jain on Caring for Diabetic SeniorsProgram is designed to move the needle on diet and exercise among seniors with diabetes

By Aine Cryts

Behaviors can lead to diabetes, and behaviors can be modified.

—Sachin Jain, former senior adviser at the Centers for Medicare & Medicaid Services


to over $197 billion and likely is over $200 billion for 2015.

If diabetes expenses grow at the same rate as overall

costs, we can expect diabetes healthcare to consume

1.2% of the GDP by 2024. This is equivalent to the per-

centage of GDP attributed to agriculture and fisheries.

These numbers are big enough to make us pause

and think. Spending on healthcare can be good—higher

expenditures on cancer care are linked to better out-

comes—but in the case of diabetes, more spending

likely means worsening outcomes. More people with

significant end-organ involvement are suffering com-

plications of therapy such as hypoglycemia. Approxi-

mately one-third of nursing home and residential facility

days are used by people with diabetes. And diabetic

patients use 43 million bed days per year in acute-care

hospitals.

Diabetes is a prevalent and costly condition. In this

essay, I will put it into perspective in terms of con-

tribution to overall health expenditures and to the entire

U.S. economy. Considering the amount of money spent

on diabetes, there is an opportunity for healthcare pro-

viders to assume more responsibility and receive more

rewards for the care of people with diabetes.

Health Affairs recently published an article, “National

health expenditure projections, 2014-24: spending growth

faster than recent trends” (Keehan et al. 2015; 34 [8]:

1407-1417),” on projected healthcare expenditures

through 2024. Important projections include a further

shift toward government payment through Medicare

and Medicaid, and an increase in the percentage of

gross domestic product (GDP) devoted to healthcare

from 17.4% to 19.6%. Total expenditures are expected

to top $5.4 trillion.

Although no disease-specific projections were included,

we can estimate the impact that diabetes will have on

overall cost based on the American Diabetes Association

Scientific Statement from 2012 (Diabetes Care. 2013; 36

[4]: 1033–1046). In the 2012 report, the estimated direct

cost of diabetes care was $176 billion.

If we apply a 4% growth rate, (consistent with the

Health Affairs report), that $176 billion will have grown

EDITORIAL

Diabetes Cost Projects Raise Alarm Spending on healthcare can be good, but in the case of diabetes, more spending may mean worsening outcomes

By Edmund J. Pezalla, MD, MPH


Diabetes Costs Figure

Source: American Diabetes Association

Largest Components of Diabetes Medical Expenditures

Prescription medications to treat complications

Anti-diabetic agents and diabetes supplies

Physician office visits

Hospital inpatient care total medical cost

Nursing/residential facility stays

12%

9%

8%

10%Other

43%

18%

People with diagnosed diabetes incur average medical expenditures of about $13,700 per year, of which

about $7,900 is attributed to diabetes. Source: American Diabetes Association


manage the care of these patients in a patient-centered

and evidence-based manner. This is a huge opportunity

for providers who must transition from fee-for-service

and bed days to population health and outpatient care.

There is a lot of technology available to help people

who have diabetes. This ranges from new pharmaceuti-

cals to devices to mobile apps. No one of these items

will cure or fix our diabetes problem. However, using a

combination of these in a thoughtful way and in the con-

text of basic good medical care can make a difference.

The real problem is not lack of funding (we pay plenty

for diabetes care) or lack of technology, but lack of orga-

nization and focusing on what really matters before the

patient progresses to hospitalization.

Edmund J. Pezalla, MD, MPH, is the section editor for Man-aged Healthcare Executive’s Diabetes Health Management topic resource center. Pezalla is vice president and national medical director for pharmaceutical policy and strategy, Aetna.

Lowering cost, improving qualityThere are clearly things we can do to lower costs and im-

prove care. Forty three percent of expenditures attri buted

to diabetes are for hospital inpatient stays while only 9%

of expenditures are for physician office visits and 18% of

expenditures are for medications. Surely we can shift the

balance away from rescue and problem solving to proactive

intervention and preventing or delaying disease progression.

With diabetes becoming a significant portion of the

national economy, it should also become a focus for in-

vestment. Over 59% of diabetes patients and a much

larger portion of diabetic costs are born by Medicare and

Medicaid. This should make diabetes a national priority.

But, we should not wait for federal action. Diabetes ser-

vices, medications, and labs are all covered by both com-

mercial and government health plans. Providers, and in

particular those providers who are accepting risk through

value-based arrangements, should be organizing to

Telemedicine and telehealth are

broad terms that refer to a range of

tech nologies and services. At the

heart of both of these is the ability to

improve care through the easy ex-

change of information between pa-

tients and providers.

Some of the technologies that fall

into this category include video con-

ferencing with doctors, use of email

or specialized websites, mobile ap-

plications on cell phones, and auto-

mated transmission of data from

devices and monitors to healthcare

professionals. Telemedicine has be-

come more common and more so-

phisticated over the past few years.

Telemedicine addresses a number

of important overarching issues in our

healthcare system as well as specif-

ic issues related to diabetes care.

1. Manpower. The Affordable Care

Act and launch of insurance ex-

changes has increased the num-

ber of Americans with health in-

surance and the number seeking

care. This is increasing the burden

on a healthcare system with too

few providers, and distribution is-

sues in terms of medical special-

ties and geographic location. Tele-

medicine can help fill in some of

these gaps.

2. Specialty care. Many medical

spe cialties are short staffed or not

available in remote or rural areas.

Telemedicine programs can help

make the specialists who reside in

a large city and practice at a major

center available to patients and

pri mary care physicians anywhere

in the country. This is of special in-

terest in diabetes because endo-

crinologists and diabetologists are

not available everywhere. In addi-

tion, diabetic patients may have

need for ophthalmology and other

services that may not be readily

available.

3. Team care. The use of multispe-

cialty teams has been shown to be

ad vantageous in a number of

health care settings, but not all

team mem bers can be co-located.

This is especially true of mental

health pro fessionals and social

workers who may be in short sup-

ply in some lo ca tions.

4. Data transfer and monitoring.

Glucose meters, continuous glu-

cose meters, and insulin pumps

generate a great deal more data

and more accurate data than pre-

viously used hand-written logs.

This data can now be passed

seamlessly from the patient’s de-

vices to healthcare professionals

who can use available software to

analyze and interpret the data.

Telemedicine and diabetes: Impact on cost and quality

tackling diabetes three approaches

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