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Evidence-Based Diabetes Management Peer Exchange: Diabetes Stakeholders Summit
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Mary Caffrey
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With Rise of Diabetes Technology Comes Value-Based Payment
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With Rise of Diabetes Technology Comes Value-Based Payment

Mary Caffrey
Coverage from the first of 3 Peer Exchange™ discussions from the Diabetes Stakeholders Summit.
CGM data will be more reliable than patient logs, which could be helpful with older patients. “That helps diabetes educators and physicians with medication adjustments and lifestyle changes,” Hodorowicz said. “With the pediatric population, it’s wonderful because parents are so involved with their children’s control, especially of type 1.”

Audible alerts can help patients or caregivers avert an approaching hypoglycemic event. “Payers are starting to recognize that,” Hodorowicz said, “and it’s not just for the type 1s, it’s also for the type 2s on multiple daily insulin doses.”

Devices help, but it’s essential that patients already be engaged in their own care, Kaufman said. He pointed to a program developed by Stanford University, the Chronic Disease Management Program, which is decades old and has been highly successful with patients with T2D.9 “If your A1C was above 9%, it went down by 0.93% at 6 months, and 1.27% at 12 months with a 6-week intervention,” he said. “How does it work a year later? Because people change their lives, change their emotions; they change their sense of well-being, and, therefore, they were able to follow doctor’s orders better, follow nurse’s orders better.”

“And that becomes crucial in anything that has to do with self-management,” Kaufman added. Scanlon noted that this was work pioneered by Katie Lorig, DrPH, and remains foundational in chronic disease management.

Scanlon and Kaufman discussed the need for peer-to-peer support, either in person or in digital formats. Gabbay noted that vast potential for the latter is “just beginning to be tapped.” “Continuous glucose monitoring certainly helps, and even the simple ability of downloading blood glucose meter data and looking at that with the patient is really helpful,” he said. Providers don’t want too much data, however, and decision support tools help manage it all, which he called the next revolution.

“The next revolution after that,” Kaufman said, “is being able to assess it in the moment and give feedback to the individual in the moment.” The challenge, he noted, is that managing diabetes requires patients to constantly make micro decisions. No single decision is hugely important; it’s the sum of them that determines the outcome. The perfect device would require no interaction.

It’s hard to balance the desire for tools without overloading patients to the point of “alarm fatigue,” when they tune out the efforts to help them, Snow said, “because it just gets in the way of living.”

Payer Coverage, Patient Choice in Insulin Pumps

In this rapidly evolving area, Gabbay said, the FDA appears to be open to approving devices more quickly that it had been. “The floodgates are about to open because there are a whole series of iterative changes that can be made to push forward semiautomated insulin delivery,” he said.

As Scanlon noted, however, the issue is figuring out for whom is the device appropriate. “And how do we determine appropriateness?” he asked.

“That’s one of the great challenges, because there’s not a lot of good data that identifies who makes a good pump user,” Snow said. “We can extrapolate [whom] we believe that might be, but there’s not really a lot of data that [are] going to predict for the person sitting in front of you, whether they are likely to succeed or fail.”

Gabbay said that this is changing with the movement toward semiautomatic delivery; the bar is no longer as high for patients’ carb-counting and insulin-adjustment skills. “You could take patients with poor glycemic control and maybe not terribly adherent and [put them] on semiautomated insulin delivery, and that would at least improve their blood sugars overnight, and they would benefit,” Gabbay said.

CMS approved external insulin pumps for T1D and T2D Medicare patients who had been on multiple daily injections (and who have less control as they learn to use the pump in the first year), Hodorowicz noted. “The cost benefit has to be there for CMS to approve coverage for such an expensive item,” she said.

When asked about the differences between models and patient preferences, Hodorowicz said that a waterproof device is important to many patients. Some devices are disposable; some offer wireless infusion versus manual control. Different types of alarms matter to patients, as does ease of calibration. “I think the ease factor is critical,” she said.

CGM devices are on the verge of becoming much smaller and cheaper, Gabbay said, although pumps may remain relatively expensive and complex. Snow noted a possible disconnect between what makes sense from an individual’s point of view versus the population perspective. Giving an expensive device to a patient with a high glycated hemoglobin who seems unmotivated and unengaged may not make sense, but if a person’s A1C of 10% drops by 1.5%, then the population has become healthier overall.

A person with T2D with poor control could benefit from a continuous glucose monitor, Kaufman said, by identifying personal patterns and seeing the connection between certain foods and spikes in blood glucose. “The question becomes, can it become a behavior-change incentive to allow you to become even better at managing your own condition?” he said.

The panel discussed an agreement that will require most adult UnitedHealth patients with diabetes to transition to Medtronic pumps and CGM devices as warranties expire.10 “Sadly,” Gabbay said, “it’s somewhat inevitable because there will be competition around price, the same kind of things that happen in the pharmacy world—I don’t see why it won’t happen in the device world.”

Snow said that historically, if 2 drugs have equal efficacy but 1 is cheaper, the savings are passed down the line and ultimately result in lower premiums. “Clearly, there can be a benefit without a detriment of care,” he said.

Scanlon asked if payment models would change in this area, too. “Without a doubt,” Snow said. “It is the direction of the payer industry.” Many pharmaceutical companies have entered these agreements, “and the device companies are looking that way, as well,” he said.

“The idea of just paying for your treatment is one that was there in the past, but more and more the question is: is there a value from your drug, from your device? Regardless of what it is, is it adding value in terms of either less expensive care or better care? And it doesn’t have to be both.”

Gabbay added that A1C is no longer the only measure of success. “If you reduce hypoglycemic episodes, well, that’s probably a good thing, and that should be a metric, as well.”

The field of diabetes technology has entered an exciting era, Kaufman said. “A paradigm shift is happening,” he said. “We’ve got consumerism, where individuals are taking more control and responsibility for many things, including their health and health care. We’ve got technology being able to deliver something in the moment. You have it in your pocket at all times.

“We’ve got the concept of population health, the concept of value-based care coming to a health system that wasn’t set up that way. If the patient is at the center, we always think of them as what’s most important and their needs, that we, as healthcare providers and payers and employers and health systems, will make it so that we’ll help patients have those outcomes that they need.”

1. Caffrey M. Medicare’s Diabetes Prevention Program is coming, but CMMI has work to do. The American Journal of Managed Care® website. ajmc.com/conferences/ada-2017/medicares-diabetes-prevention-program-is-coming-but-cmmi-has-work-to-do. Published June 11, 2017. Accessed June 27, 2017.

2. Caffrey M. Medtronic announces outcomes-based agreement with Aetna for diabetes patients. The American Journal of Managed Care® website. www.ajmc.com/newsroom/medtronic-announces-outcomes-based-agreement-with-aetna-for-diabetes-patients. Published June 26, 2017. Accessed June 27, 2017.

3. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403. doi: 10.1056/NEJMoa012512.

4. Medicare Diabetes Prevention Program expansion. CMS website. cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07.html. Published July 7, 2016. Accessed June 26, 2017.

5. Caffrey M. Medicare to fund Diabetes Prevention Programs, Burwell says. The American Journal of Managed Care® website. ajmc.com/focus-of-the-week/0316/medicare-to-fund-diabetes-prevention-programs-report-says. Published March 23, 2016. Accessed June 27, 2017.

6. Quilliam BJ, Simeon JC, Ozbay AB, Kogut SJ. The incidence and costs of hypoglycemia in type 2 diabetes. Am J Manag Care. 2011;17(10):673-680.

7. Centers for Medicare and Medicaid Services (CMS) classify therapeutic continuous glucose monitors (CGM) as durable medical equipment (DME) under Medicare Part B [press release]. San Diego, CA: Business Wire; January 12, 2017. businesswire.com/news/home/20170112006146/en/Centers-Medicare-Medicaid-Services-CMS-Classify-Therapeutic. Accessed June 27, 2017.

8. Caffrey M. Medicare coverage for CGM caught in regulatory limbo. The American Journal of Managed Care® website. ajmc.com/focus-of-the-week/0517/medicare-coverage-for-cgm-caught-in-regulatory-limbo. Published May 9, 2017. Accessed June 27, 2017.

9. Lorig K, Ritter PL, Ory MG, Whitelaw N. Effectiveness of a generic chronic disease self-management program for people with type 2 diabetes: a translation study. Diabetes Educ. 2013;39(5):655-663. doi: 10.1177/0145721713492567.

10. Close K, Brown A. UnitedHealthcare chooses Medtronic as preferred insulin provider starting July 1. diaTribe website. diatribe.org/unitedhealthcare-chooses-medtronic-preferred-insulin-pump-provider-starting-july-1. Published May 3, 2016. Accessed July 27, 2017.
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