Published Online: June 30, 2013
E. Albert Tzeel, MD, MHSA
Both the prevalence of type 2 diabetes mellitus (DM) and its associated costs have been rising over time and are projected to continue to escalate. Therefore, type 2 DM (T2DM) management costs represent a potentially untenable strain on the healthcare system unless substantial, systemic changes are made. Managed care organizations (MCOs) are uniquely positioned to attempt to make the changes necessary to reduce the burdens associated with T2DM by developing policies that align with evidence-based DM management guidelines and other resources. For example, MCOs can encourage members to implement healthy lifestyle choices, which have been shown to reduce DM-associated mortality and delay comorbidities. In addition, MCOs are exploring the strengths and weaknesses of several different benefit plan designs. Value-based insurance designs, sometimes referred to as value-based benefit designs, use both direct and indirect data to invest in incentives that change behaviors through health information technologies, communications, and services to improve health, productivity, quality, and financial trends. Provider incentive programs, sometimes referred to as “pay for performance,” represent a payment/delivery paradigm that places emphasis on rewarding value instead of volume to align financial incentives and quality of care. Accountable care organizations emphasize an alignment between reimbursement and implementation of best practices through the use of disease management and/or clinical pathways and health information technologies. Consumer-directed health plans, or high-deductible health plans, combine lower premiums with high annual deductibles to encourage members to seek better value for health expenditures. Studies conducted to date on these different designs have produced mixed results.
(Am J Manag Care. 2013;19:S149-S154)
Diabetes mellitus (DM) is a term used to describe a group of metabolic diseases of multiple etiologies. The condition results from defects in insulin secretion, insulin action, or both, and it is characterized by hyperglycemia with disturbances of carbohydrate, fat, and protein metabolism.1,2 Approximately 90% to 95% of patients with DM have type 2 DM (T2DM), a form of DM associated with a continuum ranging from insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with or without insulin resistance.1,2 In 2008, the Centers for Disease Control and Prevention estimated that 23.6 million Americans (7.8% of the population) had DM and another 57 million had prediabetes, a condition marked by levels of blood glucose or glycated hemoglobin (A1C) that are above normal ranges, but not high enough to be classified as T2DM.3 By 2010, that number had increased to 25.8 million Americans (8.3% of the population) with DM.4 Those numbers represent increases of at least 50% in 42 states and of 100% or more in 18 states.5 Furthermore, the prevalence of DM is projected to continue to increase. One study projected that between 2009 and 2034, the number of people with diagnosed and undiagnosed DM will increase from 23.7 million to 44.1 million and that the DM population within the Medicare-eligible population will increase from 8.2 million in 2009 to 14.6 million in 2034.6 Not surprisingly, the economic burden associated with DM is substantial and is also projected to increase. Between 2009 and 2034, annual DM-related spending is projected to increase from $113 billion to $336 billion (2007 dollars) and associated spending in the DM population within the Medicare-eligible population is projected to increase from $45 billion to $171 billion.6 The authors of this projection study astutely pointed out that without significant changes in public or private strategies, this population and cost growth will place a significant strain on an already overburdened healthcare system.6
Utilizing Treatment Guidelines and Other Evidence to Develop and Implement Medical Policies Relative to the Management of DM
There are 3 primary DM management goals for payers. One of these goals is to optimize resource management through unit cost management and rebate contracting. A second goal of improving clinical management is achieved through fostering adherence and persistence to treatment, providing patient care services and therapy case management, and ensuring demonstrated outcomes. The third goal is to ensure appropriate use of treatments through adherence to clinical guidelines and treatment algorithms, use of formulary/preferred products, and proper use of prior authorizations and step edits. Through the use of clinical guidelines and treatment algorithms, such as the most recent American Diabetes Association/European Association for the Study of Diabetes (ADA/EASD) management guideline,7 managed care organizations (MCOs) can make decisions regarding appropriate use of treatments. For example, the information in Table 1, drawn from an MCO pharmacy coverage policy,8 reflects the ADA/EASD recommendations for the use of glucagon-like peptide-1 (GLP-1) analogues. It is important to note that MCOs rely on guidelines and treatment algorithms rather than just US Food and Drug Administration (FDA) indications, as GLP-1 analogues are FDA approved as monotherapy without the precondition of patient failure on other pharmacotherapies.9-11 As guidelines and treatment algorithms are updated based on evidence-based data, MCOs update their pharmacy coverage policies to reflect new treatment recommendations.
Impact of Disease Management Programs
In general, DM disease management programs consist of 3 principal elements: target identification and outreach, engagement and education along with incentives, and lifestyle modification and follow-through. These programs are designed to limit the medical and economic burden of DM by attempting to detect the disease early and initiate treatment to prevent advancement of prediabetes to DM and worsening of newly diagnosed DM. Results from a study published in 200212 provided excellent evidence that either a lifestyle-intervention program or the administration of metformin could prevent or delay the development of DM. Importantly, the beneficial effects of the lifestyle intervention were apparent regardless of sex, age, ethnicity, or body mass index (BMI). Study results also revealed that the efficacy of the lifestyle intervention relative to metformin was greater in older persons and in those with a lower BMI (<30 kg/m2) and that the efficacy of metformin relative to placebo was greater in those with a BMI of 30 kg/m2 or higher.12 These data provide MCOs with an excellent approach to managing DM, as they demonstrate the power of prevention. Therefore, MCOs are very interested in incentivizing patients to live the healthiest possible lifestyles in order to keep DM at bay. As a hypothetical example of an MCO-initiated, healthy lifestyle–based incentive program, members could enroll in the program and log on via computer, select an assessment tool such as a pedometer, engage in a healthy activity that is monitored by the tool and results in reward points, utilize an in-office measurement device, and redeem points for rewards at a reward center. Essentially, the goal is to foster healthy lifestyle choices and incentivize them. Such programs are focused on prevention and physical activity; provide tools and incentives to motivate members to get moving and stay moving; launch engagement and ongoing communications to help members boost activation and participation; are comprehensive, engaging, and customizable; and hold members accountable. Incentive programs theoretically hold great promise, as the data from the aforementioned study showed that members in the lifestyle intervention group had the lowest incidence of DM (number of cases/100 person years after 2.8-year follow-up: 4.8 vs 7.8 for those in the metformin group, and 11 in the placebo group), the greatest reduction in incidence of DM compared with placebo (58% vs 31% for those in the metformin group), and a lower number needed to treat to prevent 1 case in 3 years (6.9 vs 13.9 persons to prevent 1 case in the metformin group).12
In practice, the results of such initiatives have been mixed and several factors that account for barriers to progress have been identified. One study examined the business case for improved DM care from the perspective of a single health plan (HealthPartners of Minnesota).13 Investigators determined that potential benefits from DM disease management attributed to a health plan included medical care cost savings and higher premiums, and that potential costs were accrued from disease management program costs and adverse selections. Overall, it was determined that the implementation of DM disease management coincided with large health improvements and that medical care cost savings over several years were small in the closed panel medical group representing a defined population of DM patients but moderate for the health plan. Conversely, adverse selection and the timing of cost and benefits worsened the health plan business case. The business case was found to be further weakened by the very weak connection between payment systems, from purchaser to health plan and health plan to provider, to the quality of DM care. Additionally, the authors found that overlapping provider networks limited the health plan’s ability to privately capture the benefits from its investments. The study authors concluded that improved DM care was associated not only with economic benefits to health plans, but also with quality of life benefits for adults with DM.13 Regarding the difficulties in establishing MCO DM disease management programs, the results of 1 study indicated that health literacy may be an important factor for predicting who will benefit from such programs.14 Another important factor to consider is whether members will elect to participate in such programs and the implications of that decision. In a study that compared healthcare costs for patients who fulfilled health employer data and information set (HEDIS) criteria for DM and were in a health maintenance organization–sponsored disease management program with costs for those not in the disease management program, the study authors found an association between providing an opt-in disease management program and reductions in healthcare costs and other measures of healthcare use. Additional study findings demonstrated improvements in HEDIS quality of care measures.15 Lastly, cultural issues may play a role in the success or failure of MCO DM disease management programs. In a study that examined the incidence of DM-related lower-extremity complications in a cohort of patients enrolled in a DM disease management program, the study authors found that although rates of ulceration, infection, vascular disease, and lower-extremity bypass were similar to those of non- Hispanic whites, Mexican Americans had a higher incidence of amputation.16
Implications and Impact of Various Benefit Plan Designs
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