Diabetes-Related Complications: A Focus on Diabetic Macular Edema - Episode 8
Peter Salgo, MD: Let’s focus on diabetic macular edema. We’ve been circling the wagons. We talked about treatment for diabetes and getting more people in the tent. But, now we’ve got diabetic macular edema. For some people this is an inexorable progression. No matter what you’ve done, you may have delayed it, but here it is.
Let’s talk about intervention—early and late intervention. Are there cost benefits to early intervention?
John W. Kitchens, MD: Absolutely. We know that 95% of vision loss from diabetic retinopathy is preventable or treatable. So, the earlier you intervene, the better off the patient is going to do at retaining their vision and improving their vision.
And it may be that earlier intervention actually can negate some of the cost advantages or disadvantages of certain medications, and we’ll talk about that in just a bit when we talk about anti-vascular endothelial growth factor therapies. But, intervening earlier gives us a better chance of maintaining their vision and improving it.
Peter Salgo, MD: And we have data on this?
John W. Kitchens, MD: We do.
Peter Salgo, MD: How do we get this data? Is it your data? Is it practitioner data? Is it Cleveland Clinic data? Who’s got it?
Rishi P. Singh, MD: We have data that has, in a randomized clinical study, looked at this. One of the studies didn’t treat patients for a period of a year and looked at what happened when we crossed those patients over. They didn’t gain as much visual acuity after that one year time point.
That was a study that was a randomized, placebo-controlled clinical study that was prospective in nature and found that out. So, we know that the cut point is at least one year, and probably earlier than that. We don’t know about earlier, but at least one year of non-therapy leads to the survey.
And by non-therapy, I don’t mean no therapy at all. I mean just standard of care laser. Laser was the standard of care for a lot of these conditions before. It’s not anymore. It has been shown in the past few years, and in a few studies, that definitively, that laser is not the standard of care for this treatment anymore.
Peter Salgo, MD: I want to get to that in just a moment. We talked about this in general terms. Let’s see if we can get more specific. If we have data that early intervention works, that we can, if not prevent diabetic macular edema completely, can slow its progress and keep people seeing better longer, what can you do at the provider level and at the health plan coverage level to make this happen?
John W. Kitchens, MD: Well, that’s where you go back to that 50% of patients that are being screened. And if you can change that, you can increase the number of patients that we can treat earlier, dramatically.
Peter Salgo, MD: That’s it? That’s your answer? Then why don’t we just do it? We’re done. Everybody go out, do it. We’re through here. No?
John W. Kitchens, MD: That’s a major thing.
Peter Salgo, MD: It’s hard. So what’s the problem?
Rishi P. Singh, MD: Well, I think there are a couple other things too. To add to that is really a situation of our length of exams and what that does to people. I think we currently have a situation where we do dilated eye examinations. It takes people out three to four hours for that process.
Peter Salgo, MD: It does.
Rishi P. Singh, MD: Secondarily, the imaging technologies. While they’ve advanced significantly, there has never been a recommendation by the major societies that that is a potent or useful screening tool. If that was possible, then we might see a proliferation of those devices in the back of trucks walking around and going to healthcare environments to do that sort of thing.
Steven Peskin, MD, MBA, FACP: There are patient factors, there are access factors that have been described. I heard yesterday a great quote that, “The zip code is more powerful than the genetic code in determining one’s health and health status.”
So we know that, again, there are social determinants of health that play into this. So this is a multifactorial issue. Are there sometimes payer policies that might impede it? I would be disingenuous if I said no, there are no payer policies. So absolutely, there are. Certain prior authorization. These two great clinicians to my right and to my left do this every day. Sometimes they have to butt heads with some medical director somewhere or some PharmD somewhere about the appropriateness of certain treatments. So those aspects do come into play as well.
Peter Salgo, MD: But I keep coming back to, “You were very succinct, you said what you wanted to do, we know what we want to do.” Then, there’s the 50%. So it’s not working. We’re not getting where we need to be. It’s sort of like Monty Python. He said, “It’s easy to play the flute. You blow in here and move your fingers, music comes out.” But there’s a lot of business in the middle, right?
So how do we get from here to there? Anybody got a brilliant idea?
Rishi P. Singh, MD: We have to have our healthcare system pay for preventative services. And it’s something that Medicare has not done and refuses to do, still. If they ever decided to change their model, maybe this would lead to some potentially lower costs.
I’ll give you an example. At the Cleveland Clinic, we have a model where if you’re an employee, you have to be enrolled in either a chronic disease program or you have to be in a step program. You have to be able to show you have 100,000 steps per month. If you can’t show that, you have $1000 upcharge on your insurance.
That’s pretty good preventative care if you can do it and demonstrate it, and it’s something that would potentially lower the cost of healthcare if we did so. And we’ve done it for many, many years. I think it’s something that’s really led to our reduction in our overall healthcare utilization as a result of picking out populations of people that have good healthcare initiatives.
Steven Peskin, MD, MBA, FACP: We actually have a similar thing in our employer-sponsored plan around participation in a program of walking, and also an attestation that either, “I don’t smoke,” or “I’m actively involved in a program.” Those two things combine to $1000 more or less for your health benefits.
Peter Salgo, MD: So the trick is to go find your local Medicare administrator and shake that person and say, “Would you just wake up and help us out here?” Yes? No?
John W. Kitchens, MD: I think that along with education of patients. Because even if you get the services covered, you’ve got to get the patients engaged in going to get the exam done.
Peter Salgo, MD: Got it. But I thought a major selling point of, let’s call it Obamacare for lack of anything else, was the initiation of preventive healthcare and the prioritization of preventive healthcare? And you’re telling me not so much.
Rishi P. Singh, MD: My experience with Affordable Care has been that more people are insured and therefore, they are coming in because they are insured. But that doesn’t still pay for preventative services as a result of that.
Steven Peskin, MD, MBA, FACP: Well, there’s a finite list of preventative services. So the Affordable Care Act defined essential benefits, right? And some benefits have not yet deemed to be essential in the area of prevention.
Peter Salgo, MD: So that would be a hinge point for you. Make this one of the essential points. That would help the 50%.
John W. Kitchens, MD: I think the other thing is understanding that we do have treatments that dramatically improve patients’ visual acuity and reduce not only diabetic macular edema, but also reverse retinopathy. And I think when physicians and patients understand that, they’re much more engaged and interested in going to see somebody.