Reducing Cardiovascular Mortality in Patients With Type 2 Diabetes Mellitus - Episode 4
Zachary T. Bloomgarden, MD, MACE: This gets back to the point that we were discussing earlier—of community programs versus professional programs. And, even more, it pertains to the whole issue in American healthcare—of acute, episodic care versus chronic care and preventative care. Diabetes teaches us that the goal is all about lifestyle in conjunction with appropriate medical therapies.
John A. Johnson, MD, MBA: But I want to get back to community because, again, we know that when we talk about diabetes, there are health disparities. Access to care is an issue. Although there may be, in a metropolitan area, centers of excellence or endocrinologists, in some of the rural communities, there are not. So, in the managed care world, we can leverage telemedicine. We can leverage a lot of the community through our advocacy program.
Zachary T. Bloomgarden, MD, MACE: And, diabetes is a disease that’s really overrepresented in socioeconomically disadvantaged groups. I’m in New York City. There are a lot of pockets of extreme socioeconomic disadvantage, which are tremendously overrepresented in diabetes, and even more in diabetes complications, in amputations, in development of end-stage renal disease, and in cardiovascular outcomes. I think this is generally applicable across the country in all sorts of areas and we just don’t know, yet. Managed care, hopefully, can help us learn how to reach these populations.
John A. Johnson, MD, MBA: Right. Definitely, we see that access is really a big contributor to why the management of the condition has been such a challenge across the United States.
Michael Gardner, MD: Also, on the community level, you need to go to where the people are. That means having trained community volunteers who can reach out to people in their community centers, in their churches, and those sort of places, and provide basic lifestyle [information], and encouragement, and support.
I have 2 dedicated diabetes educators. However, you can’t have that in a primary care office. But, what you certainly can have, and what we try to encourage in some of our rural practices, is a diabetes champion. You might have a nurse or an MA (medical assistant) who has a particular interest in diabetes and can go to a slightly higher level of understanding, helping you to facilitate within your practice the care of those patients—reaching out to them, re-engaging them, reminding them.
Robert Gabbay, MD, PhD, FACP: This is also where the managed care community can help, because a lot of the managed care payers have disease management programs—such as WellCare. We have a diabetes management program where we have the personal health coach and the community health worker that do exactly what Michael just referenced.
Dennis P. Scanlon, PhD: How does that integrate or coordinate in a seamless fashion? Is that a telephonic service?
John A. Johnson, MD, MBA: The disease management is telephonic, but if a member transitions into case management, in some cases, that’s field-based. We take direct referrals from the provider community, whether from the specialist or primary care physician. We use surveillance for our historical claims data—our HRA (health risk assessment) data for members that joined the plan—and we find out that they do have diabetes and they’re not connected to care. We want to make sure they have a home, a medical home, and that they’re connected to a doctor that we can partner with.
Then, we consider how to wrap them around the services for weight management and nutrition counseling. What we’re seeing is the referrals from the primary care physicians are just not there. Again, we’d like to have physicians refer more of their patients to the managed care community in a collaborative way. Our role is to be more supportive, not intrusive. So, we’re just seeing a lot of these programs as somewhat underutilized.
Zachary T. Bloomgarden, MD, MACE: One out of every 10 adults in America has diabetes. And, in a physician’s practice, I don’t care where it is (whether it’s in rural Alabama or in the inner-city New York), it’s going to be way more than 1 out of 10. So this is highly prevalent. These are people who are sick. They’re the ones who incur much greater healthcare costs, personal costs, and illness, and all the adverse outcomes of diabetes. We have to learn how to take the resources that you’re offering, use the resources of a nurse champion in a physician’s office, and then really make it work to help people.
Robert Gabbay, MD, PhD, FACP: Joslin has a program where we take our educators and train primary care practice medical assistants on some of the basics around diabetes and create that local champion. It’s been super effective because, again, there are not enough endocrinologists or diabetes educators. Leveraging that knowledge, more broadly, by training individuals and then guiding them along the way, I think, is really the long-term answer.
John A. Johnson, MD, MBA: And I think the final point I want to make is that the managed care community can incentivize providers to participate and obtain that type of certification, such that the reimbursement offsets the cost—the startup cost. There are various ways it can be done—an enhanced fee schedule, care coordination. At the end of a quarter you can do a shared risk agreement and spread the cost from a cost avoidance model. So, there are ways we can incentivize providers and make it more attractive for them to want to become [part of] a patient-centered medical home.
Robert Gabbay, MD, PhD, FACP: Broadly, that’s been helpful. The programs that have it, have done 2 things. They provide some extra resources for the practice, but the second piece is [that they provide] someone to guide them on how to change. It’s changing their model and they may not be able to figure it out because they’re trying to do this while they’re seeing, you know 20, 30 patients a day.
John A. Johnson, MD, MBA: For the managed care community, it’s okay to do that because with the additional cost, downstream, it’s cost avoidance from readmissions.
Robert Gabbay, MD, PhD, FACP: Absolutely.
Zachary T. Bloomgarden, MD, MACE: I just wanted to say that, so often, it’s perceived, not entirely incorrectly, as an adversarial relationship. We need prior approval for this, and this, and this, and this, and this. It’s a huge burden for physicians actually caring for human beings with illness. So, I applaud what you’re saying and I only hope that this is something that can be translated, so that physicians don’t see the managed care companies as their adversaries, and [instead] begin to see them as a beneficial partner. But, it will require work on everyone’s part.