Incentivizing Comprehensive Care Approaches within the Management of Diabetes

Treatment strategies for diabetes should include a comprehensive approach involving multidisciplinary care teams.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: You started to talk a little bit about incentivizing people, which will address treatment from several directions? Can you find a way? A multispecialty approach perhaps. Whether it’s done by 1 clinician or several clinicians. Would you incentivize them if they really bring all those aspects; prevent strokes, prevent CKD [chronic kidney disease], improve glucose, and improve lipids, etc? Can you incentivize them?

Jaime Murillo, MD: I think there is an opportunity. This is obviously a multi-stakeholder approach to incentivize this, way of seeing treatment. You talked at the beginning about partnering with the community, for instance, in care. There is a massive opportunity for us to include community health workers and health clinics within the community and partner with them because sometimes we think that we cannot give the most expensive medications to every single one of them. What do we do with that? Do we just watch them? How about if we actually instituted holistic approaches, and then partner with groups that are going to do intensive lifestyle interventions? Coach those patients to change their behaviors. Go with them to the supermarket. What are you shopping for? Let me help you with that and so on. Can we build a system that would incentivize that approach? The answer is yes. Why not? We should be doing that. I’m hopeful that we’ll get to a point where it’s not about a transactional type of medicine, but it’s more about paying for control and paying for outcomes. Then we’ll have a different mindset.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: How often do insurance companies update their policies? What causes them to do that beyond just an occasional guideline?

Jaime Murillo, MD: You’ll be surprised to hear that the moment [the] FDA approves a product, the moment guidelines change, there’s an immediate reaction. What I like about that is the fact that the society that is issuing the guidelines are now more aware that they cannot wait 5 to 6 years before they update the guidelines. Because, usually, by the time they get updated, those bylaws are almost obsolete. The dynamism of updating guidelines and standards of care will benefit everyone because then the insurance company will see those updates and then will act upon them because it’s about following the standard of care.

Eugene E. Wright, JR. MD: You’ve hit on something that’s near and dear to me. I like the idea that you are moving more quickly to provide coverage. Access still remains an issue for many patients, particularly for those patients who I would say could benefit the most from that. How can we work together to improve access for those who would clearly benefit the most? We know who they are. We see them back in the [emergency department]. We see them in the dialysis units. It just seems that early on when we had the opportunity, we were missing some of that.

Jaime Murillo, MD: Team approach is the answer. There is no question. I think everybody knows there is a shortage of physicians. There is also a shortage of specialists. It will become worse. If we continue healthcare the way we’ve done for the past few decades, we’re never going to solve that problem. Empowering the primary care physician, empowering the specialists to coordinate work and utilize a team around them; pharmacists, social workers, community health workers, nurses, and advanced practice clinicians, to just name some of them. That is the answer. Because then, you can have an initial evaluation, and then this titration, we can do it effectively and quickly. [It’s more beneficial] to put a person into the system than just depending on the availability of a single provider.

Eugene E. Wright, JR. MD: Jaime, can I just ask you to add one word to that? You said empowering. Can you say incentivizing? Empowerment is one part. But we all know as you say, busy clinicians don’t have much time. There needs to be some incentive in there. I think with uACR [urine albumin to creatinine ratio], for instance. eGFR [estimated glomerular filtration rate] getting into HEDIS [The Healthcare Effectiveness Data and Information Set] guidelines, if that gets into the MIPS [Merit-Based Incentive Payment System], the Medicare Incentive Payment System. That will help as well. I think those incentives with empowerment, can really drive practice behavior.

Jaime Murillo, MD: I completely agree. I’ve been in several forums where there is an agreement. For instance, just to take that example, the community health workers. Michigan just recently passed a bill appropriating $23 million for community health workers to highlight their work. Wal-Mart actually provides free training to their associates to become community health workers.

Eugene E. Wright, JR. MD: Sure.

Jaime Murillo, MD: Because they realize there is an opportunity to enhance the level of care. The ability to provide those incentives, I think, is there. We should definitely look forward to that.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Jaime, you mentioned several times how powerful guidelines are.

Jaime Murillo, MD: Yes.

Yehuda Handelsman, MD, FACP, FNLA, FASPC, MACE: Andyou have a direct relationship with a lot of providers. I hate the word provider; professionals and clinicians, you have relationships with. You mentioned IT [information technology].

Transcript edited for clarity.

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