Managed care organizations (MCOs) are uniquely positioned to make significant contributions to diabetes care. Most MCOs have information systems that collect various types of data from internal data sources (ie, paid claims), as well as selected external sources (ie, pharmacy benefit management companies, laboratories, and disease management vendors). MCOs aggregate and analyze this data, allowing for the identification and stratification of populations of individuals with certain chronic clinical conditions, such as diabetes. After populations have been identified, MCOs apply various interventions designed to close gaps in care identified by analysis of the data, such as failure to get an HbA1C test or noncompliance with prescribed medications.
The impact on clinical outcomes of these programs, collectively known as disease management programs, depends on a number of things, including:
• Robustness of the aggregated data
• Design of the interventions
Do they help foster behaviors that are tied to improved outcomes?
• Cost-effectiveness of the program
MCOs are in a good position to foster innovations in chronic illness management as illustrated in papers in this issue of the Journal. MCOs, particularly staff and group models, have an organizational infrastructure that facilitates design, implementation, and payment for delivery system enhancements that provide a better care experience for individuals with chronic illnesses, such as diabetes. Group visits are one such example.
Group visits allow a cohort of patients with similar conditions to meet on a regular basis over time. Physicians, nurses, dieticians, and/or other health professionals moderate the group visits, provide targeted education, and perform routine health tests, such as blood glucose and blood pressure. The group visit also fosters peer-to-peer learning and support. Group visits are usually longer and occur more frequently than regularly scheduled one-on-one physician visits provided in traditional office practices; therefore, they may not be a viable alternative for all individuals with chronic illness. Group visits result in good patient satisfaction, better clinical outcomes, and a reduction in healthcare utilization.2
Clancy and colleagues, in this issue of the Journal, document that group visit patients show reduced emergency department use and lower total charges compared with usual care patients.3 After controlling for endogeneity (the potential of unobserved patient characteristics to affect adherence to the intervention), group visit patients have lower outpatient costs, primarily attributable to a reduction in specialty care visits.
Other innovative MCO practices include multidisciplinary visits where diabetic patients can have all of their diabetes- related needs attended to on a one-stop basis with consultation with a cardiologist, neurologist, nephrologist, podiatrist, certified diabetic educator, and/or dietician as needed. Nurse case management,4 peer-led support groups,5 and same-day appointment protocols6 are other delivery system innovations that have been developed and/or honed in MCOs. Because MCOs are organized systems of care that provide healthcare to defined populations within a defined budget, we can anticipate that experimentation and testing of new delivery system designs will continue as MCOs try to balance the need to achieve good clinical outcomes and patient satisfaction with the reality of having to provide care with resource limitations.
Payment Practices That Reward Improvements in Care and/or Outcomes—Pay for Performance
MCOs have contributed to health services research in a number of ways. First, MCOs provide a rich source of data that can be analyzed to assess the effectiveness of practice patterns. Several examples of the usefulness of MCO data appear in this issue of the Journal. Young and colleagues used data from a large nonprofit health maintenance organization to design and test the predictive power of a Diabetes Complications Severity Index (DCSI).8 Dailey and Strange, in their paper examining hypoglycemic risk of insulin glargine versus NPH in type 2 diabetes, point out that “insurance claims data provide another important source for evaluating not only the incidence of severe hypoglycemic events, but also their economic impact.”9 Several of the studies cited in this paper are based on data from MCOs.
A number of MCOs have health services researchers on staff and some even have their own research departments or organizations. Their research has contributed significantly to our knowledge of the effectiveness (or lack thereof) of many medical practices.
Finally, it is important to acknowledge the contributions to diabetes knowledge of the ongoing Translating Research Into Action for Diabetes (TRIAD) study (www.triadstudy.org). TRIAD is a national multicenter study that was created to determine how managed care systems influence the processes and outcomes of diabetes care. Ten health plans and 66 provider groups have participated in the TRIAD study. This collaboration has resulted in the publication of more than 25 high-quality research papers covering the impact of diabetes on individuals as well as many aspects related to the quality of care provided to diabetic patients.
Private Sector Public Health
MCOs have and will continue to contribute to improved diabetes care and diabetes prevention programs.
interest with any entity that would pose a conflict of interest with the subject
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1. Mattke S, Seid M, Ma S. Evidence for the effect of disease management: Is $1 billion a year a good investment? Am J Manag Care. 2007;13:670-676.
3. Clancy DE, Dismuke CE, Magruder KM, Simpson KN, Bradford D. Do diabetes group visits lead to lower medical care charges? Am J Manag Care. 2008;14:39-44.
5. Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a selfmanagement program on patients with chronic disease. Eff Clin Pract. 2001;4:256-262.
7. Fischer MA, Schneeweiss S, Avorn J, Solomon DH. Medicaid priorauthorization programs and the use of cyclooxygenase-2 inhibitors. N Engl J Med. 2004;351:2187-2194.
9. Dailey G, Strange P. Lower severe hypoglycemia risk: insulin glargine versus NPH insulin in type 2 diabetes. Am J Manag Care. 2008;14:25-30.