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Keynote Address Informs on Improving Diabetes Care Delivery and Outcomes

Evidence-Based Diabetes ManagementPatient Centered Diabetes Care 2015
Volume 21
Issue SP9

In the keynote presentation at Patient-Centered Diabetes Care 2015, Robert A. Gabbay, MD, PhD, discusses how new payment models can improve care in both type 1 and type 2 diabetes.

In his keynote presentation at Patient-Centered Diabetes Care (PCDC) 2015, “Diabetes care—where is it headed?” conference chair Robert Gabbay, MD, PhD, chief medical officer and senior vice president of Joslin Diabetes Center and editor in chief of Evidence-Based Diabetes Management, provided an overview of the programs at Joslin and the care models being implemented to improve patient health in the long term.

At Joslin, said Gabbay, there is a successful integration of 3 main groups:

  • The basic research group, with a focus on addressing diabetes complications, developing new treatments, altering clinical care, and preventing diabetes.
  • The “metrics-driven” clinical care group, which provides care to man-age the disease and associated complications.
  • Innovation in care delivery group, with a focus on solutions to wellness and employer issues among others.

Gabbay highlighted several discoveries by scientists within the basic research group, such as determining the precise degree of inflammation of the pancreas to use as an early indicator of type 1 diabetes mellitus, the development of several drugs focused on inflammation in type 2 diabetes mellitus, and discoveries that have led to improved management of diabetes-related complications such as retinopathy.


“I am a firm believer that creating the right payment incentives is one piece of the puzzle in terms of driving innovation,” said Gabbay. The movement from fee-for-service (FFS) to value-based care is rapidly gaining momentum, he said, as is accountable care. Together, they will influence how we think about care delivery. He emphasized that this shift is already happening, with a third of outpatient care reimbursement for the Medicare population scheduled to be linked to value by the end of 2016. Gabbay predicted that this may also influence private health plans, which typically follow the federal government’s lead. Eighty-five percent of all traditional Medicare payments will be tied to quality or value by 2016, said Gabbay, with that number reaching 90% by 2018.

A recent analysis by Catalyst for Payment Reform found that 42% of the $360 billion Medicare paid to providers in the FFS program in 2013 were for value-based payment methods.1


Long-term complications in diabetes patients significantly increase the total cost of care, said Gabbay, but these costs can be prevented by closely monitoring glycated hemoglobin, blood pressure, and cholesterol. He pointed out that endocrinologists, primary care providers, and diabetes educators, while at the lower end of the cost curve, are of high value. In his opinion, investing in outpatient care can significantly reduce long-term costs.

Innovative reimbursement models that several private payers are testing can al-ter care delivery, according to Gabbay; but before any changes are made, “It’s critical to measure the quality of care. You can’t improve anything you don’t measure, be-cause you wouldn’t know if you have improved it at all.”

Gabbay went on to explain 3 concepts that in his opinion can transform care delivery in diabetes, starting with population management. According to Gabbay, when a provider starts thinking about delivering an intervention to move the population in a specific direction, there will be a change in the way he thinks about how that care is delivered, which highlights the importance of the second concept, that of care continuum. Because long-term complications in diabetes have a big impact on patient performance, investing in some aspects of continuity of care could deliver big returns, he said. The third concept is the idea of team-based care practiced at Joslin for quite a while, he said a shift from physician-based care to coordinated, physician-led interprofessional team care.


But the bottom line, says Gabbay, is that measuring and quantifying everything is the first step to embracing transformative models that can help in achieving the triple aim of improved patient experi-ence, improved outcomes, and lower cost of care. He went on to show that Joslin exceeded the American Diabetes Association Healthcare Effectiveness Data and Information Set (HEDIS) benchmarks for diabetes clinical quality of care. (HEDIS measurements evaluate an institution against the national comparator data.) According to Gabbay, the biggest chal-lenge providers face is placing a finger on the total cost of care for their patients, and increased transparency concerning the cost of care could go a long way to-ward improving the value of that care. While providing data on per capita costs for Medicare beneficiaries treated for diabetes (see ), Gabbay pointed out that “The risk-adjusted cost of care for Joslin patients is significantly lower than the national average, and significantly lower than 1 standard deviation below the per capita cost.”

Finally, Gabbay showed results from Joslin’s patient satisfaction survey and indicated that the institution is currently developing strategies to improve patient access, for which Joslin received lower approval ratings in the patient surveys than in other areas.


Moving on to the patient-centered medical home (PCMH) model that has revolutionized primary care, Gabbay indicated that the care model has been successful in both physician-led and nurse practitioner—led settings. The model is built around a belief in enhanced patient access, with a focus on quality and safety; while several studies have provided evidence that the model works on those principles, he said that studies evaluating improvements in cost have yielded mixed results. Although reimbursement changes are important to the process, they have not proved effetive in transforming clinical practice models, said Gabbay.

Returning to the principle of team-based care, Gabbay said setting goals for the entire team to achieve has been fruitful. Another successful effort in which Joslin has participated is practice facilitation, where a practice facilitator supports different practices with quality improve-ment processes, providing feedback and benchmarking. He said that Joslin worked with the Agency for Healthcare Research and Quality to compile a guidebook on practice facilitation.

But a PCMH, Gabbay emphasized, cannot work in isolation, without a cooperative medical neighborhood; organized sharing of quality information between the specialists and primary care physicians is important for achieving the desired long-term care outcomes. Citing the hub-and-spoke model of Project ECHO,2 Gabbay explained that it creates a case-based learning platform by connecting providers within a network an ideal model in specialist-deficient regions. Some of this can be achieved, he said, via e-consults and teleconsults, along with developing centers of excellence that can integrate practice units around a specific focus, and then replicating this model at other sites of care.

Gabbay summed up by saying, “The key innovation for us is bundling those things together, doing an in-depth assessment initially, and then a variety of services, whether they’re inpatient care, primary care, specialty services around complication, care that can be optimized, a number of tools around patient engagement, and then ultimately tying that all together around population health.”


1. Medicare’s value-based care payments gaining momentum. HealthLeadersMedia website. http://health-leadersmedia.com/content/HEP-316072/Medicares-Valuebased-Care-Payments-Gaining-Momentum.Published May 6, 2015. Accessed May 15, 2015.

2. Project ECHO. The University of New Mexico website. http://echo.unm.edu/. Accessed May 18, 2015.

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