Adapting payment models to reward outcomes is key to making lifestyle change fit into a managed care framework, several articles find.
Virta Health’s Mike Payne MBA, MSci, was on to something when he took his inspiration from Nudge co-author Richard Thaler, PhD, earlier this year. Payne cited Thaler for an essay in Evidence-Based Diabetes Management™ (EBDM™), which proved fortuitous when the behavioral economist won the Nobel Prize in October, giving readers another opportunity to appreciate Payne’s point: if payers want to promote healthy behavior, they must figure out how to reward highly repeatable small pushes, what Thaler calls “nudges.”
Changing behavior to promote health, with technology, support, or through some other means, has been the unsolvable problem of diabetes management for decades, but one that payers from Medicare on down cannot quit trying to fix, given the enormous costs the country faces from diabetes, obesity, and related cardiovascular diseases. The March issue of EBDM™ looked at these questions from multiple angles.
Here are the 5 most-read articles of 2017 in the journal:
5. Medicare and CGM, Omada Health Hires, Council for Diabetes Prevention Officers
Leading the news roundup was one of the most important milestones for people with diabetes of the past decade: the decision by CMS to update its definition of durable medical equipment to allow for reimbursement of the Dexcom G5 continuous glucose monitoring (CGM) system, which had previously received a new indication from FDA for dosing. The change applies will allow virtually Medicare beneficiaries with type 1 diabetes and those with type 2 diabetes on intensive insulin therapy to gain access to CGM. To be sure, there have been some administrative hiccups, but this was a watershed moment after many years of advocacy.
4. Diabetes: An Opportunity to Have a Lasting Impact on Health Through Lifestyle Modification
Three cardiologists—Hena N. Patel, MD; Andrew M. Freeman, MD, FACC; and Kim A. Williams MD, FACC—offered a thorough review of evidence in nutrition, physical activity, mindfulness, as well as the need to educate physicians and allied health professionals on the importance of emphasizing the role of lifestyle change in diabetes management. Williams, the 2015-2016 president of the American College of Cardiology, offered inspiration for the EBDM™ special lifestyle issue when he hosted a standing-room-only, half-day intensive on lifestyle evidence at the 2016 ACC meeting in his hometown of Chicago.
3. Can Yoga, Mindfulness Fit With Managed Care?
There is compelling evidence to include yoga in any regimen to reduce stress, reduce fasting glucose, and prevent or treat diabetes. Payer coverage, however, is another matter. The problem, as one well-known yoga therapist put it years ago, is conforming to the dictates of managed care would strip away the very things that make yoga what it is: spiritual, deep, open to new things, and—adaptable to the individual. Experts in this article said the path to payer coverage for yoga would be long.
But since this article appeared, the need to find less expensive, healthier ways to deal with chronic pain, has caused a rethinking of that assessment. In November, the Institute for Clinical and Economic Review (ICER) found there’s sufficient evidence for payers to cover yoga for chronic back pain. ICER did not evaluate yoga for diabetes treatment or prevention in this review, but yoga enthusiasts were happily surprised.
2. Making Diabetes Self-Management Education Patient-Centered: Results From a North Carolina Program
Not every person with diabetes has access to an academic medical center. Some do not have health insurance. Rural areas in the Southeast have high concentrations of people living with type 2 diabetes or at risk of developing it, and these patients often need the most support in learning to make healthier lifestyle choices. Paige Johnson Cartledge, RN, BSN, wrote about a “home grown” program that helps meet patients where they are to lower glycated hemoglobin levels while dealing with cultural food patterns and family demands. Real-life problems—like how to avoid sweets when baby-sitting grandchildren—are addressed directly with coaching and support. Patients are taught to monitor their own blood glucose.
1. A Bundle of Nudges: Healthcare Payment in an Era of Behavioral Science
Virta Health’s Payne notes that the minute-by-minute decision-making that gives rise to chronic disease demands minute-by-minute solutions—and with them, payment models that are a radical departure from the fee-for-service paradigm. Payment per nudge is one option—a difficult one. So is payment for a bundle of nudges and a desired clinical outcome. Of note, Payne compared his concept to CMS’ Comprehensive Care for Joint Replacement (CJR) model in orthopedic care, which many payers viewed as a success. However, CJR drew the ire of former HHS Secretary Tom Price, MD, and has since been scaled back.
As the Medicare Diabetes Prevention Program is poised to launch in early 2018, Payne calls on CMS to rethink its position on virtual program delivery, and to see technology as essential to the “bundle of nudge” delivery of better care at a lower cost.