Updates to Treatment Guidelines: Effects on Payers

John A. Johnson, MD, MBA: The updated guidelines have basically stated that we need to add more medications to our preferred drug list so that providers and members have access to those medications to ensure that those with comorbid conditions (not just diabetes, but hypertension, hyperlipidemia, or previous heart attacks or strokes) have access to one or more medications. [This can help] to ensure that, downstream, we reduce the risk of subsequent complications.

At WellCare, we make medications in these classes available to our members to ensure that they receive the care that they need in the most cost-effective way.

Guidelines are just a tool—a reference point. When a clinician evaluates a diabetic patient, the treatment plan, or care plan, is very individualized. There are certain medications that are more appropriate for one diabetic and not appropriate for another—depending on whether they have concomitant hypertension, concomitant heart disease, or concomitant renal failure.

As a result of these carve-outs, it’s very difficult to sort of paint the entire diabetic community with one brush and one color. It is very individualized, and medicine is still an art. It does require some artistic ability and clinical acumen of the physician to design an appropriate individualized care plan.

So, at WellCare, we partner with providers for that very reason. We don’t anticipate that they will treat all of our diabetic members the same. Our hope is, again, to use proxies for care—such as A1C control and blood glucose control. These proxies give us a guide of how well you’re managing the clinical outcomes of those diabetics. We’re not expecting the clinicians to use the standards literally. We expect them to be used as a guide. Then, from that guide, [clinicians can] carve out those appropriate elements that you still need to hit the target.

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