Reducing Cardiovascular Mortality in Patients With Type 2 Diabetes Mellitus - Episode 10
John A. Johnson, MD, MBA: I think back to an example that Michael referenced earlier—leveraging telemedicine in those communities where there are not enough endocrinologists to provide that specialty support to the primary care physician. How can we connect those primary care doctors to an endocrinologist? How can we use those virtual visits not just to connect patients to a doctor, but to connect doctors to each other and leverage the technology in very innovative ways?
Dennis P. Scanlon, PhD: We spent a lot of time earlier talking about the patient-centered medical home and different care models, team-based care, care coordination, and such. I’m wondering if you have thoughts on some related topics which you hear a lot about—the use of mobile technology and different ways of communicating with patients and with care teams?
We hear about behavioral economics and incentives. Mark Fendrick, MD, the co-editor-in-chief of The American Journal of Managed Care, is famous for value-based insurance design and thoughts about wanting to make drugs free out-of-pocket to patients because compliance will go up. I’m wondering if you’re seeing much of these things happening—innovations like using technology or using behavioral science in economics—and the role that you might see that play going forward?
Robert Gabbay, MD, PhD, FACP: I think all 3 of those things are playing out in a variety of different areas. They’re typically in small pilots where evidence suggests it’s quite helpful. In the digital technology area, I think there’s a lot of excitement about it. From my perspective, thinking of it as a standalone intervention that’s going to make a difference is probably not the right way to think—but it’s one tool as part of a broader engagement. Health coaching through that certainly can be effective.
One thing that I think all of us as providers have done, even before the technology was available, was get glucose values between visits and make adjustments in medication based on that. That now becomes so much simpler to do with a variety of technologies that can upload [glucose test results from patients’] meters.
The piece that has sort of lagged behind has been getting payment models to incentivize that kind of activity because, typically, it’s been something we’ve all done just because we know it’s the right thing to do. Therefore, it doesn’t happen in the systematic way that it really could.
John A. Johnson, MD, MBA: Like most managed care companies, WellCare has a mobile app for our members. We can push disease-specific information through the mobile app. There’s recent federal law changes around what we can text our members unless they opt in to the programs, and there’s limitations on texting communication to cell phones.
But, nonetheless, we do offer it for (let’s say) our high-risk pregnant moms who have diabetes or gestational diabetes. If they’ve opted in, we can text them disease-specific information about their diabetes and diabetes management. So, through the use of both a mobile app and texting where the members have opted in, we have been able to leverage those technologies.
Dennis P. Scanlon, PhD: Do we have to worry about multiple messaging—too much information? We get texts from our providers, and we get texts from our health plans. It would seem important to me that there be some degree of coordination so we don’t overwhelm patients.
Zachary T. Bloomgarden, MD, MACE: I think what we have to do is put as many resources into developing smart apps for individuals with illness, especially diabetes, as we do into developing drugs. The drugs are developed because the reimbursement is so high. The apps are a nice add-on, but there’s nothing to pay for it. We have to really say to ourselves, “These are resources that will lead to more motivation, to less cost, and to give patients the ability to understand their disease.”
Three or 4 years ago I wrote an editorial for the Journal of Diabetes about this with Samuel Dagogo-Jack, MD, who is president of the American Diabetes Association now. We talked about how we look forward to this, and I must say that over the ensuing few years, I’ve been disappointed that we haven’t seen the development of the kind of apps that will take step counts on your cell phone, take the medications, and so on and then whip it all together in some way that’ll help people do better.
Robert Gabbay, MD, PhD, FACP: I think you’re absolutely right. The good news is that some of the big players in this space, like Google and Apple, are really targeting this as a way to aggregate all of the data that we have on our phones, and elsewhere, into a single source.
I’m a little nervous about that being the full answer because I don’t think it is. It’ll be a nice tool. A great example where technology has really improved care for many of us that have patients has been giving them a continuous glucose monitor. They’re able to see their blood sugars, and they often will improve their diabetes just by having more information. That’s not universally true with every patient, but certain ones will. Similarly, as you’re saying, if you had all of the data aggregated for a subset of society, it will drive improvements.