Managing Diabetes The Challenge of Multiple Chronic Conditions

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Managing DiabetesThe Challenge of Multiple
Chronic Conditions

• James M Schibanoff MD
• Editor-in-Chief
• Milliman Care Guidelines

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Diabetes Today

• Type I accounts for 5-10 of diabetes
• Type II accounts for 90-95 and increasing
• Prevalence in adults 9.6 (20.8 million
  Americans)
• Diabetic adults twice as likely to die as
  non-diabetics of same age
• Leading cause of blindness ages 20-74
• Leading cause of end-stage renal disease

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Diabetes Today

• In comparison with other chronic diseases,
  diabetes is relatively well understood and there
  is broad-based agreement about how to manage it,
  but.
• National Healthcare Quality Report 2005 (AHRQ)
• Hb A1c test performed within year 90
• Hb A1c level lt7 39.8
• About 50 of patients do not follow their
  diabetes medication prescriptions

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Patients with Multiple Chronic Conditions
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The Challenge is Filling the Gaps

• Affordability
• Quality
• Evidence
• Care Delivery
• Personal Life Style

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Affordability Gap

• Milliman Medical Cost Index 13,000 per year
  per family
• DISTRIBUTION OF FAMILY INCOME, UNITED STATES,
  2002
• Average income 66,970 (Median about 50,000)

SOURCE Bureau of the Census website
http//ferret.bls.census.gov/macro/032003/faminc.
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Insurance Premium vs. Income
SOURCE Carroll, John. Erosion of
Employer-Sponsored Health Care. Managed Care.
January 2007, Volume 16, Number 1,
18-29. Retrieved at www.managedcaremag.com.
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Is Medicare headed for insolvency?
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Question Has current approach to disease
management made medical care more
affordable?Answer Probably not

• Objective studies in literature equivocal
• Medicare Coordinated Care Demonstration 2 year
  results
• Difficult to measure
• Randomized controlled trials uncommon
• Selection bias
• Regression to mean

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Regression to mean illustration
SOURCE Ortne, Nick. Milliman Research Report.
Insight into Two Analytical Challenges for
Disease Management. April 2004. Retrieved at
www.milliman.com.
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Are we getting our moneys worth?
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Quality Gap
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Evidence Gaps

• Triple challenge
• Knowledge created at faster rate than we can
  apply to patient care
• Clinical questions growing at faster rate than
  can be answered by traditional research methods
• Current research methods have serious limitations

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National Library of Medicine MEDLINE

• Contains 15 million citations
• 5,000 journals in 37 languages
• 2,000-4,000 references added daily (623,000 in
  2006)

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Evidence Gaps

• Randomized controlled trials (RCTs) are
  considered the gold standard of evidence but
  apply only to select populations with a low
  comorbid disease burden.
• For patients with multiple comorbidities,
  medication intolerances, poor adherence, or
  limited cognition, the evidence base is largely
  nonexistent

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Steps in the Knowledge Chain

• 7 Steps each with a 20 drop off leads to 21
  adoption rate

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Care Delivery Gaps

• Coordination of care fragmented care leads to
  omissions and overlaps

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Care Delivery Gaps Health Plan

• Adverse selection and retention
• Plan turnover
• Financing disincentives
• Helping the competition

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Health plan vs Carve-out disease management

• A single Carve-out DM vendor could
• Eliminate adverse selection and competitive
  disincentives
• Portable across insurers
• Separate ordinary care from diabetes care
• Duplicate infrastructure of health plan and
  vendor

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Care Delivery Gaps Physicians

• Impending shortage of primary care physicians
• General internists vastly outnumbered by medical
  subspecialists
• Fewer general internists are entering practice
• Generalists are paid considerably less than
  specialists

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Why are Primary Care Physicians Vital to Chronic
Disease Management?
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Family Medicine Residency Positions and Number
Filled by U.S. Medical School Graduates
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Proportions of Third-Year Internal Medical
Residents Choosing Careers as Generalists,
Subspecialists, and Hospitalists
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Personal Lifestyle Chronic Disease Care Differs
from Acute Care

• Patient behavior is the most important
  determinant of outcome

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Is it all bad news? Help is on the way

• Care Delivery
• Practice redesign
• Personal Health Record
• Care coordination tools
• Peer support models
• Evidence
• Quality

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Care delivery Medical home proposals

• Personal physician to
• Coordinate and facilitate patients care
• Advocate for and guide patient through complex
  health system
• Assume accountability
• Components are
• Multidisciplinary team
• Clinical decision support tools to guide decision
  making at point of care
• Ongoing plan of care
• Enhanced access to care (email, etc)
• Quality outcomes
• Health information technology
• Self-management support

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Medical home versus current disease management
approaches

• Current disease management relies on care
  managers provided by health plan or contracted
  disease management company
• Emphasis is on relationship of care manager and
  patient with periodic input requested from
  patients physician
• Current disease management more inclined to have
  single disease focus
• Accountability diffuse

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Medical home requires

• Change in traditional role of physician
• Redesign of practice
• Considerable new technology
• New reimbursement system for qualifying practices
• Care coordination fee (capitation model)
• Fee-for-service visit fee
• Pay-for-performance incentive

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Is the medical home concept effective?

• Current best evidence is favorable but is either
  indirect or preliminary

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Information Technology support of medical home

• Patient registries
• Reminder systems
• Personal health record (PHR)
• Interoperable
• Portable
• Guidelines and care coordination tools

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Diabetes Assessment
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Quality Improvement

• Quality measure development
• Ambulatory Quality Alliance (AQA)
• National Quality Forum (NQF)
• Joint Commission
• Public reporting
• Pay-for-performance

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The new evidence concepts

• The rapid-learning healthcare system
• Practice-based evidence

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Personal lifestyle improvementSelf Management

• Increasing role of peer support
• Information support
• Emotional support
• Shared problem solving
• Leads to increased
• Confidence (self-efficacy)
• Perceived social support
• Understanding of self-care

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Affordability?
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Prediction

• In comparison with other chronic diseases,
  diabetes is relatively well understood and there
  is broad-based agreement about how to manage it,
  and
• Our healthcare system will deliver superior
  diabetes care through innovations in care
  delivery, evidence, technology, and quality
  improvement

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