Short-term gains possible with diabetes outcomes
Program pays for itself within a year
It was six years ago that the landmark Diabetes Control and Complications Trial (CCT) proved conclusively through an intensive nine-year study that tight glucose control reduces the risk of complications by 50% to 75% in patients with Type I (insulin-dependent) diabetes. This was good news for the nearly 14 million Americans who have diabetes.
The DCCT study proved once and for all that long-term management of blood sugar levels would pay off in improved outcomes. But does intensively managing diabetic populations reduce costs? And are there any short-term gains?
The DCCT wasn’t set up to answer those questions, nor has a study been done in the intervening years to focus on cost issues. The National Institutes of Health did some modeling based on the DCCT that projects the additional costs involved in long-term glucose management, but the models don’t fully address whether the costs are offset by the reduction in complications.
Lacking short-term incentives, managed care companies (MCOs) have been slow to embrace comprehensive disease management programs for diabetic populations. They have believed that the return on their investment would be long in coming, if ever, given that the enrollees may not stay in the MCO’s plan long enough to justify the cost.
Now there is evidence that even short-term, intensive management of blood sugar levels and other clinical measures can drastically improve outcomes and pay for a program in its first year. And best of all, this proof comes from the front lines of medical care — the physician’s office, which means it’s based on real-world data, not a carefully controlled clinical study or a projection based on historical models.
Nashville, TN-based Diabetes Treatment Centers of America (DTCA) has developed just such a disease management program, called Diabetes NetCare. A pilot of 115 patients showed an 83% drop in inpatient admissions within six months of implementation, while direct health care costs fell by nearly 26%, from $546 to $405 per month.
Now DTCA is conducting the program for insurers and managed care companies in diabetic populations as large as 2,500 people. The NetCare client base includes 10 health maintenance organizations, including Principal Healthcare in Kansas City, MO, and five other locations, Health Options in three markets in Florida, and United Healthcare in one market in Texas. Together, these programs comprise nearly 16,000 enrollees with diabetes. CIGNA in Hartford, CT, has just rolled out another version of the program in two markets involving 17,000 patients.
While DTCA executive vice president Robert E. Stone doesn’t promise the pilot’s 26% savings, he does expect results significantly better than the 8% to 9% savings promised in DTCA’s contracts, and in many contracts, it is necessary for the program to pay for itself in its first year. The savings in the pilot were due almost entirely to an 89% reduction in inpatient utilization and a 67% decrease in emergency department utilization.
Other results garnered with this small group of patients include: patients receiving retinal eye exams rose from 28% to 80%; patients getting annual foot exams increased from 3% to 99%; patients receiving serum creatinine tests to assess kidney function grew from 55% to 90%; and glycosylated hemoglobin percentages decreased about 10% for both Type 1 and Type 2 patients.
What gets measured
As these results show, the program is predicated on a number of critical indicators. "We measure a variety of clinical outcomes and we measure both process and what percentage of the population got what tests over time," explains Stone. "Some of that is tied to the existing standards of care and some isn’t. It’s just a function of what we’re looking at. We also measure objective outcomes, particularly with respect to hemoglobin A1C, which is the gold standard marker for metabolic control in this population."
In addition to measuring hemoglobin A1C, the rate of foot exams, dilated retinal exams, and the rate of microalbumin urine testing, DTCA measures current health status. These inputs do two things, Stone says. They give DTCA the data to evaluate the effectiveness of the program, and they drive the stratification model, which dictates the nature, frequency, and types of interventions patients get.
The stratification model recognizes that not every person in a diabetes population is at the same clinical level. "Some of them are essentially walking healthy and well-managed," says Stone. "And some are at a level where complications and other health problems are beginning to manifest. Some are in an acute situation. Then some defy classification: teenagers, for instance. Women who are pregnant or are contemplating pregnancy are in a group by themselves because there are all kinds of issues associated with them."
But basically the stratification model has three levels: Level I is the walking healthy. Level II includes those having some sort of manifestation of disease. It may be just elevated A1Cs, or it may be something like beginning retinopathy. Level III is an acute management phase. It includes the teenagers and pregnant women and any other patient who needs frequent contact, such as those with comorbid conditions like congestive heart failure or respiratory disease.
The underlying standards
In deciding what to measure, DTCA began with the American Diabetes Association (ADA) guidelines, which is a consensus document developed by physician members in that organization. Then DTCA’s medical advisory and scientific advisory councils combed over the standards and current literature, adding to and modifying the guidelines to augment care. For example, DTCA’s standards of care include the recommendation for aspirin therapy for those patients at risk for cardiac disease, a recommendation that appeared in the literature after the last version of the ADA standards was approved.
"We have the advantage of getting a significant amount of real-world, real-time physician input into all of our processes and program designs," Stone says. "So we’ll start with a generally accepted standards package, and then expand upon that based on the experience that our affiliated physicians are having with patients in their offices every day."
The standards-of-care document is then given to the client’s medical director and physician leadership committee for review. It’s not always a smooth transition. "You can’t walk up to a doctor and say, OK, with your diabetics, you’ve got to do these 20 things,’" admits Stone. "It becomes a question of how you educate and support the provider network into changing their behaviors in a way that will be consistent with best outcomes. And so we may choose to focus on two or three things in the beginning part of the process in terms of our interactions with the physicians, although our staffs in the market are working on all of the interventions.
"What we’re about is getting both physicians and patients to change their behavior and then to sustain that behavior change. That doesn’t happen easily. If it did, it would have already happened."
Nancy Tilson-Mallett, MD, FACP, is a physician in the Medical Group of Kansas City (MO) and sits on the principal physician board that oversees the Diabetes NetCare program. She says her colleagues are very comfortable with DTCA’s approach, as well as the guidelines and research underpinning the program. "All physicians are naturally defensive about someone telling them what to do in their practice, but DTCA was very professional in their approach. We were extensively involved in setting up the guidelines, and we’re very happy with the results."
Data come back to her in the form of quarterly reports by mail and faxes on information that is required for point-of-service interaction with the patient. While she knows that care for all her diabetic patients has improved, she is most impressed with the degree of compliance she observes among her patients today. And she admits, her own behavior has changed as well.
"I’m much more in tune with the treatment regimens for all my diabetic patients," she says. "For instance, I now look at feet every time I see a diabetic patient. I didn’t use to do that. In fact, I have a poster on my wall that says, If you’re diabetic, take off your shoes.’"
Who does the measuring?
The NetCare program uses the provider’s existing physician network, supplemented by DTCA physician extenders: diabetes educators, nurse case managers, and dietitians. Most of the nurses are RNs with some type of advanced practice training. The physician assistants are housed in offices in each market, i.e., city, town, or county. Through telephone calls and office and home visits, the DTCA personnel track and monitor all diabetic patients within an HMO’s plan, creating an electronic medical record for each of these patients. Those records are housed in DTCA’s mainframe in Nashville.
Tilson-Mallett also has met all of the nurses that serve her patients from the local DTCA office and is enthusiastic about their interventions. "I’ve reviewed their credentials and their training, and it’s excellent," she says.
At each interaction with the patient, a report is generated that eventually becomes part of that medical record. For example, if the patient comes in for an office visit, that visit and whatever transpired during the visit is logged. If follow-up is necessary, the case manager for that patient will find a prompt on her computer screen the next morning, with information on the nature of the follow-up.
"When our people come in every morning and turn on their computers, they get a hot list of things they need to do for the members they are assigned to," adds Stone. "They make sure that the various processes of care and interventions that are called for by the current stratification level are being carried out on a timely basis."
In most cases, lab and pharmacy data are transmitted directly to DTCA from the labs and pharmacy benefit managers. When an electronic record is not available from the doctor’s office or the laboratory or pharmacy, the DTCA case managers work with providers to secure the information themselves. The idea is to have a seamless record of the patient’s interaction within the provider’s systems.
The HMO also provides claims data on each patient directly to DTCA. This is a crucial step in the process because it allows DTCA to track costs per patient as well as health status and outcomes. The company is using The Lewin Group in Reston, VA, to verify outcomes on this huge database.
"The client doesn’t do any of the input or measuring at this time," says Stone. "Hopefully, we can avoid that. There are some rubs; it’s not all a smooth, downhill ride. In some circumstances, we can’t get contract lab data, so we fall back to a more manual system of chart review. In some cases, we don’t get an automatic return of information we request from ophthamologists from the dilated retinal exams, so we follow up. So there’s a lot of physician interaction that is necessary in order to make the database as complete as it can possibly be."
Tools are modified for diabetics
The survey tools DTCA uses to measure its patients’ outcomes and health status are a mix of proprietary instruments developed in-house and modified industry standards. To assess patient function and quality of life, DTCA uses a QofL survey from Solution Point (which merged with DCG Research in 1996) in Dallas. It also uses Solution Point’s survey tools to assess patient and physician satisfaction.
The patient self-assessment instrument is a modified SF-12. The forms for assessing each of the patient interventions (e.g., eye exams, foot exams, A1Cs, etc.) are electronic forms developed by DTCA and are part of its proprietary program. (See sample form, p. 9.)
[For more information, contact Robert E. Stone, executive vice president, Diabetes Treatment Centers of America, One Burton Hills Blvd., Nashville, TN 37215. Telephone: (615) 665-7760; e-mail: [email protected].]
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