Information technology long has been touted as a facilitator of outcomes improvement in healthcare. How that proposition might play out in the next decade is likely to be strenuously tested when it comes to helping patients/healthcare consumers manage their diabetes and prediabetes, as two recent articles in the American Journal of Managed Care online indicate.
As Mary Caffrey wrote in an AJMC article entitled “How Technology Can Bring Diabetes Prevention, Care to the Masses,” and published online on April 9, “Diabetes, by the numbers, is staggering: 29 million Americans have it; most have type 2 disease. Another 86 million have prediabetes, which means they are at risk of progressing to diabetes. Between the shortage of endocrinologists and primary care physicians swamped with newly insured patients, just seeing everyone is challenge,” McCaffrey noted. Furthermore, she noted, “That’s assuming all who need to be treated for diabetes can travel to a doctor regularly, because many cannot. So, how can the healthcare system meet this need? Technology can, and should, offer solutions for both prevention and treatment of diabetes, according to a speaker and panelists who appeared Friday at Patient-Centered Diabetes Care, presented by The American Journal of Managed Care,” she reported.
Referencing the announcement three weeks ago on the part of the federal Centers for Medicare & Medicaid Services (CMS) that it would offer the National Diabetes Prevention Program (NDPP) through Medicare, McCaffrey described a presentation at that event that was made by Mike Payne, chief commercial officer and head of medical affairs at Omada Health. Payne had expressed great enthusiasm over the CMS announcement, noting that, to date, only 1 percent of those who could benefit from the NDPP have gone through the program.
The key point here is that one-on-one behavioral counseling for diabetic and pre-diabetic patients needs to be encouraged via reimbursement incentives. What’s more, McCaffrey noted in her report, Payne had indicated that the Omada program, as successful as it had been in its “intensive counseling” focus,” would be difficult to scale up, on the kind of scale that will be needed going forward.
In a similar vein, AJMC online offered another article, “Dr. Lonny Reisman Discusses Big Data and Diabetes Care.” That article showed a short video interview with Dr. Reisman, a specialist physician and the CEO of HealthReveal, a New York City-based company that specializes in “leveraging advanced analytics and biomonitoring for early detection and diagnostic and treatment guidance to preempt the advance of disease.”
As HealthReveal’s website notes, Dr. Reisman “is Founder and Chief Executive Officer of HealthReveal. Previously, Lonny served as Aetna's chief medical officer for six years. During his tenure at Aetna he was responsible for the company's clinical strategy to improve the health of Aetna's members and helped build a better healthcare system supported by evidence-based accountability by every participant. He led healthcare system change through Aetna's clinical thought leadership, Innovation Labs, clinical policy and integrated system design.”
Responding to questions from AJMC around the topic of how diabetes care might benefit from the use of big data, Reisman said that “I think diabetes care is complex in many ways. There’s clearly an emphasis on glycemic control and, to the extent that there are risks to hypoglycemia, we’re learning, for example—there’s collaboration between Medtronic and IBM Watson—we’re learning how to predict hypoglycemia in patients at risk. There are certainly issues with poor glycemic control, severe hyperglycemia, and control of [hemoglobin] A1C. So again,” he said, “understanding what combinations of drugs work, patient preferences, where the evidence is compelling regarding other benefits of certain drugs; Jardiance is an example where we’ve seen cardiovascular outcomes improved in well-conducted trials. So there’s just so much that we can do regarding what’s effective, learning what patients are willing to do or need to do in order to improve adherence and behavior.”
Both of these articles, coming from different conceptual places, point to key elements that need to be considered going forward. As a society, the United States (along with many other societies moving in the same direction) is facing a tsunami of diabetes, with the percentage of Americans who will eventually be diagnosed with diabetes or pre-diabetes eventually becoming overwhelming. Think about it: potentially 120 million Americans needing to be care-managed and health-monitored with regard to one chronic illness? And that doesn’t even take into account the other main chronic illnesses that make up the oft-referenced “big five” of chronic diseases: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and coronary artery disease (CAD), and asthma.
So on the one hand, big- data analytics are absolutely going to need to be applied to predicting chronic illness, and most particularly diabetes, in order to identify individuals at risk for diabetes and pre-diabetes (as well as, of course, the other high-volume chronic illnesses). Much of the activity around identification is perforce going to take place at the accountable care organization (ACO)/population health level, with the clinical leaders of patient care organizations and collaboratives that have taken on financial risk-based contracts, identifying individuals at clinical risk for developing diabetes and pre-diabetes, as early and “upstream” as possible. That is the “big data” side of this equation.
Then, patient care organization and ACO leaders are going to have to figure out how to better engage those individuals who are diabetic and pre-diabetic in ways to become more proactive in their health maintenance and health improvement, and that also will require new (and new-ish) technologies (and of course, that goes for patients with the other four of the “big five” chronic illnesses as well; and, it should be noted, significant numbers of Americans have two or even three of these diseases). Advice and information about nutrition, exercise/fitness, and other health concerns and issues, will have to be made not only easily accessible, but also proactive and truly engaging. While it is absolutely true that much information is available now to anyone who is motivated to seek it, the sad reality is that literally tens of millions of Americans are not seeking that information, are not seeking key insights that can help them improve their health status and physical fitness.
Many issues arise in this regard. For one, what will the role of employer-purchasers be? That has long been a problematic issue. It has been shown that minor financial encouragements can have a mild impact on behavior—for example, giving employees credits for joining health clubs or participating in fitness programs—employees have reacted very negatively to anything that smacks of “fat tax”-type negative inducements. But employer-purchasers may simply end up soon running out of patience, and could be truly delighted by the introduction of encouraging technologies in this area.
Meanwhile, as providers take on more and more financial risk for covered lives, and move further into collaboration around population health with health plans, the horizon looks bright for the introduction of “technologies of encouragement,” as I will call them here, into care management schemas. Clearly, there is a gap right now between the typical nurse care manager-/case manager-based telephone care management programs, and what patients with chronic illness like diabetes will need to do to become more engaged in their own healthfulness.
This gap was explored in a very intriguing session I attended at the HIMSS Conference in Las Vegas in March. Pam Nicolson, a senior executive from Centura Health in Denver, co-presented with Jeff Margolis, well-known in U.S. healthcare as a senior executive at TriZetto, and who is now a senior executive with the Denver-based WellTok, presented on a very innovative initiative that they’re involved in, along with folks from IBM Watson as well. As I noted in my report from HIMSS16 on the presentation, “The initiative that Margolis and Nicholson described was a project to create what is called CafeWell, a consumer-facing app that helps guide consumers who have chronic illnesses through lifestyle choices, including asking basic health questions and selecting healthy food and restaurant choices, among other choices. As Margolis emphasized, the decision was made at the outset not to try to provide actual clinical or medical advice. At the same time, the 60 consumers who participated in the pilot project around CafeWell are all active patients in the healthcare system.”
And I quoted Margolis as saying that “Most of what we call healthcare is really sick care. We return people to their green line,” he said—the health status that a patient enjoyed before a major illness or injury cared for by the healthcare system—“and that’s important, and we have to do it” as a healthcare system. I was born with Crohn’s disease; it is genetic,” he disclosed. “I’ve dealt with it my whole life, and have spent 100 days as an inpatient.” Gesturing to a line on a projected slide, he said, “This is my morbidity curve; we all have a natural morbidity curve. But the whole idea of health optimization is to bend the morbidity curve of individuals.”
So this is precisely the gap that remains between care delivery and care management, and patients’/consumers’ self-management of their own health. And that’s where all the genius that exists in our industry is going to need to be applied to building solutions that will truly engage individuals with chronic illnesses like, and especially including, diabetes, in order that they can become better motivated to take care of themselves during the 99.9 percent of the time when they are not “patients,” but simple people. A challenge? It is indeed. But it’s one that must be addressed, and soon, as the tsunami of diabetes comes ever closer to crashing hard onto the capability of our society to manage it.