QUALITY: Diabetes and the modern disease management girl

So I spent the last couple of days at a disease management conference that focused on diabetes care.

There is general agreement that — at least 15 years since everyone has understood the problem — the health care system suffers from a lack of transparency, information systems, rational incentives, and care quality. Diabetes care is a microcosm of that. Type II Diabetes is a disease that’s primarily caused by years of poor living and poor care (obesity and metabolic syndrome being typical precursors). Once people get it less than 50% of them are correctly diagnosed, and after that the care of diabetics tends to be poor. Only around half get all the recommended tests and care that they need. And yet for a long time (since the DCCT trial back in the early 1990s) it’s been well known that regular monitoring of blood glucose levels can reduce the risks of further damage from diabetes. And those risks are nasty and expensive–blindness, limb amputations and heart disease. Getting diabetics to do all the things that they should do to reduce their dependence on glucose, and control their insulin levels is a great application of the education, monitoring and bullying that is modern disease management.

Disease management really started out as a front for drug company marketing so that they could pretend that they could work with PBMs and wrap services around their pills that would improve patient care. Of course they were also taken by the concept that disease management programs tend to suggest that sick people should take more drugs than they currently do. Of course some of those drugs might be generics….

But when you get beyond the high meaning rhetoric, disease management is complicated and confusing. Within the population with diabetes there are levels of illness, not to mention co-morbidities. Within disease management there are different ways of getting to patients (such as occasional mailers, phone calls, and constant monitoring via telemedicine). Once you get into the management of diabetics (or any other disease management program) it gets more complicated depending on who you are. Integrated systems want to control the costs of their sickest members; health plans typically want to sell value added services to their customers; and employers (and government) want to try to prevent the costs with their disease. But we live in a world where most diabetes disease management is developed for the less sick diabetic patient in a commercial population, while the greatest need — and potentially greatest savings — may be for a much sicker diabetic on Medicare or Medicaid.

But at a practical level, that all means that there is no clear focus on which patients to pursue. Should health plans be looking at their healthy commercial populations, or should they be ignoring them and going after the really sick people in their plans –who may be on their way into Medicare within a few years and give them no return? In the commercial world disease management services for diabetics cost something like $3 pmpm. Intervention using a telemedicine system (like the Health Buddy) can be around $50 pmpm. Obviously you need some pretty immediate savings if you are spending that much, and the VA at least seems to have decided that it is getting a return. But then again, Florida Medicaid in a rather biting criticism of Pfizer Health Solutions last year, felt that the returns from phone-based DM weren’t so great. But overall I came away from the conference no clearer on where on the financial graph the lines of the cost of intervention versus the value of the benefit intersect. And I’m not sure that anyone else really knew either.

What was interesting is how little was known about what the real ROI of different interventions on different types of people. One plan sent out postcards even though they believed them to be ineffectual because a drug company sponsored them. I mentioned to the people next to me that DM had gone full circle and was back to being drugcompany marketing. Even the phone calls may or may not be effective depending on their frequency and what was communicated in the call.

There’s an initiative in Tennessee, run by the Center for Evidence-Based Medicine at Vanderbilt in which the Blues are paying primary care docs to act as educational coaches for diabetics. This seems to be working (although it’s early days) and is having some good results, as are the folks at the VA with their nurse practitioner-led interventions and monitoring. But overall this is an industry that really doesn’t have its story straight as to what works consistently, and what’s worth paying for.

And of course while most payers don’t know if they can look forward to reaping the benefits of a costly intervention down the line, selling DM services will remain problematic. That’s why the Medicare CCIP demonstration projects about to take place are so important. The Medicare population is ground zero for DM especially for diabetics. Let’s hope that the CCIP experience tells us what DM can hope to achieve, and give us a level playing field on which to judge the value of the various interventions.

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  1. Every one for control Diabetes try to control their food’s and diet’s label.And regular examine label of there Diabetes.My aunt infected by Diabetes in last year and now he try to control her diabetic diet meals and food’s.

  2. I completely agree with all your comments, my wife is a type 1 Diabetic who attended an excellent 5 day Diabetic Education course run by the UK NHS funded DAFNE http://www.dafne.uk.com/index-2.html where they liberate Diabetics by assisting them to self-manage their condition. Unfortunately only a few are fortunate enough to be able to attend these courses. However having completed the course I discovered that my wife was doing some complicated mental arithmetic in order to calculate the volume of insulin to compensate for: Blood Sugar; Carbs consumed and post injection exercise.
    Being a hobbyist product designer I developed a simple calculator which would prompt the input of this information and automatically make the calculations. I then started talking to the industry in order to establish a distribution network in order to sell the Calculator, this is when I started to realize how fragmented the Education of Diabetics is in the Western World.
    There is no ‘standard’ method of teaching a diabetic, when they are diagnosed they are given a blood meter (and 20 blood testing strips) and an insulin pen, shown how to use them, and sent home to manage as best as they can.
    I would like to see four ‘standards’ for instruction/education developed and agreed by the professionals;
    1. Type 1 – for those using short acting insulin injecting with pens
    2. Type 1 – for those using pumps
    3. Type 2 – for those on tablets/insulin
    4. Type 2 – on diet control
    This would then assist the whole community involved with diagnosing/educating diabetics to maintain a standard.
    Or am I being too naïve and simplistic?
    See below some details of how my Insulin Unit Calculator works:
    For people who inject insulin with a basal/bolus regimen, it’s often difficult to calculate the proper pre-meal dose. After watching my partner struggle with the math for fifteen years, I decided to design a simple calculator to mimic the mental process that she uses to calculate her meal-time dose of insulin.
    To calculate the number of meal-time insulin units to inject, you must establish the following:
    1. Blood sugar level (using a blood glucose meter).
    2. The grams of carbohydrates consumed, from which you derive the number of insulin units needed to cover that intake.
    3. The amount of exercise to be taken post-injection.
    The mental process you must undertake to calculate your insulin dose is as follows:
    1. Blood Sugar: Suppose your blood sugar reading is 195 and your target blood sugar is 105. Subtracting 105 from 195, you get 90, which is how much you need to lower your blood sugar. One insulin unit lowers your blood sugar by 55 points, so you divide 95 by 55 to get 1.6 is the number of units you need to lower your existing blood sugar.
    2. Carbohydrates: Now you have to count carbohydrates to figure out how many additional units of insulin you need to inject to cover your carb intake. If your ratio of insulin to carbs is 1 unit to 10 grams, 60 grams of carbohydrates requires 6 additional units of insulin.
    3. Exercise: If post-injection activity is planned, then you need to calculate how much less insulin will be necessary.
    The above is the process that you carry out at every meal. The Insulin Unit Calculator merely mimics this process, as follows:
    When the calculator is turned on, Blood Sugar appears on the display. You input your blood sugar reading (195) and press the ENTER key. The calculator automatically makes your first calculation: 195 – 105 = 95 ÷ 55 = 1.6.
    As soon as the ENTER key is pressed, Carbohydrates appears on the display. You must now mentally calculate the grams of carbohydrates you consumed and then, based on your carb to insulin ratio, calculate the number of insulin units required to cover that carb intake. For example, 60 carbs at a 10:1 ration = 6 units of insulin. You key the number 6 into the calculator and press ENTER again.
    Exercise then appears on the display to prompt you to think about upcoming exercise. The calculator offers four options, from zero to three. 0 denotes no exercise, and 3 denotes heavy exercise. If 2 is entered, the calculator subtracts 2 insulin units from the equation.
    When the ENTER key is pressed following the exercise input, the calculator automatically makes the total calculation: 195 – 105 = 95 ÷ 55 = 1.6 + 6 = 7.6 – 2 = 5.6 units
    The above may look complicated, but using the calculator is really very simple. All you do is the following:
    Enter your blood sugar (195)
    Enter insulin units to compensate for carbohydrates consumed (6)
    Enter an exercise value to compensate for exercise (2)
    The calculator displays the insulin units to be injected (5.6 Units)
    My partner, who uses her calculator every day, says, “It is such a relief to know that I am calculating all the elements and getting the right number of insulin units to inject. My blood sugar is now much more stable”
    This new calculator is not currently available to the general public, the manufacturer is currently seeking a partner who will be able to distribute it to all diabetics and their educators, if a representative of such a company is interested they could make contact through the Website http://www.thorpe-products.com
    Insulin Unit Calculator
    By Neil Bason
    Managing Director
    Thorpe Products Ltd.

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