2. Managing Diabetes The Challenge of Multiple Chronic Conditions James M Schibanoff MD Editor-in-Chief Milliman Care Guidelines

3. 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

4. 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 <7% = 39.8% About 50% of patients do not follow their diabetes medication prescriptions

5. Patients with Multiple Chronic Conditions

6. The Challenge is Filling the Gaps Affordability Quality Evidence Care Delivery Personal Life Style

7. 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.

8. 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.

9. Is Medicare headed for insolvency?

10. Question: Has current approach to disease management made medical care more affordable? Answer: Probably not 1.Objective studies in literature equivocal 2.Medicare Coordinated Care Demonstration: 2 year results 3.Difficult to measure Randomized controlled trials uncommon Selection bias Regression to mean

11. 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.

12. Are we getting our money’s worth?

13. Quality Gap

14. 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

15. 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)

16. 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

17. Steps in the Knowledge Chain 7 Steps each with a 20% drop off leads to 21% adoption rate

18. Care Delivery Gaps Coordination of care: fragmented care leads to omissions and overlaps

19. Care Delivery Gaps: Health Plan Adverse selection and retention Plan turnover Financing disincentives Helping the competition

20. 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

21. 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

22. Why are Primary Care Physicians Vital to Chronic Disease Management?

24. Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates

25. Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists

26. Personal Lifestyle: Chronic Disease Care Differs from Acute Care Patient behavior is the most important determinant of outcome

27. 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

28. Care delivery: Medical home proposals Personal physician to: –Coordinate and facilitate patient’s 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

29. 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 patient’s physician Current disease management more inclined to have single disease focus Accountability diffuse

30. 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

31. Is the medical home concept effective? Current best evidence is favorable but is either indirect or preliminary

32. Information Technology support of medical home Patient registries Reminder systems Personal health record (PHR) –Interoperable –Portable Guidelines and care coordination tools

33. Diabetes Assessment

34. Quality Improvement Quality measure development –Ambulatory Quality Alliance (AQA) –National Quality Forum (NQF) –Joint Commission Public reporting Pay-for-performance

35. The “new” evidence concepts “The rapid-learning healthcare system” “Practice-based evidence”

36. Personal lifestyle improvement: Self 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

37. Affordability?

38. 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