1. Diabetes, Disparities, Demographics: Making a Difference BCBSA Congressional Briefing Eduardo Sanchez, MD, MPH, FAAFP Vice President and Chief Medical Officer Blue Cross and Blue Shield of Texas October 12, 2011

2. Place Matters Determinant of Diabetes? People living in low-income communities are 80% more likely to be hospitalized for diabetes or related complications, compared with those living in affluent areas. Source: AHRQ

3. Relationship Between Social Determinants and Mortality in 2000 Source: AJPH

4. Personal Choice or Healthy Food Accessibility? Low income areas have 1/3 fewer grocery stores than higher income neighborhoods. Corner stores and gas stations typically charge 1½ times the price of similar items in grocery stores. Not having automobile or adequate public transportation can reduce access to affordable, healthy food. Less expensive foods are often high in calories and fat. Limited time and knowledge of food preparation can increase demand and consumption of prepackaged or processed foods. Community Health and Food Access: The Local Government Role; http://icma.org/activeliving

5. Diabetes Prevalence by Race/Ethnicity, Texas, 2008 State of Texas9.7%1,205,993 Race/EthnicityPrevalenceEstimated # of People White, Non-Hispanic 8.3%736,987 Black, Non-Hispanic13.0%251,543 Hispanic 11.1%680,351 Other 7.5%59,389 Source: Texas Behavioral Risk Factor Surveillance System, Statewide BRFSS Survey, 2008 Note: All reported rates (%) are weighted for Texas demographics and the probability of selection and thus are not derived from the simple division of numerator and denominator cases.

6. Texas Projected Diabetes Cases 2000 - 2040 Source: Texas Diabetes Council; uses 2007 diabetes prevalence by race/ethnicity from BRFSS and population data from the Texas State Data Center - Office of the State Demographer, Institute for Demographic and Socioeconomic Research. Uses 0.5 migration scenario.

7. New England Journal of Medicine 2010;363:1196-119 9/23/2010 There is a gap between the existing evidence that supports proven interventions and the translation of this knowledge into policy and practice. Diabetes care, simultaneous control of glucose levels, blood pressure, and lipid levels is achieved in less than 10% of people with diabetes. There is a consensus that effective and comprehensive strategies necessitate: –a mix of evidence-based environmental, regulatory, and behavioral interventions at the population and individual levels; –a shifting of health care systems from curative models suited to acute illnesses to more integrated primary care systems with considerable patient empowerment; and –appropriate restructuring of financial and insurance systems.

8. National Strategy for Quality Improvement in Health Care Better Care Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe. Healthy People/Healthy Communities Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care. Affordable Care Reduce the cost of quality health care for individuals, families, employers, and government.

9. The Community Guide – Diabetes Health care system-level interventions Case management interventions to improve glycemic control R Disease management programs R Self-management education –In the community gathering places (adults; type 2) R –In the home (children, adolescents; type 1) R –In the home (type 2) I –In recreational camps I –In worksites I –In school settings I Source: AHRQ

10. BCBSTX Diabetes Control Strategy Community Health Member Education – Web Site Member Wellness Metabolic Syndrome Program Condition Management Bridges To Excellence Patient-Centered Medical Home Accountable Care Organizations

11. Marathon Kids ® Kids walk or run 26.2 miles! Children participating in Marathon Kids exercised more, ate more fruits and vegetables, and had a better self-image than non-participants. Promote Health/Prevent Childhood Obesity Free community and school-based program for K-5 th grade Targets children most vulnerable to sedentary lives, obesity and Type 2 diabetes Challenges kids to run or walk 26.2 miles over six-month period Funded by corporations, foundations and private donations Offered in nine cities across the country, including Dallas, Houston, Austin, and El Paso This program really works...

12. About Bridges To Excellence Bridges to Excellence programs are offered nationally by the Health Care Incentives Improvement Institute (HCI3) Organization awards recognition to clinicians who demonstrate that they provide quality care that meets or exceeds established guidelines Recognizes clinicians in all 50 states with “formal” programs in more than 22 states, including BCBSNM, BCBSOK and BCBSTX Has the potential to significantly improve the quality of care experienced by patients with diabetes and to reduce the financial and human burden of unnecessary hospital visits and complications

13. Bridges to Excellence Results Several studies have shown that BTE participation leads to:

14. Recognized providers are more cost-effective in treating patients with diabetes Source: Bridges to Excellence “Five Years On: Bridges Built, Bridges to Build,” 2003 - 2008 Promoting Quality Diabetes Care: Bridges to Excellence Number of Diabetics with At Least One Episode YearRecognized Non- Recognized 2003271294 2004260351 2005290368 Diabetes Costs per Patient by Type of Provider

15. The BCBSTX BTE Program Experience Financial rewards program ($100 per BCBSTX patient per year) for physicians who have achieved BTE recognition in Diabetes Care and/or Cardiac Care Diabetes program initiated in June 2009 and Cardiac program started in June 2010 In Texas, there are 356 Diabetes Care recognized physicians treating more than 14,500 members with diabetes Cardiac program has 168 Cardiac Care recognized physicians treating more than 1,300 members with cardiac disease BTE Program has paid out more than $975,000 in incentives since inception In 20 Texas counties, will give a bonus of $500 to any physician that is either currently recognized or achieves BTE Diabetes Care recognition by 12/31/2011 to cover data submission fees and offset administrative expenses for data collection and submission

16. Salud por Vida/Health for Life Focus on Five Texas Counties SPV/HFL Initiative Goals –Improve medical management of diabetes –Ensure patients receive all recommended services –Enhance the availability and provision of diabetes self- management education

17. Energy IntakeEnergy Expenditure Energy Balance Individual Factors Behavioral Settings Social Norms and Values  Communities  Worksites  Health Care  Schools and Child Care  Home  Demographic Factors (e.g., age, sex, SES, race/ethnicity)  Psychosocial Factors  Gene- Environment Interactions  Other Factors  Government  Public Health  Health Care  Agriculture  Education  Media  Land Use and Transportation  Communities  Foundations  Industry Food Beverage Retail Leisure and Recreation Entertainment Physical Activity Sectors of Influence Food & Beverage Intake A socio-ecological approach for preventing and a managing diabetes Adapted from: Institute of Medicine, Progress in Preventing Childhood Obesity, 2007, pg 20

18. results Management vs. Prevention Managing disease… Preventing disease… …Great. …Better!