Video The Emerging Foundational Role of Sensor-Based CGM for Managing Diabetes in the Managed Care Setting Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides The Emerging Foundational Role of Sensor-Based CGM for Managing Diabetes in the Managed Care Setting Overview Continue to Test Back to Symposium uh Good day everybody. Thanks for joining us at the at today's conference navigating and deploying a sensor based uh glucose monitoring program within the managed care environment. Uh and appreciate your time and attendance at this at this conference. As you know, this is a program that is certified jointly for cmi continuing medical education by the University of Massachusetts Medical School and receive commercial support for for an education grant from Abbott, excuse me, Abbott diabetes care. So thanks very much for attending this. Uh Today we're going to cover in this conference some key topics that are important for pharmacists and farm Ds who are working in or closely with managed care organizations uh in uh coordinating better control of patients with diabetes. Uh We hope that you will get out of this. Uh some key some key ideas in assisting with control of these patients. Uh And speaking today other than myself is Dr Earl Hirsch who's a professor of medicine, head of the diabetes treatment program at the University of Washington Medical Center and medical director of the University of Washington Medical center in diabetes care. Uh Dr Deanna Isaac's whose farm d with a clinical pharmacy specialist and continuous glucose monitoring program, Coordinator for the Cleveland clinics, diabetes center. Susan Cornell who's a farm d uh an associate director of experiential education and a professor of pharmacy practice for a Midwestern University College of Pharmacy uh in Illinois and dr Vivian fonseca who is a professor of medicine and pharmacology. The assistant dean for clinical research at Tulane University and chief of the section of endocrinology there at the university Health science center in new Orleans Louisiana. This entire program, as I said before, uh an additional diabetes continuing medical education offerings will be available as a clinical excellence webcast on multiple clinical websites including www dot diabetes cast dot com. And today slides will be available for download at that site. Any questions about diabetes management may be submitted to uh W W dot I Q. And a dash cmi dot com. So look forward to seeing any questions that you might have from today's program. Again, today's program, I'm going to start the discussion today on emerging foundational role of sensor based uh continuous glucose monitoring for managing diabetes in the managed care setting. Uh And we'll give some perspectives of folks in uh that in managed care and how they think about continuous glucose monitoring. Yeah. So why don't we start with a few facts with regards to diabetes? Uh these all come from the CDC statistics uh that were reported in 2020 and a very eye opening when it comes to understanding the impact that diabetes has on the population and costs and health care. Keeping in mind that almost 10.5% of the population in the United States uh suffers uh in one aspect from diabetes, this does not include those who suffer from prediabetes, which would add a significant number to this population. Yeah. of those 34 million people, almost 27 million Um have been diagnosed and another 7.3 million are undiagnosed with diabetes yet have all the signs and symptoms but haven't seen haven't sought medical attention at this point. Uh kids are impacted as well. Uh And um we we keep very close tracks on that as well. Um 5.2% of US adults have been diagnosed with having type line Uh diabetes. Um and about 10.9 of all US adults with diagnosed with diabetes will be starting insulin in order to treat their condition again. For those uh Oops sorry for those who who are treating diabetes, you've come to recognize that diabetes is a multifaceted condition uh cardiovascular metabolic and renal complications, highlight the array of conditions that are suffered by patients uh in the sequel, a state of who have diabetes keep in mind that these are the root for other conditions. Which also complicate the clinical picture which include neurological factors um such as peripheral neuropathy, strokes etcetera, ophthalmological problems. We all are aware of diabetes retinopathy which can impact patients with with uncontrolled diabetes. And of course anything is routed through micro vascular disease which impacts uh peripheral limbs uh skin and other aspects of health, causing a sequel to a massive quality of problems. Yeah. When it comes to direct costs associated with diabetes. This too is an eye opener. As you'll notice the annual cost of diabetes treatments uh in 2017 was $327 billion. The increase in that, I'm sure the latest statistics will show that it's it's much more significant than that even on a proportional basis as obesity continues to plague as an endemic problem within the U. S. Um Also as a significant is it's almost 2.5 times more expensive uh in treating patients with diabetes with diabetes than it is in treating patients and treating people in general. And of course the increase Uh in treating patients who have had diabetes has gone up well over 25% in just the last five years alone, some of it with technology, much of it with treating um uh sick. Well um in these patients that have had longstanding diabetes as lifespan continues to grow. But we're seeing many more sick. Well in these patients, Uh prescription drugs, something that's going to be near and dear to this audience is heart uh is about 30% of the total cost of treating these patients. So keep that in mind as we go through as you hear the rest of the faculty presenting um Indirect costs, how this impacts the society in general. You know, while this might not have been something that we were as aware of uh in the past, uh certainly with the pandemic being the way it is for COVID-19, we've seen an increase in focus on indirect costs And while we have limited that the COVID-19 with diabetes keep in mind that we're seeing a significant impact from patients who suffer from diabetes that develop problems and complications to it absenteeism as a result of patients who got to take care of their acute problems that might be related to diabetes. $3.3 billion, productivity-related issues, um um inability to work due to some disability. Somebody who was previously a driver, for example, who now suffers from vision problems or peripheral neuropathy can no longer drive. You know, what's the impact of that to society? Uh And of course any early mortality associated with patients who who are suffering from diabetes, obviously dying at a much younger age than the average lifespan. So why is this so important? Again, you know, diabetes is uh don't forget value based care is something that we're all focused on right now. If you're, you know, anywhere within managed care, you've heard you've had to have heard the term value based care. So what is value based care? It's really easy to understand as it represents, health outcomes achieved per dollar spent the better the outcome, the lower the cost, the more impressive the value. Um And remember that this should be from the focus of the customer, always the customer, correct. Which is in this case the patient. How can we have a better outcome for our patients for our members if you're in managed care on the planned side, but always focus on the patient. Of course it doesn't line all stakeholders within the system. So the payer, the plan, the um the uh the physician uh the provider all are aligned in the under these circumstances. Uh And again the the idea is to measure this based on outcomes from a quality perspective outcomes that are achieved not by volume of services that are delivered or process measures performed. Which is how we currently do a lot of the quality measures. And you do understand that for example, um when we'll talk about some of the heat is measure is making sure you get a hemoglobin, A one c you know, that is the quality measure that's used in hiatus. The important measure is making sure it's within a therapeutic that glucose is closer to a normal range which really is the outcome and leads to fewer sick. Well in a much longer time span between sick well or the initiation of the diagnosis of diabetes and sick. Well. Yeah. Right. So when we talk about value based care, we talk about it in a few different stages. As you know, stage one of value based care. Typically as a pay for performance uh program. Again, most commonly we look at quality measures. First for pay for performance um and these can be derived in a few different ways. So first and foremost, most plans are looking at uh heat this type of measures and you are probably aware hiatus or healthcare effectiveness data in from and information set uh from N. C. Q. A. Or stars. Which is the use of heat is type measures uh in achieving a level of stars rating for Medicare plans really looks at some of the process measures from making sure patients or getting the kind of care that they need that they're getting their kidney kidneys tested that they're getting their eyes examined that they're getting their skin looked at and that their blood is tested on a regular basis. They're also starting to look at some outcomes as it relates to making sure that the human glove and a one C's below certain levels. Caps or consumer assessment of health care providers systems. Make sure that you know gets an idea of the patient experience that they have within the health care system that it meets their needs that they have access and availability of certain providers and services within their system. Also. Uh Ask them for more information about how they feel they were treated within their health care system. Could they get appointments? Could they see their doctors? Did their doctors listen to them that they get the test that they needed? Did they get referred to specialists when they felt that they needed to see a specialist? Did the doctor listen to them and answer their questions? All of these are the focus of of cap surveys again. So getting the consumer's perspective that experience uh in health care uh and a focus on some of the scores that are more highly weighted within diabetes and other diseases. Um, it's important and of course we want to make sure that if people have to be admitted to the hospital, um, that they are in fact not readmitted for the same problem. So their care is appropriate and timely as well as their discharge and their follow up care is completed. What's important here in this first stage of pay for performance is there's very little focus on the cost of care or the spend associated with it. Okay, so this is really focused on two out of three areas that we consider part of the triple aim of healthcare, which looks towards improving the quality of health care, improving the patient experience within the health care system and then making sure that health care remains efficient and affordable. The second part of the second stage of value based care looks at something that we've come to call game sharing, where there's an opportunity for the plan and the provider to share in the savings that have been attained by making sure that quality and um, the experience as well as the total cost of care has been, uh, has become much more efficient. So it really takes in more of the triple aim perspective. So, when we talk about that, as we have listed here, we add to the prior slide, looking at the total cost of care, whether you can adhere to the budget within that's been set based on the risk based patient mixed within the population that you are caring for. Um any savings that are that are attained by providing the right care at the right time. Would in fact be shared between the plan and the provider. However, it's not necessarily a 5050 split. There may be some first dollars charges upfront depends on the how the way things are arranged in the negotiations between the plan and the provider. The important thing to note here is that this is upside potential. Only any losses in the overall cost of care associated with these types of programs is absorbed by the health plan which obviously tends to have deeper pockets um than the than the providers do. Uh And the third the next stage, the third stage of value based care typically is known as either capitation or full risk, also a percent of premium. And this is where the provider group will work within a given budget. That is determined between negotiations between the health plan and the provider and should be based on the ability of the provider to take risk on a screw. A specific group of services which they can provide. So typically they will uh look towards if there are multi uh multi specialty group, look at the specialties that are provided uh If they've got their own contracts such as through accountable care organizations or through independent practice associations. So a C. E. O. S. Or IPASS and you may have heard those terms before. Um They will take, they can take, for example full risk through those agreements in many states and be able to share in any budgetary savings as well as um other opportunities to gain incentives for the care that they provide within that group. Um And this again will be based on certain risk fours to help determine the per member per month payment that they'll receive on the capitated or targeted dollars. There has to be a very clear method of attribution of the members to a specific, usually it's a primary care provider, primary care physician, an internist family physician pediatrician or sometimes an obstetrician, gynecologist. Uh And there's a way to determine the attribution of members to those providers either through direct attribution, meaning a member chooses a primary care physician and that primary care physician stays of record. And the dollars will go to that physician or to that group that that physician is affiliated with. Or there will be an attribution through the types of visits that the member has to the providers such as evaluation and management services, preventive services, et cetera. Um And that will be determined through the plan and the provider themselves. Uh So how does there, how is there? How is their compensation through this? What's the compensation model? Typically there's a fee for service model come up, come through this that goes through the accountable care or organization or the I. P. A. Part of it maybe capitation based. There's a base salary and bonus model as well. There's additional compensation to the ace to the accountable care organization or I. P. A. That can be based on services that are provided in addition to basic services such as credentialing care management, um customer service calls etcetera. And that will be further negotiated between the accountable care organization and the health plan. Right? So when it comes to diabetes and specifically to continuous glucose monitoring, how are those costs directly related again? Uh If you stop and think the hospital admissions and again this is a paper that was recently produced um that compared glucose monitoring with self glucose monitoring meaning finger sticks in adults. Which can be somewhat of a barrier for some people as you've come to understand. Um And if you stop again and look what are the costs related to luke, continuous glucose monitoring or to glucose monitoring itself. If you stop and look at hospital admissions for hypoglycemia and you take a look at this range of costs across the U. S. And across various products. Take a look at the total cost for self glucose monitoring per person per year and versus the continuous glucose monitoring being significantly lower. Understanding that by having continuous glucose monitoring. You can significantly reduce the number of hospital admissions for both hyper and hypoglycemia as well as understanding that you will delay. Um And some studies have not some there are many studies that have shown and I'm sure we'll talk more about it in the conference following my introduction will delay the development of these long term sick well uh in patients with diabetes, therefore reducing and in some cases significantly the number of hospital admissions and thereby saving significant costs uh in these patients. Mm And here you get an idea of the number of hospitalizations among adults uh for diabetes. And again, you can take a look here if you stop and think, You know, 7.8 million Uh admissions with diabetes is actually listed as one of the top five diagnoses or 339 admissions per 1000. Uh cardiovascular disease, esky, Mick, heart disease stroke amputations. DK A diabetes ketoacidosis. I don't see hypoglycemia here, but that's also significant as well in these patients. Fortunately we've seen an ever improving use of continuous glucose monitoring over time In patients with Type one diabetes. And here you have a rough idea. From 2011 through 2018, there's been over a six fold increase in the number of the percent of patients that are using continuous glucose monitoring as part of their regimen for making sure they're staying healthy. So that's that's an amazing uh improvement. Uh And uh also amazing for coverage of these procedures of this process um by health plans who will allow members to use this. So as you go through uh the rest today, think about some of these questions. And we'll talk a little bit more about these questions in a little while after we go through a few clinical scenarios that I've experienced through my years more more closely as friends and as a clinician. Um But you will see you know, think about this you know, does the use of continuous glucose monitoring makes sense? I think we've already answered that question from our from the evidence that you know that I was able to present during my introduction. Um Should plans purchase continuing glucose monitors or should they just cover continuous glucose monitors? I get that question a lot should groups at risk for a cost of care and quality measures insist on the use of continuous glucose monitors for for some of their patients. And should there be guidelines established to improve uh continuous glucose monitors over a finger sticks uh supplies and if so what are they? So think about those for a few minutes while we go through a few examples of some people that have unfortunately suffered um from the problems with diabetes. Again. Uh These are really friends of mine that unfortunately have have suffered through some problems with diabetes over the years. LK is a 78 year old man Who had a very long history of type two diabetes for the last five or so years. He's been on insulin. Um but he's also had other problems. He smoked for two packs per day for more than 30 years which led to his having a ephemeral public, he'll bypass for severe peripheral vascular disease. In fact, he was very lucky. He came to me with this problem and I referred him to a college friend of mine who is the chair of vascular surgery in a large health system here in new york. And he was able to do quite a bit of work on LK and really helped save his leg, which he still has to this day uh Over the last three years, however, he's developed some moderate dementia. He forgets a lot of things, he forgot forgets to take his insulin and then sometimes he doubles his those these are things that we've all heard about and had to have had to deal with, possibly for relatives, but definitely for others. Uh He was very non compliant with his finger stick glucose levels regularly. Uh And because of these changes in his medication, he had bouts of severe hypoglycemia with falls and sync api um There was several times where his wife found him in the bathroom unconscious. The last event he was found on the kitchen floor un arouse herbal. Um he had to be taken to the hospital at least six times over the last years now. It's probably up to eight. And unfortunately he remains uh in a long term unit in the facility due to his severe sickle secondary to his uncontrolled diabetes. So that gives you a very clear idea on the long term problems one has with uncontrolled diabetes and uh particularly hypoglycemia in this case. Uh And another situation R. P. Is a 67 year old man with a long history of type one diabetes. Um He's had this since childhood. Uh He, unlike my other friend, has been very compliant with diet and glucose monitoring. Uh He he was participated in regular exercise. And by this I mean running biking. He was a ballplayer baseball very compliant with his doses and his diet. Um He would finger stick about five or six times a day. Um not unusual for him to get up in the middle of a client meeting uh and go to the bathroom just to make check his sugar because he wasn't feeling 100% In the 1990s. Uh he had, my friend had an episode of increased bloating constipation as well as not feeling right. He would he would fill early. Um He had an extensive work up at that time and was diagnosed with with gastro praecis which is you know, it infects the autonomic nervous system where the stomach and the rest of the G. I. Track fails to push food through uh in a timely basis and causes delays. Therefore when you eat, you fill up very quickly and sometimes it leads to excessive vomiting if the food doesn't empty within a certain period of time from the stomach. Um And so he required some extensive treatment there uh and other medication. Unfortunately, in 2013, um my friend noted non healing wound on his ankle. They started on conservative management and wound care. The wound, however, did not appropriately respond. His studies showed that he had severe disease peripherally. There was little hope of healing and that's very different from this first case, where the condition was high up in the ephemeral, pop little arteries, this was in the small arteries, the micro vascular circulation. And so there was little hope of this, these particular wounds healing uh and the decision made was made to perform a below knee amputation, which fortunately he was able to get a prosthesis um which allowed him to remain fully active uh and lead a high quality of life. Uh He now has a continuous glucose monitor in place so he can continue to do well and hopefully fight off any further. Uh Long term Sabella, excuse me for his condition um and he continues to do well and in fact, he is a uh a patient advocate for patients with longstanding diabetes and juvenile diabetes. So he's done a yeoman's job in dealing with this. So uh just getting back to the questions that we asked earlier. So the first question which I neglected to put here and I said as I said before that, you know, does the use of continuous glucose monitoring make sense. And the answer obviously is the evidence does show that it does make sense. As I said before to cover this for certain types of patients. Should plans purchase continuous glucose monitors or cover them? The answer to that is most plans are it doesn't make sense. It is not cost effective for them to buy continuous glucose monitor systems. They're not a distribution center. However, they should be covering these systems for those members that are deemed to be eligible and be able to negotiate a cost effective pricing for these for members where it's appropriate for for them to use these systems so that price is not a barrier for them. Uh And I know that this is being investigated by various pairs as well as by state and the federal government for members on Medicaid and Medicare. So hopefully by our next conference, we can talk about that as well. Should groups at risk for cost of care and quality measures, insists on the use of continuous glucose monitors. And the answer I think is an obvious one. Since there's evidence that continuous glucose monitoring system can be a key part of a program that improves outcomes and saves money with fewer hospitalizations for hyper and hypoglycemia, it does make sense to cover these if you're a group at risk and place appropriate members that meet your criteria On these monitors, especially those with who are insulin dependent and type one diabetes. They should clearly be on continuous glucose monitoring systems. Should there be guidelines established to approve C. G. M. S. For patients over finger stick supplies and monitors? If so what they are? Uh Absolutely. It clearly makes sense uh that there should be some criteria, particularly if you're an insulin dependant uh if your insulin dependent. Um But again it really also depends on the willingness of the individual member of the individual patient to participate in the program. Um And again, if there are patients who are oral, use oral hypoglycemic agents most of the time, they're only testing their blood. Uh Once or twice a day cops. Most indications are for no more than twice a day. Uh And so it's unlikely at this time that there is an indication for those patients who are on a oral hypoglycemic agents. Um So I hope that answers the questions again. Thank you for participating in this conference and I hope I was able to give you a brief introduction to this. I look forward to hearing more from our esteemed faculty uh to talk more about these treatment of these patients uh in an effective manner. And I now will turn this over to Dr Hirsch for his uh for his program. Thank you again Published October 19, 2021 Created by Related Presenters Jerry Frank, MD Principal, COPE Health SolutionsHuntington Station, New York
