Notes from the Avalere Dabetes / Broaden Your View Conference in Washington DC:Newt Gingrich, former Speaker of the US House of Representatives and shy-not commentator on the failings of medical care: served as the dinner speaker and revealed that he and a colleague from Congress have penned a soon-to-appear editorial recommending the creation of the Office of the “National Diabetes Coordinator.” Big problems warrant big solutions. He also had countless and worn anecdotes that contrasted the “world that works” vs. the “world that doesn’t work” but a fav of the DMCB was the observation that during the time a UPS driver makes a delivery to an average physician’s office, the computing power in that office is temporarily doubled.
Dan Mendelson, President Avalere Health: Republicans, Democrats and policy makers have merged into a perfect storm on the need for 1) coverage expansion, 2) cost containment, 3) quality improvement and 4) health information technology. This will probably kick off the national dialog on diabetes and chronic illness care in January 2009. Nationally sanctioned “comparative effectiveness research” (CER) is being supported by a counter-intuitive coalition of policy makers and managed care organizations: they believe it will help rationalize coverage decisions. Device manufacturers and pharma are opposed because CER can be used to deny coverage for worthwhile or innovative treatments.
Other insights from other speakers:
The ABCs: Access to a healthcare service = adequate payment. Payment in turn depends on coverage, which in turn depends on demonstrable and meaningful increases in quality. This is best demonstrated in randomized controlled clinical trails (RCTs). “RCTs don’t necessarily need to be published, you just need to know the results.” A national office for “comparative effectiveness research” will help.
Woeful physicians: Much of diabetes care for physicians is an intellectual pursuit, not a money maker. Office surveys have shown that endocrinologists consistently underbill for their services, using the Level 4 E&M code an average 53% of the time, versus oncologists using Level 5 E&M 51% of the time. Billing for group visits, diabetes self management training and continuous glucose monitoring may improve patient care and endocrinologists’ cash flow.
Medicare Coverage of medical devices is more complicated than you thought: Absent a “National Coverage Decision” (NCD) from the Medicare program, “Local Coverage Decisions” (LCDs) are used regionally at a State level to adjudicate coverage of medical devices. LCDs can be determined by evaluation (literature reviews), regulatory considerations (which may hamper a LCD) and collaboration (new device manufacturers are encouraged to enter the LCD process as early as possible).
Are we worrying about the right things? Glycemic control does not substantially increase life span in older Type 1 diabetes and does not prevent the slow progression of cardiovascular disease in Type 2 diabetes. Only 33% of vision loss in Type 2 diabetes is due to diabetic retinopathy and 90% of the retinopathy that does occur can be successfully treated despite a high A1c level. Only 10% of persons with type 2 diabetes develop kidney complications and blood pressure control is more important than the A1c.
The Disease Management Care Blog also heard about insulin pumps. It wonders if coverage of pumps should contingent on participation in an accredited disease management program.
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There is growing evidence that so-called "disease management" programs managed by third-party providers do NOT prove their worth, at least in terms of saving money on healthcare spending. According to a study issued by the RAND Corporation, such programs appear to improve the quality of health care, but there is actually little evidence that such efforts actually save money. The RAND study is not the first to raise this question. A 2004 report from the Congressional Budget Office (CBO) raised its own concerns, saying that there was "insufficient evidence" that disease management programs can reduce overall health spending, or generate savings for federal health programs such as Medicare, which prompted a bigger investigation into the issue. Diabetes is perhaps the condition most often targeted by such disease management programs because it is relatively easy to do a glycosated hemoglobin (better known as the HbA1c) blood test to show reported progress (or lack thereof) if average blood glucose is the only criteria being examined, while other chronic conditions are more difficult to quantify results, relying on more qualitative measures of patient condition.
An October 20, 2004 article published in The Wall Street Journal cited statistics from Mercer Human Resources Consulting which indicated a growing percentage of employer-sponsored health plans were offering disease-management programs. A more recent article indicates that health insurance plans and employers nationally in 2005 spent about $1.2 billion on disease management programs, with 96% of the top 150 U.S. health insurance companies offering some form of "disease management" program, apparently with little to show for that investment. Most health plans outsource such work to more than 100 companies that have crowded into the market. Typically, chronically ill patients are monitored over the phone via nurse call centers, which work with information provided by labs, doctors and pharmacies. But these plans sometimes use automated response systems (e.g. robocalls) to check on patients, rather than actual people. The evidence also suggests that disease-management programs have been expanded to include depression, cancer, kidney disease, obesity and lower-back pain. But money talks, but the dollars being spent on these programs have yet to prove their worth.
In the effort to manage costs, healthcare providers have been suckered into paying third-party disease management programs that do little, if anything, to actually improve patient outcomes. We should be more closely examining what a so-called disease management programs; in most cases they are lining the pockets of vendors, but doing nothing to help patients effectively manage their conditions.
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