Diabetes management presents a costly challenge for health plans

Cost of epidemic exceeds $132 billion a year

Diabetes has reached epidemic proportions in this country. More than 21.8 million Americans have diabetes today, and an additional 42 million people have pre-diabetes and are at risk for developing the disease in the future, according to estimates from the Centers for Disease Control and Prevention (CDC).

In 2002, the last year for which data are available, the economic impact of diabetes exceeded $132 billion. Direct medical costs totaled $92 billion, with $40 billion in indirect costs, such as lost work days and disabilities, the CDC reports.

Since 1976, the death rate from diabetes has increased by 45%, during a period when deaths due to heart attack, stroke, and cancer have declined, according to the CDC.

According to a study by the Agency for Healthcare Research and Quality (AHRQ), fewer than half of adults diagnosed with diabetes say they receive all three of the yearly medical tests needed to manage the disease. Only 41.7% of those surveyed reporting having been checked for blood sugar level, diabetic retinopathy or other eye damage caused by diabetes, and foot and sore irritation, three tests considered critical for controlling diabetes.

"Diabetes is a silent killer in America. There is a big epidemic, and we are seeing significant increases in people with kidney disease and blindness related to diabetes. It represents a big cost to the American health care system and, as an insurer, it's a big cost to us," adds Anthony Nguyen, MD, MBA, FACHE, medical director for Blue Cross of California. The health plan targets pre-diabetics and members at risk for complications of diabetes for its individualized case management programs.

The problem is exacerbated by the fact that many people with diabetes have a limited understanding of diabetes and how it can affect them, according to the Diabetes Roundtable, a multidisciplinary group of diabetes experts convened by the American Association of Diabetes Education and the American Association of Clinical Endocrinologists.

In a study commissioned by the group and conducted by Harris Interactive, half of the patients surveyed said they had little or no understanding of their hemoglobin A1C level and were unsure if they had had it checked.

More than 80% of the physicians responding to the same survey expressed frustration with the number of their Type 2 diabetes patients who do not follow the treatment regimen.

The biggest challenge for diabetes disease management is that most diabetics are in denial. Patients with abnormal blood sugar levels often don't look at it seriously and realize the impact of what could happen to them if their blood sugar levels stay unchecked, points out Lori Pennito, RN, program coordinator for heart and diabetes program at ConnectiCare, a regional HMO with headquarters in Farmington, CT.

"Most of them are living their lives without noticing any effects of the disease. Vascular changes are silent until something catastrophic occurs. Our case managers try to help the members understand that diabetes is progressive and the disease's effects can be catastrophic," she adds.

ConnectiCare uses pharmacy data to identify members with diabetes and laboratory data to identify members whose blood sugar levels are above recommended levels to a case management program.

The problem of out-of-control diabetes is more acute among minority populations, according to the AHRQ, which reports that, in comparison with non-Hispanic whites, blacks were almost five times more likely to be hospitalized for uncontrolled diabetes and Hispanics were 3.6 times more likely to be hospitalized.

Part of the problem is that health plans don't typically tailor their disease management programs to people from other cultures, says Jon Shematek, MD, vice president, quality and medical policy for CareFirst BlueCross and Blue Shield, an Owings Mill, MD-based health plan.

In an effort to improve the overall health of the community it serves, CareFirst is collaborating on a pilot project to improve diabetes care among patients at La Clinical Del Pueblo, a Washington, DC, clinic that provides care for a large Latino population.

"Our goal is to make sure these patients understand their disease and are taking steps to manage it. If a patient with diabetes doesn't receive evidence-based care, he is likely to incur tragic and expensive complications, such as blindness, heart attacks, stokes, amputations, and kidney failure," Shematek points out.

The American Diabetes Association recommends the following as "optimal" care for diabetics:

  • a hemoglobin A1C level of less than 7%;
  • blood pressure less than 130.80 mmHg;
  • use of a statin drug to normalize cholesterol levels;
  • an LDL cholesterol level of less than 100 gm/dl and an HDL cholesterol level of ≥ 40 mg/dl for men and 50/mg dl for women;
  • trigylcerides less than 150 mg/dl;
  • a body mass index of less than 25 kg/m;
  • use of baby aspirin daily;
  • no smoking.