DTCA bags elusive goal of short-term diabetes savings
DTCA bags elusive goal of short-term diabetes savings
Intensive management also improves outcomes
Bean counters at one of the country's largest diabetes treatment centers are applauding intensive management of diabetic patients because it not only improves outcomes, but saves money in the short term.
Diabetes Treatment Centers of America in Nashville, TN, announced it saved 12.3% or $50 per member per month in direct health care costs for participants in Diabetes Netcare, its comprehensive health care management system, in the first year of operation.
This means a savings of $600,000 for health plans with 1,000 diabetic members, according to the first set of outcomes data ever to integrate health status and financial data by The Lewin Group, published in the August issue of the Journal of Clinical Endocrinology and Metabolism.
The National Institute of Health's Diabetes Control and Complications Study (DCCT), completed in 1994, showed greatly reduced risks of complications or progression of complications for diabetics who maintained their blood sugar close to normal.
"What the trial did not address in any way was whether or not that kind of program could be implemented in a real-world setting on an economic basis that made sense," says Robert Stone, MBA, DTCA's executive vice president.
Stone says DTCA discovered that a DCCT-like program can be implemented to improve outcomes, and keep patients and physicians happy, all "for less money than is currently being spent in providing health care to that population."
Robert Rubin, MD, president of The Lewin Group, in Fairfax, VA, and lead author of the article, notes that the DCCT was criticized on two fronts: the high motivation of participants and the high cost of their protocol ($4,000 to $5,800 per participant in the intensively treated population).
The Lewin Group's study showed dramatic increases in the numbers of diabetics availing themselves of tests aimed at early diagnosis and prevention of complications and corresponding decreases in costs in the Diabetes Netcare program, available in 14 markets and studied in seven. Specifics of those locations were not disclosed for proprietary reasons, although the article says the markets are in the Southeast, Midwest, South and Mid-Atlantic states.
DTCA initiated the Diabetes Netcare plan to include a multidisciplinary team approach designed to "improve the clinical outcomes of people with diabetes, while at the same time addressing the concerns of managed care regarding short-term savings," Rubin writes.
Most managed care plans provide some preventive services to diabetics, but few offer comprehensive diabetes management. A recent Gallup survey showed about a third of health plans available to employees offer diabetic education classes. Annual eye exams and quarterly HbA1c (glycosylated hemoglobin) tests are covered by only half.
Diabetes Netcare began by removing what Stone calls "artificial barriers" to care by ensuring each plan covered HbA1c tests, eye and foot exams, pharmaceutical costs, and cholesterol screenings for diabetic patients.
The Lewin Group's analysis of the Diabetes Netcare plan showed, for example, that the number of diabetic members receiving an HbA1c test each year increased from 34% to 76% in the first year of the test. Those receiving annual eye exams increased from 23% to 40%; foot exams, up from 2% per year to 25% and cholesterol screenings, up from 39% to 63%.
DTCA officials say the HbA1c results are particularly significant because the test measuring long-term blood glucose levels is an important predictor of complications such as cardiovascular disease, eye problems, nerve damage, and kidney malfunction. Data showed an average drop in HbA1c results from 8.9 to 8.5, a decrease Rubin calls "clinically significant."
Stone says, "If you go back to the results from the DCCT, they showed a continuing correlation between risk reduction for complications [for] each .1 drop in A1c." The latest data, not included in the study for the article, he adds, actually shows the HbA1c levels dropping even further, to 8.1.
Based on claims data from each of the participating plans, The Lewin Group showed a 10.9% drop in total per member per month health care for all diabetic members regardless of severity of the disease or whether treatment was rendered for a condition directly related to diabetes.
The cost of doctor visits for diabetics increased slightly, by 2.1%, compared to a drop of .6% for non-diabetic members.
While prescription drug costs are escalating for all groups (by 16.4% for non-diabetics) the prescription costs for diabetics escalated at a rate 1.8% slower than for non-diabetics.
Perhaps most significantly, the cost of inpatient hospital care dropped by 26% for the diabetic group, compared to a drop of only 2.2% for non-diabetics, and the cost of outpatient care dropped by 10.4%, compared to only 2% for non-diabetics. (See graph, p. 111.)
In dollar terms, this translates a drop from $406 to $362 in the average cost per diabetic member per month. (See graph, p. 111.)
Per-month cost of inpatient care dropped from $182 to $135. Outpatient care costs dropped from $84 to $76. While the cost of doctor visits was minimally higher ($45 compared to $44) and the cost of prescriptions increased from $66 to $76.
By comparison, DTCA says disease management programs for congestive heart failure and asthma will net only 13 cents and 3 cents per member per month, respectively, after program costs. In addition, DTCA says, those sample groups were composed of members with only the most severe forms of the disease and those with less severe forms of the disease, who are not being managed, will likely deteriorate over time.
Historically, according to the article in the Journal of Clinical Endocrinology and Metabolism, one in seven dollars spent on health care in the United States is spent on the country's 10.2 million diabetics, who comprise 5.1% of the population. Because of the high complication rate among diabetics, medical expenditures for their care are nearly four times as high as expenditures for non-diabetics. Rubin describes that as a "significant burden "on the U.S. health care system.
The Lewin Group's data were derived from baseline and clinical data from seven commercial health plans made up of 360,000 members with 7,000 diabetic members. Rubin expects the improvements observed in the one-year trial to only get better over time as costly complications are averted.
"Payers around the country now have real-world evidence that investing in a population management program for their members with diabetes will pay off quickly," Stone says.
"By expanding rather than limiting care for people with diabetes, we can help the healthcare industry reduce the financial burden of diabetes on the economy."
James Gaume, MD, chairman of diabetic control and medical director of the Center for Diabetes Metabolic and Endocrine Disorders at St. Thomas Health Center in Nashville, TN, says DTCA's program has across-the-board benefits. But, as a physician who has been part of a team integrating DCCT protocol into a comprehensive care program for the past two years, Gaume also notes its drawbacks.
"At issue for the provider is if you're in a market where DTCA has a diabetes program and a payer, and Anthem has a program and Aetna has a program and Healthnet has a program, everyone has their own disease management program with slightly different variations, slightly different requirements, different methods," Gaume says. "It's a burden to the provider."
Gaume envisions a day when all the recommendations of the DCCT and DTCA-like programs will be implemented, when they are able to apply the standard of care to all their patients. Then "DTCA becomes superfluous."
In the end, he says, "It's the kind of thing that needs to be incorporated into the daily practice of physicians."
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