cation nonadherence––an issue that clearly warrants further study. Future research should seek to expand on the parameters of this study, including laboratory data, and extending the analyses beyond second-line therapy by utilizing a prospective, longitudinal study design.6 n
References
1. International Diabetes Federation. IDF Diabetes Atlas, 6th edition. Key findings 2014. www.idf.org/diabetesatlas/update-2014. Accessed January 5, 2014. 2. National Committee for Quality Assurance. Improving quality and patient experience: the state of healthcare quality 2013. October 2013. www.ncqa.org/Portals/0/ Newsroom/SOHC/2013/SOHC-web_version_report.pdf. Accessed Januray 5, 2014. 3. Curkendall SM, Thomas N, Bell KF, et al. Predictors of medication adherence in patients with type 2 diabetes mellitus. Curr Med Res Opin. 2013;29:1275-1286. 4. Davies MJ, Gagliardino JJ, Gray LJ, et al. Real-world factors affecting adherence to insulin therapy in patients with type 1 or type 2 diabetes mellitus: a systematic review. Diabet Med. 2013;30:512-524. 5. Delamater AM. Improving patient adherence. Clin Diabetes. 2006;24:71-77. 6. Frois C, Dea K, Ling D, et al. The burden of “serial non-adherence” in patients
with type 2 diabetes. Poster presented at: European Association for the Study of Diabetes Conference; September 15-19, 2014; Vienna, Austria. 7. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38:140-149. 8. Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166:1836-1841. 9. Lau DT, Nau DP. Oral antihyperglycemic medication nonadherence and subsequent hospitalization among individuals with type 2 diabetes. Diabetes Care. 2004;27:2149-2153. 10. Jha AK, Aubert RE, Yao J, et al. Greater adherence to diabetes drugs is linked to less hospital use and could save nearly $5 billion annually. Health Aff (Millwood). 2012;31:1836-1846. 11. Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27:1218-1224. 12. HealthIT. Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information: Report to Congress. June 2013. US Department of Health & Human Services, Office of the National Coordinator for Health Information Technology. www.healthit.gov/sites/ default/files/rtc_adoption_of_healthit_and_relatedefforts.pdf. Accessed June 8, 2014. 13. Academy of Managed Care Pharmacy. Pharmacists as vital members of accountable care organizations. www.amcp.org/aco.pdf. Accessed January 12, 2015.
Diabetes Management: A Payer Perspective An Interview with John Fox, MD, MHA
D
r Fox is a Senior Medical Director and Associate Vice President of Medical Affairs at Priority Health, Grand Rapids, MI. Priority Health is a provider-sponsored health plan with 640,000 members. Dr Fox is responsible for technology assessment, care innovation, and medical home program development at Priority Health. His areas of emphasis include pay-forvalue contracting, integrated specialty pharmacy, and surgical optimization initiatives. In a recent interview, Dr Fox discussed the impact of type 2 diabetes on Priority Health and its membership. Q: What is the economic impact of type 2 diabetes on your organization? Dr Fox: Diabetes is prevalent among our membership––nearly 7% of our adult members have diagnosed diabetes, and more than double that number have metabolic syndrome. The cost of managing patients with diabetes is substantial; the average per member per month medical and pharmacy costs incurred by a patient with diabetes is more than triple the corresponding costs incurred by our members overall.
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Q: Has your plan stratified members with diabetes to identify high-risk patients? What process was used to segment your members? Dr Fox: Yes, we use a commercially available tool to segment our overall patient population, including patients with type 2 diabetes, into 7 segments, from very low risk to very high risk. The majority of our patient population with diabetes falls into segments 3, 4, 5, and 6. The segment assigned to members with diabetes depends on their comorbidities, their likelihood of hospitalization, and other factors that predict increased healthcare utilization. However, we go beyond the initial segmentation and look within each segment at additional factors to determine whether we will intervene. The risk of hospitalization and the presence of comorbidities are often triggers for case management, but we also look at other data, including the level of glycemic control and medication adherence. As a result, members may have asthma, diabetes, or congestive heart failure, but if their diabetes is well-controlled, they will not necessarily receive the same interventions as a member with hemoglobin A1c
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level of 8.5 who has been admitted to the hospital for diabetes or for heart failure. Q: In your organization, what are the primary unmet needs in managing members with type 2 diabetes? Dr Fox: The first unmet need is improving self-management in patients with diabetes. We are actively trying to build that capacity through patient population management––truly trying to understand the social determinants and the barriers that our members face in reaching a desired health outcome. For some patients, health is not their highest priority. Their highest priorities may include ensuring that they have food on the table, gas in the car, and money for rent. As an organization, we are trying to develop better systems for assessing why patients have difficulty reaching their health goals, and what barriers they have to overcome in order to address their health goals. Assessing patient activation (eg, knowledge, skills, and confidence) is critical. In addition to activation, I believe there are 2 issues––affordability and biopsychosocial factors––that impact patients’ ability to achieve their personal health goals, or even make their health a priority. Q: As part of your overall efforts, has your organization evaluated medication adherence in your members with type 2 diabetes? What were the findings? Dr Fox: Yes, we assess the medication possession ratio (MPR), and analyze adherence across the different drug classes for type 2 diabetes and for other disease states. From a population perspective, we strive for a minimum MPR target of 80%. Overall, we found that adherence rates range from 60% to 90% in diabetes, depending on the drug class. In addition, adherence rates vary by the insured patient population; for example, commercial members tend to be more adherent to their medications than Medicaid members. In terms of drug classes, the rates are comparable for oral versus injectable agents. Clearly, there is room for improvement. Q: What interventions are being implemented to improve adherence? Dr Fox: Our case managers have access to patient-level adherence data. MPR is a useful measure of adherence, but it does not tell us everything. For example, we do not necessarily know when or why a member stopped taking a medication. Nevertheless, the MPR data are useful to the case manager and can help to initiate patient discussions. In addition to case management, we strive to improve adherence through our medication therapy management (MTM) initiatives. Medicare has criteria for who qualifies for MTM; we use the same criteria for our commercial
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patient populations. Although the scope of MTM is broader than medication adherence, it is an important aspect of comprehensive diabetes management. MTM and comprehensive medication review services can be provided by pharmacists embedded in practices or by retail pharmacists. We are currently paying for and measuring MTM services provided by embedded pharmacists. However, recognizing that adoption of this model will be slow, we are also working to create collaborative relationships between community-based pharmacies and regional health information exchanges to give pharmacists access to patients’ medical history through a Virtual Integrated Patient Record. This will give pharmacists information about patients’ drug allergies, comorbidities, drug refill history, and more. We believe that having this information at their fingertips will improve pharmacists’ productivity, contribute to improved medication adherence, and, ultimately, we hope that it will improve patient health outcomes.
We are working on diabetes-specific benefit designs that are intended to improve access to medications, improve self-management, and improve sustainable behavior change. Although Priority Health does not have a direct monetary stake in this venture, we are contributing some of the development costs to create the linkages and expand the infrastructure. This is important because we cannot hire enough pharmacists in our integrated delivery systems to do this today; therefore, we have to take advantage of community-based pharmacists who work in independent pharmacies and chains. We have several other population-level initiatives. One is a brand-for-generic program, where we partnered with manufacturers to reduce the cost outlay for patients and to allow us to provide branded drugs at a generic copay. In addition, we are working on diabetes-specific benefit designs––incentive and engagement programs that are intended to improve access to medications, improve self-management, and improve sustainable behavior change. Q: How will you address the nonadherent members who are stubbornly resistant to outreach and engagement? Dr Fox: We need to do a better job of identifying the barriers to effective self-management, whether it is depression, substance abuse, unemployment, or other issues. There will certainly always be patients who are challenging to reach. What will define success in the future is––
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Can we identify and resolve the underlying challenges that prevent individuals from changing their health behaviors? Embedding social workers and psychologists who have specific skills in engaging people and discerning the underlying barriers will help. That does not mean we always have solutions, but at least it changes our definition of patients from nonadherent to patients who desire to take care of themselves but do not have the tools, the financial resources, or the support network to accomplish this goal. Q: What if you had a delivery device that could deliver an antidiabetes drug to a patient for an extended period? Would that be attractive to a payer organization? Dr Fox: Certainly, it would be desirable to any payer or provider organization at financial risk if we could demonstrate that adherence was improved. This is similar to the use of long-acting injectable antipsychotic agents in patients with schizophrenia. Taking it a step further, however, you would also need to demonstrate that the use of this device reduced the risk for complications, resulting in improved outcomes compared with the current standard of care. If the evidence is compelling, we would certainly be interested in a novel way to improve medication adherence. In addition, manufacturers may offer risk-based contracts or payers may demand risk-based contracts, which ensure manufacturer accountability for improved outcomes. Q: How do you expect diabetes management to evolve in the future? Dr Fox: At the patient population level, there will be further efforts to identify members with prediabetes or with metabolic syndrome, allowing us to intervene earli-
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er. We are not sure whether it will be a cost-effective strategy, but we believe it is important to improve the identification of patients with diabetes. At an individual patient level, we will continue to focus on removing the barriers to improving engagement and self-management. We are using multiple smartphone and web-based applications to help engage patients with diabetes and with other chronic conditions, and I believe that this trend will continue in the future. The reality is that we do not have a sufficient number of case managers to go around, so we need other tools to help us engage patients. Patients have different preferences for engagement. For example, some patients prefer to talk to case managers on the phone, see them in person, or not see them at all. Other patients want to receive educational materials in the mail or via e-mail. By tailoring engagement to each patient’s preferences, we will have a better chance of reaching that patient and making a difference. If we can provide patients with self-management tools that help them to take better care of themselves without needing the case manager, so much the better. In the future, I can envision our organization taking advantage of other technology solutions to help extend the reach of case management and provide our members with the information needed to help them better self-manage their chronic disease, including diabetes, on a daily basis. For example, wearable technology is intended to help patients better manage their health conditions, including diabetes. Show me evidence that wearable devices impact health outcomes and reduce the total cost of diabetes care, and I predict that there will be a rapid adoption of this technology by patients and by payers. n
www.AHDBonline.com
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References
1. International Diabetes Federation. IDF Diabetes Atlas, 6th edition. Key findings 2014. www.idf.org/diabetesatlas/update-2014. Accessed January 5, 2014. 2. National Committee for Quality Assurance. Improving quality and patient experience: the state of healthcare quality 2013. October 2013. www.ncqa.org/Portals/0/ Newsroom/SOHC/2013/SOHC-web_version_report.pdf. Accessed Januray 5, 2014. 3. Curkendall SM, Thomas N, Bell KF, et al. Predictors of medication adherence in patients with type 2 diabetes mellitus. Curr Med Res Opin. 2013;29:1275-1286. 4. Davies MJ, Gagliardino JJ, Gray LJ, et al. Real-world factors affecting adherence to insulin therapy in patients with type 1 or type 2 diabetes mellitus: a systematic review. Diabet Med. 2013;30:512-524. 5. Delamater AM. Improving patient adherence. Clin Diabetes. 2006;24:71-77. 6. Frois C, Dea K, Ling D, et al. The burden of “serial non-adherence” in patients
with type 2 diabetes. Poster presented at: European Association for the Study of Diabetes Conference; September 15-19, 2014; Vienna, Austria. 7. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: a patient-centered approach: update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2015;38:140-149. 8. Ho PM, Rumsfeld JS, Masoudi FA, et al. Effect of medication nonadherence on hospitalization and mortality among patients with diabetes mellitus. Arch Intern Med. 2006;166:1836-1841. 9. Lau DT, Nau DP. Oral antihyperglycemic medication nonadherence and subsequent hospitalization among individuals with type 2 diabetes. Diabetes Care. 2004;27:2149-2153. 10. Jha AK, Aubert RE, Yao J, et al. Greater adherence to diabetes drugs is linked to less hospital use and could save nearly $5 billion annually. Health Aff (Millwood). 2012;31:1836-1846. 11. Cramer JA. A systematic review of adherence with medications for diabetes. Diabetes Care. 2004;27:1218-1224. 12. HealthIT. Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information: Report to Congress. June 2013. US Department of Health & Human Services, Office of the National Coordinator for Health Information Technology. www.healthit.gov/sites/ default/files/rtc_adoption_of_healthit_and_relatedefforts.pdf. Accessed June 8, 2014. 13. Academy of Managed Care Pharmacy. Pharmacists as vital members of accountable care organizations. www.amcp.org/aco.pdf. Accessed January 12, 2015.
Diabetes Management: A Payer Perspective An Interview with John Fox, MD, MHA
D
r Fox is a Senior Medical Director and Associate Vice President of Medical Affairs at Priority Health, Grand Rapids, MI. Priority Health is a provider-sponsored health plan with 640,000 members. Dr Fox is responsible for technology assessment, care innovation, and medical home program development at Priority Health. His areas of emphasis include pay-forvalue contracting, integrated specialty pharmacy, and surgical optimization initiatives. In a recent interview, Dr Fox discussed the impact of type 2 diabetes on Priority Health and its membership. Q: What is the economic impact of type 2 diabetes on your organization? Dr Fox: Diabetes is prevalent among our membership––nearly 7% of our adult members have diagnosed diabetes, and more than double that number have metabolic syndrome. The cost of managing patients with diabetes is substantial; the average per member per month medical and pharmacy costs incurred by a patient with diabetes is more than triple the corresponding costs incurred by our members overall.
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Q: Has your plan stratified members with diabetes to identify high-risk patients? What process was used to segment your members? Dr Fox: Yes, we use a commercially available tool to segment our overall patient population, including patients with type 2 diabetes, into 7 segments, from very low risk to very high risk. The majority of our patient population with diabetes falls into segments 3, 4, 5, and 6. The segment assigned to members with diabetes depends on their comorbidities, their likelihood of hospitalization, and other factors that predict increased healthcare utilization. However, we go beyond the initial segmentation and look within each segment at additional factors to determine whether we will intervene. The risk of hospitalization and the presence of comorbidities are often triggers for case management, but we also look at other data, including the level of glycemic control and medication adherence. As a result, members may have asthma, diabetes, or congestive heart failure, but if their diabetes is well-controlled, they will not necessarily receive the same interventions as a member with hemoglobin A1c
www.AHDBonline.com
April 2015
l
Supplement
Diabetes Management Perspective
level of 8.5 who has been admitted to the hospital for diabetes or for heart failure. Q: In your organization, what are the primary unmet needs in managing members with type 2 diabetes? Dr Fox: The first unmet need is improving self-management in patients with diabetes. We are actively trying to build that capacity through patient population management––truly trying to understand the social determinants and the barriers that our members face in reaching a desired health outcome. For some patients, health is not their highest priority. Their highest priorities may include ensuring that they have food on the table, gas in the car, and money for rent. As an organization, we are trying to develop better systems for assessing why patients have difficulty reaching their health goals, and what barriers they have to overcome in order to address their health goals. Assessing patient activation (eg, knowledge, skills, and confidence) is critical. In addition to activation, I believe there are 2 issues––affordability and biopsychosocial factors––that impact patients’ ability to achieve their personal health goals, or even make their health a priority. Q: As part of your overall efforts, has your organization evaluated medication adherence in your members with type 2 diabetes? What were the findings? Dr Fox: Yes, we assess the medication possession ratio (MPR), and analyze adherence across the different drug classes for type 2 diabetes and for other disease states. From a population perspective, we strive for a minimum MPR target of 80%. Overall, we found that adherence rates range from 60% to 90% in diabetes, depending on the drug class. In addition, adherence rates vary by the insured patient population; for example, commercial members tend to be more adherent to their medications than Medicaid members. In terms of drug classes, the rates are comparable for oral versus injectable agents. Clearly, there is room for improvement. Q: What interventions are being implemented to improve adherence? Dr Fox: Our case managers have access to patient-level adherence data. MPR is a useful measure of adherence, but it does not tell us everything. For example, we do not necessarily know when or why a member stopped taking a medication. Nevertheless, the MPR data are useful to the case manager and can help to initiate patient discussions. In addition to case management, we strive to improve adherence through our medication therapy management (MTM) initiatives. Medicare has criteria for who qualifies for MTM; we use the same criteria for our commercial
Supplement
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April 2015
patient populations. Although the scope of MTM is broader than medication adherence, it is an important aspect of comprehensive diabetes management. MTM and comprehensive medication review services can be provided by pharmacists embedded in practices or by retail pharmacists. We are currently paying for and measuring MTM services provided by embedded pharmacists. However, recognizing that adoption of this model will be slow, we are also working to create collaborative relationships between community-based pharmacies and regional health information exchanges to give pharmacists access to patients’ medical history through a Virtual Integrated Patient Record. This will give pharmacists information about patients’ drug allergies, comorbidities, drug refill history, and more. We believe that having this information at their fingertips will improve pharmacists’ productivity, contribute to improved medication adherence, and, ultimately, we hope that it will improve patient health outcomes.
We are working on diabetes-specific benefit designs that are intended to improve access to medications, improve self-management, and improve sustainable behavior change. Although Priority Health does not have a direct monetary stake in this venture, we are contributing some of the development costs to create the linkages and expand the infrastructure. This is important because we cannot hire enough pharmacists in our integrated delivery systems to do this today; therefore, we have to take advantage of community-based pharmacists who work in independent pharmacies and chains. We have several other population-level initiatives. One is a brand-for-generic program, where we partnered with manufacturers to reduce the cost outlay for patients and to allow us to provide branded drugs at a generic copay. In addition, we are working on diabetes-specific benefit designs––incentive and engagement programs that are intended to improve access to medications, improve self-management, and improve sustainable behavior change. Q: How will you address the nonadherent members who are stubbornly resistant to outreach and engagement? Dr Fox: We need to do a better job of identifying the barriers to effective self-management, whether it is depression, substance abuse, unemployment, or other issues. There will certainly always be patients who are challenging to reach. What will define success in the future is––
www.AHDBonline.com
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Can we identify and resolve the underlying challenges that prevent individuals from changing their health behaviors? Embedding social workers and psychologists who have specific skills in engaging people and discerning the underlying barriers will help. That does not mean we always have solutions, but at least it changes our definition of patients from nonadherent to patients who desire to take care of themselves but do not have the tools, the financial resources, or the support network to accomplish this goal. Q: What if you had a delivery device that could deliver an antidiabetes drug to a patient for an extended period? Would that be attractive to a payer organization? Dr Fox: Certainly, it would be desirable to any payer or provider organization at financial risk if we could demonstrate that adherence was improved. This is similar to the use of long-acting injectable antipsychotic agents in patients with schizophrenia. Taking it a step further, however, you would also need to demonstrate that the use of this device reduced the risk for complications, resulting in improved outcomes compared with the current standard of care. If the evidence is compelling, we would certainly be interested in a novel way to improve medication adherence. In addition, manufacturers may offer risk-based contracts or payers may demand risk-based contracts, which ensure manufacturer accountability for improved outcomes. Q: How do you expect diabetes management to evolve in the future? Dr Fox: At the patient population level, there will be further efforts to identify members with prediabetes or with metabolic syndrome, allowing us to intervene earli-
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er. We are not sure whether it will be a cost-effective strategy, but we believe it is important to improve the identification of patients with diabetes. At an individual patient level, we will continue to focus on removing the barriers to improving engagement and self-management. We are using multiple smartphone and web-based applications to help engage patients with diabetes and with other chronic conditions, and I believe that this trend will continue in the future. The reality is that we do not have a sufficient number of case managers to go around, so we need other tools to help us engage patients. Patients have different preferences for engagement. For example, some patients prefer to talk to case managers on the phone, see them in person, or not see them at all. Other patients want to receive educational materials in the mail or via e-mail. By tailoring engagement to each patient’s preferences, we will have a better chance of reaching that patient and making a difference. If we can provide patients with self-management tools that help them to take better care of themselves without needing the case manager, so much the better. In the future, I can envision our organization taking advantage of other technology solutions to help extend the reach of case management and provide our members with the information needed to help them better self-manage their chronic disease, including diabetes, on a daily basis. For example, wearable technology is intended to help patients better manage their health conditions, including diabetes. Show me evidence that wearable devices impact health outcomes and reduce the total cost of diabetes care, and I predict that there will be a rapid adoption of this technology by patients and by payers. n
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April 2015
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