Needed: A Prevention Strategy To Stop Amputations Among Minority Populations Living With Complex Diabetes

When President Joe Biden rightly called out the unsustainably high price of insulin in his 2022 State of the Union Address, he wasn’t saying anything new for most industry observers. Rising insulin prices have been the subject of national conversation for years, and the push for a reasonable cap on out-of-pocket expenses has been a perennial rallying point among providers and patient advocates.

Allyson Y. Schwartz

Capping insulin costs is an important step, but it is just a start if we are going to stop people living with early diabetes from experiencing a worsening of their condition.

The statistics and the people behind those numbers demand greater attention, smarter care, and a life free of the serious consequences of uncontrolled, complex diabetes.

Consider these numbers. More than 37 million people are living with diabetes in the United States — and a further 96 million individuals have prediabetes. As many as half of those with diagnosed disease have some degree of diabetic neuropathy, or reduced sensation in the peripheral nervous system, which is often exacerbated by poor blood glucose control.

Without the right kind of preventive care and supportive treatment, patients with diabetic neuropathy are more likely to develop foot ulcers and severely restricted blood flow, both of which can swiftly lead to gangrene and the need to amputate toes, feet,or entire lower limbs.

More than 140,000 diabetic amputations occur each year. Up to 80% of people who undergo an amputation will die within five years of the procedure. Even a single foot ulcer is associated with higher mortality.,= The five-year mortality rate for people with first-time foot ulcers is approximately 40%.

The risk of amputation is especially high for Black Americans. In fact, they lose their limbs at three times the rate of other communities. Black Americans are not the only population at risk. Hispanic and Native American patients also have a significantly higher risk.

Jon Bloom, M.D.

High amputation rates are clustered geographically in areas with high scores on the CDC Social Vulnerability Index and the heaviest concentrations of Black Americans. These areas, many of which are in the Deep South, map directly to known food deserts, pharmacy deserts, designated healthcare provider shortage areas, and lower rates of health literacy.

Without access to healthy foods to prevent diabetes, pharmacies to access medications, or qualified primary and specialty care providers to prevent or treat the condition as it develops, residents of these areas don't have tools to manage diabetes. Amputation may becomethe only option.

As a clinician and long-time policy maker, we have seen and heard firsthand from patients and family members who are living with complex diabetes and related comorbidities. Too often, these patients are left on their own to deal with severe pain or, worse, life-altering surgeries to remove limbs. We must focus our collective efforts on creating a system of preventive checkpoints for people with diabetes before they hit the point of no return.

To succeed, we need to launch a dedicated initiative that combines policy levers, reimbursement strategies, technical innovation, and boots-on-the-ground care to move forward with the ultimate goal of reducing the need for amputations among at-risk populations living with complex diabetes.

Encourage more providers and health plans to share financial risk

Today, fee-for-service health systems offer poor financial incentives for preventive care that is focused on reducing avoidable utilization. While shared financial risk between providers and health plans with alignment on shared goals to reduce unnecessary use of inpatient and emergency room visits is slowly becoming a priority, the reality is that more work needs to be done to drive these types of collaborations that provide value for patients over the long term. More needs to be done to amplify the success of these new payment arrangements for other providers and health plans to encourage progress in their journey from volume to value.

For example, one study in Southern California found that team-based care techniques associated with value-based care achieved greater improvements in glycemic and lipid control, diabetes self-management, and emotional distress compared to the usual standard of care. The intervention group also saw a 12.6% reduction in total healthcare costs compared to a 51.7% increase over baseline in the standard care cohort.

Value-based care is quickly gaining ground, but advanced contracts with downside risk components still account for a relatively small proportion of payments. Accelerating the adoption of pay-for-performance models will be crucial for ensuring access to proactive, preventive healthcare, along with the use of new technologies that can lead to better care and better outcomes for complex diabetic patients.

Meet patients where they are with technology and education

As a healthcare system, we have done a poor job of bringing timely, accessible care to the patients who need it most. Care delivery that is centered around inpatient facilities, best known for acute episodic care, limits access and fails to address preventive interventions and chronic care management.

What patients with chronic conditions such as diabetes need more than anything today is an integrated and coordinated healthcare system that caters to their specific healthcare needs and prioritizes early intervention and continuity of care to manage their conditions over time.

Culturally competent and empathetic diabetes educators are important care team members who can build strong relationships with patients to better understand their day-to-day life challenges. We need many more of these clinical facilitators to bridge the gaps in care and coordinate services for people in underserved areas.

Self-management is also a key component of success in a patient-centered, nonhospital-based healthcare system. But informed self-care doesn’t occur on its own. Patients need education, regular check-ins, emotional and mental health support, and home-based remote monitoring technologies, all of which can create a culture of care around each patient, their families, and caregivers. Providers working with patients and their families also need to closely collaborate in order to stay ahead of healthcare ailment before it is a full-blown chronic disease.

We have seen the difference home-based care can make in the lives of people with chronic conditions, particularly in managed care arrangements. That said, we need to do more to employ user-friendly, affordable technologies to enable homes to be a part of a patient place of care. From Bluetooth-enabled blood pressure cuffs, glucose monitors, and more, we can now use innovation to keep patients connected and empower them to stay on top of their health.

To do this, we must align reimbursement mechanisms to encourage team-based care and remote monitoring. In doing so, we can encourage self-care, provide more effective preventive care, offer additional options for care monitoring now handled by primary care providers, and reduce use of expensive acute care settings.

Develop resilient communities with access to diabetes care resources

Still, it will take even more to stave off amputations. It will take a healthier, more supportive community, too. We must ensure that the places in which people live, work, and play are safe, secure, and supportive for people with diabetes. We can do this by implementing policies that encourage physicians, nurses, and other clinicians to practice in underserved and rural areas, including expanding the availability of telehealth in remote regions.

Physicians like Foluso Fakorede, M.D., are a prime example of the type of mission-driven clinicians that we need to stave off the life-altering complications of diabetes with at-risk patient populations. Fakorede moved from New Jersey to rural Mississippi to improve access to quality care and build preventive strategies that would decrease amputation rates. In just over three years, Fakorede reduced amputations by 88% under his team’s care in the Mississippi Delta. Today, Dr. Fakorede and team continue to set the bar high for how clinicians can and must take community-based approaches grounded in education and prevention in order to avoid unnecessary deaths and loss of limbs resulting from chronic diseases like diabetes.

We can also enlist the help of community-based organizations, such as nonprofits and faith-based groups, to conduct outreach to people with diabetes and offer resources to help them stay healthier. These entities can educate patients, host National Diabetes Prevention Programs, and help address the social determinants of health that can make it difficult to conduct self-care.

By creating a community-based support system that helps individuals feel heard, respected, and supported by people and organizations in health and social services they can trust, we can better ensure that those in need of health services, particularly those at risk of chronic diseases, like diabetes.

There is no time to waste. The number of people with diabetes is growing daily. To launch this large-scale, multidimensional prevention strategy for patients living with complex diabetes, we’ll need sustained support from all stakeholders. We’ll also need commitment and compassion to achieve a preventive care model for complex diabetes in minority populations.

If we commit to further aligning financial incentives, adopting innovative home-based preventive strategies, and fostering the holistic health of underserved communities, we will be able to reduce the number of diabetic amputations and improve the quality of life for millions of Americans who have been invisible for far too long.

Allyson Y. Schwartz is a former congresswoman and former president and CEO of the Better Medicare Alliance, an advocacy and research organization for Medicare Advantage. She currently serves on the advisory board of Podimetrics.

Jon Bloom, M.D., is a CEO and president of Podimetrics, a company that provides payers and providers services to prevent compliations of high-risk diabetes.