Tackling Diabetes While Curbing Costs

Diabetes, especially Type 2 diabetes, has a split personality. It is one of the most common diseases in the United States; currently 1 in 10 Americans has Type 2 diabetes, and some projections show that proportion increasing to 1 in 3 by midcentury. Diabetes is also among the country’s costliest diseases. Medical expenditures for people who have diabetes are $16,752 per year, on average, of which about $9,600 is attributed to diabetes, according to the American Diabetes Association. Those expenditures are approximately 2.3 times higher than those, on average, for people without diabetes.

The dire facts and figures about diabetes could fill pages. But diabetes is also one of the most preventable and, under the right circumstances, manageable diseases. Diet and exercise can lower the risk of getting prediabetes, which is defined by A1C and blood sugar levels that are above normal but shy of those that would indicate diabetes. Doses of healthy eating and physical activity can lower the risk of prediabetes worsening and crossing the line into full-fledged diabetes. Once people have diabetes, lifestyle changes, medications and monitoring for neuropathy, among other things, can lower the risk of developing complications such as lower-limb amputations and cardiovascular disease.

Payers and others are keeping tabs on the efforts to prevent and control diabetes. “Quality metrics associated with diabetes have gained increased national support, and efforts to improve care have been associated with improved control of blood glucose in acute care settings,” says Sally O. Gerard, D.N.P., RN, CDE, CNL, a diabetes educator at Stamford Health, a healthcare system in Stamford, Connecticut. “A more focused analysis of costs associated with diabetes would strengthen efforts for organizational support of diabetes improvement initiatives.”

Sally O. Gerard

Here’s a look at how three healthcare organizations have addressed the management of diabetes and its related costs.

Geisinger Health System

The Geisinger Health System is an integrated delivery system headquartered in Danville, Pennsylvania, a small town about 150 miles northwest of Philadelphia. For years, Geisinger has enjoyed a reputation for delivering high-quality, relatively low-cost care — a city on the hill amid a healthcare system that teems with expense and waste. As such, it’s not surprising that Geisinger has an inventive, well-rounded program for tackling diabetes.

“Since both of these conditions (diabetes and prediabetes) can be managed and even reversed with lifestyle changes, we have directed our efforts to programs that support long-term behavior changes that support a healthy lifestyle,” says Allison Hess, Geisinger’s vice president of health and wellness. “These programs complement existing clinical interventions targeted at diabetes management.”

Allison Hess

Almost two decades ago, the health system started a diabetes care management program led by registered nurses who were also certified diabetes educators. The program combined education and glucose monitoring to improve diabetes management. Over the years, the diabetes programs have evolved, and diabetes educators are now part of a larger care team of primary care providers, pharmacists, health coaches and clinical nutritionists, among others. The team closely monitors patients. Beyond managing blood glucose and A1C levels, the groups adjust medications and guide patients through managing their disease themselves as much as possible.

Geisinger also has an innovative outcomes-based wellness program, including diabetes management, for its employees. The program was designed to help employees maintain and enhance their well-being through comprehensive benefits, health education and resources. The flagship is myHealth Rewards, a wellness program that provides discounts on insurance costs as incentives for members who reach certain health goals. The program is voluntary and participation is not 100%, so Geisinger conducted a clinical trial last year to test which email strategy is most effective at getting people to join.

For several years now, the American Diabetes Association has put a lot of effort and money into bringing prediabetes management into clinical and public health practice. The push was predicated in part on results of the Diabetes Prevention Program (DPP), a multicenter trial funded by the NIH that showed that diet and physical activity leading to weight loss could reduce the chances of developing diabetes by 58%. Various government programs have been launched to prevent diabetes and prediabetes, including a lifestyle change program recognized by the CDC. At Geisinger, 59% of myHealth Rewards participants with an AlC in the prediabetes range decreased their blood glucose to a normal level. Hess says the myHealth Rewards program has also reduced the incidence of unmanaged Type 2 diabetes as well as long-term complications of the disease, including stroke and heart attack.

Geisinger has also launched the Fresh Food Farmacy program to pilot “food as medicine” for people with Type 2 diabetes. The program provides 10 meals a week consisting of nutritious foods — whole grains, lean meats, fruits and vegetables — for patients who are food insecure and have uncontrolled Type 2 diabetes. The meals are paired with clinical support and education, including individual and group sessions.

“Early indicators have shown promising results,” says Hess. Many patients have successfully lowered their A1C levels, fasting blood sugar, weight, triglycerides and low-density lipoprotein cholesterol. And how about costs? “We are currently looking at the financial outcomes, including emergency department visits and hospital admissions,” says Hess.

Geisinger also offers the CDC lifestyle program, which was inspired by the DPP trial results, to the community and employees. “When individuals participating in the program successfully achieve at least a 5% weight loss and at least 150 minutes of physical activity per week, they lower their risk of diabetes, heart disease and stroke,” Hess says.

Before social distancing, when in-person support was seen as a way of helping people stay the course on behavioral changes, Geisinger had encouraged participants to bring a caregiver, a family member or a friend to program meetings. More than 550 people have attended at least one session since the program was initiated in 2016. Fifty-six percent of participants lost weight, and of those, 33% lost at least 5% of their body weight.

In addition to achieving the highest tier of CDC recognition, Geisinger was recently approved as a Medicare DPP supplier. This allows for reimbursement for providing the DPP plan to at-risk Medicare beneficiaries. This is especially important because diabetes affects more than 25% of Americans ages 65 and older.

Indiana University Health

The state of Indiana is not a standout when it comes to diabetes. Based on deaths from the disease, it ranks 26th in the country. CDC data show that 10.4% of Indiana’s adults have been diagnosed with diabetes, which is higher than the national average of 8.5% but less than the proportion in Alabama (13.2%) and Arkansas (12.1%). But patients with diabetes have always represented a substantial proportion of physicians’ panels at Indiana University (IU) Health, says Victoria Bratcher, director of population health for the 17-hospital healthcare system headquartered in Indianapolis.

Victoria Bratcher

Three years ago, the system began a concerted, multispecialty initiative to address diabetes more effectively through comprehensive management programs. It zeroes in on social determinants of health and lifestyle factors that contribute to poor management of diabetes, such as barriers to healthy food, poor medication management and care coordination. One program weaves together diabetes education and pharmacy services to provide better coordinated care. IU Health’s education program is accredited by the American Association of Diabetes Educators and consists of two classes. One is a self-management class in which patients learn about diabetes and how to better manage their disease.

The other is an individualized class with a dietitian who teaches patients about making healthful food choices and provides a meal plan designed to help keep diabetes well managed. (Foods with a low glycemic index can help avoid spikes in blood sugar levels.) While addressing the social determinants of health has been part of the program for a while, the focus on food is relatively new. Pharmacists are also on the care team, performing medication reconciliation and offering guidance to keep A1C levels under control. If these efforts are not effective in holding down someone’s A1C level, then the patient is referred to an endocrinologist, says Bratcher.

IU Health is also actively addressing food insecurity by addressing any education gaps and supplying food and other resources, such as transportation, as needed. Cost sharing can be a hurdle to taking medications that control diabetes, so an IU diabetes educator works with patients on finding ways to get prescription assistance from drug companies, if the patient is eligible, or copay cards.

The results of these efforts are showing up as solid progress if not quite show-stopping success. Since 2017, IU Health has increased the number of patients who are considered to have their diabetes well managed by 8.3%, according to Bratcher. Reductions in A1C levels among Medicare beneficiaries have resulted in a $80 to $100 per-member, per-month reduction in Medicare expenditures.

Stamford Health

Three years ago, Stamford Health implemented a comprehensive set of care initiatives to improve patient outcomes, including mortality and length of hospital stay. Previous efforts had focused on improving glucose control in critically ill patients and were successful. The organization then turned its attention to the people who weren’t so ill.

“Decreasing length of stay is the most direct link to financial savings currently available for patients with diabetes, as poor glucose control can result in extended stays,” says Gerard, the diabetes educator. Stamford Health formed an interdisciplinary team to address improvements for noncritical patients in 2017. The institution employs quality initiatives set by the Society of Hospital Medicine that support comprehensive programs across the continuum of care.

Among its efforts was formation of a glycemic care committee comprising an interdisciplinary team of providers to address blood glucose control in noncritical patients. The team assessed opportunities to improve care based on glucose data, systems analysis, end-user feedback and patient outcomes.

The team also evaluated existing orders related to blood glucose control and updated them to provide more evidence-based treatments. Insulin is the primary medication used to treat hospitalized patients with diabetes, and in a hospital setting, it is considered a high-risk medication because it can push blood sugar levels too low. For patients requiring blood glucose testing, nurses were given standing physician orders to treat hypoglycemia with an appropriate medication. Parameters for the appropriate treatment were added to each patient’s electronic medical record to reduce wait times for treatment. These changes allowed nurses to move quickly to treat hypoglycemia. Stamford Health is also teaching nurses about the variances of blood sugar levels, insulin use and the timing of medications with meals to guard against any blood sugar-related dangers.

Karen Appold is a medical writer who lives in the Lehigh Valley area of Pennsylvania.