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United Against Diabetes and Cardiovascular Disease. UAD/CVD Update. Knut Ringen, DrPH, MHA, MPH Stoneturn Consultants. Supported by. The situation. 2007—Start-up 2008-2010—Treading water during financial crisis 2009-2013—ACA distraction and opportunity 2013—Getting re-started.

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UAD/CVD Update

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Uad cvd update

United Against Diabetes and Cardiovascular Disease

UAD/CVD Update

Knut Ringen, DrPH, MHA, MPH

Stoneturn Consultants

Supported by

www.uad-cvd.org


The situation

The situation

  • 2007—Start-up

  • 2008-2010—Treading water during financial crisis

  • 2009-2013—ACA distraction and opportunity

  • 2013—Getting re-started

www.uad-cvd.org


Uad cvd mission

UAD/CVD Mission

Only organization dedicated to:

  • Reducing prevalence of chronic diseases in working families

  • Developing and testing strategies for prevention, early detection and aggressive management of diabetes/CVD in multiemployer health plans

  • Helping multiemployer plans adopt evidence-based programs

www.uad-cvd.org


How we started in 2007

How we Started in 2007

www.uad-cvd.org


Uad cvd update

www.uad-cvd.org


Our message 1

Our Message # 1

  • Diabetes is epidemic

  • 2006: 15% of target population over age 40 has diabetes

    • 2/3rds know it

    • Already 10-15% of health and welfare costs

www.unitedagainstdiabetes.org


Our message 2

Our Message # 2

  • Diabetes can be managed

  • To do so, health and welfare funds must become proactive

  • Each fund can do it alone, or we can do it together

  • We think a common approach is best

www.unitedagainstdiabetes.org


Why diabetes and cvd

Why Diabetes and CVD?

www.uad-cvd.org


Making the link diabetes and cvd

MAKING THE LINKDiabetes and CVD

  • 68% of patients with diabetes don’t think CVD is a serious complication

  • 60% don’t even think they are at risk

    Even though

  • 2 out of 3 patients with diabetes die prematurely from CVD

    Making the Link is an ADA/AHA joint initiative

www.uad-cvd.org


Making the link diabetes and cvd costs 2007 08

MAKING THE LINKDiabetes and CVD Costs, 2007-08

Making the Link is an ADA/AHA joint initiative

www.uad-cvd.org


Recent national developments

Recent National Developments

www.uad-cvd.org


Uad cvd update

ObesityInAmerica.Org

www.uad-cvd.org


Uad cvd update

Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2009

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics


Uad cvd update

Source: 2005–2008 National Health and Nutrition Examination Survey.


Estimated lifetime risk of developing diabetes for individuals born in the united states in 2000

Estimated lifetime risk of developing diabetes for individuals born in the United States in 2000

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics


Uad cvd update

Source: 2007–2009 National Health Interview Survey estimates projected to the year 2010.


Uad cvd update

Distribution of Age at Diagnosis of Diabetes Among Adult Incident Cases Aged 18–79 Years, United States, 2008

16.8%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics


Uad cvd update

Distribution of Age at Diagnosis of Diabetes Among Adult Incident Cases Aged 18–79 Years, United States, 2008

15.1%

16.8%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics


Uad cvd update

Rate of new cases of type 1 and type 2 diabetes among youth aged <20 years, by race/ethnicity, 2002–2005

<10 years

10–19 years

Source: SEARCH for Diabetes in Youth Study

NHW=non-Hispanic whites; NHB=non-Hispanic blacks; H=Hispanics; API=Asians/Pacific Islanders; AI=American Indians


Where we are now

Where We Are Now

www.uad-cvd.org


Claims analysis results for a basic trade

Claims Analysis Results for a Basic Trade

  • Member employee population is aging.


Claims analysis results for a basic trade1

Claims Analysis Results for a Basic Trade

  • Prevalence of diabetes and hypertension are increasing.


Claims analysis results for a basic trade2

Claims Analysis Results for a Basic Trade

  • Prevalence of diabetes and hypertension are increasing.


Our premise

Our Premise

  • Multiemployer funds are a unique niche in health care coverage

    • There is no research foundation on what works best for multiemployer funds

  • Multi-employer funds have unique strengths

    • Very stable populations

    • A high degree of trust

www.uad-cvd.org


What uad does for h w funds

What UAD Does for H&W Funds

  • Provide information: An objective , non-commercial resource on chronic disease prevention and control

    • www.uad-cvd.org

  • Perform studies:

    • Claims data analysis

    • Conducts pilot studies to provide evidence-based best practices

      • Communications

      • Screening and early detection

      • Incentives

      • Centers of excellence/”medical homes”

www.uad-cvd.org


Uad cvd organization

UAD/CVD Organization

www.uad-cvd.org


Staying focused on key risk measures

Staying Focused on Key Risk Measures

  • Weight/BMI

  • Blood sugar

  • Blood cholesterol

  • Blood pressure

  • Smoking

www.uad-cvd.org


Recommendations to funds

Recommendations to Funds

WWW.UNITEDAGAINSTDIABETES.ORG


Uad cvd algorithm

UAD/CVD Algorithm

www.uad-cvd.org


Uad cvd update

Eligible Participants

Notify about Program

Health Risk Appraisal

Identify participants at risk for disease

Claims data

Identify participants with disease using HEDIS criteria


Uad cvd update

Eligible Participants

Notify about Program

Health Risk Appraisal

Identify participants at risk for disease

Claims data

Identify participants with disease using HEDIS criteria

Medical Screening Exam

HbA1c, BP, Total Non-HDL, Smoking


Uad cvd update

Eligible Participants

Notify about Program

Health Risk Appraisal

Identify participants at risk for disease

Claims data

Identify participants with disease using HEDIS criteria

Medical Screening Exam

HbA1c, BP, Total Non-HDL, Smoking

No Disease

HbA1c< 5.8

No CVD

Non- Smoker

Pre-DM

HbA1c 5.8-7.0

Pre-CVD

Blood pressure

DP 80-90/SP 120-130

Cholesterol

Total non-HDL: 120-130 mg/ml

DM

HbA1c>7

CVD

Blood pressure

DP >90/SP >130

Cholesterol

Total non-HDL: >130 mg/ml

Smoker

No DM

No CVD


Uad cvd update

Eligible Participants

Notify about Program

Health Risk Appraisal

Identify participants at risk for disease

Claims data

Identify participants with disease using HEDIS criteria

Medical Screening Exam

HbA1c, BP, Total Non-HDL, Smoking

No Disease

HbA1c< 5.6

No CVD

Non- Smoker

Pre-DM

HbA1c 5.6-6.4

Pre-CVD

Blood pressure

DP 80-90/SP 120-139

Cholesterol

Total non-HDL: 120-130 mg/ml

DM

HbA1c >6.5

CVD

Blood pressure

DP >90/SP >140

Cholesterol

Total non-HDL: >130 mg/ml

Smoker

No DM

No CVD

Annual Medical Exam

Provide Self-mgt Guide

Lifestyle Change

Medications as Needed

Daily Aspirin (if high risk)

Annual Medical Exam

No Co-morbidity

Co-morbidity

Provide Self-mgt Guide

Lifestyle Change

Medications as Needed

Daily Aspirin

Annual Medical Exam

Smoking cessation

Daily Aspirin for

Men age >45 and

Women age >55

Annual Medical Exam

Evaluate for Depression

Evaluate for Depression

PBM review

For Smokers

Smoking Cessation

Provide Self-mgt Guide

Lifestyle Change

Medications as Needed

Daily Aspirin

Annual Medical Exam

Refer to Specialty Practice

For Smokers

Smoking Cessation

PBM review

Lab value review (if available)

Provide Self-mgt Guide

Lifestyle Change

Medications as Needed

Daily Aspirin

Annual Medical Exam

PBM review

Lab value review (if available)

Quarterly case mgr review

Annual

Case Mgr Review

For Smokers

Smoking Cessation

For Smokers

Smoking Cessation

Case Mgr Review:Quarterly

PBM review

Lab value review (if available)

PBM review

Lab value review (if available)

Case Mgr Review

Depression: Monthly

Other: Quarterly

Case Mgr Review

Monthly

www.uad-cvd.org


How to implement algorithm step 1

How to Implement Algorithm:STEP 1

DESIGNATE A STAFF MEMBER

  • Responsible for implementing UAD program

  • UAD will provide training and technical support

www.uad-cvd.org


How to implement algorithm step 2

How to Implement Algorithm:STEP 2

NOTIFY PARTICIPANTS ABOUT PROGRAM

  • Participation is key to program success

  • Continuous communication is key to program participation

  • UAD can provide communications materials

www.uad-cvd.org


How to implement algorithm step 3

How to Implement Algorithm:STEP 3

START IDENTIFYING PARTICIPANTS WITH DIABETES OR CVD RISK

  • Offer HRA

    • UAD has developed a HRA targeted to our funds

  • Start mining your claims data

    • UAD has developed a Claims Analyzer tool

www.uad-cvd.org


How to implement algorithm step 4

How to Implement Algorithm:STEP 4

ENCOURAGE PARTICIPANTS AT RISK

TO GET A MEDICAL SCREENING

  • All participants over age 45

  • All participants under age 45 at risk

  • All men 35-45

  • UAD has developed a screening guideline

www.uad-cvd.org


How to implement algorithm step 5

How to Implement Algorithm:STEP 5

PROVIDE PRO-ACTIVE DISEASE MANAGEMENT

SUPPORT TO PARTICIPANTS WITH DISEASE OR EARLY SIGNS OF DISEASE

  • Smoking cessation

  • Disease management guide

  • Daily aspirin

  • Centers of excellence for patients w/ multiple disorders

  • Disease/case management support

  • Make use of UAD Guidelines and materials

www.uad-cvd.org


How to implement algorithm step 6

How to Implement Algorithm:STEP 6

MONITOR PARTICIPANTS WITH DISEASE

TO MAKE SURE

THEIR TREATMENT IS BEING OPTIMIZED

  • Use medical and pharmacy claims data

www.uad-cvd.org


Does it work results from 5 years of experimentation in one fund

Does it work?Results from 5 years of experimentation in one Fund

www.uad-cvd.org


Comparison of dm participants to matched controls

Comparison of DM Participants to Matched Controls

  • Compliance: DM better on all HEDIS scores

www.uad-cvd.org


Comparison of dm participants to matched controls1

Comparison of DM Participants to Matched Controls

  • Compliance: DM better on all HEDIS scores

  • Costs: DM declined 22%; controls 2%

www.uad-cvd.org


Comparison of dm participants to matched controls2

Comparison of DM Participants to Matched Controls

  • Compliance: DM better on all HEDIS scores

  • Costs: DM declined 22%; controls 2%

  • DM intensity impact on costs:

    • Coaching (intense): 41%

    • Newsletters (less intense): 29%

www.uad-cvd.org


Multiemployer fund compared to commercial health plans

Multiemployer Fund Compared to Commercial Health Plans

  • Compared to PPOs: MF DM Participants did as well as PPOs on most HEDIS Scores

www.uad-cvd.org


Multiemployer fund compared to commercial health plans1

Multiemployer Fund Compared to Commercial Health Plans

  • Compared to HMOs: MF DM Participants did not do as well as HMOs on most HEDIS Cores

www.uad-cvd.org


Does a more proactive dm program expose trustees to greater liability

Does a more Proactive DM Program Expose Trustees to Greater Liability?

www.uad-cvd.org


Uad cvd update

In the fund studied, trustees had no problem obtaining a Health Benefit Purchaser’s Liability Insurance Policy at very little additional premium cost

www.uad-cvd.org


The uncertainty factor

The Uncertainty Factor

www.uad-cvd.org


Likely roi

Likely ROI

Note: there are no controlled studies of ROI in Multiemployer plans

www.uad-cvd.org


Prevention is problematic costs of diabetes prevention program

Prevention is ProblematicCosts of Diabetes Prevention Program

Best Case Scenario

12-15 Yrs of Net Outlays

25-30 Year to

“Black Friday”


Fradkin nih

Fradkin (NIH)

  • "Effective therapy entails up-front costs with savings realized decades later. Thus, it is likely that savings from diabetes prevention and control in middle-aged adults will accrue to Medicare, but Medicare does not fund their care during this period."


Conclusion

Conclusion

  • Diabetes screening and early detection are not “low lying fruit” in terms of cost control

  • Disease management is fairly low-lying with reasonable ROI if implemented carefully

  • Improvements in vaccination/immunization rates are likely to produce costs savings with short time-horizons

www.uad-cvd.org


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