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Managing Diabetes The Challenge of Multiple Chronic Conditions. James M Schibanoff MD Editor-in-Chief Milliman Care Guidelines. Diabetes Today. Type I accounts for 5-10% of diabetes Type II accounts for 90-95% and increasing Prevalence in adults 9.6% (20.8 million Americans)

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Managing DiabetesThe Challenge of Multiple Chronic Conditions

James M Schibanoff MD


Milliman Care Guidelines

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Diabetes Today

Type I accounts for 5-10% of diabetes

Type II accounts for 90-95% and increasing

Prevalence in adults 9.6% (20.8 million Americans)

Diabetic adults twice as likely to die as non-diabetics of same age

Leading cause of blindness ages 20-74

Leading cause of end-stage renal disease

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Diabetes Today

In comparison with other chronic diseases, diabetes is relatively well understood and there is broad-based agreement about how to manage it, but….

  • National Healthcare Quality Report 2005 (AHRQ)

    • Hb A1c test performed within year = 90%

    • Hb A1c level <7% = 39.8%

  • About 50% of patients do not follow their diabetes medication prescriptions

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The Challenge is Filling the Gaps

  • Affordability

  • Quality

  • Evidence

  • Care Delivery

  • Personal Life Style

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Affordability Gap

  • Milliman Medical Cost Index = $13,000 per year per family


    Average income $66,970 (Median about $50,000)

SOURCE: Bureau of the Census website

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Insurance Premium vs. Income

SOURCE: Carroll, John. Erosion of Employer-Sponsored Health Care. Managed Care. January 2007, Volume 16, Number 1, 18-29.

Retrieved at

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Question: Has current approach to disease management made medical care more affordable?Answer: Probably not

  • Objective studies in literature equivocal

  • Medicare Coordinated Care Demonstration: 2 year results

  • Difficult to measure

    • Randomized controlled trials uncommon

    • Selection bias

    • Regression to mean

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Regression to mean illustration medical care more affordable?

SOURCE: Ortne, Nick. Milliman Research Report. Insight into Two Analytical Challenges for Disease Management. April 2004.

Retrieved at

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Are we getting our money’s worth? medical care more affordable?

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Quality Gap medical care more affordable?

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Evidence Gaps medical care more affordable?

Triple challenge:

  • Knowledge created at faster rate than we can apply to patient care

  • Clinical questions growing at faster rate than can be answered by traditional research methods

  • Current research methods have serious limitations

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National Library of Medicine MEDLINE medical care more affordable?

  • Contains 15 million citations

  • 5,000 journals in 37 languages

  • 2,000-4,000 references added daily (623,000 in 2006)

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Evidence Gaps medical care more affordable?

Randomized controlled trials (RCTs) are considered the gold standard of evidence but apply only to select populations with a low comorbid disease burden.

For patients with multiple comorbidities, medication intolerances, poor adherence, or limited cognition, the evidence base is largely nonexistent

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Steps in the Knowledge Chain medical care more affordable?

7 Steps each with a 20% drop off leads to 21% adoption rate

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Care Delivery Gaps medical care more affordable?

Coordination of care: fragmented care leads to omissions and overlaps

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Care Delivery Gaps: Health Plan medical care more affordable?

  • Adverse selection and retention

  • Plan turnover

  • Financing disincentives

  • Helping the competition

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Health plan vs Carve-out disease management medical care more affordable?

  • A single Carve-out DM vendor could:

    • Eliminate adverse selection and competitive disincentives

    • Portable across insurers

    • Separate ordinary care from diabetes care

    • Duplicate infrastructure of health plan and vendor

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Care Delivery Gaps: Physicians medical care more affordable?

  • Impending shortage of primary care physicians

    • General internists vastly outnumbered by medical subspecialists

    • Fewer general internists are entering practice

    • Generalists are paid considerably less than specialists

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Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists

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Personal Lifestyle: Chronic Disease Care Differs from Acute Care

Patient behavior is the most important determinant of outcome

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Is it all bad news? Help is on the way …… Care

  • Care Delivery

    • Practice redesign

    • Personal Health Record

    • Care coordination tools

    • Peer support models

  • Evidence

  • Quality

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Care delivery: Medical home proposals Care

  • Personal physician to:

    • Coordinate and facilitate patient’s care

    • Advocate for and guide patient through complex health system

    • Assume accountability

  • Components are:

    • Multidisciplinary team

    • Clinical decision support tools to guide decision making at point of care

    • Ongoing plan of care

    • Enhanced access to care (email, etc)

    • Quality outcomes

    • Health information technology

    • Self-management support

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Medical home versus current disease management approaches Care

  • Current disease management relies on care managers provided by health plan or contracted disease management company

  • Emphasis is on relationship of care manager and patient with periodic input requested from patient’s physician

  • Current disease management more inclined to have single disease focus

  • Accountability diffuse

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Medical home requires Care

  • Change in traditional role of physician

  • Redesign of practice

  • Considerable new technology

  • New reimbursement system for qualifying practices

    • Care coordination fee (capitation model)

    • Fee-for-service visit fee

    • Pay-for-performance incentive

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Is the medical home concept effective? Care

Current best evidence is favorable but is either indirect or preliminary

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Information Technology support of medical home Care

  • Patient registries

  • Reminder systems

  • Personal health record (PHR)

    • Interoperable

    • Portable

  • Guidelines and care coordination tools

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Diabetes CareAssessment

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Quality Improvement Care

  • Quality measure development

    • Ambulatory Quality Alliance (AQA)

    • National Quality Forum (NQF)

    • Joint Commission

  • Public reporting

  • Pay-for-performance

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The “new” evidence concepts Care

  • “The rapid-learning healthcare system”

  • “Practice-based evidence”

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Personal lifestyle improvement: CareSelf Management

  • Increasing role of peer support:

    • Information support

    • Emotional support

    • Shared problem solving

  • Leads to increased

    • Confidence (self-efficacy)

    • Perceived social support

    • Understanding of self-care

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Prediction Care

In comparison with other chronic diseases, diabetes is relatively well understood and there is broad-based agreement about how to manage it, and…

Our healthcare system will deliver superior diabetes care through innovations in care delivery, evidence, technology, and quality improvement