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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 diabetes the challenge of multiple chronic conditions

Managing DiabetesThe Challenge of Multiple Chronic Conditions

James M Schibanoff MD


Milliman Care Guidelines

diabetes today
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

diabetes today4
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
the challenge is filling the gaps
The Challenge is Filling the Gaps
  • Affordability
  • Quality
  • Evidence
  • Care Delivery
  • Personal Life Style
affordability gap
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

insurance premium vs income
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

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
regression to mean illustration
Regression to mean illustration

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

Retrieved at

evidence gaps
Evidence Gaps

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
national library of medicine medline
National Library of Medicine MEDLINE
  • Contains 15 million citations
  • 5,000 journals in 37 languages
  • 2,000-4,000 references added daily (623,000 in 2006)
evidence gaps16
Evidence Gaps

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

steps in the knowledge chain
Steps in the Knowledge Chain

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

care delivery gaps
Care Delivery Gaps

Coordination of care: fragmented care leads to omissions and overlaps

care delivery gaps health plan
Care Delivery Gaps: Health Plan
  • Adverse selection and retention
  • Plan turnover
  • Financing disincentives
  • Helping the competition
health plan vs carve out disease management
Health plan vs Carve-out disease management
  • 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
care delivery gaps physicians
Care Delivery Gaps: Physicians
  • 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
Proportions of Third-Year Internal Medical Residents Choosing Careers as Generalists, Subspecialists, and Hospitalists
personal lifestyle chronic disease care differs from acute care
Personal Lifestyle: Chronic Disease Care Differs from Acute Care

Patient behavior is the most important determinant of outcome

is it all bad news help is on the way
Is it all bad news? Help is on the way ……
  • Care Delivery
    • Practice redesign
    • Personal Health Record
    • Care coordination tools
    • Peer support models
  • Evidence
  • Quality
care delivery medical home proposals
Care delivery: Medical home proposals
  • 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
medical home versus current disease management approaches
Medical home versus current disease management approaches
  • 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
medical home requires
Medical home requires
  • 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
is the medical home concept effective
Is the medical home concept effective?

Current best evidence is favorable but is either indirect or preliminary

information technology support of medical home
Information Technology support of medical home
  • Patient registries
  • Reminder systems
  • Personal health record (PHR)
    • Interoperable
    • Portable
  • Guidelines and care coordination tools
quality improvement
Quality Improvement
  • Quality measure development
    • Ambulatory Quality Alliance (AQA)
    • National Quality Forum (NQF)
    • Joint Commission
  • Public reporting
  • Pay-for-performance
the new evidence concepts
The “new” evidence concepts
  • “The rapid-learning healthcare system”
  • “Practice-based evidence”
personal lifestyle improvement self management
Personal lifestyle improvement:Self 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

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