HJNO Jan/Feb 2023

CHANGING THE CARE: DIABETES MELLITUS 14 JAN / FEB 2023 I  HEALTHCARE JOURNAL OF NEW ORLEANS   signed primary care teams using the Care Model Process, with implementation of stan- dardized workflows and proactive engage- ment of patients, the results improved steadily over time. In 2004 when they started, only 5% of their patients met all five measures. But by 2011, 42% of patients met all five measures, subsequently improving to 66% in the years that followed. Let’s pause to put that 66% num- ber into proper perspective. 66% across all five measures was a rolled yield, meaning that to achieve that number, teams had to exceed 90% success rates across each of the five in- dividual metrics. The work favorably impacted both quality and cost. Those patients meet- ing the optimal diabetes measure cost about $1500 per year, while those with poorly man- aged diabetes cost $20,000 per year. Indeed, in the year 2011 — when they were still only at 42% of patients meeting all five measures — compared to the HealthPartners members who failed to get all the recommended care, those who did get all the recommended care suffered 364 fewer heart attacks ($35,000 per episode), 68 fewer leg amputations ($26,000 per episode), 625 fewer eye complications ($250 to $3000 per episode), and 1200 fewer emergency room visits ($750 per episode). If you do the math, it means that in just one year those patients who benefited from the high- est quality care were over $15.5 million less expensive than those who had poorer quality. The unfortunate reality is that for traditional health systems who do not have their own health plan like HealthPartners, investing in an initiative that would remove over $15 million in revenue from their budget would constitute a negative return on investment for the improve- ment initiative. And because of their fiduciary obligation to the organization and to the bond holders, chief financial officers of traditional health systems would consider it a breach of their fiduciary duty to pursue such an initia- tive. But that mindset traps these systems in a perpetually reactive, downstream response to ongoing crises and complications instead of proactively designing a system that prevents them from happening in the first place. These health systems may point the finger of blame at the commercial payers, insisting that they are only responding to current market incentives. The commercial payers in turn may take aim at the health systems, asserting that they are driving up the cost of care, all while passing on the cost increases to consumers in the form of ever-increasing premiums. Caught in the cross- hairs are the providers who find themselves “drowning” — aka burning out — in the down- stream river of complications that relentlessly persist in the absence of meaningful change. The future of diabetes care I will never forget the first time I ever saw a list of my own quality metrics for diabetes con- trol. I had probably been in practice for around seven years or so and tried my hardest every day to stay as up to date as possible and deliver high-quality care. And yet, on a comparative list of about 30 of my fellow primary care provid- ers for a standard diabetes quality metric, my name was in the middle of the pack — average performance. I was surprised because although the doctor at the top of the list was indeed a good doctor, I didn’t think he was better than I was. But I took it upon myself to speak with him and find out why his numbers were better than mine. It turns out that we were both treating diabetes mellitus the same way. It’s just that he had much more reliable systems and processes than I did. For one thing, I would tell my uncon- trolled diabetics to follow up with me in three months. He would make sure their follow-up appointment was scheduled before they even walked out the door. I would dispense enough refills on their medications to last them a year. He would only dispense enough to last them 90 days to ensure they would come back in three months’ time. It was my first lesson in how processes and systems of care could favorably impact quality. After incorporating some of his approaches into my own practice, I watched my own numbers improve to equal his own. I still see patients part-time, and, over the years, I’ve continued to embrace ways of im- proving quality. I also have a quality dashboard where I can continuously monitor how I am do- ing across a wide array of performance metrics. Currently, I would never expect anything less than 90% of my patients achieving goal glyce- mic control for diabetes (as indicated by a mea- sure known as hemoglobin A1c < 7.0 in most patients and < 8.0 in some patients). I will hold myself accountable to this standard no matter how “difficult” or challenging these patients might be. They could be of very low socioeco- nomic status or low health literacy; they could have impaired self-efficacy or suffer frommental health disorders; or they could have maladap- tive coping mechanisms such as emotional eating, cigarette smoking, or excessive alcohol use. None of that matters if you have the right team in place, supported by a value-driven, outcomes-based economic model that proper- ly aligns clinical and financial incentives of care. How is that possible? First, the same as managing hypertension — just following a standardized care pathway for sequentially prescribing medications with reminders for fol- low-up and timely monitoring of labs will very likely result in at least >75-80% rates of goal glycemic control. This approach can even be digitized and scaled broadly across a popula- tion using glucometers that upload blood sug- ar readings to a cloud-based server where the information can be acted upon by pharmacists and health coaches. From a purely pharmaco- logic perspective, it is essential to make sure that metformin is part of that initial regimen. Here is where traditionalists can get it wrong from the start. My own experience is that >90% of patients tolerate metformin as long as we teach them how to take it properly. It is very im- portant that the medication be taken with the right combination of protein and carbohydrate and that we start at low dosages while gradu- ally escalating the dose upward as tolerated. Too many patients are not taught how to take metformin properly, and they experience sig- nificant gastrointestinal complaints, thus giv- ing up on a very important medication before it even has a chance to work. Adding the new SGLT2 inhibitors and GLP1 receptor agonists in appropriate patients is likewise very important. And if insulin is required to achieve control, then using the lowest dose possible to avoid weight gain and the vicious cycle of increasing insulin resistance is of paramount importance. Next, we need to avoid surrogation , mean- ing that we cannot allow ourselves to get too caught up in a narrow surrogate process mea- sure like percentage of patients achieving ad- equate glycemic control. Don’t get me wrong — this measure is important, it’s just incom-