AJMC Peer Exchange: Nationwide, Patient-Centered Strategy Needed to Battle Obesity, Type 2 Diabetes

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The American Journal of Managed Care opens its conference, Patient-Centered Diabetes Care: Putting Theory in Practice, with a peer exhange among leading experts who concluded that a nationwide, patient-centered effort is needed to turn the tide on rising rates of obesity and type 2 diabetes mellitus in the United States.

From left, Drs. Handelsman, Lopes, Salgo, Uusinarkus, and Dunn.

AJMC Peer Exchange: From left, Drs. Handelsman, Lopes, Salgo Uusinarkus, and Dunn.

We have to figure out what works, and more importantly, what does not work.

Fighting the nation’s related epidemics of obesity and type 2 diabetes mellitus will take a nationwide strategy that increasingly tailors treatment to individual patient needs, and new approaches are need to get patients to take medications and make lifestyle changes to be healthier.

That was the consensus of an expert panel convened Thursday by The American Journal of Managed Care to open its two-day conference, “Patient-Centered Diabetes Care: Putting Theory into Practice,” which is taking place at the Princeton Marriott at Forrestal. The conference continues today, opening with a keynote address by Robert A. Gabbay, MD, chief medical officer at the Joslin Diabetes Center, Harvard Medical School.

Panelists taking part were Jeffrey D. Dunn, PharmD, MBA, senior vice president, VRx Pharmacy Services, LLC, Salt Lake City, Utah; Yehuda Handelsman, MD, FACP, FACE, FNLA, medical director and principal investigator, Metabolic Institute of America, Tarzana, Calif., and president-elect of the American Association of Clinical Endocrinologists (AACE); Maria Lopes, MD, MS, chief medical officer, AMC Health, New York City; and Kari Uusinarkaus, MD, FAAFP, FNLA, associate medical director, adult primary care and health management, Colorado Springs Health Partners, Woodland Park, Colo.

Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and associate director of surgical intensive care, New York-Presbyterian Hospital, served as moderator. The 90-minute discussion covered the challenges to treatment, including woeful adherence rates to therapies despite recent advances in medication; how to weigh medical therapy against surgical options; and when the newest classes of diabetes therapies, the DPP-4s inhibitors, GLP-1 receptor agonists, and SGLT2 inhibitors are indicated. The webcast will be shown on http://www.ajmc.com in upcoming weeks.

The discussion opened with a snapshot of obesity and diabetes in the United States, where the latest figures reported by the American Diabetes Association (ADA) show nearly 26 million people are affected by diabetes, almost all off it type 2. Increases in diabetes have tracked rising rates of obesity geographically in recent decades, a point Dr. Handelsman noted when he said that California “is where Mississippi was,” years ago.

Dr. Handelsman said that “turning the tide,” on diabetes would require a “nationwide, proactive intervention,” with government health agencies taking a role. The trends are not good, the panelists agreed. Dr. Uusinarkaus said though his home state of Colorado is statistically the nation’s fittest, “Our obesity has finally crept up. … The trends are certainly in the wrong direction.”

The statistics outlined by Dr. Salgo are alarming: He quoted an ADA study that shows the economic costs of diabetes are $245 billion a year in the United States, including $176 billion in direct medical cost (28 percent is for medication).

When asked by Dr. Salgo if therapies alone could do the trick, given the woeful statistics on lifestyle modification, Dr. Handelsman insisted that past failure could not be a reason to give up things like better diet and exercise. “We know changing lifestyle works,” he said.

The challenge comes when it’s time to pay for intensive, personalized efforts to help patients exercise and make better food choices over the long haul. These interventions are expensive, and not all insurers or employers are willing to include these items in a health plan.

Dr. Lopes agreed that prevention has to be part of the solution if the nation is to “bend the cost curve” on treating diabetes and its many complications. Tailoring treatment to individual patients is essential, she said.

“We have to figure out what works, and more importantly, what does not work. A lot of this is going to be predicated on data from real-world situations,” Dr. Lopes said. The panelists agreed that methods such as using newsletters or mailed reminders to diabetes were outdated and simply did not work. Group counseling has produced better results, Dr. Lopes said.

New therapies that help patients lose weight alongside controlling diabetes offer promise, for the patient can see the progress; studies show that glycated hemoglobin (A1C) levels drop along with weight loss, even when the amount lost is initially small. Dr. Uusinarkaus said the promise of significant weight loss can help motivate a patient who might refuse an injectable drug for diabetes to give it a try.

Dr. Dunn said payers and pharmacy benefit managers are open to new approaches and are not unwilling to pay for relatively expensive new therapies if they see signs of progress. Payers and employers balk, he said, when a patient is taking up to four drugs and still not achieving control of A1C or blood pressure.

“Every plan out there has thrown everything under the sun at diabetes,” Dr. Dunn said. Plans cannot afford to provide intensive monitoring of every person with diabetes, but it does make financial sense to identify those patients most at risk of hospitalization or serious complications, and aim highly targeted efforts at guiding them to better health. “We need risk stratification and coordination,” he said. “It has to be done on the right patients.”

Dr. Dunn also called for shared risk among providers, payers, and the pharmaceutical companies that develop new, expensive treatments. Right now, he said, the risk is all on the payer, and that cannot continue.

About the Journal

The American Journal of Managed Care, now in its 20th year of publication, is the leading peer-reviewed journal dedicated to issues in managed care. In December 2013, AJMC launched The American Journal of Accountable Care, which publishes research and commentary devoted to understanding changes to the healthcare system due to the 2010 Affordable Care Act.

Mary Caffrey mcaffrey(at)ajmc(dot)com
(609) 731-8802 (Friday only)

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