What’s old is new again

What’s old is new again

Here in the beautiful city of Chicago, home of the World Champion Chicago Cubs, the city continues to struggle with a common problem; lowering the cost of health care for city employees. Like many employers, the city instituted a health and wellness program to help employees achieve better health and wellness. A program which cost the city $10.5 million over a three-year period. A program which was just extended for another year at a cost of $5.8 million even though the city’s Inspector General Joe Ferguson, per a story in the Chicago Sun Times; “raised “serious questions” about whether Mayor Rahm Emanuel’s highly touted wellness program was “achieving any demonstrable benefits or whether it will ever do so.”

The full story which can be read at http://chicago.suntimes.com/politics/emanuel-extends-wellness-contract-despite-ig-concerns/ outlines many of the issues facing health and wellness programs and also should send a warning message to every company in the increasingly crowded interconnected diabetes management (IDM) space.

While many see IDM as the future the truth is IDM is merely an old concept reformulated with advanced technology. Back in the day before everyone had a smartphone and there were no way cool whiz bang apps something called disease management (DM) was the all the rage. The goal of disease management back then was the same goal touted by IDM, help patients better manage their diabetes so they can achieve better outcomes which ultimately would lower costs.

There was only one problem with DM, as whiz bang and way cool as these programs were the savings generated basically came from keeping insulin using patients out of the hospital. Back then Diabetic Investor wondered why any employer would pay for DM for all their employees with diabetes when the employees who really needed the help were easy to identify. As we noted back then why pay for 100 participants when only 20 really need the help.

This is one of the biggest issues facing IDM, demonstrating REAL cost savings for all patients with diabetes no matter which drugs they use. The fact is IDM’s main goal is to prevent or delay a patient from developing many of the costly complications associated with poorly controlled diabetes. Put more simply savings that AREN’T achieved over the short but long term. Put even more simply the success of IDM should really be judged on something NOT happening.

Now think about this just for a moment from the perspective of an employer. As the Chicago example notes these programs aren’t cheap and showing real savings isn’t easy either. The harsh reality is the real savings won’t kick in until these patients are no longer covered by the city’s plan but have moved onto Medicare. Yes, we know there are studies that show that employers on average save $3,500 in healthcare costs for each 1% drop in HbA1c but when looked at closely these savings largely come from keeping employees with diabetes out of the emergency room.

Perhaps a better argument for IDM is that the average male employee misses 11 days of work due to their diabetes, the average female 9 days. Therefore, it could be argued that IDM is a tool to enhance employee productivity. That savings would come from less doctor visits and keeping the employee where they belong, at work. As valid as this argument is, it must be balanced against the cost of any program, will the savings generated by the program more than offset the cost of the program.

Even more complex is just what is the definition of success. Research tells us that using HbA1c alone as the measure of success or failure does not tell the whole story. Research also tells us that all patients should not be held to the same standard, that for some patients there is greater risk at striving for an HbA1c of 7 or below, that for these patients we should accept a higher than “normal” HbA1c. Research is also telling us the glycemic variability plays just as important role as HbA1c, that there can two patients with the exact same HbA1c but vastly different glycemic profiles. That the patients who keeps their glucose levels in a tighter range stands a better chance at avoiding costly complications. Put simply a consensus is building that HbA1c is an incomplete metric for measuring control.

Let’s be clear here we see value in IDM, that when used as designed it can help patients achieve better outcomes. The problem is one of money, can the cost of IDM be offset by the savings it’s supposed to generate, the exact same problem faced when DM was all the rage. The technology used with IDM may be way cool and whiz bang but the problems facing this way cool whiz bang technology are no different than the issues that faced old fashioned DM.

Just to make this an even more complex issue think about the time and effort involved at achieving better outcomes no matter which metrics are used. Diabetes is not like a broken arm where a simple X-Ray reveals when this break has healed. A patient does not start using IDM one day and see improvements the next. The truth is it takes time and sustained effort by the patient to achieve better outcomes. That even if they are getting great advice from IDM, that the information is relevant and actionable its ultimately up to the patient. As we have said many times, IDM can provide the how to, it cannot provide the want too.

Want to throw even more gas on this raging fire consider that diabetes changes over time. That managing diabetes changes as the patient ages.

To Diabetic Investor this all comes to down to what it always comes down too, money. Who makes it, who saves it and who spends it. This was true back in the days of DM and is true today with IDM. As Momma Kliff used to say; “Advanced technology is a wonderful thing but no amount of advanced technology can change issues that have existed for years. It cannot change one very fundamental set of facts, that most of these patients have a disease they would rather not have in the first place. A disease which requires lots of effort to manage properly. Technology is part of the answer but not the only answer.”