Let’s Talk Diabetes

Diabetes is a top category of spend for most plan sponsors. According to the American Diabetes Association, people diagnosed with diabetes incur average medical expenditures of $16,752 per year, of which about $9,601 is attributed to diabetes. On average, people with diagnosed diabetes have medical expenditures approximately 2.3 times higher than what expenditures would be in the absence of diabetes.[I]

As a diabetes educator for more than two decades, why did you decide to focus your attention there? Why do you think diabetes is so important?

Tara Higgins:

My passion for diabetes education started while working as a consultant in long-term care facilities. CMS mandates that every person in a nursing home has to have their medical chart reviewed by a pharmacist once a month. Within that review process, I realized, “Gosh, a lot of these people have diabetes.”

In pharmacy school, you learn about how drugs work, but diabetes has expanded and changed, and it’s really about understanding the regimens in good detail. I felt furthering my diabetes education was necessary to do my job correctly and service the patients. If people weren’t on the right medication regimen with their diabetes, they would have poor outcomes.

Diabetes management can transcend medications. Things like nutrition, activity level, stress, and other factors also are important. Whether it’s working with patients one-on-one, holding group classes, or looking at it from a population health management strategy—as I do in this job—being a diabetes educator is always beneficial.

As you were specializing in diabetes and applying your education in the field, what surprised you or your patients?

Tara Higgins:

The biggest thing is that patients assume physicians understand how drugs work. Of course, they understand it to a degree. Still, diabetes is complicated. For example, some medications work better in a patient’s fasting state, meaning they don’t have food in their body at that time, versus drugs that work better in a postprandial state (after eating). Patients can find it a little shocking to understand that different medications work differently and can work in concert with each other for even greater outcomes or effects. It’s shocking to patients because they assume that physicians know everything, yet physicians don’t always understand how to optimize the effectiveness of the medications.

The evolution of primary care medicine is a factor. Access to specialists has reduced over time. In this paradigm, primary care physicians and providers have even more disease states requiring expertise. Patients with diabetes used to be sent to an endocrinologist for their medication regimen and diabetes education. Now, it’s more the primary care provider’s responsibility to provide that assistance and education, as well as managing the medications.

It was eye-opening through my experience to see that most of my patients had difficulty handling their diabetes because of things other than their diabetes. For example, stress at work; stress at home; financial issues; and basic necessity issues, such as food insecurity, housing situations, or having three generations living under one roof and somebody else doing the cooking. Those types of things were out of their control, and they couldn’t necessarily address independently.

It takes a village to manage diabetes for an individual. I think for many people, it’s tough to say, “I can’t do this on my own. I need help.” Whether that be social supports from their family and friends or additional resources from their primary care physician. Sometimes, it’s tough for patients to admit that they need the support of others to be successful.

When you think about what you’ve done in the diabetes space, what would you say is the contribution or success story that makes you most proud?

Tara Higgins:

A couple of things come to mind. Many years ago, when patient registries were starting to evolve, I was part of a statewide initiative here in Rhode Island, where we got providers to begin using patient registries. Data is so powerful. It was a great experience to see physicians take a step back and reevaluate their approach to patients with diabetes. The ability to guide physicians with data, identify areas of improvement on the standard of care, and share opportunities to move that needle was fantastic.

For me, population health management strategies are exciting. I love to use data to drive outcomes and show providers meaningful population details.

Diabetes is very number-driven, and I think people can wrap their heads around that. It is a little easier to understand statistics than something more subjective, like the behavioral health space, where you’re talking about depressive symptoms and how people feel. With diabetes, it’s more black and white. You can show people the numbers and say, “Okay, this is how you’ve improved.” Looking at the improvement over time can equip people with the information they need.

You mentioned the evolution of diabetes over time, how things have expanded and changed? Is there any news or changes in the diabetes landscape that excites or concerns you?

Tara Higgins:

There’s an organization here in Rhode Island that I care about a great deal. It’s called Camp Surefire, and it’s for kids with diabetes. I was invited to be a board member of the organization, and it has been an exciting opportunity to work with these kids. Many of them have type 1 diabetes, which is a much smaller percentage of people with diabetes. However, we’ve learned enough about diabetes that we’re on the cusp of the artificial pancreas and trying to recreate what the body is supposed to do for people who have diabetes. That’s exciting!

We also have continuous blood glucose monitoring. It’s literally checking somebody’s blood sugar every two to three minutes without having to do a finger stick. It is continuously feeding to an electronic device the information to say that person’s blood sugar is trending up or down. You can see the impact of food, activity, and stress on blood sugar.

When I was in school over 20 years ago, the number of medications to treat diabetes was limited. We’ve advanced from a technology standpoint in the diabetes space. The continuation of that technology evolution means we’re going to have some sort of an artificial pancreas available in the not too distant future. I heard about it when I was in school two decades ago, but now we’re much closer to this truly happening!

Today, we have many different categories that we can use to treat diabetes, which I think is great because it allows for various choices depending on the individual and their needs. Previously, it was more cookie-cutter as to how you approached the treatment of diabetes. With the increase in options, it can be more tailored to what’s going on with an individual. We can cater to what they need, where they are in their disease progression or different individual factors.

What about Camp Surefire? How did they approach camp during COVID-19?

Tara Higgins:

They went virtual. It was pretty amazing. The camp created kits for every camper, and counselors hand-delivered or mailed out these kits to the kids. The kits included a Camp Surefire mask, a camp shirt that said “the quarantine edition,” and a plethora of information about dealing with their diabetes.

There were online camp sessions run by a physician who oversees the camp, Dr. Greg Fox, and activities from the counselors.

It was a great success, given that they weren’t able to be in person, and the kids still had a great time. The biggest thing is for kids to connect with other kids that have diabetes, so they understand they’re not alone. Other kids are going through similar scenarios. That connection is important. The camp provides a social network where they can ask each other questions, lean on each other, and provide support while forging lasting friendships. In fact, two of the camp directors met at camp, and they’re married with their first child.

It’s a great program!

This question feels like I’m bringing us down after talking about something so uplifting, but let’s unpack what you referenced earlier about innovation in the diabetes space. Diabetes continues to be a top category of spend for most plan sponsors. We know formulary changes are coming in 2021 that impact populations with diabetes. Have you worked with any plans with innovative approaches or cost management strategies that you consider best practices?

Tara Higgins:

I’ve talked to a lot of plan sponsors about this because, obviously, to your point, diabetes is a top concern. Prior to joining PSG, when I was working at a health plan, we did a pilot study with our employees. We used them as the impetus to determine if we should develop a full program.

We learned through offering reduced copays for diabetes medication that people who were already adherent (doing a good job taking their medication) improved their adherence slightly. However, the flip side was that we found people who were in the 50 percent or less category of taking their medication regularly:

• didn’t engage in the program; or
• didn’t have an improvement in their adherence.

Why do you think that is?

Tara Higgins:

One of the things I talk about with plan sponsors is the three Cs of why people struggle with their diabetes.

1. Cost. The costs associated with diabetes include medications, test strips, and more.
2. Concern. There are concerns about side effects. People also worry about what the medication is going to do to their bodies.
3. Commitment. There is an element of commitment and understanding that this is a long-term, lifelong condition: “I need to commit today to improve my health to prevent those long-term consequences.”

And, understanding that I might feel okay today, but I might not feel okay in two years. So it’s that asymptomatic part of diabetes where people might not necessarily feel bad, but their blood sugars and things going on because of their diabetes are causing damage to their body.

From a plan sponsor standpoint, they often look at the cost component. It’s common to hear questions like, “Can we make it easier for our members to get diabetes medications?” For example, plan sponsors implement preventive lists, thereby reducing or bypassing the deductible phase. This approach allows their members to access diabetes medications at a lower price.

That’s like having a three-legged stool and only using one leg. You also have to address the member concerns and how to get the members committed to taking care of themselves.

The programs with the best success are the ones that are multi-pronged. Think beyond access through things like reducing the copay amount and removing the financial barriers. I’d recommend best practices like partnering with local provider groups. This approach can seem overwhelming to large national plans, but if you have 5,000 individuals in a specific area, look to partner with a medical group in that area to provide diabetes education. I encourage plans to be innovative and think about what offerings they can provide.

Another area is looking at, I’ll say telephonic-based or virtual-based programs like Livongo, for example. Some of the PBMs also are offering diabetes programs that are telephonic and virtual.

The most successful and most significant return on investment goes beyond just reducing the pharmacy piece. Plans must think about it more globally from both a medical and pharmacy spend perspective. Ultimately, diabetes is cardiovascular disease, meaning people will end up with heart attacks and strokes. It requires a global perspective.

In the same vein of thinking about it more globally, not just thinking about cost, have you encountered anyone who’s thinking through diabetes in that sense of the whole person coming to work? Their holistic well-being and not just the cost of their diabetes medication?

Tara Higgins:

The organizations that deploy more of a diabetes management process versus just reducing drug costs are more apt to get it.

One of the things that makes Artemetrx a valuable tool is the disease management module that is now available. Artemetrx’s Total Cost of Care feature allows users to perform in-depth analysis within a population of members with diabetes. The filtering capabilities enable us to drill down to member, drug, provider, and claim level views. This data empowers us to measure the effectiveness of therapy and identify at-risk members experiencing escalations in costs, such as hospitalizations or ER visits.

When we have both the medical and pharmacy data, plans can manage complex disease states like diabetes appropriately. You should consider deploying programs based on the severity of the condition.

Highly complex members often are costly because they might be going to the emergency room or hospitalized frequently. They probably need a very high touch program.

Middle ground members need an assortment of offerings from a diabetes management standpoint. This type of member could benefit from a wellness perspective, like gym memberships or other ways to get people to be more physically active.

Lower risk members might be newly diagnosed or at risk for developing diabetes (the pre-diabetes population).

What are some strategies or things that you can deploy on the health and wellness side?

Tara Higgins:

There is no cookie-cutter approach. If there was, nobody would have diabetes as their top spend, right? It’s looking at diabetes both from a disease management standpoint and a health and wellness standpoint. Plans can offer any number of benefits to the membership.

One component that isn’t talked about very frequently is behavioral health. It might be getting people to access their employee assistance program, for example. Addressing other social issues going on within their lives can help deal with their chronic condition. There’s a multitude of things you have to do to be successful.

Do you feel like people are making that connection between disease management and general wellness?

Tara Higgins:

Many of the groups we work with get it, but I don’t know if every plan out there is necessarily correlating how wellness will help from a disease management standpoint.

Depending on who the plan sponsor is—and this could be from the perspective of a health plan, health system, or even an employer group—how long do you keep your employees? How long are your employees part of your organization? Wellness is more of a longer-term investment. It’s different for every plan sponsor.

It’s all about being data-driven and identifying your most immense opportunities. For example, suppose you have a particular geo-location that has a higher incidence of diabetes. In that case, it might make sense for you to deploy a disease management program within that population. You can then assess the success of the smaller scope program. It may make sense to implement it more globally. Either way, use your data to find your smartest starting point!

I’ve seen a recurring theme with all the pharmacists I know. It’s all about the data.

Tara Higgins:

Well, as pharmacy geek people, we like data. Over time, I’ve started to appreciate data even more from the population perspective. That’s not necessarily how all pharmacists think. Nor is it what I was taught in school. However, thinking about how you will best manage your population means taking a step back and reviewing data at a higher level than unique individual members. For example, “Okay, I’ve got X amount of people with diabetes. What’s going on with them? What are some of the common themes I’m seeing? What are some of the strategies that could be deployed to improve the health of those individuals?”

Thank you for your insights on diabetes! If there’s one key message you hope the reader takes away from this discussion, what would it be?

Tara Higgins:

The treatment of diabetes cannot be done in isolation. It really is cardiovascular disease, so you have to look at it from the ABCs of diabetes:

• A1C control, which is your blood sugar control
• Blood pressure
• Cholesterol

Diabetes management is about thinking beyond isolated elements, like blood sugar control. The more people think about diabetes as cardiovascular disease, the more it will change the mindset of what diabetes is. I think people, when you say cardiovascular disease or heart disease, people go, “Oh, that’s important.” Well, one of the leading causes of death for people with diabetes is a heart attack. Plan sponsors that are set up for success from a diabetes management perspective take care of all the components of diabetes and work to prevent those major complications.

Learn more about Tara Higgins, PharmD and all the premier pharmacists on Team PSG here.

[i] https://diabetes.org/resources/statistics/cost-diabetes