AAPPO ACT on Diabetes Initiative

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Best Practices In Care ManagementIdentification,
Care, Outcomes Measurement

• AAPPO ACT on Diabetes Initiative

July 12, 2007  
Dexter W. Shurney, MD, MPH, MBA Senior Vice
President and Chief Medical Officer
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Agenda

• Defining the problem
• Practical Solutions
• Outcomes Measurement
• Q A

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Company Background

• Nations largest provider of disease management
  and comprehensive care enhancement services
• Specific programs for wellness, disease
  management and high risk care management
• Largest provider of Health Care Support,
  supporting 26.4 million lives
• 90 health plan customers and over 1000
  Employer/ASO customers representing approximately
  85 of U.S. commercially-insured eligible lives
• Proven programs with large scale, third party
  validated outcomes
• 13 Care Enhancement Centers (Health and Care
  Support)

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Tale of Two Epidemics
"Increases in diabetes cases have been going on
for 15 years, and it doesn't look like it's
slowing down." Reviewing data from the National
Health Interview Survey, Geiss' team found that
from 1990 to 2005, cases of diabetes increased
from 26.4 per 1,000 people to 54.5 per 1,000
people, a 4.6 percent increase each year. Geiss
believes the diabetes epidemic is largely being
driven by obesity Linda S. Geiss, Chief of
diabetes surveillance CDC
Source HealthDay News, June 23, 2007
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Weight Matters

• The prevalence of diabetes increases in a
  dose-response relationship with increasing BMI.
  BMI 35. 38 of the excess risk of diabetes
  could be avoided if their BMI did not exceed 30.
  (Int.J. Obesity Related Metabolic Disorders,
  2000)

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Unabated Trend
BMI 30, or 30 lbs. overweight for 5'4"
person 2005                                 
Number of severely obese people increasing The
number of Americans 100 pounds or more overweight
increased 50 percent from 2000 to 2005, twice as
fast as moderately obese people April 9 (UPI) --
CDCs Behavioral Risk Factor Surveillance System
(BRFSS).
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Obesity Trends Among U.S. AdultsBRFSS, 1991,
1996, 2003
(BMI ?30, or about 30 lbs overweight for 54
person)
In 1995, obesity prevalence in each of the 50
states was less than 20 percent. In 2000, 28
states had obesity prevalence rates less than 20
percent.
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Participating in No Physical Activities in the
Last Month
More than 50 of U.S. adults do not get enough
physical activity to provide health benefits
Source Behavioral Risk Factor Surveillance
System, CDC.
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Cost of Obesity

• Obesity drove 27 of medical cost increases
  between 1987 and 2001
• Source Kenneth E Thorpe, Curtis S Florence,
  David H Howard, Peter Joski, The Impact of
  Obesity on Rising Medical Spending, Health
  Affairs, Web Exclusive, October 20, 2004

Highest rate of increase in medical and
disability - claims costs is among 30 to 49 year
olds, and both are due to obesity. Helen
Darling, president NBGH
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Cost of Obesity
6,822

• The average 3-year medical care costs among
  employees with BMI at risk was 52 higher than
  medical care costs among lean employees. The
  average 3-year cost of absenteeism among
  employees with BMI at risk was more than twice
  that of lean employees.
• Burton WN, Chen C-Y, Schultz AB, Edington DW. The
  economic costs associated with body mass index in
  a workplace. J Occup Environ Med 199840786-792.

4,496
1,546
683
BMI at risk defined as 27.8 kg/m 2 for men
and 27.3 kg/m2 for women
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Path of Destruction
Unhealthy Lifestyles

• Too much food
• Wrong foods
• Sedentary
• Disfunctional stress
• Lack of sleep
• Inadequate health monitoring

• CVD and strokes
• Renal Failure
• Blindness
• Neuropathy / foot ulcers / amputations
• Sexual Dysfunction
• Gastroparesis
• Birth Defects
• Infections

• Hypertension
• Dyspipidemia
• Gallstones
• Osteoarthritis
• Sleep Apnea
• Cancer
• Colorectal
• Prostate
• Breast
• Gallbladder
• Endometrial
• Gout
• GERD
• Reproductive Problems
• Depression

• Medical cost increases
• Average medical costs for an individual with
  diabetes are 10,071/yr. compared to 2,669 for a
  person without diabetes.(ADA 2002)
• Productivity loss
• Premature death and disability

Diabetes
Obesity
Consequences
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Lifestyle Current State of Affairs

• .

• More than 50 of U.S. adults do not get enough
  physical activity to provide health benefits
• Activity decreases among those with lower incomes
  and less education.
• Insufficient physical activity is not limited to
  adults. About two-thirds of young people in
  grades 912 are not engaged in recommended levels
  of physical activity.
• In 2005, only one-fourth of U.S. adults ate five
  or more servings of fruits and vegetables each
  day.

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Focus on Disease Progression

Pain and Suffering / Cost
Natural Progression





Diabetic Sequela




Diabetes



Metabolic Syndrome


Obesity

Overweight
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Focus on Disease Progression

Diabetic Sequela
Diabetes
More Focus Here Is Also Warranted
Metabolic Syndrome
Obesity
Overweight
Key Intervention is Lifestyle change It is
also The Common Intervention Across all stages
of disease progression.
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The Many Benefits of Lifestyle Change

• Reduce risk for Heart Disease and Stroke
• Back Pain
• Osteoporosis
• Psychological benefits including stress hardiness

Benefits of Exercise
Exercise

• A minimum of at least 30 minutes of moderate
  intensity exercise daily resulted in a reduced
  risk of coronary heart disease by more than
  2-fold (Diabetes Care, 2005)
• Walking and losing 15 pounds decreased the risk
  of getting diabetes by 58 (NIH Study n3,284)

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• Rethinking Wellness

Johns Hopkins/ Healthways Outcomes
Summit November 2006
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What We Know

• Risk is most often associated with
  lifestyle/behavior choices. The majority of
  common diseases are preventable or controllable
• Risk factors predict future disease state or
  health conditionAND costs
• Small lifestyle/behavior changes can have
  exponential improvement on health AND costs
• Most people have at least one modifiable
  (improvable) risk factor

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Metabolic Syndrome

• Employers may maximize their value by
  concentrating wellness, disease management and
  lifestyle intervention programs on those with
  metabolic syndrome.
• A constellation of 3 or more of the following
  risk factors including -Increased waist
  circumference
• -Elevated triglycerides -Reduced
  HDLC -Elevated blood pressure -Elevated fasting
  glucose

Cited from Milliman report Metabolic syndrome
and Employer Sponsored Medical Benefits An
Actuarial Analysis, March 2006
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Facts and FiguresMetabolic Syndrome

• About 1 in 5 Americans meet the accepted criteria
  for metabolic syndrome
• Two-fold increase in risk for cardiovascular
  disease and an approximate five-fold increase in
  risk for developing diabetes compared to people
  without the syndrome
• Cardiovascular diseases cost the United States
  more than 300 billion.

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Obesity Metabolic Syndrome Program
Health Support
Care Support
Strat 3
Strat 4
Strat 1
Strat 2
Health Coaches Prochange online
RN led care team

• First line of therapy recommended is Drug therapy
  for
• Dyslipidemia
• Elevated blood pressure
• Elevated glucose
• Lifestyle interventions to reduce the risk
  factors
• Weight loss
• Increased physical activity
• Modification of a low fat diet

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Approach for Success
Key Elements

• Detailed/Individualized patient assessments
• Individualized approach to goal setting
• Overcoming obstacles to change health behavior
• Sustained contact

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Core Tactics

• Tailored communication
• Interactivity
• Self-monitoring
• Ipsative feedback

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Bringing it to Life for the Patient

• Establishing a Routine
• Portion Control
• Glycemic Index and Load
• Exercise
• Coping Skills

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Measuring Savings

• Since Metabolic Syndrome is primarily a risk
  profile it requires a different approach to cost
  savings than traditional DM models.
• Examples
• Reduced Trend in Future Disease Prevalence (CAD
  and Diabetes)
• Attributable Risk / NNT
• Risk Reduction Modeling (Dee Edington)

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Method I Reduced Trend in Future Disease
Prevalence
Cost avoidance is demonstrated by bending the
trend of prevalence in the diseases that
metabolic syndrome often precedes, for example
diabetes and CAD.
Not to scale--for Illustrative Purposes Only
Example For every 100 individuals identified
with Metabolic Syndrome, reducing a 10 trend of
becoming diabetic to 5 would result in a savings
of 35,000 before fees. ADA finding a person
with diabetes costs roughly 7000 extra/yr than a
non-diabetic.
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Method II Attributable Risk / NNT
Each component of the syndromes constellation of
risks raises the likelihood that a future bad
event will occur.
Not to scale--for Illustrative Purposes Only

Risks
Obesity Alone
MetaS w/ Co-Morb
MetaS Alone
Non-Obese
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Method II Attributable Risk / NNT

• Number Needed to Treat (NNT)
• The number of people that would need to be
  treated in order to prevent one adverse event.
• Equals 1/ AR
• Example Bad events (CAD related or becoming
  diabetic) over 3 years for individuals with MetaS
  is 40 vs 10 w/o MetaS. Therefore, AR .4 - .1
  .3 and NNT 1/.3 3.33
• Question What are the costs to treat 3-4
  individuals to avoid the costs of one bad event?

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Method III Risk Reduction Model
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Contact Information
Dexter Shurney, MD, MBA, MPH Senior Vice
President / Chief Medical Officer 3841 Green
Hills Village Drive Nashville, TN.
37215 615-565-5932 dexter.shurney_at_healthways.com
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Questions?