Overcoming Health System Complexity, Fragmentation in Diabetes Care
Participating in an Institute for Healthcare Improvement Forum panel session on Dec. 11, endocrinologist Jeffrey Boord, M.D., M.P.H., chief quality and patient safety officer at Parkview Health in Fort Wayne, Indiana, spoke about some ways to overcome health system complexity and fragmentation in diabetes care.
Boord set the stage for his talk by noting that the rapid growth of diabetes in the U.S. is outpacing the ability to care for those affected. In his state of Indiana, 45% of adults in Indiana have diabetes or pre-diabetes. Additionally, the costs of diabetes care are staggering, with over $400 billion in total costs, including over $300 billion in direct medical expenditures for diabetes care in 2022.
Despite all that healthcare spending, Boord said, many people with diabetes remain undiagnosed and untreated. “There's strong evidence that diabetes self-management and support services improve diabetes outcome, yet it is massively underutilized, and many patients, particularly those in rural communities, do not have ready access to diabetes education services,” he said.
We have more therapies to manage diabetes and control glucose than we ever have before, and yet these therapies remain unaffordable for many patients. He noted that GLP-1 drugs are indeed a game-changer, “but there is an elephant in the room, which is the cost these medications. The newer GLP-1 agonists have a retail price over $1,000 per month, and we have to figure out ways to get these medications for our highest-risk patients at an affordable cost.”
Often, he added, we are not achieving the key outcomes in diabetes care. Only about half of patients achieve good glucose control, as evidenced by a hemoglobin AIC level at or below 7 and less than one in four persons with diabetes in the United States achieve optimal control of glucose, blood pressure and cholesterol together.
Boord asked the question: Why is it that despite over $300 billion in direct healthcare expenditures, we are not getting the kind of outcomes that we want? “It really comes down to two things: complexity and fragmentation in our health system,” he said. “Fragmentation is defined as siloed or heterogeneous health services that occur because of a lack of unified goals, policies, incentives and information across stakeholders. This fragmentation even occurs within our own healthcare organizations, and this is a huge opportunity for us because breaking down fragmentation, addressing complexity within your own organization, has tremendous power.”
Boord noted that the overwhelming majority of diabetes care in the United States is provided by primary care providers. “We all know that we have a shortage of primary care providers in the United States, particularly in rural and underserved communities. However, the shortage of diabetes and endocrinology specialty care is even more acute,” he said. There are only about 6,000 endocrinologists in the United States, about 4,500 of whom are in active clinical practice, and we have only about 350 endocrinology fellows who graduate programs in the United States annually.
Only 24.7% of U.S. counties have at least one pediatric or adult endocrinologist or diabetologist. What does this mean? Boord said we have to do things differently. “We have to work collaboratively with primary care. We have to come up with new solutions.”
Boord then turned to some specific examples from Parkview’s experience innovating in this space, including embedding pharmacists in primary care practices.
Parkview has invested resources through the 340B program to help provide a robust diabetes population care system through pharmacy services. “We have been able to embed pharmacists in clinical practice who can provide clinical support for things such as prior authorizations, appeals, facilitating clinical care, titrating therapy and extending that primary care/specialty care team,” Boord said. “We have pharmacy technicians who work alongside them and can help with things like prior authorizations, medication access and medication assistance to help patients who are having difficulty paying for medications.”
Diabetes clinical pharmacists are embedded in 24 of Parkview’s primary care sites. That pharmacist can prescribe titrate therapy, manage high blood pressure and cholesterol and also refer patients for diabetes screenings, Boord explained. “They typically engage with the patient for up to six months with frequent interactions, and they can really help drive that care plan. If necessary, they can even refer them out to the endocrinology practice. We have seen remarkable reductions in glucose with A1C at six months going down by almost two points. We've seen improvement in diabetes screening with eye exams, cholesterol control and also nephropathy screening. We've also even seen evidence of decreased acute care utilization from diabetes-related care visits and also hospitalizations related to diabetes.”
This facilitates driving patient-centered care, giving patients access to the medications and support they need to successfully meet their personal care goals. We really can transform how we deliver care in an integrated way.
Boord also highlighted a model of direct-to-employer contracting being deployed at Parkview. ‘This really gives us a way to provide a patient-centered care model that also aligns the financial incentives. This is a per-member per-month model. It's direct-to-employer contracting, so we can align the benefit structure and the service delivery so that it's patient-centered for employed persons, and we can go out to the site of business. We remove those barriers to access. We align the benefits so that they're not paying co-pays. We know what's on their medication formulary, and in two visits, we can provide all they care that they need at their workplace. And this is coordinated. It goes into our electronic health records, so their primary care provider is directly part of the process and informed, and it really helps remove a lot of those barriers, because we bring the care to the patient.”
Other speakers on the panel spoke about the potential of transitional care coordination and remote patient monitoring to power care management.
An IHI meeting audience member asked how to help patients who have been seen by endocrinology specialists transition back to primary care. “One of the biggest enablers to that is that enhanced primary care model,” Boord said. “The more resources that are embedded in primary care, the easier it is to graduate patients back to that primary care setting.”
The other part, he added, is that “we as endocrinologists have to be willing to let go and be able to identify when we're meeting the goals and that they can be back in that primary care setting, but have an open door of access and communication so that the primary care provider doesn't have to start all over again — being able to reach out to us in peer-to-peer consultation so that we can determine when patients really do need to be referred back.”
