Making the Unseen, Seen: Prioritizing Cost-Effective Preventive Foot Care

Oct. 17, 2023
Two healthcare industry leaders look at the devastating impact of diabetic foot amputations, and the need for systemic approaches to change

by Sukanya Soderland, senior vice president and chief strategy officer at Blue Cross Blue Shield of Massachusetts and Jon Bloom, M.D., CEO and co-founder of Podimetrics

Every three minutes in the United States, someone has a limb amputated due to diabetes. The process is as traumatic as it is expensive: A single lower-limb amputation can cost more than $100,000 in direct spending, and 62 percent of patients die within five years of the event.

These patients often come from traditionally underserved populations, including Black and Latinx communities, that disproportionately experience complex diabetes and its burdens. 

While the U.S. health system is becoming more aware that these disparities exist, we still struggle to take action to address the shortfalls and connect people with the resources they need to avoid amputations and other costly complications from diabetes, such as the 85% of diabetic foot ulcers that are preventable.

Getting ahead of rising risks can reduce spending by $8,000 to $13,000 per member each year, as well, according to research from Intermountain Healthcare. America’s health plans need to pull back the curtain on health disparities and take a hard look at what we can do to put preventive care for diabetes in the spotlight.

Identifying the scope and scale of the unseen population

As a starting point, health plans need to get their arms around data specific to patients with complex diabetes and decipher what that data really means in terms of attributing spend to specific disease states. 

Today, many analytics and risk stratification initiatives are built by using diagnosis and service codes to place individuals into defined disease buckets. But health plans don’t focus enough on how multiple chronic conditions interact with each other, driving spending across disease states and blurring cost lines.

We know, for example, that people with open diabetic foot ulcers, which often indicate poorly controlled diabetes, are more likely to experience cardiovascular issues, including being three times more likely to be hospitalized for circulatory diseases and twice as likely to be hospitalized for congestive heart failure.

As a result, we think of the downstream spend on cardiovascular disease as the primary cost driver, not diabetes, and allocate our dollars accordingly without focusing enough on controlling diabetes earlier in the disease progression. That leaves the needs of the rising-risk diabetes population unaddressed and inaccurately minimizes the costs associated with this small but high-spending population.

Those transitions from one major disease state to multiple comorbidities are where the greatest cost-savings opportunities lie. Plans need to gain visibility into all the costs and codes associated with diabetes care and common comorbidities, integrating social determinants of health (SDOH) data into predictive algorithms, equipping patients with home-based monitoring tools to inform their activities, and working to increase representation in clinical trials around diabetes progression and treatment.

Building partnership between health plans and members

For many consumers, health plans still occupy an adversarial role in their quest to get the care they need. Most member-plan contact only occurs when there’s a problem to be solved. But plans can become more proactive allies in anticipating and responding to members.

For example, using human-centered strategies for member-focused interactions can help to build and maintain trust. For operational leaders, this includes creating workflows that attract and retain top member-facing talent and developing performance metrics that prioritize member satisfaction and problem solving, even at the expense of traditional key performance indicators, such as call times and volumes.

Sometimes this means spending some extra time listening to patients who are confused, overwhelmed, or distraught. Conversations like these, which can be difficult in nature, often help build longer-term trust between health plan and member.

When interacting with members, care management staff need to be empowered to provide culturally aware, socioeconomically sensitive support through techniques, like motivational interviewing, and should be given the time and tools to collaborate more closely with clinical care providers, social workers, digital health platforms, and community-based resources to ensure comprehensive care for higher-needs members. 

Connecting with the community to build trust and take meaningful action

Working directly with community representatives helps health plans understand the touch points that matter most to the people they serve. These may include moments in time where people are most receptive to making a positive change (immediately after a diagnosis, a child’s high school graduation, etc.) or organizations that have meaningful connections with people and their families (community centers, schools, and more).

In many communities, faith-based groups are the ideal partners for making a big impact on education and building connections. Churches, temples, mosques, and other religious institutions are strong fellowship hubs that can host diabetes screenings, hold nutrition classes, or simply reinforce the importance of making positive lifestyle choices.

Organizations like the Partners in Health and Wholeness (PHW), a multi-faith program developed by the North Carolina Council of Churches, supports healthy communities through events, financial support, and peer-to-peer education. PHW works closely with partners such as county health departments and other nonprofits to ensure alignment with broader community health initiatives. Members are eligible to apply for small financial grants to use for hosting health fairs and screening events, cooking and exercise classes, educational materials, and additional activities for community members.

Health plans that invest in creating pathways to connect with historically unseen populations before they become extremely ill will be crucial for containing spending, fostering better outcomes, and breaking the cycle of health disparities in underserved communities. Health plans would be well-served to reassess how they are supporting some of their most at-risk populations, especially those living with complex diabetes. Doing so will not only improve health outcomes, but it will also put a significant dent in total costs of care for minority patients who are hit hardest by chronic diseases like diabetes. 

Sukanya Soderland is senior vice president and chief strategy officer at the Boston-based Blue Cross Blue Shield of Massachusetts. Jon Bloom, M.D., is CEO and co-founder of the Somerville, Mass.-based Podimetrics.

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