ABOUT THE SERIES

Roughly 26 million Americans have diabetes and the number is expected to soar in the coming years, reaching nearly half of all Americans by 2020. Diabetes is responsible for $116 billion in direct medical costs annually. Hospitals and health systems will be challenged in the coming years to improve health for this population. In this yearlong series, H&HN will examine the impact the diabetes epidemic is having on the delivery system and how hospitals are responding. Articles will appear every other month in the magazine; look for additional multimedia content in H&HN Daily.

Framing the Issue

  • About 26 million Americans have diabetes — 19 million diagnosed and 7 million undiagnosed.
  • Diabetes is responsible for $116 billion in direct medical costs and $58 billion in indirect costs.
  • Diabetics are at higher risk of heart disease, stroke and high blood pressure than the general population.
  • Much of the demand for diabetes care will come on the outpatient side.

The already alarming and still growing wave of diabetes cases is crashing into a health care delivery system that was not designed to handle chronic disease. The epidemic will test whether the health care field can transform itself to meet the demands of the disease and the Affordable Care Act.

About 26 million Americans have diabetes — 19 million diagnosed and 7 million undiagnosed, according to the National Institutes of Health. Estimates show that by 2050 between 1 in 3 and 1 in 5 Americans will have the disease. Reasons for the spike include the aging population, growth of the populations at high-risk of type 2 diabetes, and people with diabetes who are living longer.

At the same time that the number of diabetics is increasing, health reform will do away with the barriers that blocked their access to care. "Hospitals are going to see an increase in the number of people with diabetes, because people who were formerly denied coverage because of their disease or got dropped from their insurance plans because they have diabetes will now have the opportunity to get the type of treatment they need, whether it's inpatient or outpatient care," says LaShawn A. McIver, M.D., American Diabetes Association managing director for public policy and strategic alliances.

The demand for care already overwhelms the supply of physicians. The nation has about 3,000 endocrinologists and trains about 150 new ones each year, notes David M. Harlan, M.D., chief of the diabetes division and co-director of the Diabetes Center of Excellence at the University of Massachusetts Medical School and UMass Memorial Health Care. "If you do the math and assume, incorrectly, that all those endocrinologists are doing nothing more than seeing patients with diabetes nonstop from 7:30 a.m. to 6 p.m. Monday through Friday, those specialists would have about 15 minutes per year to see all those 26 million patients," he says. "This is clearly inadequate and isn't going to make a dent."

Much of diabetics' care falls on primary care physicians, Harlan says, but they, too, lack the capacity to address diabetes in office visits that usually cover multiple health problems.

A population in need

The epidemic takes a huge toll on the nation's health and finances. Diabetics are at higher risk of heart disease, stroke and high blood pressure than the general population. The condition can cause vision loss, kidney disease and nerve damage, and can result in lower-limb amputation.

Each year, diabetes is responsible for $116 billion in direct medical costs and $58 billion in indirect costs, such as disability, lost work and early death, according to the Centers for Disease Control and Prevention.

To deal with the demands the diabetes epidemic places on the system, health care organizations need to develop innovative, coordinated approaches to care in all parts of the continuum. At the same time, ACA payment and health care quality provisions, and the law's emphasis on chronic disease and care coordination heighten the need for hospitals to take a fresh look at how they approach diabetes care.

"What the Obama administration is attempting to do in overhauling our health care system truly is a transitional moment in history for us in health care because it involves a systems change," McIver says. "It's not just individual behavior, it's not just providers, it's not just reimbursement, and it's not just hospital care. It's the whole system."

Hospitals are in a unique position to spearhead change across the care continuum. "Health systems are a critical community resource to coordinate services for populations," says Joan H. Moss, R.N., senior vice president at Sg2, a suburban Chicago health care information and consulting firm. "It's an area where we see greater interest, commitment and investment."

As public and private payers increasingly move toward risk-based contracting, hospitals and health systems have to look at the total cost of care, and the financial incentive shifts to managing such co-morbid conditions as diabetes. "So there is both the financial incentive and certainly the continued commitment of health systems to community health," Moss says.

Hospitals already are creating programs to address the epidemic. "We see everything from disease management programs to group visits for diabetic patients; disease registries; more community outreach and prevention, particularly at the adolescent level, trying to deal with the obesity epidemic;, all the way to the use of bariatric surgery," Moss says.

Much of the demand for diabetes care will come on the outpatient side. Sg2 forecasts a 66 percent increase in the various types of outpatient services, including patient evaluation, diabetes education, diagnostic testing and e-visits, over the next 10 years. Hospitals seeking to improve diabetes care must focus attention on outpatient care. In addition, hospitals that purchase primary care or endocrinology practices take on more responsibility for outpatient diabetes care, notes Yehuda Handelsman, M.D., immediate past president of the American Association of Clinical Endocrinologists and president and medical director of the Metabolic Institute of America. "They will have to offer centers that deal with people with diabetes with education, with outpatient management." Hospital outpatient diabetes centers can serve both as an extension of hospital care and a way to earn patient loyalty, he notes.

Patient engagement

Many hospitals have developed diabetes centers or have diabetes management programs. Diabetes management requires a team approach involving physicians, nurses, dietitians, pharmacists and diabetes educators. Hospitals often are best able to support the comprehensive team approach for their physicians, whether they are employed or independent but aligned, Moss adds.

But a stark look at diabetes prevalence and physician supply shows the need to broaden the base of care beyond health care providers, Harlan says. That means getting patients actively involved in their care management. "You could have the world's most expert and dedicated treatment team, but if the patient is not involved in that process, it doesn't matter," he says.

Experts talk about patients not being compliant with their treatment regimens, Harlan notes. But often the problem is "learned helplessness" among diabetic patients. "A lot of patients who have trouble with their glycemia pretty quickly learn, 'If I call my doc, I'm either going to be put off or they're not going to answer my question,' so they stop calling," he explains.

Diabetics also can be overwhelmed by the complexity of managing the disease — measuring their blood sugar, changing their diets, watching their weight, and taking insulin or other medications. "They will tell you that the day they were diagnosed with type 2 diabetes, they were given a second full-time job they didn't want," Harlan says. "This second job asks them to take off a day of work four to five times a year and spend half the day looking for a parking place and waiting in a waiting room for incredibly inefficientinteractions to answer their questions and advise them on how to do better."

Here hospitals have a role to play, too, by investing in information technology that enables diabetic patients and their care teams to exchange data easily via computer. "Both parties will be happier and achieve better outcomes than the first scenario," Harlan says.

UMass Memorial Health Care was the first hospital to use one such technology, MyCareTeam. The software platform is integrated with the hospital's Allscripts electronic record. It allows patients to regularly transmit their blood glucose readings directly from their glucose meters — along with blood pressure, weight, vital signs, caloric intake and exercise — to a database through the Internet.

The system presents patients and their care teams with data in an organized way that allows them to immediately see patterns in their blood glucose levels, Harlan notes. Because the software is integrated into the EHR, it can generate alerts that are routed to the care team when preset triggers, such as too many high blood sugar readings, are hit. "That's a lot cheaper and more proactive than waiting for the patients to come to see you for their next appointment or end up in emergency department because they've had lows or highs," Harlan says.

The technology eases the care management burden for the provider team because patients are doing their data uploads from home. This enables the hospital's diabetes clinic to run more efficiently and gives physicians more time to focus on the sickest patients. "The amplifying effect is [that] now the patient is engaged a little bit more," Harlan adds.

Online patient networks, run by private entities, insurers or health care organizations, also can help patients learn the "tricks of the trade" on how to live with diabetes without going through the trouble of contacting their doctors, says Ann Christensen, president of Innosight Institute, a nonpartisan think tank. "You've got a whole universe of people who are now trying to figure out alternative sweeteners and alternative ways to cook and eat. Having resources for patients to be able to learn about those things and exchange information with each other is very important."

A team approach

Given the physician shortage and payers' emphasis on value, hospitals should look at how to best utilize their nonphysician practitioners on diabetes management teams. For example, telehealth systems that utilize nurses or nurse practitioners are not only good for patients, but also use less-expensive practitioners to reduce physician workloads, Christensen notes.

Moss points to the Dryer Medical Clinic in Chicago's suburbs as an organization making wise use of nonphysician practitioners. The clinic, an affiliate of Advocate Health Care, has a health management program through which trained clinical pharmacists help patients and their physicians manage the medications used to treat diabetes and its associated conditions.

"They determined that the pharmacist, of all of the team members for the diabetic population, was the key professional to really manage these diabetic patients," Moss says. The pharmacists conduct patient visits and, barring any complications, patients only need to see their physician for diabetes once a year.

The program's strengths are that it is clinic-based, is supportive of and collaborative with medical staff, targets the expertise of the right professional for each patient's needs, and has clinical pharmacists working to the full extent of their license, Moss says. "Health systems need to continue to look at patient populations and really think about the interdisciplinary team and how they can create delivery systems that maximize individuals' working at the top of their licenses," she adds.

On the inpatient side, diabetics typically aren't admitted for their diabetes. Indeed, Sg2 predicts a 26 percent decline over the next 10 years in admissions that list diabetes as the primary diagnosis. But as the incidence of diabetes grows nationwide, hospitals can expect to see an increase in patients with diabetes as a comorbidity. At UMass, at least 35 percent of the patients have abnormal blood glucose levels, and the percentage is about the same at most hospitals, Harlan says.

Diabetes complications put these patients at higher risk of infection, falls, bed ulcers and blood sugar swings. Diabetics' lengths of stay are typically one or two days longer than those of the general inpatient population, and they are more likely to be readmitted within 30 days of discharge, Harlan notes.

ACA payment provisions are making hospital inpatient management of diabetic patients more imperative than ever. The law includes Medicare payment penalties for hospitals with the most health care-associated conditions and those with excessive 30-day readmissions. The conditions in the ACA's hospital-associated condition provision are the same as those already targeted by Medicare. These include many conditions for which diabetics are at high risk: manifestation of poor glycemic control, surgical infections, pressure ulcers and injury from falls.

Studies have shown that proper inpatient glycemic control reduces a diabetic's risk of complications and lowers length of stay. Some hospitals, depending on their size and surgical volume, have established blood glucose management teams to improve the quality of care and outcomes. These teams, which include pharmacists, physicians and dietitians, are devoted to managing admitted patients' blood sugar. They look at daily runs of patients with high blood sugar and round on those patients to review their cases and to discuss with the attending and consulting physicians how to correct the problem.

Most doctors in the hospital don't know how to control a patient's blood sugar or don't want to, Harlan says. "They have a standard order set, and if it works for you, great. If it doesn't, they just ignore it."

When Harlan worked at the NIH, he helped to create a blood glucose management service at the institute's Clinical Center in Bethesda, Md. The multidisciplinary team, which has met daily since 2007, writes orders for insulin and blood glucose monitoring, instead of simply making recommendations to the primary team on the ward. The system allows the primary team to focus on whatever medical problem brought the patient to the hospital without worrying about blood sugar control.

From the inpatient setting, care has to transition quickly back into outpatient diabetes management, Harlan says. "Our big vision is to develop great capacity and systems for the outpatient so we can tell any inpatient we see, 'Tomorrow we want you to come to your first outpatient visit so we can start helping you manage your diabetes,' and we make it easy for them."

No amount of in-hospital education can prepare patients to manage their disease, Harlan says. "Right now [the way] the system is, you give them education and you check all the appropriate boxes with the insurance company that you've given this patient education, but if you ask the patient what they've learned, they've learned 'blah, blah, blah, diabetes.' "

Community partnerships

The UMass diabetes center offers diabetes education, consultations for nutrition and insulin management, and behavioral modification to help diabetics adopt healthier habits. In addition, its MyCareTeam website offers educational materials patients can turn to at any time day or night. The center is working on putting educational videos on the site so when patients have questions, "they click on a button and there's a YouTube video from the diabetes educator whom they've met already telling them again what they do, whenever they want it, 24/7, 365 days a year, and it's free," Harlan says.

The growing epidemic also is spurring hospitals to create innovative diabetes prevention programs. An estimated 79 million American adults have pre-diabetes, according to the CDC.

For example, some hospitals are creating partnerships with YMCAs to provide health and wellness programs and access to affordable exercise to address proactively the obesity epidemic that is helping to fuel the diabetes epidemic.

Some hospitals have become recognized providers of the National Diabetes Prevention Program. The CDC-led effort is a public-private partnership of community organizations, private insurers, employers, health care organizations and government agencies that offer an evidence-based lifestyle change program for people at high risk for type 2 diabetes. The lifestyle changes reduce the risk of developing type 2 diabetes by 58 percent in persons at high risk for the condition, according to the CDC. The YMCA and UnitedHealth Group were the program's first partners.

As hospitals and health systems increasingly take on risk-based contracting, the incentive will shift toward preventing diabetes among their patient populations, and blending screening, outpatient and inpatient care, and self-management programs together in a comprehensive line of diabetes services.

Hospitals, particularly those moving into risk-based contracting, are using their EHRs to create disease registries so they know which patients are diabetic, and are developing risk-stratification strategies. "They recognize how important it is to connect the appropriate level of resources or programmatic interventions to the risk of patients," Moss says.

The risk-stratification approaches vary. Some organizations assign patient risk by disease state, and others are looking at acuity of illness. Risk stratification can be used in physician offices to determine which patients are at risk of developing diabetes; in diabetes management to determine which patients are at risk of developing complications; and in the inpatient setting to determine which patients are at risk of readmission.

"Health systems are responding to the idea of creating value, whether it's related to effectiveness in managing length of stay and cost per case, effectiveness in managing 30-day readmissions, or effectively reducing avoidable admissions, and clearly diabetes falls into this area," Moss says.

Through such efforts as accountable care organizations, the ACA "is pushing the envelope on how we think about our health care system and what changes are needed to catapult us onto a better trajectory," McIver says. "It's not just how we bring down the cost of care, but how we improve the lives of people who have chronic diseases like diabetes."

— Geri Aston is an H&HN contributing editor.

Executive Corner

Epidemic numbers

About 26 million Americans have diabetes. By 2050, between 1 in 3 and 1 in 5 Americans will have the disease. Hospitals and health systems can expect to see more diabetics as the incidence rises and because the Affordable Care Act will remove insurance barriers to coverage starting in 2014. The demands of the diabetes epidemic require creation of innovative, coordinated approaches to care in all parts of the continuum.

Outpatient demand

Demand for outpatient care, especially diabetes management, will increase sharply in the coming years. The physician shortage means patients must be more involved in their care management. Online disease management systems linked with the hospital's EHR engage patients by enabling them to enter their blood glucose readings electronically so they and their care team can better manage the disease.

Comorbidity

Hospitals can expect to see an increase in admitted patients with diabetes as a comorbidity. The ACA penalties for health care-associated conditions and readmissions make hospital inpatient management of diabetic patients more imperative than ever. Some hospitals are creating inpatient blood glucose management teams to improve diabetic patients' outcomes.

Incentivizing prevention

Risk-based contracting shifts incentives toward preventing diabetes among the insured patient population and blending screening, outpatient and inpatient care, and self-management programs into a comprehensive line of diabetes services. Disease registries and risk -stratification programs help hospitals and health systems direct resources and interventions to the highest-risk patients.