Key Considerations For Implementing Diabetes Management Programs

April 29, 2021 - With numerous combinations of comorbidities and lifestyles at play in the member population with diabetes, payers have a lot to consider when creating or expanding their diabetes management programs.

Diabetes is one of the most expensive conditions in the US. This disease impacts over 32.2 million Americans and was responsible for approximately $327 million in healthcare spending and lost productivity in 2017.

Since diabetes management may look different for each member, payers are constantly looking for versatile ways to offer support.

“We firmly believe that lifestyle has the power, not only to prevent but also to treat and reverse type 2 diabetes,” Angie Kalousek, senior director of lifestyle medicine at Blue Shield of California (Blue Shield), told HealthPayerIntelligence. “And that's really how we set up our platform.”

Blue Shield has announced new features for its diabetes management tool, Wellvolution. The payer introduced Wellvolution in 2019 as a wellness programming platform that combined virtual care and brick-and-mortar capabilities. However, with these latest features, the payer targeted members with type 2 diabetes.

READ MORE: Multiple Chronic Conditions, Race Impact Diabetes Medicare Spending

“Wellvolution really has this kind of end-to-end holistic approach to treating the person and understanding not only their physical needs but also their social and mental needs,” Kalousek explained.

While some payers focus on individual diabetes management, others may also collaborate with employers to address the condition.

“Diabetes is a serious workforce issue,” John DeGruttola, senior vice president of sales and marketing at Optima Health, said in a recent press release. “We have found that services such as virtual clinics, online coaching, and access to wellness information positively impact the health of employees and family members, thus providing healthcare cost savings for companies.”

Optima Health’s diabetes management pilot program for employer-sponsored plan members and Medicare members with type 2 diabetes started in 2020 and the payer recently released the results. DeGruttola explained to HealthPayerIntelligence some of the major takeaways from the program and how to engage members and employers in diabetes management efforts.

Although each member’s experiences and needs are different, there are a couple of overarching strategies that can foster a holistic diabetes management program.

Address mental, behavioral health comorbidities

READ MORE: UPMC Diabetes Wellness Program to Cut Drug Spending, Chronic Care

Since diabetes may produce, coincide with, or exacerbate mental health needs, payers should offer support for depression, anxiety, and behavioral healthcare issues alongside or as part of their diabetes management strategies.

According to the Centers for Disease Control and Prevention (CDC), patients with diabetes can be twice to three times as likely to experience depression as their non-diabetic peers, but only a quarter to half of all patients with diabetes and depression are diagnosed and treated for their mental health condition.

The cost of depression for patients with diabetes can be high. Depression may add $143 to the average annual out-of-pocket healthcare spending for patients with diabetes, according to a study by GoodRx, and anxiety can add $251 to their average out-of-pocket healthcare spending.

If payers’ diabetes management strategies neglect to incorporate mental health support, they are missing a significant opportunity to improve patient outcomes and reduce healthcare spending for patients and payers alike.

“Care coordination between mental health providers and traditional providers—it’s critical,” Kalousek emphasized.

READ MORE: CVS Health Expands Diabetes Program, Includes Preventive Care

As a result, Kalousek shared that Blue Shield is working towards including a mental health support module in the company’s Wellvolution platform.

One major behavioral health concern for diabetes patients that Kalousek highlighted is smoking.

The Food and Drug Administration has labeled cigarette smoking a risk factor for type 2 diabetes. The federal site states that cigarette smokers are 30 to 40 percent more likely to get type 2 diabetes than those who do not smoke and that smoking also increases the risk of complications for patients with type 2 diabetes.

Despite the known risks, the National Diabetes Statistics Report 2020 found that roughly 21.6 percent of patients with diabetes reported being tobacco users, 15.0 percent said that they were current smokers, and 36.4 percent had quit smoking but had used at least 100 cigarettes in their lifetimes.

Payers can step in to educate members about the risks and ensure that they have access to resources to help them quit smoking.

“We want to make sure that our type two diabetic members can also enroll in tobacco cessation programs as they're on their pathway to treatment and reversal,” Kalousek said.

Incorporate wellness programming

In addition to mental and behavioral health concerns, payer diabetes management strategies should be prepared to support chronic disease management for a variety of comorbidities.

One of the optimal strategies for reducing the risks of comorbidities in members with diabetes is to engage in an active and healthy lifestyle.

According to Johns Hopkins Medicine, for patients who are at risk of developing diabetes, losing 10 to 15 percent of their body weight can reduce their risk by 58 percent.

For patients who already have type 2 diabetes, some studies have indicated that higher exercise volume might allow patients to discontinue their glucose-lowering medications over the course of 10 years, although the researchers noted that the conclusion required further analysis.

“Weight loss is a critical factor to help and control diabetes,” said DeGruttola.

Optima Health developed its type 2 diabetes program around this assertion.

For members who already had type 2 diabetes, the payer implemented a virtual care program through which members could access lifestyle coaching and education. Additionally, members received blood glucose monitors, test strips, and A1C kits to help assess glucose levels. They could also connect with endocrinologists using telehealth.

Participants who entered the Optima Health program with A1C levels exceeding 9.0 percent saw, on average, a 2.8 percent decrease in their A1C levels by the end of the year-long pilot, compared to a 1.3 percent decline among Optima Health members with diabetes who did not use continuous glucose monitoring.

For context, a good goal for most patients with diabetes is to have an A1C measurement that is under 7.0 percent, according to the American Diabetes Association.

Blue Shield’s program is taking a slightly different approach to addressing lifestyle decisions in diabetes management.

Members may recognize that weight control is a major part of diabetes management but lack the resources to make healthier choices, Blue Shield recognized.

For example, Medicare Advantage members who face food insecurity are 50 percent more likely to have diabetes, according to Humana’s 2019 Bold Goal Progress Report. With limited access to regular, health meals, these patients will struggle with diabetes management and, very likely, with other chronic disease management needs.

“We know there are a lot of people that are experiencing food insecurity,” Kalousek acknowledged. “Members want to address type 2 diabetes, but they don't have access to the healthy fruits and vegetables and healthy meals that will help them do that.”

To help Blue Shield members access food and pursue a healthy lifestyle, Blue Shield added a healthy meal delivery program to its Wellvolution platform for low-income members. Eligible individuals can receive six months of meals that are designed to adhere to the dietary demands of diabetes and chronic disease management.

“We're seeing people meet really clinically significant outcomes,” said Kalousek.

Take steps to keep members engaged

A major challenge that diabetes management programs—such as Blue Shield’s and Optima Health’s programs—may face is to keep members engaged in the programs. However, there are steps that payers can take to circumvent that issue.

First, communicating well is critical, DeGruttola emphasized. Payers and employers should ensure that members are aware of their diabetes management programs and that members continue to have access to information about them.

For Optima Health, this means engaging members through social media, text, email, and various other channels. The payer also maintains sites that contain archives of videos and testimonials from individuals who have experience with diabetes management.

Second, payers should partner with employers to support members’ diabetes management efforts and keep members in the diabetes management program.

Employers can help ensure member engagement by implementing incentives and by promoting the program to employees.

“We work with employers on many fronts, communicating and increasing engagement and awareness,” said DeGruttola.

Finally, making healthcare decisions with members instead of for members—shared decision-making—is an empowering and effective approach to keeping members engaged and helping them achieve their goals.

Blue Shield incorporated a shared decision-making tool as a critical new component to its Wellvolution platform.

The tool asks members a series of questions about their condition, their current diabetes management activities, and about how they want to manage diabees. Based on members’ responses, the platform produces a report that members can share with the individuals who are involved in their healthcare decision-making process.

“We did a full consumer co-design session and we said, ‘When you're making decisions about your healthcare, who do you involve?’” Kalousek said.

“And the truth is that, yes, members involved their doctors, obviously. That's a really big component of making decisions about healthcare. But in most cases they then come home and they talk to their spouse, they talk to their kids, they talk to their best friend who knows something about health. Everybody has their own unique circle of people that help them make decisions about their healthcare.”

Recognizing the surrounding factors that influence how members manage their diabetes is key to creating a strong diabetes management program.