The diabetes and obesity epidemics mean more Americans may suffer from heart disease before they turn 65, challenging payers to craft better intervention models that help prevent serious cardiovascular events and increased spending on acute care.
But new payment and management models do show potential for mitigating the worst of the trends, a new study in the American Journal of Managed Care suggests.
About 12 percent of American adults have diabetes, most of them Type 2, and many children and young adults are finding themselves at risk of diabetes and the related problems of metabolic syndrome, obesity and pre-diabetes.
By some measures, America's youth are heavier, less physically active and developing Type 2 diabetes at a higher rate than their parents' generation did in their adolescence -- and they could become the first generation since 1950 to have higher rates of cardiovascular disease than their parents.
For insurers, this portends a future of spending heavily on chronic disease treatment for both young and old -- baby boomers and their children and grandchildren -- in a trend that promises to strain public payer programs and vex commercial plans.
The challenge, argue Geisinger Health System physician Frederick Bloom, MD, and colleagues in the AJMC paper, is sculpting the various prevention and treatment approaches supported by evidence into practical guidelines and payment models for clinicians.
Innovative care models
Bloom and colleagues studied a team-based model, called the diabetes system of care, combining a bundle of diabetes measures, workflow redesigns, information tools and financial incentives, in patients covered by the Geisinger Health Plan, the insurance arm of the Geisinger Health System in Pennsylvania.
"A key aspect of this program," they wrote, is that the incentives were awarded only when a physician's patients met all nine of the goals, including A1C blood sugar results of less than 8 percent, patient-specific LDL cholesterol goals, blood pressure controlled to under 140/80, annual urine protein testing and queries of smoking status.
Over a three year period starting in January 2006, the outcomes of this "all-or-none bundle" were measured in 4,950 adults with diabetes at Geisinger primary care sites and compared to 4,950 diabetic Geisinger Health Plan members treated elsewhere without the diabetes system of care.
Examining the claims data from the two groups of patients, Bloom and colleagues found that the diabetes care system was associated with a "statistically significant lower risk of macrovascular and microvascular disease end points."
About 8 percent of patients treated with in the Geisinger system of care suffered from a heart attack over the three years, compared to 9.3 percent of those in the control group; 5.1 percent of system-treated patients suffered a stroke, compared to 5.7 percent of those in the control group; 11.5 percent of the system-treated patients developed macrovascular disease, compared to 12.5 percent of those in the control group; and 7 percent of the system-treated patients developed retinopathy, compared to 7.6 percent in the control group.
While appearing modest, Bloom and colleagues argue that the impact of the diabetes system of care is substantial when calculating the number of patients needed to treat to reach the observed benefits -- 82 patients needed to treat to prevent one heart attack, 178 to prevent one stroke, and 151 to prevent one case of retinopathy.
"Perhaps the most notable finding is the apparent early impact of the care model," they added. "The findings suggest an impact in the first three years with the possibility that a reduction in risk began to emerge after the first year."