What Is the Role of the Provider in Guiding People to Better Adherence?

Michael Gardner, MD: You want to be careful that the patients aren’t starting to get notices [like] you and I were talking about earlier, [such as], “This patient isn’t on a [drug].” Because then you get alert fatigue.

Robert Gabbay, MD, PhD, FACP: Absolutely.

Dennis P. Scanlon, PhD: We have a lot of change in the payment landscape, and some of you have mentioned some of the problems of payment and some of the new ways in which we’re paying—anything from accountable care organizations of different lavors, to bundled payment, to episode-based payment, total cost of care, etc, etc. This is an equal alphabet soup. For care for diabetes patients, what are your thoughts on whether any of these new payment models are really influencing any of the practice that’s being delivered?

Robert Gabbay, MD, PhD, FACP: I think it’s starting [to influence practice]. And I believe that the promise is really great in this area, particularly if the time horizon is long enough, because in the end, we know how to prevent a large part of the complications and, essentially, a large part of the costs related to diabetes by getting better blood sugar control, cholesterol control, blood pressure control, and screening for complications.

Often, if you look at the numbers, you know, nationally, that they’re quite poor in terms of the percentage of individuals with diabetes that meet all those different characteristics. The interventions that would get you there happen to be ones that there’s little or no reimbursement for. So, if the shift is really about lowering long-term costs, which is really [the] total cost of care that all these models are based on, that allows a shifting of resources in a direction where you can invest in the types of things that we know are effective.

Dennis P. Scanlon, PhD: Over that period of time, yes.

John A. Johnson, MD, MBA: Again, in the managed care space, we enter into, and create, a lot of these shared-risk agreements with upsides where the downstream savings are split between the plan and the IPA (independent practice association), hospital, or provider. At WellCare, we design a lot of our value-based purchasing contracts on that principle. A lot of our patient-centered medical home providers [also function on the] same principle. “How can we incentivize you to move the needle for quality, improve outcomes and member experience, but, at the same time, save money downstream?”

Zachary T. Bloomgarden, MD, MACE: I think what’s missing in the equation is getting the pharmaceutical industry to participate in this and have some way for managed care and industry to get, essentially, revenue-neutral ways of providing all the medicines that a given individual, or that a population of individuals, will need so that they can receive what we now consider to be optimal care and not break the bank.

And I think it’s possible. We’ve got these ideas. Industry wants to provide the new medicines. There are all kinds of negotiations. Too many people are left paying full retail and suffering. But, we could see a light at the end of the tunnel where we’ll be able to get the good medicines for glycemic control, lipids, and blood pressure to the patients to really promote the health that we want.

John A. Johnson, MD, MBA: Even if you look at data from [the] Centers for Medicare & Medicaid Services, the United States is the super power in the world, and we have the highest medical cost, but yet our quality is not matching that. We make all these agents available to the public, but yet our quality and our outcome performance, despite the fact that all these tools are available, just isn’t there.

Robert Gabbay, MD, PhD, FACP: From the health-system perspective, you know the financial incentives are in an opposite direction. That’s shifting now, which is good. But, obviously, in the old fee-for-service model, the inadvertent investments in building more OR (operating room) space is for better or worse.

Complication care is a money-making business; complication prevention is a money-losing business. Until that shifts, that’s really going to be the thing that will change things, and I think it’s happening as risk is being shifted to healthcare organizations to manage themselves.