) has become one of the biggest buzzwords in healthcare. In the quest to provide more complete care-and lower healthcare costs-stakeholders across the healthcare industry, are realizing that treating a patient doesn’t have to begin or end in a hospital.

SDOH encompass a variety of factors, from housing availability to water access to income to food stability-not typically factors considered by most stakeholders.

There’s no question that SDOH affect health outcomes, but stakeholders are grappling with how big a role they should take in addressing them. As Benjamin Zaniello, chief medical officer at 

, a network for care coordination, put it, addressing SDOH is “not simply a healthcare problem. It’s a societal problem. We have not yet fully addressed food and shelter and security in either rural areas like Kentucky or urban areas like Chicago or New York. To expect hospital physicians to fix those problems within their four walls is an unreasonable expectation.”

Social Determinants of Health Play Growing Role in Hospital, Payer Strategies

However, he adds, “health systems do tend to gravitate toward where the money is. There is a widespread perception that focusing on SDOH have a measurable impact on healthcare quality and costs. I think there will be increasing investment in this area.”

The trend is already gathering steam: according to a 

 of hospitals looking at SDOH, 88% at least screened for social needs-an indication that SDOH are, if nothing else, coming into focus.

As more attention is placed on lowering costs, experts say SDOH are likely to become a larger part of the healthcare conversation. 

Zaniello says that “In the ED, providers and social workers will tell you that social determinants-specifically, challenges with food, shelter and security-are directly tied to the huge volumes of patients admitted to EDs. The expression for a huge volume of ED admissions, for a ‘hot and a cot,’ was always taken as being dismissive of patient’s needs-but it probably most accurately describes them! And now that health systems are increasingly taking on risk, they are more incentivized to leverage their hard-earned insight into the ways social determinants undermine the cost of healthcare.”

often touted as the next great innovation in healthcare

Sashi Padarthy, AVP, Healthcare Business Consulting at 

, a technology consulting firm, says that machine learning will be one of the most important technologies for success. He sees AI being used to detect SDOH factors in EMRs, which can then notify providers and care managers in real time.

Currently, he says, “capture of SD data is still very much based on manual, and often time-consuming processes (e.g., care managers often leverage standard paper-based questionnaires). Recent advancements in artificial intelligence and machine learning-new methods of identifying SDoH-have started to show significant promise. These new methods leverage the data that is already present within a patient’s electronic health record as an input to a machine learning model that analyzes and predicts the likelihood the patient is at risk for a SDOH.”

Padarthy points to Lucina Health’s program that utilized AI to identify mothers at risk for pre-term births, taking medical and socio-economic factors into account to determine the best care plan. The initial results of the program, which began in May of last year, have been largely successful: preterm births have been reduced by 13% for the high-risk group.

Another AI technology aiding communication between CBOs and providers is natural language processing (NLP), a tool already in use in many health systems. 

, an IQVIA company, is an NLP tool that takes account of SDOH. Linguamatics’ director of clinical analytics, Elizabeth Marshall, points out that “SDOH are much more likely to be documented in clinical notes than anywhere else. This information is captured by a diligent clinician, especially when they believe it to be an issue that may be impeding health conditions for the patient.” She says some clients are beginning to use this information in their analytics-already many organizations are using NLP to track if patients smoke or abuse alcohol.

Currently, says Jacob Reider, MD, CEO of the nonprofit 

, Albany, New York, SDOH are usually being addressed not by health organizations, but by community-based organizations (CBOs) in conjunction with health organizations. “I think this is appropriate,” says Reider. “We need not seek to see medical care providers grow their skill sets to take on these services. Rather, medical care providers should partner with CBOs to make sure that these needs are addressed.”

Because of this, one of the largest ways technology is helping address SDOH is by improving communication between CBOs and health organizations. Reider points to the success of close-loop referral systems like 

, calling them the “most important new category of tools in this space.” These types of systems connect social care and medical care providers. “This makes the right thing to do-screening for SDOH and then referring patients with social care needs to appropriate providers-the easy thing to do,” Reider says. “And that’s precisely what great technology should be doing for us.”

Three Ways to Better Address Social Determinants of Health

Padarthy calls this type of communication “social prescribing,” saying that it’s likely going to become one of the most important ways technology addresses SDOH. “Just like prescribing medications and sending the prescription to a pharmacy, social prescription allows providers to search and notify the nearest shelter, food bank, or transportation service and send the information to them to make it easy for patient and frictionless,” he says.

, which is already involved in the space, or companies like Lyft and Uber that are working on how their services can be used to coordinate transportation.

Another concrete example Padarthy cites comes from United Healthcare, which 

 that providers could use to document SDOH needs among their Medicare population. Between January 2017 and the end of 2018, their providers made 560,000 referrals to social services, equivalent to $250 million in social value.

It’s also important to give patients the ability to communicate needs as well, beyond those given during an examination. Rhonda Mims, executive VP and chief public affairs officer at 

, a health plan provider based in Tampa, Florida, describes the success of WellCare’s Community Connections model, which launched in 2011. Part of that model (among other technology advances like capturing transactions in an EHR and sharing that information with partners like state agencies and providers) is a call center. Mims says that in their first year in 2011, the organization received 5,000 calls. Currently, they now field 105,000 calls per year, including requests for food, medication assistance, transportation, and housing support.

In the future, experts say this type of information exchange will be much more commonplace.

Reider says that in 15 years, everyone will control all of their health information with a biometric key. Then social and medical care providers, as well as trusted family and friends, will be able to input information, order services (based on their role), and all communicate with one another more easily. “The core of this infrastructure will be communication rather than documentation,” Reider says, “and yet an accurate picture of the needs of an individual and the services provided will be painted automatically by natural language processing (NLP), machine learning, and perfectly-designed user experiences.”

The most important currently available technology is mobile, according to Harry Soza, president and CEO of 

, a technology company that partners with health plans and providers to advance population health management. “Smartphones and mobile devices are widely adopted and used daily across all socioeconomic levels and ages-including Baby Boomers, who tend to have chronic conditions that can be affected by SDOH,” he says.

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Compared with telephonic methods, Soza adds, mobile is far more efficient and results in much more reliable patient information. He says that mobile provides payers and providers opportunities to use targeted outreach methods to educate members both about their disease and also provide information about relevant CBOs. Some-whom Soza refers to as “progressive payers”-are even offering apps to that enable both face-to-face appointments and the ability to flag SDOH issue. Once those issues are flagged, the app can direct them to resources. “Offering this seamless experience will greatly increase the likelihood that members will participate,” Soza says.

Once patients do participate, providers can start to glean more information about patients. Face-to-face interactions via remote patient monitoring (RPM) don’t only involve faces. Mims points out that “RPM allows care to focus on factors that may negatively affect a person’s health that are not controlled inside the hospital. Through phone and video conference, doctors gain perspective on a patient’s life and step in when needed. Also, virtual care allows doctors to see every aspect of a patient’s home setting, which can help assess health issues that a patient might not otherwise reveal.”

Articles

How technologies are helping health systems think about-and mobilize on-social determinants of health.

How Technology is Addressing SDOH

Nearly 10% of the U.S. population, or 30.3 million people, have diabetes, according to the CDC. Technology is a large part of the research being put into the latest treatments for diabetes, with efforts to help patients manage their diabetes in safer more effective ways. Here are some of the most recent technology tools being researched and developed for diabetes treatment and management:

First interoperable insulin pump approved

The first insulin pump that can work with other diabetes therapy systems was 

 insulin pump has an under-the-skin insulin delivery system that works interoperable with automated insulin dosing, continuous glucose monitoring, blood glucose meters, and other diabetes technology that assists with treatment and management.

The insulin pump is described as an alternate controller enabled (ACE) infusion pump, because its ability to work with other diabetes technology allows treatment to be more customizable.

“The marketing authorization of the first ACE insulin pump intended for interoperable use has the potential to aid patients who seek more individualized diabetes therapy systems and opens the door for developers of future connected diabetes devices to get other safe and effective products to patients more efficiently,” says FDA commissioner Scott Gottlieb, MD.

Continuous glucose monitoring for diabetes prevention

As diabetes continues to climb globally, researchers say that mobile apps and wearables will allow everyone, even people without diabetes, the tools to monitor their glucose levels.

 by Stanford University researchers found that even people without diabetes find value in continuous glucose monitoring and can make behavior and dietary changes based off of tracking and better understanding how blood sugar varies throughout the day.

Five Diabetes Factors Health Execs Should Care About

“We found that many individuals considered nondiabetic by standard measures, in fact, experienced frequent elevations in blood glucose levels into the impaired glucose-tolerant or diabetic range,” the study’s authors reported.  “We developed a model for determining the ‘glucotype’ of an individual, a more comprehensive measure of the pattern of glucose excursions than the standard laboratory tests in current use.”

By helping people become more aware of glucose level fluctuation, the researchers say that they could prevent and drastically lower type 2 diabetes complications. With the aid of a web portal, the researchers were able to make access to glucose readings easier for people to understand.

Insulin capsules for type 1 diabetes treatment

Researchers at the Massachusetts Institute of Technology (MIT) are developing a treatment for type 1 diabetes that could eliminate the need for patients to administer insulin via injections. A pill the size of a blueberry is being tested to deliver insulin directly to a patient’s stomach. The biodegradable pill would contain a small needle that would administer compressed, freeze-dried insulin directly into a patient’s stomach lining or small intestine.

 released in the February 2019 edition of 

 introduces the MIT research on oral delivery of insulin for type 1 diabetes treatment as a simple and low-invasive treatment compared to treatments that involve injections.

The researchers, who have tested the capsule on animals-only, say it has a sugar coating that dissolves in the stomach and releases a spring that attaches the needle to the stomach lining or small intestine with no pain being felt by the patient.

In trials, the researchers found it took about an hour for the full dose of insulin to be administered. After the insulin dose, up to five milligrams in testing, the capsule passes through the digestive system.

The researchers at MIT are working with diabetes healthcare company Novo Nordisk to continue testing of the insulin capsule, along with developing other ways the capsule can be used to administer proteins to patients in a safe and easy way.

Donna Marbury is a writer in Columbus, Ohio.

How new technologies are helping patients with diabetes better manage the disease.

3 Novel Diabetes Treatments Improving Patient Care

Since first running for office, President Donald Trump made it clear that he was not in favor of the ACA and he and the Republican party have made several, mostly unsuccessful, attempts to

Among efforts to undermine the ACA, the Trump Administration has reduced or eliminated the federal role in administering certain individual markets and created an alternative individual health insurance market independent of the ACA.

Last year, the Trump Administration passed a tax bill that eliminated the ACA’s tax penalty for not obtaining health coverage that took effect in 2019, impacting the ACA marketplaces and possibly reshaping how Americans will get health insurance in the years ahead.

Then in December, Texas U.S. District Judge Reed O’Connor 

, and though his decision was stayed pending an appeal and many believe that the judge’s ruling won’t stand, it has caused some states to take steps to protect the ACA.

If his decision is upheld, approximately 10 million people on Medicaid would be left uninsured. As the ACA protects those with preexisting health conditions and without the law, those who suffer from disabilities, chronic illnesses and rare diseases will have a difficult time receiving private coverage.

So where does that leave the ACA in 2019?  David Prescott, PhD, assistant professor and the director of the Health Administration and Public Health program at 

, says-as the history of the ACA already suggests-one predicts the future of ACA at one’s peril.

ACA 2019 Enrollment Down: 5 Things Health Execs Should Know

“Already the law has been challenged in the Supreme Court, enacted at different levels by different states, and changed from its original form,” he says. “Currently, the major challenge to the law is whether the elimination of the requirement that all citizens must have health insurance (or pay a penalty) means that the entire ACA, as it now stands, is unconstitutional.” 

The challenge is that the number of uninsured Americans is starting to rise again and many experts argue over exactly why this is occurring. Regardless, Congress has not been able to develop consensus on a plan to scale back or eliminate ACA without putting a large number of Americans back in the uninsured category.

Daniel E. Trucil, a spokesperson for the 

, says the organization continues to express concern for the future stability of high-quality, person-centered, and affordable health care should bipartisan collaboration falter when it comes to health reform.

“The ACA has improved access to health insurance for more than 20 million Americans through the expansion of Medicaid and the introduction of an insurance marketplace,” he says. “Several critical elements of the law serve the growing needs of older adults specifically, from the closing of the Medicare prescription ‘donut hole’ to the elimination of cost-sharing deductibles or copayments for vital preventive health services.”

For that reason, the organization believes the ACA can be improved and any future action on health reform must do all it can to protect high-quality, person-centered, and affordable health coverage.

So, while the ACA is under attack, it continues to be very valuable to the public and there is no serious alternative.

Theresa Hush, CEO of Roji Health Intelligence LLC, feels there will be continuing efforts in the administration to dismantle key provisions of the ACA, yet despite all the attempts to limit the ACA and to lower its marketing approach to the public, the program has held up remarkably well under pressure.

“It speaks to the demand of people to have healthcare in the U.S. that it has withstood the pressure,” she says. “We also know that there has not been a significant decrease in the number of people without insurance, despite the cost of procurement.” 

Peter Hollmann, MD, chief medical officer for University Medicine, a Rhode Island-based academic and patient care medical group practice, and former medical director for Blue Cross and Blue Shield of Rhode Island for 20 years, says while there have been federal executive and legislative actions which have the potential to undermine the successes of the ACA, it remains the law and continues to benefit many citizens from those who never had coverage to those who had good coverage all along.

“It is a major contributor to insurance rate/cost stability across all segments: Medicaid, 

, Commercial Exchange/Individual and Small Group and traditional employer based self-insured and fully-insured products,” he says. “It creates a more level playing field and increases the pool of the insured. It has driven many delivery system reforms and changes that have improved quality and reduced what would have been even higher costs.”

Additionally, the ACA improves the health of communities which makes them more successful and productive and less subject to public health crises and epidemics and has been important to saving safety net providers (hospitals, health centers and professionals) by improving their revenue. 

“Any repeal by legislation or judicial act is fraught with peril as many financial and other changes are set in motion,” Hollmann says. “One cannot simply undo the law, but a very complex unwinding would be necessary.”

The State of Employer-Sponsored Healthcare

Sapan Desai, MD, Northwest Community Healthcare in Arlington Heights, Illinois, and a consultant to major healthcare corporations, says the future of ACA is really dependent on a data-driven approach to healthcare. For instance, the use of sophisticated data analytics tools, such as the QuartzClinical cloud-based platform or the IBM Truven platform, will continue to accelerate the discussion around high-quality care for a low cost.

“As we continue to transition away from a fee for service model to a value-based model that emphasizes high-quality healthcare, the industry is seeing numerous trends in medicine,” he says. “First, physicians are now acutely aware of how long their patient stays in the hospital, whether or not they are readmitted, and also what the cost of that care is. The drive has been to continue to improve the quality of care provided while decreasing costs. This trend will continue to accelerate in 2019.”

, the largest publicly-operated health care plan in the country, says the ACA is still alive and going strong.

“The two setbacks that we’re dealing with now are the loss of the tax to enforce the mandate and what impact that might have on the individual market,” he says. “Our experience here is that we have continued to grow our exchange product line [in the individual market] and so we are not quite sure how that loss of the tax as an incentive for the mandate is really going to play out.”

While he admits that the other hangover is the case in Texas and the intervention by the new House of Representatives to have that overturned, Baackes believes it is somewhat of a distraction-common opinion among many in the health care industry is that the judge’s logic in coming up with his ruling is flawed and will not be sustained.

“I think ‘repeal and replace’ is dead and this Texas court ruling is the last time we’ll deal with this,” he says. “I do think most politicians are looking at how to make healthcare even broader, in terms of the government’s role, which is why you see all the progressive campaigning on Medicare-for-all or single payer. I think that will not prevail.”

Medicare for All: Four Things Health Executives Should Know

Instead, Baackes believes they will go back to the ACA and finally begin to address improvements to the plan or make technical amendments that have not been addressed since the bill was passed because of the constant drumbeat of “repeal and replace.”

“Our organization, as primarily a Medicaid managed care plan, has to make sure that we protect access to care for our members, and protect adequate funding to keep the program going,” he says. “We view all of this activity going on as potentially threatening. We do see plenty of opportunities for improvement.”

For example, California Governor Gavin Newsom has proposed a number of things that are favorable to making sure there is access to affordable healthcare for more people and is taking a hard look at how it’s going to sustain Medicaid funding in the long run.

 that would cover young immigrant adults who are in the U.S. illegally; making it a requirement for all consumers in the state to carry health insurance; and increasing subsidies for middle-class families to help those who need it.

“Most people think of the individual markets as the biggest part of the ACA, but the biggest impact was really the expansion of Medicaid, so making that expansion sustainable over time is critical,” Baackes says. “California relies on a lot of well-thought-out, but incredibly complex, ways to fund Medi-Cal (that state’s name for Medicaid). And it’s all around making sure the state’s contribution or the state’s share of Medi-Cal, which is a shared expense with the federal government, is sustainable.”

Baackes would like to see all states bring back the mandate penalty, and restore the cost-sharing reduction (CSR) payments. However, he thinks the main focus should be on the states that did not expand Medicaid.

“A number of them have come back and tried to do the expansion through waivers, where they write the rules, and CMS says, ‘ok, you can do it this way in your state,’” he explains. “We must address the states that have held out and not done the expansion, because those states are losing out on federal funds, and in places like Texas, we still have an extremely high uninsured rate.”

, a Somerville, Massachusetts-based company that offers cost-effective consulting services to the health industry, believes the Texas ACA case will very likely be overturned and since there was no major movement on a complete ACA repeal last term, with the Democrats having a majority in the House now, it is even less likely that there will see successful efforts to repeal the ACA in 2019 or anytime soon.

“While the current administration has already taken action to weaken the ACA and the individual market, there are not many actions left that the administration can take to significantly degrade the law,” she says. “There needs to be continued focus on short-term health plans and other mechanisms that undermine the ACA. States have the authority to guard against these efforts to undermine the ACA by implementing restrictions on short term and association health plans and implementing a state level individual mandate.”

Rhode Island is one such state taking action to make key provisions of the ACA state law. Hollmann’s optimistic belief is that the ACA will remain and remain true to the key goals it represents, but that refinement will occur.

“We believe there is generally strong support of many key provisions and solid support of most. Effective legislative processes would improve weakness and address problems in the law,” he says. “Any law of this importance and scope has needed refinement. Medicare is constantly evolving, for example. When Medicare started, it did not include coverage for dialysis patients. Drug coverage is fairly recent in the life of Medicare.”

While some detractors have suggested a better law is possible, they must consider this position in light of generations of healthcare leaders and legislators who were never successful with coming up with much of anything at all after the creation of Medicare and Medicaid (including the children’s health insurance expansions).

Hush says that until there is a consensus for an alternative, she doesn’t see a lot of options for replacement.

“Medicare-for-All is the proposed solution by progressives, but there are significant obstacles to its passage,” she says. “I think it is more likely that some major parts of the ACA will be sustained, including expansion of Medicaid coverage, until we see health costs begin to rise dramatically again.”

The American Geriatrics Society’s view is that the threats to the law are not positive for anyone whether a Medicare recipient, their family member, their caregiver (e.g., healthcare worker for those who need assistance) or their hospital or doctor.

“We need to strengthen geriatrics care and support lower paid workers who provide crucial services while barely able to support themselves,” Trucil says. “At least we can help them afford their own healthcare.”

Hollmann adds that the main point that is often overlooked is that this is not just about 26-year-olds, or poor people getting Medicaid or subsidized coverage: this law has benefitted everyone.

“It is not just about insurance,” he says. “It is about innovation, quality, and system change that is essential to preserve the economic growth and stability of our nation.”

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years. 

Healthcare experts weigh in on what we can expect in 2019 and beyond.

The Future of the ACA

The cost of specialty drugs compared to the volume used is somewhat akin to the long-supported statistic that 20% of patients represent 80% of healthcare costs.

While specialty drugs comprise only 1.9% of total prescription volume, they account for 37.4% of spending within the retail and mail order distribution channels, according to 

PBMI estimates that by 2020, specialty drugs will account for half of total U.S. drug spend. They have increased 55% under the medical benefit since 2011.

“Today hundreds of specialty drugs are available, giving patients access to potentially life-changing treatments. Specialty pharmaceuticals are the fastest growing and most expensive segment of pharmacy care. As a result, specialty conditions drive a disproportionate segment of total health care costs,” says Michael Zeglinski, senior vice president of specialty pharmacy at 

, UnitedHealth Group’s pharmacy care services business.

Almost half of the 150 drugs studied by America’s Health Insurance Plans in 2016 cost in excess of $100,000 per year, with expenditures for 3% of the drugs studied exceeding $500,000 dollars per patient per year.

Industry players continue to seek ways to manage specialty pharmaceutical costs in light of the many triggers pushing prices well above those for regular branded drugs.

PBMI says many employers have introduced high-deductible plans to encourage members to make better decisions; create specialty drug tiers; use coinsurance for cost sharing; place prior authorization and step therapy on certain drugs; and exclude certain specialty drugs.

Benefit design is one of the most efficient ways to keep drug prices in line, says Ken Majkowski, PharmD, chief pharmacy officer of Bethlehem, Pennsylvania-based 

-a discount prescription program partnership-pointing to closed formularies that exclude certain medications.

For example, when new hepatitis C drugs began entering the marketplace in 2014, 

, a St. Louis-based PBM, only covered Viekira Pak (ombitasvir/paritaprevir/ritonavir and dasabuvir) for the condition but added Harvoni (ledipasvir/sofosbuvir) in 2017.

 (NFP) lists Epclusa (sofosbuvir/velpatasvir), Harvoni, Vosevi (sofosbuvir/velpatasvir/voxilaprevir), and Zepatier (elbasvir/grazoprevir) for hepatitis C. CVS Health recognizes Sovaldi and Harvoni.

Express Scripts rolled out its National Preferred Flex Formulary on January 1, 2019, to provide a way for plans to cover lower list price products, such as new authorized alternatives with less reliance on rebated brands.

Majkowski says that 10 years ago, it cost about $1 billion to bring a drug to market, which has jumped to $2.7 billion today, 

-partially attributable to the high cost of conducting safety and immunogenicity trials on biologics that have a smaller test population.

He realizes, however, that some biologics are worth their weight in gold: List prices for Sovaldi ($84,000 per course of treatment) and Harvoni ($94,500) tip the scales but have proved to cure 

The alternative would be a liver transplant, pricing out at an estimated $812,500 from 30-day pre-transplant to 180-day post treatment including surgery, care, and suppressants according to Milliman.

How the Specialty Pharmaceutical Market is Changing

Newer to the tool set in the industry are copayment accumulator programs, in which a drug coupon will not count toward a patient’s deductible or out-of-pocket cost limits, resulting in patients having to pay more for their drugs once a coupon expires.

“From a tactical perspective, prior authorization, including documentation of a particular condition and eligibility for the treatment are essential,” says Bruce Sherman, MD, chief medical officer, National Alliance of Healthcare Purchaser Groups. “Because some of the identified treatments address only one specific mutation, it’s critical that genetic abnormality has to be in evidence for the treatment to be effective.”

He sees novel contracting approaches as one solution to nibbling away at costs. “Most of these contracts are value-based, in that the patients have to respond to treatment for the drug manufacturer to be paid,” he says. “Amortized payments are another potential solution.”

Jennifer Furhmann-Berger, PharmD, senior vice president, clinical services, at 

, a pharmacy benefits administrator headquartered in Bonita Springs, Florida, believes in the power of communication. To overcome what she considers potential issues related to specialty drugs- such as fear of injections, lack of adherence, switching drugs but continuing to get both prescriptions, and improper drug storage-she says Benecard communicates with pharmacists and nurses to monitor these issues, along with potential side effects, and contacts physicians if non-adherence becomes a problem. “We are continually looking at claims and trends for safety and appropriateness issues,” she says.

She says Benecard relies on pharmacogenetics-not trial and error-to determine whether a patient can metabolize a drug or not. "If one doesn’t work, then we choose a different drug or dosage,” she says.

“We believe that putting the client at the center of care and pharmacists at the point of sale, enabled by clinical edits, keeps our trend down,” she says. Benecard manages specialty drug pricing by passing through the acquisition cost to payers, thus providing savings to plan sponsors.

Do Drug Discounts Contribute to Rising Prices?

The company also works closely with plan sponsors to determine which drugs should be reimbursed through the medical versus the pharmacy benefit.

OptumRx uses a variety of strategies to manage the continuing high cost of specialty drugs:

. OptumRx provides patients with healthcare specialists and counselors who offer education and support via routine medication monitoring, personalized follow-ups, and in-home onboarding for patients new to treatment.

2. OptumRx’s oncology Split Fill program

, OptumRx takes an individualized approach to patients who take cancer medications that may cause severe side effects by providing half a month's supply to patients for the first six fills. Pharmacy care providers check in with them early and often to manage potential clinical side effects, discontinuations, or adherence issues. In addition, pharmacy clinicians conduct regular drug utilization reviews and then notify a patient, caregiver, and provider of any recommended changes in dosage or medication. 

Early results from these programs have shown 96% of enrolled patients are more likely to tolerate therapy. For those who don’t, OptumRx helps them through discontinuation, resulting in pharmacy savings of $2,500 per patient per year.

 The tool helps prescribing physicians identify alternative, equally effective treatments at a lower cost, view a patient’s drug coverage, and determine if prior authorization is required. To date, one out of five transactions with a recommended alternative resulted in the provider choosing an alternative drug, delivering significant cost savings for patients and payers, Zeglinski says.

The real-world strategies used to manage the high cost of specialty meds.

How Payers Are Keeping Specialty Drug Costs Down

For all the progress science and medicine have made over the last century in treating diabetes-particularly adult-onset diabetes-we haven’t done a very good job of preventing it.

 in the U.S. since the early 1990s, diagnosed diabetes rates have doubled over the last 20 years. On the current pace, 40% of Americans will be living with diabetes or prediabetes within the next few years, and diabetes-related spending and lost productivity will cost the country $500 billion annually within the next decade.

It is one of the nation’s costliest public health emergencies-and it will remain so, unless we make a coordinated effort to bend the curve. I talk to clinicians and subject-matter experts about diabetes care often, and have come to understand there are a few ways we should approach this:

 like diabetes might have seen their primary care physician three or four times a year. Apart from those visits, they were on their own when it came to managing their disease.

We can’t allow that to happen anymore. It takes a multidisciplinary team to address diabetes symptoms, especially when it comes to patients with records of poor treatment adherence. That means PCPs, endocrinologists, pharmacists, social workers, diabetes educators, and behavioral health specialists have to be on the same page when it comes to creating individualized treatment plans and identifying the barriers to care that exist for so many patients living with diabetes.

Of course, if providers and insurers are focused solely on disease management, we’ve already lost the battle. We have a lot of analytical tools at our disposal, and we need to better utilize them in order to identify those living with prediabetes conditions, allowing our care teams to intervene before it becomes a chronic disease.  

Emerging research confirms what we’ve pretty much known all along-the key to preventing and mitigating type 2 diabetes is tied to what we eat.

As providers, we have to acknowledge that what we’ve done for the last 30 years-actively prescribing medicines and passively monitoring a patient’s diet-has not been terribly effective. That means embracing a more nutrition-centric treatment model and taking a more active role in dietary control. Some providers have even opened fresh food “farmacies” where dieticians, in consultation with physicians, can “prescribe” several days’ worth of free fruits, vegetables, and high-protein foods to type 2 diabetes patients who are also food insecure.

The Benefits of a Team-Based Approach in Disease Management

For many patients, medication is a simpler fix than lifestyle modification-even if those medications are extremely costly. But it’s our job to help patients and their families understand that eating well allows them to live well, too. It’s hard work for all stakeholders, but the health benefits are evident.

Many patients living with diabetes are very good about monitoring their blood sugar levels and responding accordingly. Others need more hands-on care.

Fortunately, there are a number of new technologies that help patients manage their diabetes and more easily understand their glucose readings. These Internet-connected technologies also present clinicians, researchers, insurers, and others a great opportunity to collect and share diabetes data, with an end goal of providing predictive, real-time care to patients living with the disease. And smartphones, growing more ubiquitous each year, have the potential to become the standard platform for remote monitoring, education, and clinician consultation.

That potential is exciting for those of us in healthcare, but the race to make sense of these rich streams of data may be confusing in the short term. Providers, insurers, and device manufacturers will have to work together to ensure that these new technologies are cost-effective and tied to appropriate reimbursement schedules.

But if we can sort through those issues-and I believe that we will-we have a remarkable opportunity to avert new diabetes cases, and to improve the lives of millions of existing diabetes patients with more responsive, more convenient, more affordable care.

 editorial advisor, is president and CEO of Allegheny Health Network (AHN), an integrated healthcare delivery system that serves Western Pennsylvania. AHN is part of the Highmark Health family of companies.

Diabetes is one of the nation’s costliest public health emergencies. Here are three fresh approaches that can make a difference.

3 New Approaches to Provide Individualized Diabetes Care

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The life of a patient diagnosed with diabetes is complicated.

“Treating diabetes is not simple,” says Gregory J. Deines, DO, division chief, Diabetes & Endocrinology of 

 in Grand Rapids, Michigan. “It involves a complex medication regimen.”

, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Published studies estimate between 38% and 93% of those patients are noncompliant with their treatment regimen. “It is a significant number, no matter which end of the range,” says Patricia L. Bononi, MD, medical director for the Center for Diabetes at 

Often, patients see their treatment as too difficult, too expensive or interfering with their daily activities. “There is a lot of work associated with having diabetes,” Bononi stresses.

One of the biggest issues with diabetes is that patients usually don’t feel any symptoms until they experience a medical event, such as a heart attack or stroke, says Jason Bhan, MD, co-founder and chief medical officer of 

“Until then, there is little or no consequence for their behavior,” he notes. “As long as patients don’t feel like they need to take something, there is a whole list of reasons for them to not take their medications.”

But compliance is a medical necessity. The key is to create a setting where patients understand complying with their treatment plan is necessary to their health, but providers understand the variables that stop patients from being in compliance. To create such a setting, providers have developed team-based care solutions that examine medical and nonmedical conditions that prevent compliance.

A complex disease such as diabetes requires a team-based approach to help patients comply with their regimen, providers say. The team can be comprised of endocrinologists, pharmacists, dieticians, social workers, educators, and behavioral health specialists. Each specialist uses their skills to discover the motivations of a patient. By fostering a one-on-one relationship with patients, and not just telling them what they should do, the chances of compliance increase.

“It’s important to think in terms of a team approach, even for physicians who may not be blessed with a complex [healthcare] system,” says Edward Dick, MD, senior vice president of Integrated Health Services at 

 in San Antonio, Texas. “They need to develop a team within the community and with payers.”

Survey: Patients Reveal Biggest Negative Effects of Diabetes

Methodist Healthcare Ministries sees patients at two San Antonio clinics, many of whom are at 200% of the federal poverty level and lack insurance. Often, a diagnosis of diabetes is incidental to why a patient originally sought treatment.

Patients at this income level face a number of self-determinant challenges, Dick says. For example, getting to an appointment might be difficult because of issues related to a job, transportation or childcare.

“That’s why we have the [different] specialists offer as many services as possible during one visit,” Dick says. “We try to find alternative means of education to make sure patients can actually achieve their goals. The team has to recognize that patients have their own priorities, and those priorities are not always the same as physicians.”

Allegheny Health Network’s team evaluates patients during a 12-week period at a diabetes specialty center. Not only are there medical tests, but the team addresses obstacles that might prevent an improvement in treatment compliance, Bononi says. Moreover, the team provides quality metrics and education and serves as a resource to primary care practices.

“Since primary care is where the vast majority of patients receive their diabetes care, it’s important that they can access education there,” Bononi says. “And it’s important that the staff has the knowledge to help coach patients.” In Grand Rapids, Deines says one issue is that patients simply can’t take their medications every day-whether the reason is cost, quality of life issues, or other variables. So, the team tries to get to know and understand the personal circumstance of patients, as well as their desired outcomes and goals.

“Once you understand what motivates and drives your patients’ decisions, you can better partner with them,” Deines notes. “We can employ resources to help with issues like income, beliefs, or ideas about certain treatments.”

While it’s a medical fact that hitting certain blood pressure and blood glucose numbers are critical for long-term health, sometimes patients are simply concerned with enjoying their favorite hobby unimpeded by possible side effects, Deines says. “The healthcare team must understand the patient’s complete situation,” he maintains.

The multidisciplinary approach has had a positive impact on many patients. “They come to our clinic, and they tell us it’s the first time anyone asked about their goals and what’s important to them,” Deines says. “The outcomes are much improved.”

Some patients come to a Methodist Healthcare Ministries clinic and tests reveal an A1c level of 13% (The target A1c level for individuals with diabetes is usually less than 7%). Normally, these patients would immediately start on a regimen that includes several medications and intensive lifestyle changes, Dick says. But working with patients individually, some choose to start on only 

 In some instances, lifestyle changes and metformin can reduce A1c levels significantly.

“Thanks to the hard work of our patients and care team, our diabetes outcome measures are trending favorably,” Dick says. “But we know there is much more work to be done.”

Allegheny Health Network’s initiatives have paid dividends, especially in the area of education. Bononi says she was surprised by a statistic that indicated 31% of prescriptions written for diabetes are never filled. Expense is one reason; another is patients don’t like to take more medications than they feel are necessary. They’re also skeptical about the medication’s efficacy or have concerns about side effects.

“That’s where our pharmacists have helped us,” she says. “They do a great job of explaining how the medications work, and why they are beneficial.”

In 2018, Prognos conducted extensive research on a subset of its patient population diagnosed with diabetes, examining patients prescribed first-line medication therapy-either or both metformin and sulfonylureas-during the first half of 2017 and were on no prior medications during the previous year.

While not examining compliance and noncompliance, Bhan says care managers can use the research to motivate noncompliant patients into taking their medications and maintaining a healthier lifestyle more regularly.

“If just 20% to 25% of patients can be moved from non-adherence to adherence by educating and engaging them, that’s a huge number in savings and morbidity,” Bhan stresses. “It’s much easier to engage patients around hard facts versus hypotheticals.”

The patient population with better control of their diabetes utilizes less resources, including emergency department visits and hospitalizations, and have fewer rates of complications, such as end-stage renal and cardiovascular disease.

“Patients want to live their lives as close to normal without their treatment getting in the way,” Deines says. “We have to partner with patients so they can achieve that goal. But we have to help patients understand they can better achieve that goal if they adhere to their treatment plan.”

Ken Krizner is a freelance writer based in Cleveland, Ohio. 

A complex disease such as diabetes requires a team-based approach to help patients comply with their regimen.

Managed Healthcare Executive April 2019 Issue

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3 Novel Diabetes Treatments Improving Patient Care

The Future of the ACA

How Payers Are Keeping Specialty Drug Costs Down

3 New Approaches to Provide Individualized Diabetes Care

11 Soft Skills Healthcare Executives Need to Succeed

Team Approach Offers Hope of Increasing Diabetes Treatment Compliance

How Health Systems Use Pharmacists to Reduce Readmissions

Cost Challenges Ongoing with Diabetes Drugs

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