The disease management and insurer initiatives changing the diabetes landscape.
Diabetes is the most expensive chronic health condition in the United States. Medical expenses for people with diabetes cost approximately $9,600 more annually than individuals who don’t have this disease, the American Diabetes Association (ADA) reports. In 2017, costs of diabetes care amounted to a staggering $237 billion in direct medical costs and $90 billion in reduced productivity, according to a 2018 ADA study, for a total of $327 billion-an increase of 26% since 2012.
The largest contributors to the cost of diabetes are higher use of prescription medications beyond diabetes medications ($71.2 billion); greater use of hospital inpatient services ($69.7 billion); medications (oral agents and insulin-approximately $15 billion for insulin alone); supplies to directly treat diabetes ($34.6 billion); and more office visits to physicians and other healthcare providers ($30 billion).
Among the two types, type 2 diabetes is much more common-the CDC reports 29 million cases. This disease usually begins when muscle, liver, and fat cells misuse insulin. Consequently, the pancreas produces more insulin to keep up with increased demand. But over time, the pancreas can't make enough insulin and blood glucose levels rise.
About 1.25 million Americans have type 1 diabetes. This occurs when an infection or another trigger causes the body to mistakenly attack cells in the pancreas that produce insulin, making insulin replacement therapy essential.
Given its high cost and prevalence, finding better ways to treat this disease are vital. Here are five new advances in disease management.
1. New medications
FDA-approved in December 2017, Ozempic (semaglutide) is the newest diabetes medication in the United States, says Schafer Boeder, MD, endocrinologist and assistant professor of medicine of the Division of Endocrinology and Metabolism, University of California San Diego. As a GLP-1 receptor antagonist, it works by increasing insulin secretion when eating meals and slowing down digestion. It also decreases the release of glucagon, a hormone that acts in opposition of insulin and raises blood glucose. Semaglutide reduces average blood glucose levels without increasing hypoglycemia (a state of low blood sugar levels). It also decreases appetite and promotes weight loss.
Furthermore, semaglutide’s cardiovascular outcomes trial had favorable results. It showed a 26% reduction in the combined outcome of cardiovascular death, nonfatal heart attack, or nonfatal stroke (mostly due to decreased heart attacks in patients taking the drug), Boeder says. This medication improves blood glucose control, which leads to reduced incidences of expensive complications such as eye, renal, and vascular disease, and heart attack.
SGLT-2 inhibitors, such as Farxiga (dapagliflozin) and Jardiance (empagliflozin) comprise a newer class of diabetes drugs established in 2013. These oral medications, taken once daily, help reduce blood glucose levels through a unique mechanism that eliminates more sugar than normal through urination. “By removing excess sugar from the body before it's absorbed, patients may have minor weight loss,” says Hester Hommel, PharmD, MPH, CDE, a specialist pharmacist at Express Scripts in Fairfield, Ohio. “These medications also tend to remove excess water from the body, which can lower blood pressure.”
Recent studies show that these drugs produce favorable outcomes, including fewer cardiac events and a lower risk of heart failure. “These added benefits may reduce the number of medications patients need, and may also reduce the need for costly hospitalizations and procedures related to heart disease,” Hommel says.
2. Concentrated insulin
Concentrated Humulin R U-500 (insulin human injection), which is prescribed to patients with high insulin needs, is now available in a prefilled pen. “This improves ease of administration and reduces the chance of dosing errors (which can lead to devastating low blood glucose events and additional hospitalizations,” Boeder says.
Other concentrated insulins, U-200 degludec (Tresiba) and U-300 glargine (Toujeo), both act as ultra-long acting basal insulins, given once daily. “They have slightly less variability throughout the day than other basal insulins, and have lower hypoglycemia rates,” Boeder says.
“These products are good options for patients who need larger doses of insulin, including those who have insulin resistance, which is common in individuals with type 2 diabetes,” Hommel says. Previously, patients who needed high doses of insulin had to endure multiple injections, which often caused discomfort, scarring, and irregular absorption.
3. Glucose monitoring devices and sensors
These systems, such as Dexcom’s G6 continuous glucose monitoring system and Abbott’s Freestyle Libre continuous glucose monitoring system, allow patients to monitor their blood sugar throughout the day without sticking their finger to obtain a blood sample, Hommel says. The patient wears a sensor that has a small wire inserted into the skin. The sensor continuously measures glucose levels in surrounding tissues, which correlates to glucose levels in the blood. Sensors can be worn for several days, before needing a new one. Some systems can communicate with an insulin pump to help regulate an insulin dose automatically.
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“This technology is best for patients who use insulin,” Hommel says. “It gives both the patient and healthcare provider far more data points to evaluate their diabetes control than they would get from finger-stick testing. Changes in blood sugar can be more easily detected and the cause for the change can be more readily identified. Some systems have an alarm feature to warn patients when their blood sugar is trending out of range, thereby preventing dangerously low blood sugars and allowing patients to act more quickly.”
“Low blood sugars can be very dangerous and require emergency treatment, so preventing those occurrences can help to avoid unnecessary costs of care,” Hommel says. The extra data acquired by monitoring sugars 24/7 can improve blood sugar control, and has been shown to lower hemoglobin A1c.
4. Artificial pancreas
In February 2018, the FDA approved Medtronic’s MiniMed 670G for patients with type 1 diabetes. The device is a combination of a continuous glucose monitoring device and an insulin pump that delivers the insulin dose. “The two devices communicate and adjust insulin flow to more closely mimic normal pancreatic function,” Hommel says. “Patients still have to count carbohydrates and give a dose of insulin from the pump before eating.”
“This type of system can more closely regulate insulin and blood sugar levels and can respond to both high and low blood sugar levels without a patient’s manual input,” Hommel says. “This is a good option especially for children with type 1 diabetes who have difficulty controlling blood sugars.”
Patients using this system have been shown to have better control and fewer episodes of both low and high blood sugars. A1c levels are improved and patients have fewer medical emergencies from hypoglycemia or diabetic ketoacidosis, a dangerous condition that develops when blood sugars are extremely high, Hommel says.
Boeder adds that more advanced artificial pancreas systems, including fully closed-loop systems that can give insulin doses when needed to cover meals or high glucose levels, remain in clinical trials.
5. Ready-to-use auto-injector
Manufactured by Xeris Pharmaceuticals to treat severe hypoglycemia, the ready-to-use Glucagon Rescue pen is currently under FDA review. “Xeris has developed a stable glucagon solution that is pre-loaded in an auto-injector pen,” Boeder says. “It is for a second party to use when an individual has severe hypoglycemia and is unable to treat themselves.”
“This device is much easier to use and therefore more reliable than the current glucagon rescue kit, which requires multiple steps to properly administer,” Boeder says. It could help treat hypoglycemia and prevent hypoglycemia-related death and hospitalizations.”
Insurer initiatives to cut costs
With costs of diabetes care at record highs, health insurers are taking innovative steps to prevent diabetes, control costs of care, and improve the quality of care. Here are five current initiatives.
1. Employ a prevention program
LA Care Health Plan has launched a CDC-recognized Diabetes Prevention Program (DPP) that targets individuals with pre-diabetes, a condition in which blood sugar levels are elevated, but not high enough to be diagnosed with diabetes, says Richard Seidman, MD, MPH, chief medical officer of the Los Angeles, California-based insurer, the largest publicly-operated health plan in the country.
Research shows that individuals with pre-diabetes who lose 5% to 7% of their body weight can reduce the risk of developing type 2 diabetes by 58%. The DPP’s goal is to promote behavior change that results in healthier eating, increased physical activity, and at least 5% body weight loss. A trained lifestyle coach teaches the year-long program.
The program is available at more than 150 locations across Los Angeles County, in addition to eight online programs, Seidman says. For members who can’t commit to a year-long program, LA Care offers in-person health education workshops for pre-diabetes, in addition to telephonic diabetes education with a dietitian. Members may also access an online health portal for workshops, a comprehensive health education library, healthy recipes, and general information from a health coach.
2. Provide diabetes support
LA Care offers an ADA recognized diabetes self-management education (DSME) program for members diagnosed with type 1 or 2 diabetes. DSME consists of telephonic diabetes education with a registered dietitian over four months. At the end of the intervention, more than 70% of members reported that they were meeting their personal goals for monitoring, taking medication, problem solving, healthy eating, being active, and reducing risks.
Additionally, LA Care contracts with a vendor that provides in-person DSME and will soon add telehealth as a delivery mode to increase access and improve cost effectiveness, Seidman says. LA Care has five family resource centers across the county that offer additional support to members with diabetes, including free workshops and exercise classes.
3. Help with disease management
LA Care offers a diabetes disease management program to all members with diabetes. They receive interventions based on their severity level. Members of all severity levels receive a welcome packet and annual health education mailings, and members stratified with a higher severity level are assigned to a registered nurse for telephonic condition monitoring. They receive appropriate referrals such as social work, community programs, and dietitian services. The program provides a comprehensive, coordinated approach to improve members’ clinical condition and quality of life.
Inpatient members with high severity diabetes who didn’t have the intervention experienced 202% more inpatient hospital admissions than those engaged with program. This equates to a $1,686 savings per member per month (PMPM). These same members who weren’t engaged in the program experienced 72% more emergency department visits than those who participated in the program. This equates to a $70 savings PMPM.
4. Improve medication adherence
Health Care Service Corp.’s (HCSC) Pharmacists Adding Value & Expertise (PAVE) program works directly with select pharmacies to promote medication adherence for Medicare, Medicaid, and retail-exchange members with a focus on disease state literacy and adherence to diabetes, hypertension, and cholesterol medications, says Jay Gandhi, vice president, Enterprise Pharmacy, HCSC. HCSC uses pharmacy claims information to provide PAVE pharmacists with insight into members’ medication adherence. Pharmacists ask patients why they aren’t adhering to their medications and how they can remember or be encouraged to do so. Since the program began in January 2016, it has expanded to reach 20,000 members. In 2018, PAVE pharmacies saw an 11% increase in medication adherence for members with diabetes.
PAVE delivers savings by working with pharmacists to educate members on their pharmacy medication to improve health outcomes, Gandhi says. The program also increases members’ medication compliance by working with providers to address or remove therapies and convert members to preferred formulary products based on the latest formulary options.
Since its start in January 2016, PAVE has expanded to reach 20,000 members. In 2018, PAVE pharmacies saw members with diabetes increase their medication adherence by 11%.
5. Offer screening programs
HCSC launched a diabetic retinopathy pilot program with federally qualified health centers in Chicago. Diabetic retinopathy is the most common cause of vision loss among people with diabetes. High blood-sugar levels damage small blood vessels in the tissue that lines the back of the eye. HCSC donated hand-held digital cameras to health centers to improve screening rates for diabetic retinopathy, says Esther Morales, divisional vice president, Quality Management Programs, HCSC.
Images of the eye taken at the health centers are transmitted to eye specialists, who typically deliver a diagnostic report within 90 minutes. Participating health centers provide free screenings for any patient who needs one, regardless of their insurer. To date 1,100 patients have been scanned. Fifteen percent of patients had potential signs of diabetic retinopathy, who were referred to in-network eye specialists.
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“The program provides a method for early detection, so patients can address the condition early on,” Morales says. “Generally, the earlier any diabetes complication is identified, the better the patient’s outcomes and the less money the insurer will need to spend. Diabetic retinopathy worsens the longer patients go without treatment and can lead to blindness.”
The program’s goal is to increase patients’ access to diabetic retinopathy screenings in federally-qualified health centers. More than 1,100 patients have been screened to date.
Karen Appold is a medical writer in Lehigh Valley,Pennsylvania.