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  • Apr 11, 2018

Barbara Rutkowski, EdD, MSN, CCM - Vice President, Clinical Operations, Advanced Plan for Health 

All entities managing health plans – self-insured employers, health plans, brokers and more – need to take note of the impact of diabetes on the health of their members and the financial bottom line of their health plans. Particular focus needs to be put on the recent changes to care guidelines for diabetic control as they aim to improve diabetic care – but differ –  which is causing confusion.

In 2018, the American Diabetes Association (ADA) made significant changes by incorporating various individualized factors, adding cardiovascular drugs for those with hypertension or heart disease, modifying the HbA1c goals for diabetics with certain characteristics, and providing consideration to children and pregnant women.

Prevalence of Diabetes

Did you know that 30.3 million American, or 9.4% of our population had diabetes in 2015 according to the ADA?  Of these, about 23.1 million were diagnosed and another 7.2 million did not know they had diabetes. Another 84.1 million Americans age 18 and older had prediabetes. Diabetes is more prevalent in Seniors, where 12 million or some 25.2 percent have diabetes. Every year, 1.5 more Americans are diagnosed with diabetes.

Medical literature titled Management of diabetes mellitus in hospitalized patients states the following: “Patients with type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for treatment of conditions other than the diabetes. In one study, 25 percent of patients with type 1 diabetes and 30 percent with type 2 diabetes had a hospital admission during one year; patients with higher values for glycated hemoglobin (A1c) were at highest risk for admission. The prevalence of diabetes rises with increasing age, as does the prevalence of other diseases; both factors increase the likelihood that an older person admitted to a hospital will have diabetes.”

These are all sobering statistics. 

What’s more, new medications are rapidly coming onto the market, enabling providers to better address concurrent conditions like hypertension, heart disease and obesity, along with blood glucose control.

What needs to be understood about the new diabetic disease control guidelines is that they have personalized the control criteria in consideration of individuals’ needs, life circumstances, age, ethnicity, sensitivity to glycemic control agents, willingness to comply with treatment, general health and concurrent disease conditions.

There is a now a sharper focus on prevention and early intervention for diabetes and other serious health conditions that impact member health, including socioeconomic factors that may limit member ability to afford needed medications. The premise behind the ADA guidelines is to delay damage to body systems from cardiovascular disease and diabetes and optimize health.

HbA1c Guideline Controversy

After years of trying to get the 3-month blood glucose average (known as the HbA1c) under 7 or even under 6, the new ACP guidelines have reversed that stance.

The American College of Physicians (ACP) published new Guidelines in March of 2018, indicating that an HbA1c between 7% and 8% is a good goal for most, non-pregnant Type II diabetics, because it balances the harms of low blood sugar and the high cost of new drugs with reasonable control.  According to the ACP research, keeping the HbA1c lower did not result in fewer deaths, strokes or heart attacks, but did put more diabetics in danger of hypoglycemia with its associated potential health jeopardy.

However, the ACP is being faulted by experts (such as The American Diabetes Association (ADA), The Endocrine Society, the American Association of Clinical Endocrinologists (AACE), and the American Association of Diabetic Educators (AADE)), because the ACP failed to study the newer drugs (and their effects on high risk diabetics with cardiovascular disease) in its research underlying the new Guidelines. Some experts feel this is a step backward.

According to an Endocrine Society press release, “ACP’s guidance also does not consider the positive impact of several newer medication classes (SGLT2 inhibitors and GLP-1 receptor agonists) demonstrated in more recent clinical trials to improve mortality and morbidity in high-risk patients with type 2 diabetes. These medications have been associated with low risk for hypoglycemia, have favorable effects on weight and demonstrate improved cardiovascular disease outcomes.”

Now it is a matter of weighing the cost versus the benefit of newer drugs. For most practitioners, achieving the best glycemic control possible with a safe margin for those prone to hypoglycemic episodes is the goal. In the short term, health plans are incurring higher diabetes-related pharmacy costs, which will hopefully result in better member health, lower costs, and fewer hospitalizations in the long run.

The press release further stated that these organizations do not agree with the higher HbA1c levels specified in the ACP Guidelines, but believe that the individualized, patient-centered approach to treating diabetic members with the inclusion of newer drug therapy and its protective cardiovascular effects and improved glycemic control need to be an integral part of diabetic care.  All agree that individual health status, chronic health conditions, age, ethnicity, sensitivity to glycemic control agents, willingness to comply with treatment, the financial burden and situational factors need to be considered in crafting the plan of care with the patient.

The new views on Diabetic Guidelines seem to regard the HbA1c measurement as one indicator of glycemic control and health, and they encourage providers to consider all elements in context that may be impacting each individual diabetic.

The danger in these conflicting guidelines and viewpoints is that primary care physicians may be confused about the desired standard of care and best practice goals.

The ideal situation is for providers to work collaboratively with patients to optimize their glucose control. While cost considerations, lifestyle and hypoglycemia risks are top considerations, diabetic and blood pressure control are critical in reducing and / or delaying adverse effects on most body systems, especially, kidneys, heart, brain, circulation, eyes and neurologic structures. Amputation is also a complication of poor diabetic control, as are wounds that won’t heal and infections.

Improving Clinical and Financial ROI

The emphasis on treating pre-diabetes and aggressively managing new diabetics is resulting in fewer long-term complications, while improving the lives of plan members and optimizing the plan’s bottom line. Ideally, aggressive and early intervention, when pre-diabetes and diabetes are first diagnosed, helps to minimize complications and set good habits for managing diabetes and general health.

Advanced Plan for Health (APH) has the Poindexter analytics tools to identify members at-risk for diabetes and other co-morbidities to support intervention and management that can improve health and compliance with the physician’s treatment plan.  Poindexter also delivers the ability to measure clinical and financial impact and outcomes on a program-by-program basis.

Once at-risk members are identified, one means to reach and influence members requiring clinical support and guidance is through a Nurse Navigator program.

One large APH self-insured employer client,
realized an annual PMPM cost reduction
of more than 30 percent in 2017
(compared to the previous calendar year)
through member participation in their
Nurse Navigator program that is overseen
and managed in partnership with APH.
This successful program supports
many at-risk members,
including those with diabetes.

Two key features of innovative Nurse Navigation Programs (and others like it) are the sophisticated, but easy-to-use Poindexter advanced and predictive analytics platform combined with the warm personal touch of experienced, local Nurse Navigators.

For employers and their members who are supported by area Nurse Navigators, the local advantage is a great benefit.  Meaning that local Nurse Navigators know the area resources, culture and providers. They understand how to set achievable SMART (specific, measurable, attainable, realistic and timely) health goals and mentor participants in better caring for themselves and their chronic health conditions.

Nurse Navigators provide relevant education and boost compliance with physician treatment plans. Diabetic members benefit from personalized guidance and ideas on controlling their blood sugars and blood pressures, being more active, altering eating patterns to incorporate their culture into healthier food options, getting adequate rest and sleep, and finding ways to make life more rewarding.

Nurse Navigation Programs are most successful when members set their own goals and are supported with individualized help in accessing the coordinated healthcare needed – whether that is the Employee Assistance Program, their Health Plan benefits, their primary care provider, inpatient follow-up, claims assistance, after hours testing appointments or case management.

Quite often, Nurse Navigators who perform in-person visits with members support program adoption by assisting with on-site wellness activities and speaking at company meetings to gain visibility and proximity to employees who need their services.

Telephonic Nurse Navigation can also be targeted and successful with the right top management support, analytics, promotional activities and incentives.


For more information on how Advanced Plan for Health is supporting our clients in identifying those needing diabetes support, as well as supporting their innovative programs such as Nurse Navigation, please contact us here.