3/29/2017 What Managed Care Needs to Know About Novel Therapies in the Evolving Management of Type 2 Diabetes For Audio Please call 866‐206‐0240, Participant Code 64953949# If you are having difficulties logging in or calling in, please contact Jeremy at [email protected]. To Receive your certificate, please be sure to complete the online evaluation survey. Please email Katie at [email protected] for the survey link. Faculty Disclosure: Dr. Reid serves as a consultant and on an advisory board for Boehringer Ingelheim, Janssen, Lilly USA, Novo Nordisk and Sanofi. His presentation has been peer reviewed. Planning Committee Disclosure: Bill Williams, MD has no real or perceived financial relationships to disclose. Jacquelyn Smith, RN, BSN, MA, CMCN has no real or perceived financial relationships to disclose. Katie Eads has no real or perceived financial relationships to disclose. Will Williams has no real or perceived financial relationships to disclose. 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This activity is supported by an educational grant from Lilly USA, LLC What Managed Care Needs to Know About Novel Therapies in the Evolving Management of Type 2 Diabetes TIMOTHY S. REID, M.D. MERCY DIABETES CENTER JANESVILLE, WI 1 3/29/2017 The Cost of Diabetes 29.6 Million Americans with Diabetes $245 Billion Spent for Diabetes 1 in 5 Health Care Dollars spent on patients with diabetes 1 in 3 Medicare Dollars spent on patients with Diabetes Diabetes Medical Expenditures are 2.3x higher 3835 People will be diagnosed with diabetes today http://www.diabetes.org/diabetes-basics/statistics/infographics/adv- staggering-cost-of-diabetes.html (Accessed 4 March 2017) http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html Rank Cause of Death US Total Cost 1 Heart Disease $190 Billion 2 Cancer $227 Billion 3 Chronic Lung Disease $65 Billion 4 Stroke $34 Billion Accidents 5 $308 Billion 6 Alzheimer’s Dse $70 Billion 7 Diabetes $112 Billion 8 Renal Disease $61 Billion 9Pneumonia and Flu $40 Billion 10 Suicide $34 Billion Total Cost: $1.1 Trillion http://247wallst.com/special-report/2012/01/18/1-1-trillion-what-the-10-leading-causes-of-death-cost-the-u-s-economy/3/ 2 3/29/2017 Objectives: 1. Discuss methods to enable optimal cost management of novel therapies to be realized by multiple T2DM stakeholders including managed care organizations 2. Analyze strategies used by managed care organizations to facilitate high quality care for members with T2DM, and how newer therapies affect those strategies 3. Discuss how newer therapies have affected managed care professionals in the T2DM arena 4. Role of medical directors and payers in Type 2 Diabetes management Two of the Major Diabetes Management Guidelines: 1. American Diabetes Association:1 1. Widely distributed 2. Primary Care Aware 3. Referenced by many organizations 2. Am. Association of Clinical Endocrinologists:2 1. Well Know to Diabetes Specialists 2. Comprehensive 3. Detailed Strength of Recommendations 1. Effectiveness 2. Side Effects 1. http://professional.diabetes.org/content/clinical-practice-recommendations 2. https://www.aace.com/publications/algorithm 3 3/29/2017 Start with Monotherapy unless: A1c is greater than or equal to 9%, consider Dual Therapy A1c is greater than or equal to 10%, blood glucose is greater than or equal to 300 mg/dl, or patient is markedly symptomatic, consider Combination Injectable Therapy. (See Figure 8.2) Monotherapy Metformin Lifestyle Management Efficacy* high Hypo Risk low risk Weight neutral/loss Side Effects GI/lactic acidosis Costs* low If A1c target not achieved after approximately 3 months of monotherapy, proceed to 2‐drug combination (order not meant to denote any specific preference –choice dependent on a variety of patient ‐ & disease‐specific factors): Dual Therapy Metformin + Lifestyle Management Sulfonylurea Thiazolidinedione DPP‐4 Inhibitor SGLT‐2 Inhibitor GLP‐1 receptor agonist Insulin (basal) Efficacy* high high intermediate intermediate high highest Hypo Risk moderate risk low risk low risk low risk low high risk Weight gain gain neutral loss loss gain Side Effects hypoglycemia edema, HF, fxs rare GU, dehydration, fxs GI hypoglycemia Costs* low low high high high high If A1c target not achieved after approximately 3 months of monotherapy, proceed to 3‐drug combination (order not meant to denote any specific preference –choice dependent on a variety of patient ‐ & disease‐specific factors): Triple Therapy Metformin + Lifestyle Management Sulfonylurea Thiazolidinedione DPP‐4 Inhibitor SGLT‐2 Inhibitor GLP‐1 receptor agonist Insulin (basal) TZD SU SU SU SU TZD or DPP‐4 ‐i or DPP‐4 ‐i or TZD or TZD or TZD or DPP‐4 ‐i or SGLT‐2‐i or SGLT‐2‐i or SGLT‐2‐i or DPP‐4 ‐i or SGLT‐2‐i or SGLT‐2‐i or or or or GLP‐1‐RA or GLP‐1‐RA Insulin or GLP‐1‐RA Insulin GLP‐1‐RA or Insulin or Insulin or Insulin Combination Injectable Therapy (See Figure 8.2) Copyright ©2017 American Diabetes Association Diabetes Care2017 Jan; 40(Supplement 1): S64‐S774 Reprinted with permission from American Association of Clinical Endocrinologists © 2016 AACE. Garber AJ, Abrahamson MJ, Barzilay JI, et al. AACE/ACE comprehensive type 2 diabetes management algorithm 2016. Endocr Pract.2016;22: 84‐113 4 3/29/2017 Two Diabetes Management Guidelines: 1. They both speak to the comprehensive nature of diabetes management 1. Lifestyle modifications 2. Dietary recommendations 3. Medication initiation and combinations 4. Referrals and Screenings 1. http://professional.diabetes.org/content/clinical-practice-recommendations 2. https://www.aace.com/publications/algorithm Two Diabetes Management Guidelines: 1. Implementation: 1. Used Largely as Medication Roadmap 2. Many times not encultured into the actual point of care experience 3. Can lead to poly-pharmacy 1. http://professional.diabetes.org/content/clinical-practice-recommendations 2. https://www.aace.com/publications/algorithm 5 3/29/2017 What Does This Mean For Managed Care? Large Population with Diabetes Chronic and Progressive Disease State Best Practices requires a hands on approach for both provider and Care organizations Expensive to treat effectively Expensive to ignore Federal/Medicare/CMS Diabetes is one of the significant focus areas: Value-Based Programs Better Health Care for Individuals Better Health for Populations Lower Cost Quality Payment Program Advanced Alternative Payment Models Merit-based Incentive Payment System 8 Diabetes Specific Measures https://qpp.cms.gov/measures/quality 6 3/29/2017 Managed Care Approach Case Management Chronic Care Model Physician Education and Incentives P4P Education Formulary Management Primarily Managing High Cost Medications Drug:Drug Issues Managed Care Approach Case Management Chronic Care Model Self-Management Support Decision Support Delivery System Design Clinical Information Systems Organization of Health Care Community E.H. Wagner, C. Davis, J. Schaefer, M. Von Korff, B. Austin, “A survey of leading chronic disease management programs: are they consistent with the literature,: Managed Care Quarterly 7(1999):(3)56-66. 7 3/29/2017 Managed Care Approach Case Management Patient Heroism Persistent Determination A Hero or Heroine is a person or main character of a literary work who, in the face of danger, combats adversity through impressive feats of ingenuity, bravery or strength, often sacrificing his or her own personal concerns for some greater good.1 1. Wikipedia, Hero Definition Managed Care Approach Case Management Patient Heroism Persistent Determination Are we there to support their heroism in a meaningful way? 8 3/29/2017 Managed Care Approach Case Management Government Workplace Community Social Patient Workers Family Care Managers Providers Managed Care Approach Case Management http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf p. S53 Copyright ©2017 American Diabetes Association Diabetes Care2017 Jan; 40(Supplement 1): S11-S24” 9 3/29/2017 Managed Care Approach Case Management: Adherence – How well a patient’s behavior corresponds to a health care provider’s recommendation1 Compliance - The proportion of administered doses/prescribed doses over a period to time1 Concordance – involvement of patients in decision-making to improve patient compliance with medical advice2 1. Garcia-Perez L, Alvarez M, et. Al. Adherence to Therapies in Patients with Type 2 Diabetes. Diabetes Therapy 2013 4:175-194. 2. Wikipedia: Concordance Managed Care Approach Case Management: Adherence – How well a patient’s behavior corresponds to a health care provider’s recommendation Medications/Therapy Lifestyle Exercise Dietary Many Factors Age Information Perception and Duration of Disease Dosing Complexity Poly-therapy