This document discusses three approaches to tackling diabetes in specific populations: seniors in the Bronx, NY, veterans, and American Indians/Alaska Natives. For seniors, it highlights the importance of diabetes education programs to help patients better manage their condition and medications. It describes a program at Montefiore Medical Center that provides group education sessions. For veterans, it discusses a research study providing group appointments for diabetes monitoring and education. Finally, it notes the high rates of poverty, substance abuse and diabetes among American Indians/Alaska Natives and the need for innovative care approaches for this population.

1. Published as a supplement to
Supported by
NOVEMBER 2015
Tackling Diabetes:
Three Approaches
Combating diabetes among seniors, veterans,
and American Indians and Alaska Natives
requires new strategies

2. 2 Tackling Diabetes: Three Approaches
If you want to see what the melting pot
of America looks like, visit the Bronx,
New York. Here—in one of New York
City’s five boroughs—you’ll hear accents
from Bangladesh, India, Pakistan, Ghana,
and other places around the globe.
Unfortunately, you’ll also find a high
prevalence of diabetes in the Bronx,
says Joel Zonszein, MD, director of the
Clinical Diabetes Center at the Univer-
sity Hospital of the Albert Einstein College of Medicine, a division of Monte-
fiore Medical Center.
More than 14% of the population in the Bronx has diabetes, according to
an April 2013 data brief from the New York City Department of Health and
Mental Hygiene. Case in point: A 50-year-old man who used to work as a
doorman in NewYork City. He’s been on disability since the age of 38—that’s
because of his worsening diabetes, congestive heart failure, obesity, and
smoking history. His leg has been removed below the right knee, he experi-
ences moderate kidney disease, and he frequently spends long periods of
time as an inpatient for treatment of his congestive heart failure.
The cost to this man and his family—both in terms of his ability to work
and function—is enormous. And the future’s not bright—that is, if nothing’s
done about it.
More than 9% of the U.S. population has diabetes today, according to the
2014 National Diabetes Statistics Report from the Centers for Disease Con-
trol and Prevention.
“That number could jump to three in 10 [people] if nothing’s done to stop
this chronic disease in its tracks,” says Zonszein.
A supplement supported by BOEHRINGER-INGELHEIM
PHARMACEUTICALS, INC., Copy­right 2015 and pub-
lished by Advanstar Com­mu­ni­cations, Inc. No portion of
this program may be reproduced or transmitted in any
form, by any means, without the prior written permis-
sion of Advanstar Communications, Inc. The views and
opinions expressed in this material do not necessarily
reflect the views and opinions of Advanstar Communica-
tions, Inc. or Managed Healthcare Executive®
.
Supported by
Published as a supplement to
NOVEMBER 2015
Tackling Diabetes:
Three Approaches
Combating diabetes among seniors, veterans,
and American Indians and Alaska Natives
requires new strategies
In the Bronx,
New York City,
14% of the population
has diabetes.
Source: New York City Department
of Health and Mental Hygiene
29.1 million people or 9.3% of the
U.S. population has diabetes.
Source: Centers for Disease Control and Prevention: National Diabetes Statistics Report:
Estimates of Diabetes and Its Burden in the United States, 2014.
—Diagnosed—
21.0 million people
—Undiagnosed—
8.1 million people
Aine Cryts is a freelancer based in Boston. She
is a frequent contributor to Managed Healthcare
Executive on topics such as diabetes, oncology,
hospital admissions and readmissions, senior
patients, and health policy.
Edmund J. Pezalla, MD, MPH, is vice president
and national medical director for pharmaceutical
policy and strategy, Aetna. He has more than 20
years of experience in managed care and related
areas. He received his medical and under­grad­uate
degrees from Georgetown University and trained
in general medicine and pediatrics at the Bethesda
Naval Hospital. He holds an MPH from the
University of California, Berkeley.
Ann Bullock, MD
Acting Director
Division of Diabetes Treatment and Prevention
Indian Health Service
Helena Duffy, NP
Adult Health
Montefiore Medical Center
Dianne Howard
Director, Risk and Benefits Management
Palm Beach County School District
West Palm Beach, Florida
Sachin H Jain, MD
Chief Medical Officer
CareMoreHealth System
Sharon Movsas
Diabetes Education Program Coordinator
Montefiore Medical Center
Karen Mulready
Director, Product Development
UnitedHealthcare
William Yancy, MD
Research Scientist
Center for Health Services Research
in Primary Care
Durham VA Medical Center
Joel Zonszein, MD
Director, Clinical Diabetes Center
University Hospital, Albert Einstein
College of Medicine
Montefiore Medical Center

3. 3Published as a promotional supplement to Managed Healthcare Executive®
The challenge of tackling
seniors’ type 2 diabetes
“The main problem these last few years is that many
patients have this disease but they don’t go to have it
checked,” says Zonszein. “They may feel well with type
2 diabetes, but [the disease is] silent ... Many people
live with these problems and don’t go to see the doctor,
which results in the late diagnosis of diabetes and these
other diseases.”
Even if seniors do see a doctor, that doctor visit often
doesn’t translate into patients taking action to combat
the disease’s progression, he says. “We need these pa-
tients to make lifestyle changes, we need them to eat
better and exercise. We need them to take medications
for their blood pressure or diabetes or high cholesterol,”
he says.
Another issue is that some patients don’t take their
medications because they’re afraid of the side effects
and/or are deterred by the costs. “In the Bronx, it’s even
more complicated by the fact that the patient population
watches a lot of TV. Unfortunately, we have a lot of law-
yers [in TV commercials] announcing the side effects of
diabetes medications,” he says.
Zonszein believes that the solution to many of these
problems is patient education about diabetes treat-
ment. Montefiore Medical Center’s program is called
the PROMISED (Proactive Managed Intervention Sys-
tem for Education in Diabetes) Diabetes Self-Manage-
ment Education Program and involves diabetes educa-
tion in a group setting. These sessions are led by
certified diabetes educators who coach and educate el-
derly patients.
“It’s too much for primary care physicians to teach
and manage diabetes for these patients,” says Sharon
Movsas, diabetes education program coordinator at
Montefiore. “It’s very time consuming. And it’s unrealis-
tic that a primary care physician can spend that much
time with their patients.”
One of the most important goals of the group classes
is to teach patients to partner with their doctor, says
Helena Duffy, NP, who teaches in the diabetes educa-
tion program. “In the past, the doctor was seen as an
authority who would tell you what to do. In the class,
patients learn about the need to be involved in creating
their own plan.”
Many of the patients have developed, or will develop
other conditions that go along with diabetes, such as
stroke, cardiovascular disease, cognitive impairment,
and depression, says Movsas. To help, diabetes edu­
cators assist seniors with simplifying their medication
regimens, educate them about what each medication
is for, and provide tips on how to remember to take
their medications.
Most people come into the class with the goal of get-
ting off medication, says Movsas. “At the end of the
class, one of our goals is to make sure that they’re able
to make better decisions about medication. Many of
them actually come out of the class, and we see their
LDL [low-density-lipoprotein] cholesterol levels going
down tremendously because they’ve started to take
their statin, whereas before the class started they were
scared that it would hurt their liver or their kidneys. It
really makes a huge difference in outcomes.”
Covered by most insurance plans, diabetes education
classes at Montefiore include five two-hour sessions
that take place once a week. As a follow-up, participants
are also eligible for medical nutritional therapy each year.
Group sessions for veterans
with type 2 diabetes
More than seven in 10 veterans who receive VA care are
either overweight or obese, according to the Office of
Research & Development at the U.S. Department of
re
Source: Centers for Disease Control and Prevention: National Diabetes
Statistics Report: Estimates of Diabetes and Its Burden in the United
States, 2014.
American Population with Diabetes
2010 2012
MillionsofPeople
35
30
25
20
15
10
5
0
25.8
29.1
The percentage of Americans age 65
and older with diabetes remains high,
at 25.9%, or 11.2 million seniors with
diagnosed and undiagnosed diabetes.
Source: National Diabetes Statistics Report, 2014

4. 4 Tackling Diabetes: Three Approaches
program also includes the opportunity for veterans to
have their feet monitored for any signs of sores and
to receive regular eye exams. Many of the veterans who
arrive for these group appointments are overweight and
have A1c1 levels of 8 or above. At this point, more than
100 veterans have been through the program.
Yancy started working with the first group of partici-
pants about eight months ago and intends to work with
an additional 100 veterans in this research study.
Driving innovation in care among
the Native American population
More than 5 million people self-identify as American
Indian and Alaska Native, according to the U.S. Census
Bureau. The Kaiser Family Foundation highlights that
Native Americans experience significantly higher rates
of poverty than the overall population—41% versus
25%.
American Indians and Alaska Natives are also more
likely than any other racial group to have had either an
alcohol or drug abuse disorder in the past year—and
those substance abuse disorders often complicate the
treatment of diabetes. A 2011 report from the Indian
Health Service (IHS) notes that the rate of alcohol-
related deaths among this population is 519% higher
than for any other race in the country. IHS is an agency
within the Department of Health and Human Services
that is responsible for providing federal health services
to American Indians and Alaska Natives. As if that’s
not enough, more than 16% of Native Americans also
struggle with diabetes.
Veterans Affairs (VA), and that’s leading to high rates of
diabetes among veterans. According to the VA, 24% of
veterans have diabetes.
“It’s just not efficient to provide one-on-one diabetes
education with veterans. We bring groups of [about 10]
patients together and teach them about diabetes,” says
William Yancy, MD, a research associate at the VA Med-
ical Center in Durham, North Carolina. They also get to
know each other and come to rely on each other for
social support,” he says. These group appointments
take place every one or two months; veterans also
meet individually with a clinician who might adjust their
medications.
As with seniors, veterans involved in group diabetes
appointments really care about getting off their diabetes
medication, says Yancy, who also serves as director of
the Duke Diet and Fitness Center at Duke University.
“We don’t necessarily get them off their medications.
We do get them to change their diets and increase their
physical activity so they don’t need to take as much of
their medications.”
These group appointments are part of a VA-funded
research study, and the veterans involved are primarily
middle aged or elderly, although there are some young-
er veterans in their 20s and 30s who participate. The
Boehringer-Ingelheim Supplement — Tackling Diabetes: Three Approaches — MHE November 2015
American Indians/Alaska Natives Figure 1
Source: IHS Diabetes Care and Outcomes Audit
IHS Diabetes Care and Outcomes Audit
Mean A1c: 1996 to 2014
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
MeanA1c(%)
Audit Year
10.0
9.5
9.0
8.5
8.0
7.5
7.0
6.5
6.0
The estimated number of veterans
with diabetes: nearly one in four.
Source: The U.S. Department of Veterans Affairs

5. 5Published as a promotional supplement to Managed Healthcare Executive®
clinicians can see how they are doing in terms of meet-
ing the standards of care. Now that most physicians use
electronic health records, Bullock says the team can
audit many more charts. The 2015 audit, which looks at
treatment provided in 2014, included a review of more
than 116,000 medical charts of people with diabetes
across the country at IHS, tribal, and urban Indian health
organizations.
The IHS Diabetes Care and Outcomes Audit for 2015
revealed that key outcome measures for Native Ameri-
cans with diabetes showed achievement at or near na-
tional targets.
Some findings include:
• A1c1 mean: 8.1
• Blood pressure: 65% have blood pressure lower
than 140/90 mm Hg
IHS also reports a decrease in end-stage renal dis-
ease (ESRD) among Native Americans. Between 2000
and 2011, ESRD incidence rates decreased 43%, more
than for any other racial group in the country.
Ann Bullock, MD, acting director of the division of di-
abetes treatment and prevention with IHS, credits the
U.S. Congress with continuing to fund programs around
the country that help to treat Native Americans with di-
abetes. That’s since the Balanced Budget Act of 1997,
when Congress established the Special Diabetes Pro-
gram for Indians (SDPI) and provided $150 million over
five years for the prevention and treatment of diabetes
in American Indians and Alaska Natives. Funds have
been reauthorized through fiscal year 2017. Since the
SDPI started, there has been a 10% reduction in the
average A1c1 levels among Native Americans, accord-
ing to a January 2015 report from IHS.
This funding provides support for 336 community-
directed diabetes programs in 35 states that implement
evidence-based diabetes treatment and prevention pro-
grams. An additional 66 demonstration projects suc-
cessfully completed a six-year program that translates
the results of diabetes prevention and cardiovascular
disease risk reduction research into what IHS calls “di-
verse, real-world Indian health settings.”
Since the 1990s, IHS has also produced the Diabetes
Care and Outcomes Audit, an audit of patients’ medical
charts during which Bullock and others look at the stan-
dards of care and consider how well providers are meet-
ing those standards. The team reviewing the medical
charts looks at blood sugars, blood pressures, and cho-
lesterol and whether patients are taking an aspirin a day
if they should be, for example.
Bullock says that the findings aggregate on a national
level but are also fed back to individual sites of care so
American Indians/Alaska Natives Figure 2
Source: Centers for Disease Control and Prevention: National Diabetes Statistics Report: Estimates of Diabetes and Its Burden
in the United States, 2014.
Rates of Diagnosed Diabetes by Race/Ethnic Background
Non-Hispanic
whites
Asian
Americans
Hispanics Non-Hispanic
blacks
American Indians/
Alaska Natives
Percentofpopulation
Race/Ethnic Background
20
15
10
5
0
7.6
9.0
12.8 13.2
15.9
Alcohol-related deaths among
American Indians and Alaska Natives
are 519% higher than any other race in
the country. More than 16% of Native
Americans also struggle with diabetes.
Source: Indian Health Service (IHS)

6. 6 Tackling Diabetes: Three Approaches
market for 10 years. I typically spend 20 minutes on the
phone with insurance companies per patient per medi-
cation to get them approved.
Managed Healthcare Executive: What are some of
the unique care coordination approaches you have
taken for managing these patients effectively?
Zonszein: First, every Monday morning, we meet as an
interdisciplinary team to discuss our most challenging
diabetes cases.That’s where we feature these patients’
vitals on a white board.
The meetings result in a total breakdown in the silos
that often exist in the treatment of diabetes. That’s be-
cause the entire care team—which includes nurses and
physicians and pharmacists—is at the same table dis-
cussing one patient at a time. The outcome of those
meetings is a consultation letter that’s sent to the pa-
tient’s primary care provider; then our team focuses on
outcomes follow-up.
The second part is a structured group education pro-
gram, which involves patients meeting with various
healthcare practitioners on a regular basis. We set con-
crete goals for patients, such as setting up an appoint-
ment with a nutritionist. We ask patients what they’re
eating. We hold them accountable with their medica-
tions and help them switch if they experience side ef-
fects.
Managed Healthcare Executive: How are
you measuring success with the diabetes
education program?
Zonszein: These diabetes patients’ A1c1 levels improve
by 10%, one year after their participation in the diabetes
education program—from 43% to 53% achieving their
A1c1 goal of less than 7. One year after participating in
the education program, diabetics’ ability to get their LDL
cholesterol under 100 improves by 14%—from 53% to
67% at their goal.
The Bronx. It’s a place many immigrants call home.
This New York City borough is also host to a higher
than average prevalence of diabetes. More than 14% of
its residents have the chronic disease, according to an
April 2013 data brief from the NewYork City Department
of Health and Mental Hygiene. Joel Zonszein, director
of the Clinical Diabetes Program at the University Hos-
pital of the Albert Einstein College of Medicine, a divi-
sion of Montefiore Medical Center, is in the thick of
things every day, attempting to engage Bronx patients
in their diabetic care.
Here, he discusses the unique challenges associated
with diabetes care in that area, as well as some of the
successful approaches to caring for these patients that
health plans and providers across the country may want
to emulate.
Managed Healthcare Executive: What are you
finding out about the populations that you
serve in the Bronx and their unique health
management challenges?
Zonszein: We’re seeing a major problem with diabetes
among Bangladeshis now living in the Bronx. We also
have a lot of people from India, Pakistan, Yemen, and
Ghana, all of whom are at very high risk for diabetes.
The main problem we’ve seen in the Bronx is that
many patients have the disease, but they don’t go to the
doctor to check for it because they feel well. Type 2 dia-
betes is typically accompanied by obesity, high blood
pressure, and high cholesterol levels.
We have a lot of people with Medicare, Medicaid, and
limited resources. The newer medications for diabetes
can seldom be prescribed because insurance compa-
nies create artificial barriers that impede our patients’
access to those medications.
Patients in the Bronx are being treated with what I
call “20th century” medications—not 21st century
medications. When a patient goes to the clinic, it’s very
difficult to prescribe a medication that has been on the
QA
Empowering Diabetes Patients in the Bronx
Plans and providers across the country should
pay attention to these successful strategies
By Aine Cryts

7. 7Published as a promotional supplement to Managed Healthcare Executive®
Diabetes Health Plan, Howard says 19% of its medical
and pharmacy costs were related to diabetes treatment.
“It all boils down to dollars and cents,” she says. “It gets
your attention when your claims keep going up.”
As much as $34 million of the $170 million the school
district was spending on healthcare each year was relat-
ed to diabetes care for employees. Those costs were
highest among employees who were overweight and
experiencing metabolic challenges and comorbidities.
On the payer side, a two-year study by UnitedHealth-
care evaluated how the Diabetes Health Plan impacted
620 enrollees.The study found that these enrollees cost
Dianne Howard, director of risk and benefits man-
agement at Palm Beach County School District in
West Palm Beach, Florida, helped save her employer
about $4 million over two years after deciding that the
district would participate in UnitedHealthcare’s Diabe-
tes Health Plan. As a result of her decision, Palm Beach
County School District’s employees with diabetes are
healthier, too.
The Diabetes Health Plan, launched by UnitedHealth-
care in 2009, provides special medical and pharmacy
benefits to diabetic and prediabetic employees for com-
panies that elect the plan. According to the payer, enroll-
ees receive the following:
• No or reduced cost for diabetes-related doctor visits;
• No or reduced cost for select diabetes-related medi-
cations and supplies;
• Reminders for important tests and exams; and
• A personal scorecard to help them keep track of re-
quired doctor visits, lab tests, and wellness programs.
The program’s goal is to help enrollees prevent com-
plications by receiving evidence-based care from their
physician, while addressing conditions related to diabe-
tes, including blood pressure, obesity, and depression.
UnitedHealthcare’s nurses also work with members to
develop a personal action plan to help them manage the
disease.
Positive results
As a result of the Diabetes Health Plan, the Palm Beach
County School District’s prediabetes and diabetes em-
ployees experienced a 17% decrease in emergency room
visits in just the first year; at the same time, the hospital
readmission rate went down .4%, says Howard.
More good news: Primary care visits among this em-
ployee population went up 3.6%, says Howard. “That’s
a good thing,” she says, “because that increase in pri-
mary care visits means employees are actively manag-
ing their disease.”
In 2010, before the school district participated in the
Boehringer-Ingelheim Supplement — Tackling Diabetes: Three Approaches — MHE N
Pre-diabetes Figure 1
Source: Centers for Disease Control and Prevention: National
Diabetes Statistics Report: Estimates of Diabetes and Its Burden
in the United States, 2014.
Estimated Diabetes Costs in the United States
Indirect costs (disability, work loss, premature death)
Direct medical costs
2012 Total (direct and indirect)
After adjusting for population age and sex differences, average
medical expenditures among people with diagnosed diabetes
were 2.3 times higher than among people without diabetes.
$245 billion
$176 billion
$69 billion
FEATURE
Treating Diabetes and Prediabetes,
One Member at aTime
New program finds that member perks lead
to higher engagement, lower costs
By Aine Cryts
In 2012, 86 million Americans
age 20 and older had prediabetes;
this is up from 79 million in 2010.
Source: Centers for Disease Control and Prevention:
National Diabetes Statistics Report: Estimates of Diabetes
and Its Burden in the United States, 2014.

8. 8 Tackling Diabetes: Three Approaches
January, UnitedHealthcare identifies the appropriate
employees based on high blood pressure and high-
cholesterol measurements. “Over the last couple of
years, we’ve started to look at the progression of dia­
betes, which has caused us to focus on how we can
really prevent prediabetes,” says Howard.
Onboarding prediabetic employees presents its own
challenges. “What we’ve found is most people don’t
know they’re prediabetic,” says Karen Mulready, direc-
tor of product development at UnitedHealthcare. When
enrollees find out they’re prediabetic, they then have a
conversation with their physician and are told to watch
their blood sugar. They’re also educated about fitness
and nutrition, she says.
UnitedHealthcare finds out which employees are eli-
gible to be included in the prediabetes and diabetes
plans by conducting a historical claims review, accord-
ing to Mulready. Once employees are identified, the
payer sends them a letter informing them of their partic-
ipation in the program.
Enrollees meet with a nurse who shows them how to
check their blood sugar, according to guidelines set by
the American Diabetes Association. They are also re-
quired to visit their doctor, get their eyes checked, and
have their A1c1 levels monitored, says Mulready.
“We’re asking members to be compliant with evi-
dence-based medicine,” she says. Patients see their
less, were more compliant with evidence-based guide-
lines, and demonstrated greater management of their
disease than those who did not participate. The study’s
findings were released in 2013.
The specific findings are:
• Costs grew 4% more slowly for enrolled employees;
• 75% of enrolled employees were compliant with evi-
dence-based medicine guidelines, compared to 61%
of unenrolled employees; and
• 21% of enrollees experienced a reduction in their
health risk scores (which are used to measure expect-
ed healthcare costs for an individual or a population).
• UnitedHealthcare says 35 employers nationwide
have chosen to provide the plan to their employees.
The Diabetes Health Plan today includes approxi-
mately 22,000 enrolled members with diabetes and
prediabetes.
How it works
Howard says the program is administered by United-
Healthcare. The only way she finds out which employ-
ees are involved in the Diabetes Health Plan is when
her team receives a question about the plan from an
employee.
Employees are automatically enrolled in the program,
although they can choose to opt out. Howard says some
prediabetic and diabetic employees do opt out of the
program—generally because of their fears about being
labeled with a chronic disease and the impact that could
have on their ability to get health insurance in the future.
In the prediabetes program that was introduced in
In the United States, people with
diabetes are twice as likely as the
average person to have depression.
Source: Eqede LE, Zheng D, Simpson K. “Comorbid depression
is associated with increased health care use and expenditures
in individuals with diabetes.” Diabetes Care. 2002;25(3):464-470.
In 2009–2012, of adults aged 18 years or older with diagnosed diabetes,
71% had blood pressure greater than or equal to 140/90 mm Hg
or used prescription medications to lower high blood pressure.
Source: Centers for Disease Control and Prevention: National Diabetes Statistics Report:
Estimates of Diabetes and Its Burden in the United States, 2014.
In 2011, about 282,000 emergency
room visits for adults aged 18 years
or older had hypoglycemia as the
first-listed diagnosis and diabetes
as another diagnosis.
Source: Centers for Disease Control and Prevention:
National Diabetes Statistics Report: Estimates of Diabetes
and Its Burden in the United States, 2014.

9. 9Published as a promotional supplement to Managed Healthcare Executive®
next year to enroll, she wants to make sure they “value”
the program and participate fully.
Onboarding employees hasn’t always been easy, says
Howard. The school district received some negative
feedback the first year it participated, largely because
of the introductory materials employees received about
the program. The school district continues to work
closely with UnitedHealthcare to ensure the intro­
ductory letters patients receive at home are “more
approachable” and address any potential privacy con-
cerns. Today, Howard says, the response from employ-
ees is mostly positive—in great part because their
copays have gone down. “Everybody likes it when they
can save money.”
physician to have their blood sugars taken, and that in-
formation is integrated and automated within the pay-
er’s systems. Enrollees, who receive online and written
communications by mail from UnitedHealthcare
throughout the year, can track their progress online.
If school district employees don’t comply with at least
three of the plan’s requirements, they’re pulled out of
the program—and then they have to wait a full year to
get back into it, says Howard. “We do that because
those employees aren’t going to get better [if they don’t
adhere to the plan requirements]. That’s when we get
the calls from employees, because they don’t want their
copays to go up,” she says.
While school district employees have to wait until the
If health plan members are aware
of their health statistics, they can
know if they are, or are not, in the
appropriate health ranges. It is a first
step toward empowering members
to take charge of their health.
But most people do not know
their biometrics, according to a re-
cent HealthMine survey of 561 con-
sumers. Specifically, the survey
found that 83% of consumers do not
know, or track, their blood glucose
level.The cost of ignorance about di-
abetes is colossal, adding up to $322
billion per year, according to the
American Diabetes Association.That
figure includes loss of productivity
due to illness and disability. That
means American consumers—even
those who are healthy—are each
paying $1,000 a year for diabetes.
“Chronic illness is a huge cost to
health plans but averting it and man-
aging it down to the individual level
can improve the health of the group
and lower overall costs,” says Bryce
Williams, CEO and president of
HealthMine.
The survey also found:
• 81% of people don’t know their
cholesterol level;
• 79% of people don’t know their
body mass index; and
• 68% of people don’t know their
blood pressure.
Williams offers three ways health-
care executives can help manage
members’ blood glucose levels:
1. Help identify those at risk for dia-
betes.
2. Help avert diabetes by encourag-
ing members to maintain a regi-
men of diet and exercise.
3. Ensure adherence to the proper
medications.
Williams also says health plans
should implement programs to help
members know and track their
average blood sugar over time with
an A1c test and know their health
status.
“Follow recommended preventive
health actions and find out risks,”
Williams says. “Aggregate both clini-
cal and wellness data across many
sources to present it in one mean-
ingful way to the individual.”
He also recommends a rules-
based expert system that measures
individual health data against clinical
criteria, then automatically recom-
mends personalized health actions
for each member. Results of the clin-
ical analysis highlight the riskiest as-
pects of health, he says.
“Empower members with knowl-
edge and guidance of what to do
and when to do it,” Williams says,
adding that plans should provide
health support articles, videos, tools,
and support forums. “Guide mem-
bers and motivate toward improve-
ment.”
Finally, plans should help track
members’ progress and provide re-
wards for successes, says Williams.
“Track both positive behaviors and
positive outcomes and reward those
[members] that make the effort [to
improve] with points, redeemable
for things such as gift cards, fitness
devices, entries into large sweep-
stakes, and discounts on the costs
of healthcare.”
Blood glucose awareness: The first step to lowering diabetes costs

10. 10 Tackling Diabetes: Three Approaches
ence an amputation rate that is 66% lower than the
Medicare fee-for-service average. In addition, the aver-
age A1c1 level for members in the program is 7.07; 7.0
is considered to be good clinical control of diabetes.
Managed Healthcare Executive: Why
is the program designed this way?
Jain: Physicians don’t have the time to deliver all the
coaching and education they need to empower patients
to manage their own diabetes—and that’s a central piece
of this work. We have primary care doctors within the
Medicare Advantage plan who refer patients to the Care­
More Care Center. CareMore is reimbursed by Medi-
care through its Medicare Advantage plans per enrollee.
The CareMore Diabetes Program includes diabetic
foot care with an on-site podiatrist, access to wound
care-certified nurse practitioners, and transportation to
CareMore Care Centers.
Managed Healthcare Executive: The prediabetes
program is a more recent addition to CareMore
Care Centers. What’s the status on that program?
Jain: The measures for identifying members for the
pre­diabetes program include a body mass index consid-
ered to be obese, physical inactivity, family history, and
A1c1 levels. We start­ed our planning in March 2015 and
went live in June 2015.
We started on June 1 to identify our at-risk patients—
from among the 100,000 people we insure nation-
wide—and we identified 2,000 patients whose hemo-
globin A1c1 levels were at the prediabetic stage. That’s
who we’re targeting with our program. It’s based now in
California and Arizona.
We don’t have a lot of data on the diabetes prevention
program yet. However, we’re already hearing from pa-
tients who are getting their A1c1 levels returning to the
normal range after just three months in the program.
The number one challenge facing diabetic patients is
health literacy, says Sachin Jain, MD, chief medical offi-
cer at Cerritos, California-based CareMore Health System
(a subsidiary of Anthem), which operates Medicare Advan­
tage plans and CareMore Care Centers to care for the
plans’ patients in an outpatient setting. “[Seniors] don’t
necessarily understand that many of their behaviors that
can lead to diabetes are under their control—and that they
can modify these behaviors,” says Jain, a former senior
adviser at the Centers for Medicare Medicaid Services.
For this reason, CareMore has created an innovative
diabetes program, designed to move the needle on diet and
exercise among seniors with diabetes. Here’s more on
the program, what it entails, and how it is helping patients.
Managed Healthcare Executive: How does the
CareMore program seek to improve the type
of care seniors with diabetes receive?
Jain: During patients’ visits at an outpatient CareMore
Care Center, physicians can help address some of the
root issues related to diabetes. That involves providing
education about diet, managing their medications, and
checking their blood sugar.
Physicians can also provide exercise guidance to se-
niors. For instance, physicians can identify and recom-
mend that seniors work out at the Nifty at Fifty gyms
that are located at or near the CareMore Care Centers.
At these senior-appropriate gyms, seniors can be sure
they’re working out at the appropriate tolerance.
According to internal CareMore studies, the patients
who take part in CareMore’s diabetes program experi-
QA
CareMore’s Sachin Jain on Caring
for Diabetic Seniors
Program is designed to move the needle on diet
and exercise among seniors with diabetes
By Aine Cryts
Behaviors can lead to diabetes,
and behaviors can be modified.
—Sachin Jain, former senior adviser at the Centers
for Medicare Medicaid Services

11. 11Published as a promotional supplement to Managed Healthcare Executive®
to over $197 billion and likely is over $200 billion for 2015.
If diabetes expenses grow at the same rate as overall
costs, we can expect diabetes healthcare to consume
1.2% of the GDP by 2024. This is equivalent to the per-
centage of GDP attributed to agriculture and fisheries.
These numbers are big enough to make us pause
and think. Spending on healthcare can be good—higher
expenditures on cancer care are linked to better out-
comes—but in the case of diabetes, more spending
likely means worsening outcomes. More people with
significant end-organ involvement are suffering com­
plications of therapy such as hypoglycemia. Approxi-
mately one-third of nursing home and residential facility
days are used by people with diabetes. And diabetic
patients use 43 million bed days per year in acute-care
hospitals.
Diabetes is a prevalent and costly condition. In this
essay, I will put it into perspective in terms of con-
tribution to overall health expenditures and to the entire
U.S. economy. Considering the amount of money spent
on diabetes, there is an opportunity for healthcare pro-
viders to assume more responsibility and receive more
rewards for the care of people with diabetes.
Health Affairs recently published an article, “National
health expenditure projections, 2014-24: spending growth
faster than recent trends” (Keehan et al. 2015;​34​[8]:​
1407-1417),” on projected healthcare expenditures
through 2024. Important projections include a further
shift toward government payment through Medicare
and Medicaid, and an increase in the percentage of
gross domestic product (GDP) devoted to healthcare
from 17.4% to 19.6%. Total expenditures are expected
to top $5.4 trillion.
Although no disease-specific projections were included,
we can estimate the impact that diabetes will have on
overall cost based on the American Diabetes Association
Scientific Statement from 2012 (Diabetes Care. 2013;​36​
[4]:​1033–1046). In the 2012 report, the estimated direct
cost of diabetes care was $176 billion.
If we apply a 4% growth rate, (consistent with the
Health Affairs report), that $176 billion will have grown
EDITORIAL
Diabetes Cost Projects Raise Alarm
Spending on healthcare can be good, but in the case of
diabetes, more spending may mean worsening outcomes
By Edmund J. Pezalla, MD, MPH
Boehringer-Ingelheim Supplement — Tackling Diabetes: Three Approaches — MHE November 2015
Diabetes Costs Figure
Source: American Diabetes Association
Largest Components of Diabetes Medical Expenditures
Prescription medications
to treat complications
Anti-diabetic agents and
diabetes supplies
Physician office visits
Hospital inpatient care
total medical cost
Nursing/residential facility stays
12%
9%
8%
10%
Other
43%
18%
People with diagnosed diabetes
incur average medical expenditures
of about $13,700 per year, of which
about $7,900 is attributed to diabetes.
Source: American Diabetes Association

12. 12 Tackling Diabetes: Three Approaches
manage the care of these patients in a patient-centered
and evidence-based manner. This is a huge opportunity
for providers who must transition from fee-for-service
and bed days to population health and outpatient care.
There is a lot of technology available to help people
who have diabetes. This ranges from new pharmaceuti-
cals to devices to mobile apps. No one of these items
will cure or fix our diabetes problem. However, using a
combination of these in a thoughtful way and in the con-
text of basic good medical care can make a difference.
The real problem is not lack of funding (we pay plenty
for diabetes care) or lack of technology, but lack of orga-
nization and focusing on what really matters before the
patient progresses to hospitalization.
Edmund J. Pezalla, MD, MPH, is the section editor for Man-
aged Healthcare Executive’s Diabetes Health Management
topic resource center. Pezalla is vice president and national
medical director for pharmaceutical policy and strategy, Aetna.
Lowering cost, improving quality
There are clearly things we can do to lower costs and im­
prove care. Forty three percent of expenditures attri­buted
to diabetes are for hospital inpatient stays while only 9%
of expenditures are for physician office visits and 18% of
expenditures are for medications. Surely we can shift the
balance away from rescue and problem solving to proactive
intervention and preventing or delaying disease progression.
With diabetes becoming a significant portion of the
national economy, it should also become a focus for in-
vestment. Over 59% of diabetes patients and a much
larger portion of diabetic costs are born by Medicare and
Medicaid. This should make diabetes a national priority.
But, we should not wait for federal action. Diabetes ser-
vices, medications, and labs are all covered by both com­
mercial and government health plans. Providers, and in
particular those providers who are accepting risk through
value-based arrangements, should be organizing to
Telemedicine and telehealth are
broad terms that refer to a range of
tech­nologies and services. At the
heart of both of these is the ability to
improve care through the easy ex-
change of information between pa-
tients and providers.
Some of the technologies that fall
into this category include video con-
ferencing with doctors, use of email
or specialized websites, mobile ap-
plications on cell phones, and auto-
mated transmission of data from
devices and monitors to healthcare
professionals. Telemedicine has be-
come more common and more so-
phisticated over the past few years.
Telemedicine addresses a number
of important overarching issues in our
healthcare system as well as specif-
ic issues related to diabetes care.
1. Manpower. The Affordable Care
Act and launch of insurance ex-
changes has increased the num-
ber of Americans with health in-
surance and the number seeking
care. This is increasing the burden
on a healthcare system with too
few providers, and distribution is-
sues in terms of medical special-
ties and geographic location. Tele-
medicine can help fill in some of
these gaps.
2. Specialty care. Many medical
spe­cialties are short staffed or not
available in remote or rural areas.
Telemedicine programs can help
make the specialists who reside in
a large city and practice at a major
center available to patients and
pri­mary care physicians anywhere
in the country. This is of special in-
terest in diabetes because endo-
crinologists and diabetologists are
not available everywhere. In addi-
tion, diabetic patients may have
need for ophthalmology and other
services that may not be readily
available.
3.Team care. The use of multispe-
cialty teams has been shown to be
ad­vantageous in a number of
health­­care settings, but not all
team mem­bers can be co-located.
This is especially true of mental
health pro­fessionals and social
workers who may be in short sup-
ply in some lo­ca­tions.
4. Data transfer and monitoring.
Glucose meters, continuous glu-
cose meters, and insulin pumps
generate a great deal more data
and more accurate data than pre-
viously used hand-written logs.
This data can now be passed
seamlessly from the patient’s de-
vices to healthcare professionals
who can use available software to
analyze and interpret the data.
Telemedicine and diabetes: Impact on cost and quality