A Guide for Managed Care to Provide Clinicians with Tools to Support the Delivery of Consistent High-Quality Care
Reviewed by Daniel Schultz, Doctor of Pharmacy Candidate, University of Florida College of Pharmacy
The first presentation focused on HEDIS, a widely used set of measurements of healthcare performance in the United States and is currently in use by the NCQA. It takes into account the effectiveness and patient satisfaction of the services provided, and measures access to care and how well an organization educates its members on making informed healthcare decisions. The four core attributes of HEDIS measurements are relevance, scientific soundness, feasibility and standardization.
In 2011, HEDIS focused on 8 specific “domains” of care, in order to improve quality, which were: effectiveness of care, access to care, satisfaction with care experience, use of services, cost of care, health plan descriptive information, stability of health plan, and informed healthcare choices. Diabetes was a special focus within effectiveness of care. Members were identified by either pharmacy data or diagnosis, and were assessed by HbA1c, eye exams, LDL, nephropathy, and blood pressure. HEDIS also looked at relative resource use to demonstrate that the most expensive care is not necessarily synonymous with the best care.
The second presentation focused on evidence based guidelines for use in clinical practice in the management of type2 diabetes. The presenter highlighted the increasing prevalence of diabetes in the US, especially in the southeast, and briefly covered the dual etiology (insulin resistance and beta cell dysfunction) of type 2 diabetes. Several clinical trials were highlighted, focusing primarily on the fact that reductions in HbA1c directly correlate with a reduction in complications. The presentation mentioned all available classes of antidiabetic medications, the pros and cons of each, as well as newer drugs in development, most notably the SLGT-2 inhibitors. SLGT-2 inhibitors offer a modest HbA1c reduction (0.5-0.7%) by inhibition of glucose reabsorption in the kidneys, thus increasing urinary glucose excretion. Another class of drugs currently in development are the glucokinase inhibitors, but these have showed significant hypoglycemia in early clinical trials. The use of combination oral therapies in achieving a higher HbA1c reduction were also addressed.
The presenter then talked about strategies for insulin therapy, including a self-titration schedule for adjustment of basal insulin dose based on FPG readings. He also outlined the advantages of insulin pens (more convenient, more accurate dosage, easier to use for those with visual or motor impairments, and less injection pain), and ways to overcome patient barriers to insulin use, such as not blaming the patient, discussing real risks, and starting with a simple regimen (i.e., a glargine pen at bedtime).
The third presentation was about delivery of high quality care through a managed care organization. Some challenges for the managed care system included implementation of pay for performance programs, understanding patient challenges, improving compliance, and providing clinicians with the tools they need to consistently give high quality care. Elements of a successful diabetes management program included full transparency, attainable goals, use of evidence based guidelines, a flexible formulary design, and inclusion of all patients with diabetes.
HEDIS measurements were also addressed, showing major improvements in all measured categories. Lastly, the presenter also covered value-based benefits design, which is based on the following three principles: the value equals the clinical benefit achieved for the money spent, services differ in the benefits they produce, and the value of services depends on who receives them. The goal is to remove economic barriers to treatment and promote adherence through reduction of patient out of pocket cost.