Innovation ’19: Diabetes Management

In diabetes management, vive la différence makes all the difference

A program at Purdue succeeds by giving people with the disease many choices for how to manage the condition.

Lola Butcher
Contributing Editor

Diabetes’ devastating toll on American health—and health care expenditures—is only going to get worse, but employers and insurers are trying new strategies to fight the scourge. “We’re certainly getting smarter about it every day,” says Candace Shaffer, director of benefits for Purdue University.

By 2030, almost 40 million American adults—or nearly 14% of the adult population—will be diagnosed with either type 1 or type 2 diabetes, according to the latest projections from the CDC. That’s a steep increase from the 22.3 million—about 9% of the population—diagnosed as of 2014.

The total costs of diagnosed diabetes increased 26% between 2012 and 2017, when the tab hit an estimated $327 billion, according to research funded by the American Diabetes Association. That included $237 billion in direct medical costs and $90 billion in reduced productivity.

2017 per capita health care expenditures in the U.S., by diabetes status and site of care

Source: American Diabetes Association, “Economic Costs of Diabetes in the U.S. in 2017,” March 2018

All of this makes diabetes one of an employer’s or health plan’s biggest challenges, but they are not helpless, Shaffer says.

Purdue covers about 26,000 lives, including employees, their dependents, and a few others; claims data show that about 10% have been diagnosed with diabetes. Since 2013, the university’s main campus in West Lafayette, Ind., has had an onsite clinic that offers a diabetes management program for those with type 2 diabetes or its prediabetes precursor—high blood sugar levels but not high enough for a diagnosis of diabetes.

But some employees at the main campus did not like the group-session approach offered at the clinic. And Purdue has employees elsewhere—at two branch campuses and, because it’s a land grant university, the university is the employer for extension service staff throughout Indiana. So, three years ago Shaffer started adding new options. She helped to arrange a contract with Virta Health, a San Francisco startup selling diabetes management programs that Virta says can reverse the disease. The onsite clinic introduced coaching via telephone for those who could not or did not want to come to the clinic.

Candace Shaffer

“It’s like having a new body,” says Candace Shaffer about some of the success participants have seen in a weight-loss program that she helped to establish at Purdue University.

The clinic’s program—either in-person classes or telephone coaching—primarily encourages patients to follow the Comprehensive Health Improvement Program (CHIP), a plant-based weight-management approach. Virta Health’s virtual coaches use the ketogenic diet, which restricts carbohydrates.

By offering an array of options, Shaffer wants to give everyone an opportunity to find what works best for them.

“There are all these different things to consider—your learning style, your personality, your food preferences and your schedule,” she says. “I just want our employees and their families to be successful and find something they can commit to. And everyone is different.”

Results are encouraging. In 2017, 35% of the 379 individuals engaged in the clinic-based type 2 diabetes management program spent $100 or more on diabetes medication per year; in 2018, after a year of coaching, 26% were using that much medication.

Meanwhile, about 75% of the more than 100 people participating in the remote ketogenic program lowered their HbA1c levels by at least one point during the first year after enrolling.

“It’s life-altering to change that A1c,” Shaffer says. “And one third of those people have reduced their body weight by 10% or more. Research shows that is pretty significant—it’s like having a new body.”

Other public payers are ramping up their diabetes management efforts. In California, Medi-Cal, the state’s Medicaid program covering more than 13 million residents, is moving upstream in an effort to reduce the number of people who move from prediabetes to diabetes. Starting this year, it added the Diabetes Prevention Program (DPP) as a covered service for adults with prediabetes. Research shows that individuals with prediabetes who participate in the DPP, a lifestyle-change program recognized by the CDC, can cut their risk of developing type 2 diabetes by 58%. DPP is well established but coverage to pay for it is still new and inching forward.

L.A. Care Health Plan, the largest publicly operated plan in the country, contracted with Solera Health to provide the program, which requires weekly in-person sessions for six months, followed by monthly meetings for six months. The health plan may offer a digital version of the program eventually, says Richard Seidman, MD, its chief medical officer. “L.A. Care is anticipating that, through the DPP, members will eat healthier and increase their physical activity enough to reach 5% body weight loss,” he says.

The program has incentives for results. The vendor gets paid when program participants hit certain milestones, such as attending a certain number of classes or achieving that 5% weight-loss target. The health plan’s members will receive financial incentives for making lifestyle changes that produce measurable results.

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