Monday, November 16, 2009

Big U.S. Drugstore Chains Working to Shake Up Diabetes Management

While the benefits of intensive diabetes management are well-established, overall, the U.S. healthcare system receives failing scores relative to most other developed countries when it comes to diabetes care. (catch my post from last year here). It's not for a lack of spending; We spend more per capita than any other country on earth, yet U.S. patient outcomes for most chronic diseases (including diabetes) is worse than most other countries, and merely on-par with such developing countries as Brazil or Jordan, in spite of significantly outspending these countries. One reason is a lack of care coordination and what I refer to as the "compartmentalization" of healthcare in the U.S. (By that, I mean that patients see a primary care doctor, an endocrinologist, perhaps a diabetes educator, nutritionist, ophthalmologists, and potentially cardiologists, dermatologists, gastroenterologists, gynecologists, and a number of other specialty doctors, with no one who can really oversee the overall coordination of all of this "care", which is a job usually left to primary care doctors, but a lack of decision-making authority on whether the care will even be paid for effectively limits U.S. Primary Care doctors' ability to truly coordinate patient care in an effective manner).

Last year, The New York Times featured an editorial which concluded that our abysmal rankings for chronic disease care was best summarized in a single sentence: "The care Americans with chronic conditions received — or more often did NOT receive — ought to be a cause for shame."

These findings are a surprise to some, who love to trumpet U.S. healthcare as being "the best in the world", and while that description may be appropriate in some cases, the claim really should contain a footnote similar to those in drug advertisements which says something along the lines of "Results are not typical. Generally, U.S. Healthcare rates are the top of the world for those who can afford it, but the vast majority of patients with chronic conditions receive care that is comparable to developing countries."

How did we get into this predicament?

James Hirsch, in his book "Cheating Destiny: Living With Diabetes, America's Biggest Epidemic" describes the U.S. healthcare system as one that deals extraordinarily well in dealing with acute illnesses, but not really designed to handle chronic conditions which are becoming increasingly common as medicine moves away from a model of eradicating diseases to a model of managing diseases on a chronic basis, without actually curing very many maladies.

The disconnect is that the U.S. system will readily pay to amputate limbs or will readily pay for heart bypass surgery, but will make patients jump through all sorts of hoops to cover the very things (including coverage of education, medicines, and testing supplies, while simultaneously nickel and diming them for such basic care) that could easily prevent such drastic treatments from ever being a necessity.

Aside from the cost, the main issue of lack of coordination among the various medical providers involved. After all, doctors can make recommendations, only to have their recommendations overruled by those who actually pay for patient care. Referrals and pre-approvals are perhaps two of the most notable examples of just how the disjointed U.S. healthcare system creates barriers to effective chronic disease care.

A handful of U.S. healthcare providers, most notably Kaiser Permanente, scores very well in this regard (in spite of frequent complaints about getting insulin pump coverage from many patients in the Kaiser system). But Kaiser is somewhat unique in the world of healthcare in that everyone (doctors, nurses, lab technicians, pharmacists, specialists, educators, etc.) in the Kaiser system is on Kaiser's payroll, and there is excellent system-wide coordination of care. But in the more typical U.S. healthcare model, the PPO (preferred provider organization) plan, there is no centralized coordination of care, rather the care-givers are paid for each treatment procedure performed, but they are generally not rewarded (financially, at least) for overall patient outcomes. And for those left completely out of the system due largely to costs, the health outcomes are quite poor, which helps to explain the comparatively low U.S. rankings.

As politicians promote their healthcare agendas, however, another potentially important player is stepping in and could profoundly impact this equation: large pharmacy chains.

In much the same way as small corner grocery stores and bodegas are increasingly being seen by public health officials as linchpins in public health campaigns [see here for details] as part of the solution rather than part of the problem, we are seeing some fundamental but important changes in the way healthcare is delivered, we may soon see another important player use its influence on care for some with chronic conditions.

Walgreens Takes Care

In July 2009, one of the nation's largest pharmacy chains, Walgreen Corp., announced plans to pilot a program offering chronic disease care in its 345 "Take Care" walk-in health clinics found in 19 states. Until this plan was announced, these had mostly focused on routine health problems, like sore throats, ear infections, etc. rather than dealing with chronic care.

Although company CEO Greg Wasson declined to specify where the pilot program would run, we do know that these programs will focus (at least initially) primarily on the more common type 2 diabetes, probably with focus on how patients can incorporate different elements of their care ranging from diet management and exercise into patients' treatment plans. Although that still leaves nearly 3 million Americans with type 1 diabetes out of the equation, if the type 2 treatments work, we could see type 1 treatment added down the road.

CVS Maintenance Choice

Meanwhile, although rival CVS has similar Minute Clinics in many of its stores, that company hasn't created a chronic care platform yet, but could depending on the Walgreen's experience. But CVS has been working on an issue that is a barrier to drug compliance, specifically working to better integrate its large pharmacy benefits manager (Caremark) seamlessly into its retail stores. According to the company, CVS Caremark is now presenting its [relatively new] "Maintenance Choice" offering to payers. Maintenance Choice allows consumers to purchase 90-day prescriptions [for chronic conditions] at CVS stores for the same price as at mail."

Although analysts still question the economics of the CVS Maintenance Choice program, there is no denying the program's growth. Patients don't really care how CVS makes money, however, but the program does deliver genuine patient benefits. Rather than dealing with cumbersome mail-order delivery which is often a deterrent to drug compliance (that, along with cost), increasing numbers of patients can walk into their local CVS retail pharmacy and pick up a 90 day supply of insulin and other diabetes-related prescriptions and pay the same price as if they ordered them from Caremark by mail.

(This might also help to resolve the complaints of improperly shipping insulin without temperature-controlled shipping packages, but also makes it easier for patients to deal with.)

Both programs are still in their infancy, but both have potential to influence patient outcomes, especially for patients with chronic conditions such as diabetes.

Only time will tell.


Red Sphynx said...

Scott – this is an interesting post with a lot of info that I'd not seen before. Thanks.

...But there's something dropped whenever you talk about the sorry state of diabetes management and don't use the word "carbohydrate".

Red Sphynx said...

I wonder how it would change my PPO if they were paid based on my A1c. Would they quit telling me to eat more carb and less fat for my type 2 diabetes? said...

Scott, as you know very well, the overall health care system, just like each individual's health care, is very complicated. A one-size-fits-all approach is ineffective and enormously expensive.

In the case of diabetes, as you mentioned, there are big differences between Type 1 and Type 2. In many cases, Type 2 diabetics could be educated to eat low-carb diets, thus avoiding expensive medications and later complications like amputation and blindness.

I can't speak for anyone else, but in my experience, almost all my health care providers have brushed off my requests for dietary (non-prescription) approaches. Instead, they have urged me to eat a "balanced" (high-carb) diet, and then to cover the glucose spikes with pills or insulin.

The over-prescribing of America is a very costly and unhealthy problem. Turning the treatments over to drugstore chains will not help, nor will the current health care debates over who will pay for all the drugs. Until Americans learn to make meaningful lifestyle changes, all the competing drug payment schemes are the wrong prescriptions for America's physical and fiscal health.

Scott S said...

Thanks for your comments.

The issue of carbohydrates is a sore spot, and it's one that the self-appointed American Diabetes Association, which is really a trade association of doctors but excludes many others including nurse educators seem to be only acknowledging only after being forced by study after study proving its worth. Having said this, when it comes to reform, the U.S. cannot afford to count any party who delivers care, including drugstore chains when it comes to cost containment.

As for lifestyle changes, while it is true that the U.S. system tends to rely too much on drug treatment, there are also problems with the food system in the U.S. in that overprocessed foods are those that get the most attention while healthier foods tend to be found on the periphery of a typical U.S. supermarket thanks to things like slotting fees paid for by big marketers including companies like General Mills, Kraft, Nestle, Coca Cola, Pepsi and Procter & Gamble, while small farmers and healthier fare don't get the same attention or displays.

There is a move towards more "whole foods" (not to mean a specific food retailer) thanks to organizations like Slow Food USA, which is helping to promote the film Food, Inc. and that agenda, but these organizations also need a place in the conversation, not to be systematically excluded from the table thanks to high-priced lobbyists.

The big issue is that we as consumers also need to be willing to influence change with our dollars and votes, but that is relatively uncommon.

Camilla said...

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Camilla said...

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Camilla said...

Fun that you like my blog. Iam not good in english but little. Are you reading my diabetes blog? You can go in to google translate from swedish to english :)