Glycemic Control Is the Bottom Line

Dennis P. Scanlon, PhD: I sort of sense a tension, but also agreement here, that there’s a fine line between the balancing act of what’s right and what’s appropriate given the many choices, but at the end of the day, how clinicians and patients can get what’s needed. Beyond what we’ve talked about, are there any ideas or solutions about how we can get payers, providers, and patients to sort of work this out a little more effectively?

Mary Ann Hodorowicz, RDN, MBA, CDE: I’d like to jump in on that, because I took some notes last night. Just like this panel is doing this “think tank,” and exchanging of ideas, why can’t payers like Aetna or UnitedHealthcare have think tank summits where they bring the providers and the payers together, at least once or twice a year in different regions of the country, to discuss the issues on each side of the fence to make better payer decisions, better provider clinical decisions, and to get the people together? Not to bring politics into this, but one of the things that people like about President Trump is that he likes to talk to people. Let’s get the people in the room. Let’s get all of the chief executive officers of the oil companies, and all the CEOs of the car companies, and let’s talk and have an understanding. I think that would be a really important step forward.

Kenneth Snow, MD, MBA: Well, I’ll tell you that is actively going on, particularly in places where there’s a relationship on value-based contracting or an accountable care organization (ACO) where the physician group has taken on some risk, or has taken on some reward if their patients do well. There are usually quality metrics within that, so you can’t do well cost-wise by doing poorly clinically.

For instance, one common metric is an A1C (glycated hemoglobin) over 9%. No one should have an A1C over 9%. We will have conversations with ACO partners where they want to spend that money. We want them to spend that money, and we want to get that A1C for that member down. And we’re discussing ways that we can do that and leverage whatever’s available to make sure we know if there is an issue of inadequate therapy that they’re receiving. Is it inadequate education, and they need to utilize their benefit to see an educator or a nutritionist? Is it a pharmacy issue? Do we need to mobilize whatever resources are available to make sure that the therapy gets covered? So, those conversations are now occurring.

Zachary Bloomgarden, MD: Honestly, saying that the A1C over 9% is the issue is really far away from some of the science, because there is very good evidence that a person who develops diabetes, let’s say, at age 65, has a life expectancy of well over a decade. And we have good trials that compare A1Cs of less than 7%, or with A1Cs of greater than 8%, and show that retinopathy occurs more commonly. Myocardial infarction occurs more commonly. Careful analysis of the cardiovascular outcome trials shows that it’s really all about glycemic control. And so, what we want and what we think is appropriate is to encourage approaches to therapy that don’t cause hypoglycemia, don’t cause weight gain, and do lead to excellent glycemic control. It’s constantly a moving target because we have better treatments.

Robert Gabbay, MD, PhD, FACP: I think we need a greater sharing of information and transparency. There’s no reason that every provider shouldn’t be able to know, when they’re talking to a patient, about what insulin to go on, or which one would be the cheapest for them? That should be clear information that is just available at the point of care. And then, the other piece is, if we want to sort out the high costs of insulin, we really need to understand what goes into that. So, we need greater transparency on how this process works, because right now it’s pretty murky.

Dennis P. Scanlon, PhD: How prices are determined.