6-minute recap of key takeaways
What else can be done to address the behavioral health needs of patients? I hear screening and referral but we still have the stigma and insufficient access to specialists.
The vision is to de-centralize the knowledge and have the ability to have someone see a mental health professional virtually. You are seeing all these companies pop up where they will engage you via text, via Zoom - however you want to engage. That is the future of mental health. What I am lobbying for is to make it front and center for chronic disease because there is no health without mental health. If we keep trying to put a Band-Aid on the overall problem, we are never going to solve it. I think we need to encourage the Payers and show them the data, which is part of what we are going to do with this study. We will show them data that compares those who have a mental health intervention in addition to the rest that Cecelia is going to provide and show them better outcomes. It really is extremely obvious for my point of view, yet they still want to see the data. And certainly, in primary care there is tons of data that if you layer in mental health, even in primary care, the outcomes are very cost efficient for the payer.
There is a “no wrong door” approach. Stigma is a big issue. There are many people who are marginalized in society, as well as in the healthcare delivery system, because of their diabetes, not even solely because of their mental health condition. We are really pushing for the “no wrong door”, so when I am ready for that care, I can receive it. We are very hopeful that we can see some data from Cecelia Health, who has been identifying this for us over the years, being able to do some direct referrals at the moment when people are ready for that help.
There are two parts. One is, with a lot of apps showing up and different technologies, it is critical that the engagement takes place in a medically proven protocol. We spent the last decade developing clinical pathways. Someone is overwhelmed with their diabetes – how are you going to handle that from an emotion perspective, the behavioral perspective and do it in a safe way? All those protocols are critical – and whether they use Cecelia or some other technology - it is a must have. The other part is paying attention to social determinants of health – the human part – and looking at food insecurity, making sure we’re leveraging the resources provided by the payer that might even provide resources to food, food pantries, community resources and that is critical for us to take a look at the whole patient and make sure that whatever entry point they have to our eco system, we are delivering the whole value to them.
What is the future of telemedicine reimbursement post Covid? Everyone seems to agree that it will be important, but will the coverage fall of as time goes on.
What I am hearing today is very exciting. It’s going to be how we leverage telemedicine from our perspective going forward. Yes, telemedicine is here to stay. Yes, Payers want it. For post-COVID, which will be with us for a while, our vision is to have our members continue to have access to these valuable resources. One reason why we partnered with Cecelia Health, one of the first community-based organizations that we did partner with, is access to CDEs. We saw that there were many of our members who couldn’t access CDEs, especially through their community. Now, over the years, as Cecelia Health has evolved its thinking and we are with them on this journey, the second part of the vision is to quickly find if members have some life event that has made them more vulnerable. Could be depression, anxiety, loss of job, loss of home, new onset hypertension. Whatever it is, a provider like Cecelia Health is embedded in our network system, they now have access to all those resources as well. They don’t have to say “Healthfirst, may I refer someone for this particular social need?” Instead, they have access to whatever we have access to. Evolving so we can actually impact quality of life and if we are able to put in place the [Virtual Clinic Model] we discussed, I think we can actually get to the point where our members don’t have to experience complications, they don’t have to see their lives fall apart. They are owning their condition and making it work for them and then also contributing to the dialogue about what is best for people living with diabetes. So, reducing the incidence of complications of diabetes, which are devastating, but also making sure that when a life event happens, allowing that member to have access to these services they need as quickly as possible.
I'm impressed by your understanding of diabetes and the whole-patient view that you have of the condition. In your estimation, how well is diabetes understood by the rest of your organization and your payer peers? Has COVID-19 changed payer understanding and their approach?
We are all learning, and the reason is because most of us are not living with diabetes ourselves, so we are speaking to this from the outside in. The opportunity is to begin to learn more about what the actual experience is, as well as the evidence-based root causes of why people with diabetes do well and don’t do well. We have much to learn, but I feel very lucky to work in New York State where we have a pretty proactive forum of medical directors from all health plans who meet to look at best practices and certainly in the MedicAid program promote best practices as well.
What is expectation around reimbursement for telehealth and remote diabetes care management? Will it go back to lower level or stay at the higher level.
At least from the point of view of CMS, we have seen over the period of COVID attention to make sure people get access to telehealth. What we are doing as a Payer is encouraging our physician and other practices to qualify for ongoing telehealth. Telehealth is an investment; it's not just picking up your phone and speaking to a patient. There has to be an attention to privacy, confidentiality, etc. We are going to have to be sure that we have a contingent of practices that are equipped to do telemedicine. We have a value-based model at HealthFirst, so for us telehealth showed value anyway. I think that many insurers feel the same way - that this is going to be the way that we serve our clients better in the future, whether they are consumers, small businesses, large businesses, etc. I think there is going to be a shift to telmedicine, this blended reimbursement model. How quickly all the payers get there depends on who is driving that marketplace.
I like the idea that the clinical team can work with the patient wherever they are, due the flexibility that telehealth offers. However, the way current MD licenses are issued are on a state level, and insurers often won’t cover remote visits for out-of-state patients. How does Cecelia Health plan to overcome this hurdle with your Virtual Clinic?
The network for the Cecelia Health Virtual clinic includes Endocrinologists licensed for every state in the United States. All patients will be seen virtually by an Endocrinologist licensed in the state where they reside. The goal is to ensure that they remain with the same CDCES, as that is the person with whom they will interact with regularly, building a trusting relationship in the process. By ensuring that the day-today management and data gathering approach remains consistent, we expect that switching states should be a fairly seamless process for someone enrolled in Cecelia Health’s virtual clinic.
Please share more information about the virtual clinic. When is it due to launch? What services will it offer?
In 2019, the Helmsley Charitable Trust funded the Jaeb Center’s pilot study to assess whether CGM could be successfully introduced outside of a clinic, using Cecelia Health’s CDCESs to administer training, coaching, and ongoing support. The results showed that every participant was able to adopt and adhere to CGM for the length of the 12 week study. The combination of their adoption of the technology and education from Cecelia Health’s expert clinicians led to the following outcomes
- 1.3pt Decrease in A1c Levels
- 11% Increase in Mean Time in Range
- Reduction in Severe Hypoglycemia (74% of patients at start to 26% at end)
- Decrease in Diabetes Distress (Down from 91% at start to 59% at study end)
As a result, we are launching the first vertically integrated Virtual Diabetes Specialty Clinic on August 1st, 2020, that will deliver the full spectrum of diabetes and mental health personalized care to improve both clinical and psychosocial outcomes for people with diabetes.
Our team of licensed endocrinologists in all 50 states will be able to use CGM data and utilize CDCES recommendations to identify dosage and titration changes to enable PWDs to live and empowered life with diabetes. The intent is to reduce geographic and economic barriers to care for people with type 1 and type 2 diabetes in the United States.
What does the panel think of the 2019-2020 ADA guidance on the use of a low carb way of eating as the most effective means of blood glucose control?
The 2019-2020 ADA Standards of Medical Care in Diabetes has a lot to say about the nutrition recommendations for PWD. To put a single spotlight on low carb eating plans may result in a broad shadow over other important recommendations and other meal plans.
We know for a fact that there is not ONE ideal plan (percentage of calories from carb, protein and fat) for people with diabetes. Therefore, it is important to find an approach that a person is willing and able to follow, and to achieve an appropriate energy intake.
There are many meal plans that offer benefits. A low-carb plan can lower blood glucose. The Mediterranean Diet has demonstrated benefits in reducing risk of major cardiovascular events. The DASH diet is particularly effective in lowering blood pressure. The vegan plan has powerful antioxidant properties that fight disease. A low-fat plan is effective for weight loss and for reducing risk of diabetes. All of these have demonstrated benefits and overlapping benefits.
Therefore, we are free to help patients select the meal plan that fits their personal preference and rest in the knowledge that they all can be safe and effective.
Are you seeing an increase in CGM adoption among the Type 2 population to overcome limited access to in-person lab visits? Even those who aren't yet on insulin?
For Type 2, CGM coverage can be a challenge which makes adoption harder. Some clinics have received Libres to provide patients to wear with a few sensors. This can allow the patient to see what it's like wearing a CGM/see the data they can get. It also gives the HCP a better picture of how a patient is doing and can sometimes be used to go to insurance companies to request coverage. With this being said, we are not seeing a direct increase of CGM usage in the Type 2 population due to lack of access to lab testing.
The key with CGM adoption (no matter the therapy) is for the patient to understand the value, the "why CGM?". CGM can be a powerful tool to show a patient how they could possibly benefit from other therapies. The key is having someone help them understand the data and teaching them how to use the data to help manage their diabetes. It is fairly common to see patients started on CGM first and then move to a pump because they have data to see how other therapies could benefit them.
What is the frequency of remote visits conducted Cecelia Health with people living with diabetes? How frequently do you view patient data?
The frequency varies based on the type of referral that is sent and the patients’ needs. Some clinics only requested we help a patient upload prior to their visit and these patients would typically get one session with a CDCES. The goal is at least 2 visits (maybe one prior to a clinic appointment and another visit 1 week later to review data/reports and anything after the patients HCP appointment), but we have had as many as 7 visits spaced at 1-week intervals. If data review is part of the referral, we are typically doing this weekly for 4-5 weeks.
In addition to diabetes-related technology, such as BGM/CGM, what is your view on the role of other technologies that track co-morbid conditions, such as BP, weight, heart rate/rhythm and depression? How are these technologies integrated into the services your clinic offers?
We request that, in preparation for the visit, the patient weighs them self and does a home blood pressure (when possible). Most patients are willing to do this. We do not routinely ask them to check their pulse, but if indicated, I will ask them to do this during the televisit. In a small number of cases, where hypertension is a major concern, blood pressure has not been well-controlled, and the patient cannot measure their own blood pressure at home (or have a family member do it), I have arranged for the patient to come to our diabetes center for a quick nurse visit for vital signs, and if needed, lab testing.
In previous telemedicine projects, we have provided patients with scales as well as home blood pressure devices that transmit their blood pressure and pulse to us. These were very useful. As telemedicine becomes more routine, it is hoped that insurers will pay for such devices for selected patients.
Re: depression. Our LPNs prepare ("room") the patient prior to the provider televisit (including providing instructions on how to connect for the video visits). This preparation also includes administering over the phone the PHQ. They first ask the 2 questions in the PHQ-2, and if the score is 3 or higher, they open the full PHQ9 and ask the remaining 7 questions. The answers are entered into our EMR. We are immediately alerted if the score is 10 or higher or if there is a positive response to the suicide question.
What is the payment model that your clinic currently uses? Is it one that focuses on quality as opposed to fee for service? Do you think that it’s a valid concern that some hospital systems get paid more for a patient who gets admitted for DKA three times a year, and not for services (remote or in person) to prevent those admissions in the first place?
SUNY Upstate still primarily uses a fee-for-service model. The fact that preventive services are under appreciated (and under-funded) has been a long-standing concern and remains a major concern. What we are seeing in the industry overall however, is that increasingly we are shifting to a value-based reimbursement methodology.
When it comes to effective diabetes management, the upfront costs of preventative care and educations are offset significantly by fewer complications and hospitalizations. This is a huge benefit to the health of individuals living with diabetes, as well as a financial benefit to both insurers and health systems.
The hope is that more health systems and insurers adopt this approach more broadly in the near future.
I believe there is a significant unmet need in chronic kidney disease among patients with diabetes. Do you agree that it appears to be underdiagnosed and the UACR test in particular is underutilized for identifying deteriorating kidney function? What do you think should be the approach to prevent that from happening?
At least once a year adults with diabetes should have a serum creatinine (eGFR) and urine albumin : creatinine measured. We are cognizant of this and do these measurements. When abnormal, it is important to further evaluate and treat the patient. Just ordering the lab test is not enough.
Practices have utilized different strategies to help busy clinicians remember to screen for CKD. To name a few:
- The EMR can be used to generate automatic reminders.
- People with diabetes, as part of their diabetes education, should be given a check list of tests that should be done routinely - not only lab work with recommended frequency for each test, but also eye, foot and dental exams.
- In some practices staff review records/flowsheets ahead of time and alert clinicians/pend orders when routine screenings are due (not only for CKD, but also A1c, eye exams, foot exams lipid panels, mammography, vaccinations etc). We do not have staff available to do this.
- We use a diabetes template note when we see our patients. The note displays most recent screenings relevant to diabetes (such as the most recent serum creatinine, eGFR, urine albumin : creatinine, A1c, lipid panel, ALT). This serves as a reminder to order tests when they are due.
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