University unveils plan
to encourage use of medications to control diabetes
University employees and their dependents who have any form of diabetes will be able to receive some of their medications free through an innovative new pilot program aimed at encouraging the use of medicines that can help prevent the disease's worst long-term effects.
Beginning July 1 participants will be charged no co-payment for certain drugs that control blood sugar, lower blood pressure, cut the risk of heart and kidney problems, and ease depression. All of the drugs chosen for "free co-pays" have been shown to help prevent diabetes complications that can be debilitating or fatal. Co-pays for other drugs in the same classes will be reduced by 50 or 25 percent.
Participants also will receive educational materials to help them understand how to improve their health and reduce the chance of diabetes complications. More than 2,000 of the 69,700 employees and dependents covered by U-M benefits currently take medication for diabetes.
The concept for the program came from U-M research that has shown the potential health value of removing any cost barrier that might keep people with some chronic illnesses from getting beneficial medications, tests and screenings. U-M research also has suggested that the approach may save individuals, employers, insurers and society money in the long run by preventing or delaying costly complications ranging from heart attacks and strokes to blindness and amputations.
The U-M program, called MHealthy: Focus on Diabetes, is the first known in the nation to be designed specifically to evaluate the impact of targeted co-pay reduction for preventive medications. Although several companies have reduced or waived co-pays as part of employee health promotion or disease management programs, and at least one has reported cost savings linked to such programs, the specific impact of reduced drug co-pays has not been measured.
"Chronic diseases like diabetes pose a real and growing threat to the health of our employees and their dependents, and to our society. We must find a better way of encouraging prevention now so we can reduce the human and economic costs down the road," President Mary Sue Coleman says. "We hope this effort will yield solid results for our own community, and provide a model for others. Although it will cost us money in the short run, we anticipate it will save money and lives in the long run."
The decision to start with diabetes, says Executive Vice President for Medical Affairs Dr. Robert Kelch, stemmed from a University analysis that showed much room for improvement is needed in the use of preventive medications and other measures for diabetes among members of M-CARE, the U-M-owned managed care company.
The fact that diabetes affects so many people, and that proper treatment has been shown to reduce the risk of complications and early death by up to 50 percent, also played an important role.
"Because the evidence of preventive benefit from certain medications is so strong, and because the opportunity to improve is so great, diabetes is a natural place to start," says Kelch, who chairs the Michigan Healthy Community Initiative task force that has developed the program as part of a University-wide health improvement effort. He notes that similar analyses of preventive care for employees with cardiovascular disease and asthma revealed additional opportunities for future quality-improvement projects, which now are being considered.
The new program will be open to all U-M employees and their dependents with diabetes regardless of health insurance plans. U-M prescription drug benefits are offered through a single plan, allowing the program's effects to be evaluated.
The evaluation component of the program will be headed by Dr. Allison Rosen, an assistant professor of internal medicine at the Medical School, one of the researchers whose work inspired the new project. Rosen led a 2005 computer-model study that showed that making certain drugs free to older diabetics would prevent health problems and premature death, while ultimately saving money. She also has a paper in the April Journal of General Internal Medicine showing that half of older diabetics don't take drugs to protect their hearts and kidneys, and an editorial in Medical Care.
"Academics like myself have repeatedly demonstrated through study after study that increased co-pays decrease the likelihood that patients will adhere to their prescriptions, and that in turn this poor adherence to certain medications harms their health," she says. "But there has been a disconnect between what academia is demonstrating and what has been done in real-world prescription drug benefit design."
She notes that on a national level, employers have tended to increase the out-of-pocket costs to employees no matter what the potential long-term benefit of their drugs.
"This program will test whether we can improve both the quality and the value of care for people with diabetes, and will stand as an example of what can be done, with an in-depth evaluation to tell if there has been a difference," says Rosen, who also has appointments in the School of Public Health and VA Ann Arbor Healthcare System.
The program will offer free or reduced co-pays for the following classes of drugs that have been shown to help people with diabetes:
• Blood-sugar control drugs of any kind, including insulin, which can be used alone or in combination to help patients' bodies process sugar from food;
• Cholesterol-lowering drugs called statins, which can reduce the extra-high risk of heart attacks and strokes that people with diabetes face;
• Blood-pressure lowering drugs of all kinds, including newer classes of medications called ACE inhibitors and ARBs, which also can reduce cardiovascular risk;
• Antidepressants, which can relieve the depression that many people with diabetes suffer and can increase their chances of sticking to lifestyle and medical regimens.
• Employees and dependents that have M-CARE health insurance also will receive free yearly eye exams to try to catch early signs of diabetic retinopathy, a major cause of blindness.
During the next two years, U-M will evaluate how well the program is doing by tracking aggregate ordering and refill data from its prescription drug benefit system, as well as total health expenditures for all participants, and eye exam data for participants insured through M-CARE. The data will be compared with prescription refill data for the same medications from a group of non-U-M employees with diabetes who will receive educational materials but no co-pay reduction.
The project is being co-directed by Zelda Geyer-Sylvia, executive director and CEO of M-CARE; Dr. Mark Fendrick, professor of internal medicine and public health who co-directs the Center for Value-Based Insurance Design; and Dr. William Herman, director of the University's Michigan Diabetes Research and Training Center, M-CARE medical director for disease management, and a leading national figure in research on preventive measures in diabetes.
For information on the project and the Michigan Healthy Community initiative, visit www.umich.edu/~hraa/mhealthy.
The case for diabetes medication adherence
The latest edition of the Merck Manual says "about half of patients who leave a physician's office with a prescription take the drug as directed." Failure to take medication properly in general is estimated to cost 125,000 lives a year, and result in a 10 percent increase in hospitalization. It also costs nearly $100 billion for the treatment of disease complications and billions more in disability and lost productivity.
The federal Centers for Disease Control and Prevention (CDC) have reported that:
• 20.8 million Americans, or 7 percent of the population, have diabetes; 14.6 million of them are aware of this, but 6.2 million people are undiagnosed;
• Diabetes alone costs the United States $92 billion for medical care and $40 billion related to disability, work loss and premature death;
• The disease was the sixth-leading cause of death listed on U.S. death certificates in 2002, and likely is underreported;
• Adults with diabetes have heart disease death rates about 2 to 4 times higher than those without the disease; stroke risk 2 to 4 times higher; and about 73 percent either have high blood pressure or use medicine to control blood pressure;
• Diabetes is the leading cause of kidney failure, accounting for 44 percent of new cases in 2002. More than 44,000 people with diabetes begin kidney dialysis each year;
• About 60-70 percent of people with diabetes have mild to severe forms of nervous system damage that may contribute to foot and leg amputations;
The CDC also has shown that management of the disease through medication, diet and exercise works to prevent complications, such that:
• For every percentage-point drop in blood sugar levels people with diabetes reduce their risk of eye, kidney and nerve diseases by 40 percent;
• For every 10-point drop in blood pressure, they reduce their risk of any complication by 12 percent;
• Heart and blood vessel complications can be improved 20 to 50 percent when cholesterol levels are controlled;
• Severe vision loss due to diabetic eye disease can be reduced by an estimated 50 percent to 60 percent with early detection and treatment.