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A practical solution for managing diabetes

Addressing the needs of all diabetic members

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Diabetes is one of the most important health challenges facing the U.S. Its impacts on health, health spending, and business productivity are already high, and, without proper interventions, promise to go higher still. That’s why OptumRx has developed a comprehensive approach to managing and controlling diabetes.

We asked David Calabrese, who is the President of OptumRx to give his perspective on what makes the OptumRx Diabetes program special:

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"The OptumRx Diabetes Management program offers a market-leading program that helps members control blood sugar, A1C levels and co-morbidities. Our unique combination of advanced analytics, targeted outreach for improved member engagement and comprehensive clinical intervention allows members to achieve positive results and optimal health outcomes. Through Machine Learning and Artificial intelligence, we are able to identify varying levels of risk for disease progression and complications, and tailor clinical interventions to improve overall results per individual."

David Calabrese, Chief Pharmacy Officer of OptumRx


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We’ll explain more about the program below. But first, let’s quickly review some of the basic contours of the problem. (You can explore the origins and scope of the diabetes epidemic in much greater detail by using the “Related Resources” on the right.)

Epidemic proportions

According to the Centers for Disease Control (CDC), diabetes is an epidemic that currently affects over 30 million Americans, a number that is forecast to rise to nearly 55 million people over the next decade.1, 2

When we add the number of people with prediabetes (who are at increased risk of developing type 2 diabetes), more than 100 million Americans are impacted by this epidemic.3

This chart illustrates the growth in type 2 diabetes in the U.S. through the year 2030:

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Population Health Management. Diabetes 2030: Insights from Yesterday, Today and Future Trends. Published February 1, 2017.

Sugar sickness

There are two types of diabetes. With type 1 diabetes, the body doesn't make enough insulin. In type 2 diabetes, the body cannot use its own insulin as well as it should. Type 2 diabetes accounts for about 90% of all diagnosed cases of diabetes.1

Ordinarily, we use insulin to regulate the sugar (glucose) in our blood. When the body doesn’t have enough insulin, or can’t use it effectively, sugar builds up in the blood, which we call diabetes.1

The consequences of uncontrolled blood sugar can be severe. High blood sugar levels can lead to heart disease, stroke, blindness, kidney failure, and amputation of toes, feet, or legs. Specifically:

  • Diabetes is the leading cause of kidney failure, lower-limb amputations, and adult-onset blindness.4
  • More than 20% of all health care spending is for people with diagnosed diabetes.4
  • Diabetes is commonly ranked as the seventh leading cause of death in the United States, but may be much higher.4

Diabetes spending

Over time the cost of diabetes-related care has risen sharply, and now constitutes one of the primary drivers of health care spending in the United States. Total spending for diagnosed diabetes in 2017 was $327 billion, a 26% increase from 2012.5

Diabetes now accounts for over 20% of all health care spending in the U.S.5

Top cost drug class

Any discussion of the cost of treating diabetes needs to include the cost of the drugs used to treat it. Currently, the cost of diabetes medicines is plagued by the twin problems of increased utilization and rising unit cost.6 Indeed, total spending on diabetes medications outstrips all others, even cancer drugs (see below).

This chart demonstrates how diabetes has consistently stayed at the top of the drug spending list (unadjusted for discounts or rebates):

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IQVIA Institute. Medicine Use and Spending in the U.S. A Review of 2017 and Outlook to 2022. April, 2018.

Costs set to explode

We mentioned $327 billion in total costs for diagnosed diabetes in 2017. This includes $237 billion in direct medical costs and $90 billion in reduced productivity to business.5

And yet the share of spending payers are dedicating to people with diabetes continues to rise. The reasons are simple: the population of diabetics is increasing, and the costs associated with treating them are also increasing on a per-capita basis.6

This projection shows diabetes-related health care spending rising rapidly in the coming decade or so – to more than half-trillion dollars per year:

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Population Health Management. Diabetes 2030: Insights from Yesterday, Today and Future Trends. Published February 1, 2017.

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Diabetes cost drivers

Since type 2 diabetes accounts for the vast majority of all diabetes diagnoses, we will focus our analysis there.

Diabetes is highly dependent on patient self-management.7 Some people with type 2 diabetes can manage their diabetes with healthy eating and exercise.8 In other cases doctors may also prescribe medications and/or insulin to help the patient meet their target glucose levels.8

In either case, it’s very important for patients to carefully follow their prescribed regimen.9 For example, not taking prescribed medications correctly may lower blood glucose, and cause insulin levels to go up. When this happens, the medicines become less effective.9

Unfortunately, studies have shown that almost 50% of diabetes patients fail to reach their clinical blood glucose goals.7

Patients who don’t stay adherent to treatment place a significant burden on both themselves, and on the larger health care system, with increased costs, morbidity, and mortality. It is estimated that diabetes accounts for over $24 billion in wasteful and avoidable spending – the second largest avoidable health care cost in the U.S.7

The OptumRx solution

The OptumRx Diabetes Management program can help members achieve positive health outcomes and control costs. Controlling diabetes helps to improve health outcomes and may reduce average health care costs up to 10% — based on fewer hospitalizations and ER visits.10

The OptumRx Diabetes Management program provides targeted guidance and services designed to prevent costly and clinically dangerous complications. The program consists of fully integrated management strategies that bring together data, insight and clinical skills from a broad range of sources, including pharmacy, medical, ancillary care, and lab results. Using machine learning and artificial intelligence, we focus on controlling diabetes by identifying risk levels of members.

  • Lower-risk diabetic members are offered basic diabetes education to improve their understanding of the disease. We monitor these members daily, and intervene at crucial points in their care to help them stay adherent to their medications.
  • High-risk members are offered more comprehensive and personalized care, connecting them with certified diabetes educators for more hands-on clinical expertise and support.

Our unique combination of data, analytics and health care expertise serve as the foundation of our diabetes solution. For example, a crucial component of the program is medication adherence monitoring. We monitor medication compliance for antidiabetic therapy and 18 other medical conditions, including common co-morbidities associated with diabetes. In addition, our gaps-in-care program will retrospectively review our member claims for chronic diseases and close any gaps in medication therapy by actively reaching out to the patient’s provider.

The diabetes management program is another example of how OptumRx is tackling the biggest challenges in health care. Click here to see an in-depth discussion of the details. Or, see the list of associated resources on the right-hand side of the page.

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  1. Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion. Diabetes and Prediabetes. Page last updated: January 24, 2019. Accessed February 27, 2019.
  2. Population Health Management. Diabetes 2030: Insights from Yesterday, Today, and Future Trends. Published February 1, 2017. Accessed February 27, 2019..
  3. Centers for Disease Control and Prevention. Prediabetes: Your Chance to Prevent Type 2 Diabetes. Page last updated: February 22, 2019. Accessed February 27, 2019.
  4. Centers for Disease Control and Prevention. About Diabetes. Page last updated: June 1, 2017. Accessed on February 27, 2019.
  5. American Diabetes Association. Diabetes Care. Economic Costs of Diabetes in the U.S. in 2017. Published March 2018. Accessed on February 13, 2019.
  6. Internal OptumRx data.
  7. American Journal of Managed Care (AJMC). Strategies for Addressing the Cost of Nonadherence in Diabetes. Published on: August 21, 2017. Accessed February 27, 2019.
  8. American Diabetes Association. Living With Diabetes /Treatment and Care/ Medication. Accessed on February 27, 2019.
  9. Centers for Disease Control and Prevention. Living with Diabetes/Stay Healthy. Page last updated: April 6, 2018. Accessed February 27, 2019.
  10. Journal of Managed Care Pharmacy (JMCP). Medical claim cost impact of improved diabetes control for Medicare and commercially insured patients with type 2 diabetes. Published October 19, 2013. Accessed February 27, 2019.
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This article is directed solely to its intended audience about important developments affecting the pharmacy benefits business. It is not intended to promote the use of any drug mentioned in the article and neither the author nor OptumRx has accepted any form of compensation for the preparation or distribution of this article.

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