Diabetes, Disparities, Demographics:Making a Difference

BCBSA Congressional Briefing

Eduardo Sanchez, MD, MPH, FAAFPVice President and Chief Medical Officer

Blue Cross and Blue Shield of Texas

October 12, 2011

Place Matters

Determinant of Diabetes?

• People living in low-income communities are 80% more likely to be hospitalized for diabetes or related complications, compared with those living in affluent areas.

Source: AHRQ

Relationship Between Social Determinants and Mortality in 2000

0 50 100 150 200 250 300

Area level poverty

Income inequality

Individual poverty

Low social support

Racial segregation

Low education level

Deaths (1000s)

Source: AJPHSource: AJPH

Personal Choice or Healthy Food Accessibility?

• Low income areas have 1/3 fewer grocery stores than higher income neighborhoods.

• Corner stores and gas stations typically charge 1½ times the price of similar items in grocery stores.

• Not having automobile or adequate public transportation can reduce access to affordable, healthy food.

• Less expensive foods are often high in calories and fat.

• Limited time and knowledge of food preparation can increase demand and consumption of prepackaged or processed foods.

Community Health and Food Access: The Local Government Role; http://icma.org/activelivingCommunity Health and Food Access: The Local Government Role; http://icma.org/activeliving

Diabetes Prevalence by Race/Ethnicity, Texas, 2008

State of Texas 9.7% 1,205,993

Race/Ethnicity Prevalence Estimated # of People

White, Non-Hispanic 8.3% 736,987

Black, Non-Hispanic 13.0% 251,543

Hispanic 11.1% 680,351

Other 7.5% 59,389

Source: Texas Behavioral Risk Factor Surveillance System, Statewide BRFSS Survey, 2008

Note: All reported rates (%) are weighted for Texas demographics and the probability of selection and thus are not derived from the simple division of numerator and denominator cases.Note: All reported rates (%) are weighted for Texas demographics and the probability of selection and thus are not derived from the simple division of numerator and denominator cases.

Texas Projected Diabetes Cases 2000 - 2040

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

2000 2010 2020 2030 2040

Nu

mb

er

of

Dia

be

tes

Ca

se

s

Hispanic (Prevalence = 12.3%) Black, non-Hispanic (Prevalence = 12.9%)

White, non-Hispanic (Prevalence = 8.5%) TOTAL (Prevalence = 10.3%)

Source: Texas Diabetes Council; uses 2007 diabetes prevalence by race/ethnicity from BRFSS and population data from the Texas State Data Center - Office of the State Demographer, Institute for Demographic and Socioeconomic Research. Uses 0.5 migration scenario.

Source: Texas Diabetes Council; uses 2007 diabetes prevalence by race/ethnicity from BRFSS and population data from the Texas State Data Center - Office of the State Demographer, Institute for Demographic and Socioeconomic Research. Uses 0.5 migration scenario.

New England Journal of Medicine 2010;363:1196-1199/23/2010

• There is a gap between the existing evidence that supports proven interventions and the translation of this knowledge into policy and practice.

• Diabetes care, simultaneous control of glucose levels, blood pressure, and lipid levels is achieved in less than 10% of people with diabetes.

• There is a consensus that effective and comprehensive strategies necessitate:

– a mix of evidence-based environmental, regulatory, and behavioral interventions at the population and individual levels;

– a shifting of health care systems from curative models suited to acute illnesses to more integrated primary care systems with considerable patient empowerment; and

– appropriate restructuring of financial and insurance systems.

National Strategy for Quality Improvement in Health Care

• Better CareImprove the overall quality, by making health care more patient-centered, reliable, accessible, and safe.

• Healthy People/Healthy CommunitiesImprove the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.

• Affordable CareReduce the cost of quality health care for individuals, families, employers, and government.

The Community Guide – Diabetes

• Health care system-level interventions

Case management interventions to improve glycemic control R

Disease management programs R

• Self-management education

– In the community gathering places (adults; type 2) R

– In the home (children, adolescents; type 1) R

– In the home (type 2) I

– In recreational camps I

– In worksites I

– In school settings I

Source: AHRQ

BCBSTX Diabetes Control Strategy

• Community Health

• Member Education – Web Site

• Member Wellness

• Metabolic Syndrome Program

• Condition Management

• Bridges To Excellence

• Patient-Centered Medical Home

• Accountable Care Organizations

Marathon Kids®

Kids walk or run 26.2 miles!

• Children participating in Marathon Kids exercised more, ate more fruits and vegetables, and had a better self-image than non-participants.

Promote Health/Prevent Childhood Obesity

• Free community and school-based program for K-5th grade

• Targets children most vulnerable to sedentary lives, obesity and Type 2 diabetes

• Challenges kids to run or walk 26.2 miles over six-month period

• Funded by corporations, foundations and private donations

• Offered in nine cities across the country, including Dallas, Houston, Austin, and El Paso

This program really works...

About Bridges To Excellence

• Bridges to Excellence programs are offered nationally by the Health Care Incentives

Improvement Institute (HCI3)

• Organization awards recognition to clinicians who demonstrate that they provide quality

care that meets or exceeds established guidelines

• Recognizes clinicians in all 50 states with “formal” programs in more than 22 states,

including BCBSNM, BCBSOK and BCBSTX

• Has the potential to significantly improve the quality of care experienced by patients with

diabetes and to reduce the financial and human burden of unnecessary hospital visits

and complications

Bridges to Excellence Results

Several studies have shown that BTE participation leads to:

Recognized providers are more cost-effective in treating patients with diabetes

Source: Bridges to Excellence “Five Years On: Bridges Built, Bridges to Build,” 2003 - 2008

Promoting Quality Diabetes Care:Bridges to Excellence

Number of Diabetics with At Least One Episode

Year RecognizedNon-

Recognized

2003 271 294

2004 260 351

2005 290 368

Diabetes Costs per Patient by Type of Provider

The BCBSTX BTE Program Experience

• Financial rewards program ($100 per BCBSTX patient per year) for physicians who have achieved BTE recognition in Diabetes Care and/or Cardiac Care

• Diabetes program initiated in June 2009 and Cardiac program started in June 2010

• In Texas, there are 356 Diabetes Care recognized physicians treating more than 14,500 members with diabetes

• Cardiac program has 168 Cardiac Care recognized physicians treating more than 1,300 members with cardiac disease

• BTE Program has paid out more than $975,000 in incentives since inception

• In 20 Texas counties, will give a bonus of $500 to any physician that is either currently recognized or achieves BTE Diabetes Care recognition by 12/31/2011 to cover data submission fees and offset administrative expenses for data collection and submission

Salud por Vida/Health for Life

• Focus on Five Texas Counties

• SPV/HFL Initiative Goals

– Improve medical management of diabetes

– Ensure patients receive all recommended services

– Enhance the availability and provision of diabetes self-management education

Energy Intake Energy Expenditure

Energy Balance

Individual Factors

Behavioral Settings

Social Norms and Values

Communities

Worksites

Health Care

Schools and Child Care

Home

Demographic Factors (e.g., age, sex, SES, race/ethnicity)

Psychosocial Factors

Gene-Environment Interactions

Other Factors

Government

Public Health

Health Care

Agriculture

Education

Media

Land Use and Transportation

Communities

Foundations

IndustryFoodBeverageRetailLeisure and

RecreationEntertainment

Physical Activity

Sectors of Influence

Food & Beverage Intake

A socio-ecological approach for preventing and a managing diabetes

Adapted from: Institute of Medicine, Progress in Preventing Childhood

Obesity, 2007, pg 20

results

Management vs. Prevention

Managing disease… Preventing disease…

…Great. …Better!