Dr Sherman serves as the Medical Director for the Employers Health Coalition, Inc, Canton, OH. He is also the consulting Medical Director for the US benefits team at Wal-Mart Stores, Inc, and the Medical Director of RightOpt, Buck Consultants at Xerox private health insurance exchange. Dr Sherman is a member of the clinical faculty in the Department of Medicine at Case Western Reserve University School of Medicine, Cleveland, OH. He is a member of the Board of Directors for the Integrated Benefits Institute. Dr Sherman has presented workforce health and productivity management strategies to diverse audiences and has published many related articles.
In a recent interview, Dr Sherman discussed diabetes management in the workforce, focusing on issues of medication nonadherence.
Q: Based on your experience, what percentage of the workforce population has been diagnosed with type 2 diabetes?
Dr Sherman: Across the organizations that I represent, the prevalence of diagnosed type 2 diabetes mellitus in the workforces ranges from 6% to 9%.
Q: Have the organizations you represent assessed the impact of diabetes on productivity and/or presenteeism?
Dr Sherman: We have not measured it directly, but we have applied modeling tools in an effort to gauge the impact on employees. In particular, we found that the American College of Occupational and Environmental Medicine's Blueprint for Health tool is useful in providing insight into disease-specific health and productivity costs.
Q: Approximately how much of every dollar that is spent on healthcare goes to support a patient with diabetes?
Dr Sherman: In my experience, costs that are directly attributable to diabetes average approximately 5%. However, I would add the caveat that diabetes costs are frequently underestimated, because the majority of the analytical tools measure the cost of the diabetes diagnosis rather than the total costs incurred by a patient with diabetes. As a result, we tend to underestimate the cost impact of diabetes-related complications, as well as of closely related comorbidities, such as obesity, dyslipidemia, and high blood pressure. For example, individuals with diabetes are twice as likely to have heart disease, but current analytic approaches frequently fail to include those costs in the overall measurement of diabetes costs. The result is that employers risk underestimating the significance of effective diabetes management.
Q: Does your organization sponsor condition management programs that are targeted toward employees with diabetes? If so, please describe the diabetes programs.
Dr Sherman: Yes, we are involved in several different condition-specific programs, including one for employees with type 2 diabetes. Family members are eligible to participate in these programs. There are several incentives for individuals to participate, including zero-dollar copayments for selected generic medications and/or blood glucose testing supplies. Of course, these incentives are based on active, ongoing participation in the program.
Q: Have you evaluated the impact of the current condition management programs?
Dr Sherman: We have not yet collected enough data to quantify the impact of the programs. As we amass more data, we intend to look at a broader set of metrics, such as all diabetes-related costs and the distribution between ambulatory services, emergency department utilization, and hospital-based utilization, including rehospitalizations. We are also hoping to evaluate absenteeism and presenteeism that are attributable to diabetes and diabetes-associated conditions. By analyzing the broader impact of these programs, we expect to discern their value in a way that resonates more clearly for employers, beyond cost control.
Q: As part of your overall efforts, have you also evaluated medication adherence in your employees with type 2 diabetes?
Dr Sherman: Yes, we have evaluated adherence, and found it to be suboptimal in our workforce population.
Four years ago, our coalition published the results of a study that aggregated medication adherence data by physician rather than by patient. In our research, which included approximately 4000 commercially insured individuals with diabetes, we found substantial variability in physician-level patient adherence; some physicians had patients with consistently poorer medication adherence than others. The results were consistent across several medication classes, including diabetes, hypertension, and dyslipidemia. Physicians have a critical role in counseling and communicating the importance of medication adherence to their patients, independent of other interventions that may be implemented in an effort to improve adherence.
Q: What interventions have employers undertaken in an effort to improve medication adherence among their employees and their dependents with type 2 diabetes? Have these interventions been successful?
Dr Sherman: Several employers are offering value-based insurance designs that have reduced or waived copayments for certain drugs. Although these designs have shown modest improvement in adherence (ie, increase in adherence by 1.5% to 6%), clearly there are more fundamental issues contributing to nonadherence that need to be addressed. Therefore, I think it is important that we look beyond the financial considerations. There are fundamental patient awareness issues that must be addressed, and thus far, most large-scale interventions have not been particularly successful.
Q: Overall, what are the largest unmet needs in addressing medication adherence among patients with type 2 diabetes mellitus?
Dr Sherman: There is a need for substantially more diabetes education and awareness regarding the importance of self-management, including adherence to prescribed medications. These initiatives must address foundational elements in people's lives that affect their perception of health as a priority. With wage stagnation in recent years, many individuals are under financial pressure, and there is no easy fix for that. People must be more engaged in their own health and must recognize that their health should be more of a priority than it is currently; this is likely best achieved through a multidisciplinary effort that includes all members of the healthcare delivery team. Although progress in medication adherence and self-management can be achieved, it remains a challenge to fully engage individuals in their own care. Novel approaches may be needed to improve adherence; for example, drug delivery devices that reduce the need for active patient involvement.
Q: As a representative of the employer segment, what are your expectations regarding contracted payers and the management of your employees with type 2 diabetes? Have those expectations been met?
Dr Sherman: In my experience, payer-led chronic condition management programs have had limited success and, overall, substantial opportunities exist to improve condition management. Although case management may be effective for the highest-risk individuals, the broader patient population requires a different type of support. The focus needs to shift away from managing the disease to supporting life activities in spite of the disease. As such, this more comprehensive approach becomes more patient-centric and is more likely to attract patient interest and engagement. Payers may be able to contribute, but in my view, chronic care management is more likely to be effective in an integrated, coordinated primary care setting.
Biography
An Interview with Bruce Sherman, MD, FCCP, FACOEM