Dr Balfour is the former President and Medical Director at Sharp Rees-Stealy Medical Group, San Diego, CA. He served as President of the Sharp Rees-Stealy Medical Group Board of Directors between 1985 and 2014. Dr Balfour is a former Associate Professor of Medicine, Department of Medicine, University of California, San Diego School of Medicine.
He was President of the American Medical Group Association and a founding board member of the Council of Accountable Physician Practices. He is a Fellow and past governor of the American College of Physicians.
Sharp Rees-Stealy Medical Group started the first commercial accountable care organization (ACO) for Preferred Provider Organization (PPO) members in California with Anthem Blue Cross in 2011, and participated in the Pioneer ACO program for Medicare beneficiaries between 2012 and 2014.
In a recent interview, Dr Balfour discussed the management of patients with type 2 diabetes in the accountable care and integrated health system environments at Sharp Rees-Stealy Medical Group and Sharp Healthcare.
Q: How prevalent is type 2 diabetes among Sharp Rees-Stealy Medical Group's members?
Dr Balfour: The prevalence of type 2 diabetes is high among Sharp's members. Sharp has 18,000 members with diabetes, which is approximately 11% of our total membership. Nearly 20% of our members are seniors, and we have a substantial number of Hispanic members as well. The prevalence of diabetes is disproportionately high in these patient populations, and affects our overall diabetes prevalence rate.
Q: How does Sharp Rees-Stealy Medical Group evaluate the impact of diabetes on the health plan?
Dr Balfour: We look closely at hospitalization rates for our members with diabetes, because hospitalization is a major cost driver to the health plan. The specific metric that we use is bed days; that is, the number of admissions per thousand multiplied by the average length of stay.
Q: What is your organization doing to actively manage type 2 diabetes on a patient population level right now?
Dr Balfour: Patient population management of diabetes has been a major thrust in our organization for many years. In California, the commercial pay-for-performance initiatives are predicated on the concept of Perfect Care, in which quality measures are grouped into “all-or-none” bundles. In order to meet the Perfect Care requirements, participating organizations must meet the performance goal for all individual measures for a given patient, and any missing parameters result in a score of 0. Diabetes is an important component of this commercial pay-for-performance program, accounting for 20% of the total eligible payout.
We are very focused on Perfect Care, and Sharp Rees-Stealy Medical Group has performed extremely well, winning the American Medical Group Association Acclaim Award (their most prestigious quality award) in 2014.
Q: What provider-focused interventions have you implemented?
Dr Balfour: We perform a comprehensive gap analysis that we transmit to our physicians electronically. We give all providers a list of their patients whose hemoglobin (Hb) A1c levels are not under control, and encourage them to speak with their patients. The communications are typically informational, but the implementation of this intervention is truly a team effort.
We have social workers, case managers, and disease managers who play an important role in helping the physicians and the patients. Our efforts fit in well with the mission of accountable, patient-centered primary care.
Q: Have you measured the impact of your quality efforts on the health outcomes of patients with diabetes?
Dr Balfour: Yes, we have. There is no question that we have seen a substantial decrease in amputations. We have also seen a decrease in blindness among our patients with type 2 diabetes. There remains room for improvement, but our efforts thus far have yielded measurable gains in quality.
Q: How is Sharp Rees-Stealy Medical Group's relationship with the ACO set up?
Dr Balfour: We participated in the Medicare Pioneer ACO program until June 2014, via a limited liability corporation that included Sharp Healthcare, Sharp Rees-Stealy Medical Group, and Sharp Community Medical Group, an independent practice association. This program included approximately 1000 physicians, the 7 hospitals that are owned by Sharp, and several participating nursing homes and hospice.
Currently, we are participating in 2 commercial ACOs and expect to join another ACO in the near future.
Q: How are members with diabetes managed in the ACO environment?
Dr Balfour: We had several data challenges in the Pioneer ACO that limited our ability to effectively communicate information to our physicians and their patients. Only approximately 50% of the participating members had Medicare Part D coverage; the other members had supplemental insurance, TRICARE or US Veterans Association coverage, coverage through their spouses, or possibly no pharmacy benefits. We only had access to patients' pharmacy data from the Medicare Part D plans, and the pharmacy benefit managers operating in California were also missing data for a large percentage of members. As a result, there were major information gaps, and it was difficult to communicate robust patient-level data to our physicians.
Furthermore, we had no influence on formularies or on benefit structures—those elements were controlled by the payer, whether it was a Medicare Part D plan, supplemental insurer, or whoever was providing the health insurance coverage. It was difficult, because we did not know which medications patients were taking unless they had a medical encounter, usually an office visit. At that point, our physicians would go over the medication reconciliation very carefully, but it was very frustrating and time-consuming.
Regarding the commercial ACOs, Sharp-Rees Stealy Medical Group has been participating in a successful program with Anthem PPO members since 2011. Although formulary decisions are made by Anthem, the plan has pharmacy data for all its members, making it easier for us to keep our physicians informed.
Q: What has your organization done to encourage medication adherence by your members with type 2 diabetes?
Dr Balfour: Our case managers work with high-risk patients in an effort to improve their self-management skills, including adherence to prescribed medication.
In diabetes, we are fortunate to have HbA1c levels as a metric that corresponds to glycemic control, as well as informs the physician on how well the patient has adhered to prescribed therapy during a period of 6 to 8 weeks. If patients are not properly taking their medications during that period, their HbA1c levels will be elevated. As mentioned earlier, we provide our physicians with that information on a regular basis.
We also provide our physicians with patient-level medication refill rate information. However, in diabetes it can be challenging to assess adherence based on refill data, because the majority of patients take multiple drugs, and physicians are frequently switching or adding medications in an effort to maintain glycemic control with oral therapies.
Q: What interventions have been implemented for high-risk patients?
Dr Balfour: We had a program for patients whose HbA1c levels exceeded 9%. We trained all the primary care nurses to instruct patients on how to self-administer insulin, whether it was administered with a pen or a vial and syringe. In addition, the nurses educated patients to be aware about the risk for hypoglycemia. We found this approach to be effective from an educational standpoint, but there are other barriers we face regarding insulin.
Physicians are hesitant to start insulin treatment for multiple reasons. First, patients think they failed in their treatment, and are reaching the end of their chronic disease. Next, many patients are reluctant to administer frequent injections. Furthermore, it takes time to instruct the patient, and there are concerns about the risk for hypoglycemia.
To counter these concerns, we initiated this primary care–based patient-centric program and found it to be helpful in educating our higher-risk patients.
Q: What changes do you expect in managing members with diabetes in the future?
Dr Balfour: I think that cure is the ultimate goal, and there are researchers exploring the possibility of islet-cell transplants and other procedures with curative intent.
In the meantime, the early identification and treatment of diabetes is important. If patients are able to maintain good glycemic control from the outset, it makes a big difference in limiting the complications of diabetes.
Lifestyle changes will also continue to be an important issue. In several sectors, there is a movement to encourage individuals to change their sedentary ways and to reduce obesity; these efforts would help to stem the tide of diabetes we have seen in the past few decades.
For patients with diabetes, I believe that extended-release drugs are going to be very important, because they require less frequent injections compared with short-acting agents. Novel delivery devices are also likely to play an important role. I expect to see more therapeutic innovations that will keep patients from constantly reminding themselves that they have diabetes.
Biography
An Interview with Donald C. Balfour III, MD, FACP