Viewpoints

Healthcare professionals in traditional clinical practice have not often had the opportunity to validate best practices among a large sample of patients. Recently, however, the introduction of the Centers for Medicare and Medicaid (CMS) Medical Shared Savings Program (MSSP) for Accountable Care Organizations (ACOs), where providers are incented for reduced healthcare costs as well as improved quality of care, has brought with it the requirement for ACO participants to track and publicly report their results.

One such ACO in Texas covering thousands of patients with type 2 diabetes mellitus (T2DM) has implemented an innovative, multi-year, comprehensive care plan that includes point-of-care (POC) in-office testing for their patients. The results of this program, which were just presented at the 2016 American Diabetes Association annual meeting in New Orleans, demonstrated that the care plan significantly reduced healthcare costs while improving patients’ outcomes – effectively creating a blueprint that could be replicated on a much larger scale to help combat the growing epidemiological and economic impact of T2DM in the United States. 

The Rio Grande Valley (RGV) ACO in Southern Texas is one of more than 4,000 ACOs that were established as part of the Affordable Care Act’s Medicare Shared Savings Program to improve the quality of care and reduce unnecessary costs for Medicare Fee-For-Service beneficiaries. Despite what one could argue is a challenging demographic, the RGV ACO has realized significant savings while delivering quality scores that are among the best in the nation. The team at the RGV ACO has made diabetes control a focus and developed a set of innovative strategies to better manage this devastating condition that affects approximately 45% of their patient population – many of whom lack health literacy and are not educated about the role of a healthy diet and other lifestyle interventions that can help keep their T2DM stable. Additionally, many also do not have the money for their T2DM medication copayments, nor can they afford to go to the gym or buy nutrient-dense foods to support healthful lifestyles and eating patterns.

In addition to increased office efficiency, the benefits of POC testing for HbA1c and lipids include better delivery of care, education and training; prevention of additional visits for laboratory tests and follow-up; and additional patient compliance due to improved understanding.

RGV’s T2DM care program encompasses a wide range of strategies. Staff follow up patient visits with phone calls to remind them about blood glucose monitoring or to make medication adjustments, and uncontrolled patients are linked to nutritionists and certified diabetes educators. Staff are also alerted about care gaps through RGV’s electronic health records platform. RGV ACO uses point-of-care systems for measuring HbA1c and lipids because they allow clinicians to take immediate action on the test results. Getting HbA1c and lipid results during the visit means that they make the most of each visit with no need to spend additional time later to pull charts for review and follow up with patients after lab results are returned in the following days. Less time is spent chasing results and patients with phone calls and letters. In addition to increased office efficiency, the benefits of POC testing for HbA1c and lipids include better delivery of care, education, and training; prevention of additional visits for laboratory tests and follow-up; and additional patient compliance due to improved understanding. 

To date, more than 6,000 patients have been enrolled in this innovative care plan. Results have shown significant improvements in all quality measures, including HbA1c levels, blood pressure and tobacco non‐use, among others. From 2012 to 2014, the number of patients with comprehensive T2DM control increased from 12 to 49 percent, and the number of patients with HbA1c > 9 percent decreased from 17.81 to 12.83 percent. For the composite score of T2DM metrics, RGV achieved the top 1 percent of all ACOs in the nation. RGV ACO also reduced the per capita costs for its Medicare beneficiaries by 14 percent.

“The results of our program are especially gratifying because they show that T2DM can be successfully and cost-effectively managed among patients who are traditionally difficult – and expensive – to treat,” said Jose F. Pena, MD, Chief Executive Officer and Chief Medical Director, RGV ACO. “We now know definitively that there is no ‘silver bullet’ when it comes to managing T2DM. Healthcare providers need to use a wide range of interventions and strategies, including rapid point-of-care testing, frequent phone calls by care coordinators and others that are culturally tailored to their patients.”

While the RGV ACO is but one case study, it demonstrates that there can be a successful approach to comprehensive diabetes care in challenging populations that both reduces healthcare spending but also increases the quality of care. Improved control of diabetes and increased efficiencies in health care delivery are goals that bring with them benefits for diabetes patients of all ages and in private pay fee-for-service models as well.