Rem Laan became Executive Director of the Sansum Diabetes Research Institute in Santa Barbara, CA, last Spring. Before that, he spent more than 10 years with Roche Diabetes, which he entered via a previous position as Director of Marketing for Disetronic Medical Systems (remember their insulin pumps, which became Accu-Chek Spirit?)
Rem tells us he came away from our 2013 DiabetesMine Innovation Summit both inspired and frustrated -- which was all about the messed-up healthcare reimbursement system in this country, of course. He's given this a lot of thought, and today right here at the 'Mine, he issues a New Credo and Call to Action on how this might be better approached:
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A Call-to-Action by Rem Laan
I was an observer of the "discussion" that took place between participants and presenters at the Payer Panel: Addressing Diabetes Tools & Innovations at the recent DiabetesMine Innovation Summit at Stanford. As a result I would like to propose a new way of evaluating diabetes tools and innovations. Specifically — Do they increase patient engagement? Here is why I think this is the right question to ask:
Diabetes is not like other chronic conditions. Diabetes success requires a patient who is willing (motivated) and able (educated) to self-manage their disease 24/365. This can only be achieved by patients who are highly engaged in their own care. So Rule #1: almost anything that increases patient engagement will be medically effective.
Randomized Clinical Trials (RCTs) are not the best way to measure the medical effectiveness of diabetes tools and innovations. This is because, unlike drugs or pacemakers, diabetes tools and innovations require the patient to operate and make decisions about the use of the device. Because of this, there is no way to "blind" a study and there can be no placebo. As a result, medical outcomes for diabetes devices are often better in well-designed prospective observational studies than in RCTs. So Rule #2: we need to take a broader view of how medical evidence is obtained.
Use of diabetes devices is self-regulating. People with diabetes won't pay for and use technologies they don't believe are effective. If they see no benefit, and they have any out-of-pocket cost, they will stop using it. This is even truer if the technology causes pain (like BGM can). So Rule #3: people won't use what they don't believe is effective and therefore there will be no cost (or benefit) to the payer.
The ultimate payers (government and employers) need to be as concerned about indirect costs like sick days, loss of productivity and avoided future costs as they are about direct medical costs in the short term. These indirect costs and avoided future costs can be difficult to measure but they are real. How high will these indirect and avoided future costs be by 2050 if the CDC's projection comes true and 1 out of every 3 Americans has diabetes? So Rule #4: we need to consider all of the costs when we make cost-benefit decisions, not just the direct ones or the ones we can easily measure.
I would like to challenge payers, employers, physicians and patients to start a new dialog about the importance of patient engagement and to come up with new ways of measuring medical and cost effectiveness that take patient engagement into account. Here are two possible ways in which you can help to start this dialog:
- Discuss these issues with the benefits manager for your employer and ask that local employers, local payers, people with diabetes and the local chapter of the American Diabetes Association meet to share their experiences and discuss how to use benefit plan design to encourage patient engagement rather than discourage it.
- Write to your elected representatives in Washington and ask that an inter-agency task force consisting of at minimum FDA, AHRQ, CMS, NIH, OMB, PCORI (plus other relevant organizations?) be created to discuss these issues and formulate a government payer position on the importance of patient engagement and ways to increase it through grants, benefit plan design, the device approval process, cost-effectiveness analysis, etc.
Readers: We think this is powerful stuff. Please let us know how you might be thinking of taking this credo to heart and taking action.