Since diabetes is one of the few chronic conditions that can be very effectively managed by an individual, why are there so many people with poorly managed diabetes? Despite conventional logic, it’s not that most people aren’t willfully noncompliant with their diabetes care. Instead, many have extenuating socioeconomic or other circumstances that can lead to drifting away from their care plans.

There is an opportunity in value-based care to engage diabetic patients more effectively through data-driven personalized care interventions.  By merging rich, non-traditional data sources such as purchase trends with foundational elements like claims and clinical services, trusted care team members can develop one-of-a-kind insights into individuals’ risks and behaviors. Translating broad, extensive multiple data sets into actionable information specific to an individual holds the potential to better manage populations while simultaneously changing the trajectory for each patient living with a chronic disease.

On this week’s episode, we have: Richard Mackey, Chief Technology Officer at CCS, a company that transforms chronic care management by combining equipment and products with comprehensive education, monitoring, and coaching…serving more than 400 employers and more than 1,800 managed care plans nationally to support patients with diabetes.  Joining Richard on the podcast is Jean-Claude Saghbini, Chief Technology Officer at Lumeris who also serves on the advisory board for CCS.

Richard and Jean-Claude address how technology-assisted disease management makes the patient experience less arduous. They also discuss how devices and digital tools such as continuous glucose monitors, insulin pumps, chatbots and smartphones can generate an enormous amount of new and unique data. The information from these additional data feeds can be used to derive valuable insights into both the individual and population levels to drive the future of personalized care.

Episode Bookmarks:

01:30 Data-driven, personalized care interventions are key to effective chronic disease management.

02:00 Introduction to Richard Mackey and Jean-Claude Saghbini.

02:45 An overview of technology-assisted disease management.

04:00 Support Race to Value by subscribing to our weekly newsletter and leaving a review/rating on Apple Podcasts.

05:00 Diabetes is such a significant problem in the United States, affecting over 37 million people, and it leads to numerous health complications.

07:00 Richard provides his perspective on the potential for aggregating disparate data sources and applying advanced analytics to transform diabetes outcomes.

08:30 How technology solutions can enhance the relationship between the care provider and the patient.

09:00 An overarching data interoperability framework is not necessarily required to leverage the power of data and technical solutions.

09:30 Jean-Claude on balancing the aims of interoperability, data normalization, and predictability in data flows with current day realities.

12:00 The importance of partnerships in driving scale in population health management through combined data feeds and biometric capabilities.

13:00 Richard expounds on the importance of partnerships in data-driven solutioning and medical device optimization for effective delivery of VBC.

14:30 Jean-Claude on how healthcare organizations can extract insights from technology to change the trajectory of disease in their patient population.

16:00 Predictive analytics can accelerate progress in understanding relationships between external factors and human biology.  

17:30 Richard discusses the impact of predictive analytics to enhance the reengineering of clinical pathways to deliver personalized care to patients.

18:15 The unique opportunity to customize patient segmentation at the individual-level (versus relying just on profiling patients at the population-level).

19:45 Jean-Claude on how SDOH predictive models focused on housing instability or transportation access can be combined with clinical data.

21:00 “We are at the intersection of both AI and enhanced accessibility of data.  This will ultimately change the trajectory of chronic disease in our country.”

22:00 Diabetes supply ordering patterns can be an early indicator that there’s a problem with a person’s self-care routines.

22:45 How consumption-focused data can be used to support more effective chronic disease management for diabetes.

25:00 The correlation between medical cost savings and lower Hemoglobin A1c scores in diabetic populations (e.g. a 1% reduction in HbA1c is associated with a 9.8% reduction in TCOC).

25:45 In general, on average, a patient with an A1c > 9% costs $10,000 dollars per year more than a patient with an A1c < 7%.

26:30 “We certainly see that better care and lower cost care go hand in hand.  The shift from FFS to value-based care will give us the outcomes we want in terms of cost and quality.”

27:00 “The keys to value-based care success are alignment of incentives, technology enablement, and effective change management.”

29:00 Adherence to continuous glucose monitoring (CGM) therapy results in a 20% reduction in excess healthcare utilization for diabetic patients.

30:00 “Technology-assisted disease management and health coaching is not just a transaction.  It is an important relationship with the patient that reinforces the provision of primary care.”

31:00 A digital front door can improve communication, care coordination, and population health management, ultimately leading to better patient outcomes and more efficient healthcare delivery.

31:45 “It is important for us to have a holistic, 360-degree view of the patient to drive and fuel care management interactions.”

32:00 The importance of self-managed care options in diabetes to empower the healthcare consumer to maintaining their care plan.

33:30 How successful technology to improve healthcare consumerism is not always front-facing and often runs behind the scenes.

34:45 The inevitable shift away from inpatient hospitalizations and procedures to care being delivered more in the home.

36:30 Richard shares the story of how his father was burdened with a fragmented and complicated diabetes care experience.

37:45 The opportunity to improve outcomes in value-based care by creating an integrated, seamless experience for patients suffering with diabetes.

39:00 Even the most sophisticated data-driven intervention runs the risk of failure if it is not backed by an established, trusted bond between patients and a provider.

40:30 The power of data to empower care for diabetes by interdisciplinary teams.

42:00 “Data can only be effective to drive population health outcomes if there is trust between the provider and the patient.”

42:30 Data consistency, predictive analytics, workflow integration of recommendations, and provider centricity as keys to success in developing trust.

44:30 “Healthcare data is the lifeblood of modern medicine, but it’s value is limited with patient trust. Trust is the currency that enables the exchange of health information and empowers patients to take control of their health.” – Karen DeSalvo

46:00 Everyone is touched by diabetes.  Now is the opportunity to make a difference!