Care Management Simulation -- Measure Success at 10 Years or 25?

Yesterday’s Washington Post headline shouted “Study Raises Questions About Cost Savings From Preventive Care.” The article itself captured some of the nuance of this article that the headline did not.

The Post was reporting on a Health Affairs web article that simulated potential savings from improved diabetes management. The improved management would lead to an improvement in hemoglobin AIC (a long-term measure of blood sugar control) and blood pressure – both are agreed to be indicative of better diabetes control. The simulation suggested substantial savings from major complications of diabetes including blindness, kidney failure, amputations, stroke, and coronary artery disease. However, these savings were not enough to pay for the intervention to improve diabetes care.

You read that correctly – the cost of improved management of diabetics would be more – not less -- in the 10 year or the 25 year time horizon.

The authors’ argument – a bit academic – is that the ‘excess’ cost of better management of diabetics is less pronounced at 25 years than at 10 years. Therefore, it’s unfair for the Congressional Budget Office to give thumbs down to an intervention based on a projections of results over ten years. Alas, with this particular simulation, the CBO would still give a thumbs down for results of a program that would increase the federal deficit over 25 years (just not as much per year).

A few other tidbits from this journal article: The intervention model suggested that the highest payoff over 25 years was in the youngest diabetics; there was cost saving in the population of diabetics 24-30. Of course, that’s a pretty small cohort. The simulation also suggested that the cost of diabetes direct care would increase by about $600 per year based on increased testing and more use of medications. This is no surprise, but a blow to the argument that better diabetes care can save money over the short-run.

Most of what we do in the medical field doesn’t save money over a 1, 5, 10 or 20 year time horizon. The medical ‘industry’ delivers better quality (or quantity) of life – and does it in a manner which is (usually) cost effective –not cost saving. No one thinks it saves money to dialyze a patient whose kidneys have failed, or to replace a worn out hip. These interventions yield quality adjusted life years at a reasonable price. So too, more intensive, evidence based care of diabetics can mean a diabetic will have improved vision, won’t have a stroke, and won’t need kidney dialysis. Even if this effort doesn’t save money, it seems like a good idea.

The best idea is to get the benefit of better health care and not spend so much on program costs. How can we do that? We should dramatically decrease the cost of chronic disease management programs using remote monitoring technology. This might also allow for better patient selection – making expensive interventions only for those diabetics who really needed them. We need improved patient engagement, including more effective programs and better incentives that fully employ the lessons of behavioral economics. We also need to improve the care delivery system itself, as interventions to augment the delivery system are by nature expensive and duplicative.