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Diabetes Management Program in Managed Care—Authors’ Response

The Lewin Group Fairfax, Virginia 22031

We would like to thank Gregg et al. (in the letter above) for their thoughtful comments. While we agree with many of the points they have raised, we appreciate this opportunity to clarify some issues and address their questions and concerns.

We concur with Gregg et al. that a randomized control trial is the most accurate method of assessing the effectiveness of an intervention; however, the only data available to conduct this study were retrospective, observational data. Without external funding, an RCT was time and cost-prohibitive. Gregg et al. have criticized our study for not providing an appropriate control, indicating that the decrease observed in hospital utilization may have been a factor of changing practice patterns. In our study, a decrease of inpatient hospital costs of 26% was seen between the baseline and follow-up periods (1). By way of contrast, in the American Diabetes Association study (2) on the economic consequences of diabetes, they observed a 26% decrease in inpatient hospital costs between 1992 and 1997. Given that in less than one year our patients’ hospital costs decreased by as much as those for diabetics as a whole over five years, it is likely that the changes observed were largely due to the Diabetes NetCare intervention as opposed to changing practice patterns.

As stated in the discussion, the net savings realized by an HMO using this program would be a function of the financial arrangements between DTCA and the HMO. The actual program implementation costs are proprietary and, therefore, could not be included in our paper. We did, however, perform a break-even analysis using DTCA economic data, and found that the program broke even in the first year at 1,265 plan members with diabetes.

While it is possible that some of the clinical process improvements noted in this study may have resulted from better physician accounting, in a retrospective study such as this one, we are forced to rely on the data reported by physicians. In answer to the study design questions raised by Gregg et al., we provide the following explanation. There were 78,913 baseline diabetic member months and 71,295 follow-up diabetic member months included in our study. There were fewer diabetic member months in follow-up than in baseline because the number of months of follow-up for the plans was generally shorter than the baseline period of one year. In our clinical analysis, we analyzed data from 50,328 diabetic member months in the baseline period and 71,295 diabetic member months in the follow-up period. The baseline clinical diabetic member months are lower than the overall baseline diabetic member months because baseline clinical data was collected through chart review only for those patients in the plan at the time NetCare was implemented. Therefore, approximately 28,000 diabetic member months from the baseline period were excluded from our analysis because the patients left the plan before implementation of the NetCare program. However, those diabetic member months were included in our financial and hospital utilization analyses.

We agree with Gregg et al. that the issue of whether comprehensive diabetes care can result in clinical improvements in conjunction with short-term cost savings is important. We urge Gregg and his colleagues in the federal government to sponsor a randomized controlled trial using NetCare as one arm to resolve the issues he has raised. Until then, we believe our results validate the hypothesis that effectively managing patients with diabetes results in lower costs and better clinical outcomes, even at one year.

Footnotes

Received November 4, 1998. Address correspondence to: Robert Rubin, M.D., The Lewin Group, Inc., 9302 Lee Highway, Suite 500, Fairfax, Virginia 22031.

References

1. Rubin RJ, Dietrich KA, Hawk AD. 1998 Clinical and economic impact of implementing a comprehensive diabetes management program in managed care. J Clin Endocrinol Metab. 83:2635–2642.[Abstract/Free Full Text]
2. American Diabetes Association. 1998 Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes Care. 21:296–309.[Abstract]

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