Type 2 diabetes mellitus (T2DM) is a dangerous disease out of control: US Centers for Disease Control and Prevention (CDC) data for 2007–2010 showed that 47.5% of adults with diabetes had average blood glucose (HbA1c) levels exceeding the American Diabetes Association (ADA) target of 7.0%. The ADA estimates that T2DM accounts for $1 of every $5 spent on health care in the United States, and the CDC puts diabetes prevalence at 8% of the US population. A December 2014 ADA report pointed to a 74% increase in the cost of prediabetes and an 82% increase in the cost of undiagnosed diabetes between 2007 and 2012.
Enter the Florida Health Care Coalition (FHCC), a consortium of Florida-based employers intent upon giving their 2 million employees access to high-quality health care at the best price. In 2004–2006 the FHCC had worked with Philip C. Chen, MD, PhD, FCAP, then chief executive officer of Cognoscenti Health Institute (CHI), a private clinical laboratory in Orlando, to advance diabetes wellness programming in central Florida. For a more ambitious FHCC-sponsored follow-on project, Dr. Chen reached out to James M. Crawford, MD, PhD, FCAP, then chair of the Department of Pathology, Immunology, and Laboratory Medicine at the University of Florida (UF) College of Medicine, Gainesville, to ask if UF could work with the FHCC as the contracting research organization (CRO) and with Dr. Crawford as signatory principal. In turn, the FHCC identified a major local employer with a worksite wellness program that was willing to provide a home for the project, and contracted with the Florida Hospital Diabetes Institute for education.
Although nobody used the term at the time, they were building a medical neighborhood with expertise in population health and clinical informatics. The endeavor was centered around a worksite wellness program expanded to include education, quarterly fasting laboratory draws, nurse-provided telephone counseling, and outreach to participants' primary care physicians via a UF endocrinologist and physician’s assistant. Because noninterference in employees' relationships with their physicians was a pillar of the program, UF clinical staff would simply alert their community-based colleagues of outlier test results and offer to consult if needed. The pieces were in place.
Today, Dr. Crawford is executive director and senior vice president of laboratory services at the North Shore-LIJ (NSLIJ) Health System and professor and chair, Department of Pathology and Laboratory Medicine, Hofstra NSLIJ School of Medicine in Hempstead, New York. Dr. Crawford is an eloquent advocate for pathologist leadership in public health and the patient-centered medical neighborhood. But when he picked up the telephone that day in Gainesville, Dr. Crawford says, he was only an academic liver pathologist. He had never taken responsibility for a large population health research project. In retrospect, that telephone call was a major inflection point in his career. But at the time, it was a daunting proposal.
"As signatory principal, I was accountable for the University of Florida acting responsibly as a CRO," Dr. Crawford says. It was with some degree of trepidation that he took on what UF promised to do, which was to run the program. "I did it because of my belief in the importance of pathology and pathologists providing leadership in the public health space," he says, "but it took a remarkable team coming together to make it possible."
The UF Institutional Review Board required that the research group operate at arm’s length from wellness programming, which would complicate the planning but keep the feedback loop clean. Dr. Crawford pulled together a UF team with expertise in endocrinology, epidemiology, biostatistics, nursing, and administration. CHI would give the biostatisticians participant data from quarterly blood draws, including body mass index, serum glucose, HbA1c, and low-density lipoprotein. Participants’ insurance claims data would be used for cost calculations.
The employer had stipulated that UF researchers would have access to data from only those employees who provided consent and enrolled in the program. In the absence of a control group, the UF team used extended longitudinal tracking of claims data for the 12 months before program launch (2007–2008), for the 12-month diabetes wellness program itself (2008–2009), and for another 12 months after the program ended (2009–2010), effectively making the participants their own controls.
At the end of the 12-month program, the 151 participating employees with diabetes had highly significant improvements in serum laboratory indices and better diabetes control as measured by the proportion with HbA1c levels below 7.0%. There was a 50% drop in hospital admissions, when compared with the 12 months prior to the program. Total health care claims costs increased minimally, from $731 per member per month (PMPM) in the 12 months prior to $744 PMPM during the intervention, a rate that compared favorably with national benchmarks.
However, these results failed to continue. Twelve months after the program ended, the frequency of hospital admissions had returned to prior high levels and health care costs had risen substantially—to $806 PMPM. Still, during the intervention, rigorous attention to laboratory test findings, collaboration, communication, and support across the medical neighborhood had improved population health. After studying results of the pilot, the employer modified its employee wellness programming to ensure sustainable outcomes moving forward.
"Accountable care is the whole system that wraps around the medical home and patient-centered care," Dr. Crawford says. "And guess what? That's the sweet spot of pathology. That's precisely what we do: Pathologists support integrated care across the entire breadth of the human condition."
Pathologists can find a natural niche in population wellness, Dr. Crawford says, even if they must be the ones to carve it out. Find people who are interested in this type of work, he says, and become a part of the team that makes things happen. At the very least, he says, "You are experts in running effective health care systems— pulling data together and making it relevant."
"An accountable care organization supports the medical homes that are the physician-based practices and the entire complexity of the system that goes with it,” Dr. Crawford says, which takes in the specialists, the ancillaries, the hospitals, and the nursing homes. “The laboratory informs the decision making that makes all of this health care possible. That's the guiding vision. And that’s what we’re now trying to do in the North Shore LIJ Health System.”
Bevis CC, Nogle JM, Forges B, et al. Diabetes wellness care: a successful employer-endorsed program for employees. J Occup Environ Med. 2014;56(10): 1051–1061.