Webinar Series: Diabetes Epidemic & Action Report (DEAR) for Washington State - How We Are Doing and How We Can Improve April 22, 2015
Qualis Health A leading national population health management organization The Medicare Quality Innovation Network - Quality Improvement Organization (QIN-QIO) for Idaho and Washington The QIO Program One of the largest federal programs dedicated to improving health quality at the local level 2
Session 1: Overall Findings from DEAR April 22, 2015 Speakers: Vazaskia Caldwell, Washington State Health Care Authority Angela Kemple, Washington State Department of Health Colette Rush, Department of Social and Health Services Moderator: Matthew Green, Washington State Department of Health 3
630,300 People in Washington have diabetes (2013 estimate) 4
Nearly 1.9 million Adults in Washington have prediabetes (2013 estimate). 11 out of 12 of them don t know it. 5
$4 billion spent on direct medical expenditures on diabetes in Washington in one year (2012 estimate). 6
Introduction How and why the report was created Colette Rush Burden of Diabetes in Washington Angela Kemple Actions to Address Burden through 10 Goals Vazaskia Caldwell and Colette Rush 7
Diabetes Epidemic and Action Report Quantifies epidemic Identifies specific goals Recommends next steps 8
Legislation Authorizing the Report Engrossed Substitute Senate Bill 5034 Section 211(3), section 213(17), and section 219(23) of this bill directed and allocated funds for the Health Care Authority, the Department of Social and Health Services, and the Department of Health, respectively, to:...develop a report on state efforts to prevent and control diabetes. The [agencies] shall submit a coordinated report to the governor and the appropriate committees of the legislature by December 31, 2014 9
Agency Contributors 10
Stakeholder Organizations 11
Terminology Incidence and prevalence Age-adjusted versus crude Confidence intervals Small Numbers
People with Diabetes in Washington Total population in 2013: 6,882,400 Youth <20 years with Diabetes: 4,400 (0.25% nationally a ) Adults 20+ years with Diagnosed Diabetes: 451,700 (8.8%) 5% nationally a have Type 1 Diabetes: 22,600 95% nationally a have Type 2 Diabetes: 429,100 Adults 20+ with Undiagnosed Diabetes: 174,200 (3.4% nationally a ) b Total Diabetes Population: 630,300 (about 9% or one in 11 people) a National percentages from most recent (2014) National Diabetes Fact Sheet by CDC applied to Washington State population counts. b No data source for youth <20 years.
Diabetes Prevalence Trends in WA and U.S. 12 10 Washington US Age-adjusted Percent 8 6 4 2 4.0% or 140,800 adults 7.3% 8.0% or 452,500 adults 0 Source: Washington State and US Behavioral Risk Factor Surveillance System Surveys, 1993-2013. *Data not comparable to earlier years due to changes in methods of collecting and analyzing data.
Disparities in Diabetes Prevalence Age-Adjusted Percent 25 20 15 10 5 0 Statewide 15 13 12 12 11 8 11 10 6 12 9 7 6 Source: Washington State Behavioral Risk Factor Surveillance System Survey, 2011-2013. Abbreviations: AIAN, American Indian/Alaska Native; NHOPI, Native Hawaiian/Other Pacific Islander. *Non-Hispanic, single race only. Note: Prevalence of diabetes by education among adults 25 years.
Diabetes in Youth Type 1 diabetes increased from 1.5 per 1,000 youths <20 in 2001 to 1.9 in 2009. Non-Hispanic white highest prevalence of type 1 diabetes. Type 2 diabetes increased from 0.3 per 1,000 youths 10-19 years to 0.5 over same period. Type 2 diabetes lower among non-hispanic white youth than among other groups. Source: SEARCH For Diabetes In Youth Study, CDC and NIH.
Prevalence of Diabetes a Among Apple Health Enrollees Dual Eligible Elderly Non-Elderly 30.8% 44.4% ACA expansion (Jan 2014): 1.2 to 1.6 million people Medicaid Only Elderly Disabled Adults Non-Disabled Adults Disabled Children 4.2% 1.6% 16.9% 29.0% With Diabetes: 89,820 (7.5%) 17% Apple Health adults versus 8% adults statewide (2012) Non-Disabled Children 0.3% 0% 10% 20% 30% 40% 50% Percent Source: Washington State Department of Social and Health Services, Research and Data Analysis Division, Client Outcomes Database, State Fiscal Year 2011. a Presence of type 1 or type 2 diabetes identified by diagnosis, pharmacy prescription, or CARE assessment using state fiscal year 2010 and 2011 claims, encounters, or assessment data.
Prevalence of Diabetes Among Uniform Medical Plan Members a Age Group 65 Medicare < 65 21.7% 30.7% 35.8% 45.8% With Diabetes: 23,400 (11%) Non- Medicare 65 18-64 < 18 0.4% 0.4% 6.8% 8.5% 19.6% 25.6% Females Males 0% 10% 20% 30% 40% 50% Percent Source: Uniform Medical Plan 2013 claims data from Public Employees Benefits Board Managed Care source claims database. a Presence of type 1 or type 2 diabetes identified by counting number of members who had a claim with a diabetes diagnosis in calendar year 2013.
Births to Mothers with Gestational Diabetes Nearly 1 in 14 (7%) of live births are affected by gestational diabetes. 35 11 Asian* 11 Maternal Age 30-34 25-29 20-24 8 5 3 NHOPI* Hispanic AIAN* Black* 8 8 6 6 <20 2 White* 5 0 5 10 15 0 5 10 15 Percent Live Births Percent Live Births Source: Washington State Birth Certificates, 2010-2012. Abbreviations: AIAN, American Indian/Alaska Native; NHOPI, Native Hawaiian/Other Pacific Islander. *Non-Hispanic, single race only.
Diabetes-related Ambulatory Care Sensitive Conditions Among Adults with Diabetes a Long-term complications 75 Short-term complications 68 Lower-extremity amputation* 12 Uncontrolled diabetes 6 Source: Washington State Hospital Discharge Data and Behavioral Risk Factor Surveillance System Survey, 2012. a Agency for Healthcare Research and Quality, Prevention Quality Indicators. Hospitalizations among adults 18 years. Excludes obstetric admissions and transfers from other institutions. *Among hospitalizations with any-listed diagnosis of diabetes. 0 20 40 60 80 100 Hospitalization Rate per 10,000 Adults with Diabetes
Complications Among Adults with Diabetes a Heart disease 281 Lower extremity condition* 90 Stroke 72 Pneumonia or Influenza 59 0 100 200 300 Hospitalization Rate per 10,000 Adults with Diabetes Source: Washington State Hospital Discharge Data and Behavioral Risk Factor Surveillance System Survey, 2012. a Hospitalizations with any-listed diagnosis of diabetes among adults 18 years. *Peripheral arterial disease, ulcer, inflammation, infection, or neuropathy.
Diabetes Mortality In 2012 diabetes was the 7 th leading cause of death. 1,652 people in Washington died from diabetes, and diabetes contributed to an additional 3,910 deaths. Age-adjusted diabetes death rates increased between 1999 2012 from 72 to 77 deaths per 100,000 people (opposite of national decreasing trend)
Age-Adjusted Rate Per 100,000 People Disparities in Diabetes Deaths a 300 Statewide 250 200 150 100 50 0 59 76 95 146 148 183 56 67 82 108 46 65 76 90 104 Percent Population in Poverty Percent Population are College Graduates b Source: Washington State Death Certificates, 2010-2012. Abbreviations: AIAN, American Indian/Alaska Native; NHOPI, Native Hawaiian/Other Pacific Islander. a Deaths with any mention of diabetes as a listed cause of death. b Among people 25 years. *Non-Hispanic, single race only.
Prediabetes Prediabetes, U.S., 2009-2012 37% 20+ years 51% 65+ years Applied to 2013 WA population 1,895,000 20+ years 477,900 65+ years Only 7% of adults report ever being told by doctor they have prediabetes. Source: National Diabetes Fact Sheet, CDC, 2014.
Financial Costs of Diabetes in Washington, 2012 Diabetes $4 billion in direct medical expenditures $1.4 billion in lost productivity Prediabetes $709 Million in direct medical expenditures Gestational Diabetes $23 Million in direct medical expenditures Sources: American Diabetes Association diabetes cost estimates applied to Washington population counts. Cost studies used to estimate prediabetes and gestational diabetes costs.
The Progression of Diabetes Type 1 Type 2 Healthy Healthy There are no known means of preventing type 1 diabetes, and no modifiable risk factors. Risk Factors Prediabetes Diabetes Diabetes Complications Complications Hospitalization Hospitalization Death Death 26
DEAR Identified 10 Goals A. Expand access to Diabetes Prevention Programs B. Increase access to physical activity/active living C. Increase access to healthy foods and beverages D. Get more people with diabetes into Diabetes Education E. Increase periodontal care for people with diabetes F. Better coordinate care for people with both diabetes and mental illness G. Expand access to Living Well programs H. Use Community Health Workers I. Get more stakeholders involved J. Improve availability of data 27
Ensure All Appropriate populations Have Access to the Diabetes Prevention Program Healthy Risk Factors Prediabetes Diabetes in Washington State Report recommends: Department of Health and the Health Care Authority develop a pilot project proposal to test enrollment of a subset of the Washington Apple Health population in the existing Diabetes Prevention Program. Develop a budgetary proposal to fund a sufficient sample population for the pilot, so the results can provide necessary financial and health outcome information to assess the impact on costs and return on investment. Use the results of this evaluation to inform future legislation and budgets for Apple Health policy. Statewide: All adults in Washington need access to DPP, whatever their source of insurance or insurance status. 28
Increase Access to Safe and Affordable All Active Living Report recommends: Promote the establishment, improvement, and use of indoor and outdoor spaces that are safe, tobacco free, accessible, and appropriate for play and physical activity. Maximize opportunities to safely be physically active in daily transportation such as by walking or biking to school or work, through community design and transportation planning. Increase active time in early learning sites and physical education in schools. Statewide: The Governor s Healthiest Next Generation Initiative has shone a spotlight on the issue of healthy weight among children. Physical activity opportunities need to be culturally relevant and include persons of all abilities in order for all populations to partake of them. 29
Increase Access to Healthy foods and All Beverages Report recommends: Ensure healthy foods and beverages, including water, are available in schools and early learning facilities. Include healthy eating concepts and language in municipal policies and tools such as comprehensive plans, zoning, ordinances, permits, and licensing rules. Promote affordable healthy food and beverage options in corner stores, including ensuring the ability to accept WIC/SNAP. Improve mechanisms for purchasing foods from farmers markets and farms, including ensuring the ability to accept WIC/SNAP and farm-to-institution programs. Statewide: For the many low-income residents of our state, access to affordable healthy foods is out of reach. 30
Ensure All People with Diabetes Receive Diabetes Complications Hospitalization Self-Management Education Report recommends: Require the Health Care Authority and the Department of Health to jointly develop a plan to increase appropriate use of the existing Diabetes Self-Management Education benefit in Apple Health and PEBB by October 2015. Statewide: Diabetes Self-Management Education provided by a trained Diabetes Educator is already included in most health benefits, however, it is underutilized. By working with private and public partners, such as managed care organizations, quality improvement organizations, diabetes educators, health systems, and health care providers, use of existing resources can be maximized to connect all people with diabetes in Washington to this guideline-based service. 31
Ensure People with Diabetes Have Access to Guideline-Based Oral Health Treatment Diabetes Complications Hospitalization Report recommends: Direct Apple Health to evaluate the expansion of treatment of periodontal disease among people with diabetes to align with the American Dental Association recommendations. Direct, and if needed, provide supplemental funding for, the Health Care Authority to analyze dental and medical data within the PEBB population, so that accurate estimates of potential costs savings can be calculated. Statewide: Apple Health enrollees need more access to dentists and oral health professionals. Health professionals and consumers need more information about the connections between oral health and diabetes. All residents of Washington with diabetes need adequate oral health care. 32
Enhance Care Coordination for People with Diabetes Complications Hospitalization Both Diabetes and Mental Illness Report recommends: Continue to support and enhance existing initiatives, such as the Health Home Program and those established in Senate Bill 6312 (2014). Continue to identify resources for co-located services and methods that lead to better care coordination for people who have a mental health diagnosis and diabetes. Support the Plan for a Healthier Washington s regionally responsive payment and delivery systems, which are driven by integrated purchasing of physical and behavioral health care. Support availability of evidence-based programs, such as diabetes self-management education and chronic disease self-management, to the population of people with both diabetes and a mental health diagnosis. 33
Ensure All Appropriate Populations Have Access to Chronic Disease Self-Management Education Diabetes Complications Hospitalization Report recommends: Develop a proposal to make Chronic Disease Self- Management Education programs available to all adults covered by Apple Health and PEBB. Remove barriers to coverage that are limiting the number of Apple Health and PEBB enrollees who are using currently available education programs. Statewide: All adults with chronic health conditions would benefit from these and other evidence-based education programs. Implementation of the Plan for a Healthier Washington should include consideration of how these programs could be funded and administered at the regional level. One possibility is regional funding structures in which all health plans could participate. 34
Ensure Involvement of Community Health Workers in Populations with the Greatest Needs Diabetes Complications Hospitalization Report recommends: Ensure that the services of Community Health Workers are included among the health services eligible for payment, regardless of which payment model is used. Use a combination of public health and health systems funding at a regional level, in alignment with the Plan for a Healthier Washington, to ensure that Community Health Workers are available where needed. Statewide: We need greater efforts to support community health workers overall. It is essential to not underfund community health workers and the organizations that employ them. Using community health workers to address diabetes prevention and management is one strategy that can be tailored for use in populations that are culturally and linguistically different from the dominant culture. 35
All Increase Stakeholder Involvement in Policymaking that Pertains to Diabetes Report recommends: Expand the Diabetes Network Leadership Team to include more stakeholders, including those representing youth and adults with type 1 diabetes. Ensure state agencies with ability to impact diabetes prevention and care, including Office of the Superintendent of Public Instruction, Dept. of Corrections, Dept. of Services for the Blind, Dept. of Early Learning, Dept. of Transportation, and others, are represented Ensure the Diabetes Network Leadership Team has an ongoing role in providing recommendations and data to further the goals identified in this report. Encourage private partners, such as researchers, nonprofit organizations, and health systems, to participate. 36
Support the Plan for a Healthier Washington s Investment in Analytics, Interoperability & Measurement All Report recommends: Increase participation of health care purchasers and payers in the All Payers Claims Database. Financially support efforts to develop and maintain population health data systems on diabetes risk behaviors, risk factors, care practices, morbidity, and mortality. Support enhancement of information exchange and extraction capacity for data to drive decisions and funding. Leverage and bridge to the Healthier Washington common performance measures set and other performance measurement strategies. Identify ways to ensure more consistent and accurate collection and coding of data so that differences among and between populations can be identified. 37
Diabetes Epidemic Calls Us to Action Nearly 2 million people in Washington are on the verge of diabetes, but most don t know it. Prevention works. Actions that support management, including selfmanagement, for diabetes keep the disease from progressing, and lower costs. 38
How to Get Involved Join next noon-1 p.m. webinars in series May 20, 2015 - Session 2: Community-based actions that can promote improvement in health outcomes related to diabetes and prediabetes June 17, 2015 - Session 3: Clinical interventions that can help prevent and manage diabetes Join a Diabetes Network Leadership Team workgroup (email Diabetes@doh.wa.gov) Disparities Providers Employers/Insurers Contact Qualis Health to learn how you can get involved with DSMP (Lisa Packard: lisap@qualishealth.org) 39
Questions? 40
Resources & Contact Information Link to the DEAR Report: http://doh.wa.gov/dear Vazaskia Caldwell, Washington State Health Care Authority Email: vazaskia.caldwell@hca.wa.gov Angela Kemple, Washington State Department of Health: Email: Angela.Kemple@DOH.WA.GOV Colette Rush, Department of Social and Health Services: Email: RushC@dshs.wa.gov For more information about Qualis Health s Everyone with Diabetes Counts program visit: http://medicare.qualishealth.org/edc 41