This post was produced in conjunction with the American Diabetes Association.
Providers of diabetes care are under pressure. Lots of it. All players in the diabetes space know that treating the condition is inherently complex, leaning heavily upon lifestyle and behavioral change. On top of this, a flurry of exciting medical advances is challenging providers in their decision-making. All points intersect to show a greater need for personalized care, with an intimate understanding of the individual patient as prerequisite—and at a higher volume. We also know, though, that the incentives are not currently aligned to reward providers for the type of work and engagement that’s needed to provide this level of quality care.
So: What do providers want?
At the core of providing great care must be an ecosystem-wide understanding of the value of the provider-patient relationship.
First and foremost, providers seek to provide great diabetes care. “The level of responsibility is immense,” says Dr. Jeff Dobro, CMO of One Medical, a member-based, national primary medical group that directly employs over 360 providers. “We take patient care very seriously.”
At the core of providing great care must be an ecosystem-wide understanding of the value of the provider-patient relationship. In speaking to a number of providers, we heard four main categories of need:
1. Time to Provide Patient-Centric Care
It takes time to get to know a patient and build a strong provider-patient relationship. A provider should be recognized, not penalized, for trying to stay engaged. “To treat diabetes well, you have to know the patient, who they are, their struggles and motivations,” says Dr. Matthew Freeby, Director of the Gonda Diabetes Center at UCLA and a trained endocrinologist and diabetes specialist. “The U.S. healthcare system does not reward staying engaged in that patient’s care, which is vitally important in diabetes. Day-to-day glycemic management is impacted by so many factors and often requires more engagement than other disease processes.”
A major pain point: the excessive amount of time providers spend proving themselves to payers, rather than treating patients. Dr. David Harlan, Director of the Diabetes Center of Excellence at UMass Memorial Health Care, argues that what the patient needs is a doctor—not someone to fill out forms or negotiate a payment. “When I have to call an insurance company and explain, and I’m talking to some recent college graduate, and I get an automated menu and listen for several minutes—that’s time I could be spending with another patient,” says Harlan, adding: “Having to speak to someone who knows nothing about the patient and convince them—that’s a waste of time.”
“Nowhere in the equation of the finances is how well the patient is doing.”
Harlan cites a broken healthcare finance system as the root of the problem. “Nowhere in the equation of the finances is how well the patient is doing,” says Harlan. “Therefore, we’ve gotten very good at writing long patient notes.” He adds that the only way to bill for a 30-minute visit with a patient is for him to document things in the patient’s chart, where he’ll be asked to talk about some preconceived number of organ systems, to analyze a predetermined number of body parts, and to analyze an arbitrary number of complex situations. Then compliance officers read these notes, and then payers do the same. “In other words, we’re guilty until proven innocent,” says Harlan. “You get these very long elaborate notes that are largely fiction—they’re not focused on patient health.”
Dobro says that One Medical has built a model to challenge this, with 95% of appointments starting on time, the average visit being 27 minutes long, average waiting time of 30 seconds, and 24/7/365 access to a virtual medical team. In constructing the company around the patient as the center of the health system, Dobro’s second priority is to avoid provider burnout and produce a satisfying experience for the provider. These two aims work congruously, with providers having half the usual patient panel, being capped at 16 patients a day, offering same-day or next-day appointments, and patients determining how long their appointments are. Dobro says that this allows providers to develop a longitudinal relationship with their patients.
2. Tech that Enables Shared Decision-Making
The majority of diabetes patients are treated by primary care providers (PCPs), not endocrinologists. It is up to the PCP to decide at what point to engage a diabetes specialist. Typically, diabetes specialists like Freeby will accept patients who require insulin and more medication. Such partnership requires an increased level of shared medical decision-making. It can get complicated.
“Providers need tools to help them know that they’re doing the right thing. Otherwise, they may be relying on memory and the difficult task of staying current on the latest Cochrane review.”
And while diabetes has always been a complex condition to treat, new medical advances have changed the landscape of decision-making. The era of three straightforward classes of diabetes medications has come and gone. “It’s a blessing and a curse for my primary care colleagues,” says Freeby. With the influx of new, often exciting medicines at their disposal, particularly with Type 2 Diabetes, providers not specializing in diabetes are faced with the challenges of choice. One Medical’s Dobro has an interesting take on shared decision-making. He wants to see vetted and curated options among diabetes management solutions, with vetting criteria including outcomes, patient satisfaction data from vendors, patient budget, and insurance coverage. “Providers need tools to help them know that they’re doing the right thing,” says Dobro. “Otherwise, they may be relying on memory and the difficult task of staying current on the latest Cochrane review.”
3. Tech that Is Built Around the Provider-Patient Dynamic
While multiple companies and foundations seek to use algorithms for insulin titration with real-time feedback, these attempts to take the provider out of the equation may fall short. Providers want to see technology that takes algorithms full circle, handing data back to providers in a way that allows them to provide feedback that enacts meaningful change. The missing piece: a person with the knowledge and a meaningful relationship with both the PCP and the patient. “I look at the future as developing closer, collaborative relationships,” says Dobro. “There’s a disconnection—there’s so much that the individual patient is experiencing that never gets communicated back to the provider in any kind of organized way. We need to use technology to help inform the provider-patient relationship.”
Today’s tools will do well to center around the expertise of the provider, in diabetes care, and on the patient. “For diabetes, I contend that we don’t have enough to be ready for technology that functions like a driverless car,” says Harlan. “I love the tools! But they’re undervaluing the relationship part. Anyone that claims otherwise is not taking care of diabetes patients.” Harlan contends that current tech is indeed astounding—but if a provider doesn’t guide patients in using it, many if not most of these patients will not put them to proper use. “For the next 20 years, in my patients,” says Harlan, “I don’t see them being widely adopted without a diabetes specialist’s hands.”
Another opportunity area: enabling communication between provider and patient. This means helping providers know patients better, improving patient-provider conversations, and increasing the frequency of engagement. Payers are starting to foot the bill for video technology, reducing commute times in cities, and allowing patients to stay longer at work.
“It all comes down to how we use technology better. We need to get to know patients more, and we need to document, which takes time and effort. How can technology make that easier?”
While in-person interactions have long been seen as the gold standard, video technology allows providers to move beyond the office and into the patient’s home, even seeing what might be in the kitchen. “It all comes down to how we use technology better,” says Freeby. “We need to get to know patients more, and we need to document, which takes time and effort. How can technology make that easier?”
We cannot neglect that these tools must be built for provider workflows. Freeby says that while we can now provide care to patients in ways beyond the office visit, providers are just beginning to understand how to incorporate that technology into their own practice under the current model of care. He and his colleagues are seeing positive results already by using these new technologies, and see much room for growth. As such, One Medical transitioned from using commercial electronic health record (EHR) systems that were not provider-, particularly PCP-, friendly to building their own EHR systems, working technology into the daily workflows of providers. One Medical’s virtual medical team is designed to allow providers to concentrate their energies on patient-facing time.
4. Ways to Empower our Patient Partners
Lastly, great diabetes care comes back down to the empowerment, education, and level of ownership of patients. “I tell my patients, ‘I’m never giving up on you,’” says Harlan. “I can’t give you good health, but I can give you the opportunity.”
“I tell my patients, ‘I’m never giving up on you,’ I can’t give you good health, but I can give you the opportunity.”
Freeby says that technology needs to focus on providing education for patients, too. “We provide one-on-ones and workshops in endocrine and primary care offices throughout health system, and they work, but as the population changes, can we deliver that care in models that impact the whole population? Online, phone, text? People learn in different ways. We’re committed to adding various tools to address the needs of a very diverse and growing population with diabetes.”
One Medical is providing interpersonal training to help providers frustrated with lifestyle and behavioral change needs that go beyond screenings. Currently, most providers do not have tools or training in motivational, interview-based conversation.
What’s at Risk?
To understand what’s at stake here, we must look to larger population trends for context, such as an increase in comorbidities and an alarming rise in the number of diabetic patients (now 7.2% of the total U.S. population).When the geometrically increasing volume of diabetes patients crashes into an insufficient number of trained endocrinologists, we have a problem. Even among those trained, says Harlan, many may not want to see patients with diabetes. These patients require 30-45 minutes, when a thyroid case can be seen in 10 minutes. “If driven purely by the finances of medicine, other than a passion for patients with diabetes,” says Harlan, “it’s hard to practice in this environment. Diabetes for the patient is a second full-time job.”
Harlan projects that fewer and fewer people will go into this specialty. With medical students leaving school $200,000-$400,000 in debt, new physicians may feel compelled to follow the money. And with only about 6,000 adult endocrinologist in the country (many not seeing patients with diabetes) and the threat of a decrease in future trainees, knowledge of diabetes care is becoming a limited commodity.
Across the board, we heard our providers show excitement for the technology—with an ask: that device companies engage with them early on. Tech still needs the expertise of providers in diabetes care, provider workflows, and patient needs. Providers in turn need the expertise of those developing technology to protect, enable, and grow the relationships between provider and patient. According to Harlan, “The rising tide will raise all boats.”