2021 Missouri Diabetes Report Report to the General Assembly on diabetes-related efforts in the Missouri HealthNet Division and the Missouri Department of Health and Senior Services. RSMo 191.990 2021 Part I. Burden of Diabetes in Missouri Missouri Diabetes Report It is estimated that nearly 516,000 adult Missourians had doctor-diagnosed diabetes in 2020, with a prevalence of 10.8% (Table 1), slightly lower than the national median prevalence of 10.9%1. In Missouri, the prevalence of diagnosed diabetes increased with age, but rates were not significantly different between sex or race. Adults living in households with a combined income under $25,000 had a higher prevalence than those with a household income of $50,000 or greater. Additionally, the prevalence among adults who reported schooling beyond high school education was significantly lower than those who did not complete high school. The prevalence among uninsured individuals was significantly less than those who were insured. However, this has previously been attributed to the increased likelihood that uninsured individuals are younger and therefore less likely to be diagnosed. Demographic data (Table 1) was collected from individuals who were formally diagnosed with diabetes; however, the 2013-2016 National Health and Nutrition Examination Survey estimated that 4.3% of adults in the United States have undiagnosed diabetes2. Assuming the same prevalence in Missouri, it is likely that approximately an additional 200,000 cases are unaccounted for in the current data. Table 1. Prevalence of Diabetes among Adults age 18 or older, Missouri, 2020 Number* Percent (95% CI**) Number* Percent (95% CI**) Overall 721,117 15.1 Household Income ($) Diagnosed 515,766 10.8 (10.0 - 11.6) <15,000 77,134 19.8 (15.6 - 24.0) Undiagnosed# 205,351 4.3 (5.5 - 5.1) 15,000-24,999 109,310 15.1 (12.5 - 17.7) Age (years) 25,000-34,999 58,420 12.2 (9.4 - 15.0) 18-24 5,586 1.0 (0.8 - 2.0) 35,000-49,999 82,422 11.4 (9.0 - 13.7) 25-44 60,056 3.8 (2.8 - 4.9) 50,000-74,999 79,079 9.7 (7.7 - 11.7) 45-64 210,084 13.4 (11.9 - 14.9) ≥75,000 111,122 6.8 (5.6 - 8.0) ≥ 65 233,805 22.1 (20.2 - 24.1) Education Race Less than High School 72,357 15.9 (12.3 - 19.4) White 394,706 10.6 (9.7 - 11.4) High School or Equivalent 169,212 11.3 (9.9 - 12.7) African-American 62,728 12.2 (9.5 - 14.9) More than High School 263,697 11.2 (8.7 – 10.5) Other 53,780 10.0 (7.0 - 13.0) Insurance Status Sex Uninsured 27,770 4.6 (2.8 - 6.4) Male 269,784 11.7 (10.5 - 12.9) Insured 475,616 11.7 (10.9 - 12.6) Female 243,429 9.9 (8.9 - 10.9) *The number of adults in each subcategory may not add up to the total diagnosed number due to rounding and estimation methods. **CI: 95% Confidence interval #Estimated based on the 2013-2016 National Health and Nutrition Examination Survey Sources: Missouri and National Behavioral Risk Factor Surveillance System (BRFSS), U.S. Census Bureau Population Survey (data.census.gov) The prevalence of diabetes does vary across the state (Map 1). Prevalence rates were highest in southeast Missouri, especially in the Bootheel region. Rates were lowest in central and west- central Missouri. The core counties of the largest cities in Missouri all had rates in the highest quintile (Jackson and Greene counties and St. Louis City). 3 2021 Missouri Diabetes Report Map 1. Prevalence of Diabetes in Missouri Counties, 2019 Percent of Adults 20+ with Diagnosed Diabetes Lowest Quartile Quartile 2 Quartile 3 Highest Quartile Bany Source: CDC Behavioral Risk Factor Surveillance System (BRFSS) and the US Census Population Estimates Program, 2019 In 2019, diabetes led to 16,737 emergency room (ER) visits, with an age-adjusted rate of 2.58 visits per 1,000 population. The diabetes ER rate was lowest for those under 15 (0.39) and was highest for the 45-64 year olds (4.33). Both the 45-64 and 65 and over (3.88) groups had significantly higher rates than the state average. There were 15,575 inpatient hospitalizations with diabetes as the primary diagnosis in 2019, for an age-adjusted rate of 23.27 per 10,000 population. The 65 and over population had the highest inpatient hospitalization rate at 42.81 while the 45-64 grouping had the second highest rate at 38.13. Both were significantly higher than the state rate. The 2019 death count for diabetes was 1,652 which ranked as the 7th leading cause of death in Missouri. The age adjusted rate was 20.9 per 100,000 population. As with most death age groupings, the 65 and over group had the highest death rate at 111.4 and accounted for over 70% of all diabetes deaths. African-Americans had statistically significantly higher rates compared to whites for ER visits, inpatient hospitalizations and deaths. For ER and hospitalizations, African-American rates were about 2.5 times higher. For deaths, the rate was not quite double (35.5 versus 19.5). 4 2021 By gender, rates were statistically significantly higher for males compared to females for both Missouri Diabetes Report hospitalizations and deaths. The hospitalization rate was 36% higher (27.07 versus 19.86) while the death rate was 64% higher (26.5 versus 16.1). However, there were no significant differences for ER rates (2.61 versus 2.56). (Table 2) Table 2. Diabetes Emergency Room Visit, Inpatient Hospitalization, and Death Rates, Missouri 2019 Emergency Room Visits Hospitalization Death Count Rate per 1,000 95% CI Count Rate per 10,000 95% CI Count Rate per 100,000 95% CI Total 16,737 2.58 (2.5-2.6) 1 5,575 23.27 (22.9-23.6) 1,652 20.9 (19.8-21.9) Less than 15 449 0.39 (0.36-0.43) 479 4.21 (3.8-4.6) # ## ## 15-24 1,228 1.55 (1.5-1.6) 1,311 16.50 (15.6-17.4) # ## ## Age 25-44 4,175 2.64 (2.6-2.7) 3,261 20.64 (19.9-21.4) 56 3.6 (2.7-4.6) Group 45-64 6,764 4.33 (4.2-4.4) 5,963 38.13 (37.2-39.1) 409 26.2 (23.7-28.8) 65+ 4,119 3.88 (3.8-4.0) 4,547 42.81 (41.6-44.1) 1,183 111.4(105.0-117.7) White 12,156 2.17 (2.1-2.2) 1 1,237 19.41 (19.0-19.8) 1,384 19.5 (18.4-20.5) Race African American 3,948 5.42 (5.3-5.6) 3,762 50.73 (49.1-52.3) 242 35.5 (31.2-40.3) Male 8,202 2.61 (2.6-2.7) 8,772 27.07 (26.5-27.7) 942 26.5 (24.8-28.2) Sex Female 8,533 2.56 (2.5-2.6) 6,789 19.86 (19.4-20.4) 710 16.1 (14.9-17.3) * Rates were age-adjusted to the 2000 US Standard Population. ** Some records with missing age information were not used to calculate age adjusted rates, therefore the totals will not exactly match the age breakout categories. *** Emergency Room Visit totals had 2 records and Hospitalizations had 14 records with missing demographic information. # Number too small to display ## Rate not calculated due to low count/unstable rate. Data Source: Missouri Information for Community Assessment (MICA), and Missouri Department of Health and Senior Services Bureau of Health Care and Data Dissemination In 2017, the American Diabetes Association (ADA) estimated that together the direct medical cost and indirect cost of diabetes was $6.7 billion in Missouri.3 However, the ADA also estimates that many diabetes management and prevention strategies continue to be highly cost effective. For people with type 2 diabetes, self-monitoring blood sugar three times a day only costs around $3,700 per Quality-Adjusted Life Year (QALY) compared to self-monitoring once a day. Diabetes Self-Management Education Support (DSMES) was also found to be very cost- effective at $5,047 per QALY compared to usual care.4 In addition, most type 2 diabetes prevention interventions that were included in a 2020 review were found to be either cost- effective or cost-saving.5 For additional detailed diabetes data on risk factors, complications, preventive care practices, gestational diabetes, and other information, please visit the Missouri Diabetes Profile at https://healthapps.dhss.mo.gov/MoPhims/ProfileBuilder?pc=7. 5 2021 Part II: Current Programs Missouri Diabetes Report 1. Current Diabetes Programs at MO HealthNet Division (MHD): a. Primary Care Health Home (PCHH) Program Missouri's Primary Care Health Home State Plan Amendment was formally approved December 23, 2011. Services began January 1, 2012. In July 2011, Department of Social Services, MO HealthNet Division (MHD) solicited applications from primary care providers interested in participating in the PCHH initiative. The PCHH program began with a total of 24 primary care health home organizations operating health homes in 86 sites throughout Missouri. After three additional open enrollment periods, there are currently 43 PCHH provider organizations with a total of 195 clinic sites providing health home services to more than 36,000 individuals. The populations eligible for the PCHH Program originally included those with two or more chronic conditions or one chronic condition and a risk factor for a second. Patients with diabetes are considered to have one chronic condition and be at risk for a second. The eligibility criteria has since been updated to include pediatric asthma and obesity (in order to prevent full-blown type 2 diabetes) as stand-alone conditions. Anxiety, depression, chronic pain and substance use disorder have all been added as conditions that require a second qualifying condition or risk factor for enrollment. Current enrollment in the PCHH exceeds 36,000 and has been steadily increasing. An average of 43% of all people enrolled have a diagnosis of diabetes and 47% of all participants are considered obese based on their height and weight. The nurse care managers work with each participant to create an individualized patient-driven care plan that includes small steps to achieve attainable goals. This program first addresses the social determinants of health and the patients’ overall well-being to manage stress and other challenges. According to Healthy People 2030, “social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. They can be grouped into 5 domains: economic stability, education access and quality, health care access and quality, neighborhood and build environment, and social and community context.”6 Yearly, the health home staff receive supplementary funding to contribute to essential educational items that participants may not be able to afford on their own. Items purchased include large blood pressure cuffs, low-carbohydrate food pantry items, daily pill boxes, dental kits, diabetes foot care kits, diabetes meal planner plates, glucometers, health alert bracelets, lancets, measuring cups, pedometers, scales, test strips, and extra wound care dressings. The additional funding is often also used to allow for extra educational time with a Registered Dietician, Pharmacist, or a Community Health Worker (CHW) that works closely with participants and their caregivers in their homes with medication support, meal planning, and hands-on cooking lessons. Those with high blood glucose levels are encouraged to call the nurse care manager daily with their readings and meet with their provider monthly until their levels improve. Care Manager Registered Nurses send achievement certificates when participants meet their 6 2021 individualized goals, successfully managing their diabetes. Nurses keep participants Missouri Diabetes Report engaged and motivated by trying innovations such as Facebook Live Cooking Shows, Zumba and Tai Chi classes, and providing fresh fruits, herbs, and vegetables through gardens or onsite pantries. Clinical outcomes achieved thus far include, but are not limited to, clinically significant improvements in LDL levels, blood pressure, and Hemoglobin A1c (HbA1C) levels. The decreases in LDL translate to a 20% decrease in coronary heart disease; the decreases in blood pressure translate to a 16% decrease in coronary heart disease and a 42% decrease in stroke; and the decreases in HbA1c translate to a 21% decrease in diabetes mellitus related deaths, a 14% decrease in myocardial infarction, and a 37% decrease in microvascular complications respectively in the impacted population7. In 2019, of the people with a first reading of HbA1c greater than nine (the blood level that begins to adversely affect multiple vital organs in the human body) 66% of participants saw significant improvement in their HbA1c after 12 months in the PCHH program. The PCHH program has also demonstrated reductions in emergency department use and hospital admissions, as well as shown associated cost savings in hospitalizations and pharmacy waste/use. The MHD program staff work with the Missouri Primary Care Association’s (MPCA) Practice Transformation Coaches to provide multiple trainings throughout the year for health care teams to accelerate positive outcomes for patients with diabetes. Trainings include Trauma-Informed Methods for Primary Care, Motivational Interviewing for Preventative Care, and the 8 Dimensions of Wellness to support all aspects of their patients’ lives. The PCHH providers network with other health care teams to improve their own workflows and learn about new and tested diabetes interventions. MHD also currently provides funding for over 50 CHWs in 28 Community Health Centers (CHCs) across Missouri to assist high risk, medically complex individuals with managing their healthcare and addressing needs related to social determinants of health. The addition of these services came as a result of the CHW pilot in southwest Missouri that showed greater reductions in emergency department visits for individuals enrolled in PCHH who had access to a CHW compared to those that did not (38% decrease compared to 8% decrease). The pilot also showed greater reductions in hospitalizations (16.6% decrease for individuals with a CHW compared to 6% decrease in individuals who did not have access to a CHW). MHD awarded a grant through MPCA to Great Mines Health Center (GMHC) for a CHW High Utilizer pilot program. GMHC partnered with Washington County Ambulance District (WCAD) and designed their pilot program to avoid unnecessary transports and reduce the number of clients with uncontrolled diabetes. CHWs are working jointly with WCAD to help lower Emergency Department rates, provide resources, and educate the population with uncontrolled diabetes within Washington County. This program allows these chronic care patients to be treated and seen in their homes, allowing better compliance. In home appointments through this partnership are scheduled and tracked through GMHC’s Electronic Medical Record (EMR). 7 2021 b. Managed Care and Disease Management Missouri Diabetes Report The managed care plans provide care management and/or disease management services to select members as outlined below. Members are evaluated by the health plans to determine eligibility for these services. Care management services focus on enhancing and coordinating a member’s care across an episode or continuum of care; negotiating, procuring, and coordinating services and resources needed by members/families with complex issues; ensuring and facilitating the achievement of quality, clinical, and cost outcomes; intervening at key points for individual members; addressing and resolving patterns of issues that have negative quality cost impact; and creating opportunities and systems to enhance outcomes. The health plans may use Section 2703 designated health home providers or Local Community Care Coordination Program (LCCCP) providers to perform care management functions if the health home practice and LCCCP provider are members of the health plan network. Disease management involves the intensive management of a particular disease or syndrome. Disease management encompasses all settings of care and places a heavy emphasis on prevention and maintenance. It is similar to care management, but more focused on a defined set of programs relative to an illness or syndrome.8 The health plans provide disease management programs for major depression, asthma, and at least one of the following: obesity, diabetes, hypertension, or attention deficit hyperactivity disorder (ADHD). The health plan may use Section 2703 designated health home providers to perform disease management functions if the health home practice is a member of the health plan network. The health plans also develop and provide a Local Community Care Coordination Program (LCCCP) using a delivery model of choice that provides care management, care coordination, and disease management with a local healthcare provider. All LCCCPs incorporate the following principles: all members will have a selected primary care provider; care is provided by a physician-directed team that collectively cares for the member; care coordination across all aspects of health care; care management services; and recognition and referral to necessary community and social support resources. In addition to the services listed in the comprehensive benefit package, the health plan provides specified services to children under 21 years of age and pregnant women with Medical Eligibility (ME) codes 18, 43, 44, 45, and 61. This includes diabetes self- management training for persons with gestational, type 1, or type 2 diabetes. Healthcare Effectiveness Data and Information Set (HEDIS) data for calendar year 2019 for MHD managed care plans show improvement on several measures in comparison to 2017. Specifically, the rate of individuals with diabetes receiving eye exams increased from 42% to 65%, and those with controlled blood pressure rose slightly from 58% to 61%. Other measures were quite stable between the two years, showing little change, including individuals with diabetes who had a HbA1c test (81% in both years), those with their HbA1c levels being under control (40% in 2019 vs. 39% in 2017), and those who received a nephropathy screening (85% in 2019 vs. 86% in 2017). The rate of 8 2021 individuals with an HbA1c rate that is poorly controlled (>9.0) is also essentially Missouri Diabetes Report unchanged at 51%, in 2019 compared to 52% in 2017. c. Home Telemonitoring, Wireless Patient Reminder Services Program, and Medication Therapy Management Telemonitoring is a small contracted program for patients who meet specific criteria, including chronic diagnoses such as diabetes, and participants with a history of frequent hospital and/or emergency department visits. The contractor, CoxHealth at Home, supplies in-home monitors that collect patients’ vital signs and other clinical information and relays the data electronically to a nursing station for analysis and oversight. If potential problems are detected in values such as those for blood glucose, blood pressure, patient weight, etc., the nursing staff can intervene and/or make a visit to the patient’s home. If necessary, the patient will be directed for medical treatment. The goal is to help keep patients out of the hospital and/or emergency department. For state fiscal year 2021 there was an average of 80 participants per month enrolled in the telemonitoring program. The Wireless Patient Reminder Services Program utilizes PageMinder as a contractor to provide wireless patient reminder notification services to individuals with chronic conditions, including diabetes. Notifications consist of reminders to take medications at scheduled times, to test blood sugar, etc. Goals include helping patients adhere to their treatment regimens so they can avoid unnecessary hospitalizations and emergency department visits. For state fiscal year 2020 there were 538 participants per month enrolled in the Wireless Patient Reminder Services Program. Medication Therapy Management (MTM) is for pharmacist professional services to educate and counsel patients about potential gaps in treatment. For example, a pharmacist will receive a notification that a patient using his or her pharmacy does not have a claim for an annual foot exam, or perhaps no laboratory claim to indicate that he or she had a regular HbA1c screen. The pharmacist will “reserve” an intervention opportunity and when the patient shows up in the pharmacy, the pharmacist counsels the patient about the need to adhere to evidence-based treatment protocols for their diabetes (among other disease states). The pharmacist must be properly qualified and enrolled to provide and bill MHD for these services. Below (Table 3) is the MTM report for time period 10/01/20 – 09/30/21. All patients have a diagnosis of diabetes according to paid medical claims history. Table 3. Medication Therapy Management (MTM) Usage and Cost Savings, Missouri, 2021 Unique Number of Number of Pharmacy Medical Patients patients with MTM savings for savings for with MTM interventions these 25 these 25 Diabetes interventions provided for patients patients these 25 (annualized) (annualized) patients 9 2021 MTM 66,866 25 57 -$10,126 $124,290 Missouri Diabetes Report Messages The MTM program was approved by Centers for Medicare and Medicaid Services (CMS) effective January 1, 2013 and providers continue to enroll in the program to provide interventions. d. Pharmacy Benefit On April 1, 2020 MHD bought continuous glucose monitors under the pharmacy benefit, allowing participants to receive these devices at the pharmacy with a simple prior authorization. These devices allow participants, and their caregivers, to monitor blood sugar levels without multiple finger sticks. Participants place the device and receive alerts and readings on their smartphone, smart watch, or manufacturer device. Since implementing coverage over 1,700 continuous glucose monitors have been paid for by MHD. In 2021, MHD purchased tubeless insulin pumps under the pharmacy benefit, allowing participants to receive these devices at the pharmacy with a simple prior authorization. These devices are able to deliver insulin to participants and adjust the dose according to what the participant is doing, allowing them to play basketball, swim, and shower, without having to worry about insulin delivery. Combined with the continuous glucose monitor, participants are able to better control their diabetes, leading to improved long term outcomes. Since implementing coverage over 100 participants are receiving tubeless insulin pumps monthly through MHD. e. Biopsychosocial Treatment of Obesity for Youth and Adults MHD is implementing coverage for biopsychosocial treatment of obesity for youth and adult participants in 2021. Youth services are available for eligible participants 20 years of age and younger while adult services are available for those 21 years of age and older. These services are consistent with recommendations from the United States Preventive Services Task Force (USPSTF). The goal of these services is to improve health outcomes for youth and adult populations by promoting improvements in weight status and reducing the incidence of comorbid conditions, such as diabetes, by focusing on the integration of medical nutrition therapy and behavioral health counseling services to facilitate behavior changes. f. Diabetes Prevention Services MHD implemented coverage for Diabetes Prevention Program Services for adult participants on September 1, 2020. Services are available for eligible participants ages 21 and older with the goal of preventing the progression to type 2 diabetes and improve health outcomes for high-risk adults by managing obesity and associated co-morbidities. Services are recommended by a physician and/or other licensed practitioner and focus on structured interventions that include behavioral counseling that concentrates on weight reduction and lifestyle changes. The National Diabetes Prevention Program (National DPP) is one such program. 10