Having diabetes is expensive. The more than 34.2 million Americans who have been diagnosed with either Type 1 or Type 2 diabetes can expect to spend more than twice as much as people without diabetes on their healthcare each year. In addition to the healthcare needs imposed by diabetes itself, at least some of these costs are due to people skipping recommended preventative care such as primary care visits, with no-show rates among people with diabetes measured around 16%. These visits are important for both patients, who can identify and address problems earlier when they are easier and less expensive to treat, and health systems, who recognize immediate economic value from the care delivered.

Given the costs associated with diabetes, health systems, payers, employers, and other stakeholders invest heavily in various behavioral interventions that can address symptoms and improve outcomes. These interventions often focus on lifestyle changes (like diet or exercise), adherence to recommended medication or blood sugar testing regimens, or condition-specific education. It makes sense then that estimates of the value of these interventions often focus on the impact of lifestyle changes. Fewer interventions focus on appropriate utilization of preventative care such as regular primary care appointments. Yet, primary prevention and regular care deliver value to the health system beyond their direct impact and have been considered as components of a value-based agreement for diabetes care. And we know Precision Nudging™ for Diabetes moves overdue patients to schedule and attend those primary care visits. We believe a focus on primary care and well visits as a modifiable behavior for people with diabetes will improve outcomes. Calculating the economic value of primary care for diabetes is important to help health systems prioritize interventions targeting PCP visits in their patient support offerings.

The Economic Impact Model

Lirio has developed a conceptual model and process to prospectively estimate the downstream economic benefits of Precision Nudging for diabetes to a health system. This model focuses on revenue to the health system rather than a specific clinical outcome, given the established relationship between primary care and improved patient outcomes. The model supports value-based pricing for organizations implementing Precision Nudging for the first time. Being able to forecast the total economic value of an intervention has been identified as a critical prerequisite for widespread adoption and helps health system customers more quickly identify which interventions are effective.

Lirio’s model stratifies patients by risk level as indicated by their most recent HbA1c value. The American Diabetes Association recommends people with diabetes visit their providers more frequently if their A1c is in a moderately (7-9) or poorly controlled range (above 9), compared to well controlled (under 7). Accordingly, Lirio’s Precision Nudging for Diabetes prompts patients to visit their PCP at a frequency based on their last recorded A1c value. The economic model accounts for the direct revenue health systems recognize from these visits based on the payer mix of the patients with diabetes and the CPT codes that are relevant in a typical diabetes well visit, as well as inpatient services needed. For example, about 22% of people with diabetes smoke, so about 22% of diabetes primary care visits may include a CPT code related to tobacco cessation counseling. The result of the model is a dollar value per primary care appointment that represents the economic impact of a visit to the health system. Once that value has been calculated, it can be used to inform value-based pricing and to prioritize Precision Nudging in the mix of patient support programs.

Although we developed this model to understand the economic value of Precision Nudging, we believe it helps create a case to promote primary care for chronic conditions more generally. In an example of a hypothetical health system based on national average data, the dollar value per visit was almost $1300. Across tens of thousands of patients in a health system who are recommended to see their PCP between one and four times per year, that value becomes quite significant.

Read the Research Paper

Learn the details of the economic impact model for estimating the value of primary care visits for patients with diabetes to a health system by reading our article in JMIR Formative.