UnitedHealthcare’s Level2 is a value-based care program that combines wearable technology with customized clinical support to help improve the health of people living with Type 2 diabetes. Rhonda Randall, D.O., chief medical officer for UnitedHealthcare’s commercial business, recently spoke with Healthcare Innovation about data presented at the 2024 American Diabetes Conference on Level2’s new “Assured Value Program,” which aims to ensure eligible employers realize value with the program.
Healthcare Innovation: Before we talk about the Level2 program, could you give us a little bit of detail about your background and what your role as chief medical officer in the United Healthcare's commercial business entails?
Randall: Sure. I am a family physician and a geriatrician, and have responsibility for all of our commercial employer and individual clinical programs, which includes population health and disease management and support. So things like Level2 certainly fall within that. I've been in the healthcare industry for 25 years, and in the first part of my career, I spent a significant amount of time in government programs, Medicare and Medicaid, and the second half of my career with employers.
HCI: From United Healthcare's perspective, could you talk a little bit about how significant an issue Type 2 diabetes is for members and their employers, and has it been getting more challenging over time?
Randall: Yes, it is important to start with the grounding of why it matters. We know that more than 38 million Americans have diabetes and that has been on the rise for the last several decades, and that's just the individuals who have been told they have diabetes by their physician, right? We know that behind the 38 million Americans who have diabetes, there are more who have it and haven't been diagnosed yet. And there's a really significant number of individuals who have pre-diabetes, which puts them at very high risk of developing diabetes. Type 2 diabetes leads to things like blindness and kidney disease. It's the number one cause for people ending up with renal failure and needing dialysis or a kidney transplant. So getting a diagnosis of diabetes or pre-diabetes early, so that you're empowered to partner with your physician and your family on a treatment plan and getting your blood sugar under control are really mainstays. It's possible to bring that blood sugar into a normal level with combinations of awareness, coaching, lifestyle support and sometimes medications.
HCI: Before the Level2 program, has UnitedHealthcare developed other care management programs in the commercial space to improve outcomes for diabetic patients.
Randall: We have had programs evolve over many decades. Early on, things like disease management programs were really the mainstay of how you cared for chronic conditions like diabetes. That was really based on looking at who had a claim fordiabetes and making a phone call with a well-trained, experienced nurse. We can find examples of that dating back to the 1990s. But here we are in the in the 2020s and we want to look at modern ways to engage people who have chronic conditions like diabetes. Now we have additional ways to get more real-time information to understand who may have the condition and additional ways to reach out. Many more of our members are using our digital assets, for example. I think there's been a really nice evolution in identification and engagement when people decide that it's right for them, and when they're open to receiving that support. I think another thing that has changed is really understanding when one plus one can equal three. What I mean by that is a continuous glucose monitor all by itself hasn't been shown to be very effective, but if you put a continuous glucose monitor in combination with coaching and support and lifestyle modification and appointments with your physician, it's been shown to be very effective at reducing blood sugar.
HCI: In Medicare and Medicaid, we hear that a lot of these patients are dealing with health-related social issues that need to be addressed as well. Is that less of an issue in the commercial space, or still an important consideration when working with diabetic patients?
Randall: It is almost equally as important in the commercial space. In all of our patient support programs, including Level2, we look for opportunities to address social drivers of health and where we can reduce barriers — so things like access to healthy food, access to transportation, etc., that can be barriers to achieving your healthcare goals. We think about whole-person care, which is not just your medical care, but also your behavioral healthcare and the support around social needs.
HCI: Can you talk in more detail about Level2?
Randall: We've had it for quite some time. It has gone through development over that period of time, and what we're sharing now is the Level2 Assured Value Program. We shared a study in the American Diabetes Association scientific sessions showing that individuals who were enrolled in Level2 had a clinically meaningful improvement in their hemoglobin, A1C, which is a measure of your blood sugar control, over a multi-month period of time.
[In UnitedHealthcare’s study, 73% of UnitedHealthcare members enrolled in Level2 with a starting hemoglobin A1C above 7.0 had a clinically meaningful improvement in this measurement. Among members included in the study, the average reduction in A1C was 1.39 percentage points after one year and 1.36 at two years, demonstrating that Level2 can lead to sustained, lower glucose levels among participants.]
Based on that evaluation and what we've seen as far as success in this program with individuals who are enrolled and engaged, we're introducing the Level2 Assured Value Program for employers that have more than 125 covered employees who have Type 2 diabetes. And that is really us saying that we're guaranteeing the value of the program to the employer. Employers who are already partnering with United Healthcare have an opportunity to add this onto their current offering.
HCI: How does this work intersect with the surge in the usage of new obesity drugs. Are there issues for payers in terms of studying their effectiveness in the shorter and longer term, and then under what circumstances to cover them?
Randall: You're probably thinking in particular of GLP-1s. Those medications were initially studied and approved for use in diabetes. While they are an expensive medication, we do see that when they're paired with a solution that includes coaching and lifestyle modification, that employers are going to get more value out of those types of medications. So we partner with the member and their treating physician — it's the treating physician who's making the decision on the best class of medication for the individual. The information that we're providing that physician, often from the continuous glucose monitor, can help them make the best choice. They're going to see the patterns in when is the blood sugar spiking? Is it not going to baseline while this individual is sleeping? There are different classes of drugs that work with those patterns, so that information that we share with the member and the physician can be really helpful in drug selection. But I think what's really important is that combination of whole-person care that's partnering that lifestyle and coaching along with the drug if it's appropriate to be prescribed.
HCI: Are there other other innovations taking place with remote patient monitoring and care management combinations for other chronic diseases that United Healthcare is either involved in or already or looking at?
Randall: There have been other remote patient monitoring programs for other diseases that the industry and United Healthcare have looked at. The one that we have found the most success around is a continuous glucose monitor paired with a comprehensive lifestyle modification program in Level2.
HCI: I've interviewed other people about home blood pressure monitoring for people with hypertension. Has that shown results?
Randall: With the ones around blood pressure monitoring, it really is around population selection. That's not something that we're focused on in the commercial space. Population health really is about stratification. There has been some monitoring around asthmatics; there is certainly some home monitoring that can be done with premature babies. There are high-risk pregnancies with blood pressure monitoring.
HCI: Is there anything else about Level2 that that you'd want to stress?
Randall: I think the only other thing that I would mention is how incredibly high the satisfaction scores are for individuals who work with this program. Level2 has a net promoter score of 82. If you think about some of the industry benchmarks around healthcare in general and net promoter scores, 82 is a really high score. So individuals who are engaged in this program are really happy with the care team and the support that they're receiving in addition to the great outcomes, and I think those go hand in glove.
HCI: Do the people stay in the program for a fairly long time, or is there a set amount of time that it is prescribed?
Randall: They have access to the support and the coaching, as long as their employer for the Assured Value Program is making it available to them. We do find a significant number of the members who engage in this engage more intensely early on, and then they develop their own skill set and tools on how to recognize when their blood sugar's high. They might not have had to wear their continuous glucose monitor for quite some time, and then they see themselves sliding backwards, and wear it again for a period of time. They get that real-time information — when I have orange juice or coffee with or without sugar in the morning, I can see the difference in how that affects my blood sugar throughout the day. Or if I take a walk after a meal, you really get that immediate feedback. So some individuals progress through that and develop those skills on their own, so it really becomes personalized.
