Barriers and Potential Solutions to Providing Optimal Guideline-Driven Care to Patients With Diabetes in the U.S.

Robert A. Vigersky, Md; Karen Fitzner, Phd; Jenifer Levinson, Ab


Diabetes Care. 2013;36(11):3843-3849. 

In This Article

Conclusions and Recommendations

This modeling study demonstrates that compensation for optimal diabetes care is inadequate and inconsistent with national standards. Even using conservative assumptions regarding reimbursement, the model results suggest that provider costs greatly exceed reimbursement for most patients for standards-based care. Indeed, the three scenarios for type 2 diabetes while representing a spectrum of age, weight, and comorbidities are relatively straightforward cases commonly seen in a primary care setting, suggesting that the reimbursement gap would be even larger for more complex cases. There are several limitations of our modeling study. First, it uses time estimates based on input from experienced diabetes providers, which might be substantially different with another panel of experts or of primary care providers (PCPs). PCP organizations were invited to join the DWG but chose not to do so. The vast majority of people with diabetes receive their health care from PCPs and not diabetes specialists; yet, their care is no less governed by the standards of care than is care from specialists. While magnitude of the misalignment of incentives to provide guideline-driven care is likely to be less for a PCP because of the diversity of illness that they see, it will still be substantial given the prevalence of diabetes in the U.S. In addition, the model assumes that all standards-based services included in the model will be covered by all payers. Finally, it assumes that providers will receive full reimbursement for the services provided and that they can collect the full patient copayment/coinsurance amounts from all patients. Indeed, the sensitivity analyses show that the model is sensitive to assumptions about coverage of services and level of reimbursement, and the gap between provider costs and reimbursement would increase significantly under differing assumptions. The modeling study confirms general perceptions of an untenable situation in which providers are financially unable to meet the established standards of diabetes care that would prevent or delay costly diabetes complications. The panels' time estimates were high and were guided by the stated goal of what it would take to produce guideline-driven care. We believe that these time estimates are likely to represent the large amount of unreimbursed care that is generally provided to patients with diabetes.

The DWG recommends the following changes, which are arrayed across three areas of provider engagement: care management, payment reform, and workforce supply. We recognize that some of the care management and payment reform options may not be appropriate or possible in some practice settings at this time.

Care Management

Diabetes is unique among chronic diseases in that, by definition, it requires a high level of engagement and never-ending self-management by patients and (often) their family members. Improved glycemic control and thereby reduced complications can be enhanced with greater provider focus on care management. In fact, enhanced provider/patient communication leads to greater adherence among patients with diabetes.[16] Among the strategies to accomplish this are the following:

  1. Increasing the use of shared decision making with providers discussing the standards of care, the treatment options, and their recommendations with patients to maximize patient engagement in self-management of diabetes. This heightened understanding increases a patient's motivation and sense of empowerment to reach treatment goals that are their own rather than those of their providers.[17,18]

  2. Creating strong teams to implement the shared decision-making approach and promoting the use of the core team explicitly to patients. The core team includes a physician (or nurse practitioner or physicians assistant), a nurse, a dietitian, and a CDE. Other team members that can assist with care include a podiatrist, a pharmacist, and a psychologist or social worker. Each of these provider types manages aspects of the standards of care such as glucose monitoring, diabetes self-management education, nutrition therapy, and psychosocial assessment and care.[19]

  3. Leveraging existing health information technology more fully to assist patients in diabetes self-management and track blood glucose values and overall performance.[20–25]

  4. Prescribing electronically to improve monitoring of medication adherence. The use of electronic prescribing has increased dramatically in recent years. By mid-2012, 48% of physicians in the U.S. are using e-prescribing systems—an increase from 7% in 2008;[26–28]

  5. Participating in patient registries or locally based databases to track and trend goal achievement. Recent emphasis on coordinated care models that are currently being piloted and adopted provides an opportunity for registries to be designed and implemented in a more coordinated and comprehensive fashion. Accountable Care Organizations and patient-centered medical homes (PCMHs) require the collection and sharing of data on their patient populations.[29–31]

Payment Reform

Consideration of a broad spectrum of payment solutions is necessary to fully address provider barriers. The problem of inadequate reimbursement is twofold. First, much of the care delivered to diabetes patients is not described by existing CPT codes that determine coverage and payment, is considered by payers to be included or "bundled" into existing CPT codes, or is described by existing CPT codes that are not covered or reimbursed by payers. Second, in cases where appropriate codes exist, the associated payments are often insufficient. Both of these problems are exacerbated by the large amount of non–face-to-face care delivered to patients with diabetes. Better aligning payment with desired patient outcomes can both improve outcomes and lower costs through decreasing emergency department and inpatient hospital use. For example, contracting with third-party payers for pediatric and adolescent diabetes intensive case-management services has been an effective strategy, since it allows for intensive education and immediate access to the diabetes care team for crisis management.[32]

The solutions include the following:

  1. Reviewing and revising billing codes in the current fee-for-service system to more appropriately describe the work being performed and ensuring that the coding results in adequate payment.

  2. Testing and implementing new payment models that reward providers for supplying optimal care to patients with diabetes. Payment models that hold promise for diabetes include the following:

    1. The episode-of-care payment model that allows for reimbursement of multiple services at one time covering different providers and different types of care. Unlike fee-for-service models, it creates efficiencies by encouraging provider teams to work with a set amount of funding for each care episode and to tailor that experience to the patient's needs. Several pilot programs of diabetes episode-of-care payments, including the PROMETHEUS payment model for diabetes, are under way, but there are no published results at this time.[33]

    2. The patient-management-fee model that provides a monthly per-patient payment for all care. It would facilitate extensive care coordination, education, and training services and cover the various patient-management activities required to achieve optimal patient outcomes, including between-visit care via phone or e-mail and excluding acute services such as episodes of ketoacidosis. The payment would account for the multidisciplinary team required for optimal care, allowing for education services from diabetes educators, nutritionists, and dietitians as appropriate. This model could include a pay-for-performance adjustment.

    3. The diabetes-focused PCMH option that both encourages care coordination and aligns reimbursement incentives while incorporating guideline-directed quality measures that benefit the patient. Initial evidence suggests that such a model has potential benefits for patients, providers, and payers.[30,34,35] It would place value on the services necessary to provide optimal diabetes care (e.g., between-visit care and patient education).

These payment models could be applied to a system whereby there are shared (i.e., group) medical appointments. Some studies of shared medical appointments have shown improvement surrogate end points of A1C and cardiovascular risk in patients with diabetes.[36,37] Such shared medical appointments may be used as an integral part of the PCMH.

Workforce Supply

The current supply of diabetes specialists, including both physician and nonphysician providers, is inadequate to meet the demands of today and certainly will fall short of future needs, including many of the care management and innovative payment recommendations. Wait times for appointments range from 3 to 9 months, and many practices are closed to accepting new diabetic patients.[38] Expanding the workforce is a necessary investment if we are to have a chance at resolving the barriers to optimal diabetes care. The solutions include the following:

  1. Forgiving educational loans to make diabetes care an attractive choice for new medical professionals. Such programs, similar to the National Health Service Corps and state-supported programs, could be implemented by state or federal agencies, private sector organizations, and educational institutions through funding from nonprofit foundations and trusts.[39–41] This could counteract the reputation of diabetes care as an underpaid professional endeavor that dissuades providers from seeking to enter it as they face looming debt repayment. For physicians, these programs could operate in a manner similar to existing, successful loan-forgiveness programs for PCPs and physicians working in rural and underserved areas.[42] Offering similar types of loan-forgiveness programs and other financial assistance to potential CDEs and to RDs specializing in diabetes patient care is equally critical.[43]

  2. Realigning financial incentives to allow for more time with diabetic patients and for the provision of non–face-to-face care. This will project a more positive image for those who work to keep diabetic patients healthy.

  3. Encouraging diabetes-centric professional societies to promote the positive attributes of working with diabetic patients to medical, nursing, pharmacy, and nutrition students.

  4. Better educating PCPs including nurse practitioners and physicians assistants on the current standards of care, the principles of proactive management, and the need for timely referral to specialist. This training approach acts as a "force multiplier," thereby mitigating some of the specialist work force supply issues.

In summary, the DWG has found that delivering high-quality, guideline-based diabetes care is unrealistic given the current care and payment paradigms and proposes alternative approaches that may mitigate the increasing medical and financial burdens of this epidemic chronic illness.