Will Bundled Measures Improve Diabetes Care?

Neil Chesanow

Disclosures

August 13, 2014

In This Article

A Solution for the Diabetes Epidemic?

As hospitals purchase primary care practices, patient-centered medical homes (PCMHs) and accountable care organizations proliferate, and healthcare systems move toward consolidation, a population-based solution to one of the nation's most pressing problems -- the diabetes epidemic -- remains elusive.

However, the Geisinger Healthcare System in Danville, Pennsylvania, the nation's largest rural integrated system, has developed a systematic approach that has produced enviable outcomes. It can serve as a roadmap to guide doctors, payers, and healthcare organizations out of the dilemma.

A Flood of Referrals From Primary Care

In 2012, the latest year for which statistics are available, 29.1 million Americans -- 9.3% of the population -- had diabetes, reports the American Diabetes Association (ADA), with 1.7 million new cases in 2012 alone.[1] Over one quarter of seniors have diagnosed and undiagnosed diabetes.[1]

The epidemic is overwhelming the nation's 352,000 internists, family physicians, and pediatricians.[2] Even though patients with private insurance now spend an average of 18.53 minutes with a primary care physician, according to the National Ambulatory Care Survey, it isn't nearly enough.[3]

"For the vast majority of our patients, we block 30 minutes for a routine diabetes follow-up," says Bill Law, MD, an endocrinologist in Knoxville, Tennessee, and a past president of the American Association of Clinical Endocrinologists and the American College of Endocrinology. "There's no question that there are not nearly enough endocrinology physicians available to provide care for all of the patients with diabetes in the country -- a rapidly growing number, I might add."

Even if primary care doctors had more time to spend with diabetic patients, getting an appointment is no easy task. A 2013 study by the Massachusetts Medical Society found the average wait time to see a family physician was 39 days; for internists, it was 50 days; for pediatricians, it was 25 days.[4] Moreover, one half or fewer of primary care practices surveyed were not accepting new patients.[4]

As a result, endocrinologists are being overwhelmed by referrals of diabetic patients who could treated in a primary care setting if primary doctors had more time.

"We frequently feel compelled to, in essence, take over management of diabetes patients' hypertension, or their hyperlipidemia, or their thyroid disease, or their osteoporosis, because the primary care doctor doesn't have time to manage those well either," Dr. Law says.

Fewer than 5000 adult endocrinologists and fewer than 900 pediatric endocrinologists are currently in clinical practice, and the number of new endocrinologists isn't close to keeping pace with the demand.[5] One reason: compensation. In Medscape's 2014 Compensation Report, endocrinologists ranked 21 out of 25 specialties, with an average compensation of $184,000.[6]

"The problem is that society wants us to go into great detail and take a careful history and physical exam, educate the patients very intensively, empower them with knowledge, etc. -- but that takes time," Dr. Law points out. "The more time you spend with one patient, the less money you get paid. It's the opposite of what any logical system would do."

The doctors at Geisinger have figured out how to get a grip on the problem at the primary care level by focusing on overall outcomes rather than individual metrics, such as getting patients' hemoglobin A1c levels under control.

It's neither a quick fix nor inexpensive, but their system has produced remarkable results: Over a five-year period, during which Geisinger's diabetic population grew from 24,000 to 27,000 patients, there was a 550% improvement in their comprehensive diabetes scores, says family physician Thomas Graf, MD, Chief Medical Officer for Population Health. Here's how Geisinger doctors did it.

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